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Leeman M, Wetterling M, Kåredal M, Hedmer M. Development and validation of a quantitative wipe sampling method to determine platinum contamination from antineoplastic drugs on surfaces in workplaces at Swedish hospitals. J Oncol Pharm Pract 2024:10781552241259405. [PMID: 38835271 DOI: 10.1177/10781552241259405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Abstract
INTRODUCTION Antineoplastic drugs (ADs) are frequently used pharmaceuticals in the healthcare, and healthcare workers can be occupationally exposed to ADs. Monitoring of surface contamination is a common way to assess occupational exposure to ADs. The objective was to develop and validate a sensitive and quantitative monitoring method to determine surface contaminations of Pt as a marker for Pt-containing ADs. The surface contaminations of Pt-containing ADs were monitored at four Swedish hospital workplaces. METHODS An analytical method was developed based on inductively coupled plasma mass spectrometry. The wipe sampling procedure was validated regarding different surface materials. The stability of collected wipe samples was investigated. Workplace surfaces were monitored by wipe sampling to determine contaminations of Pt-containing ADs. RESULTS A wipe sampling and analytical method with a limit of detection of 0.1 pg Pt/cm2 was developed. Pt was detected in 67% of the wipe samples collected from four workplaces, and the concentrations ranged from <0.10 to 21100 pg/cm2. In 4% of samples, the detected surface contaminations of Pt in three hospital wards were above proposed hygienic guidance value (HGV) of Pt. In the hospital pharmacy, 9% of the detected surface contaminations of Pt were above lowest proposed HGV. CONCLUSIONS A user-friendly, specific, and sensitive method for determination of surface contaminations of Pt from ADs in work environments was developed and validated. A large variation of contaminations was observed between detected surface contaminations of Pt in samples collected in wards, and it likely reflects differences in amounts handled and work practices between the wards.
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Affiliation(s)
- Mats Leeman
- Department of Occupational and Environmental Medicine, Region Skåne, Lund, Sweden
- Division of Occupational and Environmental Medicine, Department of Laboratory Medicine, Lund University, Lund, Sweden
| | - Maria Wetterling
- Department of Occupational and Environmental Medicine, Region Skåne, Lund, Sweden
| | - Monica Kåredal
- Department of Occupational and Environmental Medicine, Region Skåne, Lund, Sweden
- Division of Occupational and Environmental Medicine, Department of Laboratory Medicine, Lund University, Lund, Sweden
| | - Maria Hedmer
- Department of Occupational and Environmental Medicine, Region Skåne, Lund, Sweden
- Division of Occupational and Environmental Medicine, Department of Laboratory Medicine, Lund University, Lund, Sweden
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Arnold S, Jeronimo M, Astrakianakis G, Kunz M, Petersen A, Chambers C, Malard Johnson D, Zimdars E, Davies HW. Developing wipe sampling strategy guidance for assessing environmental contamination of antineoplastic drugs. J Oncol Pharm Pract 2023; 29:1816-1824. [PMID: 35924415 PMCID: PMC10687812 DOI: 10.1177/10781552221118535] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/13/2022] [Accepted: 07/15/2022] [Indexed: 11/16/2022]
Abstract
Surveillance for environmental contamination of antineoplastic drugs has been recommended by authoritative bodies such as the United States Pharmacopeia and the National Association of Pharmacy Regulatory Authorities. Clear guidance is needed on how to develop sampling strategies that align with surveillance objectives efficiently and effectively. We conducted a series of simulations using previously collected surveillance data from nine cancer treatment centers to evaluate different sampling strategies. We evaluated the impact of sampling 2, 5, 10, or 20 surfaces, at monthly, quarterly, semi-annual, and annual frequencies, while employing either a random or sentinel surface selection strategy to assess contamination by a single antineoplastic drug (AD) or by a panel of three ADs. We applied two different benchmarks: a binary benchmark of above or below the limit of detection and AD-specific hygienic guidance values, based on 90th percentile values as quantitative benchmarks. The use of sentinel surfaces to evaluate a three-drug panel relative to 90th percentile hygienic guidance values (HGVs) resulted in the most efficient and effective surveillance strategy.
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Affiliation(s)
- Susan Arnold
- School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Matthew Jeronimo
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - George Astrakianakis
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Miranda Kunz
- School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Ashley Petersen
- School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | | | | | | | - Hugh W Davies
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
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3
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Bláhová L, Bláha L, Doležalová L, Kuta J, Hojdarová T. Proposals of guidance values for surface contamination by antineoplastic drugs based on long term monitoring in Czech and Slovak hospitals and pharmacies. Front Public Health 2023; 11:1235496. [PMID: 37780438 PMCID: PMC10537921 DOI: 10.3389/fpubh.2023.1235496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 08/22/2023] [Indexed: 10/03/2023] Open
Abstract
Introduction The exposures to hazardous antineoplastic drugs (AD) represent serious risks for health care personnel but the exposure limits are not commonly established because of the no-threshold effects (genotoxic action, carcinogenicity) of many ADs. In this study, we discussed and derived practically applicable technical guidance values (TGV) suitable for management of AD risks. Methods The long-term monitoring of surface contamination by eight ADs was performed in pharmacies and hospitals in the Czech Republic and Slovak Republic in 2008-2021; in total 2,223 unique samples were collected repeatedly in 48 facilities. AD contamination was studied by LC-MS/MS for cyclophosphamide, ifosfamide, methotrexate, irinotecan, paclitaxel, 5-fluorouracil and gemcitabine and by ICP-MS for total Pt as a marker of platinum-based ADs. Results The study highlighted importance of exposure biomarkers like 5-fluorouracil and especially carcinogenic and persistent cyclophosphamide, which should be by default included in monitoring along with other ADs. Highly contaminated spots like interiors of laminar biological safety cabinets represent a specific issue, where monitoring of contamination does not bring much added value, and prevention of staff and separated cleaning procedures should be priority. Rooms and surfaces in health care facilities that should be virtually free of ADs (e.g., offices, kitchenettes, daily rooms) were contaminated with lower frequency and concentrations but any contamination in these areas should be carefully examined. Discussion and conclusions For all other working places, i.e., majority of areas in pharmacies and hospitals, where ADs are being prepared, packaged, stored, transported, or administered to patients, the study proposes a generic TGV of 100 pg/cm2. The analysis of long-term monitoring data of multiple ADs showed that the exceedance of one TGV can serve as an indicator and trigger for improvement of working practices contributing thus to minimizing of unintended exposures and creating a safe work environment.
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Affiliation(s)
- Lucie Bláhová
- RECETOX, Faculty of Science, Masaryk University, Brno, Czechia
| | - Luěek Bláha
- RECETOX, Faculty of Science, Masaryk University, Brno, Czechia
| | | | - Jan Kuta
- RECETOX, Faculty of Science, Masaryk University, Brno, Czechia
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Speranza ED, Jeronimo M, Colombo M. Initial assessment of multi-compound antineoplastic drug surface contamination in Argentinean healthcare centers: Insights into occupational exposures in South America. J Oncol Pharm Pract 2023:10781552231188320. [PMID: 37470481 DOI: 10.1177/10781552231188320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
INTRODUCTION Antineoplastic drug contamination can result in severe health effects for healthcare workers exposed to them. Despite the worldwide growing concern regarding these drugs and sustained monitoring efforts in developed countries, there is almost no data about surface contamination levels in Argentina, in particular, and South America, in general. METHODS Antineoplastic drug contamination was measured in three Argentinean public hospitals (pharmacy and daycare center areas) by surface wiping and liquid chromatography coupled with tandem mass spectrometry. RESULTS AND DISCUSSION Eleven drugs were detected, in 51 of 58 sampled surfaces, in variable concentrations from 0.00064 to 7.3 ng cm-2, with cyclophosphamide, gemcitabine, and paclitaxel as the most prevalent drugs. This highly variable antineoplastic distribution reflects differences in facility layout, number of patients, antineoplastic drug use, etc., at each hospital. Values exceeding the 1 ng cm-2 threshold were detected in 13 surfaces of the two hospitals handling the largest amounts of antineoplastic drugs. The cyclophosphamide 75th percentile averaged 0.030 ng cm-2 comparable to the high values reported more than 10 years ago for developed countries, emphasizing the potential of reducing antineoplastic contamination by implementing routine monitoring and improved cleaning and handling procedures. CONCLUSION This study is the first survey of multi-compound surface antineoplastic contamination in Argentinean (and South American) hospitals, providing a baseline against which future studies can be compared. Widespread antineoplastic contamination has been detected on numerous surfaces, with concentrations surpassing suggested threshold exposure levels (1 ng cm-1) for some surfaces in two of the sampled hospitals.
