Occupational hazards to health care workers: Diverse, ilbdefined, and not fully appreciated Roscoe M. Moore, Jr., DVM, MPH, PhD Ronald G. Kaczmarek, MD, MPH Rockville,

Maryland

Health care workers are challenged by an imposing group of occupational hazards. These hazards include exposure to ionizing radiation, stress, injury, infectious agents, and chemicals. The magnitude and diversity of these hazards are not fully appreciated. The acquired immunodeficiency syndrome epidemic has created additional occupational hazards and has focused attention on the problem of occupational hazards to health care workers. Concern over the nosocomial transmission of the human immunodeficiency virus has contributed to efforts to implement universal infection control precautions and to decrease needlestick injuries. Health care organizations and providers, who have prompted health and safety campaigns for the general public, should not overlook the dangers associated with the health care setting. (AM J INFECT CONTROL 1991;18:316-27)

Health care workers (HCWs) confront a diverse array of occupational hazards. Many of the problems are similar to those encountered by workers outside the health care industry, such as stress and lumbosacral injury. Other problems, illustrated by exposure to infectious agents, are unique to the health care setting. Review articleP have described the broad range of occupational hazards to which HCWs are exposed. The challenges posed by occupational hazards are constantly evolving. The development of new medical therapies and technology can create additional risks. For example, the use of dynamic computerized tomography (CT) scanning, a new diagnostic imaging procedure, can potentially increase the exposure of certain HCWs to ionizing radiation.5 It has been sugFrom the Center for Devices and Radiological and Drug Administration.

Health, Food

Reprint requests: Roscoe M. Moore, Jr., DVM, MPH, PhD, Division of Biometric Sciences HFZ-116, Center for Devices and Radiological Health, 12200 Wilkins Ave., Rockville, MD 20852. 17/46/22997

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gested that ribavirin, a relatively new antiviral agent, may adversely affect the health of personnel who administer this agent.6 The evolution of infectious agents, ranging from the acquisition of antibiotic resistance by bacteria to the spread of relatively new agents such as the human immunodeficiency virus (HIV), is another development that affects the nature of occupational health hazards. All the occupational hazards faced by HCWs cannot be fully discussed within the scope of one article. This article will attempt to focus on selected hazards of particular interest and importance that illustrate that occupational hazards to HCWs are diverse, ill-defined, and not fully appreciated. Strategies to protect HCWs will be discussed. A more detailed discussion of occupational hazards faced by HCWs can be found in Occupational Medicine: State of the Art Reviews.’ RADIATION

Ionizing radiation is used for a multitude of purposes in medicine, including diagnosing duodenal ulcers, pancreatic neoplasms, and pneu-

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monia, as well as treating neoplasms such as cancer of the cervix. Scattered radiation is generated during many diagnostic radiologic procedures. Incident photons of the primary x-ray beam get scattered by electrons in the body of the patient. It is important to note that the scattered radiation can have almost as much energy as the primary beam and therefore represents a safety hazard for health care personnel who remain in exposure rooms during x-ray procedures.’ A number of HCWs are exposed to scattered radiation, including radiologists, x-ray technologists, nuclear medicine technologists, invasive cardiologists, operating room personnel, and neonatal care unit personnel. Limits on the occupational exposure to ionizing radiation have long been established. The maximum permissible annual whole body dose is 5 rem. No more than 3 rem may be received during a 13-week period.’ A limit on the radiation exposure of the fetus of an occupationally exposed female employee has also been created. The limit is 0.5 rem for the entire gestation period.‘O Studies have demonstrated that the mean radiation exposure of physicians during cardiac catheterization, as measured at the collar level, is approximately 10 to 15 milliroentgens (mR) per procedure.“, ‘* Physician radiation exposure during an upper gastrointestinal series, a far less complex procedure than cardiac catheterization, is in the range of 1 to 2 mR per procedure. Several areas of occupational exposure to ionizing radiation deserve special attention. Interventional radiology is a new, rapidly expanding subspecialty of diagnostic radiology. Interventional procedures such as percutaneous angioplasty require health care personnel to be in the fluoroscopy suite for extensive periods of time that are far longer than the fluoroscopy times used for other procedures, for example, an upper gastrointestinal. series. HCWs employed in interventional radiology can receive monthly doses in excess of prorated annual limitsI Dynamic CT scanning is another new diagnostic modality. Contrast material is injected intravenously as the patient is being scanned. This results in personnel (e.g., the physician injecting the contrast) being present in the CT room during the scan. A study by Kaczmarek

