Health-Care Workers and Latex Allergy

Health-Care Workers and Latex Allergy

Heather N. Zak

LATEX HYPERSENSITIVITY has become a concern among health-care workers within the United States as well as around the world. Latex hypersensitivity resulting from the increase in latex glove use is a universal concern, as evidenced by precautions implemented by the Centers for Disease Control and Prevention in 1987.[1] No clear instances of hypersensitivity resulting from rubber gloves were reported until Nutter described a case of contact urticaria to latex gloves in 1979.[2] Today, numerous medical products and gloves contain latex. Reactions to these products include delayed-type hypersensitivity[3-6]–a T-cell-mediated reaction usually to chemicals, immediate-type hypersensitivity,[7-9] and IgE antibody-mediated allergy to protein antigens. Unfortunately, there is no cure for latex hypersensitivity, and avoidance is the only option for affected healthcare workers. In this article, we address the causes of latex hypersensitivity, define the types of reactions to latex, and report the prevalence and high-risk groups among health-care workers. In addition, tests for latex hypersensitivity, safety precautions, as well as attitudes, perceptions, and knowledge of health-care workers regarding latex hypersensitivity will be discussed.

Causes of Latex Allergy

The adoption of universal precautions in the late 1980s likely contributed to the increased incidence of latex hypersensitivity. Given the emergence of the human immunodeficiency virus (HIV) and other bodyfluid-transmitted infections, health-care workers have been advised that they should wear gloves whenever there is exposure to body fluids.[1] Hence, there has been a dramatic increase in glove use among healthcare workers.

Both examination and surgical gloves are major sources of latex exposure in health-care settings.[10,11] Many other medical supplies, such as dental rubber dams, tubing, blood pressure cuffs, and facemasks contain latex (Table 1). Latex gloves contribute higher amounts of latex allergen than other latex medical supplies.[10] Although most health-care workers develop latex hypersensitivity through increased glove use, latex hypersensitivity can also result from contact with other latex-containing products.[12]

Table 1.–Medical Supplies that Contain Latex[12,14,50,52]

Medical supply

Adhesive bandages

Adhesive tape

Airways–oral and nasal

Amalgam carriers

Anesthesia bags

Anesthetic carpules

Bile bags

Bite blocks

Blood pressure cuffs

and tubing

Bulb syringes

Bouffant tubing

Catheters

Chest tube drainage tubing

Colostomy pouches

Crutch pads

Dental rubber dams

Drains

Dressings

Elastic wrap

Electrode bulbs, pads, and

grounding

Endotracheal tubes

Enema kits

Feeding nipples

Fluid-circulating warming

blankets

Gastroscopy tubes

Gloves

Goggles

Identification bands

Incubator

Intestinal tubes

Irrigator tubing

Intravenous (IV) injection

ports, medication pumps,

and tubing

Liquid droppers

Medication vial stoppers

Nasogastric tubes

Operation room (OR) masks,

hats, and shoe covers

Orthodontic elastics

Orthopedic appliances

Ostomy bags

Oxygen masks

Penrose drain

Polishing discs

Prophylaxis cups

Protective sheets

Pulmonary resuscitator bags

Pulse oximeters

Reflex hammers

Respirators

Rubber pads

Stethoscope tubing

Stoppers

Suction catheters

Suction tips

Surgical gowns and drapes

Syringes

Teeth protectors

Tourniquets

Tracheal tubing

Tubing

Tympanometers

Vascular stockings

Ventilator circuits, hose,

balloons, and bellows

Waterproof mattress covers,

table covers, and stretchers

Wheelchair cushions and

tires

Wound drainage pouches

To meet increased demands for latex gloves, new glove-manufacturing companies have arisen in tropical areas close to the rubber tree plantations.[13] Given that these companies were onsite, chemical denaturing and hydrolysis were not needed for the preservation of latex.[14] This reduction in processing time is perhaps responsible for the increase in antigens responsible for the latex hypersensitivity. Unfortunately, there is no published literature that details levels of antigens in latex gloves prior to the increased demand. Therefore, as a result of universal precautions, exposure to latex increased while, at the same time, latex was more antigenic. Collectively, these factors may have resulted in an increased incidence of latex hypersensitivity.[14]

