67 Occupational Allergy to Natural Rubber Latex (NRL)
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67 Occupational Allergy to Natural
Rubber Latex (NRL)
Henning Allmers
Department of Dermatology, Environmental Medicine and Health Sciences, University of
Osnabrueck, Osnabrueck, Germany
Department of Occupational Medicine, University of Osnabrueck, Osnabrueck, Germany
Core Messages care workers (HCW) during the 1990s and early 2000s.
● During the 1980s and 1990s, the need for protection of During the 1980s and 1990s, the need for the protection of
health care workers from HIV and Hepatitis B and health care workers from HIV as well as Hepatitis B and
C viruses led to an increased use of powdered natural C viruses led to an increased use of powdered natural
rubber latex (NRL) examination gloves that contami- rubber latex (NRL) examination gloves that contaminated
nated the room atmosphere with NRL-allergens the room atmosphere with NRL-allergens adhering to
adhering to cornstarch glove powder. cornstarch glove powder (> Fig. 67.2) (Turjanmaa 1987;
● The NRL-allergens adhering to cornstarch powder Baur and Jäger 1990; Baur et al. 1998; Allmers et al. 1998).
led to type-I sensitization in up to 17% of health care Up to 17% of health care workers developed
personnel mainly through inhalation. a sensitization to NRL, up to 5% developed occupational
● In most cases the first symptom of NRL-allergy was asthma after first suffering from urticaria of the hands as
urticaria of the hands when wearing powdered NRL symptom of an immediate-type allergy to NRL when
gloves. wearing powdered examination or surgical gloves
● Ninety percent of NRL asthma sufferers could recall (Charous et al. 2002). During the late 1990s and early
having urticaria of the hands when wearing NRL 2000s several studies showed that recommendations to
gloves more than 6 months prior to developing allergic use powder-free and low-allergen gloves as preventive
respiratory tract symptoms. measures led to successful secondary and primary preven-
● Even in NRL-asthma cases confirmed by inhalation tion of NRL-allergy. By the mid 2000s, there was a steady
exposure up to 5% of patients had negative skin- decline of new cases and in most Western countries there
prick-tests and no detectable specific IgE-antibodies are only few new cases in the health care community
to NRL-allergens. (Sussman et al. 1998; Allmers et al. 2002, 2004). There
● Patients who have been diagnosed with type-I NRL- have also been reported cases in other professions using
allergy might have a lifelong risk of developing an powdered NRL gloves like food handlers and security
anaphylactic shock when being exposed to NRL- screeners but the epidemic among health care workers is
containing devices such as gloves during diagnostic history (Fish 2002; Bousquet et al. 2006; LaMontagne et al.
or therapeutic medical, surgical, or dental procedures. 2006). Children, especially spina bifida sufferers, who
Negative skin-prick-tests and negative specific IgE- require multiple surgeries during early childhood are
antibodies to NRL-allergens do not rule out also at risk of becoming NRL-sensitized, depending on
a relevant sensitization to NRL. the amount of exposure to NRL-allergens through gloves
and catheterization devices.
1 Introduction
2 Definition
This chapter is mainly concerned with the occupational
allergy to natural rubber latex (NRL) from the rubber tree When talking about a type-I allergy to latex allergists are
(Hevea brasiliensis) (> Fig. 67.1). A phenomenon that can referring to an immediate-type allergy to latex from the
almost be called historic in 2011 but was a problem of H. brasiliensis (rubber) tree or natural rubber latex (NRL).
epidemic proportions for the Western hemisphere’s health There have been reports that NRL can also cause type-IV
T. Rustemeyer, P. Elsner, S.M. John & H.I. Maibach (eds.), Kanerva’s Occupational Dermatology,
DOI 10.1007/978-3-642-02035-3_67, # Springer-Verlag Berlin Heidelberg 2012
756 67 Occupational Allergy to Natural Rubber Latex (NRL)
. Fig. 67.2
ADP Cornstarch powder on the surface of an NRL
examination glove
● Asthmatic reactions and hyperventilation may also
. Fig. 67.1 start after inhalation of NRL-allergens. Sometimes
Harvesting natural rubber latex from the rubber tree hyperventilation during an asthma attack has been
(H. brasiliensis) misdiagnosed as an anaphylactic reaction.