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et al .5 demonstrated the resulting radiation exposure to the radiologist to be appreciable: 9 to 15 mR per scan. Nuclear medicine entails the injection of radioisotopes into the patient. The radioisotopes emit radiation that is detected by gamma cameras to form an image. The patient continues to emit radiation after the completion of the study. The dose rate of radiation emitted after injection with most radioisotopes is low. Personnel located a distance of 10 cm from a patient who has just completed an average bone scan would potentially receive 9.6 mrem/hr.14 Ultrasonographers can be exposed to ionizing radiation emitted from patients who earlier in the day underwent nuclear medicine studies. It is not uncommon for patients to undergo nuclear and ultrasound studies in the same day. The ultrasonographer must be in close physical proximity to the patient for a period of 10 to 1.5 minutes to perform the ultrasound examination. Although the dose from one person would be small, the cumulative annual dose could be substantial, as high as 1.5 rem/yr according to one estimate.” The cornerstones of radiation protection are time, distance, and shielding. They all must be judiciously employed to minimize occupational exposures to ionizing radiation. Time in this context refers to the time that a HCW is exposed to ionizing radiation. Holding other factors constant, reducing the fluoroscopy time for a given procedure reduces the dose to health care personnel in the lluoroscopy room. Careful patient scheduling can reduce the radiation dose to ultrasonographers. The intensity of scattered radiation relative to the primary beam decreases with the square of the distance from the center of the beam on the patient’s surface.8 It is crucial that HCWs such as intensive care unit personnel be an adequate distance away from sources of scatter radiation (e.g., portable x-ray examinations). Shielding refers to barriers that can block radiation. The use of shielding allows HCWs to get closer to the source of radiation with a similar level of protection. Lead-lined and concrete walls are examples of barriers. Leaded aprons play an integral role in protecting bone marrow, one of the organs most sensitive to radiation. The radiation dose to per-

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sonnel can also be reduced by the use of leaded glasses and thyroid shields. The relationship between exposure to relatively high doses (100 to 300 rad) of ionizing radiation and an increased risk of the subsequent development of neoplasms has been recognized. Studies of Japanese atomic bomb survivors,‘6 patients treated for ankylosing spondylitis,17 and women who underwent multiple chest fluoroscopies during therapy for tuberculosis” have all demonstrated an increased incidence of cancer. Leukemia, particularly the myelocytic type, is one of the most important radiation-induced cancers. The exact shape of the dose-response curve for exposure to low doses of ionizing radiation is unknown. Prudence dictates that occupational doses should be kept as low as reasonably achievable and always less than the occupational limit of 5 rem of whole body radiation per year. 8TRESS

HCWs are subject to many sources of occupational stress. Some of the causes, such as lack of autonomy, are similar to those experienced by non-HCWs. Many of the stressors are unique to the health setting, ranging from emotionally disturbed patients to exposure to infectious agents. The acquired immunodeficiency syndrome (AIDS) epidemic has created additional stress for many HCWs. l9 Proper handling of sharp medical devices such as needles and appropriate use of barrier precautions can decrease but not eliminate the possibility of occupational transmission of human immunodeficiency virus (HIV).20 No curative therapy exists for HIV infection. HCWs are often keenly aware of the severe dementia, cachexia, and suffering AIDS patients frequently have. Potential secondary transmission to spouses and/or offspring is another concern for HCWs. The extent of the stress induced in HCWs by the AIDS epidemic was clearly demonstrated in a study by Link et al.*’ of medical house officers in New York City. Forty percent of the house officers reported that concern over the occupational transmission of HIV had increased the

