Latex gloves hand health workers a growing worry
Latex is in the air.
By Margaret Veach
Seventeen years ago, Dale Long, DO, thought he was allergic to the powder inside latex surgical gloves.
“Whenever anyone in the OR would put on or remove their gloves, that powder would fly, and I’d start to wheeze,” he said. “I’d have to hold my breath. I got to where I could hold it for three minutes by the OR clock.”
Though eventually diagnosed with latex allergy, Dr. Long managed to continue working for a while “by shooting up with epinephrine every 15 minutes” whenever he was at the hospital. No longer able to practice in a health care facility, he is now the medical director at a prison.
In 1988, Barbara Zucker-Pinchoff, MD, went into anaphylactic shock during the C-section delivery of her second child. She thought she was allergic to the Fentanyl used in the epidural, but an allergy to latex was diagnosed two years later.
Unwilling to stop working, she hoped that taking medication and avoiding latex as much as possible would be enough to bring the allergy under control. Despite those precautions, she went into anaphylactic shock on the job six months ago and is now on total disability.
Both physicians are allergic to natural rubber latex, the milky sap from which surgical and examination gloves are made. They’re not alone; it is estimated that 10% to 17% of U.S. health care workers are sensitive to latex.
Exactly how many of these workers are physicians is not known. Latex-sensitive doctors have been reluctant to discuss their condition for several reasons. They are primarily afraid of losing their job, but also concerned about being stigmatized or thought of as a quitter.
“It’s the most embarrassing thing that’s ever happened to me—to have to face the limitations,” said Dr. Long, a general practitioner in Terre Haute, Ind.
“Physicians are fantastic at denial,” Dr. Zucker-Pinchoff adds. “We can’t imagine such a thing will happen to us and we can’t imagine doing anything but practicing medicine.”
Physicians are beginning to come forward, however. In August, Dr. Zucker-Pinchoff established Physicians Against Latex Sensitization—PALS—a forum for physicians living with latex allergies as well as those concerned about stopping the increase in sensitization.
Why the sudden rise?
Although natural rubber latex has been used in health care for nearly 100 years, the number of reported cases of latex allergy has risen sharply only within the past 10 years.
By 1987, when the Centers for Disease Control and Prevention issued universal precautions, latex had already been found to be a highly effective barrier to HIV and other infectious agents. Consequently, by mandating barriers such as gloves to control the spread of bloodborne pathogens, “OSHA just about mandated latex exposure,” said Donald Beezhold, PhD, senior scientist at the Guthrie Research Institute.
“There’s no doubt that universal precautions played a role,” in the proliferation of latex gloves on the market, said Lauren Charous, MD, chair of the American College of Allergy, Asthma and Immunology.
According to some estimates, the use of latex medical gloves jumped from 12 billion pairs in 1987 to more than 200 billion pairs per year today, with the demand sometimes exceeding the supply.
How manufacturers attempted to meet that demand is thought by many to be at the heart of the growing number of latex allergies and the related lawsuits. At least 150 lawsuits—“the tip of the iceberg,” according to New York attorney David Rheingold—have been filed around the country. Rheingold estimates that as many as 5,000 lawsuits could be filed eventually.
Among the complaints alleged are that glove manufacturers took production shortcuts to meet demand, resulting in defective gloves high in allergens.
Because latex proteins are water-soluble, a thorough rinsing leaches away excess proteins, resulting in gloves much lower in allergens. But that step adds to the time and cost of production. “The manufacturers were taking the shortest route to the biggest profits,” Rheingold said.
“That’s just simply not the case,” said Geoffrey Fenton, spokesman for Allegiance, the glove manufacturing company spun off from Baxter Healthcare Corp. last year. Gloves of inferior quality did appear on the market in the latex 1980’s, Fenton said, but they were produced by small, inexperienced startup companies in Malaysia, not by the large manufacturers.
Major medical glove manufacturers, on the defensive since the first lawsuit was filed in 1991, insists that the effectiveness of latex as a barrier to infectious agents far outweighs its allergenicity. Nevertheless, they have taken various steps to address the allergy issue, from developing extensive latex education programs to offering a wide range of synthetic and powder-free gloves. Many of them are also quick to point out that they voluntarily began several years ago to label their latex-containing products.
To label or not to label?
Despite such claims, many of the lawsuits filed also assert that manufacturers knew their latex-containing products could cause allergies yet did not label them with appropriate warnings or a list of contents.
In fact, labeling was the central issue in the only latex allergy lawsuit decided so far. In June, a New Jersey court decided in favor of glove manufacturer Smith & Nephew. Despite the lack of a warning label, the jury ruled that the company did not fail to warn purchasers that its gloves could produce an allergic reaction.
