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.     

Natural rubber latex protein reduction with an emphasis on enzyme treatment

Natural rubber latex (NRL), derived from the Hevea brasiliensis tree, is a material used to manufacture products in health care, including medical gloves. Proteins are a naturally occurring component of NRL. These proteins, which can be present on the surface of NRL gloves, have been related to hypersensitivity reactions in some humans who come into contact with them. These same proteins also help to maintain the latex colloidal stability during collection and transport prior to manufacture. Consequently, when measures are taken to remove or degrade these proteins, other problems can be introduced, such as destabilization of the latex and changes in its coagulation properties. Practical methods are available to reduce the extractable antigenic protein content of NRL products. We describe here methods of reducing proteins in commercial-grade NRL and finished products. NRL gloves manufactured with adequate leaching can produce products with lower levels of extractable antigenic proteins. Emphasis is given here to enzyme treatment of NRL, as this process is very effective in reducing antigenic proteins in NRL. While this technology adds marginally to the production cost of standard grades of NRL, it is still quite cost-effective when compared with postwashing NRL products or the use of synthetic latex. Moreover, enzyme-treated NRL maintains the excellent physical properties and performance of NRL.     

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.     

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.     

Immune response modulation by curcumin in a latex allergy model

Background

There has been a worldwide increase in allergy and asthma over the last few decades, particularly in industrially developed nations. This resulted in a renewed interest to understand the pathogenesis of allergy in recent years. The progress made in the pathogenesis of allergic disease has led to the exploration of novel alternative therapies, which include herbal medicines as well. Curcumin, present in turmeric, a frequently used spice in Asia has been shown to have anti-allergic and inflammatory potential.

Methods

We used a murine model of latex allergy to investigate the role of curcumin as an immunomodulator. BALB/c mice were exposed to latex allergens and developed latex allergy with a Th2 type of immune response. These animals were treated with curcumin and the immunological and inflammatory responses were evaluated.

Results

Animals exposed to latex showed enhanced serum IgE, latex specific IgG₁, IL-4, IL-5, IL-13, eosinophils and inflammation in the lungs. Intragastric treatment of latex-sensitized mice with curcumin demonstrated a diminished Th2 response with a concurrent reduction in lung inflammation. Eosinophilia in curcumin-treated mice was markedly reduced, co-stimulatory molecule expression (CD80, CD86, and OX40L) on antigen-presenting cells was decreased, and expression of MMP-9, OAT, and TSLP genes was also attenuated.

Conclusion

These results suggest that curcumin has potential therapeutic value for controlling allergic responses resulting from exposure to allergens.     

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.     

Approaches to prevention and treatment of latex allergy

Data on sensitization to latex as well as measures aimed at prevention and treatment of latex allergy, are presented. The intensity of the symptoms manifestation of latex allergy was shown to depend on the duration of contact with latex. To prevent the development of latex allergy, the following preparations were used: the antihistaminic preparation Claritine, the immunocorrecting preparations Ruzam and polycomponent vaccine VP-4. The use of Claritine was shown to lead to the alleviation of the symptoms of latex allergy, but after treatment with Claritine was stopped the symptoms of latex allergy reappeared. The clinical effect lasted for as long as 2 months after treatment with Ruzam, while in case of polycomponent vaccine VP-4 use remission was registered even 3 months later. The data presented thus confirm topicality of the latex allergy problem and practical importance of using the immunocorrecting preparations Ruzam and polycomponent vaccine VP-4 for its prevention and treatment.     

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.     

Prevention of occupational asthma in Ontario

Occupational asthma continues to be one of the most common occupational lung diseases in industrialized areas. Primary and secondary preventive measures have been well described, but there are relatively few studies to support the effectiveness of such measures, although the benefits of tertiary measures such as early recognition and removal from further exposure to a causative sensitizing agent are well recognized. In Ontario, a combined approach of preventive measures has shown effectiveness in allergy and asthma from occupational exposure to natural rubber latex. In addition, a program to reduce exposure to diisocyanates and introduce medical surveillance was associated with earlier diagnosis and fewer cases in a compensation population. However there remain barriers to the early diagnosis of occupational asthma in Ontario, especially in workers of lower education and lower income. In addition, there is recognized need for further physician education to allow early suspicion and diagnosis of occupational asthma.     

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.     

植物过敏性蛋白质及其生物学功能

在引起I型超敏反应的变应原中 ,植物的花粉、果实和汁液可以分别作为吸入性变应原 (inhalentallergen)、食入性变应原 (ingestentallergen)、接触性变应原 (contactentallergen)使过敏者患上鼻炎、哮喘、枯草热等疾病。而其中引起这些超敏反应的植物类蛋白质本身在植物体内亦行使着特定的生物学功能。对这些植物类过敏性蛋白质的研究不仅在植物学本身研究中具有一定意义 ,同时在变态反应性疾病的免疫治疗中亦具有重要的应用价值。目前 ,这类涉及植物学、免疫学和变态反应学的研究逐渐形成了一个新的交叉研究领域。     

Survey on the impact of comorbid allergic rhinitis in patients with asthma

Background

Allergic rhinitis (AR) and asthma are inflammatory conditions of the airways that often occur concomitantly. This global survey was undertaken to understand patient perspectives regarding symptoms, treatments, and the impact on their well-being of comorbid AR and asthma.

