Radiation protection in a cohort of healthcare workers: knowledge, attitude, practices, feelings and IR-exposure in French hospitals.

The number of healthcare workers occupationally exposed to ionizing radiation (IR) is increasing every year. As health effects from exposure to low doses IR have been reported, radiation protection (RP) in the context of occupational activities is a major concern. This study aims to assess the compliance of healthcare workers with RP policies, according to their registered cumulative dose, profession, and perception of radiation self-exposure and associated risk. Every healthcare worker from one of the participating hospitals in France with at least one dosimetric record for each year 2009, 2014, and 2019 in the SISERI registry was included and invited to complete an online questionnaire including information on the worker's occupational exposure, perception of IR-exposure risk and RP general knowledge. Hp(10) doses were provided by the SISERI system. Multivariate logistic regressions were used. Dosimeter wearing and RP practices compliance were strongly associated with 'feeling of being IR-exposed' (OR = 3.69, CI95% 2.04-6.66; OR = 4.60, CI95% 2.28-9.30, respectively). However, none of these factors was associated with RP training courses attendance. The main reason given for non-compliance is unsuitability or insufficient numbers of RP devices. This study provided useful information for RP policies. Making exposed workers aware of their own IR-exposure seems to be a key element to address in RP training courses. This type of questionnaire should be introduced into larger epidemiological studies. Dosimeter wearing and RP practices compliance are associated to feeling being IR-exposed. RP training courses should reinforce workers' awareness of their exposure to IR.

Occupational exposure to ionizing radiation in medical staff: trends during the 2009-2019 period in a multicentric study.

OBJECTIVES: Health workers exposed to ionizing radiation account for + 50% of workers exposed to man-made radiation in France. Over the last decade, the use of radiation in medicine has increased due to the introduction of new practices. The EXposition des Professionnels de santE aux RayonnemenTs ioniSants study aims to evaluate and characterize the trends in radiation exposure of health workers in France between 2009 and 2019. METHODS: This retrospective study includes all health workers with at least one dosimetric record in the system for occupational dosimetry registration (Système d'information de la surveillance de l'exposition aux rayonnements ionisants) database for each of the years 2009, 2014, and 2019, in the hospitals included in the study. Individual external doses and socio-professional data were collected. Statistical analyses include descriptions, graphs, and logistic regressions. RESULTS: A total of 1457 workers were included (mean age: 39.8 years, 59% women). The average exposure significantly decreased between 2009 and 2019 (-0.008 mSv/year, p < 0.05). There were large discrepancies in trends according to professions, departments, hospitals, and gender. Over the 10-year study period, radiologic technologists and physicians were the most exposed (0.15 mSv (95%CI 0.14-0.16) and 0.13 mSv (0.06-0.21), respectively), but their exposure tended to decrease. Workers in nuclear medicine departments had the highest radiation exposure (0.36 mSv (0.33-0.39)), which remained stable over time. Thirty-eight percent of recorded doses were nonzero in 2009, decreasing to 20% in 2019. CONCLUSIONS: This study allowed to identify physicians and radiologic technologists in nuclear medicine departments as the most exposed medical workers in France, and to show an overall decrease trend in radiation exposure. This should be instructive for radiation monitoring and safety of exposed medical workers. KEY POINTS: • Radiation exposure of healthcare workers in most medical departments has steadily decreased between 2009 and 2019 in several French hospitals. • The number of zero doses consistently increased during the study period. • Workers in nuclear medicine departments are the most exposed, especially radiologic technologists and physicians.

Association between COVID-19 infection and work exposure assessed by the Mat-O-Covid job exposure matrix in the CONSTANCES cohort.

