natural rubber latex hypersensitivity in health care worker
DESCRIPTION
Presented by Theerapan Songnuy, MD. November2, 2012TRANSCRIPT
NATURAL RUBBER LATEX ALLERGY IN HEALTH CARE
WORKERTheerapan Songnuy
Overview
Background Common Antigens in Latex Epidemiology Clinical Manifestations Diagnosis Management
Background
Natural Rubber : a processed plant product derived from the “cytosol”, or latex of rubber tree
Hevea brasiliensis
John W Yunginger. Natural Rubber Latex Allergy. In Middleton’s 7th Ed : 1019-1026.
Background
Ninety percent of harvested rubber was made into dry sheets for rubber thread products etc.
The remaining, dipped product, is non-coagulated and ammoniated made for rubber gloves, condom & balloons
Most of allergic reactions are from dipped products
John W Yunginger. Natural Rubber Latex Allergy. In Middleton’s 7th Ed : 1019-1026
Background
Rubber gloves is processed by adding various compounds :accelerators, antioxidants, & secondary preservatives
Emulsion of cornstarch & coagulant are also used
Protein content of raw latex is about 15 mg/ml - Latex functional unit is cis-1,4-polyisoprene,
providing structural integrity ( 60%) - Latex cytosol contains enzymes ( 40%)
John W Yunginger. Natural Rubber Latex Allergy. In Middleton’s 7th Ed : 1019-1026
Common Latex Products Balloon Bandages ( adhesive) Blood pressure cuffs Condoms Dental dam Diaphragms Elastic Gloves Pacifiers Tourniquets
Adapted from American Latex Allergy Association . http://www.latexallergyresources.org/topics/. Accessed on Oct
28,2012
Epidemiology
General population incidence is 1-2 % High risk group - patient with spina bifida, the highest incidence 20-67 % - health care workers especially working in operating room, laboratories, or hemo-dialysis centre - atopic patient - patient with multiple surgeries - hand dermatitis - food associated latex allergy Teylor JS, Erek E. Latex allergy: diagnosis and management. Dermatol Ther. 2004; 17(4):289-301
Wakelin SH, White IR. Natural rubber latex allergy. Clin Exp Dermatol. 1999; 24(4):245-248
Adapted from American Latex Allergy Association . http://www.latexallergyresources.org/topics/. Accessed on Oct 28,2012
Latex Allergen
Proteins present in raw latex & rubber products Leached from rubber gloves by skin moisture Be adsorbed to powder inside gloves,
becoming airborne Respirable particles can be shed from powder-
free latex gloves FDA : Powder glove ; < 120 mg of powder Powder-free glove ; < 2 mg of powder Occup Environ Med 2001; 58:479-481
Common Latex Allergens
Clinical and Experimental Allergy 2008;38:898-912
Clinical and Experimental Allergy 2008;38:898-912
Objectives
Material & Method- Health care worker have used gloves- Fujita Health University Hospital- SPT with NRL glove extracts & recombinant allergens- Diagnosis : symptom when expose to latex & SPT + or NRL glove-use test +- Extract of glove : 1 gm into 5ml of phosphate buffer saline Ph 7.2- Measure allergen by ASTM D 5712-95 method- FITkit used to calculate individual allergen
Allergology International 2009;58:347-355
Allergology International 2009;58:347-355
Allergology International 2009;58:347-355
Allergology International 2009;58:347-355.
Allergology International 2009;58:347-355
Allergology International 2009;58:347-355
AllergolInternational 2009;58:347-355
Allergology International 2009;58:347-355
Common allergen
Hev b 6.02 is the most common allergen among HCWs sensitized occupationally
Epidemiology
Objectives
To analyze the prevalence of latex allergy To describe characteristics of health care
worker who has latex allergy
Material & Methods
A self-administered questionnaire : work activity, history of symptoms, allergic reaction to latex products
Skin prick test : commercial latex extracts Serum specific IgE to latex
J Investig Allergol Clin Immunol 2011; 21(6): 459-465
Total workers 620
J Investig Allergol Clin Immunol 2011; 21(6): 459-465
J Investig Allergol Clin Immunol 2011; 21(6): 459-465
J Investig Allergol Clin Immunol 2011; 21(6): 459-465
J Investig Allergol Clin Immunol 2011; 21(6): 459-465
J Investig Allergol Clin Immunol 2011; 21(6): 459-465
J Investig Allergol Clin Immunol 2011; 21(6): 459-465
Allergic to latex (%) Non-Allergic to latex (%)
Latex Allergy in Primary Care Providers
-The prevalence of latex allergy is 5.9%
Latex Allergy in Dental Students:A Cross-Sectional Study
Mukda Vangveeravong MD, Jintana Sirikul MD Tassalapa Daengsuwan MD
J Med AssoThai 2011; 94(Suppl. 3): S1-S8
Objectives
