Medical Surveillance for Health Care Workers Exposed to Hazardous Drugs

Summary

Health care workers who handle, prepare, or administer hazardous drugs may face risks to their own health such as skin rashes, cancer, and reproductive disorders. NIOSH recommends that employers establish a medical surveillance program to protect workers who handle hazardous drugs in the workplace.

Description of Exposure

Drugs are considered hazardous if studies in animals or humans show that exposures to them have a potential for causing cancer, reproductive toxicity, birth defects, or acute harm to health. In the United States, an estimated 5.5 million health care workers are potentially exposed to hazardous drugs or drug waste at their worksites.

Many hazardous drugs are used to treat illnesses such as cancer or HIV infection (see Figure 1). For the patients, the potential benefits of hazardous drugs outweigh the possible negative side effects. However, exposed health care workers risk the same side effects with no positive benefit. Workers exposed to hazardous drugs have developed skin rashes, adverse reproductive effects, and possibly leukemia and other cancers. For example, nurses and pharmacists who were exposed to hazardous drugs at their worksite reported an increase in adverse reproductive events including spontaneous abortions, stillbirths, and congenital malformations compared with unexposed health care workers [NIOSH 2004].

Exposure to hazardous drugs may occur through inhalation, skin contact, skin absorption, ingestion, or injection. Inhalation or skin contact and absorption are the most likely ways a worker may be exposed to hazardous drugs. However, ingestion (from hand to mouth) or injection through a needlestick or sharps injury is possible.

Medical Surveillance

A comprehensive approach to minimizing worker exposure should be used as part of a safety and health program that includes engineering controls, good work practices, and personal protective equipment (PPE) supported by a medical surveillance program. Medical surveillance involves collecting and interpreting data to detect changes in the health status of working populations potentially exposed to hazardous substances. The elements of a medical surveillance program are used to establish a baseline of workers’ health and then monitor their future health as it relates to their potential exposure to hazardous agents.

Employers should ensure that health care workers who are exposed to hazardous drugs are routinely monitored as part of a medical surveillance program [ASHP 2006; OSHA 1999]. This includes workers who directly handle hazardous drugs such as nurses, pharmacists, and pharmacy technicians. In addition, other workers (e.g., nurses’ aides, laundry workers) who may come directly into contact with patient wastes within 48 hours after a patient has received a hazardous drug should be included in a medical surveillance program.

Elements of a Medical Surveillance Program

The elements of a medical surveillance program for hazardous drugs should include (at a minimum):

• Reproductive and general health questionnaires completed at the time of hire and periodically thereafter.
• Laboratory work, including complete blood count and urinalysis completed at the time of hire and periodically thereafter. Additional tests, such as liver function and transaminase tests, may be considered.
• Physical examination completed at the time of hire and then as needed for any worker whose health questionnaire or blood work indicates an abnormal finding.
• Follow-up for those workers who have shown health changes or have had a significant exposure (substantial skin contact, cleaning a large spill [a broken bag, leaking IV line], etc.).

Periodic health questionnaires and laboratory results should be looked at for trends that may be a sign of health changes because of exposure to hazardous drugs. If health changes are found, the employer should take the following actions:

• Evaluate current protective measures:
1. Engineering controls (biological safety cabinets/isolators, ventilation, closed system transfer devices, and closed IV systems).
   • Compare performance of controls with recommended standards.
   • Conduct environmental sampling when analytical methods are available.
2. Policies for the use of PPE and employee compliance with PPE use and policies.
3. Availability of appropriate PPE such as double gloves, nonpermeable gowns, and respiratory protection.
• Develop plan of action that will prevent further employee exposure.
• Ensure confidential notification of any adverse health effect to an exposed worker and offer alternative duty or temporary reassignment.
• Provide ongoing medical surveillance of all workers at risk to determine whether the new plan is effective.

Acknowledgments

The principal authors of this document were Melissa Leone, Apria Healthcare; Melissa McDiarmid, University of Maryland; Marty Polovich, Oncology Nursing Society; Barbara Coyle, Wisconsin State Laboratory of Hygiene; Luci Power, University of California Medical Center in San Francisco, and Thomas H. Connor and Laurence D. Reed of the National Institute for Occupational Safety and Health. John J. Whalen, under a contract with the Division of Federal Occupational Health, served as the lead writer/editor.

References

1. ASHP (American Society of Health-System Pharmacists) [2006]. ASHP guidelines on handling hazardous drugs. Am J Health-Syst Pharm 63:1172–1193.
2. NIOSH [2004]. NIOSH alert: preventing occupational exposures to antineoplastic and other hazardous drugs in health care settings. Cincinnati, OH: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 2004–165.
3. OSHA [1999]. Controlling occupational exposure to hazardous drugs. In: OSHA Technical Manual (TED 01–00–015: TED 1–0.15A), Section VI, Chapter 2. [www.osha.gov/dts/osta/otm/otm_vi/otm_vi_2.html]. Washington, DC: Occupational Safety and Health Administration. Date accessed: September 26, 2005.

For More Information

NIOSH has published an Alert describing measures to control worker exposure to hazardous drugs: www.cdc.gov/niosh/docs/2004-165/.

Additional information about hazardous drugs is available on the NIOSH website at www.cdc.gov/niosh/topics/hazdrug/default.html. To receive copies of NIOSH publications, contact NIOSH at:

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Or visit the NIOSH Web site at www.cdc.gov/niosh.

For a monthly update on news at NIOSH, subscribe to NIOSH enews by visiting www.cdc.gov/niosh/eNews.

This document is in the public domain and may be freely copied or reprinted. NIOSH encourages all readers of the Workplace Solutions to make them available to all interested employers and workers.

As part of the Centers for Disease Control and Prevention, NIOSH is the Federal agency responsible for conducting research and making recommendations to prevent work-related illness and injuries. All Workplace Solutions are based on research studies that show how worker exposures to hazardous agents or activities can be significantly reduced.

Medical Surveillance for Health Care Workers Exposed to Hazardous Drugs
DHHS (NIOSH) Publication No. 2007-117
April 2007

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Disease Control and Prevention
National Institute for Occupational Safety and Health