Evaluation of Exposures 

to Healthcare Personnel 

from Cisplatin during a 

Mock Interperitoneal 

Operation

James Couch MS, CIH, REHS/RS

Gregory Burr, CIH

Health Hazard Evaluation Report

HETA 2009-0121-3106

University Medical Center

Las Vegas, Nevada

March 2010 

Department of Health and Human Services

Centers for Disease Control and Prevention

Workplace

Safety and Health

 National Institute for Occupational 

Safety and Health

This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific 

facility evaluated and may not be universally applicable. Any recommendations made are not to be 

considered as final statements of NIOSH policy or of any agency or individual involved. Additional HHE 

reports are available at http://www.cdc.gov/niosh/hhe/
The employer shall post a copy of this report 

for a period of 30 calendar days at or near 

the workplace(s) of affected employees. The 

employer shall take steps to insure that the 

posted determinations are not altered, defaced, 

or covered by other material during such 

period. [37 FR 23640, November 7, 1972, as 

amended at 45 FR 2653, January 14, 1980].
Health Hazard Evaluation Report 2009-0121-3106 Page i

Appendix A

Report Abbreviations.......................................................................ii

Highlights of the NIOSH Health Hazard Evaluation............ iii

Summary ............................................................................iv

Introduction..........................................................................1

Assessment.........................................................................3

Results.................................................................................8

Discussion ...........................................................................9

Conclusions.......................................................................10

Recommendations.............................................................10

References ........................................................................12

Contents

Tables ................................................................................17

Methods.............................................................................13

Occupational Exposure Limits and Health Effects.............14

Acknowledgments

Appendix B

Appendix C

Acknowledgments and Availability of Report.....................21
Page ii Health Hazard Evaluation Report 2009-0121-3106

μg Microgram

μg/m3 Micrograms per cubic meter

ACGIH® American Conference of Governmental Industrial Hygienists

AIHA American Industrial Hygiene Association

BEI® Biological exposure index

CFR Code of Federal Regulations

cm Centimeter

GA General area

HHE Health hazard evaluation

IARC International Agency for Research on Cancer

ICP-MS Inductively coupled plasma mass spectrometry

IV Intravenous

LOD Limit of detection

LOQ Limit of quantification

MDC Minimum detectable concentration

mL Milliliter

NAICS North American Industry Classification System

NIOSH National Institute for Occupational Safety and Health

OEL Occupational exposure limit

OSHA Occupational Safety and Health Administration

PBZ Personal breathing zone

PEL Permissible exposure limit

PPE Personal protective equipment

REL Recommended exposure limit

STEL Short-term exposure limit

TLV® Threshold limit value

TWA Time-weighted average

UMC University Medical Center

WEEL Workplace environmental exposure level

Abbreviations
Health Hazard Evaluation Report 2009-0121-3106 Page iii

Highlights of the

NIOSH Health

Hazard Evaluation

The National Institute 

for Occupational 

Safety and Health 

(NIOSH) received a 

request for a health 

hazard evaluation 

from the management 

of the University 

Medical Center in Las 

Vegas, Nevada. The 

request concerned 

potential healthcare 

personnel exposures 

to cisplatin during a 

mock interperitoneal 

procedure.

What NIOSH Did

● We evaluated the facility on May 11–12, 2009.

● We took wipe samples and area and personal breathing zone 

air samples for cisplatin. Samples were taken during the 

pharmacy preparation, a mock interperitoneal procedure, 

cleaning of the operation room, and sterilization of the 

surgical equipment.

● We checked to see if the gloves worn by the employees 

protected them from cisplatin. We did this by asking 

employees to wear cotton gloves beneath their chemotherapyapproved gloves, which were then analyzed for cisplatin.

What NIOSH Found

● Cisplatin was not found in any of the general area or 

personal breathing zone air samples.

● Cisplatin was found on one of 15 wipe samples collected. 

This wipe sample was taken on the operating room floor 

after the mock interperitoneal procedure before the room 

was cleaned. No cisplatin was found at this same location 

after the operating room was sanitized.

● Cisplatin was not found on any of the cotton glove samples.

What Managers Can Do

● Require employees to wear two pairs of chemotherapy 

protective gloves.

● Train employees on the importance of minimizing splashes 

and spills of cisplatin solution. Such incidents should be 

promptly cleaned up and materials properly disposed in 

chemotherapy receptacles.

What Employees Can Do

● Follow the health and safety measures put into action 

by hospital management such as wearing two pairs of 

chemotherapy-approved gloves.

● Place cisplatin-contaminated equipment and materials in 

appropriate receptacles for either disposal or sterilization.

