# Presentation: 351248

## Natural Latex Allergy/Irritation

- by
- XXXXXXXXX
- Department of Veterans Affairs

## Natural & Synthetic Latex

**Latex** - particles in a  liquid lattice suspension
-           (synthetic rubber/polymer or natural)
- Synthetic (polyethylene, polyurethane, neoprene, nitrile) - Synthetic Rubber Latex does not come from plants
- Natural rubber (Milky sap from 2,000 species of plants - Hevea brasiliensis tree in Southeast Asia
**Production** of synthetic rubber/polymer and natural rubber is a complex multi-step process involving a number of chemicals (vulcanize or cross-link rubber, preserve, and aid production)

## Allergy

- Immune response to a foreign invading substance/agent, e.g.,  often an invading foreign protein called an Antigen.
- When exposed the body reacts producing chemicals and antibodies to destroy the antigen.
- Allergic symptoms from cellular chemical(s), such as histamines
- Allergies acquired
- Allergies often genetic (food groups -Atopic individuals)
- Allergic response may be induced

## Latex Allergy

- A latex allergy is a reaction to a material on or contained in latex.
- A natural latex allergy is a type of reaction to _one of many proteins_ contained in natural rubber latex.

## Allergy/Irritation

- Both Natural and Synthetic Rubber
- Chemicals in rubber
- Accelerators (Speeds cross-linking e.g., thiurams - 60%)
- Antioxidants (Preservatives  e.g., phenolics)
- Other Latex Products
- Paint?  -  Natural Latex?
- Masking Tape? Likely
- Outside Rubber the Cause?
- methyl methacrylate monomer - penetrate glove

**Notes:**
Natural rubber contains proteins, lipids, nucleotides, and cofactors.  THEN
There are over 200 agents added to natural latex during the manufacturing process.
Manufactures formulate their natural latex gloves with different amounts of natural rubber proteins (3,000-fold difference between manufacturers)
Synthetic rubber latex gloves may contain some of the same additives as natural rubber latex

## Irritant

- Frequent handwashing with inadequate drying, rinsing, and removal of oils
- Aggressive scrubbing
- Climatic extremes
- Mechanical abrasion  -  e.g., glove powders
- Skin not allowed to breath - i.e., prolonged glove use

## Allergy/Irritation

- Mild Acute
- Redness
- Itching, burning, and tingling
- Mild Chronic
- Dry, cracked and scaly skin
- Among persons with mild forms of latex allergy - No way to predict how serious reactions will develop.
- Severe (Urticaria/asthma/anaphylaxis)
- Immediate (0-30 minutes) with spread to areas remote to site contact (respiratory distress to anaphylaxis) -- IgE-mediated hypersensitivity

## Latex Allergy

- FDA (1988 -1992) - 1,000 cases 15 deaths
- American College of Allergy, Asthma and Immunology - An epidemic for health care workers (July 1997)
- CDC
- 1% general population
- 2.9 to 17 % health care workers
- Diagnosis difficult
- History
- No Routine Testing

**Notes:**
The true natural latex sensitivity/allergy is from the proteins

## Natural Latex Problem?

- Clinically and Pathologically - Similar
- Mechanical Irritation
- Glove Component
- Latex Glove Not Appropriate to All Tasks (e.g., methyl methacrylate monomer which can penetrate many gloves - bone cement)

## Risk Factors

- Frequency and Duration of Exposure (multiple glove use, wearing for extended periods, skin breakdown, failure to wash hands, multiple surgery, perspiring under gloves)
- Route of Exposure (through cuts or lesion, mucous membranes, circulatory system
- Type of Glove (exam. vs. surgical, powdered vs. powdered free, high/low protein)
- Predisposing Factors (host family - history, immune-compromised, atopic)

## Tests

- Patch Test - not for natural latex proteins (reagent in future - Greer (Johns Hopkins) skin test reagent - (systemic reaction mild - treatment without epinephrine)
- Skin Prick Test - not for natural latex proteins
- Wearer or Use Test - not for natural latex proteins
- RAST Test (Radio-allergosorbert) - Approved by FDA for natural latex protein
- 80% sensitivity
- 100% specific in non-atopic individuals
- May be + and no symptoms or - with symptoms

