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By Rosaline Parson, RN, BSN, CEN, CCRN
Gloves firstentered the healthcare scene in 1889 when an operating room nurse developed severedermatitis from mercuric chloride, which was used as a cleansing agent. The GoodyearRubber Co. made two pairs of thin rubber gloves with gauntlets to protect her hands. Theprototype gloves worked so well that eventually the entire surgical team requested thegloves.
Over the past 10 years, the growth in latex use has been associated with universalprecautions. The Bloodborne Pathogens Standard requires gloves to be worn when it isreasonable to anticipate hand contact may occur with blood, other potentially infectiousmaterials, mucous membranes, non-intact skin, or contaminated items or surfaces, and whenperforming most vascular access procedures.1 In a recent clarification, OSHAhas said that "gloves made of natural rubber latex (NRL) as well as syntheticmaterials have been cleared for marketing as medical gloves by the FDA and can be usedeffectively for barrier protection against bloodborne pathogens."2
With the advent of universal precautions to protect against HIV, hepatitis, and otherviruses, the US glove market quickly reached 10 billion pairs annually. More than 200types of gloves are available on the market with an overwhelming choice of materials,design, and cost.3 Recently, new glove challenges have arisen with theemergence of latex allergy among patients and health professionals. With the addition ofburgeoning healthcare costs and lowered reimbursement, it's more important than ever thathealthcare workers and materials managers know how to select the right glove.
Latex gloves are derived from a natural product of the rubber tree Heveabrasiliensis. Some of the proteins in natural rubber are essential for enhancingbarrier protection, but a subset of those latex proteins are also allergens. Sensitizationto NRL is caused by direct contact with latex gloves and antigens that become aerosolizedby glove powders in the donning process.
Due to the occupational threat of HIV, Hepatitis B, and other infectious agents in thehospital environment, the Centers for Disease Control and Prevention (CDC) issueduniversal precautions in 1987 that emphasized the need for glove barrier protection. Withhealthcare workers wearing gloves more often, and for longer periods of time, incidents ofskin reactions have increased dramatically. Although the prevalence of latex allergy inthe general public is low (1% to 6%), the risk for healthcare workers becoming sensitizedto latex ranges from 8% to 17%.
There are three types of reactions to latex gloves originating from three distinctlydifferent physiological mechanisms: irritant contact dermatitis, allergic contactdermatitis (also called Type IV delayed hypersensitivity), and urticaria (also known asType I immediate hypersensitivity or IgE/histamine-mediated allergy).
Irritant contact dermatitis is a direct injury to the skin cells followed by localinflammation. The first symptoms are generally redness and swelling with associateditching or burning. Continued contact results in lesion formations that often appear asdermal fissures. Chronic conditions are associated with dry, thickened skin, cracks, andpapules (bumps). Causative agents include pH extremes, residual soaps and disinfectants,excessive glove chemicals, and insufficient leaching. Gloves worn too long withoutallowing the skin to air can result in hyperhydration, a condition rendering the skinsusceptible to injury. Intracellular desiccation and surface abrasion caused by glovepowder may initiate, aggravate, or amplify irritant reactions.
Allergic contact dermatitis (Type IV) is a cell-mediated allergic response to specificchemicals often referred to as contact sensitizers. The chemicals that are primarilypresent in most glove formulations are mercaptobenzothiazole (MBT), thiurams, andcarbamates. Less frequently, individuals may develop a reaction to other glove chemicalssuch as antioxidants, colorants, and antimicrobials. Each time the skin is exposed to thespecific antigenic chemicals, more cells are sensitized, increasing the intensity and areaof the reaction. Because allergic contact dermatitis includes inflammatory mechanismssimilar to those seen in irritant contact dermatitis, it is often difficult to distinguishbetween the two reactions. The process may be aided by remembering that irritation isconfined to the area of glove contact while allergic contact dermatitis may extend beyondthe border of the glove.
Immediate hypersensitivity (Type I) can occur in genetically predisposed individualsand may show no symptoms during the process of sensitization. Repeated exposure with theallergen amplifies the production of allergen specific IgE antibodies, which attach toincreasing numbers of mast and basophil cells. When triggered by allergen contact, thesecells release immunological mediators, such as histamine. The following symptoms mayappear within minutes of exposure: local or systemic urticaria, hay fever-like symptoms,abdominal cramps, difficulty in breathing, rapid heart rate, blood pressure drop, and,potentially, anaphylactic shock. Examples of immediate Type I hypersensitivity reactionsoccur with penicillin and bee sting allergies. The allergens specific to gloves areproteins in the latex sap of Hevea brasiliensis (rubber tree). Individuals inhigh-risk occupational groups may be able to delay or avoid exposure by using gloves thatare powder-free, low in protein allergens, and/or made from non-natural rubber latexmaterials.
