|
|
|
|
|
|
|
|
NIOSH Publication No. 2004-102:Antineoplastic Agents - Occupational Hazards in Hospitals |
September 2004 |
|
||
| The purpose of this brochure is to make you aware of the adverse health effects of antineoplastic agents, describe how you can be exposed to these agents, and provide and identify control methods and work practices to prevent or reduce your exposure to antineoplastic agents. Contents
| |
|
||||
Antineoplastic agents are widely used in cancer therapy because they can inhibit growth by disrupting cell division and killing actively growing cells. These agents can also cause health effects among health care workers who work with them. A summary of these health risks and means for protecting workers are available in a recent NIOSH Alert [NIOSH 2004].
The following list contains commonly used antineoplastic agents and some of the cancers treated by these agents [Rogers 1987; Chabner et al. 1996; Jochimsen 1992; McFarland et al. 2001]:
Alkylating agents (interfere with normal mitosis and cell division)
Antimetabolites (interfere with folic acid, purine, and pyrimidine synthesis)
Antibiotics (cause single- and double-strand DNA breaks)
Natural products (antimitotic agents) (block mitosis and produce metaphase arrest)
Miscellaneous agents
Some of these antineoplastic agents are also being used for
other purposes such as the treatment of nonmalignant diseases. Examples include
the use of methotrexate for rheumatoid arthritis [Baker et al. 1987], cyclophospha
mide for multiple sclerosis [Moody et al. 1987], and
5-fluorouracil for psoriasis [Abel 2000].
The purpose of this brochure is to
— make you aware of the adverse health effects of antineoplastic agents,
— describe how you can be exposed to these agents, and
— provide and identify control methods and work practices to prevent or reduce your exposure to antineoplastic agents.
The following symptoms and health effects have been reported in hospital workers exposed to antineoplastic agents:
If you experience any of these health problems when working with antineoplastic agents, report them to your supervisor or safety officer.
Statistically significant genotoxic effects and genetic damage (for example, increased micronuclei formation and increases in sister chromatid exchange and chromosomal aberrations) have been reported in hospital pharmacists and nurses exposed to antineoplastic agents. Little information is available about the risk of cancer related to exposure of hospital workers to antineoplastic agents [Burgaz et al. 1999; McDiarmid et al. 1992; Oestreicher et al. 1990]. However, one case of bladder cancer in a pharmacist was attributed to her routine exposure to antineoplastic agents. Apparently, she had no other exposures to known occupational or environmental carcinogens [Levin et al. 1993]. An undifferentiated carcinoma of the nasopharyngeal type was identified in a nurse who had been employed for 12 years in a clinical oncology department where antineoplastic agents were frequently used (cyclophosphamide, methotrexate, and vincristine, for example) [Gabriele et al. 1993]. Skov et al. [1990, 1992] reported an increased risk for leukemia among Danish physicians and nurses who handled antineoplastic agents.
Workers in hospitals who might be exposed to antineoplastic agents include the following:
Workers are most likely to be exposed to antineoplastic agents by breathing them, ingesting them unintentionally, or having skin contact with them during the following procedures:
Workers can also be exposed to contaminated carpeting.
Protect yourself by using the following control methods and work practices:
For more information about how to protect yourself, refer to NIOSH [2004] and OSHA guidelines for controlling hazardous drugs [OSHA 1999].
Protect yourself with the following safety tips:
Case 1—While preparing a vincristine solution in a horizontal laminar-flow air hood, a pharmacy technician inhaled an aerosol of the solution. His symptoms included sneezing, hot flashes, swelling of his eye lids, shortness of breath, chest tightness, and congestion. He immediately sought medical attention in the emergency room, where he also complained of slight shortness of breath. He was treated intramuscularly with Benadryl ® and instructed to take Benadryl by mouth the next day. By the following morning, all of his symptoms were gone [McDiarmid and Egan 1988].
