While many drugs act as a lifeline, mitigating symptoms and treating an illness, some are hazardous and have the potential to put the world’s 59 million health care workers administering them at risk. Given the current crisis, never has the health of front-line workers — and thus the availability of personal protective equipment — been more critical.
The U.S. National Institute for Occupational Safety and Health lists over 200 hazardous drugs that have the potential to cause adverse reactions — such as rashes, infertility, and even cancer, if measures aren’t taken to protect against contact. Such drugs include those used for chemotherapy, antivirals, hormones, and some bioengineered drugs.
“You need to have a complete process of safe handling, not only in the pharmacy … but during transportation, storage, dispensing, and during administration.”— Sherif Kamal, clinical pharmacist, Children’s Cancer Hospital Egypt
Sherif Kamal, a clinical pharmacist at the Children’s Cancer Hospital Egypt, has said that cancer medications, in particular, pose a great risk to health care workers, including pharmacists and nurses.
“When you are exposed through your skin, inhalation, or digestion, there are not only the systemic side effects of the anti-cancer drugs but also the risk of getting cancer,” he said. “Some exposure can cause secondary acute myeloid leukemia.”
While data is lacking on the number of health workers potentially exposed to hazardous drugs in workplaces in low- and middle-income countries, that figure in the U.S. is thought to be approximately 8 million.
Kamal called for the Egyptian government to replicate the efforts of countries such as the U.S., as well as those in the European Union, by introducing better safeguarding policies and procedures.
Hazardous drugs explained
According to the U.S. National Institute for Occupational Safety and Health, drugs are classified as hazardous if they have any one of these six characteristics:
• Genotoxicity: the ability to cause a change or mutation in genetic material.
• Carcinogenicity: the ability to cause cancer.
• Teratogenicity: the ability to cause defects in fetal development or fetal malformation.
• Fertility impairment or reproductive toxicity.
• Serious organ toxicity at low doses.
• Chemical structure and toxicity profile that mimic existing drugs determined to be hazardous.
“We need to put occupational safety and health as a mandatory standard and have it mandated by the government,” he said, adding that a certification program on safe handling for the whole of Egypt needs to be created. “We’re raising awareness that you need to have a complete process of safe handling, not only in the pharmacy and the IV admixture [a mixture of two or more drugs into IV fluid] but during transportation, storage, dispensing, and during administration, even if the drug is oral medication.”
Speaking to Devex, Kamal discussed the risks that those in the health sector face and what measures Egypt should be taking. This conversation has been edited for length and clarity.
What risks do health workers face when handling hazardous drugs?
They are exposed to a lot of risks, like when they’re handling cancer medications. We know already they face exposure through inhalation, ingestion, or contact with the chemistry of anti-cancer drugs themselves. Because of that, we use safe handling techniques, but I can tell you that in the pharmacy, we are the most exposed. Outside the pharmacy, the exposure is higher in areas where the administration is done by the nursing staff.
In my experience, everyone is taking care, and there is no stigma. It is a real, real problem. People should be aware of the risk because it is a very real risk. People should be trained and retrained on how to handle this risk.
Do you hear very often of health care workers who have been injured because of their exposure to hazardous drugs?
At the beginning of 2020 — before the coronavirus — we had a lot of meetings with pharmacists from all over Egypt, and they were all concerned that there are no policies or techniques in place for safe handling. We have great concern from the staff, and we'll work on it. We hope that the coronavirus will be finished soon and we can start to plan for 2020.
What is the status of Egypt with regard to hazardous drugs and the impact on health workers?
Since 1998, ours was the first clinical pharmacy in the whole country serving oncology patients. In 1990, it was started inside the National Cancer Institute, and we have helped more than 15 other centers open their clinical pharmacy and IV admixture activities.
In our pharmacy — not only in the training program, but in the design and operation of the pharmacy — we have integrated safe handling procedures and processes on how you select what anti-cancer drugs are going to mix and what the negative pressure of the room is. Everyone now has a big awareness about handling, and they know exactly the right design and the right equipment to purchase and handle the medication safely.
We are now working through the individual pharmaceutical society and the oncology departments to certify people in IV admixture, to train and retrain them, and also to incorporate safe handling, from receiving the medication in the receiving dock right through to waste disposal.
In my facility — but in very few other facilities — there are very strict policies and procedures. I think in other areas of the country, there is either no policy, or if there are policies, they are only on paper. I don't think outside my facility there are real safe handling procedures or policies in Egypt.
And so what would you recommend to remedy this?
We recommend that, No. 1, we make a certification program for Egypt which is designed and implemented in collaboration with the European Society of Oncology Pharmacy with its partner in Egypt, the oncology section of the Egyptian Pharmacy Society. This is now waiting for recognition by our minister of health.
Whatever I have in my facility for the design of safe handling is not [made] mandatory by our government, so we need to make it mandatory. When we do, we will work with the minister in an unparalleled program and with the different authorities in Egypt — not only the minister of health, but the pharmacy syndicates, as well as the new Egyptian drug authority — to create and implement this program and write the policies as a standard of care but then make sure that the policies are implemented.
I think this is an area of improvement regarding quality and safety in health care, not only for staff, but also for the whole health care facility, patients, and their families.
There are technologies that are now available that determine hazardous drugs surface contamination in 10 minutes, and drug contamination can be tracked over time. Utilization of such technologies can be very helpful. Further, there are technologies [including] closed-system drug transfer to prevent exposure to hazardous drugs, from drug preparation to IV administration. These technologies should be adopted in high-risk settings to advance safety.