Everything2 medical disclaimer: IANAD. As with all things medical, if in any doubt at all, seek professional advice.
Background
Latex allergy has become one of the major concerns of the healthcare industry in the USA in the years since the introduction of Universal Precautions in 1987, with up to 17 percent of all healthcare workers affected. It is not limited to US healthcare workers however; many other groups in all parts of the world suffer from this extremely debilitating illness.
The next few paragraphs contain some definitions, and are, by necessity, a bit jargon-ish. Bear with me. There is a lot to this issue.
Although latex allergy should, strictly , be called ‘natural rubber latex protein allergy’ (NRLPA), many people find it easier and more natural to use the term, ‘Latex allergy’. However, there is another type of allergic response which is entirely different in nature, but is often confused with NRLPA. That is an allergy to chemicals used in the manufacture of rubber goods,. Whereas NRLPA applies specifically to the proteins found in natural rubber latex, the chemical allergy applies to all elastomeric products, not just the ones containing natural rubber (NR).
To use the medical jargon for a moment, NRLPA is a IgE-mediated systemic response of Type I. Chemical allergies (in this context) are type IV allergic responses (cell mediated immune response), mostly to thiurams and carbamates, chemicals used in the production of many diverse rubber products.
There is a third type of contact dermatitis, usually triggered by soaps, rinses and other hand care products which have not been properly rinsed before donning gloves.
Because it is a type I allergic response, NRLPA is on a par with allergies to nuts and bee stings, which cause the body’s immune system to go into overdrive when faced with the allergen. This leads to a massive release of hormones and other chemicals, which eventually causes the body to more or less shut down and fall into anaphylactic shock. If the person is not treated quickly, then they can die. The treatment is carefully monitored doses of the hormone adrenaline, usually administered as Epinephrine.
NRLPA is especially challenging, because the proteins which trigger the reaction exist in other plant species. Some people who have a latex sensitivity are also sensitive to proteins found in certain tropical fruits, potatoes and tomatoes. Thus, these foods become as deadly to them as latex itself.
Chemical allergies (Type IV), by contrast, tend to be localised skin reactions, appearing as eczema, which are in no sense life-threatening. These can appear up to 48 hours after exposure to the chemical concerned. Although not life-threatening, such Type IV responses can be very debilitating. In some cases they can lead to very severe breathing difficulties in asthma and asthma-like attacks, for example.
Contact dermatitis is the least severe reaction, appearing as dry flaky skin, often with inflammation and cracks and sores on the affected area.
This write-up deals primarily with the first of these three types of allergy. There is a small section on chemical allergies near the end. The third type is not classed as an allergic response, and can be managed through proper washing, rinsing and drying of the hands prior to donning gloves or other hand protection.
Who is at risk?
Figures vary tremendously, but reliable research has shown that of the total population of healthcare workers in the USA, between 2.8 percent and 16.9 percent are affected by some form of allergy to rubber. The figure is so uncertain because the various research projects have concentrated on different methodologies, and different definitions of allergy. It is a fair guess that 5 to 10 percent of all US healthcare workers are in some way affected by this.
However, the highest risk group are children who have experienced multiple surgical procedures. Researchers monitor Spina Bifida children, (who tend to have many visits to the operating theatre). Between 32 percent and 51 percent of people in this group are affected by Type I NRLPA. The trigger in these cases is the use of many different surgical devices made from NR which come into intimate contact with their bodily fluids on many separate occasions. These include gloves, shunts, splints, catheters and others. There are alternatives to NR for all these products, and parents are advised that they should insist that hospitals use these alternatives whenever they operate on Spina Bifida children.
Another high risk group is hairdressers and others who routinely use latex gloves in their normal jobs. Approximately 9 percent of this group has a type I allergy to NRL.
Within the rubber industry, figures vary tremendously, but the industry accepts that between 2 and 11 percent of rubber industry workers have become sensitised to latex.
Figures for the general population are very hard to come by, but the significant factors are as follows:
- Atopic individuals are most at risk
- Use of latex products on a regular basis increases the risk
- Contact with rubber by the skin, mucous membranes or by breathing in affected aerosols increases the risk still further
Translation: if you are around rubber gloves or rubber balloons a lot, then you are at risk: if you seem to get allergies and illnesses, then you are doubly at risk.
My personal advice is that if you already have any kind of allergy, then you should try very hard to avoid blowing up balloons, and you should seek out alternatives to natural rubber when selecting condoms or protective gloves. If you have children and they have allergies or seem especially prone to illnesses, then try to avoid teats and soothers made from natural rubber, and keep exposure to rubber balloons to a minimum.
How NRLPA works (see also anaphylaxis)
Most allergies go through two or three phases, and this one is no different. At first, the person’s immune response is essentially normal. One day there comes a critical incident when the immune system reacts to a particular stimulus, but there is no external sign of this. The person has, unwittingly, become sensitised.
