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Latex Allergy: Creating a Safe Environment.

A child blowing up a balloon develops a red rash around his mouth. A dental technician experiences itching of her hands whenever she wears exam gloves. An operating room nurse has recurrent respiratory problems that seem to improve during vacations or when away from work. Shortly after receiving intravenous medication a child with spina bifida has an anaphylactic reaction. What do all of these patients have in common? It's likely they all have experienced an allergic reaction to latex.

Scope of Latex Allergy

Allergies to latex-containing substances are now recognized as a serious and prevalent problem. Problems with latex products were first reported as an irritant contact dermatitis by Downing in 1933. The first case of a Type I immediate reaction to latex was reported by Nutter (1979). In 1987, Turjianmaa reported hospital staff sensitized to latex gloves. By 1989, a strong correlation was made between idiopathic reactions in the operating room and immediate hypersensitivity to natural, latex protein (Gold et al., 1991). At that time, 450 reactions and 15 deaths secondary to balloons or rubber catheters were registered (Owenby, Tomlanovich, Sammons, & McCullough, 1991).

In 1991, the Food and Drug Administration (FDA) issued a Medical Alert (FDA, 1991), when it had received reports of over 1,000 incidents of allergic sensitization to latex. However, this number vastly underestimates the number of allergic reactions since the reporting mechanism requires identification of the specific latex-containing device to which the worker was exposed. Due to the ubiquitous nature of latex devices it may be impossible for individuals to identify a specific device. Today, the problem is most closely linked to the advent of universal precautions and the dramatic increase in the use of latex gloves since the 1980s. For example, total latex glove use in 1980 was 785 million, but by 1995 it was 9.5 billion (IMS America, 1995).

Latex sensitivity is a serious problem with major implications for health care workers and patients. Those sensitized to latex may need to change to nonlatex gloves or may be so sensitized that they can no longer be present in an environment where latex protein is aerosolized. Approximately 700,000 health care workers are affected. However, the implementation of safe environments has enabled latex-sensitized individuals to receive safe health care and, in some cases, to continue to work in the health care environment. The purpose of this article is to provide information to assist in developing policies and procedures to reduce the risk of latex sensitization and to ensure the desired outcomes for those sensitized to latex.

Mechanism of Latex Allergy

Latex is a milky cytosol containing cis-1,4 polyisoprene, lipids, and constituent proteins secreted from the rubber tree Hevea brasiliensis. Harvested mainly in southern Asia, latex is used in the manufacturing of multiple rubber (polymerized polyisoprene) products. It is secreted by lactifer cells found underneath the tree bark where it protects the tree from water loss and inhibits disease from entering the tree. Latex protein or cross-reacting protein is found in many tropical fruits, for example bananas, avocado, kiwi, apricot, European chestnuts, grapes, papaya, potatoes, passion fruit, pineapple, peaches, cherry, tomatoes and condurango, all of which can cause allergic reactions (Beezhold, Sussman, Liss, & Chang, 1996; Blanco, Carrillo, Castillo, Quiralte, & Cuevas, 1994; Kelly, 1995). There are other foods under investigation. It has not yet been established if the food allergy or latex allergy develops first; however, clinical speculation points to the development of the latex allergy first.

People are sensitized to the water-soluble and possibly membrane-bound proteins in latex through frequent contact or inhalation. Sensitization is manifested as an acute, Type I, IgE-mediated reaction which may be preceded by a delayed Type IV allergic contact dermatitis reaction. Type I is an immediate hypersensitivity to normal rubber latex protein with direct exposure transferred by touch or powder bound to glove powder and airborne. It results in various reactions such as a local wheal and flare response, swelling, generalized urticaria, or, in rare cases, anaphylaxis. Type IV allergic contact dermatitis reactions result from exposure to chemicals used in latex manufacturing. Routes of exposure include direct skin and mucous membrane contact, inhalation, and intravenous injection or ingestion.

Although any individual may develop latex protein allergy, certain groups are at higher risk of sensitization. These include people with frequent exposure and/or people with a tendency toward allergies (see Table 1).

Table 1. People at High Risk for Latex Sensitivity Risk
Category                          Type 1

Patients with neurotube           18%-68%
defects and spina bifida.

