PUBLIC HEALTH BRIEFS 18. Dressen DW, Kemp DT, Brown J, Brown WJ: Antibody response to a single intradermal booster dose of rabies human diploid cell vaccine. JAVMA 1983; 183:1468-1469.
19. Bernard KW, Mallonee J, Wright JC, et al: Preexposure immunization with intradermal human diploid cell rabies vaccine. JAMA 1987; 257:10561063.
Health Effects of a Thorium Waste Disposal Site G. REZA NAJEM, MD, PHD, Abstract: A case-control study of 112 households residing in the vicinity of a thorium waste disposal site found a higher prevalence of birth defects (RR 2.1) and liver diseases (RR 2.3) among exposed than the unexposed group. The numbers were quite small and the confidence intervals wide, however, so that no definite conclusions can be drawn from these data. (Am J Public Health 1990; 80:478480.)
Introduction Several studies have appeared in the medical literature analyzing possible adverse health effects for persons living in the vicinity of hazardous waste disposal sites.'-3 To our knowledge there is no published study in which the health effects of a thorium waste disposal site (TWDS) on the general population have been investigated, except for a community-based study in China.4 That study found no deleterious health effects from exposure to thorium, but had very low statistical power. The main concern about the possible biological effects of thorium (Th) with a half life of 1.4 x 1010 years is based on its radioactive characteristics and isotopes.5 Thorium232 is the parent of various radio-isotopes including 228Ra (radium), 228Ac (actinium), 228Th, 224Ra, and 220Rn (radon)5, Current interest is based in part on increased use of thorium as an energy source, e.g., in reactors using 232Th to produce 233U.6 Industrial and mining exposure to thorium have resulted in an increased incidence of lung cancer, pancreatic cancer, colorectal cancers, chronic respiratory diseases, liver damage, and other serious illnesses.7-9 Skeletal sarcomas, thorotrastomas, and sarcomas of the reticuloendo-thelial system have been reported from a study of patients receiving intravenous injections of thorotrast, a collodial solution of thorium oxide that was used as a contrast medium for diagnostic radiographic studies from the 1930s to the 1950s.'0 The purpose of this study was to conduct a survey of health effects of a thorium waste disposal site among members of the general population of Wayne, New Jersey, USA. Thorium Waste Disposal Site
The site is located on a 6.5 acre tract of land in Wayne Township, Passaic County in northern New Jersey, USA.* The population density in Wayne is 1,867.2 per square miles and annual per capita income is $7,725. "1 The thorium waste burial site lies within 100 feet of the sidewalk. Commercial Address reprint requests to G. Reza Najem, MD, PhD, Department of Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School, 185 S. Orange Avenue, Newark, NJ 07103-2757. Ms. Voyce is with the New Jersey Institute of Technology, Newark. This paper, submitted to the Journal July 24, 1987, was revised and accepted for publication August 1, 1989. *New Jersey Department of Environmental Protection: Site Descriptions for Hazardous Waste Sites in New Jersey. Division of Waste Management, Hazardous Site Mitigation Administration, 1984/85. © 1990 American Journal of Public Health 0090-0036/90$1.50
478
AND
LISA K. VOYCE, MSENE
businesses, a nursing home, a school bus maintenance yard, and residential homes are adjacent to the site. A drainage ditch lies at the northern and eastern borders, and drains into a brook at the northeast corner of the burial field. The brook (a tributory to the Pompton River) flows through residential areas (copy of map available on request). Fresh water wetlands lie approximately 1,800 feet to the west of the thorium waste disposal site.* From 1948 until 1971, a company extracted thorium and rare earths from monazite ore, for usage by the Atomic Energy Commission.* During its active years, the plant waste was dumped in backyard sludge piles. The wastes have been buried only in the last few years, after spending over 20 years above the ground.