Reproductive health risks associated with occupational exposures to antineoplastic drugs in health care settings: a review of the evidence

Association between job control and time to pregnancy in a preconception cohort

OBJECTIVE

To evaluate associations between low job control (operationalized as job independence and freedom to make decisions) and time to pregnancy. Low job control, a form of workplace stress, is associated with adverse health outcomes ranging from cardiovascular disease to premature mortality; few studies have specifically examined its association with reproductive outcomes.

DESIGN

We used data from Pregnancy Study Online, an internet-based preconception cohort study of couples trying to conceive in the United States and Canada. We estimated fecundability ratios (FRs) and 95% confidence intervals (CIs) via proportional probability regression models, adjusting for sociodemographic and behavioral characteristics.

SETTING

Not applicable (Web-based study).

PATIENTS

Participants self-identified as female, were aged 21-45 years, and reported ≤6 cycles of pregnancy attempt time at enrollment (2018-2022).

EXPOSURE

We assessed job control by matching participants' baseline self-reported occupation and industry with standardized occupation codes from the National Institute for Occupational Safety and Health's Industry and Occupation Computerized Coding System, then linking codes to O∗NET job exposure scores for job independence and freedom to make decisions.

MAIN OUTCOME MEASURE

Our main outcome measure was fecundability. Participants completed self-administered questionnaires at baseline and every 8 weeks for up to 12 months or until reported pregnancy, whichever occurred first.

RESULTS

Among 3,110 participants, lower job independence was associated with reduced fecundability. Compared with the fourth (highest) quartile, corresponding to the most job independence, FRs (95% CI) for first (lowest), second, and third quartiles were 0.92 (0.82-1.04), 0.84 (0.74-0.95), and 0.99 (0.88, 1.11), respectively. Lower freedom to make decisions was associated with slightly reduced fecundability (first vs. fourth quartile: FR = 0.92; 95% CI: 0.80-1.05).

CONCLUSION

Lower job control, a work-related stressor, may adversely influence time to pregnancy. Because job control is a condition of work (i.e., not modifiable by individuals), these findings may strengthen arguments for improving working conditions as a means of improving worker health, including fertility.

Reproductive outcomes among female health care workers

OBJECTIVE

Occupational exposures may be associated with reproductive health and pregnancy outcomes. This study investigated the association between occupational exposures and reproductive health, pregnancy outcomes, and the lactation period among hospital staff.

MATERIALS AND METHODS

Seven hundred thirty-three female healthcare workers from hospitals affiliated with the Tehran University of Medical Sciences were invited to participate in this cross-sectional study. The measurement method for fertility consequences was self-report. Demographic characteristics, occupational data, medical history, and reproductive history were collected via data collection form. Finally, reproductive outcomes were evaluated in different occupational hazard categories.

RESULT

Chemical exposures (solvents) were a risk factor for stillbirth. Prolonged working hours were associated with spontaneous abortion and breastfeeding periods. Shift workers did not have a higher frequency of reproductive and pregnancy outcomes, but the breastfeeding period was significantly decreased in shift workers. Psychiatric disorders were associated with preterm labour, low birth weight, and stillbirth in sequence with nervousness, depression, and mood disturbance. Furthermore, depression affects the breastfeeding period. Moreover, we found a link between job titles and infertility. In addition, socioeconomic status was related to stillbirth and infertility.

CONCLUSION

The study revealed that chemical and ergonomic exposures have associations with some reproductive outcomes. We also conclude that shift work could adversely affect the breastfeeding period. So, implementing some organizational strategies to control adverse health effects of occupational hazards and modifying shift work and working hours for nursing mothers is recommended.

Longitudinal evaluation of environmental contamination with hazardous drugs by surface wipe sampling

INTRODUCTION

Exposure of healthcare workers to hazardous drugs can lead to adverse health effects supporting the importance of a continuous monitoring program, for example, by taking surface wipe samples. The objective was to describe the results of repeated monitoring of contamination with hazardous drugs on multiple surfaces in a hospital pharmacy and at two wards using standardized preparation techniques and cleaning procedures.

METHODS

Twelve surfaces in the hospital pharmacy and at two wards were sampled and analyzed for contamination with the hazardous drugs cyclophosphamide, doxorubicin, 5-fluorouracil, gemcitabine, methotrexate, and paclitaxel. The drugs were prepared with a closed-system drug transfer device (CSTD). Sampling of the drugs was performed in four trials during eight months. Liquid chromatography tandem mass spectrometry was used for the analysis of the drugs.

RESULTS

During the four trials, contamination with five of the six hazardous drugs was found on half of the surfaces in the pharmacy and in a ward. Seventeen out of 288 possible outcomes were positive (6%), with the biological safety cabinet grate (n = 6) and scanner (n = 5) most frequently contaminated. The highest level of contamination was observed on the pass-thru window (cyclophosphamide: 2.90 ng/cm2) and the touch screen of the Diana device (5-fluorouracil: 2.38 ng/cm2). Both levels were below the action level of 10 ng/cm2.

CONCLUSIONS

The long-term use of a CSTD in combination with appropriate cleaning has proven effective in achieving low levels of surface contamination with hazardous drugs.

Residual contamination in antineoplastic drug packaging

INTRODUCTION

The handling of antineoplastic drugs should follow strict supervision and safety rules to minimize the occupational exposure risks to professionals involved. The external surface contamination of drug vials is recognized as a health risk. So, our goal was to determine if there is residual contamination on the vials and containers surface of the antineoplastic drugs doxorubicin (DOX) and cyclophosphamide (CP).

METHODS

A cross-sectional study was conducted. Samples were collected using a uniform sampling procedure on the inner surfaces of the packages/boxes and the outer surfaces of the vials. The analyzes were executed by high-performance liquid chromatography/mass spectrometry (UHPLC-MS/MS).

RESULTS

A total of 209 samples were analyzed, 66 of CP and 143 of DOX. CP levels were detected in nine samples (13.63%), three were below the lower limit of quantification (LLQ) and the other six had contamination levels ranging from 1.24 to 28.04 ng/filter. DOX levels were detected in 36 samples (25.17%), two were below the LLQ and the others had levels between 1.32 and 664.84 ng/filter. The majority of samples with residual contamination were in vials (80.0%), however, boxes also showed contamination.

CONCLUSIONS

The results revealed the presence of residual contamination in the vials and packages of CP and DOX drugs. Although the residues found in each sample are small, special care should be taken in the handling and disposal of the antineoplastic drugs. The use of personal protective equipment is fundamental while handling the vials and packaging of cytotoxic drugs.

Perception, knowledge, practices and training regarding the risk of exposure to antineoplastic drugs in three French compounding units

INTRODUCTION

Healthcare workers are exposed to hazardous drugs such as antineoplastic drugs, which have potential carcinogenic, mutagenic and teratogenic effects. Protective measures must be taken after appropriate staff training to handle antineoplastic drugs in a safe way. The objective was to assess perception, knowledge, practices and training regarding the risk of exposure of healthcare workers in three French compounding units.

METHODS

This descriptive study was based on a questionnaire made of 33 questions divided into five sections related to the handling of antineoplastic drugs: perception of the risks, knowledge of the risks, protection practices, specific training and general questions.

RESULTS

Among the 39 participants, over half considered their overall risk of exposure to antineoplastic drugs not being very low. Inhalation was known to 69.2% of them as possible route of contamination. The breakroom was identified by 28.9% of them as a place of contamination. The procedure in case of accidental exposure to antineoplastic drugs was known by 69.2%, but only half could explain it. Only 38.5% said they changed their gloves every 30 min as recommended. Barely half said that they had been trained specifically for the handling of antineoplastic drugs during an initial training. Over half wished to be informed, trained and aware of the proper handling of antineoplastic drugs.

CONCLUSION

Although some of these results are encouraging, specifically when compared to the other settings where antineoplastic drugs are handled, there is still room for improvement. Efforts to build an adapted and impactful training program must pursue.

CLINICAL TRIAL REGISTRATION

Study CONTACT, ref. 19-504.

Psychometric Testing of the Oncology Nurses Health Behaviors Determinants Scale: A Cross-Sectional Study

OBJECTIVES

Adherence by oncology nurses to chemotherapy safe handling guidelines is essential to prevent hazards of chemotherapy exposure. A review of the literature revealed the need for an instrument with evidence of reliability and validity to measure factors influencing adherence to safe chemotherapy-handling guidelines among oncology nurses. The purpose of this study was to psychometrically test the Oncology Nurses' Health Behaviors Determinants Scale (HBDS-ON) that measures the mentioned factors.