● Systemic anaphylaxis has been described in NRL-
allergic patients during medical, surgical and dental
allergies, mostly presenting as hand eczema. However in procedures where NRL-allergens adhering to gloves or
people wearing gloves this is overwhelmingly caused by other medical devices had direct contact to mucosal
a variety of different chemicals that allow the latex to tissue or was injected into the blood stream. Fatalities
polymerize, or form, into long chains that can then be have been documented.
manipulated to form solid objects. Some of these
chemicals can also cause allergic reactions that present as
mild to severe itchy, red bumps or rashes (contact derma- 4 Terminology
titis). However, these chemicals do not cause asthma-,
hives-, or hay-fever-type symptoms (Pacheco 2009). The term ‘‘latex’’ is very imprecise. It can mean:
● The milky liquid coming from a tree (e.g., rubber tree
H. brasiliensis)
3 Symptoms ● The concentrated form of this sold as a raw material
● A formulated version of this used for dipping
● Urticaria and itching in NRL-allergic individuals
● The product in the form of a sheet of rubber
occurs most commonly when wearing powdered
● An aqueous suspension of synthetic polymer, e.g.,
highly allergenic low-quality NRL gloves. However,
some inks and paints
all contact with the skin and mucosa can cause urti-
caria itching and swelling in sensitized individuals, There are two forms of natural rubber used in com-
especially unpleasant and memorable, when inflating mercially available products (Stephens et al. 2005).
balloons or using condoms. ‘‘Dry rubber’’ is different to natural rubber in the form
● Rhinitis and conjunctivitis can occur after exposure to of ‘‘latex’’; the latter form is the cause for type-I allergies
NRL-allergens in the air, frequently after use of pow- to natural rubber latex. Both originate from the rubber
dered NRL gloves or rupture of NRL-balloons. tree as liquid latex. This latex is a colloidal suspension
Occupational Allergy to Natural Rubber Latex (NRL) 67 757
of rubber particles and other materials in a liquid serum. a coating of the latex, and the latex is coagulated,
These other materials include plant cell organelles, and then cured. Leaching (or washing) can be
proteins, sugars, sterols, and fats and oils. It can be performed at the wet gel stage or after drying, by
processed via two broad routes described in the following dipping the formers in water. The product is then
sections. dried and stripped from the former and prepared
for sale.
Examples of dipped NR latex goods:
4.1 Dry Rubber (of Which ‘‘Crumb’’ is
One Form) Gloves, condoms, bottle teats, dental dam, Foley catheters,
toy balloons, cut thread, cold seal adhesives, bath mat
The latex is coagulated by treating the white milky liquid backings, carpet backings (though most are synthetic),
with an organic acid which causes the rubber to coalesce bathing caps, some mattresses (though many are
and solidify so that it can be separated from the liquid synthetic).
components. Rigorous washing and pounding stages
serve to purify the rubber and separate it from the
water-soluble components including those proteins 5 Risk Factors and Causes
which are the cause of latex protein allergy. Other proteins
will still be present, but they are non-water soluble and 5.1 Glove Use Caused the NRL-Allergy
become incorporated in the rubber matrix. The rubber is Epidemic in Health Care Workers
then dried at temperatures above 100 C and compressed
to form a bale. Health care workers and other people in other professions
To be made into a product it is heated to soften it and who inhale high allergen loads of NRL-allergens in the
cured with sulfur or other chemicals at temperatures atmosphere are at a high risk of developing an NRL-
exceeding 140 C. It may be extruded or molded into the sensitization or allergy. Staff with preexisting allergies to
final product shape. environmental allergens like pollen, house dust mites, and
Examples of dry rubber goods: pets are more likely to also develop a sensitization to NRL-
allergens.
Most NR products which are more than a few millimeter
Children, especially spina bifida sufferers, who require
thick!
multiple surgeries during early childhood are also at risk
Hoses, bearings, seals, tire components (although most car
of becoming NRL-sensitized, depending on the amount of
tires contain no significant NR), most rubber bands,
exposure to NRL-allergens through gloves and catheteri-
erasers, hot water bottles, shoe soles, car mats, wind-
zation devices.
screen wipers, sink plugs, stoppers
Historically there were several reasons for the
increased use of powdered NRL gloves in the health care
field. The need for protecting HCWs against HIV and
4.2 Latex for Liquid Processing (Most
hepatitis infection led to an increased use of powdered
Commonly Dipping)
NRL examination gloves that reached a peak in the
mid-1990s (Heilman et al. 1996; Kelly et al. 1993).