Case 2—On two separate occasions, a patient care assistant working on the oncology floor of a community teaching hospital developed a red face and rash over the arms, neck, trunk, and hands about 30 minutes after emptying a container of urine into a toilet. On both occasions, she denied having any direct contact with the urine of her two patients, as she had worn a protective gown and nitrile gloves and had followed hospital policy for the disposal of materials contaminated with antineoplastics. She had not worn a mask. The rash subsided after 1 to 2 days. After reviewing records of both hospital patients, her supervisor discovered that each patient had been recently treated with vincristine and Adriamycin ®.
The patient care assistant reported that she had no known history of allergies or recent infections, nor did she have symptoms of upper respiratory infection. She also said she had used no medication or new personal care items, cosmetics, or laundry detergents. She was not pregnant. She recalled that both patient rooms had flowers and balloons, but she said she was not sensitive to these items. No family members or close contacts developed a rash during the period of evaluation. After the patient care assistant was treated with diphenhydramine (Benadryl ®) and corticosteroids, the symptoms resolved [Kusnetz and Condon 2003].
Abel EA [2000]. Immunosuppressant and cytotoxic drugs: unapproved uses or indications. Clin Dermatol 18:95–101.
Baker GL, Kahl LE, Zee BC, Stolzer BL, Agarwal AK, Medsger TA Jr [1987]. Malignancy following treatment of rheumatoid arthritis with cyclophosphamide. Am J Med 83(1):1–9.
Burgaz S, Karahalil B, Bayrak P, Taskin L, Youngaslan F, Bökesay I, Anzion RBM, Bos RP, Platin N [1999]. Urinary cyclophosphamide excretion and micronuclei frequencies in peripheral lymphocytes and in exfoliated buccal epithelial cells of nurses handling antineoplastics. Mutat Res 439:97–104.
Chabner BA, Allegra CJ, Curt GA, Calabresi P [1996]. Chapter 51. Antineoplastic agents. In: Hardman JG, Limbird LE, Molinoff PB, Ruddon RW, Gilman AG, eds. Goodman and Gilman’s: the pharmacological basis of therapeutics. 9th ed. New York: McGraw-Hill, pp. 1233–1287.
Gabriele P, Airoldi M, Succo G, Brando V, Redda MGR [1993]. Undifferentiated nasopharyngeal-type carcinoma in a nurse handling cytostatic agents [letter to the editor]. Oral Oncol, Eur J Cancer 29B(2):153.
Jochimsen PR [1992]. Handling of cytotoxic drugs by health care workers: a review of the risks of exposure. Drug Safety 7(5):374–380.
Kusnetz E, Condon M [2003]. Acute effects from occupational exposure to antineoplastic drugs in a para-professional health care worker. Am J Ind Med 44(1):107–109.
Levin LI, Holly EA, Seward JP [1993]. Bladder cancer in a 39-year-old female pharmacist. J Natl Cancer Inst 85(13):1089–1091.
McDiarmid M, Egan T [1988]. Acute occupational exposure to antineoplastic agents. J Occup Med 30(12):984–987.
McDiarmid MA, Kolodner K, Humphrey H, Putman D, Jacobson-Kram D [1992]. Baseline and phosphoramide mustard-induced sister-chromatid exchanges in pharmacists handling anti-cancer drugs. Mutat Res 279:199–204.
McFarland HM, Almuete V, Brisby J, Delman B, Farmer D, Grant L, Hudock S, Lewis J, Malong M, Roche K, Topping D, Steinberg J, Wyrik J [2001]. 2001 Guide for the administration and use of cancer chemotherapeutic agents. Oncology special edition 4:96–105.
Moody DJ, Kagan J, Liao D, Ellison GW, Myers LW [1987]. Administration of monthly-pulse cyclophosphamide in multiple sclerosis patients. J Neuroimmunol 14:161–173.
NIOSH [2004]. NIOSH Alert: Preventing occupational exposure to antineoplastic and other hazardous drugs in healthcare settings. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health. Prepublication copy [www.cdc.gov/niosh/docs/2004-HazDrugAlert].
Oestreicher U, Stephan G, Glatzel M [1990]. Chromosome and SCE analysis in peripheral lymphocytes of persons occupationally exposed to cytostatic drugs handled with and without use of safety covers. Mutat Res 242:271–277.
