Natural rubber latex allergy in the occupational setting

Over the last decade, the prevalence of natural rubber latex (NRL) allergy has reached epidemic proportions among workers who use or who are exposed to powdered latex products. NRL-associated occupational asthma is confined largely to those exposed to powdered latex glove use or other latex aerosols. The most frequent presenting symptom of NRL allergy is contact urticaria; inhalation may cause symptoms of allergic rhinitis and asthma. Skin prick testing is the most accurate tool for diagnosis of NRL allergy. The cornerstone of management is cessation of exposure; substitution with non-NRL or nonpowdered NRL gloves results in predictable rapid disappearance of latex aeroallergen.     

Immobilization of the proteins in the natural rubber with dialdehyde sodium alginate

The biodegradable dialdehyde sodium alginate (DASA) was exploited to immobilize the proteins in the natural rubber latex (NRL) and the variations of the properties for the NRL films were estimated in detail. As demonstrated, the proteins were distributed more uniformly in the NRL films with DASA and the extractable protein (EP) content was effectively decreased. Particularly, the EP content was lowered to a value about 46 μg/g with 0.40% DASA, which could meet with the demands of the allergy protein threshold limit of 50 μg/g as described in ASTM D 5712 standard. Furthermore, there was some improve on the burial degradability of the NRL films modified with DASA. The mechanical properties, however, had no evident variation in the presence of DASA. In conclusion, the immobilization of the proteins with DASA should be a potential alternative to tackle the protein allergy problem for the NRL and its products.     

Quantitation of latex allergens

Minimizing allergen concentration in latex goods to prevent sensitization to natural rubber latex (NRL) and thereby the development of clinical allergy is acknowledged as of mutual interest for rubber manufacturers and regulatory health authorities. However, measuring total protein, the principal currently available method, cannot be deemed a satisfactory regulatory measure to control allergen content. Specific methods based on human IgE-containing reagents, such as radioallergosorbent test (RAST) inhibition, have been available in certain laboratories for demonstrating NRL allergens in rubber products but the methods lack standardization. Currently, one commercial test has become available for measuring individual NRL allergens by capture ELISA-based assays using monoclonal antibodies and purified or recombinant allergens. Such methods are specific, they can be properly standardized, and they are of sufficient sensitivity and reproducibility. Results from medical gloves collected in two national market surveys in Finland in 1995 and 1999, respectively, show that Hev b 6.02 and Hev b 5, the two major allergens for NRL-allergic adults, are the most abundant allergens regularly detectable in high- and moderate-allergen gloves. In addition, Hev b 3 and Hev b 1, the two major allergens for children with spina bifida, are also commonly found. In general, when the sum of the four allergens exceeded 1 microg/g, most NRL-allergic patients showed positive skin prick test reactions against them. Using these new methods assessment of threshold levels that could in due course become guidelines for the rubber industry and regulatory health authorities is becoming possible. Eventually, this progress is expected to lead to a declining incidence of latex allergy.     

Glove powder reduction and alternative approaches

This article addresses the role of glove powder in facilitating allergic reactions to natural rubber latex (NRL) and to the chemical additives in synthetic and NRL gloves as well as its role in eliciting postsurgical complications. Various dusting powders have been used historically to prevent gloves from sticking to each other and to facilitate donning. All have manifested adverse consequences for health care professionals and patients. Manufacturing methods for powder reduction and elimination are presented. The recently developed ASTM methods for the quantitation of powder on powder-free and powdered gloves are reviewed along with the new ASTM maximum powder limits for all medical gloves. Caution must be exercised when methods of protein and powder reduction are implemented to minimize the possibility of creating other adverse consequences.     

Medical devices manufactured from latex: European regulatory initiatives

In Europe the marketing of medical devices manufactured from latex is regulated by directives describing the essential (safety) requirements that products have to fulfill to obtain marketing approval. This paper describes the general requirements for marketing medical devices in Europe and, more specifically, the requirements for products manufactured from natural rubber latex. The requirements for marketing medical devices can be fulfilled by using the relevant harmonized European standards. These standards are regularly under revision to incorporate the latest scientific developments. For certain devices, for example, latex medical (examination and surgical) gloves, specific standards have been published. Medical devices manufactured from latex pose a serious problem because of the risk of induction of allergy both against the latex proteins inherently present (type I or immediate type allergy) and against chemicals added during processing (type IV or delayed type hypersensitivity) present as residues in the latex products. So, besides requirements for product quality in terms of barrier properties, strength, and sterility, the main focus consists of the allergy-inducing properties of the latex products. Recent developments have reopened the discussion on the value of total protein versus allergen determination in latex medical gloves. However, as long as minimal levels needed for both sensitization and elicitation have not been established, a safe maximum level for leachable proteins/allergens in latex products cannot be determined. A European Commission guidance document on the latex allergy problem is currently being drafted by experts from Competent Authorities.     

