AT DEPARTMENT OF HEALTH AND
HUMAN SERVICES
UNITED STATES FOOD AND DRUG ADMINISTRATION
CENTER FOR FOOD SAFETY AND APPLIED NUTRITION
ADDITIVES AND INGREDIENTS SUBCOMMITTEE
OF THE
FOOD ADVISORY COMMITTEE
LATEX ALLERGY
Tuesday, August 26, 2003
9:10 a.m.
St. Regis Hotel
923 16th Street, Northwest
Crystal Ballroom
Washington, D.C.
PARTICIPANTS
Johanna Dwyer, D. Sci., Chair
Richard Bonnette, Executive Secretary
MEMBERS
Jeffrey Blumberg, Ph.D.
Goulda Downer, Ph.D.
Lawrence Fischer, Ph.D.
Anthony Gaspari, M.D.
Robert Hamilton, Ph.D.
Rachel Johnson, Ph.D.
Brandon Scholz
Steve Taylor, Ph.D.
J. Antonio Torres, Ph.D.
C O N T E N T S
Welcome and Introductions
Committee Chair 5
Conflict of Interest Statements
Committee Executive Secretary 7
Welcome
Alan Rulis, Ph.D. 11
Overview of CFSAN's Office of Food Safety
George Pauli, Ph.D. 14
Charge and Questions
Laura Tarantino, Ph.D. 29
Basic Latex Allergy Background
Jay Slater, M.D. 39
Questions of Clarification 70
CDRH Proposal
Mel Stratmeyer, Ph.D. 96
Questions of Clarification 107
Safety Assessment of Food Additives
Anna Shanklin, Ph.D. 128
Questions of Clarification 151
Specific Background on Food Mediated Latex Reactions
Mark Hepp, Ph.D. 163
Questions of Clarification 183
Progress in the Management of NRL Allergy
Vesna Tomazac-Jezic, Ph.D. 200
Questions of Clarification 212
C O N T E N T S (cont.)
Invited Comment
Don Beezhold, Ph.D. 229
Questions of Clarification 243
Invited Comment from a State with Latex Food Service Glove
Prohibition
Michael Heumann 260
Questions of Clarification 283
P R O C E E D I N G S
Welcome and Introductions
DR.
DWYER: Good morning. Welcome to the latex allergy
discussion. CFSAN's concern with the
use of natural rubber latex gloves in retail food establishments and the food
service industry is focused on whether such use may result in the production of
unsafe food, and that is what we are gathered here this morning to talk about,
separating the issues related to worker exposure and occupational safety from
those of food safety.
I
am Johanna Dwyer and I am chairing this meeting today. The task before this Food Advisory
Subcommittee is to consider the available information related to food mediated
latex allergic reactions and the use of latex food service gloves in
establishments that prepare food for public consumption, so specifically, there
are several issues that FDA has requested feedback from the committee on.
The
first question that we will return to over the course of the next two and a
half days is has a positive relationship been established between the use of
natural rubber latex gloves in food service and allergic reactions to food
served in food establishments or sold at the market based on the data that are
available to the committee.
If
such a relationship exists, what is the strength of that relationship and has
it been shown to be causative. Second,
if a positive relationship has been established and shown to be causative, can
the Advisory Committee suggest science-based options to mitigate food mediated
latex allergy risk?
Finally,
if current evidence isn't sufficient to establish a relationship, what
additional questions need to be addressed to adequately understand this issue?
So,
we have got a lot of work to do. I
think our main task is to keep focused on the specific questions the agency has
asked us to answer rather than the broader questions that these issues raise.
Mr.
Bonnette.
Conflict of Interest Statements
MR.
BONNETTE: Good morning. My name is Richard Bonnette and I am the
Acting Executive Secretary for the Additives and Ingredients Subcommittee of
the full Food Advisory Committee.
I
will read into the record the temporary voting member appointment and conflicts
of interest statement.
By
the authority granted under the Food Advisory Committee charter of July 2002,
the following individuals have been appointed as temporary voting members by
Joseph A. Levitt, Director, Center for Food Safety and Applied Nutrition. Anthony Gaspari, Robert Hamilton, and Steve
Taylor.
With
regard to the issue of conflict of interest, committee members, permanent and
temporary, were screened for interests in latex glove manufacturers. As a result of this review, in accordance
with 18 U.S. Code Section 208(b)(3), Dr. Johanna Dwyer has been granted a
particular matter of general applicability waiver that permits her to
participate fully in the matters at issue.
Copies
of the waiver statement may be obtained by submitting a written request to the
agency's Freedom of Information Office, Room 12A-30 of the Parklawn Building.
We
would also like to note that Mr. Brandon Scholz is participating in this
meeting as the Industry Representative and is a non-voting participant.
It
should also be noted that Dr. Charles Reed, who will be speaking tomorrow, was
invited by the latex glove industry to speak.
With
respect to all other participants, we ask in the interest of fairness that they
address any current or previous financial involvement with any firm which makes
latex gloves.
I
will just at this time make a few housekeeping notes especially to the
committee and to the upcoming speakers.
When
you use the microphone, you have to press a little button to turn it on and
then press the button again to turn it off.
That is only an issue because we can only have four mikes open at any
one time.
We
will be using, for the speakers we will be using a hand-held wireless mouse,
and basically what you need to know to advance your slides is there is a little
trigger in the bottom that will move you onto the next slide.
DR.
DWYER: Could we go around the table and
just introduce the various members, Mr. Bonnette.
MR.
BONNETTE: Sure.
DR.
DWYER: Mr. Scholz, could you start off.
MR. SCHOLZ:
Brandon Scholz with the Wisconsin Grocer's Association.
DR.
DOWNER: Goulda Downer, President and
CEO of Metroplex Health and Nutrition Services.
DR.
JOHNSON: I am Rachel Johnson. I am Professor of Nutrition and Dean of the
College of Agriculture and Life Sciences at the University of Vermont.
DR.
GASPARI: I am Tony Gaspari. I am Professor and Chair in the Department
of Dermatology, University of Maryland School of Medicine.
MR.
BONNETTE: I am Richard Bonnette. I am the Acting Executive Secretary for this
meeting.
DR.
DWYER: Johanna Dwyer, Tufts University,
Schools of Nutrition, Science and Policy, and Medicine.
DR.
BLUMBERG: I am Jeff Blumberg. I am a Professor of Nutrition at Tufts
University.
DR.
TAYLOR: Steve Taylor. I am Professor and head of the Department of
Food Science and Technology at the University of Nebraska.
DR.
HAMILTON: Robert Hamilton. I am a Professor of Medicine and Pathology
at the Johns Hopkins University School of Medicine.
DR.
FISCHER: I am Larry Fischer from
Michigan State University, Director of the Institute for Environmental
Toxicology.
DR.
TORRES: I am Antonio Torres, Professor
of Process Engineering, Oregon State University.
MR.
BONNETTE: Next on the Program we have
Dr. Alan Rulis from the Office of Food Additive Safety.
Welcome
DR.
RULIS: Good morning everybody. It is my privilege this morning to offer a
few words of welcome to this first meeting of the newly created Additives and
Ingredients Subcommittee of CFSAN's Food Advisory Committee.
I
am Alan Rulis. Until recently, I was,
for some years, the Director of the Office of Food Additive Safety in the
Center for Food Safety and Applied Nutrition.
Now, I am working directly with our Center Director, Joe Levitt, on
another area, Applied Nutrition. But I
was granted this opportunity by the Acting Director of the Office of Food
Additive Safety, Laura Tarantino, to address you this morning.
My
main message to you assembled Subcommittee members, is thank you for giving
generously of your time and letting us benefit of your expert knowledge in dealing
with the issue of natural rubber latex in the food setting.
During
my tenure as the Director of OFAS and in other capacities in the Center, I can
verify that we have, indeed, benefitted greatly from Food Advisory
Committees. Of those Food Advisory
Committees that I have been directly involved with, in particular two that we
held on Olestra in November, 1995 and June of 1998 and, last summer, on
methylmercury in seafood, I can say that they were extremely helpful to the
agency in reaching a solid decision.
