REVISIONES

 

Antineoplastic and occupational risks for nurses: an integrative review

Antineoplásicos e os riscos ocupacionais para os enfermeiros: uma revisão integrativa

Antineoplásicos y riesgos laborales para los enfermeros: una revisión integral

 

 

de Souza, Camila Brandão*; Tovar, Juliana Rodrigues**; Dell' Antônio, Larissa Rodrigues**; Dourado , Cláudia de Souza***; Amorim, Maria Helena Costa****

*Nurse. Specialist in Occupational Nursing. Master' s degree in Health Science form the Federal University of São Paulo. The responsible researcher E-mail: ufesmila_enfer@yahoo.com.br
**Nurse for the State Secretariat of Health, the state of Espírito Santo. Master' s degree in Collective Health from the Federal University of Espírito Santo.
***Nurse. Undergraduate student for a Master' s degree in Collective Health from the Federal University of Espírito Santo.
****Holder of a Doctor' s degree in Nursing from the Federal University of Rio de Janeiro. Associate Professor in the Nursing Departament at the Federal University of Espírito Santo Mentor. Brazil.

 

 

---

ABSTRACT

Introduction: There are countless occupational hazards to which health workers who handle chemotherapeutic substances are exposed.
Objectives: To identify and describe the short-, medium- and long-term damages that are caused in the bodies of nurses and other health professionals who are exposed to antineoplastic drugs in the workplace.
Methodology: To study an integrative literature review, with data collection in the Virtual Health Library in the months from September to October 2013, the database of the Scientific Electronic Library Online, and in the databases of the Latin American and Caribbean Health Sciences, the Database of Nursing and the Medical Literature Analysis and Retrieval System Online, with the keywords: "Antineoplasicos and Risco Ocupacional and Enfermagem", "Antineoplastic and Occupational Risk" and "Antineoplastic and Nursing."
Results: Damage to genetic material, increased frequency of micronuclei in lymphocytes, increased exchange of sister chromatids, increased levels of antineoplastic urinary excretion, increased cases of cancer, increased incidence of congenital anomalies in offspring and miscarriages in the first trimester of pregnancy are some of the results found in this study.
Conclusion: The most frequent damage occurred in the deoxyribonucleic acid, and predominated in medium and long terms, with the exposure time being crucial to increasing damage. In short and long term predominated damage linked to pregnancy and the developing fetus, with increase in congenital abnormalities and abortion. Genetic monitoring as well as Personal Protective Equipment are essential to minimize damage.

Key words: Occupational Risk; Occupational Exposure; Antineoplastic; Nurses; Occupational Health Nursing.

---

RESUMO

Introdução: São inúmeros os riscos ocupacionais aos quais os trabalhadores de saúde que manipulam quimioterápicos são expostos.
Objetivos: Identificar e descrever os danos em curto, médio e longo prazo, causados ao organismo dos enfermeiros, e demais profissionais da saúde, que são expostos à antineoplásicos no ambiente de trabalho.
Metodologia: Estudo de revisão integrativa da literatura, com coleta de dados na Biblioteca Virtual da Saúde, nos meses de setembro a outubro de 2013, nas bases de dados da biblioteca eletrônica Scientific Electronic Library Online e nas bases de dados da Literatura Latino-Americana e do Caribe em Ciências da Saúde, da Base de Dados de Enfermagem e da Medical Literature Analysis and Retrieval System Online, tendo como descritores: "Antineoplasicos and Risco Ocupacional and Enfermagem", "Antineoplastic and Occupational Risk" e "Antineoplastic and Nursing".
Resultados: Danos ao material genético, aumento da frequência de micronúcleos em linfócitos, aumento da troca das cromátides irmãs, aumento do nível de antineoplásicos na excreção urinária, aumento dos casos de câncer, aumento da incidência de anomalias congênitas na prole e aborto no primeiro trimestre da gravidez são alguns dos resultados encontrados por este estudo.
Conclusão: O dano mais frequente ocorreu ao ácido desoxirribonucleico, e predominou em médio e longo prazo, com o tempo de exposição sendo decisivo ao aumento dos prejuízos. Em curto e longo prazo predominaram danos ligados à gestação e ao desenvolvimento do feto, com aumento das anomalias congênitas e aborto. Acompanhamento genético, bem como Equipamentos de Proteção Individual são fundamentais para minimizar os danos.

Palavras chave: Riscos Ocupacionais; Exposição Ocupacional; Antineoplásicos; Enfermeiros; Enfermagem do Trabalho.

