An approach to managing latex allergy in the health care worker.

Introduction

Over the past several years, many published case reports have described serious allergic reactions to products that contain natural rubber latex (1-11). The development of latex allergy requires the production of latex-specific IgE antibodies resulting from repeated long-term exposures to latex-containing products (12-17). Individuals who work in health care occupations (e.g., nurses, physicians, dentists, technologists, housekeeping staff) have been identified as at increased risk for development of a latex allergy. The increased risk presumably results from routine use of latex gloves as part of universal precautions and from inhalation of latex proteins aerosolized in glove powder (12,13,15,16,18). Health care workers should become familiar with the clinical signs and symptoms that suggest latex allergy Physicians and nurses should be prepared to give professional guidance, support, and direction to facilitate proper diagnosis and management of the condition. Once the diagnosis is made, latex-allergic health care workers need continued monitoring and assistance to prevent further adverse allergic consequences.

This article presents a proactive, directed approach to the management of latex-allergic health care workers in a hospital or clinic setting. Specific recommendations and some practical guidelines are provided.

Prevalence

Latex sensitization can be detected by a blood test for latex-specific IgE antibodies or by a skin test for reaction to latex. Many reports have suggested that latex sensitization rates among health care workers are rising and attribute the rise to continued, widespread use of latex gloves in conformity with OSHA regulations designed to protect workers from bloodborne pathogens. In 1987, a hospital in Finland skin-tested 512 hospital personnel and found a 2.9 percent prevalence of positive skin tests for latex allergy. The highest prevalence of positive latex skin tests was found among operating room personnel: 7.4 percent of surgeons and 5.6 percent of operating room nurses (16). Additional reports have shown a prevalence of latex allergy ranging from two percent to 15 percent among all health care professionals (12,16,19,20). In 1993, the prevalence of latex-specific IgE antibodies (detected by AlaSTAT EIA) was found to be 8.9 percent among registered nurses working in acute care areas in a large metropolitan hospital in Detroit (21). Similarly, 9.9 percent of procedure-oriented specialist physicians had positive skin tests for allergy to latex protein (19). Thus, the prevalence of latex-specific IgE among health care workers is high, but the percentage of those subjects who have clinical symptoms is likely to be somewhat less.

Adverse Reactions to Natural Rubber Latex

Natural rubber latex is derived from the milky white sap of the Hevea brasiliensis plant, more commonly known as the rubber tree. This sap or latex contains substantial amounts of cis-1,4-polyisoprene, from which natural rubber obtains its desirable thermal and plastic properties. During the manufacturing process, accelerators, curing agents, antioxidants, and stabilizers such as thiurams, carbamates, and mercaptomix may be added to the liquid latex. These substances can trigger Type IV (cell-mediated) immune reactions that manifest as localized contact dermatitis of the skin (14,22). This condition can be diagnosed with patch testing.

This skin condition is especially problematic for health care workers, who generally must choose either to expose their nonintact skin to bloodborne pathogens or to suffer worsening eczematous hand dermatitis from continued use of latex gloves. Furthermore, the presence of hand eczema increases the risk [TABULAR DATA FOR TABLE 1 OMITTED] of infection. Daily or chronic exposure to glove powder, compounded by sweating, rubbing, and use of caustic disinfectants, often leads to skin maceration, breakdown of its barrier protection function, and worsening appearance of the hands (22). In addition, latex proteins can trigger serious Type I (IgE-mediated) allergic reactions that are directly associated with the development of asthma, rhinocon-junctivitis, urticaria-angioedema and anaphylaxis (Table 1). The severity of symptoms appears to be, at least in part, a function of the route, quantity, and type of exposure as well as of the individual's degree of allergic sensitivity.

Health care workers with negative patch tests may develop a pseudoallergic, nonimmunologic, cutaneous response to latex gloves that appears as cracked, crusty skin lesions primarily located over the back of the hands. This reaction occurs without previous sensitization and is considered an irritant response to glove-permeating substances such as solvents or disinfectants, epoxy resins, or methylmethacrylates commonly used by housekeeping personnel, orthopedic surgeons, and dentists, respectively. Occasionally, sorbic acid, which can also act as an irritant, may be present as a preservative in glove powder (22).