They
helped ensure that our decisions of benefit of objective, public, balanced
discussion and examination of all issues from all sides. That has helped assure that we make credible
decisions that are founded firmly on scientifically sound principles and
evidence. We expect no less from this
meeting in its agenda on the issues of allergy and related issues surrounding
the use of natural rubber latex in food service.
We
expect your deliberations will help us greatly. So, again, welcome and all the best to you in your deliberations
today and in the coming day or two.
Thank
you.
MR.
BONNETTE: Next on the program, I would
like to welcome Dr. George Pauli also from the Office of Food Additive Safety.
DR.
DWYER: Dr. Rulis, while we are waiting
for the projection, could you tell us where the methylmercury final decision is
posted or published.
DR.
RULIS: Of course, as with all such
public advisory committees, there is a transcript available of that
meeting. There were recommendations
that resulted from the meeting. There
was a decision to incorporate in the Center for Food Safety and Applied
Nutrition's Priority Program, that is, the so-called Yellow Book that is the
publication of the Center's priority activities for any given year, an element
that is directly related to that advisory committee to examine the messages
that are on labels of fish that will be supplied when fish is offered for sale.
We
are to look at that carefully and decide, based on what we know at the moment
and what other organizations are doing, not only federally, but at the state
level, to derive an appropriate method for marine seafood that is in interstate
commerce relative to the methylmercury issues.
So,
we are in the process of doing that. We
are currently, in this fiscal year, working on that recommendation, and I
expect that something public will happen soon, but I can't predict when.
Overview of CFSAN's Office of Food
Additive Safety
DR.
PAULI: Thank you. Let me also join Alan in thanking you for
being here to help us weave through these tricky and sometimes controversial
issues.
I
am George Pauli, the Associate Director for Science and Policy in the Office of
Food Additive Safety.
I
thought I would take this slide just to acknowledge something that--the name of
the subcommittee Additives and Ingredients, most people would probably think
isn't that the same thing, but one of the things I want to do today is mention
a few of the differences and also, because the Office of Food Additive Safety
is responsible for our statutory obligations under the Food, Drug, and Cosmetic
Act for both additives and ingredients, I will start by introducing you to the
Office of Food Additive Safety, which will give some of you an orientation for
future meetings, as well as this one.
Looking
at our mission statement, if I can emphasize a few of those bullets, we
evaluate new applications for new ingredients or new additives. We want to make sure that everything we do
meets a high performance standard based on science, and we want to, as we are
doing today, monitor safety over time because any decision is made with the
information you have, and we are in the business of making decisions, so have
to continue to monitor to find if there is any new information that would cause
us to rethink some of our decisions.
We
also have a modest research program to try to support this monitoring effort.
A
little introduction to what the office looks like. I will just emphasize some of the different functions. The Division of Food Contact, Substance Notification,
we have responsibility for anything that becomes a component of food because
food is touching it or somehow it is getting in the food even though nobody
intends for that to happen.
We
have a Division of Petition Review for essentially new food ingredients and
color additives where there is a formal process to get an approval.
We
have a Division of Biotechnology and GRAS Notice Review, which refers to many
ingredients don't require approval, but we have to know whether they are
ingredients that don't require approval or if they are additives that must be
approved through the Division of Petition Review.
Finally,
our research wing on the far right.
One
of the things that is related to this meeting and other meetings we will be
having in the future, one of things that has come into context as being very
important in recent years is the issue of allergies. So, we now have for the first time, for about a year now, an
allergist in our office, Dr. Luccuoli, who is sitting at the side table over there.
Food
Additive Decision Framework. I will
have to recognize that under the law, different approaches are used for
distinction segments or components of food.
Sometimes people are concerned that everything should have the same
standard, but there is a higher standard for those substances that are used
intentionally in a manner whereby human have a choice to use it or don't use
it, or to use it with controls or don't use it with controls.
So,
from that standpoint, food additives, color additives, food contact substances
require a pre-market approval of a very high standard of safety. Ingredients that are generally recognized as
safe have essentially already met that safety in the scientific community at
large and put in a separate category.
Dietary
ingredients and dietary supplements are under a new framework since 1994, and
contaminants, of course, nobody wants, but it is a question of how hard you
control it that have to have a different standard, as well.
Now,
one of the things I think that is important is that all authority that we, at
the Food and Drug Administration, have to control and enhance the safety of
food is derived from the authority that has been given to us by Congress,
primarily through the Federal Food, Drug, and Cosmetic Act.
That
is certainly true of the Office of Food Additive Safety where the Federal Food,
Drug, and Cosmetic Act is the main authority we have to do anything. For that reason, we have to look at two
standpoints. Statutory standards, are
we doing something we would like to do, or have we actually been given
authority to do that, to make that kind of decision.
The
decision we make has to be consistent with the statutory standard that Congress
gave us. One of the good things of the
statutory standard is it relies on scientific principles, so we can use our
science to get the facts right, but those two parts are so fundamental you
can't ignore either one.
Now,
this advisory committee, we bring together scientists to emphasize the
scientific principles part, but we just have to recognize that what the
ultimate regulatory decision is depends also on the statutory standard.
Now,
the Food, Drug, and Cosmetic Act of 1938, a part of the New Deal legislation,
was amended several times, but four times that is particularly important to
us. In 1958, it was amended with the
Food Additives Amendment requiring pre-market approval for food additives.
In
1960, it was amended with the Color Additive Amendments for color additives and
foods, drugs, and cosmetics.
In
1994, it was amended with the Dietary Supplement Health and Education Act that
exempted certain ingredients in dietary supplements from the food additive
provisions.
In
1997, with the Food and Drug Administration Modernization Act, the regulation
of food contact substances is modified to make it streamlined through a
notification program. However, the
safety standard with the notification program for food contact substances is
the same as it was before, the data we require are the same as before. It is just the procedure that we follow to
get approvals is a little bit different.
We
look at some of the basic principles of these amendments, defines a food
additive with an exemption for those ingredients that are already generally
recognized as safe. I always use my
favorite example - no one is ever going to ask us to approve the use of water
in soda population. That is a
no-brainer, everyone knows that one.
Or
vitamin C as a nutrient supplement in many foods, however, when you have a new
ingredient where there isn't a consensus in the scientific community, where the
knowledge of it isn't widely known, then, we have the food additive.
As
I mentioned, there is also an exemption in the food additive definition now for
dietary ingredients and dietary supplements.
If something meets the food additive definition, you must have
pre-market approval before the product is sold in the U.S.
The
statute establishes the standard of review, establishes the standard of safety,
establishes formal rulemaking procedures whereby we can issue requirements or
issue approvals.
Now,
the statutory definition is a very broad one, and I do not have all the words
of the definition on this slide. There
are several examples given which would run onto about two more slides if I gave
them all.
But
we will get very broad. Any substance
which because of how it is being used, intended to be used, not accidentally,
but intended to be used results or may reasonably be expected to result,
directly or indirectly, in its becoming a component of food or otherwise
affecting the characteristics of any food.
The
definition goes on with some examples, such as sources of irradiation equipment
which can affect the characteristics of food or food additive, substances used
in the packaging, manufacture of food, and that is what we are dealing with
this week.
You
have the big exemption for those substances whose use is generally recognized
as safe, and let emphasize the word "use." We do not evaluate the safety of substances, we evaluate the
safety of how substances are used. So,
it is very much a safe under intended conditions of use standard.
Examples
of the universe that we are responsible for in our office - direct food
ingredients, sweeteners, preservatives, and the like. That would be generally food additives, but not always. Color additives are generally recognized as
safe ingredients uses, which overlaps with the direct food ingredients
certainly, and it also overlaps with food contact substances, such as iron pans
for cooking. Some of that iron is going
to get into food, but no one is concerned about that.
Food
ingredients produced using modern biotechnology to ensure that it is still the
same food and you haven't come up with something new that we don't understand,
in which case it could come in under the food additive provisions.
Processing
aids that may be in contact with food for a short time or that may be used in
food, but then are decomposed by heat or something, so that they are no longer
in the final product. As mentioned
before, food irradiation equipment and what we are focusing on this week, food
packaging and food contact substances.
Standard
for safety, which comes out of the legislative history of the food additive
amendment, is reasonable certainty of no harm, and we look at that in the words
of Congress there, "The concept involves the question of whether a
substance is hazardous to the health of man or animal."
