390 June 2013, Vol. 103, No. 6 SAMJ
Gloves made from natural rubber latex (NRL) have
been in use since the 19th century as a means of
protecting patients and healthcare workers from
contracting infectious diseases. The use of NRL
gloves has increased because of the emergence of the
human immunodeficiency virus (HIV) in the late 1980s. These NRL
gloves were produced with an excess of residual proteins and powder.
Healthcare workers (HCWs) are susceptible to sensitisation and
subsequent development of latex allergy because of frequent exposure
to NRL gloves and powder. In addition, the prevalence in certain
groups, such as people who underwent multiple operations involving
exposure to NRL-containing materials at an early age, and those with
spina bifida, urological abnormalities and short-bowel syndrome, has
been reported to be up to 60% in earlier studies. However, this high
prevalence is falling as a result of a reduction in exposure to latex.
Latex allergy is more prevalnet in atopic than non-atopic individuals. 
There is also cross-reactivity with certain foods, including kiwi fruit,
bananas, avocados and chestnuts. Such cross-reactivity may occur in
more than 50% of latex-allergic individuals, and is due to specific cross-
reacting allergens such as profilins. Notably, about 50% of medical
devices contain latex, so care has to be taken to identify them and avoid
contact by latex-sensitised and allergic individuals.
In highly industrialised countries such as those of Europe and
North America, the latex epidemic in HCWs has been partly halted by
prevention strategies such as lowering the protein content in gloves
recommended by task forces of the European and American allergy
associations. New cases of NRL allergy have been significantly
reduced, and in certain circumstances have disappeared, in countries
and hospitals where health authorities have enforced the use of low-
allergen/low-protein and non-powdered protective gloves.
The first cases of latex allergy (type I hypersensitivity) were
described in 1927 in Germany. The first case in South Africa (SA)
was diagnosed in 1993 at Groote Schuur Hospital in Cape Town, in
a nursing sister.
Latex allergy and its clinical features among healthcare
workers at Mankweng Hospital, Limpopo Province,
S M Risenga,1 BSc, MB ChB, DCH, Dip Allerg (SA), MMed (Paed), FAAAI, Cert Pulmonol (SA) Paed;
G P Shivambu,1 MB ChB; M P Rakgole,1 MB ChB; M L Makwela,1 MB ChB, DCH (SA);
S Ntuli,2 BSc, BSc Hons, MSc; T A P Malatji,2 MB ChB, M Fam Med, Dip HIV Man;
N J Maligavhada,1 BSc, MB ChB, DCH, FCPaed (SA);
R J Green,3 MB BCh, DTM&H, MMed (Paed), DCH, Dip Allerg, FCPaed (SA), FAAAAI, FCCP, PhD
1 Department of Pulmonology and Allergy, Polokwane/Mankweng Complex and University of Limpopo, Limpopo, South Africa
2 Department of Public Health Medicine, Polokwane/Mankweng Complex and University of Limpopo, Limpopo, South Africa
3 Department of Paediatrics and Child Health, University of Pretoria and Steve Biko Academic Hospital, Pretoria, South Africa
Corresponding author: S Risenga (email@example.com)
Background and objectives. Latex allergy, caused by sensitisation in atopic individuals, is a common occupational disease among healthcare
workers who use latex gloves. It may be present in non-atopic individuals as well. The main objective of this study was to document the
prevalence and disease spectrum of latex allergy at Mankweng Hospital, Limpopo Province, South Africa. The secondary objective was to
determine clinical presentation of the disease.
Methods. A cross-sectional descriptive study, with an analytical component, was conducted among healthcare workers who worked in
high-risk areas for latex sensitisation. ImmunoCAP testing was performed and followed by a skin-prick test (SPT) in those who tested
negative to the blood test.
