Exposure to hazardous drugs in healthcare: an issue that will not go away

The handling of hazardous medications by nurses and midwives: A retrospective cohort study

BACKGROUND

Occupational exposure of healthcare workers to hazardous medications can be potentially harmful. Hazardous medications can be carcinogenic, developmentally toxic, reproductively toxic, genotoxic and/or toxic to organs at low doses. These hazardous medications can be used in many healthcare settings, but published research of occupational exposure has focused almost exclusively on cancer services.

AIM

To identify the healthcare settings where nurses and midwives are responsible for the administration of hazardous medications.

METHOD

A retrospective cohort study was undertaken of all medication administration events occurring during a two-week period at a public metropolitan health service in 2023. All medication administration events from six hospital sites were identified using the electronic (Oracle Health-Cerner-Millennium®) and paper (Chemotherapy Chart) medication administration records. From all of the medications administered, the subset of medications classified as hazardous were identified based on the Victorian Therapeutics Advisory Group Framework for Handling of Hazardous Medicines (2021) and other guidelines. Poisson regression modelling was used to explore associations between the number of hazardous medications and the healthcare area where they were administered (p < 0.001).

RESULTS

Of the 121,567 administration events, 6054 (5.0 %) involved hazardous medications. The healthcare areas with the highest rate of hazardous medication administration events, as a proportion of all medication administration events, were outpatient cancer service (301/695, 43.3 %), birth suite (13/86, 15.1 %) and mental health (404/4011, 10.1 %) areas. During the two-week period, 6054 hazardous medication administration events occurred, involving 117 different medications. The greatest number of these events took place in the medical (1729/6054, 28.6 %) and geriatric (1579/6054, 26.1 %) inpatient healthcare areas. A total of 1258 nurses and midwives were directly involved in either administering, or checking and witnessing the administration of hazardous medications to 996 patients (25.2 % of the total 3958 patients). Most hazardous medications administered to patients were in an oral dosage form (5426/6054, 89.6 %).

CONCLUSION

Hazardous medications were administered in all healthcare areas, with the exception of endoscopy services. Nurses and midwives were at risk of occupational exposure from hazardous medications.

The meta-analysis of sister chromatid exchange as a biomarker in healthcare workers with occupational exposure to antineoplastic drugs

BACKGROUND

Sister chromatid exchange (SCE) can be used to identify early occupational health status in health care workers. Our aim is to comprehensively assess the relationship between long-term exposure to antineoplastic drugs (ADs) and SCE in health care workers via meta-analysis.

METHODS

Five databases were systematically searched for relevant articles published from inception to November 30, 2022. Literature data are expressed as mean difference and 95% confidence intervals (CI) or relative risk and 95% CI. For I2 > 50% trials, random effect model is used for statistical analysis, otherwise fixed effect model is used. This review was registered in the International Prospective Register of Systematic Reviews (identifier CRD42023399914).

RESULTS

Fourteen studies were included in this study. Results showed the level of SCE in healthcare workers exposed to ADs was significantly higher than in controls. The mean difference of the SCE trial was 0.53 (95% CI: 0.10-0.95, P = .01) under a random-effects model.

CONCLUSIONS

The findings suggested a significant correlation between occupational exposure to ADs in health care workers and SCE, requiring the attention of health care workers in general.

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.

Administration of antineoplastic drugs and fecundity in female nurses

BACKGROUND

We examined the association between the administration of antineoplastic drugs (AD) and fecundity among female nurses.

METHODS

AD administration and use of exposure controls (EC) such as gloves, gowns, and needleless systems were self-reported at baseline among 2649 participants of the Nurses' Health Study 3, who were actively attempting pregnancy. Every 6 months thereafter, the nurses reported the current duration of their pregnancy attempt. Multivariable accelerated failure time models were used to estimate time ratios (TR) and 95% confidence intervals (CI) adjusted for age, race, body mass index, smoking, marital status, hours of work, and other occupational risk factors.

RESULTS

Mean (standard deviation) age and BMI at baseline were 30.7 years (4.7) and 26.0 kg/m² (6.4). Forty-one percent of nurses reported ever administering AD; 30% only in the past and 11% currently. The former administration of AD (TR = 1.02, 95% CI, 0.93-1.12) was unrelated to the ongoing duration of pregnancy attempt. Among nurses currently administering AD, those who had administered AD for 6 years and above had a 27% (95% CI, 6%-53%) longer duration of pregnancy attempt than nurses who never handled ADs in unadjusted analyses. This difference disappeared in multivariable analyses (TR = 1.01, 95% CI, 0.85-1.21). 93% (n = 270) of the nurses currently administering ADs reported consistent use of EC. These nurses had a similar median duration of pregnancy attempt to those who never handled AD (TR = 1.00, 95% CI, 0.87-1.15).

