Translate this page into:
Natural rubber latex allergy
2 Safdarjung Hospital, New Delhi, India
3 School of Studies in Biotechnology, Jiwaji University, Gwalior, MP, India, India
Arun Kumar Jain
Institute of Pathology (ICMR), Safdarjung Hospital Campus, Ansari Nagar, New Delhi - 110029
|How to cite this article:
Deval R, Ramesh V, Prasad G, Jain AK. Natural rubber latex allergy. Indian J Dermatol Venereol Leprol 2008;74:304-310
AbstractNatural rubber latex (NRL) is a ubiquitous allergen as it is a component of > 40,000 products in everyday life. Latex allergy might be attributed to skin contact or inhalation of latex particles. Latex allergy is an IgE-mediated hypersensitivity to NRL, presenting a wide range of clinical symptoms such as angioedema, swelling, cough, asthma, and anaphylactic reactions. Until 1979, latex allergy appeared only as type IV delayed hypersensitivity; subsequently, the proportion of different allergy types drifted towards type IV contact allergy reactions. Several risk factors for sensitization to NRL are already known and well documented. Some authors have established a positive correlation between a history of multiple surgical interventions, atopy, spina bifida malformation, and latex allergy incidence. We suspect an increase in latex allergy incidence in association with increased atopy and sensitivity to environmental allergens in the industrial population. It is often postulated in literature that the groups of workers at risk for this allergy are essentially workers in the latex industry and healthcare professionals. In this population, direct internal and mucosal contact with NRL medical devices may be the route of sensitization as factors such as the number of procedures and use of NRL materials (catheters and tubes) were associated with increased risk of latex sensitization and allergy.
During the 1980s and the 90s, allergy to natural rubber latex had posed serious concerns, particularly in certain occupational groups exposed to latex allergens. ,,, Natural latex is a milky sap produced by many different plants. However, the latex that is used industrially is derived almost exclusively from the rubber tree, Hevea brasiliensis, which belongs to the family Euphorbaceae. This liquid sap is processed to make many rubber products used in the home as well as at workplaces, such as: balloons, rubber toys, pacifiers, baby-bottle nipples, rubber bands, adhesive tape, bandages, diapers, sanitary pads, condoms, etc. In addition, many medical and dental supplies contain latex including gloves, urinary catheters, dental dams and material used to fill root canals, as well as tourniquets and equipment for resuscitation.
Latex is composed of spherical poly-isoprene droplets coated with a layer of water-soluble proteins.  Natural rubber ( cis -1,4-polyisoprene) is a processed plant product of the commercial rubber tree, Hevea brasiliensis . It contains variable amounts of water-soluble proteins that can be recognized as allergens by the human immune system.  Allergy to latex was first recognized in the late 1970s. Since then, it has become a major health concern as an increasing number of people in the workplace are affected by latex. Healthcare workers exposed to latex gloves or medical products containing latex are especially at risk.
What is Latex Protein Allergy?
Latex concentrate contains about 1% total protein, a small fraction of which remains in the resulting manufactured product as residual extractable protein. This protein material binds to a specific human IgE antibody and has been implicated in severe allergic reactions. By contrast, dry rubber contains very little protein and is therefore much less immunogenic than latex sap.  Latex gloves cause both allergic and nonallergic symptoms to different rubber products as detailed in [Table - 1].
While irritant contact dermatitis and Type IV hypersensitivity have been known for many years Type I hypersensitivity emerged only in the late eighties. It may be worth noting that Type I hypersensitivity is not confined to natural rubber latex (NRL) products. Individuals may initially present with signs and symptoms of contact dermatitis and later with continued exposure, demonstrate potentially more severe signs and symptoms of immediate hypersensitivity mediated by IgE.
Who is at Risk for Latex Protein Allergy?
Latex allergy is reported more frequently among those heavily exposed to NRL products such as: healthcare workers, janitorial staff, hairdressers, and rubber industry workers.  Latex sensitization can occur not only through direct contact of an NRL-containing product with the skin ( e.g ., gloves) but also via mucosal ( e.g ., catheters, condoms) or parenteral routes. One of the most efficient sources of sensitization in a medical or dental environment is via aerosolized latex protein from powdered latex gloves. Powder, which is commonly used as a dry lubricant on disposable latex gloves, is an excellent carrier of allergenic latex proteins.
