Hospital determines latex allergy risks, prevalence
Combination symptoms most predictive of allergy
A study of latex allergy reactions and associated problems related to glove use among health care workers at a rural Midwestern hospital reveals a high correlation between latex allergy and dermatitis symptoms such as itchy hands and rash.
Most predictive of latex allergy is the combination of two or more types of symptoms, such as upper respiratory, lower respiratory, and dermatitis-related, the study found.
Increasing reports of possible latex allergies among HCWs at Sioux Valley Hospital in Sioux Falls, SD, prompted officials there to undertake a study to identify true latex allergy and associated risk factors, with the objective of implementing measures to minimize occupational risk, says Lisa Docken, RN, BSN, CIC, employee health and infection control director at the 3,400-worker hospital.
A 1994 incident in which a surgical technician suffered an anaphylactic reaction from a co-worker removing latex gloves in her presence also was a major catalyst for a cross-sectional study of more than 500 hospital workers.
"This incident abruptly brought to our attention the need to address this growing concern," says Docken, who reported on the hospital's research at an occupational health session of the Association for Professionals in Infection Control and Epidemiology's (APIC's) annual conference, held recently in Atlanta.1
"The emphasis on reduction of occupational exposures to infectious pathogens in the workplace has given rise to the growing and potentially life-threatening problem of latex allergies," says Docken. "The increased incidence of latex allergies was preceded by a tremendous increase in latex glove utilization."
Following implementation of the bloodborne pathogens standard, more than 1.5 million pairs of gloves were used annually by workers in her facility, Docken points out. The most commonly provided glove was powdered latex. Powder-free latex gloves were available, but were discouraged for cost-containment purposes.
"However, in the last two years, powder-free gloves have become the standard, predominantly due to employee complaints about the irritant effect of powdered latex gloves," she notes.
Specific objectives of the hospital's study were to:
*determine the prevalence of symptoms associated with latex allergy;
*establish the rate of latex sensitization;
*differentiate latex-associated allergy symptoms from those associated with other causes.
Docken says the hospital study was undertaken to uncover the answers needed to provide a cost justification for latex allergy prevention and management measures.
Symptoms not reported to employee health
Obstacles encountered included lack of a central database documenting the prevalence of symptoms or known cases of latex allergies.
"These conditions often were not reported to employee health," Docken states. "Those cases that were reported exhibited a wide range of symptoms that may or may not have been related to latex allergies."
In addition, limited diagnostic measures are available to identify true latex allergy, "and the measures that are available are distinctly different for contact dermatitis, delayed hypersensitivity response to latex, and IgE-mediated or systemic allergy to latex," she says. "Also, measures to control and prevent problems associated with IgE-mediated latex allergy are far more encompassing than for contact dermatitis due to inhalation exposure of airborne latex allergens."
Another problem was that most published recommendations for latex allergy prevention and management "lack objective data for justification," Docken adds.
The study included three components. A three-page questionnaire and interview collected demographic data, allergy history, and known exposure to latex allergens at home and at work. Respiratory status was obtained through peak flow readings.
Allergy testing was performed with a modified skin-testing procedure to confirm IgE-mediated reactions to latex. The skin test -- with latex allergen and histamine phosphate and buffer controls -- was performed by the prick method. The latex allergen extract used was standardized by the allergic diseases research unit of the Mayo Medical Center in Rochester, MN, and has been used in previous studies, Docken explains.
The study sample included symptomatic and asymptomatic employees, as well as workers with and without latex glove contact. To assist in determining the significance of airborne exposure, participation was limited to employees working within the same air-handling system of the main hospital complex.
Employees fear job loss
Study participation was voluntary and required 20 minutes of an employee's time. Reasons that employees elected not to participate -- in addition to the time commitment and lack of interest -- included: dependence on antihistamines for treatment of symptoms, which was a contraindication for testing due to inability to respond to the allergen; fear of anaphylaxis in people with suspected or confirmed latex allergy; and concerns regarding job security if they were found to be latex-allergy-positive, although the informed-consent form included assurances to the contrary.
The study sample included 547 workers in 30 job categories and 98 departments. Of those tested, 260 (47%) reported symptoms; 31 (12%) of those tested positive for latex allergy. Fifty-two percent of participants reported no symptoms believed to be associated with latex allergy; however, two people in the asymptomatic group tested positive for latex allergy.
"One of those rarely reported contact with latex products, which may have accounted for the lack of sensitization or presentation of symptoms," Docken says. "The other may represent a false-positive result."
Presence of true latex allergy (positive criterion was greater than three millimeters induration) in the total sample population tested was 6%.
"We know we have not accounted for all latex-allergic employees within our sample population," Docken notes. The 547 workers represent about 20% of the potential pool of all 2,790 employees who work within the same air-handling system.
The presence of dermatitis symptoms was strongly correlated to people testing positive for latex allergies, with 88% reporting itchy hands and 81% reporting rash. A combination of symptoms such as dermatitis or rash and upper or lower respiratory symptoms was most predictive of true latex allergy. Of those who tested positive, 24% had a combination of dermatitis, upper respiratory, and lower respiratory symptoms; 30% had both upper and lower respiratory symptoms; and 58% had upper respiratory and dermatitis symptoms.
