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Experts Address Glove-Related Latex Allergies

Article

Gloves are the workhorses of personal protective equipment (PPE), serving as a barrier to protect healthcare workers (HCWs) from a wide variety of hazardous substances, including viruses and bacteria found in blood and body fluids, as well as chemicals, detergents and sterilants encountered in the healthcare setting. But gloves are a double-edged sword, sometimes causing skin irritation and triggering allergies in HCWs as well as in patients. There are a number of adverse effects that can be caused by gloves, including latex allergies; the formation of granulomas and adhesions in surgical patients from the introduction of powder into the surgical site from gloves; the incidence of allergic reaction from glove powder that has become aerosolized; and the incidence of contact dermatitis, a condition in which the skin of hands cracks and these tiny fissures can allow bacteria to grow.

Glove material choices proliferate; they include natural rubber latex (NRL) powder and powder-free gloves, as well as vinyl, nitrile and synthetic gloves. However, to avoid the aforementioned complications, healthcare providers should verify that a glove is powder-free; not only can latex exposure occur through direct contact with the skin or mucous membranes, it can occur through the aerosolization and inhalation of airborne latex particles. The protein responsible for latex allergies has been shown to fasten to powder that is used on some latex gloves, and when they are doffed, the particles are released into the air.

Sensitivity to natural rubber latex (NRL) can range from mild to life-threatening, and allergic reaction can be caused not only by gloves, but by the plethora of medical products and devices containing NRL, including catheters and other device tubing, adhesive tape, blood pressure cuffs, elastic bandages, face mask straps and many more items. The immune system’s response to latex, a Type 1 latex hypersensitivity, is triggered when an individual predisposed to allergies is exposed to the 200-plus latex proteins that exist currently. The immune response produces immunoglobulins responsible for the symptoms of latex allergy, from simple itching to anaphylactic shock. These symptoms generally occur immediately or within one hour following cutaneous, mucous membrane, parenteral, or airborne exposure to latex in sensitized individuals, and reactions can occur as long as eight hours after first exposure. Physical manifestations of allergy or hypersensitivity include flushing, itching, or tingling of the skin with or without the presence of with hives. Other reactions can mimic those caused by hay fever and include sneezing, runny nose, itchy eyes, and asthma-like symptoms of wheezing and shortness of breath.

Latex allergy can be associated with several kinds of skin irritation. Irritant contact dermatitis is inflammation that occurs when the skin’s surface becomes dry and irritated from non-glove sources, including frequent handwashing. When chapped, dry, irritated skin comes in contact with glove powder and latex gloves, the HCW can experience painful stinging and burning sensations and the skin can become red. Continual exposure can make the skin crusty with bumps and scabs that may peel or form cracks. A reaction to the chemical additives used during the manufacturing process of gloves is what triggers allergic contact dermatitis, a skin rash with occasional oozing blisters which can form approximately 24 to 48 hours after contact.

As much as 2 percent to 17 percent of HCWs experience latex allergies or hypersensitivity, so most healthcare institutions are endeavoring to limit or eliminate NRL gloves. According to the experts at Premier, Inc., “Individuals who are latex-allergic should avoid exposure to latex. Complete avoidance is the most effective approach to preventing any allergy, although this is difficult, if not impossible, to achieve. A more realistic approach is to reduce latex exposures. Strategies to reduce exposures include the use of non-latex gloves when there is little potential for contact with infectious materials (e.g., food preparation or housekeeping) and the use of reduced latex protein, powder-free gloves when there is risk of contact with infectious materials. While there is insufficient clinical data to calculate the precise amount of extractable latex protein in a latex glove that will cause sensitization or a reaction, it is known that reduced levels of latex protein decrease the risk of sensitization. To support the identification of these gloves, the FDA permits label claims of reduced latex protein (for example, gloves with 50 micrograms or less of total water extractable latex protein per gram).1

Behrman and Howarth2 note, “Hospitals should make policy and purchasing decisions to minimize latex exposure in the institution, with the goal being to protect sensitized patients and employees as well as to reduce the risk of primary sensitization. Several cost analyses have found that becoming latex-safe is cost-effective for healthcare facilities. Minimally, this requires reducing or eliminating powdered latex examination gloves and substituting less allergenic latex gloves or, ideally, high-quality nonlatex gloves. This strategy has been shown to reduce natural rubber latex aeroallergen, sensitization of exposed HCWs, and incidence of asthma in HCWs. Follow-up studies of latex allergic HCWs have shown a reduction in latex-specific IgE antibodies after latex use is substantially reduced in the healthcare workplace.”

