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Protection from latex allergy lawsuits

By Herbert Monheit, Esq.

The seriousness of repeated exposure to the latex allergen is often not appreciated until the latex sensitive individual has a severe, immediate type I allergic reaction. With the diversity of medical disciplines reporting these responses (obstetrics, urology, radiology, anesthesiology, gastroenterology, dentistry, surgery and pediatrics) and recent reports of severe anaphylactic reactions and even fatalities, it is apparent that physicians in all specialties must be ready to deal with the clinical ramifications of an immediate type I allergic reaction to an NRL allergen.

The allergic reaction to natural rubber latex can cause health problems ranging from mild skin irritation to life threatening shock and chronic asthma. The rise in the incidence of latex allergy among health care workers has recently been the subject of media reports in the New York Times and a lead segment on ABC’s “20/20”. No wonder there is such media attention when it is estimated that 10-17 percent of all health care workers have a latex allergy—which can be a career threatening disability.

The increasing incidence of latex allergy has been linked to the accelerated demand for gloves prompted by the spread of the HIV virus. There is no cure for the sensitized individual, nor at this time is there a standard screening procedure for evaluating latex allergy. Moreover, the initial or primary effects of the exposure to the allergen appear to be relatively benign symptoms: hand itching, skin rash, hives, tears, and itching or burning eyes. These symptoms are unfortunately viewed by the exposed health care worker and patient as reversible, external conditions understood in the light of one’s personal past experience with seasonal or food allergies. Health care workers and patients simply do not associate these symptoms with an allergy, not to mention a serious medical condition which could bring their professional careers to an end.

The rash and hives, which appear externally, are reversible. However, this reversibility often masks significant internal changes which are taking place in the bronchial and lung tissue. After long term exposure, these internal tissue changes are not reversible and the worker then becomes “anaphylactically sensitive.” Thus, it is incumbent upon all physicians in health care settings to take appropriate steps which will diminish the likelihood of third party actions brought against the physician by patient and/or employee worker’s compensation claims.

Step One: Identification.

Health care workers and patients in high risk groups should be identified. Patients who have a genetic predisposition to an allergy and those who have experienced hives upon previous contact with natural rubber products are at high risk of latex allergy. Others at high risk include children with spina bifida, and children with other conditions requiring frequent operations. Others in the high risk population include patients, doctors, nurses, dentists, workers employed in the manufacture of rubber products and others who use latex gloves routinely.

Step Two: Question the Patient.

It is the physician’s duty, especially an allergist, to consider latex hypersensitivity. Irrespective of risk group status, all patients and employees should be carefully questioned to determine if there is a history of latex allergy. A history suggestive of latex sensitivity arises from symptoms set forth in the following list: hand eczema; oral itching after eating avocados, bananas and chestnuts; swelling or itching lips following blowing up of balloons; swelling or itching of lips after dental examination; swelling or itching of hands after contact with rubber gloves; local swelling and itching after vaginal or rectal examination; itching following multiple surgical procedures in infancy; unexplained anaphylaxis and/or asthma. In addition to direct questioning, all patients and employees should respond to a questionnaire which would present questions concerning medical history, surgical history, and occupational history.

Step Three: All High-Risk Patients Should Be Offered Testing for Latex Allergies.

At the present time, there is no standard test for latex allergy. The most conservative approach to the diagnosis of a type I NRL allergy is the commercially available in vitro RAST test. Latex-specific IgE antibodies in the patient’s serum can be measured with the RAST or the more recent CAP RAST system found in sera from patients with reactions caused by NRL products. The RAST is less sensitive than the direct skin prick test, and its specificity is limited to the specificity of available antigens. The best available rapid and accurate diagnostic procedure is skin testing with a latex extract or glove extract. However, it must be remembered that anaphylaxis has occurred during epicutaneous skin testing of patients with spina bifida, as well as with patients displaying a history of latex induced anaphylaxis. Further, there is the use test performed with latex gloves when there is a discrepancy between skin prick testing and a clinical history or when in vitro studies give positive reactions and the patient has not noticed any symptoms after using rubber products. These tests, of course, are not recommended for patients with a previous history of anaphylaxis and positive results on the skin prick test or a RAST test.

Step Four: Surgical Procedures Should Be Performed in an Environment Free of Latex.

All patients with spina bifida, even though they have negative histories and negative skin results, should have surgical procedures performed in an environment free of latex. This is so because the risk of sensitization in patients with spina bifida is as high as 34 percent and suggests that latex exposure should be minimized in any surgical procedure. Procedures on all patients with a positive history, regardless of their group status, should be performed in an environment free of latex. A positive history includes any immediate hypersensitive reaction associated with latex exposure. Patients with eczema, associated with latex glove use, should be considered to have a positive history. Latex glove eczema may be a precursor to Type I reactions. In any event, because there is doubt, there can be complete antigen avoidance in a surgical setting. Pre-treatment with antihistamines and cortico-steroids may be advisable. Of course, pre treatment is not a replacement for antigen avoidance and, of course, all procedures on patients with positive histories should be performed where the unexpected anaphylaxis attack can be readily treated.

A latex-free environment is one in which no personnel are wearing latex gloves in the room in which the surgery is being performed. Antigen exposure occurs through airborne particles and through intravenous fluids. The following precautions are suggested:

• No latex accessories (catheters, adhesives, tourniquets, anesthesia equipment) should come in direct contact with the patient.

• All injections should be given through a stopcock system, thus avoiding latex ports.

• Medication should be available in a non-latex covered storage vial.

• All operating room personnel should change scrub attire if they have come into contact with latex products and, of course, wash any retained latex off their hands.

• No latex products should be stored in an operating room.

While it may be impossible to make an operating room 100 percent latex free, every effort should be made to obtain a list of safe products to use, contacting manufacturers who certify in writing that a product is latex free.

Step Five: Medical Alert Bracelets and Epinephrine.

All patients identified as being latex sensitive either by history or testing should be notified to obtain a MedicAlert Bracelet and carry with them at all times Self-Injectable Epinephrine.

In summary, experience has shown that many physicians are still not sufficiently knowledgeable about latex sensitivity. In that regard, the allergist immunologist should serve not only as a physician consultant, but as a patient advocate, communicating in every way possible information about latex sensitivity to school boards, employers, patient care committees, infection control committees, medical groups and industrial representatives. The issue is more significant than ever before. Since latex gloves and condoms have become essential parts of a worldwide strategy to address the problem of the transmission of bloodborne diseases, they being a most pressing public health concern.

Herbert Monheit, Esq., is the founding partner of The Law Offices of Herbert Monheit, P.C., a personal injury law firm in Philadelphia which specializes in latex matters.

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