|
·
How
Common Is Latex Allergy? ·
Case
Reports ·
Conclusions ·
Recommendations ·
Additional
Information ·
Acknowledgements ·
References ·
Suggested
Readings ·
Notice
to the Reader |
ALERT
Preventing Allergic Reactions to Natural Rubber Latex in the Workplace
[Click below to view the original U.S.A. federal government document
at http://www.cdc.gov/niosh/latexalt.html] |
WARNING!
Workers exposed to latex gloves and other products containing natural
rubber latex may develop allergic reactions such as skin rashes; hives;
nasal, eye, or sinus symptoms; asthma; and (rarely) shock |
The National Institute
for Occupational Safety and Health (NIOSH) requests assistance in preventing
allergic reactions to natural rubber latex* among workers who use gloves and
other products containing latex. Latex gloves have proved effective in
preventing transmission of many infectious diseases to health care workers. But
for some workers, exposures to latex may result in skin rashes; hives;
flushing; itching; nasal, eye, or sinus symptoms; asthma; and (rarely) shock.
Reports of such allergic reactions to latex have increased in recent years --
especially among health care workers.
At present, scientific
data are incomplete regarding the natural history of latex allergy. Also,
improvements are needed in methods used to measure proteins causing latex
allergy. This Alert presents the existing data and describes six case reports
of workers who developed latex allergy. The document also presents NIOSH
recommendations for minimizing latex-related health problems in workers while
protecting them from infectious materials. These recommendations include
reducing exposures, using appropriate work practices, training and educating
workers, monitoring symptoms, and substituting nonlatex products when
appropriate.
NIOSH requests that
employers, owners, editors of trade journals, safety and health officials, and
labor unions bring the recommendations in this Alert to the attention of all
workers who may be exposed to latex.
.
Composition of Latex
Latex products are manufactured from a milky fluid derived from the
rubber tree, Hevea brasiliensis. Several chemicals are added to this
fluid during the processing and manufacture of commercial latex. Some proteins
in latex can cause a range of mild to severe allergic reactions. Currently
available methods of measurement do not provide easy or consistent
identification of allergy-causing proteins (antigens) and their concentrations.
Until well accepted standardized tests are available, total protein serves as a
useful indicator of the exposure of concern. [ Beezhold et al. 1996a]. The
chemicals added during processing may also cause skin rashes. Several types of
synthetic rubber are also referred to as "latex," but these do not
release the proteins that cause allergic reactions.
Products Containing Latex
A wide variety of products contain latex: medical supplies, personal
protective equipment, and numerous household objects. Most people who encounter
latex products only through their general use in society have no health
problems from the use of these products. Workers who repeatedly use latex
products are the focus of this Alert. The following are examples of products
that may contain latex:
Emergency Equipment
Blood pressure cuffs
Stethoscopes
Disposable gloves
Oral and nasal airways
Endotracheal tubes
Tourniquets
Intravenous tubing
Syringes
Electrode pads
Personal Protective Equipment
Gloves
Surgical masks
Goggles
Respirators
Rubber aprons
Office Supplies
Rubber bands
Erasers
Hospital Supplies
Anesthesia masks
Catheters
Wound drains
Injection ports
Rubber tops of multidose vials
Dental dams
Household Objects
Automobile tires
Motorcycle and bicycle handgrips
Carpeting
Swimming goggles
Racquet handles
Shoe soles
Expandable fabric (waistbands)
Dishwashing gloves
Hot water bottles
Condoms
Diaphragms
Balloons
Pacifiers
Baby bottle nipples
Individuals who already have latex allergy should be aware of
latex-containing products that may trigger an allergic reaction. Some of the
listed products are available in latex-free forms.
Latex in the Workplace
Workers in the health care industry (physicians, nurses, dentists,
technicians, etc.) are at risk for developing latex allergy because they use
latex gloves frequently. Also at risk are workers with less frequent glove use
(hairdressers, housekeepers, food service workers, etc.) and workers in
industries that manufacture latex products.
Three types of reactions can occur in persons using latex products:
Irritant Contact Dermatitis
The most common reaction to latex products is irritant contact
dermatitis -- the development of dry, itchy, irritated areas on the skin,
usually the hands. This reaction is caused by skin irritation from using gloves
and possibly by exposure to other workplace products and chemicals. The
reaction can also result from repeated hand washing and drying, incomplete hand
drying, use of cleaners and sanitizers, and exposure to powders added to the
gloves. Irritant contact dermatitis is not a true allergy.
