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Addressing occupational allergy to natural rubber latex among health care workers
Guest editorial
Addressing occupational allergy to natural rubber latex among health care workers Natural rubber latex (NRL) is the most common cause of occupational dermatitis, rhinoconjunctivitis, and asthma among health care workers. NRL-induced occupational symptoms have been recognized with increasing frequency during the past decade. Initial attempts to address the problem involved creation of “latex-free” work areas by wholesale removal of all NRL-containing products from clinics and hospitals. This approach proved simplistic and impossible to achieve; in many cases, latex-free alternative products were unavailable, and until the late 1990s, not all NRL-containing medical devices were identified on the packaging or on the devices themselves. Disposable latex medical gloves, especially those with cornstarch donning powder, were later shown to be major contributors to latex aeroallergen levels.1,2 Subsequent efforts to decrease environmental levels of latex allergens emphasized use of synthetic or powder-free latex gloves that contained less extractable protein, with the aim of creating latex-safe rather than latex-free work areas. In this issue of the Annals, Bollinger et al3 describe a four-phase institutionwide program to address the problem of occupational latex allergy. This program emphasizes early identification of latex-sensitized employees and the gradual phase-out of all NRL examination (nonsterile) and surgical (sterile) gloves. The 1,795 employees screened included all newly hired persons, current employees transferring into or within patient care areas, and individuals wishing to be tested for latex sensitization. Of this group, 8% had latex-specific immunoglobulin E antibodies by Pharmacia CAP (Phar-
VOLUME 88, JUNE, 2002
macia–Upjohn, Kalamazoo, MI) immunoassay or prick skin test with an investigational latex extract from Greer Laboratories (Lenoir, NC). Interestingly, only 57% of sensitized persons reported skin, eye, or respiratory symptoms when exposed to powdered latex gloves, whereas such symptoms were reported by 21% of those who were not sensitized. The annual cost of this screening program was $60,000. However, the authors conclude that workplace changes to accommodate NRL-sensitized employees are less expensive than worker’s compensation payments to latex-sensitized persons who may experience allergic symptoms or lose work days in an unmodified work environment. A more detailed discussion of the costs of accommodating NRL-sensitized health care workers has been published.4 The phased approach to replacement of NRL gloves described by the authors may be optimal for some clinics and hospitals. At our own medical center, we opted to measure the total extractable latex allergen in all latex gloves in stock5 and then eliminated all brands with moderate or high allergen contents throughout the whole medical center at one time.6 For clinics and hospitals interested in quantitating the latex allergen in their own gloves, similar immunoassays are available through reference laboratories or performed with commercial kits. This one-step approach has other advantages: 1) glove users and institutional committees responsible for glove purchasing are provided with quantitative data regarding latex allergen levels in various gloves; evidence-based suggestions for subsequent changes are thus more readily accepted. 2) Simul-
taneous institution-wide changeover to synthetic or low-allergen NRL gloves addresses not only the occupational latex allergies of employees, but also provides optimal flexibility and safety in caring for latex-sensitive patients. Left unanswered by this study are other questions. Since July 1999, have the 144 latex-sensitized persons identified in this cohort exhibited a decline in latex-specific immunoglobulin E as a consequence of their assignment to latex-restricted work areas? How much or how little has the demonstration of latex sensitization in asymptomatic employees altered their nonwork environment or caused increased anxiety? We look forward to followup reports as Dr. Bollinger’s project moves through the second and third phases. JOHN W. YUNGINGER, MD Department of Pediatric and Adolescent Medicine Department of Medicine Allergic Diseases Research Laboratory Mayo Clinic and Foundation Rochester, Minnesota REFERENCES 1. Swanson MC, Bubak ME, Hunt LW, et al. Quantification of occupational latex aeroallergens in a medical center. J Allergy Clin Immunol 1994;94: 445– 451. 2. Heilman DK, Jones RT, Swanson MC, Yunginger JW. A prospective, controlled study showing that rubber gloves are the major contributor to latex aeroallergen levels in the operating room. J Allergy Clin Immunol 1996; 98:325–330. 3. Bollinger ME, Mudd K, Keible LA, et al. A hospital-based screening program for natural rubber latex allergy. Ann Allergy Asthma Immunol 2002;88:560–567. 4. Phillips VL, Goodrich MA, Sullivan
541
TJ. Health care worker disability due to latex allergy and asthma: a cost analysis. Am J Public Health 1999;89: 1024 –1028. 5. Yunginger JW, Jones RT, Fransway
542
AF, et al. Extractable latex allergens and proteins in disposable medical gloves and other rubber products. J Allergy Clin Immunol 1994;93: 836 – 842.
6. Hunt LW, Boone-Orke JL, Fransway AF, et al. A medical-center-wide, multidisciplinary approach to the problem of natural rubber latex allergy. J Occup Environ Med 1996;38:765–770.