Another factor that may be responsible for the increase in antigenic load in latex is the chemical treatment of rubber trees. Mass production of rubber requires treatment of trees with phytohormones. These phytohormones increase the production of lacticifers, or cytoplasmic fluid.[15] Lacticifers are plant defense-related proteins that protect the tree from pathogens and wounding,[16,17] and they are produced in increasing amounts whenever a rubber tree is tapped for latex. Lacticifers likely have antigenic properties and have been identified in latex.[16,17] Consequently, mass production will increase the lacticifer production and will result in more antigenic latex.

In many studies, investigators have recognized latex allergens responsible for type I immediate hypersensitivity. Proteins implicated as latex allergens range from [is less than] 10kd to 110 kd.[18,19] Because of the broad range of protein sizes, identification of the specific latex allergens is difficult. In addition to the plant’s defense-related enzymes, five other major latex allergens have been identified: (1) prohevein,[20] (2) hevein, (3) prohevein C-domain, (4) hevamine,[21] and (5) rubber elongation factor.[22,23]

The antigens responsible for causing latex hypersensitivity differ, although individuals with the same history of sensitization have similar patterns of antibody specificities to latex proteins.[24] Depending on the mode of exposure to latex, certain proteins may be allergenic to some individuals, but not to others.[25] For example, spina bifida patients are exposed to latex through multiple surgical interventions at an early age, whereas health-care workers are exposed primarily through frequent glove use. Chen et al.[25] found that the rubber elongation factor bound to the IgE antibodies of latex allergic spina bifida patients more readily than to those of latex allergic health-care workers.

The source of latex may also influence which antigens are responsible for inducing the allergic response.[26] For example, treatment of latex gloves with ammonia alters the proteins capable of extraction.[26] Although these ammoniated latex proteins have different molecular weights than those of nonammoniated latex, the epitopes remain the same.[26] The ammoniated extractable latex antigens are merely breakdown products of the nonammoniated latex proteins.[26]

Types of Latex Reactions

Clinical manifestations of latex reactions vary. Irritant contact dermatitis is a nonallergic reaction that usually results from friction, occlusion, or maceration that may occur while wearing gloves. Irritant contact dermatitis manifests as dry, scaly, red, and possibly cracked skin associated with the use of certain products. Irritant dermatitis can be exacerbated by frequent hand washing, use of detergents, or exposure to irritating chemicals.[5,6] Skin affected by irritant dermatitis may be more prone to development of allergic reactions to latex of which there are two types: (1) immediate-type hypersensitivity reactions and (2) delayed-type hypersensitivity reactions.

Delayed-type hypersensitivity reactions in the skin cause what is commonly known as allergic contact dermatitis. Several hours or days following exposure, affected skin in a previously sensitized individual becomes itchy and red and may develop small vesicles or blisters. This reaction is a cell-mediated immune reaction. Reactions to latex products usually result from a hypersensitivity to one of the numerous chemicals added during processing.[5,6] The chemicals include antioxidants, antidegradents, and antizonants[5] (e.g., thiuram-mixes, carbamate-mixes, mercaptomixes[6]). Delayed-type hypersensitivity reactions rarely have associated systemic manifestations.

Immediate-type hypersensitivity reactions differ in both clinical presentation and underlying immunology. Immediate-type hypersensitivity reactions occur within minutes of exposure to latex products and are mediated by IgE to various latex proteins. The manifestations of these reactions depend largely upon the route of exposure. Contact uticaria may develop in skin exposed to latex. If the latex proteins are aerosolized, wheezing, rhinitis, and conjunctivitis may occur. Mucosal exposure frequently results in angioedema. In severely allergic persons, allergic reactions can progress to anaphylaxis–or even death. Delayed-type reactions and immediate-type reactions can also occur concurrently.[7]

