SCIENTIFIC ARTICLE
Australian Dental Journal 2002;47:(3):237-240
Minimizing the risks of latex allergy: The effectivness of written information FM Carrozzi,* CH Katelaris,* TV Burke,* RP Widmer†
Abstract Background: Latex allergy has been identified as an occupational risk for the dental profession. This study assessed whether identified latex-allergic dental personnel changed their practices after receiving verbal and written information about the management of latex allergy. Methods: A survey conducted at the 1998 Australian Dental Association Congress identified 157 dental personnel with clinical latex allergy, or at high risk from latex exposure. The workplace implications were then explained to them by a consultant allergist. Four weeks later, follow up written information on latex allergy was mailed out. The information sheet outlined possible symptoms and cross-reactions, implications for the workplace, hand care advice and management strategies to reduce latex exposure in the workplace. After six weeks, a questionnaire, designed to assess whether appropriate steps to reduce latex exposure had been taken, was mailed out. Results: Seventy per cent of the questionnaires were returned. All respondents felt the information was easy to understand and informative. While 50 per cent of respondents indicated that they had changed to powder-free or non-latex gloves, only five respondents were fully compliant with all instructions. Conclusion: Compliance with instructions regarding minimizing exposure to latex in a group of latexallergic dental personnel was poor. Key words: Latex, allergy, dental education. (Accepted for publication 23 August 2001.)
INTRODUCTION Although the importance of latex allergy and appropriate avoidance measures to minimize its development have been well documented,1 there is scant information in the literature evaluating how health care workers respond to advice given them
*Institute of Immunology and Allergy Research, Westmead Hospital, Westmead, Sydney. †Westmead Centre for Oral Health, Westmead, Sydney. Australian Dental Journal 2002;47:3.
regarding the changes necessary to reduce the impact of this increasing problem. In recent years there has been a steady increase in reports of the importance of latex allergy in health care workers.2-4 Previous studies5,6 have shown glove powder is the vehicle which enables latex allergen to become airborne. Dental workers in dental schools and clinics where there is a high rate of latex glove use may face adverse health outcomes as a result of high levels of latex aeroallergen.7 In the United States this has resulted in the National Institute of Occupational Safety and Health (NIOSH) issuing a safety alert in 1997 advising the use of powder-free gloves to reduce exposure to latex protein allergens.1 Identification of the at-risk worker is just the first step in the management of latex allergy. In order to avoid further sensitization and minimize the risk of harm at work, certain precautions are strongly recommended. Strategies such as the widespread adoption of powder-free gloves and the use of nonlatex gloves for the sensitized worker form the basis for most latex allergy management policies. This study was devised to evaluate the impact on work practices of verbal and written information given to a group of at-risk dentists identified during a screening programme at a national dental conference. M AT E R I A L S A N D M E T H O D S One hundred and fifty-seven latex allergic dental workers who were identified by a previously validated questionnaire2 alone or by the combination of the same questionnaire and skin prick testing, at the 1998 Australian Dental Association Congress (ADA Congress) participated in this study. The consultant allergist present told all dental workers who were identified as latex allergic of their diagnosis at the time of the survey. Latex allergy, its risks and implications were explained. Avoidance and management measures were also explained. They were informed they would receive an information guide on latex allergy after the ADA Congress. Four weeks later, each of the 157 latex allergic dental workers was sent an information guide about latex 237
allergy. It was specifically written for this purpose using ‘plain English’ and designed to be easy to read and understand. It explained what latex allergy is, reviewed symptoms, risks and implications of latex allergy. Hand care advice and management strategies to reduce latex exposure in the workplace were also discussed. Specifically, those with demonstrated sensitization were requested to have a ‘powder-free’ workplace by the provision of powder-free gloves to all employees and to personally use non-latex gloves. Six weeks after the information guide was sent to each participant, a questionnaire was mailed to each one. This questionnaire assessed the impact the information guide had on initiating a change in practices of the latex allergic dental workers. The format of the questionnaire was ‘yes/no’ tick box. A section for comments was also included. The questionnaire was designed to elicit information about the ease of understanding the provided information and whether the suggested strategies had been implemented. The latter questions were devised to test the understanding of the respondent regarding the suggested strategy by asking more detailed questions about the type of glove still used in the practice. In brief, the questionnaire sought the following information: had participants read the information sheet? Was it easy to understand? Were suggested practice changes outlined in the information sheet implemented? What types of gloves were currently being used? Was the work environment powder-free? And was there any additional information which they thought was missing from the information sheet? The latex allergy questionnaire and skin testing procedure conducted at the ADA Congress had been approved by the Western Sydney Area Health Service Human Research and Ethics Committee and by the Scientific Organizing Committee of the ADA Congress. All dentists identified at high risk from latex allergy were keen to receive the written information we outlined to them. Table 1. Comparison of glove use and work environment in 58 dental workers reporting changes to work practice Respondents claiming powder-free work area (n=41)
Respondents claiming some changes but not powder-free work area (n =17)
Powdered latex Powder-free latex Non- latex Combination powdered latex and powder-free latex Combination powdered latex and non-latex Combination powder-free latex and non-latex
3 26 4
2 6 7
4
0
0
1
4
1
Total (58)
41
17
Glove type
238
Table 2. Number of dental workers using a particular glove type before and after receiving the information guide Glove type Latex Power-free latex Non-latex Combination latex and powder-free latex Combination of powder-free latex and non-latex Nil used Combination latex, non-latex and powder-free latex Unsure Total
Before information guide (%)
After information guide (%)
68 (66) 17 (16) 7 (7)
37 (36) 37 (36) 15 (15)
9 (9)
6 (6)
0 (0) 2 (2)
3 (3) 3 (3)
0 (0) 0 (0)
1 (1) 1 (1)
103
103
Note: Seven participants returned forms with no names, therefore could not be analyzed in this manner.
