What kind of gloves do you wear when handling hazardous drugs?

Press Contact: Nura Sadeghpour (202) 245-0673

A study of non-pregnant and pregnant female nurses  

Female nurses who administer antineoplastic drugs – medications used to treat cancer – don’t always wear protective clothing, according to a new NIOSH studyexternal icon published online in the American Journal of Nursing, accompanied by a video abstractexternal icon. This is one of the first studies to explore the use of antineoplastic drugs and personal protective equipment among non-pregnant and pregnant female nurses.

Nurses are exposed to antineoplastic drugs, or chemotherapeutic drugs, when they administer these drugs in pill or liquid form to patients who are battling all forms of cancer. The drugs, while working to kill rapidly dividing cancerous cells of a patient can also be harmful to the healthy dividing cells of the nurse, including the cells of a developing baby. Only a few studies have explored associations between occupational exposures to antineoplastic drugs and reproductive outcomes.

In order to explore this association further, survey data were collected from more than 40,000 nurses participating in the Nurses’ Health Studyexternal icon 3, a web-based survey of U.S and Canadian nurses that began enrollment in 2010. Non-pregnant nurses reported their use of gloves and gowns when handling or administering antineoplastic drugs within the past month, and pregnant nurses reported their use during the first 20 weeks of pregnancy, a time during which the fetus is highly susceptible to exposure.

Despite long-standing recommendations for the safe handling of antineoplastic and other hazardous drugs, many nurses – including those who are pregnant – reported not wearing protective gloves and gowns, the minimum protective equipment recommended when administering these drugs.

Specifically, of the non-pregnant nurses and pregnant nurses who said they administered antineoplastic drugs during the study period:

• Twelve percent of non-pregnant nurses and 9% of pregnant nurses indicated that they never wore gloves when administering antineoplastic drugs.
• Forty-two percent of non-pregnant nurses and 38% of pregnant nurses reported never using a gown.
• During the first 20 weeks of pregnancy, about one in 10 pregnant nurses did not always wear gloves and one in two did not always wear a protective gown when administering these drugs.

“NIOSH has worked extensively to protect workers who handle antineoplastic drugs, many of which are known or probable human carcinogens,” said Christina Lawson, Ph.D., epidemiologist and lead author of the study. “Many of these drugs can also damage a person’s fertility or harm a pregnancy, for example by causing a miscarriage or birth defects, so we wanted to look at the health of pregnant nurses for this study.”

Study researchers can only hypothesize why some nurses in the study didn’t handle antineoplastic drugs safely. Previous research suggests that reasons may include prioritizing care for patients over their own personal health, lack of concern or awareness by either employee or employer of the toxicity of these drugs, and availability or opportunity to wear protective gloves and gowns.

“These data underscore the need for continued education and training to ensure that both employers and nurses—pregnant and non-pregnant—are fully aware of such hazards and of the recommended precautionary measures,” says Lawson.

The study was the result of a collaboration between NIOSH researchers, and investigators from Harvard T.H. Chan School of Public Health, Harvard Medical School, and Brigham and Women’s Hospital in Boston, Massachusetts.

For more information about NIOSH’s research and recommendations on healthcare workers, visit the NIOSH healthcare topic page. For more information on reproductive health and the workplace, visit this topic page.

NIOSH is the federal institute that conducts research and makes recommendations for preventing work-related injuries, illnesses, and deaths. For more information about NIOSH visit www.cdc.gov/niosh/.

Proper negative pressure compounding must be used if CSTDs are not employed. Negative pressure compounding is very difficult to do properly and generally results in an increase in time to prepare drugs. Therefore, CSTDs offer the additional potential advantage of reducing the time it takes to properly prepare HDs, while enhancing worker protection. A CSTD is not a substitute for a containment primary engineering controls (C-PEC) when performing HD compounding.

CSTDs MUST be used during administration of HDs, so depending on how the drugs are administered, IV tubing must be primed with a neutral solution. The CSTD must be attached to the bag or tubing before the doses are dispensed. Pharmacy must dispense the final HD dose ready for administration without further manipulation.

Personal protective equipment:

Necessary PPE includes gloves and gowns; head, hair, sleeve, and shoe covers; and eye, face, and respiratory protection. Additional detail is provided below for each:

Gloves

When chemotherapy gloves are required, they must meet American Society for Testing and Materials (ASTM) Standard D6978 (or its successor). Chemotherapy gloves should be worn for handling all HDs, including non-antineoplastics and for reproductive risk only HDs. Chemotherapy gloves must be powder-free because powder can contaminate the work area and can adsorb and retain HDs. Gloves must be inspected for physical defects before use. Do not use gloves with pin holes or weak spots.

When used for sterile compounding, the outer chemotherapy gloves must be sterile. Chemotherapy gloves should be changed every 30 minutes, unless otherwise recommended by the manufacturer’s documentation, and must be changed when torn, punctured, or contaminated. Hands must be washed with soap and water after removing gloves.

Gowns

When gowns are required, they must be disposable and shown to resist permeability by HDs. Gowns must be selected based on the HDs being handled. Disposable gowns made of polyethylene-coated polypropylene or other laminate materials offer better protection than those made of uncoated materials. Gowns must close in the back and must have no front opening, be long sleeved, and have closed cuffs that are elastic or knit. Gowns must not have seams or closures that could allow HDs to pass through.

The HD-resistant gown cannot be worn longer than the time indicated by the gown manufacturer. In the absence of permeation information, operators should change the gown every 2-3 hours or immediately after a spill or splash. To avoid spreading HD contamination and exposing other health care workers, a gown that was used in an HD handling area should never be worn in other areas.

Head, hair, shoe covers

Head and hair covers (including beard and moustache, if applicable), shoe covers, and sleeve covers provide protection from contact with HD residue. When compounding HDs, a second pair of shoe covers must be donned before entering the C-SEC and doffed when exiting the C-SEC. Shoe covers worn in HD handling areas must not be worn to other areas to avoid spreading HD contamination and exposing other health care workers.

Disposable sleeve covers may be used to protect areas of the arm that may come in contact with HDs. Disposable sleeve covers made of polyethylene-coated polypropylene or other laminate materials offer better protection than those made of uncoated materials.

Eye and face protection

Many HDs are irritating to the eyes and mucous membranes. Appropriate eye and face protection must be worn when there is a risk for spills or splashes of HDs or HD waste materials when working outside of a C-PEC; for example, administration in the surgical suite, working at or above eye level, or cleaning a spill. A full face-piece respirator provides eye and face protection. Goggles must be used when eye protection is needed. Eye glasses alone or safety glasses with side shields do not protect the eyes adequately from splashes. Face shields in combination with goggles provide a full range of protection against splashes to the face and eyes. Face shields alone do not provide full eye and face protection.

Respiratory protection

Personnel who are unpacking HDs that are not contained in plastic should wear an elastomeric half-mask with a multi-gas cartridge and P100-filter until assessment of the packaging integrity can be made to ensure no breakage or spillage occurred during transport. If the type of drug can be better defined, a more targeted cartridge can be used.

Surgical masks do not provide respiratory protection from drug exposure and must not be used when respiratory protection from HD exposure is required. A surgical N95 respirator provides the respiratory protection of an N95 respirator, and like a surgical mask, provides a barrier to splashes, droplets, and sprays around the nose and mouth.

For most activities requiring respiratory protection, a fit-tested NIOSH-certified N95 or more protective respirator is sufficient to protect against airborne particles. However, N95 respirators offer no protection against gases and vapors and little protection against direct liquid splashes (see the Centers for Disease Control and Prevention’s (CDC’s) Respirator Trusted-Source Information).