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NOTICE TO THE READER In this third printing, minor changes have been made In some wording of the text for additional clarity.

DHHS (NIOSH) Publication No. 97-135

First Printing -June 1997 Second Printing -August 1997 Third Printing -August 1998 Preventing Allergic Reactions to in the Workplace

WARNING! Workers exposed to latex gloves and other products containing natural rubber latex may develop al!lergic reactions such as skin ; ; nasal, eye, or sinus symptoms; ; and (rarely) shock. -

Workers with ongoing exposure to natural rubber la­ 6. Learn to recognize the symptoms of latex : tex* should take the following steps to protect them­ skin rashes; hives; flushing; itching; nasal, eye, or si­ selves: nus symptoms; asthma; and shock.

1 . Use non latex gloves for activities that are not likely to 7. If you develop symptoms of , avoid direct involve contact with infectious materials (food prepa­ contact with latex gloves and products until you can ration, routine housekeeping, maintenance, etc.). see a physician experienced in treating latex allergy. 8. If you have latex allergy, consult your physician re­ 2. Appropriate barrier protection is necessary when han­ garding the following precautions: dling infectious materials. t If you choose latex gloves, use powder-free gloves with reduced con­ • Avoid contact with latex gloves and products. tent.* • Avoid areas where you might inhale the powder from the latex gloves worn by others. 3. When wearing latex gloves, do not use oil-based hand creams or lotions (which can cause glove de­ • Tell your employers, physicians, nurses, and den­ terioration) unless they have been shown to reduce tists that you have latex allergy. latex-related problems and maintain glove barrier pro­ tection. • Wear a medical alert bracelet. 9. Take advantage of all latex allergy and training 4. Frequently clean work areas contaminated with latex provided by your employer. dust (upholstery, carpets, ventilation ducts, and ple­ nums).

5. Frequently change the ventilation filters and vacuum bags used in latex-contaminated areas.

"In this warning sheet, the term "latex" refers to natural rubber latex and includes products made from dry natural rubber. Natural rubber latex is the product manufactured from a milky fluid derived mainly from the rubber , . tCDC (Centers for Disease Control and Prevention) [1987). Recommendations for prevention of HIV transmission in health-care settings. MMWR 36(82). *The goal of this recommendation is to reduce exposure to allergy-causing (). Until well accepted stan­ dardized tests are available, total protein serves as a use­ Dust produced by removing a latex glove contain­ ful indicator of the exposure of concern. ing powder.

Please tear out and post. Distribute copies to workers. See back of sheet to order complete Alert. For additional information, see N/OSH Alert: Preventing Allergic Reactions to Natural Rubber Latex in the Work­ place (DHHS [NIOSH] Publication No. 97-135). Single copies of the Alert are available free from the following:

Publications Dissemination, EID National Institute for Occupational Safety and Health 4676 Columbia Parkway Cincinnati, OH 45226-1998

Fax number: (513) 533-8573 Phone number: 1-800-35-NIOSH (1-800-356-4674) E-mail: [email protected]

U.S. Department of Health and Human Services l"f'!J Public Health Service w/OSH Centers for Disease Control and Prevention National Institute for Occupational Safety and Health Preventing Allergic Reactions to Natural Rubber Latex in the Workplace

WARNING! Workers exposed to latex .gloves and other products containing natural rubber latex may develap allergic reacUons SL!Ch as s~in rashes; hives; nasal, eye, or sinus symptoms; asthma; and (rarely) shock.

The National Institute for Occupational also presents NIOSH recommendations for Safety and Health (NIOSH) requests assis­ minimizing latex-related health problems in tance in preventing allergic reactions to workers while protecting them from infec­ natural rubber latex· among workers who tious materials. These recommendations use gloves and other products containing include reducing exposures, using appro­ latex. Latex gloves have proved effective in priate work practices, training and educat­ preventing transmission of many infectious ing workers, monitoring symptoms, and diseases to health care workers. But for substituting non latex products when appro­ some workers, exposures to latex may re­ priate. sult in skin rashes; hives; flushing; itching; nasal, eye, or sinus symptoms; asthma; NIOSH requests that employers, owners, and (rarely) shock. Reports of such allergic editors of trade journals, safety and health reactions to latex have increased in recent officials, and labor unions bring the recom­ years-especially among health care workers. mendations in this Alert to the attention of all workers who may be exposed to latex. At present, scientific data are incomplete regarding the natural history of latex allergy. - ::r 't. ------=-=-- -- ' BACKGROUND Also, improvements are needed in methods I • used to measure proteins causing latex al­ lergy. This Alert presents the existing data Composition of Latex and describes six case reports of workers Latex products are manufactured from a milky who developed latex allergy. The document fluid derived from the rubber tree, Hevea brasiliensis. Several chemicals are added to this fluid during the processing and manufac­ ·In this document, the term "latex" refers to natural ture of commercial latex. Some proteins in rubber latex and includes products made from dry natu­ latex can cause a range of mild to severe al­ ral rubber. Natural rubber latex is the product manu­ factured from a milky fluid derived mainly from the lergic reactions. Currently available methods rubber tree, Hevea brasiliensis. of measurement do not provide easy or