DATA SOURCES

Methodological research of a quantitative cross-sectional survey design was used. The study surveys were administered by email to a sample of 108 oncology nurses. Cronbach alpha, item analysis, exploratory factor analysis using principal axis factoring, and convergence validity testing were used to test reliability and validity.

CONCLUSION

Factor analysis yielded six subscales, each having acceptable internal consistency reliability (Cronbach alpha between 0.70 and 0.88). The subscales included four oncology nurse health beliefs (perceived threat, benefits, barriers, and self-efficacy), cues to action, and personal protective equipment availability and accessibility. Convergence validity testing results support the Oncology Nurses Health Behaviors Determinant Scale (HBDS-ON) construct validity. Oncology nurses' self-efficacy to adherence to chemotherapy-handling guidelines, the perceived barriers to adhere to chemotherapy-handling guidelines, and cues to action are associated with adherence to chemotherapy-handling guidelines.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses' health beliefs, the cues to action, and personal protection equipment availability and accessibility are important determinants of nurses' adherence to chemotherapy-handling guidelines. The HBDS-ON is an instrument that has evidence of reliability and validity and could be used in practice to measure these determinants.

Risk assessment of personnel exposure in a central cytotoxic preparation unit using the FMECA method

INTRODUCTION

Personnel involved in the preparation of cytotoxics are exposed to them and the resulting risks. To protect themselves, many means of protection are currently implemented. Nevertheless, the exposure of these manipulators remains a possibility to be considered.

MATERIALS AND METHODS

The study was conducted during the period (October-November 2022) in the pharmacy of the National Institute of Oncology (INO), a hospital structure specializing in cancer care. The Failure Mode, Effects and Criticality Analysis method was used to assess the risks of exposure of personnel in a central cytotoxic preparation unit and then calculate the criticality index (CI  =  severity  ×  frequency  ×  detectability). The risks were classified into toxic, traumatic, chemical, and environmental risks. We have cited 12 failure modes of which nine are minor and three are major. The three major modes cited are essentially related to the particulate environment, direct contact and daily passive inhalation of handling.

CONCLUSION

Our study shows that in our institution, the analysis of the risk of exposure of personnel to cytotoxics remains important, hence the interest of automaton in charge of preparations and which will gradually take charge of all the preparations. The existing procedures and the pharmacotechnical equipment used also contribute to protection and risk reduction.

Impact of Educational Intervention on Compliance of Health Care Workers Towards Chemotherapy Handling Guidelines

Background

Chemotherapy safety guidelines have been enacted to minimize their side effects on healthcare providers when handling medications. The aim of this study is to assess the impact of an educational intervention on healthcare workers' compliance with chemotherapy safety guidelines.

Methods

In this study, we used a quasi-experimental, pre-post testing design. It was conducted in the Oncology center at King Saud University Medical City (KSUMC) in Riyadh, Saudi Arabia. All healthcare workers involved in the preparation and administration of chemotherapy medications in KSUMC were invited. We evaluated Educational intervention to ensure the compliance of healthcare workers with standard safety guidelines through a questionnaire with 29 questions in total.

Results

Fifty-two participants were eligible in this study. Overall, the score for mean compliance with workplace guidelines among the participants increased from 17.62∓0.78 to 18.17∓0.80 out of 19. Multiple liner regression indicates that there are no variables among the included variables predicting a change in post-intervention.

Conclusion

This study indicates that educational intervention is the only effect of compliance in the included sample. Education safety training could improve healthcare workers' knowledge and consequently improve their compliance in the preparation and administration of chemotherapy medication.

Real-world study of the leakage of two types of infusion bags in multicenter pharmacy intravenous admixture service (PIVAS)

Background: This study sought to analyze the leakage rate, economic loss caused by leakage, leakage reasons, and usage of upright polypropylene infusion bags and non-polyvinyl chloride (PVC) infusion bags, two types of closed intravenous infusion containers used in pharmacy intravenous admixture service (PIVAS), to improve the product quality of drug infusion packaging materials, reduce drug and clinical economic losses, and reduce the safety hazards of medication. Method: A real-world study was used to collect statistics for these infusion containers. The study was conducted in 21 hospitals in China from September to December 2022. Upright polypropylene infusion bags or non-PVC infusion bags in PIVAS of these 21 hospitals were chosen as the research material. Results: In total, 2,349,899 upright polypropylene infusion bags and 3,301,722 non-PVC infusion bags were collected. Eleven cases of upright polypropylene infusion bag leakage occurred (with a the leakage rate of 0.05‱), and 394 cases of non-PVC infusion bag leakage occurred (with a leakage rate of 1.19‱). The leakage rate of non-PVC infusion bags was significantly higher than that of upright polypropylene infusion bags (p < 0.01). The main reason for leakage in upright polypropylene infusion bags was sharp objects such as glass fragments or aluminum caps piercing the bag. The main reason for leakage in non-PVC infusion bags was squeezing, stacking, and uneven arrangement that causes folding of edges. For non-PVC bags, additional reasons for leakage included leakage at the nozzle joint, excessive manual or machine throwing force, and excessive dosage. The economic loss of upright polypropylene infusion bags was 1,116.56 CNY. The economic loss of non-PVC infusion bags was 32,210.86 CNY. Conclusion: Based on real-world study data on the leakage of upright polypropylene infusion bags and non-PVC infusion bags in multicenter PIVAS, it can be concluded that the leakage rates of upright polypropylene infusion bags are significantly lower than those of non-PVC infusion bags in PIVAS, and the economic losses due to upright polypropylene infusion bags are lower than those due to non-PVC infusion bags in PIVAS. Therefore, we can infer that upright polypropylene infusion bags are superior to non-PVC infusion bags.

Knowledge and practices about safe handling regarding the risk of exposure to antineoplastic drugs for caregivers in compounding units and in operating rooms performing HIPEC/PIPAC

INTRODUCTION

Ever since the late 1970s, occupational exposure associated with the handling of antineoplastic drugs (ADs) in the healthcare environment has been highlighted and demonstrated. Contamination was detected in both operating rooms (OR) and compounding units (CU), where healthcare workers handle and are exposed to ADs in different ways. In the OR, the risk of exposure is higher and the staff receives less training in handling ADs than in the CU. This study aimed to assess and compare knowledge and practices about the safe handling of ADs by caregivers working in these two locations, namely the CU and OR.

METHODS

Two questionnaires (one each for the OR and CU) were created by two investigator pharmacists and were completed during a personal interview of 20 min. The questions were related to the following topics: training, knowledge about occupational exposure and questions related to protective practices. A scoring system was implemented to assess the knowledge and practices of each participant.

RESULTS

In total, 38 caregivers working in the OR and 39 in the CU were included in our study. Significantly more CU staff had specific initial training (p < 0.001) and ongoing training (p < 0.001) in handling ADs. Concerning the knowledge score, OR caregivers had a significantly lower median score for contamination routes (p < 0.001), contamination surfaces (p < 0.001), existing procedures (p < 0.001) and total knowledge (p < 0.001) than CU caregivers. Concerning protective handling practices of ADs, the two locations had nonsignificantly different median scores (p = 0.892).

CONCLUSION

This study suggests that there is still room for improvement in terms of knowledge and protection practices when handling ADs. An appropriate and tailored training program should be developed and provided to all caregivers who handle or come in contact with ADs.Clinical trial registrationStudy CONTACT, ref. 19-504.

Predictors of community pharmacists' readiness to manage the effective and safe use of oral anticancer medicines in a developing setting

BACKGROUND

There is a paucity of studies about the readiness of community pharmacists to manage the safe and effective use of oral anticancer medicines (OAMs) in developing settings.

OBJECTIVES

Using the readiness component (knowledge and willingness) of the situational theory of leadership, the study assessed community pharmacists' readiness to manage the safe and effective use of OAMs in Qatar, and also identified its significant predictors.

METHODS

A cross-sectional assessment of 252 community pharmacists was conducted with a pre-tested 48-item questionnaire. Readiness was assessed with a 5-point Likert-type scale and the maximum obtainable score was 70. The mean was used as the cut-off point to categorize willingness and knowledge as either high (≥ mean) or low (< mean). Independent t-test, one-way analysis of variance and multiple linear regression was used for data analyses.

