Prevention of IgE Sensitization to Latex in Health Care Workers After Reduction of Antigen Exposures

Latex Allergy in Children

Notwithstanding the efforts made in the last decades to mitigate the consequences of natural rubber latex allergy, this disease continues to be a major health problem, especially in developing countries. The categories of patients with greater and frequent exposure to latex (such as health care professionals and, in the pediatric field, subjects who undergo repeated surgery, e.g., those suffering from spina bifida and urogenital malformations) have an increased risk of developing sensitization and allergy to latex. Herein we provide an overview of the current knowledge and practical recommendations with a focus on epidemiology, diagnostics, and management (including both prevention and therapy) in order to guide a correct recognition and containment of this potentially fatal condition.

Update on latex allergy: New insights into an old problem

Despite the efforts made to mitigate the consequences of this disease, natural rubber latex allergy (NRLA) continues to be a global health problem and is still considered one of the main worries in the working environment in many countries throughout the world. Due to thousands of products containing latex, it is not surprising that the current statistics suggest that prevalence remains high among healthcare workers and susceptible patients. In developed countries, reduction in the prevalence of IgE-mediated allergy to latex proteins from gloves may lead to lax attention by health care personnel. On the other hand, this situation is different in developing countries where there is a lack of epidemiological data associated with a deficit in education and awareness of this issue. The aim of this review is to provide an update of the current knowledge and practical recommendations regarding NRLA by allergologists from different parts of the world with experience in this field.

Incidence of and risk factors for perioperative or periprocedural anaphylaxis in the United States from 2005 to 2014

BACKGROUND

The estimated worldwide incidence of perioperative or periprocedural anaphylaxis (PA) is between 1 in 1250 and 1 in 20,000 procedures.

OBJECTIVE

To evaluate the incidence of PA in the United States and compare patient characteristics and underlying risk factors using a large national database.

METHODS

Using deidentified data from the nationwide inpatient sample from 2005 to 2014, we identified cases of PA through the International Classification of Diseases, Ninth Revision, Clinical Modification codes and conducted a retrospective analysis.

RESULTS

Among 35,647,347 surgeries and procedures, there were 5458 (0.015%) PA cases identified. The incidence of PA was 15.3 cases per 100,000 procedures. When compared with controls, PA cases had an increased mortality (3.4% vs 1.4%; P < .001), median length of stay (5 vs 3 days; P < .001), and median hospital cost ($45,155 vs $24,734; P < .001). The age group between 18 and 34 years (odds ratio [OR], 1.34; 95% confidence interval [CI], 1.13-1.58; P < .001) and female sex (OR, 1.40; 95% CI, 1.31-1.49; P < .001) were associated with increased odds of PA. Transplant (OR, 3.35; 95% CI, 2.59-4.34; P < .001), hematologic (OR, 1.63; 95% CI, 1.30-2.05; P < .001), vascular (OR, 1.49; 95% CI, 1.30-1.67; P < .001), and cardiac (OR, 1.47; 95% CI, 1.30-1.67; P < .001) procedures were at increased risk for PA. Several comorbidities were associated with PA including chronic pulmonary disease (OR, 1.41; 95% CI, 1.31-1.51; P < .001).

CONCLUSION

The incidence of PA is 1 in 6531 procedures, with a mortality of 1 in 191,652 procedures. PA has worsening outcomes compared with controls. The risk factors of PA include age, sex, procedure type, and comorbidities.

Latex Allergy: Current Status and Future Perspectives

Allergy to natural rubber latex (NRLA) from Hevea brasiliensis is a relevant public health issue, in particular in healthcare workers and groups at risk. Clinical manifestations of NRLA can range from mild skin disorders to life-threatening systemic reactions. Prevention measures remain the gold-standard treatment for patients suffering from NRLA, but the only etiological therapy able to influence the natural history of NRLA is specific desensitization. This review aims to underline the epidemiological, clinical and diagnostic aspects of NRLA, and carries out a complete and wide-ranging review of the current literature on NRLA management and immunotherapy.

Anaesthetic management of patients with pre-existing allergic conditions: a narrative review

This narrative review seeks to distinguish the clinical patterns of pre-existing allergic conditions from other confounding non-allergic clinical entities, and to identify the potential related risks and facilitate their perioperative management. Follow-up investigation should be performed after a perioperative immediate hypersensitivity to establish a diagnosis and provide advice for subsequent anaesthetics, the main risk factor for perioperative immunoglobulin E (IgE)-mediated anaphylaxis being a previous uninvestigated perioperative immediate hypersensitivity reaction. The concept of cross-reactivity between drugs used in the perioperative setting and food is often quoted, but usually not supported by evidence. There is no reason to avoid propofol in egg, soy, or peanut allergy. The allergenic determinants have been characterised for fish, shellfish, and povidone iodine, but remain unknown for iodinated contrast agents. Iodinated drugs may be used in seafood allergy. Evidence supporting the risk for protamine allergy in fish allergy and in neutral protamine Hagedorn insulin use is lacking. Conversely, cross-reactivity to gelatin-based colloid may occur in α-gal syndrome. Atopy and allergic asthma along with other non-allergic conditions, such as NSAID-exacerbated respiratory disease, chronic urticaria, mastocytosis, and hereditary or acquired angioedema, are not risk factors for IgE-mediated drug allergy, but there is a perioperative risk associated with the potential for exacerbation of the various conditions.