1 consistent identification of allergy-causing Latex in the Workplace proteins (antigens) and their concentrations. Workers in the health care (physicians, Until well accepted standardized tests are nurses, dentists, technicians, etc.) are at risk available, total protein serves as a useful in­ for developing latex allergy because they use dicator of the exposure of concern. [Beezhold latex gloves frequently. Also at risk are work­ et al. 1996a]. The chemicals added during pro­ ers with less frequent glove use (hairdressers, cessing may also cause skin rashes. Several housekeepers, food service workers, etc.) and types of are also referred to workers in industries that manufacture latex as "latex;' but these do not release the proteins products. that cause allergic reactions.

Products Containing Latex TYPES OF REACTIONS TO LATEX A wide variety of products contain latex: medi­ cal supplies, personal protective equipment, and Three types of reactions can occur in persons numerous household objects. Most people who using latex products: encounter latex products only through their general use in society have no health problems • Irritant from the use of these products. Workers who • Allergic contact dermatitis (delayed repeatedly use latex products are the focus of ) this Alert. The following are examples of prod­ ucts that may contain latex: • Latex allergy

Irritant Contact Dermatitis Emergency Office Supplies Racquet Equipment Rubber bands handles The most common reaction to latex products Blood pressure soles cuffs Expandable is irritant contact dermatitis-the development Stethoscopes Hospital Supplies fabrics of dry, itchy, irritated areas on the skin, usually Disposable gloves Anesthesia masks (waistbands) Oral and nasal Catheters Dishwashing the hands. This reaction is caused by skin airways Wound drains gloves irritation from using gloves and possibly by ex­ Endotracheal tubes Injection ports Hot water Tourniquets Rubber tops of posure to other workplace products and chemi­ Intravenous tubing multidose vials cals. The reaction can also result from repeated Dental dams Diaphragms hand washing and drying, incomplete hand Electrode pads Household drying, use of cleaners and sanitizers, and ex­ Personal Objects Baby posure to powders added to the gloves. Irri­ Protective Automobile nipples Equipment Motorcycle and tant contact dermatitis is not a true allergy. Gloves bicycle Surgical masks handgrips Goggles Carpeting Allergic Contact Dermatitis Respirators Swimming Rubber aprons goggles Allergic contact dermatitis (delayed hypersen­ sitivity, also sometimes called chemical sensi­ Individuals who already have latex allergy should tivity dermatitis) results from exposure to be aware of latex-containing products that may chemicals added to latex during harvesting, trigger an allergic reaction. Some of the listed processing, or . These chemicals products are available in latex-free forms. can cause skin reactions similar to those

2 Allergic Reactions to Natural Rubber Latex caused by poison ivy. As with poison ivy, the usually begins 24 to 48 hours after contact and may progress to oozing skin blisters or spread away from the area of skin touched by the latex.

