Natural Rubber Latex Allergy

8/10/2019 Natural Rubber Latex Allergy

1/35


2/35


3/35

NATURAL RUBBER LATEX ALLERGY:CONSIDERATIONS FOR ANESTHESIOLOGISTS

This document has been developed by the Task Force on Latex Sensitivity of the ASACommittee on Occupational Health of Operating Room Personnel but has not beenreviewed or approved as a practice parameter or policy statement by the ASA House of

Delegates. Variances from recommendations contained in this document may beacceptable based on the judgment of the responsible anesthesiologist. The recommen-dations are designed to encourage quality care and safety for patients and health care workers in the workplace but cannot guarantee a specific outcome. They are subject torevision from time to time as warranted by the evolution of technology and practice.

Copyright 2005 by the American Society of Anesthesiologists. All rights reserved.

Natural Rubber Latex Allergy: Considerations for Anesthesiologists


4/35

Natural Rubber Latex Allergy: Considerations for Anesthesiologists

TABLE OF CONTENTS

Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Identification of High-Risk Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Routes of Exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Signs and Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Operating Room Management of the Patient With Latex Allergy . . . . . . . . . . . . . 2 Treatment of Latex Allergy Reactions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Chemistry of Latex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Glove Technology and Manufacturing Standards . . . . . . . . . . . . . . . . . . . . . . . . . . 5Clinical Manifestations of Latex Allergy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Routes of Exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Populations at Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Prevention of Reactions in Previously Sensitized Individuals . . . . . . . . . . . . . . . . 12Management of Latex-Sensitive Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Treatment of an Allergic Reaction to Latex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Management of the Health Care Worker With Latex Allergy . . . . . . . . . . . . . . . 18Management of Health Care Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Future Directions and Implications for Anesthesiologists . . . . . . . . . . . . . . . . . . 19Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

TABLES Table 1: Types of Reactions to Latex Gloves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Table 2: Diagnosis of Latex Allergy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Table 3: Screening Questionnaire for Latex Sensitivity . . . . . . . . . . . . . . . . . . . . 13 Table 4: Checklist for Management of Latex-Allergic Patients . . . . . . . . . . . . . . 15 Table 5: Treatment of Latex-Induced Hypersensitivity Reactions . . . . . . . . . . . . 17

APPENDIXES Appendix A: Contents of a Latex-Safe Cart . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Appendix B: Legislative, Regulatory, Legal and Informational . . . . . . . . . . . . . . 21

REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24


5/35

LATEX ALLERGY FOR THE ANESTHESIOLOGIST: A SUMMAR

BACKGROUND

Allergy to natural rubber latex (NRL, or latex), which contains a complex blend of water-soluble plant proteins, has become a major source of concern in clinical prac-tice. The Food and Drug Administration (FDA) has received incident reports of thou-sands of allergic reactions involving latex-containing medical products, includinganaphylaxis, cardiac arrests and deaths. Latex is the inciting factor in at least 10 percentof the anaphylactic reactions reported under anesthesia. Anesthesiologists, nurse anes-thetists, operating room and critical care nurses and surgeons are at high risk of devel-oping hypersensitivity to latex as a result of occupational exposure.

Identification of High-Risk Groups

1. Patients with a history of multiple surgical procedures, including those withmyelomeningocoele (spina bifida) and congenital genitourinary tract anomalies.Patients with spina bifida have a 30-70 percent incidence of latex allergy.

2. Health care personnel with occupational exposure. Latex allergy is a major occupa-tional health problem among health care personnel since the prevalence of latex sen-

sitivity may be as high as 17 percent. Approximately 70 percent of adverse eventsto latex reported by the FDA involve health care workers.3. Other individuals with occupational exposure to natural rubber latex , including

hairdressers, greenhouse workers and those in latex product manufacturing.4. Individuals with a history ofatopy, hay fever, rhinitis, asthma or eczema .5. Individuals with ahistory of food allergy to tropical fruits (such as avocado, kiwi,

banana), chestnuts, stone fruits and additional specific foods.

Routes of ExposureSensitization to latex can occur as a result of contact via skin or mucous membranes

or by inhalation, ingestion, and parenteral injection or wound inoculation. Latex glovesare the source of exposure and sensitization among most medical personnel. Gloves vary considerably in their latex content and ability to produce allergy. Powder in gloves, which is used to facilitate donning, enhances the potential for sensitization by transcu-taneous or inhalation exposure.

Signs and Symptoms

Three types of reactions can occur in individuals. The first two are generalized reac-tions and are not life-threatening:

1. Irritant contact dermatitis, usually due to drying and cracking of the skin.2. Type IV (contact) hypersensitivity also know as delayed type hypersensitivity.

Natural Rubber Latex Allergy: Considerations for Anesthesiologists 1


6/35

Usually occurs over a 24-hour period, is cell mediated and is limited to the site of con-tact (for example, skin reactions similar to poison ivy).

3. Type I (IgE-mediated) hypersensitivity also known as immediate type hyper-sensitivity. This is a true allergic reaction and can have localized or systemic symptomsthat can include:

a. Hives, erythema, urticaria which may be localized or generalized.b. Upper respiratory symptoms, including stuffy or runny nose, cough, asthma.c. Red, itchy eyes, angioedema of eyelids.d. GI symptoms, including diarrhea, nausea, vomiting, cramping.e. Headache, anxiety, shortness of breath, itching.g. Anaphylaxis, tachycardia, hypotension, cardiovascular collapse.

Operating Room Management of the Patient With Latex Allergy

1. Identify each patient who is at risk. A careful history frequently will elicit episodesof previous allergic reactions or risk factors.

2. Patients who have a suggestive history and confirmatory laboratory findings must bemanaged with complete latex avoidance.

3. When possible, the patient should be scheduled for elective surgery as the first caseof the day. Airborne latex-laden particles are presumed to be at their minimum lev-els at that time.

4. Signs displaying Latex Allergy should be posted on all O.R. doors. No one shouldenter the O.R. with latex gloves, without scrubbing after taking off latex gloves or while wearing latex-laden clothing from previous latex exposure.

5. Preview all equipment to be used, looking for possible latex-containing products.6. A latex-free cart should accompany the patient throughout his/her hospital stay.

Treatment of a Latex Allergic Reaction

1. Contact dermatitis and Type IV reactions:a. Avoid irritating skin cleansers.b. Topical corticosteroids can be applied locally for rashes or hives.

2. Type I latex reactions:a. Mild reactions respond well to antihistamines, and topical nasal steroids may be

useful.b. Hives are treated with antihistamines and systemic steroids.c. A reaction with airway involvement may require the use of systemic steroids,

bronchodilators, endotracheal intubation and epinephrine.d. In the case of anaphylaxis, a formal anaphylaxis protocol is advisable.

3. Latex-free precautions must accompany the patient throughout the perioperativeperiod (PACU, ICU and discharge unit).

4. The details of any allergic reaction should be clearly documented on the patientschart. Report any latex-induced reactions to the FDA MedWatch program (1-800-FDA-1088).

2 American Society of Anesthesiologist


7/35

INTRODUCTION

Natural rubber latex (NRL, natural rubber, or latex) is a processed plant productthat is manufactured using the milky cytosol harvested from the rubber tree,Hevea braziliensis (Weeping Wood Tree). During latex processing, several chemi-cals are added to achieve the desired characteristics that have made it a ubiquitouscomponent of many medically related products. These characteristics includeexcellent barrier qualities, deformability, elasticity, tactile sensitivity and high ten-sile strength.

