latex allergy
DESCRIPTION
Latex Allergy. INTRODUCTION. NRL Allergy: it is a complex issue. Complex due to several reasons: Different types of materials are foreign to the human body, can cause somewhat similar allergi c reactions. Sensitization is in itself a complicated area for medical diagnosis. - PowerPoint PPT PresentationTRANSCRIPT
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Latex Allergy
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INTRODUCTION
NRL Allergy: it is a complex issue. Complex due
to several reasons:
• Different types of materials are foreign to the human
body, can cause somewhat similar allergic reactions.
• Sensitization is in itself a complicated area for
medical diagnosis.
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Introduction - cont’d.• Not all NRL products or NR products are processed
and manufactured the same way, including the same or similar products.
• There is confusion on what products are made from natural rubber or synthetic rubber or a combination of both.
• The term latex, itself, is used for different types of natural and synthetic “dipped” and “liquid” products.
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Introduction - cont’d.
• Finally, the problems and confusion
between latex sensitization and
chemical sensitization exist.
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Topics for Discussion
• Latex and its production
• Latex allergy and its ascent
• Diagnosing latex allergy
• Challenges & management of latex allergy
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What is Latex?• Processed product from the cytosol of Hevea brasiliensis
found in Africa and Southeast Asia.
• Small rubber particles suspended in “serum”, with 1-2% protein
• > 200 polypeptides: > 50 allergenic
• Hev b 1,2, and 6: Major allergenic proteins
• Not be confused with petroleum-based synthetic rubbers.
• Chosen as glove material because of its excellent combination of non-porosity and flexibility
Latex exporters
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Natural Rubber (2 Forms)
• Latex -- stable aqueous dispersion of polymer particles
• Coagulum -- bulk-phase elastomeric material
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Raw Latex Composition
• Polyisoprene 31 - 26%
• Water 58 - 65%
• Protein 1.5 - 3.0%
• Carbohydrates, Lipids,Inorganics, Other ~ 4.0%
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Possible NR Latex Additives
• For emulsion stabilization: ammonia (collection cups)
• Primary Preservatives: sodium sulfite or formaldehyde
• Secondary Preservatives: e.g., zinc dithiocarbamate, zinc oxide
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Dry Natural Rubber Processing
• Coagulation: Addition of formic acid
• Autocoagulation of latex dispersion (cuplumps)
• Additional processing, including chopping, grinding, water washing, drying, heat (smoke) - stabilization, and sheeting or baling
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Residual Protein ContentDepends on Processing
• Field processing of latex
“liquid or dry”
• Manufacturing procedures
– natural rubber latex (NRL) – dry rubber
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NRL Proteins Characterization
• 50 to 100 identified in NRL
• Molecular weights 10 to 70 kDalton
• Not all exhibit IgE binding due to epitope differences
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Extractable Protein (EP) Levels
• NRL - generally higher (concentrated)
• Dry NR - generally lower
(acidified, macerated, multiple water washing, heat processing)
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EP in NRL Dipped Products
• Higher EP levels ~ allergic response in atopic
individuals – NRL dipped products - range of
concentrations– Less than 0.020 to 1.680
[mg-EP/g-rubber]
(See handout - Tables 1 & 2: Yip, et al., 1994)
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EP in Dry NR Products
• Very low EP levels ~ weak to no allergic
response
– Dry Rubber - negligible to no EP– Less than 0.020 to 0.034
[mg - EP/g-rubber]
(See handout - Table 4: Yip, et al., 1994)
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Creating Rubber from Latex
11
22
55
33
44
77
66
88
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Latex allergy (to gloves etc)Hospital staff 10% latex allergic, often hand
eczema, atopics at increased risk • Symptoms:
– urticaria (75-100%)
– conjuctivitis (20-45%), rhinitis (15-50%)
– asthma (3-30%)
– anaphylaxis (6-8%)
Don’t despair!Use non-latex gloves (vinyl, nitril or plastic)Use non-powdered, treated latex gloves
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Where is Latex Found?Where is Latex Found?• Emergency Equipment
– BP cuffs, stethoscopes, gloves, ET tubes, electrode pads, tourniquets, IV tubing, syringes, airways
• PPE– Gloves, goggles, masks, rubber aprons
• Hospital Supplies:– Anaesthetic masks, catheters, drains, injection ports, multi-dose-vial tops
• Office Supplies:– Rubbers, rubber-bands, mouse pads
• Household objects:– Car tyres, cycle handles, carpeting, swimming-goggles, racquet handles, shoe
soles, expanadable fabric (waistbands), dishwashing gloves, hotwater bottles, condoms, pacifiers, diaphragms, balloons, pacifiers, baby-bottle-nipples
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Glove Reactions: 3 TypesTypes– Irritant (Not allergic)
• Erythema, dryness, scaling, vesiculation andvesiculation and crackingcracking• Skin irritation due to frequent glove-wearing, incomplete
hand-drying, workplace chemicals, powder reactions– Delayed contact hypersensitivity (Not latex)
• Develops in 24-48 hrs; lasts days-weeks
• Eczematous; often identical appearance to irritant reaction
• Chemical additives such as ammonia, antioxidants and accelerators (eg. thiurams and carbamates) are commonly implicated.
