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HHE local health department survey Attachment B - Example of an HHE report.pdf

Surveys of State, Tribal, Local and Territorial (STLT) Governmental Health Agencies

Example Report

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Attachment B: HHE local health department survey, Example HHE report

Workplace

Safety and Health

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Disease Control and Prevention

National Institute for Occupational
Safety and Health

Attachment B: HHE local health department survey, Example HHE report

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].

Attachment B: HHE local health department survey, Example HHE report

Contents
Report

Abbreviations.................................................................................................ii
Highlights of the NIOSH Health Hazard Evaluation.........................iii
Summary..........................................................................................................v
Introduction....................................................................................................1
Assessment......................................................................................................3
Results...............................................................................................................4
Discussion........................................................................................................8
Conclusions.....................................................................................................9
Recommendations..................................................................................... 10
References..................................................................................................... 13

Appendix A

Methods......................................................................................................... 15

Appendix B

Occupational Exposure Limits and Health Effects.......................... 16

Acknowledgments

Acknowledgments and Availability of Report................................. 23

Health Hazard Evaluation Report 2010-0068-3156

Page i

Attachment B: HHE local health department survey, Example HHE report

Abbreviations

ACGIH®
BSC
CDC
CFR
HEPA
HHE
IARC
IV
LOD
LOQ
NAICS
ND
NIOSH
ng/sample
ng/100 cm2
OEL
OSHA
PEL
PPE
REL
STEL
TLV®
WEEL™

Page ii

American Conference of Governmental Industrial Hygienists
Biological safety cabinet
Centers for Disease Control and Prevention
Code of Federal Regulations
High-efficiency particulate air
Health hazard evaluation
International Agency for Research on Cancer
Intravenous
Limit of detection
Limit of quantitation
North American Industry Classification System
Not detected
National Institute for Occupational Safety and Health
Nanograms per sample
Nanograms per 100 square centimeters
Occupational exposure limit
Occupational Safety and Health Administration
Permissible exposure limit
Personal protective equipment
Recommended exposure limit
Short-term exposure limit
Threshold limit value
Workplace environmental exposure level

Health Hazard Evaluation Report 2010-0068-3156

Attachment B: HHE local health department survey, Example HHE report

Highlights of the
NIOSH Health
Hazard Evaluation

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.

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 workrelated exposures to
chemotherapy drugs.

●● 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.

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Highlights of the
NIOSH Health
Hazard Evaluation
(continued)

●● Use a biological safety cabinet that does not recirculate
exhaust air when you prepare volatile chemotherapy drugs
like carmustine and 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 storage 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.

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Attachment B: HHE local health department survey, Example HHE report

Summary

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.

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

Health Hazard Evaluation Report 2010-0068-3156

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Attachment B: HHE local health department survey, Example HHE report

Summary
(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.
Keywords: NAICS 541940 (Veterinary Services), chemotherapy,
oncology, anti-neoplastic, hazardous drugs, veterinary,
cyclophosphamide, ifosfamide, doxorubicin, surface wipe samples,
air samples

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Attachment B: HHE local health department survey, Example HHE report

Introduction

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 the drugs on a per patient basis and then
transported the drugs 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).
Figure 1. Veterinary technician wearing
PPE while preparing chemotherapy
drugs in a Class 2 BSC.

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
a procedure that required at least two employees or students
to restrain the animals for IV catheter placement and drug

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Attachment B: HHE local health department survey, Example HHE report

Introduction
(continued)

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.

Figure 2. Intravenous administration
procedure for doxorubicin.

After receiving chemotherapy, animals were taken to radiology/
ultrasound, the nursing care unit, or the critical care unit for
further diagnostics, medical care, or observation. 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.

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.

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Health Hazard Evaluation Report 2010-0068-3156

Attachment B: HHE local health department survey, Example HHE report

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.

