WORKPLACE SOLUTIONS

From the National Institute for Occupational Safety and Health

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

National Institute for Occupational Safety and Health

Summary

Health care workers who handle 

hazardous drugs are at risk of skin 

rashes, cancer, and reproductive 

disorders. NIOSH recommends 

that employers provide appropriate personal protective equipment (PPE) to protect workers 

who handle hazardous drugs in 

the workplace.

Personal Protective Equipment for 

Health Care Workers Who Work with 

Hazardous Drugs 

Description of

Exposure

Health care workers face serious health 

risks when exposed to hazardous drugs. 

This is a group of drugs that cause specific health effects such as cancer or 

birth defects, or are highly toxic at low 

doses. A list of hazardous drugs has 

been developed by NIOSH [2004]. For 

patients, potential benefits of treatment 

outweigh the risks from adverse side effects. However, health care workers 

should minimize their exposure and 

health risks.

In the United States, an estimated

8 million health care workers [BLS 

2007] are potentially exposed to hazardous drugs or drug waste at their worksites. These workers include pharmacy 

and nursing personnel, physicians, operating room personnel, veterinary personnel, shipping and receiving personnel, laundry workers, waste handlers, 

and maintenance workers. They may 

be exposed to hazardous drugs when 

they handle drug vials; compound, administer, or dispose of hazardous drugs; 

clean spills; or touch contaminated surfaces. These activities may create aerosols, thereby increasing the risk of exposure [NIOSH 2004]. Inhalation, 

ingestion, (from hand to mouth), injection with a sharp, and transconjunctival 

or skin absorption are possible routes of 

exposure.

Controls 

NIOSH recommends minimizing exposure to hazardous drugs [NIOSH 

2004] through primary prevention 

measures such as engineering controls, 

administrative controls, and personal protective equipment (PPE). Engineering controls include Class II or 

III biological safety cabinets (BSC), 

compounding aseptic containment isolators, closed system transfer devices, and needleless systems. Administrative controls include implementing 

work practices, management policies, 

and training programs to reduce worker risk. A medical monitoring program 

serves as a form of secondary prevention by identifying indicators of exposure or early disease [NIOSH 2007]. 

PPE should be used when engineering 

controls and/or administrative controls 

are not feasible in reducing exposures 

to hazardous drugs or when other control measures are not available or practical [OSHA 1999]. PPE should always 

be used in the context of an overall 

health and safety program that provides adequate training, retraining, and 

periodic testing of the workers’ knowledge of the proper use of PPE. 

PPE

PPE such as NIOSH-certified respirators and protective clothing must be 

used to reduce exposure to hazardous drugs when other measures are not 

possible. The following general guidelines apply to PPE use and care:

 Select specific respirators and protective clothing based on an assessment 
of your potential exposure to hazardous drugs.

 Understand the proper use and limitations of any selected PPE to ensure that it functions properly.

 Use care in donning and removing all items to prevent 

damage to PPE and to reduce the spread of contamination.

 Ensure that all PPE fits correctly and is constructed of 

materials that are appropriate for hazardous drug exposure [NIOSH 2004].

 Donning and removal of PPE should follow local hospital procedures and the manufacturer’s instructions.

Gloves

Surfaces in areas where hazardous drugs are present may 

be contaminated with these drugs [NIOSH 2004]. Not all 

gloves offer adequate protection from dermal exposure to 

hazardous drugs. Some gloves may permit rapid permeation 

of hazardous drugs. For example, polyvinyl chloride exam 

gloves offer little protection against drug exposures [Wallemacq et al. 2006]. Although thicker gloves may offer better protection, glove thickness does not always indicate the 

level of protection and may make work activities more difficult. Instead, it is important to rely on test information 

provided by the glove manufacturer that demonstrates permeation resistance to specific hazardous drugs. Currently, guidelines are only available for testing “chemotherapy 

gloves” [ASTM 2005] and information may not be available 

for other types of hazardous drugs. 

