Latex gloves have proved effective in preventing transmission of many infectious diseases to health care workers. But for some workers, exposures to latex may result in allergic reactions. Reports of such reactions have increased in recent years--especially among health care workers.

What is latex? In this article, the term "latex" refers to natural rubber latex, the product manufactured from a milky fluid derived from the rubber tree, Hevea brasiliensis. Several types of synthetic rubber are also referred to as "latex," but these do not release the proteins that cause allergic reactions. What is latex allergy? Latex allergy is a reaction to certain proteins in latex rubber. The amount of latex exposure needed to produce sensitization or an allergic reaction is unknown. Increasing the exposure to latex proteins increases the risk of developing allergic symptoms. In sensitized persons, symptoms usually begin within minutes of exposure; but they can occur hours later and can be quite varied. Mild reactions to latex involve skin redness, rash, hives, or itching. More severe reactions may involve respiratory symptoms such as runny nose, sneezing, itchy eyes, scratchy throat, and asthma (difficult breathing, coughing spells, and wheezing). Rarely, shock may occur; however, a life-threatening reaction is seldom the first sign of latex allergy.

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Who is at risk of developing latex allergy?

Health care workers are at risk of developing latex allergy because they use latex gloves frequently. Workers with less glove use (such as housekeepers, hairdressers, and workers in industries that manufacture latex products) are also at risk.

Diagnosing Latex Allergy

Latex allergy should be suspected in anyone who develops certain symptoms after latex exposure, including nasal, eye, or sinus irritation; hives; shortness of breath; coughing; wheezing; or unexplained shock. Any exposed worker who experiences these symptoms should be evaluated by a physician, since further exposure could result in a serious allergic reaction. A diagnosis is made by using the results of a medical history, physical examination, and tests.

Taking a complete medical history is the first step in diagnosing latex allergy. In addition, blood tests approved by the Food and Drug Administration (FDA) are available to detect latex antibodies. Other diagnostic tools include a standardized glove-use test or skin tests that involve scratching or pricking the skin through a drop of liquid containing latex proteins. A positive reaction is shown by itching, swelling or redness at the test site. However, no FDA-approved materials are yet available to use in skin testing for latex allergy. Skin testing and glove-use tests should be performed only at medical centers with staff who are experienced and equipped to handle severe reactions.

Testing is also available to diagnose allergic contact dermatitis. In this FDA-approved test, a special patch containing latex additives is applied to the skin and checked over several days. A positive reaction is shown by itching, redness, swelling, or blistering where the patch covered the skin.

Occasionally, tests may fail to confirm a worker who has a true allergy to latex, or tests may suggest latex allergy in a worker with no clinical symptoms. Therefore, test results must be evaluated by a knowledgeable physician.

Is skin contact the only type of latex exposure?

Studies of other allergy-causing substances provide evidence that the higher the overall exposure in a population, the greater the likelihood that more individuals will become sensitized [Venables and Chan-Yeung 1997]. The amount of latex exposure needed to produce sensitization or an allergic reaction is unknown; however, reductions in exposure to latex proteins have been reported to be associated with decreased sensitization and symptoms [Tarlo et al. 1994; Hunt et al. 1996].

Figure 1. Dust produced by removing a latex glove containing powder

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The proteins responsible for latex allergies have been shown to fasten to powder that is used on some latex gloves. When powdered gloves are worn, more latex protein reaches the skin. Also, when gloves are changed, latex protein/powder particles get into the air, where they can be inhaled and contact body membranes (see Figure 1) [Heilman et al. 1996]. In contrast, work areas where only powder-free gloves are used show low levels or undetectable amounts of the allergy-causing proteins [Tarlo 1994; Swanson et al. 1994].

Wearing latex gloves during episodes of hand dermatitis may increase skin exposure and the risk of developing latex allergy. The risk of progression from skin rash to more serious reactions is unknown. However, a skin rash may be the first sign that a worker has become allergic to latex and that more serious reactions could occur with continuing exposure [Kelly et al. 1996].

How is latex allergy treated?

Detecting symptoms early, reducing exposure to latex, and obtaining medical advice are important to prevent long-term health effects. Once a worker becomes allergic to latex, special precautions are needed to prevent exposures. Certain medications may reduce the allergy symptoms; but complete latex avoidance, though quite difficult, is the most effective approach. Many facilities maintain latex-safe areas for affected patients and workers.

Are there other types of reactions to latex besides latex allergy?

Three types of reactions can occur in persons using latex products:

• Irritant contact dermatitis
• Allergic contact dermatitis (delayed hypersensitivity)
• Latex allergy

Irritant Contact Dermatitis

The most common reaction to latex products is irritant contact dermatitis -- the development of dry, itchy, irritated areas on the skin, usually the hands. This reaction is caused by skin irritation from using gloves and possibly by exposure to other workplace products and chemicals. The reaction can also result from repeated hand washing and drying, incomplete hand drying, use of cleaners and sanitizers, and exposure to powders added to the gloves. Irritant contact dermatitis is not a true allergy.

Chemical Sensitivity Dermatitis

Allergic contact dermatitis (delayed hypersensitivity, also sometimes called chemcial sensitivity dermatitis) results from exposure to chemicals added to latex during harvesting, processing, or manufacturing. These chemicals can cause skin reactions similar to those caused by poison ivy. As with poison ivy, the rash usually begins 24 to 48 hours after contact and may progress to oozing skin blisters or spread away from the area of skin touched by the latex.

Latex Allergy

Latex allergy (immediate hypersensitivity) can be a more serious reaction to latex than irritant contact dermatitis or allergic contact dermatitis. Certain proteins in latex may cause sensitization (positive blood or skin test, with or without symptoms). Although the amount of exposure needed to cause sensitization or symptoms is not known, exposures at even very low levels can trigger allergic reactions in some sensitized individuals.