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Affiliation(s)
- Eric D Speranza
- Laboratorio de Química Ambiental y Biogeoquímica, Universidad Nacional de La Plata-Universidad Nacional Arturo Jauretche, Buenos Aires, Argentina
- Consejo Nacional de Investigaciones Científicas y Técnicas, C.A.B.A., Argentina
| | - Matthew Jeronimo
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Manuel Colombo
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
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Saint-Lorant G, Vasseur M, Allorge D, Beauval N, Simon N, Odou P. Four-year follow-up of surface contamination by antineoplastic drugs in a compounding unit. Occup Environ Med 2023; 80:146-153. [PMID: 36717254 DOI: 10.1136/oemed-2022-108623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 12/21/2022] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Guillaume Saint-Lorant
- ULR 7365-GRITA-Groupe de Recherche sur les Formes Injectables et les Technologies Associées, University of Lille, Lille, France .,Pharmacy, CHU Caen, Caen, France
| | - Michèle Vasseur
- ULR 7365-GRITA-Groupe de Recherche sur les Formes Injectables et les Technologies Associées, University of Lille, Lille, France.,Pharmacy, CHU Lille, Lille, France
| | - Delphine Allorge
- ULR-4483-IMPECS-IMPact de l'Environnement Chimique sur la Santé humaine, University of Lille, Lille, France.,CHRU, Lille, France
| | | | - Nicolas Simon
- ULR 7365-GRITA-Groupe de Recherche sur les Formes Injectables et les Technologies Associées, University of Lille, Lille, France.,Pharmacy, CHU Lille, Lille, France
| | - Pascal Odou
- ULR 7365-GRITA-Groupe de Recherche sur les Formes Injectables et les Technologies Associées, University of Lille, Lille, France.,Pharmacy, CHU Lille, Lille, France
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Lema-Atán JÁ, Lendoiro E, Paniagua-González L, Cruz A, López-Rivadulla M, de-Castro-Ríos A. LC-MS-MS Determination of Cytostatic Drugs on Surfaces and in Urine to Assess Occupational Exposure. J Anal Toxicol 2022; 46:e248-e255. [PMID: 36164930 PMCID: PMC9872221 DOI: 10.1093/jat/bkac073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/11/2022] [Accepted: 10/19/2022] [Indexed: 02/02/2023] Open
Abstract
The ever-increased usage of cytostatic drugs leads to high risk of exposure among healthcare workers. Moreover, workers are exposed to multiple compounds throughout their lives, leading to cumulative and chronic exposure. Therefore, multianalyte methods are the most suitable for exposure assessment, which minimizes the risks from handling cytostatic drugs and ensures adequate contamination containment. This study describes the development and full validation of two liquid chromatography-tandem mass spectrometry methods for the detection of gemcitabine, dacarbazine, methotrexate, irinotecan, cyclophosphamide, doxorubicinol, doxorubicin, epirubicin, etoposide, vinorelbine, docetaxel and paclitaxel in working surfaces and urine samples. The urine method is the first to measure vinorelbine and doxorubicinol. For surfaces, limits of detection (LOD) and limits of quantification (LOQ) were 5-100 pg/cm2, and linearity was achieved up to 500 pg/cm2. Inaccuracy was between -11.0 and 8.4%. Intra-day, inter-day and total imprecision were <20%, except for etoposide and irinotecan (<22.1%). In urine, LOD and LOQ were 5-250 pg/mL, with a linear range up to 1,000-5,000 pg/mL. Inaccuracy was between -3.8 and 14.9%. Imprecision was <12.4%. Matrix effect was from -58.3 to 1,268.9% and from -66.7 to 1,636% in surface and urine samples, respectively, and extraction efficiency from 10.8 to 75% and 47.1 to 130.4%, respectively. All the analytes showed autosampler (6°C/72 h), freezer (-22°C/2 months) and freeze/thaw (three cycles) stability. The feasibility of the methods was demonstrated by analyzing real working surfaces and patients' urine samples. Contamination with gemcitabine, irinotecan, cyclophosphamide, epirubicin and paclitaxel (5-4,641.9 pg/cm2) was found on biological safety cabinets and outpatients' bathrooms. Analysis of urine from patients under chemotherapy identified the infused drugs at concentrations higher than the upper LOQ. These validated methods will allow a comprehensive evaluation of both environmental and biological contamination in hospital settings and healthcare workers.
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Affiliation(s)
- José Ángel Lema-Atán
- Toxicology Service, Institute of Forensic Sciences, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Elena Lendoiro
- Toxicology Service, Institute of Forensic Sciences, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Lucía Paniagua-González
- Toxicology Service, Institute of Forensic Sciences, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Angelines Cruz
- Toxicology Service, Institute of Forensic Sciences, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Manuel López-Rivadulla
- Toxicology Service, Institute of Forensic Sciences, University of Santiago de Compostela, Santiago de Compostela, Spain
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Occupational Exposure Assessment to Antineoplastic Drugs in Nine Italian Hospital Centers over a 5-Year Survey Program. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19148601. [PMID: 35886450 PMCID: PMC9321125 DOI: 10.3390/ijerph19148601] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 06/20/2022] [Accepted: 07/07/2022] [Indexed: 11/17/2022]
Abstract
In the present study, surface contamination where antineoplastic drugs (ADs) are present was investigated, as occupational exposure risk is still an open debate. Despite recommendations and safety standard procedures being in place in health care settings, quantifiable levels of ADs are being reported in the recent literature. Thus, a survey monitoring program was conducted over five years (2016–2021) in nine Italian hospitals. The repeated surveys produced 8288 data points that have been grouped according to the main hospital settings, such as pharmacy areas and patient care units. Based on the most often prepared ADs, the investigated drugs were cyclophosphamide (CP), gemcitabine (GEM), 5-fluorouracil (5–FU), and platinum compounds (Pt). Patient care units had a frequency of positive wipe samples (59%) higher than pharmacies (44%). Conversely, pharmacies had a frequency of positive pad samples higher (24%) than patient care units (10%). Moreover, by statistical analysis, pad samples had a significantly higher risk of contamination in pharmacy areas than in patient care units. In this study, the 75th and the 90th percentiles of the contamination levels were obtained. The 90th percentile was chosen to describe a suitable benchmark that compares results obtained by the present research with those previously reported in the literature. Based upon surface contamination loads, our data showed that 5–FU had the highest concentration values, but the lowest frequency of positive samples. In pharmacy areas, the 90th percentile of 5–FU data distribution was less than 0.346 ng/cm2 and less than 0.443 ng/cm2 in patient care units. AD levels are higher than those reported for health care settings in other European countries yet trends of contamination in Italy have shown to decrease over time.
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8
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Papastergiou J, Smiley T. Evaluation of Current Hazardous Drug Exposure Control in Community Pharmacy. J Pharm Technol 2022; 38:155-158. [PMID: 35600277 PMCID: PMC9116126 DOI: 10.1177/87551225211072743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Purpose: To evaluate effectiveness of current hazardous drug exposure control practices in community pharmacies through identification of commonly contaminated surfaces. We also assessed the decontamination effectiveness of 5 different cleaning agents. Methods: This study was prospective and nonrandomized and conducted in 2 phases. In phase 1, 15 common areas used in the dispensing process were tested at each of 4 pharmacies in Toronto Ontario, Canada. Testing was conducted using the BD® HD Check System, a rapid, point-of-care, hazardous drug detection system that is able to identify contamination with methotrexate (MTX) and cyclophosphamide (CYP) and doxorubicin. In phase 2, 5 different cleaning agents (70% isopropyl alcohol, Lysol® spray, Ecolab® retail multiquat sanitizer, Ecolab retail multisurface and glass cleaner with peroxide, and Ecolab QSR heavy-duty degreaser) were tested for their ability to eliminate contamination. Results: All 4 pharmacies tested positive for contamination with MTX (25.8% of surfaces). Contamination with CYP was less frequent, with only 3 sites and 18.2% of surfaces testing positive. Of the 5 cleaning agents tested, only Ecolab QSR heavy-duty degreaser was able to eliminate contamination with MTX. None of the agents were successful against CYP. Conclusions: The results illustrate an unacceptable prevalence of hazardous drug contamination in community pharmacy settings. The BD HD Check System can serve to rapidly detect common high-risk areas for surface contamination. Decontamination protocols against MTX may include Ecolab QSR heavy-duty degreaser. Novel agents must be identified to remove contamination caused by CYP.
