DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

National Institute for Occupational Safety and Health

Summary

Healthcare workers who prepare, 

administer, or transport hazardous 

drugs or dispose of hazardous drug 

waste may face risks to their own 

health such as skin disorders, reproductive disorders, and possibly 

cancer. NIOSH recommends that 

employers establish a medical surveillance program as part of a comprehensive prevention program 

that also minimizes worker exposure through engineering controls, 

good work practices, and personal protective equipment (PPE) and 

provides education about working 

with hazardous drugs. 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 an initial baseline 

of workers’ health and then monitor their future health as it relates to 

their potential exposure to hazardous agents. This information can be 

used to identify and correct prevention failures leading to disease. Early identification of health problems 

can also benefit individual workers.

Figure 1. Multi-channel infusion pump 

for delivery of chemotherapy.

Medical Surveillance for Healthcare 

Workers Exposed to Hazardous Drugs

Description of

Exposure

Drugs are considered hazardous if studies in animals or humans show that they 

have the potential to cause cancer, reproductive toxicity, birth defects, or damage 

to organs at low doses [NIOSH 2004]. In 

the United States, an estimated 8 million 

healthcare workers are potentially exposed to hazardous drugs or drug waste 

at their worksites [BLS 2011]. Healthcare 

workers who should be included in the 

medical surveillance program are workers who may be exposed to hazardous 

drugs directly such as nurses, pharmacists, and pharmacy technicians; or other workers (e.g., nurses’ aides, laundry 

workers) who may come into contact 

with hazardous or patient waste [OSHA 

1999; NIOSH 2004; ASHP 2006; ONS 

2011]. Table 1 lists job titles that may involve handling hazardous drugs. Workers may be exposed to hazardous drugs 

when they create aerosols, generate dust, 

clean up spills, or touch contaminated 

surfaces when compounding, administering, or disposing of hazardous drugs 

or patient waste [NIOSH 2004].

Exposure to hazardous drugs may occur through skin contact, inhalation, 

ingestion, or injection. Skin contact 

and inhalation are the most likely ways 

Table 1. Job titles that may 

involve exposure to hazardous 

drugs:

1. Pharmacists and pharmacy 

technicians

2. Nurses (RNs, ARNPs, LPNs)

3. Physicians and physician assistants

4. Operating room personnel

5. Home healthcare workers

6. Veterinarians and veterinary 

technicians

7. Environmental service workers 

(housekeeping, laundry, maintenance workers)

8. Workers who ship, transport, or 

receive hazardous drugs
a worker may be exposed to hazardous drugs. However, ingestion (from hand to mouth) or injection through a needle 

stick or sharps injury is also possible.

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 drug treatment outweigh the possible negative side effects. However, exposed healthcare workers risk the same side effects with 

no benefit. Workers exposed to hazardous drugs have developed skin disorders, 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 

healthcare workers [NIOSH 2004]. A recent epidemiological evaluation of nurses found a statistically significant, 

nearly 2-fold increase in risk for spontaneous abortion 

among those exposed to antineoplastic agents for more 

than 1 hour per day during the first trimester [Lawson et. 

al. 2012]. 

Medical Surveillance

NIOSH recommends medical surveillance of workers 

who handle hazardous materials and are therefore at risk 

of adverse health effects from exposure. The goal of medical surveillance is to minimize adverse health effects in 

workers exposed to hazardous substances. By identifying and correcting failures in exposure prevention (identified through medical surveillance), employers can limit exposure and prevent adverse health outcomes in other 

workers (primary prevention). In addition, by identifying the earliest reversible biologic effects, exposure can 

be reduced or eliminated, and further adverse health effects can be limited in individual workers (secondary prevention). Medical surveillance is a second line of defense, 

augmenting the protection afforded by engineering controls, other administrative controls, work practice controls, PPE, and worker education about the hazards of the 

materials they work with or they may come into contact 

with in the course of their duties [NIOSH 2004; 2009]. An 

effective surveillance program begins with a hazard identification program that is integrated with surveillance for 

disease or illness. The following types of data are often 

obtained and evaluated by medical surveillance programs: 

1. Medical (including reproductive) and occupational history

2. Physical examination

3. Laboratory studies

4. Biological monitoring

Elements of a Medical

Surveillance Program

Several important issues should be considered in designing 

a medical surveillance program for workers responsible for 

handling hazardous drugs. The first is to develop an organized 

approach to identifying workers who are potentially exposed 

to hazardous drugs on the basis of their job duties. The second 

is to provide medical surveillance that is appropriate to the exposure because the various classes of hazardous drugs differ 

in their modes of action and may affect specific target organs. 

Because healthcare workers are typically exposed to numerous hazardous drugs [NIOSH 2004; 2012], no single biological monitor is suitable for all of these drugs. Organizations 

should use the information obtained through medical surveillance to help affected workers and to identify and correct system failures that may have resulted in harmful exposures.

