Chemotherapy 

Drug Evaluation at a 

Veterinary Teaching 

Hospital – Michigan

James Couch, CIH, MS, REHS/RS

John Gibbins, DVM, MPH

Thomas Connor, PhD

Health Hazard Evaluation Report

HETA 2010-0068-3156

April 2012

Revised April 2013

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

Workplace

Safety and Health

 National Institute for Occupational 

Safety and Health
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].

Revision Summary: The original final report contained technical inaccuracies 

in the process description, erroneous references to the chemotherapeutic drug 

carmustine which was never used by the veterinary hospital, and mistakenly cited 

linear feet per minute measurements as cubic feet per minute measurements.
Health Hazard Evaluation Report 2010-0068-3156 Page i

Report Abbreviations................................................................................................i

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

Summary .........................................................................................................v

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

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

Results..............................................................................................................4

Discussion.......................................................................................................8

Conclusions....................................................................................................9

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

References.................................................................................................... 13

Contents

Acknowledgments Acknowledgments and Availability of Report................................ 2

Appendix A Methods........................................................................................................ 15

Appendix B Occupational Exposure Limits and Health Effects......................... 16
Page ii Health Hazard Evaluation Report 2010-0068-3156

Abbreviat

ACGIH® American Conference of Governmental Industrial Hygienists

BSC Biological safety cabinet

CDC Centers for Disease Control and Prevention

CFR Code of Federal Regulations

HEPA High-efficiency particulate air

HHE Health hazard evaluation

IARC International Agency for Research on Cancer

IV Intravenous

LOD Limit of detection

LOQ Limit of quantitation

NAICS North American Industry Classification System

ND Not detected

NIOSH National Institute for Occupational Safety and Health

ng/sample Nanograms per sample

ng/100 cm2 Nanograms per 100 square centimeters

OEL Occupational exposure limit

OSHA Occupational Safety and Health Administration

PEL Permissible exposure limit

PPE Personal protective equipment

REL Recommended exposure limit

STEL Short-term exposure limit

TLV® Threshold limit value

WEELTM Workplace environmental exposure level 
Health Hazard Evaluation Report 2010-0068-3156 Page iii

The National Institute for 

Occupational Safety and 

Health (NIOSH) received 

a confidential employee 

request for a health 

hazard evaluation from a 

veterinary teaching hospital 

in Michigan. Employees 

were concerned about 

reproductive problems and 

hair loss that they associated 

with work-related exposures 

to chemotherapy drugs.

Highlights of 

NIOSH 

Hazard Eval

What NIOSH Did

● We evaluated the facility on September 13–15, 2010.

● We took surface wipe and air samples for cyclophosphamide, 

ifosfamide, and doxorubicin. These substances are 

chemotherapy drugs.

● We talked with employees privately about their work.

● We discussed the occupational risks associated with 

chemotherapy drugs to the employer, employees, and 

students.

● We met with university officials in charge of the veterinary 

teaching hospital’s occupational health and safety program.

What NIOSH Found

● Cyclophosphamide and ifosfamide were found in 4 of 44 

surface wipe samples.

● Cyclophosphamide and ifosfamide were not found in 

air samples.

● Some employees reported headache, nausea, and abnormal 

menstruation. These symptoms have been reported with 

occupational exposure to chemotherapy drugs in earlier 

studies. They also have other causes.

● No employees reported hair loss at the time of our interviews.

● Most employees were not satisfied with the occupational 

health and safety program, particularly in the areas of 

training, supervisor communication, and re-use of disposable 

personal protective equipment.

● Employees did not report using personal protective 

equipment every time they administered chemotherapy drugs.

What Managers Can Do

● Ask employees to select training topics. They may also be able 

to assist in developing training materials.

● Tell employees about safe work practices involving 

chemotherapy drugs.

● Limit employee access to the pharmacy, chemotherapy drug 

preparation room, and administration area. Keep doors 

leading to these areas closed as much as possible.
Page iv Health Hazard Evaluation Report 2010-0068-3156

● Use a biological safety cabinet that does not recirculate 

exhaust air when you prepare a volatile chemotherapy drug 

such as Mustargen®.

● Post “Chemotherapy Drug Administration in Progress” signs 

when preparing and administering chemotherapy drugs to 

remind staff to follow proper procedures.

● Wear two pairs of chemotherapy protective gloves when 

decontaminating the biological safety cabinet and when 

administering chemotherapy drugs. You should also wear a 

protective gown for these tasks.

● Use separate cleaning supplies for the chemotherapy drug 

preparation room and administration area. Store these 

supplies in the area where they are used.

● Follow the hospital’s procedure when handling soiled 

bedding and blankets used by animals receiving 

chemotherapy.

● Place color-coded collars on animals recently treated with 

chemotherapy drugs. Treat their body fluids as chemotherapy 

drug spills.

● Do not allow eating and drinking in areas where 

chemotherapy drugs are handled, administered, or stored.

What Employees Can Do

● Follow standard operating procedures that have been 

established for work tasks. Always wear the required personal 

protective equipment.

● Attend health and safety training and participate in safety 

meetings.

● Do not eat or drink in areas where chemotherapy drugs are 

handled or stored.

Highlights of 

NIOSH 

Hazard Eval

 (continued

 
Health Hazard Evaluation Report 2010-0068-3156 Page v

NIOSH investigators 

evaluated chemotherapy 

drug exposures and their 

possible relationship to 

reproductive problems and 

hair loss among employees 

at a veterinary teaching 

hospital. Cyclophosphamide 

and ifosfamide were 

detected on some surface 

wipe samples, but not in the 

air. We could not determine 

if the health effects reported 

by employees were work 

related; however, similar 

effects have been reported 

with occupational exposure 

to chemotherapy drugs in 

other studies.