Individuals who have undergone multiple surgical or dental procedures are also at high risk. Children with neural tube defects (spina bifida, meningomyelocele) also have a high prevalence of latex allergy. , Direct internal or mucosal contact with NRL devices appears to be an important route of sensitization in these patients as well as for those with congenital urologic abnormalities. Lastly, persons with atopy are also at increased risk, along with those with preexisting hand dermatitis.
Signs and Symptoms of Latex Allergy
An immediate allergic reaction may occur within minutes of coming into contact with latex. Symptoms of a reaction include hives, wheezing, coughing, shortness of breath, sneezing, nasal congestion, runny nose, conjunctivitis, nasal, palatal, or ocular itching, urticaria, naso-rhinitis, asthma and hypotension. ,,,, Hives can appear anywhere on the body and not necessarily at the point where direct contact with the latex occurred. Immediate reactions can be life-threatening when blood pressure drops, airways blocked, and the throat closes.  This condition can eventually progress to anaphylaxis. ,,, These symptoms can be exacerbated in certain people when specific foods are ingested due to cross-allergenicity. , A person who comes in contact with latex may sustain a mild allergic reaction. However, when ingesting a cross-reacting food later, new reactions can occur within 5-30 minutes, resulting in itching and irritation of oral tissues, swelling of the lips and tongue, and sometimes papules or blistering of these tissues. 
Other Associated Allergies
Allergy to latex rubber involves sensitization to multiple constituent proteins. Therefore, different groups of patients respond to specific latex proteins in various ways. , These groups of proteins are found in many products including, but not limited to, certain tree pollens, some plants, and (most commonly) fresh fruits. , Fresh fruits that commonly cause hypersensitivity when associated with latex proteins are avocado, banana, celery, chestnut, and pear. Less common are apricot, buckwheat, cherry, fig, grape, kiwi, mango, melon, nectarine, orange, papaya, passion fruit, peach, peanut, pineapple, plum, potato, tomato, and walnut. ,, The problem manifests itself in two ways: (1) the fruit allergy triggers previously undiagnosed recognition of the latex allergy or (2) after years of latex exposure and latex sensitivity, the person develops fruit allergies. Whether this dual latex-fruit sensitivity is determined by common antigens or cross-reacting antigens has yet to be determined. ,
Global Prevalence of Latex Allergy
In recent years, allergy to NRL has emerged as a major allergy among certain occupational groups and patients with underlying diseases such as acquired immune deficiency syndrome (AIDS) and other viral infections. The sensitization and development of latex allergy has been attributed to exposure to products containing residual latex proteins. 
Most epidemiological studies show a sensitization prevalence of around 5-17 and 3.7-8.0% in healthcare and rubber industry workers, respectively. ,,, Sensitization prevalence is 12.5, 18-37 and 34-67% among anesthesiologists,  individuals who have undergone multiple surgical procedures ,, and children with neural defects, respectively. ,, Lastly, persons with atopy (atopic eczema, allergic rhinitis, hay fever, or asthma) are also at notably increased risk along with those with preexisting hand dermatitis.  Reports of immediate hypersensitivity to latex have increased dramatically since the first case was reported by Nutter. 
In 2005, Johar et al ,  investigated the prevalence of latex allergy in a cohort of 24 children suffering from spina bifida in South Africa and found latex sensitization in 16.7% of the cases. Khader et al ,  reported the prevalence of latex (gloves) allergy among healthcare workers in Jordan to be 13.6%.  In the same year, Proietti et al,  studied latex allergy among healthcare workers and observed that 60 subjects were associated with work-related symptoms, and 35 (2.7%) out of these 60 subjects, who were also atopic, had latex allergy. This study confirmed that atopy is an important factor that should be considered as a risk for the development of latex allergy. In an another study in Trieste, Filon and Radman  concluded that unnecessary glove use, the use of non-powdered latex gloves by all healthcare workers, and the use of non-latex gloves by sensitized subjects could restrict the progression of latex symptoms, and could avoid new cases of sensitization.
Natural rubber ( cis -1,4-polyisoprene) is a processed plant product of the commercial rubber tree, Hevea brasiliensis . It contains variable amounts of water-soluble proteins that can be recognized as allergens by the human immune system.  Despite this recognition, latex allergy remains the second most common cause of intra-operative anaphylaxis,  and one in fifty healthcare workers becomes sensitized to latex each year through exposure to latex gloves. , Adverse reactions due to latex products have recently been documented by Huber and Terezhalmy,  and researchers have emphasized its key role in allergenicity. 
