To latex or not to latex

To latex or not to latex, that is the question

by Susan Cantrell, ELS

Do you think that emerging infectious diseases are mainly fodder for exotic novels and movies, far removed from our daily lives? Not so. Emerging infectious diseases are responsible for an issue that has assumed prominence in healthcare workers’ (HCWs) daily lives during recent years. The dramatic rise in latex allergy, in a roundabout way, is the result of emerging infectious diseases.

Jimmie McRay, Clinical Consultant, Ansell Healthcare Products, Inc, Red Bank, NJ, explained: "In the late 1980s, there was a tremendous increase in the use of latex gloves as protection from exposure to infectious agents such as human immunodeficiency virus (HIV), hepatitis B and C, and other bloodborne infections. The establishment of Universal Precautions (now called Standard Precautions) in the Bloodborne Pathogen Standard (OSHA 29CFR 1910.1030 [3] [1]) brought increased use of, and much greater exposure of HCWs and patients to, natural rubber latex (NRL) products."

Linda Bell, Clinical Practice Specialist, American Association of Critical Care Nurses, Aliso Viejo, CA, told HPN, "I remember the year we first started using full protection when caring for HIV patients. Latex gloves were as good as gold because they were so scarce. The worldwide demand went up, and makers couldn’t keep up. Later, a bunch of people became allergic; they had to find something else."

And indeed the glove industry has been working hard at providing synthetic substitutes. But should we be quick to dismiss NRL, the gold standard for gloves? Well, consider this: A lot of HCWs aren’t allergic to NRL, and there are ways to minimize the risk of becoming allergic.
Ansell’s DermaPrene
Ultra Surgical Glove
There are three adverse reactions associated with gloves: irritation, a non-allergic reaction; type IV hypersensitivity, caused by chemicals used in manufacture of both NRL and synthetic gloves; and type I hypersensitivity to NRL protein allergens.

According to Esah Yip, PhD, Director of the Malaysian Rubber Export Promotion Council, Kuala Lumpur, Malaysia, "The allergy was due to an older generation of latex gloves. There was no control over the residual protein levels, and protein is the culprit of the allergy. It is a type I allergy that also can be caused by other proteins such as can be found in certain foods."

McRay also mentioned other predisposing factors including, "history of frequent exposure to latex; history of multiple invasive surgical procedures; being immunocompromised, as are individuals such as pediatric spina bifida patients; and having existing plant or food allergies."

"A lot of people are not bothered by these proteins," noted Yip, "but a small number of people are genetically predisposed and are very much disturbed by them. Current technology has substantially reduced the amount of residual protein in NRL gloves. The problem now is that there are still a lot of gloves on the market that are not of that quality. The Food and Drug Administration (FDA) has yet to come up with a regulation that sets the upper limit of the protein and powders to be used in these gloves."

Another factor that latex-allergic individuals must be aware of is the practice of using powdered gloves. Powder makes it easier to put on the gloves. Mike Mattos, General Manager, of Kimberly-Clark’s Medical Gloves business said: "A number of organizations, including the Association of Operating Room Nurses; the National Institute for Occupational Safety and Health; the American Academy of Allergy, Asthma, and Immunology; and the American College of Allergy, Asthma, and Immunology, have all stated that a powder-free environment helps reduce the risk of reactions. If you choose to use latex products, choose those that are powder-free, low in NRL proteins, and low in chemical accelerators."

A scary aspect of the latex-powder issue is that the latex protein can bind to the powder, become dispersed in the air, and be inhaled, representing a sometimes life-threatening danger to those individuals Kimberly-Clark’s TACTYLON glove who are allergic. The person affected might not even be wearing the gloves but simply happen to be in the vicinity of the airborne particles. If persons are not yet allergic to NRL but inhale these airborne particles often enough, they can become sensitized, which can lead to an allergic reaction.

Powder can dry and crack skin, and that’s definitely not just an aesthetic problem. "Intact skin is the best defense against bloodborne pathogens," said Mattos. "Compromised skin allows for easy ingress of potentially deadly pathogens. HCWs should select gloves that are powder-free, low-allergen, and low in chemical levels. Doing so will reduce the likelihood of developing hand-health issues, and healthcare facilities can avoid having to purchase special hand-health gloves that traditionally are sold for a premium."

The FDA requires that surgical gloves be wiped with a sterile wet sponge or towel after putting them on; nevertheless, powder can remain on the gloves and cause serious complications. Mattos noted, "Glove powder has been associated with an increased risk of infection, transporting of allergens and potentially infectious microorganisms, hand irritation, increased scar formation, respiratory complications, delayed wound healing, and erroneous laboratory results. During surgeries, powder has been associated with misdiagnosis of cancer, catheter occlusions, infertility, and intestinal obstruction."

Powder can be deposited in surgical wounds, increasing the incidence of adhesions, granulomas, starch peritonitis syndrome or starch meningitis, fibrosis, clots, and more. Further operations may be required to resolve these complications.

