Medical Surveillance for Health Care 


Workers Exposed to Hazardous Drugs
 

Summary 

Health care workers who handle, prepare, or administer hazardous drugs may face risks to 

their own health such as skin 

rashes, cancer, and reproductive disorders. NIOSH recommends that employers establish 

a medical surveillance program 

to protect workers who handle 

hazardous drugs in the workplace. 

Description of 

Exposure 

Drugs are considered hazardous 

if studies in animals or humans 

show that exposures to them have 

a potential for causing cancer, reproductive toxicity, birth defects, 

or acute harm to health. In the 

United States, an estimated 5.5 

million health care workers are 

potentially exposed to hazardous drugs or drug waste at their 

worksites. These workers include 

pharmacists and pharmacy technicians, nursing personnel, physicians, operating room personnel, 

practices. Workers may be exposed 

to hazardous drugs when they create aerosols, generate dust, clean 

up spills, or touch contaminated 

surfaces when preparing, administering, or disposing of hazardous 

drugs [NIOSH 2004]. 

Many hazardous drugs are used 

to treat illnesses such as cancer or 

HIV infection (see Figure 1). For 

the patients, the potential benefits of hazardous drugs outweigh 

the possible negative side effects. 

However, exposed health care 

workers risk the same side effects 

with no positive benefit. Workers 

exposed to hazardous drugs have 

developed skin rashes, adverse reproductive effects, and possibly 

leukemia and other cancers. For 

example, nurses and pharmacists 

who were exposed to hazardous 

drugs at their worksite reported 

an increase in adverse reproductive events including spontaneous 

abortions, stillbirths, and congenital malformations compared with 

unexposed health care workers 

[NIOSH 2004]. 

Figure 1. Multi-channel infusion 

pump for delivery of chemotherapy. 

Exposure to hazardous drugs may 

occur through inhalation, skin contact, skin absorption, ingestion, or 

injection. Inhalation or skin contact and absorption are the most 

likely ways a worker may be exposed to hazardous drugs. However, ingestion (from hand to mouth) 

or injection through a needlestick 

or sharps injury is possible. 

shipping and receiving person- DEPARTMENT OF HEALTH AND HUMAN SERVICES 

nel, waste handlers, maintenance Centers for Disease Control and Prevention 

workers, and workers in veterinary National Institute for Occupational Safety and Health 
 

 

 

 

 

 

 

 

 

 

Medical Surveillance 

A comprehensive approach to minimizing worker exposure should be used as part of a safety and 

health program that includes engineering controls, good work practices, and personal protective 

equipment (PPE) supported by a medical surveillance program. Medical surveillance involves collecting and interpreting data to detect changes in 

the health status of working populations potentially exposed to hazardous substances. The elements 

of a medical surveillance program are used to establish a baseline of workers’ health and then monitor 

their future health as it relates to their potential exposure to hazardous agents. 

Employers should ensure that health care workers 

who are exposed to hazardous drugs are routinely 

monitored as part of a medical surveillance program 

[ASHP 2006; OSHA 1999]. This includes workers 

who directly handle hazardous drugs such as nurses, pharmacists, and pharmacy technicians. In addition, other workers (e.g., nurses’ aides, laundry 

workers) who may come directly into contact with 

patient wastes within 48 hours after a patient has 

received a hazardous drug should be included in a 

medical surveillance program. 

Elements of a Medical 

Surveillance Program 

The elements of a medical surveillance program for 

hazardous drugs should include (at a minimum): 

■	 Reproductive and general health questionnaires 

completed at the time of hire and periodically 

thereafter 

■	 Laboratory work, including complete blood count 

and urinalysis completed at the time of hire and 

periodically thereafter. Additional tests, such as 

liver function and transaminase tests, may be 

considered. 

■	 Physical examination completed at the time of 

hire and then as needed for any worker whose 

health questionnaire or blood work indicates an 

abnormal finding 

■	 Followup for those workers who have shown 

health changes or have had a significant exposure 

(e.g., substantial skin contact, cleaning a large 

spill [a broken bag, leaking IV line], etc.) 

Periodic health questionnaires and laboratory results should be looked at for trends that may be a 

sign of health changes because of exposure to hazardous drugs. If health changes are found, the employer should take the following actions: 

■	 Evaluate current protective measures: 

1. Engineering controls (biological safety cabinets/ 

isolators, ventilation, closed system transfer devices, and closed IV systems) 

—	 Compare performance of controls with 

recommended standards. 

—	 Conduct environmental sampling when 

analytical methods are available. 

2. Policies for the use of PPE and employee compliance with PPE use and policies 

3. Availability of appropriate PPE such as double 

gloves, nonpermeable gowns, and respiratory 

protection 

■	 Develop plan of action that will prevent further 

employee exposure. 

■	 Ensure confidential notification of any adverse 

health effect to an exposed worker and offer alternative duty or temporary reassignment. 

■	 Provide ongoing medical surveillance of all workers at risk to determine whether the new plan is 

effective. 

Acknowledgments 

The principal authors of this document were Melissa Leone, Apria Healthcare; Melissa McDiarmid, 

University of Maryland; Marty Polovich, Oncology Nursing Society; Barbara Coyle, Wisconsin State 

Laboratory of Hygiene; Luci Power, University 

of California Medical Center in San Francisco, and 

Thomas H. Connor and Laurence D. Reed of the National Institute for Occupational Safety and Health. 
 

 

 

 

 

John J. Whalen, under a contract with the Division 

of Federal Occupational Health, served as the lead 

writer/editor. 

References 

ASHP (American Society of Health-System Pharmacists) [2006]. ASHP guidelines on handling hazardous drugs. Am J Health-Syst Pharm 63:1172–1193. 

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, 

Public Health Service, Centers for Disease Control 

and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication 

No. 2004–165. 

OSHA [1999]. Controlling occupational exposure 

to hazardous drugs. In: OSHA Technical Manual (TED 01–00–015: TED 1–0.15A), Section VI, 

Chapter 2. [www.osha.gov/dts/osta/otm/otm_vi/ 

otm_vi_2.html]. Washington, DC: Occupational 

Safety and Health Administration. Date accessed: 

September 26, 2005. 

For More Information 

NIOSH has published an Alert describing measures to control worker exposure to hazardous drugs: www.cdc.gov/ 

niosh/docs/2004-165/ 

Additional information about hazardous drugs is available on 

the NIOSH Web site at www.cdc.gov/niosh/topics/hazdrug/ 

default.html. To receive copies of NIOSH publications, contact NIOSH at 

NIOSH 

Publications Dissemination 

4676 Columbia Parkway 

Cincinnati, OH 45226–1998 

Telephone: 1–800–35–NIOSH (1–800–356–4674) 

Fax: 513–533–8573 ■ E-mail: pubstaft@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. ■

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 illness and injuries. All Workplace Solutions are based on 

research studies that show how worker exposures to hazardous agents or activities can be significantly reduced. 

DHHS (NIOSH) Publication No. 2007–117 

Medical Surveillance for Health Care Workers 

Exposed to Hazardous Drugs 

Safer • Healthier • PeopleTM 
 

 

Medical Surveillance for Health Care 


Workers Exposed to Hazardous Drugs
 

DHHS (NIOSH) Publication No. 2007–117 April 2007 

DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Centers for Disease Control and Prevention 

National Institue for Occupational Safety and Health 

4676 Columbia Parkway 

Cincinnati, OH 45226–1998