Koh et al ,  investigated the amounts of specific allergens found in rubber gloves that cause NRL allergy. They found that NRL allergen levels were high in the majority of examination gloves used by healthcare workers and thus, were more likely to cause NRL allergy among sensitized persons.
Crippa et al ,  investigated latex protein content in different medical devices and devices commonly used in general practice to acquire information for the prevention of latex allergy among healthcare workers and in the general population. A high level of latex protein was found in medical devices such as elastic bandages (81.57%), tourniquets (74.09%), Foley′s urinary catheters (68.35%), Penrose drainage (67.25%) and taping (39.6%), and in common devices, such as rubber inner-soles (84.20%), toy balloons (78.62%), latex mattresses (74.27%), household rubber gloves (49.10%), working gloves (38.25%), and inflatable floating mattresses (32.10%). They concluded that every natural rubber object should be systematically labeled as "containing latex" along with the warning that "this item may cause allergic reactions in sensitized subjects".
In 1998, the United States Food and Drug Administration (FDA) mandated that products that contain latex be labeled as such.  Products can no longer be labeled as "hypoallergenic" because the FDA has received several reports of allergic reactions to medical gloves labeled in this way. The FDA also requires labeling of dry natural rubber although this type of rubber is less allergenic. The FDA ruling also mandates that nonmedical devices that make contact with human skin/tissue such as adhesives used on Band-Aids, also be labeled.
In the last few years, latex allergy has been recognized as a potential medical problem in India. Latex allergy is reported more frequently among those heavily exposed to NRL products such as latex gloves and other medical supplies used by healthcare workers as well as household gloves, elastic bandages, condoms, envelop adhesive, rubber bands, infants′ and children′s bottle nipples etc used by housekeepers, latex industry workers, and food service workers. However, latex allergy has received very little attention in Indian studies as evidenced by the absence of scientific, practical, and systematic data on the subject. Pherwam et al ,  reported latex sensitivity among operation theater personnel in India and found nurses and ward boys to be the most susceptible to sensitization in comparison to surgeons and anesthetists, but the sample size was too small to draw any further conclusions.
Manufacture of Latex
Manufacturers have produced latex gloves for over 100 years and are now aware of the increase in allergic problems due to latex. It is estimated that 2, 50, 000-5,00,000 healthcare workers are now sensitized to latex protein in the US alone. There are more than 30 companies that manufacture gloves and their leaching and washing requirements may be reduced or eliminated. Thus, residual accelerators and water-soluble proteins are not removed from the gloves, which in turn results in sensitization to latex. The composition of the milky white sap that is tapped from the tree is detailed in [Table - 2].
Accurate measurement of the protein in latex medical products is difficult, especially as the chemical additives to the latex interfere in protein estimation assays.  Most of the proteins are water-soluble and readily leach out of the latex, but complete extraction is possible overnight. It is now established the proteins in natural rubber latex and their derivatives are the causes of NRL allergy. The corn starch procedure used for manufacturing of the latex gloves does not itself contain allergenic components, but acts as a carrier for latex proteins. Eleven latex proteins have been registered as latex allergens by WHO.
Diagnosis of Latex Allergy
Preparation of latex allergens from glovesLatex medical gloves are obtained commercially. Pieces of gloves of different brands are extracted in phosphate buffered saline (PBS) at pH 7.2 at room temperature for one hour with continuous stirring.  However, overnight extraction at 4° C is preferred for complete extraction. The antigen is prepared in a w/v (weight/volume) ratio of the raw material and the phosphate buffered saline. The resulting extract is centrifuged to remove any particulate contamination to give clear test extracts. The supernatant is dialyzed against distilled water with frequent changes followed by centrifugation, and then lyophilized after filtration through a sterile 0.22 mm filter (Millipore ® ).
Skin prick test (SPT)
Skin prick tests are performed to diagnose latex allergy and subsequent confirmation is done by in vitro methods for latex-specific IgE antibodies in patients′ sera of patients. Allergenicity can be assessed semiquantitatively with the help of a skin prick test (SPT) as the size of the reaction is dependent on and directly proportional to the quantity of allergens to which the patient has IgE antibodies. SPT is an ideal test from a biological point of view, but this approach cannot be used routinely as a test for monitoring allergen content in latex gloves due to ethical constraints. SPT is performed on latex users with latex antigen reconstituted in 50% glycerinated PBS buffer, to identify possible sensitization patterns from latex. Histamine (1 mg/mL) and phosphate buffered Saline (PBS) are used as positive and negative controls, respectively. The reaction is read after 15-20 minutes and grading is done according to the standard criteria. 