Latex industry workers              11%

Patients with chronic instru-     6.5%
mentation exposure (for exam-
ple, gastrointestinal tract
anomalies, multiple surgeries).

Health care workers               10%-17%
(dental 38%)

Category                                Reference

Patients with neurotube           Meeropol, Kelleher, & Bell
defects and spina bifida.         (1990); Yassin et al., (1992)

Latex industry workers            Tarlo, Wong, Roos, & Booth
                                  (1990)

Patients with chronic instru-     Beezhold, Kastyal, & Wiseman
mentation exposure (for exam-     (1994)
pie, gastrointestinal tract
anomalies, multiple surgeries).

Health care workers               Lagier, Vervloet, Lhermet,
(dental 38%)                      Poyen, & Charpin (1993);
                                  Yassin et al. (1994)


Manifestation of a Reaction to Latex

Skin reactions to latex are common. Irritant contact dermatitis is nonallergic dermatitis which is restricted to the area of contact. This is caused by excess wearing of latex gloves and enhanced by skin abrasions, hyperhydration, use of alcohols, soaps, or detergents.

Delayed (Type IV) hypersensitivity (for example, allergic contact eczematous dermatitis) is the most common reaction to latex and can be related to chemicals used as accelerators or antioxidants in the vulcanization of latex products. This type may be diagnosed by patch testing. In a Type IV reaction, the patient is repeatedly exposed to an offending antigen, usually a chemical. Repeated exposure after sensitization causes an allergic contact dermatitis (dry crusty bumps, erythema, pruritus, scaling vesicles, papular lesions at site of contact including the palms). These reactions are usually not life threatening and may be treated by altering the individual's exposure by using nonantigenic alternative products. Health care workers with contact dermatitis secondary to latex gloves rarely develop IgE-mediated anaphylaxis. However, some may progress to latex glove IgE-induced symptoms including urticaria, conjunctivitis, rhinitis, or asthma after developing eczematous contact dermatitis.

Immediate (Type I) hypersensitivity (contact urticaria/systemic reactions) occurs in response to contact with latex protein in the environment. The patient may react within minutes with either local or systemic symptoms. Symptoms include local and/or generalized urticaria, rhinitis, nasal pruritus, conjunctivitis, angioedema, asthma, wheezing, bronchospasm, shock, and/or systemic life-threatening anaphylactic reactions. Aerosolization of latex protein bound to the cornstarch donning powder of latex gloves may also cause respiratory contact symptoms (Beezhold, Kastyal, & Wiseman, 1994).

Diagnosis and Treatment

Early diagnosis of latex allergy is needed to stop the progression of the disease. The diagnosis of latex sensitization is made after a thorough history, blood test for IgE antibodies to latex (RAST or ELISA), skin prick test to the latex antigen conducted by an allergist, patch test conducted by a dermatologist, and/or a glove challenge (Kelly, Kurup, & Zacharisen, 1993). The skin prick test used in Europe and Canada has not been standardized for use in the United States. Self-made serums for skin prick tests have been used, but report random false positives and negatives. If the patient has a strong history and is blood test negative, a latex challenge test is performed by an allergist with emergency equipment available in case of anaphylaxis. Once the diagnosis is made a management plan is instituted.

The primary principle in allergy is to avoid contacting the offending agent by limiting environmental contact with products that contain latex. This becomes difficult in the health care environment when direct contact as well as inhalation contact may induce symptoms. Communication, documentation, and coordination of care are essential to avoid inadvertent contact with latex (see Table 2). A step-wise approach is provided to assist nurses and patients in setting up a protocol to deal with latex allergy (see Table 3). The protocol must address all aspects of patient care (admission, hospital stay, discharge) and employee protection.

Table 2.

Questions to Detect Suspected Latex Sensitization

* Have you ever been diagnosed as being sensitive to latex? Have you ever experienced anaphylaxis when exposed to natural rubber latex?

* Have you ever developed a skin rash or pruritus after contact with latex such as blowing up balloons, wearing latex cleaning gloves or condoms, or when your doctor or dentist has touched you with latex gloves?

* Have you experienced sneezing, coughing, burning, itching, watery eyes, trouble breathing when you are exposed to latex?

* Do you have food allergies especially to chestnuts, kiwi, pitted fruits, potatoes, tomatoes, or peanuts?