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stress at least moderately. Ten percent thought they had contracted AIDS at some point in their training, 24% of the house officers would not voluntarily treat AIDS patients, and 36% planned to make career decisions that would decrease the number of AIDS patients they would have to treat. Work weeks as long as 120 hours, highlighted by continuous 36-hour shifts, pose another source of stress for house officers. The sleep deprivation resulting from such schedules has an adverse impact on the psychologic health and job performance of house officers. A range of adverse psychologic effects related to sleep deprivation in house officers has been described and includes difficulty in thinking, depression, irritability, and depersonalization.** Absence of free time damages personal relationships such as marriages. Decreased job performance also occurs. Sleep-deprived interns were found to be less likely to diagnose cardiac arrhythmias correctly than when rested.23 New York is the first state to mandate a reduction in the number of hours house officers must work. The Bell Commission was instrumental in highlighting the adverse effect of overworking house officers on the quality of patient care.24 As of July 1, 1989, house officers’ hours are limited to 80 per week, with shifts no longer than 24 hours. One 24-hour period of free time per week is required. Night floats are used by many institutions to eliminate the need for 36-hour shifts. Should the New York reforms prove to be successful, other states may adopt similar programs. Shift work is another source of stress for many HCWs. More than one third (37%) of hospital workers participate in shift work.25 Sleep disorders, fatigue, and dyspepsia are all commonly found among shift workers.26 Personal and family life may suffer because the schedule of the shift workers is out of synchrony with the schedules of family and friends. Malpractice suits have emerged as a major problem. Physicians are probably the most heavily impacted professionals, but virtually any HCW may be included in a lawsuit. Malpractice premiums have risen dramatically within the past two decades. Obstetricians and

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neurosurgeons may pay annual premiums in excess of $ 100,000.27 An increase in the number of suits and the size of awards has fueled the extraordinary rise in malpractice premiumsz8 Physicians have a substantial degree of stress during malpractice litigation. The fear of malpractice also creates stress during the practice of medicine. Physicians may view patients from an adversarial standpoint because of the threat of malpractice litigation.2g High levels of occupational stress have been linked to an increased risk of stress-related illnesses. Chronic stress may increase the risk of alcoholism, drug abuse, and suicide.3o Weiman31 has reported that both low and high levels of occupational stress are related to an increased incidence of stress-related disease. Occupational stress can also lead to burnout. Patrick32 has described the elements of burnout, which include emotional exhaustion, a shift toward negative attitudes, and a sense of personal devaluation. Fatigue, sleep disturbances, decreased appetite, and headaches may also occur in burnout victims. Depression, anger, and/or withdrawal may be present. Intensive care unit, bum unit, emergency room, and operating room personnel are particularly vulnerable to bumout.33 No single approach can fully address the problem of occupational stress for HCWs. House officers would benefit most greatly from a reduction in their work week per the recommendations of the Bell Commission. Unskilled workers might be helped most by an increase in salary. Tort reform may reduce the stress induced by malpractice suits. General measures that can reduce occupational stress include adequate staffing, scheduled rotation of unit assignments, training staff to recognize the symptoms of burnout, attention to career planning, support and. counseling groups, and inservice training sessions.34 INJURY

HCWs are frequently subject to injury while on the job. The spectrum of occupational injury that may affect HCWs is broad. Back injuries and patient violence are two particularly noteworthy problems.

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Back injury

Although lumbosacral pain is a problem for the general population, many HCWs are at increased risk. A study of Swedish nursing aides reported that 46.8% of study participants had back pain. 35 A survey of British nurses found a 43% prevalence of back pain?6 American nurses engaged in clinical’ work reported back pain more than twice as frequently as a control population of unit service coordinators who performed clerical tasks.37 Falls and the lifting of patients are two of the most significant contributors to the problem of lumbosacral injury. Many HCWs, for example, nurses and radiologic technicians are required to lift heavy, even morbidly obese patients as part of their required duties. Patients can be difficult to lift, particularly when they are uncooperative.38 The need to wash the floors of health care facilities frequently results in the presence of wet floors. HCWs must move swiftly to patient rooms to respond to emergency situations such as cardiopulmonary resuscitation. This requirement and the frequent presence of wet floors contributes to the incidence of falls by HCWs. Other causes of lumbosacral injury include moving equipment, pushing carts, and using chairs that are not ergonomically appropriate.3g Programs to prevent back injuries must be multifaceted. Features of a comprehensive program include adequate staffing, ready availability of mechanical devices for lifting and transferring patients, the training of workers regarding correct lifting procedures, and back exercise programs. Training programs alone may be an inadequate response. Dehlin and Berg:’ in their study of Swedish nursing aides, did not find that group training was successful in preventing back pain. The nurses in the study by Harber et al?’ also had a high rate of back pain, despite their training in prevention of back pain. Patient

