Burden, Need and Impact

Burden

Adverse health effects associated with exposure to antineoplastic drugs are well documented and include acute effects such as nausea, headache, skin and eye irritation, and hair loss, as well as long-term effects such as DNA damage, miscarriage, leukemia and other cancers.^3-8 The current NIOSH list of antineoplastic and other hazardous drugs in healthcare settings comprises nearly 220 drugs and continues to grow.⁹

NIOSH found over 400 healthcare workers reported acute illnesses or injuries related to disinfectant exposure from 2002-2007 in 4 states.¹⁰ Environmental services workers were the most common occupation (24%), followed by nursing and medical assistants (16%), technicians (15%), and nurses (11%). Healthcare workers account for about 16% of all occupational asthma cases and that up to 24% of these cases are due to exposure to cleaning agents.¹¹ Healthcare workers have one of the highest prevalences of occupational asthma at 8.8%, compared to 7.2% among all workers.^12-13

Need

While national guidelines exist for the safe handling of antineoplastic drugs, information is lacking on adherence to these guidelines by healthcare workers and employers. A NIOSH survey conducted among members of professional healthcare organizations including oncology nurses, pharmacists, and pharmacy technicians found that 47% of pharmacy practitioners who compounded antineoplastic drugs in the seven days prior to the survey did not always wear the recommended two pairs of chemotherapy gloves, and 10% did not wear even a single pair.¹⁴ The same survey found that 12% of oncology nurses and others who administer antineoplastic drugs took home potentially contaminated clothing.¹⁵

There is a need to develop measurement methods for cleaning and disinfecting exposures related to respiratory and dermal health effects.¹⁶ Surveillance is also needed to better understand potential barriers to reporting illness related to cleaning and disinfection products in HCSA workplaces.¹⁷

Impact

The number of hazardous drugs and chemicals in the HCSA sector continues to grow as advances are made in chemical engineering and pharmaceutical manufacturing. Likewise, pressure on facilities to manage infectious disease risks has introduced stronger and more toxic cleaning products into the HCSA sector. NIOSH protects workers in the HCSA sector by publishing a list of hazardous drugs and issuing alerts on preventing occupational exposures. The potential impact of this prevention is not insignificant – the HCSA sector will account for almost 40% of the projected job growth from 2014 to 2024, more than any other industry sector.¹⁸

⁵ Valanis, B.G., W.M. Vollmer, K.T. Labuhn, and A.G. Glass: Acute symptoms associated with antineoplastic drug handling among nurses. Cancer Nurs. 16:288–295 (1993).

⁶ Skov, T., B. Maarup, J. Olsen, M. Rorth, J. Winthereik, and E. Lynge: Leukaemia and reproductive outcome among nurses handling antineoplastic drugs. Br. J. Ind. Med. 49:855–861 (1992).

⁷ Lawson, C.C., C.M. Rocheleau, E.A. Whelan, et al.: Occupational exposures among nurses and risk of spontaneous abortions. Am. J. Obstet. Gynecol. 206:327.e1–8 (2012).

⁸ Richardson David B, Cardis Elisabeth, Daniels Robert D, Gillies Michael, O’Hagan Jacqueline A, Hamra Ghassan B et al. Risk of cancer from occupational exposure to ionising radiation: retrospective cohort study of workers in France, the United Kingdom, and the United States (INWORKS). BMJ 2015;351:h5359

Burden

Infectious diseases are an ongoing concern among healthcare and social assistance workers:

• The World Health Organization estimates that 37.6% of Hepatitis B, 39% of Hepatitis C and 4.4% of HIV/AIDS in healthcare workers around the world are due to needlestick injuries.¹⁹
• A survey conducted by the National Nurses United (NNU) found that 87% of surveyed nurses in the U.S. indicated that their hospital had not provided education on Ebola with the ability for the nurses to interact and ask questions.²⁰
• Influenza vaccination rates for the 2014-15 season among healthcare personnel was lowest for those working in long-term care settings (63.9%) and among nursing assistants and aides (64.4%).²¹

Need

There are several areas in which more research could help reduce transmission of infectious diseases:

• Prevention of transmission in HCSA workers depends on stopping sharps injuries and other blood and body fluid exposures. Unfortunately, surveillance for this issue is fragmented and only limited data is available to estimate the full burden of needlestick injuries.
• The 2014 Ebola Outbreak highlighted the need for preventing occupational infectious disease transmission in healthcare settings. After caring for a patient with Ebola, two nurses in Dallas, Texas contacted the disease and demonstrated the need for training and preparedness among healthcare personnel in the US.
• In many cases, interventions exist to prevention transmission; however, much remains unknown regarding emerging infectious diseases. Numerous opportunities exist for research with relevance and impact.