Elements of a medical surveillance program for workers exposed to hazardous drugs should include the following:

 Reproductive and general health questionnaires completed at the time of hire and periodically thereafter (see 

ONS 2011 for a sample questionnaire). Unless information about relevant symptoms and medical events such 

as spontaneous abortions is deliberately sought, their 

occurrence is likely to go unreported. Opportunities to 

identify patterns of occurrence implying defects in engineering controls, technique, or other preventive measures may be similarly missed.

 History of drug handling as an estimate of prior and current exposure, including dates of duty assignment related to hazardous drugs and similar types of information.

 A plan to provide initial baseline clinical evaluation, including 

appropriately targeted medical history, physical examination, 

and laboratory testing for workers identified as being potentially exposed to hazardous drugs that anticipates their potential toxicities.

 A follow-up plan as needed for workers who have shown 

health changes suggesting toxicity or who have experienced an acute exposure (substantial skin contact or inhalation exposure, cleaning a large spill [a broken IV bag, 

leaking IV line], etc.).

If clinical laboratory studies and/or biological monitoring is 

contemplated, a rational approach to selecting clinical studies would consider the toxicity patterns of the drugs to which 

workers are exposed. 

Medical surveillance program results should be examined 

in aggregate for trends that may be a sign of health changes because of exposure to hazardous drugs. If health changes 

are found during follow-up evaluations, the employer should 

take the following actions:
 Evaluate current protective measures that are already 

in place: 

— Engineering controls (Class II biological safety cabinets/compounding aseptic containment isolators, 

robotic systems, ventilation, closed system transfer 

devices, and closed IV systems).

 Compare performance of controls with recommended standards. 

 Conduct environmental sampling when analytical methods are available. 

— Policies for the use of PPE and worker compliance with PPE use and policies. 

— Availability of appropriate PPE such as double 

gloves tested for use with hazardous drugs [ASTM 

2005], nonpermeable gowns, and respiratory protection [NIOSH 2009].

 Verify that all controls are in proper operating condition 

and monitor worker compliance with existing policies or 

when new policies go into effect. 

 Develop a plan of action that will prevent further worker exposure. 

 Ensure confidential two-way communication between a 

worker and the employee health unit regarding notification: 

— By any worker wishing to discuss a change in health 

condition such as pregnancy or chronic illness with 

the employee health unit, or 

— By the health unit, when communicating the finding of an adverse health effect and instructions for 

follow-up back to the workers. 

 If an employee health unit is not available for a facility, 

workers should be encouraged to address exposure issues 

with their primary medical provider. 

 Provide ongoing medical surveillance for all workers at 

risk to determine whether the new plan is effective.

Acknowledgments

The principal authors of this document were Melissa McDiarmid, University of Maryland; Martha Polovich, Oncology 

Nursing Society; Luci Power, Power Enterprises; and Thomas H. Connor and David Weissman of NIOSH. 

The current document supersedes DHHS (NIOSH) Publication No. 2007–117, written by Melissa Leone, Apria Healthcare; Melissa McDiarmid, University of Maryland; Martha 

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 NIOSH. 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. 

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 [2011]. Occupational employment statistics homepage. May 2011 employment and wage estimates. Washington, DC: Bureau of Labor Statistics, [http://www.bls.

gov/oes/home.htm]

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 206:327.e1−8.

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, [http://www.cdc.gov/niosh/docs/2004-165/]. 

NIOSH [2009]. NIOSH: Workplace Solutions: Personal Protective Equipment for Health Care Workers Who 

Work with 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. 2009–106, [http://www.cdc.gov/niosh/docs/

wp-solutions/2009-106/].

NIOSH [2012]. NIOSH list of antineoplastic and other 

hazardous drugs in healthcare settings (2012). 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. 2012–150, 

[http://www.cdc.gov/niosh/docs/2012-150/]. 

ONS (Oncology Nursing Society) [2011]. Safe handling of 

hazardous drugs. Polovich M, ed. 2nd ed. Pittsburgh, PA: 

Oncology Nursing Society. 

OSHA [1999]. Controlling occupational exposure to hazardous drugs. In: OSHA technical manual (TED 01–00–015: 

TED 1–0.15A), Section VI, Chapter 2. Washington, DC: 

Occupational Safety and Health Administration, [http://

www.osha.gov/dts/osta/otm/otm_vi/otm_vi_2.html]
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

Official Business

Penalty for Private Use $300

For More Information

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.

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: 

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.

Safer • Healthier • PeopleTM November 2012

Medical Surveillance for Health Care Workers

Exposed to Hazardous Drugs

DHHS (NIOSH) Publication No. 2013–103

(Supersedes 2007–117)