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Affiliation(s)
- John Papastergiou
- Shoppers Drug Mart, Toronto, ON, Canada
- University of Toronto, Toronto, ON,
Canada
- University of Waterloo School of Pharmacy,
Waterloo, ON, Canada
| | - Tom Smiley
- University of Waterloo School of Pharmacy,
Waterloo, ON, Canada
- Pharmavision Health Consulting Inc., Paris,
ON, Canada
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9
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Eisenberg S. Closed safety system for administration (CSSA): proposal for a new cytotoxic chemotherapy acronym. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2022; 31:S26-S32. [PMID: 35648666 DOI: 10.12968/bjon.2022.31.10.s26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
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.
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Affiliation(s)
- Seth Eisenberg
- Professional Practice Coordinator, Infusion Services, Seattle Cancer Care Alliance, Seattle, Washington USA
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10
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Gerding J, Anhäuser L, Eickmann U, Nienhaus A. A simple approach to assess the cancer risk of occupational exposure to genotoxic drugs in healthcare settings. J Occup Med Toxicol 2022; 17:8. [PMID: 35365163 PMCID: PMC8973544 DOI: 10.1186/s12995-022-00349-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 03/21/2022] [Indexed: 11/10/2022] Open
Abstract
Background Several drugs for human use possess genotoxic properties as a necessary consequence of their intended therapeutic effect (e.g. antineoplastics). Health workers may be exposed to these chemicals in various occupational settings such as dose preparation and administration. To date, there are no quantitative risk assessment models to estimate the cancer risk of health workers due to the handling of genotoxic drugs. We therefore developed a quantitative risk assessment model to assess the cancer risk of occupational exposure to genotoxic drugs in healthcare settings based on the threshold of toxicological concern (TTC) concept. This model was used to evaluate the cancer risk of health workers due to the handling of genotoxic drugs in modern health care facilities. Methods We modified the threshold of toxicological concern (TTC) concept to fit the purpose of occupational cancer risk assessment. The risk model underlying ICH guideline M7 (R1): “assessment and control of DNA reactive (mutagenic) impurities in pharmaceuticals to limit potential carcinogenic risk” was used as a starting point for our model. We conducted a short review of studies on the occupational exposure of health workers to genotoxic drugs. These occupational exposure data were compared to the acceptable exposure levels resulting from our TTC based risk model. Results Based on the threshold of toxicological concern (TTC) concept, we defined an acceptable daily intake (ADI) of 4 μg/day as threshold of no concern for the exposure of health workers to genotoxic drugs. Regarding the dermal exposure of health workers to genotoxic drugs, we derived a corresponding acceptable surface contamination level (ASCL) of 20 ng/cm2. Both ADI and ASCL are usually not exceeded in modern healthcare settings. Current safety precautions provide sufficient protection to health workers. Conclusions The application of our model indicates that workers in modern healthcare facilities are not at risk of developing work related cancer above widely accepted cancer risk levels due to the occupational exposure to genotoxic drugs. Hence, the present study may assist employers and public authorities to make informed decisions concerning the need for (further) protective measures and during risk communication to health workers.
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Affiliation(s)
- Johannes Gerding
- Department for Occupational Medicine, Hazardous Substances and Public Health, German Social Accident Insurance, Institution for the Health and Welfare Services (BGW), Pappelallee 33/35/37, 22089, Hamburg, Germany.
| | - Lea Anhäuser
- Department for Occupational Medicine, Hazardous Substances and Public Health, German Social Accident Insurance, Institution for the Health and Welfare Services (BGW), Pappelallee 33/35/37, 22089, Hamburg, Germany
| | - Udo Eickmann
- Department for Occupational Medicine, Hazardous Substances and Public Health, German Social Accident Insurance, Institution for the Health and Welfare Services (BGW), Pappelallee 33/35/37, 22089, Hamburg, Germany
| | - Albert Nienhaus
- Department for Occupational Medicine, Hazardous Substances and Public Health, German Social Accident Insurance, Institution for the Health and Welfare Services (BGW), Pappelallee 33/35/37, 22089, Hamburg, Germany.,Competence Centre for Epidemiology and Health Services Research for Healthcare Professionals (CVcare), University Medical Centre Hamburg-Eppendorf (UKE), Martinistraße 52, 20246, Hamburg, Germany
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11
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Bishay S, Michalowska-Suterska M, Edling A, Battle J. Evaluation of the hazardous drug surface contamination in pharmacy compounding and administration clinical setting after adoption of standardized cleaning workflow and a closed system transfer device. PHARMACEUTICAL TECHNOLOGY IN HOSPITAL PHARMACY 2022. [DOI: 10.1515/pthp-2022-0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Objectives
The compounding and administration of hazardous drugs present a potential risk to healthcare worker and patient safety. This study sought to evaluate the HD surface contamination in multiple pharmacy and nursing areas that include standardized cleaning techniques and utilization of closed system transfer devices.
Methods
This study was conducted at six different areas in the pharmacy and nursing areas. Each area was assessed three times for five different HD’s surface contamination at an initial, 3 month, and 6 month follow up. Hazardous drug surface testing was performed for five most compounded HDs. A total of 90 individual samples were taken and analyzed during the study.
Results
A total of 30 samples were collected at three different timepoints for a total of 90 individual samples and analysis results. All 90 samples were negative (below the lower limit of detection; 0.01 ng/cm2), for their respective drug residue.
Conclusions
The method and design described in this evaluation may offer a way to determine if a facility’s current HD work practices and controls retain reduced HD surface contamination based upon published threshold values. Adoption and utilization of standardized work, including use of a closed system transfer device, and cleaning practices, described in this study, may present an option for facilities to retain reduced HD surface contamination, based upon previously determined threshold values.
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Affiliation(s)
- Sally Bishay
- Inpatient Pharmacy, Stamford Hospital , Stamford , CT , USA
| | | | - Andrea Edling
- Inpatient Pharmacy, Stamford Hospital , Stamford , CT , USA
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12
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Kåredal M, Jönsson R, Wetterling M, Björk B, Hedmer M. A quantitative LC-MS method to determine surface contamination of antineoplastic drugs by wipe sampling. JOURNAL OF OCCUPATIONAL AND ENVIRONMENTAL HYGIENE 2022; 19:50-66. [PMID: 34723774 DOI: 10.1080/15459624.2021.2000617] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
The main objective was to develop a wipe sampling test to measure surface contamination of the most frequently used antineoplastic drugs (ADs) in Swedish healthcare and, furthermore, to develop an analysis method sensitive enough to assess low levels of contamination. Two wipe sampling tests with separate sample processing methods assessing (i) cyclophosphamide (CP), ifosfamide (IF), 5-fluorouracil (5-FU), etoposide (ETO), gemcitabine (GEM) and cytarabine (CYT) (Wipe Test 1); and (ii) GEM, CYT and methotrexate (MTX) (Wipe Test 2), respectively, were developed by optimization of absorption and extraction efficiencies using different wipe tissue materials, tissue wetting solution, and extraction solvents. A fast liquid chromatography tandem mass spectrometry method was developed for simultaneous detection of the studied ADs. The limit of quantification for the method was between 0.04 to 2.4 ng/wipe sample (0.10 to 6.1 pg/cm2 for an area of 400 cm2) and at 50 ng/sample the within-day precision was between 1.3 and 15%, and the accuracy between 102 and 127%. Wipe Test 1 was applied in an assessment of cleaning efficiency of five different cleaning solutions (formic acid, water, sodium hydroxide, ethanol, and sodium dodecyl sulfate (SDS) for removal of ADs from surfaces made of stainless steel or plastic. For CP, IF, 5-FU, GEM, and CYT 92% of the AD were removed regardless of surface and cleaning solution. In conclusion, a user-friendly assessment method to measure low levels of seven ADs in the work environment was developed and validated. Assessment of the decontamination efficiency of cleaning solutions concerning removal of ADs from stainless steel showed that efficiencies differed depending on the AD with water being the least effective cleaning agent. The results suggests that a combination of different cleaning agents including detergent and a solution with an organic component would be optimal to efficiently remove the measured ADs from surfaces in the workplace.