Product labeling has been important to the latex allergy issue for several years. In 1993, the Food and Drug Administration recommended that medical device manufacturers voluntarily label their products that contain natural rubber latex. Then in June 1996, the FDA published a proposed ruling that would make such labeling mandatory; final regulations, expected by the end of the year, would require all medical devices containing natural rubber latex to be labeled accordingly, including warnings of the possibility of allergic reaction.
Some believe the labels are too little, too late. Dr. Charous questions why the FDA has taken four years to come up with wording for latex product labels. “The FDA is not protecting workers or patients,” he said. “It’s more strict about food labeling than about medical-device labeling.”
Another doctor who believes the FDA could do more is Lise Borel, DMD, a dentist who had to quit practicing three years ago because of her severe latex allergy. “Health care workers need to know what can happen to them,” said the executive director of Education for Latex Allergy / Support Team & Information Coalition, or ELASTIC.
Legislators in Minnesota, New York and Oregon have introduced bills banning powdered latex gloves in health care facilities entirely.
New York’s bill, introduced this June, was shelved but may be submitted again next year.
Oregon’s bill has been stalled too. Sen. Thomas Wilde, who introduced the bill, said that lobbying against it by glove manufacturers, particularly Allegiance, was so strong that its sponsors “folded their tents and went home.”
Fenton, who acknowledges that Allegiance was against the bill, said the company opposes any proposed legislation “that would limit the choice of health care providers.”
Pennsylvania has taken a different route to protect patients and health care workers: education. Wanda Filer, MD, the state’s physician general, has written to more than 50 organizations and state health centers to bring the potential dangers of latex to their attention. That mailing included a copy of the latex allergy alert issued by the National Institute for Occupational Safety and Health in June.
“To us, the critical issue is to get the word out,” said Dr. Filer, a family physician in York, Pa., whose own latex sensitivity was diagnosed early in her career.
Providers’ solutions fit like a glove
Many hospitals across the country began addressing the issue of latex sensitivity several years ago. In 1993, Shriners Hospital for Children in Springfield, Mass., became one of the first hospitals in the nation to go “latex-safe”. The hospital now uses only powdered nonlatex gloves for examinations, said Ellen Meeropol, pediatric nurse practitioner. “Nonlatex alternatives have improved so much in the past eight years,” she said.
Another facility that has made major changes is the Mayo Clinic. Almost three years ago, the clinic undertook a study to identify gloves low in latex allergens. By phasing out high-allergen latex gloves entirely, the facility is now latex safe.
Although Mayo’s physicians adapted well to the change, it wasn’t necessarily easy. When certain gloves were phased out, “there were plenty of complaints and cries of ‘scare tactic’,” said John Yunginger, MD, an allergy researcher at Mayo who helped develop the clinic’s glove-use policy. “Gloves are an item of attire for surgeons. The types of gloves they wear are a matter of habit and personal preference.”
Accordingly, physicians should play a role as more hospitals create latex-safe environments and pursue other fixes. So much could be at stake.
Physicians shouldn’t have to choose between quitting medicine and being sick, Dr. Borel said. “Why should you lose a career because of something so inconsequential as a medical glove?”
Allergy can go hand-in-glove with latex
There are two types of allergic reactions to latex.
Type IV hypersensitivity, or allergic contact dermatitis, is an immunological response to the chemicals added to the latex during manufacture. The reaction, which includes itching, swelling and redness that may extend beyond the areas of skin exposed to the latex, can develop as much as three days after the exposure and can last for several days. This type of reaction is not life-threatening, though it can lead to increased risk of Type I allergy.
Type I, or immediate, hypersensitivity is an immunological response to the latex proteins themselves. If absorbed through the skin, the latex allergens can produce urticaria; if introduced into the blood, they can result in anaphylaxis, the most severe reaction. Life-threatening symptoms include breathing trouble and rapid loss of blood pressure.
The lungs are apparently the most common route to sensitization. Latex gloves are powdered with cornstarch to make them easier to slip on and off. The cornstarch binds to the proteins in the natural latex, explains Donald Beezhold, PhD, senior scientist at the Guthrie Research Institute.
When the powdered gloves are snapped on and off, the starch becomes airborne, carrying the proteins with it. Once inhaled, those proteins are quickly absorbed by the body. And with each additional exposure to latex, the individual becomes more sensitized.
Article by Margaret Veach
First published in American Medical News on October 13, 1997
The American Medical Association
Reproduced here with permission.