Impact

Addressing infectious disease threats in the HCSA sector will require a multifaceted approach driven by evidence-based practices, thoughtful occupational health research and comprehensive surveillance. In addition to increasing worker health and safety, these efforts can also reduce costs.  Vaccinating employees for influenza and reducing influenza-related absenteeism can save U.S. employers $2.58 for every dollar invested in a vaccination program.²² NIOSH protects workers in the HCSA sector by developing and evaluating personal protective equipment and issuing guidance for workers on emerging infectious diseases. The potential impact is not insignificant – the HCSA sector will account for almost a third of the projected job growth from 2012 to 2022 – adding 5 million jobs during this period with a total employment of nearly 22 million (13.6% of U.S. workforce) in 2022.²³

Burden

According to the Bureau of Labor Statistics for 2013, there were 167,150 total injury and illness cases with days away from work in HCSA sector.  This accounted for 18.2% of all such cases in all private industry. The highest incidence rate of injury and illness cases with days away from work was in nursing care facilities (110.5 cases per 10,000 FTEs) and community care facilities for elderly (88.6 cases per 10,000 FTEs).  The following occupations had the highest incidence rates (number in parenthesis = cases per 10,000 FTE): nurse orderlies (245), psychiatric aides (237), dietetic technicians (236), and occupational therapy aides (221).

Need

HCSA ranks second to Transportation & Warehousing in MSD incidence rate (the number of new cases each year per 10,000 full-time workers). The rate is quite high compared to other industries – the incidence rate for MSDs in HCSA private industry establishments is 50% higher than the average for all private industry establishments. The incidence rate for MSDs in HCSA state and local government establishments are even higher, 72% and 19% higher respectively than HCSA private industry establishments.

Within HCSA, some jobs have higher MSD rates than others, such as nurses and nursing assistants. In 2013, nursing assistants had the highest number of cases and 2nd highest incidence rate of MSDs among all occupations across all ownerships (i.e., private industry and state & local gov’t establishments).²⁴

Impact

Expanding the NIOSH effort on this goal will advance NIOSH impact on developing effective and practical strategies to prevent MSDs in HCSA, which will also impact other industrial sectors including construction, public safety, services, oil and gas, and manufacturing. NIOSH has a track record of implementing and evaluating interventions for reducing MSDs and is poised to continue such work in this sector.  The Revised NIOSH Lifting Equation (RNLE) helps healthcare workers determine how much weight can be safely lifted without using assistive equipment. Other resources such as the Safe Lifting and Movement of Nursing Home Residents continue to provide guidance to employers and workers in the HCSA sector.

Burden

A safety culture reflects the shared commitment of management and employees toward ensuring the safety of the work environment. There are indications that safety culture in HCSA is not as prevalent as it could be:

• Nurses consistently report the highest levels of job stress of all health are professionals.²⁵
• In a 2011 survey sponsored by the American Nurses Association, nurses said that job stress was one of their two top safety and health concerns.²⁶
• Nurses extended work shifts are associated with negative well-being and patient measures.²⁷
• In a survey of veterinarians, male and female respondents had a higher lifetime prevalence of depressive episodes and suicidal ideation than the general population of US adults.²⁸

Need

Interventions aimed at decreasing stress in the work place have had limited success, and those with success, have been implemented inconsistently. Interventions have included: altering work conditions to be more conducive to employee coping, employee training in stress management, development of employee assistance programs, and employee training in identification of stressful relationships. It has been noted that the best way to combat work-related stress would be to implement multiple strategies simultaneously.²⁹

Impact

Research on effective work organization interventions that reduce occupational stress and improve worker health, safety, and well-being, has high potential for adoption within the healthcare industry. For example, information about NIOSH training for nurses on shiftwork and long work hour schedules was widely disseminated by NIOSH partners (such as the American Nurses Association) and is being offered for continuing education credits at some nursing schools. It is likely that occupational stress interventions developed for the HSA sector will have applicability for many other sectors, particularly integrative interventions that address worker health and well-being both on and off the job.

Burden

Many healthcare and social assistance workers experience violence on the job.

• Psychiatric and substance abuse hospitals had the highest incident rate for violence related injuries (135 cases per 10,000 FTE), 32 times the private industry average and over 8 times the HCSA sector average.³⁰
• Occupations of highest risk from violence related injuries include nursing aides, psychiatric aides, home health aides, nurses, nursing assistants, and veterinary technologists and veterinary assistants.³¹

Need

Research is needed on impediments to implementing proven best practices to prevent workplace violence; economic evaluation of costs, benefits and return-on-investment; intervention effectiveness; adapting existing educational materials for newly recognized occupations and work settings, and evaluation of prevention strategies and programs. These research efforts can take advantage of current NIOSH strengths on partnership, global advancement in health-and-injury informatics, and worldwide new big-data methods for increased national impacts. Partnering with the NIOSH Occupational Health Equity Program, the HCSA program is well-suited to translating and disseminate research to reach healthcare and social assistance workers across socio-demographic groups.

Impact

NIOSH will continue its efforts developing effective and practical strategies to design out workplace violence risks, craft engineering solutions, and implement organizational interventions to reduce workplace violence incidents and prevent injuries. NIOSH has a track record of implementing and evaluating interventions for reducing workplace violence and is poised to continue such work in this sector. Over 25,000 individuals have registered for NIOSH’s online Workplace Violence Prevention Training for Nurses with over 18,000 nurses receiving continuing education credits.