NIOSH Recommends Medical Surveillance for Hazardous Drugs Exposure

By Roy Maurer Dec 4, 2012

Employers should conduct “medical surveillance” as part of a comprehensive safety program, according to the National Institute for Occupational Safety and Health (NIOSH).

The federal agency published an update Nov. 19, 2012, to its 2007 hazardous drugs exposure guidelines, emphasizing the establishment of medical surveillance for health care workers who prepare, administer or transport hazardous drugs or dispose of hazardous drug waste.

NIOSH dropped the recommendation of routine periodic laboratory testing on exposed workers, pointing to evidence that it is not very valuable. The agency still advocates initial baseline evaluations that include laboratory testing.

NIOSH emphasized that medical surveillance programs feature periodic reproductive and general health questionnaires, worker histories of drug handling, and follow-up plans for workers who show health changes suggesting toxicity or have had acute exposure to a hazardous drug.

Who Is Exposed to Hazardous Drugs?

In the United States, an estimated 8 million health care workers are potentially exposed to hazardous drugs or drug waste at their worksites, according to the U.S. Bureau of Labor Statistics.

Drugs are considered hazardous if studies in animals or humans show that they have the potential to cause cancer, reproductive toxicity, birth defects or damage to organs at low doses, NIOSH said. The following health care workers should be included in medical surveillance programs: nurses, pharmacists and pharmacy technicians, physicians and physician assistants, operating room personnel, home health care workers, veterinarians and veterinary technicians, environmental service workers (housekeeping, laundry, mainte­nance workers) and workers who ship, transport or receive hazardous drugs.

Exposure to hazardous drugs may occur through skin contact, inhalation, ingestion or injection. Workers may be exposed to hazardous drugs when they create aerosols, generate dust, clean up spills or touch contaminated surfaces when compounding, administering or disposing of hazardous drugs or patient waste.

Establishing a Medical Surveillance Program

Medical surveillance is a second line of defense, NIOSH said, enhancing the protection afforded by engineering controls, other administrative controls, work practice controls, personal protective equipment (PPE) and worker education about the hazards of the materials they work with or they may come into contact with in the course of their duties.

An effective surveillance program begins with a hazard identification program that is integrated with surveillance for disease or illness, NIOSH said.

Elements of a medical surveillance program for workers exposed to hazardous drugs should include the following:

  • Reproductive and general health questionnaires completed at the time of hire and periodically thereafter. Unless information about relevant symptoms and medical events is deliberately sought, the symptoms or events are likely to go unreported, NIOSH said. These queries will provide opportunities to identify defects in engineering controls and other preventive measures which may have been missed.
  • History of drug handling as an estimate of prior and current exposure, including dates of duty assignment related to hazardous drugs and similar types of information.
  • A plan to provide an initial baseline clinical evaluation, including appropriately targeted medical history, physical examination, and laboratory testing for workers identified as being potentially exposed to hazardous drugs that anticipates their potential toxicities.
  • A follow-up plan as needed for workers who have shown health changes suggesting toxicity or who have experienced an acute exposure, such as substantial skin contact or inhalation exposure.

Medical surveillance program results should be examined in aggregate for trends that may be a sign of health changes because of exposure to hazardous drugs, NIOSH said.

What If Workers Are Found to Be Exposed

If adverse health effects due to exposure are found as a result of the surveillance program, NIOSH advised the employer take the following actions:

  • Evaluate current protective measures that are already in place, including engineering controls and policies for the use of PPE and worker compliance with PPE use.
  • Verify that all controls are in proper operating condition and monitor worker compliance with existing policies or when new policies go into effect.
  • Develop a plan of action that will prevent further worker exposure.
  • Ensure confidential communication between workers and employee health personnel regarding notification by any worker wishing to discuss a change in health condition or when communicating the finding of an adverse health effect back to the workers.
  • If employee health personnel are not available, workers should be encouraged to address exposure issues with their primary medical provider.
  • Provide ongoing medical surveillance for all workers at risk to determine whether the new plan is effective.

Roy Maurer is an online editor/manager for SHRM.

Follow me on Twitter @SHRMRoy

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