A probabilistic assessment of the impact of interventions on oncology nurses' exposure to antineoplastic agents

Occupational Exposure to Antineoplastic Drugs in Twelve French Health Care Setting: Biological Monitoring and Surface Contamination

Antineoplastic drugs used in the treatment of cancers have an intrinsic toxicity, because of their genotoxic, teratogenic, and carcinogenic properties. Their use is recognized as an occupational hazard for healthcare workers (HCWs) who may be exposed. The purpose of this article is to present biological- and environmental-monitoring data collected in twelve French hospitals over eight years. Urine samples were collected from a wide range of HCWs (250 participants) from pharmacy and oncology units, including physicians, pharmacists, pharmacy technicians, nurses, auxiliary nurses, and cleaners. The investigated drugs were cyclophosphamide, ifosfamide, methotrexate, and α-fluoro-β-alanine, the main urinary metabolite of 5-fluorouracil. Wipe samples were collected from various locations in pharmacy and oncology units. More than 50% of participants, from all exposure groups, were contaminated with either drug, depending on the unit, the day, or the task performed. However, workers from oncology units were more frequently exposed than workers from pharmacy units. Significant contamination was detected on various surfaces in pharmacy and oncology units, highlighting potential sources of exposure. Risk-management measures should be implemented to reduce and maintain exposures at lowest-possible levels. In addition, regular exposure assessment, including biological and environmental monitoring, is recommended to ensure the long-term efficiency of the prevention measures.

Permeation measurement of 27 chemotherapy drugs after simulated dynamic testing on 15 surgical and examination gloves: A knowledge update

Purpose

Exposure to anticancer drugs is one of the known risks for people working in specialist oncology units. Wearing gloves is a vital form of personal protection. The aim of this study was to assess, in close to real use dynamic conditions, the permeability of 15 surgical and examination gloves made from different materials when exposed to 27 anticancer drugs included in the list from international Guides and Recommendations.

Methods

Gloves were tested by using controlled dynamic conditions replicating flexion and extension movements that mimic typical clinical applications. Tests were performed at 37°C or at 43°C for 30 min and anticancer drugs were tested at the highest concentration used in clinical practice. To determine the permeation rate, the quantification of anticancer drugs was performed with selective and sensitive analytical methods such as inductively coupled plasma-mass spectroscopy and liquid chromatography-mass spectrometry.

Results

All the gloves met the EN 16523-1 European standard (1000 ng/(min.cm2)). The penetration rate of busulfan, carmustine and thiotepa exceeded the ASTM D-6978-05 American standard (10 ng/(min.cm2)) with several surgical and/or examination gloves. This standard was met in all of cases when double gloving was used. Breakage of several nitrile gloves was observed in relation with the excipient used by drugs suppliers.

Conclusions

Permeation is a complex multifactorial phenomenon. However, we have suggested that the thickness of the glove and three physicochemical parameters (molecular weight, topological polar surface area and hydrogen bond donor) of the drug were the main parameters affecting permeation.

Occupational exposure of pharmacy technicians and cleaning staff to cytotoxic drugs in Dutch hospitals

Many studies into surface contamination of hospital environments have demonstrated that occupational exposure to cytotoxics through the dermal route remains a possible risk. In this study, we assess the actual dermal exposure of the hands of pharmacy technicians and cleaning personnel in a panel of hospitals performing tasks that pose a risk of exposure. We compare the dermal exposure to a tentative limit value for cyclophosphamide. Pharmacy technicians and cleaning personnel were asked for hand rinsing after performance of nine tasks previously identified as posing a risk of occupational exposure. All samples were analyzed for the presence and quantity of eight antineoplastic drugs. By using data on both the frequency of the performance of the tasks and the measured dermal contamination during these tasks, weekly exposure to the marker drug (cyclophosphamide) was calculated. In five Dutch hospitals, 70 hand rinse samples and 8 blanks were collected. These were analyzed and results were used to calculate weekly exposure. The tentative limit value used was 0.74 µg of cyclophosphamide. For cleaning personnel, all results remained below this threshold value. For pharmacy technicians, the compounding itself also remained well below the limit; however, the task involving preparatory work, as well as the checking of compounded drugs, had a 13% chance of exceeding the limit. All of the highest values were found when employees were not wearing gloves on these tasks. Cleaning personnel and pharmacy technicians compounding cytotoxic drugs in our study were sufficiently protected from occupational exposure. In contrast, pharmacy technicians who perform preparatory and finishing tasks (before and after the actual compounding) are not protected enough when they do not wear gloves.

