The toxic effects of antineoplastic drugs used for cancer treatment have been well known since their introduction in the 1940s. However, beyond the patient safety concerns arising from the necessary therapeutic use of these drugs, the occupational risks to health care workers handling these drugs in the course of their duties still need to be fully addressed. Worldwide, more than 11 million new cases of cancer are diagnosed each year, and that number is expected to rise to 16 million by 2020 (WHO 2005). Treatment for many of these cases relies principally upon antineoplastic chemotherapy (Chabner et al. 1996). With approximately 100 different antineoplastic drugs now in use (NIOSH 2004, 2012) and many more under development, chemotherapy has opened new avenues, providing remission from the disease and the possibility of a cure in some cases. Addressing the formidable toxicity of these drugs, however, has been an ongoing challenge for clinicians and, more recently, for the occupational health community.
Over the last 20 years, an international consortium of content experts in occupational health, hospital pharmacy, and oncology nursing have combined their respective insights into a harmonized body of recommended practices for the safe transport, compounding, administration, and disposal of hazardous chemotherapy drugs (OSHA 1999; ISOPP 2007; Polovich 2011; ASHP 2006; NIOSH 2004). All these documents recommend a combination of hazard controls that include (1) engineering solutions to physically isolate the worker from drug exposure, to the extent possible; (2) administrative controls and work practices that further minimize drug contact through a designated organization of work, specialized worker training, and specified methods used to perform work tasks; and (3) use of personal protective equipment and apparel to minimize drug contact with the skin or respiratory tract.
These exposure control methods are applied in a specified order of preference, as listed above. This hierarchy reflects the relative degree of protection each method provides. In the United States of America, the European Union, and certain other regions, applying this combination of controls in the order listed is the recognized standard of professional practice for handling chemotherapy and other hazardous drugs (NIOSH 2004; CEC 1990; ISOPP 2007).
In low-resource countries, where the more costly engineering solutions such as biologic safety cabinets may be prohibitively expensive, there is necessarily an overreliance on the other elements of the hazard control hierarchy. Identifying dedicated areas for hazardous chemotherapy drug storage and compounding, restriction of personnel access to these areas, meticulous adherence to work practices that minimize drug aerosol production and work environment contamination, together with painstaking attention to worker training and skills assessment are the most reasonable set of alternatives to the internationally recognized best-practices approach described above.
This monograph describes in detail the rationale for and approaches to implementation of these alternative approaches to safe handling of hazardous chemotherapy drugs in low-resource settings.
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