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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.
ICT: What specific protections do your gloves offer?
Taylor and Campbell: The use of medical gloves is a critical component of a hospital’s infection control program. The two primary considerations of glove selection should be barrier protection and allergen content. Reliable two-way protection from cross-contamination is the primary reason that medial professionals wear gloves. Medical gloves must meet FDA requirements, providing a continuous and durable layer of material that is flexible, free from holes, breaches and cracks, and strong enough to prevent breakage during use. The materials most widely used in today’s medical gloves are latex, nitrile, neoprene, polyisoprene and polyvinyl chloride. Ansell offers a full range of latex, and latex-free alternatives which meet or exceed FDA guidelines for medical gloves. Latex remains the gold standard for hand barrier protection due to its strength, durability, elasticity, fit and comfort, and relatively low cost. We offer a full range of surgical and examination gloves that are both powder-free and powdered. For HCWs concerned about latex we offer non-latex choices such as nitrile, neoprene, polyisoprene and polyvinyl chloride. The DermaPrene® Ultra powder-free neoprene surgical glove is safe for latex sensitive (Type1 Allergy / Latex Allergy) and chemical-sensitive (Type IV Allergy / Chemical Allergy) healthcare workers and patients. The DermaPrene® IsoTouch™ powder-free polyisoprene delivers the performance characteristics of latex without the risks of latex sensitization. The Micro-Touch Affinity neoprene exam gloves are recommended as an alternative to NRL because of its similarity to latex with respect to fit, feel, comfort and barrier protection. Neoprene can be used in all risk settings and Ansell offers gloves FDA-approved for use with certain chemotherapy drugs. The Micro-Touch Nitrile family of exam gloves is recommended as an alternative to NRL for conditions where high strength and chemical protection are required. Nitrile can be used in all risk settings and Ansell offers gloves FDA-approved for use with certain chemotherapy drugs. The Micro-Touch Elite stretch vinyl exam gloves are recommended as an alternative to NRL where there is a low risk of exposure to blood, body fluids or chemicals.
Hinsch: Molyncke gloves offer the Lowest Hole AQL of 0.65 percent, which provide the best barrier protection with fewer manufacturing glove holes. A surgical glove is a good barrier unless it has a hole in it. Exclusively powder-free gloves eliminate powder problems for healthcare workers and patients. Synthetic gloves enable latex-sensitive and latex-allergic healthcare workers and patients to avoid exposure and reactions to latex allergens. Low-protein latex gloves reduce the possibility of developing latex sensitivities and latex allergies that cause protein allergy reactions by reducing the exposure levels. By preventing exposure to latex antigens, the number of future sensitizations and the number of future latex allergies can be reduced. Low amounts of extractable glove chemicals reduces chances of sensitization or skin reactions to glove chemicals such as accelerators. Our patented puncture indication system permits rapid visualization of holes when contacting blood or other body fluids. Visualization permits the wearer to take corrective action that can reduce the wearer’s potential exposure to bloodborne pathogens. Low dermatitis potential assures the user that the gloves have been tested and proven to be very skin compatible. Intact skin is the most important barrier to infection and skin irritations can violate that skin integrity. Non-pyrogenic surface protects wearers from pyrogen and endotoxin skin irritation and reduces patients’ potentially dangerous exposure to pyrogens and endotoxins.
Boothe: The CDC’s Guideline for Isolation Precautions states that either NRL or nitrile gloves are preferable to vinyl for clinical procedures that require manual dexterity and/or will involve more than brief patient contact. As an alternative to natural rubber latex, Kimberly-Clark Health Care offers powder-free nitrile exam gloves, which are appropriate for a variety of durability challenges including specialty applications such as chemotherapy administration and sterile task usage. Our nitrile glove portfolio features a unique tiering program based on the levels of protection needed for the clinical task or procedure being performed such as general examinations or phlebotomy, to longer duration tasks in harsher environments like chemotherapy delivery. Our nitrile gloves offer the flexibility and sensitivity of natural rubber latex and make donning easier, with a fit that is preferred by users for less hand fatigue throughout long shifts.
Yip: One single important function of wearing medical gloves is to seek barrier protection for healthcare personnel and their patients against viral transmission and other potentially infectious micro-organisms that may lead to harmful diseases such as HIV, hepatitis B, etc. NRL gloves are known to have very effective barrier properties as mentioned above. In addition, latex gloves also have a unique resealing property when latex gloves encounter tiny needle punctures. Synthetic gloves like vinyl and nitrile lack such capability. It is also notwithstanding the fact that NRL gloves have high durability, excellent tactile sensitivity, comfort and fit, which are critical glove qualities that manufacturers of synthetic alternatives are attempting to simulate.
ICT: What are your best suggestions for avoiding compromising the integrity of the gloves during donning, wear, and doffing, as well as skin-care suggestions?
