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CLINICAL REVIEW Review of

Lester Cheng, MD, and Daniel Lee, MD

Background: Allergy to latex has become an increasing concern to many patients and health care providers. Health care providers should become aware of this problem and develop strategies for treatment and prevention. Methods: We searched MEDLINE from 1990 to 1998 for the topics of latex allergy using the key words "la­ tex" and "allergy." Other sources were found from back-referencing these references and from the Internet. Results: Latex allergy is emerging as a clinical and occupational health problem. Understanding the clinical and immunologic features, which range from dermatitis to , can provide the basis of preventive and therapeutic strategies. Conclusion: The clinician should be able to recognize latex allergy and educate patients about the potential hazards of latex-containing products. Providers can develop a plan for protecting patients and health care staff from latex exposure as well as treating allergic reactions when they occur. (J Am Board Fam Pract 1999;12:285-92.)

In recent years patients and health care workers MEDLINE using the key words "latex" and "al­ have experienced a marked increase in serious al­ lergy." These articles were reviewed based on lergic reactions to latex! as a result of the increased their relevance to this review. Additional articles exposure and sensitization to latex products in the dating before 1990 were accessed by cross-refer­ health care industry, particularly latex gloves. Uni­ encing the more recent articles. versal precautions were implemented as a health care policy in 1987 as a result of the human im­ Epidemiology

munodeficiency virus (HIV) epidemic and spread General Population http://www.jabfm.org/ of hepatitis. At that time 1 billion gloves were im­ The overall incidence of latex allergy is unknown, ported into the United States annually. The fol­ but the prevalence in the general nonatopic popu­ lowing year more than 8 billion gloves were im­ lation is estimated to be less than 1 percent.3 In a ported.2 This dramatic increase in the use of latex recent study in Detroit, however, 1000 blood gloves has greatly contributed to the higher inci­ donors were tested for (IgE) dence of latex allergic reactions. Moreover, pa­ specificity for latex. Results showed a 6.4 percent tients and health care workers are not the only positive response, which suggests a much higher on 23 September 2021 by guest. Protected copyright. ones at risk for latex exposure. With more than prevalence in the general population than first 40,000 commercial products in the marketplace presumed.4 These results were basically replicated that contain latex, persons in other occupations in another study, where the prevalence of latex and a considerable portion of the general popula­ sensitization in persons attending health screening tion are at risk for latex exposure and sensitization. was 6.6 percent. 5

Methods Patient Population More than 500 titles were found during a search In the fall of 1989, the Food and Drug Adminis­ of the medical literature from 1990 to 1998 in tration (FDA) began receiving reports of patients going into anaphylactic shock while receiving bar­ ium enemas. Barium was originally suspected as Submitted, revised, 19 February 1999. From the Santa Monica-UCLA Family Practice Residency the sole culprit, but it was soon discovered that the Program (LC, DL), and the Department of Family Medicine, latex-cuffed enema tip was the cause of 16 deaths UCLA School of Medicine (DL), Santa Monica, Calif. Ad­ 6 dress reprint requests to Daniel Lee, MD, 1255 15th St, overall. This finding led to an increased aware­ Santa Monica, CA 90404. ness of the risk of type I allergy associated with la-

