Latex Allergies and the Compounding Problem of Cross-Reactants.

Introduction

This paper started as a brief to a workers' compensation attorney who had a health care client suffering from a latex allergy. As the brief was developed, it rapidly became apparent that the contents should be shared with colleagues in the environmental health professions. To the extent that readers work with latex, especially the kind of latex protective equipment supplied by least-cost vendors, the following may be of interest. An additional concern arises from the insertion of defense proteins into genetically engineered plants. Creating resistance to pests and pathogens through defense proteins is becoming a standard practice in the nation's food and fiber production industry. Many of these defense proteins will cross-react with allergens and potentiate an immune response.

The use of latex safety equipment has escalated in the last two decades. Although much of this usage at first involved medical gloves, many other products also contain latex. The major impetus for the use of such material derived from the advent of AIDS. With the recognition of hepatitis C as another major issue, there was again a considerable increase not only in the use of medical gloves but also in the demand for condoms. As the usage and availability of medical latex gloves increased, their cost dropped. Latex gloves became ubiquitous. They are now cheaply available by the bagful at paint stores, auto parts outlets, and sundry other venues.

At the same time, latex hypersensitivity--that is, Type I allergy--has increased and continues to do so [1,2]. Latex hypersensitivity constitutes an emergency public health issue. This allergy now affects an estimated 10 percent of health care workers [2]. The figure can easily be extended to include those in the environmental health profession who use these protective devices.

Allergic reactions to natural rubber latex (NRL) are now being reported more frequently in the lay and nonmedical press. These stories cover the general population as well as the patient and health care populations. Indeed a wide number of natural and man-made environmental cross-reactants exacerbate these conditions. For example, "defense proteins," new and soon-to-be-ubiquitous genetically engineered proteins that improve resistance to diseases in agricultural products, are major cross-reacting allergens to NRL. These immunoglobulin (IgE)-bound reactions occur with "prohevein," which is the major allergen in NRL, and with prohevein-like defense proteins in 70 to 88 percent of persons allergic to NRL.

Generally, the symptoms of latex allergy can include the following wide range: hives, contact dermatitis, rhinitis, allergies of the upper respiratory tract, conjunctivitis, local angioedema, asthma, hypotension, and anaphylactic shock--the last ending at times in death.

Within the last two decades, anaphylaxis from latex products has been recognized as a rapidly growing medical crisis. A few examples from the medical literature will help illustrate this point. Tan et al. discuss the perioperative collapse of patients who were sensitized to latex and the cross-reaction with certain anesthetic agents [3]. For the patient needing surgery within the abdominal wall, Marquet et al. discussed the relationship between latex allergy and the formation of adhesions in the gut [4]. Not noted--but it would be a logical jump--are adhesions in general, which may present themselves in other areas of trauma or surgery. One critical area may be adhesions of the spinal chord following injury. Abeck et al., reporting in a German journal, discussed anaphylactic reactions in cases of crossreactivity with food items [5]. For postoperative recovery, one must now consider cross-reactants found in hospital meals. These issues, already important to the patient, may take on medico-legal proportions no t previously appreciated. With the ever-escalating costs associated with medicine and workers' compensation, the issue looms.

Currently the increase in latex hypersensitivity is seen predominantly among health care workers because they are the largest users of latex products. While most forms of Type I allergy caused by other environmental allergens can be treated by pharmacotherapy or specific immunotherapy, this option seems not to be available for NRL. Thus, in the health care industry as well as other businesses that use NRL products, minimizing exposure to latex proteins by provision of other materials has come to be seen as the most cost-effective preventive measure against latex allergy. Some studies, however, seem to raise questions as to whether merely replacing latex with nonallergenic materials is sufficient. Williams et al. have demonstrated that the very small, respirable particulate matter of the powder associated with latex carries the allergen into the air. These particles are of a size that allows them to remain airborne for hours. Thus, they become part of the internal air supply and are broadly distributed and re circulated by large ventilation systems.

For practitioners who work in organizations that depend on the typical "least-cost" contractor for supplies, there is another potential twist to this story. Williams et al. have demonstrated that gram-negative bacterial endotoxins (GNBEs) are a highly significant contaminant of some glove-manufacturing processes [6]. The effects of GNBEs are skin irritation, induced respiratory problems, fever, and shock. The highest levels of endotoxins were found in the typical nonsterile-exam glove, with powdered gloves tending to contain more endotoxins and proteins. These highly respirable GNBE particles were mainly found on the insides of the gloves and were not physically associated with the powder. The particles would be easily released into the air in the "explosive" snap with which the gloves are sometimes pulled off. This is something to think about next time you "shoot" a pair of used gloves across the room at the waste container. The GNBEs may be responsible for the disproportionate enhancement of delayed and im mediate hypersensitivity reactions to the chemicals and proteins found in latex gloves.