No one glove material is impervious to all chemicals. The range of effects from thesedifferent chemicals can be broad. Some are immediate and obvious as the gloves literallydissolve. In others, the chemicals can degrade the barrier effectiveness, but the gloveappears to remain intact. For example, polyvinyl chloride (PVC) is resistant to oxidation,acids, alkalis, fats, and some alcohol but not organic solvents. Nitrile is resistant tomany chemicals and oil-based products. Chloroprene offers good resistance to chemicals,atmospheric degradation, oils, and fats. Polyurethane has no accelerators, residual odor,or taste. When chemicals are anticipated, workers need to know in detail the hazards andlimits of exposure as described in the Material Safety Data Sheet as well as themanufacturing product information sheet.
The major role of examination gloves is to provide barrier protection againstinfectious agents and bodily fluids. Besides latex gloves, several additional examinationglove types are available, including PVC, nitrile, and polyurethane.
Latex: NRL gloves remain the first choice of many healthcare workers: the gold standardof functionality, comfort, tactile sensitivity, and low cost against which allalternatives were judged. However, the increase in latex allergies has caused thenon-latex glove market to expand exponentially.
Synthetics: The three major categories of synthetics are plastics, like polyvinylchloride (PVC); elastomers, like nitrile and polychloroprene (copolymer plastics are usedin non-medical settings, such as food handling); and polyurethane. Elastomers, neoprene,and copolymers of styrene butadiene rubber are more common in surgeon's gloves.
PVC remains the most widely used non-latex glove. PVC provides adequate barrierprotection, especially for short-term procedures or general patient care. Furthermore PVChas a relatively low cost, is easily available, and avoids concerns regarding latexsensitivity.
Nitrile costs more than PVC, but it delivers more. Its barrier properties, fit, andfunction have been shown to be similar to latex. However, unlike PVC, the nitrile tends tostretch and relax with hand movement, which translates to a soft, comfortable, flexiblefit even during extended wear and hand manipulation. The majority of nitrile gloves arepowder-free with a polymer coating added for ease of donning.
Polyurethane is the most recent entry in the examination glove market, and its cost iscomparable to nitrile. This propriety product does not contain NRL and is safe to use byindividuals who are sensitive to the proteins that are found in NRL. No accelerators, likethose found in nitrile, neoprene, chloroprene, and natural latex gloves or plasticizersfound in vinyl gloves, are added to the polymer during manufacturing, consequentlycreating the first "clean" glove. This creation will virtually eliminate thepotential for Type I and Type IV allergic reactions. Polyurethane offers outstanding touchsensitivity, protection, fit, and comfort unparalleled in a synthetic examination glove.Most importantly, this glove has no residual odor and/or taste for improved comfort forboth patient and healthcare professional.
As with examination gloves, the major protective role of surgical gloves isagainst bloodborne and other pathogens. Focus on surgical gloves has been less than thelow-cost examination glove. Primary reasons for this are the frequency and duration ofuse, the number of workers that use the product, and that surgeons require greaterdexterity and tactile sensitivity. Sterile surgical gloves are available in NRL as well asthe other synthetic gloves that are listed above, just at a higher cost.
Since gloves were introduced, the search has continued for a dry lubricant thatwould make donning easier, absorb perspiration, and avoid friction. Early agents, fromclub moss to talc, did all the above but contaminated the environment with particulatematter and caused post-operative complications. Today's surgical gloves use a USP-definedabsorbable dusting powder: a chemically cross-linked cornstarch to which no more than 2%of magnesium oxide is mixed to prevent caking.
Cornstarch is the most common powder for both latex and synthetic examination gloves.Since exam gloves are not sterilized like surgical gloves, the cross-linking in thecornstarch particles does not break down and, thus, is far less absorbable than the powderon surgical gloves. The cross-linked cornstarch can abrade delicate tissues in the eye orinternal ears and can affect the lungs, especially the underdeveloped respiratory pathwaysof premature babies and other at-risk patients. A powder-laden environment is also apotential source of respiratory problems and asthma-like attacks for healthcare workers.4All environments including the surgical arena are at risk when powder is present.
Today, the primary concern of powder is the potential allergen, as in latex proteins orchemicals, used in NRL and synthetic glove manufacturing. These proteins attach themselvesto the powder and are aerosolized on donning or removal. As a result of these concerns,several professional healthcare organizations have recommended that, in addition todiscontinuing unnecessary use of latex gloves, healthcare institutions implementlow-allergen and powder-free gloves whenever possible.