** Surveys of the New Jersey Department of Environmental Protection showed readings of 40-1491 uR/hour (uR = micro-rad, micro being 10-6) in various regions classified as contaminated areas; Sheffield Brook contamination occurs within 10 meters of both sides. Soil samples revealed Thorium (232Th), Radium (238Ra) and Uranium (238Ur) in the contaminated regions. Water samples from Sheffield Brook and the drainage ditch showed mainly alpha and beta activity. Most of the air concentrations (ambient and indoor) were within the background radiation levels (approximately 150 mrem/year) The US Environmental Protection Agency (EPA) standard for home concentration is below 4 pCi/ liter.*** The residents of the households in the vicinity of the thorium waste disposal site and in the vicinity of contaminated Sheffield Brook have not been tested for radioactive materials uptake. Methods The exposed population included 76 households within three blocks adjoining the contaminated areas. The 76 comparison (unexposed) households included all houses located on about 9th and 10th blocks distance from the thorium waste disposal site and contaminated Sheffield Brook. Households were accepted for inclusion in the study if they had resided at the present address for at least five years. Eleven and 10 households of the exposed and unexposed groups, respectively, did not meet the criteria for eligibility, 10 and nine households, respectively, did not participate in the study due primarily to members not being at home at the time of scheduled interviews or having moved out without leaving forwarding addresses. Face-to-face interviews of all 112 households (362 members), using a structured questionnaire, were carried out by one interviewer who did not know exposure status; 32 household members who did not agree to a face-to-face **New Jersey Department of Environmental Protection. Unpublished data. ***US Environmental Protection Agency, Office of Radiation Programs, Washington, DC 20406. Further details on measurements of exposed areas are available on request to author (Najem). AJPH April 1990, Vol. 80, No. 4
PUBLIC HEALTH BRIEFS TABLE 1-Demographic Variables among Exposed and Comparison Groups Variables
Group
Comparison Group
# of Persons studied # of Households studied % of Persons Age 50 & over % of Persons Age 18 & under Duration of Residence Mean duration* % Under 10 Years % 10-20 Years % Above 20 Years Annual Family Income % Less than $15,000 % $15,000-$49,000 % $50,000-$59,000 % $60,000+
171 55 29 27
191 57 32 26
13.3 Years 42 23 35
17.2 Years 23 9 68
9 65 20 6
9 63 21 7
Exposed
'Mean duration difference = 3.9 years (95% Cl =
-.71, -7.23)
interview were interviewed by telephone. For each disease or condition reported by the participants, we asked respondents whether they obtained the diagnostic information directly from their physicians; we did not obtain or review medical records. The risk ratios associated with the disease were estimated by calculating relative risk ratios.'2 Cornfield's 95%
confidence intervals (CI) and Miettinen's 95% CI were computed by using True Epistat computer software.'3 The Mantel-Haenszel method of controlling for confounding variables was used by using the SAS (Statistical Analysis System) computer software. 14 Results and Discussion There were no important differences in age, sex, race, income, marital status, or religious affiliation of the exposed and comparison groups, but the comparison group had resided longer in the community (Table 1). There were no differences in smoking history, alcohol consumption, frequency of eating local produce, and history of working in a chemical industry, or in reported history of cancer between the two groups (Table 2). Although there was a higher prevalence of birth defects and liver diseases among the exposed than the control group, numbers are small and confidence intervals wide (Table 3). After adjusting for duration of residency and alcohol consumption, the estimated risk ratios were very similar, except for 1.1 (95% CI = .05, 78.4) for low birth weight and 2.9 (95% CI = .12, 168.24) for liver diseases. ACKNOWLEDGMENTS This study was presented in part at the XI Scientific Meeting of the International Epidemiological Association, Helsinki, Finland, August 1987.