There have been cases of intraoperative anaphylaxis in patients from the use of latex surgical gloves.[27,28] Landwehr and Boguniewicz postulated that latex gloves are as common a cause of intraoperative anaphylaxis as anesthetics, muscle-relaxing agents, blood products, or antimicrobials.[14] Other latex products that reportedly have caused intraoperative anaphylaxis include the manometry catheter with a latex balloon[29] and the pulmonary artery catheter with a latex balloon.[30] One case study revealed that anaphylaxis was caused by a needle that was passed through a rubber stopper filling a syringe that was then injected into a patient.[31]

Given that the extent of a reaction is dependent on the route of exposure, airborne latex antigens pose a severe threat to latex-allergic individuals.[13] Latex proteins are absorbed onto powder, which lubricates the gloves.[13] When gloves are snapped off the hand, latex proteins bound to the powder are aerosolized into the environment.[13] In one study, investigators showed that the amount of aerosolized particles from the gloves coincided with the amount of powder in latex gloves used at the premises.[11,32,33] High levels of latex aeroallergens have been detected in areas of heavy glove use, such as operating rooms, emergency rooms, and intensive care units.[11] These aerosolized latex protein particles can be inhaled, thus initiating an immediate hypersensitivity reaction.

Prevalence among Health-Care Workers

Anyone can develop latex allergy, but health-care workers are at a high risk of developing latex hypersensitivity. Increased latex glove use, increased duration of use, and increased latex concentration levels are associated with development of latex hypersensitivity.[34] Health-care workers in the United States use latex gloves in as many as 98% of the procedures they perform (Table 2).[9]

Table 2.–Prevalence of Glove Use, by Year

Year published

and study

reference Country Profession

1983[79] United Kingdom Dentists

1987[80] United States Dentists

1988[81] United States Dentists

1987[82] United Kingdom Dental students and staff

1988[83] United States Dentists

1989[84] United States Hospital employees

1989[84] United States Dentists

1989[86] Norway Dentists

1990[87] United States Dentists

1991[88] England and Wales Dentists

1992[89] United States Hospital employees

1992[90] United States Dentists

1993[91] United States Occupational therapists

1993[92] United Kingdom Dental students

1994[93] England and Wales Dentists

1994[94] Sweden Dentists

1994[95] United States, Phlebotomists

Canada, and

Australia

1995[96] United Kingdom Dentists

1995[97] Ireland General practitioners

1996[9] United States Hospital employees

1996[98] Australia Dentists

1996[99] United States Emergency medical providers

1996[51] United States Dental professionals

1997[100] United States Long-term care

facility employees

1997[101] United Kingdom Dental students

Year published

and study Prevalence

reference Country of use (%)

1983[79] United Kingdom 63

1987[80] United States 79.8

1988[81] United States 18

1987[82] United Kingdom 11

1988[83] United States 78.3

1989[84] United States 52.5

1989[84] United States 76

1989[86] Norway 92

1990[87] United States 80

1991[88] England and Wales 68

1992[89] United States 88.5

1992[90] United States 91.6

1993[91] United States 92

1993[92] United Kingdom 57.9

1994[93] England and Wales 83

1994[94] Sweden 29

1994[95] United States, 80.5

Canada, and

Australia

1995[96] United Kingdom 75

1995[97] Ireland 75

1996[9] United States 98

1996[98] Australia 84.6

1996[99] United States 90

1996[51] United States 85

1997[100] United States 82

1997[101] United Kingdom 100

In one dental school study, investigators found that the prevalence of a positive skin test to latex increased with duration of time at the school.[35] First- and second-year students had very little exposure to latex, and none of the students were latex allergic. Third-year students, who had more exposure to latex, showed a prevalence of 3% latex hypersensitivity. Among fourth-year students, the prevalence increased to 6%. Graduate students and staff members–all of whom had the highest and longest latex exposure–showed a 25% latex allergy response.[35]

In the United States, the prevalence rate of latex hypersensitivity among health-care workers has ranged from 3.8% to 17%.[36,37] Worldwide prevalence of latex hypersensitivity among health-care workers has ranged from 2.8% to 12.1% (Table 3).[38,39] Shown in Figures 1 and 2 are existing published data that highlight the prevalence of latex hypersensitivity among health-care workers over time and health-care workers’ glove use over time. These figures are in contrast with the literature that indicates that both latex allergy and glove use have increased concomitantly.[14,26,40-42]

