Chemical Hazards for Healthcare Workers

Aerosolized Medications

Aerosolized medications treat respiratory diseases and infections.  These medications use a nebulizer or other type of aerosol generator when given to patients. Healthcare workers can be exposed to these medications during treatments.

The following aerosolized medications have been found to be harmful:

• Ribavirin and pentamidine have been linked to harmful reproductive effects^1,2
• Amikacin has been linked to respiratory irritation and kidney toxicity³
• Colistin has been linked to asthma and labored breathing⁴
• Tobramycin has been linked to asthma-like symptoms⁵

How Employers and Employees Can Reduce Aerosolized Medication Exposure

Wear protective gloves and gowns to avoid skin contact with hazardous drugs. Wear appropriate respiratory protection during activities where hazardous drug aerosols are generated.⁶

Use aerosol delivery devices with inspiratory and expiratory one-way valves and with an expiratory filter. This minimizes inhaling aerosolized pentamidine.⁷

Anesthetic Gases

General anesthesia prevents patients from feeling pain during surgery. Waste anesthetic gases (WAGs) are anesthetic gases and vapors that leak into the surrounding room. Healthcare workers who are exposed to WAGs may have adverse health effects.
Acute exposure to halogenated anesthetics can cause¹

• Headache
• Drowsiness
• Difficulties with judgment and coordination

Long-term exposure to halogenated anesthetics may cause harmful reproductive effects and cancer.²

How Employers and Employees Can Reduce Anesthetic Gases Exposure

• Use anesthesia machines with scavenging systems; older machines may not be equipped with such systems.^1,2
• Use closed system or low flow anesthesia instead of high flow anesthesia when administering anesthetic gases to patients, when practicable.^1,2
• Start anesthetic gas flow AFTER applying delivery mask or airway mask to patient.²
• Use a key-filler or other closed-system device when filling anesthesia vaporizers. This minimizes exposure to halogenated anesthetics from spills and vaporization.^1,3,4
• Provide employees initial and annual refresher training on anesthetic gas hazards and ways to minimize exposure.^1,2
• Ensure employees can easily find the anesthetic gas safe handling procedures.¹

Antineoplastic Drugs

Antineoplastic drugs treat cancer, arthritis, multiple sclerosis, and other non-cancer medical conditions.  Chemotherapy, cytotoxic, and oncology drugs are also antineoplastic drugs. NIOSH classifies most antineoplastic drugs as hazardous. Many are carcinogens with no safe level of exposure.
Examples of workers who are at risk

• Pharmacists
• Veterinarians
• Veterinary Technicians
• Custodial Workers
• Nurses
• Nursing Aids

Job tasks at most risk

• Preparing and administering these drugs
• Shipping and receiving these drugs
• Laundering linens and towels
• Handling patient bodily waste (including animal patients)
• Cleaning areas where drugs have been handled

Healthcare workers exposed to chemotherapy drugs have increased risk of

• Leukemia
• Other cancers
• Adverse reproductive outcomes
• Chromosomal damage

How Employers and Employees Can Reduce Antineoplastic Drug Exposure

• Avoid skin contact with liquid antineoplastic drugs. During administration or compounding activities, always wear
  • two pairs of chemotherapy gloves, and
  • a nonabsorbent gown with a closed front and tight-fitting cuffs.^1-5
• When administering, prime I.V. tubing with a non-hazardous drug containing liquid.^2-5
• Use supplementary engineering controls to reduce likelihood of exposure to liquid or aerosolized antineoplastic drugs.^2-5 Closed system drug-transfer devices and needleless systems are two examples of engineering controls.
• When preparing antineoplastic drugs use a biological safety cabinet. ^2-5
• Avoid taking home clothing and items that may be contaminated with antineoplastic drugs.^2-5
• Provide training to employees on the hazards of antineoplastic drugs and safe handling precautions to minimize exposure. Provide information and training at the time of initial job assignment and annually thereafter.^2-5
• Provide medical surveillance for employees exposed to hazardous drugs and encourage them to participate. Employers can use the information to identify and correct prevention failures. Medical surveillance can also identify health problems earlier in exposed workers.^2-6

Chemical Sterilants

Chemical sterilants treat surgical instruments and medical supplies so that patients are not exposed to pathogens. Though chemical sterilants are important for patient care, they can be hazardous to healthcare workers.

Common chemical sterilants used in healthcare include¹

• Ethylene oxide (EtO)
• Hydrogen peroxide gas plasma (HPGP)
• Vaporized hydrogen peroxide
• Immersion and vapor phase peracetic acid (PAA)

Acute exposure to EtO can cause²

• Respiratory irritation
• Headache
• Nausea
• Shortness of breath

Chronic EtO exposure may cause²

• Cancer
• Reproductive effects
• Mutagenic changes
• Neurotoxicity
• Sensitization

Acute exposure to HPGP and PAA may cause^3,7

• Upper respiratory tract irritation
• Skin irritation when there is contact with liquid solutions

How Employers and Employees Can Reduce Chemical Sterilant Exposure

• Train employees on the hazards of EtO, HPGP, and PAA prior to working with these and other sterilants.^4,6
• Ensure employees have access to standard operating procedures for the safe use of these sterilants.^4,6
• Hospital employers need to use a single chamber sterilization process for EtO.⁵ For example, the sterilization and aeration take place in one unit. EPA prohibited the use of separate units in March 2010. This was done to eliminate EtO exposure while transferring the load from the sterilizer to the aerator.

High-Level Disinfectants

High-level disinfectants (HLDs) chemically disinfect reusable, medical, and dental devices. HLDs prevent healthcare-associated infections among patients.