RESULTS

The mean SD score for the readiness of community pharmacists was 39.3 ± 11.2 (min = 11, max = 70). Only a minority of the respondents expressed an excellent understanding of the chemotherapy cycles (19.6%; 45/230), and familiarity with targeted anticancer therapy (14.3%; 33/230), side effects (22.2%; 51/230), and dosing of OAMs (14.4%; 33/230). Employment status, number of OAMs prescriptions dispensed per month and adequacy of the contents related to OAMs in undergraduate training were the significant predictors of readiness (R2 = 0.558, (F (11, 209) = 3.559, p = 0.0001).

CONCLUSIONS

Community pharmacists' readiness appear inadequate especially regarding its dosing, side effects, handling, and disposal of OAMs. These inadequacies probably underline community pharmacists' low familiarity and comfortability with dispensing and educating patients on the effective and safe use of OAMs.

Influence of occupational exposure to antineoplastic agents on adverse pregnancy outcomes among nurses: A meta-analysis

AIM

This study aimed to explore the relationship between nurses' occupational exposure to antineoplastic agents and adverse pregnancy outcomes.

DESIGN

Meta-analysis.

METHODS

Data were retrieved from studies published before April 2022 in PubMed, the Cochrane Library, the Web of Science, Embase databases, the China National Knowledge Infrastructure (CNKI), China Biology Medicine disc (CBM), China Science and Technology Journal databases (VIP) and Wan Fang databases (WF). Stata MP (Version 17.0) was used to conduct this meta-analysis.

RESULTS

The current evidence shows that occupational exposure to antineoplastic agents increases nurses' risk of spontaneous abortions, stillbirths, and congenital abnormalities. It is necessary to pay attention to occupational exposures caused by antineoplastic agents, especially for female nurses of reproductive age. Managers should take timely and effective countermeasures to ensure their occupational safety and reduce the risk of adverse pregnancy outcomes.

The Factors That Influence Chemotherapy Exposure Among Nurses: An Integrative Review

BACKGROUND

Exposure to chemotherapy is an occupational hazard predisposing nurses to severe health effects. The purpose of this integrative review was to identify the recent literature describing the risk factors for occupational exposure to chemotherapy among nurses.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology was employed to conduct the review. The databases searched were Scopus, PubMed, and CINAHL using the search terms "chemotherapy," "drugs," "exposure," and "nurses." Included articles were published between January 2010 and February 2022, published in peer-reviewed journals for research conducted in the United States, and written in English language. Excluded articles were studies that did not involve nurses in their samples. Review articles, books, theses, and dissertations were excluded as well. The Johns Hopkins Nursing Evidence-Based Practice Model was used to assess the level of evidence from the reviewed studies.

FINDINGS

Fourteen studies were included in this review. Ten studies were rated on Evidence Level III, two on Evidence Level II, one on Evidence Level I, and one on Evidence Level V. The main risk factors for occupational exposure were nurses' knowledge of chemotherapy handling guidelines, nurses' adherence to using the personal protective equipment, nurses' health beliefs regarding chemotherapy exposure, and workplace-related factors such as workload and managerial support.

CONCLUSION

Addressing the identified risk factors would protect nurses from chemotherapy exposure. More research on nurses' health beliefs regarding chemotherapy exposure and the cues to adhere to chemotherapy handling guidelines in the work environment is needed.

Evaluation of long-term data on surface contamination by antineoplastic drugs in pharmacies

PURPOSE

The handling of antineoplastic drugs represents an occupational health risk for employees in pharmacies. To minimize exposure and to evaluate cleaning efficacy, wipe sampling was used to analyze antineoplastic drugs on surfaces. In 2009, guidance values were suggested to facilitate the interpretation of results, leading to a decrease in surface contamination. The goal of this follow-up was to evaluate the time trend of surface contamination, to identify critical antineoplastic drugs and sampling locations and to reassess guidance values.

METHODS

Platinum, 5-fluorouracil, cyclophosphamide, ifosfamide, gemcitabine, methotrexate, docetaxel and paclitaxel were analyzed in more than 17,000 wipe samples from 2000 to 2021. Statistical analysis was performed to describe and interpret the data.

RESULTS

Surface contaminations were generally relatively low. The median concentration for most antineoplastic drugs was below the limit of detection except for platinum (0.3 pg/cm²). Only platinum and 5-fluorouracil showed decreasing levels over time. Most exceedances of guidance values were observed for platinum (26.9%), cyclophosphamide (18.5%) and gemcitabine (16.6%). The most affected wipe sampling locations were isolators (24.4%), storage areas (17.6%) and laminar flow hoods (16.6%). However, areas with no direct contact to antineoplastic drugs were also frequently contaminated (8.9%).

CONCLUSION

Overall, the surface contaminations with antineoplastic drugs continue to decrease or were generally at a low level. Therefore, we adjusted guidance values according to the available data. The identification of critical sampling locations may help pharmacies to further improve cleaning procedure and reduce the risk of occupational exposure to antineoplastic drugs.

Safe handling of hazardous drugs

Background: This evidence-based practice guideline was developed to update and address new issues in the handling of hazardous drugs including being compliant with NAPRA (National Association of Pharmacy Regulatory Authorities) and USP 800 (United States Pharmacopeia) standards, the use of personal protective equipment and treatment in diverse settings including in the home setting. Methods: This guideline was developed from an adaptation and endorsement of existing guidelines and from three systematic reviews. Prior to publication, this guideline underwent a series of peer, patient, methodological and external reviews to gather feedback. All comments were addressed and the guideline was amended when required. This guideline applies to and is intended for all health care workers who may come into contact with hazardous drugs at any point in the medication circuit. Results: The recommendations represent a reasonable and practical set of procedures that the intended users of this guideline should implement to minimize the opportunity for accidental exposure. These recommendations are not limited to just the point of care, but cover the entire chain of handling of cytotoxics from the time they enter the institution until they leave in the patient or as waste. Conclusions: Decreasing the likelihood of accidental exposure to cytotoxic agents within the medication circuit is the main objective of this evidenced-based guideline. The recommendations differ slightly from previous guidelines due to new evidence.

Four-year follow-up of surface contamination by antineoplastic drugs in a compounding unit

OBJECTIVES

This study aimed to monitor the contamination by antineoplastic drugs on work surfaces in a compounding unit 4 years after its implementation.

METHODS

This descriptive study was done in a unit performing on average 45 000 preparations per year. Surface sampling points (N=23) were monitored monthly in the frame of routine activity from the opening of an anticancer drug compounding unit. Contamination with nine antineoplastic drugs (cyclophosphamide, ifosfamide, dacarbazine, 5-fluorouracil, methotrexate, gemcitabine, cytarabine, irinotecan and doxorubicin) was assessed on wipes with a local liquid chromatography coupled with a tandem mass spectrometer analysis. The contamination rate (CR, %) was prospectively monitored every month during the entire study period. The occurrence of critical incidents was also registered. The effect of each safety measure implemented during this period was also analysed.

RESULTS

Based on the 1104 samples collected between March 2016 and March 2020, the CR was 18.5%. If three different critical incidents among a vial breakage that occurred were individually considered, this CR was slightly lower than that in the literature. Eight months after opening and taking different corrective actions, the overall CR dropped from 42.39% to 11.52% (p<0.001). Contamination was limited to the area that includes the compounding room and, more precisely, the welder and the QC-Prep⁺ sampling points.

CONCLUSIONS

From the beginning of the study and from month to month, surface contamination was limited to the nearest sampling points to the compounding unit. This 4-year monitoring study allowed us to determine the intravenous conventional antineoplastic drugs and sampling points to be focused on.

Pregnancy, obstetrical and neonatal outcomes in women exposed to physician-related occupational hazards: a scoping review

OBJECTIVE

Evidence is needed to guide organisational decision making about workplace accommodations for pregnant physicians. Our objective was to characterise the strengths and limitations of current research examining the association between physician-related occupational hazards with pregnancy, obstetrical and neonatal outcomes.

DESIGN

Scoping review.

DATA SOURCES

MEDLINE/PubMed, EMBASE, CINAHL/ EBSCO, SciVerse Scopus and Web of Science/Knowledge were searched from inception to 2 April 2020. A grey literature search was performed on 5 April 2020. The references of all included articles were hand searched for additional citations.

ELIGIBILITY CRITERIA

English language citations that studied employed pregnant people and any 'physician-related occupational hazards', meaning any relevant physical, infectious, chemical or psychological hazard, were included. Outcomes included any pregnancy, obstetrical or neonatal complication.