Results. Two hundred screening questionnaires were distributed to healthcare workers at the hospital. Of these 158 (79.0%) were returned,
with 59 participants meeting the inclusion criteria (experiencing symptoms due to wearing latex gloves). The mean age of the participants
was 39.6 years (standard deviation 9.8 years, range 20 - 60 years). There were more females (98.1%) than males (1.9%). Glove-related
symptoms were present in 59 subjects (37.1%), in 7 (11.9%) of whom the ImmunoCAP was positive to latex (95% confidence interval
4.2 - 22.9%). Fourteen participants were lost to follow-up before the SPT was performed. Thirty-eight of the participants with negative
ImmunoCAP tests underwent SPT. Positive SPTs were reported in 5 of these 38 workers (13.2%), indicating that the ImmunoCAP test
missed 11.1% (5/45) of latex-allergic individuals. The prevalence of latex allergy in this study was 8.3% (12/144). A denominator of 144 was
used, as there is a possibility that some of the 14 individuals lost to follow-up could have tested positive to latex sensitisation by SPT. The
symptoms experienced by latex-sensitised workers were rhinitis (100.0%), asthma (50.0%), dermatitis (25.0%), severe anaphylaxis (8.3%),
abdominal pain (8.3%) and angio-oedema (8.3%).
Conclusion. Our findings reveal that latex allergy is a problem at our hospital. The prevalence of 8.3% is comparable to findings in other
South African centres. We recommend a latex-free protocol for high-risk areas and healthcare workers.
S Afr Med J 2013;103(6):390-394. DOI:10.7196/SAMJ.6011
391 June 2013, Vol. 103, No. 6 SAMJ
Reactions to NRL gloves can present in three ways:
1. Contact dermatitis on the hands after wearing gloves resulting
from mechanical friction and drying due to dry powder particles.
This is not an immune-mediated reaction and accounts for the
majority of latex-induced skin rashes.
2. Allergic contact dermatitis is a type IV delayed hypersensitivity
reaction usually caused by the chemical accelerators (such as
carbamates, thiurams and benzothiazoles) used in the manufacture of
NRL gloves. This is a cell-mediated immune response that develops
24 - 48 hours after exposure to latex.
3. The type 1 immediate hypersensitivity reaction to latex, an IgE-
mediated hypersensitivity reaction to latex protein, can result from
contact with latex allergens through the skin or mucous membranes.
It has not been documented that the powder used in latex gloves is
allergenic, but it may carry latex proteins that can lead to an allergic
reaction on coming into contact with mucous membranes. Symptoms
usually begin within minutes of exposure. This is the most serious
type of latex allergy and may be fatal.
This study’s main objective was to determine the prevalence of
latex allergy at Mankweng Hospital, a 500-bed rural tertiary teaching
hospital of the University of Limpopo, Polokwane Campus, Limpopo
Province, South Africa. The secondary objective was to determine the
disease spectrum of affected staff members exposed to latex gloves.
Material and methods
A cross-sectional descriptive study was conducted among HCWs
(nurses, medical doctors and cleaners) working in high-risk areas of
Mankweng Hospital. The great majority of HCWs at highest risk of
latex sensitisation are nurses. Ethics clearance was obtained from the
Ethics Committee of the University of Limpopo, Polokwane Campus.
The participants signed forms indicating their informed consent to
participate in the study.
Participants were recruited during March - December 2011 from
the intensive care unit, labour ward, gynaecology and postnatal
ward, casualty, outpatient department, neonatal intensive care unit,
antenatal clinic, operating theatre, central sterilising department,
radiology, high care, and the Thuthuzela Rape Clinic. The hospital
has a nursing staff complement of 704 and has a policy of keeping
nurses in their preferred workstations permanently. All participants
had been in their workstation for a year or more. The number of
nurses in different stations is shown in Table 1.
We assumed the prevalence of type 1 latex allergy in the study
population to be about 10%, with a margin of error of 4%. In order to
be 95% confident we needed to have a total of 200 HCWs in high-risk
areas using simple random sampling.
Development and logistics
We conducted a small-scale pilot study of 10 participants in January
2011 to test our questionnaire. We then started our study by having a
discussion on latex allergy in every workstation in order to explain the
study and answer questions. Questionnaires and information on latex
allergy were given to HCWs who wanted to participate in the study. We
collected blood from participants who met the inclusion criteria and
later did skin-prick tests (SPTs) in those whose blood tests were negative.