The first description of allergic reactions resulting from rubber gloves appeared inthe American literature in 1933.1 Sporadic accounts of delayed contact dermatitisappeared in subsequent years. A sharp increase in the number of reports of latex-induced allergic reactions began to appear in the late 1980s. This increase occurred

shortly after the promulgation of Universal Precautions by the Centers for DiseaseControl,2 during which time the annual use of surgical gloves increased from 800 mil-lion to more than 20 billion.3

As the exposure to latex products continued to increase, so did the incidence andseverity of reported allergic reactions. Slater documented anaphylaxis and the firstdeaths resulting from exposure to latex in 1989.4 Reports of intraoperative ana-phylaxis from latex exposure quickly followed.5,6 Ownby et al. in 1991 described aseries of patient deaths resulting from exposure to latex cuffs on barium enema

catheters.7

In 1989, 0.5-percent of reported cases of intraoperative anaphylacticshock were the result of latex allergy. Two years later, that number had increased to12.5 percent,8 in 1999, 16.6 percent9 and remained consistent at 16.7 percent in2003.10 Latex anaphylaxis may actually be decreasing currently because of theattentiveness shown in the past decade to early identification and avoidance meas-ures as well as prompt treatment.11 It is currently estimated that as many as 17 per-cent of health care workers (1 million individuals)12 and 73 percent of frequently exposed patients, such as those with spina bifida, have been sensitized* to the latexallergen.13 Recent data indicate a prevalence of latex sensitivity among anesthesiol-ogists of 12.5 percent14 to 15.8 percent.15

Latex is ubiquitous in medical equipment and devices. Patients and health careproviders are at risk for developing sensitization to latex and possibly serious allergicreactions following exposure to any of these products. The purpose of this booklet isto identify the risk factors among anesthesiologists and their patients for such aller-gic reactions and to recommend strategies for avoidance as well as treatment shouldallergic reactions develop.


*Sensitization is the process of developing an immunologic reaction to an antigen. In the case of latex sen-sitivity, this involves development of an IgE antibody to proteins found in latex. Patients are frequently asymptomatic until a threshold of exposure triggers anallergic reaction.

Allergy is an acquired, abnormal immune response to a substance (an antigen) that does not normally causea reaction.


8/35


Chemistry of Latex

Natural rubber** (cis-1,4-polyisoprene) is synthesized by specialized lactifer cellsof the tree Hevea braziliensis , indigenous to Brazil but commercially cultivated in West Africa and Southeast Asia. Other rubber-producing species include the North American desert shrub guayule (Parthenium argentatum) and the common ornamen-tal rubber plant (Ficus elasticus ).

Natural rubber latex consists of a complex mixture of polyisoprene, lipids, phos-pholipids and proteins. The total amount of protein present in natural rubber latex isrelatively constant at 1.6 percent-2.0 percent by weight. The amount of extractableprotein in the final manufactured latex product, however, can vary widely. The totalprotein concentration of glove extracts has been found to range from 3 to 337 micro-grams/gram.16 A number of chemicals, including preservatives (ammonia or sodium

sulfate), accelerators (thiurams, thiocarbamates, mercapto compounds, thioureas),antioxidants (phenylenediamine) and vulcanizing compounds (sulfur) are added dur-ing the manufacturing process to yield the final product. These additional chemicalsaccount for as much as 5 percent of the final weight of a manufactured glove.

The protein content of latex is responsible for the majority of generalized allergicreactions to latex. The proteins are found in three distinct formulations: water-sol-uble, starch-bound or latex-bound. There are at least 240 potentially allergenic pro-teins in the processed latex product. Eleven sensitizing proteins have been identified

or cloned so far and have been assigned allergen designations of Hev b1-b11 by theInternational Union of Immunological Societies. The protein content of latex gloves can vary up to 1,000-fold among different lots

marketed by the same manufacturer and 3,000-fold between gloves from differentmanufacturers.17 In general, the protein content and allergen levels are highest inpowdered examination gloves and lowest in powderless gloves, which undergo addi-tional washing and chlorination. These processes result in protein denaturation anddecrease the total protein content.

Three laboratory assays are currently available to determine the quantity of pro-tein in a specimen. The Lowry test, a chemical method based on the binding of chromogenic dye to protein residues, is the least sensitive of the three methods butis currently the national standard (American Society for Testing and Materials, ASTM D5712). There are also two immunochemical tests: the Latex EnzymeLinked Immunosorbent Assay for Antigenic Protein (LEAP), which uses rabbitIgG, and the Radioallergosorbent Test (RAST), which is a human IgE inhibitionassay. The ASTM is currently considering a new standard for glove protein levelsbased on the Enzyme-Linked Immunosorbent Assay (ELISA), which can detectprotein levels


9/35

removal of surgical gloves. A typical pair of surgical gloves carries as much as 700 mgof cornstarch powder.18 Cornstarch particles readily adsorb latex allergens and increaseallergenicity of the gloves.19 Additionally, cornstarch carrying the latex allergen is easi-ly aerosolized and has been associated with respiratory allergic symptoms.20

Glove Technology and Manufacturing Standards

The Code of Federal Regulations currently categorizes medical gloves as Class Imedical devices, despite an ongoing effort to reconsider their classification as Class IIdevices.* Absorbable dusting powder for lubricating gloves is a Class III medical device.Since September 30, 1998, specific warning signage has been required on latex-con-taining products, such as Caution: This product contains natural rubber latex whichmay cause allergic reactions.

A number of alternative glove materials are available, including synthetic rubber, vinyl, nitrile, tactylon, neoprene, elastyren and polyurethane. Each of these materialshas specific qualities that permit (or prevent) their use in various clinical situations.Historically, glove manufacturers have most frequently utilized latex because it is themost economical alternative possessing the desired physical properties.

Several characteristics of medical gloves are of importance when considering utility and safety, includingbarrier effectiveness, protein levels, powder content and endotoxin levels.

Barrier effectiveness is the ability of a material to withstand vigorous physical, bac-

terial or viral testing. The Food and Drug Administration (FDA) and the AmericanSociety for Testing and Materials (ASTM) have established standards for surgicalgloves. These standards address such performance issues as barrier protection confi-dence (number of tears, holes or other defects), resistance to penetration from blood-borne pathogens and various strength requirements. The current acceptable quality level (AQL) using ASTM Standard D 3577-88 (Standard Specification for RubberSurgical Gloves) is 2.5 meaning that 2.5 gloves per 100 are allowed to have barrierdefects. The allowable failure rate for non-sterile examination gloves is 4 percent.

Although the FDA now requires identification of the latex content of medicalequipment, and some glove manufacturers label the protein levels of their gloves, thereis no requirement to quantify the allergen level. While a correlation exists between totalprotein and allergen content, the concepts are not identical. The amount and type of protein as well as the manufacturing process determine the allergenicity or antigenicity of the latex product. Ammonia, which is usually added to the fresh latex as an antico-agulant during the harvesting process, decreases extractable protein levels. However,gloves are typically produced by a process of dipping,which is associated with the great-


*Class I means the devices are subject to only general controls sufficient to provide reasonable assurance of the safety and effectiveness of the device, but the device is not life-supporting or life-sustaining and doesnot present a potential unreasonable risk of illness or injury.Class II means general controls alone areinsufficient to provide reasonable assurance of safety and effectiveness and there is sufficient information toestablishspecial controls , including the promulgation of performance standards, postmarket surveillance,patient registries, development and dissemination of guidance documents.Class III means the class of devices for which premarket approval is or will be required.


