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A key consideration for the selection of medical gloves is barrier integrity.

Many healthcare personnel assume that all well manufactured gloves will maintain the same barrier protection throughout the course of their activities, but this is NOT an accurate assumption. Regardless of the quality of the manufacturing process, the material from which the glove is made will have its own strengths and limitations.

The three primary materials from which examination gloves are made include natural rubber latex (NRL), and, two synthetic glove materials, acrylonitrile-butadiene (Nitrile), and polyvinyl chloride (Vinyl, PVC). Each of these materials will differ, sometimes dramatically, in strength and durability when subjected to various stresses under different conditions (See Image 1).

NRL gloves are made from a milk-like substance derived from the rubber tree, Hevea brasiliensis. Processed NRL has a molecular structure that allows for the properties of stretchability and elasticity that are ideal for tasks involving rigorous manipulation. These properties enable the glove to stretch when challenged and return rapidly to its original shape.1 NRL gloves are highly durable,2 tear and puncture resistant and provide resistance to the penetration of many chemicals. They also provide excellent comfort, ease of movement and tactile sensitivity.2,3 However, NRL gloves do have some limitations. The barrier properties of NRL may deteriorate when exposed to petroleum-based products, ozone, oxygen, or ultraviolet light.2,4

Nitrile is a synthetic material comparable to NRL in maintaining its barrier protection during rigorous use. It is resistant to oil-based products,5,6 glutaraldehydes,3 and many other chemicals.2 Nitrile gloves have excellent in-use durability and are highly resistant to abrasion and punctures.7 They also provide excellent comfort, ease of movement and tactile sensitivity.1,8 Nitrile does have some limitations. For instance, nitrile is susceptible to deterioration by ozone, oxygen, and ultraviolet light. Historically nitrile has not been as flexible as natural rubber latex.

Vinyl is a synthetic material that is resistant to oils and ozone and is generally less expensive than natural rubber latex or nitrile; however, vinyl has several limitations. Vinyl has a rigid and brittle molecular structure that can fracture or separate when the material is manipulated. Even with the addition of many chemicals used to enhance softness and stretchability, vinyl is still less capable than NRL and nitrile of maintaining its integrity when challenged during use.3 This material has limited elasticity and strength and does not withstand being snagged, repeatedly jabbed, or stretched. It has less durability and limited use with chemicals. It is not recommended for use with chemotherapeutic drugs, glutaraldehyde or alcohol.^9,10

Table 1 is a summary of four published barrier studies performed on examination gloves over the last decade. In these studies, gloves were used for routine healthcare tasks [e.g., unscrewing caps off of irrigation fluid; manipulating sharp instruments, taping dressings in place and picking up different sized objects]. In all cases, the vinyl glove material had the highest percentage of barrier breach or leakage. The nitrile glove material did as well or better than the natural rubber latex material. Of particular interest, the 2004 Kerr study noted that glove wearers are often not aware of a breach in their glove barrier protection. In fact, 78% of the barrier breaches were not recognized by the glove wearer, and the majority of these defects were located in the finger regions of the gloves.⁸

A second consideration when selecting gloves is their potential for eliciting reactions and powder complications.

Medical gloves have been associated with irritant and allergic reactions. These glove-associated reactions have been divided into 3 types: Irritation, Type IV, Chemical Allergy, and Type I, Natural Rubber Latex (NRL) Protein Allergy.

Irritation, the most commonly seen glove-associated reaction,13,14 is a non-allergic reaction that may occur in any individual whether they wear NRL or synthetic gloves. The reaction may be caused by the presence of chemicals, powder and/or endotoxin left on the glove post-manufacture;15 friction that may occur if the glove fits too tightly and rubs continuously against the skin,14 or air occlusion when gloves are worn too long and the skin cannot breathe.14

The development of allergies in genetically predisposed individuals is dependent upon contact with the allergen(s) over a period of time. For example, a healthcare worker who has been wearing medical gloves for years with little or no skin problems or allergic symptoms begins to have allergic reactions. A typical question from this individual might be "why now?" The answer for genetically predisposed individuals lies in their repeated exposure to the specific allergen(s) to which they are vulnerable. As exposure increases, their level of sensitization rises, until after a period of time, their unique critical symptom threshold is reached. At this point, further exposure to the allergen can result in a reaction. The time required to reach this "symptom threshold" differs depending upon each individual’s genetic make-up, environment and allergen exposure.15

A Type IV, Chemical Allergy is a T-cell mediated, allergic response to specific chemicals added during glove manufacturing.13,14,16 Chemical accelerators (e.g. thiurams, thiazoles, carbamates) have been linked to glove-associated Type IV, Chemical Allergies more than any other chemical used in the manufacture of gloves.14,16,17 It should be noted that although one or more accelerators are necessary in the manufacturing of most medical gloves [NRL or synthetic], the type and quantity used vary by manufacturer.

