職業衛生介入計畫對醫院化療相關作業人員化療藥劑暴露風險之影響

How an Occupational Intervention Program Can Reduce the Risk of Exposure to Antineoplastic Drugs of Health Care Workers

楊宗勳(TSONG-HSUN YANG)

指導教授 ： 陳叡瑜

臺北醫學大學/公共衛生暨營養學院/公共衛生學研究所/碩士(2011年)

https://doi.org/10.6831/TMU.2011.00148

摘要

醫院化學治療工作人員，在進行化療藥劑調配、傳送與注射給藥等流程，亦或進行病人照護與環境清理時，皆有可能暴露化療藥劑，研究指出職業暴露化療藥劑可能會增加罹癌及生殖危害風險。近幾年國內在北部幾家醫院進行化療藥劑環境表面污染偵測，大部份操作場所均被證實有化療藥劑殘留現象。本研究之目的係評估醫院化療作業場所環境表面污染之清潔效果，及執行介入計畫之改善成效。

　　本研究立意選取台灣台北地區兩家醫院（醫院A：醫學中心；醫院B：區域醫院）內的腫瘤病房護理站與化療門診部門進行研究，除環境污染偵測外，並以此二單位內的護理人員，以及全院內的清潔人員、傳送人員以及被服人員作為研究對象。在考量藥物使用頻率、樣本穩定性，以及偵測極限三方面以後，選用鉑類化療藥劑作為監測指標性藥物，以感應耦合電漿質譜儀（ICP-MS）分析總鉑（Pt）量，首先進行第一次環境採樣監測，並以尿液作為人員暴露生物監測，以評估接觸化療作業之人員可能的潛在暴露風險，並藉由作業觀察分析環境污染原因後，進行環境清潔介入計畫，採用介入單張以及與管理單位溝通作業觀察發現之問題，並輔以清潔教育訓練兩周後，進行第二次環境採樣監測，並評估介入成效。

　　研究結果顯示，本介入計畫可以有效降低環境污染濃度。在介入前後共收集936個環境表面擦拭樣本。結果發現，介入前之清潔前後鉑金屬濃度中位數分別為4.58 pg/cm2和7.5 pg/cm2；而介入後之清潔前後鉑金屬濃度中位數分別為4.21 pg/cm2和0.75 pg/cm2。在鉑金屬測出率的結果中，介入前之清潔前後測出率分別為83.8%和85.9%；而介入後之清潔前後測出率分別為84.6%和67.5%。在環境清潔後的污染濃度變化比例的結果中，介入前有49.6%的採樣點的鉑金屬檢出濃度在清潔後有下降，介入後有70.9%的採樣點的鉑金屬檢出濃度在清潔後有下降。除環境表面擦拭樣本外，本研究以工作人員尿液中鉑金屬濃度作為體內暴露指標，兩院共收集117名人員的尿液樣本（暴露組43名，非暴露組72名）。結果發現，所有尿液樣本中的鉑金屬濃度皆小於偵測極限（0.997 ppt）。由於目前國內外尚未針對化療藥物訂定環境濃度限值，因此各國均未例行評估化療藥劑暴露的潛在風險，本研究嘗試將所有採樣點分成地板表面、環境桌面、工作車桌面與其他表面四個區域，再分別針對清潔前後環境檢測結果，以四分位距作為風險分級的依據，分成低度風險（＜Q2）、中度風險（Q2≦∼＜Q3）以及高度風險（≧Q3）三個等級，希望未來可作為暴露風險閾值訂定之參考依據。

關鍵字

化療藥劑 ； 鉑製劑 ； 環境表面擦拭樣本 ； 職業衛生介入計畫

並列摘要

Antineoplastic drugs are commonly used in hospitals for cancer treatment, and some negative effects may occurred in the process of preparing, transporting, and injecting antineoplastic drugs. Epidemiological studies have found that the exposure of antineoplastic agents were associated with reproductive and carcinogenic effects. The aim of this study was to evaluate the effects of an occupational intervention program on the decrease in environmental contamination after cleaning routine.

　　A medical center (hospital A) and a regional hospital (hospital B) in Taipei, Taiwan were selected to monitor the antineoplastic agent levels and exposures on hospital staff and facility. The study database has included 936 surface wipe samples in oncology wards and clinics before and after intervention and 117 hospital workers’ urine samples. Platinum was used as a pollution indicator of antineoplastic drugs because it is relatively stable in the environment than other drugs and the platinum-containing drugs (Cisplatin, Carboplatin, Oxaliplatin) are commonly used drugs. ICP-MS was used to determine the concentration of platinum and the method detection limit (MDL) was 0.0124 pg/cm2 for wipe sample and 0.997 ng/L for urine sample. Intervention program included discussion and correction the operation procedures and personnel training. Environmental measurements were conducted again after 2 weeks of intervention

　　The results showed that in pre- intervention, median values of Pt concentration were 4.58 and 7.5 pg/cm2 before and after cleaning routine. After intervention, Pt concentration median values were decreased significantly after cleaning routine (from 4.21 decline to 0.75 pg/cm2). Also, in pre- intervention, the detection rates were 83.8% and 85.9%, before and after cleaning. After intervention, the detection rates were 84.6% and 67.5%, before and after cleaning. There were 49.6% of the sample concentration decrease after cleaning before intervention and 70.9% after intervention. Concentrations of all urine samples were under detection limit (0.997 ng/L). In order to set a reference value for environmental control, a concept of risk classification was introduced. All surface wipe samples data were stratified into 4 types (floor surface, environment surface, work truck surface and other surface), and divided into low risk (<50 percentile), moderate risk (50≦percentile <75), and high risk (≧75 percentile) three levels according to the concentrations of each type of samples. If a large amount of environmental samples were collected as database, a value bellow 50 percentile could be recognized as low risk environment, on the contrary when concentration is above 50 percentile( i.e. moderate and high risk) an environmental control program should be activate.

並列關鍵字

Antineoplastic drug ； Platinum ； Surface wipe sample ； Occupational intervention program

參考文獻

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