Follow these work practices when using gloves:

 Inspect gloves for defects before use and change gloves 

on a regular basis. Changing recommendations vary from 

30–60 minutes [NIOSH 2004; ASHP 2006]. Whenever 

gloves are damaged or contact with a drug is known or suspected, carefully remove and dispose of them properly.

 Use powder-free gloves since the powder can contaminate the work area and can adsorb and retain hazardous drugs.

 Wear two pairs of gloves when compounding, administering, and disposing of hazardous drugs.

 Sterile chemotherapy gloves are required for compounding of sterile preparations under USP Chapter <797>.

 Wear the inner glove under the gown cuff and the outer glove over the cuff. Place gloves with long cuffs over 

the cuff of the gown to protect the wrist and forearm 

[ASHP 2006; Polovich et al. 2005].

 When compounding sterile preparations, sanitize gloves 

with sterile 70% alcohol spray or gel and allow them to 

dry; ensure that the selected gloves are not degraded by 

alcohol.

 When removing double gloves, turn gloves inside-out so 

that contaminated surfaces do not touch uncontaminated surfaces.

 Wash hands thoroughly with soap and water both before 

donning and after removing gloves.

Gowns

Proper gowns protect the worker from spills and splashes of hazardous drugs and waste materials. Gowns should 

not have seams or closures that could allow drugs to pass 

through. They should have long sleeves with tight fitting 

cuffs. Disposable gowns made of polyethylene-coated polypropylene or other laminate materials offer better protection than those of non-coated materials [NIOSH 2004; 

ASHP 2006]. Cloth laboratory coats, surgical scrubs, or 

other absorbent materials permit the penetration of hazardous drugs, and can hold spilled drugs against the skin and increase exposure. 

Follow these work practices when wearing gowns:

 Dispose of gowns after each use. Reusing gowns increases the likelihood of exposure to hazardous drugs.

 Wear gowns whenever there is a possibility of splash or 

spill as in compounding or administration of hazardous 

drugs.

 Do not wear gowns outside the compounding or administration area to avoid spreading drug contamination to other areas and possibly exposing nonprotected workers.

 If no permeation information is available for the gowns 

you use, change them every 2 to 3 hours or immediately after a spill or splash [ASHP 2006].

Respiratory Protection

For most activities requiring respiratory protection, a 

NIOSH-certified N–95 or more protective respirator is sufficient to protect against airborne particles [NIOSH 2005]; 

however, these respirators offer no protection against gases and vapors and little protection against direct liquid 

splashes. A surgical N-95 respirator provides the respiratory protection of an N-95 respirator and the splash protection provided by a surgical mask. Surgical masks alone 

do not provide respiratory protection from drug exposure 

and should not be used to compound or administer drugs 

[NIOSH 2004]. 

Follow these recommendations when using respiratory protection:

 Use an appropriate full-facepiece chemical cartridge-type 

respirator [42 CFR* 84; NIOSH 2005] for events such as 

large spills when an intravenous (IV) bag breaks or a line 

*Code of Federal Regulations. See CFR in references.
disconnects and leaks, or where there is known or suspected airborne exposure to vapors or gases.

Following medical evaluation, fit-test and train workers to 

use respiratory protection. Follow all requirements in the 

Occupational Safety and Health Administration respiratory 

protection standard [29 CFR 1910.134] (www.osha.gov/

SLTC/etools/respiratory/index.html).

Eye and Face Protection

Proper eye and face protection is needed whenever hazardous drugs may splash in the eyes since many hazardous 

drugs are irritating to eyes and mucous membranes and may 

be absorbed by the eyes.

Follow these work practices when using eye and face protection:

 Use eye and face protection when compounding a drug 

outside the BSC or isolator (e.g., in the operating room), 

working at or above eye level, cleaning a BSC or containment isolator, or cleaning a spill. 

 Use face shields in combination with goggles to provide 

a full range of protection against splashes to the face and 

eyes. Face shields alone do not provide full eye and face 

protection.

 Do not use eye glasses or safety glasses with side shields, 

as they do not offer adequate protection to the eyes 

from splashes.

 A full-facepiece respirator also provides eye and face 

protection.

