Latex Allergy

COURSE PRICE: $10.00

CONTACT HOURS: 1

This course will expire or be updated on or before July 1, 2014.

ABOUT THIS COURSE
You must score 70% or better on the test and complete the course evaluation to earn a certificate of completion for this CE activity.

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Wild Iris Medical Education, Inc. is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

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Wild Iris Medical Education, Inc. provides educational activities that are free from bias. The information provided in this course is to be used for educational purposes only. It is not intended as a substitute for professional health care. See our disclosures for more information.


Latex Allergy

By Christine M. Calson, BA, MA

Christine Calson is a freelance writer and high school teacher. The daughter of a Northern California physician, she grew up with an interest in both medicine and education. She pursued the latter by receiving a degree in English and Spanish and embarking on a teaching career that took her to Arizona, Nevada, and eventually back to California. Christine has a Masters in Education and enjoys adapting her teaching knowledge to the medical field as a writer for Wild Iris Medical Education, Inc.

This course is based largely on information from the Centers for Disease Control and Prevention and the website UpToDate.com.

COURSE OBJECTIVE:  The purpose of this course is to provide healthcare workers with information about how to identify, treat, and prevent latex allergy.

LEARNING OBJECTIVES

Upon completion of this course, you will be able to:

  • Define latex allergy and describe its epidemiology.
  • Identify the symptoms of latex allergy and its related conditions.
  • Explain treatment options for latex allergy.
  • Discuss how to use latex or alternative products safely in the workplace to minimize/prevent latex allergy.

WHAT IS LATEX ALLERGY?

Latex allergy is an IgE-mediated sensitization to naturally occurring proteins found in latex, a kind of rubber harvested from the Hevea brasilensis (Hev b) tree. For people susceptible to latex allergy, the proteins in the rubber can cause a reaction within minutes of exposure. Typical reactions range from redness and itching to more severe responses like nasal congestion and asthma. The allergy most commonly affects healthcare workers and others who are exposed to latex gloves through their employment. Patients receiving medical care may also develop the allergy when they come into contact with latex in a treatment setting.

There are thirteen known Hev b allergens that stimulate elevated IgE antibody responses. The prevalence of these allergens in latex products depends on the manufacturing process and the nature of the latex used.

Latex is harvested from trees in Africa and Southeast Asia. During its manufacturing process, it is separated into three layers. The upper layer is used for solid molding of products like catheters, syringe plungers, and shoe soles. Such items contain low levels of allergens, in part due to their inability to withstand the high heat used in manufacturing.

The bottom two sap-like layers cannot be used for solid rubber products. Instead, porcelain molds are dipped into this kind of latex to make a wide variety of items, including gloves, condoms, catheters, and balloons. Most latex allergies stem from contact with this kind of latex, which contains higher levels of Hev b allergens. These allergens can be transmitted via direct cutaneous contact. Moreover, because latex gloves have historically been treated with donning powder, allergens attach themselves to the cornstarch and can be inhaled.

WHAT IS AN IgE ANTIBODY?

“IgE” stands for the protein immunoglobulin E. In an allergic person, this antibody is released as part of the body’s immune response to what it mistakenly views as a harmful substance (i.e., pollen, mold, or food particles). IgE antibodies are specific to individual allergens; the IgE antibody produced for latex is different than that produced for cat dander, for example.

LATEX ALLERGY’S RISE

The incidence of latex allergy ballooned during the 1990s. What caused this sudden and dramatic rise in the prevalence of the allergy? There were several factors at play:

  • In 1992, the Occupational Safety and Health Administration mandated the Bloodborne Pathogens Standard that required glove use by all healthcare workers, who were directed to take “universal precautions.”
  • The existing supply of latex couldn’t keep up with demand.
  • Young Hev b trees were stimulated with chemicals so that they would produce more latex; they also produced more allergens.
  • Latex was not stored for its customary waiting period before being manufactured, which additionally increased the levels of allergens in the latex. “Higher levels of protein exacerbated the problem of latex allergy among the medical and dental communities by increasing H. brasiliensis allergen exposure” (Hamilton, 2011a).

Photo

In 1992, OSHA mandated the use of protective gloves
as a Universal Precaution for all healthcare workers.
(Source: OSHA.)