TABLE 2-Comparison of Risk Factors among Exposed and Comparison Individuals and Households
Individuals
Ever smoked
Exposed Group (N: 171)
Comparison Group
57 persons
64 persons
Risk Ratio (95% Cl)
(N: 191)
0.94
(.63, 1.57) Ever smoked cigarettes Average # cigarettes smoked per day Average # of years smoked 3+ alcoholic drinks per day at present 3+ alcoholic drinks per day in past Drinking 5 oz per week at present History of working in a chemical industry
96% of smokers 21 cigarettes
94% of smokers 18 cigarettes
19 years
22 years
10 persons
12 persons
0.93
37 persons
32 persons
(.36, 2.37) 1.37 (.78, 2.40)
13 persons
25 persons
20 persons
31 persons
0.54 (.25, 1.15) 0.7
(.36, 1.30)
Households Grow vegetables Cancer among first degree relatives
19 households 31 households
23 households 31 households
1.1
(.48, 2.44)
TABLE 3-Diseases and Adverse Birth Outcomes among Exposed and Comparison Groups
Exposed Group N = 171
Comparison Group N = 191
Risk Ratio
95% Cl
3 7 6 13 4 9 11
6 13 7 14 2 5 10
0.6 0.6 1.0 1.0 2.3 2.1 1.2
.11, 2.52 .21, 1.62 .27, 3.24 .44, 2.43 .35, 12.0 .62, 7.25
Low Birthweight Skin diseases Anemia Spontaneous abortion Liver diseases* Birth defect** Cancer"'
.48,3.26
'Including: jaundice and hepatomegaly.
**Born with birth defects at the present address including: cerebral palsy, congenital heart disease, inguinal hemia, hemangioma, foot
deformities, other bone and joint deformities.
"'Including: leukemia, bone cancer, lung cancer, larynx cancer, and nose cancer.
AJPH April 1990, Vol. 80, No. 4
479
PUBLIC HEALTH BRIEFS
REFERENCES 1. Janerich DT, Burnett WS, Feck G, Hoff M, Nasca P, Polednak AP, Greenwald P, Vianna N: Cancer incidence in the Love Canal area. Science 1981; 212:1404-1407. 2. Budnick LD, Sokal DC, Falk H, Logue JN, Fox JM: Cancer and birth defects near the Drake Superfund Site, Pennsylvania. Arch Environ Health 1984; 39:409-413. 3. Buffler PA, Crane M, Key MM: Possibilities of detecting health effects by studies of population exposed to chemicals from waste disposal sites. Environ Health Perspect 1985; 62:423456. 4. High Background Radiation Research Group, China: Health Survey in high background radiation areas in China. Science 1980; 209:877-880. 5. Lederer CM, Hollander JM, Shirley VS (eds): Table of Isotopes. 7th Ed. New York: John Wiley, 1978. 6. Rickard CL, Dahlberg RC: Nuclear power: a balanced approach. Science 1978; 202:581-584.
7. Farid I, Conibear SA: Hepatic function in previously exposed thorium refinery workers as compared to normal controls from the health and nutrition survey. Health Phys 1983; 44:221-230. 8. Polednak AP, Stehney AF, Lucas HF: Mortality among male workers at a thorium-processing plant. Health Phys 1983; 44:239-251. 9. Meyer HR, Till JE, Bomar ES, Bond WD, Morse LE, Tennery VJ, Yalcintas MG: Radiological impact of thorium mining and milling. Nucl Saf 1979; 20:319-330. 10. Stover BD: Effects of thorotrast in humans. Health Phys 1983; 44:253-257. 11. Garwood AN: The New Jersey Municipal Data Book. Montclair, NJ: New Jersey Association, 1988. 12. Mantel N, Haenszel W: Statistical aspect of the analysis of data from retrospective studies of disease. JNCI 1959; 22:719-748. 13. Gustafson TL: True Epistat Manual. 2d Ed. Epistat Services, Texas: Richardson, 1987. 14. SAS Institute, Inc: SAS User's Guide: Statistics Version 5 edition. Cary, NC: SAS Institute, 1985.