[Figures 1-2 ILLUSTRATION OMITTED]

Table 3.–Prevalence of Latex Allergy

Year published

and study Profession Prevalence

reference Country studied of allergy (%)

1987[72] Finland Hospital and

laboratory

employees 2.8

1992[46] United States Physicians 9.9

1992[73] France Nurses 10.7

1994[37] United States Hospital

employees 17

1995[74] United States Nurses 8.2

1995[45] Belgium Hospital

employees 4.7

1996[51] United States Dental

professionals 12

1996[75] United States Emergency

medicine

providers 10

1997[76] Canada Dental students

and staff 10

1997[39] Canada Hospital

employees 12.1

1998[77] United States Dental

professionals 6.2

1998[78] Canada Nurses 6.9

1998[36] United States Dental

professionals 3.8

The data from the published literature do not show a parallel relationship between latex hypersensitivity and glove use (Figs. 1 and 2). This ecological comparison shows a different relationship than expected–perhaps reflective of the research methods used for the testing of latex hypersensitivity. There are many inconsistencies between the studies, such as study year, population sample, and testing standards. In many studies, a study year was not included, so the publication year was the plotted date. Another limitation among these studies was the population sample. In most of the studies, prevalence of latex allergy was addressed in a single hospital, but the investigators extrapolated it to the prevalence of all health-care workers. Latex gloves have various levels of latex allergens, depending on the brand and type of latex worn.[43,44] Some latex gloves have more latex allergens, which coincides with the amount of latex antigen in the air.[11,32] Hence, in hospitals at which predominately high-allergen gloves are worn, individuals are at a higher risk of developing a hypersensitivity to the latex than those in hospitals where low-allergen gloves are worn.

Another discrepancy among the studies was the lack of a testing standard. In many of the studies, investigators used different latex sources as the extract to be tested. In addition, there are a variety of definitions of a positive skin-prick test, which alters the prevalence of hypersensitivity. For example, in one study, researchers identified a positive skin-prick test as 3 mm greater than the negative control,[45] whereas in another study investigators identified a positive skin-prick test as 5 mm greater than the negative control.[46] Finally, in yet another study, researchers identified a positive reaction to latex skin-prick test as a wheal size equal or greater than the codeine phosphate skin prick.[47] Clearly, if the true prevalence of latex allergy is to be found, latex testing must be standardized.

Atopy is a risk factor for developing latex hypersensitivity. Health-care workers who are atopic develop latex hypersensitivity more frequently than those who are not atopic.[41,48] Taylor et al.[49] reviewed 44 patients with latex hypersensitivity and found that 77% of them were atopic, and all but 2 patients were health-care workers.

In addition to occupational exposures, other high-risk factors for developing latex hypersensitivity are known, including latex exposure through surgical intervention. For example, people with spina bifida are exposed to latex through numerous surgeries, diagnostic testing, and examinations throughout their lives. According to the Spina Bifida Association of America, 18-73% of children with spina bifida have latex hypersensitivity.[50] This high prevalence is directly related to chronic exposure to latex.

A health-care worker is at an especially high risk if he or she, in addition to being atopic, has undergone previous surgeries. Safadi et al.[51] noted a 38% prevalence of symptoms related to occupational exposure to latex; 38% of those with symptoms had a history of atopy and 65% had undergone past surgery. Given the high risk that exists via occupational exposure to latex, healthcare workers must be aware that additional factors, such as those mentioned above, may increase the probability of developing latex hypersensitivity.

Testing for Latex Allergy

Diagnosis of latex allergy is made from patient history and diagnostic tests. Although tests can confirm hypersensitivity, the most important tool for identifying those at risk is a comprehensive medical history. Investigators should question every health-care worker to assess his or her risk for developing latex hypersensitivity. The questions should include the following: history of allergies to foods or medications; history of asthma or eczema; adverse reactions (i.e., hives, wheezing, rashes, coughing, or difficulty breathing) following contact with balloons, condoms, rubber balls, or any other rubber product; and adverse reactions following dental procedures.[52] Previous surgeries, number of surgeries, and any complications during surgery should also be noted.[52] Results of any previous allergy testing should be reviewed. Positive responses to these questions will identify health-care workers who are at high risk of developing hypersensitivity to latex.