violence

HCWs must often treat emotionally and/or psychologically disturbed persons such as elderly patients with organic brain syndrome, teenagers with drug-induced psychosis, and

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schizophrenic psychiatric patients. Disturbed persons with the potential for violence can be encountered in almost any health care setting. The emergency room and the psychiatric ward are two areas where health care personnel are particularly at risk for patient violence.4 Several studies of the magnitude of patient assaults on HCWs can be found in the literature. Madden et a1.4Onoted in a study of 115 psychiatrists that 42% had been physically attacked by a patient at some point. Almost three fourths (74%) of 101 therapists surveyed in the Cincinnati, Ohio, area had been the victim of a patient assault at least once?’ An annual assault rate, based on ward reports, of approximately 140 per 100 nursing staff was estimated at a Maryland psychiatric hospital.42 Underreporting of assaults is a problem because of peer pressure, desire to avoid lengthy paperwork, and fear of the accusation of patient abuse.43 The severity of patient assaults extends from mild ecchymoses to disability and death. Staff victimized by patient assault often experience anger, fear, anxiety, and depression.44 The posttraumatic stress disorder, classically seen in combat veterans, has also been described:’ A number of measures offer the potential to reduce the number and severity of patient assaults on HCWs. Staff can be trained in proper procedures for the confrontation of aggressive patients. Alarm systems, both telephone and electronic, allow threatened employees to summon help.43 A study at Atascadero Hospital in California noted that the incidence of staff injuries doubled between Sunday and Monday. This may be related to an abrupt change in patient and staff activity during the same time frame. A more gradual change in activity might decrease patient violence.“6 INFECTIOUS Tuberoulosis

AQENTS

Infection with Mycobacterium tuberculosis remains an important occupational hazard for many HCWs. The incidence of the disease has declined dramatically since 1900, although this decline has been recently reversed?’ Lack of familiarity with the disease may cause clinicians to fail to suspect and make the diagnosis. This problem is compounded by the frequent failure of the disease to present classi-

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cally, particularly among the elderly.48 The disease may be detected only at autopsy.49 Transmission of tuberculosis from undiagnosed, untreated patients to HCWs has been well documented.50 The dramatic increase in the incidence of HIV-related disease expected within the next several years may increase the occupational risk of tuberculosis infection for HCWs. Active tuberculosis infection is associated with HIV infection.” The immunodeficiency caused by HIV infection facilitates the reactivation of tuberculosis. Aerosolized pentamidine is used to treat pneumonia caused by Pneumocystis carinii, the leading cause of death in patients with AIDS. It is also used to prevent such infections in HIV-infected patients with low T4 cell counts. The use of aerosolized pentamidine may increase the occupational risk of tuberculosis infection. An investigation of a Florida health clinic observed that HCWs who were tuberculin test positive were far more likely than control subjects to have been present in a room where aerosolized pentamidine was administered .52 The Advisory Committee for the Elimination of Tuberculosis has made a number of recommendations to reduce the occupational risk of tuberculosis infection.53 These recommendations include the initiation of antituberculous therapy in patients that may have infectious tuberculosis before aerosolized pentamidine therapy is begun. Patient care rooms must be properly ventilated. The air in rooms where cough-inducing procedures are conducted should be exhausted directly to the outside. Barrier precautions such as masks should be used appropriately by HCWs, particularly during such invasive procedures as bronchoscopy. Hepatitis

B virus

The hepatitis B virus (HBV) is a DNA virus that is found in relatively high concentration in blood and is also present in other body fluids, including saliva .% HBV possesses the ability to survive for extended periods in the environment, as long as 7 days at room temperature.55 HCWs are known to be at increased risk of HBV infection. It has been estimated by the Centers for Disease Control (CDC) that each