● Avoid splashing or spilling cisplatin during the 

interperitoneal procedure. Promptly clean up spills if they 

occur.
Page iv Health Hazard Evaluation Report 2009-0121-3106

Summary

NIOSH investigators 

evaluated potential 

cisplatin exposures 

before, during, and after 

a mock interperitoneal 

procedure. We detected 

no cisplatin in any air or 

hand-wipe samples. We 

did detect cisplatin in 

one surface wipe sample 

collected on the operating 

room floor after the mock 

procedure before the 

room was sanitized. No 

cisplatin was found at this 

same location after the 

room was sanitized. We 

recommend that surgical 

staff continue to use 

chemotherapy-approved 

gloves and handle 

the cisplatin solution 

carefully.

On March 24, 2009, NIOSH received a management request for 

an HHE at the UMC, in Las Vegas, Nevada. The HHE request 

was submitted because a new medical procedure was being 

proposed, and some hospital staff were concerned about potential 

exposures to cisplatin.

On May 11–12, 2009, we visited UMC to evaluate potential 

exposures to cisplatin during a mock demonstration of the new 

interperitoneal procedure. We collected GA and PBZ air samples 

and wipe samples for cisplatin. We evaluated the effectiveness 

of the chemotherapy-approved gloves worn by the employees by 

asking employees to wear cotton gloves beneath their 

chemotherapy-approved gloves. These cotton glove samples were 

then analyzed for cisplatin.

No cisplatin was detected in any GA air samples (MDC = 0.016 

μg/m3), personal breathing zone air samples (MDC = 0.058 μg/m3), 

or cotton glove samples (LOD = 0.009 μg/sample). Cisplatin was 

detected above the LOQ of 0.031 μg/sample on one of the 15 

wipe samples taken. This surface wipe sample was taken on the 

operating room floor near the surgical technician. No cisplatin 

was detected in surface wipe samples taken in the same area both 

prior to the interperitoneal procedure and after the room was 

sanitized (LOD = 0.007 μg/sample). This suggests that the UMC 

environmental services staff effectively removed any cisplatin 

contamination following the interperitoneal procedure.

We recommend that employees continue to double-glove by 

wearing two pairs of chemotherapy-protective gloves. We also 

recommend that management stress to employees the importance 

of minimizing splashes and spills. Cisplatin solution splashes 

or spills should be cleaned up promptly with proper disposal in 

chemotherapy receptacles.

Keywords: NAICS 622110 (General Medical and Surgical 

Hospitals), cisplatin, antineoplastic drugs, air samples, surface 

wipe samples, glove samples
Health Hazard Evaluation Report 2009-0121-3106 Page 1

Introduction

On March 24, 2009, NIOSH received a management request for 

an HHE at the UMC, in Las Vegas, Nevada. The UMC opened in 

1931 and employs more than 4,000 employees. The HHE request 

was submitted because a new procedure was being proposed, and 

potential exposures to cisplatin concerned some hospital staff. 

Cisplatin is an inorganic, antineoplastic oncology drug approved 

by the Federal Drug Administration for treatment of cancers such 

as bladder and ovarian cancer [NCI 2009]. Cisplatin has been 

categorized as a probable human carcinogen by the IARC [IARC 

2004].

On May 11–12, 2009, NIOSH investigators visited UMC 

to evaluate potential exposure to cisplatin during a mock 

demonstration of a proposed new interperitoneal procedure. We 

met with management and employee representatives and observed 

work processes/practices and workplace conditions. During the 

opening meeting we discussed the nature of the HHE and the 

types of sampling to be performed to evaluate cisplatin exposures. 

Representatives from the Service Employees International Union 

and hospital management were present during the meeting and 

provided input into other areas of concern within the hospital. We 

collected air, wipe, and cotton glove samples and analyzed them for 

cisplatin. A closing meeting was held on May 12, 2009, with UMC 

management, employees, and the Service Employees International 

Union to summarize site visit activities and provide preliminary 

findings. This was followed up with a letter dated August 4, 2009, 

that provided a preliminary summary and recommendations 

(sample results were not available at the time of the letter).

Process Description

Various UMC departments and personnel are potentially exposed 

to cisplatin during the preparation of the cisplatin solution 

by hospital pharmacy staff; the use of the cisplatin during the 

interperitoneal procedure; and the subsequent sanitization of the 

operating room, sterilization of medical equipment, and disposal of 

the potentially contaminated materials following completion of the 

interperitoneal procedure. To prepare the desired concentration, 

an employee in the hospital pharmacy injects cisplatin into an IV 

bag containing a saline solution. The pharmacy employee dons 

PPE (surgical mask, two pairs of chemotherapy protective gloves, 

chemotherapy protective covering, and hairnet) and performs the 

procedure in a ventilated laboratory hood. A nurse delivers the IV 

bag to the operating room.
Page 2 Health Hazard Evaluation Report 2009-0121-3106

Introduction 

(continued) The interperitoneal procedure is performed in an operating room 

by a surgeon, surgical technician, anesthesiologist, and nurses. 