DATA EXTRACTION AND SYNTHESIS

Physician-related occupational hazards included physician work, healthcare work, long work hours, 'demanding' work, disordered sleep, night shifts and exposure to radiation, chemotherapy, anaesthetic gases or infectious disease. Data were extracted independently in duplicate and reconciled through discussion.

RESULTS

Of the 316 included citations, 189 were original research studies. Most were retrospective, observational and included women in any occupation rather than healthcare workers. Methods for exposure and outcome ascertainment varied across studies and most studies had a high risk of bias in data ascertainment. Most exposures and outcomes were defined categorically and results from different studies could not be combined in a meta-analysis due to heterogeneity in how these categories were defined. Overall, some data suggested that healthcare workers may have an increased risk of miscarriage compared with other employed women. Long work hours may be associated with miscarriage and preterm birth.

CONCLUSIONS

There are important limitations in the current evidence examining physician-related occupational hazards and adverse pregnancy, obstetrical and neonatal outcomes. It is not clear how the medical workplace should be accommodated to improve outcomes for pregnant physicians. High-quality studies are needed and likely feasible.

Study on the Use of Ozone Water as a Chemical Decontamination Agent for Antineoplastic Drugs in Clinical Settings

The exposure of healthcare workers to antineoplastic drugs in hospitals has been recognized to be harmful. To minimize the risk of exposure, the removal of these drugs from work environments, such as compounding facilities, has been recommended. In our previous paper, the degradation and inactivation efficacy of ozone water, which is being introduced into Japanese hospitals as a chemical decontamination agent, was reported for its effects on typical antineoplastic drugs (gemcitabine, irinotecan, paclitaxel). This article aims to further investigate the efficacy of ozone water for eight antineoplastic drugs to clarify its application limitations. A small amount (medicinal ingredient: typically ca. 1.5 μmol) of formulation containing 5-fluorouracil, pemetrexed, cisplatin, oxaliplatin, cyclophosphamide, ifosfamide, doxorubicin, or docetaxel was mixed with 50 mL of ozone water (~8 mg/L), and the resulting solutions were analyzed by high-performance liquid chromatography over time to observe the degradation. Consequently, the ozonation was overall effective for the degradation of the drugs, however this varied depending on the chemical structures of the drugs and additives in their formulations. In addition, after the parent drugs were completely degraded by the ozonation, the degradation mixtures were subjected to 1H nuclear magnetic resonance spectroscopy and evaluated for mutagenicity against Salmonella typhimurium strains and cytotoxicity against human cancer cells. The degradation mixtures of cisplatin and ifosfamide were mutagenic while those of the other drugs were non-mutagenic. Further, the ozonation resulted in clear decreases of cytotoxicity for 5-fluorouracil, oxaliplatin, and doxorubicin, but increases of cytotoxicity for pemetrexed, cisplatin, cyclophosphamide, and ifosfamide. These results suggest that the ozone water should be restrictedly used according to the situation of contamination in clinical settings because the ozonation enhances toxicity depending on the drug even if degradation is achieved.

Healthcare Waste-A Serious Problem for Global Health

Healthcare waste (HCW) is generated in different healthcare facilities (HCFs), such as hospitals, laboratories, veterinary clinics, research centres and nursing homes. It has been assessed that the majority of medical waste does not pose a risk to humans. It is estimated that 15% of the total amount of produced HCW is hazardous and can be infectious, toxic or radioactive. Hazardous waste is a special type of waste which, if not properly treated, can pose a risk to human health and to the environment. HCW contains potentially harmful microorganisms that can be spread among healthcare personnel, hospital patients and the general public, causing serious illnesses. Healthcare personnel are the specialists especially exposed to this risk. The most common medical procedure, which pose the highest risk, is injection (i.e, intramuscular, subcutaneous, intravenous, taking blood samples). The World Health Organization (WHO) estimates that around 16 billion injections are administered worldwide each year. However, if safety precautions are not followed, and needles and syringes are not properly disposed of, the risk of sharps injuries increases among medical staff, waste handlers and waste collectors. What is more, sharps injuries increase the risk of human immunodeficiency virus (HIV), hepatitis B and C viruses (HBV/HCV), tuberculosis (TB), diphtheria, malaria, syphilis, brucellosis and other transmissions. Disposing of medical waste in a landfill without segregation and processing will result in the entry of harmful microorganisms, chemicals or pharmaceuticals into soil and groundwater, causing their contamination. Open burning or incinerator malfunctioning will result in the emission of toxic substances, such as dioxins and furans, into the air. In order to reduce the negative impact of medical waste, waste management principles should be formulated. To minimize health risks, it is also important to build awareness among health professionals and the general public through various communication and educational methods. The aim of this paper is to present a general overwiev of medical waste, its categories, the principles of its management and the risks to human health and the environment resulting from inappropriate waste management.

A LC-MS/MS based methodology for the environmental monitoring of healthcare settings contaminated with antineoplastic agents

Background

Adverse health events associated with the exposure of healthcare workers to antineoplastic drugs are well documented in literature and are often related to the chemical contamination of work surfaces. It is therefore crucial for healthcare professionals to validate the efficiency of safety procedures by periodic biological and environmental monitoring activities where the main methodological limitations are related to the complexity, in terms of chemical-physical features and chemical-biological stability, of the drugs analyzed.

Materials and methods

Here we describe the evaluation and application of a UHPLC-MS/MS based protocol for the environmental monitoring of hospital working areas potentially contaminated with methotrexate, iphosphamide, cyclophosphamide, doxorubicin, irinotecan, and paclitaxel. This methodology was used to evaluate working areas devoted to the preparation of chemotherapeutics and combination regimens at the University Hospital "San Giovanni di Dio e Ruggi d'Aragona" in Salerno (Italy).

Results

Our analyses allowed to uncover critical aspects in both working protocols and workspace organization, which highlighted, among others, cyclophosphamide and iphosphamide contamination. Suitable adjustments adopted after our environmental monitoring campaign significantly reduced the exposure risk for healthcare workers employed in the unit analyzed.

Conclusion

The use of sensitive analytical approaches such as LC-MS/MS coupled to an accurate wiping procedure in routine environmental monitoring allows to effectively improve chemical safety for exposed workers.

The Development and the Content Validation of the Oncology Nurses Health Behaviors Determinants Scale

OBJECTIVE

Chemotherapy exposure is an occupational hazard affecting oncology nurses. The adherence to chemotherapy-handling guidelines is essential to prevent exposure to these drugs. Oncology nurses' health beliefs and the cues in the environment are factors influencing the adherence to these guidelines. There is a lack of instruments with evidence of reliability and validity in the literature that address these factors. The purpose of this article is to describe the development and the content validation of the Oncology Nurses' Health Behaviors' Determinants Scale relative to adherence to chemotherapy-handling guidelines.

DATA SOURCES

This study was conducted in two phases: item development, then, content validation using a quantitative cross-sectional design with an exploratory part. A convenience sample of seven experts reviewed the items for relevance, wording, and comprehensiveness. The initial version of the scale that was sent to experts contained 65 items.

CONCLUSION

The Oncology Nurses' Health Behaviors Determinants' Scale has evidence of content validity. Twenty-eight items in the final instrument met the required level of content validity (item content validity index = 0.83). Four additional items were retained due to conceptual significance. Two items were added. The final scale contains 34 items with a total scale content validity index = 0.90.

IMPLICATIONS FOR NURSING PRACTICE

This newly developed instrument could be used to assess the factors that influence chemotherapy exposure among oncology nurses in the light of the Health Belief Model. Following that, interventions can be developed and implemented to foster greater adherence to safe chemotherapy handling guidelines.

From a Chemotherapeutic Drug to a High-Performance Nanocatalyst: A Fast Colorimetric Test for Cisplatin Detection at ppb Level

A rapid point-of-care method for the colorimetric detection of cisplatin was developed, exploiting the efficient conversion of the chemotherapeutic drug into a high-performance nanocatalyst with peroxidase enzyme mimics. This assay provides high specificity and ppb-detection sensitivity with the naked eye or a smartphone-based readout, outperforming many standard laboratory-based techniques. The nanocatalyst-enabled colorimetric assay can be integrated with machine-learning methods, providing accurate quantitative measurements. Such a combined approach opens interesting perspectives for the on-site monitoring of both chemotherapeutic patients to achieve optimal treatments and healthcare workers to prevent their unsafe exposure.

