Special Feature
Latex Allergy: An Increasing "On the Job" Risk
By John O’Donnell, RN, MSN, CRNA, Bettina Dixon, RN, MSN, CRNA, and Leslie A. Hoffman, RN, PhD
The population at risk for latex allergy includes individuals with exposure to latex rubber early in life, rubber industry workers, and healthcare providers.1 As healthcare providers, we are trained to provide care for patients. When a latex reaction occurs, the situation is reversed and we may need to provide care for a fellow healthcare provider, as well as for the patient. This essay will focus on the incidence of true latex allergy in healthcare workers, legal and disability issues, and guidelines for prevention and management of an immunologic response.
Incidence of Latex Allergy
As many as 8-20% of health care workers regularly exposed to latex are sensitized.2 In a 1996 epidemiologic study of 1351 hospital workers, Liss et al3 reported a 12.1% incidence of latex sensitization, identified by the skin prick test. Among subgroups, lab workers had a 16.9% incidence, while nurses and physicians had a 13.3% incidence. Sensitization was associated with a history of atopy, allergy to certain food groups, work-related symptoms (rhinoconjunctivitis, hives, wheezing), and the amount of glove use.
Konrad et al4 reported a 15.8% incidence of latex sensitivity among 101 anesthesiologists and nurse anesthetists (CRNAs) when both skin prick and scratch tests were used. Spirometry, performed on sensitized individuals, revealed a decrease in peak expiratory flow rates during working hours, especially during the day shift. From a study of 168 anesthesiologists and CRNAs, Brown et al5 reported a 19.6% incidence of Type IV skin reactions (see Table 1) based on history of a delayed cutaneous reaction to latex gloves. Of the total group, 12.5% were identified as sensitized and 2.4% were overtly symptomatic and required medication prior to work and avoidance of latex contact. Factors that correlated with development of latex allergy included Type IV glove sensitivity, food cross-reactivity (bananas, kiwis, avocados), and a history of atopy. In this study, factors not shown to increase risk included duration and extent of exposure to latex, race, and sex.5
Could a Latex Reaction Happen to You or Your Colleague?
Our experience suggests that such reactions, while not frequent, are becoming more common. Moreover, they present a unique dilemma, as the health care provider may be carrying out a vital service, as illustrated by the following example.
A 42-year-old CRNA was called to a small community hospital operating room (OR) at 10:00 pm to assist with an emergency bowel resection. As she entered the OR hallway, workmen who were removing ductwork as part of a renovation project passed her with an open container of the construction debris and she noticed a significant amount of "dust" in the air. Continuing to the OR, she met with the anesthesiologist and prepared for the case. Anesthesia was induced and the patient was stabilized. The CRNA then experienced rhinitis, conjunctivitis, and became increasingly short of breath. She reported her symptoms to the anesthesiologist, who assessed her distress and instructed her to use a metered dose albuterol inhaler. Epinephrine was available, but was not used because the respiratory symptoms quickly improved. She was able to finish the procedure and her shift.
Two weeks later, while assisting in a hip revision procedure, she suffered similar symptoms that did not resolve with albuterol. She was immediately sent to the emergency department, where she was given a nebulized treatment of albuterol and oral diphenhydramine (Benadryl). Again her symptoms abated and she was referred to an immunologist.
Follow-up investigation revealed that the ductwork was 20 years old and the "dust" probably included latex-impregnated powder. Past medical history revealed a 20-year history of seasonal allergies, occasional rhinoconjunctivitis at work, urticarial hand rash 30-60 minutes after use of latex gloves, and wheezing on one occasion following latex glove use. A radio-allergosorbent test (RAST) for latex-specific IgE indicated a Class 2 or "moderate" level of allergic sensitivity. The immunologist recommended complete avoidance of contact with latex and latex powder and discussed the likelihood of a more severe reaction with continued exposure.
