Latex sensitivity exam identifies those at risk
Questionnaires flag workers who need counseling
By Sharon A. Watts, MS, RNCS
Employee Health Nurse Practitioner
Christine M. Lizewski, RN, BSN
Employee Health Nurse
Carol Grove, MSN, RNCS
Employee Health Nurse Manager
The University Hospitals of Cleveland
A plethora of articles has appeared in the professional literature in the last few years to document the maladies of latex allergy among health care workers. Issues of chronic morbidity, workers’ compensation, and even possible mortality outcomes point to the seriousness of this national health problem. At our employee health service, we endeavored to create a screening exam to determine the risk factors and objective physical findings that would indicate employees who might be at risk for serious allergic reactions to latex. When screening indicates a potential problem, then education, counseling, and appropriate job assignment can be instituted.
At the post-offer screening baseline exam, a brief history is obtained from the employee specific to latex sensitivity. (See Pre-employment Latex Sensitivity Questionnaire, p. 149.) Only employees who indicate a history of atopic disease or a problem specifically with latex products are given the more extensive history exam questionnaire to complete. (See Employee Health Service Questionnaire for Latex Sensitivity, p. 150.) A medical history of atopic disease and frequent surgeries needs to be determined.1
Symptoms within the classic atopic disease triad hay fever, eczema, or asthma are important to note. Specifically, eczema related to latex-containing products that produce pruritis and erythema must be clearly documented. Asthma triggered by exposure to latex products is particularly worrisome.
Additionally important to atopy is a history of allergy to foods that create cross-reactivity in the sensitization process, such as avocados, bananas, chestnuts, kiwi, and papaya.2 Food allergies may not necessarily be elicited on a routine allergy question, as most people think primarily of drug reactions only. It has been shown that latex, avocado, chestnut, and banana show cross-reactivity upon testing, and results suggest that the four share common antigenic determinants.2
Specific markers on the physical exam also may indicate presence of latex allergies. Eczema of the hands, particularly with open cracks, is a major concern. A pruritic rash at the glove line would raise suspicions of latex sensitivity. Allergic shiners, wheezing, and boggy turbinates would indicate a tendency to asthma or allergies.
Laboratory data offer an additional resource for employee health practitioners to determine presence of latex sensitivity in employees. Institutions may consider the radioallergosorbent test (RAST) as an adjunct diagnostic tool. The RAST is an in vitro test that assesses the ability of serum to bind to an antigen and then to bind to a radio-labeled antibody to IgE.3 A RAST is approximately 50% sensitive for latex allergy.4
According to Donald Beezhold, PhD, a latex sensitivity researcher at the Guthrie Research Institute in Sayre, PA, there are three different RAST tests with similar levels of specificity and sensitivity on the market in the United States.5 Results may vary according to the assay utilized by individual labs. A test value greater than 300% of control is considered specific to the antigen tested.6 The RAST test costs approximately $10.
Weighing accuracy against risk
Most allergists consider skin tests for latex allergy preferable to the RAST test because of the increased sensitivity (85%), rapidity, ease of performance, and low cost.4 However, due to the potential risks of anaphylaxis, most employee health departments deem it prudent to avoid latex skin testing. The majority of employees at our clinic are referred to their primary medical doctor, an allergist, or a dermatologist for RAST or skin testing and subsequent treatment plan.
Once a potential or current employee is determined to be latex-sensitive, many educational and management issues need to be addressed. Avoidance is the cornerstone for lifelong management of latex sensitivity. Substitution of vinyl gloves is essential for employees with minor skin irritation sensitivity. Individuals with more severe cracking skin resistant to dermatologic treatment or with anaphylactic reactions require individual assessment of appropriate job placement. Use of medical identification bracelets and epi-pens is advised when anaphylaxis is a problem, as well as job transfers or retraining.
Three years ago, our institution was faced with the dilemma of having to reassign three nurses and one radiology technician due to recently discovered latex sensitivities and potential for anaphylaxis. The Occupational Health and Safety Committee had just begun its literature search on latex sensitivity due to patient care concerns. The committee chairperson, who also was the nurse manager of employee health, recognized the significance of the problem affecting direct patient caregivers and realized that the issue had to be handled at a higher management level due to the need for decisions that involved financial and philosophical commitments.
The committee was restructured to include a dermatologist as chair, several other physicians (anesthesiologist, allergist, surgeon, internist, oral surgeon, and employee health medical director), a law department representative, purchasing department director, senior vice president of nursing, chief of staff, pharmacy co-director, infection control nurse, senior vice president of human resources, and head nurses from various services.
They struggled with many issues, including the institution philosophy of "no latex" vs. a "low-latex" environment. Equipment purchasing, changing to new gloves (i.e., nonlatex), and staff education became extensive undertakings. A hospital policy was approved after many rewrites.
The most complex task was the human resources issue of job placement or retraining the four latex-sensitive staff members, and determining if job candidates with known or potential latex sensitivity should or could be hired after their initial offer without encountering disability/discrimination issues. Those concerns eventually were worked out through implementation of a transitional duty program. In addition, the employee relations department offers a small-scale outplacement service for career change counseling, job strategizing, resume writing assistance, and a preferred hire process. In addition, individuals who decide to change careers are entitled to the full educational benefits offered by our institution for a year, even if they go off-roll.
The process of evolving into a "low-latex" environment in approximately two years was difficult, but it became a reality. The employee health service now uses questionnaires, educates employees and candidates with an information packet, follows up with primary care physicians to determine the best plan for employees and their patients, and maintains a database of latex-sensitive staff members. It was a major initiative for such a large institution, but with many dedicated staff members and the commitment of the senior administrative staff, a safer environment and increased awareness for patients and employees was created.