* During any surgery did you experience difficulty breathing, Low blood pressure, rash, or other symptoms that may have been related to latex?

* Do you work at a job where you are frequently exposed to latex?

* If occupational exposure, do you have a history of allergies (especially foods known to cross react with latex), asthma, or problems with rhinorrhea, conjunctivitis, and wheezing that increases at work and is relieved when away for the weekend?

Table 3.

Setting Latex Allergy Guidelines

1. Establish a multidisciplinary latex allergy committee to include key departments (medical/surgical/anesthesia/allergy staff, nursing, risk manager, materials management, radiology, lab, emergency, physical therapy, respiratory therapy, admitting, education, administration, pharmacy, central processing, employee health and quality improvement), to form a uniform policy for latex-sensitized patients and personnel.

2. Review the literature for new developments in the last 12 to 24 months (key words: natural rubber latex, latex, rubber, allergens, aeroallergens, anaphylaxis, contact dermatitis).

3. Clarify the latex rubber content of all products used in the facility in writing and on file from manufacturers or distributors. There are over 20,000 medical devices that contain latex.

4. Set up a uniform system to list latex-containing and latex-free alternatives. This list must be updated and disseminated on a scheduled basis.

5. Develop carts with latex-free emergency equipment and adequate substitute devices. The environment should be as latex free as possible.

6. Make recommendations for purchase of powder-free, Low-allergen latex gloves or synthetic gloves to minimize allergen exposure to health care workers and patients.

7. Develop and disseminate educational materials for staff and patients. Educate personnel of the personal risks of latex allergy.

8. Develop standard questions to be asked of all patients/employees aimed at detecting undiagnosed or confirmed latex allergy (see Table 2).

9. Establish a system to review all suspected reactions to natural rubber latex and monitor the effectiveness of the use of latex-avoidance procedures.

Treatment of latex allergy consists of avoiding all contacts with latex and symptomatic management. Continued contact with latex can worsen the sensitization. Medication can be used to mask the symptoms, but continued exposure only serves to further debilitate the patient (American Academy of Asthma, Allergy and Immunology, 1993; Kelly, 1995).

Should the patient be exposed to latex and react, a therapeutic plan may be indicated. When patients experience a reaction, a therapeutic plan guides the treatment of such problems as urticaria, swelling, and respiratory symptoms. This includes administering 0.3 to 0.5 epinephrine HCL (1:1,000 dilution) subcutaneously and repeating every 15 to 30 minutes. Transport the patient to emergency care as warranted and remove irritant or allergen.

Benadryl[R] (25-50 mg PO, TID-QID) can be used to treat pruritus. If a vascular, oozing skin rash develops, apply cold compresses of Burrow's solution 1:20 strength for 20 to 30 minutes, 4 to 6 times per day. After vesiculation has resolved, apply a drying lotion to affected areas as needed. A topical steroid (1% cream) may also be needed.

Patients in a high-risk group who have not exhibited symptoms of latex allergy should avoid exposure to latex products. Patients with a suspected or known diagnosis of latex allergy should be encouraged to see a specialist for evaluation. If the allergy is confirmed patients should follow the guidelines in Table 4.

Table 4.

Suspect or Known Latex-Sensitive Patient Self-Care Practices

1. Wear a medical bracelet alerting others to your risk with latex products.

2. Avoid all contact with latex.

3. Inform employer and medical personnel about your latex allergy.

4. Carry a prefilled, injectable epinephrine.

5. Avoid beta blockers which may potentiate allergic reactions.

6. Carry synthetic gloves and tourniquet.

7. Arrange in advance for latex-safe medical and dental care.

Health Care Workers and Latex Allergy

Health care workers can decrease exposure and transfer of latex protein by using powder-free low allergen latex gloves and by washing hands after each wearing of gloves (see Table 5) (Charous, Hamilton, & Yunginger, 1994; Truscott & Roley, 1995). The term "hypoallergenic glove" is not a standard term and refers to contact chemical sensitization not to latex-protein allergens. This labeling is disallowed by the FDA (1996).

Table 5.

Hospitalized Latex-Sensitive Patient Recommendations

1. Assess all patients for latex sensitivity. Identify latex-allergic patients with an allergy bracelet. Make a clear notation in the medical record of how a diagnosis or suspected diagnosis was made. Patient's hospital room door should be labeled to avoid latex products being inadvertently brought into the room.