Comparison of Antineoplastic Drug Handling Policies of Hospitals with OSHA Guidelines: A Pilot Study BARBARA VALANIS, DRPH, KATHLEEN DRISCOLL, JD, Abstract: Hospital antineoplastic drug handling policies of 24 hospitals in eight Southwestern Ohio counties were compared with recommendations of the 1986 Occupational Safety and Health Administration (OSHA) guidelines. Although most study facilities where antineoplastics are handled have policies, content varies and is generally less complete than OSHA guidelines, particularly regarding storing, transporting, and disposing of drugs; managing equipment; informing personnel of risk; and surveillance. Recommendations for personal protection concur more closely with OSHA guidelines than do other content areas. (Am J Public Health
1990;80:480-481.) Introduction Evidence of probable risk associated with staff handling of antineoplastic drugs led the US Occupational Safety and Health Administration (OSHA) to issue comprehensive guidelines covering staff training and surveillance; use and care of protective equipment, apparel, and techniques; and storage, disposal, and transport of drugs and contaminated equipment.' Concerned about moral and legal issues, many hospitals have also developed institutional policies. This study investigated the status of facility policies for handling antineoplastic drugs in hospitals and home health care agencies in eight southwestern Ohio counties and compared policy content to OSHA guidelines. Methods
In July 1986, a questionnaire, modeled after Tortorici's2 was mailed to the directors of the 32 hospitals and 25 community health agencies in the eight predominately rural counties comprising Region I of the Cancer Control Consortium of Ohio. Respondents were requested to enclose their facility's antineoplastic drug handling policy. Policy content Address reprint requests to Barbara Valanis, DrPH, Center for Health Research, Kaiser Permanente, 4610 S.E. Belmont Street, Portland, OR 97215. Co-authors Driscoll and McNeill are with the College of Nursing and Health, University of Cincinnati. This paper, submitted to the Journal April 18, 1989, was revised and accepted for publication October 2, 1989. © 1990 American Journal of Public Health 0090-0036/90$1.50
480
AND
VIRGINIA MCNEIL, MSN
was compared with that of the 1986 OSHA guidelines using an investigator-designed tool for systematically coding content relative to OSHA guidelines. For each item, the facility policy is rated 0 if the item is absent and 1 if the item is included. The instrument yields a maximum total score of 219 and five subscores: 1) General Guidelines (37); 2) Protective Equipment (14); 3) Facilities for Mixing and Storing Agents (15); 4) Protective Apparel (49); and 5) Protective Techniques (104). The content analysis was conducted by one investigator (KD).
Results Twenty-four hospitals and 11 community health agencies responded, a response rate of 75 percent for hospitals, 44 percent for home health agencies. Administrators of 20 of the hospitals report antineoplastics are mixed and administered at their facility and one home health agency administers premixed antineoplastics; 18 of the 20 hospitals and the home health agency have implemented an antineoplastic drug handling policy. Eleven hospitals submitted their policy for analysis. All 11 policies are less comprehensive than OSHA guidelines. Total policy scores of individual facilities ranged from 26 to 92 of a possible 219. The mean total score was 50.6 (median score 41). Areas least addressed under "General Guidelines" were maintaining files on specific antineoplastic agents and providing staff with information on known risks, medical policies, safe handling of investigational drugs as they are introduced, and follow-up evaluation of staff knowledge and competence regarding antineoplastic drug handling. Least addressed under "Protective Equipment" were procedures for installation, maintenance, and decontamination of hoods, while unaddressed content under "Facilities for Mixing and Storing Agents" related to reserving a hood only for mixing antineoplastics, posting warning signs, listing drugs covered by cytotoxic policies, and labeling stored antineoplastics. Under "Protective Apparel" recommendations for use of protective apparel during drug mixing conformed better to OSHA guidelines than recommendations for administration, while those for excreta handling and cleaning up spills were generally inadequate. Recommendations for glove and gown use were more often consistent with OSHA recommendations than for use of masks or eye protection. Under "Protective Techniques" least frequently AJPH April 1990, Vol. 80, No. 4
19. Bernard KW, Mallonee J, Wright JC, et al: Preexposure immunization with intradermal human diploid cell rabies vaccine. JAMA 1987; 257:10561063.