A Type I, NRL Protein Allergy is the least common but, potentially, the most serious of the three glove-associated reactions.17 This is an IgE antibody mediated allergy to the naturally occurring proteins found in raw natural rubber latex from the rubber tree.16,18,19

In addition to the irritant and allergenic potential, powder complications have also been associated with medical gloves. A powdered glove has powder on both its outer and inner surfaces. The amount of powder on the glove will differ depending upon the manufacturing process. Once in the healthcare environment, this powder may be dispersed by direct and indirect contact, aerosolization and torn or perforated gloves. This powder, released into the healthcare environment, has been linked to glove-associated reactions, respiratory complications, impaired wound healing and faulty laboratory results.

Powder particles can be a concern for the wearer as powder may serve as an irritant. Chemical contact sensitizers, which may be carried by the powder, can trigger Type IV, chemical reactions. NRL proteins can adhere to the powder particles and be released into the surrounding environment or directly on NRL protein sensitive individuals. This may precipitate a Type I, allergic reaction in NRL allergic individuals. It has been reported that powdered NRL gloves are the most common item contributing to the latex load in healthcare facilities.15,20-22

Respiratory complications may merely be an irritant activity due to the particulate nature of the powder or an allergic or toxic reaction to the substances carried on the powder.21,23

Powder can have multiple adverse effects on wounds including inflammation, adhesions, granulomas, infection and prolonged healing. Once introduced into the wounds, the powder particles can act as foreign bodies, eliciting an escalation of the inflammatory process. Several studies have shown that it takes time for glove powder to dissolve. Most powder will dissolve within 3 to 6 weeks but it has been shown that, in some cases, powder may remain unabsorbed in the body for weeks to years. If the powder remains and dissolves slowly, it may promote chronic inflammation.21-29

Glove powder may also cause complications in the laboratory. Powder can be responsible for physical interference, absorption, transport, and cross-contamination during the performance of a number of assays.30-34

Considerations for the appropriate selection of medical gloves include barrier integrity and potential complications. Barrier integrity is a major concern for the wearer; therefore, it is critical to understand that this is determined by not only the quality of the manufacturing process, but also the base material of the glove. Additionally, potential complications from glove-associated reactions and powder are critical considerations as they may impact not only the wearer but also the patient. Anyone who wears medical gloves can develop a glove-associated irritation. Genetically predisposed individuals may become allergic to either the chemicals or protein found in certain glove materials. As an irritant and a vehicle for substances such as chemicals, protein, and microorganisms, glove powder has been identified as a contributor to glove-associated reactions, respiratory complications and poor wound healing. Powder has also been implicated in faulty laboratory test results. A thorough understanding of these issues will enable healthcare personnel to make a more informed decision when selecting medical gloves.

References:

1. Rego A, Roley L. 1999 Oct. In-Use Barrier Integrity of Gloves: Latex and Nitrile Superior to Vinyl. American Journal of Infection Control 27(5): 405-410.

2. Hinsch M. 2000 April. Selecting Surgical Gloves. Surgical Services Management 6(4):36-41.

3. Infection Control Nurses Association (ICNA). 1999 Sep. ICNA Glove Usage Guidelines. ICNA Glove Usage Guidelines, UK.

4. Occupational Safety and Health Administration. 1991 Dec 6. 29 CFR Part 1910.1030 Occupational Exposure to Bloodborne Pathogens; Final Rule. Federal Register 56(235): 64004-64182.

5. Ghosal K, Szymanski R. 2000 Jan/Feb. Nitriles- versatile glove materials, Rubber Asia. 14(1):27-30.

6. Seil DA, Wolf FR. 1995. Chapter 11: Nitrile and Polyacrylic Rubbers. In: Rubber Technology, 3rd ed. Maurice Morton, ed. London:Chapman & Hall, 322-338.

7. Huggins K. 1999. A Hand in the Glove: Lessons Learned About Glove Selection. Infection Control Today 3(2).

8. Kerr LN, Chaput MP, Cash LD, et al. 2004 Sep. Assessment of the Durability of Medical Examination Gloves. Journal of Occupational and Environmental Hygiene 1: 607-612.

