Healthcare and Social Assistance

Participating core and specialty programs: Authoritative Recommendations, Engineering Controls, National Center for Production Aging and Work, and Personal Protective Technology.

Employers, workers and manufacturers use NIOSH information to reduce hazardous exposures that contribute to cancer and adverse reproductive outcomes among healthcare and social assistance workers.

NOTE: Goals in bold in the table below are priorities for extramural research.

  Health Outcome Issue Target population Research needed
A Cancers,

Adverse reproductive outcomes

Development of closed drug transfer systems Management, medical workers who handle hazardous drugs (includes human and veterinary) Intervention
B Cancers,

Adverse reproductive outcomes

Development of exposure controls, including local exhaust ventilation for hazardous drugs Management and workers in inpatient and outpatient clinics where hazardous drugs are administered (includes human and veterinary) Intervention
C Cancers (also infectious diseases) Development of exposure controls, including local exhaust for surgical smoke Human surgical, human outpatient, veterinary work settings Intervention
D Adverse reproductive outcomes, Cancers Development of exposure controls, including local exhaust for waste anesthetic gases Management and workers administering anesthetic gases or caring for patients recovering from anesthetic gas administration, especially recovery room nurses (includes human and veterinary) Intervention
E Cancers, Adverse reproductive outcomes Adherence to Safe Handling of Hazardous Drug Guidance Range of work settings, such as: pharmacy, outpatient clinics, veterinary medicine InterventionTranslation
F Cancers Development of exposure assessment tools for assessing environments and for hazard surveillance Nurses, others with potential carcinogenic exposures (includes human and veterinary) Basic/etiologic

Surveillance research

Activity Goal 1.3.1 (Basic/Etiologic Research): Conduct basic/etiologic research to better assess relationships between level of exposure and risk for cancers and adverse reproductive outcomes in healthcare and social assistance.

Activity Goal 1.3.2 (Intervention Research): Conduct studies to develop and assess the effectiveness of interventions to prevent exposures to hazardous drugs and other chemicals linked to cancers and adverse reproductive outcomes among healthcare and social assistance workers.

Activity Goal 1.3.3 (Translation Research): Conduct translation research to understand barriers and aids to implementing best practices for the safe handling of hazardous drugs and other chemicals linked to cancers and adverse reproductive outcomes among healthcare and social assistance workers.

Activity Goal 1.3.4 (Surveillance Research): Conduct surveillance research to develop new tools and methods for assessing the burden of work-related exposures to carcinogens among healthcare and social assistance workers.


Human and animal healthcare workers are routinely exposed to hazardous drugs and other chemicals. NIOSH estimates that about 8 million healthcare workers in a wide range of occupations (e.g., pharmacists, nurses, physicians, veterinarians, and workers in environmental, laundry or waste handling services) are potentially exposed to hazardous drugs [NIOSH 2016]. Exposure to antineoplastic or chemotherapy drugs have been linked to multiple health effects ranging from skin rashes and asthma to adverse reproductive outcomes, as well as leukemia and other cancers [Lawson et al. 2012; Skov et al. 1992]. Other chemicals commonly found in healthcare settings include cleaning and disinfecting (C&D) agents, high level disinfectants (HLDs), anesthetic gases, surgical smoke, aerosolized medications, and chemical sterilants including ethylene oxide [Casey et al. 2017; Saito et al. 2015; Steege et al. 2014]. Exposure to these substances have been linked to adverse reproductive effects and cancer and other health effects.


Efforts to translate research into practice by identifying and disseminating best practices to reduce chemical exposures are needed where mature best practices already exist, such as for hazardous drugs. Research to develop interventions to reduce exposures to chemical hazards and to demonstrate the effectiveness of interventions are needed in areas where there are gaps, such as for controlling exposures to waste anesthetic gases. Surveillance and basic/etiologic research continues to be important in order to document the burden and magnitude of work-related exposures and assess relationships between exposures and other risk factors with adverse health outcomes. Unless new sources of information become available, repeat discrete studies over time will be needed to track progress in applying prevention measures and the success of those measures.

Employers and workers use NIOSH information to mitigate the effects of work organization to help prevent cancer and cardiovascular disease among healthcare and social assistance workers.