A self-administered questionnaire was designed to elicit any allergic
symptoms, collecting the following information: (i) demographic
data; (ii) symptoms; (iii) family history; (iv) food allergy (avocados,
bananas, carrots, pineapples and watermelons); (v) previous allergy
evaluation and therapy; (vi) hospitalisation; and (vii) surgery. The
questionnaire was in English, the official language used to record
patient information at the hospital. HCWs in different workstations
were addressed to explain the study, and questions asked were clarified.
They were addressed in English, Sepedi, Tshivenda and Xitsonga,
the four common languages spoken at the hospital. For the few
participants who could not understand English well, the information
was interpreted in their home language by the investigators, who
can speak all three African languages. There is evidence that a
questionnaire addressing past symptoms of latex allergy can be
useful in screening for latex allergy. Questionnaires are particularly
useful in the identification of sensitised and asymptomatic patients
belonging to high-risk groups and in prevalence studies.
Participants were required to score their symptoms after exposure to
latex as absent, mild, moderate or severe and to state whether they were
Table 1. Number of healthcare workers and participants per workstation
Intensive care unit
Labour ward + antenatal clinic
Obstetrics and gynaecology
Neonatal unit (including NICU)
Central sterilisation and supply department
Thuthuzela (rape centre)
Total population per
Study sample per
% of study sample per
NICU = neonatal intensive care unit.
392 June 2013, Vol. 103, No. 6 SAMJ
work-related or not. Symptoms were graded as severe if the participant
had needed medical attention or admission to hospital.
Inclusion criteria for further study (latex sensitisation and allergy
testing) were: (i) confirmed or suspected latex allergy; (ii) severe
reaction after exposure to latex; (iii) allergy to food that cross-reacts
with latex; (iv) any other symptom with work-related deterioration;
(v) 1 or more severe symptoms listed in the questionnaire; (vi) 2 or
more moderate symptoms in the questionnaire; and (vii) 4 or more
mild symptoms in the questionnaire. Fifty-nine participants met
these inclusion criteria for latex sensitisation and allergy testing.
Specifc IgE measurements
The k82 Latex ImmunoCAP system (Phadia, Uppsala, Sweden) was
used to determine serum-specific IgE to latex antigens. The latex
allergen components documented on this system are Hev b 1, Hev b
2, Hev b 3, Hev b 5 Hev b 6.01, Hev b 6.02, Hev b 7.01, Hev b 7.02 Hev
b 8, Hev b 9, Hev b 10 and Hev b 11. The first 7 latex allergens listed
above are of medium to high significance, with Hev b 7.01 through
Hev b 11 having low significance in HCWs and children with spina
bifida. There is cross-reactivity, especially to bananas, avocados
and kiwi fruit, with Hev b 6.01 through Hev b 6.03. Hev b 8 to Hev
b 11 reveal low cross-reactivity with some fruit and mould allergens.
 A value of >0.35 kU/l was considered positive. Clotted blood was
collected and sent to Lancet Laboratory, Polokwane, for testing.
SPTs were performed on subjects who tested negative to blood tests.
We used standardised 1 mm-tipped lancets (ALK-Abello, Madrid,
Spain) and latex extracts (500 µg/ml protein concentrate). Histamine
(10 mg/ml) was used as a positive control and normal saline as a
negative control (ALK-Abello). A drop of the extract was placed
on the volar area of the forearm and introduced into the epidermis
through lancet puncture. The result was examined after 15 minutes
and the average diameter of the wheal measured. A positive result
was interpreted as an average diameter of ≥3 mm compared with the
A total of 158 HCWs (all nurses) returned the questionnaires and
therefore participated in the baseline study, giving a participation
rate of 79.5% (158/200). Doctors and cleaners did not return the
questionnaires, perhaps because they did not regard themselves as
being at risk for latex allergy. Demographic characteristics of the
study participants are presented in Table 2.