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Affiliation(s)
- Monica Kåredal
- Department of Occupational and Environmental Medicine, Region Skåne, Lund, Sweden
- Division of Occupational and Environmental Medicine, Department of Laboratory Medicine, Lund University, Lund, Sweden
| | - Rebecca Jönsson
- Department of Occupational and Environmental Medicine, Region Skåne, Lund, Sweden
| | - Maria Wetterling
- Department of Occupational and Environmental Medicine, Region Skåne, Lund, Sweden
| | - Birgitta Björk
- Department of Occupational and Environmental Medicine, Region Skåne, Lund, Sweden
| | - Maria Hedmer
- Department of Occupational and Environmental Medicine, Region Skåne, Lund, Sweden
- Division of Occupational and Environmental Medicine, Department of Laboratory Medicine, Lund University, Lund, Sweden
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13
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Valero García S, Centelles-Oria M, Palanques-Pastor T, Vila Clérigues N, López-Briz E, Poveda Andrés JL. Analysis of chemical contamination by hazardous drugs with BD HD Check ® system in a tertiary hospital. J Oncol Pharm Pract 2021; 28:1583-1593. [PMID: 34565241 DOI: 10.1177/10781552211038518] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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14
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Developing a Fast Ultra-High-Performance Liquid Chromatography–Tandem Mass Spectrometry Method for High-Throughput Surface Contamination Monitoring of 26 Antineoplastic Drugs. SEPARATIONS 2021. [DOI: 10.3390/separations8090150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Growing attention on carcinogenicity and mutagenicity of antineoplastic drugs (ADs) from the International Agencies has led to the present strict safe handling and administration regulations. Accordingly, one of the most common ways to assess occupational exposure to these substances is to identify and quantify possible surface contamination inside hospital preparation and administration units. Thus, it is essential to develop a fast and high-throughput monitoring method capable of identifying a significant number of ADs. The present study reports developing a UHPLC–MS/MS analysis to screen 26 ADs surface contamination through wipe test sampling. A Cortecs UPLC T3 50 × 2.1 mm (1.6 µm) column was selected to perform the analysis, using the evaluations of previous studies and the Product Quality Research Institute (PQRI) database. The design of experiments (DoE) methodological approach was used to optimize the chromatographic conditions concerning the best separation between all ADs. The limits of quantification for the analytes were between the pg/mL and ng/mL orders, and the turnaround time was limited to about 15 min. The obtained accuracy was mostly between 90% and 110% for all the analytes, while the precision was under 10% and a low matrix effect was observed for said analytes. Only vindesine and docetaxel presented lower performances.
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15
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Labrèche F, Ouellet C, Roberge B, Caron NJ, Yennek A, Bussières JF. Occupational exposure to antineoplastic drugs: what about hospital sanitation personnel? Int Arch Occup Environ Health 2021; 94:1877-1888. [PMID: 34410477 DOI: 10.1007/s00420-021-01731-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 03/19/2021] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Occupational exposure to antineoplastic drugs (ANPs) occurs mainly through dermal contact. Our study was set up to assess the potential exposure of hospital sanitation (HS) personnel, for whom almost no data are available, through contamination of surfaces they regularly touch. METHODS In the oncology departments of two hospitals around Montreal, surface wipe samples of 120-2000 cm2 were taken at 10 sites cleaned by the HS personnel and five other sites frequently touched by nursing and pharmacy personnel. A few hand wipe samples were collected to explore skin contamination. Wipes were analyzed by ultra-performance liquid chromatography tandem-mass spectrometry for 10 ANPs. RESULTS Overall, 60.9% of 212 surface samples presented at least one ANP above the limits of detection (LOD). Cyclophosphamide and gemcitabine were most often detected (52% and 31% of samples respectively), followed by 5-fluorouracil and irinotecan (15% each). Highest concentrations of five ANPs were found in outpatient clinics on toilet floors (5-fluorouracil, 49 ng/cm2; irinotecan, 3.6 ng/cm2), a perfusion pump (cyclophosphamide, 19.6 ng/cm2) and on a cytotoxic waste bin cover (gemcitabine, 4.97 ng/cm2). Floors in patient rooms had highest levels of cytarabine (0.12 ng/cm2) and methotrexate (6.38 ng/cm2). Hand wipes were positive for two of 12 samples taken on HS personnel, seven of 18 samples on nurses, and two of 14 samples on pharmacy personnel. CONCLUSIONS A notable proportion of surfaces showed measurable levels of ANPs, with highest concentrations found on surfaces cleaned by HS personnel, who would benefit from appropriate preventive training. As potential sources of worker exposure, several hospital surfaces need to be regularly monitored to evaluate environmental contamination and efficacy of cleaning.
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Affiliation(s)
- France Labrèche
- Chemical, Biological, Mechanical and Physical Risk Prevention, Institut de recherche Robert-Sauvé en santé et en sécurité du travail, 505 De Maisonneuve Blvd. West, Montréal, QC, H3A 3C2, Canada. .,Service de santé au travail, Direction de santé publique de 1 Estrie, CIUSSE - CHUS de Sherbrooke, Sherbrooke, QC, Canada.
| | - Capucine Ouellet
- Chemical, Biological, Mechanical and Physical Risk Prevention, Institut de recherche Robert-Sauvé en santé et en sécurité du travail, 505 De Maisonneuve Blvd. West, Montréal, QC, H3A 3C2, Canada
| | - Brigitte Roberge
- Chemical, Biological, Mechanical and Physical Risk Prevention, Institut de recherche Robert-Sauvé en santé et en sécurité du travail, 505 De Maisonneuve Blvd. West, Montréal, QC, H3A 3C2, Canada
| | - Nicolas J Caron
- Centre de Toxicologie du Québec, Institut national de santé publique du Québec, Québec, QC, Canada
| | - Ahmed Yennek
- Service de santé au travail, Direction de santé publique de 1 Estrie, CIUSSE - CHUS de Sherbrooke, Sherbrooke, QC, Canada
| | - Jean-François Bussières
- Département de pharmacie, Unité de recherche en pratique pharmaceutique, CHU Sainte-Justine, Montreal, QC, Canada.,Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada
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16
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Jeronimo M, Arnold S, Astrakianakis G, Lyden G, Stewart Q, Petersen A, Chambers C, Malard Johnson D, Zimdars E, Kaup H, Davies HW. Spatial and Temporal Variability in Antineoplastic Drug Surface Contamination in Cancer Care Centers in Alberta and Minnesota. Ann Work Expo Health 2021; 65:760-774. [PMID: 33889938 DOI: 10.1093/annweh/wxab013] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 01/26/2021] [Accepted: 02/04/2021] [Indexed: 11/13/2022] Open
Abstract
The health risks of exposure to antineoplastic drugs (ADs) are well established, and healthcare professionals can be exposed while caring for cancer patients receiving AD therapy. Studies conducted worldwide over the past two decades indicate continuing widespread surface contamination by ADs. No occupational exposure limits have been established for ADs, but concerns over exposures have led to the development of guidelines, such as United States Pharmacopeia (USP) General Chapter <800> Hazardous Drugs-Handling in Healthcare. While recommending regular surveillance for surface contamination by ADs these guidelines do not provide guidance on sampling strategies. Better characterization of spatial and temporal variability of multidrug contamination would help to inform such strategies. We conducted surface-wipe monitoring of nine cancer care centers in Alberta, Canada and Minnesota, USA, with each center sampled eight times over a 12-month period. Twenty surfaces from within pharmacy and drug administration areas were sampled, and 11 drugs were analyzed from each wipe sample. Exposure data were highly left-censored which restricted data analysis; we examined prevalence of samples above limit of detection (LOD), and used the 90th percentile of the exposure distribution as a measure of level of contamination. We collected 1984 wipe samples over a total of 75 sampling days resulting in 21 824 observations. Forty-five percent of wipe samples detected at least one drug above the LOD, but only three of the drugs had more than 10% of observations above the LOD: gemcitabine (GEM) (24%), cyclophosphamide (CP) (16%), and paclitaxel (13%). Of 741 wipe samples with at least one drug above LOD, 60% had a single drug above LOD, 19% had two drugs, and 21% had three drugs or more; the maximum number of drugs found above LOD on one wipe was 8. Surfaces in the compounding area of the pharmacy and in the patient area showed the highest prevalence of samples above the LOD, including the compounding work surface, drug fridge handle, clean room cart, passthrough tray, and hazardous drug room temperature storage, the IV pump keypad, patient washroom toilet handle, patient washroom door handle, nurses' storage shelf/tray, and patient side table. Over the course of the study, both 90th percentiles and prevalence above LOD varied without clear temporal patterns, although some centers appeared to show decreasing levels with time. Within centers, the degree of variability was high, with some centers showing changes of two to three orders of magnitude in the 90th percentile of drug concentrations month to month. A clear difference was observed between the six centers located in Alberta and the three in Minnesota, with Minnesota centers having substantially higher percentages of samples above the LOD for CP and GEM. Other factors that were associated with significant variability in exposures were drug compounding volume, size of center, number of patients seen, and age of the center. We hope that demonstrating variability associated with drug, surface, clinic-factors, and time will aid in a better understanding of the nature of AD contamination, and inform improved sampling strategies.