  Health Outcome Issue Worker population Research needed
A Cancers, Cardiovascular disease Work-related stress, anxiety, depression, fatigue as a result of suboptimal work organization Nurses, certain types of physicians, home health care workers, environmental services workers, veterinary/animal care workers Basic/etiologic

Activity Goal 1.4.1 (Basic/Etiologic Research): Conduct basic/etiologic research to better understand the relationship between work organization and cancers, and work organization and cardiovascular disease, in healthcare and social assistance.


Work in Healthcare (human and animal) and Social Assistance is often associated with high levels of stress resulting in multiple adverse health outcomes. The American Nurses Association surveyed its members in 2011 and found that 74% of respondents had concerns about the effects of stress and overwork. This survey also found that 53% of nurses worked some mandatory or unplanned overtime each month [ANA 2011]. In one survey of veterinary personnel, 35% consider their job dangerous, 34% reported adverse effects from workplace stress, and 42% of veterinarians experienced or witnessed workplace abuse [Fowler et al. 2016]. Psychological stress is associated with adverse cardiovascular health outcomes [Lagraauw et al. 2015].Risks of long shift work include reduced job performance on the job, obesity, injuries, and a wide range of chronic diseases [Caruso 2014]. Five or more years of rotating nightshift work is associated with an increased risk of coronary heart disease [Vetter et al. 2016]. The International Agency for Research on Cancer considers shift work with circadian rhythm disruption as a carcinogen [Straif 2007].


Little is known about the biologic link between shift work and cancer or cardiovascular disease. Similarly, the link between work-related stress, anxiety, depression, fatigue and adverse health outcomes such as cardiovascular disease needs to be better understood. Research to quantify these risk factors, document exposure-response relationships, and better define mechanisms for causation of adverse health outcomes by these risk factors is needed.

ANA [2011]. 2011 ANA Health and Safety Survey. Silver Spring, MD: American Nurses Association,

Caruso CC [2014]. Negative impacts of shiftwork and long work hours. Rehabil Nurs 39(1), 16-25,

Casey ML, Hawley B, Edwards N, Cox-Ganser JM, Cummings KJ [2017]. Health problems and disinfectant product exposure among staff at a large multispecialty hospital. Am J Infect Control 2017 May 23, [Epub ahead of print]

Fowler HN, Holzbauer SM, Smith KE, Scheftel JM [2016]. Survey of Occupational Hazards in Minnesota veterinary practices in 2012. J Am Vet Med Assoc 248(2):207-18,

Lagraauw HM, Kuiper J, Bot I [2015]. Acute and chronic psychological stress as risk factors for cardiovascular disease: Insights gained from epidemiological, clinical and experimental studies. Brain Behav Immun 50:18-30,

Lawson CC, Rocheleau CM, Whelan EA, Lividoti Hibert EN, Grajewski B, Spiegelman D, Rich-Edwards JW [2012]. Occupational exposures among nurses and risk of spontaneous abortions. Am J Obstet Gynecol 206(4):327,

NIOSH [2016]. NIOSH list of antineoplastic and other hazardous drugs in healthcare settings, 2016. By Connor TH, MacKenzie BA, DeBord DG, Trout DB, O’Callaghan JP. Cincinnati, OH: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication Number 2016-161,

Saito R, Virji MA, Henneberger PK, Humann MJ, LeBouf RF, Stanton ML, Liang X, Stefaniak AB [2015]. Characterization of cleaning and disinfecting tasks and product use among hospital occupations. Am J Ind Med 58(1):101-11,

Skov T, Maarup B, Olsen J, Rørth M, Winthereik H, Lynge E [1992]. Leukaemia and reproductive outcome among nurses handling antineoplastic drugs. Br J Ind Med 49(12):855-61.

Steege AL, Boiano JM, Sweeney MH [2014]. NIOSH health and safety practices survey of healthcare workers: training and awareness of employer safety procedures. Am J Ind Med 57(6):640-52,

Straif K, Baan R, Grosse Y, Secretan B, El Ghissassi F, Bouvard V, Altieri A, Benbrahim-Tallaa L, Cogliano V; WHO International Agency For Research on Cancer Monograph Working Group [2007]. Carcinogenicity of shift-work, painting, and fire-fighting. Lancet Oncol 8:1065–1066,

Vetter C, Devore EE, Wegrzyn LR, Massa J, Speizer FE, Kawachi I, Rosner B, Stampfer MJ, Schernhammer ES [2016]. Association between rotating night shift work and risk of coronary heart disease among women. JAMA 315(16):1726-34,

Page last reviewed: April 24, 2018