Hazardous Drugs: Good for Patients, Bad for Healthcare Workers

Wegener’s granulomatosis is a disorder that causes inflammation of the blood vessels in some parts of the body, leading to blood flow problems in affected organs. Until the 1970s, the disease was treated with steroids—but these could only slow the progression of the disease. Patients with Wegener’s granulomatosis generally died within a few months.

Enter cyclophosphamide. The drug, a derivative of mustard gas, was originally developed (and is still used as) a chemotherapeutic agent. For patients with Wegener’s, it was a lifesaver. Used together with steroids, it improves the prognosis for up to 90% of patients, contributing to full remission in 75% of cases.

That’s just one dramatic example of the upside of chemotherapeutic drugs.

What’s the Down Side?

Unfortunately, cyclophosphamide—as you might expect, from a drug that was developed from a chemical warfare agent—doesn’t do a healthy body any favors. It is a known carcinogen, with no safe threshold dose. It can have mutagenic, teratogenic, and reproductive health effects. It can be absorbed through the skin, inhaled, or ingested. The people at highest risk of nontherapeutic exposure to cyclophosphamide are the workers in healthcare facilities who handle it in receiving, storage, compounding, administration, and waste disposal areas.

Now, multiply the possible adverse health effects of cyclophosphamide—which are similar to those of many antineoplastic drugs—by the approximately 200 chemicals on the List of Antineoplastic and Other Hazardous Drugs published by the National Institutes for Occupational Safety and Health (NIOSH). Then imagine a worker who handles just five or ten such drugs every day at work. That should give you some idea of the potential magnitude of the problem of occupational exposure to hazardous drugs.

Of course, the whole point of chemotherapy and other drug treatments that occur in a medical environment is for the medication to go into the patient, right? Not somewhere else. So it’s very unlikely that healthcare workers would be exposed to something like that. Right?

Routes of Occupational Exposure

Some hazardous drugs are administered intravenously, and some are packaged in glass vials or ampules, so naturally, injection exposures are a concern. Respiratory exposures can occur when patients receive aerosolized or inhaled medication because the chemical can be released into the air. In surgical suites, surgical staff can be exposed to airborne anesthetics. But research indicates that the most common route of exposure to hazardous drugs is through dermal exposure.

One study, conducted by NIOSH in 2010, looked at environmental surface contamination at three different cancer centers in the United States. Surface contamination with hazardous drugs was found in both the preparation and administration areas of all three sites—with the worst contamination in the smallest sites. Sources of contamination identified in this and other studies include:

• Contaminated vials. Drug residue has been found on commercially distributed vials—both generic and brand name—in Europe, North America, and Asia.
• Spills. Workers may be exposed when medication spills or while they are cleaning up a spill.
• Aerosol generation. Aerosols are airborne—until they settle on environmental surfaces. And nebulizer treatments aren’t the only way to generate stray aerosols. The way that injectable drug vials and syringes are handled can generate both powder and liquid aerosols, leading to surface contamination.
• Vaporization. Some hazardous drugs vaporize at room temperature—and again, once they’re in the air, they may also settle on surfaces.
• Contaminated skin. Once workers have touched a contaminated surface—a vial, an IV bag, a syringe—they can (and do) transfer that contamination to all kinds of different surfaces. A 2013 Canadian study found hazardous drug residues on pens, elevator buttons, box cutters, and other commonly-handled items.

Safe work practices can help to prevent such exposures. Tomorrow, we’ll look at some of the reasons workers give for failing to comply with safe work practices—and what employers can do to help improve compliance.