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tex products. Patients with are at in­ study it was estimated that 2.5 percent of hospital creased risk for latex sensitization because they are employees had occupational secondary to frequently exposed to latex from urethral latex . 18 The prevalence of latex­ catheterizations, multiple surgeries, and ventricu­ specific IgE antibodies in atopic and nona topic loperitoneal shunt placement early in life. The children with was 6 percent com­ prevalence of allergy in these patients ranges from pared with OJ 7 percent in the general population. 28 to 67 percent'? Pediatric patients with spina bi­ The high rate of sensitization to latex in children fida have a risk of latex-related anaphylaxis during with diabetes is secondary to the high rate of surgery that is 500 times greater than that of the in the study population. Atopic patients with dia­ general population. The marked increase in latex betes, however, might be at risk for reactions sec­ allergy in these spina bifida patients more likely ondary to latex from insulin vials and syringes. 19 results from extensive latex exposure early in life Finally, in patients being evaluated for allergy, the rather than a genetic predisposition. prevalence of latex-specific IgE antibodies was 12 Pregnant woman have also been found to be at percent.20 risk for sensitization to latex. Four women devel­ oped systemic allergic reactions during delivery as Pathophysiology a result of exposure to surgical latex gloves worn by Latex is the milky sap obtained by tapping the the obstetrician.8 In another study the incidence of rubber tree, Hevea brasiliensis. It is derived from latex sensitivity in an ambulatory surgical popula­ cells of the lactiferous system and is easily har­ tion was also found to be 6.7 percent (n - 996).9 vested. 21 The raw product is mixed with a preserv­ ative, such as ammonia; it is then concentrated Health Care Workers and shipped as a latex concentrate.22 Commercial The prevalence of latex allergy among health care use began with the discovery of vulcanization in workers is estimated between 5 to 10 percent.3,IO,11 1839 by Charles Goodyear. Vulcanization (heat­ In a study of registered nurses the prevalence of la­ ing in the presence of sulfur) greatly enhances the tex sensitization was 8.9 percent (n - 741).12 In an­ elasticity, strength, and stability of latex. Numer­ other study the prevalence of latex sensitization in ous chemical accelerators reduce the temperature a hospital employee population was approximately and time required.23 These accelerators can cause

8 percent (n - 135),13 and in another hospital set­ allergic reactions and are responsible for manyhttp://www.jabfm.org/ ting, the prevalence oflatex sensitization was 12.1 cases of . lo Chemically, latex percent among workers (n - 1351).14 contains proteins, cis-polyisoprene, water, and lipids. The proteins cause the severe immediate Other At-Risk Populations hypersensitivity reactions. 1,24 Workers in the latex-manufacturing industry are More than 50 different proteins have been im­ also at risk, with one glove-manufacturing plant plicated in the allergic response, with up to a total reporting a 3.7 percent prevalence of occupational of 240 different proteins found in latex.25 Latex on 23 September 2021 by guest. Protected copyright. asthma based on positive skin-prick testing and products are made either by pouring the rubber spirometric data. ls Workers at a latex doll-manu­ into molds or by forming a coating in a dipped facturing plant were also found to be sensitized to process, as is done with gloves, balloons, and con­ latex sensitization. 16 Many other persons are at doms. Dipped or very soft rubber products appear risk, especially the police and emergency medical to have the highest content of latex proteins and, personnel, food handlers who work in cafeterias therefore, have the greatest allergenic potential. and fast-food restaurants, and sanitation engineers Systemic reactions to latex can result from ex­ in various fields, all of whom can wear latex gloves posure to latex protein by various routes, including for prolonged periods. the skin, mucous membranes, inhalation, and in­ travascular or internal tissue. Medical devices that Atopic Patients have been reported to trigger serious systemic re­ Persons with atopy have higher risk for latex al­ actions by cutaneous exposure include anesthetic lergy. Two studies found that 54 and 57 percent of masks, tourniquets, electrocardiogram electrodes, persons with latex allergy had a history of atopy adhesive tapes, catheters, and ileostomy (asthma, , or ).17,18 In the same bags. Most severe reactions to latex have resulted

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Table 1. Products That Contain Latex.