During the mock procedure, all employees in the operating room 

except the surgeon wore powered air purifying respirators with 

high efficiency particulate air filters, two pairs of chemotherapy 

protective gloves, a chemotherapy protective covering over scrubs, 

and disposable coverings over shoes. The surgeon, a nonhospital 

employee, chose a surgical mask as his only PPE during the 

procedure. Powered air purifying respirators with a high efficiency 

filter were chosen by the hospital management because the 

procedure was new to the hospital and because of the uncertainty 

about the airborne exposure hazard. The cisplatin solution is 

emptied by tubing from the IV bag directly into an open body 

cavity where the surgeon manipulates the target organs in an 

effort to increase cisplatin absorption. The mock interperitoneal 

procedure used a metal pan (room temperature) to simulate the 

open body cavity. The dwell time of the cisplatin solution ranges 

from 20–90 minutes based upon the treatment protocol. At the 

end of the desired dwell time the cisplatin solution is suctioned out 

of the body cavity into a closed container. The body cavity is then 

closed and the patient is removed to recovery. Disposable items are 

placed into waste receptacles labeled as chemotherapy waste.

Surgical equipment and other items that may be reused are 

packaged in a yellow chemotherapy waste bag and sent to the 

Sterile Processing department. Upon receipt in Sterile Processing, 

the equipment is rinsed with water to remove gross contamination, 

washed with a 10% bleach/water solution, and then placed into a 

1% sodium thiosulfate/water solution (to neutralize any residual 

chlorine).

Environmental Services personnel sanitize the operating room 

by wiping down the walls, floors, and any other accessible 

surfaces with a 10% bleach solution and then again with a 

sodium thiosulfate solution to neutralize any residual chlorine. 

All disposable material is placed into waste receptacles labeled as 

chemotherapy waste. Environmental Service employees wore a 

powered air purifying respirator with a high efficiency particulate 

filter, two pairs of chemotherapy protective gloves, a chemotherapy 

protective covering over scrubs, and disposable coverings over 

shoes.
Health Hazard Evaluation Report 2009-0121-3106 Page 3

Assessment

On May 11–12, 2009, we collected air, wipe, and cotton glove 

samples and analyzed them for cisplatin. The mock interperitoneal 

procedure introduced a 5% cisplatin solution (100 mL of cisplatin 

in 1,900 mL of saline) into a metal pan. Neither the cisplatin 

solution nor the metal pan was heated to simulate the body 

temperature of the open cavity during the actual procedure. The 

surgeon allowed the 2,000 mL cisplatin solution to dwell in the 

metal pan for 20–25 minutes while intermittently manipulating 

the solution with his gloved hands to simulate massaging the 

solution into the target organs. The cisplatin solution was then 

suctioned out of the metal pan. All disposable material was then 

packaged into chemotherapy bags and placed in the corner of 

the room to be removed by Environmental Services. All reusable 

equipment was packaged in chemotherapy bags and sent to Sterile 

Processing.

General area air samples were taken using a high volume sample 

pump operating at 15 liters per minute. PBZ air samples were 

collected using air sampling pumps operating at 4 liters per 

minute. All of the air samples were taken for the duration of the 

mock interperitoneal procedure (approximately 45 minutes). Figure 

1 shows the locations of GA and PBZ samples along with basic 

dimensions of the operating room. Figure 2 shows a GA and PBZ 

sample being collected during the mock interperitoneal procedure.
Page 4 Health Hazard Evaluation Report 2009-0121-3106

Assessment (continued)

Figure 1. Operating Room 9 dimensions, orientation of air and wipe samples, location of ventilation 

supply and exhaust, and background sample location outside the operating room.
Health Hazard Evaluation Report 2009-0121-3106 Page 5

Assessment (continued)

Figure 2. General area and personal breathing zone samples collected 

during the cisplatin interperitoneal mock procedure.

Surface wipe samples were taken using Alpha Texwipe® swabs 

moistened with deionized water. A 10 cm x 10 cm square template 

was used to determine a 100 cm2 sampling area. The surface wipe 

samples were collected on the floor in three locations before the 

mock procedure, immediately after the mock procedure, and after 

the room was sanitized. Figure 3 shows the location of the surface 

wipe samples. Figure 4 shows a NIOSH investigator collecting a 

surface wipe sample.
Page 6 Health Hazard Evaluation Report 2009-0121-3106

Assessment (continued)

Figure 3. Diagram of Operating Room 9 showing the location of the

wipe samples and room dimensions.
Health Hazard Evaluation Report 2009-0121-3106 Page 7

Assessment (continued)

Figure 4. Collection of wipe sample with Alpha Texwipe swabs with a 

100 cm2 template.