Routes of Latex Exposure

Exposure to latex may occur by a cutaneous, mucosal, visceral, or intravascular route. The broad spectrum of allergic manifestations is largely determined by the multiple routes of latex antigen exposure and sensitization (23-30).

Between January 1988 and September 1992, the Food and Drug Administration (FDA) received 1,133 reports of systemic reactions to 30 different types of medical devices. Of these reactions, 408 involved exposures to latex exam gloves, and 77 were related to latex surgical gloves (23). Cutaneous exposure to a variety of other latex health care products, including anesthesia masks, tourniquets, electrocardiographic electrodes, adhesive tape, and elastic bandages, has also triggered contact urticaria and systemic allergic reactions (23,24). Moreover, products used in the home have triggered local and systemic allergic reactions when they come into contact with skin. Examples include condoms, balloons, Koosh[TM] balls, and sporting goods (24). Serious allergic reactions may be more likely to occur when the skin is moist from perspiration (e.g., under gloves) or handwashing (15). Furthermore, skin breakdown may promote absorption of soluble latex proteins, leading to further sensitization and risk of development of systemic latex allergy.

TABLE 2

Latex Product and Alternatives List

Product Containing Latex            Alternative

Ace bandage, brown                  Ace bandage, white cotton

Ambu bag                            Prewash multiple times(*)

Anesthesia                          bag Neoprene anesthesia bag
                                    (kept in anesthesia work room)

Antiembolism stockings (TEDs)       Kendall SCD stockings with
                                    stockinette underneath

Arthroscopy tubing sets, 3M

Band-aids                           2 x 2 with silk tape

Bite block                          Plastic oral airway; padded
                                    tongue blade

Blood pressure cuff                 Nylon or vinyl one (kept in
tubing and bladder                  anesthesia work room)

Buretrols                           Do not use

Catheters: coude, Fogarty, Foley,   All silicone or vinyl catheters;
Malecot, nephrostomy, red rubber    do not inject through ports; use
                                    a Terumo syringe for
                                    instillation; do not use gloves
                                    in kits

Chest drainage systems tubing       Cover tubing with stockinette or
                                    avoid skin contact(*)

Cholangiocath

Coban                               Ace bandage, white cotton; Conco
                                    nonlatex bandage

Dilators: bougie, mercury-filled,
Hurst

Ear tubing                          Suction tubing

Esmarch bandages                    Spectrum Esmarch

Gloves, surgical                    Nealon

Gloves, exam                        Tactyl exam gloves

IV bag (injection port)             Do not puncture ports(*)

IV tubing (injection ports)         Use stopcock; do not puncture
                                    ports(*)

Levine tubes                        Salem sump

Magnetic pad                        Do not use

Manometer, bladder

Medications, multidose vial         Consult pharmacy for latex-free
                                    alternatives; if no alternative
                                    available, remove stoppers; do
                                    not inject or withdraw through
                                    stoppers(*)

Mouth gags                          Silicone mouth gag

Penrose drain                       Nealon glove cut into strip; all
                                    silicone drains

Prep kits                           Remove gloves; use Nealon gloves

Rubber bands                        Vessel loops

Rubber dams                         Nealon glove cut into pieces

Rubber shods                        Metal clamps; Fogarty clamps;
                                    silicone tubing

Spronet dressing, Acme              Stockinette

Sleeve, sterile Kimberly Clark      Change gowns

Shunt, Inhara Pruitt                Shunts: Javid, Sundt

Surgiport III disposable trocar,    Avoid use
autosuture

Suture bag (adhesive)               Avoid use

Syringes, single use (monojet, B    Terumo syringes
& D)

Tape, cloth adhesive                Tape: silk, plastic, waterproof

Tourniquets, rubber                 Use single-use blood pressure
                                    cuff, PyMah

* Indicates item for which latex contact has been minimized but not
eliminated.