OBJECTIVES: The COVID-19 pandemic has brought to light a new occupational health threat. We aimed to evaluate the association between COVID-19 infection and work exposure to SARS-CoV-2 assessed by a job-exposure matrix (JEM), in a large population cohort. We also estimated the population-attributable fraction among exposed subjects. METHODS: We used the SAPRIS-SERO sample of the CONSTANCES cohort, limited to subjects actively working, and with a job code available and a questionnaire on extra work activities. The following outcomes were assessed: COVID-19 diagnosis was made by a physician; a seropositivity to the ELISA-S test ('serology strict') and ELISA-S test intermediate with positive ELISA-NP or a positive neutralising antibodies SN ('serology large'). Job exposure was assessed using Mat-O-Covid, an expert-based JEM with an Index used as a continuous variable and a threshold at 13/1000. RESULTS: The sample included 18 999 subjects with 389 different jobs, 47.7% were men with a mean age of 46.2 years (±9.2 years). The Mat-O-Covid index taken as a continuous variable or with a threshold greater than 13/1000 was associated with all the outcomes in bivariable and multivariable logistic models. ORs were between 1.30 and 1.58, and proportion of COVID-19 attributable to work among exposed participants was between 20% and 40%. DISCUSSION: Using the Mat-O-Covid JEM applied to a large population, we found a significant association between work exposure to SARS-CoV-2 and COVID-19 infection, though the estimation of attributable fraction among exposed people remained low to moderate. Further studies during other exposed periods and with other methods are necessary.

Nurses' internal contamination by antineoplastic drugs in hospital centers: a cross-sectional descriptive study.

OBJECTIVE: The aim of this study was to assess internal antineoplastic drugs (ADs) contamination in the nursing staff in French hospital centers, using highly sensitive analytical methods. METHODS: This cross-sectional study included nurses practicing in care departments where at least one of the five ADs studied was handled (5-fluorouracil, cyclophosphamide, doxorubicin, ifosfamide, methotrexate). The nurses study participation lasted 24 h including collection of three urine samples and one self-questionnaire. All urine samples were assayed by ultra-high-performance liquid chromatography-tandem mass spectrometry methods with very low value of the lower limit of quantification (LLOQ). RESULTS: 74 nurses were included, 222 urine samples and 74 self-questionnaires were collected; 1092 urine assays were performed. The percentage of nurses with internal AD contamination was 60.8% and low levels of urinary concentrations were measured. Regarding nurses with internal contamination (n = 45), 42.2% presented internal contamination by methotrexate, 37.8% by cyclophosphamide, 33.3% by ifosfamide, 17.8% by 5-fluorouracil metabolite and 6.7% by doxorubicine. Among the positive assays, 17.9% (n = 26/145) were not explained by exposure data from the self-questionnaire but this could be due to the skin contact of nurses with contaminated work surfaces. CONCLUSIONS: This study reported high percentage of nurses with internal ADs contamination. The low LLOQ values of the used analytical methods, allowed the detection of ADs that would not have been detected with the current published methods: the percentage of contamination would have been 17.6% instead of the 60.8% reported here. Pending toxicological reference values, urine ADs concentrations should be reduced as low as reasonably achievable (ALARA principle).

Biomonitoring of occupational exposure to 5-FU by assaying α-fluoro-ß-alanine in urine with a highly sensitive UHPLC-MS/MS method.

5-Fluorouracil (5-FU) is one of the most widely used antineoplastic drugs handled by healthcare professionals (HCP). To monitor occupational exposure to 5-FU, a highly sensitive ESI-UHPLC-MS/MS method was developed for the assay of its main human metabolite, α-fluoro-ß-alanine (FBAL), in urine. After a derivatization step, solid phase extraction was used for the urine. Good linearity (r > 0.996), precision (CV < 14.76%), and accuracy (bias < 12.16%) were achieved. The lower limit of quantification (LOQ), 20 pg ml-1, is the lowest one published to date. Seven urine samples from 73 HCP exposed to 5FU were positive for FBAL, indicating 5FU contamination (9.6%). FBAL urine concentrations ranged from 25 to 301 pg ml-1. Such an efficient analytical tool combining high specificity with high sensitivity is essential for the reliable detection and routine biological monitoring of healthcare professionals occupationally exposed to this widely used antineoplastic drug. This method allows biomonitoring of occupational exposure to 5-fluorouracil in a routine manner, with the aim of assessing the effectiveness of collective and individual protective measures.

Measles outbreak linked to insufficient vaccination coverage in Nouvelle-Aquitaine Region, France, October 2017 to July 2018.

On 30 October 2017, an outbreak of measles started in the Nouvelle-Aquitaine (NA) region in France among Bordeaux University students before spreading to other regions. Until 1 July 2018, 1,101 cases were reported in NA, including 98 complications and two deaths. Cases were related to clusters (e.g. students, healthcare workers) in 16%; 81% of cases were not vaccinated against measles as recommended. Vaccination coverage above herd immunity threshold remains the main preventative outbreak measure.