Nutter  was probably the first to describe a positive skin test to latex and used 5% of natural latex which had been extracted over a period of 24 hours. Later on, Turjanmaa et al ,  were the first to show that extracts of latex gloves can cause positive skin prick test (SPT) reactions in patients who are allergic to NRL.
Intradermal test (ID test)This test is performed on the volar surface of both the arms by injecting allergen extracts intradermally using sterilized or disposable tuberculin syringes fitted with 26 Gauge fine needles, producing intradermal blebs that are about 3 mm in diameter. The size of the reaction is less dependent on the amount introduced than on the concentration of the allergen extract. A weal reaction less than 5 mm in diameter is regarded as a negative reaction. Buffered saline is used as a negative control and histamine phosphate (1:10,000) as a positive control. Individual test sites are 5 cm apart from each other, the tests are read after 15-20 minutes and grading is done according to standard criteria. 
In vitro laboratory tests
The quantification of latex-specific serum IgE is carried out by using the ELISA technique. The antigen is coated onto the polypropylene plates and serum containing specific IgE against latex antigen is added Detection is done by adding anti-human IgE secondary antibody-streptavidin peroxidase conjugate.
There are many substances in rubber that can cause delayed type IV response and patch testing may be necessary to confirm the skin reaction. Also, immediate and delayed reactions may occur in the same subject. 
Contact testThis test is performed when immunoassay test results are negative, but the history of symptoms is compelling. A fingertip is cut from a latex glove, dampened with water, and placed on the person′s finger for 15 minutes. A positive test results in urticaria with itching or erythema. If no reaction occurs, placing an entire dampened glove on the hand for 15 minutes or until a reaction occurs is considered to be safe. ,,
Avoidance and Education
Programming and educationEducation is very important in controlling allergic reactions and starts with the latex-sensitive individual. The person who is diagnosed with latex sensitivity needs to be educated on the condition and should understand prevention and avoidance techniques.  The second level of education is for the individual to notify his or her employer of the condition so that latex-free alternatives can be made available. ,, The third level of education involves the employer; employers must establish policies and procedures to ensure the safety of the latex-sensitive person. All other employees must be informed of practices to prevent exposure of the sensitive individual to latex and to recognize the signs and symptoms of an allergic reaction.  Employers also need to conduct worksite evaluations to identify areas posing potential problems. 
To help reduce the occurrence of latex allergies among healthcare workers and patients, the American College of Allergy, Asthma, and Immunology has established new practice guidelines: 
- Develop educational programs to promote awareness of the allergy.
- Encourage manufacturers of latex products to label them accurately.
- Fund projects to develop adequate alternatives to rubber products.
- Establish standards for the maximum level of allergens permitted in latex gloves.
- Develop an improved and more time-efficient method for the diagnosis of latex allergies.
There should be more publicity and time spent understanding latex allergies within the educational framework. The employer should conduct in-service training for athletic education and associated personnel (teachers, coaches, etc) responsible for administering first aid. Information sessions for athletes and parents concerning the possibility of latex sensitivity should also be provided. This will help increase the awareness of potential latex sensitivity with product use.
Patients who are known to be allergic should avoid any product that might contain latex until the latex content is determined by contacting the manufacturer. Even products labeled "safe latex" (which indicates lower proportions of natural latex) can cause latex allergy. There is no safe latex for latex allergy sufferers.
Although medications are available to reduce the symptoms of latex allergy, no cure for latex allergy exists. Type I reactions are treated as any other systemic allergic reaction. The cornerstones of treatment are epinephrine and antihistamines (H1 antagonists); systemic corticosteroids and H2 blockers may be useful. Type IV reactions (localized contact dermatitis) can be treated with topical steroids along with patient education to avoid further exposures.
Alternatives to Latex
Avoidance of the provoking agent (latex allergen) is the most effective way to manage any allergy. Latex-free synthetic rubber such as neoprene, nitrile, styrene butadiene rubber (SBR), butyl and vitron are polymers that are available as alternatives to natural rubber. There are no naturally occurring proteins in them and they are not responsible for latex allergy. Labeling is extremely important, but mandatory labeling is currently not required by law.