So
the harm we are talking about is harm to health. It says "man or animal" because the same applications
apply to ingredients in packaging used for animal feed for pets or
food-producing animals.
"Safety
requires proof of a reasonable certainty that no harm will result from the
proposed use of an additive." You
will hear this a few more times before this week is over.
I
have to also note--again, it's the words of Congress--"It does not--and
cannot--require proof beyond any possible doubt that no harm will result under
any conceivable circumstances."
I
have to say we are in the business of making decisions. We cannot expect absolute certainty in any
decision, but when are you to the reasonable stage, when are you going over the
edge, or where don't you have enough information to proceed at all is part of
the judgment that comes in here and where we ask for help.
For
a new food additive, petitioner has the burden to demonstrate this reasonable
certainty of no harm, and again I have emphasize from the intended use of the
additive. We find that there are some
things that we regulate that may cause health problems when used in a totally
different manner, and we just can't address other uses outside of the intended
use with food.
From
doing that, we look at whether we have adequate data to say reasonable
certainty of no harm has been demonstrated.
Now,
part of understanding what reasonable certainty is, is today's food--and I have
put in quotation marks, "New" and "Today" because this has
been going on for 45 years now--there is an underlying assumption in the food
additives amendment that unprocessed food from the farm is safe and that no one
should be allowed to use some substance in a manner to make that food less
safe.
So,
it gives us a little bit of an idea of what we mean by "safe" and
"certainty." We are looking
at food as being the gold standard. Of
course, one thing we know today, that we didn't know in 1958, is that is again
not absolute safety.
The
olden days, which I define as from 5 to 30 years ago, we managed to do
everything in our office by strong control.
We had food additive petitions, we had color additive petitions, and if
something did not require approval because it was generally recognized as safe,
we had GRAS affirmation petitions even when approval was not required.
Now,
the petition review process, just to give you an idea of what we were looking
at, it is not an academic inquiry or academic research. Many times one sees data and say this is
interesting, I would like to explore that more, but if it doesn't get right at
the food safety decision, we don't go there.
It
will have to be focused on safe under conditions of use, not on interesting
things that are beyond that. Therefore,
it is not a search for complete knowledge, can't assure safety with absolute
certainty, does not weigh risks and benefits.
People
are often surprised at that, but as I mentioned before, there is an underlying
assumption that food is safe, if that's the case, why would you take a risk
with something, what benefits are there?
You already have a safe food.
Again,
I think we are looking at things maybe a little different in some ways today,
but that still is what the law is. That
is still the standard. We don't weigh
risks and benefits, and it is not intended to enforce or limit consumer or producer
choices among safe foods. There is no
need base here.
We
sometimes see in some countries of whether there is a need to use
something. That is not one of our
standards. The standard is, is it safe
under the conditions of use. The
marketplace will decide whether they need it, the consumer will decide whether
to buy it, the producer will decide whether or not it is in their interests to
use that substance, that material.
The
food additive decision process does, in fact, ensure safety as we look through
what we have done for the last 45 years.
We have a good track record.
Occasionally, uncertainty comes in, but we haven't really seen safety
issues with things that have been approved.
The safety issue is more with ingredients that were used prior to that
time.
It
is a consensus decision. No individual
is ever responsible for the decision.
We share that responsibility, we argue with each other, and eventually,
someone, possibly the Commissioner or possibly the Secretary of Health and
Human Services may make the ultimate decision.
The ultimate decision rests with the Secretary of Health and Human
Services, but that authority is delegated down for decision. That doesn't require such a high level of
person.
Today
and sort of the shape of the future, we have had consultations on modifications
of food through bioengineering actually since 1994. We now have programs where people who conclude that the way they
intend to use an ingredient is generally recognized as safe because the law
doesn't require approval.
We
do have a program where they can notify us just to make sure that we don't have
people working at cross purposes, one person concluding one thing and FDA
concluding something else and saying we will meet you in court, so we have a
program where companies do let us know, for those ingredient uses that they
think do not require approval, and we have food contact substance notification,
which as I mentioned before require all the data of the old petitions, but
under a current law, since 1997, a law which took effect a few years later, we
get notifications with the data why the use of a food contact substance is
safe, and we at FDA have 120 days to disagree with that if we believe that they
have not met their burden.
Now,
a final little issue of looking back at everything we look at. If you look at whole foods, you have to evaluate
those differently than you do ingredients.
You don't get 100-fold safety factors from toxicity data for whole
foods.
As
we go from the bottom working upward in the slide, we get to human exposure
that gets less and less, and where we generally require less data, but we can
apply safety factors, we are looking at things that are used at levels faro
below where they would cause any harm, and now again, as we are reminding
ourselves this week, we are even getting into the allergy area where one question,
how low do you have to go when you are considering the safety of something that
may be allergenic.
That
is not on this chart, but I would put that up sort of at the top end of the
very small amounts of things that we are concerned with.
I
hope this gives you a little understanding of the responsibilities of our
office, and, hence, the responsibilities of this subcommittee that we are going
to be looking for advice.
If
anyone has any particular questions, I would be happy to try to answer them;
otherwise, we will move on to our next speaker.
DR.
DWYER: Thank you very much.
Two
things, just a quick one. Does everyone
have the handout on the committee?
Okay. Could you please see to it
that everybody has all the handouts.
Secondly,
are there any questions after that illuminating introduction? Any questions from the committee?
Thank
you for setting this process in context.
Since
there are no questions, I think we can proceed to Dr. Tarantino, who is at the
Office of Food Safety and Quality, and she is going to give the committee its
charge and review the questions.
Dr.
Tarantino.
Charge and Questions
DR.
TARANTINO: Thank you, Dr. Dwyer and
members of the Additives and Ingredients Subcommittee. Good morning.
As
she said, I am Laura Tarantino, and as Alan said, I am currently Acting
Director of the Office of Food Additive Safety, and my job here is to go from
the very general introduction to begin to outline your task that we are going
to ask you about for the next couple of days and to amplify a little bit on the
charge and questions and what we are after that Dr. Dwyer read to you earlier.
I
am going to join George and Alan in also thanking you for taking time out of
what I know are busy schedules to come to D.C. and to help us with what I think
you are going to find to be a challenging and a little bit of a vexing issue,
at least it has been for us, so we are looking forward to your help.
That
issue obviously has to do with latex allergy and I know we are aware and you
are all aware that allergy and response to natural rubber latex is a very real,
very significant public health issue, and a very serious and sometimes actually
life-altering concern for those that are affected.
Those
that are affected, as you know, are particularly groups that have had prolonged
heavy exposure to natural rubber allergens, such as healthcare workers, people
in the rubber industry, and patients, particularly young patients who have been
subject to a number of surgeries.
The
latex allergy resulting from that occupational exposure or medical exposure has
been the subject of a lot of study, a lot of work over the last decade or so,
and there has been a variety of government agencies, professional
organizations, patient groups, other groups that have been very involved with
taking steps to try to reduce the risks associated with that occupational or
medical exposure risk.
You
are going to hear about some of those steps at this meeting, but as you heard a
few minutes ago, our authority and our focus here is specifically on latex
allergy as it relates to food safety and food additive safety.
As
noted in the background materials that you have had, I think, natural rubber is
an approved food additive. It is
approved for a variety of uses actually including some food contact
applications, and George mentioned those food contact applications being, well,
food contact, one of which is latex gloves that are used in food service
applications.
The
pertinent regulations that allowed this use were actually promulgated in the
1960s through the process that was outlined by Dr. Pauli, that is, there were
petitions. There were petitions that
had data and information which allowed and supported a finding of safety, a
finding of reasonable certainty of no harm for those uses.
Well,
why are we here? What happened since to
come before this committee? Obviously,
one of the things that has happened is the use of natural rubber latex
particularly for gloves has increased dramatically both in the medical care
setting to try to quell the transfer of microorganisms and infectious disease,
and in the food setting as we attempted to try to control foodborne illness.
So,
during this period, then, there was an increase in exposure to latex by a
number of people and during that time, then, there is a population of
individuals who are sensitized to natural rubber latex allergens in the
population, this population started to appear.
Then,
we at CFSAN started getting reports of people who were sensitized to natural
rubber latex allergen, who are allergic to latex, who believed that they were
having a reaction to food that had been handled and touched and worked on by
food safety workers using latex gloves.