Chemical Sensitivity Dermatitis
Allergic contact dermatitis (delayed
hypersensitivity) results from exposure to chemicals added to latex during
harvesting, processing, or manufacturing. These chemicals can cause skin
reactions similar to those caused by poison ivy. As with poison ivy, the rash
usually begins 24 to 48 hours after contact and may progress to oozing skin
blisters or spread away from the area of skin touched by the latex.
Latex Allergy
Latex allergy (immediate hypersensitivity) can be a more serious
reaction to latex than irritant contact dermatitis or allergic contact
dermatitis. Certain proteins in latex may cause sensitization (positive blood
or skin test, with or without symptoms). Although the amount of exposure needed
to cause sensitization or symptoms is not known, exposures at even very low
levels can trigger allergic reactions in some sensitized individuals.
Reactions usually begin within minutes of exposure to latex, but they
can occur hours later and can produce various symptoms. Mild reactions to latex
involve skin redness, hives, or itching. More severe reactions may involve
respiratory symptoms such as runny nose, sneezing, itchy eyes, scratchy throat,
and asthma (difficult breathing, coughing spells, and wheezing). Rarely, shock
may occur; but a life-threatening reaction is seldom the first sign of latex
allergy. Such reactions are similar to those seen in some allergic persons
after a bee sting.
Studies of other allergy-causing substances provide evidence that the
higher the overall exposure in a population, the greater the likelihood that
more individuals will become sensitized [Venables and Chan-Yeung 1997]. The
amount of latex exposure needed to produce sensitization or an allergic reaction
is unknown; however, reductions in exposure to latex proteins have been
reported to be associated with decreased sensitization and symptoms [Tarlo et
al. 1994; Hunt et al. 1996].
The proteins responsible for latex allergies have been shown to fasten
to powder that is used on some latex gloves. When powdered gloves are worn,
more latex protein reaches the skin. Also, when gloves are changed, latex
protein/powder particles get into the air, where they can be inhaled and
contact body membranes (see Figure 1) [Heilman et al. 1996]. In contrast, work
areas where only powder-free gloves are used show low levels or undetectable
amounts of the allergy-causing proteins [Tarlo 1994; Swanson et al. 1994].
Wearing latex gloves during episodes of hand dermatitis may increase
skin exposure and the risk of developing latex allergy. The risk of progression
from skin rash to more serious reactions is unknown. However, a skin rash may
be the first sign that a worker has become allergic to latex and that more
serious reactions could occur with continuing exposure [Kelly et al. 1996].
Workers with ongoing latex exposure are at risk for developing latex
allergy. Such workers include health care workers (physicians, nurses, aides,
dentists, dental hygienists, operating room employees, laboratory technicians,
and hospital housekeeping personnel) who frequently use latex gloves and other
latex-containing medical supplies. Workers who use latex gloves less frequently
(law enforcement personnel, ambulance attendants, funeral-home workers, fire
fighters, painters, gardeners, food service workers, and housekeeping
personnel) may also develop latex allergy. Workers in factories where latex
products are manufactured or used can also be affected.
Atopic individuals (persons with a tendency to have multiple allergic
conditions) are at increased risk for developing latex allergy. Latex allergy
is also associated with allergies to certain foods especially avocado, potato,
banana, tomato, chestnuts, kiwi fruit, and papaya. [Blanco et
al. 1994; Beezhold et al. 1996b]. People with spina bifida are also at
increased risk for latex allergy.
Latex allergy should be suspected in anyone who develops certain
symptoms after latex exposure, including nasal, eye, or sinus irritation;
hives; shortness of breath; coughing; wheezing; or unexplained shock. Any
exposed worker who experiences these symptoms should be evaluated by a
physician, since further exposure could result in a serious allergic reaction.
A diagnosis is made by using the results of a medical history, physical
examination, and tests.
Taking a complete medical history is the first step in diagnosing latex
allergy. In addition, blood tests approved by the Food and Drug Administration
(FDA) are available to detect latex antibodies. Other diagnostic tools include
a standardized glove-use test or skin tests that involve scratching or pricking
the skin through a drop of liquid containing latex proteins. A positive
reaction is shown by itching, swelling or redness at the test site. However, no
FDA-approved materials are yet available to use in skin testing for latex
allergy. Skin testing and glove-use tests should be performed only at medical
centers with staff who are experienced and equipped to handle severe reactions.