• Similar mechanism to watch contact allergy
– True latex allergy
Most adverse reactions to gloves are non-allergic
Any form of dermatitis increases risk of true latex sensitisation
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Case 1: Ms FR 29F• Background:
– Dental practice secretary:
• Also sterilises equipment: frequent glove use
– Asthma / rhinitis
• Dental problems began 12/99
– Dyspnoea and an urticarial eruption locally
– Responded to Ventolin without need for Adrenaline or steroids.
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Case 1: Ms FR 29F
• Further questioning:
– Asthma had been quiescent: No ventolin puffer at home
• However, 2-3 months needing ventolin 3 x / day 3 x / week at work
– Also, rhinitis became worse at work, changing from its usual seasonal periodicity
– Particular association of respiratory problems with glove-wearing (herself or colleagues)
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Case 1: Ms FR 29F• Diagnosis:
– CAP: 0
– Latex SPT: 5mm
• Management
– No latex powder at work
– Antihistamines
– Optimise background asthma / rhinitis control
– Nasal steroids
– Medi-Alert bracelet
– No adrenaline given in absence of history of life-threatening reactions
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Type I (IgE) Allergy Cascade
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What Are the Features of Latex What Are the Features of Latex Allergy?Allergy?
• Contact urticaria
• Occupational rhinitis and asthma
• Angioedema / airway obstruction
• Anaphylaxis
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Rising Latex Allergy
• Adoption of universal precautions since 1987
• Changes in latex antigenicity due to changes in manufacturing processes forced by rising demands for latex products: Less leaching
– 3000 x difference in latex antigen levels from different manufacturers
– ?Poorer processing in Asian factories: allergenic
• Increased diagnostic suspicion and better diagnostic tools
• Mirrors the unexplained general increase in all atopic diseases over the last few decades, particularly in developed nations.
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Rising Allergy: Why?• Genetic factors:
– important, but don’t explain rapid rise• Atopic disorders: 1/3 (developed)• Life-style: “Dust-mite” households• Early infections:
: RSV : measles, hepatitis A, TB
• Vaccinations: ?BCG protective• Diet and intestinal microflora• Anthroposophic lifestyle:
– 13% vs 25% atopy (OR 0.6)– Less antibiotics, fewer vaccines, live lactobacilli
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Prevalence of Latex Allergy
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Levels and Routes of ExposureLevels and Routes of Exposure• Powdered gloves greatest culprit for rise in latex allergy
– Allergenic latex proteins fasten to powder particles
• Higher surface area of particles allows more efficent protein delivery to skin
– Particularly relevant in people with dermatitis or prior skin damage, a demonstrated risk factor for developing true latex allergy
• Also delivers latex protein across mucosae and serosae during operations and procedures such as catheterisation
• Aerosolisation of powder delivers latex antigens across respiratory membranes, inducing rhinitis and asthma
• ? Adjuvant effect of cornstarch powder
• Protein-poor powder-free latex gloves less sensitising than protein-rich powdered gloves*
* Levy DA et al. Powder-free protein-poor NRL latex gloves and latex sensitisation. JAMA 1999;281:988
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Risks for Latex Allergy• Atopy (in 57%)
• Recurrent operations / instrumentations
– Spina bifida patients ++ (prevalence 28%-67%)
– Others e.g. congenital urinary abnormalities, cerebral palsy, quadriplegia
• Consider in any patient who develops peri-operative anaphylaxis
• Latex industry workers• Health workers: 10% sensitisation; 1-8% significant reaction
• Allergies to unusual foods
• Other people with latex glove exposure:
– Hairdressers, food-handlers, housekeepers,..