Health Effects of a Thorium Waste Disposal Site G. REZA NAJEM, MD, PHD, Abstract: A case-control study of 112 households residing in the vicinity of a thorium waste disposal site found a higher prevalence of birth defects (RR 2.1) and liver diseases (RR 2.3) among exposed than the unexposed group. The numbers were quite small and the confidence intervals wide, however, so that no definite conclusions can be drawn from these data. (Am J Public Health 1990; 80:478480.)
Introduction Several studies have appeared in the medical literature analyzing possible adverse health effects for persons living in the vicinity of hazardous waste disposal sites.'-3 To our knowledge there is no published study in which the health effects of a thorium waste disposal site (TWDS) on the general population have been investigated, except for a community-based study in China.4 That study found no deleterious health effects from exposure to thorium, but had very low statistical power. The main concern about the possible biological effects of thorium (Th) with a half life of 1.4 x 1010 years is based on its radioactive characteristics and isotopes.5 Thorium232 is the parent of various radio-isotopes including 228Ra (radium), 228Ac (actinium), 228Th, 224Ra, and 220Rn (radon)5, Current interest is based in part on increased use of thorium as an energy source, e.g., in reactors using 232Th to produce 233U.6 Industrial and mining exposure to thorium have resulted in an increased incidence of lung cancer, pancreatic cancer, colorectal cancers, chronic respiratory diseases, liver damage, and other serious illnesses.7-9 Skeletal sarcomas, thorotrastomas, and sarcomas of the reticuloendo-thelial system have been reported from a study of patients receiving intravenous injections of thorotrast, a collodial solution of thorium oxide that was used as a contrast medium for diagnostic radiographic studies from the 1930s to the 1950s.'0 The purpose of this study was to conduct a survey of health effects of a thorium waste disposal site among members of the general population of Wayne, New Jersey, USA. Thorium Waste Disposal Site
The site is located on a 6.5 acre tract of land in Wayne Township, Passaic County in northern New Jersey, USA.* The population density in Wayne is 1,867.2 per square miles and annual per capita income is $7,725. "1 The thorium waste burial site lies within 100 feet of the sidewalk. Commercial Address reprint requests to G. Reza Najem, MD, PhD, Department of Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School, 185 S. Orange Avenue, Newark, NJ 07103-2757. Ms. Voyce is with the New Jersey Institute of Technology, Newark. This paper, submitted to the Journal July 24, 1987, was revised and accepted for publication August 1, 1989. *New Jersey Department of Environmental Protection: Site Descriptions for Hazardous Waste Sites in New Jersey. Division of Waste Management, Hazardous Site Mitigation Administration, 1984/85. © 1990 American Journal of Public Health 0090-0036/90$1.50
478
AND
LISA K. VOYCE, MSENE
businesses, a nursing home, a school bus maintenance yard, and residential homes are adjacent to the site. A drainage ditch lies at the northern and eastern borders, and drains into a brook at the northeast corner of the burial field. The brook (a tributory to the Pompton River) flows through residential areas (copy of map available on request). Fresh water wetlands lie approximately 1,800 feet to the west of the thorium waste disposal site.* From 1948 until 1971, a company extracted thorium and rare earths from monazite ore, for usage by the Atomic Energy Commission.* During its active years, the plant waste was dumped in backyard sludge piles. The wastes have been buried only in the last few years, after spending over 20 years above the ground.