So,
now, then, the question for us becomes what is the evidence that the use of
natural rubber latex and contact with food may render the food unsafe. If you want to put it another way, this use
of natural rubber latex, is it possible that that use may no longer reach
reasonable certainty of no harm.
As
you are going to hear over the next day or two, this isn't a simple or
straightforward question, or maybe I should say the answers to the question
aren't simple or straightforward.
So, with this background, then, let me return
then to the charge and questions that were provided to you this morning and
read to you early.
To
repeat what we mentioned, our concern is that this use is focused on whether
such use may result in the production of unsafe food and that it is important
to separate issues related to worker exposure and occupational safety from
those of food safety while not minimizing the issues that are related with that
worker safety and occupational use, but that is different from where we want
you to focus your attention right now.
So,
the task before you is to consider the available information relating to food
mediated latex allergic reactions and the use of latex food service gloves and
establishments that prepare food for public consumption.
That
is, we have been collecting relevant information related to reported food
mediated latex allergic reactions, and we are asking that you look at this
information, tell us whether there is information out there that we are not
aware of that is relevant, and evaluate the scientific evidence that is out
there and which would serve as the basis for any regulatory action we might
take.
That
is, we are asking you what is the strength of the science, what is the strength
of the available information, and, in fact, then, considering that available
information, this is kind of the threshold question for us - has a positive
relationship been established between the use of natural rubber latex gloves in
food service and allergic reactions to food served in those establishments
based on the available data? If it exists,
what is the strength of the relationship, and has it been shown to be
causative?
So,
this is important because any regulatory action we might take is going to have
to rely on the scientific evidence, which in a decision we are going to have to
document, support by a record, and must withstand scientific challenge.
So,
weighing all the evidence before you here, we are looking for your advice about
the strength of the evidence and whether it establishes a link between the use
of the gloves and food mediated latex allergic reactions.
If
the answer to that threshold question is yes, the evidence does establish a
causative relationship, then, we are asking you where does the scientific
evidence lead us to scientifically justifiable options on our part.
For
example, is the evidence out there leading to powder versus non-powder? Is it leading to protein levels,
manufacturing methods? Are there things
that are already happening now that are getting at the question of making these
gloves less of a problem?
So,
the meaning of this question is if it's yes, then, what does it tell us and
what kind of options should we be looking at that we can justify by the data.
On
the other hand, if the evidence in front of us does not allow us to reach a
conclusion, we are looking to you if you have ideas about specific information
or data or studies that you think would be particularly helpful for us, so that
we can decide whether there is a positive relation or not.
So,
that is pretty much your job. We are
very pleased to begin this discussion with you and look forward to your input
and advice, and I look forward to what is going to be I think an enlightening
discussion over the next two days, so thank you very much.
DR.
DWYER: Are there any questions from the
committee? Dr. Taylor.
DR.
TAYLOR: Dr. Tarantino, your questions
to us focus on the use of latex gloves.
Is that the only indirect contact with foods that is to be considered by
this committee?
DR.
TARANTINO: Very good question, because
you will hear later this afternoon that there are other uses and food uses both
as direct and food contact uses of gloves, so you are quite right. I think people this afternoon will say most
of the association that we have been presented with appears to be with gloves,
but I think it is a very, very valid question for you to consider as to whether
is it really gloves, is it only gloves.
This
afternoon, people will tell you about the other food contact uses that are out
there and approved. It's a good
question.
DR.
DWYER: But we are to consider only the
gloves, is that correct?
DR.
TARANTINO: If you decide that all the
data that you are presented with suggests that there are other sources of latex
allergens in food that are relevant, we would like that information.
DR.
DWYER: Dr. Taylor, do you want to
pursue that further?
DR.
TAYLOR: Well, I am just sitting here
thinking that if this committee should decide after hearing all the evidence
that this use is hazardous for some consumers, then, that has implications for
other uses of latex in contact with food, as well.
So,
it is hard for me to separate the two.
DR.
TARANTINO: I think in the course of the
talks, you will hear what kind of evidence and what is in the literature, and
what has appeared to point to gloves as being the primary issue. It is clear that latex and rubber has been
used for millennia, and latex allergy appears to be something that has appeared
in recent years.
I
think that is one of the things that you need to be looking at as you are
presented with the evidence that is in front of us.
DR.
DWYER: We will put a placeholder on
that and come back to it. We also need
to continually ask the questions of the various speakers, and I think we need
to do it right after the speakers speak, because some of them leave.
Thank
you, Dr. Tarantino.
We
are going to take a break now, but we have got a committee that can drink
coffee fast, and with your indulgence, we will make the break 15 minutes.
We
will see you back here in 15 minutes sharp, so we can get back on
schedule. We are a little off.
[Recess.]
DR.
DWYER: I have been asked, to make it
easier, they take complete transcripts of these deliberations and if we could
identify ourselves, when you turn on the microphone, if you would just say your
name, it makes it much easier for the transcript to reflect who said what. So, I would appreciate that.
The
next speaker should be particularly informative. We are fortunate to have Dr. Slater, who is with the Center for
Biologics Evaluation and Research at the agency, and he is going to present a
useful background for us on the whole issue of latex allergy.
I
also trust that you have all had your box, if you will, or not a box, but a big
group of materials that was sent to us late last week, and you may want to
refer to that, as well.
Dr.
Slater, are you all set with our audiovisuals?
DR.
SLATER: I think I am.
DR.
DWYER: Thank you for coming and we are
looking forward to hearing what you have to say.
Basic Latex Allergy Background
DR.
SLATER: Thank you for inviting me. When I was asked several weeks ago to
present this general overview, I was pleased to accept subject to sort of time
constraints in that I just got back from vacation yesterday, but I am
especially pleased about two things that surprised me when I came here this
morning.
One
is that there are at least two people on your committee that probably could
give this talk in my place, so I am glad that they are willing to listen to
me. The other is, as I looked over the
program, I see that there are many speakers who are in some ways partially
going to be covering the same ground.
That
is, in part, an unavoidable consequence of having several people come up and
talk and each give a little bit of background, so I really want to thank the
conference organizers, Dr. Hepp in particular, for putting me early in the
program, so I have a chance to say the things first and perhaps steal their
thunder.
Latex
allergy is a clinical syndrome and it is easy for us to get caught up in words,
but I think we have to step back and talk about what it is that we call latex
allergy. Now, there are more precise
terms that one could use. Latex allergy
are two words that almost everybody uses.
There is some imprecision there, but I think we can live with that as
long as we set the ground rules when we start.
Latex
allergy is a clinical syndrome that is characterized by these kinds of clinical
reactions upon exposure to natural rubber latex, and the reactions can be any
or all of these types of reactions. It
can be urticaria, which is hives, rhinoconjunctivitis, the sort of standard hay
fever symptoms, wheezing, and notice I use wheezing and not asthma, asthma
being a chronic disease. This is acute
wheezing associated with latex exposure.
Finally,
the entity that we all fear the most is anaphylaxis, and anaphylaxis is a
systemic multisystem allergic reaction that may include any or all of the above
plus hypotension and general vascular collapse.
I
didn't bring my favorite anaphylaxis slide, which actually came out of some
work that was being done at Johns Hopkins several decades ago with regard to
their studies of patients with bee sting allergy, but suffice as to say that
anaphylaxis, while we very glibly as allergists sort of hand our patients
single doses of epinephrine to treat anaphylaxis, anaphylaxis is, in fact,
extremely difficult to treat even under the best of circumstances, and the
mortality is significant, and certainly the mortality risk is significant.
Now,
there are other clinical syndromes that are called latex allergy, as well, and
I am going to mention those to exclude them at this point. Contact urticaria, simple hiving at the spot
where you are exposed to a substance can be the same kind of reaction as latex
allergy, but there are certainly several case reports that suggest that some patients
with contact urticaria alone have a different pathophysiologic mechanism going
on.
Certainly,
individuals with contact dermatitis, which is a poison ivy-like reaction on
exposure to latex product, that is clearly a different pathophysiologic
mechanism. This, by the way, is a
fairly common entity among healthcare workers and individuals who wear rubber
gloves. It can also happen as a cause
of foot dermatitis from rubber products that leach through the sox to the feet.