The CRNA was subsequently able to successfully convert her department to powderfree, nonlatex gloves. She assumed more administrative responsibilities in order to decrease her clinical commitment. She now wears a medic alert bracelet and carries a kit with epinephrine, diphenhydramine, and a bronchodilator.
In our experience, this case is not unique. During the 1998-1999 academic year, we are aware of two graduate-nursing students who experienced serious latex reactions. The first case was a 34-year-old nurse anesthesia student who experienced a severe reaction to "hypoallergenic" latex gloves while starting an IV. Her symptoms progressed from an immediate urticarial hand rash to wheezing and hypotension. She was placed on an OR gurney and was treated with oxygen, intravenous fluids, subcutaneous epinephrine (300 ug), intravenous diphenhydramine, and intravenous methylprednisolone. Her care was directed by an anesthesiologist, and she was sent home with oral diphenhydramine. In the second case, a 35-year-old nurse practitioner student experienced a latex reaction during an office-based bronchoscopy procedure. The mask she wore was labeled "glass and latex-free." However, within minutes she experienced a burning sensation on her nose and cheekbones that rapidly evolved into a localized urticarial reaction. The reaction progressed to include dyspnea and hypotension. She required parenteral fluids and epinephrine. Her care was managed by the supervising pulmonologist.
The literature reveals a growing number of similar cases. Hunt et al6 reported 16 anaphylactic reactions to latex, six of which occurred during testing for latex sensitivity. Rosen et al7 described five cases in health care workers, including two physicians, a lab technician, a physical therapist, and an ICU nurse. Symptoms ranged from cutaneous urticaria with rhinoconjunctivitis to severe respiratory and cardiovascular reactions. Yoshino et al8 reported a life-threatening reaction in a surgeon with no history of glove-related reactions or atopy, which was triggered by donning a pair of gloves. He developed clinical anaphylaxis and required treatment with oxygen and intravenous fluids along with parenteral epinephrine, diphenhydramine, and corticosteroids.
Governmental Regulations
Extensive controversy exists with respect to how problems relating to latex allergy should be managed. In response to the increasing incidence of exposure-related problems, the Occupational Safety and Health Administration (OSHA) issued a technical bulletin in April 1999, which included recommendations to reduce exposure to natural rubber latex (NRL) gloves.9 In this bulletin, OSHA suggested three measures:
• selection of NRL gloves as a choice for workers only in situations requiring protection from infectious agents;
• choice of nonpowdered NRL gloves with a low protein content; and
• providing alternative non-NRL gloves for workers allergic to NRL gloves.
This bulletin generated intense protest from glove manufacturers and medical experts. OSHA was accused of circumventing normal rule-making procedures, promoting "hysteria" in health care workers, and creating a situation that could encourage bloodborne disease transmission. Fears were expressed that this ruling might cause health care workers to abandon universal precautions and/or their careers. Concerns were also voiced that the public might refrain from using safe sexual practices, e.g., latex condoms. Prior recommendations of the National Institute of Occupational Safety and Health (NIOSH) generated similar criticism.10 The OSHA guidelines clearly parallel the prior NIOSH recommendations. (See Table 1.) Both sets of guidelines were designed to inform employers and employees about mechanisms that would enhance their safety with respect to NRL gloves.
| Table 1 |
| 1997 NIOSH Recommendations |
| Employers
• Provide workers with non-latex gloves to use when there is little potential for contact with infectious materials (for example, in the food service industry). • Appropriate barrier protection is necessary when handling infectious materials (CDC 1987). If latex gloves are chosen, provide reduced-protein, powderfree gloves to protect workers from infectious materials. • Ensure that workers use good housekeeping practices to remove latex-containing dust from the workplace. • Provide workers with education programs and training materials about latex allergy. • 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. • Evaluate current prevention strategies whenever a worker is diagnosed with latex allergy. Workers • Use nonlatex gloves for activities that are not likely to involve contact with infectious materials (food preparation, routine housekeeping, maintenance, etc.). • Appropriate barrier protection is necessary when handling infectious materials (CDC 1987). If you choose latex gloves, use powderfree gloves with reduced protein content. • Use appropriate work practices to reduce the chance of reactions to latex. • Take advantage of all latex allergy education and training provided by your employer. • 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. • If you have latex allergy, consult your physician. • Carefully follow your physician’s instructions for dealing with allergic reactions to latex.