9. Klein RC, Party E, Gershey EL. 1990 Aug. Virus Penetration of Examination Gloves. BioTechniques 9(2): 196-199.

10. Association for the Advancement of Medical Instrumentation (AAMI). 2005 Dec 6. Chemical Sterilization and High-Level disinfection in Health Care Facilities. ANSI/AAMI ST58-2005; Approved 6 Dec 2005.

11. Kerr LN, Boivin WS, Chaput MP, et al. 2002 Sep. The Effect of Simulated Clinical Use on Vinyl and Latex Exam Glove Durability. Journal of Testing and Evaluation 30(5): 415-420.

12. Korniewicz DM, El-Masri M, Broyles JM, et al. 2002 Apr. Performance of Latex and Nonlatex Medical Examination Gloves during Simulated Use. American Journal of Infection Control, 30(2): 133-8.

13. Reese DJ, Reichl RB, McCollum J. 2001 September. Latex Allergy Literature Review: Evidence for Making Military Treatment Facilities Latex Safe. Military Medicine 166(9): 764-770.

14. Page EH, Esswein EJ. 2000 Oct. NIOSH Health Hazard Evaluation Report. HETA 98-0096-2737, CDC: NIOSH publications office. 1-26.

15. Association of periOperative Registered Nurses. 2008. AORN Latex Guideline. In: Perioperative Standards and Recommended Practices, 2008 Edition. Denver: AORN, Inc., 87-102.

16. Taylor JS, Leow YH. 2000 July-August. Cutaneous Reactions to Rubber. Rubber Chemistry and Technology: Rubber Reviews 73(3):427-85.

17. Cohen, DE, et al. 1998. American Academy of Dermatology’s Position Paper on Latex Allergy. J Am Acad Dermatol 39(1):98-106.

18. Occupational Safety and Health Administration. 1999. OSHA Technical Information Bulletin: Potential for Allergy to NRL Gloves and other Natural Rubber Products. 1-9.

19. Warshaw EM. 1998 Jul. Latex Allergy. Am Acad Dermatology 39(1): 1-24.

20. ECRI, A Nonprofit Agency. 2000 February-March. Synthetic Surgical Gloves, Evaluation. Health Devices 29(2-3):37-66.

21. Beezhold D. 2000 Winter. Medical Glove Safety. The Guthrie Journal 69(1): 1-5. Online: www.guthrie.org.

22. Tomazic V, Shampaine E, Lamanna A, Withrow T, Adkinson F, Hamilton R. 1994 April. Cornstarch Powder on Latex Products Is an Allergen Carrier. J Allergy Clin Immunol 93:751-758.

23. Center for Devices and Radiological Health. 2008 Jan 22. Guidance for Industry and FDA Staff: Medical Glove Guidance Manual. Online: www.fda.gov/cdrh. Accessed 6/2/2008.

24. Hunt T, Slavin JP, Goodson WH. Starch powder contamination of surgical wounds. Arch Surg 1994 Aug:129:825-828.

25. Thompson JM, McFarland GK, Hirsch JE, Tucker SM. 1997. Second Line of Defense: The Inflammatory Response. In: Mosby’s Clinical Nursing, 4th ed. Thompson JM, McFarland GK, Hirsch JE, et al, eds. St. Louis: Mosby, 1075-6.

26. Holmdahl L. 1997 May. Mechanisms of Adhesion Development and Effects on Wound Healing. Eur J of Surgery 163(579 Suppl): 7-9.

27. Jaffrey DC, Nade S. 1983 Jul. Does Surgical Glove Powder Decrease the Inoculum of Bacteria Required to Produce an Abscess? Journal of the Royal College of Surgeons of Edenburgh 28(4): 219-222.

28. Baruchin AM, Ben-Dor D, Eventhal D. 1995. Starch Granuloma Following Liposuction — The Persisting Hazards. The American J of Cosmetic Surgery 12(2): 165-167.

29. Ellis H. 1997 May. Hazards from Surgical Gloves. Ann R Coll Surg Engl 79(3): 161-163.

30. De Lomas J; Sunzeri F; Busch M. 1992. False-Negative Results by Polymerase Chain Reaction Due to Contamination by Glove Powder. Transfusion 93:32(1):83-85.

31. Hamlin CR; Black AL; Opalek JT. 1991. Assay Interference Caused by Powder from Pre-Powdered Latex Gloves. Clin Chem 37(8):1460.

32. Newsom SWB, Shaw P. 1997 May. Airborne Particles from Latex Gloves in the Hospital Environment. Eur J Surgery 163(579 Suppl):31-33.

33. Lampe A; Pieterse-Bruins H; Egter Van Wissekerke J. 1988 Nov 12. Wearing Gloves as Cause of False-Negative HIV Tests. Lancet 1141.