Food and Drug Administration (FDA)-cleared HLDs contain one or more of these ingredients¹ (this is not a full list):

• Glutaraldehyde
• Ortho-Phthaldehyde
• Peracetic acid
• Hydrogen peroxide
• Hypochlorous acid
• Hypochlorite

Acute health effects of exposure to HLDs include

•  Dermatitis
•  Mucous membrane irritation
•  Skin and respiratory tract irritation
•  Aggravation of pre-existing asthma and asthma-like symptoms such as wheezing and shortness of breath.^3-6

Chronic exposure to HLDs may cause asthma and asthma-like symptoms^7,8  or reproductive effects.

Research has shown hydrogen peroxide may be mutagenic in animals.⁹

How Employers and Employees Can Reduce High-Level Disinfectant Exposure

• Ensure employees are trained on HLD hazards. Before working in an area that uses HLDs, train employees to use best practices to minimize HLD exposure.¹⁰
• Ensure spill kits are available for appropriate clean-up of HLD spills.¹¹
• Employees should wear protective gloves and water-resistant gown or outer garment when handling HLDs.^11-13

Nitrous Oxide

Dental practitioners may be exposed to excessive levels of nitrous oxide when recommended controls aren’t use or used properly. This includes

• engineering controls (e.g., patient nasal scavenging mask or local exhaust ventilation (LEV) near the patient’s mouth),
• administrative controls, and
• work practice controls.

Acute work-related exposure to nitrous oxide may cause

• Lightheadedness
• Eye and upper airway irritation
• Cough
• Shortness of breath
• Decreases in mental performance and manual dexterity

Chronic work-related exposure to high levels of nitrous oxide may cause

• Increased risk of neurologic, renal, and liver disease
• Increased risk of miscarriage and fertility issues

How Employers and Employees Can Reduce Nitrous Oxide Exposure

• Use a soap solution to test for connection leaks every day before first use and whenever you change a gas cylinder. ^2-3
• Start nitrous oxide gas flow AFTER placing a nasal mask over the patient’s nose.^2-3
• Turn off nitrous oxide gas flow BEFORE turning off oxygen flow to the patient.^2-3
• Ensure employees can easily find the nitrous oxide safe handling procedures.^2-3
• Provide initial and yearly refresher training on nitrous oxide exposure health effects and ways to minimize exposure.³

Surgical Smoke

During surgical procedures, lasers and electrosurgical devices produce smoke. This surgical smoke has a bad odor and can make it hard for a surgeon to see the surgical site. Each year, over half a million healthcare workers including surgeons, nurses, surgical technologists, and others are exposed to surgical smoke.²

Surgical smoke may contain^1-3

• Toxic gases
• Vapors and particulates
• Viable and non-viable cellular material
• Viruses
• Bacteria

Transmission of human papillomavirus (HPV) by surgical smoke has not been proven but is a concern.⁴

Acute health effects of exposure to surgical smoke^1-3,5 include

• Eye, nose, and throat irritation
• Headache
• Cough
• Nasal congestion
• Asthma and asthma-like symptoms

Researchers don’t know much about the health effects of chronic exposure to surgical smoke.

How Employers and Employees Can Reduce Surgical Smoke Exposure

• Have employees use local exhaust ventilation (LEV) for all procedures with surgical smoke. Use smoke evacuators in situations with considerable plume. Use room wall suction systems to control small amounts of smoke when there is adequate room air ventilation.^3,5-8
• Employers should train employees on the hazards of surgical smoke and how to minimize exposure before working in areas where surgical smoke is generated.⁹
• Employers should ensure procedures are available to address surgical smoke hazards.⁸

Employees exposed to surgical smoke should use respiratory protection for particulates such as a properly fitted, N95 filtering facepiece respirator rather than a surgical or laser mask.⁸ Although LEV should always be used, this level of respiratory protection is especially important in situations where LEV is lacking or not functioning properly.

Other Related Resources

• Hazardous Drug Exposures in Health Care
• Occupational Latex Allergies
• Chemical Safety/NIOSH
• Workplace Solutions: Medical Surveillance for Health Care Workers Exposed to Hazardous Drugs
• The Effects of Workplace Hazards on Female Reproductive Health
• Reproductive Health and the Workplace

Anesthetic Gases

• Waste Anesthetic Gases – Occupational Hazards in Hospitals
• Precautionary practices for administering anesthetic gases: A survey of physician anesthesiologists, nurse anesthetists and anesthesiologist assistants

Antineoplastic Drugs

• Closed System Drug-Transfer Device (CSTD) Research
• NIOSH list of antineoplastic and other hazardous drugs in health care settings 2016
• Oncology Nursing Society (ONS) Chemotherapy and Biotherapy Guidelines and Recommendations for Practice
• Occupational Exposure to Antineoplastic Agents and Other Hazardous Drugs

Chemical Sterilants

• Ethylene Oxide (EtO): Evidence of Carcinogenicity
• Ethylene Oxide and Hydrogen Peroxide Gas Plasma Sterilization: Precautionary Practices in U.S. Hospitals
• Guideline for Disinfection and Sterilization in Healthcare Facilities
• Formaldehyde
• Public Health Statement for Formaldehyde

High-Level Disinfectants

• Glutaraldehyde: Occupational Hazards in Hospitals
• Guideline for Disinfection and Sterilization in Healthcare Facilities
• Precautionary Practices of Healthcare Workers Who Disinfect Medical and Dental Devices Using High-Level Disinfectants

Nitrous Oxide

• Exposure control practices for administering nitrous oxide: A survey of dentists, dental hygienists, and dental assistants

 Surgical Smoke

• Control of Smoke from Laser/Electric Surgical Procedures
• Secondhand smoke in the operating room? Precautionary practices lacking for surgical smoke