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Latex Allergy. INTRODUCTION. NRL Allergy: it is a complex issue. Complex due to several reasons: Different types of materials are foreign to the human body, can cause somewhat similar allergi c reactions. Sensitization is in itself a complicated area for medical diagnosis.

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introduction
INTRODUCTION

NRL Allergy: it is a complex issue. Complex due to several reasons:

  • Different types of materials are foreign to the human body, can cause somewhat similar allergic reactions.
  • Sensitization is in itself a complicated area for medical diagnosis.
introduction cont d
Introduction - cont’d.
  • Not all NRL products or NR products are processed and manufactured the same way, including the same or similar products.
  • There is confusion on what products are made from natural rubber or synthetic rubber or a combination of both.
  • The term latex, itself, is used for different types of natural and synthetic “dipped” and “liquid” products.
introduction cont d1
Introduction - cont’d.
  • Finally, the problems and confusion between latex sensitization and chemical sensitization exist.
topics for discussion
Topics for Discussion
  • Latex and its production
  • Latex allergy and its ascent
  • Diagnosing latex allergy
  • Challenges & management of latex allergy
what is latex
What is Latex?
  • Processed product from the cytosol of Hevea brasiliensis found in Africa and Southeast Asia.
  • Small rubber particles suspended in “serum”, with 1-2% protein
      • > 200 polypeptides: > 50 allergenic
      • Hev b 1,2, and 6: Major allergenic proteins
  • Not be confused with petroleum-based synthetic rubbers.
  • Chosen as glove material because of its excellent combination of non-porosity and flexibility

Latex exporters

natural rubber 2 forms
Natural Rubber (2 Forms)
  • Latex -- stable aqueous dispersion of polymer particles
  • Coagulum -- bulk-phase elastomeric material
raw latex composition
Raw Latex Composition
  • Polyisoprene 31 - 26%
  • Water 58 - 65%
  • Protein 1.5 - 3.0%
  • Carbohydrates, Lipids,

Inorganics, Other ~ 4.0%

possible nr latex additives
Possible NR Latex Additives
  • For emulsion stabilization: ammonia (collection cups)
  • Primary Preservatives: sodium sulfite or

formaldehyde

  • Secondary Preservatives: e.g., zinc dithiocarbamate, zinc oxide
dry natural rubber processing
Dry Natural Rubber Processing
  • Coagulation: Addition of formic acid
  • Autocoagulation of latex dispersion

(cuplumps)

  • Additional processing, including chopping, grinding, water washing, drying, heat (smoke) - stabilization, and sheeting or baling
residual protein content depends on processing
Residual Protein ContentDepends on Processing
  • Field processing of latex

“liquid or dry”

  • Manufacturing procedures
    • natural rubber latex (NRL)
    • dry rubber
nrl proteins characterization
NRL Proteins Characterization
  • 50 to 100 identified in NRL
  • Molecular weights 10 to 70 kDalton
  • Not all exhibit IgE binding due to epitope differences
extractable protein ep levels
Extractable Protein (EP) Levels
  • NRL - generally higher (concentrated)
  • Dry NR - generally lower

(acidified, macerated, multiple water washing, heat processing)

ep in nrl dipped products
EP in NRL Dipped Products
  • Higher EP levels ~ allergic response in atopic individuals
    • NRL dipped products - range of concentrations
    • Less than 0.020 to 1.680

[mg-EP/g-rubber]

(See handout - Tables 1 & 2: Yip, et al., 1994)

ep in dry nr products
EP in Dry NR Products
  • Very low EP levels ~ weak to no allergic response
    • Dry Rubber - negligible to no EP
    • Less than 0.020 to 0.034

[mg - EP/g-rubber]

(See handout - Table 4: Yip, et al., 1994)

latex allergy to gloves etc
Latex allergy (to gloves etc)