The mean age of the study participants was 39.6 years (standard
deviation (SD) 9.8 years, range 20 - 60 years). There were more
females (98.1%) than males. Fourteen participants did not continue
with the study due to: death (2), proving untraceable (4), and refusal
to continue for personal reasons (8). Glove-related symptoms were
present in 59 HCWs (37.1%), of whom 7 (11.9%) had positive SPTs
to latex (95% confidence interval 4.2 - 22.9%). Latex (K82) titres of
the participants who tested positive were, in ascending order, 0.87
kU/l, 1.16 kU/l, 2.51 kU/l, 3.61 kU/l, 7.74 kU/l, 14.5 kU/l, and 45
kU/l. Thirty-eight participants with negative blood tests underwent
SPTs, 5 of which were positive, with readings of 3 mm, 3 mm, 4 mm,
4 mm and 7 mm.
Positive SPTs were reported in 5 out of 38 workers with negative
blood tests (13.2%), indicating that blood tests missed 11.1% of
latex-allergic individuals (5/45). The prevalence of latex allergy
among HCWs was 8.3% (12/144), after adjusting for the 14
subjects lost to follow-up before SPT. The symptoms experienced
were rhinitis in 12 (100.0%), asthma in 6 (50.0%), dermatitis in 3
(25.0%), anaphylaxis requiring mechanical ventilation for 2 weeks
in 1 (8.3%), urticaria in 1 (8.3%), abdominal pain in 1 (8.3%) and
angio-oedema in 1 (8.3%).
The number of latex-sensitised or allergic individual HCWs per
workstation was also determined (Table 3). The proportion was
highest among labour ward staff.
Clinical symptoms in participants who met inclusion
criteria for sensitisation testing
The clinical symptoms of the participants are listed in Table 4. Of
note is that 54 participants had more than one symptom. Among
those who were positive to either the ImmunoCAP test or the SPT,
symptoms were as follows: 5 had 1 symptom, 4 had 2 symptoms and
the other 3 had 3 or more symptoms. All the participants who tested
positive had rhinitis, and half had asthma. There was no statistically
significant difference between the sensitised (latex-positive) and non-
Table 2. Demographic characteristics of the study participants
20 - 247
25 - 2921
30 - 34 21
35 - 39 29
40 - 4424
45 - 49 30
Table 3. Prevalence of latex allergy and sensitisation according to workstation
Prevalence of latex
Labour ward and antenatal
Intensive care unit
Obstetrics and gynaecology
393 June 2013, Vol. 103, No. 6 SAMJ
sensitised (latex-negative) groups with regard to rhinitis, asthma,
anaphylaxis requiring ventilation, abdominal pain, urticaria and
angio-oedema (p>0.05). A statistically significant association was
observed with regard to dermatitis in terms of latex exposure in the
two groups (p<0.05).
The participation rate was adequate, with 79% answering the
questionnaires. The sample was not obtained by random selection,
however, but depended on participants returning questionnaires. As
a result, generalisability to the hospital may not be possible.
Among the 59 participants who met the inclusion criteria (symptoms
due to using latex gloves), 12/45 (26.7%) tested positive for latex
sensitisation by ImmunoCAP or SPT. The findings are comparable to
those of studies conducted at Dr George Mukhari Hospital (Pretoria)
(22%) and Groote Schuur Hospital (Cape Town) (25.3%).
Our latex allergy prevalence of 8.3% is higher than the 4.2% at the Dr
George Mukhari Hospital, which is our sister hospital. This difference
can partly be explained by the fact that in the latter study only the
ImmunoCAP test was performed, with no SPT follow-up. We calculated
our prevalence with only the ImmunoCAP without an SPT result in the
participants with negative blood tests and found a prevalence of 4.9%
(7/144), similar to that of the Dr George Mukhari study.
