Memorandum by the Latex Allergy Support
Group
BACKGROUND
1. The UK Latex Allergy Support Group (LASG)
is a voluntary self-help organisation founded in 1996, with 300+
members. The aims of the Group are to raise awareness of latex
allergy, provide support for those affected, and promote the safe
and appropriate use of latex products and equipment. An advisory
panel provides advice on medical and technological issues.
2. Allergy to natural rubber latex (NRL)
was first described in 1979 and, as with other allergies related
to an underlying atopic susceptibility, the past 15 years has
seen its recognition as a health issue of increasing importance.
Latex allergy is thought to affect less than 1 per cent of the
general population, although is commoner in certain groups who
are regularly exposed to latex such as healthcare workers from
widespread use of protective gloves, and most notably patients
with spina bifida who have been exposed to NRL gloves and catheters.
3. Latex allergy is a reaction to the constituent
proteins of NRL and is an example of an "immediate"
Type I IgE-associated reaction, where symptoms generally appear
within minutes of exposure. This is quite different from allergy
to chemicals used in the manufacture of rubber, which is a "delayed"
Type IV hypersensitivity reaction taking some hours or days to
manifest clinically. These two quite separate conditions are often
confused by the public, and also by healthcare staff. Similar
confusion often exists between "glove allergy" (which
is usually a non-immunological irritant reaction) and latex allergy.
4. The clinical effects of latex allergy
are similar to those from peanut allergy in that most will have
relatively mild local reactions, some will have more troublesome
local and respiratory problems and a few will be at risk of potentially
fatal anaphylactic reactions. It is not possible at present to
predict which individuals may progress from mild reactions to
anaphylaxis, or when a more severe reaction may occur. The greatest
potential danger to an allergic individual comes from mucosal
contact (surgical/medical/dental/obstetric gloves must be avoided)
or from inhalation of latex (carried in the air by powder from
glove or balloon). Patients presenting with anaphylactic reactions
during surgery or with occupational asthma may be found on subsequent
investigation to be latex allergic.
5. A diagnosis of latex allergy may have
profound consequences for the patient from worry about the ubiquitous
nature of NRL in the environment together with its potential for
serious reaction. In addition, proper investigation of latex allergy
is itself not without hazard. It is therefore important that patients
with suspected latex allergy are referred to appropriately trained
practitioners for accurate confirmation of the diagnosis (or equally
important exclusion of this) and sound advice to be given, generally
by an allergist, dermatologist or other clinician with a sub-speciality
interest.
6. There is an overlap between NRL (a plant
product) allergy and food (usually fresh fruit) allergy due to
common / cross-reacting antigens. An allergic reaction to banana,
kiwi or avocado (for example) may be the first clinical presentation
of a previously undiagnosed latex allergy.
QUALITY OF
LIFE
7. Although there is an extensive published
literature on latex allergy, there has been surprisingly little
investigation into the impact of this condition on Health Related
Quality of Life (HRQoL). Two surveys have been conducted in the
UK.
8. The first study of 50 latex-allergic
adults from Wales showed that some had experienced severe impairment
of HRQoL as a result of their NRL allergy. Twenty five per cent
required to change the nature of their work as a direct result
of their allergy, this varying from transfer to a "latex-safer"
environment within healthcare to the necessity for full career
change. Thirty three per cent experienced difficulties when visiting
doctor or dentist, such as having to explain necessary precautions
or supplying their own latex-free gloves.
9. A further specific latex allergy HRQoL
questionnaire survey of 153 adult LASG members showed that the
highest scoring questions (ie having most impact on QoL) related
to worry, mood and situations where latex avoidance could be problematic.
Eighteen per cent were not working and 25 per cent had required
to change jobs because of their latex allergy.
10. The same survey of 28 child LASG members
showed that their highest scoring questions related to restriction
of diet, play and sports, whereas for their parents worry about
possible anaphylaxis or other severe physical reactions to latex
had the most impact on QoL. Nine children had experienced difficulty
at school because of their latex allergy.
11. The employment difficulties reported
above contrast with studies from other countries where affected
individuals have been accommodated more easily, suggesting that
with careful case management the effects on employment can be
mitigated. This perhaps reflects a lack of support from or understanding
of latex allergy by UK employers or line managers.