[Accidents exposing to blood in France]. / Accidents exposant au sang en France.

Occupational blood and body fluids exposure. Occupational blood and body fluids exposure (BBFE) is a serious daily risk to healthcare workers (HCW) wherever they work (i.e. hospital, nursing home or private care). The knowledge of BBFE epidemiology over these 3 sectors of care allows HCF to be aware of BBFE circumstances and can enhance prevention in order to improve overall BBFE prevention. The improvement for compliance with standard precautions and protocols to prevent exposure to BBFE and the increase of safety device disposal use are the main keys of HCW safety.

Accidents exposant au sang en france Les professionnels de santé, quel que soit leur lieu d'activité (hôpital, établissement médico-social et ville), sont, au quotidien, susceptibles d'être victimes d'accidents exposant au sang. La connaissance des données épidémiologiques de ces accidents dans les trois secteurs de l'offre de soins permet aux professionnels de santé d'être conscients des circonstances de ces accidents pour mettre en place les mesures de prévention ad hoc. L'amélioration du respecter des précautions standard et des protocoles pour prévenir l'exposition au sang et aux liquides biologiques ainsi que la mise à disposition croissante des dispositifs médicaux de sécurité sont les principales clefs de la sécurité d'exercice des professionnels.

Factors associated with internal contamination of nurses by antineoplastic drugs based on biomonitoring data from a previous study.

Internal contamination of healthcare professionals by antineoplastic drugs (ADs) remains a current occupational health issue, particularly because these compounds are classified as dangerous to handle by the NIOSH. In order to improve preventive actions, a study of the factors associated with this internal contamination was conducted among nursing staff in health care institutions. This study is a statistical analysis of metadata from a cross-sectional observational study conducted among nurses in two French hospitals. The internal contamination of each nurse was assessed in a previous study and was defined by whether or not at least one studied AD was detected in at least one urine sample. Three urine samples and a self-questionnaire were collected for each participant. Analysis of five ADs (cyclophosphamide, ifosfamide, metabolite of 5-fluorouracil, methotrexate, doxorubicin) were performed by liquid chromatography coupled to tandem mass spectrometry. A multivariate stepwise descending regression model was used to determine factors associated with internal contamination by coupling data from a self-questionnaire with internal contamination data. A total of 74 nurses participated to the study and 68 were included for this work: 39 nurses with and 29 without detectable internal ADs contamination. Two protective factors of internal contamination could be identified: a high "glove wearing score" (OR: 0.957; 95%CI: 0.93-0.98; p < 0.01) and a high "total number of years handling ADs and/or caring for patients treated with ADs" (OR: 0.797; 95%CI: 0.67-0.91; p < 0.01). In addition, three factors contributing to internal contamination were identified, namely "feeling sufficiently informed about tasks exposing to ADs" (OR: 9.585; 95%CI: 2.23-57.05; p < 0.01), "disposal of a waste bin containing equipment used for administration of the ADs studied" (OR: 8.04; 95%CI: 1.87-46.08; p < 0.01) and "changing sheets and/or making bed of a patient treated by one of the ADs studied" (OR: 10.479; 95%CI: 1.43-133.30; p < 0.05). Thus, the use of gloves when handling ADs directly or indirectly and the contaminating nature of certain tasks should be taken into account when (1) implementing preventive actions in health care services and (2) training and informing exposed staff. Further studies would be desirable to confirm these results and extend them to other professional categories.

Emotional Exhaustion, a Proxy for Burnout, Is Associated with Sleep Health in French Healthcare Workers without Anxiety or Depressive Symptoms: A Cross-Sectional Study.