2. Ensure that all personnel in contact with the patient are aware of the latex precaution and what must be done. Staff must wash their hands and cover their clothing to keep residual latex from the patient.

3. Gloves used in the patient's room, whether they actually contact the patient or not, should be nonlatex.

4. Pre-packaged kits and trays that contain latex products should not be used.

5. Place three-way stopcocks in intravenous lines for administering medications.

6. Medication should have the stoppers removed so as to not draw up through rubber top.

7. Surgical patients should be scheduled as the first case of the day to reduce exposure to airborne latex from previous surgeries.

8. Notify anesthesia so that proper equipment and pre-surgical prophylaxis (if necessary) can be initiated.

9. Mark the patients OR cart and OR doors for latex allergy.

10. Avoid contact with all latex products during peri-operative care.

a. Remove all latex gloves from the patient's operating suite and immediate holding area.

b. Prepare the extremity that will be used to monitor blood pressure with a cotton barrier to minimize exposure to the latex tubing.

c. Use nonlatex catheter equipment.

11. The scrub nurse should maintain a latex-free environment throughout the procedure.

12. Communication with the post-anesthesia staff prior to the patient's arrival is essential to maintain the latex-free environment.

Health care workers who might be allergic to latex should be promptly evaluated. Until the allergy has been ruled out they must stop personal use of latex in the work and home environment. They need to maintain skin integrity and treat dermatitis at onset. Once their latex allergy is confirmed, health care workers should wear an allergy alert identification, gain a knowledge and understanding of systemic reaction to latex, inform their primary care provider, dentist, and other medical professionals, and carry vinyl or nonlatex gloves and injectable epinephrine (Epi Pen or Ana Kit) with them at all times.

Summary of Recommendations for Latex Testing and Avoidance

* Have a question regarding latex allergies in all histories.

* Offer testing to patients at high risk before all medical or dental procedures.

* Patients with spina bifida should avoid latex from birth.

* Patients with Type I, IgE-mediated reactions should wear a medical alert identification, and carry nonlatex gloves and self-administered epinephrine.

* Health care facilities should identify and have available nonlatex alternatives and latex-safe areas.

* Health care facilities should establish policies and procedures to deal with employees allergic to latex.

* Establish a therapeutic plan for treating a person with latex allergy.

* Lobby the FDA to establish labeling guidelines for latex-containing medical devices.

Following these guidelines while tailoring them to your needs will result in improved quality of care for patients and health care workers sensitized to latex protein. However, complete avoidance of latex protein is likely to be impossible even in the best of situations as adequate substitute materials may not be available. In an ideal world, the proper substitutes for latex would be available, but as of today a totally latex-free environment is impossible. There-fore, the aim is to create a latex-safe environment.

Health care practitioners must work with manufactures to see that adequate substitute equipment is made of equal quality and priced competitively. Home products should be properly labeled and a list of product alternatives is needed.

Preventing complications related to latex sensitivity requires ongoing awareness and vigilance by health care providers. Patient and staff education must be reinforced on a regularly. Continuous monitoring of equipment and supplies is needed to assure that changes in manufacturing techniques have not altered their latex content. Maintaining a latex-safe environment is not easy, but with careful planning it is possible.

To learn more about latex allergy, the following resources are available: The American Nurses Association Guidelines (American Nurses Association [ANA], 1996) The Illinois Nurses Association position paper, bibliography and resource list (Illinois Nurses Association, 1996), and NIOSH Alert with strategies for preventing allergic reactions to latex (National Institute of Occupational Health and Safety, 1997).

References

American Acadamy of Allergy, Asthma and Immunology. (1993). Task force on allergic reaction to latex committee report. Journal of Allergy and Clinical Immunology, 92(1, Pt. 1), 16-18.

American Nurses Association. (1996, June). Latex allergy: Protect yourself, protect your patients (WP-7). Washington, DC. American Nurses Publishing.

Beezhold, D.H., Sussman, G.L., Liss, G.M., & Chang, N.S., (1996). Latex allergy can induce reactions to specific foods. Clinical and Experimental Allergy, 26, 416-422.