Latex Allergy Latex allergy (immediate hypersensitivity) can be a more serious reaction to latex than irritant contact dermatitis or allergic contact dermati­ tis. Certain proteins in latex may cause sensiti­ zation (positive blood or skin test, with or without symptoms). Although the amount of exposure needed to cause sensitization or symptoms is Figure 1. Dust produced by removing a latex glove not known, exposures at even very low levels containing powder. can trigger allergic reactions in some sensi­ tized individuals. The proteins responsible for latex have been shown to fasten to powder that is used Reactions usually begin within minutes of ex­ on some latex gloves. When powdered gloves posure to latex, but they can occur hours later are worn, more latex protein reaches the skin. and can produce various symptoms. Mild re­ Also, when gloves are changed, latex protein/ actions to latex involve skin redness, hives, or powder particles get into the air, where they itching. More severe reactions may involve res­ can be inhaled and contact body membranes piratory symptoms such as runny nose, sneez­ (see Figure 1) [Heilman et al. 1996]. In con­ ing, itchy eyes, scratchy throat, and asthma trast, work areas where only powder-free (difficult breathing, coughing spells, and gloves are used show low levels or undetect­ wheezing). Rarely, shock may occur; but a life­ able amounts of the allergy-causing proteins threatening reaction is seldom the first sign of [Tarlo 1994; Swanson et al. 1994]. latex allergy. Such reactions are similar to those seen in some allergic persons after a . Wearing latex gloves during episodes of hand dermatitis may increase skin exposure and the risk of developing latex allergy. The risk of pro­ gression from skin rash to more serious reac­ LEVELS AND ROUTES OF EXPOSURE tions is unknown. However, a skin rash may be the first sign that a worker has become al­ Studies of other allergy-causing substances lergic to latex and that more serious reactions provide evidence that the higher the overall could occur with continuing exposure [Kelly et exposure in a population, the greater the likeli­ al. 1996]. hood that more individuals will become sensi­ tized [Venables and Chan-Yeung 1997]. The amount of latex exposure needed to produce WHO IS AT RISK? sensitization or an allergic reaction is unknown; however, reductions in exposure to latex pro­ teins have been reported to be associated Workers with ongoing latex exposure are at risk with decreased sensitization and symptoms for developing latex allergy. Such workers in­ [Tarlo et al. 1994; Hunt et al. 1996]. clude health care workers (physicians, nurses,

Allergic Reactions to Natural Rubber Latex 3 aides, dentists, dental hygienists, operating room a drop of liquid containing latex proteins. A employees, laboratory technicians, and hospi­ positive reaction is shown by itching, swelling tal housekeeping personnel) who frequently use or redness at the test site. However, no FDA­ latex gloves and other latex-containing medi­ approved materials are yet available to use in cal supplies. Workers who use latex gloves less skin testing for latex allergy. Skin testing and frequently (law enforcement personnel, ambu­ glove-use tests should be performed only at lance attendants, funeral-home workers, fire medical centers with staff who are experienced fighters, painters, gardeners, food service work­ and equipped to handle severe reactions. ers, and housekeeping personnel) may also develop latex allergy. Workers in factories where Testing is also available to diagnose allergic latex products are manufactured or used can contact dermatitis. In this FDA-approved test, also be affected. a special patch containing latex additives is ap­ plied to the skin and checked over several Atopic individuals (persons with a tendency to days. A positive reaction is shown by itching, have multiple allergic conditions) are at in­ redness, swelling, or blistering where the patch creased risk for developing latex allergy. Latex covered the skin. allergy is also associated with allergies to cer­ tain foods-especially , , ba­ Occasionally, tests may fail to confirm a worker nana, , chestnuts, kiwi fruit, and . who has a true allergy to latex, or tests may [Blanco et al. 1994; Beezhold et al. 1996b]. suggest latex allergy in a worker with no clini­ People with are also at increased cal symptoms. Therefore, test results must be risk for latex allergy. evaluated by a knowledgeable physician.

TREATING LATEX ALLERGY DIAGNOSING LATEX ALLERGY

Once a worker becomes allergic to latex, spe­ Latex allergy should be suspected in anyone cial precautions are needed to prevent expo­ who develops certain symptoms after latex ex­ sures--during work as well as during medical posure, including nasal, eye, or sinus irritation; or dental care. Certain medications may reduce hives; shortness of breath; coughing; wheez­ the allergy symptoms, but complete latex ing; or unexplained shock. Any exposed worker avoidance (though quite difficult) is the most who experiences these symptoms should be effective approach. Many facilities maintain evaluated by a physician, since further expo­ latex-safe areas for affected patients and sure could result in a serious allergic reaction. workers. A diagnosis is made by using the results of a medical history, physical examination, and tests.

