NIOSH warns workers and employers about dangers of latex exposure

Federal agency seeks to prevent allergic reactions among HCWs

Disabled health care workers turned activists are hailing the recently issued National Institute for Occupational Safety and Health (NIOSH) alert as a much-needed first step in making hospitals latex-safer work environments, which will help minimize latex-related health problems in workers.

The NIOSH warning states that "workers exposed to latex gloves and other products containing natural rubber latex may develop allergic reactions such as skin rashes; hives; nasal, eye, or sinus symptoms; asthma; and (rarely) shock." The document also presents recommendations for both workers and employers for reducing exposures, using appropriate work practices, training and education, monitoring symptoms, and substituting nonlatex products when appropriate.1

Reports of allergic reactions among HCWs have increased in recent years. DeLon Hull, PhD, deputy director of NIOSH’s division of surveillance, hazard evaluations, and field studies in Cincinnati and a lead author of the alert, says the agency became aware of the "magnitude of the problem" a year and a half ago while holding open meetings to develop a national occupational research agenda.

"We heard from concerned individuals and groups about this problem, and that’s when we became aware we needed to do something to address it. We put together a working group to look deeper into the problem, and the group felt that the NIOSH alert was the appropriate response, that more information needed to be in the hands of the workers," Hull tells Hospital Employee Health.

Latex sensitization of HCWs, mainly as a result of exposure to latex gloves in the workplace, is a serious problem affecting significant numbers of workers. "It certainly has consequences outside of the workplace too, because, once sensitized, people have to be careful of other latex exposures as well," he says. (See list of products to be wary of on p. 100.)

NIOSH’s main recommendation reads as follows: "If you choose to use latex [gloves], use powder-free low-protein," Hull states. (See case reports, p. 99.)

The proteins responsible for latex allergies fasten to powder used on some latex gloves, allowing more latex proteins to reach the skin and to be released into the air, where they can be inhaled. Work areas where only powder-free gloves are used show low levels or undetectable amounts of allergy-producing proteins.2,3

Hospital workers at risk for developing allergy are those with ongoing latex exposure, such as physicians, nurses, aides, operating room employees, lab technicians, housekeeping personnel, ambulance attendants, and food service workers.

Reports about latex allergy prevalence vary greatly, the recommendations point out. Recent reports indicate that about 8% to 12% of HCWs are sensitized to latex, compared with about 1% to 6% of the general population.4-6

According to NIOSH, reasons for the large numbers of latex allergies reported among HCWs include increasing reliance on latex gloves to prevent transmission of bloodborne pathogens, the U.S. Occupational Safety and Health Admini stration’s (OSHA) bloodborne pathogens standard requirement that employers provide gloves and other protective measures for employees, production changes in latex glove manufacturing to meet increased demand, and increased physician familiarity with latex allergy and improved methods for diagnosing it.

Employers urged to protect HCWs

"Latex allergy in the workplace can result in potentially serious health problems for workers, who are often unaware of the risk of latex exposure," NIOSH points out. However, the alert states that those health problems can be prevented or minimized by heeding the following recommendations:

Employers:

1. Provide workers with nonlatex gloves to use when there is little potential for contact with infectious materials (for example, in food service).

2. Appropriate barrier protection is necessary when handling infectious materials. If latex gloves are chosen, provide reduced-protein, powder-free gloves to protect workers from infectious materials.

3. Ensure that workers use good housekeeping practices to remove latex-containing dust from the workplace:

— Identify areas contaminated with latex dust for frequent cleaning (upholstery, carpets, ventilation ducts, and plenums).

— Make sure workers change ventilation filters and vacuum bags frequently in latex-contaminated areas.

4. Provide workers with education programs and training materials about latex allergy.

5. Periodically screen high-risk workers for latex allergy symptoms. Detecting symptoms early and removing symptomatic workers from latex exposure are essential for preventing long-term health effects.

6. Evaluate current prevention strategies whenever a worker is diagnosed with latex allergy.

Workers:

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

3. When wearing latex gloves, do not use oil-based hand creams or lotions unless they have been shown to reduce latex-related problems.

4. Frequently clean work areas contaminated with latex dust (upholstery, carpets, ventilation ducts, and plenums).

5. Frequently change the ventilation filters and vacuum bags used in latex-contaminated areas.

6. Learn to recognize the symptoms of latex allergy: skin rashes; hives; flushing; itching; nasal, eye, or sinus symptoms; asthma; and shock.

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

8. 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 powder from latex gloves worn by others.

— Tell your employers, physicians, nurses, and dentists that you have latex allergy.

— Wear a medical alert bracelet.

9. Take advantage of all latex allergy education and training provided by your employer.

The NIOSH recommendations represent "a step," but an "incomplete" one, says B. Lauren Charous, MD, director of the allergy and respiratory care center at Milwaukee Medical Clinic and a national advocate for latex-disabled HCWs, many of whom are his patients.

"It hedges on the question of powdered gloves," Charous maintains. He notes that on one hand, the recommendations call for use of powder-free gloves when latex gloves are used. On the other hand, the guidelines instruct workers to remove latex-containing dust from the workplace and to avoid areas where they might inhale latex glove powder.

"I don’t think this is very clear," he says, "and I don’t think the onus should be on the employee. This is a question of workplace safety. I’m opposed to the notion that it is up to the employee to defend his own inhaled-air safety. His atmosphere has to be made safe."