To evaluate potential dermal exposure we asked employees to wear 

100% cotton gloves (Lab Safety Supply, Janesville, Wisconsin)

beneath their Biogel® latex gloves or nitrile chemotherapy 

protective gloves. The cotton gloves were then collected and 

analyzed for cisplatin to evaluate potential dermal exposure from 

permeation or leakage through the gloves or contamination when 

the employee donned or doffed them. Wearing sterile gloves, 

we removed the cotton gloves from the employees after they had 

removed their outer chemotherapy protective gloves. Figure 5 

shows a NIOSH investigator removing the cotton glove sample 

after the employee had already removed the nitrile chemotherapy 

protective gloves. The cotton gloves were worn beneath 

chemotherapy protective gloves so NIOSH investigators could 

evaluate permeation by cisplatin and hand contamination from 

donning/doffing the gloves.

All of these sample media were analyzed for cisplatin (as platinum) 

by ICP/MS. More information on the air, surface, and glove 

sample collection and analysis is provided in Appendix A. 

Information on OELs and health effects for cisplatin are discussed 

in Appendix B.
Page 8 Health Hazard Evaluation Report 2009-0121-3106

Assessment (continued)

Results

Air samples (GA and PBZ) were collected in the Inpatient 

Pharmacy, the operating room (before, during, and after the 

mock procedure, and then during the operating room

 sanitization), and Sterile Processing. Airborne cisplatin was not 

detected; concentrations were below the MDC (0.016 μg/m3

 for 

the GA air samples and 0.058 μg/m3

 for the PBZ air samples). The 

air sampling locations and results are presented in Appendix C, 

Table C1.

Surface wipe samples were taken in the Inpatient Pharmacy, the 

operating room, Sterile Processing, and from the hands of two 

employees. All wipe sample results are shown in Appendix C, 

Table C2. Cisplatin was detected in one surface wipe sample that 

was collected on the floor after the mock interperitoneal procedure 

but before the operating room was sanitized. Figure 3 illustrates the 

location of the wipe samples taken on the floor of the operating 

room.

Figure 5. NIOSH investigator collecting a cotton glove sample.
Health Hazard Evaluation Report 2009-0121-3106 Page 9

Results (continued) No cisplatin was detected (LOD = 0.009 μg of cisplatin per sample) 

on any of the cotton gloves worn beneath the chemotherapy 

protective gloves. As shown in Appendix C, Table C3, cotton glove 

samples were worn by employees in the Inpatient Pharmacy, during 

the mock interperitoneal procedure, and during room sanitization 

and equipment sterilization.

Cisplatin was detected on only one surface wipe sample. Because 

no cisplatin was detected at this sample location before the mock 

interperitoneal procedure and after the room was sanitized, this 

result suggests that the floor became contaminated with cisplatin 

during the mock interperitoneal procedure but was effectively 

removed during the sanitization process. It also shows the potential 

for chemotherapy drug contamination of the floor that could 

contribute to employee exposure to chemotherapy drugs.

Cisplatin was not detected on any air samples. This is not 

unexpected because cisplatin in a saline solution has a low vapor 

pressure (approximate to water), meaning that it will not readily 

volatilize at room temperature [Bedford Laboratories 2009]. 

Additionally, in the mock interperitoneal procedure the cisplatin 

solution was gently hand-stirred but not agitated, further lessening 

the chance that an airborne mist or aerosol could be created. There 

are no occupational exposure limits specifically for cisplatin in the 

air or on surfaces.

Cisplatin was not detected on any cotton gloves worn beneath 

the chemotherapy protective gloves that are normally worn when 

handling chemotherapy drugs. These results suggest that the 

chemotherapy protective gloves were protective against permeability 

of cisplatin during this mock procedure and that the glove donning 

and doffing procedures followed by the UMC staff did not result 

in skin contact with cisplatin.

Our findings only apply to this mock procedure. Additional 

monitoring during an actual procedure is needed because of the 

variations listed below or if any substantial changes are made to the 

procedure. Potential exposures to hospital staff during an actual 

procedure may differ based upon the following:

● Absorption of platinum from the cisplatin solution into the 

patient’s body

Discussion
Page 10 Health Hazard Evaluation Report 2009-0121-3106

Discussion (continued) ● Placing surgical instruments directly into the aluminum 

basin, an action that would not have occurred during an 

actual procedure

● Amount of manipulation of the cisplatin solution by the 

surgeon

● Temperature of the aluminum basin holding the cisplatin 

solution being lower than the temperature of a body cavity, 

which may lead to a difference in volatilization of materials

Based on our observations and review of standard operating 

procedures, UMC employees are potentially exposed to cisplatin 

when mixing this drug in the pharmacy, administering it during 

the mock interperitoneal procedure, sanitizing the operating room 

following cisplatin use, and cleaning and sterilizing the medical 

instruments. However, the use of chemotherapy protective gloves 

was effective in preventing dermal exposure to cisplatin during all 

of these activities. Results from the wipe sampling demonstrated 

that the mock interperitoneal procedure resulted in limited 

contamination with cisplatin, and that sanitation procedures 

effectively removed this contamination. Results from air sampling 

indicate that no detectable airborne exposure to cisplatin occurred 

during preparation of the cisplatin solution, during the mock 

interperitoneal procedure, or during room sanitizing or instrument 

sterilization.

