Reactions to Natural Rubber Latex (NRL) products impact on healthcare practitioners (and other workers in residential and healthcare settings) because:
- They are at increased risk of developing NRL allergy through the repeated use of NRL gloves.
- They may need to manage NRL-sensitive patients, both previously undiagnosed and those have already informed them about their allergy.
- They have a statutory responsibility to reduce risk of sensitisation in themselves, their colleagues and their patients.
- They may be responsible for diagnosis and referral. In certain settings, such as GP practices and residential care homes, they may be the first port of call for sensitised individuals who may or may not suspect that they have an NRL allergy. It is important that the GP is able to identify patients with suspected NRL allergy to allow prompt referral to a diagnosing physician (dermatologist or immunologist) for further investigation.
There are a range of health & social care disciplines and settings in which NRL may be encountered:
- A&E department
- Ambulance service
- Clinical Commissioning Groups (CCGs)
- Dental practice
- GPs and surgeries
- Housekeeping & domestic services
- Occupational health
- Operating theatres
- Pre-assessment & outpatients clinic
- Residential care
On this page we will outline the ways in which healthcare settings can minimise the risk of sensitisation among staff; manage sensitised workers and patients with known or unknown NRL sensitivity; and manage allergic reactions to NRL.Reducing the Risk of Sensitisation Among Staff
All staff at risk of NRL sensitisation should be screened and monitored before and during employment. All staff should be educated about NRL allergy, its recognition and management.
- Assessment of all new staff should be encouraged using a pre-employment screening tool.
- If staff are identified as sensitised to NRL, employers must undertake risk-assessment to ensure that the working environment is safe for the employment of the prospective member of staff. Risk minimisation and education of colleagues is vital.
- In line with the Disability Discrimination Act 1995, individuals who are sensitised to NRL should stop using NRL medical gloves and be provided with gloves made from an alternative material. They should also avoid areas where NRL glove powder particles are likely to be airborne, (Health Service Circular HSC 1999/186).
Protecting against NRL sensitisation
It is important for staff to protect themselves against breaches of the skin barrier, which can result from frequent use of skin cleansers and occlusive glove-wear, especially if they have an atopic background (asthma, hay fever or flexural eczema) where damage to the skin from irritants is more common. A compromised skin barrier will increase your chance of developing Type IV rubber chemical or Type I NRL allergy. Hand-disinfectant agents and protective gloves need to be selected with great care and it is also important to use a suitable aqueous based emollient if skin has any tendency to dry out.
Here are some hand protection measures that staff can take:
- Don’t wear rings or other jewellery on the hands;
- Wear a new disposable pair of gloves for each contact with blood or body fluids;
- Wash, disinfect and dry hands after wearing gloves, as well as between each glove change;
- Prolonged unnecessary use of gloves should be avoided;
- Do not wear NRL gloves where there is no operational need (e.g. for tasks with no risk of cross-infection from blood-borne pathogens).
- Use cool/tepid water when washing, to keep hand temperature down;
- Use hand-wash agents sparingly; Rinse thoroughly to remove all traces of hand wash;
- Pat skin dry rather than rubbing it;
- Use soft towels (disposable);
- Ensure hands are dry before putting on gloves;
- Use non-powdered gloves with low levels of NRL proteins and residual chemicals;
- Choose the right size of gloves;
- Minimise contact with other potential irritants/allergens in the surgery (e.g. acrylic powders/anti-microbial solutions);
- Outside work, don’t forget to protect hands when gardening/doing household chores etc.
If staff or patients are not NRL-sensitive and NRL gloves are worn, Powder-Free and Low Protein (<50ug/g) gloves should be worn. Always ensure that gloves comply with national and international standards of performance (British and European Standard BSEN 455). They should carry the ‘CE’ mark.
For more information about choosing gloves, and rules for glove use, see Do gloves need to be worn?
Special note on catering staff in a healthcare setting
NRL gloves are widely used in both domestic and commercial food preparation. However, some people become allergic to the proteins in NRL, and subsequent reactions to NRL-containing products can range from mild to severe, occasionally even life-threatening.
This may not only impact on the staff who wear the gloves but also on NRL-sensitive people who eat the food that has been handled or prepared with hands wearing NRL gloves, as the proteins can be transferred onto the food or its packaging. Food contaminated with NRL in this way can cause allergic reactions, which may be severe, in people with NRL allergy if eaten.
Natural rubber latex gloves are simply not required in catering environments as there are synthetic alternatives which will give an equally effective barrier. In many catering establishments, blue vinyl single-use gloves are being worn for food handling and preparation where there is a need for gloves to be worn. More important is thorough hand-washing to ensure good hygiene and keeping your hands in good condition, although it is accepted that customers tend to prefer seeing staff wearing gloves because they believe them to be “cleaner” than bare hands.