Burnout is frequent among healthcare workers, and sleep problems are suspected risk factors. The sleep health framework provides a new approach to the promotion of sleep as a health benefit. The aim of this study was to assess good sleep health in a large sample of healthcare workers and to investigate its relationship with the absence of burnout among healthcare workers while considering anxiety and depressive symptoms. A cross-sectional Internet-based survey of French healthcare workers was conducted in summer 2020, at the end of the first COVID-19 lockdown in France (March to May 2020). Sleep health was assessed using the RU-SATED v2.0 scale (RegUlarity, Satisfaction, Alertness, Timing, Efficiency, Duration). Emotional exhaustion was used as a proxy for overall burnout. Of 1069 participating French healthcare workers, 474 (44.3%) reported good sleep health (RU-SATED > 8) and 143 (13.4%) reported emotional exhaustion. Males and nurses had a lower likelihood of emotional exhaustion than females and physicians, respectively. Good sleep health was associated with a 2.5-fold lower likelihood of emotional exhaustion and associations persisted among healthcare workers without significant anxiety and depressive symptoms. Longitudinal studies are needed to explore the preventive role of sleep health promotion in terms of the reduction in burnout risk.

Urine biomonitoring of occupational exposure to methotrexate using a highly sensitive UHPLC-MS/MS method in MRM3 mode.

Methotrexate (MTX) is widely used as antineoplastic drug (AD) and as an immunosuppressive. As a result, many healthcare professionals are exposed to this drug which is classified as dangerous to handle due to its reproductive toxicity in humans. Since the 1990 s, cases of internal contamination of professionals handling this molecule have been reported in the literature and even recently MTX was detected in the urine of professionals. To date, there is no toxicological reference value for occupational exposure to MTX. Given the toxicity of this molecule, the internal contamination of professionals must be reduced and kept as low as possible according to the ALARA principle (as low as reasonably achievable). The aim of this work was to develop an UHPLC-MS/MS method in MRM (Multiple Reaction Monitoring) and MRM3 modes for routine application in MTX occupational biomonitoring. Good linearity (r greater than 0.997), precision (CV < 15 %), and accuracy (94.97-97.80% of the nominal value in MRM mode; 105.90-112.25% in MRM3 mode) were achieved. This method is reliable with high specificity and high sensitivity especially in MRM3 mode and has better LOD and LLOQ (1 ng/L and 2.5 ng/L) than published methods to date. The MRM3 mode increases the signal-to-noise ratio compared to the MRM mode. It was then applied routinely for the biological monitoring of healthcare professionals exposed to methotrexate. One hundred and seventeen urine samples from 93 healthcare professionals occupationally exposed to methotrexate were analyzed. Fifteen healthcare professionals (16.1 %) were found to be contaminated with methotrexate. Urine concentration levels ranged from 2.5 to 380 ng/L with a median value of 8.9 ng/L. Such efficient analytical tool is essential for the routine biological monitoring of healthcare professionals exposed to methotrexate. It also enables the traceability of occupational exposure to this molecule and the evaluation of the effectiveness of preventive measures such as individual and collective protective equipment.

Development of a Questionnaire for the Search for Occupational Causes in Patients with Non-Hodgkin Lymphoma: The RHELYPRO Study.

Non-Hodgkin lymphoma (NHL), multiple myeloma and chronic lymphocytic leukemia are possibly related to environmental and/or occupational exposure. The primary objective of this study was to develop a questionnaire for screening patients with these blood disorders who might benefit from a specialized consultation for possible recognition of the disease as an occupational disease. The study included 205 subjects (male gender, 67.3%; mean age, 60 years; NHL, 78.5%). The questionnaire performed very satisfactorily in identifying the exposures most frequently retained by experts for their potential involvement in the occurrence of NHL. Its sensitivity and specificity in relation to the final expertise were 96% and 96% for trichloroethylene, 85% and 82% for benzene, 78% and 87% for solvents other than trichloroethylene and dichloromethane, 87% and 95% for pesticides, respectively. Overall, 15% of the subjects were invited to ask National Social Insurance for compensation as occupational disease. These declarations concerned exposure to pesticides (64%), solvents (trichloroethylene: 29%; benzene: 18%; other than chlorinated solvents: 18%) and sometimes multiple exposures. In conclusion, this questionnaire appears as a useful tool to identify NHL patients for a specialized consultation, in order to ask for compensation for occupational disease.

A highly sensitive UHPLC-MS/MS method for urine biological monitoring of occupational exposure to anthracycline antineoplastic drugs and routine application.