Latex Allergy Reaches Epidemic Proportions

By the mid-1990s, increased exposure to latex among healthcare workers resulted in allergy incidence of epidemic proportions. Estimates about the prevalence of the allergy are dependent on the testing methods used, as some Hev b proteins are more readily detected with skin tests, for example; yet it is estimated that between 10.7% to 12.1% of general healthcare workers were affected. In the mid-1990s, estimates also suggest that 3.0% to 9.5% of the general population suffered from latex allergy. Patients with multiple surgeries were a particularly high-risk group, especially children with spina bifida. An estimated one third to two thirds of all children who had surgery during the 1990s became sensitized to latex (Hamilton, 2011a).

Controlling an Epidemic

In response to the dramatic rise in latex allergy cases, powder-free latex gloves were manufactured and adopted in the workplace. In the 1990s, one study found that from the elimination of powder alone, the allergy’s prevalence fell from 12.1% to 4% among healthcare workers (Hamilton, 2011a). Hamilton (2011a) further states that “it can be assumed that rates have decreased even further with the increased use of non-latex gloves. However, new cases of latex allergy continue as a result of inadvertent exposures from high levels of Hevea allergen in less obvious sources, such as toy balloons and dental dams.” Moreover, latex allergy remains a larger problem for countries outside the U.S. and for non-health-related occupations that still used powdered gloves.

CLINICAL MANIFESTATIONS OF LATEX ALLERGY

How latex allergy manifests itself is dependent on the route of exposure (inhalation vs. cutaneous contact); the amount of allergen in a product; and the underlying mechanism of a reaction (irritant, non-IgE-mediated, or IgE-mediated) (Hamilton, 2011a). The most common manifestation of latex allergy is irritation of the skin—the hands in particular—due to glove usage. However, not all skin reactions are allergic responses. Symptoms may follow one or more of the following paths.

Chemical Sensitivity Dermatitis

Chemical sensitivity dermatitis, also known as allergic contact dermatitis, is a T cell-mediated allergic response. This response is a hypersensitivity to chemicals used in the manufacturing of latex products. Symptoms include:

  • Rash
  • Itching
  • Fissures
  • Dryness
  • Redness

Onset occurs 1 to 4 days after direct skin contact. Initial appearance resembles acute eczematous dermatitis, often with vesicles. Over time and with increased exposure, affected skin becomes drier and crustier.

Photo

Example of a skin reaction to latex. (Source: Chris Wheatley.)

Allergic Contact Urticaria

Allergic contact urticaria is the most common allergic reaction to latex. This IgE-mediated immediate type hypersensitivity produces symptoms such as:

  • Redness
  • Itching
  • Wheal and flare reactions at the site of contact
  • Itchy throat

Onset generally occurs within 10 to 15 minutes of direct contact. Allergic contact urticaria can be followed by contact dermatitis; also, sensitization may worsen with on-going exposure to latex.

Photo

Contact urticaria from wearing latex gloves. (Source: CDC.)

CASE

NANCY’S LATEX ALLERGY
Nancy works as an LVN in an oncologist’s office. For several years, she has regularly worn gloves to administer procedures to patients, and she has never had any problem with sensitization, though she feels like her hands are habitually dry. She decides to start applying hand lotion several times throughout the course of a day to alleviate her discomfort. After two days, she notices that her hands start to itch within ten minutes of donning her gloves. When she removes the gloves, her skin looks red and inflamed, and she can see wheals and flares of redness all along the backsides of her hands. She washes consistently with soap and water after use, but each time she puts her gloves on, the itching seems to start sooner and feel more uncomfortable. When sneezing, watery eyes, and nasal congestion develop, Nancy suspects latex allergy is involved; she contacts an allergist for advice about how to proceed.

Rhinoconjunctivitis and Asthma

Rhinoconjunctivitis and asthma are more severe reactions and are usually triggered by aerosol allergens. These reactions include a number of responses:

  • Sneezing
  • Itching
  • Watery eyes
  • Nasal congestion
  • Rhinorrhea
  • Hives
  • Constricted breathing (asthma)

The symptoms of rhinoconjunctivitis are identical to the symptoms of pollenosis, so it is imperative to note the temporal relationship between exposure to latex and the onset of symptoms. Also, it is possible to develop latex asthma without a pre-existing history of the disease (Hamilton, 2011a).

Anaphylaxis

Anaphylaxis is an extreme allergic reaction that causes airway constriction and/or obstruction, skin and intestinal irritation, and a change in heart rhythm. Anaphylactic responses to latex are very rare, but they can be life threatening. Anaphylaxis is seldom the first sign of an allergy.

