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Archives of International Surgery / September-December 2013 / Vol 3 / Issue 3 201

Latex glove allergy: The story behind the“invention” of the surgical glove and the

emergence of latex allergy

ABSTRACT

Latex rubber gloves have become increasingly common over the last 30 years. This has led to an increase in allergy to natural rubber

latex (NRL) proteins in health care professionals using protective gloves and/or in those exposed to products made of NRL. This has

led to a growing need to monitor the allergenicity of gloves and other latex goods to prevent sensitization and clinical allergy. There is

still considerable amount of misinformation regarding latex allergy. In this article, we examine the history behind the “invention” of

the surgical glove, the emergence of latex allergy and the diagnostic tests available and possible remedies. We searched PubMed and

MedLine using key words such as Latex allergy, surgical gloves, rubber, immunoglobulin E proteins, radioallergosorbent test. Recent

and old papers on the subject were reviewed and analyzed. Surgical gloves were a huge milestone in the field of surgery as it allowed

the development in the field of asepsis. It was instrumental in reducing the rates of infection and making health care professionals

think about aseptic techniques. However, the emergence of latex allergy over the last few decades has proved a challenge in the

perioperative setting. Surgical gloves are important tools in performing safe surgery. However, the increasing incidence of latex

allergy and its effects on theatre personnel is of great concern.

Key words: Latex allergy, radioallorgosorbent test, surgical gloves

Anokha Oomman, Susmita Oomman1

Department of Plastic Surgery, Morriston Hospital, Swansea, 1Department of Anaesthesia, Withybush General Hospital,

Haverfordwest, Pembrokeshire, UK

Address for correspondence: Dr. Anokha Oomman,

8, Maple Avenue, Haverfordwest SA61 1EF,

Pembrokeshire, UK.

E-mail: [email protected]

delivering babies.[2] In 1843, the process of vulcanization

was discovered almost at the same time by Charles

Goodyear and Nathaniel Hayward in the United States

and Thomas Hancock in England, which allowed the

possibility of making rubber gloves that were stable. [3] In

1889, William Halstead ordered a pair of rubber gloves

from the Goodyear tyre company as the carbolic acid he

was using to sterilize his instruments were damaging the

hands of his scrub nurse (who later on became his wife)

and causing her severe dermatitis.[4]

Allergy to latex rubber gloves has become increasingly

common today. Looking back 30 years ago, chances arethat most health care professionals didn’t know what latex

allergy was. However, over the last decade the incidence

of natural latex glove allergy has increased in prevalence

and attained world-wide importance.[5,6] This is thought

to be due to the huge rise of the use of the latex gloves

following the recommendations in 1987 by the US Center for

Disease Control, which suggested that latex gloves should

be used for “touching blood and bodily fluids and handling

items or surfaces soiled with blood or bodily fluids and for

Review Article

IntroductionLatex products have been in use since 1600 BC in

Mesoamerica.[1] However, surgical latex gloves were

“invented” only in the late 1890’s. Several individuals

have helped in the “invention” of the rubber surgical

gloves.[2] In 1813, Adam Elias von Siebold first suggested

that physicians should protect themselves from infections

by wearing horse or swine bladder as gloves whilst

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Oomman and Oomman: Latex glove allergy: A Review

202 Archives of International Surgery / September-December 2013 / Vol 3 / Issue 3

performing vascular access procedures”.[7] This surge in

the use of latex gloves led to an increase in concomitant

exposure.[6] The increase in demand in latex gloves meant

that during importation products were not subjected to

rigorous quality assurance procedures appropriate for

medical devices.[6] It remains unclear whether the increase

in allergic reactions to natural rubber latex (NRL) is a

direct result of increased glove use or abnormally high

levels of residual latex antigen in those gloves as a result

of manufacturing issues.[7]

The first published case of immediate hypersensitivity

to natural latex was in 1979, which documented case of

a woman with a history of dermatitis who presented with

pruritis after 5 min of wearing latex gloves. A skin prick

test with natural rubber glove extract demonstrated a

wheal on testing.[8]

EpidemiologyLatex sensitization prevalence rate ranges from 2.9%

to 22% in health care workers and from 0.12% to about

20% in occupationally unexposed populations.[9] It can

present with glove hypersensitivity, contact urticaria,

rhinitis, conjunctivitis, asthma and anaphylaxis. [10] It

has been suggested that there is an association between

long-term work in health care institutions and latex

sensitization.[11] Studies have shown that sensitization is

related to the degree of exposure.[11,12] Health care workers

at the beginning of their training have the same likelihood

of latex allergy as the general population.[12]

What is Latex?