The prevalence of latex allergy at other SA teaching hospitals and
institutions has been reported as: Groote Schuur Hospital (Cape Town)
9.2%, Red Cross War Memorial Children’s Hospital (Cape Town) 5%,
Tygerberg Hospital (Parow, Cape Town) 20.8% and the South African
Institute of Medical Research, now the National Health Laboratory
Service (Johannesburg), 10.5%. Our prevalence of 8.3% is comparable
to most of these, with only Tygerberg Hospital demonstrating a higher
prevalence of 20.8%. The actual prevalence of latex sensitisation may be
higher than these figures suggest, because some studies show that 25%
of SPT-positive patients may be asymptomatic.
Rates of latex sensitisation and allergic reactions have increased
in HCWs exposed to NRL since the 1980s, with prevalences of
6.9 - 17% reported.[11,12] A study on primary prevention of NRL
allergy in Germany by Allmers et al. has confirmed a positive
correlation between the use of powdered NRL gloves and suspected
occupational latex allergy. There is recent evidence that rates
of NRL allergy have fallen significantly as a result of latex-free
environment strategies and use of low-allergen, powder-free gloves
in some industrialised countries. Termination of exposure to NRL
products is an accepted means of secondary prevention in latex-
The commonest presenting symptoms in both latex-positive and
-negative participants who met the inclusion criteria were nasal
(100.0% and 74.5%, respectively), followed by asthma in latex-
positive (50.0%) and contact dermatitis in latex-negative subjects
(46.8%). Other symptom profiles did not reveal any significant
differences between latex-positive and -negative participants. There
was no statistically significant difference in symptoms between the
latex-sensitised and non-sensitised participants, except in those who
presented with dermatitis. This can be explained by the fact that the
k82 ImmunoCAP does not test some Hev b allergens such as Hev b
6.03, Hev b 12 and Hev b 13. SPTs may be negative even in people
who are sensitised or allergic to latex, as sensitivity has been shown
to be 93 - 96%.
Shortcomings of the study
Greater participation, especially by doctors, would have improved
the power and generalisability of the study. Several participants
only had blood testing performed without follow-up SPTs, which
could have influenced the prevalence, as some might have tested
positive by SPT.
NRL allergy has been shown to be an important cause of occupational
disease. It is important to increase awareness of the sensitising and
disease-causing effect of latex gloves in HCWs. Powdered gloves may
cause serious latex allergy problems because the latex proteins adhere
to the powder, become airborne and are subsequently inhaled. This
can cause sensitisation in atopic individuals.
Powdered latex gloves can be a hazard not only to the wearer but
also to other people in the workstation. The importance of creating
latex-free workplaces cannot be over-emphasised, as evidenced by one
of our participants who developed anaphylaxis requiring mechanical
ventilation. In an ideal situation latex-free gloves should be used,
especially in high-exposure areas. This is not feasible in most settings,
however, because of the high cost of these gloves. It is therefore
recommended that powder-free, low-allergen gloves be used as a
preventive measure because of their ability to decrease sensitisation.
Individuals who are sensitised to latex should avoid direct contact with
latex gloves but can work at the station with other workers provided the
latter are using powder-free gloves.
Once an individual is sensitised it is difficult to prevent the
emergence of symptoms, especially systemic reactions on contact with
latex. Everyone with proven latex allergy should wear a Medic Alert
bracelet or band to help HCWs avoid using latex-containing products
Table 4. Clinical signs and symptoms
Latex-positive group (sensitised)
Latex-negative group (non-sensitised)
Anaphylaxis needing ventilation
*Fisher’s exact test.
RESEARCH Download full-text
394 June 2013, Vol. 103, No. 6 SAMJ
such as urinary catheters, endotracheal tubes, oxygen facemasks and
laryngeal airways when caring for them.
The prevalence of latex allergy in HCWs at Mankweng Hospital
is significant, and represents a serious occupational disease. It
is important to strive for a latex-free working environment for
HCWs, especially atopic workers. Risk risk of latex allergy could be
minimised by decreasing extractable proteins in latex products. This
may reduce the risk of litigation against the hospital and Department
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Accepted 18 February 2013.