Study the prevalence of latex-related symptoms
Study latex-sensitization Study risk factors
J Med AssoThai 2011; 94(Suppl. 3): S1-S8
Material & Method
A cross-sectional study Dental students Faculty of dentistry, Chulalongkorn
University Dec 2007-May 2008 Questionnaires Skin prick test ; using 3 latex extracts
prepared from Proglove, Doctor Plus gloves & a commercial latex allergen(Stallergens, France)
J Med AssoThai 2011; 94(Suppl. 3): S1-S8
J Med AssoThai 2011; 94(Suppl. 3): S1-S8
J Med AssoThai 2011; 94(Suppl. 3): S1-S8
J Med AssoThai 2011; 94(Suppl. 3): S1-S8
J Med AssoThai 2011; 94(Suppl. 3): S1-S8
J Med AssoThai 2011; 94(Suppl. 3): S1-S8
J Med AssoThai 2011; 94(Suppl. 3): S1-S8
J Med AssoThai 2011; 94(Suppl. 3): S1-S8
Latex Allergy in Dental Students:A Cross-Sectional Study
The prevalence of latex allergy is 5 % Common signs & symptoms : pruritus,
eczema & contact urticaria The latex sensitization rate was 14.2% Risk factors : personal history of allergic
disease, duration & frequency of exposure
Primary prevention should be considered J Med AssoThai 2011; 94(Suppl. 3): S1-S8
Clinical Manifestation
Latex Allergic Contact Dermatitis( type 4)
Irritant Contact Dermatitis (non-immune)
Am Fam Physician 2009; 80(12): 1413-1418
Latex Anaphylaxis
Rapidly increase of latex allergy from 0.5% before 1980 to 20% in 2002 ( France)
Thirty percent of patients had history of symptoms suggestive of latex sensitization
Some countries have implemented reducing latex exposure, incidence became decreased
Anesthesiology 2005 ; 102(5): 897-903Ann Fr Anesth Reanim 2004;23(12):1133-43
Clinical Manifestation
INJ OCCUP INVIRON HEALTH 2011;17:17-23
INJ OCCUP INVIRON HEALTH 2011;17:17-23
INJ OCCUP INVIRON HEALTH 2011;17:17-23
Clinical symptomsSkin : 2.4% urticaria 4.8% rash within 1 hr 3% rash beyond contacted area
Upper respiratory tract : 5.4% coryza 3.8% sneezing spells
Lower respiratory tract : 1.5% cough 1.5% wheezing 1.4% shortness of breath
Anaphylaxis 15 ( 0.3% )
INJ OCCUP INVIRON HEALTH 2011;17:17-23
Diagnosis
Skin testing - commercial extracts - extracts of rubber products
Diagnosis
Latex specific IgE antibodies - strong /weak point - sensitivity - specificity - improved sensitivity by using
recombinant latex protein
Diagnosis
Challenge Studies - Nasal & bronchial inhalation - “ Use test”
Management
Latex avoidance - documentation of latex sensitization - education - provided non-latex gloves/materials - labeling latex products Latex-safe medical environment - level of threshold limit for aeroallergen < 0.6 ng/m3Am J Public Health 1999;89: 1024JACI 1998; 101: 24
Latex Allergy: a follow up study of 1040 health care worker
Filon FL, Radman G. Environ Med 2006;63:121
Objectives: To evaluate incidence/prevalence of latex
related symptoms & latex sensitization between pre & post implementation of powder-free gloves with low latex release
Material & Methods
Subjects : 1040 health care workers At Triestle hospital, Italy Base line 1997-1999 , follow up in 2000-
2002 Evaluate : questionnaires, physical exam,
skin prick test & serum specific IgE antibody
Measure : prevalence of latex related symptoms, sensitization
Results
Environ Med 2006;63:121
Results
Participants characteristics who have symptoms related to latex glove use
- work seniority - work place ; OR, lab, surgery ward - latex glove use per day Odd ratio of possible risk factor and glove related
symptom - SPT to latex - SPT to inhalant allergen - personal atopy - family history of atopy - being female
Environ Med 2006;63:121
Environ Med 2006;63:121
Results
Environ Med 2006;63:121
Implication from this study
Avoidance of unnecessary glove utility Non-powder latex glove in all workers Non-latex glove in sensitization workers
Stop worsening latex symptom Prevent new case of sensitization
Immunotherapy
Subcutaneous immunotherapy with natural rubber latex : decreases skin & respiratory symptoms but induces systemic reaction
Sublingual immunotherapy with a commercial NRL extract : safe & efficacious ( pediatric patient)
JACI 2006; 6: 96Euv Ann Allergy Clin Immunol 2008;40(4):142-147
Conclusion
Latex allergy increased in the past decades following “ universal precaution” policy
High risk group are health care workers & patients with spina bifida
Latex gloves vary in their latex allergen & particles from powdered latex gloves produce airborne latex allergen
Diagnosis requires history , SPT, latex-sIgE Ab or challenge testing
Optimal management includes education & avoidance of latex products
THANK YOU VERY MUCH