Latex is the milky fluid derived from the lactiferous cells

of the rubber tree, Hevea brasiliensi.[13] It contains a large

variety of sugars, lipids, nucleic acids and highly allergenic

proteins. The milky fluid is made to undergo a complex

process when ingredients such as sulfur and organic

chemicals are added. The allergic protein components

cannot be fully removed during the manufacturing

process.[14]

These latex proteins present in the glovesmediate latex allergy and have been shown to adhere to

glove powder, which acts as a vehicle for the allergens. [15]

Cornstarch powder is the donning agent used in making

latex gloves in order to make them easier to put on and take

off, it can remain in the air for as long as 5 h.[16] Powdered

gloves have higher latex allergen content than powder-free

gloves.[17] There is evidence that the use of powdered gloves

is associated with a substantially higher prevalence and

rate of latex sensitization.[6]

Latex Sensitization versus Latex

Allergy?

The presence of immunoglobulin E (IgE) antibodies

specific to latex without symptoms is defined as latex

sensitization. [11] Whilst latex allergy is described as an

immunologically mediated reaction to latex that are eithertype IV or type I mediated hypersensitivity. It is believed

that latex sensitization can occur through skin contact or

through inhalation of the aerosol glove powder coming into

contact with the mucous membranes of the nose and lungs.[18]

In sensitized individuals, re-exposure to latex antigens may

result in anaphylaxis, urticaria, angioedema, asthma and

allergic rhinitis.[11] There seems to be a greater risk of

sensitization associated with spina bifida, multiple surgeries,

history of atopy and some food allergies (e.g. banana, Avocado,

Kiwi and Chestnut).[5] Essentially patients with medical

problems that cause frequent NRL exposure during surgery

or catheterization are at a high risk for NRL protein allergy.

Latex gloves are associated with 3 types of adverse

reactions: Irritant contact dermatitis, immediate-type

(type I) allergic reactions and allergic contact dermatitis

(type IV or delayed type hypersensitivity reactions).[5]

Immediate reaction appears within 30 min of contact with

latex and is due to proteins present in the NRL. The main

symptoms are urticaria and edema. However asthma, nasal

congestion and conjunctivitis may be noted if the mucous

membranes are breached.[19] If the latex protein comes into

contact with broken skin then very rarely anaphylactic

reactions may occur. The delayed hypersensitivity reaction

occurs after contact with latex and usually occurs by 24-

48 h. It is caused by accelerating agents that have been

added to latex in the manufacturing process. This leads to

allergic contact dermatitis of the skin and is characterized

particularly by an erythematous or itching rash on the back

of the hands.[14]

Diagnosing Latex Allergy

The clinical diagnosis of latex-induced contact urticaria is

based on a compatible history and evidence of sensitizationto NRL. The diagnosis of latex allergy should not be made

on the basis of either of these criteria alone.[20]

Methods available to measure NRL allergen activity

1. Skin prick testing:

A microscopic amount of an allergen is introduced

into patient’s skin by pricking the skin with a needle.

The immune response in terms of an urticarial rash or

more worrying anaphylaxis is noted.[13,21] The size of the




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Archives of International Surgery / September-December 2013 / Vol 3 / Issue 3 203

reaction is dependent on and is directly proportional to

the quantity of allergens to which the patient has IgE

class antibodies. A patch test can also be done. This

involves a 2-day occlusion of the test material to intact

skin and the response is noted after 48-72 h. Patch

testing however, could lead to sensitivity in previously

non-sensitized individuals.[14]

2. Human IgE-based immunologic inhibition assays:

There are two different types of immunoassays

available. Radioallegosorbent test inhibition and

enzyme-linked immunosorbent assay inhibition test.

They both help in measuring “total” allergen content.

It involves the reaction of the patients serum with an

antigen polymer complex in the presence of a labeled

IgE antibody.[22]

3. Methods based on immunoelectrophoresis and

imunoblotting:

Studies have described a large variety of NRL proteins

binding IgE from sera of NRL allergenic patients.[23]

However if a patient’s history is strongly suggestive

of latex allergy; then even if his tests are negative, he

should still be managed as a latex allergy.[13]

Hospital Staff Allergic to Latex

There is evidence to suggest that latex containing gloves

are the primary source of allergen in the health care

environment. Avoiding contact with latex-containing

gloves is the most effective method of preventing

sensitization of high-risk groups. Measures to create

a “latex-safe” environment should be undertaken for

healthcare workers who are sensitized to latex. In an

attempt to create a latex safe environment it has been

suggested that latex gloves should only be used under

universal precautions. Therefore, it should not be used

by domestic staff, food handlers and transportation

personnel. Low-allergen, non-powdered latex gloves

should be used as they reduce sensitization. Lastly

hospital staff that are allergic to latex should be provided

with latex free gloves. [5]

It has been suggested that questionnaires relatingto latex allergy should be included as part of pre-

employment assessment, with examinations in the hospital

Occupational Health Department, especially when dealing

with individuals who might be working in an environment

such as operating theater where frequent glove use is

anticipated.[24,25] This will help identify individuals who are

at risk of developing latex allergy. If a patient or a health

care professional is allergic to latex allergy, then avoidance

and substitution of latex gloves is essential. By avoiding

exposure to the allergens, most adverse responses to latex

gloves can be controlled. Latex-free alternatives include

nitrile, vinyl, neoprene and styrene butadiene.[23]

Why Don’t We Switch to Non-latex

Gloves?