Methods

Survey participants were adults with asthma (n = 813) and parents of children with asthma (n = 806) from four countries each in the Asia-Pacific region and Europe. Patients included in the survey also had self-reported, concomitant AR symptoms. Patients and parents were recruited by telephone interview or by direct interview.

Results

Most patients (73%) had pre-existing symptoms of AR when their asthma was first diagnosed. Shortness of breath (21%) was the most troublesome symptom for adults, and wheezing (17%) and coughing (17%) the most troublesome for children. Patients used different medications for treating asthma (most commonly short-acting β-agonists and inhaled corticosteroids) and for treating AR (most commonly oral antihistamines). The concomitant presence of AR and asthma disrupted the ability to get a good night's sleep (79%), to participate in leisure and sports activities (75%), to concentrate at work or school (69% of adults, 73% of children), and to enjoy social activities (57% of adults, 51% of children). Most patients (79%) reported worsening asthma symptoms when AR symptoms flared up. Many (56%) avoided the outdoors during the allergy season because of worsening asthma symptoms. Many (60%) indicated difficulty in effectively treating both conditions, and 72% were concerned about using excessive medication. In general, respondents from the Asia-Pacific region reported more disruption of activities caused by symptoms and more concerns and difficulties with medications than did those from Europe. Differences between the two regions in medication use included more common use of inhaled corticosteroids in Europe and more common use of Chinese herbal remedies in the Asia-Pacific region.

Conclusion

Results of this survey suggest that comorbid asthma and AR substantially impact patient well-being and that the worsening of AR symptoms in patients with asthma can be associated with worsening asthma symptoms. These findings underscore the need for physicians who treat patients with asthma to evaluate treatment options for improving symptoms of both AR and asthma when present concomitantly.

     

Asthma in the Elderly

Fifteen patients who developed asthma after the age of 60 years are reported. Attention is drawn to apparent difficulties of diagnosis in this age group. A history of chronic bronchitis is common, and a change in symptoms, especially the abrupt onset of increased breathlessness, wheezing, and paroxysmal nocturnal dyspnoea, should arouse suspicion of the development of asthma. A past or family history of allergy is confirmatory evidence, as is the presence of blood or sputum eosinophilia. Retrosternal pain is not uncommon, and angina pectoris or left ventricular failure must be excluded. Chest radiographs showed changes consistent with old quiescent tuberculosis in five patients; careful follow-up is therefore essential as asthma in this age group often requires steroid therapy.     

Assessment and treatment of laboratory animal allergy

Laboratory animal allergy (LAA) is a form of occupational sensitivity affecting up to one third or more of exposed workers. Symptoms involve the eyes, nose, skin, and lower respiratory tract. Asthma may develop in 20 to 30% of sensitized individuals. An occupational medical history is the primary tool if a diagnosis of LAA is suspected. The diagnosis is confirmed by demonstrating the presence of immunoglobulin E antibodies to laboratory animal allergens by skin testing or in vitro assays. If laboratory animal allergen-induced asthma is suspected, measurements of lung function are necessary for confirmation and assessing the degree of impairment. One approach to the problem is presented in this article. For individuals with LAA, avoidance of exposure is the primary treatment. For individuals who continue to work in the environment, pharmacological treatment of their symptoms may be necessary. Methods to prevent the development of LAA are also discussed.     

Severe asthma and the omalizumab option

Atopic diseases and asthma are increasing at a remarkable rate on a global scale. It is now well recognized that asthma is a chronic inflammatory disease of the airways. The inflammatory process in many patients is driven by an immunoglobulin E (IgE)-dependent process. Mast cell activation and release of mediators, in response to allergen and IgE, results in a cascade response, culminating in B lymphocyte, T lymphocyte, eosinophil, fibroblast, smooth muscle cell and endothelial activation. This complex cellular interaction, release of cytokines, chemokines and growth factors and inflammatory remodeling of the airways leads to chronic asthma. A subset of patients develops severe airway disease which can be extremely morbid and even fatal. While many treatments are available for asthma, it is still a chronic and incurable disease, characterized by exacerbation, hospitalizations and associated adverse effects of medications. Omalizumab is a new option for chronic asthma that acts by binding to and inhibiting the effects of IgE, thereby interfering with one aspect of the asthma cascade reviewed earlier. This is a humanized monoclonal antibody against IgE that has been shown to have many beneficial effects in asthma. Use of omalizumab may be influenced by the cost of the medication and some reported adverse effects including the rare possibility of anaphylaxis. When used in selected cases and carefully, omalizumab provides a very important tool in disease management. It has been shown to have additional effects in urticaria, angioedema, latex allergy and food allergy, but the data is limited and the indications far from clear. In addition to decreasing exacerbations, it has a steroid sparing role and hence may decrease adverse effects in some patients on high-dose glucocorticoids. Studies have shown improvement in quality of life measures in asthma following the administration of omalizumab, but the effects on pulmonary function are surprisingly small, suggesting a disconnect between pulmonary function, exacerbations and quality of life. Anaphylaxis may occur rarely with this agent and appropriate precautions have been recommended by the Food and Drug Administration (FDA). As currently practiced and as suggested by the new asthma guidelines, this biological agent is indicated in moderate or severe persistent allergic asthma (steps 5 and 6).     