Latex Allergy Risks Live On

Reduction in the prevalence of IgE-mediated allergy to latex proteins from gloves in patients may lead to lax attention by health care personnel to avoid use of latex products in latex-allergic subjects. Recent evidence from the Pennsylvania Patient Safety Reporting System shows an alarming continuation of adverse events mostly from latex urinary catheters. We are strongly advocating that health care personnel must continue to pay close attention to avoidance of latex in patients with a history of latex allergy.

Latex Allergy: Where Are We Now and How Did We Get There?

Latex allergy emerged as an epidemic of anaphylaxis, occupational asthma, and clinical dilemmas in the 1980s. A systematic recognition, investigation, discovery, epidemiology, and prevention strategy followed. International attention and collaborations of investigators, government agencies, manufacturing, and health policy resulted in near elimination of a global epidemic. This article summarizes nearly 4 decades of work in control of this epidemic and focuses attention on future problems that still require resolution.

Occupational Respiratory Allergic Diseases in Healthcare Workers

Healthcare workers (HCWs) are exposed to a range of high and low molecular weight agents that are allergic sensitizers or irritants including cleaners and disinfectants, natural rubber latex, and various medications. Studies have shown that exposed HCWs are at risk for work-related rhinitis and asthma (WRA). Work-related rhinitis may precede development of WRA and should be considered as an early marker of WRA. Avoidance of causative exposures through control strategies such as elimination, substitution, engineering controls, and process modification is the preferred primary prevention strategy for preventing development of work-related allergic diseases. There is limited evidence for the effectiveness of respirators in preventing occupational asthma. If sensitizer-induced WRA is diagnosed, it is important to avoid further exposure to the causative agent, preferably by more rigorous application of exposure control strategies to the workplace. This review focuses on allergic occupational respiratory diseases in HCWs.

Occupational Latex Allergy: the Current State of Affairs

PURPOSE OF REVIEW

Allergy to natural rubber latex (NRL) reached epidemic proportions during the nineties and led to intense preventive efforts. The aim of this review was to provide a comprehensive compilation of the current status of occupational NRL allergy.

RECENT FINDINGS

Recent advances led to the characterization of 15 NRL allergens and the development of assays for measuring the allergen content of NRL materials and specific IgE antibodies against NRL allergen components. Preventive measures aimed at reducing workplace exposure to NRL allergens were associated with decreasing incidence rates of NRL allergy. However, a pooled analysis of epidemiological surveys published during the last 10 years provided prevalence estimates of NRL sensitization and allergy similar to those derived from studies conducted before 2003. Substantial progress has been made in the understanding and prevention of NRL allergy, although the disease may still remain a worldwide cause of concern.

Practical Management of Patients with a History of Immediate Hypersensitivity to Common non-Beta-Lactam Drugs

Immediate hypersensitivity reactions to medications are among the most feared adverse drug reactions, because of their close association with anaphylaxis. This review discusses a practical management approach for patients with a history of an immediate hypersensitivity to a non-beta-lactam medication, where reexposure to the implicated, or similar, medication is clinically necessary. Mechanisms associated with severe immediate hypersensitivity reactions include IgE-mediated mast cell activation, complement-mediated mast cell activation, and direct mast cell activation. Immediate hypersensitivity reactions may also be mediated by vasodilators, other pharmacologic mechanisms, or be secondary to underlying patient-specific biochemical abnormalities such as endocrine tumors or chronic spontaneous urticaria. The key features in the reaction history and the biochemistry of the implicated medication are discussed. Most individuals with a history of immediate hypersensitivity to a medication, who require reuse of that drug, can be safely retreated with a therapeutic course of the implicated drug after a full-dose challenge, graded challenge, or desensitization, with or without premedication and/or any preliminary diagnostic testing, depending on the specific situation.

Current prevalence rate of latex allergy: Why it remains a problem?

Objectives:

This article aims to review the current prevalence rate of latex allergy among healthcare workers, susceptible patients, and the general public, and to investigate why latex is still a ubiquitous occupational health hazard.

Methods:

Scientific publications on PubMed, particularly those published within the last five years, and current regulations from agencies such as Food and Drug Administration (FDA) were reviewed. Consumer and commercial products that may contain latex were also surveyed.