** Surveys of the New Jersey Department of Environmental Protection showed readings of 40-1491 uR/hour (uR = micro-rad, micro being 10-6) in various regions classified as contaminated areas; Sheffield Brook contamination occurs within 10 meters of both sides. Soil samples revealed Thorium (232Th), Radium (238Ra) and Uranium (238Ur) in the contaminated regions. Water samples from Sheffield Brook and the drainage ditch showed mainly alpha and beta activity. Most of the air concentrations (ambient and indoor) were within the background radiation levels (approximately 150 mrem/year) The US Environmental Protection Agency (EPA) standard for home concentration is below 4 pCi/ liter.*** The residents of the households in the vicinity of the thorium waste disposal site and in the vicinity of contaminated Sheffield Brook have not been tested for radioactive materials uptake. Methods The exposed population included 76 households within three blocks adjoining the contaminated areas. The 76 comparison (unexposed) households included all houses located on about 9th and 10th blocks distance from the thorium waste disposal site and contaminated Sheffield Brook. Households were accepted for inclusion in the study if they had resided at the present address for at least five years. Eleven and 10 households of the exposed and unexposed groups, respectively, did not meet the criteria for eligibility, 10 and nine households, respectively, did not participate in the study due primarily to members not being at home at the time of scheduled interviews or having moved out without leaving forwarding addresses. Face-to-face interviews of all 112 households (362 members), using a structured questionnaire, were carried out by one interviewer who did not know exposure status; 32 household members who did not agree to a face-to-face **New Jersey Department of Environmental Protection. Unpublished data. ***US Environmental Protection Agency, Office of Radiation Programs, Washington, DC 20406. Further details on measurements of exposed areas are available on request to author (Najem). AJPH April 1990, Vol. 80, No. 4
PUBLIC HEALTH BRIEFS TABLE 1-Demographic Variables among Exposed and Comparison Groups Variables
Group
Comparison Group
# of Persons studied # of Households studied % of Persons Age 50 & over % of Persons Age 18 & under Duration of Residence Mean duration* % Under 10 Years % 10-20 Years % Above 20 Years Annual Family Income % Less than $15,000 % $15,000-$49,000 % $50,000-$59,000 % $60,000+
171 55 29 27
191 57 32 26
13.3 Years 42 23 35
17.2 Years 23 9 68
9 65 20 6
9 63 21 7
Exposed
'Mean duration difference = 3.9 years (95% Cl =
-.71, -7.23)
interview were interviewed by telephone. For each disease or condition reported by the participants, we asked respondents whether they obtained the diagnostic information directly from their physicians; we did not obtain or review medical records. The risk ratios associated with the disease were estimated by calculating relative risk ratios.'2 Cornfield's 95%
confidence intervals (CI) and Miettinen's 95% CI were computed by using True Epistat computer software.'3 The Mantel-Haenszel method of controlling for confounding variables was used by using the SAS (Statistical Analysis System) computer software. 14 Results and Discussion There were no important differences in age, sex, race, income, marital status, or religious affiliation of the exposed and comparison groups, but the comparison group had resided longer in the community (Table 1). There were no differences in smoking history, alcohol consumption, frequency of eating local produce, and history of working in a chemical industry, or in reported history of cancer between the two groups (Table 2). Although there was a higher prevalence of birth defects and liver diseases among the exposed than the control group, numbers are small and confidence intervals wide (Table 3). After adjusting for duration of residency and alcohol consumption, the estimated risk ratios were very similar, except for 1.1 (95% CI = .05, 78.4) for low birth weight and 2.9 (95% CI = .12, 168.24) for liver diseases. ACKNOWLEDGMENTS This study was presented in part at the XI Scientific Meeting of the International Epidemiological Association, Helsinki, Finland, August 1987.
