Latex hypersensitivity is an emerging hazard for patients and healthcare personnel. Since the widespread adoption of universal precautions, use of natural rubber latex gloves has increased dramatically with an associated increase in the reported number of allergic reactions to natural rubber latex (NRL). The most serious hypersensitivity, type I or IgE antibody mediated, may produce urticaria, wheezing, angioedema, or anaphylaxis.
The earliest reports of intraoperative latex hypersensitivity, anaphylaxis, and circulatory collapse occurred in children, many of whom had spina bifida and had multiple exposures to medical devices containing NRL. Similar episodes have occurred in adult patients with anaphylaxis occurring after contact between NRL gloves and mucosal surfaces or intra-abdominal structures. Others have reported allergic reactions to airborne latex antigens.
Anesthesia personnel and other healthcare workers with frequent contact with NRL gloves are at risk for latex sensitivity. The prevalence of IgE mediated allergy to NRL ranges from 3%-70% in published studies of healthcare workers. Operating room personnel are more likely to have latex sensitivity than other hospital workers, probably as a result of greater exposure to NRL gloves. A study of anesthesia staff demonstrated that 16% has a positive skin test to latex extract. Factors linked to latex sensitization in healthcare workers include other allergic conditions or atopy, duration of NRL glove use, and years of employment.
Local reactions to NRL gloves may result from chemicals or additives used during the manufacturing process. Delayed (type IV) hypersensitivity may also result in response to contact with latex or additives in the glove material. Skin irritation or eczematous dermatitis may facilitate passage of latex proteins through the skin, but these conditions have not been linked to latex sensitization. Although some brands of NRL gloves may be labeled as “hypoallergenic,” this only indicates that there are additives in the gloves. “Hypoallergenic” NRL gloves still contain latex allergen and should not contact latex sensitive individuals.
NRL in gloves contains many latex proteins with varying allergenicity. Total protein concentration is not a sensitive measure of the allergic potential of NRL gloves, rather it appears that the amount of specific, as yet unidentified, protein(s) is a better predictor. The amount of extractable latex allergen in NRL gloves varies over 3000-fold among different manufacturers and may even vary by lots from a single producer.
Cornstarch is the most widely used lubricant for gloves. It has been shown that extractable NRL protein allergen adheres to this powder, and therefore powdered gloves have a higher level of extractable protein allergen than powder-free gloves. Additionally, latex allergens carried on powder are easily aerosolized when gloves are donned or removed. These aerosolized latex-powder particles can provoke respiratory symptoms if inhaled by latex-sensitive individuals and may contribute to latex sensitization by providing high levels of latex protein to the respiratory mucosa. Surveys have documented that the highest levels of latex aeroallergens in the hospital can be found in the operating room because of the routine use of powdered NRL gloves.
Chlorination of NRL gloves during the manufacturing process reduces the tackiness of the latex surface, thereby eliminating the need for powder. These powder-free NRL gloves are an alternative to the powdered varieties and should reduce latex reactions by eliminating aeroallergens. Chlorination may adversely affect some of the mechanical and physical properties (tensile strength) of NRL gloves, but the advantages of reducing the extractable protein allergens and eliminating the need for powder appear to outweigh this. Other alternatives to NRL gloves include products made of other materials such as vinyl, but these may have physical properties that are unacceptable for some tasks since they might be more likely to tear with vigorous use.
Since only the symptoms of latex hypersensitivity can be treated and since the immunologic changes can not be reversed, prevention of sensitization by avoidance of latex products remains the primary prevention strategy. Nonlatex gloves and other products should be used for tasks for which they are suitable and for contacting patients with known or suspected latex allergy. When caring for patients without latex allergy and when NRL gloves must be used by personnel, nonpowdered gloves are preferred since the level of aeroallergens will be reduced. Finally, when the first two strategies are not feasible, powdered NRL gloves should be washed to remove the powder or gloves with low levels of latex protein should be utilized. In areas of the hospital where there has been conversion to total use of non-latex gloves, thorough cleaning of all surfaces is advocated to remove latex containing powder from previous use so that additional exposure is abated. Finally, allergic co-workers will be affected by aerosolized latex if some individuals continue to use powdered NRL gloves. Latex free devices should be available and protocols formulated for use with latex sensitive patients.
Because of the significance of this health problem, the National Institute for Occupational Safety and Health (NIOSH) issued an alert in June, 1997 (NIOSH publication No. 97-135) and the Food and Drug Administration (FDA) has considered requests to ban use of powder in NRL gloves. Additionally, the Centers for Disease Control and Prevention (CDC) has proposed guidelines to prevent latex sensitivity in hospital personnel. Information regarding each of these federal actions can be obtained on the respective agency’s website (NIOSH: http:// www.cdc.gov/niosh/homepage.html; FDA: http:// www.fda.gov; CDC: http://www.cdc.gov). Another website that may be consulted is that of the American College of Allergy, Asthma, and Immunology (http://allergy.mcg.edu).
For individuals very concerned about latex allergy, the FDA and 15 other government agencies and professional associations sponsored a live teleconference, “Natural Rubber/Latex Allergy: Recognition, Treatment, and Prevention” in 1998.
Dr. Berry is Professor of Anesthesiology at Emory University School of Medicine, Atlanta, GA, and also Chair of the ASA Committee on Occupational Health of Operating Room Personnel.
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