|Year : 2018 | Volume
| Issue : 2 | Page : 122-126
Prevalence and associated factors of latex-related symptoms and sensitization at a multispecialty hospital: A cross-sectional study
Jandhyala Sridhar, Rahul Ray
Department of Dermatology, INHS Asvini, Mumbai, Maharashtra, India
|Date of Submission||14-Sep-2018|
|Date of Acceptance||06-Dec-2018|
|Date of Web Publication||10-Jan-2019|
Surg Cmde, VSM Rahul Ray
Department of Dermatology, INHS Asvini, Colaba, Mumbai - 400 005, Maharashtra
Source of Support: None, Conflict of Interest: None
Background and Aim: Upsurge in usage of latex gloves over the last few decades, coupled with the proliferation of medical latex products at the workplace, has led to a higher incidence of latex-related symptoms among health-care workers (HCWs). This study aimed to assess the prevalence and associated factors of latex glove-related symptoms and sensitization among HCW at a multispecialty hospital. Materials and Methods: The study included all the paramedical personnel and nurses employed at a multispecialty hospital where powdered latex gloves were in use. Consenting participants were evaluated by a questionnaire for symptoms of latex allergy, followed by a skin prick test (SPT) for evaluating sensitization to latex allergen. Statistical Analysis Used: Mean, standard deviation, and Student's t-test were used for continuous data. Categorical data were analyzed using the Chi-square test. Odds ratios and 95% confidence intervals were calculated. Results: Latex glove-related symptoms were present in 25 (10.91%) HCWs. Symptoms suggestive of Type I latex allergy were reported in 11 (4.8%), while those of contact dermatitis were reported in 17 (7.42%) HCWs. Of the 229 HCWs, 37 (16.16%) had a personal history of atopy; 14 (6.11%) were SPT positive to latex allergen. Conclusions: In this study among Indian HCW, there was a significant correlation of latex glove-related symptoms with the duration of glove use, personal atopy, and SPT positivity to latex allergen. Questionnaire-based evaluation of allergic symptoms along with SPT positivity was found to be a useful identifier of true latex allergy.
Keywords: Allergy, glove, health-care workers, hypersensitivity, latex, sensitization
|How to cite this article:|
Sridhar J, Ray R. Prevalence and associated factors of latex-related symptoms and sensitization at a multispecialty hospital: A cross-sectional study. J Mar Med Soc 2018;20:122-6
| Introduction|| |
Gloves provide an effective barrier to pathogens for health-care workers (HCWs). Low cost, durability, high-tensile strength, and elasticity of natural rubber latex make it the preferred material not only for gloves but also a wide range of medical products. The need for protection against HIV and hepatitis B and C viruses and the introduction of universal precautions in the health-care industry led to an upsurge in latex glove usage among HCW. Allergy to latex has in recent years emerged as an important occupational health concern among HCW., Worldwide, the current prevalence rate of latex allergy among HCW is estimated to be 9.7%, as compared to 4.3% in the general population. In the 1990s, latex allergy peaked among HCW in Europe and North America but declined subsequently owing to improvements in the glove manufacturing process, educational and practical interventions, and the use of low-protein, powder-free gloves. In Asia, the current prevalence of latex allergy remains high at an estimated average of 12.1%, as compared to 5% in Europe and North America.
Exposure risk to HCW stems from direct contact with medical latex products as well as respiratory mucosal exposure to the aerosolized powder of latex gloves, apart from general exposure to household latex products. Symptoms related to latex glove usage may include itching, redness, or rash over the hands and wrists, urticaria, rhinorrhea, chest tightness, and even anaphylactic shock. Latex allergy among HCW may thus entail costs in terms of sickness at work, additional expenditure on latex-free products, personnel reassignments, and disability claims. It is therefore essential to recognize HCW sensitized to latex to establish appropriate prevention and treatment strategies. Despite the importance of this problem, to date, few studies are available from India on the subject., The aim of this study was to evaluate the prevalence and associated factors of latex-related symptoms and sensitization among Indian HCW.
| Materials and Methods|| |
The study was cross-sectional in design. A universal sample comprising all the 257 paramedics and nurses posted at a multispecialty hospital of the Armed Forces was included in the study. The Institutional Ethics Committee cleared the study protocol and written informed consent was obtained from each participant. Consenting participants answered a self-administered questionnaire and were interviewed by a single investigator. The questionnaire was drawn from another study, customized, pilot tested, and validated. Skin prick test (SPT) with latex allergen was done for all the participants. At the time of the study, powdered latex gloves were being used at the hospital.