Medical Products Nasopharyngeal and oro- Household and Personal Items Infant and Child Items Adhesive tape pharyngeal airway tubes Automobile tires Balloons Ambu bags Reservoir breathing Bath mats Bottle nipples Blood pressure cuffs bags Buttons on electronic Elastic in clothing and dis- Bulb syringes Rubber syringe stoppers equipment . posable diapers Crutches Stethoscope tubing Carpet backing and pads Halloween masks (arm and hand pads) Teeth protectors Computer mouse pads Infant pacifiers Electrocardiogram Tourniquets Rubber balls electrode pads Tympanometers Contraceptive sponges Rubber toys Elastic bandages Urinary catheters Diaphragms Electrode pads Ventilator bellows and Dishwashing gloves Sports Items Endotracheal tube hoses Foam rubber Athletic shoe soles Face masks, straps Wheelchair tires, Hot water bottles Rubber boats Gloves cushions Pencil erasers Scuba face masks Mattresses on Wound drains Rubber bands Sports racquet handles stretchers Rubber cements Swimming caps and goggles

from latex proteins contacting mucous membranes lar that the immune system recognizes these as la­ of the mouth, vagina, urethra, or rectum. Materials tex proteins and then responds to it. The most used in dentistry, including gloves, mouth bite common cross-reactivity has been found between plates, and orthodontic elastics, are potential aller­ latex and such foods as banana, , chestnut, gic sources. For infants pacifiers might be a possi­ passion fruit, kiwi fruit, potatoes, and tomatoes, all ble source of exposure to latex early in of which have been found to be antigenically simi­ life. 26 Some of the most severe reactions to latex lar to latex (Table 2).32 Other foods, including figs, have resulted from contact between the rectal mu­ , celery, melons, pineapples, milk, , cosa and balloon catheters used for barium ene­ and grapes, and pitted fruits, such as cherries, mas; these reactions are thought to be due to the peaches, and apricots, can also cross-react and high absorption rate of the rectum.6 cause symptoms. In one study, 42.6 percent of pa­ Cornstarch powder is applied to latex gloves tients known to be allergic to latex reported aller­

during the manufacturing process to prevent gic symptoms after ingestion of cross-reactive http://www.jabfm.org/ stickiness and to give the gloves a smooth feel. La­ fruits, including kiwi, banana, pineapple, passion tex protein particles have been shown to adhere to fruit, and .32 the surface of these cornstarch particles, which then become aerosolized on removal of the Clinical Manifestations gloves.25 ,27 Airborne latex protein absorbed by the There are three main types of latex sensitivity re­ cornstarch glove powder has been found to be re­ actions. Irritant contact dermatitis (nonimmune) lated to asthmatic reactions. Health care workers has a gradual onset, taking days, and is caused by on 23 September 2021 by guest. Protected copyright. who use gloves or work in a latex-laden environ­ accelerators and chemicals used in the latex glove ment are thus susceptible to occupational 28 30 bronchial asthma. - Table 2. Foods That Cross-React With Latex. Many case reports describe severe intraopera­ tive anaphylaxis associated with surgical gloves Common Other Foods Cross-Reactivity That Can Cross-React coming into contact with the peritoneum and vis­ cera; these tissues readily absorb the water-soluble Avocado Apples latex proteins.3o Intravascular administration ofla­ Banana Apricots Chesmut Celery tex proteins can result from disposable syringe Kiwi fruit Cherries plungers, medications stored in vials with rubber Passion fruit Figs stoppers, and intravenous tubing with latex injec­ Grapes Melons 1).28,31 tion ports (Table Milk Because latex is a natural product of the rubber Papayas tree, many other fruits in this family of plants will Peaches have similar proteins. These proteins are so simi- Pineapples

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Table 3. Questionnaire to Determine Latex Sensitivity.

Allergies 1. Do you have a history of hay fever, eczema, asthma, , , or allergic reactions to certain drugs? 2. Do you have a history of allergic reactions (, swelling, oral itching, or wheezing) after eating certain foods such as bananas, , kiwi, chestnuts? Occupationally related symptoms 3. Have you ever had an allergic response to something in your work environment? 4. Are you exposed to any latex-containing products at work? 5. Have you ever developed a rash on your hands after wearing latex gloves? If so, how long after wearing the gloves did the rash develop, and what did the rash look like? Risk factors for latex allergy 6. Do you have spina bifid a or urinary tract problems requiring frequent catheterizations? 7. Have you ever had an operation? If so, how many? 8. Have you ever worked in an environment with latex products? Hidden reactions to latex 9. Have you ever had a rash, swelling, shortness of breath, itching, cough, wheezing, or itchy eyes while wearing household gloves, blowing up a balloon, using a condom or diaphragms, or after a rectal or vaginal examination? 10. Have you ever had an allergic reaction without a known cause, especially during surgery, hospitalization, or dental procedure?

