Outline Latex Allergy Policy

Please note. This policy was written specifically for the Bro Morgannwg NHS Trust in South Wales in around 2000. The Trust  kindly gave permission to publish the document on this web site. The aim of this is to reduce the amount of work required for trusts and hospitals to produce their own policy. However, neither Bro Morgannwg NHS Trust nor SMTL will accept liability for any consequences of using this document.

If you intend to use this document as the basis for your own local policy, please ensure that you edit it to remove references to names and telephone numbers local to Bro Morgannwg NHS Trust.

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Bro Morgannwg NHS Trust
DRAFT Latex Allergy Policy (June 2000).

Contents

• Contents
• 1 Introduction
  • 1.1 Goals of the Policy.
• 2 What is Latex ?
• 3 Clinical problems with latex medical devices.
  • 3.1 Routes of Exposure
  • 3.2 Extent of the problem.
  • 3.3 Irritant contact dermatitis.
  • 3.4 Allergic contact dermatitis (Type IV Delayed Hypersensitivity)
  • 3.5 Immediate Hypersensitivity (Type I).
• 4 Diagnosing those at risk.
  • 4.1 Staff
  • 4.2 Patients
• 5 Prevention
  • 5.1 Use of low protein devices.
  • 5.2 Use of non-latex devices.
  • 5.3 Housekeeping
• A. Glossary
• B. References
• C. Equipment Selection.
• D. Screening Questionnaire for Staff.
  • Date Of Completion Of Form:
  • Name:
  • Job Title:
  • DOB:
  • Place of work:
• E. Screening Checklist for Patients.
• F. What is Latex ?
  • F..1 What is latex composed of ?
  • F..2 Latex Processing.
• G. Authors

 

1 Introduction

The introduction in 1987 of Universal Blood and Body Fluid Precautions aimed to reduce the risk of transmission between patients and staff of various pathogens, especially viruses. There has subsequently been a great increase in the use of latex gloves by health care workers.

As the frequency and duration of the use of latex products has increased, the emergence of various forms of latex sensitivity has been identified as a problem both for patients and staff.

 

1.1 Goals of the Policy.

 

1. Prevention of symptoms due to Latex allergy in both staff and patients
2. Ensuring safe treatment for latex allergic patients
3. Ensuring safe working practices for latex allergic staff

 

2 What is Latex ?

Latex is the protective fluid contained in tissue beneath the bark of the rubber tree, Hevea Brasiliensis.

Natural rubber latex (NRL) is a cloudy white liquid, similar in appearance to cows milk, collected by cutting a thin strip of bark from the tree and allowing the latex to exude into a collecting vessel.

The latex collected from the rubber tree is composed of rubber particles, protein, water and other substances.

Processing of the latex (e.g., centrifugation and leaching) can all affect the level of protein in the finished product.

Some glove manufacturers wash the gloves in a chlorinated solution to reduce the tackiness of the latex to avoid having to powder the glove. Chlorination followed by prolonged leaching reduces the protein levels, producing a glove low in protein.

 

3 Clinical problems with latex medical devices.

 

3.1 Routes of Exposure

The potential routes of exposure to latex allergens are:

 

• Cutaneous - via gloves, tapes, masks, urine drainage bags;
• Mucous membranes - via products used in dentistry, anaesthesia and rectal examinations, including eye and ear droppers;
• Intra-uterine devices
• Inhalation - via aerosolisation of glove powder;
• Internal tissue - via latex products used in surgery;
• Intravascular - via latex products used in intravascular devices (e.g., IV cannulae) or devices used to deliver IV fluids and injectables (syringes and IV administration sets).

 

3.2 Extent of the problem.

In a questionnaire survey, 8.8% of personnel in the US Army Dental Corps reported skin reactions to latex gloves (not all of these would be Type 1) with a response rate of 65%.

Finnish data has shown 7.4% of physicians working in operating departments to have contact urticaria (type 1 allergy) to latex.

A UK study reports 47.5% of 7,436 respondents stating they had skin rashes with latex gloves, although the majority of these are not likely to be type 1 allergy, and this study relied on self reporting with a sample size of approx. 32,000.

Other studies in the USA have shown only 5% of those reporting they had latex skin reactions to actually have positive skin prick tests to latex.

In general surgical patients, the estimated prevalence of type 1 allergy is less than 1%. In certain groups, however, it may be much higher - 28-67% of paediatric patients with spina bifida have latex specific IgE, with an associated risk of operating room anaphylaxis 500 times that of the general population.