Details of demographic data, employment duration, duration of glove use, and personal history of atopy were collected. Any history suggestive of (a) Type I latex allergy occurring within 2 h of glove use (urticaria, rhinorrhea, chest heaviness, and dyspnea) and (b) contact dermatitis of the hands/wrists (pruritus, erythema, or papulovesicles) was drawn from each participant. For symptomatic HCW under treatment, a “washout” period of 10 days was observed for ongoing topical therapy over the hands (topical corticosteroids and emollients) as well as systemic therapies (antihistamines and glucocorticoids). Participants who gave a history of anaphylaxis/severe asthma were excluded from the study.
The test was performed over the volar region of the forearm. After disinfecting the skin with alcohol, three sites were marked, each 3 cm apart. A drop each of (a) sterile saline solution (sodium chloride 0.95%) as negative control, (b) latex antigen containing 12.5 mg/mL of latex mix (Creative Drug Industries, Navi Mumbai), and (c) histamine dihydrogen chloride solution 1% as positive control were placed over the marked sites. The skin was pricked through each drop using separate disposable lancets. Anaphylaxis tray and emergency oxygen were kept as standby. Interpretation of results was by measuring the maximum wheal diameter at 20 min. Values >3 mm were considered positive.
Continuous data were presented as mean and percentages. Pearson's Chi-square test, odds ratios (ORs), and 95% confidence intervals (CIs) were calculated using the Epi Info web application (version 7.2, Centers for Disease Control and Prevention, US Department of Health and Human Services). P < 0.05 was considered statistically significant.
| Results|| |
Of a total of 257 HCWs, 229 (89.1%) consented to participate in the study. Of these, 178 (77.73%) were male (all paramedical personnel) and 51 were female (all nurses). The mean age was 28.3 years with average work experience of 10.7 years.
Out of 229 HCWs, 25 (10.91%) reported at least one latex glove-related symptom. Symptoms suggestive of Type I latex allergy were reported in 11 (4.8%), while those of contact dermatitis were reported in 17 (7.42%) HCWs (three HCWs had features of both). Ongoing therapy for latex glove-related symptoms was withdrawn 10 days before SPT evaluation in respect of seven HCWs (topical corticosteroids – three HCWs and oral antihistamines – four HCWs).
Glove-related symptoms as per age group, gender, employment seniority, place of work, and latex glove use are summarized in [Table 1]. Employment seniority >10 years correlated with low occurrence of latex-related symptoms (OR = 0.28 CI 0.11–0.72) [Table 2]. Thirty-seven HCWs (16.16%) had a personal history of atopy, of whom 12 (32.43%) were symptomatic with latex glove-related symptoms. Symptoms of glove allergy correlated with personal atopy (OR = 6.61; 2.72–16.08) and a duration of glove use of at least 4 h/day (OR = 2.56; CI 1.10–5.96) [Table 2].
|Table 1: Characteristics of the participants with symptoms related to latex glove use|
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|Table 2: Distribution of various factors related to glove-related symptoms|
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Of the 229 HCWs, 14 (6.11%) were SPT positive to latex allergen [Figure 1]. SPT positivity to latex allergen strongly correlated with symptoms of Type I allergy (OR = 7.73; CI 2.42–24.64) and personal atopy (OR = 5.56; CI 1.07–28.69).
|Figure 1: Skin prick test positivity to latex allergen (central circle marked 2)|
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| Discussion|| |
Over the last decade, latex allergy has been recognized as a potential medical problem in India. A study from Kerala among 234 clinical laboratory workers found a prevalence of 3% for latex glove-related symptoms, while another from Rajasthan among 163 dental professionals revealed a prevalence of 16%. Two other studies, from Sri Lanka and South Africa, revealed prevalence rates of 15.4% and 4.6%, respectively, for latex glove-related symptoms., In a multicenter Chinese survey of 8485 nurses, the overall prevalence of latex glove allergy was 8.8%. In this study, glove-related symptoms were present in 10.91% of HCW who were using powdered latex gloves.