HEALTHCARE
12. Visits to healthcare settings are a
major concern for patients with latex allergy because of the widespread
presence of NRL (mainly gloves) together with frequently reported
lack of healthcare staff knowledge or understanding of this condition.
In the survey of 153 LASG adult members mentioned above, 80 per
cent reported reactions to NRL-containing medical equipment, 60
per cent had experienced at least "some difficulty"
in obtaining medical and/or dental care due to their latex allergy,
and only 5 per cent were confident that they would be cared for
in a latex-safe environment if they were to be admitted to hospital.
13. NRL is a hazardous substance for the
purposes of the Control of Substances Hazardous to Health (COSHH)
Regulations 2002, and healthcare organisations are expected to
have in place robust policies, both to minimise the development
of latex allergy in the workforce, and also to provide a latex-safe
environment for allergic patients and staff. The UK Health and
Safety Executive (HSE) have a web-site on latex allergy aimed
at healthcare employers and employees which explains about latex
allergy and how staff and patients may be protected http://www.hse.gov.uk/latex/index.htm
14. A National Patient Safety Agency (NPSA)
Patient Safety Information Notice published the results of a survey
of NHS organisations in England and Wales in 2005, from which
three broad conclusions emerged http://www.npsa.nhs.uk/site/media/documents/1079_Patient%20safety%20information.pdf:
(a) local organisations should ensure that
they have a comprehensive working policy on the use and purchasing
of latex products, supported by efficient management arrangements
(only 60 per cent had such a policy at the time of the survey—although
this had risen to 85 per cent by 2006, continuing frequent reported
incidents relating to communication and documentation suggest
lack of education and/or enforcement).
(b) products and packaging containing latex
need to be easily identifiable—labelling and catalogue descriptions
need to be unambiguous and clear (identification of latex content
of medical equipment continues to be a problem and there is at
present no European latex symbol for industry to adopt).
(c) there is a need for greater choice of
effective and cost-effective latex-free products and equipment—this
remains a concern for many NHS purchasers and managers.
15. Natural rubber latex has many positive
attributes. Comfort, strength, biological protection and low cost
have made latex gloves the standard choice for use within healthcare.
Recognition of the problem with latex allergy has led manufacturers
to reduce protein content and remove powder from medical gloves,
although it is not yet possible to completely remove all NRL allergens.
16. Although reduction in NRL allergen content
of medical gloves appears to have substantially reduced the number
of healthcare staff acquiring latex allergy, the need remains
to provide a safe environment within healthcare for those who
are already allergic, a few of whom react to even tiny amounts
of NRL in the environment. The recent NPSA survey and ongoing
reports of adverse incidents show that there is still much to
do to safeguard affected individuals.
17. Non-latex (synthetic) gloves are now
readily available for allergic staff and patients, and advances
in technology are making these a viable alternative to latex gloves
for all staff. Some healthcare establishments have already effected
such a change, although concern has been expressed in some quarters
on issues relating to synthetic glove supply, degree of protection
and potential for adverse reaction.
18. The Partnership Support Unit of the
Scottish Executive Health Department released a document in 2005
giving guidance on glove choice for staff working in NHS Scotland.
This advised that latex gloves may continue to be used when justified
by risk assessment, but that unnecessary routine use of latex
gloves should be identified and discouraged.
19. Otherwise within the UK, there has been
no clear agreement or guidance on whether healthcare organisations
should:
(a) continue with routine use of latex gloves,
except for those who are already sensitised or allergic, because
their benefits outweigh the risk of causing allergic reactions;
or
(b) eliminate the risk of latex allergy by
switching to synthetic gloves, considering the allergy risk to
be greater than the risk of blood-borne virus infection or synthetic
glove reaction
This decision has been left up to each individual
healthcare organisation to make. LASG feels that this is unsatisfactory,
and that clearer advice on this issue should be provided at national
level, and be subject to regular review in the light of ongoing
experience and technological advances.
20. A further issue within healthcare relates
to the use of NRL in the manufacture and presentation of medicines,
eg rubber vial stoppers. Sourcing information of NRL content and
latex-free alternatives (eg vaccines) can be problematic. An accurate
and up-to-date national database would assist healthcare staff
in safe choice of medication for patients with NRL allergy.