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year the occupational transmission of HBV occurs in 12,000 HCWs and approximately 250 HCWs die as a consequence of occupationally acquired HBV infection.56 Antibodies to HBV are found more often in HCWs such as emergency ward nurses than in the general population.” The risk of HBV infection is greatest among HCWs who frequently contact blood, for example, pathologists, phlebotomists, surgeons, and emergency room personnel. Adverse sequelae of HBV infection include acute fulminant hepatitis, cirrhosis of the liver, and hepatocellular carcirloma.58 Occupational transmission of HBV can occur via a number of routes.5g Needlestick transmission is probably the most important route. Transmission through contamination of mucous membranes is also possible. Mouth pipetting in the laboratory setting can lead to HBV transmission. “Splash conjunctivitis,” blood splashed into the eye, can occur in the surgical environment and result in the transmission of HBV. Fortunately, both primary and secondary prevention of HBV infection is possible. Plasma-derivedbo and recombinant yeastderived6* HBV vaccines have been demonstrated to be safe and effective. HCWs at increased risk of HBV infection should.be vaccinated. Secondary prevention in the form of immunoglobulin also must play a role in the prevention of occupational HBV infection, because of noncompliance by HCWs with vaccine recommendations and the failure of protective antibody levels to develop in all HBV vaccine recipients.60s 61 HIV

The occupational transmission of the HIV is probably the most feared nosocomial infection of HCWs. The virus has been detected in virtually all body fluids, including blood, semen, saliva, and cerebrospinal fluid.62 Accidental needlestick transmission has been responsible for the majority of documented cases of occupationally acquired HIV infection.2’ Prospective studies have indicated the risk of transmission of HIV per needlestick is substantially lower than the corresponding risk of HBV transmission. On the basis of presently available data, the HIV transmission risk via an acci-

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dental needlestick during the care of an HIVinfected patient is less than l%, approximately 1 in 250.63 The lower concentration in serum of HIV compared with HBV may contribute to the lower efficiency of needlestick transmission. Rare cases of nonneedlestick occupational transmission of HIV, believed to be transmitted through nonintact skin or possible mucous membrane exposure, have also been reportedF4 An effective vaccine for HIV is not available and is not anticipated in the near fi.tture.62 No safe and effective curative therapy for HIV infection is presently available. A trial of prophylactic zidovudine after an accidental needlestick is now under way,65 but results are probably a considerable time away because of the low incidence of transmission without prophylactic zidovudine. Therefore the prevention of occupational transmission of HIV must depend on preventing exposure of HCWs to HIV. This entails measures, including avoiding needlestick injuries and using appropriate barrier precautions, that also prevent the occupational transmission of other viruses in blood or other body fluids. Reducing the incidence of needlestick injuries can decrease the potential for the occupational transmission of infectious agents. Needles are ubiquitous devices in the health care setting. They are used for a myriad of purposes, including venipuncture, arterial blood sampling, and medication administration. Consequently, many HCWs are at risk for needlestick injury. The transmission of HBV and HIV by needlestick injury has already been discussed. Overall, 20 diseases have been reported to be transmitted by this route, including malaria, brucellosis, blastomycosis, and staphylococcal infections .66 The CDC has established guidelines for the proper handling of needles!’ Puncture-resistant containers for needle disposal should be conveniently located. Central to the guidelines is a recommendation not to recap needles. Many needlestick injuries occur during the recapping process. It is unknown to what extent HCWs are adhering to the CDC recommendations. The Center for Devices and Radiological Health (CDRH), a unit of the Food and Drug Administration, in collaboration with the state health