Based on our findings we encourage UMC to use the following 

recommendations to develop an action plan based, if possible, on 

the hierarchy of controls approach (Appendix B: Occupational 

Exposure Limits and Health Effects). This approach groups actions 

by their likely effectiveness in reducing or removing hazards. 

In most cases, the preferred approach is to eliminate hazardous 

materials or processes and install engineering controls to reduce 

exposure or shield employees. Until such controls are in place, or 

if they are not effective or feasible, administrative measures and/or 

personal protective equipment may be needed.

Conclusions

Recommendations
Health Hazard Evaluation Report 2009-0121-3106 Page 11

Recommendations

(continued) Administrative Controls 

Administrative controls are management-dictated work practices 

and policies to reduce or prevent exposures to workplace hazards. 

The effectiveness of administrative changes in work practices 

for controlling workplace hazards depends on management 

commitment and employee acceptance. Regular monitoring and 

reinforcement are necessary to ensure that control policies and 

procedures are not circumvented in the name of convenience 

or production. The following administrative controls are 

recommended to reduce the employees’ personal exposures to the 

cisplatin.

1. Minimize splashing and spilling the cisplatin solution by 

gently manipulating the solution within the cavity and at 

target organ(s) when possible.

2. Promptly clean and dispose of any cisplatin solution spilled 

during the procedure.

3. Continue to use two pairs of chemotherapy protective gloves 

when handling cisplatin and other chemotherapy drugs.

4. Continue to wear chemotherapy protective gowns made of 

polyethylene-coated polypropylene.

5. Institute an awareness training program that includes 

management and employees learning more about 

cisplatin and other antineoplastic drugs. The following 

websites provide more information on occupational and 

environmental exposures, scientific research, and health 

concerns related to antineoplastic drugs:

● NIOSH: http://www.cdc.gov/niosh/topics/

antineoplastic

● OSHA: http://www.osha.gov/SLTC/hazardousdrugs/

recognition.html

In 2004, NIOSH issued an Alert titled, “Preventing Occupational 

Exposure to Antineoplastic and Other Hazardous Drugs in Health 

Care Settings” that details methods to eliminate or minimize 

occupational exposures [NIOSH 2004]. The document is an 

excellent resource for both management and employees to review 

to gain understanding in how to work safely with hazardous drugs.
Page 12 Health Hazard Evaluation Report 2009-0121-3106

Recommendations

(continued)

References

The results of additional monitoring during an actual procedure 

can assist in determining whether downgrading the level of personal 

protection equipment is appropriate.

Bedford Laboratories [2009]. Cisplatin material safety data sheet. 

Bedford Laboratories, Bedford, Ohio. [http://www.bedfordlabs.

com/BedfordLabsWeb/products/msdses/Cisplatin-1mgRev307.

pdf]. Date accessed: December 2009.

IARC [2004]. IARC monographs on the evaluation of the 

carcinogenic risk of chemicals to humans. Lyons, France: World 

Health Organization, International Agency for Research on Cancer. 

[http://www.iarc.fr]. Date accessed: November 2009.

NCI [2009]. Cisplatin. Bethesda, Maryland. National Cancer 

Institute. [http://www.cancer.gov/cancertopics/druginfo/cisplatin]. 

Date accessed: November 2009.

NIOSH [2004]. NIOSH Alert: Preventing occupational exposure 

to antineoplastic and other hazardous drugs in health care settings. 

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 No. 

2004-1193.
Health Hazard Evaluation Report 2009-0121-3106 Page 13

Air samples were taken using Quick Take 30 high volume sample pumps (15 liters per minute) for GA 

samples and AirChek 2000 air sampling pumps (4 liters per minute) for PBZ samples. These samples were 

taken for the duration of the mock interperitoneal procedure (approximately 45 minutes). The sample 

media were analyzed for platinum (and then calculated as cisplatin) by ICP/MS with an LOD of 0.009 

μg of cisplatin per sample and an LOQ of 0.029 μg of cisplatin per sample. The MDC of cisplatin in GA 

samples was 0.016 μg/m3 based on a 576-liter air sample. The MDC of cisplatin in PBZ samples was 0.058 

μg/m3 based on a 157-liter air sample. The sampling method is an internal procedure developed by Bureau 

Veritas North America.

Wipe samples were taken using Alpha Texwipe swabs moistened with deionized water. A 10 cm x 10 

cm square template was used to determine a 100 cm2 sampling area. The sample media was analyzed for 

platinum (and then calculated as cisplatin) by ICP/MS with an LOD of 0.007 μg of cisplatin per sample 

and an LOQ of 0.031 μg of cisplatin per sample.