Closed safety system for administration (CSSA): proposal for a new cytotoxic chemotherapy acronym

Exposure to cytotoxic chemotherapy can result in acute and chronic conditions including nausea, headaches, rashes, miscarriages, infertility and genetic aberrations. Surface contamination can occur during drug administration, and can subsequently spread throughout the healthcare environment. Dermal contact with contaminated surfaces can lead to drug absorption. Closed system drug-transfer devices (CSTDs) were initially developed to protect pharmacists during compounding. Components include a vial adapter to prevent pressurisation leakage and a syringe connector for transferring the drug to the intravenous infusion bag. Membrane-based CSTDs require a Luer adapter for drug administration whereas Luer system-based products do not. Most European nurses are familiar with needleless connectors. Unfortunately, these devices do not provide protection from chemotherapy exposure. To decrease confusion, CytoPrevent, a multi-national, primarily European organisation has proposed the term 'closed safety system for administration' (CSSA) for Luer based CSTDs. Along with education, the new term can help promote safety for nurses administering cytotoxic chemotherapy.

Evaluation of three barrier-type closed system transfer devices using the 2015 NIOSH vapor containment performance draft protocol

Background

Closed System Transfer Devices (CSTD) have been developed to reduce healthcare worker exposure to hazardous drugs during medication handling. To evaluate CSTD performance in preventing the escape of drug vapors, the National Institute for Occupational Safety and Health (NIOSH) developed a 2015 draft testing protocol incorporating two compounding tasks utilizing 70% isopropyl alcohol (IPA) as a medication surrogate.

Purpose

The objective of this study was to evaluate the performance of three CSTDs (Chemolock [ICU Medical Inc., San Clemente, CA], PhaSeal [BD, Franklin Lakes, NJ], and Equashield [Equashield, Port Washington, NY]) in preventing the escape of drug vapor in accordance with the 2015 NIOSH draft protocol during simulated compounding and administration tasks.

Methods

The protocol was modified for the CSTDs to be used in accordance with manufacturer instructions for use and to represent clinical practice through repeated CSTD connections. Tasks were executed with each of the three CSTDs using 70% IPA as the medication surrogate to simulate compounding of a lyophilized drug, intravenous (IV) bag preparation (task 1), and bolus administration through an IV set (task 2). A positive control was performed by completing both tasks in duplicate, utilizing a needle and syringe instead of the CSTD to simulate preparation and injection through luer connectors. Differences in time to complete each simulated task was also evaluated.

Results

The three CSTDs had statistically equivalent performance and maintained IPA vapor levels below the limit of detection (LOD) of 1.0 ppm. Positive controls had mean vapor release of 17.40 ppm and 23.45 ppm for tasks 1 and 2, respectively. Positive controls also required statistically longer mean time to complete both tasks, followed in decreasing order by PhaSeal, Equashield, and Chemolock.

Conclusions

This study suggests that when evaluated in accordance with the 2015 NIOSH draft protocol, the three CSTDs are equivalent in their ability to prevent IPA vapor release while differences in time required for task completion may exist.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40267-022-00905-x.

Exposure to Antineoplastic Drugs in Occupational Settings: A Systematic Review of Biological Monitoring Data

The high toxicity of antineoplastic drugs (ADs) makes them dangerous not only for patients, but also for exposed workers. Therefore, the aim of this review was to provide an updated overview of the biological monitoring of occupational AD exposure in order to extrapolate information useful to improve risk assessment and management strategies in workplaces. Several studies demonstrated that remarkable portions of healthcare workers may have traces of these substances or their metabolites in biological fluids, although with some conflicting results. Nurses, directly engaged in AD handling, were the occupational category at higher risk of contamination, although, in some cases, personnel not involved in AD-related tasks also showed quantifiable internal doses. Overall, further research carried out on greater sample sizes appears necessary to gain deeper insight into the variability retrieved in the reported results. This may be important to understand the impact of the extent of ADs use, different handling, procedures, and cleaning practices, spill occurrence, training of the workforce, as well as the adoption of adequate collective and personal protective equipment in affecting the occupational exposure levels. This may support the achievement of the greatest clinical efficiency of such therapies while assuring the health and safety of involved workers.

Occupational risks to pregnant obstetrics and gynaecology trainees and physicians: Is it time to think about this?

The proportion of women in the workforce has been steadily increasing worldwide. Women now constitute approximately 75% of the global health workforce and almost 90% in nursing and midwifery professions. The present times have witnessed a dramatic gender shift in the speciality of obstetrics and gynaecology. Women now comprise a significant proportion of practicing obstetrics and gynaecology specialists all over the world. In 2018, more than 80% of resident doctors and nearly 60% of physicians in the speciality were female, far exceeding any other surgical speciality. Most resident doctors and a significant proportion of practising physicians in obstetrics and gynaecology are in the reproductive age group. They will become pregnant at some point in their training program or career. The present review focuses on all work-related exposure risks for pregnant obstetrics and gynaecology professionals. It discusses the risks of infectious diseases, radiation, stress, violence against doctors, and even peer support (or lack of it) that can have deleterious effects on the health of pregnant physicians and the health of their unborn foetuses.

Breast Cancer Risk Among Female Health Professionals: A 35-Year Population-Based Longitudinal Cohort Study in Taiwan

INTRODUCTION

Breast cancer is the most frequently diagnosed cancer among women worldwide. Previous studies have found a higher risk in nurses but no clear relationship among other health professionals. This study aims to investigate the risks of incident breast cancer among female health professionals compared with that among nonhealth professionals in Taiwan.

METHODS

This longitudinal observational cohort study included >35 years (1979-2016) of data from 4 nationwide population-based databases in Taiwan and identified matched cohorts with 1-to-2 propensity score matching between 277,543 health professionals and 555,086 nonhealth professionals. This study calculated total person-years for study subjects and compared breast cancer incidence between matched health and nonhealth professionals. Multivariable Cox proportional hazards and competing risk analyses were used, stratified by birth age, job tenure categories, and types of health professional license. Statistical analyses were conducted in 2019-2020.

RESULTS

Health professionals had a significantly higher risk of breast cancer (hazard ratio=1.34, 95% CI=1.28-1.41; subdistribution hazard ratio=1.36, 95% CI=1.30, 1.42). Elevated risk of breast cancer incidence was associated with birth age, job tenure, and several health professional license types, including physician, pharmacist, registered nurse, midwife, medical technologist, and psychologist.

CONCLUSIONS

Elevated breast cancer risk was found overall in female health professionals. Regular ultrasonography for younger women and mammography for those aged >45 years may be necessary in the annual labor physical examination for female health professionals.

Knowledge about antineoplastic drugs: implications for the health of nursing workers in a general hospital

OBJECTIVES

to understand, from a worker's health perspective, the knowledge of nursing professionals about the use of antineoplastic drugs in a general hospital.

METHODS

a descriptive and exploratory study with a qualitative approach. It was conducted at a university hospital, between April and August 2018, with 35 nursing professionals who responded to a semi-structured interview. Thematic analysis was used for data treatment.

RESULTS

from the data, three thematic categories emerged, related to the nursing professionals' knowledge about antineoplastic drugs and their effects on workers' health; situations in which exposure to these drugs occurs; and protection mechanisms for the patient, the environment, and the worker.

FINAL CONSIDERATIONS

the nursing professionals had little knowledge about antineoplastic drugs. The practices related to handling and the necessary protective measures to deal with these drugs were empirically determined and relatively subsidized the knowledge acquired by the professionals.

Risk management in an anticancer drug preparation unit: use of Preliminary Risk Analysis method and application to the preparation process

Objectives

Preparation of injectable anticancer drugs in hospital pharmacies, in particular of cytotoxics, is a high-risk activity. We used Preliminary Risk Analysis (PRA) to analyse the risks in the different steps of our anticancer drug circuit, including the preparation step (PRA1). Then, to prepare an important change in management of the circuit with the software Chimio® (pooling of three databases for subcontracting), we repeated the analysis of preparation step (PRA2). PRA is known to be time and resource consuming. To overcome this, we developed a strict organisational framework to perform the analysis within a reasonable amount of time. We present the PRA method including its practical implementation, and its application to the anticancer drug preparation process, before and after pooling of Chimio® databases.

Methods

PRA has two main stages, PRA “system” and PRA “scenario”. A multidisciplinary working group is created for the entire PRA process. PRA “system” is an exploratory and qualitative stage. PRA “scenario” requires the creation of risk assessment tools and decision tools before actually developing, analysing and treating scenarios, with risk reduction actions structured in an action plan. For PRA2 we used the same working group, assessment and decision tools as for PRA1 and we only analysed dangerous situations (DS) that appeared or changed towards more risk, requiring a new action plan. The different PRA only required four 2 h meetings thanks to the investment of a coordinator who is expert in the method.