Summ

In February 2010, NIOSH received a confidential employee HHE 

request concerning exposure to chemotherapy drugs at a university 

veterinary teaching hospital (veterinary hospital) in Michigan. 

Employees were concerned that exposure to chemotherapy drugs 

may cause adverse health effects such as reproductive problems and 

hair loss.

We visited the veterinary hospital in September 2010 and 

observed work practices and workplace conditions. We talked with 

employees about their health and workplace concerns related to 

chemotherapy drugs. We collected surface wipe and air samples 

for the chemotherapy drugs cyclophosphamide, ifosfamide, and 

doxorubicin. We gave a presentation on the occupational risks 

associated with chemotherapy and other hazardous drugs to the 

employer, employees, and students. We also met with university 

officials responsible for the veterinary hospital’s occupational 

health and safety program.

Cyclophosphamide was detected in 4 of 44 surface wipe 

samples, ranging from ND (< 5 ng/100 cm2

) to 240 ng/100 cm2. 

All detectable levels of cyclophosphamide were found in the 

chemotherapy drug preparation room and administration area. 

Ifosfamide was detected in 2 of 44 surface wipe samples, ranging 

from ND (< 2 ng/100 cm2

) to 37 ng/100 cm2. We detected neither 

cyclophosphamide nor ifosfamide in the air samples. Doxorubicin 

was not detected (LOD = 7 ng/sample) in any of the surface wipe 

or air samples, but we believe the recovery of doxorubicin from 

these samples may have been poor because of the length of time 

the samples were stored frozen before analysis.

Most employees we talked with were not satisfied with the 

health and safety program, particularly in the areas of training, 

supervisor communication, and required re-use of disposable 

PPE. A few employees reported that they did not always wear 

appropriate PPE when administering chemotherapy drugs. 

Three employees reported health effects (headache, nausea, 

and abnormal menstruation) that have been associated with 

chemotherapy exposure in prior studies, but that also have a 

variety of other etiologies. No employees reported hair loss at the 

time of our evaluation.

We were unable to determine if the health effects reported by 

employees were work related. However, similar effects have been 

reported with occupational exposure to chemotherapy drugs 
Page vi Health Hazard Evaluation Report 2010-0068-3156

Keywords: NAICS 541940 (Veterinary Services), chemotherapy, 

oncology, anti-neoplastic, hazardous drugs, veterinary, 

cyclophosphamide, ifosfamide, doxorubicin, surface wipe samples, 

air samples

Summ

 (continued) in other studies. We have provided recommendations that may

reduce chemotherapy drug exposure, address employee concerns 

about their workplace health and safety program, and lead to more 

consistent work practices and personal protective equipment use.
Health Hazard Evaluation Report 2010-0068-3156 Page 1

Introduct

On February 26, 2010, NIOSH received a confidential employee 

request for an HHE at a veterinary teaching hospital (“veterinary 

hospital”) in Michigan. The veterinary hospital provides routine 

care and oncology services to large and small animals. Canines 

and felines constitute the majority of the oncology department’s 

patients. Veterinary hospital employees were concerned about 

adverse health effects from the use of chemotherapy drugs in the 

oncology department.

On September 13–15, 2010, NIOSH investigators visited 

the veterinary hospital and met with representatives of the 

employer, two employee unions, and students. During the 

opening meeting we discussed surface and air sampling for 

chemotherapy drug exposures. We toured the veterinary hospital 

to observe work processes, practices, and workplace conditions. 

We collected surface wipe and air samples and analyzed them 

for cyclophosphamide, ifosfamide, and doxorubicin. We also 

interviewed staff confidentially to discuss their work practices, 

medical history, and symptoms as well as their personal assessment 

of training and supervision. We held a closing meeting on 

September 15, 2010, with employer and union representatives to 

summarize our activities and provide preliminary findings. We sent 

a letter dated October 13, 2010, with preliminary findings.

Process Description

Chemotherapy drugs were received at the veterinary hospital 

pharmacy as powders, liquids, or premixed solutions. Pharmacy 

personnel dispensed oral drugs on a per patient basis for owner 

administration at home. Owners received instructions on how to 

safely handle these medications. Drugs that were administered at 

the veterinary hospital were transported to the chemotherapy drug 

preparation room (Room D157) where they were refrigerated and 

stored until needed. The drugs were removed and prepared in a 

Class 2 BSC in the chemotherapy preparation room. Air exhausted 

from the BSC passed through a HEPA filter and was recirculated 

back into the room (Figure 1).

Animals typically receive several diagnostic procedures before 

receiving chemotherapy drugs to ensure that they are healthy 

enough to receive the treatment. Animals were kenneled in the 

administration area (Room D159) until cleared for treatment. 

Once cleared, animals received the chemotherapy drugs in 

Figure 1. Veterinary technician wearing 

PPE while preparing chemotherapy 

drugs in a Class 2 BSC.
Page 2 Health Hazard Evaluation Report 2010-0068-3156

a procedure that required at least two employees or students 

to restrain the animals for IV catheter placement and drug 

administration. Animals were placed on the treatment table 

and prepared by shaving and disinfecting the area where the IV 

catheter was placed. The administering technician then injected 

the chemotherapy drug. Figure 2 illustrates a chemotherapy drug 

injection process.

After treatment, animals were removed from the table and 

kenneled in the administration area or in cages or runs in adjacent 

areas (Figure 3). Employees then decontaminated the treatment 

table and surrounding floor with a bleach solution. The IV tubing, 

bag, and other potentially contaminated items were placed in 

chemotherapy-approved disposal containers, and the area was 

wiped with a 10% bleach solution and allowed to dry.