Airborne allergens typically target the respiratory tract and eyes, causing rhinitis, asthma, and conjunctivitis. Health care workers with latex sensitivity may be at risk for developing acute or chronic symptoms of asthma, including wheezing upon subsequent or continued exposure to latex proteins. A recent study concluded that occupational asthma in response to latex occurs in 2.5 percent of hospital personnel. The report considered exposure to latex gloves and aerosolized glove powder significant risks to the respiratory health of employees (30).

Latex antigen spread over a large mucosal or visceral surface area may precipitate an acute life-threatening anaphylactic reaction in a sensitized individual (28,29). Barium enema examinations that use previously manufactured latex retention catheters and intraoperative manipulation that uses latex gloves have both prompted this kind of reaction.

Intravascular exposure from IV bags and tubing, as well as from medications stored in latex-capped multidose vials, also can pose a significant risk to allergic subjects.

Allergic reactions in sensitized health care personnel do not necessarily require direct latex exposure. In settings such as hospitals or clinics, where powdered latex gloves are routinely used, latex may be present on doorknobs, flat surfaces, and the clothing of health care workers (25-27). These hidden exposures are especially troublesome for highly sensitized individuals who may have recurrent episodes of wheezing from coming in contact with doorknobs, counters, and equipment previously touched by other hospital employees wearing latex gloves. The affected individual, co-workers, supervisors, and the treating physician should continually monitor the work environment for possible undetected latex exposure sources and should institute appropriate interventions.

The American College of Allergy, Asthma, and Immunology has established new practice guidelines to help curtail the latex allergy epidemic among health care workers. These guidelines recommend the following:

1. development of educational programs that promote awareness of latex allergy in health care workers;

2. proper labeling of latex-containing products by manufacturers;

3. funding of projects to develop a nonallergenic, cost-effective, biosynthetic alternative rubber product;

4. mandates for maximum levels of extractable allergen in latex gloves; and

5. development of serologic methods to improve and speed the diagnosis of latex allergy (20).

Health Professional Screening

We have developed a health professional screening method to confirm the current number of workers with documented latex sensitivity (prevalence) and to assist in the identification of individuals with new or previously unidentified allergic manifestations to latex products (incidence) (Table 1).

A positive response to one or more of the questions on the screening questionnaire would prompt the health care provider to perform the more detailed questionnaire at the time of the clinic visit or hospitalization (Figures 1 and 2). The detailed questionnaire is designed to gather information pertaining to allergic-based multiorgan system involvement in response to common medical or personal exposures to latex. All questionnaires can be electronically administered or mailed periodically to all hospital or office employees, so that the database can be updated continually.

Clinical Evaluation and Management of Health Care Workers

The authors recommend the following algorithmic approach to the evaluation and [TABULAR DATA FOR FIGURE 1 OMITTED] management of health care workers (Figure 3). After the initial screening questionnaire is administered, individuals with "no" responses to the six screening questions are assessed as not currently manifesting latex allergy. Therefore, standard care guidelines are recommended. These guidelines consist of widespread use of powderless gloves available in the least antigenic form, as well as strict handwashing to curtail the development of latex allergy (31,32). Vinyl gloves are a safe, latex-free alternative for multipurpose, nonpatient-care activities. However, vinyl gloves may not provide a completely effective barrier to viruses. Therefore, when handling blood and body fluids, health care workers who are allergic to latex should wear alternative, nonlatex, biosynthetic gloves (33).

If one or more "yes" responses are obtained on the screening questionnaire, the more detailed questionnaire will provide valuable information for the treating physician. If no history of allergic reactions or anaphylaxis is elicited on the detailed questionnaire, standard latex avoidance guidelines are recommended (Figure 3). If the worker presents with a positive or questionable latex allergy, the individual should have further evaluation in an employee health, staff-screening, or primary care clinic. The evaluating physician would then make recommendations about appropriate and reasonable latex-avoidance parameters and would base future clinical decisions on the specific characteristics of the latex allergy.

An allergy consultation is recommended for immediate allergic symptoms, including generalized urticaria, respiratory symptoms, facial or lip swelling, or anaphylaxis. If latex skin testing, RAST, or AlaSTAT EIA confirms the presence of antibody to latex, strict latex avoidance should be advised.