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Attachment B: HHE local health department survey, Example HHE report

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

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Health Hazard Evaluation Report 2010-0068-3156

Attachment B: HHE local health department survey, Example HHE report

Results
(continued)

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

Pharmacy

Drug
Preparation
Room (D157)

Sample Description

Results, ng/100 cm2
Cyclophosphamide

Receiving table

Plastic bin for transporting chemotherapy drugs

Desktop near oral chemotherapy pill cabinet

Countertop adjacent to small refrigerator and BSC

Top of chemotherapy waste disposal bin

Countertop adjacent to small refrigerator and BSC

BSC working surface

BSC airfoil

BSC top portion of cabinet (estimated area)

BSC underneath the grate

240

Floor directly in front of BSC

Administration
Area (D159)

Room D161
Reception
Area
Women’s
Locker Room
Radiology
Room (A135)
Laundry

Ifosfamide

(5)

Chemotherapy drug administration table (stainless steel area)

Tool cart with various supplies and instruments

Exam table on the soft padding

Exam table on the soft padding after doxorubicin
administration

(11)

Floor near technician after doxorubicin administration

Floor between examination tables

Chemotherapy waste disposal lid after doxorubicin

Telephone in cubicle near hallway door (estimated area)

Discharge medical records bin

Countertop in area behind reception desk

Reception area floor

Reception desk near computer

Changing area floor

Floor near door

Room #4 on exam table under X-ray

Floor next to exam table

Sandbag used to position animals

Floor in front of washer

Washer loading door (estimated area)

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Attachment B: HHE local health department survey, Example HHE report

Results
(continued)

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

Results, ng/100 cm2

Sample Description

Cyclophosphamide

Ifosfamide

Floor directly outside pharmacy mixing room D157

Floor directly outside the chemotherapy administration
room

Floor directly outside the technician offices

Floor inside technician office area

Floor entering technician office from administration

Floor at corner of hallway away from reception area

Floor near door to Room D165

Floor near drain in the run area

Technician office, on table by door to administration

Keyboard on the middle desk

Room D165

Conference room table

Ward 1 (D100)

Floor next to animal treated with vincristine

Room D112A

Floor near chemotherapy treated animal

Ultrasound

Floor near drain

Small Animal

Reception area floor near front door

LOD

LOQ

Oncology
Hallway

Room D158A
Room D161

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.

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.

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Health Hazard Evaluation Report 2010-0068-3156

Attachment B: HHE local health department survey, Example HHE report

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 cubic 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].

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Attachment B: HHE local health department survey, Example HHE report

Discussion

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 carmustine and
mustargen, two chemotherapy drugs that are more volatile than
cyclophosphamide, ifosfamide, or doxorubicin, were prepared in
the BSC. Sampling and analytical methods do not exist for either
carmustine or mustargen on work surfaces or in the air.
We learned that the veterinary hospital was transitioning to
preparing carmustine and mustargen in a chemical fume hood
(which did not recirculate exhaust air) instead of the BSC. We
agree that neither carmustine nor mustargen should 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

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Attachment B: HHE local health department survey, Example HHE report

Discussion
(continued)

should not be prepared in a chemical fume hood because the
sterility of 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. More volatile
chemotherapy drugs such as carmustine and mustargen have the
potential to enter the work area if they are 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.

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Attachment B: HHE local health department survey, Example HHE report

Recommendations

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.

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Recommendations
(continued)

2. Do not prepare volatile chemotherapy drugs such as
carmustine and 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.

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Recommendations
(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.

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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.
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.

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References
(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.

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Appendix A: Methods

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.

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Appendix B: Occupational Exposure Limits and Health Effects
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 8to 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
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Appendix B: Occupational Exposure Limits and Health Effects
(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

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Appendix B: Occupational Exposure Limits and Health Effects
(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].
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Appendix B: Occupational Exposure Limits and Health Effects
(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.

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Appendix B: Occupational Exposure Limits and Health Effects
(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 and
Availability of Report

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.

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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.

National Institute for Occupational
Safety and Health

Delivering on the Nation’s promise:
Safety and health at work for all people
through research and prevention.

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: [email protected]
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.

File Type	application/pdf
File Title	HHE 2010-0068-3156
Subject	NAICS 541940 (Veterinary Services), chemotherapy, oncology, anti-neoplastic, hazardous drugs, veterinary, cyclophosphamide, ifos
Author	The National Institute for Occupational Safety and Health
File Modified	2012-05-15
File Created	2012-04-05