Hospitals are addressing these issues by implementing latex-safe zones throughmultidisciplinary committees. Responsibilities of this committee will include thecoordination of system-wide efforts. Policy and procedures, standards of care, protocols,or guidelines will be formulated and reviewed through this central body of knowledge.
Some studies suggest that the typical hospital can save from 10 to 15% of totalglove budget by managing usage correctly, choosing the appropriate gloves, and buying inbulk and from right vendors. In the past, one of the easiest ways to keep costs down wasto use latex gloves. But a recent study from Emory University suggests that hospitals mustaddress the rising costs related to patient and employee allergy reactions, especiallyallergens in NRL medical products.
Occupational latex allergy was first reported by US healthcare workers in 1992, andprevalence figures since then have varied from 8 to 17%. Sensitization to latex is causedby direct contact with latex and by latex antigens that become aerosolized with glovepowders in the donning process. Phillips Goodrich and Sullivan completed a cost-analysisstudy comparing the costs of converting to a latex-safe environment vs. the status quostrategies in three different types of facilities in Georgia: a tertiary care hospital, acommunity hospital, and an outpatient internal medicine clinic.5 Eachinstitution reported the type, quantity, and manufacturer of gloves purchased; the pricesof the gloves were obtained from the manufacturers. The researchers then substituted theunit price for the comparable non-latex glove alternative to calculate the healthcarefacilities' annual glove costs, if they created a latex-safe setting.
In this study, a latex-safe approach was more expensive for each facility when onlyglove costs were considered. However, this changed when potential disability costs wereintroduced into the financial decision. It was also noted, based on documented prevalencerates, that 8% of employees routinely exposed to latex gloves would develop IgE-mediatedlatex allergy, with 2.5% of this number also developing latex-related asthma. Whencalculating only the cost of diagnosis (not treatment) and using Georgia's workers'compensation benefits for RNs (the largest group of healthcare workers affected by latexallergy), it was found that only 1% or fewer of those at risk for latex allergy needed tobecome fully disabled, or fewer than 2% to become partially disabled for the latex-safeapproach to be financially viable. The calculations did not include increased sick leave,decreased job productivity, and medical care costs for disabled employees, nor did theyinclude costs of developing and implementing policies for avoiding latex use or in-servicetraining. An additional study from Hopkins validated the hospital's conversion tosynthetics as having minimal cost impact. This was related to volume purchasing and GroupPurchasing Organization (GPO) contracting.6
Does changing latex policy work? Some supporters believe changes will minimize the riskfor sensitization of predisposed healthcare workers. A study that was completed at Hopkinsproved this belief. It proved that people that were already allergic to latex have shown adecrease in symptoms and serum IgE anti-latex levels once they are able to practice strictlatex avoidance. Another study demonstrated symptoms ranging from rhinitis andconjunctivitis to asthma and anaphylaxis. Six months later these workers lost allergicskin and respiratory symptoms associated with latex product use when the environment waschanged to latex-safe. At 15 months, the group had lost all detectable laboratorysensitivity as well.6
As the impact of latex allergy has become clearer, it is now recommended thatindividuals with latex allergy or workers whose tasks do not involve potential forbloodborne exposure reduce exposure to latex by using a synthetic glove alternative. IfNRL gloves are chosen to be used in these circumstances, they are recommended to below-allergen and non-powdered.6 In fact, the Food and Drug Administration (FDA)is considering reclassifying latex gloves from Class I to Class II medical devices. Thiswould require more stringent reporting when allergic reactions occur. In September 1998,the FDA began requiring manufacturers to put allergy warnings on products or packing thatcontain latex. Some states recently considered banning or limiting the use of latexproducts.
NRL allergy is a serious medical problem for many patients and a devastatingoccupational disease for the healthcare provider. Since there is no treatment for latexallergy, except for complete avoidance, ways to decrease exposure must occur.P
Rosaline Parson, RN, BSN, CEN, CCRN, is vice president, Clinical Resources, MaxximMedical, Inc. (Clearwater, Fla).
For a list of references, access the ICT Web site.
TYPE OF REACTION
IIrritant Contact Dermatitis
Localized reaction. Appears where there is glove-to-tissue contact. Burning, itchy, and dry, cracked skin is common.
Allergic Contact Dermatitis (Type IV)
Non-localized reaction can present beyond the area of direct tissue exposure. Swelling, pustules, and above symptoms are common. Symptoms are reoccurring.
Immediate Allergic Hypersensitivity (Type I)
Systemic allergic response to NRL protein allergens. Runny, itchy nose, watery eyes, and shortness of breath may be indicators. Can cause permanent disability and may be fatal in rare instances.
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