## Gloves

**Protective rubber gloves:**
- In OR by American surgeon Halstead just over 100 years ago.
- Protect against harsh disinfecting agents.  Efficacy in reducing transmission of infection.
**Use** of protective natural rubber latex has increased (BBP)

## Skin Care

- Minimize contact with causative agents
- Irritants
- Proper selection of gloves
- For chemicals being worked with
- Substitute gloves containing chemical causing reaction
- Minimize natural latex protein contact (low protein or synthetic)
- Use skin emulsion
- Glove liners

## Skin Emulsion & Soap

- Impact of emulsion on glove
- Degradation of the glove
- Leaching out NLP or chemical constituents
- Hasten transfer of latex protein
- Impact on antibacterial soap (30 sec. washing for rig.)
- Degradation of the glove
- Leaching out NLP or chemical constituents
- Hasten transfer of latex protein
- Allergen (preservatives, e.g., methy(chloro) iothiazolinone and glutaraldehyde) - antiseptics - antimicrobial (CDC and APIC - Guidelines for handwashing and hand antisepsis in health care settings - non antimicrobial)
- Impact of antibacterial soap and emulsion combination

**Notes:**
CDC advises hospitals to reserve antibacterials for patients in high risk situations
CDC - Hospital Infections Program - Antibacterial soaps remove 97 % of bacterial on people’s  hands compared with 95% with non-antibacterial soap

## Low Protein Gloves

- Modified Lowry Test - Protein in glove water extracts.  American Society for Testing and Materials (ASTM)
- Latex Enzymelinked Imunosorbent assay (ELISA) - Has not been validated against specific allergen-measuring methods.
- RAST Inhibition - Lack of standardized NRL allergen.

## Agency Actions

- Occupational Safety and Health Administration _[(OSHA Latex page)](http://www.osha-slc.gov/SLTC/latexallergy/index.html)_
- 29 CFR 1910.1030 (d)(3)(iii) - Bloodborne
- 29 CFR 1910.1200 and .1450 - HazCom
- 29 CFR 1910.138 - General Gloves
**(http:www.osha-slc.gov/OshDoc/Interp-data/INTERP_19960111B.html)**
- Food and Drug Administration
- Rule on labeling on in effective
- Has an _[alert](http://www.fda.gov//medwatch/report/desk/casestud.htm)_ to health care professionals

**Notes:**
OSHA regulates but defers labeling to FDA
FDA has a rule - FDA has issued a medical alert to advise health professional of hazard

## Agency Actions (continued)

- National Institute for Occupational Safety and Health
**NIOSH Alert - **
- CDC & Health and Human Services
- Guidelines for Infection Control in Health Care Personnel - 1998
- Office of Workers’ Compensation Programs
- OWCP

**Notes:**

Compensable
Source code 0761 for natural latex
0762 for chemical component
Nature (NO CHANGE) 710 inhalation or 730 for absorption
Nature code AR for sensitivity/allergy systemic
AD for dermal

## Agency Actions (continued)

- Americans with Disabilities Act or
-    Federal Rehabilitation Act of 1973
- Pre-employment physical - conditional only
- Essential job functions of this position
- Accommodation

## Latex Allergy Resources

- Videos
- Protecting Against Latex Allergy (Spina Bifida Association)
- The Latex Allergy Dilemma by Envision Incorporated.
- Books
- Protective Gloves for Occupational Use by Gunh A. Mellstrom. P.D.., Ph.D. (OSHA Library)
- World Wide Web
- Foundation for Latex Allergy Research and Education
- Latex Allergy Information Service

## Department of Veterans AffairsLatex Allergy Preventionhttp://www.va.gov/vasafety

## VA Natural Latex Policy

- Prevent, where possible, exposure by at-risk patients and employees
- Minimize employee contact
- Synthetic or low NLP gloves
- Use the right gloves
- Eliminate where possible vehicles for NLP (Powder)
- Provide accommodation
- Track OWCP claims
- Facility Safety Committee
- Skin emulsions/moisturizers
- Washing hands after wearing gloves

**Notes:**
.
Hand washing important.

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