Allergy concerns spur new move to eliminate use of latex gloves

Johns Hopkins makes the switch: 'We don't want to do harm to anyone'

Officials of Johns Hopkins Hospital and University in Baltimore, one of the nation's most prestigious medical institutions, have decided to toss out all nonsterile latex examination gloves and replace them with vinyl counterparts, a move that some observers think will motivate many other facilities to follow suit.

Actually, what started out several years ago as a trickle of institutions trying to make their environments safer for both health care workers and patients is becoming more of a steady movement, says Debra Adkins, RN, director of the Education for Latex Allergy Support Team and Information Coalition (ELASTIC), a national activist education and support group in Torrington, CT.

Adkins hopes Johns Hopkins' action will set an example for even more institutions, precipitating a foreseeable end to the epidemic of latex allergies among HCWs.

"I will be pleased to resign from my position in about three years because I don't think it will be a problem anymore," she says.

Recent reports about latex allergy prevalence among HCWs indicate that about 8% to 12% are sensitized, compared with about 1% to 6% of the general population.1-3 Hospital workers at risk for developing latex allergy are those at risk for ongoing exposure, such as physicians, nurses, aides, operating room employees, lab technicians, housekeepers, ambulance attendants, and food service workers.

According to the National Institute for Occupational Safety and Health (NIOSH), a main reason for the large numbers of latex allergies among HCWs is increasing reliance on latex gloves to prevent transmission of bloodborne pathogens. NIOSH recently issued a warning to hospitals and other health care employers that workers exposed to latex gloves are at risk for allergic reactions. It recommended methods of reducing those exposures, one of which is providing nonlatex gloves wherever possible.4 (See Hospital Employee Health, September 1997, pp. 97-101.)

In another recent federal government action to reduce latex hazards for HCWs, the Food and Drug Administration (FDA) last year began requiring medical devices containing latex - including latex gloves - to be labeled with a warning that the product could cause allergic reactions.5 (See Hospital Employee Health, December 1997, pp. 138-140.)

Eliminating latex exam gloves at Hopkins will help protect both patients and HCWs, says Edward Bernacki, MD, MPH, director of occupational safety and health and chair of the joint committee on health, safety and the environment for the institution's hospital and university. While HCW allergies have not been a major problem there, Bernacki says protecting workers as well as patients is important.

"Our basic thrust is to minimize risk to patients, but latex exam gloves are so ubiquitous that it could be a significant problem. Eliminating nonsterile latex gloves drops the risk about 95%," he says.

Educating workers is necessary

The switch, which is set to take place this spring, is not without challenges. Approximately 10,000 HCWs will be affected in an institution that uses 210,000 boxes of latex exam gloves per year. Prior to decision-making, employees were allowed to evaluate vinyl gloves and indicate their preference - latex or vinyl. While 60% said they preferred vinyl gloves, that means "40% of the people don't want them," Bernacki points out. "Now we'll have to do an educational program, and we've got our work cut out for us."

Cost and protection factors also have been investigated, and Bernacki says officials are satisfied that vinyl gloves will be just as protective and not more expensive, so employees cannot argue those points. Anyone still concerned about protection can double-glove in situations that might cause gloves to tear and expose workers to bloodborne pathogens.

"We know we'll never get 100% acceptance in this crowd because people have personal preferences for gloves they've used over the years. But basically, there's the overriding issue that we don't want to do harm to anyone," he says. "Everybody buys into reducing the risk for patients, but [employees] still think it will never happen to them."

Jeanne Culver, RN, COHN, director of employee health services at Emory University Hospital in Atlanta, says education is the best way to handle that perception. Emory eliminated all latex exam gloves in early 1995, making it one of the first U.S. hospitals to do so. Culver says any resistance to the switch dissolved when occupational health nurses made the facts known.

First, they began screening employees for latex allergy in 1992 and spent time during annual assessments educating workers about the risks.

It's not just the worker's health at stake

"Screening allowed us to know the extent of the problem and to communicate effectively to employees so they could understand in real terms that this was a significant threat to their health, and even if they weren't having a problem themselves, their use of latex products could seriously jeopardize someone else's health, whether a patient or a coworker," Culver says. "When staff understood that, they had a whole different attitude and did not think that we were giving them an inferior product."

Employee health also distributed information from the FDA and the Centers for Disease Control and Prevention indicating that intact vinyl provides a barrier equal to latex. Questions about barrier protection and convenience of use for certain tasks are employees' two main concerns, she notes. For the latter, while some vinyl gloves might be too baggy or could interfere with tactile sensitivity for certain procedures, the available sizes and fit of vinyl gloves are acceptable to most employees. Vinyl gloves are not appropriate for some tasks, such as pelvic exams or pharmacists' preparation of chemotherapy drugs, so Emory provides nitrile gloves for those procedures, another type of nonlatex material.