TABLE 2-Comparison of Risk Factors among Exposed and Comparison Individuals and Households
Individuals
Ever smoked
Exposed Group (N: 171)
Comparison Group
57 persons
64 persons
Risk Ratio (95% Cl)
(N: 191)
0.94
(.63, 1.57) Ever smoked cigarettes Average # cigarettes smoked per day Average # of years smoked 3+ alcoholic drinks per day at present 3+ alcoholic drinks per day in past Drinking 5 oz per week at present History of working in a chemical industry
96% of smokers 21 cigarettes
94% of smokers 18 cigarettes
19 years
22 years
10 persons
12 persons
0.93
37 persons
32 persons
(.36, 2.37) 1.37 (.78, 2.40)
13 persons
25 persons
20 persons
31 persons
0.54 (.25, 1.15) 0.7
(.36, 1.30)
Households Grow vegetables Cancer among first degree relatives
19 households 31 households
23 households 31 households
1.1
(.48, 2.44)
TABLE 3-Diseases and Adverse Birth Outcomes among Exposed and Comparison Groups
Exposed Group N = 171
Comparison Group N = 191
Risk Ratio
95% Cl
3 7 6 13 4 9 11
6 13 7 14 2 5 10
0.6 0.6 1.0 1.0 2.3 2.1 1.2
.11, 2.52 .21, 1.62 .27, 3.24 .44, 2.43 .35, 12.0 .62, 7.25
Low Birthweight Skin diseases Anemia Spontaneous abortion Liver diseases* Birth defect** Cancer"'
.48,3.26
'Including: jaundice and hepatomegaly.
**Born with birth defects at the present address including: cerebral palsy, congenital heart disease, inguinal hemia, hemangioma, foot
deformities, other bone and joint deformities.
"'Including: leukemia, bone cancer, lung cancer, larynx cancer, and nose cancer.
AJPH April 1990, Vol. 80, No. 4
479
PUBLIC HEALTH BRIEFS
REFERENCES 1. Janerich DT, Burnett WS, Feck G, Hoff M, Nasca P, Polednak AP, Greenwald P, Vianna N: Cancer incidence in the Love Canal area. Science 1981; 212:1404-1407. 2. Budnick LD, Sokal DC, Falk H, Logue JN, Fox JM: Cancer and birth defects near the Drake Superfund Site, Pennsylvania. Arch Environ Health 1984; 39:409-413. 3. Buffler PA, Crane M, Key MM: Possibilities of detecting health effects by studies of population exposed to chemicals from waste disposal sites. Environ Health Perspect 1985; 62:423456. 4. High Background Radiation Research Group, China: Health Survey in high background radiation areas in China. Science 1980; 209:877-880. 5. Lederer CM, Hollander JM, Shirley VS (eds): Table of Isotopes. 7th Ed. New York: John Wiley, 1978. 6. Rickard CL, Dahlberg RC: Nuclear power: a balanced approach. Science 1978; 202:581-584.
7. Farid I, Conibear SA: Hepatic function in previously exposed thorium refinery workers as compared to normal controls from the health and nutrition survey. Health Phys 1983; 44:221-230. 8. Polednak AP, Stehney AF, Lucas HF: Mortality among male workers at a thorium-processing plant. Health Phys 1983; 44:239-251. 9. Meyer HR, Till JE, Bomar ES, Bond WD, Morse LE, Tennery VJ, Yalcintas MG: Radiological impact of thorium mining and milling. Nucl Saf 1979; 20:319-330. 10. Stover BD: Effects of thorotrast in humans. Health Phys 1983; 44:253-257. 11. Garwood AN: The New Jersey Municipal Data Book. Montclair, NJ: New Jersey Association, 1988. 12. Mantel N, Haenszel W: Statistical aspect of the analysis of data from retrospective studies of disease. JNCI 1959; 22:719-748. 13. Gustafson TL: True Epistat Manual. 2d Ed. Epistat Services, Texas: Richardson, 1987. 14. SAS Institute, Inc: SAS User's Guide: Statistics Version 5 edition. Cary, NC: SAS Institute, 1985.