Sleeve, Hair, and Shoe Covers

Other types of PPE may be used to reduce exposure or to 

protect workers from contamination.

 Use sleeve covers constructed of coated materials to 

provide additional protection for the areas of the arms 

that come in contact with the BSC.

 Use hair and shoe covers constructed of coated materials to reduce the possibility of particulate or microbial 

contamination in clean rooms and other sensitive areas.

 Do not wear shoe covers outside drug compounding areas to avoid spreading drug contamination to other areas 

and possibly exposing nonprotected workers. 

PPE Disposal

 Consider all PPE worn when handling hazardous drugs 

as being contaminated with, at a minimum, trace quantities of hazardous drugs. 

 Contain and dispose of such PPE either as trace or bulk 

contaminated waste [NIOSH 2004].

Acknowledgments

The principal authors of this document were Thomas H. 

Connor and Laurence D. Reed, National Institute for Occupational Safety and Health; Martha Polovich, Oncology Nursing Society; Melissa A. McDiarmid, University of 

Maryland; Melissa M. Leone, Apria Healthcare; and Luci A. 

Power, University of California Medical Center, San Francisco. John J. Whalen, under a contract with the Public 

Health Service, Division of Federal Occupational Health, 

served as the lead writer/editor.

References

ASHP [2006]. ASHP guidelines on handling hazardous drugs. 

Am J Health-Syst Pharm 63:1172–1193.

ASTM [2005]. Standard practice assessment of resistance of 

medical gloves to permeation by chemotherapy drugs. West 

Conshohocken, PA: American Society for Testing and Materials. ASTM D 6978–05.

BLS [2007]. Occupational employment and wage estimates,

May 2006 [http://146.142.422oeshome.htm#overview].

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

NIOSH [2004]. NIOSH Alert: preventing occupational exposures 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. 2004–165.

NIOSH [2005]. NIOSH respirator selection logic 2004. 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. 2005–100.

NIOSH [2007]. NIOSH Workplace Solution: medical surveillance for health care workers exposed to hazardous drugs. 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. 2007–117.

OSHA [1999]. Categorization of drugs as hazardous. In: OSHA 

technical manual, TED 1–0.15A, Sec VI, Chapter II. Washington, DC: U.S. Department of Labor, Occupational Safety and 

Health Administration [www.osha.gov/dts/osta/otm/otm_vi/

otm_vi_2.html#2]. 

U.S. Pharmacopeial Convention [2008]. Pharmaceutical compounding sterile preparations. Chapter <797>. 31st ed. Rockville, MD: United States Pharmacopeial Convention. 

Polovich M, White JM, Kelleher LO, eds. [2005]. Chemotherapy and biotherapy guidelines and recommendations for practice. 2nd ed. Pittsburgh, PA: Oncology Nursing Society.

Wallemacq PE, Capron A, Vanbinst R, Boeckmans E, Gillard 

J, Favier B [2006]. Permeability of 13 different gloves to 13 

cytotoxic agents under controlled dynamic conditions. Am J 

Health-Syst Pharm 63:547–556.
DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

National Institute for Occupational Safety and Health

4676 Columbia Parkway

Cincinnati, OH 45226–1998

safer • healthier • peopletm

Official Business

Penalty for Private Use $300

For More Information

To receive more information about hazardous drugs and 

other occupational safety and health topics, contact 

NIOSH at

Telephone: 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.

Mention of any company or product does not constitute 

endorsement by NIOSH. In addition, citations to Web 

sites 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 Web sites.

This document is in the public domain and may be 

freely copied or reprinted. NIOSH encourages all 

readers of the Workplace Solutions to make them 

available to all interested employers and workers.

As part of the Centers for Disease Control and Prevention, NIOSH is the Federal agency responsible for conducting research and making recommendations to prevent work-related illnesses and injuries. All Workplace 

Solutions are based on research studies that show how 

worker exposures to hazardous agents or activities can be 

significantly reduced.

Personal Protective Equipment for Health Care 

Workers Who Work with Hazardous Drugs

DHHS (NIOSH) Publication No. 2009–106

October 2008