Results:

Approximately 12 million tons of natural rubber latex is produced annually and is widely used to manufacture millions of consumer and commercial products. Only limited number of latex-derived products have been approved and regulated by government agencies, such as FDA, whereas the majority of finished products do not label whether they contain latex. Owing to millions of unidentifiable products containing latex and many routes for exposure to latex, preventing contact with latex allergens and reducing the prevalence of latex allergy are more difficult than expected. Reported data suggest that the average prevalence of latex allergy worldwide remains 9.7%, 7.2%, and 4.3% among healthcare workers, susceptible patients, and general population, respectively.

Conclusions:

Latex-derived products are ubiquitous, and latex allergy remains a highly prevalent health risk in many occupations and to the general population. Developing alternative materials and increasing the ability to identify and label latex-derived products will be practicable approaches to effectively control the health risks associated with latex.

Prevalence of latex allergy among healthcare workers in Izmir (Turkey)

The purpose of this study was to determine prevalence of natural rubber latex (NRL) allergy among healthcare employees and identify sensitive individuals. A total of 1,115 healthcare workers (HCWs) employed in Izmir Tepecik Education and Research Hospital participated in the study. Information on age, gender, occupation, history of allergy, and complaints were collected through a questionnaire. Serum latex-specific IgE level was determined. Among HCWs enrolled in the study, prevalence of latex sensitization was determined as 4.2%. More frequent occurrence of latex allergy was detected among nurses. Family history of allergy and history of personal food allergy were significantly more often noted among individuals with latex allergy. Latex is considered to be the leading source of occupational health problems.

Occupational rhinitis and other work-related upper respiratory tract conditions

The nose and upper airways form the initial area of impact for air pollutants and allergens. The development of nasal allergies in the workplace (occupational rhinitis) may herald subsequent development of occupational asthma. Exposure controls, periodic surveillance, and early intervention may circumvent work-related airways disease and prevent unnecessary worker impairment and disability.

Self-reported hand symptoms: a role in monitoring health care workers for latex sensitization?

BACKGROUND

The use of powdered natural rubber latex (NRL) gloves increased greatly in the 1980s because of concerns about transmission of blood-borne infections and the subsequent implementation of universal precautions. The most common clinical reactions to glove use are irritant and T-cell-mediated contact dermatitis. However, IgE-mediated immediate reactions to latex have become a serious concern for health care workers (HCWs). The diagnosis of latex allergy requires a comprehensive medical history and diagnostic tests. The skin prick test is the preferred diagnostic method, although it can be time-consuming.

OBJECTIVE

To determine the role of hand symptoms reported on questionnaires in monitoring HCWs for latex sensitization.

METHODS

Questionnaires were completed by 804 HCWs at 2 hospitals. Using a positive skin prick test (SPT) result as a criterion standard of latex sensitization, the diagnostic performance of hand symptoms was evaluated.

RESULTS

Increasing latex glove use was strongly related to increasing reports of hand symptoms. Hand symptoms were highly associated with glove-related respiratory and systemic symptoms. A positive SPT result was seen in 5% of HCWs and increased with the number of hand symptoms: 0 (1.6%), 1 to 2 (3.4%), and 3 to 7 (19.0%). Participants reporting more than 2 hand symptoms were 11 times more likely to have positive SPT results compared with those with 2 or fewer hand symptoms.

CONCLUSION

Hand symptoms are closely associated with latex sensitization. Questionnaires should be useful in health monitoring for HCWs who use latex gloves.

Analysis of available diagnostic tests for latex sensitization in an at-risk population

BACKGROUND

Lack of a Food and Drug Administration (FDA)-approved skin testing reagent for latex allergy in the United States requires reliance on patient history and serologic assays for diagnosis.

OBJECTIVE

To determine the diagnostic sensitivity, specificity, and predictive values of an FDA-cleared antilatex IgE serology test and an enzyme-linked immunosorbent assay (ELISA) with various sources of latex protein antigens in an at-risk but unselected population of health care workers.

METHODS

Health care workers underwent duplicate latex and serologic testing for latex specific IgE with the CAP assay and ELISA from June 1, 1998, through December 31, 2002. Logistic regression with receiver operating characteristic curve analysis determined the values, resulting in 98% and 99% specificity for the CAP assay and ELISA, respectively.

RESULTS

Results of paired skin and serologic tests were available for 792 participants. Forty duplicate skin test results (5%) were positive. For the CAP assay, sensitivity was 35%; specificity, 98%; positive predictive value, 48.3%; and negative predictive value, 96.6%. ELISA demonstrated similar results. Multivariable logistic regression yielding a 98% or 99% specificity for the various ELISAs demonstrated that the adjusted odds of a positive skin test result significantly increased with positive CAP assay and ELISA results using a powdered glove extract.

CONCLUSIONS

The performance of the FDA-cleared antilatex IgE serologic test for latex allergy has much lower sensitivity than previously reported. This finding confirms that this serologic test should be used only for patients with a history of latex allergy and not for screening the population with a low prevalence of latex sensitization.