St. Clair Hunte, BSc (Hons), RGN, DPNS, PGCE.
Clinical Nurse Procurement Manager at Bradford Teaching Hospital NHS Foundation Trust
The use of gloves is now a fundamental part of health care. Despite the problems associated with natural rubber latex (NRL), it remains the preferred material for glove manufacture. Since the mid-1980s the use of gloves as an element of personal protective equipment has become an everyday part of clinical practice (Pratt et al, 2000). The use of gloves plays a key role in reducing the transmission of micro-organisms between health-care workers and patients, and vice versa. Gloves also help prevent the exposure of skin to chemicals, hazardous drugs and various cleaning agents.
This review explores the criteria that must be considered when selecting gloves for clinical use. The issue of NRL allergy is highlighted with the various alternatives to NRL explored.
The use of gloves is largely determined by local policy and the procedure in question. Local policies and guidelines are usually drawn up in association with the infection control and occupational health departments, in line with national policy.
Guidelines on glove use
- Gloves should be worn where there is a risk of infection
- Wear gloves only when necessary
- Gloves should be worn when in direct contact with blood, body fluids, non-intact skin or mucus membranes
- Do not use powdered gloves in the healthcare arena as the protein allergens in NRL bind to the cornstarch powder and may become airborne (Edlich et al, 2001)
- Gloves should fit correctly as noted by the Health and Safety Executive (1992). (This legislation refers to the fact that personal protective equipment is not suitable if it does not fit correctly)
- Ensure hands are washed thoroughly before donning gloves and as soon as they are removed
- The wearing of gloves is no substitute for good hand hygiene
- Change gloves after every episode of patient care
- Do not wash or use alcohol-based gels or lotions on gloves to reduce usage
- Ensure the correct type of glove is used for the correct procedure.
Health-care workers need to follow local policy/guidelines when using gloves. Guidelines linked to a risk assessment should refer staff to the most appropriate course of action.
A risk assessment (Infection Control Nurses’ Association, 2002) will explore the following:
- The specific nature of the task
- The type of contamination
- Whether the task is sterile or non-sterile
- Whether the patient (or member of staff) has NRL sensitivity
- Types of glove used for various procedures:
- Sterile latex (or a synthetic alternative) surgeons’ gloves - surgical procedures
- Sterile latex (or a synthetic alternative) examination gloves - minor surgery, aseptic procedures with potential of exposure to blood/body fluids, aseptic pharmaceutical preparation
- Non-sterile latex or alternative - non-aseptic procedures, including those involving potential exposure to blood/body fluids, those involving sharps or cytotoxic material and those which may pull twist or stretch the gloves
- Vinyl non-sterile gloves - short, non-aseptic procedures, those with a low risk of blood contamination, those which will not pull or twist the glove and cleaning with detergent
- Polythene non-sterile - food preparation and handling.
Natural rubber latex gloves
NRL gloves have been the dominant choice of health-care workers for many years as they provide some of the protection noted above. The nature of the material lends itself to a fit, which provides comfort for the user and allows the maintenance of fine hand movement.
Allergy to NRL products is a significant cause of occupational asthma and contact dermatitis in the UK. Some 17% of health-care workers are known to have been sensitised to NRL: the NHS is the largest market for latex gloves and of other NRL-containing medical products (Nielsen et al, 2000).
What is NRL?
NRL can be defined as a watery suspension of small polymeric particles. From a botanical perspective latex is used as a synonym for natural rubber latex. It is derived from the Hevea brasiliensis tree, which is widely grown in South East Asia. Latex is composed of approximately 34% rubber polymer, 2% protein molecules, 60% aqua with the remainder comprising resins, sugar, ash and fatty acids (Mellstrom, 1994).
To turn the NRL into a glove it undergoes several complex manufacturing processes. To aid vulcanisation and long-term preservation, various chemicals are added. The protein content of the NRL aids elasticity and tensile strength, the two key qualities that make NRL so popular.
Although frequent prolonged use of NRL gloves contributes to allergy induction it is not known exactly why NRL gloves are such potent sensitisers. It is possible that the vulcanisation process changes some NRL protein structures, causing them to increase their allergenicity. This direct relationship between allergen concentration and sensitisation is well documented. Sporik (1999) noted that it is the levels of leachable protein molecules that are the sensitising agent. A reduced level of protein molecules results in a reduction to the risk of developing sensitisation (Turjanmaa et al, 1999). However, consideration should also be given to allergy caused by chemical residues left on the gloves during the manufacturing process.
Types of allergy
There are two distinct types of allergy associated with NRL gloves. They are known as Type I and Type IV allergy. Type I allergy provokes an immediate (or within minutes) reaction and it is mediated by antibodies (IgE). It is more pronounced and potentially more serious, with a risk of anaphylaxis. Other symptoms include urticaria, asthma (or wheeze), and a sudden fall in blood pressure.