Outcome of occupational latex allergy--work ability and quality of life

Objective

The quality of life (QOL) and work ability of health care workers allergic to natural rubber latex (NRL) were assessed after implementation of regulations on powder-free NRL gloves in Germany.

Methods

196 HCW with reported NRL allergy answered a questionnaire (response rate 58%) containing the Work Ability Index (WAI), Mini Asthma Quality of Life Questionnaire (MiniAQLQ), and Dermatology Life Quality Index (DLQI).

Results

63.2% still had NRL-related symptoms during the last 6 month. However on a scale from 0 to 10, the intensity of NRL-related symptoms decreased from 8.5 before to 2.3 after implementation of regulations on powder-free NRL gloves. A higher number of subjects were able to avoid NRL in the private than in the work environment (85% vs. 61%). NRL-related symptoms decreased and WAI increased with successful avoidance of NRL at workplace (b = 0.23, p = 0.003). QOL was only little affected by NRL allergy (mean: MiniAQLQ = 6.0; DLQI = 4.1).

Conclusions

Although there was improvement after implementation of powder-free NRL gloves, there is still a considerable number of HCW with NRL-related symptoms. Further investigations on latex avoidance and the cause of persisiting allergic symptoms in HCW with NRL allergy are therefore needed.     

Measurement of latex proteins and assessment of latex protein exposure

Reduction of protein levels in manufactured natural rubber latex products is important for preventing sensitization and adverse allergic reactions to latex. Because of the complex nature of latex extracts, accurate protein measurement is a challenge. Standard total protein assays were effective in reducing protein levels from what were once extremely high levels, but these assays are plagued with false-positive reactions and limited sensitivity. An ELISA for antigenic protein has been standardized and promises to provide more consistent measurement of the proteins with potential to cause adverse reactions. Antigenic proteins represent the total protein fraction with potential to be allergenic. Measuring antigenic protein in a consistent manner should help to further reduce the level of sensitizing protein and further reduce allergic reactions to latex-medical products.     

Virus penetration of examination gloves

Examination gloves worn for protection from biohazards were sampled and evaluated for their ability to exclude virus particles. We found that thin gloves manufactured from polyethylene or polyvinyl chloride are ineffective barriers while gloves of thin latex are superior but not without failure. Polyethylene and polyvinyl chloride gloves had failure rates of 40% and 22%, respectively. Following exposure to the common disinfectant, 70% ethanol, these failure rates increased to 94% and 56% for polyethylene and polyvinyl chloride gloves, respectively. Latex, although permeable to ethanol, was penetrated by virus less than 1% of the time regardless of whether the latex had been pre-exposed to disinfectant or not. This study highlights the need for caution on the part of those who rely upon examination gloves for protection from infectious agents as well as the need for establishing more adequate standards and testing procedures for their manufacture.     

Serogroup quantitation of multivalent polysaccharide and polysaccharide-conjugate meningococcal vaccines from China

The active components of most meningococcal vaccines are four antigenic serogroup capsular polysaccharides (A, C, Y, W135). The vaccines, monovalent or multivalent mixtures of either free polysaccharides or polysaccharides conjugated to antigenic carrier proteins, may be in liquid or lyophilised formulations, with or without excipients. Acid hydrolysis and chromatographic methods for serogroup quantitation, which were previously optimised and qualified using polysaccharide-based standards and a narrow range of real vaccines, are here challenged with multiple lots of a broad assortment of additional multivalent polysaccharide-based meningococcal vaccine products. Centrifugal filtration successfully removed all interfering lactose excipient without loss of polysaccharides to allow for the determination of Y and W135 serogroups. Replicate operations by three different analysts indicated high method reproducibility. Results indicated some lot-to-lot and product-to-product variations. However, all vaccines were within general specifications for each serogroup polysaccharide, with the exception of all lots of one polysaccharide vaccine – which by these methods were found to be deficient in the serogroup A component only. These robust techniques are very useful for the evaluation of antigen content and consistency of manufacture. The deformulation, hydrolysis and chromatographic methods may be adaptable for the evaluation of other types of polysaccharide-based vaccines.     