Results

In PRA1, the riskiest phase was production while it was the verification and delivery of the finished product in PRA2. The risks were mainly related to management, human and technical dangers in PRA1. Human danger was found to be the main danger in PRA2, followed by organisational danger. Among the 264 scenarios described in PRA1, six of criticality 3 and 69 of criticality 2 have been associated with risk reduction actions. These actions mainly involved managing the risk of human error, with the control system Drugcam® and the standardisation of the pharmaceutical assistants’ training program. In PRA2, 11 scenarios were analysed, including three of criticality 3 and 4 of criticality 2 for which risk reduction measures were taken.

Conclusions

PRA allowed us to perform an in depth analysis of the highly specific and technical process of anticancer drug preparation. Human danger was one of the most important dangers identified, and it should always be taken into consideration, whatever the measures taken to prevent it. PRA2 was extremely useful to plan the organisation that would result from the new Chimio® database, while involving the team and winning its commitment. It allowed an exhaustive and structured anticipation of this major change. Practical aspects of PRA method implementation we have adopted facilitate its application and can help to deploy it on many areas in our hospitals. Indeed, besides an exhaustive analysis of the risks, this approach promotes collaboration, develops a quality culture and is an excellent tool for team and project management, as well as communication.

Exposure To Cytotoxic Drugs Threatens The Health Of Staff In Oncology Wards

Background — Cancer is one of the leading causes of death worldwide. Using cytotoxic drugs for cancer treatment is increased. The hazardous effects of occupational exposure to cytotoxic drugs are challenging. Objective — This study aimed to compare the frequency of adverse effects and using personal protective equipment (PPE) between the staff of oncology wards and other hospital wards staff in Iran. Methods — A cross-sectional study with a control group was conducted on female staff members in educational hospitals, selected through convenience sampling. A data collection form was designed for this study. It includes demographic data, acute complications (allergic and neurologic reactions), chronic complications (infertility, menstrual disorders, malignancy, and congenital malformations), and use of PPE. Data analysis was performed using SPSS software through Chi-square and Mann-Whitney tests. Results — The frequencies of chronic complications were not statistically different between the two groups. The frequency of itching (P=0.001), hair loss (P=0.003), itchy eyes (P=0.001), watery eyes (P=0.001), runny nose (P=0.003), headache (P=0.001), vertigo (P=0.007), and nausea (P=0.008) were significantly higher in oncology wards nurses. Among different PPE, only the frequency of using the mask (P= 0.001), and glasses (P=0.027) were significantly higher in the staff of oncology wards. Conclusion — Despite the frequency of acute complications of exposure to cytotoxic drugs, oncology staff does not fully adhere to the standard precautions. Providing effective training and emphasis on implementing accreditation laws can improve the existing situation.

Analysis of chemical contamination by hazardous drugs with BD HD Check® system in a tertiary hospital

The presence of contamination in the healthcare work environment by one of the types of hazardous drugs, cytostatics, has been found in multiple international studies. Recent studies and guidelines recommend surface monitoring for risk assessment of healthcare professionals' exposure. The availability of detection techniques is critical to successfully carry out this type of monitoring. The use of new semi-quantitative techniques allows quicker results. The main objective of this study was to determine the existence of hazardous drugs on the working surfaces in different locations of a tertiary hospital using the BD HD Check^® semi-quantitative device. The presence of methotrexate, doxorubicin and cyclophosphamide was analysed at 80, 89 and 82 locations in 10, 13 and 11 clinical units, respectively. A total of 251 samples were analysed. The monitoring results were positive for 13.1% of the analysed samples, with 36.3% of the methotrexate samples, 0% of the doxorubicin samples and 4.9% of the cyclophosphamide samples. Mapping the presence of HD in our hospital has allowed us to evaluate the effectiveness of controls established in the hospital to minimise the exposure of healthcare professionals to hazardous drugs. The speed in obtaining results has enabled immediate corrective actions in cases where contaminated surfaces were detected.

Infantile neuroblastoma and maternal occupational exposure to medical agents

BACKGROUND

Healthcare workers are often exposed to hazardous agents and are at risk for adverse health consequences that affect not only themselves but also their infants. This study aimed to examine whether such occupational exposure increased the risk of childhood cancer in offspring.

METHODS

We used the dataset of the Japan Environment and Children's Study, a nationwide birth cohort involving over 100,000 mother-child pairs. Information was obtained via successive questionnaires that were completed until the child turned 1 year of age. The parents were asked whether they occupationally handled medical agents during pregnancy.

RESULTS

A total of 26 infants developed neoplasms: neuroblastoma, leukemia, and brain tumor. The incidence of neuroblastoma was significantly higher in infants whose mothers were exposed to radiation (3/2142: 140.1 per 100,000 population) than in those who were not (12/90,384: 13.3 per 100,000 population). Multivariable regression analyses revealed a close association between maternal irradiation and the development of neuroblastoma (adjusted incident rate ratio: 10.68 [95% confidence interval: 2.98‒38.27]).

CONCLUSIONS

The present study demonstrated, for the first time, a potential association between maternal occupational exposure and the occurrence of neuroblastoma in offspring. Further studies involving the large pediatric cancer registries are needed to confirm these preliminary results.

IMPACT

Healthcare workers are often exposed to hazardous agents and are at risk for adverse health consequences that affect not only themselves but also their infants. This study examined the association between such occupational exposure and offspring's cancers that developed until the age of 1 year. Maternal exposure to ionizing radiation was associated with infantile neuroblastoma in offspring. Further studies involving the large pediatric cancer registries are needed to confirm these preliminary results.

Validation of chemotherapy drug vapor containment of an air cleaning closed-system drug transfer device

PURPOSE

The purpose of this study was to test the efficacy of ChemfortTM, an air filtration closed-system drug transfer device to prevent release of chemotherapy drug vapors and aerosols under extreme conditions. The air cleaning system is based on the adsorption of drug vapors by an activated carbon filter in the Vial Adaptor before the air is released out of the drug vial. The functionality of the carbon filter was also tested at the end of device's shelf life, and after a contact period with drug vapors for 7 days. Cyclophosphamide and 5-fluorouracil were the chemotherapy drugs tested.

METHODS

The Vial Adaptor was attached to a drug vial and both were placed in a glass vessel. A needle was punctured through the vessel stopper and the Vial Adaptor septum to allow nitrogen gas to flow into the vial and to exit the vial via the air filter into the glass vessel which was connected to a cold trap. Potential contaminated surfaces in the trap system were wiped or rinsed to collect the escaped drug. Samples were analyzed using liquid chromatography tandem mass spectrometry.

RESULTS

Cyclophosphamide and 5-fluorouracil were detected on most surfaces inside the trap system for all Vial Adaptors without an activated carbon filter. Contamination did not differ between the Vial Adaptors with and without membrane filter indicating no effect of the membrane filter. The results show no release of either drug for the Vial Adaptors with an activated carbon filter even after 3 years of simulated aging and 7 days of exposure to drug vapors.

CONCLUSIONS

Validation of air cleaning CSTDs is important to secure vapor and aerosol containment of chemotherapy and other hazardous drugs. The presented test method has proven to be appropriate for the validation of ChemfortTM Vial Adaptors. No release of cyclophosphamide and 5- fluorouracil was found even for Vial Adaptors after 3 years of simulated aging and 7 days of exposure to drug vapors.

Nurses' internal contamination by antineoplastic drugs in hospital centers: a cross-sectional descriptive study

OBJECTIVE

The aim of this study was to assess internal antineoplastic drugs (ADs) contamination in the nursing staff in French hospital centers, using highly sensitive analytical methods.

METHODS

This cross-sectional study included nurses practicing in care departments where at least one of the five ADs studied was handled (5-fluorouracil, cyclophosphamide, doxorubicin, ifosfamide, methotrexate). The nurses study participation lasted 24 h including collection of three urine samples and one self-questionnaire. All urine samples were assayed by ultra-high-performance liquid chromatography-tandem mass spectrometry methods with very low value of the lower limit of quantification (LLOQ).