After receiving chemotherapy, animals were occasionally taken 

to radiology/ultrasound, the nursing care unit, or the critical 

care unit for further diagnostics, medical care, or observation 

only on an as-needed basis. Animals also were walked indoors 

or outside the veterinary hospital. After completing treatment, 

animals were discharged to their owners with instructions on how 

to safely handle the animal’s urine, feces, and vomit that could be 

contaminated with chemotherapy drugs. The owners were also told 

how to safely clean up accidents and were informed about PPE that 

could be worn when cleaning up after the animals.

Introduct

 (continued

Figure 2. Intravenous administration 

procedure for doxorubicin.

Figure 3. A chemotherapy drugtreated canine in a labeled kennel. 

The label warned employees of 

potential chemotherapy drug cross 

contamination and identified the 

chemotherapy drug used.
Health Hazard Evaluation Report 2010-0068-3156 Page 3

Assessment

On September 13–15, 2010, we collected surface wipe and air 

samples for cyclophosphamide, ifosfamide, and doxorubicin, 

chemotherapy drugs commonly used at this veterinary hospital. 

Appendix A contains additional sampling and analytical 

information. Surface wipe samples were collected in the 

chemotherapy drug preparation room and administration area. We 

collected samples on surfaces where we believed the potential for 

chemotherapy drug contamination was greatest. Offices, employee 

break rooms, and public reception areas where no PPE was used 

were also sampled to learn whether chemotherapy drugs were 

inadvertently spread beyond treatment areas.

We collected area air samples in the chemotherapy drug preparation 

room and administration area and a background area air sample 

from a clerical area. Because cyclophosphamide, ifosfamide, and 

doxorubicin have low vapor pressures (meaning that they are 

unlikely to volatilize during administration) we used an air flow 

sampling rate of 15 liters per minute to increase our ability to 

detect low airborne concentrations. We also visually examined the 

BSC, reviewed its certification records, and asked employees and 

managers about their work practices when using the BSC.

We held confidential interviews with 13 randomly selected 

employees who directly worked with chemotherapy drugs. Job 

titles included veterinarians and licensed veterinary and pharmacy 

technicians. We asked about their work history, health concerns, 

and medical history. We asked for their personal assessment of 

safety policies and procedures, knowledge about recommended 

disposal methods for chemotherapy drugs and supplies, and 

satisfaction with the veterinary hospital’s health and safety 

program. We also asked about the PPE used when they handled 

chemotherapy drugs and their perceptions about communication 

with their supervisor about safety issues related to chemotherapy 

drug handling and administration.

We informally talked with employees and observed work practices 

in other areas of the veterinary hospital including radiology, critical 

care and nursing care units, other patient wards, the laundry, 

and grounds keeping. We assessed employees’ knowledge about 

handling animals that had received chemotherapy drugs, disposal 

of chemotherapy drugs, and cleaning procedures.
Page 4 Health Hazard Evaluation Report 2010-0068-3156

Results

Surface Wipe and Air Sampling

As shown in the table, most of the surface sample results (40 of 44) 

were below the LOD of 5 ng/sample for cyclophosphamide and 2 

ng/sample for ifosfamide. The highest result, 240 ng/100 cm2

 for 

cyclophosphamide, was collected beneath the BSC grate, and all 

detectable levels of cyclophosphamide and ifosfamide were from 

samples collected in and around the BSC in the chemotherapy 

drug preparation room (D157). This suggests the potential for 

chemotherapy drug exposures to employees compounding or 

mixing in the BSC. No doxorubicin was detected (LOD = 7 ng/sample)

in any of the surface wipe samples. However, the recovery of 

doxorubicin from these samples may have been poor because the 

samples were frozen prior to analysis.

Cyclophosphamide and ifosfamide were not detected (minimum 

detectable concentration was 0.07 nanograms per cubic meter for 

a 7,000-liter air sample) in general area air samples collected from 

the chemotherapy drug preparation room, the administration area, 

and an office behind admissions. Doxorubicin was not detected 

(minimum detectable concentration was 0.1 nanograms per cubic 

meter for a 7,000-liter air sample) but its recovery may have been 

poor because the samples were stored frozen prior to analysis.

Employee Interviews

The median age of the 13 employees we interviewed was 34 years 

(range: 27 to 55 years). The median number of years employees had 

worked with chemotherapy drugs, either at this veterinary hospital 

or in other workplaces, was 4.5 years with a range of less than 1 

to 30 years. Most employees denied any health symptoms while 

handling or working around chemotherapy drugs. Three employees 

reported headache, and one reported occasional nausea and facial 

flushing. One employee reported abnormal menstruation that 

began after starting work with chemotherapy drugs. No employees 

reported hair loss at the time of the interviews.