 

3.3 Irritant contact dermatitis.

This is common housewives hand dermatitis. In most cases it is caused by damage to the skin from repeated exposure over a long period of time to water, soap and other detergents (such as surgical scrub). It is not due to an allergy to latex.

 

3.3.0.1 Symptoms

It usually presents as a dry, itchy red rash on the back of the hands and fingers. There may be episodes of blistering and weeping of affected skin which may swell. After prolonged involvement, the skin may become dry, thickened and scaly. Symptoms may appear to be aggravated by latex gloves, largely through the effect of occlusion, friction or the powder contained therein.

 

3.3.0.2 Diagnosis

Diagnosis, after history and examination, may be confirmed by demonstrating negative patch tests, thereby ruling out an allergic basis for the dermatitis.

 

3.3.0.3 Treatment

Treatment is with non-irritating soap substitute emollient creams, topical steroids and reducing irritant exposure. Paradoxically this usually involves recommending greater use of latex gloves for protection during wet work.

 

3.4 Allergic contact dermatitis (Type IV Delayed Hypersensitivity)

This is less common than irritant contact dermatitis. It is predominantly an allergy to the residues of the chemical accelerating agents used in latex and plastics manufacturing.

 

3.4.0.1 Symptoms

The symptoms and signs are often indistinguishable from irritant contact dermatitis as above. Frequently the two conditions coexist. There may be dermatitis at other sites exposed to latex such as under the waist-band or on the soles. Secondary spread of dermatitis to non-exposed skin can occur.

 

3.4.0.2 Diagnosis

Diagnosis is by demonstrating positive patch tests to one or more of the latex accelerators. Once established, this form of allergy is permanent.

 

3.4.0.3 Treatment

Treatment requires the stringent avoidance of gloves and other garments containing the responsible agent , along with topical treatment as above. Although prolonged contact must be avoided, transient contact is not usually a problem.

 

3.5 Immediate Hypersensitivity (Type I).

This is much rarer than the above forms of contact dermatitis. However, it is very important as it can cause severe and even fatal reactions.

 

3.5.0.1 The role of protein.

Type I hypersensitivity is due to an IgE response to natural latex protein. It should be noted that latex protein may adhere to particles of starch powder inside gloves, and the powder aerosol may thus also induce symptoms

 

3.5.0.2 Symptoms

Symptoms usually develop within 5-30 minutes of exposure and diminish rapidly once contact with the latex material has ceased. It may present with immediate itching and swelling of the fingers or hand when a latex glove is worn. This is more likely to occur at sites where the skin is broken or affected by dermatitis.

More serious are symptoms of anaphylaxis. These are more likely to occur when there has been latex contact with the mucous membranes or body cavities (as in surgery). Anaphylaxis may present with any or all of the following:

 

• Local or generalised itching, urticaria and/or angio-oedema.
• Rhinitis and/or conjunctivitis.
• Asthma.
• Extreme anxiety.
• Nausea, vomiting and abdominal pain.
• Tachycardia with or without hypotension.
• Faintness or loss of consciousness.
• Cardio-respiratory arrest.

If anaphylaxis is suspected, immediate medical assistance should be summoned. Please see section 4.2.4 on page .

 

3.5.0.3 Diagnosis

Diagnosis of Type 1 latex protein sensitivity may be confirmed by sending blood for specific IgE test to latex protein or by skin prick testing. The Dermatology or Occupational Health departments will advise on this for patients and staff respectively.

Patients or staff confirmed as having Type 1 latex protein sensitivity must take stringent steps to avoid latex contact. They should be advised regarding obtaining a warning device such as a Medic Alert bracelet.

 

4 Diagnosing those at risk.

 

4.1 Staff

 

4.1.1 Current employees

 

4.1.1.1 Diagnosis

Employees who think they may have latex allergy should self refer to the Department of Occupational Health. Managers who are concerned that an employee may have latex allergy must refer to the Department of Occupational Health. The Department of Occupational Health will be able to undertake all necessary measures to diagnose Type 1 latex allergy. Appropriate advice is available on any work related medical conditions.

 

4.1.1.2 Management

Advice regarding latex avoidance will be given¹. The Department of Occupational Health will review latex allergic employees after avoidance advice has been given to ensure symptom control. If necessary the Trust will support the employee by re-deployment and retraining in the case of allergic reactions unresponsive to avoidance precautions. In some cases ill-health retirement may be appropriate where the aforementioned options fail or are not possible.