Strong long-cuffed natural rubber latex gloves are frequently used when oven cleaning with caustic substances. There are synthetic alternatives which offer just as good personal protection, for example PVC gauntlets.
Hand-washing, glove use and hand-care for catering staff
- Wash hands gently and thoroughly before and after each task
- Keep nails short, clean and free of nail polish
- Remove jewellery
- Wet hands before using liquid and solid soaps
- Wash hands ensuring that all areas are cleaned (remember thumbs, webs between fingers and include wrists)
- Dry hands gently but thoroughly preferably using single-use soft paper towels
- Apply gloves before task and remove after task
- Select the right glove for the task
- Change gloves between tasks
- Do not wash and re-use single-use gloves
- Dispose of single-use gloves in the appropriate bin
- Care of hands
- Use perfume-free water based hand creams at the end of each working session to keep your hands in good condition. See suggested Skin care protocol
The HSE has issued useful guidance for the Catering and Hospitality industry.
If a member of staff suspects that they may be allergic to NRL, they should seek a referral to a dermatologist or immunologist via their GP so that this can be appropriately investigated as soon as signs and symptoms develop.
If a member of staff is found to be NRL sensitive, then it is essential that the work environment is adapted as soon as possible to avoid unnecessary exposure to NRL, which would increase sensitivity and put them at risk of more severe reactions.
Type I NRL allergy
If a member of staff is diagnosed with Type I allergy, it may be possible for them to continue to work in the clinical environment, although this depends on the severity of reactions they experience.
- It is important that workers learn to avoid NRL proteins in consumer and medical products both at home and at work. As gloves are the main cause of allergic reactions to NRL, it is essential to ensure that NRL gloves are replaced with suitable NRL-free gloves and that NRL-sensitive staff are not working in powdered NRL environments (ie from the use of powdered NRL gloves worn by colleagues).
- A minority of allergic workers can only work symptom-free in strict NRL-free glove environments so it may become necessary for colleagues to switch to NRL-free gloves also, or for other modifications to the work environment to be carried out.
- It is recommended that all NRL-sensitive workers wear an allergen identifier bracelet.
- If a staff member has been advised to carry adrenaline for self-administration (e.g. Emerade®, EpiPen® or Jext®), colleagues should be instructed on how to use it. (Please note that Emerade auto-injectors have been recalled and are currently unavailable)
Type IV allergy
If a member of staff is diagnosed with Type IV allergy to a rubber chemical, then they will need to find a glove that does not contain the chemical to which they are allergic. The dermatologist who has diagnosed this should be able to help with appropriate glove selection.
Dental practitioners can also check the British Dental Association information on hand dermatitis and latex allergy.
Diagnosis and communication
If following screening it is established that the patient is or may be NRL allergic, it is vital to future patient safety both inside and outside of healthcare that an accurate diagnosis is made by an appropriate diagnostician (i.e. allergist, immunologist or dermatologist), and referral initiated. It is vital to impress upon referring clinicians the importance of releasing this information to other clinical teams so that standard NRL-containing equipment can be replaced with designated NRL-free equipment for use on sensitised patients instead and allergic reactions avoided.
Admission for elective surgery or hospital treatment should wherever it is in the patient’s best interest be delayed until a definitive diagnosis is obtained. In the event of there being a delay in achieving diagnosis and the patient requiring earlier admission, all future carers must be notified of the possible diagnosis and those areas prepared to receive a patient who has been assessed as high risk.
- GP and Primary Care
- Occupational Therapy
Management of a patient with Type 1 NRL allergy
Be vigilant. Patients may not always be able to tell you that they are reacting to rubber products, or may not make the association themselves. Seek to identify at risk patients (see the screening tool) by enquiring about NRL allergy when appropriate; for example, prior to any procedure, or if the patient has dermatitis, or by taking note of any allergic reactions the patient has experienced in the past. Questions to ask include:
- Has the patient ever experienced an adverse reaction (itch or swelling) to balloons, condoms, household gloves, or associated with surgery, internal examination or dental treatment?
- Does the patient have an allergy to foods cross-reacting with NRL (e.g. banana, kiwi, avocado, chestnut)?
- Has the patient experienced hives, asthma or hay fever symptoms as a result of their work, where NRL gloves are used?
If you suspect NRL allergy in a patient, refer the patient to a dermatologist or an immunologist for diagnosis and advice. Remember, an early diagnosis may prevent unnecessary NRL exposure. This is important, as continued NRL exposure in someone who is sensitised may induce progression to more severe allergic symptoms.
It is recommended that sensitised individuals wear an allergen identifier bracelet or wristband.