manufacturing. Symptoms can include redness, tions have occurred and, if so, what type of reac­ cracks, fissures, and scaling. Allergic contact der­ tions. A history of reactivity to foods, symptoms matitis, or type 4 (delayed hypersensitivity), has an following use of a rubber condom or diaphragm, onset 6 to 48 hours after contact. Symptoms, or symptoms associated with pelvic examination which are also caused by the accelerators and should raise the suspicion of latex sensitivity chemicals, include erythema, vesicles, papules, (Table 3). pruritus, blisters, and crusting. These lesions can Because of the lack of awareness of latex allergy resemble those caused by poison ivy or poison or a concomitant history of atopic illness or both, oak. Approximately 80 percent of the immuno­ sensitized persons typically do not attribute their logic reactions are type 4. respiratory symptoms of rhinoconjunctivitis or

The third type of reaction is immediate hyper­ bronchospasm to latex exposure. For this reason,http://www.jabfm.org/ sensitivity, or type l-IgE mediated reaction, which eliciting a history suggestive of latex allergy is vi­ is caused by the latex proteins. Its onset occurs tally important before undertaking any elective within minutes and rarely lasts longer than 2 procedure during which latex exposure will occur. hours. These symptoms include local and general­ In one study, however, none of the patients whose ized urticaria, lightheadedness, , nau­ deaths were attributed to anaphylaxis caused by la­ sea, vomiting, abdominal cramps, rhinoconjunc­ tex exposure had any known risk factors other tivitis, bronchospasm, and anaphylactic shock. It is than atopic illness, illustrating that even taking on 23 September 2021 by guest. Protected copyright. the possible to have used latex for years without prob­ above precautions can be insufficient. 33 lems and suddenly progress to systemic symp­ Standardized extracts for skin-prick testing are toms. Anaphylactic reactions to latex have been not readily available in the United States. Because reported in persons who had previously experi­ such testing can cause an anaphylactic response, enced only irritant or allergic contact dermatitis.25 these tests should be conducted only at centers that have staff experienced in preparing extracts. Diagnosis FDA-approved in-vitro tests to measure latex­ Because any product containing latex can trigger specific IgE are available (Pharmacia CAP, Phar­ a reaction, cautious investigation of products at macia-Upjohn Diagnostics, Kalamazoo, Mich; home, in the workplace, and at sites of medical AlaSTAT, Diagnostic Products Corps, Los Ange­ and dental care should occur. A thorough medical les, Calif)34 The low specificity of these tests limits history is the cornerstone of the diagnosis of latex their clinical usefulness. A negative serologic test allergy. The patient should be asked about occu­ despite a strong positive history of sensitivity pational and other risk factors. Furthermore, the would suggest the value of skin-prick testing to history should determine whether previous reac- confirm the diagnosis.25