Taking a complete medical history is the first HOW COMMON IS LATEX ALLERGY? step in diagnosing latex allergy. In addition, blood tests approved by the Food and Drug The prevalence of latex allergy has been stud­ Administration (FDA) are available to detect ied by several methods: latex antibodies. Other diagnostic tools include a standardized glove-use test or skin tests that • Questionnaires to assess reactions to involve scratching or pricking the skin through latex gloves

4 Allergic Reactions to Natural Rubber Latex • Medical histories of reactions to latex­ employers to provide gloves and other containing products protective measures for their employees [29 CFRt191 0.1030, Bloodborne patho­ • Skin tests gens]. • Tests for latex antibodies in a worker's blood 3. Some manufacturers may have produced Reports about the prevalence of latex allergy more allergenic gloves because of changes vary greatly. This variation is probably due to in raw materials, processing, or manufac­ different levels of exposure and methods for turing procedures to meet the increased estimating latex sensitization or allergy. Recent demand for latex gloves [Hunt et al. 1995]. reports in the scientific literature indicate that These production changes may account from about 1% to 6% of the general population partly for the varied concentrations of ex­ and about 8% to 12% of regularly exposed tractable latex proteins reported for latex health care workers are sensitized to latex gloves (up to a 3,000-fold difference in [Kelly et al. 1996; Katelaris et al. 1996; Liss et gloves from various manufacturers) al. 1997; Ownby et al. 1996; Sussman and [Yunginger et al. 1994; Beezhold 1992]. Beezhold 1995]. Among sensitized workers, a Variations may also exist between lots pro­ variable proportion have symptoms or signs of duced by the same manufacturer. latex allergy. For example, one study of ex­ posed hospital workers found that 54% of 4. Physicians are more familiar with latex al­ those sensitized had latex asthma, with an lergy and have improved methods for diag­ overall prevalence of latex asthma of 2.5% nosing it. [Vandenplas et al. 1995]. Prevalence rates up to 11% are reported for non-health care work­ ers exposed to latex at work [van derWalle and CASE REPORTS Brunsveld 1995; Nasuruddin et al. 1993; Orfan et al. 1994; Tarle et al. 1990]. The following case reports briefly describe the experiences of six workers who developed la­ Several reasons may exist for the large num­ tex allergy after occupational exposures. These bers of latex allergies recently reported in work­ cases are not representative of all reactions to ers [Truscott 1995]: latex but are examples of the most serious types of reactions. They illustrate what has oc­ 1. Workers rely increasingly on latex gloves to curred in some individuals. prevent the transmission of human immu­ nodeficiency virus (HIV), hepatitis B virus, Case No.1 and other infectious agents-as outlined in Recommendations for Prevention of HIV A laboratory technician developed asthma Transmission in Health-Care Settings [CDC symptoms after wearing latex gloves while per­ 1987] and in Guidelines for Prevention of forming blood tests. Initially, the symptoms oc­ Transmission of Human Immunodeficiency curred only on contact with the gloves; but Virus and Hepatitis 8 Virus to Health-Care later, symptoms occurred when the technician and Public-Safety Workers [CDC 1989]. was exposed only to latex particles in the air [Seaton et al. 1988]. 2. Since 1992, the Occupational Safety and Health Administration (OSHA) has required tCode of Federal Regulations. See CFR in references.

Allergic Reactions to Natural Rubber Latex 5 Case No.2 a pair of latex gloves. He was successfully A 33-year-old woman sought medical treatment resuscitated by a cardiac arrest team [Rosen for occupational asthma after 6 months of et al. 1993]. periodic cough, shortness of breath, chest tight­ ness, and occasional wheezing. She had worked for 7 years as an inspector at a medi­ Case No.6 cal supply company, where her job included in­ An intensive care nurse with a history of runny flating latex gloves coated with cornstarch. Her nose, itchy eyes, asthma, eczema, and contact symptoms began within 1 0 minutes of start­ dermatitis experienced four severe allergic ing work and worsened later in the day (90 min­ reactions to latex. The first reaction began with utes after leaving work). Symptoms disappeared asthma severe enough to require treatment in completely while she was on a 12-day vacation, an emergency room. The second and third re­ but they returned on her first day back at work actions were similar to the first. The fourth and [Tarlo et al. 1990]. most severe reaction occurred when she put on latex gloves at work. She went into severe shock and was successfully treated in an emer­ Case No.3 gency room [Rosen et al. 1993]. A nurse developed hives in 1987, nasal con­ gestion in 1989, and asthma in 1992. Eventu­ ally she developed severe respiratory symptoms in the health care environment even CONCLUSIONS when she had no direct contact with latex. The nurse was forced to leave her occupation be­ Latex allergy in the workplace can result in po­ cause of these health effects [Bauer et al. 1993]. tentially serious health problems for workers, who are often unaware of the risk of latex ex­ posure. Such health problems can be mini­ Case No.4 mized or prevented by following the recom­ A midwife initially suffered hives, nasal conges­ mendations outlined in this Alert. tion, and conjunctivitis. Within a year, she de­ veloped asthma, and 2 years later she went into shock after a routine gynecological exami­ nation during which latex gloves were used. RECOMMENDATIONS The midwife also suffered respiratory distress in latex-containing environments when she The following recommendations for preventing had no direct contact with latex products. She latex allergy in the workplace are based on was unable to continue working [Bauer et al. current knowledge and a common-sense 1993]. approach to minimizing latex-related health problems. Evolving manufacturing and improvements in measurement methods . Case No.5 may lead to changes in these recommendations A physician with a history of seasonal aller­ in the future. For now, adoption of the recom­ gies, runny nose, and eczema on his hands mendations wherever feasible will contribute suffered severe runny nose, shortness of to the reduction of exposure and risk for the de­ breath, and collapse minutes after putting on velopment of latex allergy.