Cotton glove samples were worn beneath either Biogel latex gloves or nitrile chemotherapy protective 

gloves used by the hospital employees. NIOSH investigators, wearing sterile gloves, removed the cotton 

gloves from each employee after he or she had removed their outer chemotherapy protective gloves. Each 

pair of cotton gloves were analyzed for platinum (and then calculated as cisplatin) by ICP/MS. The LOD 

was 0.009 μg of cisplatin per sample, and the LOQ was 0.03 μg of cisplatin per sample.

Appendix A: Methods
Page 14 Health Hazard Evaluation Report 2009-0121-3106

In evaluating the hazards posed by workplace exposures, NIOSH investigators use both mandatory (legally 

enforceable) and recommended OELs for chemical, physical, and biological agents as a guide for making 

recommendations. OELs have been developed by Federal agencies and safety and health organizations to 

prevent the occurrence of adverse health effects from workplace exposures. Generally, OELs suggest levels 

of exposure that most employees may be exposed up to 10 hours per day, 40 hours per week for a working 

lifetime without experiencing adverse health effects. However, not all employees will be protected from 

adverse health effects even if their exposures are maintained below these levels. A small percentage may 

experience adverse health effects because of individual susceptibility, a preexisting medical condition, and/

or a hypersensitivity (allergy). In addition, some hazardous substances may act in combination with other 

workplace exposures, the general environment, or with medications or personal habits of the employee 

to produce health effects even if the occupational exposures are controlled at the level set by the exposure 

limit. Also, some substances can be absorbed by direct contact with the skin and mucous membranes in 

addition to being inhaled, which contributes to the individual’s overall exposure.

Most OELs are expressed as a TWA exposure. A TWA refers to the average exposure during a normal 8- 

to 10-hour workday. Some chemical substances and physical agents have recommended STEL or ceiling 

values where health effects are caused by exposures over a short period. Unless otherwise noted, the STEL 

is a 15-minute TWA exposure that should not be exceeded at any time during a workday, and the ceiling 

limit is an exposure that should not be exceeded at any time.

In the United States, OELs have been established by Federal agencies, professional organizations, state 

and local governments, and other entities. Some OELs are legally enforceable limits, while others are 

recommendations. The U.S. Department of Labor OSHA PELs (29 CFR 1910 [general industry]; 29 

CFR 1926 [construction industry]; and 29 CFR 1917 [maritime industry]) are legal limits enforceable in 

workplaces covered under the Occupational Safety and Health Act. NIOSH RELs are recommendations 

based on a critical review of the scientific and technical information available on a given hazard and the 

adequacy of methods to identify and control the hazard. NIOSH RELs can be found in the NIOSH Pocket 

Guide to Chemical Hazards [NIOSH 2005]. NIOSH also recommends different types of risk management 

practices (e.g., engineering controls, safe work practices, employee education/training, personal protective 

equipment, and exposure and medical monitoring) to minimize the risk of exposure and adverse health 

effects from these hazards. Other OELs that are commonly used and cited in the United States include 

the TLVs recommended by ACGIH, a professional organization, and the WEELs recommended by the 

American Industrial Hygiene Association, another professional organization. The TLVs and WEELs are 

developed by committee members of these associations from a review of the published, peer-reviewed 

literature. They are not consensus standards. ACGIH TLVs are considered voluntary exposure guidelines 

for use by industrial hygienists and others trained in this discipline “to assist in the control of health 

hazards” [ACGIH 2009]. WEELs have been established for some chemicals “when no other legal or 

authoritative limits exist” [AIHA 2009].

Outside the United States, OELs have been established by various agencies and organizations and include 

both legal and recommended limits. Since 2006, the Berufsgenossenschaftliches Institut für Arbeitsschutz 

(German Institute for Occupational Safety and Health) has maintained a database of international 

Appendix B: Occupational Exposure Limits and Health Effects
Health Hazard Evaluation Report 2009-0121-3106 Page 15

Appendix B: Occupational Exposure Limits and Health Effects (continued)

OELs from European Union member states, Canada (Québec), Japan, Switzerland, and the United 

States available at http://www.dguv.de/bgia/en/gestis/limit_values/index.jsp. The database contains 

international limits for over 1250 hazardous substances and is updated annually.

Employers should understand that not all hazardous chemicals have specific OSHA PELs, and for some 

agents the legally enforceable and recommended limits may not reflect current health-based information. 