Multicomponent vaccine VP-4 in the therapy of allergic diseases

In the present study the results of the polycomponent vaccine B[symbol: see text]-4 use for the therapy of patients with bronchial asthma (BA) and latex allergy were generalized. The vaccine was introduced by the nasal-subcutaneous or nasal-oral administration simultaneously with the basic therapy. Te studies were conducted first on limited groups of patients, then in the course of the State Trial with the use of placebo control. Excellent and good effect lasting for 1 year and over was registered in 36 patients (66.7%) out of 54 BA patients receiving the vaccine by the intranasal-subcutaneous method. Immunotherapy produced no positive effect in 13 patients (24.1%). Out of 35 examined patients receiving the vaccine by the intranasal oral method, excellent and good effect was registered in 26 patients (74.2%). No effect was registered in 4 patients (11.4%). In the group of 28 patients receiving placebo simultaneously with the basic therapy positive dynamics in the course of the disease was observed only in 3 patients. Treatment with polycomponent vaccine B[symbol: see text]-4 led to a prolonged (to a year and more) decrease in the frequency and severity of exacerbations, contributed to the prolongation of remissions and to a decrease in the amount of administered medicinal preparations, especially systemic corticosteroids. Immunotherapy ensured the correction of the content of lymphocyte subpopulations with markers CD3, CD4, CD72 and a rise in the titers of antibodies to antigens contained in the preparation. The use of therapeutic polycomponent vaccine B[symbol: see text]-4 for the treatment of patients with latex allergy ensured the state of prolonged remission in this group of patients. On the basis of our investigations we believe that the use of the therapeutic polycomponent vaccine B[symbol: see text]-4 may be included into the basis therapy of allergic diseases.     

Laboratory animal allergy: an update

Allergic reactions are among the most common conditions affecting the health of workers involved in the care and use of research animals. Between 11 and 44% of the individuals working with laboratory animals report work-related allergic symptoms. Of those who become symptomatic, 4 to 22% may eventually develop occupational asthma that can persist even after exposure ceases. Allergic symptoms consist of rashes where animals are in contact with the skin, nasal congestion and sneezing, itchy eyes, and asthma (cough, wheezing, and chest tightness). The generation of immunoglobulin E (IgE) antibodies is a prerequisite for the production of allergic symptoms. The mechanism by which IgE antibodies develop is becoming clearer. The propensity to produce IgE is genetically determined, and pre-existing allergy may be a risk factor for the development of laboratory animal allergy (LAA). However, exposure to animal allergens is the major risk factor for the development of LAA. Techniques to measure the airborne concentration of laboratory animal allergens have been developed. Research on animal allergens themselves indicates that many of the mouse and rat urinary proteins belong to a family of proteins called lipocalins, which share sequence homology with antigens of the parasitic agent that causes schistosomiasis. The fact that parasite infections also trigger IgE antibody responses may account for the development of LAA in persons who have never had any previous allergy. The prevention of LAA should be a major goal of an effective health and safety program in the animal research facility, and it can be accomplished by education and training of employees, reduction of exposure (including the use of personal protective gear), and changes in facility design. Medical surveillance programs can also play a role in improving health of individuals working with laboratory research animals. Early recognition of symptoms and evidence of sensitization can lead to interventions to reduce exposure and thereby avoid the long-term health consequences of LAA.     

Hevein,an allergenic lectin from rubber latex,activates human neutrophils' oxidative burst

Hevein is an N-acetyl-D-glucosamine (GlcNAc) specific lectin that has been hypothesized to participate in the IgE-mediated allergic reactions in patients with latex allergy. In this work we assessed the specificity and biological effect of hevein purified from rubber latex on human leukocytes, using epifluorescence microscopy and flow cytometry. Purified human granulocytes were stimulated in vitro with hevein, and production of oxidative radicals was measured by reduction of nitroblue tetrazolium formazan. Histochemical staining and flow cytometry showed that hevein recognizes specifically monocytes (CD14+) and neutrophils (CD16+), but not lymphoid cells. Hevein induced oxidative response in purified granulocytes; this effect was 1.3–1.5-fold higher than the effect observed with the lectin WGA (wheat germ agglutinin), or other lectins with different sugar specificity. The induced reactions and cellular recognition by hevein were inhibited with GlcNAc and its oligomers; as well as by glycoproteins containing tri-and tetra-antennary N-glycosydically linked glycans. Our findings suggest that neutrophils are the main target for latex hevein; this lectin induces production of oxidative radicals, which seem to play an important role in tissue damage during latex allergy.