10/35

est antigenicity among latex products. Conversely, chlorination, which is used duringthe processing of powder-free gloves, renders surface proteins insoluble and less sus-ceptible to migration onto the wearers skin. As a result of these and other inconsis-tencies in the manufacturing process, allergen levels vary significantly in gloves fromdifferent manufacturers and even from lot to lot produced by the same manufacturer. Amisleading claim of hypoallergenic has been a source of confusion for many healthcare workers. The label hypoallergenic specifically refers to potential sensitization to various processing chemicals that can cause contact dermatitis, and not to latex proteincontent. Gloves labeled as hypoallergenic carry as much as 192 micrograms allergen/grubber.21 As of Sept. 30, 1998, the FDA required removal of the hypoallergenic claimfrom any product that contains latex.

The term glove powder content encompasses several particulate components,including dusting or donning powder, mold-release compounds and manufacturing debris.

Dusting or donning powder must meet specifications of the United States Pharmacopoeia(USP) to be acceptable for use as a lubricant for medical gloves. Cornstarch is current-ly the lubricant most commonly used for medical gloves, but calcium carbonate, oatpowder, talc and lycopodium have all been used. The amount of particulate matter ona medium-size powdered glove is 120-400 mg. In order for a manufacturer to make theclaim that their gloves are powder free or powderless, they must either meet theFDA limit of


11/35

(Based on Hazard Information Bulletin, OSHA. 1998.)


Table 1:Types of Reactions to Latex Gloves

REACTION SIGNS/SYMPTOMS CAUSE MANAGEMENT

Irritant Scaling, drying, Direct skin Identify reaction,Dermatitis cracking of skin irritation by gloves, avoid irritant,

powder, soaps possible use ofglove liner, use ofalternative product

Type IV -Delayed Itching, blistering, Chemical additives Identify offendingHypersensitivity crusting (delayed 6- used in manufac- chemical, possible

72 hours) turing (such as use of alternativeaccelerators) product without

chemical additive,possible use ofglove liner

Type I Immediate Proteins found Identify reaction.Hypersensitivity in latex

Avoid latex-con-taining products.

Use of nonlatexor powder-free, low-protein gloves byco-workers

A. Localized Itching, hives in areacontact of contact with latex Anaphylaxis protocolurticaria (immediate)

B.Generalized Runny nose, swollenreaction eyes, generalized rash

or hives, bronchospasm,anaphylaxis


12/35

1. Irritant dermatitis. Irritant dermatitis is the most frequently observed reactionto latex products, accounting for 80 percent of work-related reactions to latex gloves.27

This type of reaction results from the drying action of the corn starch and/or other irri-tant chemicals found in gloves and can be exacerbated by the soaps and mechanical irri-tation required for surgical scrubbing. Irritant dermatitis is not mediated by theimmune system and is not a true allergy. However, the resulting deterioration in skinintegrity possibly enhances absorption of latex protein allergens and is believed to accel-erate the onset of allergic reactions.

2. Type IV delayed hypersensitivity. Type IV delayed hypersensitivity, also called T-cell mediated contact dermatitis, allergic contact dermatitis, and delayed hypersensi-tivity, directly involves the immune system, in contrast to irritant dermatitis. Amongthe immunologic responses to latex, 84 percent are Type IV.28 This type of reaction isusually a response to the chemical additives used during the manufacturing process,

specifically the accelerators, rather than to the latex proteins themselves. The resultingskin reactions are similar to those caused by poison ivy. Like poison ivy, the skin rashusually appears six to 72 hours after initial contact and may progress from a mild der-matitis to oozing skin blisters. It is important to recognize that not all patients with Type IV reactions progress to Type I reactions. However, 79 percent of Type I patientspreviously had Type IV symptoms.29

3. Type I immediate hypersensitivity. Type I immediate hypersensitivity, alsocalled IgE mediated anaphylactic reaction or anaphylactic reaction, results when an

antigen induces the production of an antibody of the immunoglobulin E class. Re-exposure to the inciting antigen triggers a cascade of events, including the release of his-tamine, arachidonic acid, leukotrienes and prostaglandins.

Reactions usually begin within minutes of exposure. Symptoms can run the entirespectrum from mild (skin redness, hives, itching), to more severe (cough, hoarse voice,chest tightness, runny nose, itchy or swollen eyes), to life-threatening (bronchospasmand shock). Type I reactions from latex exposure have been reported in patients andhealth care workers and in a variety of clinical settings, including: vaginal deliveries,30

gynecological examinations,31 dental procedures,32 intra-abdominal33 and genitourinary 5

surgery and during the act of donning gloves.34

Routes of Exposure

Latex exposure can occur as a result of contact with the skin or mucous membranesor by inhalation, ingestion and parenteral injection or wound inoculation. Amonghealth care workers, the most frequent route of exposure to latex allergens is by cuta-neous contact and/or inhalation, and the most common source is medical gloves. In thecase of cutaneous exposure, the sensitizing antigens of latex penetrate the skin afterbeing solubilized by sweat. A history of eczema or contact dermatitis is associated witha higher incidence of allergy as a result of the disruption of skin integrity. The poten-tial for harmful exposure is further enhanced by the use of powdered gloves, which pro-mote access of the allergen to the circulation.



13/35


The cornstarch powder frequently found on the inner surface of the gloves actively binds allergen. This complex is readily aerosolized with frequent glove changes. Within hospitals, the concentration of latex aeroallergens is often highest in operatingrooms, where powdered latex gloves are frequently donned and removed.34 Theaerosolized powder/allergen complex can become as dense as 1000 ng/m3 air andremain suspended in the air for up to five hours.24

The aerosolized latex allergen is readily inhaled and has been associated with con- junctivitis, rhinitis, cough, hoarse voice, chest tightness and bronchospasm. Baur et al.have demonstrated a direct relationship between the development of allergy-relatedsymptoms in hospital workers and latex allergen concentrations in their work area.35

Airborne allergens have also been shown to affect individuals who are in the immedi-ate vicinity but not themselves using latex products.36 Replacing high-allergen gloves with powderless low-allergen gloves can reduce ambient allergen levels 10-fold.34

Patients with Type I latex allergy can also develop anaphylactic reactions as a resultof exposure to certain foods, including some tropical fruits (see below). In one report,17 percent of latex allergic patients also had anaphylactic reactions to some of thesefoods.37

Populations at Risk

The reported prevalence of latex allergy varies greatly depending upon the popula-

tion studied and the methods used to detect sensitization. As is the case with all aller-gy-causing substances, the greater the exposure in a population, the greater the numberof sensitized individuals. This was well demonstrated by Tarlo et al. in a study of den-tal students.38 The incidence of positive skin tests to latex increased as a function of theduration of training: 0 percent of year one and two students, 6 percent of year three,and 10 percent of year four students.