The AlaSTAT EIA is a blood test approved by the U.S. Food and Drug Administration (FDA) for latex-specific IgE detection. The test uses liquid latex allergen rather than the solid-phase RAST allergen system. In one comparative study, AlaSTAT detected 50 of 52 suspected latex-allergic individuals (96 percent), while a RAST had a sensitivity of 46 to 83 percent (34). As with skin testing, however, the value of these tests is limited unless the results are correlated with the clinical history.

The sensitized individual should be counseled about potential inadvertent personal and medical exposures, prophylactic use of anti-allergy medications (e.g., antihistamines), the need to wear a Medic Alert[R] bracelet or tag that clearly states latex allergy, and the necessity for strict latex precautions when the sensitized individual is treated as a patient. Moreover, for health care workers with latex allergy, a medical summary should (after consultation with the employee) be sent to the supervisor, with appropriate suggestions and recommendations for latex avoidance standards in the health care setting. Workers then should be periodically re-evaluated by treating physicians for success of the prescribed interventions.

Avoidance of latex-containing products in highly sensitized individuals can be difficult. Many commonly used medical items contain latex (Table 2). Employees need to be aware that both direct and indirect contact (e.g., inhalation of aerosolized particles) can trigger an allergic reaction. Furthermore, when employees who are allergic to latex become patients, their care providers need to be aware of alternatives available for preventing allergic reactions. With advance planning, suitable latex-free substitutes and safer medical and surgical environments can be created (Table 2).

If the employee has a contact dermatitis reaction, a dermatologist (or allergist) can perform patch-testing for the glove type, the glove powder, and the most common rubber chemical additives, such as thiuram, carba mix, and mercaptomix. A standardized patch test, the TRUE test, is commercially available for this purpose (35,36). Patch-testing with a portion of the glove should not, however, be conducted in patients who have concomitant IgE-mediated symptoms; the test may provoke an immediate allergic reaction. If the patch tests are negative and the patient does not have an IgE-mediated latex allergy, standard care guidelines are recommended. If contact dermatitis is diagnosed, alternative latex or nonlatex gloves can often be purchased to exclude the specific substance causing the problem. This information is available from the manufacturer.

Recommendations for Health Care Workers

General recommendations are as follows:

* Widespread use of powderless latex gloves, in the least antigenic form, is recommended (37). As an alternative product exclusively for nondirect patient care, vinyl gloves may be used. This recommendation is specifically intended for locations such as nursing units, operating rooms, laboratories, and other work areas where closed ventilation systems may increase the number of latex particles in the air.

* Hands should be washed immediately after latex gloves are removed. This procedure should be strictly enforced.

* Personnel should be educated about potential medical, personal, and household sources of latex.

Recommendations for irritant dermatitis are as follows:

* Progressively worsening symptoms and/or development of contact urticaria directly under the latex glove should be reported to the immediate supervisor for further evaluation by the employee health clinic.

* If symptoms after use of latex gloves are limited to dry, cracked, red, irritated hands, the worker should use

1. non-petroleum-based moisturizing creams/lotions,

2. topical barrier products, and

3. cotton glove liners.

For those with diagnosed latex sensitivity, recommendations are as follows:

* Workers with contact dermatitis should

1. use topical barrier products;

2. use cotton glove liners;

3. use non-petroleum-based moisturizing agents; and

4. if symptoms persist or progress, consider further evaluation by an allergist or dermatologist.

* Workers with IgE-mediated hypersensitivity reactions to latex products (localized urticarial lesions or systemic allergic manifestations including anaphylaxis) should

1. use nonlatex, synthetic-polymer gloves and nonlatex medical devices only;

2. especially avoid handling "dipped" rubber products such as balloons, condoms, household rubber gloves, tourniquets, and dental dams, which may contain higher antigenic loads than other, "nondipped" latex products such as paints or adhesives;

3. wash their hands immediately and avoid touching mucous membranes (eyes, mouth, nose) after handling latex-containing products;

4. wear Medic-Alert jewelry clearly stating that the subject is allergic to latex products;

5. carry and know how to use an EpiPen[R], Anakit[R], or similar epinephrine administration device; and

6. inform their immediate supervisors about the severity of allergic reactions to latex products.