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Affiliation(s)
- Matthew Jeronimo
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Susan Arnold
- Division of Environmental Health Sciences School of Public Health, University of Minnesota SE Minneapolis, MN, USA
| | - George Astrakianakis
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Grace Lyden
- Division of Biostatistics, School of Public Health, University of Minnesota SE Minneapolis, MN, USA
| | - Quinn Stewart
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Ashley Petersen
- Division of Biostatistics, School of Public Health, University of Minnesota SE Minneapolis, MN, USA
| | - Carole Chambers
- Alberta Health Services, Tom Baker Cancer Clinic Pharmacy NW Calgary, Alberta, Canada
| | | | | | - Hannah Kaup
- Division of Environmental Health Sciences School of Public Health, University of Minnesota SE Minneapolis, MN, USA
| | - Hugh W Davies
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
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17
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Ml H, T W, Jq Z, Yj S, Tj G, Lk Z, J L, Jf Y. Evaluation of external contamination on the vial surfaces of some hazardous drugs that commonly used in Chinese hospitals and comparison between environmental contamination generated during robotic compounding by IV: Dispensing robot vs. manual compounding in biological safety cabinet. J Oncol Pharm Pract 2021; 28:1487-1498. [PMID: 34162245 PMCID: PMC9465550 DOI: 10.1177/10781552211023571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives The aims of the study were to evaluate the external contamination of
hazardous drug vials used in Chinese hospitals and to compare environmental
contamination generated by a robotic intelligent dispensing system (WEINAS)
and a manual compounding procedure using a biological safety cabinet
(BSC). Methods Cyclophosphamide, fluorouracil, and gemcitabine were selected as the
representative hazardous drugs to monitor surface contamination of vials. In
the comparative analysis of environmental contamination from manual and
robotic compounding, wipe samples were taken from infusion bags, gloves, and
the different locations of the BSC and the WEINAS robotic system. In this
study, high-performance liquid chromatography coupled with double mass
spectrometer (HPLC-MS/MS) was employed for sample analysis. Results (1) External contamination was measured on vials of all three hazardous
drugs. The contamination detected on fluorouracil vials was the highest with
an average amount up to 904.33 ng/vial, followed by cyclophosphamide
(43.51 ng/vial), and gemcitabine (unprotected vials of 5.92 ng/vial,
protected vials of 0.66 ng/vial); (2) overall, the environmental
contamination induced by WEINAS robotic compounding was significantly
reduced compared to that by manual compounding inside the BSC. Particularly,
compared with manual compounding, the surface contamination on the infusion
bags during robotic compounding was nearly nine times lower for
cyclophosphamide (10.62 ng/cm2 vs 90.43 ng/cm2), two
times lower for fluorouracil (3.47 vs 7.52 ng/cm2), and more than
23 times lower for gemcitabine (2.61 ng/cm2 vs
62.28 ng/cm2). Conclusions The external contamination occurred extensively on some hazardous drug vials
that commonly used in Chinese hospitals. Comparison analysis for both
compounding procedures revealed that robotic compounding can remarkably
reduce environmental contamination.
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Affiliation(s)
- Hao Ml
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Wang T
- Department of Pharmacy, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Personalized Drug Therapy Key Laboratory of Sichuan Province, Chengdu, China
| | - Zhu Jq
- Department of Pharmacy, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Personalized Drug Therapy Key Laboratory of Sichuan Province, Chengdu, China
| | - Song Yj
- Department of Pharmacy, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Personalized Drug Therapy Key Laboratory of Sichuan Province, Chengdu, China
| | - Gong Tj
- Department of Pharmacy, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Personalized Drug Therapy Key Laboratory of Sichuan Province, Chengdu, China
| | - Zou Lk
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Liu J
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Yan Jf
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, China.,Department of Pharmacy, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Personalized Drug Therapy Key Laboratory of Sichuan Province, Chengdu, China
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18
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Eisenberg S, Ito K, Rodriguez A. Hazardous Drug Contamination: Presence of Bathroom Contamination in an Ambulatory Cancer Center. Clin J Oncol Nurs 2021; 25:151-156. [PMID: 33739338 DOI: 10.1188/21.cjon.151-156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Many hazardous drugs (HDs) are excreted in urine and feces, and evidence has shown that bathrooms of patients receiving chemotherapy at home are contaminated with HDs. However, little information exists on bathroom contamination in ambulatory clinics where HDs are administered. OBJECTIVES This project aimed to determine the presence of HD residue in the patient and staff bathrooms of an ambulatory cancer center. METHODS A quality improvement project was initiated to examine potential contamination by the HDs 5-fluorouracil and oxaliplatin in a patient bathroom and a secured badge-access staff bathroom in the infusion department of an ambulatory comprehensive cancer center. Twice-daily wipe testing was conducted on the floor in front of the toilet and the flush handle for five consecutive days. FINDINGS Sixty-five percent of the samples from the floor of the patient bathroom were positive for at least one of the HDs. In the staff bathroom, 35% of the floor samples were positive for at least one HD. None of the flush handle samples were above the level of detection.
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19
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Bláhová L, Kuta J, Doležalová L, Kozáková Š, Krovová T, Bláha L. The efficiency of antineoplastic drug contamination removal by widely used disinfectants-laboratory and hospital studies. Int Arch Occup Environ Health 2021; 94:1687-1702. [PMID: 33738516 DOI: 10.1007/s00420-021-01671-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 02/12/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Antineoplastic drugs (ADs) pose risks to healthcare staff. Surface disinfectants are used in hospitals to prevent microbial contamination but the efficiency of disinfectants to degrade ADs is not known. We studied nine disinfectants on ten ADs in the standardized laboratory and realistic in situ hospital conditions. METHODS A survey in 43 hospitals prioritized nine most commonly used disinfections based on different ingredients. These were tested on inert stainless steel and in situ on contaminated hospital flooring. The effects against ten ADs were studied by LC-MS/MS (Cyclophosphamide CP; Ifosfamide IF; Capecitabine CAP; Sunitinib SUN; Methotrexate MET; Doxorubicin DOX; Irinotecan IRI; Paclitaxel PX; 5-Fluorouracil FU) and ICP-MS (Pt as a marker of platinum-based ADs). RESULTS Monitoring of the floor contamination in 26 hospitals showed that the most contaminated are the outpatient clinics that suffer from a large turnover of staff and patients and have limited preventive measures. The most frequent ADs were Pt, PX, FU and CP with maxima exceeding the recommended 1 ng/cm2 limit by up to 140 times. IRI, FU, MET, DOX and SUN were efficiently removed by hydrolysis in clean water and present thus lower occupational risk. Disinfectants based on hydrogen peroxide were efficient against PX and FU (> 70% degradation) but less against other ADs, such as carcinogenic CP or IF, IRI and CAP. The most efficient were the active chlorine and peracetic acid-based products, which however release irritating toxic vapors. The innovative in situ testing of ADs previously accumulated in hospital flooring showed highly problematic removal of carcinogenic CP and showed that alcohol-based disinfectants may mobilize persistent ADs contamination from deeper floor layers. CONCLUSION Agents based on hydrogen peroxide, peracetic acid, quaternary ammonium salts, glutaraldehyde, glucoprotamine or detergents can be recommended for daily use for both disinfection and AD decontamination. However, they have variable efficiencies and should be supplemented by periodic use of strong chlorine-based disinfectants efficient also against the carcinogenic and persistent CP.
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Affiliation(s)
- Lucie Bláhová
- Faculty of Science, Masaryk University, RECETOX, Kamenice 753/5, Building D29, 62500, Brno, Czech Republic
| | - Jan Kuta
- Faculty of Science, Masaryk University, RECETOX, Kamenice 753/5, Building D29, 62500, Brno, Czech Republic
| | - Lenka Doležalová
- Masaryk Memorial Cancer Institute, Žlutý kopec 7, 65653, Brno, Czech Republic
| | - Šárka Kozáková
- Masaryk Memorial Cancer Institute, Žlutý kopec 7, 65653, Brno, Czech Republic.,University Hospital Brno, Jihlavská 20, 62500, Brno, Czech Republic
| | - Tereza Krovová
- Faculty of Science, Masaryk University, RECETOX, Kamenice 753/5, Building D29, 62500, Brno, Czech Republic
| | - Luděk Bláha
- Faculty of Science, Masaryk University, RECETOX, Kamenice 753/5, Building D29, 62500, Brno, Czech Republic.