Anthracycline antineoplastic drugs (doxorubicin, epirubicin, daunorubicin) are "hazardous drugs for handling" by healthcare professionals. To monitor their occupational exposure, a highly sensitive ESI-UHPLC-MS/MS method for the assay of anthracyclines in urine was developed. The urine extraction consisted of SPE extraction method. A good linearity (r > 0.996), precision (CV < 14.4%), and accuracy (bias < 13.6%) were achieved for the three drugs. The lower limit of quantification (LOQ) was 10 ng/L. This LOQ value is equal to the LOQ of published methods except for epirubicin, for which the LOQ value is better by a factor of 10 (best published LOQ value: 100 ng/L). Applying this method in routine, more than 77 healthcare professionals occupationally exposed to anthracyclines were monitored and 77 urines were analyzed. Two healthcare professionals (2.6%) were found to be contaminated to doxorubicin and/or epirubicin. The measured concentrations ranged from 17.7 to 218 ng/L. Such an efficient analytical tool, combining both high specificity and sensitivity is essential for reliable highlight of contamination during biological monitoring of healthcare professionals widely exposed to these drugs. This anthracycline antineoplastic drugs exposure monitoring allows healthcare professionals for assessing effectiveness individual and collective protective measures and for ensuring traceability of occupational exposure to these drugs.

[Occupational cancers: Risks and prevention]. / Les cancers professionnels : risques et prévention.

Since 2008, cancer became the first cause of death in France, exceeding cardiovascular diseases. The part of occupational cancers is close to 5% of all cancers but may still be widely underestimated. The detection of occupational cancer risk factors remains complicated. Indeed, most occupational risk factors are also present in the general environment. Thus far, 36 substances and 13 activities have been classified as carcinogenic (Group 1) and 37 substances and 6 activities have been classified as probably carcinogenic (Group 2A) by the International Agency for Research on Cancer (IARC). The most common cancer site is the lung, followed by bladder and skin (except melanoma). The most frequently observed occupational exposure was chemicals, building and construction, mining, metal production and coal transformation. Thus far, preventive actions are mandatory in occupational health in France, and are about occupational exposure monitoring, protection of vulnerable populations and reinforced medical supervision. Research must be continued to improve the knowledge on occupational carcinogens, in order to better protect the health of workers.

Study protocol for the assessment of nurses internal contamination by antineoplastic drugs in hospital centres: a cross-sectional multicentre descriptive study.

INTRODUCTION: Antineoplastic drugs (AD) are potentially carcinogenic and/or reprotoxic molecules. Healthcare professionals are increasingly exposed to these drugs and can be potentially contaminated by them. Internal contamination of professionals is a key concern for occupational physicians in the assessment and management of occupational risks in healthcare settings. Objectives of this study are to report AD internal contamination rate in nursing staff and to identify factors associated with internal contamination. METHODS AND ANALYSIS: This trial will be conducted in two French hospital centres: University Hospital of Bordeaux and IUCT-Oncopole of Toulouse. The target population is nurses practicing in one of the fifteen selected care departments where at least one of the five studied AD is handled (5-fluorouracil, cyclophosphamide, doxorubicin, ifosfamide, methotrexate). The trial will be conducted with the following steps: (1) development of analytical methods to quantify AD urine biomarkers, (2) study of the workplace and organization around AD in each care department (transport and handling, professional practices, personal and collective protection equipments available) (3) development of a self-questionnaire detailing professional activities during the day of inclusion, (4) nurses inclusion (urine samples and self-questionnaire collection), (5) urine assays, (6) data analysis. ETHICS AND DISSEMINATION: The study protocol has been approved by the French Advisory Committee on the Treatment of Information in Health Research (CCTIRS) and by the French Data Protection Authority (CNIL). Following the opinion of the Regional Committee for the Protection of Persons, this study is outside the scope of the provisions governing biomedical research and routine care (n°2014/87). The results will be submitted to peer-reviewed journals and reported at suitable national and international meetings. TRIAL REGISTRATION NUMBER: NCT03137641.

LUCSO-1-French pilot study of LUng Cancer Screening with low-dose computed tomography in a smokers population exposed to Occupational lung carcinogens: study protocol.