BALLOONS
21. Another significant concern for individuals
with latex allergy is NRL balloons. In a recent LASG survey of
109 members (83 adults, 26 parents of children), 21 had required
to use adrenaline following exposure to these. Sixty nine had
experienced symptoms just from being in an enclosed area containing
balloons and 81 said that their presence restricted access to
public premises, from which 90 thought that balloons should be
banned. Although scientific evidence is lacking on this issue,
LASG has recently petitioned the European Commission to examine
balloon safety, ways of improving this and to look at the question
of labelling.
22. In 1998, The Medical Devices Agency
(MDA) issued a Safety Notice informing healthcare organisations
of the increased risk of allergy from powdered latex gloves, and
these were subsequently removed from national contract two years
later. As NRL balloons are also powdered, it does not make sense
for healthcare organisations to permit these on their premises
(eg for displays), having already removed powdered gloves for
safety reasons. Some hospitals have taken steps to meet COSHH
regulations and ban NRL balloons, although not many to our knowledge.
OTHER ISSUES
23. There is a dearth of available data,
but anecdotal evidence suggests that latex gloves are widely used
out-with the healthcare setting, for example in garages, restaurants
and hairdressing salons. We do not know how allergenic these gloves
are, but the need to minimise costs is likely to mean that many
are cheap, powdered and highly allergenic. If this is the case,
the gloves will be a risk both for those who wear them (from developing
allergy) and also for their customers (eg from transfer of latex
allergens to car interior or food). It is possible that widespread
use of highly allergenic gloves in such occupations will produce
a similar outbreak of overt allergy that has already been encountered
in healthcare, and further study is required.
The Health and Safety Executive have recently
produced a web-site aimed at hairdressers, entitled "Let's
cut out dermatitis" (70 per cent hairdressers suffer from
this skin condition) http://www.hse.gov.uk/hairdressing/index.htm.
Non-latex gloves are specifically recommended
by HSE, and LASG would welcome similar guidance to be issued to
catering and automobile industries.
24. Similar concerns exist for latex glove
use in care homes, where controls may be laxer than is the case
within hospitals. In addition, there is some evidence that powdered
latex gloves may commonly be used in schools for eg science, home
economics and waste recycling, thus unnecessarily exposing substantial
numbers of atopic children to NRL on a regular basis. Again, further
study is required.
25. Although the Industrial Injuries Advisory
Council recommended in 2003 that NRL be added to the list of prescribed
causes of occupational rhinitis, that NRL be recognised as a cause
of occupational asthma, and that anaphylaxis resulting from NRL
allergy in healthcare workers be considered as a prescribed disease,
there still appear to be difficulties for patients obtaining benefits
or compensation for occupationally induced latex allergy.
DIAGNOSIS AND
INFORMATION
26. Investigation and management of patients
with suspected latex allergy can be time-consuming. Lack of trained
personnel and competing demands on time in specialist clinics
will inevitably compromise optimal management for some. A recent
survey of 202 UK dermatology and allergy consultants who investigate
for NRL allergy http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=search&DB=pubmed
showed substantial variation in diagnostic procedures, pointing
to a need for robust guidance to assist more consistent practice
across the country. Furthermore, patients referred with suspected
latex allergy may subsequently be found to have rubber chemical
allergy (see paragraph 3), and investigating physicians must have
knowledge of and access to appropriate investigation for each
condition.
27. The same survey showed that provision
of basic information to help allergic patients cope with what
can sometimes be a very daunting prospect is neither standard
nor consistent. LASG has produced both basic http://www.hse.gov.uk/latex/pdf/patientinfosheet.pdf
and comprehensive http://www.bad.org.uk/public/leaflets/bad_patient_information_gateway_leaflets/latex/index.asp
web-based patient information for hospital departments, although
it is not clear how accessible this is for the general public.
28. Nearly 30 years on, there remains much
confusion and misinformation about latex allergy.
LASG sees the education of all healthcare staff,
managers, employers and the general public as absolutely central
to addressing this issue.
We would welcome investment in key trained
personnel in order to deliver and maintain the correct information,
education and advice that is required throughout the country.
31 January 2007
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