[MCOH-EH] Chemo Medical Surveillance

[Hudson, T. Warner]

I agree with Mark and Melanie.  Warner

T. Warner Hudson, MD FACOEM, FAAFP
Medical Director, Occupational and Employee Health
UCLA Health System and Campus
Office 310.825.9146
Fax 310.206.4585
Pager 800.233.7231  ID 27132
E-mail twhudson at mednet.ucla.edu<mailto:twhudson at mednet.ucla.edu>
Website www.ohs.uclahealth.org<http://www.ohs.uclahealth.org>

From: MCOH-EH [mailto:mcoh-eh-bounces at mylist.net] On Behalf Of Upfal, Mark
Sent: Tuesday, May 26, 2015 6:31 AM
To: 'MCOH/EH'
Subject: Re: [MCOH-EH] Chemo Medical Surveillance

I agree as well.  I have yet to see a validated method for screening workers for outcomes in this setting.  However, we know that primary prevention (i.e. occupational hygiene/exposure control) is important and can be effective.  Monitoring should be probably focused on the environment, engineering controls, work practices and use of PPE.

Mark


Mark Upfal, MD, MPH
Corp Medical Director, DMC Occupational Health Services
4201 Saint Antoine, UHC 4G-3
Detroit, MI 48201
(313) 993-0509
www.dmc.org/ohs<http://www.dmc.org/ohs>

__________________________________________

This e-mail message and any attachments may be privileged and confidential and protected information. If you are not the intended recipient, or an employee or agent responsible for delivering this message to the intended recipient, you are hereby notified that any review, use, disclosure, dissemination, distribution or copying of this communication may be a violation of the law. Please contact the sender immediately by replying to the message and delete it from your computer. Thank You.


________________________________
From: MCOH-EH [mailto:mcoh-eh-bounces+mupfal=dmc.org at mylist.net] On Behalf Of JimGarb
Sent: Friday, May 22, 2015 12:50 PM
To: 'MCOH/EH'
Subject: Re: [MCOH-EH] Chemo Medical Surveillance
I think Melanie is right on target.  Lab abnormalities and adverse outcomes of pregnancy (or difficulty conceiving) are common and confounded by multiple other factors beside occupational exposures.  I have always thought that the most useful way to monitor this population of workers exposed to hazardous drugs was by giving them the option of completing a confidential health/exposure survey online using the medical center's intranet and feeding that data into a database.  That would allow us to look at trends in exposed groups (pharmacists, inpatient and outpatient oncology nurses) who were exposed over time to various agents to try and determine if there are unusual patterns of adverse outcomes of pregnancy or illness.  That might yield more information than chasing down individual lab abnormalities or symptoms.

Unfortunately, this was never a high enough priority for the IT department to set it up at my last place of employment, and we haven't even begun to discuss it in any serious way at the health system where I currently consult.  Perhaps someone else has developed and implemented this type of approach.

Jim

James Garb, MD FACOEM
Medical Director Occupational Health Services
Cape Cod Healthcare
Hyannis, MA

From: MCOH-EH [mailto:mcoh-eh-bounces at mylist.net] On Behalf Of Swift, Melanie
Sent: Friday, May 22, 2015 10:57 AM
To: MCOH/EH
Subject: Re: [MCOH-EH] Chemo Medical Surveillance

What a frustrating topic. This would be lovely if there was a biomarker for exposure that would be sensitive and specific for adverse effects from the drugs being handled, but this does not exist. Beth Baker did an MCOH survey several years back and found that some places do health and reproductive surveys, others add basic labs like a CBC, U/A and LFTs, while others do not do any routine medical surveillance except for acute exposures. Of those who did symptom surveys or labs, none reported this being effective or informative. (This is probably in the MCOH listserv archives somewhere, if anyone has time to search...)

Laboratory abnormalities are very common in the general population (estimates roughly 50% of the unexposed population would have some abnormal value if you do random CBC, U/A and LFTs) and if you find it in the course of a medical surveillance program, then you have some obligation to work it up or refer the patient further. Malignancy is the main concern with most chemotherapeutic agents, and CBC, U/A and LFTs are not recommended as screening tests for any malignancy.

Furthermore, reproductive surveys run the very real risk of implying to the workers that every miscarriage is work-related, even if  the rate of miscarriage is the same or lower than the general population.

We do acute and f/u evaluations after a spill or identified exposure, targeted to the specific drug and the findings one might expect at the timing indicated for that drug.

We do have a policy that allows workers who are pregnant or attempting pregnancy to request temporary reassignment.

Our safety colleagues do regular formal environmental monitoring with wipes in the pharmacy rooms with BSCs where chemo is mixed. This has been the most important thing to monitor for exposure risk and helps greatly to reassure staff of their safety.