Reactions usually begin within minutes of exposure to latex, but they can occur hours later and can produce various symptoms. Mild reactions to latex involve skin redness, hives, or itching. More severe reactions may involve respiratory symptoms such as runny nose, sneezing, itchy eyes, scratchy throat, and asthma (difficult breathing, coughing spells, and wheezing). Rarely, shock may occur; but a life-threatening reaction is seldom the first sign of latex allergy. Such reactions are similar to those seen in some allergic persons after a bee sting.

Products Containing Latex

A wide variety of products contain latex: medical supplies, personal protective equipment, and numerous household objects. Most people who encounter latex products only through their general use in society have no health problems from the use of these products. Workers who repeatedly use latex products are the focus of this Alert. The following are examples of products that may contain latex:

Emergency Equipment Blood pressure cuffs Stethoscopes Disposable gloves Oral and nasal airways	Endotracheal tubes Tourniquets Intravenous tubing Syringes Electrode pads
Personal Protective Equipment Gloves Surgical masks	Goggles Respirators Rubber aprons
Office Supplies Rubber bands Erasers
Hospital Supplies Anesthesia masks Catheters Wound drains	Injection ports Rubber tops of multidose vials Dental dams
Household Objects Automobile tires Motorcycle and bicycle handgrips Carpeting Swimming goggles Racquet handles Shoe soles Expandable fabric (waistbands)	Dishwashing gloves Hot water bottles Condoms Diaphragms Balloons Pacifiers Baby bottle nipples Band aids

Individuals who already have latex allergy should be aware of latex-containing products that may trigger an allergic reaction. Some of the listed products are available in latex-free forms.

How can I protect myself from latex allergy?

Take the following steps to protect yourself from latex exposure and allergy in the workplace:

1. Use nonlatex gloves for activities that are not likely to involve contact with infectious materials (food preparation, routine housekeeping, general maintenance, etc.).

2. Appropriate barrier protection is necessary when handling infectious materials. If you choose latex gloves, use powder-free gloves with reduced protein content.

• Such gloves reduce exposures to latex protein and thus reduce the risk of latex allergy.
• So-called hypoallergenic latex gloves do not reduce the risk of latex allergy. However, they may reduce reactions to chemical additives in the latex (allergic contact dermatitis).

3. Use appropriate work practices to reduce the chance of reactions to latex.

• When wearing latex gloves, do not use oil-based hand creams or lotions (which can cause glove deterioration).
• After removing latex gloves, wash hands with a mild soap and dry thoroughly.
• Practice good housekeeping: frequently clean areas and equipment contaminated with latex-containing dust.

4. Take advantage of all latex allergy education and training provided by your employer and become familiar with procedures for preventing latex allergy.

5. Learn to recognize the symptoms of latex allergy: skin rash; hives; flushing; itching; nasal, eye, or sinus symptoms; asthma; and (rarely) shock.

What if I think I have latex allergy?

If you develop symptoms of latex allergy, avoid direct contact with latex gloves and other latex-containing products until you can see a physician experienced in treating latex allergy.

If you have latex allergy, consult your physician regarding the following precautions:

• Avoid contact with latex gloves and products.
• Avoid areas where you might inhale the powder from latex gloves worn by other workers.
• Tell your employer and health care providers (physicians, nurses, dentists, etc.) that you have latex allergy.
• Wear a medical alert bracelet.

How Common is Latex Allergy?

The prevalence of latex allergy has been studied by several methods:

• Questionnaires to assess reactions to latex gloves
• Medical histories of reactions to latex-containing products
• Tests for latex antibodies in a worker's blood

Reports about the prevalence of latex allergy vary greatly. This variation is probably due to different levels of exposure and methods for estimating latex sensitization or allergy. Recent reports in the scientific literature indicate that from about 1% to 6% of the general population and about 8% to 12% of regularly exposed health care workers are sensitized to latex [Kelly et al. 1996; Katelaris et al. 1996; Liss et al. 1997; Ownby et al. 1996; Sussman and Beezhold 1995]. Among sensitized workers, a variable proportion have symptoms or signs of latex allergy. For example, one study of exposed hospital workers found that 54% of those sensitized had latex asthma, with an overall prevalence of latex asthma of 2.5% [Vandenplas et al. 1995]. Prevalence rates up to 11% are reported for non-health care workers exposed to latex at work [van der Walle and Brunsveld 1995; Nasuruddin et al. 1993; Orfan et al. 1994; Tarlo et al. 1990].

Several reasons may exist for the large numbers of latex allergies recently reported in workers [Truscott 1995]:

1. Workers rely increasingly on latex gloves to prevent the transmission of human immunodeficiency virus (HIV), hepatitis B virus, and other infectious agentsas outlined in Recommendations for Prevention of HIV Transmission in Health-Care Settings [CDC 1987] and in Guidelines for Prevention of Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to Health-Care and Public-Safety Workers [CDC 1989].

2. Since 1992, the Occupational Safety and Health Administration (OSHA) has required employers to provide gloves and other protective measures for their employees [29 CFR*1910.1030, Bloodborne pathogens].

3. Some manufacturers may have produced more allergenic gloves because of changes in raw materials, processing, or manufacturing procedures to meet the increased demand for latex gloves [Hunt et al. 1995]. These production changes may account partly for the varied concentrations of extractable latex proteins reported for latex gloves (up to a 3,000-fold difference in gloves from various manufacturers) [Yunginger et al. 1994; Beezhold 1992]. Variations may also exist between lots produced by the same manufacturer.

4. Physicians are more familiar with latex allergy and have improved methods for diagnosing it.