RESULTS

74 nurses were included, 222 urine samples and 74 self-questionnaires were collected; 1092 urine assays were performed. The percentage of nurses with internal AD contamination was 60.8% and low levels of urinary concentrations were measured. Regarding nurses with internal contamination (n = 45), 42.2% presented internal contamination by methotrexate, 37.8% by cyclophosphamide, 33.3% by ifosfamide, 17.8% by 5-fluorouracil metabolite and 6.7% by doxorubicine. Among the positive assays, 17.9% (n = 26/145) were not explained by exposure data from the self-questionnaire but this could be due to the skin contact of nurses with contaminated work surfaces.

CONCLUSIONS

This study reported high percentage of nurses with internal ADs contamination. The low LLOQ values of the used analytical methods, allowed the detection of ADs that would not have been detected with the current published methods: the percentage of contamination would have been 17.6% instead of the 60.8% reported here. Pending toxicological reference values, urine ADs concentrations should be reduced as low as reasonably achievable (ALARA principle).

Assessment of workplace environmental contamination and occupational exposure to cisplatin and doxorubicin aerosols during electrostatic pressurized intraperitoneal aerosol chemotherapy

BACKGROUND

Electrostatic precipitation pressurized intraperitoneal aerosol chemotherapy (ePIPAC) is a novel approach for intraperitoneal drug delivery. As ePIPAC using cisplatin and doxorubicin is performed in an operating room, the challenge is to safely deliver the chemotherapeutic aerosol intraperitoneally while preventing exposure to healthcare workers. The objective of this study was to describe cisplatin and doxorubicin workplace environmental contamination and healthcare worker exposure during ePIPAC.

METHODS

Antineoplastic drugs concentrations of cisplatin and doxorubicin were measured in wipe samples from the operating room, and urine samples were collected from healthcare workers. The air samples were collected in order to detect Cisplatin contamination. Cisplatin was analysed by inductively coupled plasma-mass spectrometry and doxorubicin by ultra-high-performance liquid chromatography coupled with tandem mass spectrometry.

RESULTS

No trace of cisplatin was found in the air. Cisplatin and doxorubicin were detected on the operating room floor, surfaces, devices and personal protective equipment even after a cleaning protocol. No traces of cisplatin or doxorubicin were found in the urine samples.

CONCLUSION

In this study, no internal contamination was found in the ePIPAC surgical team even after implementing two successive ePIPAC procedures. These results showed the effectiveness of the individual and collective protective measures applied. However, the cleaning procedure during ePIPAC should be respected to limit environmental exposure to chemotherapy to cisplatin and doxorubicin during ePIPAC.

Evaluation of Genetic Damage in Persons Occupationally Exposed to Antineoplastic Drugs in Serbian Hospitals

INTRODUCTION

Although useful in the treatment of malignant cells, antineoplastic drugs (ANPDs) as chemical genotoxic agents, can interfere with normal cell physiology causing genetic damage and unfavourable health effects, especially in occupationally exposed persons. The Cytokinesis-block Micronucleus (CBMN) Cytome assay has been widely used in human biomonitoring studies as a reliable biomarker of chemical genotoxic exposure.

OBJECTIVES

Our comprehensive research was conducted in order to evaluate micronuclei as a marker for preventive medical screening purposes for persons occupationally exposed to ANPDs.

METHODS

Using the CBMN Cytome test, peripheral blood lymphocytes of 201 control and 222 exposed subjects were screened for genetic damage.

RESULTS

Age and gender influenced micronucleus (MN) frequency, but smoking habit did not. The mean micronuclei frequencies and other parameters of the CBMN Cytome test [numbers of binuclear lymphocytes with one (MN1) or two (MN2) micronuclei] were significantly higher in the group of exposed persons. Positive correlation between duration of occupational exposure and MN frequency was revealed.

CONCLUSIONS

The results of our study performed on a large sample confirmed the capacity of the CBMN Cytome assay to serve as a reliable biomarker of long-term ANPD exposure.

Blood contamination of the pharmaceutical staff by irinotecan and its two major metabolites inside and outside a compounding unit

BACKGROUND

Caregivers in healthcare settings are exposed to a risk of antineoplastic drug contamination which can lead to adverse health effects. Biological monitoring is necessary to estimate the actual level of exposure of these workers. This study was conducted with the aim of assessing blood contamination levels by irinotecan and its metabolites of pharmaceutical staff operating inside and outside a compounding unit.

METHODS

The study took place within the pharmaceutical unit of a French comprehensive cancer centre. Blood samples were collected from the pharmacy workers operating inside and outside the compounding unit, and analysed by UHPLC-MS/MS. Plasma and red blood cell irinotecan and its metabolites (SN-38; APC) were determined with a validated analytical method detection test.

RESULTS

A total of 17/78 (21.8%) plasma and red blood cell-based assays were found to be contaminated among staff. Overall, the total number of positive assays was significantly higher for staff members working outside the compounding unit than for workers working inside it (P = 0.022), with respectively 5/42 (11.9%) and 12/36 (33.3%) positive assays. For plasma dosages, the "outside" group had a significantly higher number of positive assays (P = 0.014). For red blood cell-based assays, no significant difference was found (P = 0.309).

CONCLUSIONS

This study reveals that pharmaceutical staff serving in health care settings are exposed to a risk of antineoplastic drug contamination, not only inside the compounding room but also in adjacent rooms. The results would help to raise awareness and potentially establish protective measures for caregivers working in areas close to the compounding room as well.

Chemical risk in hospital settings: Overview on monitoring strategies and international regulatory aspects

Chemical risk in hospital settings is a growing concern that health professionals and supervisory authorities must deal with daily. Exposure to chemical risk is quite different depending on the hospital department involved and might origin from multiple sources, such as the use of sterilizing agents, disinfectants, detergents, solvents, heavy metals, dangerous drugs, and anesthetic gases. Improving prevention procedures and constantly monitoring the presence and level of potentially toxic substances, both in workers (biological monitoring) and in working environments (environmental monitoring), might significantly reduce the risk of exposure and contaminations. The purpose of this article is to present an overview on this subject, which includes the current international regulations, the chemical pollutants to which medical and paramedical personnel are mainly exposed, and the strategies developed to improve safety conditions for all healthcare workers.

Evaluation of decontamination efficacy of four antineoplastics (ifosfamide, 5-fluorouracil, irinotecan, and methotrexate) after deliberate contamination

The main objective was to determine the decontamination efficacy of quaternary ammonium, 0.1% sodium hypochlorite, and water after deliberate contamination with four antineoplastics (ifosfamide, 5-fluorouracil, irinotecan, methotrexate). A stainless-steel surface was deliberately contaminated with ifosfamide (15 µg), 5-fluorouracil (10 µg), irinotecan (1 µg), and methotrexate (1 µg). First, a single decontamination step with either water, quaternary ammonium, or 0.1% sodium hypochlorite was tested. Then, the effect of up to four successive decontamination steps with either quaternary ammonium or 0.1% sodium hypochlorite was tested. Commercial wipes consisting of two layers of non-woven microfibers with an inner layer of highly absorbent viscose fibers were used. Triplicate surface samples were obtained and tested by ultra-performance liquid chromatography tandem mass spectrometry. The limits of detection were 0.004 ng/cm² for ifosfamide, 0.040 ng/cm² for 5-fluorouracil, 0.003 ng/cm² for irinotecan, and 0.002 ng/cm² for methotrexate. After a single decontamination step, the 0.1% sodium hypochlorite eliminated 100% of contamination with 5-fluorouracil, irinotecan, and methotrexate and 99.6 ± 0.5% of ifosfamide contamination. Quaternary ammonium and water also removed 100% of the 5-fluorouracil, and 99.5% to 99.9% of the other three antineoplastics. For ifosfamide, irinotecan, and methotrexate, the decontamination efficacy increased with successive decontamination steps with quaternary ammonium. 5-fluorouracil was undetectable after a single decontamination step. Methotrexate was the only drug for which decontamination efficacy was less than 100% after four decontamination steps. 100% decontamination efficacy was achieved from the decontamination step with 0.1% sodium hypochlorite for 5-fluorouracil, irinotecan, and methotrexate. For ifosfamide, 100% efficacy was achieved only after the third decontamination step. It was possible to make all traces of antineoplastic undetectable after deliberate contamination with 5-fluorouracil, irinotecan, and methotrexate with a 0.1% chlorine solution; up to three decontamination steps were needed to make ifosfamide undetectable. Water or quaternary ammonium removed more than 99.5% of deliberate contamination. In several scenarios, it was necessary to repeat the decontamination to eliminate residual traces. More work is needed to identify the optimal decontamination approach for all of the antineoplastic drugs used.