CONCLUSIONS

Administration of ADs did not appear to have an impact on fecundity in a cohort of nurses planning for pregnancy with a high prevalence of consistent ECs. Our results may not be generalizable to women who are less compliant with PPE use or with less availability to ECs. Therefore, it is possible that we did not observe an association between occupational exposure to AD and reduced fecundity because of lower exposure due to the more prevalent use of effective ECs.

Monitoring Surface Contamination by Antineoplastic Drugs in Italian Hospitals: Performance-Based Hygienic Guidance Values (HGVs) Project

Antineoplastic drugs (ADs) will continue to represent a potential risk for personnel involved in the handling of these compounds and great concerns have been raised by the presence of ADs in many surveyed workplaces. Eight hospitals were investigated by means of wipe sampling for surface residue determination. Each wipe sample was tested for five ADs considered suitable exposure markers. Cyclophosphamide (CP), gemcitabine (GEM), 5-fluorouracil (5-FU), platinum-containing drugs (Pt), and epi-doxorubicin (EPI) contamination levels were measured in 85 per cent of the studied pharmacies and 93 per cent of outpatient care units (OpCUs). This study showed that 83 out of 349 samples were positive in Pharmacies, this proportion being statistically significant (χ2 = 42.9, p < 0.001). The positive samples provided evidence of at least one substance with levels greater than the limit of detection (LOD). The two most frequently detected substances were Pt (42%) and CP (30%). These accounted for 72 per cent of the whole dataset, followed by 5-FU and GEM. Based on the 90th percentile of wipe sampling data distribution, we suggest hygienic guidance values (HGVs) of 3.6, 1.0, 0.9, and 0.5 ng cm-2 for CP, 5-FU, GEM and Pt, respectively, as the best target levels of the surface contamination load in Italian pharmacies. The approach of proposing guidance values at the 90th percentile of results obtained from workplaces with good hygiene practice was found to be a simple and practical way of controlling occupational exposure. HGVs were challenged in this study as technical threshold limits to benchmark AD residual surface contamination at workplaces.

A UHPLC-MS/MS-based method for the simultaneous monitoring of eight antiblastic drugs in plasma and urine of exposed healthcare workers

Exposure of healthcare workers to anticancer drugs requires the combined action of environmental and biological monitoring to assess the effective level of exposure to these chemicals, to improve awareness and to avoid adverse health effects on this category of workers. Cancer chemotherapeutic drugs show different mechanisms of action due to diverse chemical structures; consequently, they differ in hydrophobicity, pharmacokinetics and pharmacodynamics. Therefore, the appearance, accumulation and elimination of each of these molecules in body fluids and tissues might be extremely variable; this prompts the need for a rapid and versatile analytical protocol for the biological monitoring of possible exposure of workers involved in the manipulation, administration and disposal of cancer chemotherapeutic drugs. In this paper we describe the development, optimization and validation of a UHPLC-MS/MS method for the simultaneous quasi-quantitative analysis of eight widely used antineoplastic drugs, which can be used for the analysis of both urine and blood samples. This methodology was applied to the biological monitoring of healthcare workers exposed to different extents to antiblastic drugs at the University Hospital "San Giovanni di Dio e Ruggi d'Aragona" in Salerno (Italy), and allowed to identify two subjects exposed to irinotecan out of a total of fifteen workers analyzed.

Foreword

There is a significant body of evidence describing the benefits of using systemic anti-cancer therapy (SACT) agents, such as chemotherapy, biological, hormone and antibiotics, to treat people diagnosed with cancer (Cancer Research UK, 2017). However, the potential improvements in survival outcomes must be regularly weighed against the risk of adverse health effects associated with exposure to them. For patients, the risks are balanced against the need to treat the cancer. For health professionals, the risks simply result from the occupational exposure that can occur when caring for patients receiving these drugs. Collectively referred to as cytotoxic agents, SACTs are known to be toxic; they are considered carcinogenic to humans, and are classified as hazardous (National Institute for Occupational Safety and Health (NIOSH), 2010).