In
addition, there is an entity that, for lack of a better term, is called
irritant dermatitis, that happens in certain individuals especially when they
take gloves and put them on and off, and the way we can distinguish this from
latex-associated dermatitis is that this happens regardless of the construct of
the glove that they are using. So, in
other words, it would occur with non-latex gloves, as well.
What
we are talking about here today are IgE mediated allergic reactions. This is sort of the standard garden variety
allergy that you are probably all familiar with either from yourselves or from
relatives who have hay fever. In IgE
mediated allergy, antigen exposure leads to the generation of a specific
antibody called IgE that recognizes that antigen. The IgE is manufactured, as are all antibodies, by plasma
cells. It is released into the blood,
diffuses into the interstitial tissue where it encounters mast cells and binds
to the surface of those mast cells.
The
mast cells then are primed and ready for the next exposure to allergen, that,
in addition to eliciting further responses among the antigen-presenting cells,
T cells and B cells, elicits a very rapid reaction in the tissue mast cells
that leads to the release of mediators.
These
mast cells are packed with granules, which you can see here, you can see
granules being released. This release
occurs not in minutes to hours, but literally in seconds, and you can talk to
any individual who has been subjected to a ragweed inhalation challenge, and
they know that they have inhaled ragweed instantaneously, it is very, very
quick.
The
mediators that are released immediately are histamine and certain proteins that
are released, as well. Subsequently, other mediators that are not preformed are
released. That can elicit just as
significant types of reactions.
Latex
allergy has actually been around for a while.
The initial reports were in the German literature in the 1930s. These involved dental patients who reacted
to exposure to latex during procedures.
But then there was a hiatus of something on the order of 40 or 50 years
before the next report appeared in 1979 in Europe, and that was followed by a
series of reports in the European literature that really didn't receive much
attention here on this side of the Atlantic, but retrospectively, really
presaged our experience almost entirely.
The
initial reports in North America were in 1989, and those reports were followed
by a spate of reports throughout the world.
The reports were all clinical reports in which the device that elicited
the allergic reaction was listed, and most of these reports centered on latex
gloves, but there certainly are plenty of reports in literature of reactions to
other latex devices - condoms, catheters, cofferdams, which are basically
large, open sheets of latex that are placed in the mouth or in other cavities
to try to block the flow of fluid to a surgical site, surgical drains, what we
used to call Penrose drains, have elicited reactions.
There
have been many reports of adhesives causing reactions although very few reports
of systemic reactions from adhesives.
Many adhesive materials contain natural rubber latex. Finally, there have been reactions
associated with exposure to latex via latex stoppers. There are hundreds of other sources of latex that have been
listed, but all in relatively small numbers.
As
was indicated before, part of the problem with latex allergy and the reason it
seems to have followed the time course that it has, has been associated with
the dramatic increase in latex glove sales worldwide, and this is from no less
a medical and statistical source than USA Today, in March 1994, which shows
nicely and graphically the increase, and this is in billions of gloves that
were sold in the United States, going from 1.4 billion in 1988 up to very high
numbers within a few years.
This
was associated with universal precautions and has certainly been implicated in
a number of sources as certainly an association and possibly causative of the
latex allergy that we have witnessed.
Now,
latex allergy can occur in the general population, and we will talk about this
in a few slides, but you are also going to hear throughout the day today about
specific risk groups that seem to be more likely than the general population to
develop latex allergy.
I
really want to preface what I am going to say about this in saying that there
is actually considerable controversy about this, and I am going to try to
present the balance to you of the controversy.
But
it was clear from initial reports, from all of the initial reports, that there
seemed to be a greater likelihood of this happening in certain groups, and the
group that I studied back in the early 1990s was the group that had
meningomyelocele or spina bifida, and children with urogenital abnormalities,
all of whom underwent multiple courses of surgery and again from many medical
centers, mainly pediatric medical centers seem to be at fairly high risk of
Type 1 latex allergy.
Other
groups that unlike myself, were not pediatricians, but took care of adults,
seemed to focus mostly on healthcare workers who appeared with latex allergy,
and, in addition, there were some reports of rubber industry workers being at
increased risk, as well.
So,
the first question is why latex and what is it about latex that seems to elicit
these kinds of reactions. Well, the
answer is that latex is a natural product.
It actually been discovered by the native populations of South and
Central America a long time ago, was used largely for recreational purposes and
sometimes to provide wound dressings, but the widespread use of natural rubber
latex really didn't develop until the 19th century when Dr. Goodyear discovered
that by a process of vulcanization, which is heating latex in the presence of
sulfur, you could make a product that really was thermally stable.
The
British, when they first got to the New World instantly saw a use for the latex
that they saw the natives getting out of the trees, and the dipped cloth into
this latex material and sent it home and voila, raincoats. The problem was that when the latex got to
the temperatures in northern Europe, the latex actually flaked and was highly
brittle and wasn't particularly useful.
So,
what Dr. Goodyear discovered was a way of turning this natural product into
something that was stable and had properties that were of great use.
The
Europeans, mainly the British, invested considerable effort to getting the
latex plants out of the New World and into the Old World, as they did with many
of the plants that they found in the New World, and Kensington Gardens in
London basically originated as a place to take New World plants and try and
grow them in the Old World.
This
met with no success when they tried to export these plants to Europe, but they
did have success in setting up plantations in North Africa, and these
plantations have names like Goodyear and Firestone, and latex is now grown in
these essentially huge biofactories that consist of the latex trees, which are
called Hevea brasiliensis.
The
latex is harvested by scoring the tree with a sharp implement, placing a spout
at the bottom of that score, and then placing a cup under the spout. The workers go out in the pre-dawn hours,
they will score the tree, put the cup in place, take a break, and come back and
collect the ounces of latex from each tree.
It is actually incredibly labor-intensive work.
The
plantations actually have their own latex manufacturing plants usually on
location.
Here
is just a diagram of the bark of the latex tree. This is the outer bark.
It shows these transverse vessels in which the latex is transported to
the surface. Latex is actually not a sap, it's a common misnomer. Sap, as we know from maple trees, is an
extracellular product that contains sugars and relatively little else.
Latex
is an intracellular product that is very rich in nucleic acids, fats, as well
as proteins, and it actually has an organelle structure to it of which the
essential function unit is the rubber particle, which is about the size of a
human red cell.
This
rubber particle contains, in its interior, pure cis-1-4-polyisoprene. That is the hydrocarbon polymer that we all
want and that we all use, but in addition, the rubber particle is coated with
multiple proteins, and there are other multiple proteins that are present in
latex as it comes out of the tree.
Another
important thing to realize is that latex gloves are dipped products. It was realized fairly early on that not all
things made out of natural rubber latex had the ability to elicit allergic
reactions with equal likelihood.
For
instance, we all know why Goodyear and Firestone have latex plantations. They are making tires. It's relatively uncommon to find somebody
who works in an auto shop who has latex allergy or who works in a tire place
who has latex allergy.
It
has happened, but when it has happened to me, I have always been able to
associate it with a medical exposure to latex gloves. Latex gloves belong to a class of latex products that are dipped
products. The tires are molded
products. In general, what has been
found just by association is that the dipped products seem to elicit reactions
much more likely. That includes
condoms, balloons, and lots of other devices.
Presumably,
the reason for this is that the temperatures that the latex is exposed to are
considerably lower in the dipping process.
It also may have something to do with the surface area of the product
itself and simply the exposure of proteins to the surface.
There
are specific allergens that have been identified, many specific allergens. This is up to date as of last month when I
updated a review article. For those of
you that aren't familiar with the allergy nomenclature, the standard allergen
nomenclature is to take the first three letters of the genus name of the source
material, the first letter of the species name, and then you have a serial
number 1, 2, 3, that is an arabic numeral, which is assigned by the committee
that accepts the names for these.
So,
latex trees are Hevea brasiliensis, hence, the first latex allergen described
is called Hev b 1, which was known as rubber elongation factor. There probably are even more latex allergens
that have not yet been described.
One
of the things that really was learned fairly early on, and key in the science
involved in this, is Dr. Tomazac here from CDRH, who will be talking to you
later in the program today, is a glove powder seems to be an important vehicle
for the dissemination of latex proteins.