|
Such recommendations, while logical, face opposition from various interest groups because of their implications for potential expense, e.g., liability insurance, diagnostics, counseling, disability, and the lack of an inexpensive alternative replacement material.2
Litigation and Disability Issues
If legal action is pursued, it often must be against the manufacturer, rather than the employer, because employees covered by workers’ compensation insurance are precluded from suing their employers. More than 150 individual suits representing health care providers are currently being pursued.11 Key issues involve how long manufacturers knew of the dangers of latex exposure but failed to warn users, and whether manufacturers intentionally produced products that increased the latex allergen (protein) content of gloves.
One case has been decided in favor of a health care worker. In February 1998, a Milwaukee jury ordered a latex glove manufacturer to pay $1 million to a radiology technician who developed a severe latex allergy alleged to be related to her work. The case is being appealed.11 Some contend that issues related to latex allergy are covered by the Americans with Disabilities Act (ADA), since latex allergy can limit one’s ability to work in patient care settings. However, the ADA does not list latex allergy as a disability. The Equal Employment Opportunities Commission has been deciding claims on a case-by-case basis.11
Managing Latex Reaction
The first step is prevention. Factors that place health care providers into high-risk categories include a history of atopy, some food allergies (for example, to kiwis, bananas, or avocados), Type IV sensitivity to latex gloves (see Table 2), and a history of frequent surgical procedures.
| Table 2 |
| Classification of Immune Reactions |
| Type I
IgE (IgG) reactions Immediate hypersensitivity Type II Antibody dependent Cytotoxic Type III Immune-complex reactions Complement activated Type IV T-cell mediated Delayed hypersensitivity Examples: Contact dermatitis; In organ rejection: host vs. graft or graft vs. host disease __________________________________________________ |
Gavalas et al12 presented an algorithm for management of anaphylaxis in the emergency department that could be implemented in other hospital areas. The algorithm grades reactions according to their severity. The following is an abridged, slightly modified version of the Gavalas algorithm.
Grade I: Minor allergic reaction: involving skin only (urticaria).
Treatment: Discontinue causative agent, place patient supine and monitor vital signs, give oral diphenhydramine (H1 antagonist), observe one hour.
Follow-up: Discharge on oral diphenhydramine for 48-72 hours; report case.
Grade II: Moderate reaction: possible skin, gastrointestinal, respiratory (dyspnea), or cardiovascular symptoms.
Treatment: Discontinue causative agent; transport to an area where resuscitation can be initiated; place patient supine and monitor vital signs; administer oxygen at high concentration; subcutaneous epinephrine; establish intravenous access and administer fluids; administer B2 agonist if dyspneic; repeat subcutaneous epinephrine or consider intravenous epinephrine if poor response.
Follow-up: Adjunctive oral or intravenous medications including diphenhydramine and/or steroids; admit and observe for 8-24 hours; report case.
Grade III: Severe/life-threatening reaction: Severe skin (angioedema), gastrointestinal, respiratory (bronchospasm, respiratory arrest), or cardiovascular (clinical shock, arrest) symptoms.
Treatment: Discontinue causative agent, transport to an area where resuscitation can be initiated; call for assistance; place patient supine and monitor vital signs; administer highest oxygen concentration available; secure airway; establish intravenous access; give intravenous epinephrine (evaluate BP); administer intravenous fluids; follow advanced cardiac life support (ACLS) protocols as needed; consider intravenous glucagon in beta-blocked patients; infuse epinephrine and/or other inotropes as needed.
