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