Also, for workers with IgE-mediated hypersensitivity reactions, the supervisor, in conjunction with hospital administration, should initiate and enforce appropriate standards for the elimination from the worker's environment of potentially harmful medical products that contain high quantities of latex antigen. Hospital administration also should assist the worker in encouraging co-workers to use nonlatex materials, especially powderless low-allergen gloves; to limit aerosolization of latex antigen; and to ensure that the affected individual has a ready supply of biosynthetic nonlatex gloves. Exclusive use of powder-free gloves in the workplace has been shown to reduce occurrence of symptoms and sensitization (27,33,38).

Education

An educational program on latex avoidance is essential for any health care worker diagnosed with a type IIgE-mediated or Type IV cell-mediated latex allergy. Regardless of severity or past symptoms, highly sensitized individuals are at increased risk for developing anaphylaxis as a result of inadvertent contact with latex. It is not uncommon for these individuals to downplay the seriousness of the condition. Education provides an opportunity to work through this denial and to maximize compliance with latex avoidance guidelines and judicious use of anti-allergy medications. Also, routes of latex exposure should be addressed, including indirect exposures. Latex products used in health care and at home and during leisure activities should be itemized. Alternatives to latex products should be reviewed with a focus on the lifestyle of the sensitized individual (e.g., for a mother, infant toys should be considered). Latex-free alternatives for protection against sexually transmitted diseases should be discussed. The importance of notifying supervisors, family members, and health care providers should be addressed. The allergic individual must be instructed to wear a Medic-Alert[R] tag at all times. When scheduling appointments for health or dental care, patients should remind health care workers about the latex allergy so that appropriate precautions are undertaken. Affected individuals should be aware of signs and symptoms of a potential allergic reaction, along with when and how to use epinephrine and when and how to seek immediate medical attention.

Impairment of Health Care Workers with Latex Allergy

Physicians caring for health care workers with latex allergy should familiarize themselves with the workers' compensation law in the state in which they practice, as well as with the Americans with Disabilities Act of 1990 (ADA) (39-41). Since latex allergy in health care workers is an occupational illness, patients will likely file workers' compensation claims. Hence, their treating physicians will be required by the workers' compensation insurance carrier to provide medical reports substantiating the claim and detailing any necessary treatment and recommendations regarding specific work restrictions. In addition, the physician may be asked to determine an impairment rating (40,42). When communicating with employers, it is important to respect patient confidentiality and share only the information that is necessary for the employer to make a reasonable accommodation. Consultation with colleagues in occupational medicine may be of assistance if the physician is unfamiliar with the intricacies of the workers' compensation system and the ADA.

Conclusion

This article provides a multidisciplinary, hospital-wide approach to dealing effectively with the latex allergy epidemic and its immediate impact on the health and well-being of individual health care workers. It has been well documented that airborne powder from latex gloves is an occupational hazard directly associated with the development of asthma, rhinoconjunctivitis, urticaria-angioedema and anaphylaxis (42). Reports also indicate that continuing chronic latex exposure may lead to permanent respiratory disability even after health care workers are removed from the exposure source (43). Therefore, the ill effects of latex allergy may be long lasting. If current estimates are correct, 10 to 17 percent of health care workers are sensitive to latex and 2.5 percent of health care workers may develop latex-induced asthma (12,30). Thus, the potential liability and workers' compensation issues are enormous. It behooves hospitals to develop effective screening and management strategies. Furthermore, it is essential that physicians and nurses give guidance to hospital administrators to promote the implementation of new latex-free environmental standards.

The authors hope that, eventually, complete latex-avoidance guidelines will be universally implemented and that a safe patient care environment will be properly maintained for all latex-allergic individuals and health care workers.

Acknowledgments

The authors thank Denise L. Floerchinger and Vicki Sears for assisting in the preparation of this manuscript and gratefully acknowledge the members of the University of Iowa Hospitals and Clinics Multidisciplinary Latex Allergy Committee for their contributions.

Corresponding Author: Thomas B. Casale, M.D., Director, Nebraska Medical Research Institute, 401 East Gold Coast Road, Suite 124, Papillion, NE 68046-4796.

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