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Table 4. Nonlatex Gloves and Product Source. are administered. Diphenhydramine (Benadryl) can be used for urticarial reactions. In the course of Material Product (Manufacturer) resuscitation, all contact with latex products should Vinyl TruTouch (Becton Dickinson) be avoided. Fluids and nebulized medications for Vinylite (SmartPractice) bronchospasm might be required. Treatment Allerderm vinyl (Allerderm Labs) should be continued with monitoring until after Royal Shield (SmartCare) symptoms resolve. It is ironic that for the exquis­ SensiCare (Becton Dickinson) Triflex vinyl (Baxter Pharmaseal) itely latex-sensitive person who develops a type 1 Nitrile N-dex (Best Company) hypersensitivity reaction, the hospital and emer­ Nitrile (Pure Advantage) gency department settings can be most fraught Allerderm Nitrile (Allerderm Labs) with danger because of the great amount of latex Neoprene Dermaprene (Ansell) found in medical equipment. Growing awareness Neolon (Becton Dickinson) of the magnitude of health risk posed by latex al­ Thermoplastic TactyLite (SmartCare) lergy might improve this paradoxical situation.25 elastomer Allergard (Johnson & Johnson) Tactyl 1 (Allerderm Labs) Management Issues Styrene-butadiene Elastyren (Hermal) In 1991 the FDA recommended that all patients block polymer be questioned for potential latex allergy, particu­ Adapted from Kam et aPR larly those with spina bifida or any patient sched­ uled for surgical or diagnostic procedures. All Treatment of Reactions physicians are requested to report all episodes of Acute systemic reactions to latex should be treated anaphylaxis during procedures requiring general in the same manner as any anaphylactic reaction. anesthesia through state health departments to the The airway, breathing, and circulation are assessed, epidemiology branch of the hospital infections oxygen is provided, and epinephrine and steroids program at the National Center for Infectious

Table 5. Operating Room Guidelines for Patients With Latex Allergy.

Latex Items Nonlatex Alternatives http://www.jabfm.org/

Implements Bulb syringes Jackson Pratt Evacuator Bulb (Davol relia Vac #100) Blanket warning mattress Completely cover with linen Blood pressure cuff and tubing Wrap with gauze or latex-free tape Catheters (Foley, caude, Malecot, red rubber) Silicon (Silastic) Foley catheter, feeding tubes, nasogastric tubes Chest tube drainage system tubing Wrap with gauze or latex-free tape on 23 September 2021 by guest. Protected copyright. Electrocardiogram lead cords Wrap with gauze or latex-free tape Fenestrated sheets Large sheets cut into shape for opening Gloves TactyLite gloves, sterile 6 1/2 to 8 1/2 SensiCare nonlatex gloves 7 to 7 liz, 8 to 8 1/2 Neuro suction tubing Neuro-Frazier Suction Connecting Tubing (Davol # 3100) Medications Intravenous irrigation solutions Do not puncture rubber ports, use stopcocks Multiple medicine vials Remove the rubber stoppers Penrose drains Jackson Pratt (Davol) drains, Hemovacs Power cords Drape with Cireon Camerce cover Rubber bands Steri Strips Syringes with black latex stopper Glass syringes Tapes, elastic bandages (Elastoplast, Ace), Paper or sirk tapes only adhesive bandages (Band-Aids), Tourniquets Nonlatex glove Urometer Remove rubber tip, use straight connector Utility drapes (stickers) Linen towels