However, an employer is still required by OSHA to protect its employees from hazards even in the absence 

of a specific OSHA PEL. OSHA requires an employer to furnish employees a place of employment free 

from recognized hazards that cause or are likely to cause death or serious physical harm [Occupational 

Safety and Health Act of 1970 (Public Law 91–596, sec. 5(a)(1))]. Thus, NIOSH investigators encourage 

employers to make use of other OELs when making risk assessment and risk management decisions to 

best protect the health of their employees. NIOSH investigators also encourage the use of the traditional 

hierarchy of controls approach to eliminate or minimize identified workplace hazards. This includes, in 

order of preference, the use of: (1) substitution or elimination of the hazardous agent, (2) engineering 

controls (e.g., local exhaust ventilation, process enclosure, dilution ventilation), (3) administrative controls 

(e.g., limiting time of exposure, employee training, work practice changes, medical surveillance), and (4) 

personal protective equipment (e.g., respiratory protection, gloves, eye protection, hearing protection). 

Control banding, a qualitative risk assessment and risk management tool, is a complementary approach 

to protecting employee health that focuses resources on exposure controls by describing how a risk 

needs to be managed. Information on control banding is available at http://www.cdc.gov/niosh/topics/

ctrlbanding/. This approach can be applied in situations where OELs have not been established or can be 

used to supplement the OELs, when available.

Cisplatin 

Although OSHA and NIOSH have not established OELs for cisplatin, it has been categorized as a 

probable human carcinogen by IARC [IARC 2004]. Because of the potential carcinogenicity of cisplatin, 

exposures to cisplatin in pure form and in dilution should be controlled to the lowest achievable levels.

References

ACGIH [2009]. 2008 TLVs® and BEIs®: threshold limit values for chemical substances and physical 

agents and biological exposure indices. Cincinnati, OH: American Conference of Governmental 

Industrial Hygienists.

AIHA [2009]. AIHA 2008 Emergency response planning guidelines (ERPG) & workplace environmental 

exposure levels (WEEL) handbook. Fairfax, VA: American Industrial Hygiene Association.

CFR. Code of Federal Regulations. Washington, DC: U.S. Government Printing Office, Office of the 

Federal Register.
Page 16 Health Hazard Evaluation Report 2009-0121-3106

Appendix B: Occupational Exposure Limits and Health Effects (continued)

IARC [2004]. IARC monographs on the evaluation of the carcinogenic risk of chemicals to humans. 

Lyons, France: World Health Organization, International Agency for Research on Cancer. [http://www.

iarc.fr]. Date accessed: November 2009.

NIOSH [2005]. NIOSH pocket guide to chemical hazards. 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 No. 2005-149. [http://www.cdc.gov/niosh/npg/]. Date 

accessed: November 2009.
Health Hazard Evaluation Report 2009-0121-3106 Page 17

Appendix C: Tables

Table C1. Cisplatin sample results for general area and personal breathing zone air samples on 

May 11–12, 2009

Sample Location Sample Description Result

(μg/m3)

 General Area Air Samples

Inpatient Pharmacy Senior pharmacy technician mixing cisplatin solution within 

chemical hood

ND*

Operating Room Near head of operating table ND*

Operating Room At the head of operating table during mock procedure ND*

Operating Room At the foot of table during mock procedure ND*

Operating Room On instrument table during mock procedure ND*

Outside In hallway, adjacent to and just outside of operating room ND*

* Not detected (concentration is below the MDC of 0.016 μg/m3, based on a 576-liter air sample)

 Personal Breathing Zone Air Samples

Operating Room Environmental Services manager sanitizing operating room 

after mock procedure

ND†

Operating Room Registered nurse preparing and spiking cisplatin IV bag ND†

Operating Room Surgical technician assisting physician ND†

Operating Room Physician administering and manipulating the cisplatin 

solution within the metal pan

ND†

Sterile

Processing

Sterile Processing manager sterilizing equipment used in 

mock procedure

ND†

† Not detected (concentration is below the MDC of 0.058 μg/m3, based on a 157-liter air sample)
Page 18 Health Hazard Evaluation Report 2009-0121-3106

Appendix C: Tables (continued)

Table C2. Cisplatin wipe sample results using Alpha TexWipe swabs on May 11–12, 2009

Sample Location Sample Description Result

(μg/sample)*

Inpatient Pharmacy Surface of chemotherapy mixing hood after cisplatin 

solution was prepared

ND†

Operating Room

(before mock interperitoneal 

procedure) 

On floor away from cisplatin ND†

On floor nearside to cisplatin ND†

On floor, at head of operating table ND†

Hand wipe from registered nurse ND‡

Hand wipe from Environmental Services manager ND‡

Operating Room

(after mock interperitoneal 

procedure but before 

sanitization)

On floor away from cisplatin ND†

On floor nearside to cisplatin 0.08

On floor, at head of operating table ND†

Sterile Processing

Surface of stainless steel decontamination sink 

(sink contained 10% bleach solution) ND†

Surface of stainless steel rinse sink ND†

On cart used to transport surgical instruments from 

operating room to sterile processing ND†

Operating Room

(after sanitization)

On floor away from cisplatin ND†

On floor nearside from cisplatin ND†

On floor at head of operating table ND†

* A 10 cm x 10 cm square disposable template was used to define the sampling area.