The condition of latex allergy may require reporting as an Industrial Disease under RIDDOR, in which case it may qualify for NHS Industrial Injuries Benefit and as a Prescribed Disease for social security purposes. Further advice on this matter is available from the Department of Occupational Health.

 

4.1.2 New employees.

The pre-employment health questionnaire asks about known allergies including latex. In addition all staff who are identified to the Department of Occupational Health by management as being exposed to latex will be asked to complete a latex allergy screening questionnaire (Appendix D). These staff will usually include all those working in clinical areas or in patient care in the community.

If latex allergy is identified and confirmed in a prospective employee the Department of Occupational Health will advise management and the employee of any adjustments needed to the working practices or workplace to accommodate the employee. The Trust will make any reasonable adjustments necessary to comply with this advice. The Department of Occupational Health will review latex allergic employees after avoidance advice has been given to ensure symptom control.

 

4.2 Patients

 

4.2.1 Screening

Careful history taking from patients admitted for emergency surgery or those in whom elective surgery is planned should identify the high risk groups. These include:

 

• atopics,
• patients with spina bifida,
• health care workers
• patients with a history of multiple surgery when young.

Specific questioning will be included in the routine nursing procedures for units where the possibility exists for mucosal exposure to latex (for example, in the short stay surgical unit, surgical outpatients, gynaecology and admission to surgical wards - see Appendix E). Patients will be questioned regarding a history of immediate reaction to skin-rubber contact such as

 

• following dental surgery,
• blowing up rubber balloons
• wearing of rubber gloves
• any history of immediate allergic reaction to fruit, especially banana and kiwi fruit

The issue of latex sensitivity will be raised at relevant departmental meetings on a regular basis to ensure that all new staff (particularly in the surgical and anaesthetics directorates) are made aware of this problem.

 

4.2.2 Diagnosis

Patients giving a history of atopy and of adverse reaction to fruit, or those giving a history of immediate adverse reaction to rubber contact should have their surgery deferred if possible. An IgE RAST test to latex protein should be carried out and a referral made to the dermatology department for further diagnosis and investigation.

 

4.2.3 Latex Avoidance

For patients who are confirmed as having latex protein sensitivity or in those in whom it is suspected from the history but emergency surgery is unavoidable, appropriate alternative equipment packs will be made available. The risk of adverse reaction during clinical examinations including dental, endoscopic and manual pelvic examinations will be brought to the attention of appropriate staff.

 

4.2.4 Anaphylaxis

Education in the recognition and management of anaphylactic reactions will be facilitated by the production of posters, to be displayed in areas of high risk of such reactions. The trust anaphylaxis policy is covered in detail in document `Management of a patient with suspected anaphylaxis' (see Appendix B).

 

4.2.5 Management of non-life threatening reactions

A patient suffering form milder reactions which do not compromise the airway or lead to cardiovascular collapse should be managed with intravenous antihistamine followed by oral antihistamine therapy (see Appendix B for details). Referral to the dermatology department may be considered appropriate if the cause of reaction is unclear.

 

5 Prevention

 

5.1 Use of low protein devices.

Sensitisation can be prevented by the use of devices low in protein. Currently, the accepted method for assaying protein in latex devices is the Modified Lowry assay.

The Surgical Materials Testing Laboratory carries out testing of medical devices for the All Wales Contracts. Part of this work includes assaying protein levels in medical devices. Reports are available from SMTL on request and on their Internet site http://www.smtl.co.uk/ which documents protein levels in various medical devices, including gloves and urinary catheters.

 

5.2 Use of non-latex devices.

The use of non-latex devices is recommended in situations where staff or patients have a known latex allergy, and contact with the device is unavoidable. Appendix C lists products known to contain latex. If you require a latex-free device, Procurement (Ext: 2993) and Theatres (Ext: 2350) keep an up to date list.

 

5.3 Housekeeping

Good housekeeping practices should be followed to remove latex-containing dust from the workplace. Areas potentially contaminated with powder from latex devices should be identified for frequent cleaning.

Ventilation filters and vacuum bags should be changed frequently in these identified areas. Appendices.

 

 

A. Glossary

 

Anaphylaxis

Anaphylaxis refers to a severe allergic reaction in which there are prominent dermal and systemic signs and symptoms. The full-blown syndrome includes urticaria (hives) and/or angio-oedema with hypotension and bronchospasm. Cardiovascular collapse or respiratory arrest may occur in severe cases.

Angio-oedema

Severe form of urticaria affecting the skin of the face, hands, or genitals and the mucous membranes of the mouth and throat. An abrupt local increase in vascular permeability results in fluid escaping from blood vessels into surrounding tissue, leading to swelling.