---

RESUMEN

Introducción: Son muchos los riesgos laborales a los que están expuestos los trabajadores de salud que manipulan quimioterápicos.
Objetivos: Identificar y describir los daños a corto, medio y largo plazo, causados en el organismo de los enfermeros y otros profesionales de la salud, que están expuestos a los fármacos antineoplásicos en el lugar de trabajo.
Metodología: Estudio de revisión integradora de la literatura, con la recogida de datos en la Biblioteca Virtual en Salud, en los meses de septiembre a octubre de 2013, en las bases de datos de biblioteca electrónica Scientific Electronic Library Online y en las bases de datos de la Literatura Latino Americana y Caribeña Ciencias de la Salud, la Base de Datos de Enfermería y el Análisis de la Literatura Médica y Recuperación del Sistema en Línea, con las palabras: "Antineoplasicos and Risco Ocupacional and Enfermagem", "Antineoplastic and Occupational Risk" y "Antineoplastic and Nursing'.
Resultados: Daño en el material genético, aumento de la frecuencia de micronúcleos en linfocitos, aumento de intercambio de cromátidas hermanas, un mayor nivel de la excreción urinaria antineoplásica, aumento de casos de cáncer, mayor incidencia de anomalías congénitas en la descendencia y aborto en el primer trimestre del embarazo son algunos de los resultados encontrados en este estudio.
Conclusión: El daño más frecuente ocurre al ácido desoxirribonucleico, el predominio a medio y largo plazo, siendo el tiempo de exposición fundamental para aumentar el daño. A corto y largo plazo predominaron daños relacionado con el embarazo y el desarrollo fetal, con aumento de anomalías congénitas y aborto. Acompañamiento genético, así como equipos de protección individual son esenciales para minimizar los daños.

Palabras clave: Riesgos laborales; exposición ocupacional; antineoplásicos; enfermeros; Enfermería del Trabajo.

---

 

Introduction

The occupational risks and hazards to which health workers are exposed are the most varied ones, as well as their consequences to the body. Danger is defined as the source or situation that has potential for harm in terms of injury and damage to the human body, health, property or the working environment, and risk is the combination of the probability of a hazardous event or exposure occurring that can cause serious injury or disease¹.

According to Ordinance No. 3214 of the Ministry of Labor of Brazil, as of 1978 through its Regulatory Standard No. 5 (NR-5), risks in the workplace can be classified as: risk of accidents, or ergonomic, physical, chemical and biologic risks². In order for them to be minimized, there needs to be a systematic action, with classification, level of acceptance, an action plan and a review of the suitableness thereof³.

There are several specialized committees, programs and services that are responsible, among other functions, for preventing occupational harm that is caused for workers, and one can cite the Internal Commissions for Accident Prevention (CIPA), Specialized service of Safety Engineering and Occupational Medicine (SESMT), the Environmental Risk Prevention Program (PPRA) and Occupational Health Control Program (PCMSO), besides required documentation, such as Technical Reports of Environmental Working Conditions (LTCAT) and the Professional Social Security Profile (PPP), which guarantee workers legal support related to future benefits that are their right and which may be required.

The National Institute for Occupational Safety and Health (NIOSH)⁴ states that health professionals who are exposed to chemotherapeutic agents as part of their professional practice should take the due precautions to eliminate or reduce exposure whenever possible. This includes the use of Personal Protection Equipment (PPE), such as gowns, gloves, masks and goggles.

Pharmacists, who prepare medications, and nurses who can both prepare as well as administer them, are the two professional groups that have the greatest potential for exposure to antineoplastic agents⁴. Furthermore, the harm done to nurses is greater and more significant than that caused to pharmacists^5-7.

These exposures can cause health effects in the short, medium and long terms. Chromosomal aberrations^8-9, damage to deoxyribonucleic acid (DNA)⁶, increased micronucleus frequency in lymphocytes⁶, increased exchange of sister chromatids⁹, increased level of antineoplastic drugs in urinary excretion⁷, an increase in cases of cancer¹⁰, increased incidence of congenital anomalies in offspring^10, and miscarriages in the first trimester of pregnancy¹¹ are some of the effects described in the literature. In order to intervene in the outcome, it is essential that all this be well known. Thus, the objective was to identify and describe the short, medium, and long term damages which are caused to the bodies of nurses and other health professionals who are exposed to antineoplastic drugs in the workplace.

 

Methodology

This is an integrative review about the occupational risks to which nurses and other health professionals are exposed upon handling antineoplastic substances.

In this study, six stages were used: identifying the issue and selecting the hypothesis for the preparation of the review, fixing criteria for inclusion and exclusion of studies, defining information that was extracted and categorizing the studies, evaluating the studies that were included, interpreting the results, and presenting the synthesis of the findings¹².