The next time the person encounters that stimulus, all hell breaks loose. The body’s immune system goes into panic mode, believing it is facing a major crisis, and all available resources are diverted to fighting the perceived threat. Eventually, so many resources are diverted that the body starts to shut down, and the patient goes into anaphylaxis. If the patient is not restored with a good dose of adrenaline, he or she may well die.
Natural rubber latex comes from trees. Trees are biological systems and, like most living systems, they depends on enzymes, proteins and other biological molecules to grow and flourish. When the latex is tapped from the tree, it contains around 2 percent of proteins. These are large biological molecules, but the number and type of proteins has never been fully documented. Furthermore, the actual proteins involved vary from tree to tree, region to region and season to season.
With NRLPA, we now know that no single protein is to blame. And this is the root of the problem. It is all but impossible to make a reliable test to check whether a person is really sensitised. First, the number of proteins which could play a role is huge, and we have not got around to testing them all yet. Second, it is almost always a cocktail of proteins which acts as the sensitiser, and as the subsequent trigger for a reaction. And this cocktail is different for every sensitised person. So, a person might have been sensitised to some obscure combination of proteins and work quite happily with gloves for a year or two, and then, suddenly, get hit by exactly the same combination of proteins and go into shock.
However, if that person were tested with the standard tests for protein allergy, they might well come out negative, because the test does not use precisely the same combination of proteins as caused the initial sensitisation. This lack of adequate tests has become a major issue in the battle to win compensation from insurers. If the tests show you as negative, then you must be negative, argue the lawyers, and this means many sufferers are effectively forced to continue working in environments which are literally life-threatening. Many sufferers choose to quit their jobs under those circumstances, leaving them with no income and no medical insurance.
What the glove makers are doing about it
They are responding. Honest!
First, the market is changing. Everyone agrees that natural latex gloves do their job very well. They are cheap, they have great stretch properties, have good barrier properties, they feel good and offer unrivalled sensitivity to the user. However, there is a growing and enthusiastic market for alternatives. Those alternatives include nitrile rubber, polychloroprene rubber, thermoplastic gloves, polyurethane and a few other materials. None of these offers the same performance as a NR glove, and none is anywhere near as cheap, but they do now sell in big numbers. Latest estimates give NR about a 90 percent share of the 30 billion-plus annual market for examination gloves.
Most of these materials have been pioneered in the surgeons’ glove market, because this market is much less price sensitive than the exam glove market. Surgeons get to choose which glove they use, whereas other staff have to use what they are given. It’s a fact of medical life.
Apart from that, they are improving the manufacturing process, washing the gloves more at the end and in some cases chlorinating them, which tends to make them less sticky and less capable of transferring proteins to the cornstarch. And finally they are also moving to low-powder and non-powder gloves. These are all good things and should certainly lead to less sensitisation in the future.
Political issues
One of the great tragedies of this case is that it has started to become a trade issue, with some Malaysians claiming that the illness does not really exist, and that the USA is trying to reduce Malaysian imports by imposing restrictions and warnings on gloves made in Malaysia
Within Malaysia, these concerns are very real,. They have seen the Oil Palm business, the timber business and other businesses suffer because of US trade sanctions imposed for very little reason except to preserve jobs and industries in North America, and do not want the same to happen with the glove business,. Furthermore, the Malaysians point out, very few Malaysians seem to become allergic to latex, despite working with raw latex and handling gloves every day of the week.
History of latex allergy
In 1987, the USA healthcare system introduced a code called Universal Precautions, which was to designed to protect healthcare workers from exposure to the AIDS virus, HIV and other blood-borne diseases. Part of that was strong advice to use latex examination gloves as a barrier to avoid any skin-to-skin contact with patients, as well as to protect against exposure to body fluids. In practice, many healthcare workers used double- and triple-gloving (using two or three layers of gloves) to ensure that the virus had no possibility of being transmitted.
This dramatically increased demand for latex gloves, notably in the USA. I can only find data for 1988, but global demand then was 12 000 million pairs per year. It is hard to know the real demand after Universal Precautions was introduced, because there was much confusion and double-and triple ordering, but nowadays, demand for gloves is running at around 30 000 million pairs per year, of which two-thirds are used in the USA.
In any case, demand increased dramatically around 1987/88. The established suppliers could not meet the demand. Faced with a choice of whom to supply, the supliers chose the customer s who had been reliable and paid the best prices in the past. This was primarily European-based hospitals. US hospitals had constantly striven to reduce the price they paid for gloves and had frequently switched suppliers on the basis of cost. Europeans, by contrast, had tended to remain loyal to one or more valued suppliers.
Malaysia was at the time the centre of the world glove and latex industry. Many entrepreneurial businessmen there saw an opportunity. They bought off-the-shelf glove making machines from Taiwan, and set up factories to make gloves. The scale of the goldrush in Malaysia is shown by the number of applications to build glove plants. In 1985 there were 4 such plants. In 1986, it was 6, but in 1987 it ballooned to 69, and was running at 20 or 30 a month in the early part of 1988. This growth was driven by very good economics. A Taiwanese plant capable of making 30 million gloves per year cost around US$250 000. The going price for gloves was about $50 per 1000, giving sales of $1.5 million in the first year of production. Many entrepreneurs found that kind of return too good to resist.