ANNALS OF ALLERGY, ASTHMA, & IMMUNOLOGY
Addressing occupational allergy to natural rubber latex among health care workers Natural rubber latex (NRL) is the most common cause of occupational dermatitis, rhinoconjunctivitis, and asthma among health care workers. NRL-induced occupational symptoms have been recognized with increasing frequency during the past decade. Initial attempts to address the problem involved creation of “latex-free” work areas by wholesale removal of all NRL-containing products from clinics and hospitals. This approach proved simplistic and impossible to achieve; in many cases, latex-free alternative products were unavailable, and until the late 1990s, not all NRL-containing medical devices were identified on the packaging or on the devices themselves. Disposable latex medical gloves, especially those with cornstarch donning powder, were later shown to be major contributors to latex aeroallergen levels.1,2 Subsequent efforts to decrease environmental levels of latex allergens emphasized use of synthetic or powder-free latex gloves that contained less extractable protein, with the aim of creating latex-safe rather than latex-free work areas. In this issue of the Annals, Bollinger et al3 describe a four-phase institutionwide program to address the problem of occupational latex allergy. This program emphasizes early identification of latex-sensitized employees and the gradual phase-out of all NRL examination (nonsterile) and surgical (sterile) gloves. The 1,795 employees screened included all newly hired persons, current employees transferring into or within patient care areas, and individuals wishing to be tested for latex sensitization. Of this group, 8% had latex-specific immunoglobulin E antibodies by Pharmacia CAP (Phar-
VOLUME 88, JUNE, 2002
macia–Upjohn, Kalamazoo, MI) immunoassay or prick skin test with an investigational latex extract from Greer Laboratories (Lenoir, NC). Interestingly, only 57% of sensitized persons reported skin, eye, or respiratory symptoms when exposed to powdered latex gloves, whereas such symptoms were reported by 21% of those who were not sensitized. The annual cost of this screening program was $60,000. However, the authors conclude that workplace changes to accommodate NRL-sensitized employees are less expensive than worker’s compensation payments to latex-sensitized persons who may experience allergic symptoms or lose work days in an unmodified work environment. A more detailed discussion of the costs of accommodating NRL-sensitized health care workers has been published.4 The phased approach to replacement of NRL gloves described by the authors may be optimal for some clinics and hospitals. At our own medical center, we opted to measure the total extractable latex allergen in all latex gloves in stock5 and then eliminated all brands with moderate or high allergen contents throughout the whole medical center at one time.6 For clinics and hospitals interested in quantitating the latex allergen in their own gloves, similar immunoassays are available through reference laboratories or performed with commercial kits. This one-step approach has other advantages: 1) glove users and institutional committees responsible for glove purchasing are provided with quantitative data regarding latex allergen levels in various gloves; evidence-based suggestions for subsequent changes are thus more readily accepted. 2) Simul-
taneous institution-wide changeover to synthetic or low-allergen NRL gloves addresses not only the occupational latex allergies of employees, but also provides optimal flexibility and safety in caring for latex-sensitive patients. Left unanswered by this study are other questions. Since July 1999, have the 144 latex-sensitized persons identified in this cohort exhibited a decline in latex-specific immunoglobulin E as a consequence of their assignment to latex-restricted work areas? How much or how little has the demonstration of latex sensitization in asymptomatic employees altered their nonwork environment or caused increased anxiety? We look forward to followup reports as Dr. Bollinger’s project moves through the second and third phases. JOHN W. YUNGINGER, MD Department of Pediatric and Adolescent Medicine Department of Medicine Allergic Diseases Research Laboratory Mayo Clinic and Foundation Rochester, Minnesota REFERENCES 1. Swanson MC, Bubak ME, Hunt LW, et al. Quantification of occupational latex aeroallergens in a medical center. J Allergy Clin Immunol 1994;94: 445– 451. 2. Heilman DK, Jones RT, Swanson MC, Yunginger JW. A prospective, controlled study showing that rubber gloves are the major contributor to latex aeroallergen levels in the operating room. J Allergy Clin Immunol 1996; 98:325–330. 3. Bollinger ME, Mudd K, Keible LA, et al. A hospital-based screening program for natural rubber latex allergy. Ann Allergy Asthma Immunol 2002;88:560–567. 4. Phillips VL, Goodrich MA, Sullivan
541
TJ. Health care worker disability due to latex allergy and asthma: a cost analysis. Am J Public Health 1999;89: 1024 –1028. 5. Yunginger JW, Jones RT, Fransway
542
AF, et al. Extractable latex allergens and proteins in disposable medical gloves and other rubber products. J Allergy Clin Immunol 1994;93: 836 – 842.
6. Hunt LW, Boone-Orke JL, Fransway AF, et al. A medical-center-wide, multidisciplinary approach to the problem of natural rubber latex allergy. J Occup Environ Med 1996;38:765–770.
ANNALS OF ALLERGY, ASTHMA, & IMMUNOLOGY