A search was conducted in the Virtual Health Library (BVS, or Biblioteca Virtual da Saúde), in the months from September to October of 2013, by using the databases of the Scientific Electronic Library Online (SCIELO), the Latin American and Caribbean Health Sciences (LILACS), the Nursing Database (BDENF, or Base de Dados de Enfermagem) and the Medical Literature Analysis and Retrieval System Online (MEDLINE), and the keywords: "antineoplastics and Occupational Risk and Nursing ", "Antineoplastic and Occupational Risk" and "Antineoplastic and Nursing", in the respective order.

The criteria for inclusion was established as being original articles that have been made available in their entirety and in online form, which were published in Portuguese, English or Spanish in the period between 2009 and 2013 containing nurses in their samples. The criteria for exclusion were established as being articles of bibliographical research and reflection, theses, dissertations and articles that have been repeated in different databases.

To select the articles, three Relevance Tests were used. In Relevance Test 1, the publication period of the studies and language were considered. In Test 2, the productions were selected by considering the suitableness of the title and the abstract in relation to the topic. In Test 3, the studies in their entirety were evaluated by considering the aforementioned issues as well as other inclusion and exclusion criteria. At that stage the articles were thoroughly analyzed by three reviewers, and the most relevant data for the study were briefly summarized and described. They are shown in Table 1, entitled "Identification and description of the main findings."

 

Results

A total of 408 articles were found in the databases searched, of which 376 were in MEDLINE, 14 were in LILACS, 12 were in BDENF, and 6 were in SCIELO. Of these, only 10 met all of the criteria for eligibility, and they were used.

They showed results that were in compliance with the objective of the study, and all of them somehow evaluated the effects of antineoplastic drugs in short, medium or long terms, not only in the bodies but also in the quality of life of workers that handled them. Much of this was in the form of case-control studies. There was a higher frequency when using the keywords "Antineoplastic and Nursing", with 358 articles. In Relevance Test 1, when using the keywords "antineoplastic and Occupational Nursing and Risk," 10 articles were found. After reading the abstracts (Relevance Test 2), only one article remained, and it was excluded after Relevance Test 3, which evaluated the full content of the study.

By using the keywords "Antineoplastic and Occupational Risk" in Relevance Test 1, 40 articles were found; while in Relevance Test 2, 10 articles remained; and at the end, in Relevance Test 3, eight articles met all the criteria for eligibility.

By using the keywords "Antineoplastic and Nursing", 358 works were found, of which four remained after performing Relevance Test 2, and at the end, 2 articles were selected.

The reasons for excluding articles from Relevance Test 2 and putting them in Relevance Test 3 were: Repetition in different databases (2), not presenting results nor conclusions, articles that were not yet completed (1), or a qualitative study, which did not present results (1). The total is 5 exclusions.

After performing the analysis, significant occupational impact on the workers was noticed. In the short term, workers who manipulated antineoplastic drugs during pregnancy had significantly higher rates of congenital abnormalities in the eyes of their offspring¹⁰, and they were more likely to have miscarriages, even in the first three months of pregnancy¹¹. In the medium term there was chromosome damage^5,6,8,11,7, aberrant lymphocytes, deletions, gaps and ruptures⁵, aberrations in chromatids^8,11, decreased production of lymphocytes⁸, and increased frequency of micronuclei^6,14. Over the long term, nurses who handled chemotherapeutical substances had a higher risk of their children being born with a cleft lip/cleft palate, as well as a higher risk of breast cancer and rectal cancer¹⁰.

The most common risk factors for increasing occupational harm were: being a nurse^5,6,7,10, the workplace¹⁰, the amount of time in being exposed to antineoplastics^5,9,10, idade^5,9,11, not using or misusing PPE^5,11,15, and consuming alcohol⁶ and tobacco ^9,11.

In Table 1, the 10 articles that met all inclusion criteria and were approved in all of the relevant tests are identified and described. The details that are described succinctly and objectively include the Article Identification, stating the title and author of each article, the journal in which it was published, the year of publication, the study location, the objectives thereof, the methodology used, the population that was studied, and finally, the Main Conclusions.

 

Discussion

There have not been many studies with satisfactory methodological quality that analyze the occupational risks to which nurses and health staff are exposed upon handling antineoplastic substances.