When asked how satisfied they were with their work area’s 

present health and safety program, 10 of 13 employees reported 

“not satisfied,” while three employees reported being “somewhat 

satisfied” or “satisfied.” When asked if written policies were 

available at their work area regarding PPE use, 11 of 13 reported 

no written policies were available. Regarding self-reported 
Health Hazard Evaluation Report 2010-0068-3156 Page 5

Table. Chemotherapy drugs in surface wipe samples collected on September 13–15, 2010

Location Sample Description Results, ng/100 cm2

Cyclophosphamide Ifosfamide

Pharmacy

Receiving table ND ND

Plastic bin for transporting chemotherapy drugs ND ND

Desktop near oral chemotherapy pill cabinet ND ND

Countertop adjacent to small refrigerator and BSC ND ND

Top of chemotherapy waste disposal bin ND ND

Drug 

Preparation 

Room (D157)

Countertop adjacent to small refrigerator and BSC ND ND

BSC working surface 77 ND

BSC airfoil ND ND

BSC top portion of cabinet (estimated area) ND ND

BSC underneath the grate 240 37

Floor directly in front of BSC (5) 29

Administration 

Area (D159)

Chemotherapy drug administration table (stainless steel area) ND ND

Tool cart with various supplies and instruments ND ND

Exam table on the soft padding ND ND

Exam table on the soft padding after doxorubicin 

administration (11) ND

Floor near technician after doxorubicin administration ND ND

Floor between examination tables ND ND

Chemotherapy waste disposal lid after doxorubicin ND ND

Room D161 Telephone in cubicle near hallway door (estimated area) ND ND

Reception 

Area

Discharge medical records bin ND ND

Countertop in area behind reception desk ND ND

Reception area floor ND ND

Reception desk near computer ND ND

Women’s 

Locker Room

Changing area floor ND ND

Floor near door ND ND

Radiology 

Room (A135)

Room #4 on exam table under X-ray ND ND

Floor next to exam table ND ND

Sandbag used to position animals ND ND

Laundry

Floor in front of washer ND ND

Washer loading door (estimated area) ND ND

Results

 (continued
Page 6 Health Hazard Evaluation Report 2010-0068-3156

PPE use, 70% reported “always” wearing double gloves when 

administering chemotherapy drugs, and 60% reported “always” 

wearing disposable gowns. Several employees reported concerns 

about being required to re-use disposable PPE items such as gowns 

because of cost concerns. Most employees demonstrated a good 

working knowledge of the proper procedures for the disposal of 

chemotherapy drugs and administration supplies.

Oncology 

Hallway

Floor directly outside pharmacy mixing room D157 ND ND

Floor directly outside the chemotherapy administration 

room

ND ND

Floor directly outside the technician offices ND ND

Floor inside technician office area ND ND

Floor entering technician office from administration ND ND

Floor at corner of hallway away from reception area ND ND

Floor near door to Room D165 ND ND

Room D158A Floor near drain in the run area ND ND

Room D161 Technician office, on table by door to administration ND ND

Keyboard on the middle desk ND ND

Room D165 Conference room table ND ND

Ward 1 (D100) Floor next to animal treated with vincristine ND ND

Room D112A Floor near chemotherapy treated animal ND ND

Ultrasound Floor near drain ND ND

Small Animal Reception area floor near front door ND ND

LOD 5 2

LOQ 17 7.3

ND = not detected (result was below the LOD)

( ) Sample results in parentheses were between the LOD and the LOQ, meaning that they have more 

uncertainty associated with them.

Table. Chemotherapy drugs in surface wipe samples collected on September 13–15, 2010 (continued)

Location Sample Description Results, ng/100 cm2

Cyclophosphamide Ifosfamide

Results

 (continued
Health Hazard Evaluation Report 2010-0068-3156 Page 7

Results

 (continued) Review of the Biological Safety Cabinet

and Other Workplace Observations

The Class 2 BSC was certified annually as recommended by CDC 

[CDC 2007]. According to veterinary hospital records the BSC met 

the recommended exhaust flow rate of 100 linear feet per minute 

with the sash open to the typical operating height. The BSC 

was equipped with a HEPA filter and recirculated 100% of the 

exhausted air back into the chemotherapy drug preparation room.

Some veterinary hospital employees voluntarily wore elastomeric 

half-mask respirators equipped with organic vapor cartridges when 

they prepared and/or administered chemotherapy drugs. We noted 

that when chemotherapy drug-treated animals were taken to other 

areas of the hospital or returned home they were no longer visually 

identifiable as having recently received chemotherapy drugs. A 

treated animal can spread unmetabolized chemotherapy drugs 

through biological fluids such as urine, feces, and vomit [Pellicaan 

and Teske 1999].
Page 8 Health Hazard Evaluation Report 2010-0068-3156

DisCussio

We found cyclophosphamide and ifosfamide in a few surface wipe 

samples, mainly in and around the BSC in the chemotherapy drug 

preparation room. Although we did not detect doxorubicin, it is 

important to note that the samples were frozen for approximately 

9 months while an analytical method was developed. NIOSH has 

conducted stability studies of cyclophosphamide and ifosfamide 

when collected on surface wipe samples, and no recovery 

degradation was observed [Burr 2011a]. However, NIOSH chemists 

have observed in laboratory experiments that doxorubicin 

degraded after being frozen [Burr 2011b]. Therefore, we cannot 

exclude the chance that doxorubicin may have been present when 

the samples were collected.

One limitation to this evaluation is that we collected surface 

wipe samples over 3 days, and this short time period may not be 

representative of typical exposures. Levels of chemotherapy drugs on 

surfaces may vary over time depending on patient load, quantities 

of drugs, and whether proper work practices are followed. Another 

limitation is that the surface wipe samples were analyzed only for 

cyclophosphamide, ifosfamide, and doxorubicin, although the 

veterinary hospital uses other hazardous drugs [NIOSH 2010]. 

Because the possibility remains that other hazardous drugs may be 

present or that exposures could be greater at other times, we consider 

it prudent to control potential chemotherapy drug exposures to 

levels as low as reasonably achievable.

The absence of cyclophosphamide, ifosfamide, or doxorubicin 

in air samples is not unexpected considering these drugs are not 

volatile at room temperature. However, because doxorubicin 

can degrade when frozen we cannot exclude the possibility that 

it may have been present when the air samples were collected 

[Burr 2011a,b]. In this evaluation we learned that Mustargen, a 

chemotherapy drug that is more volatile than cyclophosphamide, 

ifosfamide, or doxorubicin, was prepared in the BSC. A sampling 

and analytical method does not exist for Mustargen on work 

surfaces or in the air.

