CLEANING GUIDELINES


measured based on the guidelines. Contamination of various parts of the working environment became evident. In four hospitals in the Netherlands, wipe testing for fluorouracil (5FU), cyclophosphamide (CP), ifosfamide (IF) and methotrexate (MTX) and measurement of anti-cancer agents in urine were carried out. The results showed that the trays and tables in the safety cabinets and floors, chairs and beds in the wards were contaminated. Furthermore, contamination was found on the floors of rooms other than the mixing rooms, washed sample glasses and other such places. Thus, articles published in the 1990s reported exposure to and contamination with anti-cancer agents, even when the guidelines were followed.


Current practice Today, in hospitals worldwide, anti-cancer agents are handled mainly in a pharmacy where a cleanroom and safety cabinet are installed and the pharmacists mix the agents while wearing personal protective equipment (PPE). It has taken about 20 years for hospital pharmacies in Japan to establish such facilities. The guidelines for the safe handling of anti-cancer agents were issued in 1994 and are still in use today.


In 2004, the NIOSH issued guidelines


on ‘Preventing Occupational Exposures to Antineoplastic and other Hazardous Drugs in Healthcare Settings’. The difference from earlier guidelines was the recommendation to use closed system drug transfer devices (CSTDs) during the mixing and dosing of anti-cancer agents. CSTDs can prevent both the leakage of anti-cancer agents and the escape of gaseous components, and thus can prevent the spread of contamination. In 22 US hospitals that introduced CSTDs, levels of CPA were reported to have decreased by 95 per cent, IF by 90 per cent and 5FY by 65 per cent after CSTDs were introduced. The outsourcing of tasks within medical institutions continues to increase and many rely on external contractors for the cleaning of restrooms and laundry. The use of PPE is indicated when cleaning toilets used by chemotherapy patients during the period when exposure to anti- cancer agents is possible. Furthermore, contaminated linen should be washed twice (once on a prewash) and separately from other linen. When the linen is to be taken off site, it should be placed in two sealed bags, one inside the other. Anti-cancer agents can, in some cases,


remain in the patient’s system for up to seven days before excretion, so the handling of the materials must be adapted to the properties of each agent. The authors interviewed eight external contractors on the cleaning of restrooms


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and laundry at medical institutions. They work at eight medical institutions with 200 to 1100 beds. Their remit includes not only offices and waiting rooms but also anti- cancer agent related areas. Specifically, seven companies cleaned chemotherapy rooms and three mixing rooms in the pharmacies. Only one of the eight companies knew the risks of anti-cancer agents. Similarly, only one company had cleaners use PPE to prevent exposure. Only a small number of companies were surveyed, so it is impossible to offer a firm conclusion, but the results suggest that education provided for the staff of outsourcing companies is insufficient/ inadequate.


Outsourcing


In Japan the outsourcing of tasks at medical institutions, such as the cleaning of restrooms and laundry, is widespread, but the risk of contamination by anti- cancer agents excreted by patients is not well known. Healthcare providers such as nurses and pharmacists who handle anti- cancer agents learn about the risks posed by them and a safe working environment is maintained. However, those who work at reception desks and external contractors are not informed about the risks of anti- cancer agents. It is necessary for all the staff in medical institutions and external contractors to have this information. Anti-cancer agents and their


metabolites are excreted in the urine and faeces of patients receiving chemotherapy. It takes from a couple of days to more than a week after dosage for an anti-cancer agent to be fully excreted by a patient and the patient’s excrement must be handled very carefully in the meantime.13


The linen,


sample bottles and restrooms used by patients who have received chemotherapy are contaminated, and there have been reports of nurses and cleaners handling them being exposed to the agents.14 Because of this contamination, in the guidelines for handling anti-cancer agents issued by bodies such as NIOSH and the HSE, the use of PPE is recommended when handling the linen used by a patient or their bodily waste. Similarly, CSTDs, which prevent the


leakage of anti-cancer agents during handling were recommended by NIOSH. Just as CSTDs prevent the leakage of anti- cancer agents or the escape of vaporised agents when administering them, if the drugs are mixed using a CSTD in a safety cabinet while wearing PPE, the risks of exposure are minimised.


Conclusion If appropriate measures are to be adopted, workers must understand what the risks of anti-cancer agents are, where those risks are present and how they can be effectively avoided. Appropriate handling increases both the cost and the difficulty


References 1 National Cancer Center Japan. News - 15 July 2016. [ganjoho.jp/reg_stat/statistics/stat/ short_pred.html].


2 Ishikawa S, Saeki J, Toda H et al. Exposure to antineoplastic drugs and safe handling from literature reviews. Jpn J Drug Inform 2015; 17 (1): 1-10.


3 Frost P, DeVita V. Pigmentation due to a new antitumor agent. Arch Dermatol 1966; 94: 265-8.


4 Mosci L. Astigmatism against the rule in a case of burning of the cornea by vincaleukoblastine. Ann Ophalmol Clin Ocul 1967; 93: 94-100.


5 Gottlieb JA. Hazards of handling antineoplastic drugs (letter). Pediatrics 1971; 47: 480.


6 Falk K, Grohn P, Sorsa M et al. Mutagenicity in urine of nurses handling cytostatic drugs. Lancet 1979; 1: 1250-1.


7 The Directorate of Labor Inspection in Norway. (1980) Guidelines Concerning the Handling of Cytostatic Agents.


8 The Society of Hospital Pharmacists of Australia. (1981) Guidelines for Safe Handling Cytotoxic Drugs in Pharmacy Departments and Hospital Wards.


9 The Canadian Society of Hospital Pharmacists. (1981) Guidelines for the Handling of Hazardous Pharmaceuticals.


10 The UK Health and Safety Executive. (1983) Guidelines for the Handling of Cytotoxic Drugs.


11. The US Oncology Nursing Society. (1984) Cancer Chemotherapy Guidelines and Recommendations for Nursing Education and Practice.


12 Yodaiken RE, Bennett D. OSHA work- practice guidelines for personnel dealing with cytotoxic (antineoplastic) drugs. Am J Hosp Pharm 1986; 43 (5): 1193-204.


13 Cass Y, Musgrave CF. Guidelines for the safe handling of excreta contaminated by cytotoxic agents. Am J Hosp Pharm 1992; 49: 1957-8.


14 Fransman W, Vermeulen R, Kromhout H. Dermal exposure to cyclophosphamide in hospitals during preparation, nursing and cleaning activities. Arch Occup Environ Health 2005; 78: 403-12.


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of the work and so there is a tendency for it to be avoided. In order to promote appropriate handling, education of workers is extremely important. Nothing is more effective than education in securing a safe working environment for staff, so it is necessary for employee training to be continuous. In particular, when work is outsourced, information sharing between the contracting medical facility and the service provider is indispensable. At the same time, all parties must recognise that appropriate cleaning and washing procedures will incur additional costs. Specifically, if laundry must be collected in a sealed bag and washed twice, it is easy to see that expenses will increase.


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