OSHA [1999]. Controlling occupational exposure to hazardous drugs. In: Technical Manual TED 1–0.15A. Section VI, Chapter 2. Washington, DC: U.S. Department of Labor, Occupational Safety and Health Administration, pp.1–36 [www.osha-slc.gov/dts/osta/otm/otm_abstract.html].
Rogers B [1987]. Health hazards to personnel handling antineoplastic agents. In: Emmett EA, ed. Occupational medicine, health problems of health care workers. Vol. 2, No. 3. Philadelphia, PA: Hanley & Belfus, Inc., pp. 513–524.
Skov T, Lynge E, Maarup B, Olsen J, Rørth M, Winthereik H [1990]. Risk for physicians handling antineoplastic drugs. Lancet 336:1446.
Skov T, Maarup B, Olsen J, Rørth M, Winthereik H, Lynge E [1992]. Leukaemia and reproductive outcome among nurses handling antineoplastic drugs. Br J Ind Med 49:855–861.
ASHP (American Society of Hospital Pharmacists) [1990]. ASHP Technical assistance bulletin on handling cytotoxic and hazardous drugs. Am J Hosp Pharm 47:1033–1049.
Brown KA, Esper P, Kelleher LO, O’Neill-Brace JE, Polovich M, White JM [2001]. Chemotherapy and biotherapy: guidelines and recommendations for practice. Oncology Nursing Society, Pittsburgh, PA. Library of Congress Control Number 2001097698, ISBN 1–890504–26–2.
Colligan SA, Horstman SW [1990]. Permeation of cancer chemotherapeutic drugs through glove materials under static and flexed conditions. Appl Occup Environ Hyg 5(12):848–852.
Connor TH [1999]. Permeability of nitrile rubber, latex, polyurethane, and neoprene gloves to 18 antineoplastic drugs. Am J Health Syst Pharm 56(23):2450–2453.
Connor TH, Laidlaw JL, Theiss JC, Anderson RW, Matney TS [1984]. Permeability of latex and polyvinyl chloride gloves to carmustine. Am J Hosp Pharm 41:676–679.
Falck K, Grohn P, Sorsa M, Vaino H, Heinonen E, Holsti LR [1979]. Mutagenicity in urine of nurses handling cytostatic drugs. Lancet, June 9:1250–1251.
Freeburg B [1991]. Safe handling of antineoplastic agents in the hospital setting. In: Essentials of modern hospital safety, Charney W and Schirmer J, eds. Chelsea, MI: Lewis Publishers, Inc., pp. 83–97.
Harrison BR [1994]. Safe handling of antineoplastic drugs. Top Hosp Pharm Manage 14(2):1–10.
Hemminki K, Kejyronen P, Lindholm M [1985]. Spontaneous abortions and malformations in the offspring of nurses exposed to anaesthetic gases, cytostatic drugs, and other potential hazards in hospitals, based on registered information of outcome. J Epidemiol and Community Health 39:141–147.
Kasuba V, Rozgaj R, Garaj-Vrhovac V [1999]. Analysis of sister chromatid exchange and micronuclei in peripheral blood lymphocytes of nurses handling cytostatic drugs. J Appl Toxicol 19:401–404.
Valanis BG, Vollmer WM, Labuhn KT, Glass AG [1993]. Association of antineoplastic drug handling with acute adverse effects in pharmacy personnel. Am J Hosp Pharm 50:455–462.
Mention of any company or product does not constitute endorsement by the National Institute for Occupational Safety and Health (NIOSH). In addition, citations to Web sites external to NIOSH do not constitute NIOSH endorsement of the sponsoring organizations or their programs or products. Furthermore, NIOSH is not responsible for the content of these Web sites.
To receive documents or other information about occu-pational safety and health topics, contact NIOSH at
NIOSH—Publications Dissemination
4676 Columbia Parkway
Cincinnati, OH 45226–1998
Telephone: 1–800–35–NIOSH (1–800–356–4674)
Fax: 513–533–8573
E-mail: pubstaft@cdc.gov
or visit the NIOSH Web site at www.cdc.gov/niosh
DHHS (NIOSH) Publication No. 2004–102
This
document is also available in PDF format.