Mattos emphasized this by saying, "It has been well documented for years that glove powder is a foreign Cardinal Health’s body that can result in adverse surgical outcomes Esteem polyisoprene and infertility. Ophthalmologists and gynecologists surgical glove were among the first specialists to see that adverse outcomes resulted from the use of powdered products. Although I believe most facilities have switched to powder-free gloves because of allergy issues, we need to continue to drive the conversion to powder-free to help eliminate patient complications caused by glove powder. These powder complications have been shown to cost the healthcare industry approximately $65 million per year just in re-operations alone. This doesn’t include the cost of medically managing these individuals."

Mattos continued, "HPIS (Healthcare Products Information Services, a company that tracks market trends in both the acute-care and alternate-care market segments) shows that, currently, 49% of all surgical gloves are powder-free. Latex surgical gloves drastically lag behind synthetic, with powder-free latex surgical gloves making up only 43% of the total latex market, whereas 83% of the synthetic gloves sold now are powder-free. Although powder-free–glove use continues to increase, the more important question is, ‘Why hasn’t it increased faster?’ Other countries such as the United Kingdom, Australia, and parts of northern Europe have already taken this key step toward improving patient outcomes and employee safety."

Of course, if an individual has already developed an allergy to latex, they must avoid exposure to it. OSHA requires that alternatives be provided for HCWs allergic to NRL.

And alternatives there are aplenty. Synthetics have had a hard time imitating the qualities of dexterity, tactile sensitivity, comfort, durability, and flexibility associated with NRL, but that’s changing.

"In the past, synthetic surgical gloves have not compared well against NRL," said Mattos. "Neoprene tends to be stiffer and less comfortable than NRL; therefore, the users generally have had to give up comfort and tactile sensitivity. Additionally, neoprene gloves tend to have a very slick grip, which could be detrimental in handling instruments, and the damp-hand donability was not equivalent to NRL powder-free gloves. Polyisoprene gloves have improved comfort and dexterity, but they still contain chemical accelerators associated with type IV reactions. New materials such as Kimberly-Clarks TACTYLON will soon be available that duplicate the comfort, fit, and feel of NRL but without either the proteins or the chemical accelerators. Damp-hand donability and grip also have been enhanced, providing a synthetic surgical glove that is equal to or better than NRL."

"Latex is still the gold standard," said McRay. "Of existing materials, neoprene and polyisoprene compare well to latex. Ansell’s Derma Prene Ultra surgical glove is made from neoprene and is manufactured without chemical accelerators, which is important to individuals sensitive to those used in some latex-free products. Unbroken neoprene is strong, but once broken it tends to tear easily. Tensile strength is typically 3,000 psi or better. Its elasticity is close to latex, and memory is very high, allowing the film to retain its original shape. Elongation limit is about 750%. Neoprene and other synthetics are more expensive than Ansell’s Encore brown surgical glove latex. Nitrile gloves rate about the same in tensile strength and somewhat lower in elongation. It exhibits some memory, allowing the film to adapt to the wearer’s hand. Nitrile is recommended as a preferred alternative to NRL where high strength or chemical protection is required. We recently previewed the Ansell Performance Polyisoprene (PI) surgical glove, a latex-free and powder-free glove that offers barrier protection, dexterity, elasticity, durability, and touch sensitivity on par with latex. It is more puncture-resistant than latex and neoprene. It offers similar fit, feel, and comfort as latex, all without the risks of latex allergies."

Deborah Davis, Technical Director, Gloves, Cardinal Health, McGaw Park, IL, agrees: "Polyisoprene is the synthetic that most closely mimics NRL. It has the same chemistry as NRL. Cardinal Health’s Esteem surgical glove is made of this material. This polyisoprene compound formulation was specifically engineered to emulate the desired features of NRL such as strength, barrier, elasticity, softness, and conformance to hand. Coatings eliminate the need for powder, which has been associated with dryness and irritation. Cardinal Health’s gloves with Neu-Thera are clinically proven to help relieve these symptoms, protecting hands from moisture loss, restoring smooth texture, and moisturizing flaking, irritated skin. Irritant contact dermatitis is ranked as one of the top concerns in the healthcare setting, and diseases of the skin are the number one cause of occupational illness across all professions."

You might think that with so many choices, particularly considering the consequences of latex and powder, there’d be some standardization in glove colors to avoid confusion, but that isn’t the case.

McRay said, "Ansell feels that there should be rapid identification of the gloving material at hand. One proposal being considered is to color code the gloves according to whether they contain latex."

Davis indicated that, "There has been some industry discussion about standardizing colors, but there is no consensus to date. Certain glove colors, such as blue, would not be clinically desirable for surgical gloves, because it does not provide sufficient color contrast during suturing."

In Mattos’s experience, "Typically latex gloves are beige or natural, whereas synthetic gloves are colored or white, allowing HCWs to identify gloves that are latex-free. However, not all manufacturers adhere to this, so there are colored latex gloves as well as beige or natural-colored synthetic gloves on the market. This forces the HCW to read the product labeling carefully to determine which gloves are latex-free. With the fast-paced nature of healthcare today, this heightens the chance of a latex-allergic HCW or patient being exposed to latex proteins." HPN