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May 1997
Volume 61 |
Number 5
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| Latex Allergy:
Who Is Next? |
Gail I. Randel, M.D.
In my career as an academic anesthesiologist, many changes in
anesthesia practice have been witnessed. Change can be positive;
for example, the introduction of end-tidal carbon dioxide monitoring
and pulse oximetry into the operating theater have greatly improved
patient safety.
Universal precautions were introduced as a result of the AIDS
epidemic to protect both the patient and the health care worker
from transmission of all infectious diseases. Although this reduced
the risk of transmission of bloodborne pathogens to health care
workers, a new problem was created. With the increased demand
for latex gloves, manufacturers sacrificed quality control for
increased rates of production, and lower quality latex gloves
reached the market. Currently, gloves worn to comply with universal
precautions have produced a new health concern, the development
of latex allergy in patients and many health care workers.
Latex allergy implies that an individual's immune system responds
to proteins found in natural rubber products as a foreign substance
via an IgE-mediated response. More than 1,100 severe latex allergic
reactions, including 15 deaths from anaphylaxis, have been reported
to the Food and Drug Administration between 1988 and 1992. The
reported cases involved 770 health care workers (68 percent) of
which 736 were patients at the time of their reaction. The majority
of the reactions in health care workers (408) involved the use
of examination gloves, and 77 incidents (7 percent) involved the
use of surgical gloves.
What can we offer to provide safety for both the patient and
the operating room health care team regarding latex allergy? Knowledge
regarding the facts of latex allergy will heighten awareness in
identifying patients with latex allergy. Additionally, active
involvement to educate our patients, colleagues and administration
will produce a safer work environment.
It was about two years ago that our department was faced with
a patient diagnosed with allergy to latex who was scheduled for
an elective surgical procedure. The case was rescheduled to create
a latex-safe environment. Today, our institution has successfully
provided care for more than 45 patients with latex allergy with
minimal disruption to the operating room schedule.
Four members of our department of anesthesiology also have been
diagnosed as having a latex allergy, and one of our residents
developed anaphylaxis while working in an environment with minimal
exposure to latex. Additionally, one patient had an anaphylactic
reaction to latex while undergoing a cesarean section because
she forgot to inform anyone of her allergy. By sharing with each
other the lessons learned through our experiences and from the
current research, we can provide appropriate care for our patients
and help ourselves to avoid or minimize a latex hypersensitivity
reaction.
Background Information
In 1995, Truscott and Roley described the mechanism of action
and recommended treatment for the three types of reactions associated
with latex gloves: an irritant contact dermatitis and two immunologic
mediated reactions - delayed (type IV) and immediate hypersensitivity
(type I).1 Eighty percent of the
immunologic reactions are type IV and are produced by the chemical
additives used during manufacturing to maintain the integrity
of the glove. Type I reactions occur in response to proteins that
remain in the glove. The range of type I allergic reactions can
be quite broad with severe ones resulting in anaphylaxis and death.
The remainder of this article will focus on the type I reaction.
A recent epidemiologic study reported in the lay press (New
York Times, January 29, 1997) revealed that the general population
has an increased incidence of type I and IV latex sensitivity
since 1980, with some groups demonstrating substantially higher
risks.
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Table 1
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Groups
|
% Risk of Latex Allergy
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|
1980 |
1996 |
| General population |
1 |
8 |
| Health care worker |
3 |
20 |
| Dental workers |
7 |
40 |
| Hx Spina Bifida |
18 |
72 |
Several factors seem to be associated with an increased risk
for latex allergy. Sensitization to latex increases with the number
of surgical procedures.2 In a
prospective study, Moneret-Vautrin et al. showed that an atopic
history has a synergistic effect with frequent latex exposure
and, with both conditions, the chance of developing latex allergy
increases to 36 percent.3 Health
care workers represent the largest group at risk, with females
having a higher prevalence than males. Frequent use of disposable
gloves, history of atopic disease or hand dermatitis are the major
risk factors for sensitizing the health care worker.4
Latex allergy has become an occupational hazard for health care
workers. Often, personnel may be unaware of their symptoms since
they can be as nonspecific as an upper respiratory infection (tearing,
redness, puffy eyes, nasal congestion, sneezing, chest tightness,
coughing, wheezing, hoarse voice), gastrointestinal distress,
or a nonspecific rash, pruritus or burning of the hands.5
The only clue might be temporal relationship with working hours.