Behrman and Howarth2 advise further, “Workers should receive training and education about the risks associated with latex allergies, signs and symptoms of reactions, and methods to reduce risks of exposure. Essential strategies for preventing long-term, serious health effects include periodic screening of high-risk workers for symptoms of latex allergy and alterations in the work place to minimize or eliminate exposure to latex for symptomatic workers. The information obtained from periodic screening of workers and identification of workers with latex allergies should be used for evaluation and revision of current prevention strategies.”

Glove Allergy Roundtable

ICT asked a number of industry experts to share their perspectives on this topic. Our roundtable participants are:

- Patty Taylor, vice president of marketing, North America for Ansell Healthcare

- Heather Campbell, product manager, exams for Ansell Healthcare

- Milt Hinsch, technical services director for Mölnlycke Health Care

- Kathleen Stoessel, senior manager of clinical education and accreditation for Kimberly-Clark Health Care

- Judson Boothe, marketing director of medical supplies for Kimberly-Clark Health Care

- Esah Yip, PhD, Malaysian Rubber Export Promotion Council

ICT: What are healthcare professionals’ top concerns regarding latex allergies and what specific challenges are you hearing from your customers?

Taylor and Campbell: The mix of glove materials used by medical professionals is changing as healthcare professionals become more educated about the risks associated with low-cost, high-allergen, powdered latex gloves. Current purchasing data demonstrates that an increasing number of healthcare workers (HCWs) will switch to powder-free latex or latex-free gloves to reduce their exposure to allergens and thereby reduce the risk of sensitization for themselves, their co-workers and their patients.

Hinsch: Healthcare professionals are seeing more chemical sensitivities among themselves and among patients, which are potentially being misdiagnosed as latex allergies. This tends to happen more often when patients claim to have a “latex allergy” but have never actually been tested for such, so they and the healthcare provider don’t really know. The affected individuals are generally treated as a “latex allergy” case to err on the side of caution and to protect both the patient and the institution. This causes hospitals to use more latex-free gloves than they would normally use. Generally speaking, the synthetic gloves tend to contain a greater number of accelerators, and this could possibly lead to a greater number of type IV reactions among healthcare workers in the future. (This is unproven conjecture.)

Stoessel: Top concerns for healthcare professionals regarding natural rubber latex proteins allergies include:

- What is a NRL protein allergy and how does it develop?

- How can I prevent its development?

- What precautions should be taken if this allergy is diagnosed?

A Type I, natural rubber latex protein allergy is an IgE antibody mediated allergy to the naturally occurring proteins found in raw natural rubber latex from the rubber tree, Hevea brasiliensis. It is the least common but potentially the most serious of the three glove-associated reactions. Allergic symptoms may appear locally at the point of contact or may spread throughout the body. These symptoms may include general itching; hives; itchy, watery eyes; runny nose; and facial swelling. More severe symptoms include dyspnea, hypotension, tachycardia, anaphylactic shock, and cardio-respiratory arrest. Strategies to reduce the risk of developing this allergy are to prevent initial sensitization of non-sensitized persons and to prevent reactions in individuals who are latex-sensitized. It has been noted that “The only effective prevention strategy at this time is latex avoidance.” A latex safe environment should be provided for latex allergic individuals. [AORN Latex Guideline, 2008 Perioperative Standards and Recommended Practices]

Given this information, a major challenge for healthcare professionals is to select medical gloves that provide appropriate barrier protection while minimizing or eliminating the risk of potential complications such as natural rubber latex (NRL) protein allergies.

Yip: When latex allergy was at its peak in the early 1990s, the top concern for healthcare professionals was to avoid using powdered latex gloves available at that time. These gloves were known to contain high level of residual proteins which could cause sensitization. Today, with the advancement of latex glove manufacturing technologies, a new generation of improved latex gloves with markedly reduced protein content mostly without powder is now available. The use of such gloves has been shown to vastly reduce latex sensitization and incidence of allergic reactions in hospitals, as reported by a number of independent hospital studies. More importantly, these studies demonstrated that latex allergic individuals wearing non-latex gloves, can now work alongside their co-workers and suffer no adverse reaction. As a matter of fact, the benefits of these improved low-protein latex gloves have recently been acknowledged by several well-known allergy researchers in the U.S. It was even reported that the prevalence of allergy among healthcare workers has now dropped from the more than 10 percent to as low as about 1 percent because of the improvement in glove productions. However, there still seems to be some who are not aware of such positive developments, as reflected in some published articles giving the outdated information about latex allergy. This certainly would create some unwarranted fear in the healthcare setting, to the extent of replacing latex gloves with alternatives that do not provide as effective a barrier protection as latex gloves. This could of course lead to exposing healthcare workers and their patients to unnecessary health risks. NRL gloves are well acknowledged to have the best barrier properties as compared to many synthetic alternatives, especially cheap vinyl gloves. This should be a serious concern for the healthcare industry.

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