Comparison of Antineoplastic Drug Handling Policies of Hospitals with OSHA Guidelines: A Pilot Study BARBARA VALANIS, DRPH, KATHLEEN DRISCOLL, JD, Abstract: Hospital antineoplastic drug handling policies of 24 hospitals in eight Southwestern Ohio counties were compared with recommendations of the 1986 Occupational Safety and Health Administration (OSHA) guidelines. Although most study facilities where antineoplastics are handled have policies, content varies and is generally less complete than OSHA guidelines, particularly regarding storing, transporting, and disposing of drugs; managing equipment; informing personnel of risk; and surveillance. Recommendations for personal protection concur more closely with OSHA guidelines than do other content areas. (Am J Public Health
1990;80:480-481.) Introduction Evidence of probable risk associated with staff handling of antineoplastic drugs led the US Occupational Safety and Health Administration (OSHA) to issue comprehensive guidelines covering staff training and surveillance; use and care of protective equipment, apparel, and techniques; and storage, disposal, and transport of drugs and contaminated equipment.' Concerned about moral and legal issues, many hospitals have also developed institutional policies. This study investigated the status of facility policies for handling antineoplastic drugs in hospitals and home health care agencies in eight southwestern Ohio counties and compared policy content to OSHA guidelines. Methods
In July 1986, a questionnaire, modeled after Tortorici's2 was mailed to the directors of the 32 hospitals and 25 community health agencies in the eight predominately rural counties comprising Region I of the Cancer Control Consortium of Ohio. Respondents were requested to enclose their facility's antineoplastic drug handling policy. Policy content Address reprint requests to Barbara Valanis, DrPH, Center for Health Research, Kaiser Permanente, 4610 S.E. Belmont Street, Portland, OR 97215. Co-authors Driscoll and McNeill are with the College of Nursing and Health, University of Cincinnati. This paper, submitted to the Journal April 18, 1989, was revised and accepted for publication October 2, 1989. © 1990 American Journal of Public Health 0090-0036/90$1.50
480
AND
VIRGINIA MCNEIL, MSN
was compared with that of the 1986 OSHA guidelines using an investigator-designed tool for systematically coding content relative to OSHA guidelines. For each item, the facility policy is rated 0 if the item is absent and 1 if the item is included. The instrument yields a maximum total score of 219 and five subscores: 1) General Guidelines (37); 2) Protective Equipment (14); 3) Facilities for Mixing and Storing Agents (15); 4) Protective Apparel (49); and 5) Protective Techniques (104). The content analysis was conducted by one investigator (KD).
Results Twenty-four hospitals and 11 community health agencies responded, a response rate of 75 percent for hospitals, 44 percent for home health agencies. Administrators of 20 of the hospitals report antineoplastics are mixed and administered at their facility and one home health agency administers premixed antineoplastics; 18 of the 20 hospitals and the home health agency have implemented an antineoplastic drug handling policy. Eleven hospitals submitted their policy for analysis. All 11 policies are less comprehensive than OSHA guidelines. Total policy scores of individual facilities ranged from 26 to 92 of a possible 219. The mean total score was 50.6 (median score 41). Areas least addressed under "General Guidelines" were maintaining files on specific antineoplastic agents and providing staff with information on known risks, medical policies, safe handling of investigational drugs as they are introduced, and follow-up evaluation of staff knowledge and competence regarding antineoplastic drug handling. Least addressed under "Protective Equipment" were procedures for installation, maintenance, and decontamination of hoods, while unaddressed content under "Facilities for Mixing and Storing Agents" related to reserving a hood only for mixing antineoplastics, posting warning signs, listing drugs covered by cytotoxic policies, and labeling stored antineoplastics. Under "Protective Apparel" recommendations for use of protective apparel during drug mixing conformed better to OSHA guidelines than recommendations for administration, while those for excreta handling and cleaning up spills were generally inadequate. Recommendations for glove and gown use were more often consistent with OSHA recommendations than for use of masks or eye protection. Under "Protective Techniques" least frequently AJPH April 1990, Vol. 80, No. 4