Exposure to Antineoplastic Agents Induces Cytotoxicity in Nurse Lymphocytes: Role of Mitochondrial Damage and Oxidative Stress

Cytotoxicity and mitochondrial parameters were studied in isolated lymphocytes and their mitochondria obtained from occupationally exposed nurses through inhalation exposure to antineoplastic drugs and results were compared to those of unexposed nurses. The group of occupationally exposed nurses consisted of 50 individuals ranging in age from 30 to 35 years. The control group included 50 nurses who were not occupationally exposed to the preparation and handling of antineoplastic drugs and their anthropometric and biochemical characteristics were similar to those of the expose group. All cytotoxicity and mitochondrial parameters evaluated in exposed group were significantly increased (P < 0.05) compared to the unexposed control group. Finally, the results of our study suggest that using antioxidant, mitochondrial and lysosomal protective agents can be promising drug candidates for the hospital staff in the risk of exposure to exposure to antineoplastic drugs.

An update systematic review of fetal death, congenital anomalies, and fertility disorders among health care workers

BACKGROUND

Health care workers (HCWs) are occupationally exposed to various hazards, some associated with adverse pregnancy outcomes in previous reviews. This systematic review aims at synthesizing the recent literature on occupational exposures among HCWs related to fetal death, congenital anomalies, and fertility disorders.

METHODS

We searched the Medline database from 2000 to 2015 for articles about all potential occupational exposures of women and men working in this sector.

RESULTS

We retained 32 studies, most of them (n = 30) among women HCWs. Studies based on job title reported excess risks of some congenital anomalies (especially nervous and musculoskeletal systems) among HCWs compared to non-HCWs but no evidence about fetal death. Excess risks associated with specific exposures includes reports of some congenital anomalies for women exposed to anesthetic gases. Exposure to some sterilizing agents and, with less evidence, to antineoplastic drugs and to ionizing radiation, is associated with increased risks of miscarriage but not stillbirth. Strenuous work schedules appear to be associated with fertility disorders, but the evidence is limited. Only a few studies have been published since 2000 about non-ionizing radiation, or about fertility disorders related to chemical or physical agents, or about male HCWs.

CONCLUSIONS

Despite the establishment of recommendations to limit exposures of HCWs, some excess risks of adverse pregnancy outcomes are still reported and need to be explained.

Nurses with dermal exposure to antineoplastic drugs: reproductive outcomes

BACKGROUND

Nurses and other hospital workers are exposed to antineoplastic drugs during daily activities. Previous studies suggest that antineoplastic drugs at occupational exposure levels may be toxic to reproduction, but these studies are not consistent or conclusive.

METHODS

Self-administered questionnaires were completed by 4393 exposed and nonexposed nurses employed between 1990 and 1997 (79% response). Questions were asked about pregnancy outcome, work-related exposures, and lifestyle. Exposure to antineoplastic drugs was estimated using task-based dermal exposure measurements and self-reported task frequencies. Time to pregnancy was modeled using survival analysis, and odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for other reproductive outcomes using multiple logistic regression analysis. Associations were further explored by nonparametric regression modeling.

RESULTS

Nurses highly exposed to antineoplastic drugs took longer to conceive than referent nurses (adjusted hazard ratio = 0.8; CI = 0.6-0.9). Exposure to antineoplastic drugs was associated with premature delivery (OR per unit increase in ln[exposure] = 1.08; CI = 1.00-1.17) and low birth weight (OR per unit increase in ln[exposure] = 1.11; 1.01-1.21). Penalized smoothed spline plots corroborated these log-linear relations. Spontaneous abortion, stillbirth, congenital anomalies, and sex of offspring appeared not to be related to exposure to antineoplastic drugs.

CONCLUSION

Antineoplastic drugs may reduce fertility and increase poor neonatal outcomes among occupationally exposed oncology nurses.