Bradycardia

Slow rate of heart contraction, resulting in a slow pulse rate.

Conjunctivitis

Inflammation of the conjunctiva of the eye, resulting in `pink-eye'.

RIDDOR

Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (1995)

Rhinitis

Inflammation of the nasal mucous membrane.

Tachycardia

Excessively rapid heart rate.

Urticaria

An allergic skin eruption characterised by multiple, circumscribed, smooth, raised, pinkish, itchy weals, developing very suddenly, usually lasting several hours, and leaving no visible trace.

 

B. References

 

1. Medical Devices Agency. Latex sensitisation in the Health Care Setting (Use of Latex Gloves) Device Bulletin, May 1996.
2. Welsh Office Health Department Latex Medical Gloves (Surgeons' and Examination) Powdered Latex Medical Gloves (Surgeons' and Examination) WO SAB(98)25, June 1998.
3. Welsh Office Health Department, Letter regarding WO SAB(98)25 Latex Medical Gloves (Surgeons' and Examination) Powdered Latex Medical Gloves (Surgeons' and Examination) to recipients of Safety Action Bulletins, 17th July, 1998, from Louise Geisheimer, Health Strategy Division 2.
4. Bro Morgannwg NHS Trust Management of a patient with suspected anaphylaxis - Draft policy document.

 

C. Equipment Selection.

The following devices potentially contain latex. Note - the following list is taken from an article published in `Bandolier' and should not be considered comprehensive. Annotations have been made by the authors of the Policy.

 

Adhesive Tape

 

Adhesive plasters

 

Airways

 

Blood pressure cuffs

 

Bile bags

 

Chest drainage units

 

Colostomy Pouches

 

Condom/sheath urinary collection devices

 

Dental cofferdams

 

Elastic Bandages

 

Enema tubing kits

 

Epidural catheter injection adaptors

 

Eye shields

 

ET tubes

 

Fluid warming blankets

 

Gloves

Please see separate Trust Glove Policy for details on glove selection and usage.

Haemodialysis equipment

 

Head straps

 

IV set injection ports

 

Laparoscopy insufflation hoses

 

Latex cuffs on plastic tracheal tubes

 

Mattresses on stretchers

 

Naso-pharyngeal airways

 

Neonatal incubator

 

Oral-pharyngeal airways

 

PCA syringes

 

Penrose tubing

 

Protective Sheets

 

Rectal catheters

 

Rubber suction catheters

 

Rubber breathing circuits

 

Rubber masks

 

Rubber tourniquets

 

Stethoscope Tubing

 

Stomach and GI Tubes

 

Syringes

Where injections are to be administered to patients with known Type I hypersensitivity to latex, latex-free syringes should be made available. There is, however, evidence that plastic syringes with rubber grommets can be used safely provided that the contents of the syringe are expelled immediately.

There is no evidence that use of syringes or vials containing latex contributes to the sensitisation of patients.

 

Teeth protectors and bite blocks

 

Tourniquets

 

Urinary Catheters

Data on file at SMTL (available on request) shows that the protein levels in latex catheters are very low, and therefore unlikely to sensitise patients. However, latex-free catheters (such as all-silicone catheters) should be made available for patients with known Type I hypersensitivity.

Vial Stoppers

See syringes above.

Wound drains

 

Other, non-medical, items may contain latex proteins, including carpeting, balloons, erasers, computer mouse pads and rubber bands.

 

D. Screening Questionnaire for Staff.

 

 

 

 

 

 

Latex is contained in many products in the health care setting e.g. gloves (examination and surgeons), elastic bandages, ambu bags and adhesive tape. It is also found in the home e.g. balloons, household work gloves and condoms, to name a few.

 

 

 

Date Of Completion Of Form:

 

 

Name:

 

 

Job Title:

 

 

DOB:

 

 

Place of work:

 

 

1. Medical History

    

    

   1. Do you have an allergy to any latex products ?

       

      1. What type of allergic reaction ?
      2. What latex products caused it ?
   2. Have you a personal/family history of eczema, asthma or hay fever?
   3. Do you have any allergic reactions if you eat:

      Banana

      Avocado

      Kiwi fruit

      Chestnuts

      Other nuts

      Other foods

       

   4. Have you had any of the following when exposed to latex ?

      Dermatitis/eczema

      Urticaria/"hives"/"nettle rash"

      Asthma

      Hay fever

      Tight chest

      Coughing

      Sneezing

      Rhinitis/runny nose

      Itchy or runny eyes

      Anaphylactic reaction

       