We learned that the veterinary hospital was transitioning to 

preparing Mustargen in a chemical fume hood (which does 

not recirculate exhaust air) instead of the BSC. We agree that 

Mustargen should not be handled in the BSC if some or all 

of the exhausted air is recirculated. Because a HEPA filter 

does not capture and remove drug vapors, the potential for 

recirculation exists. However, chemotherapy drugs should not 
Health Hazard Evaluation Report 2010-0068-3156 Page 9

DisCussio

 ( ) be prepared in a chemical fume hood because the sterility of Continued the drug(s) may be compromised.

Three employees reported acute symptoms that they associated 

with their work. We are unable to determine if the symptoms of 

headache, nausea, facial flushing, and abnormal menstruation were 

related to work; however, these symptoms have been associated 

with occupational exposure to chemotherapy drugs in other studies 

[Shortridge et al.1995; Connor and McDiamond 2006]. Most 

employees reported dissatisfaction with their work area’s health 

and safety program, including the lack of written policies on PPE 

use. Although most interviewed employees reported proper PPE 

use when administrating chemotherapy drugs, appropriate PPE 

should be worn at all times during drug administration.

ConClusions

Cyclophosphamide and ifosfamide, but not doxorubicin, were 

detected on some surface wipe samples, primarily in and around 

the BSC. We did not detect these chemotherapy drugs in the air. 

Because doxorubicin degrades after being frozen [Burr 2011b], 

we cannot exclude the possibility that this drug may have been 

present when the surface or air samples were collected. A more 

volatile chemotherapy drug such as Mustargen has the potential 

to enter the work area if it is prepared in the BSC because some 

of the exhausted air is recirculated. We could not determine if the 

acute health symptoms reported by employees were work related. 

Recommendations are provided below to limit chemotherapy drug 

exposure, address employee concerns about their workplace health 

and safety program, and maintain consistent work practices and 

PPE use.
Page 10 Health Hazard Evaluation Report 2010-0068-3156

Recommendatio

On the basis of our findings we recommend the actions listed 

below to create a more healthful workplace. We encourage the 

veterinary hospital to use a labor-management health and safety 

committee or working group to discuss the recommendations 

in this report and develop an action plan. Those involved in 

the work can best set priorities and assess the feasibility of our 

recommendations for the specific situation at the veterinary 

hospital. Our recommendations are based on the hierarchy 

of controls approach discussed in 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 

PPE may be needed.

Engineering Controls

Engineering controls reduce exposures to employees by removing 

the hazard from the process or placing a barrier between the 

hazard and the employee. Engineering controls are very effective 

at protecting employees without placing primary responsibility of 

implementation on the employee.

1. Exhaust 100% of the HEPA-filtered air from the BSC to the 

outdoors [NIOSH 2004].

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 is dependent 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.

1. Limit access to the pharmacy, chemotherapy drug 

preparation room, and administration area to required 

personnel.
Health Hazard Evaluation Report 2010-0068-3156 Page 11

Recommendation

(continued) 2. Do not prepare a volatile chemotherapy drug such as

Mustargen in the veterinary hospital BSC if any of the 

exhaust air is recirculated. 

3. Consult with university health and safety officials to identify 

a BSC that does not recirculate exhaust air. This BSC could 

be used to prepare more volatile chemotherapy drugs until 

engineering changes are made to the BSC in the veterinary 

hospital so that 100% of the exhaust air is directed 

outdoors.

4. Post “Chemotherapy Drug Administration in Progress” signs 

when preparing and administering chemotherapy drugs.

5. Prohibit food and drink for human consumption in areas 

where chemotherapy drugs are handled or stored.

6. Keep doors that lead to the chemotherapy drug preparation 

room and administration area closed. Using self-closing 

doors may facilitate compliance.

7. Use dedicated cleaning supplies for the chemotherapy drug 

preparation room and administration area. If possible, store 

this equipment in the same area where it is used.

8. Improve communication with critical care and nursing care 

unit, caretaking, and laundry employees about standard 

operating procedures concerning vomit, urine, and feces 

from animals that have been given chemotherapy drugs.

9. Either dispose of or properly handle soiled bedding and 

blankets from animals who have received chemotherapy 

according to existing veterinary hospital standard operating 

procedures.

10. Post warning signs outside of the veterinary hospital’s 

comparative oncology building regarding the potential for 

chemotherapy drug-contaminated animal waste. Staff should 

use this area of the building for all chemotherapy drugtreated animals.

11. Instruct all employees and students not to place unnecessary 

items, such as client records, on potentially contaminated 

examination and chemotherapy administration tables.

12.Identify animals that have received chemotherapy with 

brightly colored disposable collars or bands to alert staff that 

vomit, urine, and feces may contain chemotherapy drugs 

and that these potentially contaminated areas should be 

cleaned according to standard operating procedures.
Page 12 Health Hazard Evaluation Report 2010-0068-3156

Recommendation

(continued) 13.Create an interdisciplinary group consisting of managers,

technicians, interns, residents, and university health and 

safety department representatives to address the safety 

and health of personnel who may come in contact with 

chemotherapy drugs. This committee should meet routinely, 

communicate with staff, and work cooperatively with the 

teaching hospital safety committee.

14. Encourage participation in the voluntary, universityadministered surveillance program for employees who work 

with chemotherapy drugs. Additional information on a 

medical surveillance program is provided in the references 

[OSHA 1999; NIOSH 2004].