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Case 2: Mr PE 43M
• Community nurse• Previously healthy except for hypertension treated
with coversyl (perindopril)• 4 yrs ago: Contact eczema with latex gloves• 2 yrs ago: Allergic rhinitis• Non-latex gloves
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Mr PE 43M
• 1/97: Urticaria with facial swelling
• 5/97: Bronchospasm with glove “snapping”
• 10/97: Casualty after Indian meal
– Bronchospasm, urticarial rash, hoarseness
– Rx: phenergan, ventolin
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Mr PE: Investigations
• Latex-specific IgE CAP: Positive (2)(SPT not performed)
• SPT to HDM, grasses: Positive
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Cross reactions
• Latex is derived from a plant
- Related to other plants !
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Diagnosis of Latex Allergy
• History +++
• Demonstrate allergen-specific IgE– False negatives for objective tests occur– History is final arbiter
• Finger-use and other challenges less commonly employed
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Skin Prick Testing (SPT) vs. In-vitro Allergen-Specific IgE
• Skin prick testing is most sensitive– But increased reaction risk
• Blood testing (RAST,CAP) less sensitive
Do blood testing Do blood testing firstfirst
StandardisedStandardised Skin Test Reagents Now Available
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ChallengesChallenges of Latex Allergy (I): OH & S
• No available synthetic gloves can match the elasticity, durability, resilience, affordability and impermeability of latex
• Nevertheless, double-gloving with synthetic gloves may offer similar protection against infectious agents, albeit with impaired tactile performance
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ChallengesChallenges of Latex Allergy (II): Dollars
• Costs arise from:• the sensitisation of health care workers
• treatment of sensitised individuals; and
• changes required to minimise latex allergy sensitisation and reactions
• Up to 61% costs for surgical gloves. – Balance against long-term savings from reduced:
• treatment complications
• litigation
• workers compensation
• glove-powder-related adhesions (morbidity, further surgery)
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Latex Lists
Latex Containing Latex FreeGloves Ansell Dermaprene
Vinyl exam glovesOximeter probes Datex, OhmedaBP cuff leads MedtelECG dots 3MIV line & bungs BraunSyringes TerumoAirways, masks, bags PromedicaCatheters CookTapes Micropore, 3MDressings Opsite
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Management of Latex AllergiesAllergies: Staff & Workplace
• Glove Use:– Worker: Synthetic or non-powder latex-poor– Colleagues: Non-powdered latex-poor
• Gradual replacement of latex containing products with non-latex products where available and appropriate
• Powder: Nonpowder - 1987 65:35- 1999 50:50
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Public Health:Preventing Latex Allergy
• Glove usage*:
– Where no infectious risk: synthetic gloves
– Where infectious risk: nonpowdered low-protein latex or double-synthetic gloving
• Handcare Risk sensitisation with damaged skin
– Oil-based creams increase allergen leaching
– Wash hands after removing gloves
*NIOSH Alert: Preventing allergic reactions to NRL in the workplace. MMWR 1987;36(Suppl 2):1S-18S
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Public Health:Legislation
• 1997: Maximum allowable glove protein– ASTM: 200 g/g rubber– CEN/TC (Europe): 10 g/g rubber– AAAAI Joint Statement:
• “Only low-allergen and powder-free latex gloves should be purchased & used.”
• 1998: FDA Packaging– All medical devices coming in contact with the body must carry:
– Little compliance with disclosure of allergen levels– Use of “hypoallergenic” term not permitted
• Misleading, inconsistent
“This product contains Natural Rubber Latex”
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Ward Preparation for Ward Preparation for Latex Allergic PatientsLatex Allergic Patients
• Synthetic gloves
• Single room (prepared & latex free)
• Damp dust surfaces
• Block air-conditioning ducts
• Signs for doors (“Latex Safe”) & records
• Plan all procedures
• Prepare to treat anaphylaxis
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Support Groups
• E ducation for• L atex• A llergy• S upport• T eam and• I nformation• C oalition (inc.)