The latex is maintained as a liquid suspension, concen-
A detailed analysis of glove use is given below. Before
trated, and stabilized to produce a material suitable for
that time, NRL gloves were mostly used in the operating
making dipped goods. Most of the proteins from the tree
rooms and for sterile procedures. Increased demand for
latex remain in the latex unless measures are taken to
these gloves led to increased building of manufacturing
remove them at some stage during product manufacture.
plants close to the rubber tree plantations instead of ship-
Much less heat is applied at the curing stage. Products may
ping the raw product overseas for production of gloves
be formed by dipping, casting, or foaming. RL is an
and condoms. This change in manufacturing process
excellent material for making dipped products because it
reduced the time between harvesting of the latex milk
forms smooth, continuous films on drying that have high
from weeks to days. One hypothesis assumes that the
strength and elasticity.
protein denaturing properties of ammonia in which the
A typical, simplified, dipping process is as follows:
latex milk is put after harvesting led to a decrease of
A former such as a ceramic ‘‘hand’’ is dipped into a tank NRL-allergens in the latex milk during the shipping
of formulated latex concentrate, withdrawn with time. Another reason for an increased powder on NRL
758 67 Occupational Allergy to Natural Rubber Latex (NRL)
gloves was the cost for removing it through repeated such as avocado, banana, chestnut, kiwi, peach, tomato,
washing; therefore many cheap gloves had a large powder potato, and bell pepper, have been associated with
concentration. An increasing environmental pressure to this syndrome (Wagner and Breiteneder 2002; Kujala
reduce use of polyvinyl chloride (PVC) gloves because 1999).
they are hardly biodegradable in landfills and might pose
a hazard when burned in incinerators also developed
during the 1990s. 5.2 Time Between Start of Work and First
There is not just a single NRL-allergen. A range of Symptoms of NRL Allergy
major and minor latex allergens have been identified,
among them are Hev b 1, Hev b 3, Hev b 5, Hev b 6.01, The interval between the start of work and first symptoms
Hev b 6.02, Hev b 8, Hev b 9, and Hev b 11. Hev b 6.02 and onset of OA dropped significantly in health care workers
seems to be the most important allergen for health care starting work between 1986 and 1993 (> Fig. 67.4). The age
workers. In children with spina bifida and other patients of the subjects at the start of work was comparable. The
with NRL-allergy, there is a positive and significant self-reported first symptoms were urticaria in 39 (56%)
correlation between sensitization to Hev b 5 and the subjects, urticaria combined with other symptoms in
number of surgical interventions (Lopes et al. 2004; 8 (11%) subjects, rhinitis or asthmatic symptoms in 16
Sanz et al. 2006). (23%) subjects, and solitary conjunctivitis in one subject.
Approximately 30–50% of individuals who are aller- Of the 70 subjects with a confirmed occupational NRL
gic to natural rubber latex (NRL) show an associated allergy, only 3 (4%) reported signs of a bronchial obstruc-
hypersensitivity to some plant-derived foods, especially tion among their first allergic symptoms. There was also
freshly consumed fruits. This association of latex allergy a significant reduction in time between start of work and
and allergy to plant-derived foods is called latex- first symptoms of the respiratory tract. No difference in
fruit syndrome. An increasing number of plant sources, latency time could be found when comparing atopy
132
120 First symptoms
108 Occupational asthma
Duration to symptoms [months]
96
84
72
60
48
36
24
12
0
86/87 88/89 90/91 92/93
Start of work between:
. Fig. 67.3
Interval between start of work and first NRL allergy symptoms and occupational asthma in 70 HCWs who began work
between 1986 and 1993 (P
Occupational Allergy to Natural Rubber Latex (NRL) 67 759
(according to SPT or history) and self-reported symptoms In 1986, 48.5% of all surgical and examination gloves
of hand eczema among the three groups or when comparing purchased were made from NRL. Of the 217 million gloves,
them separately. There was also no correlation between the 19.5% were surgical and 80.5% examination gloves. The
duration of NRL-exposure and the concentration of latex- number of purchased examination gloves increased by
specific IgE-antibodies (> Fig. 67.3) (Allmers et al. 1998). 957% between 1986 and 2007. The acquisition of surgical
gloves only increased 58% during the same time period.
Overall the total number of gloves used reached 1.9 billion
5.3 Glove Use and Relevance of Airborne in 2007, an increase of 737% from 1986. Only 4% of surgical
Exposure gloves were made from non-NRL materials (> Fig. 67.9).