Follow-up: Adjunctive medications, including intravenous diphenhydramine and steroids; other adjunctive medications; admit and observe for 8-24 hours; report case.12
Modifications to this algorithm, which originated in Great Britain, involved changes to make it consistent with practice in the United States. The route for administration of epinephrine was changed from intramuscular to subcutaneous. The H1 antagonist was changed from chlorpheniramine to diphenhydramine. Finally, colloid was changed to crystalloid as resuscitation fluid. With these minor changes, the algorithm serves as an excellent blueprint for management of latex reactions.
Gavalas et al12 advocate treatment and reporting of mild reactions, which is critical because Type IV skin reactions can place individuals at risk for development of a true Type I allergic response (see Table 2). Key strategies for successful management also include early consultation with an experienced intensivist and moving the individual to an environment conducive to a spectrum of therapy up to and including emergency resuscitation. Experienced clinical consultation is essential for the identification and differentiation of the reactions, quick and decisive action with respect to airway management, selection of the appropriate epinephrine dose and route, and determining the length of follow-up observation.
An additional point relates to future patient care responsibilities. A plan needs to be developed that identifies ways to minimize risk to the health care provider such as converting to powderfree, non-NRL gloves or counseling regarding job role modification.
Summary
Life-threatening latex allergic reactions occur in health care providers in diverse situations. The literature suggests that 8-20% of health care providers are susceptible to this potentially life-threatening reaction. When such reactions occur, a key member of the team may be affected. Steps must be taken to ensure health care provider and patient safety. All health care providers should know the initial symptoms of such reactions, appropriate action to take dependent on the severity, and measures to decrease risk to ourselves and other health care providers. (Mr. O’Donnell is Director, and Ms. Dixon is a faculty member in the Nurse Anesthesia Program, University of Pittsburgh School of Nursing.)
References
1. Warshaw EM. Latex allergy. J Am Acad Dermatol 1998;39(1):1-22.
2. Holzman RS, Katz JD. Occupational latex allergy: The end of the innocence. Anesthesiology 1998;89(2): 287-289.
3. Liss GM, et al. Latex allergy: Epidemiological study of hospital workers. Occup Environ Med 1997;54: 335-342.
4. Konrad C, et al. The prevalence of latex sensitivity among anesthesiology staff. Anesth Analg 1997; 84(3):629-633.
5. Brown RH, et al. Prevalence of latex allergy among anesthesiologists: Identification of sensitized but asymptomatic individuals. Anesthesiology 1998; 89(2):292-299.
6. Hunt LW, et al. An epidemic of occupational allergy to latex involving health care workers. J Emerg Med 1995;37(10):1204-1209.
7. Rosen A, et al. Hypersensitivity to latex in health care workers: Report of five cases. Otolaryngol Head Neck Surg 1993;109(4):731-734.
8. Yoshino A, et al. Anaphylactoid reaction in a surgeon to surgical rubber gloves. Anesth Analg 1995;81(4): 878-879.
9. Occupational Safety and Health Administration. Technical Information Bulletin: Potential for Allergy to Natural Rubber Latex Gloves and Other Natural Rubber Products. Washington, DC: OSHA; April 12, 1999.
10. National Institute for Occupational Safety and Health. NIOSH Alert: Preventing Allergic Reactions to Natural Rubber Latex in the Workplace. DHHS (NIOSH) Pub. No. 97-135. Washington, DC: NIOSH; 1997.
11. Kohn P. The legal implications of latex allergy. RN 1999;62(1):63-65.
12. Gavalas M, et al. Guidelines for management of anaphylaxis in the emergency department. J Accid Emerg Med 1998;15:96-98.
13. Department of Health and Human Services, Food and Drug Administration. Natural rubber-containing medical devices; user labeling 62. Federal Register 51,021, Sept. 30, 1997.
Severe latex allergic reactions have been reported to be increased in individuals with a history of adverse reactions to which of the following foods?
a. Strawberries, pears, and watermelons
b. Kiwis, bananas, and avocados
c. Chocolate, walnuts, and peanuts
d. Crab, shrimp, and lobster
e. Eggs and wheat
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