If a patient has a confirmed NRL allergy diagnosis, label the patient’s notes clearly. If you are referring a sensitised patient to hospital for a medical or surgical procedure, remember to mention the patient’s NRL allergy, its significance and how to safely manage the patient by telephone or in the referral letter.
Avoiding contact with NRL
Contact with natural rubber latex-containing medical equipment and products (including medicines) must be avoided in patients with diagnosed or suspected Type 1 NRL allergy and NRL (protein)-free alternatives used instead. Special care must be taken with procedures that involve contact with mucosal or serosal skin surfaces (e.g. skin surgery, smear tests, coil fittings, vaginal or rectal examinations etc) or when administering parenteral medication (rubber vial stoppers).
Synthetic examination gloves will suffice for most general practice procedures. Synthetic sterile gloves are only necessary for aseptic or surgical procedures. Vinyl gloves do not afford as good a barrier against cross-infection from blood-borne pathogens as gloves made of NRL-free nitrile or neoprene materials, but may be used for low-risk tasks.
Treatment (e.g. minor surgery) at the beginning of the working day is preferred, before environmental levels of NRL allergens rise with increased activity in the surgery.
All forward planning and documentation should inform future carers of the patient’s sensitisation by effective recording in notes and the use of labels for patients notes.
Possible sources of NRL proteins in a healthcare environment include:
- Urinary catheters
- IV lines and infusion bags
- Equipment tubing
- Adhesives and dressings and their packaging
- Stoppers in vials
- Needle sheaths on pre-filled syringes
- Equipment and laboratory work previously handled with NRL gloves
- Contraceptive diaphragms
In general, resuscitation equipment should be NRL-free where possible. It is important to be prepared to treat severe allergic reactions. Ensure that a NRL-free product list is available within areas of emergency treatment.
- Oral and nasal airways
- Oxygen masks and nasal cannulae
- Self-inflating bag
- Blood pressure monitor
- Emergency medication
For the more reactive patient, other items should be checked for their NRL content.
Ensure that NRL-free emergency equipment and medicines are readily available to treat any allergic reaction from mild (e.g. urticaria and asthma) to severe reactions including anaphylaxis (laryngeal oedema / bronchospasm / cardiovascular collapse), and that staff are fully trained in resuscitation techniques. Mild reactions require avoidance of NRL, reassurance and perhaps topical or oral antihistamines with appropriate advice / monitoring / supervision. More severe reactions will require adrenaline / oxygen / paramedical support and hospitalisation.
Guidance for emergency medical treatment of anaphylactic reactions is available from Resuscitation Council (UK).
Critical emergency medical care should not be delayed to modify NRL-containing equipment, (but see above comment about being prepared, hence the importance of having readily available NRL-free supplies of medical equipment and drugs).
In healthcare settings where gloves, medical equipment or drugs containing natural rubber are used, you should ensure that you put in place, and are familiar with, where relevant:
- Minimisation of purchase of NRL-containing products through an organisational purchasing programme that only supports powder-free/low-protein NRL glove use, and wherever possible, NRL-free equipment and product purchasing.
- Check with manufacturers for the latest product information.
- Consider keeping a regularly updated database of generic and speciality-specific products that do and do not contain NRL.
- Consider introducing a local or shared NRL-free trolley or box for use with sensitised patients
- An organisational policy on action to protect patients and staff who are allergic to NRL. Click here for Resuscitation Council (UK) guidance for emergency medical treatment of anaphylactic reactions.
- Occupational Health pre-screening questionnaires, and a reporting mechanism for effective diagnostics of in-post staff
- Risk assessments undertaken for your specific department
- A screening tool for determining the allergic status of your patients/clients.
- Skin care protocol
- An Education programme to inform new and existing staff
- Posters for patient and staff information, clearly displayed and on file
- A named responsible person for managing Health and Safety
These procedures should not be too time-consuming to implement, given the links to example documentation, which can act as a basis for creating your own policies and protocols.
Occupational health staff will be required to:
- Undertake pre-employment screening of all prospective employees working in the clinical environment — this could be as simple as adding a question on the Pre-Employment Health Questionnaire.
- Provide advice on NRL-safe environments to all prospective employees and their managers.
- Provide advice on NRL protein and chemical sensitisations to all employees.
- Undertake risk assessments:
- to determine whether an NRL-safe environment within OH clinical rooms should be the ‘norm’ to prevent / reduce the incidence of exposure to NRL, to both OH personnel and clients.
- to determine whether NRL-free gloves should be used in a client testing / diagnostic situation, where the member of staff is, as yet, undiagnosed.
- Within the client’s workplace, once a positive diagnosis of NRL allergy has been made, in conjunction with the manager, to ensure a safe working environment for sensitised individuals.
- Develop a screening tool for identifying NRL Sensitivity, to assist in determining whether further diagnostics/testing are required.