Personnel can perform diagnostic tests, such as the skin-prick test, scratch test, use test, or patch test, to confirm the diagnosis of latex hypersensitivity. The skinprick test entails inserting a needle with latex solution into the patients’ skin. This is the preferred test and is the most useful test in diagnosing type I latex hypersensitivity.[49] However, there is a risk of causing anaphylaxis in highly allergic individuals.[53] The scratch test (i.e., latex solution is scratched onto the patients’ skin) has had a high false-positive rate.[49] The use test requires wearing a latex glove over one finger for an allotted time, and it correlates well with the skin-prick test. False-negative results may occur if the time allotted is insufficient[54]; the time should range between 15 and 30 min.

Investigators can also perform the patch test to diagnose natural rubber latex allergy. The patch test is performed by securing a patch of latex on the patients’ skin. The use of commercially available latex preserved with ammonia, absent other additives, has proven most successful when this test in performed.[55] This approach facilitates the diagnosis of immediate hypersensitivity and rules out allergies to rubber additives.

In vitro testing may also be useful in the diagnosis of latex allergy. The latex radioallergosorbent test (RAST) identifies specific IgE antibodies to latex in the blood. It can confirm a natural rubber latex allergy diagnosis. However, the RAST test should not be used as a screening tool because only 50% of a group of individuals identified as latex allergic by both the skin-prick test and scratch test had IgE antibodies to latex by the RAST.[49] Negative results may result from the binding of all the specific IgE to mast cells and basophils, leaving none available for binding in the RAST test. The Food and Drug Administration (FDA) has approved several latex-specific RAST tests for use in the confirmation of a latex hypersensitivity diagnosis.[56] The RAST test is not to be used as a screening tool, but, instead, as a diagnosis in response to medical history.

The FDA has proposed testing guidance methods for manufacturers to test gloves to reduce the possibility for latex users who become sensitized and to reduce the reactions of those who are latex sensitive.[57] However, the FDA has not approved standardized latex solution to be used in the in vivo tests; therefore, it is important that testing occur with more than one type of latex product, as well as with raw latex. Liquid latex gives earlier and stronger reactions than rubber latex or latex glove use. It seems that there are more antigens available in the liquid form.[55,58] Hamilton and Adkinson[59] showed that nonammoniated latex for diagnostic testing provided a more standardizable and controlled source of latex. To correctly diagnose natural rubber latex allergy, one must perform a variety of tests.

If the diagnosis of latex hypersensitivity is to be standardized, a standard procedure is necessary. Presently, a history of symptoms or high-risk individuals, a positive skin-prick test, and a positive RAST test confirms the diagnosis. However, a skin-prick test is useful only if the serum used contains the latex allergens responsible for the reaction in the individual being tested. There is no readily available standardized solution in the United States; therefore, the skin prick test may show negative findings.[59]

Policies for Ensuring Safety

Unfortunately, there is presently no cure for latex hypersensitivity. The most effective way for the reduction of reactions to latex products is for the individual to avoid all exposure to products containing latex. This approach can be challenging in the health-care setting because many medical supplies contain latex. Healthcare workers must be familiar with the diverse sources of latex to which they may be exposed. Fortunately, many nonlatex alternatives are now available. Health-care workers with latex allergy may worsen their allergic response over time as contact with latex is repeated.[8]

Not only do latex allergies threaten health-care workers, but patients are also at risk. Latex-safe environment goals are for the prevention of the development of latex hypersensitivity and a reduction of the onset of symptoms. As such, a latex-safe environment requires that the amount of latex allergen in the environment be reduced. The use of low-allergen gloves is one way that a low latex allergen setting can be achieved. The use of powder-free gloves lowers protein and chemical allergens.[10] Reducing the amount of powder in the gloves produces a concomitant reduction in the amount of inhaled latex allergen.[40]

