CDC keeps its powder dry in latex allergy cross-fire
Does agency go too far, or not far enough?
Striking a balance between polarized positions on a controversial issue, the Centers for Disease Control and Prevention is emphasizing surveillance and prevention strategies for latex allergy reactions in health care workers who must routinely don gloves under standard infection control precautions.
The recommendations are included in new guidelines for infection control in health care workers that are expected to be issued in final form in February by the CDC Hospital Infection Control Practices Advisory Committee (HICPAC).1 The guidelines also advise consideration of targeted substitution of nonlatex gloves and/or powder-free latex gloves in areas of the facility where personnel have developed latex allergy.
The American Nurses Association (ANA) in Washington, DC, praised the CDC for addressing the issue, but urged the agency to go further in emphasizing latex alternatives and powder-free gloves as effective strategies against latex allergies.
"We don’t think that they covered that issue effectively in the document," says Susan Wilburn, RN, MPH, senior specialist for occupational safety and health at the ANA.
In written comments on the draft version, the ANA cited a joint statement advocating use of powder-free latex gloves that was issued July 21, 1997, by the American College of Allergy, Asthma and Immunology (ACAAI) in Arlington Heights, IL, and the American Academy of Allergy, Asthma and Immunology (AAAAI) in Milwaukee. The statement cites studies in concluding that only powder-free latex gloves should be used because the cornstarch powder added to latex gloves to ease donning becomes a source of airborne allergens that can be inhaled by latex-sensitive workers.2-5 Accordingly, the ANA urged the CDC to recommend "institution-wide substitution of powder-free latex gloves to decrease the overall exposure of health care personnel to this hazard."
Though conceding that research is ongoing with regard to latex sensitivity, the ANA also strongly disagreed with the CDC’s decision to make no recommendation for the institution-wide substitution of non-latex products in health care settings to prevent further sensitization among health care personnel.
"While prevalence rates vary, it is clear that there is increasing sensitization," the ANA comments state.
In contrast, comments submitted by glove manufacturer Allegiance Healthcare in McGaw Park, IL, questioned whether latex allergies are truly an occupationally acquired syndrome, and stated that data do not support the contention that powdered gloves are more allergy-producing than nonpowdered. The company argued that data gathered by the CDC on latex sensitivity in occupations showed "health care workers are at no greater risk of developing latex sensitivity than other individuals who are not exposed to latex gloves at work."
However, the question of whether latex allergy is an occupational condition is irrelevant because the CDC guidelines are designed to address the worker’s anticipated job exposures, not weigh whether the potentially harmful agent in question is an equal threat in the community, says Michelle Pearson, MD, medical epidemiologist in the CDC hospital infections program and HICPAC executive secretary. Indeed, prevalence of many of the infections addressed in the guideline is no higher in health care workers than in the general population, she says.
"The whole purpose of the guideline is to protect the worker from acquiring those things [to which] they are exposed," she says. "For example, if you were to look at hepatitis B [prevalence] it would be lower in the health care worker population than in other populations. But because they are exposed to hepatitis in their work they need to get vaccinated. It is the same principle. It really is irrelevant whether the [latex allergy] prevalence is lower, higher, or the same. The point is that they are exposed to these latex products and therefore may be at risk, and we need to have recommendations to protect them."
The comments by Allegiance also stated that there is no scientific evidence to support the theory that individuals become sensitized by exposure to airborne latex particles from powdered gloves.
"The cornstarch powder on the inside of gloves may be too heavy to float around in the air, particularly after it becomes saturated with the glove wearer’s perspiration," they say. "No one has ever shown that cornstarch particles carrying natural rubber proteins actually transport themselves from one room to another in a hospital or clinic."
More than 80% of the natural rubber latex medical gloves used in the United States are powdered gloves, and a CDC recommendation to end their use could raise health care costs by millions of dollars annually, the company warned. The CDC struck something of a balance in issuing the guidance on powdered gloves, underscoring them as an option but not recommending them as strongly as the joint statement issued by the allergy clinicians.
"I think there are data to suggest that powdered gloves pose a greater problem than non-powdered gloves," Pearson says. "If you look at statements from other professionals such as the [AAAAI/ACAAI], they [are] saying powder-free gloves are the way to go. We don’t come out that strongly. We say that is an option, in terms of non-latex gloves or powder free gloves."
On the other hand, the final version will not go as far as the ANA advocates, leaving the institution-wide substitution of non-latex products as an unresolved issue, she notes. But the CDC guidelines do emphasize that facilities should develop an institutional protocol for evaluating and managing personnel with suspected or known latex allergy, including establishing surveillance for latex reactions within the facility. Educational materials and activities should be provided to inform personnel about the manifestations and potential risk of latex allergy.
"This does appear to be an increasingly recognized problem in the health care setting," Pearson says. "The institutions need to develop protocols [and] take an institution-wide approach. Workers should not only be educated about latex allergy and its manifestations, but they also should be educated about appropriate indications for glove use."
References
1. Centers for Disease Control and Prevention. Draft guideline for infection control in health care personnel, 1997; notice. 62 Fed Reg 47,276-47,327.
2. Beezhold D, Beck W. Surgical glove powders bind latex antigens. Arch Surg 1992; 127:1354-1357.
3. Tomazic V, Shampaine E, Lamanna A, et al. Cornstarch powder on latex products is an allergen carrier. J Allergy Clin Immunol 1994; 93:751-758.
4. Tarlo S, Sussman G, Contala A, et al. Control of airborne latex by use of powder-free gloves. J Allergy Clin Immunol 1994; 93:985-989.
5. Siu S, Smith G, Sussman G, et al. Reduction of airborne latex protein exposure by use of low protein, powder-free gloves. J Allerg Clin Immunol 1996; 97:325.
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