There are several populations at increased risk.1. Patients with a history of multiple surgical procedures. This group includes

patients with congenital genitourinary tract anomalies and those with spina bifida. Inone study of spina bifida patients, 60 percent were reported to have Type I latex allergy as determined by history, RAST and/or skin prick test, although not all had demon-strated allergic symptoms.39 The two main risk factors for the clinical expression of latexhypersensitivity in this population are frequency of exposure and a prior history of atopy.40 There is accumulating evidence for a genetic predilection to latex sensitivity inchildren with spina bifida.41,42

2. Health care personnel. Depending upon the methodology of diagnosis, theprevalence of latex sensitivity among health care personnel has been reported from 2.9percent43 to 17 percent.12 More recent studies of health care personnel usually havereported a higher prevalence of latex sensitivity than older ones. Approximately 70 per-cent of adverse events to latex reported in the FDAs MedWatch database involve healthcare workers, and in most cases the medical personnel were patients themselves.44 The American College of Allergy, Asthma and Immunology (ACAAI) has identified latexallergy as a major occupational health problem.45 Among health care workers, a his-


14/35


tory of atopy, eczema or hand dermatitis and frequent use of disposable gloves are asso-ciated with a greater risk for developing latex allergy.46,47

Current data indicate a prevalence of latex sensitization of 12.5 percent to 15.8 per-cent among anesthesiologists and nurse anesthetists.14,15 Brown et al. identified predis-posing risk factors such as skin symptoms with latex glove use (hives, rash, itching), ahistory of atopy and a history of allergy to certain fruits (bananas, avocados, kiwis). Incontrast to most other studies, duration of exposure to latex gloves, either by age or by years of work as an anesthesiologist, did not increase the risk of sensitization. While2.4 percent of their study population was sensitized and exhibited symptoms of latexallergy, 10.1 percent was sensitized but manifested no clinical symptoms of Type Ihypersensitivity at the time of the study. This latter group was considered to bepresymptomatic and have occult disease. The authors concluded that with furtheravoidance of latex exposure, these presymptomatic but already sensitized individuals can

reduce skin reactivity and serum levels of latex-specific IgE and prevent progression tosymptomatic disease. Their report also noted that 24 percent of the anesthesiologistsand nurse anesthetists studied had irritant or contact dermatitis.

3. Other individuals with occupational exposure such as rubber industry workersand hairdressers. The prevalence of latex allergy is thought to be similar to that of health care workers, although this population has not been studied as extensively.

4. Individuals with a history of atopy, hay fever, rhinitis, asthma or eczema. In anumber of reports examining latex allergy in various populations, atopy was one of the sig-

nificant predisposing risk factors. In a study of latex sensitization in a low-risk pediatricpopulation, Bernardini et al. reported that all the children with latex sensitization wereatopic whereas only 29 percent of non-sensitized subjects had positive skin prick respons-es to environmental or food allergens.48 Liss et al. demonstrated a five-fold increase inpositive skin tests among atopic health care workers compared to non-atopic workers.43

5. Individuals with a history of food allergy to tropical fruits (such as avocado,kiwi, banana),chestnuts or stone fruits. 49 These plants contain several proteins simi-lar, or in some cases identical, to those found in latex.

6. Individuals with severe hand dermatitis who wear latex gloves. It has been pro-posed that the dermatitis (contact or allergic) disturbs the integrity of the skin and facil-itates absorption of latex allergen.

7. General population. The prevalence of latex allergy in the general populationhas been reported to range from


15/35


16/35


17/35


1. Sex: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Male . . . . . . . Female

2. Race: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Caucasian . . Black . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Hispanic . . . . Other

3. Have you ever been told by a doctorthat you are allergic to latex? . . . . . . . . . . . . . . . . . . . . . . . . . .yes . . . . . . . . no

4. How many surgeries have you had in the past? . . . . . . . . . . . . _______________________

5. Do you suffer from:Seasonal hay fever? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes . . . . . . . . noAsthma? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .yes . . . . . . . . no

Eczema? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .yes . . . . . . . . noAutoimmune disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .yes . . . . . . . . no

6. Do you have on-the-job exposure to latex? . . . . . . . . . . . . . . .yes . . . . . . . . no

7. Were you born with problems involving your spinal cord? . . . .yes . . . . . . . . no

8. Do you catheterize yourself to urinate? . . . . . . . . . . . . . . . . . .yes . . . . . . . . no

9. Do you have any food allergies? . . . . . . . . . . . . . . . . . . . . . . . .yes . . . . . . . . no

10. Are you allergic to bananas? . . . . . . . . . . . . . . . . . . . . . . . . . .yes . . . . . . . . noKiwi fruit? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .yes . . . . . . . . noAvocados? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .yes . . . . . . . . noGuacamole? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes . . . . . . . . noChestnuts? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .yes . . . . . . . . no

11. Are you allergic to latex or products containing rubber? . . . . .yes . . . . . . . . noIf yes, are the symptoms a rash? . . . . . . . . . . . . . . . . . . . . .yes . . . . . . . . no

Hives? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .yes . . . . . . . . noItching? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .yes . . . . . . . . noWheezing? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .yes . . . . . . . . noDifficulty breathing? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .yes . . . . . . . . noWatery eyes? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .yes . . . . . . . . noAnaphylaxis? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .yes . . . . . . . . no

12. Do you have allergic symptoms while:Blowing up balloons? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .yes . . . . . . . . no

During dental examinations? . . . . . . . . . . . . . . . . . . . . . . . .yes . . . . . . . . noOn contact with diaphragms/condoms? . . . . . . . . . . . . . . . .yes . . . . . . . . noDuring vaginal or rectal exams? . . . . . . . . . . . . . . . . . . . . . .yes . . . . . . . . noWhile wearing rubber gloves? . . . . . . . . . . . . . . . . . . . . . . .yes . . . . . . . . no

(Prepared by the ASA Task Force on Latex Sensitivity, 1999.)

Table 3: Screening Questionnaire for Latex Sensitivity


18/35


19/35


PREOPERATIVE Solicit specific history of latex allergy or risk for latex allergy

History of chronic care with latex-based productsHistory of spina bifida, urological reconstructive surgery

History of repeated surgical procedures (e.g., >9)History of intolerance to latex-based products: balloons, rubber gloves, condoms,

dental dams, rubber urethral cathetersHistory of allergy to tropical fruitsHistory of intraoperative anaphylaxis of uncertain etiologyHealth care workers, especially with a history of atopy or hand eczema

Consider Allergy ConsultationIn vitro testingIn vivo testing

Minimize latex exposure for at-risk patientsLatex alert: patients with significant risk factors for latex allergy but no overt signs or symptomsLatex allergy: patients with or without significant risk factors for latex allergy and positive history,

signs, symptoms or allergy evaluation

Carefully coordinate care between surgical anesthesia and nursing teamsHave lists available of nonlatex product alternativesFirst case of the day is preferable to decrease aeroallergen concentrationDisplay Latex Allergy or Latex Alert signs inside and outside O.R.

INTRAOPERATIVE Anesthesia equipment

Latex-free gloves, airways, endotracheal tubesMasks polyvinylchloride if available or old, well-washed black rubber masksRebreathing bags neoprene if available or old, well-washed black rubber bagsVentilator bellows neoprene or silicone if available or old, well-washed black rubber bellowsBreathing circuit disposable, polyvinylchloride, packaged separately from a latex rebreathing bagRemove rubber stoppers from multidose vialsBeware of latex intravenous injection ports, Penrose-type tourniquets and rubber bands;

use nonlatex glove as tourniquet; tape latex injection ports or use silicone injection ports or stopcockBlood pressure cuffs if new latex, cover with soft cottonAmbu-type bag assure that bag and valve do not have latex components alternative is silicone

self-inflating bagCheck syringe plungers; reconstitute medications every six hoursDilute concentration of epinephrine (0.01 mg/ml, or 1:100,000) available

Surgical equipmentAvoid latex surgical glovesAvoid latex drains (e.g., Penrose drain)Avoid latex urinary cathetersAvoid latex instrument matsAvoid rubber-shod clampsAvoid latex vascular tagsAvoid latex bulb syringes for irrigationAvoid rubber bands

POSTOPERATIVE Medical Alert tag Warning sign posted on chart Warning sign posted on bed

(Modified with permission from the publisher and author. From Holzman RS. Clinical management of latex-allergic children.Anesth Analg.1997; 85:529-533.)