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20
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Saint-Lorant G, Rodier S, Guilloit JM, Ndaw S, Melczer M, Lagadu S, Palix A, Delépée R. Is the blood of a surgeon performing HIPEC contaminated by irinotecan, its major metabolites and platinum compounds? Pleura Peritoneum 2021; 6:49-55. [PMID: 34179338 PMCID: PMC8216843 DOI: 10.1515/pp-2020-0141] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 01/22/2021] [Indexed: 11/21/2022] Open
Abstract
Objectives Hyperthermic intraperitoneal chemotherapy (HIPEC) is a beneficial surgical technique for patients, but the surgeons are being exposed to cytotoxic drugs. Few biomonitoring studies were led on blood samples in the context of HIPEC. This study aimed to evaluate the surgeon’s plasmatic and red blood cell (RBC) contamination by irinotecan, two of its major metabolites and platinum compounds. Methods HIPEC procedures performed using the coliseum techniques were observed between September 2015 and April 2018 in a French comprehensive cancer center. Irinotecan and its metabolites SN-38 and APC were dosed by UHPLC with a limit of quantification determined at 50 pg/mL. Platinum compounds were dosed by inductively coupled plasma mass spectrometry with a limit of quantification determined at 16 pg/mL. Results Despite collective and personal protective equipment, 80% of plasma samples were contaminated by irinotecan and 33% by platinum compounds out of 21. The results showed that the surgeon was contaminated after HIPEC and even after a period of HIPEC inactivity. Nineteen percent of plasmatic samples and 45% of RBC samples were contaminated by SN-38, the active metabolite of irinotecan. APC was only found in some RBC samples (33%). Conclusions Even if this study shows blood contamination by irinotecan, two of its major metabolites (including active SN-38) and platinum compounds both in the plasma and RBC of a surgeon performing the HIPEC procedures, further studies should be performed to confirm these results. Additional studies should be carried out to further investigate the contamination in the context of HIPEC and more broadly in the hospital.
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Affiliation(s)
- Guillaume Saint-Lorant
- Normandie Univ, UNICAEN, ABTE, Caen, France.,Department of Pharmacy, CHU de Caen, Caen, France
| | | | - Jean-Marc Guilloit
- Department of Surgery, Comprehensive Cancer Center F. Baclesse, Caen, France
| | - Sophie Ndaw
- Toxicology and Biomonitoring Department, INRS, Vandoeuvre, France
| | - Mathieu Melczer
- Toxicology and Biomonitoring Department, INRS, Vandoeuvre, France
| | - Stéphanie Lagadu
- Normandie Univ, UNICAEN, ABTE, Caen, France.,Comprehensive Cancer Center F. Baclesse, Caen, France
| | - Agnès Palix
- Department of Occupational Health, Comprehensive Cancer Center F. Baclesse, Caen, France
| | - Raphaël Delépée
- Normandie Univ, UNICAEN, ABTE, Caen, France.,Comprehensive Cancer Center F. Baclesse, Caen, France
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21
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Chabut C, Bussières JF. Characteristics of wipe sampling methods for antineoplastic drugs in North America: comparison of six providers. PHARMACEUTICAL TECHNOLOGY IN HOSPITAL PHARMACY 2020. [DOI: 10.1515/pthp-2020-0016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Objectives
Several societies have published guidelines to limit the occupational exposure of workers. Several of these guidelines recommend periodic (once or twice a year) environmental monitoring of specific sites where antineoplastic drugs are prepared and administered. However, most of the guidelines provide no guidance concerning which antineoplastic drugs should be monitored, the preferred sampling sites, appropriate test methods or limits of detection. The aim of this study was to characterize providers that quantify antineoplastic drug measured on surfaces.
Methods
This was a cross-sectional descriptive study. To identify service providers offering environmental monitoring tests, we searched the PubMed database and used the Google search engine. We contacted each service provider by email between June 3rd and June 15th, 2020. We specified the objective of our study and described the information needed and the variables of interest with standardized questions. Additional questions were sent by emails or via teleconferences. No statistical analyses were performed.
Results
We identified six providers offering services to Canadian hospitals, either based in Canada or in the United States. Five of these providers were private companies and one was a public organization. Each service provider was able to measure trace contamination of 3–17 antineoplastic drugs. Five of the providers quantified drugs using ultra performance liquid chromatography coupled with tandem mass spectrometry (UPLC-MSMS), which allowed for lower LODs. The sixth provider offered quantification by immunoassay, which has higher LODs, but offers near real-time results; the surface area to be sampled with this method was also smaller than with UPLC-MSMS. The services offered varied among the service providers. The information about LODs supplied by each provider was often insufficient and the units were not standardized. A cost per drug quantified could not be obtained, because of variability in the scenarios involved (e.g. drug selection to be quantified, number of samples, nondisclosure of ancillary costs). Four of the six service providers were unable to report LOQ values.
Conclusions
Few data are available from Canadian service providers concerning the characteristics of wipe sampling methods for antineoplastics. This study identified six north-American providers. Their characteristics were very heterogeneous. Criteria to consider when choosing a provider include the validation of their analytical method, a low limit of detection, the choice of drugs to be quantified and the sites to be sampled, obtaining details about the method and understanding its limits, and price. This should be part of a structured multidisciplinary approach in each center.
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Affiliation(s)
- Claire Chabut
- Centre Hospitalier Universitaire Sainte-Justine , 3175 Chemin de la Côte-Sainte-Catherine , Montreal , QC , Canada
| | - Jean-François Bussières
- Centre Hospitalier Universitaire Sainte-Justine , 3175 Chemin de la Côte-Sainte-Catherine , Montreal , QC , Canada
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22
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Soubieux A, Tanguay C, Lachaine J, Bussières JF. Review of economic data on closed system transfer drug for preparation and administration of hazardous drugs. Eur J Hosp Pharm 2020; 27:361-366. [PMID: 33097620 PMCID: PMC7856154 DOI: 10.1136/ejhpharm-2018-001775] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 01/14/2019] [Accepted: 01/22/2019] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES The objectives of this study were to review economic data on the use of closed system drug transfer devices (CSTDs) for preparing and administering hazardous drugs, and to evaluate the quality of data reporting as defined by the Consolidated Health Economic Evaluation Reporting Standards (CHEERS). METHODS All references from a recent Cochrane review about CSTDs were evaluated for inclusion. A literature review was also conducted. Articles containing economic data about the use of CSTDs were retained for analysis. Two researchers independently graded the articles according to the 24-item CHEERS checklist. RESULTS Of the 138 articles identified initially, 12 were retained for analysis. Nine of these studies did not report acquisition costs or did not detail acquisition costs. Six studies reported economic benefits associated with the used of CSTDs, all related to extending the beyond-use date. The mean number of CHEERS criteria fulfilled by the included articles was 9.2 (SD 2.4). CONCLUSIONS CSTDs are costly to acquire. However, few studies have examined the economic impact of these devices, and the existing studies are incomplete. As a result, hospitals planning to implement these devices will be unable to make a sound economic evaluation. Robust economic evaluation of CSTDs is needed.
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Affiliation(s)
- Annaelle Soubieux
- Pharmacy practice research unit, CHU Sainte-Justine, Montreal, QC, Canada
| | - Cynthia Tanguay
- Pharmacy practice research unit, CHU Sainte-Justine, Montreal, QC, Canada
| | - Jean Lachaine
- Faculté de pharmacie, Université de Montréal, Montreal, QC, Canada
| | - Jean-François Bussières
- Pharmacy practice research unit, CHU Sainte-Justine, Montreal, QC, Canada
- Faculté de pharmacie, Université de Montréal, Montreal, QC, Canada
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23
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Al Alawi L, Soteriades ES, Paulo MS, Östlundh L, Grivna M, Al Maskari F, Al-Rifai RH. Environmental assessment of cytotoxic drugs in healthcare settings: protocol for a systematic review and meta-analysis. Syst Rev 2020; 9:242. [PMID: 33076972 PMCID: PMC7574301 DOI: 10.1186/s13643-020-01494-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 09/23/2020] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Occupational exposure to cytotoxic drugs is associated with various unfavorable health outcomes. This protocol reports a methodology for a systematic review and meta-analysis that aims to systematically review the published literature and quantify the level of environmental contamination of healthcare settings with cytotoxic drugs. METHODS This protocol is developed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol-2015 (PRISMA-P) guidelines. Six electronic databases (PubMed, Web of Science, Scopus, Cochrane Library, CINAHL, and EMBASE) will be searched with no restrictions on publication period. Eligible studies will be identified and data will be extracted using a predefined data extraction form by at least two independent reviewers following best practice. Eligible studies should report calculated or calculable estimates on the proportion of positive samples tested for cytotoxic drugs and/or estimates on the concentration of the cytotoxic drug(s) in the tested samples. Risk of bias (RoB) will be assessed by using the RoB in Studies estimating Prevalence of Exposure to Occupational risk factors (RoB-SPEO) tool, which developed by the World Health Organization (WHO) and International Labour Organization (ILO) for environmental and occupational health systematic reviews. The random-effects model will be used to perform meta-analyses. DISCUSSION Occupational exposure to cytotoxic drugs is associated with short- and long-term adverse health outcomes. Following this protocol, the review to be carried out will be the first to fill an evidence gap on the environmental contamination of healthcare settings with cytotoxic drugs. The findings of this review will help in the understanding of the risk of occupational exposure of healthcare workers to cytotoxic drugs and facilitate the identification of priority areas for specific interventions. ETHICS AND DISSEMINATION The systematic review methodology does not require ethics approval due to the nature of the study design. The results of the systematic review will be published in a peer-reviewed journal and will be publicly available. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42020162780 , dated July 14, 2020.