Melanie Swift, MD
Director, Vanderbilt Occupational Health Clinic
http://occupationalhealth.vanderbilt.edu

From: MCOH-EH [mailto:mcoh-eh-bounces at mylist.net] On Behalf Of Hodgson, Michael - OSHA
Sent: Wednesday, May 20, 2015 11:59 AM
To: MCOH/EH
Subject: Re: [MCOH-EH] Chemo Medical Surveillance

Hi, all, OSHA is interested in that letter, too, as we are trying to consider / updating our web work.  Melanie and Mark, would you send that to OSHA, too?

1.      It would be really interesting to know whether anyone does "surveillance" , i.e., whether you collect a CBC, whether you collect anything more, whether you collect information on reproductive efforts or outcomes, and whether you ever collect biological monitoring samples, for example after spills and other unexpected exposures (like ventilation system failures in pharmacies)

2.      Do people formally acknowledge and follow Oncology Nursing Society procedures?  Are those acknowledged and supported by your pharmacy and nursing leadership?

3.      Do people have a formal policy on managing workers of reproductive age who are considering / planning active reproduction?  Would this group be willing to answer whether

a.      You offer people a chance to transfer to a job without exposure? (men too?)

b.      Let people transfer out of an exposed job once they are pregnant?

c.       Mandate that people transfer out of an exposed job once pregnancy is known?

4.      Does anyone do formal exposure assessment, i.e., wipe samples outside of pharmacy cabinets?

Exposed here means simply working with cytotoxic agents...

Michael Hodgson, MD
OSHA Office of Occupational Medicine and Nursing

From: MCOH-EH [mailto:mcoh-eh-bounces+hodgson.michael=dol.gov at mylist.net] On Behalf Of Swift, Melanie
Sent: Wednesday, May 20, 2015 12:48 PM
To: MCOH/EH
Subject: Re: [MCOH-EH] Chemo Medical Surveillance

Our esteemed colleague Dr. Russi at Yale drafted a letter to NIOSH on this subject last summer which encapsulates this quagmire nicely.
Mark, would you to share this with the list or do you mind if I share it (I have it handy, I read it often...)

Melanie Swift, MD
Director, Vanderbilt Occupational Health Clinic
http://occupationalhealth.vanderbilt.edu

From: MCOH-EH [mailto:mcoh-eh-bounces at mylist.net] On Behalf Of Schweitzer, Kit
Sent: Wednesday, May 20, 2015 11:41 AM
To: mcoh-eh at mylist.net<mailto:mcoh-eh at mylist.net>
Subject: [MCOH-EH] Chemo Medical Surveillance

I am an Employee Health Nurse at a hospital in Oregon. Do any of you do medical surveillance for staff administering or handling chemo drugs?
If so, can you please describe your policy. If not, can you please provide reasons why.
Thank you in advance for your answer.

Kit Schweitzer, RN, BSN, COHN
Employee Health Nurse
Employee Health and Safety
Sacred Heart Medical Center
(541) 222-2544 Office
(541) 434-3140 e-Fax
3333 RiverBend Drive, Springfield, OR 97477
www.peacehealth.org<http://www.peacehealth.org/>
[cid:image001.png at 01CBF05C.90368260]


This message is intended solely for the use of the individual and entity to whom it is addressed, and may contain information that is privileged, confidential, and exempt from disclosure under applicable state and federal laws. If you are not the addressee, or are not authorized to receive for the intended addressee, you are hereby notified that you may not use, copy, distribute, or disclose to anyone this message or the information contained herein. If you have received this message in error, immediately advise the sender by reply email and destroy this message.

This message (including any attachments) is confidential and intended solely for the use of the individual or entity to whom it is addressed, and is protected by law. If you are not the intended recipient, please delete the message (including any attachments) and notify the originator that you received the message in error. Any disclosure, copying, or distribution of this message, or the taking of any action based on it, is strictly prohibited. Any views expressed in this message are those of the individual sender, except where the sender specifies and with authority, states them to be the views of Tenet Healthcare Corporation.

________________________________

IMPORTANT WARNING: This email (and any attachments) is only intended for the use of the person or entity to which it is addressed, and may contain information that is privileged and confidential. You, the recipient, are obligated to maintain it in a safe, secure and confidential manner. Unauthorized redisclosure or failure to maintain confidentiality may subject you to federal and state penalties. If you are not the intended recipient, please immediately notify us by return email, and delete this message from your computer.
-------------- next part --------------
An HTML attachment was scrubbed...
URL: <http://mylist.net/archives/mcoh-eh/attachments/20150526/3799cec7/attachment.html>
-------------- next part --------------
A non-text attachment was scrubbed...
Name: image001.png
Type: image/png
Size: 5827 bytes
Desc: image001.png
URL: <http://mylist.net/archives/mcoh-eh/attachments/20150526/3799cec7/attachment.png>