15.Instruct employees and students about safe work practices 

involving chemotherapy drugs.

16. Involve employees in selecting training topics and in 

developing training materials.

Personal Protective Equipment

PPE is the least effective means for controlling employee exposures. 

Proper use of PPE requires a comprehensive program, and calls for a 

high level of employee involvement and commitment to be effective. 

The use of PPE requires the choice of the appropriate equipment to 

reduce the hazard and the development of supporting programs such 

as training, change-out schedules, and medical assessment if needed. 

PPE should not be relied upon as the sole method for limiting 

employee exposures. Rather, PPE should be used until engineering 

and administrative controls can be demonstrated to be effective in 

limiting exposures to acceptable levels.

1. Follow the OSHA respiratory protection standard [29 CFR 

1910.134] regarding voluntary use of respirators, including 

providing Appendix D of the OSHA respiratory protection 

standard [29 CFR 1910.134] to employees.

2. Instruct employees to wear double chemotherapy protective 

gloves and a protective gown when decontaminating the 

BSC and when administering chemotherapy drugs [NIOSH 

2009]. Because of the risk for latex sensitivity, non-latex 

chemotherapy gloves are recommended. Manufacturer 

recommendations concerning the use of disposable PPE 

should be followed.
Health Hazard Evaluation Report 2010-0068-3156 Page 13

Referenc

Burr G [2011a]. E-mail on October 7, 2011, between G. Burr, Division 

of Surveillance, Hazard Evaluations and Field Studies and J. Pretty, 

Division of Applied Research and Technology, National Institute for 

Occupational Safety and Health, Centers for Disease Control and 

Prevention, U.S. Department of Health and Human Services.

Burr G [2011b]. Telephone conversation on September 29, 2011, 

between G. Burr, Division of Surveillance, Hazard Evaluations 

and Field Studies and J. Pretty, Division of Applied Research and 

Technology, National Institute for Occupational Safety and Health, 

Centers for Disease Control and Prevention, U.S. Department of 

Health and Human Services.

CDC [2007]. Primary containment for biohazards: selection, 

installation and use of biological safety cabinets. 3rd ed.

[http://www.cdc.gov/biosafety/publications/bmbl5/BMBL5_

appendixA.pdf]. Date accessed: March 2012. 

CFR. Code of Federal Regulations. Washington, DC: U.S. 

Government Printing Office, Office of the Federal Register.

Conner T, McDiarmid M [2006]. Preventing occupational 

exposures to antineoplastic drugs in health care settings. CA 

Cancer J Clin. 56(6):354–365.

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. 

2004-165.

NIOSH [2009] 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.

NIOSH [2010]. NIOSH list of antineoplastic and other hazardous 

drugs in healthcare settings 2010. 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. 2010-167.
Page 14 Health Hazard Evaluation Report 2010-0068-3156

Referenc

 (continued) OSHA [1999]. OSHA technical manual, TED 01-00-015, Sec VI,

Chapter II: Controlling occupational exposures to hazardous 

drugs. [http://www.osha.gov/dts/osta/otm/otm_vi/otm_vi_2.

html]. Date accessed: February 2012.

Pellicaan CH, Teske E [1999]. Risks of using cytostatic drugs in 

veterinary medical practice. Tijdschr Diergeneeskd 124(7):210–215.

Shortridge K, Lemasters G, Valanis B, Hertzberg V [1995]. 

Menstrual cycles in nurses handling antineoplastic drugs. Cancer 

Nurs 18(6):439–444.
Health Hazard Evaluation Report 2010-0068-3156 Page 15

Appendix A: Metho

Each surface wipe sample was collected using two Whatman filters (42-millimeter diameter) moistened 

with an extraction solvent composed of 50% acetonitrile and 50% methanol. A 10 centimeter × 10 

centimeter disposable template was used to outline a 100-square-centimeter sampling area. The sample area 

was wiped once with the first Whatman filter, then again with the second Whatman filter. A clean pair of 

chemotherapy drug resistant gloves was worn each time.

For each surface location sampled the two wipe samples were collectively analyzed by liquid 

chromatography mass spectrometry/mass spectrometry following a sampling method internally developed 

by Bureau Veritas North America. The surface wipe sample LODs and LOQs for each drug are as follows: 

cyclophosphamide (LOD = 5 ng/sample, LOQ = 17 ng/sample); ifosfamide (LOD = 2 ng/sample, LOQ = 

7.3 ng/sample); and doxorubicin (LOD = 7 ng/sample, LOQ = 23 ng/sample). All media and field blanks 

were below the LOD. Results of a storage stability study with cyclophosphamide and ifosfamide showed no 

degradation of recovery after 7 to 8 months for surface wipe samples stored frozen [Burr 2011a]. On the 

basis of these results, we do not expect significant degradation of our field samples with respect to these 

two drugs. However, NIOSH chemists have observed in laboratory experiments that doxorubicin degraded 

after being frozen [Burr 2011b].

General area air samples for cyclophosphamide, ifosfamide, and doxorubicin were taken using a Quick 

Take® 30 high volume sample pump operating at 15 liters per minute and collected on a 37-millimeter 

diameter polytetrafluorethylene filter contained in a three piece black polypropylene cassette. The 

sampling filter was supported by a stainless steel pad. The air sample LODs and LOQs for each drug are 

as follows: cyclophosphamide (LOD = 0.5 ng/sample, LOQ = 1.7 ng/sample); ifosfamide (LOD = 0.5 ng/

sample, LOQ = 1.7 ng/sample); and doxorubicin (LOD = 0.8 ng/sample, LOQ = 2.6 ng/sample). The 

sampling method was internally developed by Bureau Veritas North America; the analytical method was 

the same as was used for the surface wipe samples.