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Affiliation(s)
- Laila Al Alawi
- Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, P.O. Box 17666, Al Ain, United Arab Emirates
| | - Elpidoforos S Soteriades
- Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, P.O. Box 17666, Al Ain, United Arab Emirates
- Department of Environmental Health, Environmental and Occupational Medicine and Epidemiology (EOME), Harvard School of Public Health, Boston, MA, USA
| | - Marilia Silva Paulo
- Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, P.O. Box 17666, Al Ain, United Arab Emirates
- Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Linda Östlundh
- National Medical Library, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Michal Grivna
- Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, P.O. Box 17666, Al Ain, United Arab Emirates
| | - Fatima Al Maskari
- Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, P.O. Box 17666, Al Ain, United Arab Emirates
- Zayed Center for Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Rami H Al-Rifai
- Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, P.O. Box 17666, Al Ain, United Arab Emirates.
- Zayed Center for Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates.
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Hilliquin D, Tanguay C, Bussières JF. External contamination of commercial containers by antineoplastic agents: a literature review. Eur J Hosp Pharm 2020; 27:313-314. [PMID: 32839267 DOI: 10.1136/ejhpharm-2018-001705] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 11/12/2018] [Accepted: 12/12/2018] [Indexed: 11/03/2022] Open
Abstract
The aim of this study was to review the literature regarding the external contamination of commercial vials by antineoplastic drugs. A PubMed and CINAHL searches from 1 January 1990 to 1 May 2018 was performed with the terms: « antineoplastic agents », « environmental monitoring », « drug packaging », « vials » and « contamination ». Articles that presented results on the external contamination of commercial vials were included. Twenty-four articles were identified from 11 countries. A total of 4248 vials were sampled from 28 manufacturers. Traces were found on 56% (2379/4248) of vials. A maximum of 150 000 ng was measured on a glass vial of fluorouracil. This literature review showed that the exterior of the majority of commercial antineoplastic vials was contaminated. Manufacturers should limit this contamination. Centres are also encouraged to clean the vials on receipt. Personal protection equipment should be worn at all steps of the drug-use process.
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Affiliation(s)
- Delphine Hilliquin
- Pharmacy Practice Research Unit, Pharmacy Department, CHU Sainte-Justine, Montréal, Québec, Canada
| | - Cynthia Tanguay
- Pharmacy Practice Research Unit, Pharmacy Department, CHU Sainte-Justine, Montréal, Québec, Canada
| | - Jean-François Bussières
- Pharmacy Practice Research Unit, Pharmacy Department, CHU Sainte-Justine, Montréal, Québec, Canada.,Faculty of Pharmacy, Université de Montréal, Montréal, Québec, Canada
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Crul M, Hilhorst S, Breukels O, Bouman-d'Onofrio JRC, Stubbs P, van Rooij JG. Occupational exposure of pharmacy technicians and cleaning staff to cytotoxic drugs in Dutch hospitals. JOURNAL OF OCCUPATIONAL AND ENVIRONMENTAL HYGIENE 2020; 17:343-352. [PMID: 32633703 DOI: 10.1080/15459624.2020.1776299] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
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.
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Affiliation(s)
- Mirjam Crul
- Department of Clinical Pharmacology and Pharmacy, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Simone Hilhorst
- Department of Human Resources, Occupational Health Services, Ziekenhuis de Gelderse Vallei, Ede, The Netherlands
| | - Oscar Breukels
- Department of Hospital Pharmacy, Meander Medical Center, Amersfoort, The Netherlands
| | | | - Percival Stubbs
- Department of Human Resources, Healthteam, Haaglanden Medical Center, The Hague, The Netherlands
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Arnold S, Kaup HM. Assessing variability of antineoplastic drugs handling practices in clinical settings. JOURNAL OF OCCUPATIONAL AND ENVIRONMENTAL HYGIENE 2019; 16:757-762. [PMID: 31621520 DOI: 10.1080/15459624.2019.1667502] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The United States Pharmacopeia (USP) Chapter <800> guidelines will be adopted in the U.S. and Canada in 2019, requiring regular surface sampling for antineoplastic drug (AD) surface contamination as a means of environmental surveillance. USP Chapter <800> does not provide guidance on when and where to sample. Research to support the development of such guidance within a broader sampling strategy is limited. This study was conducted to help address some of the underlying information gaps by identifying surfaces pharmacy and nursing staff are likely to contact, presenting a potential dermal exposure risk. Observations were conducted at one regional and one urban clinic, providing insight into inter- and intra-worker variability and between-clinic differences based on size and patient load. Thirteen surfaces in the compounding pharmacies and 14 surfaces in the patient administration were initially selected for video observations. Following a preliminary assessment to eliminate surfaces that were touched infrequently or not at all, five commonly touched surfaces in the compounding pharmacy areas (vials, syringes, IV lines, IV bags, waste bags) and six commonly touched surfaces in the patient administration area (yellow containment bag, IV bag, IV line, patient port, computer workstation) were assessed further. Variability between healthcare staff and clinics in pharmacy staff was low for both the mean frequency and duration of touch to surfaces. Differences between clinics in frequency of contact among nursing staff in patient administration areas were significant (two-way ANOVA) for five of the six surfaces. Duration of contact was not significantly different except for duration of touching the IV pump. These insights will be used to give guidance in selecting locations for a longitudinal surveillance study and help tailor worker training to reduce exposure risks.
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Affiliation(s)
- Susan Arnold
- Division of Environmental Health Sciences, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Hannah M Kaup
- Division of Environmental Health Sciences, School of Public Health, University of Minnesota, Minneapolis, Minnesota
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Villa A, Molimard M, Bignon E, Martinez B, Rouyer M, Mathoulin-Pelissier S, Baldi I, Verdun-Esquer C, Canal-Raffin M. Study protocol for the assessment of nurses internal contamination by antineoplastic drugs in hospital centres: a cross-sectional multicentre descriptive study. BMJ Open 2019; 9:e033040. [PMID: 31712349 PMCID: PMC6858204 DOI: 10.1136/bmjopen-2019-033040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 09/18/2019] [Accepted: 10/07/2019] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION Antineoplastic drugs (AD) are potentially carcinogenic and/or reprotoxic molecules. Healthcare professionals are increasingly exposed to these drugs and can be potentially contaminated by them. Internal contamination of professionals is a key concern for occupational physicians in the assessment and management of occupational risks in healthcare settings. Objectives of this study are to report AD internal contamination rate in nursing staff and to identify factors associated with internal contamination. METHODS AND ANALYSIS This trial will be conducted in two French hospital centres: University Hospital of Bordeaux and IUCT-Oncopole of Toulouse. The target population is nurses practicing in one of the fifteen selected care departments where at least one of the five studied AD is handled (5-fluorouracil, cyclophosphamide, doxorubicin, ifosfamide, methotrexate). The trial will be conducted with the following steps: (1) development of analytical methods to quantify AD urine biomarkers, (2) study of the workplace and organization around AD in each care department (transport and handling, professional practices, personal and collective protection equipments available) (3) development of a self-questionnaire detailing professional activities during the day of inclusion, (4) nurses inclusion (urine samples and self-questionnaire collection), (5) urine assays, (6) data analysis. ETHICS AND DISSEMINATION The study protocol has been approved by the French Advisory Committee on the Treatment of Information in Health Research (CCTIRS) and by the French Data Protection Authority (CNIL). Following the opinion of the Regional Committee for the Protection of Persons, this study is outside the scope of the provisions governing biomedical research and routine care (n°2014/87). The results will be submitted to peer-reviewed journals and reported at suitable national and international meetings. TRIAL REGISTRATION NUMBER NCT03137641.