CLINICAL MANIFESTATIONS OF LATEX SENSITIZATION
  Symptoms Type of Reaction Onset
Chemical sensitivity dermatitis Rash, itching, fissures, dryness, redness of skin T cell-mediated 1 to 4 days after direct skin contact
Allergic contact urticaria Redness, itching skin, wheal and flare reactions at site of contact, itchy throat IgE-mediated immediate type allergic response 10–15 minutes after contact
Rhinoconjunctivitis and asthma Sneezing, itching/ watery eyes, nasal congestion, rhinorrhea, hives, constricted breathing IgE-mediated immediate type allergic response Within minutes of inhalation of airborne allergens
Anaphylaxis Constriction/obstruction of airways, skin and intestinal irritation, irregular heart rhythm IgE-mediated immediate type allergic response Within minutes after direct contact or inhalation

DIAGNOSIS OF LATEX ALLERGY

Diagnosis of latex allergy follows a sequential path. Analyzing an individual’s clinical history is the first step. A strong historical association between latex exposure and symptoms is the most reliable indicator of an allergy.

Clinical associations should be taken into consideration. A history of eczema can be an indicator of latex allergy. Also, cross-sensitization is known to exist between latex allergy and allergies to the following foods and pollens:

  • Kiwi
  • Banana
  • Avocado
  • Chestnut
  • Papaya
  • Potato
  • Tomato
  • Goldenrod pollen

If the clinical history generates a high suspicion of latex allergy, a physician may choose to follow up with further tests.

Skin testing is widely used as a diagnostic tool in Europe and Canada. Safe and effective, prick/puncture skin testing uses glycerinated latex C-serum to measure a patient’s IgE response. However, there are no commercial skin tests available in the United States. Though some allergists have attempted to make their own extracts in the office, this approach is problematic, for the allergen content varies widely in such extracts, tests can lead to false negatives, and there is the potential for systemic reactions to occur. Healthcare professionals in the United States are discouraged from attempting latex allergy skin tests due to the risks involved.

Serology testing is the preferred alternative to skin testing and is the most reliable diagnostic tool. For this process, human test serum is incubated with a Hev b allergen-containing reagent and then evaluated for Hev b-specific IgE antibodies. In the United States, the Immuno-CAP and Immulite systems are FDA approved for latex-specific IgE testing. These tests have a diagnostic sensitivity and specificity of approximately 80%.

Finally, provocation testing may be considered as a last resort when other tests come back negative yet the case history indicates an allergy. This procedure is not recommended for routine clinical use. With provocation testing, a patient is exposed to allergens for the specific purpose of provoking a skin or breathing reaction. Given the nature of the test, this method has generated concerns about safety, reproducibility, and the interpretation of results.

TREATMENT OF LATEX ALLERGY

Treating a Severe Reaction

A severe allergic reaction can produce the following symptoms:

  • Urticaria (hives)
  • Angiodema (swelling)
  • Breathing constriction
  • Flushed appearance
  • Anaphylactic shock and collapse

If you suspect a patient may be experiencing a severe allergic reaction to latex or any other substance, do not leave the individual. Monitor vital signs, ensure an open airway, and initiate CPR if required. If symptoms are severe enough to indicate a need for epinephrine, the American College of Allergy, Asthma, and Immunology (ACAAI, 2010) advises the following treatment:

  • Epinephrine 1:1000 0.3 cc subcutaneously stat (children 1:1,000, 0.01mL/kg
    up to 30 kg).
  • Diphenhydramine 50 mg. I.M. stat (children 1 mg/kg up to 50 kg).
  • Salbutamol (albuterol) 2 puffs stat (if patient conscious and wheezy).
  • Place patient in a head down position (Trendelenberg).
  • Administer oxygen by nasal cannula if patient has cardiovascular or respiratory symptoms.
  • Call for immediate assistance from ward/area and arrange transfer to the E.R. stat.
  • Repeat epinephrine q 10 minutes until patient transferred, if experiencing significant symptoms indicating a need for further epinephrine.

Alternative Treatments

Pharmacotherapy, or treatment of latex allergy with drugs, is a possible course of action yet is rarely effective. Instead, preventing a reaction in the first place is preferred.

Immunotherapy (IT) has also proven ineffective for treating latex allergy. While clinical trials show variable results, its usage has been limited by the severity and frequency of adverse reactions to the treatment. At this point in time, IT is in the research and experimental stage.