R E S U LT S The majority of the group consisted of individuals in general dentistry (68 per cent), while 16 per cent were in specialist practice. There were more males than females (60:40 per cent) and the majority were between 30 and 50 years of age. One hundred and ten (70 per cent) of the 157 dental workers who were sent information guides returned questionnaires. Attempts were made to contact those not returning questionnaires by the due date by phone, fax or another mailing. There were no obvious distinguishing features between those returning questionnaires compared to the total cohort. All respondents stated that they had read the information sheet and thought it was easy to understand. Fifty-eight (53 per cent) reported that they had implemented avoidance and management measures outlined in the information sheet and 7 per cent had implemented some changes. When responses to more detailed questions on glove use were examined, there were a number of discrepancies. Seventeen of those dentists, who stated that they had implemented the suggested policy, also said that they were working in a ‘powdered’ environment, demonstrating a lack of understanding about the basic policy. Forty-one of 58 answered ‘yes’ to working in a powder-free environment, but when we examined their responses to questions regarding the particular types of glove being used in their practices, seven respondents were still using powdered gloves. In fact, of the 58 dentists claiming to have implemented the suggested changes, only five were truly compliant with every aspect of the policy. Table 1 shows the comparison of those who reported implementing changes against their reported glove use and work environment results. Table 2 shows the glove use at screening and then after the information guide. Use of powdered latex gloves dropped from 66 to 36 per cent and those using Australian Dental Journal 2002;47:3.
Table 3. Reasons for non-compliance with advice Reason Scepticism about diagnosis of latex allergy No symptoms therefore no need to modify Glove use dependent on supply by employer Powder-free and non-latex gloves unacceptable to use
Number of respondents n=52 (47%) 4 (8%) 14 (27%) 6 (12%) 9 (17%)
non-latex gloves rose from 7 to 15 per cent after the information sheet was received. Fifty-two (47 per cent) of this group of dental workers did not implement any of the suggested changes. Reasons given for this are summarized in Table 3. DISCUSSION Latex allergy among dental personnel is an important occupational health issue. A number of strategies have been identified which, when implemented, make the workplace much safer for the sensitized worker and reduces the chances for further sensitization. Moving to the use of powder-free gloves has been identified as a major step in achieving both these goals as it eliminates the airborne latex allergen exposure, which can cause respiratory as well as cutaneous symptoms. In the present study, dental personnel identified as having a significant risk of allergic manifestations on exposure to latex were provided with an explanation of their problem and information about management strategies in both a verbal and written form. Understanding and compliance with this information was then assessed by a detailed questionnaire mailed to the participants four weeks after the information had been given. The response rate of 70 per cent is not ideal. Attempts to increase this by phone and faxing were not successful. However, the demographic profiles of the responding group did not differ significantly from the total group. It is disturbing to find that of the 58 dentists who claimed to have changed their work practices as suggested in the information sheet, only five had in fact implemented the complete advice, i.e., to use non-latex gloves themselves and to have a powder-free workplace by the provision of powder-free gloves to their staff. Following dissemination of the information sheet, use of powdered latex gloves dropped by approximately half (66 per cent beforehand compared to 36 per cent afterwards) while there was a doubling in the numbers using non-latex gloves (7 per cent beforehand to 15 per cent afterwards). Nevertheless, of the dentists returning the questionnaire, 42 per cent continued to use powdered gloves at some time during clinical practice even though this was stated as being the most important change necessary in managing latex allergy in the workplace. This fact has been emphasized recently in an editorial by Smedley.7 He states that Australian Dental Journal 2002;47:3.