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Affiliation(s)
- Antoine Villa
- Inserm U1219, Bordeaux Population Health, Université de Bordeaux, Bordeaux, France
- Consultation de Pathologie Professionnelle et de I'environnement, CHU Timone, AP-HM, Marseille, France
- Univ. of Bordeaux, Bordeaux, France
| | - Mathieu Molimard
- Inserm U1219, Bordeaux Population Health, Université de Bordeaux, Bordeaux, France
- Univ. of Bordeaux, Bordeaux, France
- Laboratoire de Pharmacologie Clinique et Toxicologie, CHU de Bordeaux, Bordeaux, France
| | - Emmanuelle Bignon
- Bordeaux PharmacoEpi (BPE, CIC 1401), Université de Bordeaux, Talence, France
| | - Béatrice Martinez
- Inserm U1219, Bordeaux Population Health, Université de Bordeaux, Bordeaux, France
- Univ. of Bordeaux, Bordeaux, France
| | - Magali Rouyer
- Bordeaux PharmacoEpi (BPE, CIC 1401), Université de Bordeaux, Talence, France
| | - Simone Mathoulin-Pelissier
- Inserm U1219, Bordeaux Population Health, Université de Bordeaux, Bordeaux, France
- Univ. of Bordeaux, Bordeaux, France
| | - Isabelle Baldi
- Inserm U1219, Bordeaux Population Health, Université de Bordeaux, Bordeaux, France
- Univ. of Bordeaux, Bordeaux, France
- GH Pellegrin, Pôle de Santé Publique, Service de Médecine du Travail et Pathologies professionnelles, CHU de Bordeaux, Bordeaux, France
| | - Catherine Verdun-Esquer
- GH Pellegrin, Pôle de Santé Publique, Service de Médecine du Travail et Pathologies professionnelles, CHU de Bordeaux, Bordeaux, France
| | - Mireille Canal-Raffin
- Inserm U1219, Bordeaux Population Health, Université de Bordeaux, Bordeaux, France
- Univ. of Bordeaux, Bordeaux, France
- Laboratoire de Pharmacologie Clinique et Toxicologie, CHU de Bordeaux, Bordeaux, France
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Hilliquin D, Tanguay C, Gagné S, Caron NJ, Bussières JF. Cross-Sectional Evaluation of Surface Contamination with Antineoplastic Drugs in Canadian Health Care Centres. Can J Hosp Pharm 2019; 72:377-384. [PMID: 31692608 PMCID: PMC6799961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Surfaces in health care centres are often contaminated with traces of antineoplastic drugs. Such contamination should be limited as much as possible, to reduce workers' exposure. OBJECTIVES The primary objective was to monitor environmental contamination with 9 antineoplastic drugs in oncology pharmacy and patient care areas of Canadian health care centres. The secondary objective was to explore the use of sodium hypochlorite as a cleaning agent for cyclophosphamide contamination. METHODS This cross-sectional evaluation was conducted from January to April 2018. Twelve standardized sites were sampled at each participating centre: 6 in the oncology pharmacy and 6 in patient care areas. Six of the antineoplastic drugs (cyclophosphamide, ifosfamide, methotrexate, gemcitabine, 5-fluorouracil, and irinotecan) were quantified by ultra-performance liquid chromatography - tandem mass spectrometry. For the other 3 antineoplastic drugs (docetaxel, paclitaxel, and vinorelbine), samples were screened for contamination but not quantified. The effect of using sodium hypochlorite as a cleaning agent was evaluated with a Kolmogorov-Smirnov test for independent samples. RESULTS Of 202 Canadian centres invited, 79 participated. A total of 887 surface samples were analyzed, 467 from pharmacy areas and 420 from patient care areas. Cyclophosphamide was the drug most often found as a contaminant (32.2% [286/887] of samples positive, 75th percentile of measured contamination 0.0017 ng/cm2, 90th percentile 0.021 ng/cm2). The front grille inside the hood (80.8% [63/78] of samples positive for at least one antineoplastic drug), treatment chair armrest (78.9% [60/76]), storage shelf in pharmacy (61.5% [48/78]), and floor in front of the hood (60.3% [47/78]) were the most frequently contaminated surfaces. Cleaning with a sodium hypochlorite solution was highly variable. Among centres that reported using sodium hypochlorite to clean armrests on patient chairs, the concentration of cyclophosphamide was lower (0.00866 versus 0.0300 ng/cm2, p = 0.014). CONCLUSIONS Despite growing awareness and implementation of new safe-handling guidelines, surfaces in health care centres were contaminated with traces of many antineoplastic drugs. Providing centres with attainable goals (e.g., 75th to 90th percentile relative to other similar centres) would help in identifying the sampling sites where improvements are needed and in achieving lower surface contamination.
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Affiliation(s)
- Delphine Hilliquin
- , DPharm, is a Research Assistant with the Unité de recherche en pratique pharmaceutique, Centre hospitalier universitaire Sainte-Justine, Montréal, Québec. At the time of the study, she was also a student in the DPharm program at Université Angers in Angers, France
| | - Cynthia Tanguay
- , BSc, MSc, is Coordinator with the Unité de recherche en pratique pharmaceutique, Centre hospitalier universitaire Sainte-Justine, Montréal, Quebec
| | - Sébastien Gagné
- , MSc, is a Chemist with the Centre de toxicologie du Québec, Institut national de santé publique du Québec, Québec, Quebec
| | - Nicolas J Caron
- , PhD, is a Chemist with the Centre de Toxicologie du Québec, Institut national de santé publique du Québec, Québec, Quebec
| | - Jean-François Bussières
- , BPharm, MSc, MBA, FCSHP, FOPQ, is Head of the Unité de recherche en pratique pharmaceutique, Centre hospitalier universitaire Sainte-Justine, and Clinical Professor with the Faculty of Pharmacy, Université de Montréal, Montréal, Quebec
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Hilliquin D, Bussières JF. External contamination of antineoplastic drug containers from a Canadian wholesaler. J Oncol Pharm Pract 2019; 26:423-427. [DOI: 10.1177/1078155219868525] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction Contamination of hospitals’ surfaces with antineoplastic drugs is documented despite safe handling practices. The exterior of commercial containers is often contaminated during the manufacturing process and can cross-contaminate hospitals’ surfaces. The aim was to investigate the contamination of the exterior of antineoplastic drug vials available in Canada in 2018. Methods Cross-sectional study. All available antineoplastic drugs vials from a single wholesaler were targeted. Containers were sampled upon their receipt by the pharmacy staff, before they were cleaned. One wipe was used to sample the external surface of five vials from a single batch from the same manufacturer. Nine antineoplastic drugs were quantified by ultra-performance liquid chromatography–tandem mass spectrometer: cyclophosphamide, docetaxel, 5-fluorouracil, gemcitabine, ifosfamide, irinotecan, methotrexate, paclitaxel, vinorelbine. Results Twenty-one samplings were done (105 containers from nine different manufacturers): cyclophosphamide = 2, docetaxel = 1, gemcitabine = 2, 5-fluorouracil = 2, ifosfamide = 2, irinotecan = 3, methotrexate = 6, paclitaxel = 2, vinorelbine = 1. One of these samplings was done on blister packaging, the remainder were done on glass vials. A total of 15/21 samples (71%) were positive to at least one drug (docetaxel, 5-fluorouracil, ifosfamide, and vinorelbine). A maximum of 272 ng/vial was quantified (gemcitabine). Cross contamination with other antineoplastic drugs was detected on 16/21 (76%) samples. Conclusion The majority of samples were positive to at least one antineoplastic drug, confirming that the exterior of antineoplastic drugs containers is still an important source of contamination. Manufacturers should reduce this contamination. Vials should be washed upon receipt, before they are stored in pharmacy. Gloves must be worn at all times to avoid occupational exposure.
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Affiliation(s)
- D Hilliquin
- Unité de recherche en pratique pharmaceutique, Département de pharmacie, CHU Sainte-Justine, Montréal, Québec, Canada
| | - JF Bussières
- Unité de recherche en pratique pharmaceutique, Département de pharmacie, CHU Sainte-Justine, Montréal, Québec, Canada
- Faculté de pharmacie, Université de Montréal, Montréal, Québec, Canada
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