Given that gloves represent the single biggest source of latex exposure in most hospitals, finding safe alternatives has become essential. In Table 4 is a list of a variety of suppliers and manufacturers of latex-alternative gloves. The quality of nonlatex products has been questioned. Vinyl gloves were more prone to punctures than latex gloves.[60] Many dentists prefer latex gloves to alternatives because they claim to have better tactile sensitivity.[61] However, the manufacturers of the newer synthetic latex-free gloves claim that the quality of their gloves is comparable–if not better than–that of latex gloves. Latex-free alternatives include nitrile, vinyl, neoprene, styrene butadiene, and tactylon. Unfortunately, there has been very little published research on the quality and characteristics of nonlatex gloves.[62]

Table 4.–Manufacturers and Suppliers of Nonlatex Gloves and Products

Manufacturer/supplier and URL Phone no.

Allegiance Healthcare 800-964-5227

http://www.allegiance.net

Allerderm Laboratories, Inc. 800-365-6868

http://www.allerderm.com

American Biomed, Inc. 281-367-3895

http://www.americanbiomed.com

Ansell Healthcare, Inc. 330-833-2811

http://www.ansell.com

Bard Medical Division, C.R. Bard, Inc. 800-526-4455

http://www.bardmedical.com

Best Manufacturing Company 800-241-0323

http://www.bestglove.com

Colonial Surgical Supply, Inc. 800-252-2425

http://www.gloveclub.com

Delta Medical Supply Group, Inc. 800-220-1262

http://www.deltagloves.com

ECI Medical Technologies, Inc. 902-543-6665

http://www.elastyren.com

Johnson & Johnson Medical Division 817-465-3141

of Ethicon, Inc.

http://www.jnjwoundcare.com

Maxxim Medical 800-727-7340

http://www.maxximedical.com

Quantum Labs, Inc. 800-328-8213

http://www.quantumlabs.com

Regent Medical 770-582-2222

http://www.regentmedical.vcom/usa rgnt

Safeskin Corportation 800-462-9989

http://wwsafeskin.com

SmartPractice, Inc. 800-522-0800

http://www.smarthealth.com

Tactyl Technologies 800-727-7340

http://millennianet.com/tactyl

Tetra Medical Supply Company 800-621-4041

http://www.tetramed.com

Tillotson Healthcare Corporation 800-445-6830

http://www.thenet.com

Trimline Medical Products Corporation 800-445-6830

http://www.trimlinemed.com

Manufacturer/supplier and URL Brand name/composition

Allegiance Healthcare Duraprene, Triflex,

http://www.allegiance.net Multi-Flex Ambi

Allerderm Laboratories, Inc. Allerderm nitrile,

http://www.allerderm.com Elastylon

American Biomed, Inc. Silicone balloon

http://www.americanbiomed.com catheters

Ansell Healthcare, Inc. Eline, Nitra-Touch

http://www.ansell.com

Bard Medical Division, C.R. Bard, Inc. Bardex silicone

http://www.bardmedical.com catheters, vinyl

catheters

Best Manufacturing Company N-dex

http://www.bestglove.com

Colonial Surgical Supply, Inc. Alpine, Bauldur, Best

http://www.gloveclub.com N-Dex, B-D Sensicare,

Glove Club Nytrile,

Royal Shield, Safeskin

Delta Medical Supply Group, Inc. Nitrex, vinyl

http://www.deltagloves.com

ECI Medical Technologies, Inc. Elastyren

http://www.elastyren.com

Johnson & Johnson Medical Division Allergard

of Ethicon, Inc.

http://www.jnjwoundcare.com

Maxxim Medical Ncolon, Sensicare,

http://www.maxximedical.com Tru-Touch

Quantum Labs, Inc. N-dex, vinyl

http://www.quantumlabs.com

Regent Medical Biogel, Safetex,

http://www.regentmedical.vcom/usa rgnt Neutroderm, Tri-Clean

Safeskin Corportation Tactylon, Safeskin

http://wwsafeskin.com nitrile

SmartPractice, Inc. Vinyl, nitrile,

http://www.smarthealth.com Tactylite

Tactyl Technologies Tactylon

http://millennianet.com/tactyl

Tetra Medical Supply Company Latex-free medical

http://www.tetramed.com supplies

Tillotson Healthcare Corporation Multi care, Pure

http://www.thenet.com Advantage, nitrile,

Dual Advantage

Trimline Medical Products Corporation Latex-free

http://www.trimlinemed.com blood-monitoring

systems

Note: URL = Uniform Resource Locator.

