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Chemotherapy – Promoting occupational safety

Chemotherapy drugs otherwise known as cytotoxic drugs or antineoplastic drugs are chemicals that affect cell growth and proliferation, most of which either bind directly to genetic material in the cell nucleus, or affect cellular protein synthesis. Although typically employed in cancer treatment, cytotoxic drugs do not distinguish between normal and cancerous cells. Chemotherapy drugs constitute the majority of hazardous drugs¹.
In terms of occupational exposure, a hazardous drug is defined as an agent that due to its inherent toxicity presents a danger to healthcare personnel¹.

These chemotherapy drugs provide therapeutic benefits to patients, but may pose health risks to workers who handle them on a daily basis. Because most chemotherapy drugs are nonselective in their mechanism of action, their adverse effects have been well recognized in patients. Similar adverse effects have been observed in healthcare workers who prepare and administer these drugs². The effects can range from acute, such as skin and mucous membrane irritation, headache, and hair loss, to more long-term effects, such as adverse reproductive outcomes (spontaneous abortion, teratogenicity) and genotoxic effects (chromosomal and other genetic damage) to possible cancer. Contaminants are spread via drips, spills, or transfer contact, this can result in patient, visitor, colleague, or passerby exposure to hazardous drugs.

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Healthcare workers are exposed to small doses of a broad range of hazardous drugs over decades, with some workers being exposed every workday, year after year. Pharmacists, nurses and support staff who handle chemotherapy drugs reconstitution and preparation, administration, waste disposal, cleaning, transportation and maintenance of cleanroom are the most at risk. They may be exposed to dozens of the more than 100 chemotherapy drugs now in use. The routes of exposure are typically by inhalation, dermal or oral. It has become important over the years for individual, institutional, national and international guidelines, policies and procedures that ensure that staff who handle chemotherapy drugs are protected from the risks of exposure.

The original concerns about worker safety appeared in the late 1970s. It became clear at the time that patients were developing secondary cancers after treatment with alkylating agents, antimetabolites, and other drugs in use then. These findings prompted a concern that healthcare workers may be at risk for similar adverse outcomes without the benefit of being treated for a life-threatening disease². Various organizations in the developed world have hence developed guidance for safe handling of “cytotoxic drugs.” These organizations included the American Society of Health-System Pharmacists, the Oncology Nursing Society (ONS), the Occupational Safety and Health Administration (OSHA) in the United States, the Society of Hospital Pharmacists of Australia, and the International Society of Oncology Pharmacy Practitioners, among others. These guidelines have been updated and revised as new information has become available.

In Ghana, standard operating procedures have been developed by Pharmacists and Nurses at institutional levels to ensure that chemotherapy drugs are prepared accurately under aseptic conditions to ensure patient safety. These procedures have also included protective measures that are aimed at providing adequate protection during hazardous compounding and administration. Institutional administrators at the various cancer centers have also provided protective equipment such as Biological safety cabinets, closed system transfer devices and personal protective equipment (PPE).

These individual and institutional efforts have however mostly been marred by financial constraints, a lack of complete understanding of the extent of damage caused by chemotherapy drug exposure and the lack of full comprehension of the available risk prevention and management tools. The biggest challenge is the lack of a national policy that provides standards for the safe handling of chemotherapy drugs as well as other hazardous drugs and addresses individual and institutional deficits. Pharmacists and nurses know that chemotherapy can be dangerous and many embrace safe handling and integrate it into their workday. Chemotherapy staff have however encountered a coworker or two who have balked at safe handling. For instance, there are staff who would perceive “gowning up” as a hustle. There are others who may perform chemotherapy reconstitution and preparation outside a biological safety cabinets or may attempt chemotherapy compounding (opening of capsules/crashing tablets) in the Pharmacy instead of a clean room. Changing the views of resistant personnel is critical to the environmental protection of all staff.

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A study by Wick and colleagues in the American Journal of Health-System Pharmacy in 2003 reinforces the necessity of complying with safe handling guidelines by all staff members regardless of their personal perspective, because one employee’s actions can affect other employees’ exposure³.

Hospital management support and assessment of compliance with safe handling guidelines are integral to promoting safety in the chemotherapy environment.
The discovery that merely handling chemotherapy drugs can lead to absorption of the chemotherapy drugs must be a key factor in the re-evaluation of safety in healthcare environments. A national policy for safe handling and environmental control must be instituted by government, professional practice organizations, pharmacy and nursing organizations, and drug and safety equipment manufacturers for health workers who handle hazardous drugs.

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