6 Allergic Reactions to Natural Rubber Latex -Frequently change ventilation filters visit the NIOSH Homepage on the World and vacuum bags used in latex-contami­ Wide Web at nated areas. http://www.cdc.gov/niosh 4. Take advantage of all latex allergy education and training provided by your employer: You may access the following latex allergy • Become familiar with procedures for pre­ websites directly or by selecting Latex Allergy venting latex allergy. through the NIOSH Homepage:

• Learn to recognize the symptoms of latex • http://mediswww.cwru.edu/dept/anesth/ allergy: skin rashes; hives; flushing; itch­ lair/lair.htm ing; nasal, eye, or sinus symptoms; asthma; and shock. • http://www. fam ilyvi llage. wisc.ed u/ lib_latx.htm 5. 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. ACKNOWLEDGMENTS 6. If you have latex allergy, consult your physi­ cian regarding the following precautions: Principal contributors to this Alert were • Avoid contact with latex gloves and other latex-containing products. R.E. Biagini, S. Deitchman, E.J. Esswein, J. Fedan, J.P. Flesch, P.K. Hodgins, T.K. Hodous, • Avoid areas where you might inhale the R.D. Hull, W.R. Jarvis, D.M. Lewis, J.A. powder from latex gloves worn by other Lipscomb, B.D. Lushniak, M.L. Pearson, E.L. workers. Petsonk, L. Pinkerton, PD. Siegal, W.G. Wippel, and K.A. Worthington. • Tell your employer and your health care providers (physicians, nurses, dentists, etc.) that you have latex allergy. Please direct comments, questions, or requests for additional information to the following: • Wear a medical alert bracelet.

Director 7. Carefully follow your physician's instructions Division of Surveillance, Hazard Evaluations, for dealing with allergic reactions to latex. and Field Studies National Institute for Occupational Safety and Health 4676 Columbia Parkway ADDITIONAL INFORMATION Cincinnati, OH 45226-1998

For additional information about latex allergy, Telephone: 513-841-4366 or caii1-800-35-NIOSH (1-800-356-4674); or 1-800-35-N IOSH ( 1-800-356-4674).

8 Allergic Reactions to Natural Rubber Latex Employers Workers Latex allergy can be prevented only if employ­ Workers should take the following steps to ers adopt policies to protect workers from un­ protect themselves from latex exposure and al­ due latex exposures. NIOSH recommends that lergy in the workplace: employers take the following steps to protect workers from latex exposure and allergy in the 1. Use nonlatex gloves for activities that are workplace: not likely to involve contact with infectious materials (food preparation, routine house­ 1. Provide workers with non latex gloves to use keeping, maintenance, etc.). when there is little potential for contact with infectious materials (for example, in the food 2. Appropriate barrier protection is necessary service industry). when handling infectious materials [CDC 1987]. If you choose latex gloves, use pow­ 2. Appropriate barrier protection is necessary der-free gloves with reduced protein content:* when handling infectious materials [CDC 1987]. If latex gloves are chosen, provide re­ • Such gloves reduce exposures to latex duced protein, powder-free gloves to protect protein and thus reduce the risk of latex workers from infectious materials.* allergy (though symptoms may still oc­ cur in some workers). 3. Ensure that workers use good housekeep­ ing practices to remove latex-containing dust • So-called hypoallergenic latex gloves do from the workplace: not reduce the risk of latex allergy. How­ ever, they may reduce reactions to • Identify areas contaminated with latex chemical additives in the latex (allergic dust for frequent (upholstery, contact dermatitis). carpets, ventilation ducts, and plenums). 3. Use appropriate work practices to reduce • Make sure that workers change ventila­ the chance of reactions to latex: tion filters and vacuum bags frequently in latex-contaminated areas. • When wearing latex gloves, do not use oil-based hand creams or lotions (which 4. Provide workers with education programs can cause glove deterioration) unless and training materials about latex allergy. they have been shown to reduce latex­ 5. Periodically screen high-risk workers for la­ related problems and maintain glove tex allergy symptoms. Detecting symptoms barrier protection. early and removing symptomatic workers from latex exposure are essential for prevent­ • After removing latex gloves, wash hands ing long-term health effects. with a mild soap and dry thoroughly.