A strategy for formulating regulation on CSTDs

This article identifies what steps need to be taken to ensure the mandatory use of closed system transfer devices by all health professionals involved in the hazardous drug journey.

New approaches to wipe sampling methods for antineoplastic and other hazardous drugs in healthcare settings

PURPOSE

At the present time, the method of choice to determine surface contamination of the workplace with antineoplastic and other hazardous drugs is surface wipe sampling and subsequent sample analysis with a variety of analytical techniques. The purpose of this article is to review current methodology for determining the level of surface contamination with hazardous drugs in healthcare settings and to discuss recent advances in this area. In addition it will provide some guidance for conducting surface wipe sampling and sample analysis for these drugs in healthcare settings.

METHODS

Published studies on the use of wipe sampling to measure hazardous drugs on surfaces in healthcare settings drugs were reviewed. These studies include the use of well-documented chromatographic techniques for sample analysis in addition to newly evolving technology that provides rapid analysis of specific antineoplastic.

RESULTS

Methodology for the analysis of surface wipe samples for hazardous drugs are reviewed, including the purposes, technical factors, sampling strategy, materials required, and limitations. The use of lateral flow immunoassay (LFIA) and fluorescence covalent microbead immunosorbent assay (FCMIA) for surface wipe sample evaluation is also discussed.

CONCLUSIONS

Current recommendations are that all healthcare settings where antineoplastic and other hazardous drugs are handled include surface wipe sampling as part of a comprehensive hazardous drug-safe handling program. Surface wipe sampling may be used as a method to characterize potential occupational dermal exposure risk and to evaluate the effectiveness of implemented controls and the overall safety program. New technology, although currently limited in scope, may make wipe sampling for hazardous drugs more routine, less costly, and provide a shorter response time than classical analytical techniques now in use.

A three-year study of a first-generation chemotherapy-compounding robot

PURPOSE

Results of a performance evaluation of an automated system for compounding antineoplastic preparations are reported.

METHODS

Three years after the pharmacy department of a hospital in Saudi Arabia installed an i.v.-compounding robot (CytoCare, Health Robotics), data captured by the pharmacy information system and the machine's integrated software were analyzed to assess the performance of the robot in terms of compounding accuracy, days of operation, and downtime.

RESULTS

The robot was used to prepare 3.82%, 10.80%, and 13.79% of selected antineoplastics compounded in 2010, 2011, and 2012, respectively. The robot failed to meet the specified dose accuracy range of ±5% in compounding 3 of 337 chemotherapy preparations (0.9%) in 2010, 349 of 1516 preparations (23%) in 2011, and 460 of 2993 preparations (15%) in 2012. The robot was operational on 40%, 39%, and 61% of available workdays in 2010, 2011, and 2012, respectively. Robot throughput relative to the pharmacy's manual compounding process was low, with substantial medication waste resulting from dose preparation failures. Implementation challenges included workflow disruptions due to robot downtime, mechanical issues (e.g., robot arm-clamping failures), difficulty obtaining gravimetric data for some drugs, and the need to recalibrate the device to accept i.v. bags, syringes, and medication vials incompatible with manufacturer specifications.

CONCLUSION

The introduction of a chemotherapy-compounding robot for preparation of patient-specific i.v. antineoplastic drugs had a limited efficiency impact in practice. This solution, with its numerous limitations and technical difficulties, is not yet mature enough for universal adoption.

Benefits of Wipe Sampling: Evaluation of Long-Term 5-Fluorouracil and Platinum Monitoring Data

Objectives:

The aim of this study was to evaluate environmental contamination levels from a large dataset of long-term monitoring data of 5-fluorouracil and platinum-containing drugs in pharmacies, and to investigate the contaminations over 15 years.

Methods:

Wipe sampling for 5-fluorouracil and platinum (marker for cis-, carbo- and oxaliplatin) was performed on-site from various surfaces in hospital and retail pharmacies with a validated sampling procedure over a period of 15 years. The 5-fluorouracil concentrations were quantified by GCMSMS and platinum concentrations by voltammetry. Statistical evaluation was performed with respect to sampling locations and years, and over the course of time.