Testing is also available to diagnose allergic contact dermatitis. In
this FDA-approved test, a special patch containing latex additives is applied
to the skin and checked over several days. A positive reaction is shown by
itching, redness, swelling, or blistering where the patch covered the skin.
Occasionally, tests may fail to confirm a worker who has a true allergy
to latex, or tests may suggest latex allergy in a worker with no clinical
symptoms. Therefore, test results must be evaluated by a knowledgeable
physician.
Once a worker becomes allergic to latex, special precautions are needed
to prevent exposures during work as well as during medical or dental care.
Certain medications may reduce the allergy symptoms, but complete latex
avoidance (though quite difficult) is the most effective approach. Many
facilities maintain latex-safe areas for affected patients and workers.
The prevalence of latex allergy has been studied by several methods:
Reports about the prevalence of latex allergy vary greatly. This
variation is probably due to different levels of exposure and methods for
estimating latex sensitization or allergy. Recent reports in the scientific
literature indicate that from about 1% to 6% of the general population and
about 8% to 12% of regularly exposed health care workers are sensitized to
latex [Kelly et al. 1996; Katelaris et al. 1996; Liss et al. 1997; Ownby et al.
1996; Sussman and Beezhold 1995]. Among sensitized workers, a variable
proportion have symptoms or signs of latex allergy. For example, one study of
exposed hospital workers found that 54% of those sensitized had latex asthma,
with an overall prevalence of latex asthma of 2.5% [Vandenplas et al. 1995].
Prevalence rates up to 11% are reported for non-health care workers exposed to
latex at work [van der Walle and Brunsveld 1995; Nasuruddin et al. 1993; Orfan
et al. 1994; Tarlo et al. 1990].
Several reasons may exist for the large numbers of latex allergies
recently reported in workers [Truscott 1995]:
1. Workers rely increasingly on
latex gloves to prevent the transmission of human immunodeficiency virus (HIV),
hepatitis B virus, and other infectious agents as outlined in Recommendations
for Prevention of HIV Transmission in Health-Care Settings [CDC 1987] and
in Guidelines for Prevention of Transmission of Human Immunodeficiency Virus
and Hepatitis B Virus to Health-Care and Public-Safety Workers [CDC 1989].
2. Since 1992, the Occupational
Safety and Health Administration (OSHA) has required employers to provide
gloves and other protective measures for their employees [29 CFR*1910.1030,
Bloodborne pathogens].
*Code
of Federal Regulations. See CFR in references.
3. Some manufacturers may have
produced more allergenic gloves because of changes in raw materials,
processing, or manufacturing procedures to meet the increased demand for latex
gloves [Hunt et al. 1995]. These production changes may account partly for the
varied concentrations of extractable latex proteins reported for latex gloves
(up to a 3,000-fold difference in gloves from various manufacturers) [Yunginger
et al. 1994; Beezhold 1992]. Variations may also exist between lots produced by
the same manufacturer.
4. Physicians are more familiar with
latex allergy and have improved methods for diagnosing it.
The following case reports briefly describe the experiences of six
workers who developed latex allergy after occupational exposures. These cases
are not representative of all reactions to latex but are examples of the most
serious types of reactions. They illustrate what has occurred in some
individuals.
Case No. 1
A laboratory technician developed asthma symptoms after wearing latex
gloves while performing blood tests. Initially, the symptoms occurred only on
contact with the gloves; but later, symptoms occurred when the technician was
exposed only to latex particles in the air [Seaton et al. 1988].
Case No. 2
A 33-year-old woman sought medical treatment for occupational asthma
after 6 months of periodic cough, shortness of breath, chest tightness, and
occasional wheezing. She had worked for 7 years as an inspector at a medical
supply company, where her job included inflating latex gloves coated with
cornstarch. Her symptoms began within 10 minutes of starting work and worsened
later in the day (90 minutes after leaving work). Symptoms disappeared
completely while she was on a 12-day vacation, but they returned on her first
day back at work [Tarlo et al. 1990].
Case No. 3
A nurse developed hives in 1987, nasal congestion in 1989, and asthma in
1992. Eventually she developed severe respiratory symptoms in the health care
environment even when she had no direct contact with latex. The nurse was
forced to leave her occupation because of these health effects [Bauer et al.
1993].
Case No. 4
A midwife initially suffered hives, nasal congestion, and
conjunctivitis. Within a year, she developed asthma, and 2 years later she went
into shock after a routine gynecological examination during which latex gloves
were used. The midwife also suffered respiratory distress in latex-containing
environments when she had no direct contact with latex products. She was unable
to continue working [Bauer et al. 1993].
