RE: "LATEX SENSITIZATION IN HEALTH CARE WORKERS AND IN THE US GENERAL POPULATION"
Lawrence D. Budnick
Occupational Medicine Service University of Medicine and Dentistry of New Jersey New Jersey Medical School Newark, NJ 071073001
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INTRODUCTION
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The Garabrant report on latex sensitization in health care workers and in the US general population, sponsored by the Allegiance Health Care Corporation (1
), misses an essential aspect in its discussion of the paper's relevance. Although Wartenburg and Buckler question the utility of these data to address a current public health concern, they note only in passing the fact that the data from the Third National Health and Nutrition Examination Survey are 1013 years old (2
). This is a key issue in assessing the relative importance of latex glove sensitization among health care workers, since the problem has been of growing importance only during the past 10 years.
In 1992, the Occupational Safety and Health Administration required employers to provide employees with gloves and other protective measures against blood-borne pathogens (3
), and there was a marked rapid increase in demand for natural rubber latex gloves. As a result, the National Institute for Occupational Safety and Health has stated, after Hunt et al (4
), that "some manufacturers may have produced more allergenic gloves because of changes in raw materials, processing, or manufacturing procedures to meet the increased demand for latex gloves" (5
, p. 5). Since then, Allegiance, which makes over 1 billion gloves annually, has introduced "technologically advanced formulations to reduce allergen levels" and "enhanced rinsing and leaching methods to reduce allergen content," because "concerns about allergy to natural rubber latex continue to be raised" (6
).
Since the brunt of the likely exposures came after the 19881991 study period, health care workers in the study would not be expected to demonstrate patterns of latex sensitivity very different from the general population. Therefore, these data from 19881991 are not relevant when discussing the differences in latex sensitization between current health care workers who were exposed since the early 1990s and the rest of the workforce.
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REFERENCES
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Garabrant DH, Roth HD, Parsad R, et al. Latex sensitization in health care workers and in the US general population. Am J Epidemiol 2001;153:51522.[Abstract/Free Full Text]
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Wartenberg D, Buckler G. Invited commentary: Assessing latex sensitization using data from NHANES III. Am J Epidemiol 2001;153:5236.[Free Full Text]
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29 Code of Federal Regulations 1910.1030. Bloodborne pathogens. Washington DC: US GPO, 1995.
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Hunt LW, Fransway AF, Reed CE, et al. An epidemic of occupational allergy to latex involving health care workers. J Occup Environ Med 1995;37:12049.[ISI][Medline]
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National Institute for Occupational Safety and Health. Alert: Preventing allergic reactions to natural rubber latex in the workplace. Cincinnati, OH: US Public Health Service, 1997. (DHHS (NIOSH) publication no. 97135).
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Allegiance Health Care Corporation, March 19, 2001 (http://www.allegiancehealthcare.com/prodserv/brands/gloves.htm).
THE AUTHORS REPLY
David H. Garabrant,
H. Daniel Roth,
Romain Prasad,
Gui-Shuang Ying and
Jay Weiss
Department of Environmental Health Sciences University of Michigan School of Public Health and University of Michigan Medical School Ann Arbor, MI 481092029
Roth and Associates Rockville, MD 20852
Department of Biostatistics University of Michigan School of Public Health Ann Arbor MI 48109
Diagnostic Products Corporation Los Angeles, CA 900455597
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INTRODUCTION
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We appreciate Dr. Budnick's response (1
) to our paper (2
). The central theme in Dr. Budnick's letter, that latex glove sensitization among health care workers has been of growing importance only during the past 10 years, deserves some discussion. It should be noted that widespread use of latex gloves by health care workers to reduce the risk of disease transmission occurred long before the 1992 Occupational Safety and Health requirement (3
). The recognition of human immunodeficiency virus as a transmissible infectious agent in the early 1980s led to increasing use of latex gloves, as did the issuance by the Centers for Disease Control of "Universal Precautions for Prevention of Viral Transmission in the Health Care Setting" in 1987 (4
). The medical literature evidenced concern about latex sensitization in health care workers as early as 1987, when Turjanmaa (5
) reported the prevalence of latex glove allergy among hospital personnel, based on skin prick tests and glove use tests. She concluded that the frequency of latex allergy was significantly higher in hospital personnel than in allergy patients and that surgeons developed the allergy especially frequently. Other authors (4
, 6
8
) reached similar conclusions that health care workers were at increased risk of latex sensitization, based on prevalence studies conducted in 19901993, in which there was a notable absence of appropriate referent groups. Sussman and Beezhold (9
) reported in 1994 that latex allergy had been increasingly recognized for the previous 6 years and that defined risk groups included health care workers.