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departments of Iowa, Maryland, and Massachusetts, is conducting a multistate investigation of needle handling practices by HCWs.6’ A contrary view of the efficacy of reducing needlestick injuries through worker training has been presented by Jagger et a1.66 HCWs interviewed by her group provided several justifications for recapping needles that included self-protection and a desire to protect others while carrying needles to the disposal container. On the basis of the interview results, many HCWs may continue to recap needles despite admonitions against the practice. Engineering changes may help reduce the incidence of needlestick injuries. Needles with features designed to decrease the likelihood of needlestick injury have been developed.69 Safety features include the retraction of the needle into the barrel after administration and the sliding of a protective safety sheath over the needle after use. Holding other factors constant, substituting procedures that do not entail the use of needles for present procedures that employ needles will reduce the incidence of needlestick injuries. Concern about the needlestick transmission of HIV may provide the necessary impetus for the design and utilization of safer needles. The appropriate use of barrier precautions, encompassing gloves, gowns, goggles, and masks, by HCWs is essential to reduce the occupational transmission of infectious agents. Unfortunately, HCWs may not be complying with universal precaution recommendations. A study conducted in the emergency department of the Johns Hopkins University Hospital reported that universal precaution recommendations were followed only 44% of the time.” Particularly worrisome was the fact that universal precaution recommendations were observed even less often when profuse bleeding (and an increased opportunity for transmission of blood-borne viruses) was present. The CDRH, in collaboration with the state health departments of Iowa, Maryland, and Massachusetts, is conducting a multistate investigation of the use of barrier precautions by health care providers7’ that may further clarify the situation.

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CHEMICALS Ethylene oxide

Ethylene oxide is an alkylating agent that is used to sterilize medical devices,72 including fiberoptic endoscopes. Central supply units and surgical rooms typify areas where ethylene oxide is used. Exposure to ethylene oxide occurs primarily through inhalation. Acute exposure to relatively high concentrations of ethylene oxide can cause skin burns, headache, nausea, and hemolysis of red blood cellsY3 Peripheral neuropathy associated with ethylene oxide exposure has also been reported.74 Chromosomes can be adversely affected by ethylene oxide. Animal studies have demonstrated that ethylene oxide is a mutagen. 75 An increased frequency of sister chromatid exchanges has been observed in workers exposed to ethylene oxide.72 A Finnish study reported an increased incidence of spontaneous abortion.76 The National Institute for Occupational Safety and Health (NIOSH) considers ethylene oxide to be a potential carcinogen in human beings.77 Engineering controls and good work practices can be employed to reduce the exposure of HCWs to ethylene oxide. Ventilation is probably the most important element of engineering controls. Good work practices include leaving the sterilizer area during the exhaust cycle and decreasing contact time with sterilized devices .78 Formaldehyde

Formaldehyde is used as a tissue sterilant or preservative. Dialysis units, pathology departments, central supply units, and gross anatomy laboratories are all areas where formaldehyde plays an important roleY9 Exposure to formaldehyde can result in adverse health effects. Dermatitis and eye and respiratory tract irritation can be caused by formaldehyde exposure.8o Sensitization to formaldehyde can also occur and may lead to asthma.*l In human beings formaldehyde is considered a potential carcinogen. Animal studies have demonstrated the mutagenic capability of formaldehyde?O The epidemiologic data are not conclusive. Studies suggesting that formalde-

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hyde exposure increases the risk of upper respiratory and lymphopoietic cancers can be found in the literature.82 However, there is a lack of consistency among the various studies that have attempted to examine the relationship between formaldehyde exposure and cancer. Recently, an independent panel reported that there was no conclusive evidence to link formaldehyde exposure to any cancer in human beings.83 Antineoplastic

drugs

Chemotherapy is often an important modality of cancer therapy. A number of antineoplastic drugs have been developed, including vincristine and cisplatin. Pharmacists and nurses exemplify HCWs that may be occupationally exposed to these drugs. HCW exposure to antineoplastic drugs occurs primarily through the dermal and inhalational routes. Aerosols can be created during drug preparation and administration.84 Spills can result in dermal exposure. A survey of hospitals demonstrated a number of procedural deficiencies in the handling of antineoplastic agents by HCWs. These deficiencies ranged from the lack of standardized procedures to the inadequate utilization of protective equipment .85,86 Animal studies have demonstrated that many antineoplastic drugs are mutagenic and/or teratogenic.8’ Studies that examined the relationship between the occupational exposure of HCWs to antineoplastic agents and increases in the frequency of sister chromatid exchanges produced conflicting results. Norppa et al?* found an increased frequency of sister chromatid exchanges; Barale et a1.89 did not. A Finnish case-control study found an association between exposure of nurses to antineoplastic agents and fetal loss.*’ A number of measures can be employed to reduce HCW exposure to antineoplastic agents. For example, drug preparation can be performed in a class II vertical laminar flow safety cabinet. Personal protective equipment such as gloves should be used during drug preparation and administration. Attention should be paid to fundamental safety practices, including handwashing and not eating or drinking in