INTRODUCTION: Guidelines concerning the follow-up of subjects occupationally exposed to lung carcinogens, published in France in 2015, recommended the setting up of a trial of low-dose chest CT lung cancer screening in subjects at high risk of lung cancer. OBJECTIVE: To evaluate the organisation of low-dose chest CT lung cancer screening in subjects occupationally exposed to lung carcinogens and at high risk of lung cancer. METHODS AND ANALYSIS: This trial will be conducted in eight French departments by six specialised reference centres (SRCs) in occupational health. In view of the exploratory nature of this trial, it is proposed to test initially the feasibility and acceptability over the first 2 years in only two SRCs then in four other SRCs to evaluate the organisation. The target population is current or former smokers with more than 30 pack-years (who have quit smoking for less than 15 years), currently or previously exposed to International Agency for Research on Cancer group 1 lung carcinogens, and between the ages of 55 and 74 years. The trial will be conducted in the following steps: (1) identification of subjects by a screening invitation letter; (2) evaluation of occupational exposure to lung carcinogens; (3) evaluation of the lung cancer risk level and verification of eligibility; (4) screening procedure: annual chest CT scans performed by specialised centres and (5) follow-up of CT scan abnormalities. ETHICS AND DISSEMINATION: This protocol study has been approved by the French Committee for the Protection of Persons. The results from this study will be submitted to peer-reviewed journals and reported at suitable national and international meetings. TRIAL REGISTRATION NUMBER: NCT03562052; Pre-results.

Highly sensitive LC-MS/MS methods for urinary biological monitoring of occupational exposure to cyclophosphamide, ifosfamide, and methotrexate antineoplastic drugs and routine application.

Highly sensitive ESI-LC-MS/MS methods were developed for urinary biological monitoring of occupational exposure to cyclophosphamide (CP), ifosfamide (IF), and methotrexate (MTX), which are hazardous antineoplastic drugs frequently handled by healthcare professionals. Extraction methods consisted of liquid/liquid extraction for simultaneous urinary CP and IF assays, and of solid phase extraction for the urinary MTX assay. A good linearity (r2>0.997), precision (CV<14.6%), and accuracy (bias<9.9%) were achieved for all compounds. The limit of detection (LOD) was 10pg/ml and the lower limit of quantification (LOQ) was 20pg/ml for all three drugs. Applying these methods in routine, more than 116 healthcare professionals occupationally exposed to antineoplastic drugs were monitored and 635 urines were analysed. Eleven healthcare professionals (9.5%) were found to be contaminated to at least one of the three antineoplastic drugs. Among analysed urines, 22 samples were found positives. The measured concentrations ranged from 20.1 to 1850pg/ml and, for six samples, concentrations were at CP trace level, between the LOD and LOQ values (10-20pg/ml). Such efficient analytical tools combining high specificity with high sensitivity are essential for reliable detection and routine biological monitoring of healthcare professionals occupationally exposed to these widely used antineoplastic drugs. These methods allow to monitor the healthcare professionals exposure to antineoplastic drugs in the aim to assess the effectiveness of collective and individual protective measures.

Impact of safety devices for preventing percutaneous injuries related to phlebotomy procedures in health care workers.

BACKGROUND: Use of protective devices has become a common intervention to decrease sharps injuries in the hospitals; however few studies have examined the results of implementation of the different protective devices available. OBJECTIVE: To determine the effectiveness of 2 protective devices in preventing needlestick injuries to health care workers. METHODS: Sharps injury data were collected over a 7-year period (1993-1999) in a 3600-bed tertiary care university hospital in France. Pre- and postinterventional rates were compared after the implementation of 2 safety devices for preventing percutaneous injuries (PIs) related to phlebotomy procedures. RESULTS: From 1993 to 1999, an overall decrease in the needlestick-related injuries was noted. Since 1996, the incidence of phlebotomy-related PIs has significantly decreased. Phlebotomy procedures accounted for 19.4% of all percutaneous injuries in the preintervention period and 12% in the postintervention period (RR, O.62; 95% CI, 0.51-0.72; P < .001). Needlestick-related injuries incidence rate decreased significantly after the implementation of the 2 safety devices, representing a 48% decline in incidence rate overall. CONCLUSIONS: The implementation of these safety devices apparently contributed to a significant decrease in the percutaneous injuries related to phlebotomy procedures, but they constitute only part of a strategy that includes education of health care workers and collection of appropriate data that allow analysis of residuals percutaneous injuries.