Results:

Overall, 3,584 wipe samples for 5-fluorouracil and 2,955 wipe samples for platinum were analysed and contamination was detected at all surface types in all 151 examined pharmacies with ranges from ND (not detectable) to 1,725,000 pg/cm² and ND to 23,068 pg/cm², respectively. Median concentrations from the different locations ranged between ND and 4.3 pg/cm² (5-fluorouracil) and 0.2 and 1.8 pg/cm² (platinum) with highest loads inside the biological safety cabinets/isolators and storage areas. Evaluation of contamination over the course of 15 years showed a substantial decrease, especially in the years after introduction of guidance values.

Conclusions:

Long-term evaluation of surface wipe samples for antineoplastic drug contamination with repeated monitoring seems to be a beneficial tool to characterize the actual exposure situation and to assess surface contamination over time. Wipe sampling is a suitable control means to evaluate the work practices and the effectiveness of applied safety and hygiene measures and to identify the potential exposure risk for health care workers.

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

OBJECTIVES

Antineoplastic drugs are known reproductive and developmental toxicants. Our objective was to review the existing literature of reproductive health risks to workers who handle antineoplastic drugs.

METHODS

A structured literature review of 18 peer-reviewed, English language publications of occupational exposure and reproductive outcomes was performed.

RESULTS

Although effect sizes varied with study size and population, occupational exposure to antineoplastic drugs seems to raise the risk of both congenital malformations and miscarriage. Studies of infertility and time to pregnancy also suggested an increased risk for subfertility.

CONCLUSIONS

Antineoplastic drugs are highly toxic in patients receiving treatment, and adverse reproductive effects have been well documented in these patients. Health care workers with long-term, low-level occupational exposure to these drugs also seem to have an increased risk of adverse reproductive outcomes. Additional precautions to prevent exposure should be considered.

Antineoplastic drugs contamination of workplace surfaces in two Portuguese hospitals

Despite the classification as known or suspected human carcinogens, by the International Agency for Research on Cancer, the antineoplastic drugs are extensively used in cancer treatment due to their specificity and efficacy. As human carcinogens, these drugs represent a serious threat to the healthcare workers involved in their preparation and administration. This work aims to contribute to better characterize the occupational exposure of healthcare professionals to antineoplastic drugs, by assessing workplace surfaces contamination of pharmacy and administration units of two Portuguese hospitals. Surface contamination was assessed by the determination of cyclophosphamide, 5-fluorouracil, and paclitaxel. These three drugs were used as surrogate markers for surfaces contamination by cytotoxic drugs. Wipe samples were taken and analyzed by HPLC-DAD. From the total of 327 analyzed samples, in 121 (37 %) was possible to detect and quantify at least one drug. Additionally, 28 samples (8.6 %) indicate contamination by more than one antineoplastic drug, mainly in the administration unit, in both hospitals. Considering the findings in both hospitals, specific measures should be taken, particularly those related with the promotion of good practices and safety procedures and also routine monitoring of surfaces contamination in order to guarantee the appliance of safety measures.

Hazardous drug residue on exterior vial surfaces: evaluation of a commercial manufacturing process

PURPOSE

Hazardous drug residue on the exterior surface of drug vials poses a potential risk for exposure of health care workers involved in handling these products. The purpose of this article is to heighten the awareness of this serious issue and to evaluate a commercial manufacturing process for removing and containing hazardous drug (HD) residue on exterior vial surfaces. Additionally, findings from this study are interpreted, incorporated into the current body of evidence, and discussed by experts in this field.

METHODS

This study includes separate evaluations for the presence or absence of surface drug contamination on the vials of 3 HD products: 5-fluorouracil, cisplatin, and methotrexate. The drug products were packaged in vials using a patented prewashing/decontamination method, application of a polyvinylchloride (PVC) base, and use of clear glass vials. An additional step of encasing the vial in a shrink-wrapped sheath was used for 5-fluorouracil and cisplatin.

RESULTS

Of all 5-fluorouracil (110 vials), methotrexate (60 vials), and cisplatin (60 vials) tested, only 2 had detectable amounts of surface residue. One 5-fluorouracil vial was found to have approximately 4 mg of 5-fluorouracil on the surface of the vial. The second contaminated vial was cisplatin, which was discovered to have 131 ng of platinum, equal to 200 ng of cisplatin or 0.2 μL of cisplatin solution, on the vial sheath.