Case No. 5
A physician with a history of seasonal allergies, runny nose, and eczema
on his hands suffered severe runny nose, shortness of breath, and collapse
minutes after putting on a pair of latex gloves. He was successfully
resuscitated by a cardiac arrest team [Rosen et al. 1993].
Case No. 6
An intensive care nurse with a history of runny nose, itchy eyes,
asthma, eczema, and contact dermatitis experienced four severe allergic
reactions to latex. The first reaction began with asthma severe enough to
require treatment in an emergency room. The second and third reactions were
similar to the first. The fourth and most severe reaction occurred when she put
on latex gloves at work. She went into severe shock and was successfully
treated in an emergency room [Rosen et al. 1993].
Latex allergy in the workplace can result in potentially serious health
problems for workers, who are often unaware of the risk of latex exposure. Such
health problems can be minimized or prevented by following the recommendations
outlined in this Alert.
The following recommendations for preventing latex allergy in the
workplace are based on current knowledge and a common-sense approach to
minimizing latex-related health problems. Evolving manufacturing technology and
improvements in measurement methods may lead to changes in these
recommendations in the future. For now, adoption of the recommendations
wherever feasible will contribute to the reduction of exposure and risk for the
development of latex allergy.
Employers
Latex allergy can be prevented only if employers adopt policies to
protect workers from undue latex exposures. NIOSH recommends that employers
take the following steps to protect workers from latex exposure and allergy in
the workplace:
1. Provide workers with nonlatex
gloves to use when there is little potential for contact with infectious
materials (for example, in the food service industry).
2. Appropriate barrier protection is
necessary when handling infectious materials [CDC 1987]. If latex gloves are
chosen, provide reduced protein, powder-free gloves to protect workers from
infectious materials.
The goal of this recommendation is
to reduce exposure to allergy-causing proteins (antigens). Until well accepted
standardized test are available, total protein serves as a useful indicator of
the exposure of concern.
3. Ensure that workers use good
housekeeping practices to remove latex-containing dust from the workplace:
4. Provide workers with education
programs and training materials about latex allergy.
5. Periodically screen high-risk
workers for latex allergy symptoms. Detecting symptoms early and removing
symptomatic workers from latex exposure are essential for preventing long-term
health effects.
6. Evaluate current prevention
strategies whenever a worker is diagnosed with latex allergy.
Workers
Workers should take the following steps to protect themselves from latex
exposure and allergy in the workplace:
1. Use nonlatex gloves for
activities that are not likely to involve contact with infectious materials
(food preparation, routine housekeeping, maintenance, etc.).
2.Appropriate barrier protection is
necessary when handling infectious materials [CDC 1987]. If you choose latex
gloves, use powder-free gloves with reduced protein content:
o So-called hypoallergenic latex
gloves do not reduce the risk of latex allergy. However, they may reduce
reactions to chemical additives in the latex (allergic contact dermatitis).
3. Use appropriate work practices to
reduce the chance of reactions to latex:
o After removing latex gloves, wash
hands with a mild soap and dry thoroughly.
o Use good housekeeping practices to
remove latex-containing dust from the workplace:
§
Frequently
change ventilation filters and vacuum bags used in latex-contaminated areas.
4.Take advantage of all latex
allergy education and training provided by your employer:
o Learn to recognize the symptoms of
latex allergy: skin rashes; hives; flushing; itching; nasal, eye, or sinus
symptoms; asthma; and shock.
5. If you develop symptoms of latex
allergy, avoid direct contact with latex gloves and other latex-containing
products until you can see a physician experienced in treating latex allergy.
6. If you have latex allergy, consult
your physician regarding the following precautions:
o Avoid areas where you might inhale
the powder from latex gloves worn by other workers.
o Tell your employer and your health
care providers (physicians, nurses, dentists, etc.) that you have latex
allergy.
o Wear a medical alert bracelet.
7. Carefully follow your physician's
instructions for dealing with allergic reactions to latex.