References

Burr G [2011a]. E-mail on October 7, 2011, between G. Burr, Division of Surveillance, Hazard Evaluations 

and Field Studies and J. Pretty, Division of Applied Research and Technology, National Institute for 

Occupational Safety and Health, Centers for Disease Control and Prevention, U.S. Department of Health 

and Human Services.

Burr G [2011b]. Telephone conversation on September 29, 2011, between G. Burr, Division of 

Surveillance, Hazard Evaluations and Field Studies and J. Pretty, Division of Applied Research and 

Technology, National Institute for Occupational Safety and Health, Centers for Disease Control and 

Prevention, U.S. Department of Health and Human Services.
Page 16 Health Hazard Evaluation Report 2010-0068-3156

Appendix B: Occupational Exposure Limits and H

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 to for 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 adverse 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 adverse 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 of 1970. 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 2010]. 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 2011]. WEELs have been established for some chemicals “when 

no other legal or authoritative limits exist” [AIHA 2011].

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

include both legal and recommended limits. The Institut für Arbeitsschutz der Deutschen Gesetzlichen 

Unfallversicherung (IFA, Institute for Occupational Safety and Health of the German Social Accident 
Health Hazard Evaluation Report 2010-0068-3156 Page 17

Appendix B: Occupational Exposure Limits and H

 (continued

Insurance) maintains a database of international OELs from European Union member states, Canada 

(Québec), Japan, Switzerland, and the United States. The database, available at http://www.dguv.de/ifa/

en/gestis/limit_values/index.jsp, contains international limits for over 1,500 hazardous substances and is 

updated periodically.

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 assessments 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.

Below we provide the OELs and surface contamination limits for the compounds we measured, as well as a 

discussion of the potential health effects from exposure to these compounds.

Cyclophosphamide

Although OSHA and NIOSH have not established OELs for cyclophosphamide, it has been categorized 

as a Group 1 Carcinogen (carcinogenic to humans) by IARC [IARC 1998]. It metabolizes in the body to 

acrolein, which can cause adverse effects in the bladder.

Cyclophosphamide is a chemotherapy drug used for a wide range of neoplastic diseases such as breast and 

lung cancer, pediatric malignancies, leukemia, and lymphomas. It can be prescribed as a single drug or in 

combination with other chemotherapy drugs and can be administered via oral tablets or intravenously.

Cyclophosphamide is normally found in a white powder form for chemical stability and is typically 

brought into liquid solution by the addition of water and infused with sodium chloride, glucose, or 

glucose/saline solutions. Once in solution, it is recommended that cyclophosphamide be administered 

to the patient within 8 hours or stored cold (but not frozen) to prevent degradation. The surface wipe 
Page 18 Health Hazard Evaluation Report 2010-0068-3156

Appendix B: Occupational Exposure Limits and H

 (continued

samples collected during this evaluation for cyclophosphamide, (as well as for ifosfamide and doxorubicin) 

were shipped cold from the field to the NIOSH laboratory. These surface wipe samples were then kept 

frozen for approximately 7 months pending development of an analytical method. There are currently no 

OELs for cyclophosphamide. However, because of its carcinogenic nature, exposures to cyclophosphamide 

should be controlled to the lowest achievable levels.

Ifosfamide

Ifosfamide is a chemotherapy drug that is used for a wide range of neoplastic diseases including ovary, 

testis, lung, breast, and soft-tissue sarcomas. It can be prescribed as a single drug or in combination with 

other chemotherapy drugs and can be administered via oral tablets or intravenously. Ifosfamide is normally 

found in a white powder form for chemical stability and is normally brought into solution by the addition 

of water and infused with sodium chloride, glucose, or glucose/saline solutions.

Ifosfamide is a not designated as carcinogenic to humans by IARC, OSHA, or NIOSH. It has been 

reported to be mutagenic in bacterial cells through the Ames test. Ifosfamide metabolizes in the body to 

acrolein, which can cause adverse effects in the bladder. There are currently no OELs for ifosfamide.

Doxorubicin

Doxorubicin is a chemotherapy drug that is used for neoplastic diseases including leukemia, soft-tissue 

sarcomas, and solid tumors such as breast and lung cancer. It can be prescribed singly or in combination 

with other chemotherapy drugs and can be administered via oral tablets or intravenously. It is categorized 

as a Group 2A Carcinogen [IARC 1987], meaning that there is inadequate evidence to designate it as a 

human carcinogen.

Chemotherapy Drugs in Healthcare Settings

Occupational exposures to chemotherapy drugs may occur through inhalation, skin contact, skin 

absorption, ingestion, or injection. Inhalation and skin contact/absorption are the most likely routes of 

exposure, but unintentional ingestion from hand to mouth contact and unintentional injection through 

a needlestick or sharps injury are also possible [Duvall and Baumann 1980; Black and Presson 1997; 

Schreiber et al. 2003].