Table 4: Checklist for Management of Latex-Allergic Patients


20/35

4. A latex-free cart containing items likely to be used should accompany thepatient throughout his/her hospital stay (Appendix A). Additionally a list of theavailable non-latex product alternatives should be prominently displayed in patientcare locations and readily available through the purchasing and central supply areasof the facility.

5. The patient should be instructed to obtain a medical alert bracelet or necklace.6. Pharmacological prophylaxis. The use of allergy-attenuating premedication

is controversial. Recommendations by Sockin and Young in 1991 included preoper-ative prophylaxis with diphenhydramine, cimetidine and methylprednisolone.63

Others have argued that pretreatment might serve only to attenuate the early immune responses, leaving anaphylaxis as the first evidence of an allergic reaction.64

More recently, Setlock et al. have demonstrated that premedication is not universal-ly successful in preventing latex anaphylaxis.65 Current opinion as expressed by

Holzman has moved away from administering allergy-attenuating premedication.66

With the ubiquitous presence of latex, it is extremely difficult to make an operat-ing room and perioperative care area completely latex free. Furthermore, the degreeof latex avoidance measures necessary to avert allergic reactions is not known. Forexample, systemic allergic reactions were reported as a result of administration of medication whose only exposure to latex was contact with the rubber stopper in themedication vial.67 Others have been skeptical that the contact between medication

and the latex plungers of disposable syringes, ports of intravenous tubing or stoppersof medication vials provides sufficient exposure to produce a reaction among latexallergic patients.68 Consistent with this opinion is a report by Yunginger et al. in which the investigators were unable to detect latex-allergenic proteins in a multi-dose vial until there had been 40 punctures.69 However, more recent data documentsthe transfer of latex proteins from medication stoppers in sufficient quantities toelicit a dermal reaction in latex allergic subjects.70

Treatment of an Allergic Reaction to Latex Contact dermatitis and Type IV latex reactions can usually be successfully treat-

ed with interventions such as the avoidance of irritating skin cleansers and treatment with topical corticosteroids.

The treatment of a systemic reaction to latex generally follows the sequence out-lined for other systemic allergic reactions (Table 5). The offending agent should beidentified and removed to limit patient exposure. This can be a difficult process when the reaction is occurring in the operating room and the source of latex expo-sure is unclear.

Type 1 latex reactions may present with a spectrum of symptoms and signs. These are generally systemic histamine-like reactions. The treatment depends uponthe severity of the symptoms.

1. Mild reactions frequently resemble an attack of hay fever and respond to anti-histamines. Topical nasal steroids may be used when rhinitis is a prominent symptom.



21/35


Table 5: Treatment of Latex-Induced Hypersensitivity Reactions

ACUTE MANAGEMENT

Initial therapy1. Stop administration/reduce absorption of offending agent

(Consider a variety of potential routes of exposure-administration, including mucosalcontact and inhalation)

2. Remove all latex from the surgical field3. Change gloves4. Discontinue all antibiotic and blood administration5. Maintain the airway and administer 100 percent O26. Intubate the trachea (as indicated)7. Administer 25-50 ml/kg of crystalloid or colloid (as indicated)8. Administer epinephrine

Intravenous: 0.1 mcg/kg or approximately 10 mcg in an adultSubcutaneous (in the absence of an I.V.): 300 mcg (0.3 mg)Endotracheal: five to 10 times the intravenous dose, or 50-100 mcg in an adultFrom a metered dose inhaler: 3 inhalations of 0.16 to 0.20 mg epinephrine/inhalationFrom a nebulizer: eight to 15 drops of 2.25 percent epinephrine in 2 ml normal saline

9. Discontinue all anesthetic agents10. Consider use of Military Anti-Shock Trousers (MAST)

11. Display prominent signs such as latex allergy or latex alert on the inside of theoperating room as well as on the entry doors for those entering

Secondary therapy1. Administer antihistamine

Diphenhydramine 1 mg/kg I.V. or IM (maximal dose 50 mg)Ranitidine 1 mg/kg I.V. (maximal dose 50 mg)

2. Administer glucocorticoidsHydrocortisone 5 mg/kg initially and then 2.5 mg/kg q 4-6 hoursMethylprednisolone 1 mg/kg initially and 0.8 mg/kg q 4-6 hours

3. Administer aminophylline for bronchospasm (may be ineffective during anesthesia)Loading dose 5 to 6 mg/kgContinuous infusion 0.4-0.9 mg/kg/hr (check blood level)

4. Administer inhaled Beta-2 agonists for bronchospasm5. Administer a continuous catecholamine infusion for blood pressure support

Epinephrine 0.02-0.05 mcg/kg/min (2-4 mcg/min)Norepinephrine 0.05 mcg/kg/min (2-4 mcg/min)

Dopamine 5-20 mcg/kg/minIsoproterenol (same dosing as epinephrine)

6. Administer sodium bicarbonate0.5 to 1 mg/kg initially, with titrations using arterial blood gas analysis


22/35

2. Hives may develop locally or systemically. Antihistamines and systemicsteroids are used to treat these symptoms.

3. A more severe reaction, involving the airway, will require more aggressivetreatment with antihistamines, systemic steroids, H2 blockers, oxygen and possibly bronchodilators, endotracheal intubation and epinepherine.

4. In the case of anaphylaxis, a formal anaphylaxis protocol is required. Anaphylaxis may require artificial airway support, intravascular volume expansion,administration of vasoactive medication and other life-support techniques. It is of critical importance to have previously created a latex-free crash cart.

5. The details of any allergic reaction should be clearly recorded, including adescription of the anesthetic agents and techniques, surgical products used, resuscita-tive measures required, laboratory evaluation as well as the perioperative course. It isimportant to immediately initiate a laboratory workup because many of the pathog-

nomonic findings of anaphylaxis, such as serum mast cell tryptase levels, complementC3 and C4, and histamine will be transiently altered but return to baseline within fourhours. With a severe reaction, elevated tryptase levels may persist for longer, evenseveral days.71 The patient should be referred to an allergist, and the patients chartshould be flagged in order to alert subsequent caregivers.

Management of the Health Care Worker With Latex Allergy

Health care workers who are regularly exposed to latex are at risk for sensitization.Personnel sensitized to latex must avoid all direct contact with latex-containing prod-ucts. For anesthesiologists, the most frequent offending products are latex examina-tion and surgical gloves. High-quality, powderless, non-latex gloves should beavailable at every anesthetizing location for individuals who prefer not to use latexproducts. Those affected should have proper allergy identification and shouldalways carry an epinephrine autoinjector device. Latex allergic anesthesiologists with positive histories and/or confirmatory laboratory tests should be counseled onthe risks of continued work in environments with high latex use and on strategies tolimit exposure.

The wearing of powderless, low-latex-allergen gloves by co-workers is also criticalbecause this simple step can reduce levels of latex aeroallergen by more than ten-foldin the operating room.34 Exposure to aerosolized latex occurs when gloves arechanged as well as when powder in the room and on clothing is mobilized. The useof powderless gloves with low (or preferably no) allergen content will limit sensitiza-tion of health care workers and allow those who already manifest inhalant allergicreactions to return to work. Moreover, the wearing of nonlatex gloves by co-workers would eliminate this significant source of allergen.

