Latex allergy

Jay E. Slater, MDCBER/OVRR/DBPAP

Laboratory of Immunobiochemistry

Symptoms of latex allergy Urticaria Rhino-conjunctivitis Wheezing Anaphylaxis

A systemic, multisystem allergic reaction that may include any and all of the above, plus hypotension

Other types of latex allergy

Contact urticaria

Contact dermatitis

Irritant dermatitis

IgE-mediated responsesIgE-mediated responses

Mast cellsMast cells

Initial reports Germany, 1930’s

Europe, 1980’s

US/Canada, 1989

Items that elicit latex allergic responses gloves condoms catheters cofferdams surgical drains latex stoppers adhesives other

7 March 1994

Risk groups Meningomyelocele Urogenital abnormalities Health care workers Rubber industry workers

Why latex?

http://www.bio.ilstu.edu/armstrong/syllabi/rubber/rubber.htm

Why latex?

From D’Auzac et al, Physiology of rubber tree latex, CRC Press, Boca Raton, 1989, p. 6

Latex gloves are “dipped” products

Hevea latex antigens Hev b 1 (REF) Hev b 2 (-1,3-

glucanase) Hev b 3 (microhelix

component) Hev b 4 Hev b 5 Hev b 6 (prohevein) Hev b 7 (patatin

analogue)

Hev b 8 (profilin) Hev b 9 (enolase) Hev b 10 (Mn-

superoxide dismutase)

Hev b 11 (class 1 chitinase

Hev b 12 (lipid transfer protein)

Hev b 13 (esterase)

Glove powder adsorbs and disseminated latex protein allergens

Giercksky, Eur J Surg 1997; suppl 579:11-14 Green, Eur J Surg 1997; suppl 579:39-40

Diagnosis of latex allergy History

Events Risk factors

Latex-specific IgE skin test serum

Intervention (challenge and/or avoidance)

Prevalence of latex allergy Questionnaire Latex-specific IgE

skin test serum

Predictive value is questionable

Skin tests none licensed in US Outside the US:

Western Allergy Services (Canada) Stallergenes S.A. (France) Lofarma (Italy) ALK Abello (Denmark)

Serum specific IgE tests Available tests (Hamilton, JACI 2002; 110(2 suppl):S47-S56) :

Pharmacia CAP (sens 70-80%, spec >90%) Hycor HyTECH (sens 70-80%, spec >90%) DPC AlaSTAT (sens 90%, spec 70%)

Specific allergens important Adding Hev b 5 to CAP increases sensitivity by 1-

2% (Lundberg, Allergy 2001; 56:794-795) Hev b 2 + 3 + 7 is 100% sensitive for spina bifida

(Kurup Clin Exp Allergy 2000; 30:359-369)

General population Seroprevalence

Reinheimer (1995): 12% Garabrant (2001) : 8-37% Grzybowski (2002): 8%

Skin tests Buckland (2002): 5% Jensen (2002): 9%

Health care worker data Multiple initial estimates: 5-10% Workers compensation claim data:

not a significant cause of work-associated disability (Horowitz et al. 2000-2002)

NHANES II : modest increased risk (OR up to 2.53 (1988-1991)

Health care workers – incidence data

769 apprentices dental, animal care, pastry-making Skin tests (for latex and program-specific

allergens) and questionnaire <44 month follow-up

Incidence of latex allergy Dental: 2.5%/year Animal: 0.4%/year Pastry: 1.6%/year

Garabrant et al. 2001

Urogenital abnormalities Spina bifida <37% bladder exstrophy, cerebral palsy,

and spinal cord injury spina bifida, atopy, and the

number of surgical interventions are independent risk factors (OR 6.76, 3.37 and 1.14/operation) (Hochleitner, et al. 2001)

Allergen Exposure SeroprevalenceSkin test prevalence

10% (Mixed A/C)67% (S/cong)

Breathing zone samplers; gloves 82% (S)

13-32% (H)54-100% (S)52% (H)81% (S)27% (C)67% (S)

Hev b 2 63% (H)7% (A)

48-65% (H)38-54% (S)

Hev b 3 79% (S) 24% (H)83% (S) 7% (A)19-32% (H)77-100% (S)83% (S)23-65% (H)30-77% (S)

Hev b 5 Gloves 65% (H)62% (A)

Hev b 1 Mattresses

23% (H)

Gloves

Gloves

Hev b 439% (H)

Allergen Exposure SeroprevalenceSkin test prevalence

64% (A+C)

83% (S/cong)66% (A)

45-55% (H)

30-69% (S)

86% (C)

58% (S)

63% (C)

58% (S)

23-45% (H)

15-77% (S)41% (A)

49% (A)

3% (C)

Hev b 6.01

Hev b 7.01

63% (H)

Hev b 6.02

45% (H)

Hev b 7.02 40% (S)

Allergen Exposure SeroprevalenceSkin test prevalence

Hev b 8.0101

3% (A)

35% (S) 88% (S)

50% (A) 100% (A)

12% (S)

20% (H)

6% (S)

24% (H)

Hev b 10.0102 27% (A)

10% (S)

0% (H)

25% (H)

80% (S)

Hev b 13 63% (H)

Hev b 8.0102

Hev b 10.0103

Hev b 11.0102

Modes of treatment 1. Avoidance 2. Avoidance 3. Avoidance 4. Other

Avoidance is hard because latex is ubiquitous in the health

care environment labeling has been erratic threshold doses (for sensitization

and reactivity) are unknown cross-reactivity with foods

Cross-reactivity banana chestnut avocado other fruits

Cross-reactivity of Hevea latex antigens Hev b 3 : red kidney bean Hev b 5 : kiwi Hev b 6 : wheat germ agglutinin Hev b 7 : potato Hev b 8 : profilins Hev b 9 : fungal enolases Hev b 10 : fungal superoxide

dismutases lysozymes: ubiquitous

Other approaches better methods of prevention premedication regimens immunotherapy

classical peptide based naked DNA

Premedication H1 antagonist (H2 antagonist) glucocorticoid (sympathomimetic)

Premedication Plausible efficacy, but No evidence that it works Anecdotal reports of

failure May lead to breach of latex

precautions

Final points…1. At this time, prevention is the only effective

treatment for latex allergy. 2. Latex allergens are ubiquitous, but  3. Gloves are the most important source of latex

allergen in the health care environment. Deal with the gloves first. Catheters are also important.

4. All latex allergy tests, whether RAST, ELISA, skin tests or challenges, are only as good as the allergens that are used. The allergens must be intact, and all significant specific allergens must be represented in the allergen mix used.

Final points…5. Testing is readily available now. The

predictive value of testing as a diagnostic tool is excellent. However, the value of such tests as a screening tool is uncertain.  

6. Premedication does not prevent antigen-induced anaphylaxis.

7. Consider food allergy. 8. There is probably no way to construct a

latex-free environment in the healthcare setting, but it is certainly possible to construct a latex-safe environment. 

Final points…

9. All latex avoidance measures come with a price (money, resources, risk of contamination, diminished barrier protection). Latex avoidance should be consonant with the risk. 

10. History alone is a poor predictor of latex allergy, but the predictive value of not obtaining a history is zero. Asking your patients if they have symptoms consistent with latex allergy is simple and quick, and should be part of routine screening for all medical and dental practitioners.