There is scientific evidence that they exist, and the damages to workers' health are unquestionable^{5,8,10-11,16-17}. A study conducted in Croatia brought together 100 women, half of whom had had contact with chemotherapeutical drugs. Of these, 7, or more than 10% of the case group, stated they had suffered a miscarriage at least once¹¹, so it is clear that antineoplastic substances cause a major interference in fetal formation. Another study, which was conducted in Canada¹⁰, evaluated a cohort group of babies who were born as of 1986, and it revealed that the children of nurses who had been exposed to these drugs during gestation had a significantly higher risk of abnormalities in their eyes. When a cumulative exposure over 10 years was taken into account, their children had higher rates of occurrence of cleft lip and cleft palate. These same women had a higher risk of developing cancer. It is a fact that handling chemotherapy drugs, whether it is over the short, medium or long term, irreversibly alters human genes.

Damage to genetic material is something that has already been well established. In Egypt⁵, in Brazil⁶, in Tunisia⁸, in Croatia¹¹, and in Italy⁷ studies have shown damage to chromosomes, most of which was evaluated by comet assay. In Egypt, the subjects of the case studies had worked with chemotherapy for 2-20 years. The damage to DNA was directly proportional to the time for which they had worked⁵.

It is clear that the use of devices which can reduce the workers' exposure are fundamental^18-19. In many cases, concern about reducing the contamination of the environment^19,20, coupled with the use of high-quality PPE ^21-22, has resulted in decreasing the harm caused by antineoplastic drugs^5,7,11.

It is not enough just to provide PPE for workers, but it is also necessary to provide continuing education so that they can be used correctly²², since the incorrect usage of them has contributed to the increased contamination of workers and damage to their bodies^5,11.

The fact that nurses represent the professional class with the highest rate of occupational injuries among those studied^5-7, may be due to less stringent measures adopted by them at the time of handling antineoplastic drugs⁵.

Studies have shown that cytogenetic vigilance^11,23 along with periodic monitoring of the health status of these workers are forms of control, and consistent attitudes, in relation to the risks that have been shown¹¹, may modify the course of the changes, thus minimizing [negative] outcomes.

 

Conclusion

This study shows that health care workers who have been exposed to chemotherapeutic agents suffer innumerous adverse effects on the body in the short, medium and long terms.

Nurses are those who are the most affected when compared to other professional groups.

The most frequent damage is that which is done to the DNA, and it was predominant in the medium and long terms. The amount of exposure time was crucial for the increase of such damages.

What stood out in the short and long terms were the damages related to the development of the fetus, thus increasing congenital anomalies.

There are many risks to which the nursing staff that handles antineoplastic drugs is exposed, with deleterious effects to one's health. Educating about, encouraging and requiring the correct usage of PPE can be a good way to start improving these indicators.

Studies should be conducted to determine the most significant risk factors among these types of exposure, and proposals should be made so that the risks and dangers can be minimized, since the benefits to cancer patients who receive chemotherapy are even greater than the risks offered to the staff that administers it.

This study brings forth contributions to nursing and all the staff that handles these medications, whereas it shows evidence that there is much to be done for the occupational safety of these workers.

 

 

Received: September 28, 2014
Accepted: October 31, 2015

 

 

References

1. OHSAS 18001:2007. Sistemas de gestão da segurança e saúde no trabalho: requisitos. São Paulo: Risk tecnologia, 2007.         [ Links ]

2. Brasil. Ministério do Trabalho (internet). Portaria n^o 3.214, 08 de junho de 1978. (acesso 2013 ago 03). Disponível em: http://portal.mte.gov.br/legislacao/portaria-n-3-214-de-08-06-1978-1.htm.         [ Links ]

3. FUNDACENTRO (2005). Diretrizes sobre Sistemas de Gestão da Segurança e Saúde no Trabalho. Versão Brasileira das Diretrizes da OIT (ILO-OSH 2001). Fundacentro, Brasil, 2005.         [ Links ]

4. The National Institute for Occupational Safety and Health (NIOSH). (internet) Occupational Exposure to Antineoplastic Agents. (acesso 2013 out 12). Disponível em: http://www.cdc.gov/niosh/topics/antineoplastic/.         [ Links ]

5. El-Ebiary AA, Abuelfadl AA, Sarhan NI. Evaluation of genotoxicity induced by exposure to antineoplastic drugs in lymphocytes of oncology nurses and pharmacists. J Appl Toxicol. 2013 Mar; 33(3): 196-201.         [ Links ]

6. Rombaldi F, Cassini C, Salvador M, Saffi J, Erdtmann B. Occupational risk assessment of genotoxicity and oxidative stress in workers handling anti- neoplastic drugs during a working week. Mutagenesis. 2009 Sep; 24(2): 143-8.         [ Links ]

7. Villarini, et al. Assessment of primary, oxidative and excision repaired DNA damage in hospital personnel handling antineoplastic drugs. Mutagenesis. 2011 May; 26(3): 359-69.         [ Links ]