Gloves
needed to be powdered in order to lubricate them. If you take a latex glove that hasn't been specially treated in
some way, or powdered, and you try and pull it on your hand, you just can't do
it. Just sort of imagine, you know,
kids trying to pull on a bathing suit that is slightly wet, it just won't slide
on the skin.
Powdering
latex gloves with powder is a form of lubricant. In the bad old days, that lubricant was talc. When the surgeons discovered that it was bad
to get talc into a surgical site, it was switched to cornstarch, which is
highly absorbable. But glove powder clear
absorbs latex antigens and disseminates the antigen proteins on the surface of
the powder.
This
is a picture of a glove with powder in the palm. This is a nice touch, taking all the powder that is on the glove
and putting it in one spot, so you can see it graphically. This is not really what happens in real
life.
This
does happen in real life. This is a
catheter that has been handled with a powder-free latex glove, and this is a
catheter that has been handled with an powdered latex glove, and you can see
the powder sitting on the surface.
So,
as an allergist, how do we diagnose latex allergy? The fact is as an allergist, the diagnosis of latex allergy is
usually not all that hard to make because, as a physician sitting across the
table from an individual patient, we have a lot of tools that really help us to
make that diagnosis.
Of
course, the first tool is a good, careful clinical history of what happened, a
description by the patient of what the events were that led up to the reaction
and/or reactions, and identification, if possible, of what the risk factors in
the specific individual might have been.
After
we do a clinical history and review all these data, then, we start looking for
evidence of latex-specific IgE, and we have two theoretical tools available to
us. One is to do skin tests, standard
allergy skin tests, injecting a small amount of the allergen into the surface
of the skin and attempting to elicit a localized allergic reaction, or we can
look for latex-specific IgE in the serum.
This
is a blood test. One form is the RAST
test you may have heard of, but there are several that are available. We will talk about this a little bit more. There is no licensed skin test reagent in
the United States, but there are several products outside the United States
that are available for those outside of the U.S.
There
are several studies that have been done with extemporaneously prepared latex
skin test reagents that really suggest that they are highly sensitive and
specific. There have been studies with
commercially prepared latex skin test reagents that indicate that they are
highly sensitive and specific, as well, but because there is not yet an
approved product in the United States for this purpose, there has been a
tremendous effort in the serologic diagnosis of latex allergy.
There
are at least three different broad commercially available products - Pharmacia
product, Hycor product, and the AlaSTAT product from DPC. These products are of varying sensitivity
and specificity. Dr. Hamilton has
studied this in great detail, and the sensitivities range from 80 to 85 percent
and up, the specificities range from 80 to 85 percent and up.
So,
for an individual physician taking care of a patient, this is actually a very
useful tool because the predictive value of the test in a patient in whom you
have sort of narrowed down the risk is really quite substantial.
In
addition, an individual physician with a patient has the advantage of
attempting certain interventions. We
can try challenges if the data here are ambiguous. We can certainly try avoidance measures to see if we can make the
patient better.
These
tools that the individual physician has are not really readily available to the
scientist of epidemiologist who is trying to determine the prevalence of latex
allergy in a population. It is a much
more difficult process to do that, because the tools that the epidemiologist
has are the questionnaire, the same latex-specific IgE tests, but remember if
you are attempting a prevalence study in a population in which the prevalence
may be relatively low, a lack of specificity in your testing can be devastating
in terms of estimating the prevalence of the problem, and the predictive value
therefore is highly questionable.
Again,
for skin testing, none is licensed in the U.S.
Outside the U.S. there are at least four products that are currently
available. These products are
standardized after a fashion and have been used in studies and are certainly
used clinically, extensively outside the U.S.
The
serum-specific IgE tests, again as reviewed by Dr. Hamilton, the Pharmacia CAP,
the Hycor HyTECH, the DPC AlaSTAT, these are the sensitivities and
specificities. Again, as I said before,
for the individual physician taking care of a patient, these are very potent
products, they are very useful, but in terms of determining population
prevalence, they can be hard to use.
Specific
allergens appear to be important, and this is sort of obvious if you think
about it, but it needs to be reemphasized.
For the value of any test that uses an allergen mixture, it is important
that the allergens in that mixture be relevant.
For
instance, no one here would think that if I skin-tested patients for latex
allergy using a cockroach allergen extract, that that extract would be of any
value whatever. It is not, and if it
were of any value, it would be purely by accident.
What
you have to have in the allergen mixture that you are testing the patient with,
either with the skin tests or with the in vitro tests, you have to have an
allergen mixture that is relevant.
For
instance, Lundberg demonstrated that by adding Hev b 5 to the Pharmacia CAP
test, you could increase the sensitivity by 1 to 2 percent, suggesting that the
Pharmacia CAP test for some reason has a relatively deficient amount of Hev b 5
in the solid phase.
Likewise,
Dr. Kurup showed that using a mixture of Hev b 2, 3, and 7 was 100 percent
sensitive for spina bifida patients, and the other allergens therefore don't
appear to be necessary.
Don't
take home the message that the other allergens aren't important, these are
relatively small studies in defined populations, but it is important to realize
that when we look at these tests, we need to actually think about what
allergens they have in them and what the stability of those allergens might be.
So,
based on all these caveats of the difficulty of prevalence studies, let's just
look very quickly at some of these prevalence studies. In the general population, seroprevalence
studies are fairly wide ranging.
In
one study, the prevalence was 8 percent, Reinheimer, which as a series of
sequential blood donor sera, the prevalence was 12 percent, and in Garabrant
study, the prevalence was somewhere between 8 and 37 percent depending on the
subgroup of subjects that were examined.
Skin
test studies again show between 5 and 10 percent prevalence in the general
population. None of these studies went
back and actually looked at these individuals to see whether they were
clinically allergic.
Those
studies that have been done have typically shown that clinical allergy appears
in fewer than half of the individuals that are either skin tests or
seropositive to latex. This shouldn't
disturb anyone in the room. This is
actually typical of specific IgE testing and is something that we are all well
familiar with.
Now,
what about the healthcare worker data?
This is the discussion that probably has generated the most heat and
possibly the least light of anything in the discussions about latex allergy.
For
years, the estimates that you could glean from articles is that the prevalence
of latex allergy among healthcare providers is something on the order of 5 to
10 percent, and there are lots of studies, especially from the 1990s, that
demonstrated that the prevalence in an individual hospital was significantly
greater if you looked at the operating room personnel or the ICU personnel, and
if you went to the social workers and the psychiatrists, there was a
substantially lower prevalence in that group.
The
NHANES II data showed a modest increased risk, an odds ratio of up to 2.5, but
in some subgroups of healthcare workers, the odds ratios were considerably
lower. Now, the problem with the NHANES
II data is that the data includes 1988, 1989, and 1990, which is clearly before
latex allergy really started to take off, and so one of the problems with this
particular study is that it probably underestimates the prevalence of latex
allergy in healthcare workers on two bases.
One
is that people who are exquisitely latex allergic in the healthcare field
usually leave the healthcare field, and therefore they don't count the
healthcare workers in the study.
The
second is that this was really started before the big upswing occurred. Horowitz and colleagues did a series of
studies looking at Workmen's Comp data from several states and really concluded
in state after state that latex allergy was not a significant cause of
work-associated disability.
Now,
remember if seroprevalence data is setting sort of a low standard, Workmen's
Comp data probably sets the very highest standard, and that is, you have to
have enough latex allergy for it to interfere with your work and for you to go
through the process of filing a Workmen's Comp claim. So, as usual, the truth lies somewhere in between.
One
of the more interesting studies came from Garabrant in 2001, and that was the
only study that I am aware of that actually looked at the incidence as opposed
to the prevalence of latex allergy in apprentices, apprentices being people
that haven't started yet in their new chosen field, and you get them before
they start in their chosen field, and then you watch them as they are learning
the ropes of their chosen field.
In
this particular study, 769 apprentices were recruited all prior to entry into
their training programs. This included
dental students, animal care technicians, and pastry makers, all of whom were
chosen because they all have exposure to latex gloves.
The
assessments were done on the basis of skin testing both for latex allergen and
for program-specific allergens. So,
program-specific allergen in dental students is just latex, but for animal
care, it would be latex in addition to dog, cat, rodent allergies, and in
pastrymaking, it was wheat allergy.