Charous says continuing to use powdered latex gloves is a matter of preference rather than necessity. "There are hospitals that have gone completely to nonpowdered and nonlatex gloves, so it can be done. If it can’t be done, [employers] have to very carefully monitor and restrict their use in particular areas, and then get anyone who is allergic to latex out of that area. Powdered gloves are the cause of respiratory allergy and occupational asthma. There is no question about that. We’ve got to do away with powdered gloves," he says. "That’s the direction we have to take."

Sue Lockwood of Grafton, WI, was one of Charous’ first patients. A former surgical tech, her occupationally acquired extreme latex allergy left her unable to work in health care or any other setting. After being diagnosed in 1991, Lockwood went on to establish and become executive director of Allergy to Latex Education and Resource Team (ALERT), which provides education and support to nearly 2,000 HCWs and others nationwide.

"I’m glad to see something come out of the government, but it’s just a beginning," Lockwood says. "There needs to be more effort and more action in the workplace to implement this. I want hospitals to see that this is coming from the government, that it provides a place to start, and to jump on it." (See editor’s note at end of article to send for ALERT’s information packet for hospitals.)

The directors of ELASTIC (Education for Latex Allergy Support Team and Information Coalition), a national activist education and support group with chapters in 46 states, also regard the NIOSH document as a first step toward preventing latex allergies. Debra Adkins, RN, of Torrington, CT, a nurse for more than 20 years until she was felled by a series of anaphylactic reactions to latex, says the recommendations "go a long way to protect health care workers. Nobody ever goes far enough for us, but it gives employers the opportunity to make changes."

Adkins notes that nurses’ aides in some facilities still wear latex gloves for tasks such as taking blood pressures and charting. "That’s ridiculous," she says. "People have to start examining what universal precautions really mean."

ELASTIC co-director Lisa Borel, DMD, a West Chester, PA, dentist who was forced to give up a 10-year practice due to latex allergy, says the guidelines are a "positive step," although they did not provide enough information on an important latex-related illness.

"They did not emphasize latex-related occupational asthma enough," Borel says, "which can be career-ending and permanent. A big part of the problem is there is not enough testing for occupational asthma that is related to latex. I wish the guidelines would have been stronger on that, but they did address many big issues."

Karen Jakpor, MD, MPH, is a Riverside, CA, OB/GYN who has written more than 100 letters to federal agencies seeking action to help prevent latex allergies since she was diagnosed with severe latex-related asthma in December 1996. She has been out of work due to her illness for about nine months but hopes to resume at least part of her practice soon in a latex-safe medical building. She also regards the NIOSH alert as a good first step, but says it is up to regulatory agencies such as OSHA to enforce it.

Shared ventilation affects whole facility

"NIOSH is an advisory agency, and it’s time for the regulatory agencies such as OSHA to follow through. OSHA has a general duty clause that says employers must provide a safe and healthful working environment, and now that NIOSH has defined what a safe and healthful working environment is in terms of latex, OSHA should start investigating reports when workers develop a serious latex allergy to make sure the entire facility is changed, rather than just a portion. The [NIOSH] alert says workers should avoid inhaling particles of latex gloves worn by others, but with shared ventilation you really need to reduce [airborne latex particles] throughout the whole facility," she maintains.

Jakpor’s fears about her own career reflect the concerns other latex-allergic HCWs face and illustrate the very real need for guidelines to prevent occupational latex allergy.

"For 10 years I studied to be an obstetrician — with college, medical school, and residency — and I’ve only been in practice for five years," she says. "I haven’t even finished paying off my medical school, and initially [when she goes back to work], I will only be able to do clinic work. That’s hard for someone who likes to deliver babies and do surgery. Some of my colleagues have referred to it as being half a doctor. I really want to be a doctor, so I’m going to try any way I can to return to work. I hope it goes well."

References

1. National Institute for Occupational Safety and Health. NIOSH Alert: Preventing Allergic Reactions to Natural Rubber Latex in the Workplace. DHHS (NIOSH) Pub. No. 97-135. Washington, DC: NIOSH; 1997.

2. Swanson MC, Bubak ME, Hunt LW, et al. Quantification of occupational latex aeroallergens in a medical center. J Allergy Clin Immunol 1994; 94:445-451.

3. Tarlo SM, Sussman G, Contala A, et al. Control of airborne latex by use of powder-free latex gloves. J Allergy Clin Immunol 1994; 93:985-989.

4. Kelly KJ, Sussman G, Fink JN. Stop the sensitization. J Allergy Clin Immunol 1996; 98:857-858.

5. Liss GM, Sussman GL, Deal K, et al. Latex allergy: Epidemiological study of hospital workers. Occup Environmental Med 1997; 54:335-342.

6. Ownby DR, Ownby HE, McCullough J, et al. The prevalence of anti-latex IgE antibodies in 1000 volunteer blood donors. J Allergy Clin Immunol 1996; 97:1188-1192.

[Editor’s note: For a copy of the NIOSH alert, call (800) 35-NIOSH and ask for Publication No. 97-135. It also is available on the Internet’s World Wide Web at http://www.cdc.gov/niosh/latexalt.html.

For a copy of ALERT’s latex-safer hospital facility packet, which includes guidelines, protocols, product lists, how-tos, and more, call (888)-97ALERT. The cost is $25, which includes mailing.]