Nitrile versus Latex for Glove Juice Sampling

The objective of this study was to explore the utility of nitrile gloves as a replacement for latex surgical gloves in recovering bacteria from the hands. Two types of nitrile gloves were compared to latex gloves using the parallel streak method. Streaks of Klebsiella pneumoniae and Staphylococcus aureus were made on tryptic soy agar plates, and the zones of inhibition were measured around pieces of glove material placed on the plates. Latex gloves produced a mean zone of inhibition of 0.28 mm, compared to 0.002 mm for nitrile gloves (p<.001). While the parallel streak method is not intended as a quantitative estimate of antimicrobial properties, these results suggest that nitrile may be a viable alternative to latex in glove juice sampling methods, since nitrile avoids the risk of latex exposure.     

Effect of pretreatment of rubber material on its biodegradability by various rubber degrading bacteria

The effect of pretreatment of several cis-1,4-polyisoprene containing rubbers on their biodegradability was examined. Tests were carried out with six recently isolated and characterized rubber degrading bacteria belonging to the genera Gordonia (strains Kb2, Kd2 and VH2), Mycobacterium, Micromonospora and Pseudomonas. All strains were able to use natural rubber (NR) as well as NR latex gloves as sole carbon source. Extraction of NR latex gloves by organic solvents resulted in an enhancement of growth for three of the selected strains. On the other hand, growth of Gordonia sp. (strain Kb2 and Kd2), Mycobacterium fortuitum NF4 and Micromonospora aurantiaca W2b on synthetic cis-1,4-polyisoprene did only occur after removal of the antioxidants, that are usually added during manufacture to prevent aging of the materials. Detailed degradation studies performed with Gordonia sp. Kb2 revealed an enhanced mineralization of pretreated NR latex gloves and mineralization of purified natural rubber (NR), indicating the actual mineralization of cis-1,4-polyisoprene rubber constituent even after removal of non-rubber constituent that may act as co-metabolic substrate and support microbial growth. Further analysis by scanning electron microscopy (SEM) clearly demonstrated the enhanced colonization efficiency of these bacteria towards pretreated NR latex gloves. Colonization was additionally visualized by staining of overgrown NR latex gloves with Schiff's reagent, and the purple color produced in the area of degradation was an evidence for the accumulation of aldehydes containing oligomers. Further enhancement of latex gloves degradation could be achieved after successive replacement of mineral salts medium during cultivation. Thereby, a rapid disintegration of untreated NR latex gloves material was accomplished by Gordonia sp. strain VH2.     

Regulatory initiatives for natural latex allergy: US perspectives

The US Food and Drug Administration (FDA) has regulatory authority over foods, human drugs, cosmetics, medical devices, radiological products, biologics, and veterinary products. Among these products, FDA believes that the use of medical devices, including medical gloves, condoms, catheters, and breathing bags, represents the greatest source of natural latex proteins to exposed individuals. A medical device is defined in the Federal Food Drug and Cosmetic Act (FFDCA) as an instrument, apparatus, implement, machine, etc., that is intended for use in the diagnosis or treatment of disease or is intended to affect the structure or any function of the body of a human or other animal, and that does not achieve any of its principal intended purposes through chemical action in the body. This article provides some brief, general background about FDA's medical device regulatory process and then addresses the issue of natural latex allergy. Finally we discuss the steps the Agency has taken to evaluate the magnitude and nature of the problem, and FDA's efforts to assist manufacturers, health professionals, and others in minimizing exposure and sensitization to natural latex proteins in medical devices.     

Toxicity effects of latex gloves on boar spermatozoa

It is known that several materials used in semen collection have been found to be detrimental to spermatozoal motility. In this study, examinations for toxic effects of latex and vinyl gloves, used with and without talcum powder on boar spermatozoa, were performed. Ten boars of known fertility with >/=80% sperm motility were divided into two groups (n = 5 boars each) for in vitro and in vivo studies. In the in vitro study, semen was collected from each of the five boars and was divided into five separate aliquots (5 ml each). One aliquot from each of the boars remained as the control, while the remaining aliquots were divided into individual treatments exposing the semen to a l cm(2) piece of latex or vinyl glove with or without talcum powder. In the in vivo experiment, semen from each of the five boars was collected using a gloved hand. During collection, the first half of the sperm-rich fraction was collected into a filtered sterile container, while the second half of the fraction was allowed to run through the palm of either a latex or vinyl powdered glove prior to collection in the container. In both experiments, semen sample motility was assessed by two independent observers at 1 minute after exposure. Results of both experiments consistently showed a significant (P<0.05) effect of latex gloves (with or without talcum powder) on boar semen when compared with the control semen. Motility was at or near 0% at 1 min after exposure to latex. No significant difference (P>0.05) in motility was observed between the control semen and the semen exposed to talcum powdered vinyl gloves. These results show that latex gloves are detrimental to boar spermatozoa. Therefore, it is suggested that when collecting boar semen vinyl gloves should be used.     