They
followed these apprentices for between two and four years. Really, the maximum was 44 months follow-up,
and I am only showing the latex allergy data here because it is all that is
really relevant to us, but among the dental students, the incidence was 2.5
percent a year.
Now,
that is very consistent with what we have learned in terms of the prevalence
data, so that certainly was interesting.
The
animal care workers, oddly enough, had a lower prevalence of 0.4 percent a
year, and the pastry workers were somewhere in between. What was very interesting, though, is that
the likelihood of developing program-specific allergy for both the animal and
the pastry workers was considerably higher than this.
So,
if you were in an animal care technician program, you were much more likely to
develop allergy to rodents than you were to latex during your apprenticeship.
Likewise, the pastry workers had much more of a problem with developing
antibodies to wheat than to latex. But,
again the prevalence here is really pretty consistent with what we have seen
before.
Now,
among the children with urogenital abnormalities, and I am sort of lumping
spina bifida in, the prevalence appears to be quite high, up to 37 percent in
some of our earlier studies.
Children
with bladder exstrophy, cerebral palsy, spinal cord injury are all at risk, and
there seem to be several independent risk factors at work here. Among the spina bifida patients, the spina
bifida is an independent risk factor, atopy is an independent risk factor, and
the number of surgical interventions are independent risk factors. So, all of these things seemed to be
associated with increased risk of latex allergy.
Now,
the next three slides are virtually unreadable in your handouts, and they are
only slightly more readable here. This
was my attempt to summarize the data for individual latex allergens that have
been described both in terms of what are the data that were actually exposed to
these individual allergens and what are the data that people are actually
allergic to these latex allergens.
I
will just skip quickly ahead, so that you can see that in terms of the
seroprevalence and skin test prevalence data, there are studies that really
will demonstrate that there are reactions to these specific allergens among all
groups of patients although the prevalence is certainly higher in some groups
of patients, you will notice, though that this is a selective list.
I
mean, for instance, there is no Hev b 9 listed here, there is no Hev b 12
listed here. That is because I wasn't
able to find any data that anyone had measured these antibodies to specific
allergens in individuals.
But
if you want to look at what the data are that were exposed to specific
allergens, it is actually quite easy.
There are only two allergens that I was able to find any evidence that
these allergens existed in commercial products.
The
first was Hev b 1, in which there is really a wealth of data from mattresses,
certainly from gloves, but also a breathing zone analyses of individuals as
they go through their work day.
So
there is really very solid evidence that people are exposed to Hev b 1 probably
in relatively large amounts. There is
also evidence that people are exposed to Hev b 5 through latex gloves, but I
was unable to find any evidence of any other of these other allergens. This doesn't mean that people are not
exposed. It just means that it hasn't
really been sorted out yet.
Latex
avoidance is hard for several reasons.
It is hard because latex ubiquitous in the healthcare environment. Labeling in the past had been erratic. That has definitely improved dramatically
through the efforts of CDRH.
But
the other problem that we are facing is that threshold doses are really unknown
both for sensitization and for reactivity.
The final reason that latex allergen avoidance is hard is that there is
this problem of cross-reactivity with foods, which I felt would be of special
interest to this committee, so I thought I would spend a couple of slides just
talking about this.
Really
going fairly far back into the clinical reports of latex allergy were reports
of individuals who were reactive both to latex and to certain fruits. The first reports were to banana, avocado,
chestnut, and if you look, it is a laundry list of basically all fruit
products.
These
reports were always a little bit hard to interpret because it was always a
little hard to sort out whether this was true cross-reactivity or just
co-sensitization, but co-sensitization is an odd thing, as well, because we
don't often see co-sensitization of banana and other product.
There
is clearly a well-documented pattern of cross-reactivity between fruits and
certain pollens that is highly specific, but this was a little hard to sort out
clinically, but since then, there were a number of immunochemical studies that
clearly showed that there was, in fact, true cross-reactivity through
inhibition.
Even
sequencing studies have gone along with the idea that there is cross-reactivity
between latex allergens and other allergens that one might encounter in a
variety of food products. Hev b 3 has
strong heat sequence homology with a protein from red kidney beans, Hev b 5
with kiwi, Hev b 6 with wheat germ agglutinin, Hev b 7 is a form of potaten,
which is a storage protein in potato, Hev b 8 is a profilin. This is a ubiquitous class of proteins in
the plant kingdom. Hev b 9 is an
enolase and has strong cross-reactivity with fungal enolases, Hev b 10 is a
superoxide dismutase likewise, and the lysozymes that have been identified in
latex are also ubiquitous proteins.
There
are other approaches that have been attempted.
I actually should step back. The
other thing to remember about avoidance is that it works, it really actually
works. Avoidance measures, when they
have been put into place for individual patients, really can help dramatically,
and avoidance measures put into a workplace.
There have been studies that have clearly demonstrated that by reducing
latex allergen exposure in a clinical laboratory in a specific unit, you can
substantially reduce the reactivity of the workers in that setting.
So,
other approaches might be better methods of prevention. I will talk briefly about premedication
regimens just because you will hear mention of it and you should sort of know
what the limitations are of that.
In
addition, there have now been at least two small studies using immunotherapy,
classical immunotherapy that appear to show some promise. Peptide-based immunotherapy and naked DNA
immunotherapy is of interest, but has not reached any stage of being studied in
humans yet.
Allergists
sometimes use premedication regimens when we know that somebody is going to be
exposed to an allergen, and these actually have been best described in the
context of contrast media reactions when individuals are exposed to
radiocontrast media. A good percentage
of individuals have mild allergic reactions which are not much of a problem,
but a small percentage of individuals have significant allergic reactions.
It
was shown long ago that by using a premedication regimen consisting either of
an H1 antagonist, an antihistamine, and a glucocorticoid, or sometimes these
two drugs in the context of H2 antagonist and sympathomimetics could really
substantially reduce the likelihood of reaction to contrast media.
The
problem with premedication regimens is it is plausible that it might work, but
there is really no evidence that it works.
There is substantial evidence with contrast media that it works, but
there is almost no evidence that it really works with protein allergens.
There
has certainly been anecdotal reports of failure and my problem with
premedication regimens is it tends to make people sloppy. If I am going into surgery and I am allergic
to latex, I really want everybody in that room to take my latex allergy very
seriously from the chief surgeon to the head nurse, to the anesthesiologist, to
the medical student that is sort of dragging in just to look at what is going
on.
I
don't want anybody to say, oh, the allergist gave him a premed regimen, I think
you are okay. I really want everyone to
take it seriously. So, since I continue
to think that avoidance is the mainstay of treatment, I am reluctant to talk
about premedication regimens just because I think it's likely to make people
sloppy.
So,
let's just make some final points and then I will be happy to take
questions. At this time, prevention is
the only effective treatment for latex allergy. Latex allergens are ubiquitous, but gloves are the most important
source of latex allergen in the healthcare environment.
It
is easy to look at a list of everything that has latex and begin to lose heart
and begin to think that this is an impossible task. If you set as your goal to expunge the environment of any latex
proteins, you have established an impossible task for yourself.
If
you establish as your goal to substantially reduce the risk and reduce
exposure, we know how to do that, and the way to do that is to deal with the
gloves first. Since so many individuals in hospitals are directly exposed to
catheters, catheters are also important, but on a national basis, on an
epidemiologic basis, gloves are the most important source of latex allergen.
All
latex allergy tests, whether they are RAST, ELISA, skin tests, or challenges,
are only as good as the allergens that are used. The allergens must be intact and all significant specific
allergens must be represented in the mix used.
Testing
is readily available now. It is not
perfect, but it is certainly good enough for us to use. The predictive value of testing as a
diagnostic tool is excellent, however, the value of such testing as a screening
tool is uncertain.
Premedication
does not work. You should always
consider food allergy. There is
probably no way to construct a latex-free environment in the healthcare
setting, but it is certainly possible to construct a latex-safe environment,
and this is a concept that was introduced many years ago, and I think is really
as valid today as it was before.
I
think the more we think about latex-safe as opposed to latex-free, the more
practical we are going to be able to be to actually help people, and I think
that is probably relevant for your discussion for the rest of this session, as
well.