Hospital staff 10% latex allergic, often hand eczema, atopics at increased risk

  • Symptoms:
    • urticaria (75-100%)
    • conjuctivitis (20-45%), rhinitis (15-50%)
    • asthma (3-30%)
    • anaphylaxis (6-8%)
  • Don’t despair!
    • Use non-latex gloves (vinyl, nitril or plastic)
    • Use non-powdered, treated latex gloves
where is latex found
Where is Latex Found?
  • Emergency Equipment
    • BP cuffs, stethoscopes, gloves, ET tubes, electrode pads, tourniquets, IV tubing, syringes, airways
  • PPE
    • Gloves, goggles, masks, rubber aprons
  • Hospital Supplies:
    • Anaesthetic masks, catheters, drains, injection ports, multi-dose-vial tops
  • Office Supplies:
    • Rubbers, rubber-bands, mouse pads
  • Household objects:
    • Car tyres, cycle handles, carpeting, swimming-goggles, racquet handles, shoe soles, expanadable fabric (waistbands), dishwashing gloves, hotwater bottles, condoms, pacifiers, diaphragms, balloons, pacifiers, baby-bottle-nipples
glove reactions 3 types
Glove Reactions: 3 Types
  • Irritant (Not allergic)
    • Erythema, dryness, scaling, vesiculation andcracking
    • Skin irritation due to frequent glove-wearing, incompletehand-drying, workplace chemicals, powder reactions
  • Delayed contact hypersensitivity (Not latex)
    • Develops in 24-48 hrs; lasts days-weeks
    • Eczematous; often identical appearance to irritant reaction
    • Chemical additives such as ammonia, antioxidants and accelerators (eg. thiurams and carbamates) are commonly implicated.
    • Similar mechanism to watch contact allergy
  • True latex allergy

Most adverse reactions to gloves are non-allergic

Any form of dermatitis increases risk of true latex sensitisation

case 1 ms fr 29f
Case 1: Ms FR 29F
  • Background:
    • Dental practice secretary:
      • Also sterilises equipment: frequent glove use
    • Asthma / rhinitis
  • Dental problems began 12/99
    • Dyspnoea and an urticarial eruption locally
    • Responded to Ventolin without need for Adrenaline or steroids.
case 1 ms fr 29f1
Case 1: Ms FR 29F
  • Further questioning:
    • Asthma had been quiescent: No ventolin puffer at home
      • However, 2-3 months needing ventolin 3 x / day 3 x / week at work
    • Also, rhinitis became worse at work, changing from its usual seasonal periodicity
    • Particular association of respiratory problems with glove-wearing (herself or colleagues)
case 1 ms fr 29f2
Case 1: Ms FR 29F
  • Diagnosis:
    • CAP: 0
    • Latex SPT: 5mm
  • Management
    • No latex powder at work
    • Antihistamines
    • Optimise background asthma / rhinitis control
    • Nasal steroids
    • Medi-Alert bracelet
    • No adrenaline given in absence of history of life-threatening reactions
what are the features of latex allergy
What Are the Features of Latex Allergy?
  • Contact urticaria
  • Occupational rhinitis and asthma
  • Angioedema / airway obstruction
  • Anaphylaxis
rising latex allergy
Rising Latex Allergy
  • Adoption of universal precautions since 1987
  • Changes in latex antigenicity due to changes in manufacturing processes forced by rising demands for latex products: Less leaching
    • 3000 x difference in latex antigen levels from different manufacturers
    • ?Poorer processing in Asian factories: allergenic
  • Increased diagnostic suspicion and better diagnostic tools
  • Mirrors the unexplained general increase in all atopic diseases over the last few decades, particularly in developed nations.
rising allergy why
Rising Allergy: Why?
  • Genetic factors:
    • important, but don’t explain rapid rise
  • Atopic disorders: 1/3 (developed)
  • Life-style: “Dust-mite” households
  • Early infections:
    • : RSV
    • : measles, hepatitis A, TB
  • Vaccinations: ?BCG protective
  • Diet and intestinal microflora
  • Anthroposophic lifestyle:
    • 13% vs 25% atopy (OR 0.6)
    • Less antibiotics, fewer vaccines, live lactobacilli
levels and routes of exposure
Levels and Routes of Exposure
  • Powdered gloves greatest culprit for rise in latex allergy
    • Allergenic latex proteins fasten to powder particles
      • Higher surface area of particles allows more efficent protein delivery to skin
        • Particularly relevant in people with dermatitis or prior skin damage, a demonstrated risk factor for developing true latex allergy
      • Also delivers latex protein across mucosae and serosae during operations and procedures such as catheterisation
      • Aerosolisation of powder delivers latex antigens across respiratory membranes, inducing rhinitis and asthma
      • ? Adjuvant effect of cornstarch powder
  • Protein-poor powder-free latex gloves less sensitising than protein-rich powdered gloves*