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areas where the drugs are prepared. A detailed discussion of work-practice guidelines for antineoplastic agents can be found in the American Journal

of Hospital

Anesthetic

waste

Pharmacy.go

gases

Anesthesiologists, nurse anesthetists, operating room nurses, and dental personnel exemplify HCWs that may be exposed to anesthetic waste gases. Commonly used anesthetic gases include halothane, enflurane, and nitrous oxide. HCW exposure occurs principally through the leakage of anesthetic gases. Leakage from equipment is a major source of such exposure. Anesthetic gases may also leak around patient face masks.” Studies have suggested that operating room personnel may have adverse health effects related to the operating room environment. For female anesthesiologists a statistically significant increased risk of spontaneous abortion has been observed.92 A statistically significant increase has been reported for the risk of spontaneous abortion among wives of dentists.93 An increased incidence of hepatic disease has been noted among operating room personnelY4 HCW exposure to anesthetic agents can be decreased through a number of steps. Areas such as the operating room, where anesthetic gases are used, should be properly ventilated. Gas scavenging systems that trap and ventilate anesthetic waste gases should be employed. Anesthetic equipment should be tested to confirm that it is functioning properly?’ The success of a program to limit occupational exposures can be monitored by chemical dosimetry. DATA SOURCES

Available data regarding occupational hazards to HCWs are inadequate to delineate or assess the problem fully.” This may be related to the vast spectrum of hazards. No one data source can encompass all the issues. This is particularly true because HCWs comprise a large, diverse group whose members range from lowskilled orderlies to highly trained professionals. Information can be obtained from a number of sources, however. Workmen’s compensation data can be a use-

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ful source of information. For example, it provides considerable insight into the problem of lumbosacral injury. In New York State several health-related occupations ranked near the top in the number of workmen’s compensation claims for lumbosacral injury.96 Unfortunately, many adverse health effects caused by occupational hazards are not sufficient to warrant a workmen’s compensation claim or are not covered by the compensation system. State laws also vary considerably from state to state. New hazards may not be included. All these factors limit the utility of using workmen’s compensation data bases to study occupational hazards to HCWs. Prospective studies can provide useful information regarding occupational hazards. The risk of needlestick transmission of HIV was estimated through a series of prospective studies.63 Not all hazards can be fully evaluated through prospective studies. First, the number of hazards surpasses the available resources for the conduct of prospective studies. Second, sample sizes of prospective studies may be too small to have sufficient power to fully delineate low levels of risk. Third, multiple exposures make studying a single agent difficult. Fourth, adverse effects that occur many years after exposure cannot be quickly demonstrated. Medical devices are an overlooked source of occupational hazards, including everything from radiology equipment falling off their mounts to electric shocks sustained by paramedics during a defibrillation effort. Postmarketing surveillance systems exist within the CDRH.9’ The Medical Device Reporting System is an example of such a system. The system requires a device manufacturer or importer to report to the Food and Drug Administration whenever the manufacturer or importer receives or otherwise becomes aware of information that reasonably suggests that one of its marketed products may have caused or contributed to a death or serious injury or has malfunctioned and the device or any other device marketed by the manufacturer or importer would be likely to cause or contribute to a death or serious injury if the malfunction were to re-

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cur. Manufacturers or importers may become aware of relevant information from individuals, institutions, medical and scientific literature, or through their own research, testing, evaluation, servicing, or maintenance of its devices. Other government agencies also provide useful data. NIOSH performs extensive research on occupational hazards and control measures and makes recommendations but does not have enforcement powers. The creation and enforcement of occupational safety standards rests with the Occupational Safety and Health Administration (OSHA). OSHA also provides consultative services. Infectious agents, as previously described, represent an important occupational hazard. The CDC plays an active role in this area, particularly through its surveillance programs. CONCLUSION