Some individuals have expressed concern about the cost associated with switching to a latex-safe environment. Many believe that a latex-safe environment will cause an increase in the costs of medical supplies.[63] FDA research confirms that synthetic rubber gloves costs can exceed latex gloves by more than 105%.[13] However, by reexamining inventory and purchases, some clinics have saved money by converting to a latex-safe environment.[64] The Mayo Clinic in Rochester, Minnesota, experienced a $200,000-plus savings by becoming a latex-safe environment, despite the fact that more gloves were purchased.[64] The clinic accomplished this by reevaluating overall glove purchases. In Iowa City, Iowa, the Oakdale Dental Clinic found that the nonlatex products costs seemed comparable with the latex product costs.[65] A hospital in Ontario, Canada, also reduced their overall costs, as well as glove purchase costs, by converting to a latex-safe hospital.[66] One example of a decrease in costs associated with the implementation of a latex-safe environment is that highly priced hypoallergenic gloves are no longer needed.[66] Therefore, after careful evaluation of inventory, latex-safe purchases could possibly reduce overall costs, despite the higher cost of gloves.

Government agencies, such as the FDA and the National Institute for Occupational Safety and Health (NIOSH), are aware of latex allergy in the workplace. In June of 1997, NIOSH issued the following warning:

The national Institute for Occupational Safety and Health (NIOSH)

requests assistance in preventing allergic reactions to natural rubber

latex among workers who use gloves and other products containing latex.

Latex gloves have proved effective in preventing transmission of many

infectious diseases to health-care workers. But for some workers, exposures

to latex may result in skin rashes; hives; flushing; itching; nasal, eye,

or sinus symptoms; asthma; and (rarely) shock. Reports of such allergic

reactions have increased in recent years–especially among health-care

workers.

At present, scientific data are incomplete regarding the natural history

of latex allergy. Also, improvements are needed in methods used to measure

proteins causing latex allergy … These recommendations (for minimizing

latex-health problems in workers) include reducing exposures, using

appropriate work practices, training and educating workers, monitoring

symptoms, and substituting nonlatex products when appropriate … (DHHS

Publication No. 97-135).

The FDA Center for Devices and Radiological Health analyzed the issue of whether the center’s policies identified the potential problems with latex in a medical glove powder report in September 1997. In that report, alternatives to the cornstarch powder used to lubricate the gloves were examined. The report also contained recommendations, and adverse health effects and glove market availability were examined. Effective September 30, 1998, the FDA required the labeling of latex products.[67]

If health-care workers’ settings are not latex-safe, there are precautions that can help protect them as individuals from latex hypersensitivity. To prevent latex hypersensitivity, one should avoid contact or have minimal contact with latex in all situations. This can be accomplished by the use of nonlatex or powder-free gloves. Another strategy is the reduction of latex hypersensitivity risk by wearing gloves appropriate to the task. Examination gloves contain higher amounts of protein antigens than sterile gloves.[10,68]

Use of examination gloves when unnecessary will increase exposure to latex antigens. Other strategies for health-care workers’ to decrease their risk of developing occupational latex hypersensitivity are listed in Table 5.