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Disease, Centers for Disease Control,35,36 Table 6. Items Contained in Latex-Free Box. In the health care setting, the two major strate­ Item or Product Name Manufacturer gies for management are (1) prevention and treat­ ment of occupational latex allergy in employees, Nonsterile examination gloves Biosafety Systems (Nitrile Plus) and (2) the safe care of the latex-allergic patient. Duraprene sterile synthetic surgeon's Baxter Healthcare The cornerstone of latex allergy treatment is gloves (size 6 1/2 to 8) avoidance. Many persons who are constantly ex­ AstroScope disposable stethoscope Omron Healthcare posed to the powdered latex glove are likely to be­ Large adult personal cuff Technol come sensitized. Workplace decisions should be (blood pressure cuft) made to reduce cumulative exposure to latex, in­ Adult personal cuff Technol cluding the widespread purchase of nonlatex Small adult personal cuff Technol gloves or nonpowdered, low-protein latex gloves. Child cuff Technol Covering skin cuts on hands with adhesive Child cuff (size 5) Technol bandages before donning latex gloves might help Pediatric cuff (size 4) Technol prevent increased IgE production. In addition, Infant cuff (size 3) Technol putting on powdered gloves cautiously will help Neonate cuff (size 1) Technol prevent inhalation of the aerosolized latex pro­ Uniquet single-use latex-free Vacutainer brand, tourniquet Becton Dickinson teins. Some newer glove products have very low Insyte intravenous catheter and Becton Dickinson, soluble and aerosol titers of proteins, but wide needle unit, 18- & 20-gauge, 1 1/4 in; Vascular Access variation remains between brands. For health care 22-gauge, 1 in workers and patients who are allergic to latex, Interlink injection site Baxter nonlatex gloves should be used (Table 4). The Na­ Intravenous loops Polymicro tionallnstitute of Occupational Safety and Health Technologies (NIOSH) recently published an advisory docu­ Microbore extension tubing Baxter Healthcare ment on natural latex rubber in the workplace. It Glass syringes LifeCare 5000 Plumset LifeShieid Abbott Laboratories recommends that nonlatex gloves be used for all primary intravenous pump set - activities that are not likely to involve contact with OL 15 gttlmL tubing infectious materials (eg, food preparation, routine Transpore I-in tape 3M/Baxter housekeeping and maintenance)Y Steri-Strips I/S in x 3 in 3M/Baxter http://www.jabfm.org/ In caring for the patient with latex sensitivity, Bioclusive transparent dressing, Johnson & Johnson the distinctions between a true type 1 and irritant 4 in x 5 in, 5 in x 7 in Medical and allergic contact dermatitis reactions caused by Bardex all-silicone Foley catheter, Bard Urological 16Fand 18F Division other factors must be considered. Any evidence of a history of type 1 reactions necessitates a latex­ free environment. In the hospital setting protocols for the emergency department, operating room, During regular physical examinations and on 23 September 2021 by guest. Protected copyright. in-patient rooms, and other areas where patients preoperative history taking and physical examina­ might come into contact with latex should be es­ tions, patients who report a history of vague aller­ tablished and should be available to all hospital gic reactions should be queried further for evi­ staff, including housekeeping staff (Tables 5 and dence of latex allergy (Table 3). Latex-sensitive 6). At the time of admission, latex allergy status patients undergoing surgery should be scheduled should be established by the history or screening as the first case of the day, when aerosolized latex questionnaire. Status should be documented and particles are the lowest. Larger hospitals should prominently displayed at the door, at the bedside, have a designated latex-free operating suite. If and on wristbands. Emergency department, oper­ blood pressure cuffs and tubing are made of latex, ating department, and crash cart supplies should the patient's extremities should be wrapped to include nonlatex products. Note that so-called hy­ prevent contact. poallergenic latex gloves are not necessarily latex­ Although it has been recommended that med­ free; they can contain considerable amounts of la­ ications not be drawn up through rubber-stop­ tex allergens and should not be worn in the pered vials or allowed to sit in preloaded syringes vicinity of persons who are allergic to latex. that contain latex rubber, and that latex ports

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Table 7. Websites for Latex Allergy Information. and cereal. 32 With the increasing use of comput­ ers and Internet access, patients can be referred to Organization Address several Websites to be informed about latex al­ PALS (Physicians Against e-mail: [email protected] lergy (Table 7). Latex Sensitization) http://www.pals.net! Latex Allergy Links page http//www.netcom.coml Conclusion -naml/latex_allergy.html When caring for patients with latex allergy, the Delaware Valley Latex Allergy http://www.la tex.org/ physician should educate patients about the po­ ELASTIC (Education for e-mail: Latex Allergy/Support Team [email protected] tential hazards of latex-containing products. & Information Coalition) http://www.netcom.coml Health care providers should also develop a plan -ecbdmd/elastic.html for protecting patients and health care workers NIOSH (National Institute http://www.cdc.gov/nioshl for Occupational Safety latexall.html from latex exposure and be able to manage allergic and Health) reactions when they occur.

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