For additional information about latex allergy, call 1-800-35-NIOSH
(1-800-356-4674); or visit the NIOSH Home Page on the World Wide Web at
http://www.cdc.gov/niosh/homepage.html
You may access the following latex allergy websites directly or by
selecting Latex Allergy through the NIOSH Home Page:
· http://mediswww.cwru.edu/dept/anesth/lair/lair.htm
-- [This
broken link reported to CWRU 22 Dec 97, replaced at Rubber Room mirror with
working link 25 Dec 97]
· http://www.familyvillage.wisc.edu/lib_latx.htm
Principal contributors to this Alert were
R.E. Biagini, S. Deitchman, E.J. Esswein, J. Fedan, J.P. Flesch, P.K.
Hodgins, T.K. Hodous, R.D. Hull, W.R. Jarvis, D.M. Lewis, J.A. Lipscomb, B.D.
Lushniak, M.L. Pearson, E.L. Petsonk, L. Pinkerton, P.D. Siegal, W.G. Wippel,
and K.A. Worthington.
Please direct comments, questions, or requests for additional
information to the following:
Director
Division of Surveillance, Hazard Evaluations, and Field Studies
National Institute for Occupational Safety and Health
4676 Columbia Parkway
Cincinnati, OH 45226-1998
Telephone: (513) 841-4366 or
1-800-35-NIOSH (1-800-356-4674).
We greatly appreciate your assistance in protecting the health of U.S.
workers.
Linda Rosenstock, M.D., M.P.H.
Director, National Institute for Occupational Safety and Health
Centers for Disease Control and Prevention
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and Clin Immunol 98 (6):1097-102.
Beezhold DH, Sussman GL, Liss GM, Chang NS [1996b]. Latex allergy can induce clinical reactions to specific foods. Clin Exp Allergy 26:416-422.
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WARNING!
Workers
exposed to latex gloves and other products containing natural rubber latex
may develop allergic reactions such as skin rashes; hives; nasal, eye, or
sinus symptoms; asthma; and (rarely) shock. |
Workers
with ongoing exposure to natural rubber latex* should take the following steps
to protect themselves:
1. Use nonlatex gloves for activities that are
not likely to involve contact with infectious materials (food preparation,
routine housekeeping, maintenance, etc.).
2. Appropriate barrier protection is necessary
when handling infectious materials**. If you choose latex gloves, use
powder-free gloves with reduced protein content.***
3. When wearing latex gloves, do not use
oil-based hand creams or lotions (which can cause glove deterioration) unless
they have been shown to reduce latex-related problems and maintain glove
barrier protection.
4. Frequently clean work areas contaminated
with latex dust (upholstery, carpets, ventilation ducts, and plenums).
5. Frequently change the ventilation filters
and vacuum bags used in latex-contaminated areas.
6. Learn to recognize the symptoms of latex
allergy: skin rashes; hives; flushing; itching; nasal, eye, or sinus symptoms;
asthma; and shock.
7. If you develop symptoms of latex allergy,
avoid direct contact with latex gloves and products until you can see a
physician experienced in treating latex allergy.
8. If you have latex allergy, consult your
physician regarding the following precautions:
o Avoid areas where you might inhale
the powder from the latex gloves worn by others.
o Tell your employers, physicians,
nurses, and dentists that you have latex allergy.
o Wear a medical alert bracelet.
9. Take advantage of all latex allergy
education and training provided by your employer.
Mention of any company or product does not constitute endorsement by the
National Institute for Occupational Safety and Health.
Copies
of this and other NIOSH documents are available from
Publications Dissemination, EID
National Institute for Occupational Safety and Health
4676 Columbia Parkway
Cincinnati, OH 45226-1998
Fax number: (513) 533-8573
Telephone number: 1-800-35-NIOSH (1-800-356-4674)
E-mail: pubstaft@cdc.gov
To receive other information about occupational safety and health
problems, call 1-800-35-NIOSH (1-800-356-4674), or visit the NIOSH Home Page
on the World Wide Web at http://www.cdc.gov/niosh/homepage.html
In this second printing, the text has been changed slightly to avoid
confusion and promote the safe use of latex gloves. On the tear-out sheet
preceding page 1 (column 1, item 3) and on page 7 (column 2, item
3, bullet 1), the text now reads as follows: When wearing latex
gloves, do not use oil-based hand creams or lotions (which can cause glove
deterioration) unless they have been shown to reduce latex-related problems
and maintain glove barrier protection. This revision makes it clear that currently available oil-based creams
and lotions destroy latex glove barrier integrity. However, future glove or
skin care technology may yield protective creams or lotions that will be
compatible with latex gloves. |
DHHS
(NIOSH) Publication No. 97-135
First
Printing - June 1997
Second
Printing - August 1997
Third
Printing - July 1998