HCWs face an imposing collection of occupational hazards. The true magnitude and range of these hazards may not be fully appreciated by workers. Presently available data are inadequate to measure completely all the risks. The AIDS epidemic has focused attention on the occupational risks to HCWs. Measures such as universal precautions and efforts to decrease the frequency of needlestick injuries have been initiated and promoted. OSHA is developing guidelines to reduce the risk of the occupational transmission of blood-borne viruses. All these steps are constructive responses. A multifaceted effort is required to address the occupational hazards of HCWs. Hospitals and other health care organizations, professional groups, manufacturers, and government agencies all must play a role. Health care organizations and HCWs have been in the forefront of many campaigns to promote health, including the use of safety belts, low-cholesterol diets, exercise, and cessation of smoking. The promotion of health and safety should not exclude the health care setting. Attacking the myriad of occupational hazards to HCWs will allow the health care community to lead by example. We thank John Cheryl Simmons

Parsley for her

for his clerical

technical assistance.

assistance

and

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References 1. Omenn GS, Morris SL. Occupational hazards to health care workers: report of a conference. Am J Ind Med 1984;6:129-37. 2. Clever LH. Health hazards of hospital personnel. West J Med 1981;135:162-5. 3. National Institute for Occupational Safety and Health. Guidelines for protecting the safety and health of health care workers, 1988. Washington, DC: Department of Health and Human Services, NIOSH publication 88119. 4. Patterson WB, Craven DE, Schwartz DA, et al. Occupational hazards to hospital personnel. Ann Intern Med 1985;102:658-80. 5. Kaczmarek RG, Rudin S, Bednarek DR, Wong R, Kaczmarek RV, Alker GV. Potential radiation hazards to personnel during dynamic CT scanning. [Letter]. Radiology 1986;161:853. 6. Centers for Disease Control. Assessing exposures of health-care personnel to aerosols of ribavirinCalifornia. MMWR 1988;37:560-3. 7. Emmett EA. ed. Health problems of health care workers. State Art Rev Occup Med 1987;2:429-649. 8. Christensen EE, Curry TS, Dowdey JE. An introduction to the physics of diagnostic radiology. 2nd ed. Philadelphia: Lea & Fehiger, 1978:54. 9. National Council on Radiation Protection and Measurements. Radiation protection for medical and allied personnel. Washington, DC: NCRP, Report 48: 1976. 10. National Council on Radiation Protection and Measurements. Review of radiation dose limit for embryo and fetus in occupationally exposed women. Washington, DC: NCRP, Report 53: 1977. 11. Rueter FG. Physician and patient exposure during cardiac catheterization. Circulation 1978;58:134-9. 12. Wold GJ, Scheele RV, Agarwel SK. Evaluation of physician exposure during cardiac catheterization. Radiology 1971;99:188-90. 13. Brateman L. A plea for sensible film badge placement in diagnostic radiology. Health Phys 1989;56:567-8. 14. Harding LK, Mostafa AB, Roden L, Williams N. Dose rates from patients having nuclear medicine investigations. Nucl Med Commun 1985;6:191-4. 15. Harvard AC. The unseen hazards of ultrasound. Br J Radio1 1989;62:295-6. 16. Land CE, Norman JE. Latent periods of radiogenic cancers occurring among Japanese A-bomb survivors. In: International Atomic Energy Agency. Late biological effects of ionizing radiation; vol 1. Vienna: Intemational Atomic Energy Agency, 1978:29-47. 17. Smith PC, Doll R. Mortality among patients with ankylosing spondylitis after a single treatment course with x-rays. Br Med J 1982;284:449-60. 18. Howe CR. Epidemiology of radiogenic breast cancer. In: Boise JD, Fraumeni JF, eds. Radiation carcinogenesis: epidemiology and biological significance. New York: Raven Press, 1984:114-30. 19. Wachter RM. The impact of the acquired immunodeficiency syndrome on medical residency training. N Engl J Med 1986;314:177-80.

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