Murine models for natural rubber latex allergy assessment

Murine models provide a powerful tool in the investigation of latex allergy and the development of intervention strategies. The immune responses to protein allergens of mice and humans are similar but differences related to the roles of IgE and IgG must be recognized. Mice have been shown to mount a dose and time-dependent IgE response to latex proteins following topical, respiratory, and subcutaneous exposures. Methods are available to evaluate cutaneous and respiratory responses to latex challenge in sensitized animals. These models have been used to investigate the role of route of exposure on the development of latex allergy and to provide a means for investigating the contribution of individual proteins to adverse respiratory and dermal responses. These models provide a mechanism for the evaluation of new technologies aimed at reducing the allergenicity of latex products, and for testing for the potential for cross-reactivity to new allergens in previously sensitized individuals. Murine models may also provide a method for testing immunotherapy strategies prior to initiating human trials.     

Interdigitated capacitive biosensor based on molecularly imprinted polymer for rapid detection of Hev b1 latex allergen

Allergen protein detection was performed by a surface imprinted layer combined with an interdigitated capacitance (IDC) transducer that allowed label-free measurements. The immobilized imprinted polymers are the probes that bind to rubber allergen proteins extracted from products such as rubber gloves. Copolymers made from methacrylic acid–vinylpyrrolidone–dihydroxyethylene-bisacrylamide (MAA–NVP–DHEBA) are soluble in aqueous solution and eliminate the denaturation of protein. When deposited as a coating onto an IDC microelectrode transduction system, such materials lead to sensors that produce capacitance responses that are clearly dependent on the concentration of the latex protein (10–900 ng ml⁻¹) in pH 7.4 buffer. The biosensor can detect Hev b1 within minutes and with a detection limit of 10 ng ml⁻¹. Different but related hevein allergenic proteins isolated from natural rubber latex from the rubber tree (Hev b1, Hev b2, and Hev b3) were distinguished by the imprinted material, depending on the dimension and conformation of these proteins with a selectivity factor of 4. They recognized Hevea latex proteins better than non-Hev b proteins, such as lysozyme, ovalbumin, and bovine serum albumin, by a factor of 2. Moreover, the sensor exhibited good operational stability of up to 180 days when used continuously at room temperature.     

Laboratory gloves as a source of trace element contamination

Contamination in a trace element laboratory can come from a variety of sources, including laboratory gloves. Therefore, vinyl and latex gloves were obtained from as many manufacturers as would supply gloves. These gloves were either prepared for acid-washing and subsequent soaking in an acid solution, or immersed in an acid solution for a duration of either 1 min or 1 h. Incubation washes were analyzed for a variety of trace elements by flame atomic abosrption spectroscopy (AAS) or inductively coupled mass spectrometry (ICP-MS). Results indicated that only three brands of vinyl gloves were acceptable for use in a trace element laboratory, whereas others had contamination of different elements. Latex gloves contained such high levels of biologically important elements that they were not considered suitable for routine trace element work. Vinyl gloves of choice should be routinely acid-washed before use in a trace element laboratory.     