"We also let [employees] know that the risk of developing latex allergy is approximately 10%, while in comparison, there's a three in 1,000 risk that they could get HIV from a blood exposure," she says. "No [occupational HIV] conversions have ever been due to failure or breakdown of a glove. That kind of factual information is what we give our employees, rather than coming out with an edict that 'we are going to switch gloves tomorrow - deal with it.'"

No employees collecting workers' comp

Emory's early switchover to vinyl exam gloves resulted from an epidemiological investigation launched in 1992 of an initial HCW index case found to be latex-allergic. The evaluation determined that 25% of the index case's unit also had the problem. By the end of 1994, the hospital had developed a sweeping latex precautions policy that included the provision for switching to nonlatex exam gloves in all clinical areas.

Since latex exam gloves were removed, no employees have been out on workers' compensation due to latex allergy. Employees with latex allergies can work anywhere in the facility, and latex-allergic patients can be placed anywhere as well, she says.

Changing exam gloves requires a commitment from top-level administrators once employee health practitioners identify the problem and increase awareness of it. Culver says hospitals that think they have no latex allergy problem among workers are not screening them properly.

"Latex allergy results from sensitization over time, so it's important not only to screen employees on preplacement, but also to continue doing it every year. Many facilities have no clue if their employees are latex-allergic, and with downsizing, many [employees] are reluctant to report. If we had relied on our injury reports, we would never had been able to determine the extent to which we had latex allergy in our facility. The only way to know that is to ask symptom-based questions, and questionnaires have to be specific to the issue of latex allergy. [Some practitioners] really don't want to know if they have latex allergies in their hospital because if they do know, they then have to do something about it," she says.

At Hospital University of Pennsylvania in Philadelphia, officials have been doing something about latex allergies among HCWs for the past year. Kathleen Bailer, RN, MSN, coordinator of nursing practice and a member of the hospital's latex committee, says planning began a year ago to convert from latex to nonlatex exam gloves after increasing numbers of employees were identified as allergic. Vinyl gloves were trialed on selected units and are now in use, despite some staff members' concerns about durability.

Bailer says nitrile gloves also are being evaluated for use in certain higher-risk areas, such as the emergency room, intensive care unit (ICU), and labor and delivery.

"We surveyed people's preferences and found that people who were in the more high-risk areas had more dissatisfaction with the vinyl gloves because they were dealing with more high-risk patients, and what they have to do is more unpredictable. In ICU, you can go in to give a medication, and all of a sudden you can be knee-deep in trouble," Bailer says.

Some employee groups thought the vinyl gloves were fine, while others said the gloves were tearing and not holding up. However, "latex gloves can tear, too," she says, "but you don't notice it as much. If you have a tear in a vinyl glove, it's more obvious."

Nitrile vs. vinyl

Reaction to the nitrile glove trialed was overwhelmingly positive. "People love it," Bailer says, "but it's more expensive." To keep costs manageable, the committee is formulating guidelines for use of nitrile and vinyl gloves. "We want to identify criteria for when it's appropriate to use a nitrile glove and when it's appropriate to use a vinyl glove. For example, when you're doing a simple dressing change, vinyl is fine. If you're doing a GI exam, it may be more appropriate to use a nitrile glove."

Bailer says reducing the number of different glove lines and purchasing fewer lines in larger quantities will be more economical as well.

Top administration supports the project, as do most employees. "People who have more sensitivity to peers who have a latex allergy seem to be more supportive of using vinyl gloves," she says. "They understand it's a big deal. It's not just a matter of changing a product. They know we have employees who have health problems related to gloves, and they appreciate why we're making this change. Even the people who were more dissatisfied with vinyl don't want to go back to latex. To them, latex is a bad thing."

[Editor's note: To obtain a copy of the NIOSH guidelines, write: NIOSH, Publications Dissemination, EID, 4676 Columbia Parkway, Cincinnati, OH 45226-1998; fax: (513) 533-8573; telephone: (800) 35-NIOSH; e-mail: pubstaft@niosdt1.em.cdc.gov.]

References

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

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

3. Ownby DR, Ownby HE, McCullough J, et al. The prevalence of anti-latex IgE antibodies in 1,000 volunteer blood donors. J Allergy Clin Immunol 1996; 97:1,188-1,192.

4. National Institute for Occupational Safety and Health. NIOSH Alert: Preventing Allergic Reactions to Natural Rubber Latex in the Workplace. Washington, DC; 1997.

5. Department of Health and Human Services, Food and Drug Administration. Natural rubber-containing medical devices; user labeling. 62 Fed Reg 51,021 (1997).