6. Evaluate current prevention strategies when­ • Use good housekeeping practices to ever a worker is diagnosed with latex allergy. remove latex-containing dust from the workplace:

*The goal of this recommendation is to reduce exposure to -Frequently clean areas contaminated allergy-causing proteins (antigens). Until well accepted stan­ dardized tests are available, total protein serves as a use­ with latex dust (upholstery, carpets, ful indicator of the exposure of concern. ventilation ducts, and plenums).

Allergic Reactions to Natural Rubber Latex 7 We greatly appreciate your assistance in pro­ transmission of human immunodeficiency vi­ tecting the health of U.S. workers. rus and hepatitis B virus to health-care and public-safety workers. MMWR 38(S-B):1-37.

CFR. Code of Federal regulations. Washing­ ton, DC: U.S. Government Printing Office, Of­ fice of the Federal Register. Heilman DK, Jones AT, Swanson MC, Linda Rosenstock, M.D., M.P.H. Yunginger JW [1996]. A prospective, controlled Director, National Institute for study showing that rubber gloves are the ma­ Occupational Safety and Health jor contributor to latex levels in Centers for Disease Control and Prevention the operating room. J Allergy Clin lmmunol 98(2) :325-330. REFERENCES Hunt LW, Fransway AF, Reed CE, Miller LK, Jones AT, Swanson MC, et al. [1995]. An epi­ Bauer X, Ammon J, Chen Z, Beckman U, demic of occupational allergy to latex involving Czuppon AB [1993]. Health risk in hospitals health care workers. JOEM 37(10):1204-1209. through airborne for patients pre-sen­ sitized to latex. Lancet 342:1148-1149. Hunt LW, Boone-Orke JL, Fransway AF, Fremstad CE, Jones AT, Swanson MC, et al. Beezhold D [1992]. LEAP: Latex ELISA for [1996]. A medical-center-wide, multidisciplinary antigenic protein. Guthrie J 61:77-81. approach to the problem of natural rubber la­ tex allergy. JOEM 38(8):765-770. Beezhold D, Pugh B, Liss G, Sussman G. [1996a] Correlation of protein levels with skin Katelaris CH, Widmer RP, Lazarus AM [1996]. prick test reactions in patients allergic to latex. Prevalence of latex allergy in a dental school. J Allergy and Clin lmmunol98(6):1097-1102. Med J Australia 164:711-714.

Beezhold DH, Sussman GL, Liss GM, Chang Kelly KJ, Sussman G, Fink JN [1996]. Stop the NS [1996b]. Latex allergy can induce clinical sensitization. J Allergy Clin lmmunol 98(5): reactions to specific foods. Clin Exp Allergy 857-858. 26:416-422. Liss GM, Sussman GL, Deal K, Brown S, Blanco C, Carrillo T, Castillo R, Quiralte J, Cividino M, Siu S, et al. [1997]. Latex allergy: Cuevas M [1994]. Latex allergy: clinical features epidemiological study of hospital workers. and cross-reactivity with fruits. Ann Allergy Occup Environ Med 54:335-342. 73:309-314. Nasuruddin BA, Shahnaz M, Azizah MR, CDC (Centers for Disease Control and Preven­ Hasma H, Mok KL, Esah Y, et al. [1993]. Preva­ tion) [1987]. Recommendations for prevention lence study of type I latex hypersensitivity of HIV transmission in health-care settings. among high risk groups in the Malaysian popu­ MMWR 36(S2). lation-a preliminary report. Unpublished pa­ per presented at the Latex Allergy Workshop, CDC (Centers for Disease Control and Preven­ International Conference, tion) [1989]. Guidelines for prevention of , , June.