† ND = not detected (below the LOD of 0.007 μg of cisplatin per sample)

‡ The hand wipe samples were collected by swabbing both hands of the employee with an Alpha TexWipe moistened with 

deionized water. A disposable template was not used for these samples.
Health Hazard Evaluation Report 2009-0121-3106 Page 19

Appendix C: Tables (continued)

Table C3. Cisplatin sample results for cotton glove samples on May 11–12, 2009

Sample Location Outer Glove Sample Description Result

(μg/sample)

Inpatient 

Pharmacy

Nitrile 

chemotherapy 

gloves

Senior pharmacy technician mixing cisplatin 

solution in chemical hood 

ND†

Operating Room Biogel Physician adding and manipulating cisplatin in the 

metal pan 

ND†

Operating Room Nitrile 

chemotherapy 

gloves

Registered nurse spiking cisplatin intravenous bag 

and assisting in the mock procedure 

ND†

Operating Room Biogel Surgical technician assisting physician during mock 

procedure

ND†

Sterile Processing Nitrile 

chemotherapy 

gloves

Manager sterilizing equipment used in mock 

procedure 

ND†

Environmental 

Services

Nitrile 

chemotherapy 

gloves

Manager cleaning/sanitizing room after mock 

procedure

ND†

Environmental 

Services

Nitrile 

chemotherapy 

gloves

Manager cleaning/sanitizing room after mock 

procedure 

ND†

* Each sample consisted of a pair of cotton gloves worn by the employee beneath their outer chemotherapy-approved 

gloves.

† ND = not detected (below the LOD of 0.009 μg of cisplatin per sample) 
This page intentionally left blank.
Health Hazard Evaluation Report 2009-0121-3106 Page 21

Acknowledgments and

Availability of Report

The Hazard Evaluations and Technical Assistance Branch 

(HETAB) of the National Institute for Occupational Safety and 

Health (NIOSH) conducts field investigations of possible health 

hazards in the workplace. These investigations are conducted 

under the authority of Section 20(a)(6) of the Occupational 

Safety and Health (OSH) Act of 1970, 29 U.S.C. 669(a)(6) which 

authorizes the Secretary of Health and Human Services, following 

a written request from any employer or authorized representative 

of employees, to determine whether any substance normally found 

in the place of employment has potentially toxic effects in such 

concentrations as used or found. HETAB also provides, upon 

request, technical and consultative assistance to federal, state, and 

local agencies; labor; industry; and other groups or individuals to 

control occupational health hazards and to prevent related trauma 

and disease.

The findings and conclusions in this report are those of the 

authors and do not necessarily represent the views of NIOSH. 

Mention of any company or product does not constitute 

endorsement by NIOSH. In addition, citations to websites 

external to NIOSH do not constitute NIOSH endorsement of 

the sponsoring organizations or their programs or products. 

Furthermore, NIOSH is not responsible for the content of these 

websites. All Web addresses referenced in this document were 

accessible as of the publication date.

This report was prepared by James Couch and Gregory Burr of 

HETAB, Division of Surveillance, Hazard Evaluations and Field 

Studies. Health communication assistance was provided by Stefanie 

Evans. Editorial assistance was provided by Ellen Galloway. 

Desktop publishing was performed by Robin Smith.

Copies of this report have been sent to employee and 

management representatives at University Medical Center, the 

state health department, and the Occupational Safety and Health 

Administration Regional Office. This report is not copyrighted and 

may be freely reproduced. The report may be viewed and printed at 

http://www.cdc.gov/niosh/hhe/. Copies may be purchased from the 

National Technical Information Service at 5825 Port Royal Road, 

Springfield, Virginia 22161.
NIOSH [2010]. Health hazard evaluation report: evaluation of exposures to 

healthcare personnel from cisplatin during a mock interperitoneal operation, 

Las Vegas, NV. By Couch J and Burr G. Cincinnati, OH: U.S. Department of 

Health and Human Services, Centers for Disease Control and Prevention, 

National Institute for Occupational Safety and Health, NIOSH HETA No. 2009-

0121-3106.

To receive NIOSH documents or information about 

occupational safety and health topics, contact NIOSH at:

1-800-CDC-INFO (1-800-232-4636)

TTY: 1-888-232-6348

E-mail: cdcinfo@cdc.gov

or visit the NIOSH web site at: www.cdc.gov/niosh.

For a monthly update on news at NIOSH, subscribe to 

NIOSH eNews by visiting www.cdc.gov/niosh/eNews.

Delivering on the Nation’s promise:

Safety and health at work for all people

through research and prevention.

 National Institute for Occupational 

Safety and Health