cornstarch on gloves is positively associated with an increase in latex sensitization both by direct skin contact and via the respiratory tract. There is little published data on the evaluation of the response of latex-sensitive dental or other health workers to suggested changes for the work environment based on the understanding we have of the mechanism of latex sensitization. An analogy may be drawn from the acceptance of infection control guidelines. In the early years of implementation of ‘universal precautions’, some dentists wore masks and gloves selectively and a number of studies investigated the reasons for this reluctance.8-10 Gloves and masks were not worn if they were considered too troublesome or if they were perceived as inadequate for offering protection against infection. Other studies have also highlighted differences between reported and observed compliance with given instructions. Freire et al.11 observed final year dental students in Brazil for compliance with infection control guidelines and compared this to self-reported compliance ascertained via a questionnaire. While the reported compliance was generally satisfactory, observed behaviour was less positive. Glove use was high but other infection control guidelines were not fully met. A recent national survey of Canadian dentists8 showed that although there were high compliance rates with single items of infection control policy, many dentists have not adopted a comprehensive range of recommendations. In a similar manner, a number of dentists in our study stated that they had followed the written recommendations, while specific questions illustrated that this was not so. McCarthy et al.8 demonstrated that dentists attending a continuing education course in the preceding two years had greater compliance with infection control guidelines, leading them to conclude that education was the key to improving compliance. However, the issue is complex and more information is required about the forms of education which are most likely to bring about the greatest change. Understanding the underlying barriers to the implementation of instructions is also required. Research has shown that human beings are unrealistically optimistic about succumbing to most common illnesses or accidents.12,13 Understanding the complex balances between these factors may lead to the development of more effective means of altering behaviour, whether it is for infection control or for minimizing the risk of latex sensitization or latex-induced allergic reactions in at-risk individuals. REFERENCES 1. National Institute for Occupational Safety and Health. Preventing allergic reactions to natural rubber latex in the workplace. DHHS (NIOSH) Publication No 97-135, Third printing July 1998. 239
2. Katelaris CH, Widmer RP, Lazarus RM. Prevalence of latex allergy in a dental school. Med J Aust 1996;164:711-714.
practitioners’ views and behaviours. Health Ed Res 1990;5:321325.
3. Amin A, Palenik CJ, Cheung SW, Burke FJ. Latex exposure and allergy: a survey of general dental practitioners and students. Int Dent J 1998;48:77-83.
10. New M, Lindsay SJE. Factors influencing dentists’ intentions to take precautions against HIV infection. J Dent Res 1990;69:968.
4. Baur X, Ammon J, Chen Z, Beckmann U, Czuppon AB. Health risks in hospitals through airborne allergens for patients presensitized to latex. Lancet 1993;342:1148-1149. 5. Tarlo SM, Sussman G, Contala A, Swanson MC. Control of airborne latex by use of powder-free latex gloves. J Allergy Clin Immunol 1994;93:985-989. 6. Hermesch CB, Spackmann GK, Dodge WW, Salazar A. Effect of powder-free latex examination glove use on airborne powder levels in a dental school clinic. J Dent Educ 1999;63:814-820. 7. Smedley J. Occupational latex allergy: the magnitude of the problem and its prevention. Clin Exp Allergy 2000;30:458-460. 8. McCarthy GM, Koval JJ, Macdonald JK. Compliance with recommended infection control procedures among Canadian dentists: results of a national survey. Am J Infect Control 1999; 27:377-384. 9. Kay EJ, Murray K, Blinkhorn AS. AIDS and immunodeficiency virus: a preliminary investigation into Edinburgh general dental
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11. Freire DN, Pordeus IA, Paixão HH. Observing the behaviour of senior dental students in relation to infection control practices. J Dent Educ 2000;64:352-356. 12. Weinstein ND. Unrealistic optimism about susceptibility to health problems: conclusions from a community-wide sample. J Behav Med 1987;10:481-500. 13. Jeffery RW. Risk behaviours and health. Contrasting individual and population perspectives. Am Psychol 1989;44:1194-1202.
Address for correspondence/reprints: Associate Professor Richard Widmer Paediatric Dentistry Westmead Centre for Oral Health Westmead Hospital Westmead, New South Wales 2145 Email:
[email protected]
Australian Dental Journal 2002;47:3.