CONCLUSION

Using validated extraction and analytic methods, all but 2 of the 230 tested vials were found to be free of surface drug contamination. Pharmacy leaders need to take an active role in promoting the need for clean HD vials. Manufacturers should be required to provide their clients with data derived from externally validated analytic studies, reporting the level of HD contamination on the exterior of their vial products.

Application and assessment of a regular environmental monitoring of the antineoplastic drug contamination level in pharmacies - the MEWIP project

A large-scale study was carried out in order to determine the contamination level of antineoplastic drugs in pharmacies and to investigate the suitability and effects of wipe sample monitoring at regular intervals. A specific study design was developed. The 130 participating pharmacies were divided into a study and a control group, carrying out five and two wipe sampling cycles, respectively. The work practice was analyzed using questionnaires to identify factors that influence the contamination level. From 1269 wipe samples, 774 (61%) were contaminated with at least one of the analyzed cytotoxic drugs: cyclophosphamide, docetaxel, etoposide, 5-fluorouracil, gemcitabine, ifosfamide, methotrexate, and paclitaxel. A significant decrease of the contamination with cyclophosphamide and 5-fluorouracil was observed in the study group. The Monitoring-Effect Study of Wipe Sampling in Pharmacies method has proven to be a reliable and affordable tool for contamination control. Based on the 90th percentile of the contamination values, a substance-independent performance-based guidance value of 0.1ng cm(-2) has been derived.

Impact of robotic antineoplastic preparation on safety, workflow, and costs

PURPOSE

Antineoplastic preparation presents unique safety concerns and consumes significant pharmacy staff time and costs. Robotic antineoplastic and adjuvant medication compounding may provide incremental safety and efficiency advantages compared with standard pharmacy practices.

METHODS

We conducted a direct observation trial in an academic medical center pharmacy to compare the effects of usual/manual antineoplastic and adjuvant drug preparation (baseline period) with robotic preparation (intervention period). The primary outcomes were serious medication errors and staff safety events with the potential for harm of patients and staff, respectively. Secondary outcomes included medication accuracy determined by gravimetric techniques, medication preparation time, and the costs of both ancillary materials used during drug preparation and personnel time.

RESULTS

Among 1,421 and 972 observed medication preparations, we found nine (0.7%) and seven (0.7%) serious medication errors (P = .8) and 73 (5.1%) and 28 (2.9%) staff safety events (P = .007) in the baseline and intervention periods, respectively. Drugs failed accuracy measurements in 12.5% (23 of 184) and 0.9% (one of 110) of preparations in the baseline and intervention periods, respectively (P < .001). Mean drug preparation time increased by 47% when using the robot (P = .009). Labor costs were similar in both study periods, although the ancillary material costs decreased by 56% in the intervention period (P < .001).

CONCLUSION

Although robotically prepared antineoplastic and adjuvant medications did not reduce serious medication errors, both staff safety and accuracy of medication preparation were improved significantly. Future studies are necessary to address the overall cost effectiveness of these robotic implementations.

[Exposure to cytotoxic drugs among health care professionals]

OBJECTIVE

To quantify levels of exposure to cytotoxic drugs among health professionals in order to establish an exposure threshold and implement measures to increase protection and safety.

MATERIAL AND METHOD

Contamination with 5-fluorouracil, gemcitabine and cyclophosphamide was measured on work surfaces in the following areas: a class II type B3 biological safety cabinet (S(1)), a treatment prep table in an antechamber (S(2)) and a desk from the administrative room in the Outpatient Unit (S(3)). We took samples from the work surfaces by wiping them with an absorbent cloth at time t(0), prior to the work session, and at t(1) after three hours of work. For each surface, we calculated the median mass value with respect to the baseline value and the 90th, 75th, 50th and 25th percentiles for each cytotoxin in μg/m(2). Distribution normality was assessed using the Shapiro-Wilk test. Statistical analysis included the Kruskal-Wallis and Mann-Whitney-Wilcoxon tests. Statistical significance was established for values of P<.05.

RESULTS

We gathered a total of 90 samples, 30 from each of the studied work surfaces. The mean recorded mass of any of the cytotoxic compounds was higher for S(1) and t(1), with values of P=.017 and P=.004 respectively. The target value for each cytotoxic drug was established at the 25th percentile, where undetectable contamination values were obtained.

CONCLUSIONS

Introducing a continuous programme to monitor work surfaces for an array of cytotoxic compounds is fundamental in order to establish acceptable levels of residual contamination and reduce exposure in the workplace.