Ultimately, the prevention of allergic reactions will occur only when institutionsadopt strict policies to protect workers from unnecessary latex exposure. NIOSH hasrecommended that employers take specific steps to protect workers from latex expo-sure and allergy in the workplace.61



23/35


Management of Health Care Facilities

A successful strategy to manage latex allergies in health care settings requires facil-ity-wide commitment.72 A multidisciplinary latex allergy task force should includebroad representation from the hospital staff: medical, nursing, administration, phar-macy, occupational health, central supply, dietary services and housekeeping.Members from this committee can provide a useful latex allergy consultation service.In addition, this committee should have the responsibility to develop60:

1. a process to evaluate all glove selection and utilization;2. a mechanism for reporting and evaluating all suspected latex reactions;3. policies and protocols for management of the latex-sensitive patient and the

latex-sensitive health care worker; and4. educational programs for all hospital employees.

Even so, the task is difficult. Specific steps to be taken by employers and workersare found in the NIOSH Alert 61 (Appendix C).

Future Directions and Implications for Anesthesiologists

Attention is now being turned to immunotherapy for latex-allergic patients, usingthe same principles of desensitization that have proven effective for patients with

insect allergy. Strategies that have been applied include subcutaneous, percutaneousand sublingual desensitization. While the latter strategies may generally be safer andmore effective,73 subcutaneous desensitization has been the more standard approach.Nevertheless, at this time, the benefits of immunotherapy include an improvement incutaneous symptoms with a possible improvement in rhinitis and asthma.74,75

Conclusion

Latex allergy continues to be an important medical problem for health care work-ers and their patients. We have re-examined the definition of latex allergy, updatedour understanding of the offending allergens, the factors that enhance sensitization,the threshold levels that sensitize and elicit reactions in sensitized individuals, currentdiagnostic techniques, avoidance measures, the barrier properties of non-latex alter-natives and the roles of premedication and immunotherapy. Fifteen years after itsemergence as an international concern in specific patient populations and ultimately in health care workers, latex allergy is a well-defined condition with established diag-nostic criteria and rational treatment and prevention strategies. However, notwith-standing an expanding fund of knowledge and a suggestion of immunotherapysefficacy, avoidance remains the only effective treatment.76


24/35

Appendix A

Contents of a Latex-Safe Cart

Latex-free or glass syringesHypodermic needlesI.V. cathetersI.V. extension tubing-polyvinyl chlorideLatex-free I.V. tubingStopcocks three-way, single, in-line manifoldLatex-free heparin lock capsLatex-free heparin lock, T-piece with side port Alcohol wipes new box

Latex-safe tape from new boxLatex-free I.V. tourniquetsSterile gauze pads Thermometer-esophagealDisposable blood pressure cuffs all sizesIsolation stethoscopeSterile cast paddingLatex-free electrocardiogram electrodes

Latex-free oximetry finger sensors disposablePolicy binder with all policies on latex protocolsNeon signs for all doorsLatex-free Ambu bagOxygen nasal cannulaOxygen extension tubingEndotracheal tubes polyvinyl chlorideOral airways polyvinyl chlorideCode and emergency medications in ampoulesVinyl gloves small, medium, and large sizesSterile synthetic gloves sizes 6 to 9100-percent silicone Foley catheter assorted sizesUrimeterQuick reference guide on latex-safe materialsEpidural and spinal traysSuction catheters polyvinyl chloride, 8-Fr to 14 Fr Anesthesia circuits latex-free bag and tubing Anesthesia machine set up for minimal latex content Anesthesia medications in ampules from pharmacy In-line high efficiency particulate air filter



25/35

Appendix B

Legislative, Regulatory, Legal and Informational Resources

Several federal agencies, state legislatures and various medical organizations havedeveloped policies regarding latex exposure.

FEDERAL AGENCIES

The U.S. Food and Drug Administration (FDA): Center for Devices and Radiological Health (CDRH):

In September 1997, the FDA issued its Medical Glove Powder Report. Ninerecommendations were made, including: 1) Establish a maximum allowable powder

level for powdered gloves; 2) Standardize the maximum allowable amount of powderon powder-free gloves; 3) Establish a maximum allowable glove protein level; and 4)Require labeling on all medical gloves of glove powder content and water-solubleprotein.

Effective September 30, 1998, the FDA requires that all medical devices contain-ing latex carry a warning for those allergic. The rule also prohibits the use of theclaim hypoallergenic on labels of products that contain latex.

The National Institute for Occupational Safety and Health (NIOSH):NIOSH issued an alert, Preventing Allergic Reactions to Natural Rubber Latex

in the Workplace, in June 1997. (DHHS Publication No. 97-135).61 In this, they listed a series of recommendations for employers and workers to minimize exposure tolatex. Prominent among these are: 1) Use of non-latex products whenever possible;and 2) When latex gloves are used, they should be powder-free.

The Centers for Disease Control and Prevention (CDC): The CDC is updating its guidelines for infection control in health care personnel.

They describe several strategies for health care workers with Latex Hypersensitivity,including: 1) Develop an institutional protocol for managing personnel with latexallergy; 2) Provide workers with a non-latex or low-allergen powderless latex gloves;and 3) Consider targeted substitution of non-latex gloves and/or powder-free latexgloves.

The Occupational Safety and Health Administration (OSHA):

OSHA Standard 29 CFR 1910.1030 contains a requirement that an employermust provide hypoallergenic gloves, glove liners, powderless gloves or other similaralternatives to employees who are allergic to latex gloves.



26/35

STATE LEGISLATION

Bills aimed at limiting the use of latex gloves have been introduced in more than adozen state legislatures. Currently, many states prohibit the use of latex gloves in thefood service industry, although none have gone as far as prohibiting the use of latexgloves in health care. Specific state regulations should be consulted.

MEDICAL ORGANIZATIONS

The American Academy of Allergy,Asthma and Immunology (AAAI):

The American College of Allergy, Asthma and Immunology (ACAAI):

ACAAI has issued guidelines urging hospital employee health services to take a

leadership position in identifying, managing and preventing latex-related problemsamong workers. Among their recommendations is that the FDA should establishmaximum levels of extractable latex allergens in gloves and that the use of powdered,high-protein latex gloves should be discouraged. In 1997, the ACAAI and the AAAIpublished a joint statement advocating the use of powder-free, low-allergen gloves toreduce aeroallergen exposure.77

The American Academy of Dermatology:

The American Academy of Dermatology released its Position Paper on Latex Allergy in July 1998. Among its recommendations are: 1) Encourage all food prepa-ration services to use only non-latex gloves. 2) Routinely use latex-safe operatingrooms for all trauma surgery. 3) Encourage all medical facilities to exclusively usepowder-free gloves with low latex allergen levels. 4) Encourage all medical facilities toprovide non-latex gloves for general physical examinations. This document also provides a detailed description of a latex-safe environment.

The American Medical Association (AMA): The House of Delegates of the AMA has passed resolutions in 1996 (503, A-96)

and 1997 (504, I-97), which supports the appropriate labeling of latex containingmedical devices with warnings about possible allergic reactions. The AMA strongly encourages health care facilities to provide non-latex alternatives of at least compara-ble efficacy alongside their latex counterparts in all areas of patient care.

LITIGATION

Workers Compensation: Disability related claims by employees who have devel-oped latex allergy are growing exponentially.

Product liability: The first product liability lawsuit against a glove manufacturer was filed in 1991. Latex-related litigation has been called the next big tort.