While the term latex allergy is often used as a general description, there are in fact two distinct mechanisms at work as follows: (a) true latex allergy (Type I hypersensitivity) and (b) contact dermatitis. True latex allergy is IgE mediated and is characterized first by an initial latex sensitization phase that is asymptomatic but SPT positive to latex extract allergens. Upon continued exposure over months to years, it transforms into true latex allergy that may present as urticaria, rhinorrhea, chest tightness/dyspnea, or potentially fatal anaphylactic shock. Contact dermatitis reactions to latex may be irritant or allergic (Type IV hypersensitivity reaction) and could occur due to thiuram accelerators added during vulcanization, as well as retarders, stabilizers, and antioxidants added during the processing of latex. In this study, the overall SPT positivity rate of 6.11% correlated significantly with Type I hypersensitivity symptoms that occurred in 4.8% of HCW (OR = 7.73; CI 2.42–24.64) but not with contact dermatitis that occurred in 7.42% of HCW (OR = 0.13; CI 0.04–0.41), underlining the mechanistic linkage between SPT positivity and the elicited Type I hypersensitivity symptoms in this study.
Employment seniority >10 years correlated with low occurrence of latex-related symptoms (OR = 0.28 CI 0.11–0.72) in this study. Phaswana and Naidoo, in their study, found that an employment duration of >20 years was protective against latex allergy, while others found that years of glove use correlated with a higher occurrence of latex-related symptoms among HCW., The “healthy worker effect” might be one explanation for the reduced prevalence rate of latex allergy with increasing employment duration; HCW who had developed latex allergy may have moved into administrative positions where the use of latex gloves is minimal.
Latex-related symptoms significantly correlated with a positive history of personal atopy (OR = 6.61; CI 2.72–16.08) in this study. Several studies have established the predominance of latex-related symptoms among individuals with atopy., Atopic individuals have a 4-fold increased risk of developing latex allergy than nonatopic individuals. In atopics, a higher tendency to produce sensitizing latex-specific IgE, coupled with an impaired skin barrier that is 20 times more previous to latex proteins may be responsible for the higher prevalence of latex-related symptoms.
In this study, the duration of glove use of at least 4 h/day correlated with the occurrence of latex-related symptoms (OR = 2.56; CI 1.10–5.96). While some studies on HCW have suggested that latex sensitivity increased with exposure time,, others did not find any significant association. Long-term wearing of latex gloves may reinforce the invasion of irritants and hydrophilic allergens on the inner surface of gloves by augmentation of the occlusive effect.
Although powdered latex gloves are still used in healthcare due to their lower price, it has been established that they have a higher allergenic protein content. Further, the cornstarch powder in gloves not only aerosolizes latex antigens, contributing to sensitization at the workplace, but may also hasten their cutaneous absorption. Powdered latex gloves have thus been identified as an important risk factor for latex sensitization in HCW. Avoidance of unnecessary glove use and introduction of powder-free latex gloves have been shown to stop the worsening of latex symptoms and prevent new cases of sensitization. For already sensitized/symptomatic or even atopic HCW, it is essential to avoid latex contact by using nonlatex gloves, and to ensure a powder-free latex glove environment at the workplace. Based on a hospital-level review of this study's findings, substitution with powder-free latex gloves was effected, and nonlatex gloves were made available to the latex sensitized/symptomatic HCW. However, we could not assess latex allergy prevalence after the corrective intervention.
Universal sampling employed for the study was a limiting feature. A larger sample size with a broader range of possible data would be more representative of the population. Furthermore, the cross-sectional study design could only determine the prevalence of Type I latex hypersensitivity and sensitization. Confirmation of Type I hypersensitivity by serum testing for latex-specific IgE and of contact dermatitis by patch testing could not be done due to logistical limitations.
| Conclusions|| |
In this study of latex allergy among Indian HCW, there was a significant correlation of latex glove-related symptoms with the duration of glove use, personal atopy, and SPT positivity to latex allergen. The latter also significantly correlated with a history of personal atopy. Questionnaire-based evaluation of allergic symptoms along with SPT positivity was found to be useful in the identification of true latex allergy.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]