Anti-IgE treatment is also currently being researched. This method, however, is not only costly but its functionality is dependent on the patient’s body weight and total serum IgE level, so it is not a viable option for many patients.

PREVENTING LATEX REACTIONS

How to Avoid Latex

The best and most effective response to latex allergy is avoidance of latex products.

Today’s healthcare professionals have several options available to them for avoiding latex in the workplace. First of all, non-latex gloves made of synthetic elastomers or non-Hevea rubber (Yulex) are the safest for prevention of latex sensitization. Note that gloves labeled “hypoallergenic,” if still made of latex, don’t reduce the risk of latex allergy but may reduce chemical sensitivity dermatitis. Powder-free gloves are an alternative for mitigating the dispersion of aerosol allergens.

Workplace guidelines need to be in place in professions that require the use of protective gloves. All employees in high-risk environments, not just those with pre-identified latex allergy, should avoid use of latex or use only powder-free products.

Individuals known to suffer from latex allergy must also take precautions to keep themselves safe. They need to carry epi-pens and non-latex gloves at all times, and they should report their allergy prior to any medical or dental procedure to avoid accidental exposure.

Responsible Usage of Latex

For those who do not have a diagnosed allergy or who are not at high risk of developing sensitization, responsible use of latex products is an option. The following steps can minimize the negative effects of latex on both the individual and the environment:

  • Use powder-free latex gloves or gloves with reduced protein content.
  • Don’t use oil-based hand creams or lotions with latex gloves, as they cause deterioration of the rubber.
  • Wash hands with mild soap and dry thoroughly after wearing gloves.
  • Educate yourself about the symptoms of latex allergy.
  • Stay alert: early detection helps control the allergy. Reduce exposure and seek medical advice if latex allergy is suspected.
  • Be aware of potential sources of allergens besides gloves. (See lists of items containing latex provided elsewhere in this course.)

Reducing Latex Exposure in the Workplace

Creation of a latex safe environment involves recognizing the importance of controlling latex exposure for allergic patients, convening a latex committee, and establishing an institutional program to eliminate exposure. A multi-disciplinary latex advisory committee should be composed of local experts with knowledge in legal matters, purchasing, occupational safety, allergy, and glove use, including surgery, medicine, and anesthesiology.
—Robert G. Hamilton, Ph.D. (2011b)

Within the workplace, healthcare professionals can take steps to minimize and prevent latex exposure. A proactive approach can benefit both patients and employees. Some institutions have chosen to eliminate latex gloves globally, while others use powder-free gloves or prioritize their use of synthetics. Whatever the approach taken, it must be comprehensive, well-informed, and purposeful.

The National Institute for Occupational Safety and Health (CDC, 1997) suggests the following strategies to reduce latex allergy in the workplace:

  • Appropriate barrier protection is necessary when handling infectious materials. If latex gloves are chosen, use powder-free gloves with reduced protein content.
  • Use non-latex gloves when there is little potential for contact with infectious materials (e.g. food service).
  • Ensure that employees use good housekeeping practices to remove latex containing dust from the workplace (frequently clean contaminated areas and change ventilation filters and vacuum bags regularly).
  • Provide employees with education programs and training materials about latex allergy. Employees should be familiar with procedures for preventing latex allergy and should learn to recognize the symptoms of latex allergy.
  • Screen high-risk employees for latex allergy symptoms periodically. Detecting symptoms early and preventing further latex exposure are essential for preventing long-term effects.
  • Reevaluate current prevention strategies whenever an employee is diagnosed with latex allergy.
  • After removing latex gloves, wash hands with a mild soap and dry thoroughly.
  • Individuals who develop symptoms of latex allergy should avoid direct contact with latex gloves and other latex-containing products until evaluated by a physician experienced in diagnosing latex allergy.

Protecting Patients

CASE

PAUL’S LATEX ALLERGY
Paul is a 10-year-old patient with cystic fibrosis (CF). As an infant, he had several gastrointestinal surgeries stemming from complications with CF, and he has been in and out of the hospital since birth. At age 4, Paul developed mild allergic contact urticaria in response to an enema performed in the hospital; a stronger reaction followed several months later, when he proved sensitive to the injection port of an IV. Identifying the rapid onset of Paul’s itching, redness, sneezing, and congestion as a possible latex allergy, his doctor included this information in the patient’s medical file and noted that all future medical procedures should be performed with latex-free materials. Paul’s parents purchased a medic-alert bracelet for their son to identify his allergy, and they make a point of explaining his needs to any healthcare providers who work with him, even going so far as to supply their own latex-free gloves if necessary. At age 10, Paul has been able to manage his allergy without developing increased sensitivity.