Several websites offer information on latex allergies, including current clinical management and prevention of allergic disorders. Answers to frequently asked questions, educational resources, and alternative products are available. 
- American Academy of Allergy Asthma and Immunology (AAAAI), http://www.aaaai.org.
- American Association of Nurse Anesthetists (AANA), http://www.aana.com/crna/prof/latex.asp.
- American College of Allergy, Asthma, and Immunology (ACAI), http://allergy.mcg.edu/physicians/ltxhome.html.
- American Latex Allergy Association and A.L.E.R.T., Inc, http://www.latexallergyresources.org.
- Latex Allergy Information Resource (LAIR), http://www.anesth.com/lair/lair.html.
- National Institute for Occupational Safety and Health (NIOSH), http://cdc.gov/niosh/latexpg.html.
- National Latex Allergy Network (NLAN), http://www.latex-allergy.org.
- Occupational Safety and Health Administration (OSHA), http://www.osha-slc.gov/SLTC/latexallergy/index.html.
- The Allergy Report,theallergyreport.org.
Slater J. Rubber anaphylaxis. N Engl J Med 1989;17:1126-30.[Google Scholar]
Sussman G, Tarlo S, Dolovich J. The spectrum of IgE-mediated responses to latex. JAMA 1991;265:2844-7.[Google Scholar]
Kurup VP, Wagner S, Breiteneder H. Hevea brasiliensis latex allergens. Can J Allergy Clin Immunol 2000;5:341-7.[Google Scholar]
Kurup VP, Fink JN. The spectrum of immunologic sensitization in latex allergy. Allergy 2001;56:2-12.[Google Scholar]
Slater JE. Allergic reactions to natural rubber. Ann Allergy 1992;68:203-11.[Google Scholar]
Wilkinson SM, Beck MH. Allergic contact dermatitis from latex rubber. Dermatology 1996;134;910-14.[Google Scholar]
McFadden ER. Natural rubber latex sensitivity seminar: Conference summary. J Allergy Clin Immunol 2002;110:137-40.[Google Scholar]
Garabrant DH, Schweitzer S. Epidemiology of latex sensitization and allergies in health care workers. J Allergy Clin Immunol 2002;110:82-95.[Google Scholar]
Hepner DL, Castells MC. Latex allergy: An update. Anesth Analg 2003;96:1219-29.[Google Scholar]
Sparta G, Kemper MJ, Gerber AC. Latex allergy in children with urological malformation and chronic renal failure. J Urol 2004;171:1647-9.[Google Scholar]
Warpinski JR, Folgert J, Cohen M, Bush RK. Allergic reaction to latex:a risk factor for unsuspected anaphylaxis. Allergy Proc 1991;12:95-102.[Google Scholar]
Oei HD, Tjiook SB, Chang KC. Anaphylaxis due to latex allergy. Allergy Proc 1992;13:121-2.[Google Scholar]
Moneret-Vautrin DA, Debra JC, Kohler C. Occupational rhinitis and asthma to latex. Rhinology 1994;32:198-202.[Google Scholar]
Thomas CL, editors. Taber's cyclopedic medical dictionary. 18th ed. Philadelphia, PA: FA Davis; 1997.[Google Scholar]
Zuskin E, Mustajbegovic J, Kanceljak B, Schachter EN, Macan J, Budak A. Respiratory function and immunological status in workers employed in a latex glove manufacturing plant. Am J Ind Med 1998;33:175-81.[Google Scholar]
Stewart CM. Allergic to latex? RDH 1996;16:22-7.[Google Scholar]
Weesner BW Jr. Latex allergies and adverse reactions:a review of the literature. J Tenn Dent Assoc 1997;77:21-6.[Google Scholar]
Warner L. Latex allergy: Policy, procedure, and latex-safe box. J Emerg Nurs 1997;23:139-41.[Google Scholar]
Gliniecki CM. Management of latex reactions in the occupational setting. AAOHN J 1998;46:82-93.[Google Scholar]
Wickware P. Latex allergy poses threat to patients, practitioners. Dermatol Times 2000;21:16.[Google Scholar]
Ownby DR. Mechanisms in adverse reactions to food: The whole body. Allergy 1995;50:26-30.[Google Scholar]