Allergic Reactions to Natural Rubber Latex 9 Orfan NA, Reed R, Dykewicz MS, Ganz M, Vandenplas 0, Delwiche JP, Evrared G, Aimont Kolski GB [1994]. Occupational asthma in a P, Van Der Brempt S, Jamart J, Delaunois L latex manufacturing plant. J Allergy Clin [1995]. Prevalence of occupational asthma due lmmunol 94(5):826-830. to latex among hospital personnel. Am J Respir Crit Care Med 151:54-60. Ownby DR, Ownby HE, McCullough J, Shafer, AW [1996]. The prevalence of anti-latex lgE Venables K, Chan-Yeung M [1997]. Occupa­ antibodies in 1000 volunteer blood donors. J tional asthma. The Lancet 349:1465-1469. Allergy Clin lmmunol97(6):1188-1192. Yunginger JW, Jones AT, Frasway AF, Kelso JM, Warner MA, Hunt LW [1994]. Extractable Rosen A, Isaacson D, Brady M, Corey JP latex allergens and proteins in disposable medi­ [1993]. Hypersensitivity to latex in health care cal gloves and other rubber products. J Allergy workers: report of five cases. Otolaryngol Head Clin lmmunol 93(5):836-842. Neck Surg 109(4):731-734.

Seaton A, Cherrie B, Turnbull J [1988]. asthma. Br Med J 296:531-532. SUGGESTED READINGS Sussman GL, Beezhold DH [1995]. Allergy to latex rubber. Ann Intern Med 122:43-46. Cassidy J [1994]. Latex glove allergy warning. Nursing Times 90(32):5. Swanson MC, Bubak ME, Hunt LW, Yunginger JW, Warner MA, Reed CE [1994]. Quantifica­ Charous BL [1994]. The puzzle of latex allergy: tion of occupational latex in a some answers, still more questions (editorial). medical center. J Allergy Clin lmmunol 94(3): Ann Allergy 73(1 0):277-281. 445-551. FDA [1991 ]. FDA medical alert: allergic reac­ Tarlo SM, Wong L, Roos J, Booth N [1990]. tions to latex-containing medical devices. Occupational asthma caused by latex in a sur­ Rockville, MD: Food and Drug Administration, gical glove manufacturing plant. J Allergy Clin MDA 91-1. lmmunol 85(3):626-631. Jones AT, Scheppmann DL, Heilman OK, Tarlo SM, Sussman G, Contala A, Swanson MC Yunginger JW [1994]. Prospective study of [1994]. Control of airborne latex by use of powder­ extractable latex contents of disposable free latex gloves. J Allergy Clin lmmunol 93: medical gloves. Ann Allergy 73(1 0):321-325. 985-989. Kaczmarek RG, Silverman BG, Gross TP, TruscottW [1995]. Abstracts: new proposals for Hamilton RG, Kessler E, Arrowsmith-Lowe JT, the increased incidences of immediate type hy­ et al. [1996]. Prevalence of latex-specific lgE persensitivity to latex. J Allergy Clin lmmunol antibodies in hospital personnel. Allergy Asthma 95(1, Part 2):252. lmmunol 76:51-56.

van der Walle HB, Brunsveld VM [1995]. La­ Kelly KJ, KurupVP, Reijula KR, FinkJN [1994]. tex allergy among hairdressers. Contact Der­ The diagnosis of natural rubber latex allergy. J matitis 32:177-178. Allergy Clin lmmunol 93(5):813-816.

10 Allergic Reactions to Natural Rubber Latex Korniewicz DM, Kelly KJ [1995]. Barrier protec­ TomazicVJ, WithrowTJ, Fisher BR, Dillard SF tion and latex allergy associated with surgical [1992]. Short analytical review. Latex-associ­ gloves. AORN 61(6):1037-1044. ated allergies and anaphylactic reactions. Clin lmmunollmmunopathol64(2):89-97. Landwehr LP, Boguniewicz M [1996]. Medical progress: current perspectives on latex allergy. TruscottW [1995]. The industry perspective on J Pediatr 128(3):305-312. latex. lmmunol Allergy Clin North America 15(1 ):89-121.

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