SCREENING PATIENTS

Healthcare professionals can greatly minimize the incidence of harmful latex exposure by screening new patients for potential risks. “Frequently, either because of a lack of awareness of latex allergy and/or because of a concomitant history of atopic illness, sensitized persons do not attribute their respiratory symptoms of rhinoconjunctivitis or bronchospasm to latex exposure. For this reason, eliciting a suspicious history before elective surgery or other major latex exposure is of utmost importance,” writes Sumana Reddy, M.D. (1998). Questioning a patient orally is one approach; administering a questionnaire (see box below) can also help identify patients who may have a history of latex allergy.

While screening patients can help prevent allergic reactions in the office or hospital, healthcare professionals also need to keep in mind the fact that even patients with no identifiable risk factors may experience a reaction to latex (Reddy, 1998). If a latex reaction is suspected, it should be documented for future reference.

LATEX SENSITIVITY SCREENING QUESTIONS FOR PATIENTS

(Answer YES or NO)

  1. Do you have a congenital urinary abnormality requiring frequent surgeries or catheterizations?
  2. Have you ever had or been told you had an allergy to latex or natural rubber products?
  3. Do you have any spinal cord deformities that have been present since birth (such as spina bifida or myelomeningocele)?
  4. Have you ever had any of the reactions listed below to rubber gloves, balloons, rubber dental dams, Band-Aids, condoms, rubber bands, rubber toys (like Koosh balls), or other items? Check any reaction you have had:

    ___ Itching or watery eyes
    ___ Itching or swelling of your lips or face
    ___ Itching on your body
    ___ Hives
    ___ Sneezing
    ___ Wheezing
    ___ Loss of consciousness
     
  5. Have you ever had an unexplained allergic reaction during surgery or other medical or dental procedures?
    If YES, what happened?
  6. Do you have allergies to bananas, kiwi, avocado, water chestnuts, or tropical fruits?
    If YES, what happened?

Source: University of Nebraska Medical Center, 2001.

PREVENTING ALLERGIC PATIENT EXPOSURE TO LATEX

If a patient is known to have an IgE-mediated immediate type hypersensitivity to latex, a latex-free environment must be established for this individual and healthcare providers must take steps to manage exposure during treatment. Recommended procedures include the following:

  • Include latex allergy information on patient's identification bracelet.
  • Label room “latex safe” and enter in all relevant areas of signage, notes, and databases.
  • Disseminate latex allergy protocol and lists of non-latex substitutes for latex-containing materials that may contact the patient.
  • Remove all latex products, including gloves, that may contact the patient.
  • Use tubing made of polyvinyl chloride (PVC) or, if using latex cuffs and tubing or tourniquets, wrap cotton gauze over patient's extremities.
  • Check adhesives and tapes, including electrocardiography electrodes and dressing supplies, for latex content
  • Have a crash cart with latex-free supplies available to follow the patient through his or her stay.
  • Notify the pharmacy and central supply that the patient is sensitive to latex so that latex contact can be eliminated when materials or drugs are prepared for the patient.
  • Notify dietary staff of relevant food allergies and avoid handling food with powdered latex gloves.
    (Reddy, 1998)

Prominently identifying patients with latex allergy and taking precautions to prevent exposure can help ensure a safe environment for medical treatment.

PATIENT EDUCATION

Once patients have been diagnosed with latex allergy, healthcare professionals need to provide guidance about where latex reactions might occur outside the medical environment. Patients may have questions about what products they need to avoid, where to purchase non-latex products, and so on. It is helpful to have pamphlets or fact sheets to distribute to patients upon diagnosis. Information provided to clients may include topics like those shown below.