The main non-NRL materials for non-sterile examination
Turjanmaa et al. in Finland reported cessation or declines gloves (1.8 billion) were vinyl (6%), neoprene/nitrile
in sensitization following changes in powder and/or (5.2%), and poly-ethylene (0.4%). Only in the section of
allergen levels in gloves in hospitals. It was possible to sterile examination gloves (26.6 million) more non-NRL
show that by switching to powder-free NRL gloves detect- material, mostly co-polymer (72.3%) than NRL gloves
able NRL aeroallergens were completely removed in (27.5%), was used. In 2007, 87.9% of all gloves used
a health care facility. Sensitized health care workers were in German hospitals were made from NRL, an increase
able to remain at work when supplied with NRL-free of >80% from 1986. Approximately 1% of NRL gloves
gloves, thus showing that these simple and practical mea- being used were powdered in 2007.
sures led to a successful secondary prevention of NRL The incidence of suspected occupational allergy cases
allergy in HCWs. The increased adherence to rules and caused by NRL rose until 1997 (OA) and 1998 (skin
technical regulations prohibiting the use of powdered allergies). By 2005, there was an 87% decrease of new
NRL gloves has led to a decrease of new cases of type-I skin allergy cases and a 95% reduction of reported new
allergic diseases (asthma and urticaria) in health care cases of OA (> Fig. 67.10). There was a positive linear
personnel. correlation between the declining purchase of powdered
The number of purchased non-sterile examination NRL examination gloves and the reduction in new
NRL gloves increased by 2,426% between 1986 and 2007 suspected occupational allergy cases.
reaching almost 1.7 billion per year. In contrast the num- Substitution of powdered NRL gloves with powder-
ber of purchased surgical NRL gloves only rose by 56% in free NRL gloves or gloves not containing NRL is
the same period (> Fig. 67.8). a useful device in reducing NRL aeroallergen loads
. Fig. 67.4
Face, flow-volume-loop, and spirometric data of dental assistant before and after challenge test with ADP, cornstarch,
powder-free, and powdered NRL gloves. Baseline: pre-exposure (FEV1: 2.9 L = 100% (baseline))
760 67 Occupational Allergy to Natural Rubber Latex (NRL)
. Fig. 67.5
Face, flow-volume-loop, and spirometric data of dental assistant before and after challenge test with ADP, cornstarch,
powder-free, and powdered NRL gloves. Negative control: cornstarch ADP 30 min exposure (FEV1: 2.9 L = 100%)
. Fig. 67.6
Face, flow-volume-loop, and spirometric data of dental assistant before and after challenge test with ADP, cornstarch,
powder-free, and powdered NRL gloves. Negative control 10 pair powder-free NRL gloves 30 min exposure (FEV1: 2.9
L = 100%)
below the assay detection limit within 24 h. Stopping aeroallergens, the use of powder-free NRL gloves is
exposure to NRL aeroallergen leads to a decrease of a sufficient measure.
specific IgE-antibody levels in sensitized individuals The glove use data indicate that there is a dose–
(> Fig. 67.11). response curve between the amount of airborne allergen
NRL allergen load adhering to clothing does not seem in the workplace and the number of people developing
to cause a significant atmospheric contamination. To pre- allergic symptoms as well as the time between exposure
vent detectable atmospheric contamination with NRL and development of first symptoms.Occupational Allergy to Natural Rubber Latex (NRL) 67 761
. Fig. 67.7
Face, flow-volume-loop, and spirometric data of dental assistant before and after challenge test with ADP, cornstarch,
powder-free, and powdered NRL gloves. Verum exposure: one pair of powdered NRL gloves 20 min exposure. Note urticaria
between the eyes and on the glabella (Coughing artefacts clearly visible, FEV1: 2.3 L = 79%)
1.600.000
powdered exam gloves
1.400.000
Purchased NRL gloves [x 1,000]
powder-free exam gloves
1.200.000 powdered surgical gloves
1.000.000 powder-free surgical gloves
800.000
600.000
400.000
200.000
0
86
8
90
92
94
6
8
00
02
04
06
8
9
9
19
19
19
19
19
19
19
20
20
20
20
. Fig. 67.8
Purchase of surgical and examination NRL gloves in all German acute care hospitals from 1986 until 2007 (Reprinted from
Allmers et al. 2004, Copyright (2004), with permission from Elsevier)
The following points suggest that inhalation of NRL- 2. The continuous inhalative contact to NRL-allergens
allergens is the major cause of sensitization: during a work shift.