Protection from chemotherapy drug exposures depends on safety programs established by employers 

and followed by employees. Factors that affect employee exposures include drug handling circumstances 

(preparation, administration, or disposal), amount of drug prepared, frequency and duration of drug 

handling, potential for absorption, use of ventilated cabinets, PPE, and work practices. The chance that 

an employee will experience adverse effects from chemotherapy drugs increases with the amount and 

frequency of exposure and the lack of proper work practices [NIOSH 2004].
Health Hazard Evaluation Report 2010-0068-3156 Page 19

Appendix B: Occupational Exposure Limits and H

 (continued

Surveys have associated workplace exposures to chemotherapy drugs with acute health effects, primarily in 

nurses. These included hair loss, headaches, acute skin and eye irritation, and/or hypersensitivity [Valanis 

1993a; Valanis 1993b]. A review of 14 studies described an association between exposure to chemotherapy 

drugs and adverse reproductive effects [Harrison 2001]. The major reproductive effects found in these 

studies were increased fetal loss [Selevan et al. 1985; Stücker et al. 1990], congenital malformations 

depending on the length of exposure [Hemminki et al. 1985], low birth weight and congenital 

abnormalities [Peel¬en et al. 1999], and infertility [Valanis et al. 1999].

Several reports have addressed the relationship of cancer occurrence to healthcare employees’ exposures to 

chemotherapy drugs [NIOSH 2004]. A significantly increased risk of leukemia has been reported among 

oncology nurses identified in the Danish cancer registry for the period 1943–1987 [Skov et al. 1992]. 

The same group [Skov et al. 1990] found an increased, but not significant, risk of leukemia in physicians 

employed for at least 6 months in a department where patients were treated with chemotherapy drugs.

References

ACGIH [2011]. 2011 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 [2011]. AIHA 2011 Emergency response planning guidelines (ERPG) & workplace environmental 

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

Black LA, Presson AC [1997]. Hazardous drugs. Occup Med: State of the Art Rev 12(4):669–685.

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

Federal Register.

Duvall E, Baumann B [1980]. An unusual accident during the administration of che-motherapy. Cancer 

Nurs 3(4):305–306.

Harrison BR [2001]. Risks of handling cy¬totoxic drugs. In: Perry MC ed. The chemo¬therapy source 

book. 3rd ed. Philadelphia, PA: Lippincott, Williams and Wilkins, pp. 566–582.

Hemminki K, Kyyrönen P, Lindbohm M-L [1985]. Spontaneous abortions and malfor-mations in the 

offspring of nurses exposed to anesthetic gases, cytostatic drugs, and other potential hazards in hospitals, 

based on registered information of outcome. J Epi¬demiol Commun Health 39:141–147.

IARC [1987]. Overall Evaluations of Carcinogenicity: An Updating of IARC Monographs Volumes 

1 to 42. Lyon: IARC monographs on the evaluation of carcinogenic risks to humans, Supplement 7. 

International Agency for Research on Cancer.
Page 20 Health Hazard Evaluation Report 2010-0068-3156

Appendix B: Occupational Exposure Limits and H

 (continued

IARC [1998]. Some antineoplastic and immunosuppressive agents. Lyon: IARC monographs on the 

evaluation of carcinogenic risks to humans; vol 26. International Agency for Research on Cancer.

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. 2004-165.

NIOSH [2010]. 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. 2010-168c. [http://www.cdc.gov/niosh/npg/]. Date 

accessed: January 2012.

Peelen S, Roeleveld N, Heederik D, Krom¬bout H, de Kort W [1999]. Toxic effects on reproduction in 

hospital personnel (in Dutch). Netherlands: Elsevier.

Schreiber C, Radon K, Pethran A, Schierl R, Hauff K, Grimm C-H, Boos K-S, Nowak D. [2003]. Uptake 

of antineoplastic agents in pharmacy personnel. Part 2: study of work-related risk factors. Int Arch Occup 

Environ Health 76(1):11–16.

Selevan SG, Lindbohm M-L, Hornung RW, Hemminki K [1985]. A study of occupa¬tional exposure to 

antineoplastic drugs and fetal loss in nurses. N Engl J Med 313(19):1173–1178.

Skov T, Lynge E, Maarup B, Olsen J, Rørth M, Winthereik H [1990]. Risk for physicians handling 

antineoplastic drugs [letter to the editor]. Lancet 336(8728):1446.

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):855–861.

Stücker I, Caillard J-F, Collin R, Gout M, Poyen D, Hémon D [1990]. Risk of spon¬taneous abortion 

among nurses handling antineoplastic drugs. Scand J Work Environ Health 16(2):102–107.

Valanis BG, Vollmer WM, Labuhn KT, Glass AG [1993a]. Acute symptoms associated with antineoplastic 

drug handling among nurses. Cancer Nurs 16(4):288–295.

Valanis BG, Vollmer WM, Labuhn KT, Glass AG [1993b]. Association of antineoplastic drug handling 

with acute adverse effects in pharmacy personnel. Am J Hosp Pharm 50(3):455–462.

Valanis B, Vollmer WM, Steele P [1999]. Occupational exposure to antineoplastic agents: self-reported 

miscarriages and stillbirths among nurses and pharmacists. J Occup Environ Med 41(8):632–638.
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Acknowledgments a

Availability of Re

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 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.

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 John Gibbins 

of HETAB, Division of Surveillance, Hazard Evaluations and 

Field Studies and by Thomas Connor of the NIOSH Division 

of Applied Research and Technology (DART). Industrial hygiene 

equipment and logistical support was provided by Donald Booher 

and Karl Feldmann of HETAB. Analytical support was provided 

by Jack Pretty of DART and Bureau Veritas North America. 

Health communication assistance was provided by Stefanie Evans. 

Editorial assistance was provided by Ellen Galloway. Desktop 

publishing was performed by Greg Hartle.

Copies of this report have been sent to employee and management 

representatives at the facility, 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.
Below is a recommended citation for this report:

NIOSH [2012]. Health hazard evaluation report: chemotherapy drug evaluation 

at a veterinary teaching hospital – Michigan. By Couch J, Gibbins J, Connor T. 

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. 2010-0068-3156.

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:

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Safety and Health