Americans with Disabilities Act (ADA): Under the provisions of the ADA,employers are required to provide reasonable accommodations to employees withmedical-related disabilities such as latex allergy. Exactly what this involves will vary



27/35

with each situation. In the case of anesthesiologists, provision of suitable alternativesto latex-containing products is considered the minimal accommodation.

OTHER ORGANIZATIONS WITH INTEREST IN ISSUES RELATED TO

LATEX SENSITIVITY

Latex Allergy Links: Provides a comprehensive, up-to-date listing of latex allergy-related sites

MedicAlert: 2323 Colorado Avenue Turlock, CA 95382 Telephone: (800) 432-5378

The Spina Bifida Association of America: 4590 MacArthur Blvd NW, Suite 250 Washington, D.C. 20007-4226 Telephone: (202) 944-3285; (800) 621-3141Fax: (202) 944-3295

American Latex Allergy Association: 3791 Sherman Road

Slinger, WI 53086 Telephone: (888) 97-ALERTFax: (262) 677-2808e-mail:

Canadian Latex Allergy Association96 Cavan StreetPort Hope, Ontario, Canada LIA 3B7 Telephone: (905) 885-5270Fax: (905) 885-2839e-mail:

LATEX-FREE PRODUCTS CAN BE ORDERED THROUGH THESE

CATALOGS:

Decent Exposures: Telephone: (800) 524-4949

CETRA Products for Latex-free Living: ; Telephone: (888) LATEX-NO



28/35

References:

1. Downing J. Dermatitis from rubber gloves. N Engl J Med.1933; 208:196-198.2. Centers for Disease Control. Recommendations for prevention of HIV trans-

mission in health-care settings. MMWR. 1987; 36:S2.3. Center for Devices and Radiological Health. Medical Glove Powder Report.

Rockville, MD, Food and Drug Administration, 1997.4. Slater JE. Rubber anaphylaxis. N Engl J Med.1989; 320:1126-1130.5. Gold M, Swartz J, Braude B, et al. Intraoperative anaphylaxis: An association

with latex sensitivity. J Allerg Clin Immunol.1991; 87:662-666.6. Leynadier F, Pecquet C, Dry J. Anaphylaxis to latex during surgery. Anaesth.

1989; 44:547-550.7. Ownby D, Tomlanovich M, Sammons N, et al. Anaphylaxis associated with

latex allergy during barium enema examinations. Am J Roentgenol.1991;1566:903-908.

8. Oulieu S, Olivier J, Bourget P, et al. [Therapeutic strategy in anaphylactoidshock during general anesthesia. Etiologic agents and diagnostic evaluation]Therapie.1995; 50:59-66.

9. Vervloet D, Magnan A, Birnbaum J, et al. Allergic emergencies seen in surgicalsuites.Clin Rev Allergy Immunol.1999; 17:459-467.

10. Mertes P, Laxenaire M, Alla F. Anaphylactic and anaphylactoid reactions

occurring during anesthesia in France in 19992000. Anesthesiology.2003;99:536-545.11. Laxenaire MC, Mertes P. Anaphylaxis during anaesthesia. Results of a two-

year survey in France.British Journal of Anaesthesia.2001; 87:549-58.12. Yassin MS, Lierl MB, Fischer TJ, et al. Latex allergy in hospital employees. Ann

Allergy.1994; 72:245-249.13. Kelly KJ, Pearson ML, Kurup VP, et al. A cluster of anaphylactic reactions in

children with spina bifida during general anesthesia: Epidemiologic features,risk factors, and latex hypersensitivity.

J Allergy Clin Immunol.1994; 94:53-61.

14. Brown R, Schauble J, Hamilton R. Prevalence of latex allergy among anesthe-siologists: Identification of sensitized but asymptomatic individuals. Anesthesiology.1998; 89(2):287-289.

15. Konrad C, Fieber T, Gerber H, et al. The prevalence of latex sensitivity amonganesthesiology staff. Anesth Analg.1997; 84:629-633.

16. Pailhories G. Reducing proteins in latex gloves. The industrial approach.ClinRev Allergy.1993; 11:391-402.

17. Yunginger JW, Jones R, Fransway A. Extractable latex allergens and proteins indisposable medical gloves and other rubber products. J Allergy Clin Immunol.1994; 93:836-884.

18. Jaffray D, Nade S. Does surgical glove powder decrease the innoculum of bacte-ria required to produce an abscess? J R Coll Surg Edinb.1983; 28:219-222.

19. Beezhold D, Beck WC. Surgical glove powders bind latex antigens. Arch Surg.1992; 127:1354-1357.



29/35

20. Vandenplas O, Delwiche JP, Depelchin S, et al. Latex gloves with a lower pro-tein content reduce bronchial reactions in subjects with occupational asthmacaused by latex. Amer J Resp Crit Care Med.1995; 151:887-891.

21. Meyer K, Beezhold D. Latex allergy: How safe are your gloves?Bull Am Coll Surg.1997; 82:13-15.

22. Ellis N. The hazards of surgical glove dusting powder.Surg Gynecol Obstet.1990; 171:521-527.

23. Tomazic VJ, Shampaine EL, Lamanna A, et al. Cornstarch powder on latexproducts is an allergen carrier. J Allergy Clin Immunol.1994; 93:751-758.

24. Swanson MC, Bubak ME, Hunt LW, et al. Quantification of occupational latexaeroallergens in a medical center. J Allergy Clin Immunol.1994; 94:445-451.

25. Karathanasis P, Cooper A, Zhou K, et al. Indirect latex contact causes urticaria/anaphylaxis. Ann Allergy.1993; 71:526-528.

26. Williams P, Halsey J. Endotoxin as a factor in adverse reactions to latex gloves. Ann Allergy Asthma Immunol.1997; 79:303-310.

27. Del Savio B, Sheretz E. Is allergic contact dermatitis being overlooked? ArchFam Med.1994; 3:537-543.

28. Heese A, Von Hintzenstern J, Peters K, et al. Allergic and irritant reactions torubber gloves in medical health services. Spectrum, diagnostic approach andtherapy. J Am Acad Dermatol.1991; 25:831-839.

29. Charous BL, Hamilton RG, Yunginger JW. Occupational latex exposure:

Characteristics of contact and systemic reactions in 47 workers. J Allergy Clin Immunol. 1994; 94:12-18.30. Laurent J, Malet R, Smiejan J, et al. Latex hypersensitivity after natural delivery.

J Allerg Clin Immunol.1992; 89:779-78031. Axelsson J, Johansson S, Wrangsjo K. IgE-mediated anaphylactoid reactions to

rubber. Allergy.1987; Natural Rubber Latex Allergy: Considerations for Anesthesiologists 42:46-50.

32. Grattan C, Kennedy C. Angioedema during dental treatment.Contact Dermatitis.1985; 13:333.

33. Gerber AC, Jorg W, Zbinden S, et al. Severe intraoperative anaphylaxis to sur-gical gloves: Latex allergy, an unfamiliar condition. Anesthesiology.1989;71:800-802.

34. Heilman D, Jones R, Swanson M, et al. A prospective, controlled study show-ing that rubber gloves are the major contributor to latex aeroallergen levels inthe operating room. J Allergy Clin Immunol . 1996; 98:325-330.

35. Baur X, Chen Z, Allmers H. Can a threshold limit for natural rubber latex air-borne allergens be defined? J Allerg Clin Immunol.1998; 101:24-27.

36. Vandenplas O, Delwiche J, Sibille Y. Occupational asthma due to latex in a hos-pital administrative employee.Thorax.1996; 51:451-453.