* Levy DA et al. Powder-free protein-poor NRL latex gloves and latex sensitisation. JAMA 1999;281:988

risks for latex allergy
Risks for Latex Allergy
  • Atopy (in 57%)
  • Recurrent operations / instrumentations
    • Spina bifida patients ++ (prevalence 28%-67%)
    • Others e.g. congenital urinary abnormalities, cerebral palsy, quadriplegia
  • Consider in any patient who develops peri-operative anaphylaxis
  • Latex industry workers
  • Health workers: 10% sensitisation; 1-8% significant reaction
  • Allergies to unusual foods
  • Other people with latex glove exposure:
    • Hairdressers, food-handlers, housekeepers,..
case 2 mr pe 43m
Case 2: Mr PE 43M
  • Community nurse
  • Previously healthy except for hypertension treated with coversyl (perindopril)
  • 4 yrs ago: Contact eczema with latex gloves
  • 2 yrs ago: Allergic rhinitis
  • Non-latex gloves
mr pe 43m
Mr PE 43M
  • 1/97: Urticaria with facial swelling
  • 5/97: Bronchospasm with glove “snapping”
  • 10/97: Casualty after Indian meal
    • Bronchospasm, urticarial rash, hoarseness
    • Rx: phenergan, ventolin
mr pe investigations
Mr PE: Investigations
  • Latex-specific IgE CAP: Positive (2) (SPT not performed)
  • SPT to HDM, grasses: Positive
cross reactions
Cross reactions
  • Latex is derived from a plant - Related to other plants !
diagnosis of latex allergy
Diagnosis of Latex Allergy
  • History +++
  • Demonstrate allergen-specific IgE
    • False negatives for objective tests occur
    • History is final arbiter
  • Finger-use and other challenges less commonly employed
skin prick testing spt vs in vitro allergen specific ige

Do blood testing first

Skin Prick Testing (SPT) vs. In-vitro Allergen-Specific IgE
  • Skin prick testing is most sensitive
    • But increased reaction risk
  • Blood testing (RAST,CAP) less sensitive

Standardised Skin Test Reagents

Now Available

challenges of latex allergy i oh s
Challenges of Latex Allergy (I): OH & S
  • No available synthetic gloves can match the elasticity, durability, resilience, affordability and impermeability of latex
  • Nevertheless, double-gloving with synthetic gloves may offer similar protection against infectious agents, albeit with impaired tactile performance
challenges of latex allergy ii dollars
Challenges of Latex Allergy (II): Dollars
  • Costs arise from:
      • the sensitisation of health care workers
      • treatment of sensitised individuals; and
      • changes required to minimise latex allergy sensitisation and reactions
  • Up to 61%  costs for surgical gloves.
    • Balance against long-term savings from reduced:
      • treatment complications
      • litigation
      • workers compensation
      • glove-powder-related adhesions (morbidity, further surgery)
management of latex allergies staff workplace
Management of Latex Allergies: Staff & Workplace
  • Glove Use:
    • Worker: Synthetic or non-powder latex-poor
    • Colleagues: Non-powdered latex-poor
  • Gradual replacement of latex containing products with non-latex products where available and appropriate
  • Powder:Nonpowder - 1987 65:35 - 1999 50:50
public health preventing latex allergy
Public Health:Preventing Latex Allergy
  • Glove usage*:
    • Where no infectious risk: synthetic gloves
    • Where infectious risk: nonpowdered low-protein latex or double-synthetic gloving
  • Handcare
    •  Risk sensitisation with damaged skin
    • Oil-based creams increase allergen leaching
    • Wash hands after removing gloves

*NIOSH Alert: Preventing allergic reactions to NRL in the workplace. MMWR 1987;36(Suppl 2):1S-18S

public health legislation
Public Health:Legislation
  • 1997: Maximum allowable glove protein
    • ASTM: 200 g/g rubber
    • CEN/TC (Europe): 10 g/g rubber
    • AAAAI Joint Statement:
      • “Only low-allergen and powder-free latex gloves should be purchased & used.”
  • 1998: FDA Packaging
    • All medical devices coming in contact with the body must carry:
    • Little compliance with disclosure of allergen levels
    • Use of “hypoallergenic” term not permitted
      • Misleading, inconsistent