Cross-Reactants Noted in the Medical Literature

As was noted above, the numerous allergens present in latex have now been found to cross-react with a broad variety of ubiquitous environmental allergens [7,8]. This situation raises the potential for increasing hypersensitivity not only inside but also outside the work environment. For readers involved in an advisory role as industrial hygienists or as experts to workers' compensation cases, the following will serve as an unexhaustive list of materials that cross-react with and may exacerbate latex hypersensitivity: apples, apricots, auto tire dust, avocados, bacterial endotoxins, bananas, buckwheat, carrots, certain anesthetic agents, cherries, chestnuts, coconuts, crustacea, Ficus benjamina, figs, fish, fresh yellow peppers, grass pollen, house dust-mite allergen, kiwi fruits, loquats, mangoes, melons, mountain cedar, papayas, passion fruit, peaches, pepper, picked peppers, potatoes, shell fish, snails, strawberries, sunflowers, tomatoes, turnips, umbellifrae, and watermelon.

Other Work-Related or Situational Associations with Allergic Reactions to Latex

In the pre-employment process, it will be increasingly important for staff to be sensitive to workplace conditions. The potential pre-existing allergic responses of new workers will present a difficult dilemma. A partial list of those with increased exposure to NRL would include shoe workers; people in glove manufacturing; lab technicians; construction workers, especially those in prefab construction; auto repair workers; hair dressers; prostitutes; couples who use condoms regularly; people who work with latex store dummies; food industry workers; dust-free assembly workers; latex mattress and furniture salespeople; auto tire and recapping workers; and lumber yard workers.

From the lists of cross-reactants and associated occupations given above, one can see that the initial development of hypersensitivity to latex may in the future occur in association not only with employment but also with everyday activities.

For example, tire dust, a ubiquitous air pollutant in any metropolitan center, is an agonist and cross-reactant with NRL allergy. This circumstance raises questions about the potential for continuous exposure and therefore the potential for an increasing problem of escalating hypersensitivity. Would a highly sensitized individual be continuously exposed in an office situation where this form of air pollution was a factor? The answer seems to be yes. Miguel et al. have discussed the ubiquitous tire debris aerosols and latex allergies in the Los Angeles Basin [9]. In addition, their paper discusses the cross-reaction of pollen from the surrounding mountain cedars as an exacerbating factor in areas of heavy urban vehicle traffic. Foam in the padding of autos and household or office furniture may constitute a continuing exposure for the highly sensitized individual. There are data in the literature on mattresses.

The nimble mind can no doubt begin to imagine any number of conditions and living or work situations that would adversely affect the already sensitized individual.

This may raise some profound questions about current workplace methods for controlling situations that affect the expanding NRL-allergic employee population. From the literature on cross-reactants, it appears that once an individual is sensitized, mere provision of "nonallergenic" gloves may be insufficient. Exposure through the behaviors of other workers who are using latex gloves or latex products may be sufficient to continue sensitization. This hazard may be seen in the aerosols of floating particulate material that result from the constant pulling off of gloves. Even when the sensitized individual enters a room or area considerably later, floating respirable matter may be available in quantities sufficient to exacerbate sensitivity.

Sensitized individuals may need to considerably alter their current lifestyles to accommodate the ubiquitous nature of agonist cross-reactants. Eventually, the hypersensitivity could approach the level at which there is considerable risk of anaphylactic shock. At this point, the individual would need to carry self-injecting equipment to ensure continued safety.

REFERENCES

(1.) Chardin, H., F.X. Desvaux, C. Mayer, G. Peltre, and H. Snchal (1999), "Protein and Allergen Analysis of Latex Mattresses," International Archives of Allergy and Immunology, 119(3): 239-246.

(2.) Mahler, V., M. Fartasch, S. Fischer, T. Fuchs, M. Gannadan, D. Kraft, G. Schuler, P. Valent, and R. Valenta (2000), "Prevention of Latex Allergy by Selection of Low-Allergen Gloves," Clinical and Experimental Allergy, 30(4):509-520.

(3.) Tan, B.B., J.S. English, P. Jones, J.T. Lear, and J. Watts (1977), "Perioperative Collapse: Prevalence of Latex Allergy in Patients Sensitive to Anesthetic Agents," Contact Dermatitis, 36(1):47-50.

(4.) Marquet, R., F. Bonthuis, R. Haverlag, H. Jeckel, P. van den Tol, and E. van Rossen, (1998), "Can Exposure to Latex Cause Adhesion Formation?" Allergy, 53(12):1229-1230.

(5.) Abeck, D., M. Boerries, C. Kuwert, J. Ring, V. Steinkraus, and D. Vielut (1994), "Anaphylactic Reactions to Food Items with Latex Allergy," Hautarzt, 45(6):364-367.

(6.) Williams, P.B., and J.F. Halsey (1997), "Endotoxin as a Factor in Adverse Reactions to Latex Gloves," Annals of Allergy Asthma, and Immunology, 79(4):303-310.

(7.) Hanninen, A.R., N. Kalkkinen, J.H. Mikkola, T. Palosuo, T. Reunala, K.T. Turjanmaa, and L. Ylitalo (1999), "Increased Allergen Production in Turnip (Brassica rapa) by Treatments Activating Defense Mechanisms," Journal of Allergy and Clinical Immunology, 104(1):194-201.

(8.) Blanco, C., T. Carillo, R. Castillo, M. Cuevas, and J. Quiralte (1994), "Latex Allergy: Clinical Features and Cross-Reactivity with Fruits," Annals of Allergy, 73(4):309-314.

(9.) Miguel, A.G., G.R. Cass, M.M. Glovsky, and J. Weiss (1996) "Latex Allergens in Tire Dust and Airborne Particles," Environmental Health Perspectives, 104(11):1180-1186.