Natural rubber latex hypersensitivity in health care worker

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