The US hospitals, desperate for any form of supply, were prepared to place an order with anyone who could promise to supply gloves. Promises were made, orders were taken, money changed hands. Not all the orders were fulfilled, partly because the increased demand had created a shortage of the raw material and partly because it take skill and know-how to make gloves, and not all of the entrepreneurs had such resources available.
Six months later, the situation was dire. There are stories of ‘entrepreneurs’ going to the professional factories, and raiding their scrap bins, re-packing the scrap gloves and selling them to the export market. There are stories of gloves with holes in, and stories of gloves which met no international standards being sold with the internationally approved markings.
It was a time of chaos for the industry, but at the time, people thought it was just a question of price, supply and demand. No-one knew at the time how much trouble was being brewed in those new factories.
A year later, things had sorted themselves out a bit. More people were producing the latex raw material, and many more factories were making gloves on brand new equipment. The US hospitals were glad to find local entrepreneurs selling their gloves cheaper than the established manufacturers, and took advantage of the price differential.
Many of the new factories thrived. Partly to keep their costs down, and partly because they did not know any better, they made billions of gloves which were neither washed, nor chlorinated and which bore large amounts of powder. All these are now believed to be significant markers in sensitising glove users.
Most of these poor quality gloves were shipped to the USA. The Europeans continued to use their trusted suppliers, and the big-name suppliers were happy to keep that business.
Within a few years some strange things started happening in the US healthcare industry. Increasing numbers of healthcare workers found their hands red and raw. Previously healthy individuals started having terrible asthma attacks. A few went into anaphylactic shock. Fortunately, they did so in hospital, and were treated quickly and effectively. There were few, if any deaths.
These strange events were linked with some unfortunate Spina Bifida children, and others who had many surgical procedures. Such people have a very high risk of developing NRLPA due to the number of times their internal fluids and tissues are brought into contact with natural rubber. The symptoms seemed the same, but there was no explanation then for the apparent increase in cases among healthcare professionals
Gradually, the culprit came to light: examination gloves made from natural rubber latex.
Some workers tried to claim occupational disability payments from their health insurance, and that brought the lawyers in. The lawyers for the insurance companies tried to claim from the glove makers. So the lawyers from the glove makers started contesting the claims, challenging the claimants and, in and in some cases, trying to discredit them and show that the claims were fraudulent. Where the claimant was successful, one clause in the final settlement was that the successful claimant could never disclose their success or how much they had been paid in compensation.
This atmosphere of claim, counter claim and secrecy has made it very hard to get worthwhile numbers out of anyone involved. There are extremely large sums of money at stake, and lawyers for both sides are not afraid of applying pressure to keep sensitive numbers secret.
The result has been a tremendous amount of secrecy and misinformation about the issues. It was only with the development of the 'net, and the ability of individuals to organise themselves by means of the internet that the issue attracted serious attention in the rubber industry.
Many, many internet-basedsupport groups were set up and flourished in the late 1990s. I came to know many of the leading lights in the movement, and heard their desperate stories. Women—mostly women—shunned by friends, lovers, employers and families. People almost driven mad by constant disbelief, constant fear that one day a colleague would test their so-called allergy by pushing a glove in their face. I heard about four-year-olds checking out shops on behalf of their allergic mothers and mothers risking everything to ensure their children did not find themselves face to face with a balloon at a store or a restaurant or a classmate’s party. I heard about women on the poverty line, thrown out of a job, their partners departed and no insurance, who had to buy expensive non-latex replacements for ordinary gadgets. Sad, sad stories.
One sufferer has kept accounts of all the costs directly attributable to her allergy, and it amounts to over $16 000 for a 16-month period.
There were payouts, rumoured to be in the millions of dollars. The glove manufacturing industry went through a dramatic phase of restructuring as companies suffered huge insurance premiums and parent companies attempted to limit their liability, but these have mostly been kept quiet.
Chemical allergies
If data on NRPLA is hard to come by, data on chemical allergies is impossible. No-one knows how prevalent chemical alergies are, or how many who suffer from NRLPA also suffer from chemical allergies.
The chemicals most prone to causing reactions are thiurams (used in accelerators) and Carbamates (an anti-degradent). These are used in many types of rubber goods, including tyres, stoppers, gloves, conveyor belts and all sorts of other things. If a person is allergic to these materials, their lives will be very difficult, as these chemicals are used in other industries as well.
Such allergic responses are often described by the patients as a latex allergy, but in fact this is not an allergy to latex, but to some chemicals used in the manufacture of rubber goods.
Unfortunately, there is very little that can be done to help these people.
Sources / further reading
- http://www.lgm.gov.my/latex_allergy/lageneral.html
- http://latexallergylinks.tripod.com/
- http://www.latexallergyresources.org/
- http://www.lasg.co.uk/
- http://www.angelfire.com/md/plaa/
- http://www.cdc.gov/ncidod/hip/blood/universa.htm
- European Rubber Journal (www.crain.co.uk/ERJ)