It might take a colleague to recognize the constellation of symptoms.
Currently, there is no cure for latex allergy other than avoidance
of the offending allergen and symptomatic treatment. If diagnosis
is delayed, symptoms may progress to more severe reactions. For
some health care workers, self-treatment and denial can delay
diagnosis, thus allowing latex allergy to progress to asthma,
anaphylaxis or even death.
Latex allergy is diagnosed by patient history and one confirmatory
test (skin prick test, radioallergosobent test (RAST), Ala-STAT
or CAP test, and/or challenge test). The skin prick test is the
most sensitive test for confirming a type I reaction. This is
performed by placing a dilute latex allergen solution on the volar
aspect of the arm and then pricking the epidermal layer of the
skin with a lancet. A positive test produces a wheal and flare
reaction. The RAST, Ala-STAT and CAP tests are used to measure
specific IgE antibodies against latex allergens in blood samples.
Since 19 latex allergens have been identified in serum samples
from health care workers and 46 allergens have been identified
in patients with spina bifida, the latex antigen used in the test
might not be the specific antigen that elicited the reaction in
the patient. The challenge test is employed if the other tests
are equivocal. It involves wearing a latex glove on one hand and
a vinyl glove as a control on the other hand.
An allergy to latex is unique in that there are multiple routes
for exposure: the latex allergen may enter the body by direct
dermal contact, absorption through abraded skin, mucocutaneous
exposure (e.g., during intubation, dental or gynecological exam),
breech in the vascular system and inhalation. Airborne latex allergen
accounts for 80 percent to 90 percent of all exposures for most
health care workers. Route of allergen exposure and dose of latex
allergen will influence the severity of the latex reaction. A
case report indicated that indirect exposure to the latex allergen
transported on the worker's clothes produced allergy in family
members.6
Extensive research is being performed on this important issue.
Medical gloves, particularly powdered gloves, are the major contributor
to latex aeroallergen.7 The concentration
of latex allergens among different brands of gloves varies by
as much as 3,000-fold, with powdered examination gloves having
the greatest concentration of latex allergens followed by sterile
gloves.8 Because of variations
in the manufacturing process, the concentration of latex allergens
varies greatly (6- to 40-fold difference) from lot to lot in the
same brand of gloves.9
Swanson and his group investigated latex aeroallergen levels
in different sites within the hospital. The concentration of latex
aeroallergen was higher in locations where powdered latex gloves
were used more commonly (13-208 ng/m3 versus 0.3-1.8
ng/m3), with the operating room area having the highest
concentration.10 In addition,
anesthetists had the highest exposure to the allergen compared
to other hospital personnel who wear gloves frequently. Allergen
was collected from surgical scrubs (200 mcg) and lab coats that
had been worn a week (>1 mg). The latex allergen becomes airborne
when gloves are donned or removed with a contribution from resuspension
from clothing.
Therefore, unless the operating room area is a latex-free environment,
the best time to provide surgical care for the latex-allergic
patient is the first case of the day when the allergen level is
at the lowest level. A 10-fold decrease in latex aeroallergen
can be accomplished by replacing high-allergen gloves for low-allergen
gloves.7
A sample 25-page questionnaire to identify latex sensitivity
is contained in "Guidelines for the Management of Latex Allergies
and Safe Latex Use in Health Care Facilities," which can
be obtained from the American College of Allergy, Asthma and Immunology
(ACAAI), 85 W. Algonquin Road, Suite 550, Arlington Heights, IL
60005; telephone (847) 427-1200. A copy of the complete document
is also available on the ACAAI Web site: <http://allergy.mcg.edu>.
The health implications for latex-sensitive health care workers
are significant because latex is so pervasive in the environment.
Leading researchers are recommending "STOP THE SENSITIZATION."
To protect sensitive patients and personnel, it has been advocated
that manufacturers of medical gloves should be encouraged to clearly
label their product to indicate the composition, including the
chemical additives, and the allergen content.11,12
As perioperative physicians, we should take an active role in
patient safety to prevent the exposure of allergic patients to
latex and to reduce sensitization of health care personnel with
repeated latex exposures. If our environment is safe for us, then
we can be assured that it is safe for our patients.
Steps to Avoid Clinical Expression of Latex
Allergy
- Eliminate the issue of airborne latex by using nonpowdered,
low-allergen latex gloves, synthetic gloves or vinyl gloves.