“This product contains Natural Rubber Latex”

ward preparation for latex allergic patients
Ward Preparation for Latex Allergic Patients
  • Synthetic gloves
  • Single room (prepared & latex free)
  • Damp dust surfaces
  • Block air-conditioning ducts
  • Signs for doors (“Latex Safe”) & records
  • Plan all procedures
  • Prepare to treat anaphylaxis
support groups
Support Groups
  • E ducation for
  • L atex
  • A llergy
  • S upport
  • T eam and
  • I nformation
  • C oalition (inc.)
  • www.latex-allergy.org
hospital management of latex allergic patients special considerations
Hospital Management of Latex Allergic Patients: Special Considerations
  • Venepuncture (tourniquets)
  • IV lines without latex ports
  • Medication vials: No latex stoppers
  • Synthetic gloves for internal examinations
  • Non-latex catheters, syringes, dressings, tapes
  • Oximeter probes
  • Sphygmomanometers: cotton-cloth cover
  • ECG dots
  • Stethoscopes
  • Kitchen staff: synthetic gloves; food allergies
public health preventing latex allergy ii
Public Health:Preventing Latex Allergy (II)
  • Interdepartmental latex committees:
    • Nursing, allergy, staff health, surgery, anaesthetics, OT, purchasing, labs, housekeeping, kitchens,…
  • Attend workplace education / training
  • Keep latex-free product registers
  • Encourage industry to label latex products
  • Pre-placement and routine staff screens
what is anaphylaxis
What is Anaphylaxis?
  • Severe systemic allergic reaction
  • Involves one or both of:
    • Respiratory difficulty (URT, asthma)
    • Hypotension
  • Other allergic features often occur in association
  • Usually immediate ( < 1/2 hour)
    • Rarely delayed (up to 6 hours)
    • Sometimes (~5%) biphasic (1h - 72 h)
anaphylaxis management
Anaphylaxis: Management

ACUTE

INTERVAL

  • Find the cause
  • Advise on prevention
    • Entire production line
  • Medic-Alert
  • Adrenaline (Epi-pen)
  • First-Aid education
  • Avoid -blockers
  • ?Immunotherapy
  • Airway
  • Adrenaline 1:1000 IM *
    • Only Hypotension / Bronchospasm
    • 0.5mL (500µg)
  • OR Adrenaline 1:10000 1 mL (100µg) slow IVI
    • profound shock
    • anaesthesia
  • Oxygen, ß2-agonists
  • IV fluids (N/S, haemaccel)
  • IV steroids, antihistamines
  • (Remove allergen)

* Project Team of the Resuscitation Council (UK). The emergency medical treatment of anaphylactic reactions. J Accid Emerg Med 1999;16:243-247

• Repeat adrenaline in 5 minutes if deteriorating

• 10% of out-of-hospital anaphylaxes require repeat adrenaline shot

management of latex allergies staff workplace i
Management of Latex Allergies: Staff & Workplace (I)
  • Same general principles as for patients
  • Safe Workplace
    • Education and Training
    • Work environment modification
      • Consider:
        • all work areas that a worker needs to go to;
        • patient movements
        • other worker contacts; and
        • common air conditioning areas.
      • Housekeeping should be meticulously carried out to remove all traces of latex allergens.
      • May require occupational rehabilitation (Rarely)
sensitisation mechanisms
Sensitisation: Mechanisms
  • Preclinical sensitisation may occur in early life
    • First exposures in infancy:
      • Bottle nipples, pacifiers, balloons,…
  • Quantity of latex and site / duration of contact important
latex questionnaire
Latex Questionnaire
  • Have you ever reacted to latex-containing products?
  • Risks:
    • Atopy
    •  3 major surgery episodes
    • Spina bifida
    • Unusual food allergies
    • HCW / At-risk occupation
    • Perioperative anaphylaxis

Score > cutoff: Measure IgE to latex ; if POSITIVE, or persistent suspicion of latex allergy, refer for specialist review

hospital management of latex allergic patients
Hospital Management of Latex Allergic Patients
  • Latex-safe environment
    • No powdered gloves: preferably, synthetic gloves only
    • Prepare OT and wards: no latex products
  • Identify allergic patients:
    • Questionnaires
    • Investigate people with unexplained anaphylaxis / unusual food allergies
  • Special labels for rooms and records
  • Admission to discharge planning
  • Plan all procedures
  • Pharmacological prophylaxis should be considered
  • Be prepared to treat anaphylaxis

Neonates with congenital abnormalities: Educate parents on  latex

summary
Summary
  • Latex allergy is a major problem
    • Latex is ubiquitous & difficult to fully avoid
  • Most adverse glove reactions are non-allergic
    • But irritant dermatitis can risk of latex sensitisation
  • Latex allergy affects up to 8% of health workers
  • Risk factors include recurrent operations, atopy & unusual food allergies
  • We must use synthetic alternatives or low-allergen powder-free latex gloves