Brehler R, Theissen U, Mohr C, Luger T. ''Latex-fruit syndrome'': Frequency of cross-reacting IgE antibodies. Allergy 1997;52:404-10.[Google Scholar]
Vickerstaff-Joneja JM. Oral allergy syndrome, cross-reacting allergens and co-occurring allergies. J Nutr Environ Med 1999;9:289-304.[Google Scholar]
Freeman GL. Cooccurrence of latex and fruit allergies. Allergy Asthma Proc 1997;18:85-8.[Google Scholar]
Frankland AW. Latex allergy. J Nutr Environ Med 1999;9:313-22.[Google Scholar]
Fuchs T, Spitzauer S, Vente C. Natural latex, grass pollen, and weed pollen share IgE epitopes. J Allergy Clin Immunol 1997;100:356-64.[Google Scholar]
Savonius B, Kanerva L. Anaphalaxis caused by banana. Allergy 1993;48:215-6.[Google Scholar]
Theissen U, Theissen JL, Mertes N, Brehler R. IgE-mediated hypersensitivity to latex in childhood. Allergy 1997;52:665-9.[Google Scholar]
Kurup VP, Sussman GL, Yeang HY, Elms N, Breiteneder H, Arif SA, et al . Specific IgE response to purified and recombinant allergens in latex allergy. Clin Mol Allergy 2005;10:3-11.[Google Scholar]
Turjanmaa K. Incidence of immediate allergy to latex gloves in hospital personnel. Contact Dermatitis 1987;17:270-5.[Google Scholar]
Lagier F, Vervloet D, Lhermet I, Poyen D, Charpin D. Prevalence of latex allergy in operating room nurses. J Allergy Clin Immunol 1992;90:319-22.[Google Scholar]
Sussman G, Gold M. Guidelines for the management of latex allergies and safe latex use in health care facilities. AORN J 1997;66:726,729-31.[Google Scholar]
Gautrin D, Ghezzo H, Infante-Rivard C, Malo JL. Incidence and determinants of IgE-mediated sensitization in apprentices. Am J Resp Crit Care Med 2000;162:1222-8.[Google Scholar]
Tarlo SM, Wong L, Roos J, Booth N. Occupational asthma caused by latex in a surgical glove manufacturing plant. J Allergy Clin Immunol 1990;85:626-31.[Google Scholar]
Brown RH, Schauble JF, Hamilton RG. Prevalence of latex allergy among anesthesiologists: Identification of sensitized but asymptomatic individuals. Anesthesiology 1998;89:292-9.[Google Scholar]
Gerber AC, Jorg W, Zbinden S, Seger RA, Dangel PH. Severe intraoperative anaphylaxis to surgical gloves: Latex allergy, an unfamiliar condition. Anesthesiology 1989;71:800-2.[Google Scholar]
Meeropol E, Frost J, Pugh L, Roberts J, Ogden JA. Latex allergy in children with mlelodysplasis: A survey of Shriners Hospitals. J Pediatr Orthop 1993;13:1-4.[Google Scholar]
Tosi L, Slater J, Shaer C, Mostello L. Latex allergy in spina bifida patients: Prevalence and surgical implications. J Pediatr Orthop 1993;13:709-12.[Google Scholar]
Michel T, Niggemann B, Moers A, Seidel U, Wahn U, Scheffner D. Risk factor for latex allergy in patients with spinabifida. Clin Exp Allergy 1996;26:934-9.[Google Scholar]
Proietti L, Gueli G, La Rocca G, Bonanno G, Vasta N, Bella R, Barbagallo S. Medicina Interna e Patologie Sistemiche: Latex allergy prevalence and atopy in 1300 health care workers. Recenti Prog Med 2005;10:478-82.[Google Scholar]
Nutter AF. Contact Urticaria to Rubber. Br J Dermatol 1979;101:597-602.[Google Scholar]
Johar A, Lim DL, Arif SA, Hawarden D, Toit GD, Weinberg EG, et al . Low prevalence of latex sensitivity in South African spina bifida children in Cape Town. Pediatr Allergy Immunol 2005;16:165-70.[Google Scholar]
Khader Y, Abu-Zaghlan M, Abu-Al Rish I, Burgan S, Amarin Z. Self-reported allergy to latex gloves among health care workers in Jordan. Contact Dermatitis 2005;6:339-43.[Google Scholar]
Filon FL, Radman G. Latex allergy: A follow up study of 1040 healthcare workers. Occup Environ Med 2006;63:121-5.[Google Scholar]