3. The decrease of new cases of NRL-sensitization when
1. The amount of gloves used in the health care field and
only powder-free gloves were used.
the total powder they release.762 67 Occupational Allergy to Natural Rubber Latex (NRL)
2500000 55
all gloves
50
all examination gloves
2000000
% of gloves without NRL 45
Number of gloves x 1,000
40
% without NRL
1500000
35
30
1000000
25
20
500000
15
0 10
86
87
88
89
90
91
92
93
94
95
96
97
98
99
00
01
02
03
04
05
06
07
19
19
19
19
19
19
19
19
19
19
19
19
19
19
20
20
20
20
20
20
20
20
Year
. Fig. 67.9
Increase of glove use and decrease of non-NRL glove material from 1986 to 2007
1.600.000 0,7
Quantity of purchased NRL-examination glove
Powdered gloves Incidence of suspected NRL-allergy cases pe
1.400.000 Powder-free gloves 0,6
Occupational asthma
1.200.000 Contact urticaria 0,5
1.000.000
1,000 HCWs
0,4
[x 1000]
800.000
0,3
600.000
0,2
400.000
200.000 0,1
0 0
91
92
93
94
95
96
97
98
99
00
01
02
03
04
05
19
19
19
19
19
19
19
19
19
20
20
20
20
20
20
. Fig. 67.10
Purchase of non-sterile NRL examination gloves in all German acute care hospitals plus incidence of suspected cases of NRL-
induced occupational asthma and contact urticaria per 1,000 insured health care workers in private and church-run acute
care hospitals from 1996 to 2005 (Reprinted from Allmers et al. 2002, 2004, Copyright (2002), (2004), with permission from
Elsevier)Occupational Allergy to Natural Rubber Latex (NRL) 67 763
40
Test dates:
Concentration of NRL-spec. IgE-antibodies [kU/L] 2.-5. September 1996
35
Intervention 15. Sept. 1996
28.-29. April 1997
30 9.-11. September 1997
15
10
5
F C E H A G B
Subjects
. Fig. 67.11
Concentration of NRL-specific IgE-antibodies in seven subjects exposed to aerogen NRL allergens before and 12 months
after the end of exposure. IgE decrease during 12 months without exposure is highly significant as determined by using the
two-sided Page test (P764 67 Occupational Allergy to Natural Rubber Latex (NRL)
a test with 10 pair of powder-free NRL-gloves over with a peak of 378 cases newly reported in 1998. By 2005,
a period of 30 min as an additional control. The verum only 38 new cases were reported, a decrease of 90%. The
challenge starts with one pair of powdered NRL gloves for cumulative costs during that period amounted to 8.1
a maximum of 20 min and if no significant allergic million € with a peak of 1.14 million € in 2000. The cost
response of the upper or lower respiratory tract occurs, per reported suspected OA case was 4,531 € for the 10-year
an additional 10 pair of powdered NRL gloves for period. In 2005, the BGW spent 0.58 million € for all NRL-
a maximum of 40 min are used. So far no subject has allergy OA cases (including suspected cases), a decrease of
had a rhinitic or asthmatic reaction when challenged with 50%. In 2001, costs for NRL-allergy cases amounted to
10 pair of powder-free NRL gloves (> Figs. 67.4–67.7). 15.4% of complete costs for all OA cases caused by aller-
gens within the BGW; in 2005 this figure came down to
7.6% (> Fig. 67.12).
7 Costs of Occupational Allergies to From 1996 to 2005, a total of 4,293 suspected cases of
Natural Rubber NRL-caused skin diseases were reported with a peak of 884
cases newly reported in 1998. By 2005, only 115 new cases
The Berufsgenossenschaft für Gesundheitsdienst und were reported, a decrease of 87%. The cumulative costs
Wohlfahrtspflege (BGW) is the statutory accident insurer during that period amounted to 12.3 million € with a peak
for non-state institutions in the health and welfare services of 1.8 million € in 2000. In 2005, the BGW spent 1.34
in Germany. All private physicians’ and dentists’ offices as million € for all NRL-allergy skin cases (including
well as all private and church-run hospitals (nearly 60% of suspected cases), a decrease of 27%. The cost per reported
all German hospitals with almost half of all hospital staff) suspected skin disease case was 2,859 € for the 10-year
are insured by the BGW. Financial data for the evaluation period. In 2001, costs for NRL-allergy cases amounted to
of suspected cases of NRL-caused OA and skin diseases as 5.6% of the total costs for all skin disease cases within the
well as compensation and treatment costs for HCWs con- BGW; in 2005 this figure came down to 4.3%.
firmed to be NRL-allergic were available for the 10-year (> Fig. 67.13) The costs for evaluating, treating, and com-
period from 1996 to 2005. Total evaluation, treatment, pensating HCWs with NRL-allergy has also decreased
and compensation cost data for all cases of OA and skin since 2000 by a cumulative amount of 1.87 million € for
diseases were also available. From 1996 to 2005, a total of skin disease cases and 1.5 million € for OA cases
1,806 suspected cases of NRL-caused OA were reported (> Fig. 67.14).