8. Bouraoui S, Brahem A, Tabka F, Mrizek N, Saad A, Elghezal H. Assessment of chromosomal aberrations, micronuclei and proliferation rate index in peripheral lymphocytes from Tunisian nurses handling cytotoxic drugs. Environ Toxicol Pharmacol. 2011 Jan; 31(1): 250-7.         [ Links ]

9. Kopjar, et al. Assessment of genotoxic risks in Croatian health care workers occupationally exposed to cytotoxic drugs: a multi-biomarker approach. Int J Hyg Environ Health. 2009 Jul; 212(4): 414-31.         [ Links ]

10. Ratner, et al. Cancer incidence and adverse pregnancy outcome in registered nurses potentially exposed to antineoplastic drugs. BMC Nurs. 2010 Sep; 9(15): 1-11.         [ Links ]

11. Kopjar, et al. The genotoxic risk in health care workers occupationally exposed to cytotoxic drugs--a comprehensive evaluation by the SCE assay. J Environ Sci Health A Tox Hazard Subst Environ Eng. 2009 Apr; 44(5): 462-79.         [ Links ]

12. Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidência na saúde e na enfermagem. Texto & contexto enferm. 2008 Oct./Dec; 17(4): 758-64.         [ Links ]

13. Pereira AL, Bachion MM. Atualidades em revisão sistemática de literatura, critérios de força e grau de recomendação de evidência. Rev gaúch enferm. 2006 dez; 27(4): 491-8.         [ Links ]

14. Stover D, Achutan C. Occupational exposures to antineoplastic drugs in an Oncology-Hematology Department. J Occup Environ Hyg. 2011 Jan; 8(1): D1-6.         [ Links ]

15. Cavallo D, Ursini CL, Rondinone B, Iavicoli S. Evaluation of a suitable DNA damage biomarker for human biomonitoring of exposed workers. Environ Mol Mutagen. 2009 Dec; 50(9):781-90.         [ Links ]

16. Huang YW, Jain L, Zhang MB, Zhou Q, Yan XF, Hua XD, Zhou Y and He JL. An investigation of oxidative DNA damage in pharmacy technicians exposed to antineoplastic drugs in two Chinese hospitals using the urinary 8-OHdG assay. Biomed Environ Sci. 2012 Feb; 25(1): 109-16.         [ Links ]

17. Mrdanovic J, Jungic S, Solajic S, Bogdanovic V and Jurisic V. Effects of orally administered antioxidants on micronuclei and sister chromatid exchange frequency in workers professionally exposed to antineoplastic agents. Food Chem Toxicol. 2012 Aug; 50(8): 2937-44.         [ Links ]

18. Forges F, Simoens X and Chauvin F. Comparative parallel assessment of a transfer device in reducing 5-fluorouracil environmental contamination inside positive air pressure isolators. J Oncol Pharm Practice. 2011 Mar; 17(1): 61-7.         [ Links ]

19. Clark BA and Sessink PJM. Use of a closed system drug-transfer device eliminates surface contamination with antineoplastic agents. J Oncol Pharm Prac. 2013 Jun; 19(2): 99-104.         [ Links ]

20. Chu WC, Hon C-Y, Danyluk Q, Chua PPS and Astrakianakis G. Pilot assessment of the antineoplastic drug contamination levels in British Columbia hospitals pre- and post-cleaning. J Oncol Pharm Practice. 2012 Mar; 18(1): 46-51.         [ Links ]

21. Capron A, Destree J, Jacobs P and Wallemacq P. Permeability of gloves to selected chemotherapeutic agents after treatment with alcohol or isopropyl alcohol. Am J Health-Syst Pharm. 2012 Oct; 1;69(19): 1665-70.         [ Links ]

22. Gulten T, Evke E, Ercan I, Evrensel T, Kurt E and Manavoglu O. Lack of genotoxicity in medical oncology nurses handling antineoplastic drugs: effect of work environment and protective equipment. Work. 2011; 39(4): 485-9.         [ Links ]

23. NIOSH. 2013. Workplace solutions: medical surveillance for health care workers exposed to hazardous drugs. (internet). DHHS (NIOSH) Publication No. 2013-103. (acesso 2013 out 14). Disponível em: www.cdc.gov/niosh/docs/wp-solutions/2013-103/pdfs/2013-103.pdf.         [ Links ]

24. Connor, et al. Evaluation of antineoplastic drug exposure of health care workers at three university-based US cancer centers. J Occup Environ Med. 2010 Oct; 52(10): 1019-27.         [ Links ]