37. Blanco C, Carrillo T, Castillo R, et al. Latex allergy: Clinical features andcross-reactivity with fruits. Ann Allergy.1994; 73:309-314.

38. Tarlo S, Sussman G, Holness D. Latex sensitivity in dental students and staff: A cross-sectional study. J Allergy Clin Immunol.1997; 99:396-401.



30/35

39. Ellsworth PI, Merguerian PA, Klein RB, et al. Evaluation and risk factors of latex allergy in spina bifida patients: Is it preventable? J Urol.1993; 150:691-693.

40. Mazon A, Nieto A, Estornell F, et al. Factors that influence the presence of symptoms caused by latex allergy in children with spina bifida. J Allerg Clin Immunol.1997; 99:600-604.

41. Hochleitner B, Menardi G, Haussler B, et al. Spina bifida as an independentrisk factor for sensitization to latex. J Urol.2001; 166:2370-2373.

42. Szepfalusi Z, Seidl R, Bernert G, et al. Latex sensitization in spina bifidaappears disease-associated. J Pediatr.1999; 134:344-348.

43. Liss G, Sussman G, Deal K, et al. Latex allergy: Epidemiological study of 1351hospital workers. Occupational & Environmental Medicine.1997; 54:335-342.

44. FDA mandatory reporting database, Oct. 1997.45. Anonymous.Task Force on Allergic Reactions to Latex. American Academy of

Allergy and Immunology. Committee report. J Allergy Clin Immunol.1993; 92:16-8.46. Hunt L, Fransway A, Reed C, et al. An epidemic of occupational allergy to

latex involving health care workers. J Occup Environ Med.1995; 37:1204-1209.47. Garabrant D, Roth H, Parsad R, et al. Latex sensitization in health care work-

ers and in the U.S. general population. Am J Epidemiol.2001; 153:515-522.48. Bernardini R, Novembere E, Ingargiola A, et al. Prevalence and risk factors of

latex sensitization in an unselected pediatric population. J Allerg Clin Immunol.1998; 101:621-625.

49. Kurup VP, Kelly T, Elms N, et al. Cross-reactivity of food allergens in latexallergy. Allergy Proc.1994; 15:211-216.50. Moneret-Vautrin DA, Beaudouin E, Widmer S, et al. Prospective study of risk

factors in natural rubber latex hypersensitivity. J Allergy Clin Immunol.1993;92:668-677.

51. Lebenbom-Mansour M, Oesterle J, Ownby D, et al. The incidence of latexsensitivity in ambulatory surgical patients: A correlation of historical factors with positive serum immunoglobin E levels. Anesth Analg.1997; 85:44-49.

52. Warshaw E. Latex allergy. J Am Acad Dermatol.1998; 39:1-24.53. Sussman G, Gold M. Guidelines for the management of latex allergies and

safe latex use in health care facilities. Arlington Heights, IL, American Collegeof Allergy, Asthma and Immunology, 1996.

54. Cohen D, Scheman A, Stewart A, et al. American College of Dermatologysposition paper on latex allergy. J Am Acad Dermatol.1998; 39:98-106.

55. Turjanmaa K, Reunala T, Rasanen L. Comparison of diagnostic methods inlatex surgical glove contact urticaria.Contact Dermatitis.1988; 19:241-247.

56. Konrad C, Fieber T, Schupfer G, et al. Comparing the Enzyme Allergosorbens and Coated Allergen Particle tests for latex allergy: Which in vitro test should be chosen by an anesthesiologist? Anesth Analg . 1998;87:1389-1392.

57. Nielsen P, Nissen D, Skov P, et al. Assessment of IgE allergen specificity amonglatex-allergic health care workers: Review of IgE-binding components of vari-ous latex extracts. Annals of Allergy, Asthma, & Immunol.2000; 85:489-494.



31/35

58. Kelly KJ, Kurup V, Zacharisen M, et al. Skin and serologic testing in the diag-nosis of latex allergy. J Allergy Clin Immunol.1993; 91:1140-1145.

59. Baur X, Chen Z, Allmers H, et al. Results of wearing test with two differentlatex gloves with and without the use of skin-protection cream. Allergy (Denmark).1998; 53:441-444.

60. Brown R, Hamilton R, McAllister M. How health care organizations canestablish and conduct a program for a latex-safe environment. JointCommission Journal on Quality & Safety. 2003; 29: 113-123. AmericanSociety of Anesthesiologists.

61. NIOSH: Preventing Allergic Reactions to Natural Rubber Latex in the Workplace. Cincinnati, OH, Department of Health and Human Services(DHHS), National Institute of Occupational Safety and Health (NIOSH), 1997.

62. Kim K, Graves P, Safadi, G, et al. Implementation recommendations for mak-

ing health care facilities latex safe. AORN. Journal 1998; 67:615-632.63. Sockin S, Young M. Preoperative prophylaxis of latex anaphylaxis. J Allerg Clin

Immunol.1991; 87:269A.64. Weiss M, Hirshman C. Latex allergy.Can J Anaesth.1992; 39: 528-532.65. Setlock MA, Cotter TP, Rosner D. Latex allergy: Failure of prophylaxis to pre-

vent severe reaction. Anesth Analg.1993; 76:650-652.66. Holzman R. Clinical management of latex-allergic children. Anesth Analg.1997;

85: 529-533.

67. Vassallo S, Thurston T, Kim S, et al. Allergic reaction to latex from stopper of amedication vial. Anesth Analg.1995; 80:1057-1058.68. Blum R, Rockoff M, Holzman R, et al. Overreaction to latex allergy? Anesth

Analg.1997; 84:467-468.69. Yunginger J, Jones R, Franswa A. Latex allergen contents of medical and con-

sumer rubber products. J Allerg Clin Immunol.1993; 91:241.70. Primeau M, Adkinson NJ, Hamilton R. Natural rubber pharmaceutical vial

closures release latex allergens that produce skin reactions. J Allergy Clin Immunol.2001; 107:958-962.

71. Schwartz L, Bradford T, Rouse C. Development of a new, more sensitiveimmunoassay for human tryptase use in systemic anaphylaxis. J Allerg Clin Immunol.1994; 14:190-204.

72. Hunt L, Boone-Orke J, Fransway A, et al. A medical center wide multi-disci-plinary approach to the problem of natural rubber latex allergy. J Occup Environ Med.1996; 38:765-770.

73. Patriarca G, Nucera E, Buonomo A, et al. New insights on latex allergy diagno-sis and treatment. J Invest Allerg Clin Immun.2002; 12:169-176.

74. Sastre, J, Fernandez-Nieto M, Rico P, et al. Specific immunotherapy with astandardized latex extract in allergic workers: A double-blind, placebo-con-trolled study. J Allergy Clin Immunol.2003; 111:985-994.

75. Leynadier F, Herman D, Vervloet D, et al. Specific immunotherapy with a stan-dardized latex extract versus placebo in allergic healthcare workers. J Allergy Clin Immunol.2000; 106:585-590.



32/35

76. Poley GJ, Slater J. Latex allergy. J Allergy Clin Immunol.2000; 105:1054-1062.77. Anonymous. AAAAI and ACAAI Joint Statement concerning the use of pow-

dered and non-powdered natural rubber latex gloves. Annals of Allergy, Asthma,& Immunol.1997; 79:487.



33/35

Notes



34/35


35/35

Natural Rubber Latex Allergy

Documents

Transcript of Natural Rubber Latex Allergy