2.000.000 € 900
Occupational asthma Compensation
1.800.000 € Confirmed cases 800
Suspected cases
1.600.000 € 700
1.400.000 € 600
Compensation (€)
Cumulative cost 1996-2005 = 8.1 million €
1.200.000 € 500
Cases
100% 100%
1.000.000 € 400
800.000 € 300
600.000 € 200
100%
50%
400.000 € 100
10.1%
200.000 € 11.5% 0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Year
. Fig. 67.12
Cost of evaluation, compensation, and treatment of NRL-caused occupational asthma (OA) as well as suspected and
confirmed cases of NRL-caused OA in BGW insured HCWs for the 10-year period from 1996 to 2005Occupational Allergy to Natural Rubber Latex (NRL) 67 765
2.000.000 € 900
100% Compensation
1.800.000 € Suspected cases 800
100% Confirmed cases
1.600.000 € 700
1.400.000 € 600
Compensation (€)
73.1%
1.200.000 € 500
Cases
Cumulative cost 1996-2005=12.3 million €
1.000.000 € 400
800.000 € 300
600.000 € 200
17%
400.000 € 100
Occupational dermatitis 13%
200.000 € 0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Year
. Fig. 67.13
Cost of evaluation, compensation, and treatment of NRL-caused skin disease as well as suspected and confirmed cases of
NRL-caused skin disease in BGW insured HCWs for the 10-year period from 1996 to 2005
3.200.000 1.400
100% Compensation
Suspected cases
2.700.000 Confirmed cases 1.200
100%
1.000
Compensation (€)
2.200.000
800
Cases
64.6%
1.700.000
Cumulative cost 1996-2005=20.5 million € 600
1.200.000
400
12.1%
700.000 200
all occupational type-I allergies to NRL 15.2%
200.000 0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Year
. Fig. 67.14
Cost of evaluation, compensation, and treatment of all NRL-caused allergic diseases as well as suspected and confirmed
cases of NRL-caused OA and skin disease in BGW insured HCWs for the 10-year period from 1996 to 2005
Recommendations to use powder-free, low- 8 Therapeutic Options
protein NRL gloves or non-NRL gloves have been
made, e.g., by the Occupational Safety & Health 8.1 Symptomatic Therapy
Administration (OSHA) in the USA and other orga-
nizations in the UK, Australia, and Scandinavia (Witt Urticaria and itching can be treated by using topic or
1999). systemic anti-histamines. Hay-fever-like symptoms can766 67 Occupational Allergy to Natural Rubber Latex (NRL)
also be treated with anti-histamines in nasal sprays or References
eye drops. Asthma attacks can be treated with rapid
acting ß2-agonists. Severely allergic individuals should Allmers H, Brehler R, Chen Z, Raulf-Heimsoth M, Fels H, Baur X (1998)
carry an epinephrine autoinjector to treat systemic Reduction of latex aeroallergens and latex-specific IgE antibodies in
sensitized workers after removal of powdered natural rubber latex
anaphylaxis.
gloves in a hospital. J Allergy Clin Immunol 102:841–846
Allmers H, Schmengler J, Skudlik C (2002) Primary prevention of natural
rubber latex allergy in the German health care system through edu-
cation and intervention. J Allergy Clin Immunol 110:318–323
8.2 Immunotherapy in NRL-Allergy Allmers H, Schmengler J, John SM (2004) Declining incidence of occu-
pational contact urticaria caused by natural rubber latex allergy in
There have been some trials using immunotherapy to treat German healthcare workers. J Allergy Clin Immunol 114:347–351
NRL-allergy. Due to the effectiveness of allergen avoidance Baur X, Jäger D (1990) Airborne antigens from latex gloves. Lancet
335:912
and observed severe side effects, immunotherapy is not
Baur X, Chen Z, Allmers H (1998) Can a threshold limit value for natural
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Chevrie K, Annesi-Maesano I (2006) Natural rubber latex allergy
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