   5. Have you ever had local reaction or swelling/itching following medical/dental examination with latex gloves?
2. Occupational History

    

    

   1. Does your current occupation involve exposure to latex ?

       

      1. If yes, on average how many hours a day do you wear latex gloves ?
      2. On average, how many times a day do you change latex gloves ?
3. Comments

    

 

E. Screening Checklist for Patients.

 

E..0.0.1 Surgical Admission

The prompts used by admitting nurses will include the following questions:

 

1. Do you have a history of atopic asthma and/or eczema.
2. Have you ever experienced itching or swelling following the wearing of household gloves ?
3. Have you ever experienced itching or swelling after eating tropical fruits such as bananas ?

If the patient answers yes to Question 1 and yes to one or both of Questions 2 and 3, the admitting nurse will refer to the medical officer who will assess each individual case and refer to the dermatologist as appropriate.

 

E..0.0.2 Day Surgical Unit

The screening questionnaire for the Day Surgical Unit will include the following question:

 

Do you have a reaction to rubber or tropical fruit ?

They will also be questioned for a list of allergies from which they suffer.

 

 

F. What is Latex ?

Latex is the protective fluid contained in tissue beneath the bark of the rubber tree, Hevea Brasiliensis.

The tree originated from Brazil (hence its name), and latex was originally gathered from wild trees in the jungles of Brazil in the 1870's. By 1890, Britain had introduced rubber plantations in Malaysia (with the help of Kew gardens and the Singapore Botanical Gardens) and was harvesting latex.

Natural rubber latex (NRL) is a cloudy white liquid, similar in appearance to cows milk. It is collected by cutting a thin strip of bark from the tree and allowing the latex to exude into a collecting vessel over a period of hours. Latex is not sap, but rather a fluid which runs in the latex ducts in the outer layers of the tree (the sap is found deeper inside the tree).

Only 10% of the production is used to manufacture latex - the rest is used to manufacture solid rubber, where the latex is allowed to coagulate, is collected, and then processed. The processing destroys most proteins due to the heat used, whereas the latex film manufacturing process means that most of the proteins stay in the latex.

 

F..1 What is latex composed of ?

The latex collected from the rubber tree is composed of rubber particles (30-40%), protein (2-3%), water (55-65%) and a mixture of other substances. The latex coagulates in the cup in which it is collected unless a stabiliser is added. Thus producers who want to produce latex (as opposed to lump rubber) usually add ammonia.

 

F..2 Latex Processing.

Once collected, the latex is processed - the rubber content is concentrated by centrifugation, and chemicals (accelerators and antioxidants) are added ready for subsequent stages in the process.

The latex is then used to manufacture the required device (glove, catheter etc) by dipping formers into the latex. The latex-covered former passes through a warm oven to turn the latex into a wet gel.

The product is now immersed into a bath or spray of water to wash out excessive additives (wet gel leaching) before being vulcanised.

During vulcanisation, the combination of heat, sulphur and accelerator cause cross-linking of the rubber, giving it strength and elasticity.

At this stage, some glove manufacturers wash the gloves in a chlorinated solution to reduce the tackiness of the latex. Most powder free gloves undergo this process. Because residual chlorine in the glove will ensure rapid deterioration of the latex product, extra washing usually takes place, which removes protein and accelerators in addition to the chlorine.

Inadequate leaching will leave high residual levels of proteins and accelerators in the latex products.

 

G. Authors

The principal authors of this document were:

 

• Dr Richard Logan, Consultant Dermatologist, POWH.
• Dr Anil Adisesh, Consultant in Occupational Health Medicine, POWH.
• Peter Phillips, Deputy Director, Surgical Materials Testing Laboratory, POWH.
• Staff Nurse Llunos Davies, Theatres, POWH.
• Mr Richard Hedges, Consultant Surgeon, POWH.

Other members of the Latex Policy Group were:

 

• Mrs Andrea Philpott, Acting Director of Nursing and Quality, Trust HQ (Chair).
• Mrs Helen James, Procurement Manager, Facilities, Trust HQ.
• Mrs Tracey Gauci, Senior Nurse, Control of Infection, POWH.
• Mrs Irene Painter, RCN Representative, Glanrhyd.
• Mr Phil Barnes, Risk Management Advisor, Trust HQ.
• Mrs Nicola Ryley, Head of Nursing Theatres and Anaesthetics, POWH.
• Mrs Alison Dando, COSHH Adviser, Trust HQ.

 

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Footnotes

... given¹

Including the provision of alternative products.