Allergic rhinoconjunctivitis, or the presence of eye and nasal symptoms, was reported by 64% of people testing positive for latex allergies. Isolated symptoms of itchy eyes were reported in 54% and rhinitis in 58% of those who tested positive.
Asthmatic symptoms did not demonstrate as high a correlation with positive tests, Docken says. Wheeze was noted in 24% of latex-positive employees, and asthma was reported in 30%. Cough and shortness of breath were not significantly different between the negative and positive groups.
"It was interesting to note that nine of the 33 positives reported anaphylaxis, but all have been able to continue to work by avoiding latex contact," she adds. No job accommodations had to be made; instead, all have switched to synthetic gloves.
Departmental trends identified
A departmental breakdown of employees testing positive revealed eight were sporadic cases among a variety of departments. Seven were employed in different medical-surgical units.
Of the departmental trends identified in the remaining positives, "the one that was of most concern to us were five CICU [cardiac intensive care unit] employees testing positive for an absolute prevalence of 6.9% [of CICU employees]. However, only 22% of the CICU employees were tested, yielding a positive rate among those screened of 31.2%," Docken says.
Four dietary employees tested positive, for an absolute prevalence of 3.7% and a 40% positive rate in the 10 people who participated in the study. Operating room personnel had a prevalence rate of about 3%, and the prevalence rate for laboratory personnel was 2.8%. In those populations, nearly 50% of personnel participated in the study.
Twenty of the 33 total positives were employed within the department of nursing; 17 were registered nurses and three were nurses' aides.
"Surprisingly, there was no significant difference between cumulative years of latex exposure and latex allergy," Docken points out. "Additional statistical analysis stratifying other risk factors is necessary to further evaluate this finding. Perhaps only the last five to 10 years make the most difference because glove use has increased during that period of time."
Another interesting finding was that employees testing positive generally had experienced more surgical procedures than those testing negative. "Again, further statistical analysis is being done to determine the significance of this independent variable," she adds.
Contact history correlates with allergy
Predictably, latex glove utilization among people testing positive was high. Although five of the 33 currently reported only rare or occasional latex glove use, they answered the question based on current use. Four of those people actually had significant latex contact prior to being diagnosed with latex allergy.
"Therefore, all but one, or 97% of persons testing positive, had a significant history of contact with latex gloves," Docken says. "It is a concern that all those reporting current glove use were still using latex gloves [before counseling]."
Only seven of the 33 testing positive had a prior diagnosis of latex allergy.
"Alarmingly, of these seven, only three described their plan of care to include contact avoidance and management of allergic symptoms and anaphylaxis," she says.
Daily contact with other latex products was reported by 61% of those testing positive. Of these 20 people reporting daily contact, however, only one did not also report significant contact with latex gloves.
"Glove exposure would appear to have significantly greater correlation to the development of latex allergy than contact with any other source of latex," Docken states.
She also notes that 79% of those testing positive reported a history of allergic tendencies in themselves and 73% in their families. No correlation was found between latex allergy and food allergies, although this association has been reported. (See Hospital Employee Health, September 1995, pp. 109-115.)
In symptomatic employees testing negative for latex allergy, some improvement in symptoms resulted from changing the type of gloves they used to powder-free or vinyl gloves, "demonstrating an irritant component of glove use," Docken adds.
Some 78% of employees testing positive reported improvement in symptoms with vinyl glove use. Some of those who did not report improvement voiced negative attitudes or experiences with vinyl gloves when they were counseled. Docken says some of those employees rejected vinyl gloves due to subjective reasons such as dissatisfaction with the gloves' fit or feel.
Only 63% of symptomatic positives noted improvement with powder-free gloves, "demonstrating the reduced latex protein content in powder-free gloves, but emphasizing the realization that powder-free latex gloves are still latex and should be avoided by allergic persons," Docken states.
Study data prompted a set of recommendations from the hospital's latex allergy task force, which include:
* Continue to educate health care workers about latex allergy due to its significant prevalence.
* Continue to offer latex allergy testing for employees, as it offers valuable information for both the individual and the institution.
* Provide avoidance counseling and education regarding the management of symptoms for employees who are latex-allergic, as they often cannot obtain adequate information from other sources.
* Evaluate the implications of preplacement latex-allergy testing for new hires to identify appropriate work accommodations and practices to avoid latex contact.
* Eliminate powdered latex gloves from the health care environment and move toward nonlatex gloves.
* Support the use of hand emollient to reduce chapping of skin, which creates open areas for latex exposure and increases sensitization risk.
* Continue to educate regarding appropriate glove selection for activities such as cleaning and disinfection, which do not require latex gloves, and general avoidance of gloves in situations where they are not necessary.
Reference
1. Docken L, Beiningen G, Bossman S, et al. Allergic reactions to latex and related problems associated with glove use among healthcare workers. Presented at the 23rd Annual Educational Conference and International Meeting of the Association for Professionals in Infection Control and Epidemiology. Atlanta; June 1996. *
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