In Type IV allergy the reaction may be protracted, occurring up to 48 hours post-contact with the NRL. The reaction is mediated by immune (T) cells. Symptoms are less severe and include itchy skin and a scaly rash.
People/groups at risk of NRL allergy
Baumann (1999) noted that health-care workers and patients who have had repeated surgical interventions are at a significantly higher risk of developing NRL allergy than those from the general population. Those with specific allergies to foods such as bananas, kiwi fruit, and even potatoes were at risk of developing NRL allergy. These cross-reactive allergens occur because the protein chains in the foods noted above and others are very similar to those protein chains identified in NRL.
Identification of high-risk groups
The key to identifying those at risk is to undertake a through history on admission. The following points need to be explored:
- Does the patient have a history of anaphylaxis associated with NRL?
- Has a positive test result for NRL allergy been established?
- Is the patient allergic to specific fruits (cross- reactive allergens)?
- Has the patient undergone repeated catheterisation or surgical intervention?
It is important that information obtained is well documented and that allergy stickers are used to alert staff to positive individuals. There will be a need to ensure that the clinical environment is safe if an allergy-positive patient is identified.
NRL allergy and the law
The Health and Safety at Work Act 1974 places a general duty on employers to keep employees and others (such as patients) healthy and safe. NRL is hazardous to health; therefore to comply with prescribed legal duties employers need to undertake an assessment to eliminate risk.
In 2002 the Control of Substances, Hazards to Health regulations stipulated that health-care environments had to undertake a formal assessment of the use of NRL gloves, with health surveillance records kept for audit purposes. Such activity will help ensure both patients and staff with known NRL allergy can work and be treated in an NRL-free environment.
NRL allergy: implications for health care
The increased use of NRL gloves by health-care workers not only poses a risk to staff but also to patients in the receipt of care given in a NRL contaminated environment. The increased sensitisation of both staff and patients is presently impacting on clinical practice and will have possible legal ramifications (Anon, 2000).
The demand for NRL-free gloves and other products is on the increase, with many companies pushing forward with new technological alternatives, some of which are viable in specific areas of clinical practice. Those involved in the procurement of supplies in health care need to take a proactive approach with manufactures to ensure cost-effective non-NRL alternatives are available in the marketplace before demand outstrips supply.
A process of glove standardisation/rationalisation using a system of critical appraisal will reduce some of the confusion associated with glove use. Such an approach will require the input of an experienced multidisciplinary team (Medical Device Agency, 1996).
Alternatives to NRL gloves
The ideal glove should be:
- Low in extractable proteins (<50ug/g)
- Low in residual chemicals
- Powder free.
Although the use of NRL-free gloves can militate against Type I reaction, a delayed Type IV reaction can still occur because the chemicals used in the manufacture of some NRL alternatives can cause localised inflammation to the contact areas.
Consideration also needs to be given to non-glove-related causes of dermatitis such as soaps or lotions. The causative agent may not actually be the glove, but rather the residual chemical irritants present before donning the glove (Truscott et al, 2003).
To comply with prescribed legal duties, employers need to provide alternatives to NRL. This is a dynamic market with numerous products being developed. The health-care worker must ensure the physical characteristics are compatible with the intended task by consulting the manufacturer’s guidelines. The following is a brief description of some of the alternatives to NRL:
A good quality nitrile glove is a suitable alternative for latex-sensitive staff or an NRL-free environment. Nitrile provides a good biological barrier and is suitable when handling certain chemicals. However, tears in the glove tend to extend quickly once initiated. With increasing numbers of companies producing nitrile gloves prices are falling but they remain a relatively expensive option.
Polythene gloves are generally loose fitting with limited tensile strength. They are not recommended for clinical areas but are useful for handling or preparing food.
Vinyl (synthetic co-polymers)
Vinyl gloves are suitable for non-aseptic procedures and tasks with a low risk of contact with body fluid. They are permeable to blood- borne viruses and are prone to leakage, having low tensile strength.
Polychloroprene has similar physical properties to NRL and is suitable for latex-free environments. They can be used when handling glutaraldehyde and when contact with body fluids is likely. However, there are environmental issues with disposal as hydrogen chloride is released on incineration.
There are other possibilities, such as Tactylon- based gloves. The key for staff and their employers is to keep up to date with the latest product developments and research.
There is no doubt that the use of gloves, in particular NRL gloves, have been pivotal in the reduction of the transmission of infection. However owing to the issues of NRL allergy there is tremendous interest in NRL-free products. Despite this, there is a lower uptake of synthetic gloves than might be expected. The selection and correct use of gloves should be a straightforward process.
Health-care workers need to be able to select a glove, which is appropriate for the intended application of care or task. Both health-care workers and their employer have a responsibility to ensure best practice is achieved. Such action will reduce associated risks for both patient and staff.
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