Beezhold, D.H., Kastyal, D.A., & Wiseman, J., (1994). The transference of protein allergen from latex gloves: A study of influencing factors. Association of Operating Room Nurses Journal, 59(3),605-613.

Blanco, C., Carrillo, T., Castillo, R., Quiralte, J., & Cuevas, M. (1994). Latex allergy: Clinical features and cross-reactivity with fruits. Annals of Allergy, 73, 309-314.

Charous, B.L, Hamilton, R.G., & Yunginger, J.W., (1994). Occupational latex exposure: Characteristics of contact and systemic reactions in 47 workers. Journal of Allergy and Clinical Immunology, 94(1),12-18.

Downing, J.G., (1933). Dermatitis from rubber gloves. New England Journal of Medicine, 208,196-198.

Food and Drug Administration. (1991). Allergic reaction to latex containing medical devices. Washington, DC: FDA Alert. MDA 91-1.

Food and Drug Administration. (1996). 21 CFR Part 801 R.F. Latex-containing devices: User labeling; Proposed rule. Federal Register, 61(122),32618-32621.

Gold, M., Swartz, J., Braunde, B., Dolovich, J., Shandling, B., & Gilmour, R.F. (1991). Intraoperative-anaphylaxis: An association with latex sensitivity. Journal of Allergy and Clinical Immunology 87(3), 662-666.

Illinois Nurses Association. (1996). Illinois Nurses Association position statement on latex allergy Chicago, IL: INA.

IMS America, Health Care Division (1995). Hospital supply index. Philadelphia, PA. IMS America.

Kelly, K.J. (1995). Management of latex allergic patients. Immunology and Allergy Clinics of North America, 15(1), 139-157.

Kelly, K.J., Kurup, V.P., & Zacharisen, M.C. (1993). Skin and serologic testing in the diagnosis of latex allergy. Journal of Allergy and Clinical Immunology 91, 104-105.

Lagier, F., Vervloet, D., Lhermet, I., Poyen,D., & Charpin, D. (1993). Prevalence of latex allergy in operating room nurses. Journal of Allergy and Clinical Immunology, 90(3 Part 1), 319-322.

Meeropol, E., Kelleher, R., & Bell, S., (1990). Allergic reaction to rubber in patients with myelodysplasia (letter). New England Journal of Medicine, 323, 1072.

National Institute of Occupational Health and Safety. (1997). NIOSH alert: Preventing allergic reactions to natural rubber latex in the workplace. Cincinnati, OH. NIOSH Publications

Nutter, A.F. (1979). Contact urticaria to rubber. British Journal of Dermatology, 101, 597-598.

Owenby, D., Tomlanovich, M., Sammons, N., & McCullough, J. (1991). Anaphylaxis associated with latex allergy during barium enema examination. American Journal of Roentgenology, 156(5), 903-908.

Tarlo, S.M., Wood, L., Roos, J., & Booth, N. (1990). Occupational asthma caused by latex in surgical gloves in manufacturing plants. Journal of Allergy and Clinical Immunology, 85(3), 626-631.

Truscott, W., & Roley, L. (1995). Glove-associated reaction: Addressing an increase concern. Dermatology Nursing, 7(5), 283-292, 303.

Turjianmaa, K. (1987). Incidence of immediate allergy to gloves in hospital personnel. Contact Dermatitis, 17, 270-275.

Yassin, M.S., Lierl, M.B., & Fischer, T.J., O'Brien, K., Cross, J., & Steinmetz, C. (1994). Latex allergy in hospital employees. Annals of Allergy, 72, 245-249.

Yassin, M.S., Sanyurah, S., Lieri, M.B., & Fischer, T.J., Oppenheimer, S., Cross, J., O'Brien, K., Steinmetz, C., & Khoury, J. (1992). Evaluation of latex in patients with meningomyelocele. Annals of Allergy, 69(9), 207-211.

Linda L. Gehring, MS, RN, CS, is Family Nurse Practitioner, Asthma and Allergy, and Lecturer/Doctoral Student, University of Wisconsin-Milwaukee, Milwaukee, WI.

Patti Ring, MS, CPNP, is Pediatric Nurse Practitioner, Spina Bifida Center, Children's Hospital of Wisconsin, Milwaukee, WI.

Acknowledgment: Marion Broome, PhD, RN, FAAN.
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Date:Dec 1, 1999
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