Chemical Decontamination of Hazardous Drugs: A Comparison of Solution Performances

OBJECTIVES

Over the past 40 years, numerous actions have been undertaken to decrease the contamination of hospital facilities by intravenous conventional antineoplastic drugs (ICADs) such as centralizing compounding in pharmacies, using personal protective equipment, specific compounding, or infusion devices. As recently proposed in the <USP800> monograph, an additional specific decontamination step must be envisaged. A recent literature review analysed and discussed the different solutions tested in terms of decontamination efficacy. This article aims to discuss the performance of these solutions in the framework of aseptic compounding.

METHODS

The same dataset used in the previous literature review was reanalysed according to other parameters so as to select decontamination solutions: overall decontamination efficiency (EffQ), tested contaminants, and the risks of use in daily practice.

RESULTS

Using an EffQ threshold of 90% resulted in discarding 26 out of the 59 solutions. Solutions were tested differently: 8 on 1 contaminant, 11 on 2 contaminants, and 14 solutions on between 3 and 11 contaminants. Three risks were identified to help make choices in routine practice: the mutagenicity of degradation products, the safety of operators and facilities, and respect for the aseptic environment.

CONCLUSIONS

From the results, performance is discussed according to specific situations: a one-time incident or the basic chemical contamination due to daily practice. Accordingly, the decontamination solution selected then required a risk analysis and an evaluation before implementing it in the daily practice of a compounding unit.

Factors influencing precautions against antineoplastic drug exposure among nurses and nurse assistants in Thailand

BACKGROUND

Antineoplastic drugs (AD) are important chemical risks for healthcare workers. Precautions against AD exposure include the use of appropriate personal protective equipment (PPE). Evaluation of PPE usage during patient care processes has not been reported in Thailand. We aimed to evaluate the level of PPE usage and factors predicting PPE usage among nurses and nurse assistants in Thailand.

METHODS

A cross-sectional survey was conducted in a university hospital and two general hospitals. The questionnaires covered demographic characteristics, self-reported use of PPE and 7 predictive factors. Mixed-effects modeling was used to determine the association between standardized score of predictive factors and PPE usage score.

RESULTS

The response rate was 78.6% and 884 participants were left for analysis after data cleaning. Among nurses (n = 499), higher PPE usage score was associated with self-efficacy (β = 0.28, 95% CI 0.21, 0.34), workplace safety climate (β = 0.27, 95% CI 0.20, 0.34), and conflict of interest (β = - 0.07, 95% CI - 0.14, - 0.01). Among nurse assistants (n = 385), higher PPE usage score was associated with self-efficacy (β = 0.27, 95% CI 0.18, 0.36), interpersonal influence (β = 0.14, 95% CI 0.04, 0.24), workplace safety climate (β = 10.29, 95% CI 0.19, 0.38), and conflict of interest (β = - 0.14, 95% CI - 0.24, - 0.03).

CONCLUSIONS

Several factors were associated with PPE usage among nurses and nurse assistants. Improved PPE usage against AD can be promoted through interventions that modify those factors.

Supportive Care Needs of Patients on Surveillance and Treatment for Non-Muscle-Invasive Bladder Cancer

OBJECTIVE

This literature review provides an overview of non-muscle-invasive bladder cancer diagnosis (NMIBC), treatment, and surveillance. Existing evidence is reviewed to identify the NMIBC patient pathway, highlight its effect on quality of life, and identify supportive care needs of this patient group. A framework to guide nurses in the care of this underserved population is proposed.

DATA SOURCES

Electronic databases including CINAHL, Medline, PsychInfo, Cochrane, and Google Scholar were searched.

CONCLUSION

NMIBC is a chronic disease with high recurrence and progression rates with most patients requiring invasive treatment and burdensome surveillance schedules with frequent hospital visits. Treatment-related side effects may interrupt therapy and possibly result in its discontinuation. Patients' quality of life can be negatively affected at various stages of the cancer trajectory. Specialist nurses provide holistic care throughout all stages of the patient journey to optimize supportive care, information provision, and delivery of appropriate treatment and surveillance protocols. NMIBC research is historically underfunded with a paucity of evidence identifying the supportive care needs of this population. Further research is urgently required to fill the gaps identified.

IMPLICATIONS FOR NURSING PRACTICE

This timely paper raises the profile of unmet supportive care needs in an underserved research cancer population. Suggestions are proposed to improve the quality of nursing care through standardized practices and the development and integration of patient pathways. Evidence of the effect of NMIBC on family members or carers is absent from the literature. Future research implications and directions are proposed.

Prepregnancy handling of antineoplastic drugs and risk of miscarriage in female nurses

PURPOSE

To examine the association betweenantineoplastic drug (AD) handling and risk of miscarriage.

METHODS

Nurses' Health Study-3 participants self-reported AD administration and engineering controls (ECs) and personal protective equipment (PPE) use at baseline. We estimated the hazard ratio (HR) of miscarriage in relation to baseline AD handling using multivariable Cox proportional regression.

RESULTS

Overall, 2440 nurses reported 3327 pregnancies, with 550 (17%) ended in miscarriages. Twelve percent of nurses self-reported currently handling AD and 28% previously handling AD. Compared with nurses who never handled AD, nurses who handled AD at baseline had an adjusted HR of miscarriage of 1.26 (95% confidence interval [CI], 0.97-1.64). This association was stronger after 12-weeks gestation (HR=2.39 [95% CI, 1.13-5.07]). Nurses who did not always use gloves had HR of 1.51 (95% CI, 0.91-2.51) compared with 1.19 (95% CI, 0.89-1.60) for those always using gloves; nurses who did not always use gowns had HR of 1.32 (95% CI, 0.95-1.83) compared with 1.19 (95% CI, 0.81-1.75) for nurses always using gowns.

CONCLUSIONS

We observed a suggestive association between AD handling and miscarriage, particularly among nurses who did not consistently use PPE and EC with stronger associations for second trimester losses.

Effectiveness of a decontamination procedure in a pharmacy buffer room contaminated by 5 antineoplastic agents

PURPOSE

Healthcare facilities are obligated to implement strategies to protect healthcare workers from exposure to hazardous drugs, including any real or potential risk from contaminated surfaces. Guidelines are broad and lack sufficient detail for healthcare facilities to establish clear effectiveness targets for their decontamination procedures. Our goal in this analysis was to measure the effectiveness of a decontamination procedure in a pharmacy buffer room contaminated with 5 antineoplastic drugs.

METHODS

Six rounds of contamination, decontamination, and wipe sampling were performed in a pharmacy buffer room designated for hazardous drug (HD) compounding. Ten locations in the buffer room were contaminated with 5-fluorouracil, carboplatin, cyclophosphamide, paclitaxel, and doxorubicin. Pharmacy staff were blinded to contamination sites. After contamination, 3 pharmacy technicians following the same decontamination procedure decontaminated the buffer room. To assess the impact of decontamination, residual hazardous drug levels were assessed after contamination and after decontamination using a commercially available wipe sampling product.

RESULTS

The mean (SD) residual contamination levels for the 239 wipe samples taken before and after decontamination were 63 (60) ng and 3.9 (8.2) ng, respectively, representing a 94% reduction in residual HD contamination. Residual contamination was not detectable (<5 ng) in 221 (~93%) of the samples after decontamination.

CONCLUSION

The employed decontamination procedures effectively reduced residual HD surface contamination.

[Working at the hospital during pregnancy: A descriptive national cross-sectional study in France]

OBJECTIVE

The objective of the article is to describe the follow-up of pregnancies at work and occupational exposure to potential risks for pregnancy.

METHODS

A descriptive cross-sectional study was performed from April 1, 2017 to October 31, 2017 in the occupational health departments of French hospitals. After delivery and at the time of returning to work, 1,165 eligible workers were interviewed by occupational health physicians (OHPs). Socio-demographic information was self-reported. Occupational exposures were assessed by an OHP. Birth weight, gestational age, and sick leaves were also collected.

RESULTS

Among recruited workers, 51.8% were exposed to more than 5 occupational hazards. Biological and physical hazards were the most common hazards at the workplace. Note that heavy lifting ≥ 15 kg concerned 9.5% of workers. Only 20.1% of workers had a specific "pregnancy at work" medical visit with OHP during pregnancy; 26.8% benefited from workstation adjustments. In contrast, the level of sick leaves was high (86.7%).

CONCLUSIONS

Our data suggest that pregnant workers in hospitals must be strictly supervised.