Taylor and Campbell: Gloving material is an important determinate of glove barrier effectiveness and other aspects of glove performance. It pays to understand the difference between gloving materials to match the glove material to the nursing task at hand. You may want to select gloves from a reliable and experienced manufacturer who can provide the pros and cons of the different gloving materials and make appropriate recommendations. According to the CDC, approximately 25 percent of nurses report symptoms or signs of dermatitis involving their hands, and as many as 85 percent give a history of having skin problems. Frequent and repeated use of hand hygiene products, particularly soaps and other detergents, is a primary cause of chronic irritant contact dermatitis among healthcare workers. Potential strategies for minimizing hand hygiene-related irritant contact dermatitis among HCWs include reducing the frequency of exposure to irritating agents, replacing products with high irritation potential with preparations that cause less damage to the skin, educating personnel regarding the risks of irritant contact dermatitis, and providing caregivers with moisturizing skin-care creams. Product selection committees should inquire about the potential deleterious effects that oil containing products may have on the integrity of rubber gloves. The newest innovation for HCWs have come in the form of protective hand-healthy coatings such as glycerin, applied to the inside of medical gloves. These coatings offer a means to help keep skin moist and intact. Ansell offers such products – the Encore® HydraSoft® and the Micro-Touch® NextStep®. Our HydraSoft technology actively retains moisture and rehydrates the skin during use while the NextStep’s glycerol coating helps maintain skin integrity.
Hinsch: Double gloving is advisable, preferably with a double glove-puncture indication glove system. Be careful when donning, especially with thinner gloves. Use gloves that are easy to don, even with damp hands. Pulling hard on gloves because they “stick” to the hands during donning can tear them. Be sure to wear the right size — too loose, and the glove can catch on instruments or other objects; too tight, and they are prone to tear from excessive stress. Be aware of how certain chemicals affect the integrity of the glove; bone cement and mineral oil are two substances that are sometimes used during a surgical procedure, but both are capable of breaking down the glove material after a period of time. The user needs to be aware of this, and needs to change gloves after handling these substances in order to maintain glove integrity. Match the thickness to the surgical procedures. For example, orthopedic procedures generally require a thicker glove or glove combination than do plastic surgery or neurosurgery. Orthopedic surgeries usually involve rough handling of large, sharp instruments and often involve exposure to sharp bone fragments. General skin-care suggestions include performing good handwashing/surgical scrub prior to, and after gloving; moisturizing skin with a water-, silicone- or glycerine-based hand product following handwashing post surgical procedure. Avoid petroleum-based hand products (oils, petroleum jelly, etc.), as they can weaken glove materials.
Stoessel: The barrier integrity of any glove may be compromised by everyday practices. Recommendations to avoid compromising the glove integrity include the following: As defects may occur during their manufacture, gloves should be inspected prior to use. The wearing of jewelry, long fingernails or artificial nails should be avoided as they may snag, tear or puncture gloves. Incompatible hand lotions may degrade the glove material and inappropriate glove donning may put undue stress on the glove. Gloves should be changed if a barrier breach is suspected. How a glove is used, the stress placed on the glove material, as well as the length of time the glove is worn can impact the barrier integrity. The rate of material fatigue can be compounded by many factors that may include rigorous manipulation, contact with various chemicals and quality of the material coverage in areas that are difficult to coat (e.g., the saddle between the fingers). Gloves that are not removed and disposed of properly can contaminate the wearer as well as the environment. Therefore appropriate removal or doffing is essential. The CDC advises that when removing gloves:
• Using one gloved hand, grasp the outside of the opposite glove near the wrist.
• Pull and peel the glove away from the hand.
• The glove should now be turned inside-out, with the contaminated side now on the inside.
• Hold the removed glove in the opposite gloved hand.
• Slide one or two fingers of the ungloved hand under the wrist of the remaining glove.
• Peel glove off from the inside, creating a bag for both gloves.
• Discard in appropriate waste container.
• Perform hand hygiene.
Since their skin is the first line of defense for HCWs, optimal skin care is essential. Individuals who wear gloves that contain powder, NRL proteins or residual chemicals post-manufacture are vulnerable to glove-associated irritation and allergies. These reactions may result in symptoms that include skin breakdown of the hands. This is of special concern for HCWs as an individual is at greater risk for infection when the natural skin barrier is compromised. Therefore, it is very important to select well-manufactured gloves that are powder-free and have low or undetectable levels of NRL proteins and residual chemicals. It is important to note that gloves are not substitutes for hand hygiene. Immediately after glove removal, hands must be thoroughly washed, rinsed and dried or appropriate hand sanitizers used.
Yip: To address the concern about barrier protection and latex allergy in workplaces, it is recommended that the healthcare facility adopt a “latex-safe” environment and not a “latex-free” one. This would involve the use of good quality low-protein latex gloves generally for all who are not sensitive to latex, but providing also good quality non-latex gloves for those who need them. Such a move is supported by OSHA as published in its latest Technical Bulletin, recommending the use of low-protein latex gloves for barrier if latex gloves are used, as well as the use of non-latex gloves with good barrier for latex sensitive individuals. (SHIB 01-28-2008 at www.osha.org) Selecting gloves to be used in a healthcare environment should be based on their ability to provide barrier protection against viral and bacterial transmission, which could otherwise lead to harmful infections. This is notwithstanding the fact that unlike the synthetic alternatives which are made from petrol chemicals and are not biodegradable, NRL gloves are environmentally friendly, being a green material and are biodegradable – an important factor in the consideration of a green hospital environment. Using gloves based solely on cost could impose a false sense of security if the gloves chosen do not provide the barrier protection needed by HCWs and their patients.
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