These concerns about latex allergies in health care workers in the early 1990s led to measurements of latex-specific immunoglobulin E in the serum of Third National Health and Nutrition Examination Survey (phase 1) participants, which form the basis for our report (2
). As our report indicates, the risks of latex sensitization among health care workers were not clearly higher than those in other occupations during that time period (19881991), contradicting the opinions that health care workers were a high-risk group at that time. Even the study by Hunt et al. (10
), which Dr. Budnick cites, showed no relation between glove use, which increased steadily throughout the early 1990s, and the number of new cases of latex allergy, which peaked in 19901991 and then declined dramatically thereafter in their study. We agree with Dr. Budnick that these data do not tell us about the risks of latex sensitization since 1991. However, our report is the only published study of which we are aware that has made direct comparisons of the risks of latex sensitization in health care workers with those in comparable nonexposed groups.
The risks of sensitization prior to the implementation of the Occupational Safety and Health Administration regulations in 1992 take on added relevance to the debate over latex glove-related sensitization because, as Dr. Budnick points out, newer gloves have reduced protein content and are frequently powder free. Our data derive from a historic period when low-protein gloves and powder-free gloves were far less common than in the late 1990s. Although Dr. Budnick suggests that the risks of sensitization must be higher than in the early 1990s, he offers no evidence to support this. Such data clearly are needed before a conclusion can be reached that health care workers are at increased risk of latex sensitization compared with the rest of the workforce. It should also be noted that numerous studies conducted since the early 1990s have shown no association between sensitization and use of latex gloves in health care work (4
, 11







20
). Conclusions about the risks of latex sensitization among current health care workers and other sectors of the workforce should be based on data, not conjecture.
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REFERENCES
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Budnick LD. Re: "Latex sensitization in health care workers and in the US general population." (Letter). Am J Epidemiol 2001;154:190.[Free Full Text]
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Garabrant DH, Roth HD, Parsad R, et al. Latex sensitization in health care workers and in the US general population. Am J Epidemiol 2001;153:51522.[Abstract/Free Full Text]
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Snyder HA, Settle S. The rise in latex allergy: implications for the dentist. J Am Dent Assoc 1994;125:10897.[ISI][Medline]
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Grzybowski M, Ownby DR, Peyser PA, et al. The prevalence of anti-latex IgE antibodies among registered nurses. J Allergy Clin Immunol 1996;98:53544.[ISI][Medline]
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Turjanmaa K. Incidence of immediate allergy to latex gloves in hospital personnel. Contact Dermatitis 1987;17:2705.[ISI][Medline]
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Berky ZT, Luciano WJ, James WD. Latex glove allergya survey of the US Army Dental Corps. JAMA 1992;268:26957.[Abstract]
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Lagier F, Vervloet D, Lhermet I, et al. Prevalence of latex allergy in operating room nurses. J Allergy Clin Immunol 1992;90:31922.[ISI][Medline]
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Arellano R, Bradley J, Sussman G. Prevalence of latex sensitization among hospital physicians occupationally exposed to latex gloves. Anesthesiology 1992;77:9058.[ISI][Medline]
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Sussman GL, Beezhold DH. Latex allergy--a clinical perspective. J Long Term Eff Med Implants 1994;4:95101.[ISI][Medline]
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Hunt LW, Fransway AF, Reed CE, et al. An epidemic of occupational allergy to latex involving health care workers. J Occup Environ Med 1995;37:12049.[ISI][Medline]
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Douglas R, Milton J, Czarny D, et al. Prevalence of IgE-mediated allergy to latex in hospital nursing staff. Aust N Z J Med 1997;27:1659.[ISI][Medline]
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Kaczmarek RG, Silverman BG, Gross TP, et al. Prevalence of latex-specific IgE antibodies in hospital personnel. Ann Allergy Asthma Immunol 1996;76:516.[ISI][Medline]
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de Groot H, de Jong NW, Duijster E, et al. Prevalence of natural rubber latex allergy (type I and type IV) in laboratory workers in the Netherlands. Contact Dermatitis 1998;38:15963.[ISI][Medline]
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Kibby T, Akl M. Prevalence of latex sensitization in a hospital employee population. Ann Allergy Asthma Immunol 1997;78:414.[ISI][Medline]
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Konrad C, Fieber T, Gerber H, et al. The prevalence of latex sensitivity among anesthesiology staff. Anesth Analg 1997;84:62933.[Abstract]
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Mace SR, Sussman GL, Liss G, et al. Latex allergy in operating room nurses. Ann Allergy Asthma Immunol 1998;80:2526.[ISI][Medline]
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Liss GM, Sussman GL, Deal K, et al. Latex allergy: epidemiological study of 1351 hospital workers. Occup Environ Med 1997;54:33542.[Abstract]
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Page EH, Esswein EJ, Petersen MR, et al. Natural rubber latex: glove use, sensitization, and latent dust concentrations at a Denver hospital. J Occup Environ Med 2000;42:61320.[ISI][Medline]
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Brown RH, Schauble JF, Hamilton RG. Prevalence of latex allergy among anesthesiologists: identification of sensitized but asymptomatic individuals. Anesthesiology 1998;89:2929.[ISI][Medline]
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Baur X, Chen Z, Allmers H. Can a threshold limit value for natural rubber latex airborne allergens be defined? J Allergy Clin Immunol 1998;101:247.[ISI][Medline]