• www.latex-allergy.org
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Hospital Management of Latex AllergicAllergic Patients: Special ConsiderationsConsiderations
• Venepuncture (tourniquets)• IV lines without latex ports• Medication vials: No latex stoppers• Synthetic gloves for internal examinations• Non-latex catheters, syringes, dressings, tapes• Oximeter probes• Sphygmomanometers: cotton-cloth cover• ECG dots• Stethoscopes• Kitchen staff: synthetic gloves; food allergies
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Public Health:Preventing Latex Allergy (II)
• Interdepartmental latex committees:– Nursing, allergy, staff health, surgery, anaesthetics, OT,
purchasing, labs, housekeeping, kitchens,…
• Attend workplace education / training• Keep latex-free product registers• Encourage industry to label latex products• Pre-placement and routine staff screens
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• Severe systemic allergic reaction
• Involves one or both of:– Respiratory difficulty (URT, asthma)– Hypotension
• Other allergic features often occur in association
• Usually immediate ( < 1/2 hour)– Rarely delayed (up to 6 hours)– Sometimes (~5%) biphasic (1h - 72 h)
WhatWhat is Anaphylaxis?
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AnaphylaxisAnaphylaxis: Management
• Airway
• Adrenaline 1:1000 IM *
– Only Hypotension / Bronchospasm
– 0.5mL (500µg)
• OR Adrenaline 1:100001 mL (100µg) slow IVI
– profound shock
– anaesthesia
• Oxygen, ß2-agonists
• IV fluids (N/S, haemaccel)
• IV steroids, antihistamineses
• (Remove allergen)
Find the causeFind the cause Advise on preventionAdvise on prevention
Entire production lineEntire production line Medic-AlertMedic-Alert Adrenaline (Epi-pen)Adrenaline (Epi-pen) First-Aid educationFirst-Aid education Avoid Avoid -blockers-blockers ?Immunotherapy?Immunotherapy
ACUTEACUTE INTERVALINTERVAL
• Repeat adrenaline in 5 minutes if deteriorating• 10% of out-of-hospital anaphylaxes require repeat adrenaline shot
* Project Team of the Resuscitation Council (UK). The emergency medical treatment of anaphylactic reactions. J Accid Emerg Med 1999;16:243-247
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ManagementManagement of Latex Allergies: Staff & Workplace (I)
– Same general principles as for patients– Safe Workplace
• Education and Training• Work environment modification
– Consider:
» all work areas that a worker needs to go to;
» patient movements
» other worker contacts; and
» common air conditioning areas.
– Housekeeping should be meticulously carried out to remove all traces of latex allergens.
– May require occupational rehabilitation (Rarely)
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Sensitisation: Mechanisms
• Preclinical sensitisation may occur in early life– First exposures in infancy:
• Bottle nipples, pacifiers, balloons,…
• Quantity of latex and site / duration of contact important
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Latex Questionnaire• Have you ever reacted to latex-containing
products?• Risks:
– Atopy 3 major surgery episodes
– Spina bifida
– Unusual food allergies
– HCW / At-risk occupation
– Perioperative anaphylaxis
Score > cutoff: Measure IgE to latex ; if POSITIVE, or persistent suspicion of latex allergy, refer for specialist review
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HospitalHospital Management of Latex Allergic Patients
• Latex-safe environment– No powdered gloves: preferably, synthetic gloves only– Prepare OT and wards: no latex products
• Identify allergic patients:– Questionnaires– Investigate people with unexplained anaphylaxis / unusual
food allergies• Special labels for rooms and records• Admission to discharge planning• Plan all procedures• Pharmacological prophylaxis should be considered• Be prepared to treat anaphylaxis
Neonates with congenital abnormalities: Educate parents on latex
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Summary
• Latex allergy is a major problem– Latex is ubiquitous & difficult to fully avoid
• Most adverse glove reactions are non-allergic– But irritant dermatitis can risk of latex sensitisation
• Latex allergy affects up to 8% of health workers• Risk factors include recurrent operations, atopy &
unusual food allergies
• We must use synthetic alternatives or low-allergen powder-free latex gloves