COMMON PRODUCTS CONTAINING LATEX

  • Gloves
  • Balloons
  • Condoms
  • Diaphragms
  • Bandages (adhesives)
  • Pacifiers/baby bottle nipples
  • Dental dams
  • Dishwashing gloves
  • Elastic
  • Spandex
CROSS-REACTIVE FOODS (with degree of association or prevalence)
High (4) Moderate (7) Low or undetermined (33)
Source: ALAA, 2011
Banana, avocado, chestnut,
kiwi
Apple, carrot, celery, papaya, potato, tomato, melons Pear, mango, sweet pepper, peach, rye, cayenne pepper, plum, wheat, shellfish, cherry, hazelnut, sunflower seed, pineapple, walnut, citrus fruits, strawberry, soybean, coconut, fig, peanut, chick pea, grape, buckwheat, castor bean, apricot, dill, lychee, passion fruit, oregano, zucchini, nectarine, sage, persimmon

For information on latex alternatives, patients can be directed to the American Latex Allergy Association (ALAA), which offers links to extensive lists for thousands of latex (see “Resources” below). The ALAA website also addresses a wide range of common questions, such as “If I am to be hospitalized or have surgery and I have the latex allergy, what precautions do I need to take?” or “Do Lance Armstrong LIVESTRONG wristbands contain natural rubber latex?”

Providing patients with information about latex allergy can minimize and help prevent serious reactions. Education allows individuals a degree of safety, security, and confidence in interacting with the world.

CONCLUSION

Latex allergy is especially problematic for those in the healthcare industry and other occupations dependent on the use of protective gloves. The allergy reached epidemic proportions in the mid-1990s because of laws mandating glove usage and changes in the manufacturing of those gloves. Greater understanding of the allergy has since led to considerable reduction in its prevalence. Thanks to the elimination of donning powder, the introduction of synthetic rubbers, and the education of the public, latex allergy has become far less prevalent in the United States over the course of the last decade. In the workplace, a well-informed plan for creating a latex safe environment can provide protection for employees and the public. While alternative treatments are under investigation, the best and most effective treatment for latex allergy continues to be avoidance of products that contain Hev b latex.

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RESOURCES

American College of Allergy, Asthma & Immunology
acaai.org

American Latex Allergy Association/ALERT
latexallergyresources.org

Centers for Disease Control and Prevention
cdc.gov/niosh/topics/latex/

OSHA
osha.gov/SLTC/latexallergy/

REFERENCES

American College of Allergy, Asthma, and Immunology (ACAAI). (2010). Guidelines for the Management of Latex Allergies and Safe Latex Use in Health Care Facilities. Retrieved May 20, 2011, from http://www.acaai.org/allergist/allergies/Types/latex-allergy/Pages/latex-allergies-safe-use.aspx#anchor448710.

American Latex Allergy Association (ALAA). (2011). Latex allergy topics. Retrieved May 21, 2011, from http://www.latexallergyresources.org/topics/.

Centers for Disease Control and Prevention (CDC). (1998). National Institute for Occupational Safety and Health (NIOSH) Publications and Products. Latex Allergy: A Prevention Guide. Retrieved May 3, 2011, from http://www.cdc.gov/niosh/docs/98-113/.

Centers for Disease Control and Prevention (CDC). (1997). National Institute for Occupational Safety and Health (NIOSH) Publications and Products. Preventing Allergic Reactions to Natural Rubber Latex in the Workplace. Retrieved May 20, 2011, from http://www.cdc.gov/niosh/docs/97-135/.

Hamilton RG. (2011a). Latex allergy: Epidemiology, clinical manifestations, and diagnosis. Retrieved May 3, 2011, from http://www.UptoDate.com.

Hamilton RG. (2011b). Latex allergy: Management. Retrieved May 3, 2011, from http://www.UptoDate.com.

National Institute of Allergy and Infectious Diseases (NIAID). (2008). Disorders of the immune system. Retrieved May 5, 2011, from http://www.niaid.nih.gov/TOPICS/IMMUNESYSTEM/Pages/disorders.aspx.

National Institutes of Health (NIH). (2010). Latex allergy. Retrieved May 4, 2011, from http://www.nlm.nih.gov/medlineplus/latexallergy.html.

Reddy S. (1998). Latex allergy. Retrieved May 27, 2011, from http://www.aafp.org/afp/980101ap/reddy.html.

Spina Bifida Foundation. Latex Committee of the Nursing and Healthcare Professionals Council. (2010). Latex in the hospital environment fact sheet. Retrieved May 9, 2011, from http://www.spinabifidaassociation.org/atf/cf/%7Beed435c8-f1a0-4a16-b4d8-a713bbcd9ce4%7D/SBA-LATEXLIST-2010-FINAL.PDF.

University of Nebraska Medical Center. (2001). Latex sensitivity screening questions for patients. Retrieved June 2011 from http://www.unmc.edu/policy/index.cfm?CONREF=85.

Weston W. (2011). Patient information: Contact dermatitis, including latex dermatitis. Retrieved May 3, 2011, from http://www.UptoDate.com.

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