The use of NRL alternative gloves has met with some

resistance. There are clinical advantages of using latex

gloves which outweigh non-latex gloves. These include

lower rates of glove tear, better tactile sensitivity, better

strength, elasticity and a better fit. The rates of viral

leakage are also noted to be higher in non-latex gloves.

Non-latex gloves have a higher rate of failure to protect

against herpes simplex virus type I.[5]

Even though, synthetic or non-latex gloves may be free of

protein, they can also cause an allergic reaction. Cases of

type 1 and type 4 hypersensitivity have been noted with thenon-latex gloves too.[21] Furthermore, disposing off latex gloves

is easier as they are biodegradable and unlike the synthetic

gloves do not produce harmful emissions when incinerated.[21]

Conclusion

NRL is a widely-used and cost-effective material, which

for the majority of the population is not a clinical risk. It

has many benefits which are yet to be equaled. However,

it remains to be seen whether an increased use of non-

latex gloves will lead to an increase in “non-latex glove”

allergies in the future.

References

1. Hosler D, Burkett SL, Tarkanian MJ. Prehistoric polymers:Rubber processing in ancient Mesoamerica Science1999;284:1988-91.

2. Ownby DR. A history of latex allergy. J Allergy Clin Immunol2002;110:S27-32.

3. Randers-Pehrson J. The Surgeon’s Glove. Springfield (IL):Charles C. Thomas; 1960.

4. Lathan SR. Caroline Hampton Halsted: The first to use rubbergloves in the operating room. Proc (Bayl Univ Med Cent)

2010;23:389-92.5. Ranta PM, Ownby DR. A review of natural-rubber

latex allergy in health care workers. Healthc Epidemiol2004;38:253.

6. Power S, Gallagher J, Meaney S. Quality of life in health careworkers with latex allergy. Occup Med (Lond) 2010;60:62-5.

7. Hunt LW, Fransway AF, Reed CE, Miller LK, Jones RT,Swanson MC, et al . An epidemic of occupational allergy tolatex involving health care workers. J Occup Environ Med1995;37:1204-9.

8. Nutter AF. Contact urticaria to rubber. Br J Dermatol1979;101:597-8.




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9. Page EH, Esswein EJ, Petersen MR, Lewis DM, Bledsoe TA.Natural rubber latex: Glove use, sensitization, and airborneand latent dust concentrations at a Denver hospital. J OccupEnviron Med 2000;42:613-20.

10. Monduzzi G, Franco G. Practising evidence -basedoccupational health in individual workers: How to deal witha latex allergy problem in a health care setting. Occup Med(Lond) 2005;55:3-6.

11. Garabrant DH, Roth HD, Parsad R, Ying GS, Weiss J. Latexsensitization in health care workers and in the US generalpopulation. Am J Epidemiol 2001;153:515-22.

12. Poley GE, Slater JE. Current reviews of allergy and clinicalimmunology. Part 1. J Allergy Clin Immunol 2000; 105:3-6.

13. Farley CA, Jones HM. Lat ex allergy. Br J Anaesth2002;2:20-3.

14. Sinha A, Harrison PV. Latex glove allergy among hospitalemployees: A study in the north-west of England. OccupMed (Lond) 1998;48:405-10.

15. Newsom SW, Shaw M. A survey of starch particle counts inthe hospital environment in relation to the use of powderedlatex gloves. Occup Med (Lond) 1997;47:155-8.

16. Woods JA, Morgan RF, Watkins FH, Edlich RF. Surgical

glove lubricants: From toxicity to opportunity. J Emerg Med1997;15:209-20.

17. Koh D, Ng V, Leow YH, Goh CL. A study of natural rubberlatex allergens in gloves used by healthcare workers inSingapore. Br J Dermatol 2005;153:954-9.

18. Jaeger D, Kleinhans D, Czuppon AB, Baur X. Latex-specific proteins causing immediate-type cutaneous, nasal,bronchial, and systemic reactions. J Allergy Clin Immunol1992;89:759-68.

19. Kujala V. A review of current literature on epidemiologyof immediate glove irritation and latex allergy. Occup Med(Lond) 1999;49:3-9.

20. Bernstein DI. Management of natural rubber latex allergy.

J Allergy Clin Immunol 2002;110:S111-6.21. Sugiura K, Sugiur a M, Hayakawa R, Sasaki K. Di

(2-ethylhexyl) phthalate (DOP) in the dotted polyvinyl-chloride grip of cotton gloves as a cause of contact urticariasyndrome. Contact Dermatitis 2000;43:237-8.

22. Palosuo T, Alenius H, Turjanmaa K. Quantitation of latexallergens. Methods 2002;27:52-8.

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25. American Latex Allergy Association. Dermatitis: Is itirritation or allergy. 2006.

How to cite this article: Oomman A, Oomman S. Latex glove allergy:The story behind the "invention" of the surgical glove and the emergence

of latex allergy. Arch Int Surg 2013;3:201-4.

Source of Support: Nil. Conict of Interest: None declared.


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