Be knowledgeable regarding latex allergen content of the gloves
you wear and those used in your working environment. Inform
the hospital administration and have an active voice in selecting
and purchasing gloves.
- Intact skin is an effective barrier, and it is important to
maintain excellent hand care. While at work, use water-base
hand lotions and cover cuts or open sores with a plastic barrier
dressing prior to wearing latex gloves. If possible, wash and
dry your hands after every glove change to decrease the load
of allergen.
- If dermatitis, erythema, rash, pruritus or burning of the
hand occurs, do not self-treat, i.e., antihistamine or steroid
cream. Seek early diagnosis if a type I or IV latex reaction
is suspected. See an allergist or dermatologist who specializes
in occupational diseases or latex allergy. The goal is to avoid
further sensitization.
- Avoid wearing work clothes (scrubs) home after working in
the operating room. Indirect exposures have caused latex allergy
in children and spouses.
- To improve patient care, develop standard questions to screen
for latex allergy in individuals who will have contact with
latex gloves or airborne allergen. Positive responses to the
following may highlight a potentially latex-sensitive patient
requiring more specific evaluation for latex allergy: 1) medical
history suggesting the presence of atopy, multiple food allergies,
eczema or asthma; 2) a history of multiple surgeries, especially
if there are intraoperative events consistent with anaphylaxis
; 3) occupational exposure to or frequent contact with natural
rubber products; or 4) an intolerance to condoms or diaphragms.
Additional Resources:
- Education for Latex Allergy/Support Team and
Information Coalition (ELASTIC, Inc.)
196 Pheasant Run Road
West Chester, PA 19380
Educational information, list of medical product manufacturers
- American College of Allergy, Asthma and Immunology
85 W. Algonquin Road, Suite 550
Arlington Heights, IL 60005
(847) 427-1200
http://allergy.mcg.edu
"Guidelines for the Management of Latex Allergies and Safe
Latex Use in Health Care Facilities"
- Spina Bifida Association of America
(800) 621-3141
List of medical and household products containing latex
References:
- Truscott W, Roley L. Glove-associated
reactions: Addressing an increasing concern. Dermatology
Nursing. 1995; 7:283-290, 303.
- Porri F, Pradal M, Lemiere C, et al. Association
between latex sensitization and repeated latex exposure in children.
Anesthesiology. 1997; 86:599-602.
- Moneret-Vautrin DA, Beaudouin E, Widmer
S, et al. Prospective study of risk factors in natural rubber
latex hypersensitivity. J Allergy Clin Immunol. 1993;
92:668-677.
- Hunt LW, Fransway AF, Reed CE, et al.
An epidemic of occupational allergy to latex involving health
care workers. J Occup Environ Med. 1995; 37:1204-1209.
- Charous BL, Hamilton RG, Yunginger JW.
Occupational latex exposure: Characteristics of contact and
systemic reactions in 47 workers. J Allergy Clin Immunol.
1994; 94:12-18.
- Karanthanasis P, Cooper A, Zhou K, et
al. Indirect latex contact causes urticaria/anaphylaxis. Ann
Allergy. 1993; 71:526-528.
- Heilman DK, Jones RT, Swanson MC, et al.
A prospective, controlled study showing that rubber gloves are
the major contributor to latex aeroallergen levels in the operating
room. J Allergy Clin Immunol. 1996; 98:325-330.
- Yunginger JW, Jones RT, Fransway AF, et
al. Extractable latex allergens and proteins in disposable medical
gloves and other rubber products. J Allergy Clin Immunol.
1994; 93:836-842.
- Jones RT, Scheppman DL, Heilman DK, et
al. Prospective study of extractable latex allergen contents
of disposable medical gloves. Ann Allergy. 1994; 73:321-325.
- Swanson MC, Bubak ME, Hunt LW, et al.
Quantification of occupational latex aeroallergens in a medical
center. J Allergy Clin Immunol. 1994; 94:445-451.
- Kelly KJ, Sussman G, Fink JN. Rostrum.
Stop the sensitization. J Allergy Clin Immunol. 1996;
98:857-858.
- Sussman GL, Beezhold DH. Safe use of natural
rubber latex. Allergy and Asthma Proc. 1996; 17:
101-102.
Gail I. Randel, M.D., is Assistant Professor
of Clinical Anesthesia at Northwestern University Medical School,
Chicago, Illinois.
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