Mertes PM, Laxenaire MC, Alla F. Anaphylactic and anaphylactoid reactions occurring during anesthesia in France in 1999-2000. Anesthesiology 2003;99:536-45.[Google Scholar]
Kantor GK. Layex Allergy Review. Publishing Hoboken NJ; 2004. p. 1-52.[Google Scholar]
Huber MA, Terezhalmy GT. Adverse reactions to latex products: Preventive and therapeutic strategies. J Contemp Dent Pract 2006;15:97-106.[Google Scholar]
Reines HD, Seifert PC. Patient safety: Latex allergy. Surg Clin North Am 2005;85:1329-40.[Google Scholar]
Koh D, Ng V, Leow YH, Goh CL. A study of natural rubber latex allergens in gloves used by healthcare workers in Singapore. Br J Dermatol 2005;153:954-9.[Google Scholar]
Crippa M, Belleri L, Mistrello G, Tedoldi C, Alessio L. Prevention of latex allergy among health care workers and in the general population: Latex protein content in devices commonly used in hospitals and general practice. Int Arch Occup Environ Health 2006;9:1-8.[Google Scholar]
Hubbard WK. Department of Health and Human Services. Food and Drug Administration: Natural rubber-containing medical devices user labeling. Fed Reg 1997;62:189.[Google Scholar]
Pherwam AV, Kurkal P, Trpathi DM, Bhutani M. The incidence of latex sensitivity amongst operation theatre personnel. Ind J Alergy Appl Immunol 2000;14:11-4.[Google Scholar]
Beezhold DH. Measurement of latex protein by chemical and immunological methods. Proceedings of "Latex Protein Allergy: the present position", Amsterdam: 1993. p. 25.[Google Scholar]
Sutherland MF, Drew JM, Rolland JE, Slater C, Suphioglu RE, O'Hehir. Specific monoclonal antibodies and human immunoglobulin E show that Hev b 5 is an abundant allergen in high protein powdered latex gloves. Clin Exp Allergy 2002;32:583.[Google Scholar]
Singh AB, Malik P, Prakash D, Gupta CK. Biological Standardization of pollen allergens from India. Asia Pac J Allergy Immunol 1992;10:103-9.[Google Scholar]
Turjanmaa K, Reunala T, Rasanen L. Comparison of diagnostic methods in latex surgical glove contact urticaria. Contact Dermatitis 1988;19:241-7.[Google Scholar]
Hadjiliadis D, Banks DE, Tarlo SM. The relationship between latex skin prick test responses and clinical allergic responses. J Allergy Clin Immunol 1996;97:1202-6.[Google Scholar]
Ebo DG, Stevens WJ, Bridts CH, De Clerck LS. Latex-specific IgE, skin testing, and lymphocyte transformation to latex in latex allergy. J Allergy Clin Immunol 1997;100:618-23.[Google Scholar]
Kim KT, Safadi GS, Sheikh KM. Diagnostic evaluation of type I latex allergy. Ann Allergy Asthma Immunol 1998;80:66-70.[Google Scholar]
Van Ketal WG. Contact dermatitis from rubber gloves after dermatitis from thiurams. Contact Dermatitis 1984;11:32-7.[Google Scholar]
Kellett PB. Latex allergy: A review. J Emerg Nurs 1997;23:27-36.[Google Scholar]
Marais GI, Fletcher JM, Potter PC. In vivo and vitro in diagnosis of latex allergy at Groote Schuur Hospital. S Afr Med J 1997;87:1004-8.[Google Scholar]
Jack M. Latex allergies: A new infection control issue. Can J Infect Control 1994;9:67-70.[Google Scholar]
Muller BA, Steelman VM, Hartley PG, Casale TB. An approach to managing latex allergy in the health care worker. J Environ Health 1998;61:8-18.[Google Scholar]
Zak HN, Kaste LM, Schwarzenberger K, Barry MJ, Galbraith GM. Health care workers and latex allergy. Arch Environ Health 2000;55:336-46.[Google Scholar]
Hammer AL, Paulson PR. Latex allergy: Implementation of an agency program. Gastroenterol Nurs 1997;20:156-61.[Google Scholar]
Anonymous. On-line resources about latex allergies. Nursing 2001;31:10-1.[Google Scholar]