Alternative sources of natural rubber

Rubber (cis-1,4-polyisoprene) is one of the most important polymers naturally produced by plants because it is a strategic raw material used in more than 40,000 products, including more than 400 medical devices. The sole commercial source, at present, is natural rubber harvested from the Brazilian rubber tree, Hevea brasiliensis. Primarily due to its molecular structure and high molecular weight (>1 million daltons) this rubber has high performance properties that cannot easily be mimicked by artificially produced polymers, such as those derived from, e.g., bacterial poly-hydroxy-alkanoates (PHAs). These high performance properties include resilience, elasticity, abrasion resistance, efficient heat dispersion (minimizing heat build-up under friction), and impact resistance. Medical rubber gloves need to fit well, be break-resistant, allow the wearer to retain fine tactile sensation, and provide an effective barrier against pathogens. The sum of all these characteristics cannot yet be achieved using synthetic gloves. The lack of biodiversity in natural rubber production renders continuity of supply insecure, because of the risk of crop failure, diminishing acreage, and other disadvantages outlined below. A search for alternative sources of natural rubber production has already resulted in a large number of interesting plants and prospects for immediate industrial exploitation of guayule (Parthenium argentatum) as a source of high quality latex. Metabolic engineering will permit the production of new crops designed to accumulate new types of valued isoprenoid metabolites, such as rubber and carotenoids, and new combinations extractable from the same crop. Currently, experiments are underway to genetically improve guayule rubber production strains in both quantitative and qualitative respects. Since the choice for gene activities to be introduced or changed is under debate, we have set up a complementary approach to guayule with yeast species, which may more quickly show the applicability and relevance of genes selected. Although economic considerations may prevent commercial exploitation of new rubber-producing microorganisms, transgenic yeasts and bacteria may yield intermediate or alternative (poly-)isoprenes suitable for specific applications. Received: 9 August 1999 / Received revision: 15 October 1999 / Accepted: 16 October 1999     

Strong conformational propensities enhance T cell antigenicity

The ability to predict T cell antigenic peptides would have important implications for the development of artificial vaccines. As a first step towards prediction, this report uses a new statistical technique to discover and evaluate peptide properties correlating with T cell antigenicity. This technique employs Monte Carlo computer experiments and is applicable to many problems involving protein or DNA. The technique is used to evaluate the contribution of various peptide properties to helper T cell antigenicity. The properties investigated include amphipathicities (alpha and beta), conformational propensities (alpha, beta, turn and coil), and the correlates of alpha-helices, such as the absence of helix-breakers and the positioning of the residues which stabilize alpha-helical dipoles. We also investigate segmental amphipathicity. (A peptide has this property when it contains at least two disjoint subpeptides, one hydrophobic, one hydrophilic.) Statistical correlations and stratifications assessed independent contributions to T cell antigenicity. The findings presented here have important implications for the manufacture of peptide vaccines. These implications are as follows: if possible, peptide vaccines should probably be those protein segments which have a propensity to form amphipathic alpha-helices, which do not have regions with a propensity to coil conformations, and which have a lysine at their COOH-terminus. The last two observations are of particular use in manufacturing peptides vaccines: they indicate where the synthetic peptides should be terminated. These implications are supported by the findings given below. The significances (p values) support the following statistical generalites about antigenic conformations: most helper T cell antigenic sites are amphipathic alpha-helices; alpha-helical amphipathicity and propensity to an alpha-helical conformation contribute independently to T cell antigenicity; there is evidence that some T cell antigenic sites are beta conformations instead of alpha-helices; T cell antigenic sites avoid random coiled conformations; and T cell antigenic sites are usually not segmentally amphipathic. alpha-Helical amphipathicity was significant, but segmental amphipathicity was not. This has implications for the dimensions of the structure interacting with the hydrophobic portion of an amphipathic T cell antigenic site. Lysines are unusually frequent at the COOH-terminal of T cell antigenic sites, even after accounting for tryptic digests. These lysines can stabilize alpha-helical peptides by a favorable interaction with alpha-helical dipoles.(ABSTRACT TRUNCATED AT 400 WORDS)     

Fluorescent staining of proteins transferred to nitrocellulose allowing for subsequent probing with antisera

A sensitive staining method for protein blots on nitrocellulose is described. It is based on the coupling of a fluorochrome, dichlorotriazynylaminofluorescein, to protein which yields products colorless in visible light but colored when protein blots are illuminated with long-range ultraviolet light. The coupling of a fluorochrome does not affect the antigenic properties of proteins and the stained blots can be subsequently probed with antisera. Thus, the method allows for the unambiguous identification of antigenic proteins transferred to nitrocellulose from sodium dodecyl sulfate-polyacrylamide gels.     

Measurement of airborne latex allergens

A method for the standardized sampling and quantification of aeroallergens was developed. It proved suitable for the analysis of allergen loads in a variety of medical settings. Several studies demonstrate that the use of powdered allergenic latex gloves leads to a significant aeroallergen load which is responsible for IgE-mediated rhinitis, bronchial asthma, and conjunctivitis in health care workers. Only nonpowdered latex gloves with low or no allergen content should therefore be used.