Table 5.–Latex Allergy Precautions[12,71]

Precautions

* Use nonlatex or powder-free, low-protein gloves

* Wash hands with pH balanced soap between glove wearing

* Rinse and dry hands thoroughly between glove wearing

* Remove gloves hourly, allowing hands to air dry

* Use non-oil-based hand creams under gloves

* Wear glove liners made of hydrogel, silicone, or other polymer under the glove

* Remove latex-containing dust from the workplace

* Take latex allergy training and education classes

Many health-care workers have already developed latex hypersensitivity. In such cases, colleagues and employers should be notified of the latex hypersensitivity. A medical alert bracelet should be worn and an auto-injectable epinephrine pen should be carried at all times.[12,69]

Employers should establish a policy on latex products and hypersensitivity.[12] Guidelines for the management of latex hypersensitive employees must be established. Latex education and training should be incorporated into orientation and training sessions. Educating health-care workers about the dangers of latex, protecting themselves from latex, and identifying allergic responses to latex should be included in the latex training sessions. If an employee becomes latex hypersensitive, it is the employer’s responsibility to counsel the latex-hypersensitive health-care worker about necessary safety precautions to take, including updating lists of latex-containing products in the building.

If a health-care worker becomes latex hypersensitive, he or she may be qualified to receive workmen’s compensation, depending upon the state in which he or she resides.[70] Health-care employees have introduced claims against employers concerning latex hypersensitivity.[71]

Attitudes, Perceptions, Knowledge

The occupational hazard of latex allergy for health-care workers has been a recent concern as investigators have made efforts to understand latex hypersensitivity. Nonetheless, research is lacking about health-care providers’ attitudes and behaviors toward, and knowledge of, latex hypersensitivity. These areas may affect the health-care workers’ practices with respect to latex or nonlatex glove use. Latex hypersensitivity poses a threat to health-care providers, and it is important that we understand how health-care providers are being educated about latex hypersensitivity and whether education proves valuable. Hospitals, clinics, and dental and physicians’ offices are developing policies on latex hypersensitivity. Developing an understanding of health-care providers’ knowledge concerning latex hypersensitivities and assessing the attitudes of health care providers toward a latex-safe environment will facilitate a “friendlier” conversion to a latex-safe environment.

A single report concerning the outcome of the attitudes and perceptions after the conversion to a latex-safe health-care facility was found.[64] The Mayo Medical Center changed to a latex-safe environment in 1994. The center developed a multidisciplinary work group to decrease the incidence of latex hypersensitivity and to protect patient and health-care workers already experiencing adverse reactions to latex. The task force published information concerning latex allergies in the clinic’s newsletters for several months to increase the awareness of the problem. The task force sent out additional newsletters explaining that use of high-allergen latex gloves would be gradually eliminated during the subsequent 6 mo. The task force provided alternate glove samples to surgeons in hopes that the alternative gloves would be compatible with their former gloves. If no gloves were acceptable, the higher-allergen latex gloves could be used. Twenty-seven months after the initial change to latex-safe gloves, only 10 of 2,000+ physicians continued to order nonapproved gloves.[64]

The Mayo Clinic is a good example of how policies can be changed in a nonthreatening manner. Several people at the clinic readily accepted the policy change of a latex-safe environment. Assessing the attitudes, perceptions, and knowledge of health-care providers will provide additional information, which will help major transitions, such as changing to a latex-safe environment. One wonders if there is a correlation between the knowledge of health-care workers and their acceptance of latex-safe environments.

Summary

The type I hypersensitivity reaction to latex antigens is a major threat to health-care workers, although a type IV hypersensitivity reaction may also occur. The transition to nonlatex products will not be easy because latex products are perceived by many health-care workers to perform better than the nonlatex counterparts. Many changes in the present use of latex products are needed if health-care settings are to be latex-safe, and we anticipate that widespread education will be required to explain the importance of these changes for the safety of patients and health-care workers. If a latex-safe environment is to be implemented at health-care facilities, personnel must understand the health-care professionals’ knowledge and attitudes regarding latex hypersensitivity.

Submitted for publication July 21, 1999; accepted for publication September 29, 1999.

Requests for reprints should be sent to Dr. Linda Kaste, Medical University of South Carolina, 173 Ashley Ave., BSB 449, PO Box 250507, Charleston, SC 29425.

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HEATHER N. ZAK College of Dental Medicine

LINDA M. KASTE Department of Stomatology

KATHRYN SCHWARZENBERGER Department of Dermatology

MARK J. BARRY Department of Stomatology

GILLIAN M.P. GALBRAITH Department of Microbiology and Immunology Medical University of South Carolina Charleston, South Carolina

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