All
latex avoidance measures come with a price - money, resources, risk of
contamination, diminished barrier protection, therefore, latex avoidance
measures should be consonant with the risk.
Again, I think this is something that you need to consider in your
deliberations here, as well. Even those
of us that have seen the damage caused by latex allergy as up close as anyone,
have to acknowledge that latex provides a very useful service, and we should
make sure that we are not throwing out the baby with the bath water.
History
alone is a poor predictor of latex allergy, but the predictive value of not
obtaining a history is zero. Again, I
am directing this more towards doctors, asking your patients if they have
symptoms consistent with latex allergy is cheap, it costs nothing, it is quick,
and it should be part of routine screening for all medical and dental
practitioners.
Thank
you very much. I am happy to take any
questions.
Questions of Clarification
DR.
DWYER: Does the committee have
questions? Dr. Hamilton.
DR.
HAMILTON: That was really a great,
great overview. Thanks.
In
reading the papers that we are going to be considering for evidence that latex
allergy when transferred onto foods causes symptoms, could you describe for us
the classical food allergy symptoms?
They were not in your second slide of classical latex allergy symptoms.
DR.
SLATER: Sure. You mean the classical food allergy symptoms from foods or from--
DR.
HAMILTON: Yes, from foods.
DR.
SLATER: Typically, most individuals
with food allergies in the United States are children. Food allergy is typically a disease of young
children. In that population, there are
really two broad syndromes that occur. One is latex-induced atopic dermatitis,
not latex, food-associated atopic dermatitis or eczema. These tend to be relatively young infants.
The
onset of the eczema used to be thought to be chronic, but actually, Hugh
Sampson's studies clearly showed that it was just about as immediate as any
other allergic reactions that we see in patients.
Again,
removal of the food from this infant's diet typically leads to a substantial
improvement in the eczema if, in fact, it is associated with that food.
The
other syndromes can be urticaria, hives, and then finally, can be respiratory
including rhinoconjunctivitis, wheezing, and, of course, the one that we are
the most concerned about is anaphylaxis.
So,
there can be a full range of reactions. Because food is ingested rather than
inhaled, the time course of the reaction can be somewhat more prolonged than
what we see with inhaled or even injected allergens. It can be as long as an hour or even two hours after exposure
that it occurs although typically, a severely allergic patient will have a
very, very rapid reaction.
Did
that answer your question?
DR.
HAMILTON: Excellent.
DR.
DWYER: Thank you.
Dr.
Johnson and then Dr. Downer.
DR.
JOHNSON: Thank you. You talked about the number one treatment as
avoidance, so my question is how do you counsel people with this allergy to
avoid foods that have been in contact with latex? You addressed it from a healthcare perspective, but didn't year
you--
DR.
SLATER: To be candid, I don't usually
address that specifically. When I have
a patient who is documented to be latex allergic, obviously, the things that we
focus on are what has caused them to react.
Usually,
that's an exposure in the healthcare setting, either my patients with spina
bifida or a healthcare worker if I am taking care of an adult. We then will focus on the cross-reactivity
between latex and foods to alert them to the possibility that they should be
aware that if they start itching when they are exposed to bananas, they should
take it seriously, and not just ignore it.
But
typically, I don't talk to them about the generic problem of indirect latex
exposure. It has not been my general
experience that it is that much of a problem with my patients. I have had patients who have come to me
asserting that they were having multiple reactions from occult sources, and
that is very difficult to sort out, and it is certainly possible that for those
patients, the occult source was an indirect exposure.
You
should understand that even though I am hedging a little bit about indirect
exposure in food, there clearly are clinical reports of indirect exposure
occurring and clearly can occur. I mean
the most dramatic one that everyone has sort of read the old literature on
this, is the nurse who retired from nursing because of her latex allergy, who
would have a severe allergic reaction whenever her physician husband came home
if he didn't change and shower before he came into the house because he had latex
powder all over him that was eliciting reactions in her.
So,
indirect exposure clearly can occur. It
is just that when you have a specific patient in front of you, you sort of work
with what they are telling you. If they
tell you they are anaphylaxing at work, you don't start wondering whether they
are also anaphylaxing at McDonald's because it is likely they would have told
you that.
You
have to also understand that whenever you evaluate a patient with any allergy,
you always have to rule out alternative hypotheses. So, I always spend a lot of time with a patient who says they are
latex allergic, making sure that they are not allergic to lots of other things
in their environment, so we really do cover that ground.
DR.
DWYER: Thank you.
Any
additional? Dr. Downer.
DR.
DOWNER: Dr. Slater, thanks for a very
informative presentation.
At
the beginning, you mentioned Type 1 latex allergy. It leads me to believe that there are more than one type. Can you tell me what they are and discuss
them briefly?
DR.
SLATER: As I said Type 1, I realized I
was introducing a term that I wasn't defining, so after telling you how careful
we had to be define terms, I violated what I was going to day. Type 1 is a terminology that I would rather
I not have used. It is an old
classification of immunologic reactions designed by Gel and Coombs. Type 1 reactions were what they called IgE
mediated reactions.
The
distinction among the reactions was very clear to them, but there are certainly
overlap syndromes, and I think it is better to really describe the mechanism
itself. So, in the Gel and Coombs terminology, though, contact dermatitis, the
poison ivy-type reaction would have been called a Type 4 reaction. You will still hear people say Type 1 versus
Type 4, but there is no Type 2 and Type 3 for latex.
DR.
DWYER: Thank you.
Now,
we have got some questions on this side from Dr. Fischer and then Dr. Torres.
DR.
FISCHER: I am wondering if a person has
latex allergies, what do you think was the sensitizing agent, do you think it
was their food initially, or is the latex proteins, are they sensitizing
initially? Do you get the question?
DR.
SLATER: I can give you my instinct, but
I think the approach that you would take to answer that question would be to
look at food allergic patients and to try to decide whether they have an
increased risk of latex allergy.
Well,
we know that they do because we know that atopy is associated with latex
allergy, and people that are food allergic are atopic, but does a person with banana
allergy or kiwi allergy, are they more likely to have latex allergy than
someone who has seafood allergy or peanut allergy, and the answer is no, they
are really not, at least that has not been my experience.
Bob,
correct me if I am wrong, I think I saw one study and there was really no
evidence of an increased prevalence among food allergic patients in particular.
The
converse, of course, is not true. There
is an increased prevalence of food allergy among latex allergic
individuals. It is not dramatically
increased, but there is an increased prevalence among latex allergic
individuals.
So,
I would think that from those data, there is not much to support the idea that
the initial sensitizing antigen exposure is foods. In terms of human data, I think that is just about all we have.
DR.
DWYER: Dr. Torres and then Dr. Gaspari.
DR.
TORRES: Page 5 of the material that was
provided to us said the FDA had proposed to require an expiration date for
latex gloves. Is there any allergic
reaction based on the decision behind this?
DR.
SLATER: I am sorry?
DR.
TORRES: It said that it proposed to
require expiration dating. Is there a
reason from an allergy reaction that you would like to have an expiration date?
DR.
SLATER: I am not the right person to
answer that question.
DR.
TORRES: Only from an allergy reason.
DR.
SLATER: I have nothing useful that I
could say about that. Believe me, if I
had something I would tell you. I just
have no answer to that.
DR.
DWYER: Mr. Bonnette, would you try to
help us to identify, over the next couple of hours, a person who can answer
that question and get back to us?
Good. The question is why did
the regulations specify expiration date, was there something about the old
latex gloves having different properties, and we will get a definitive answer
from a technical expert on that point.
Dr.
Gaspari.
DR.
GASPARI: Dr. Slater, can you address
the spectrum of the severity of the problem in latex hypersensitivity, and
other than presenting symptomatology like the patient with mild localized
urticaria after exposure to rubber latex gloves versus the patient that
anaphylaxes if there is latex powder in the room, so how good are the tools we
have at differentiating the spectrum of the exquisitely sensitive patient that
is at risk for anaphylaxis versus the patient with the mild tolerable response?
I
am interested in this question because intuitively, I might think the patient
that has a reaction in a restaurant from latex carryover may be in the more
severe category, and what kind of tools do we have using RAST beyond clinical
symptomatology to assess that spectrum.
DR.
SLATER: I think that is a very good
question, and I think what I would focus on in the answer is whether the amount
of latex-specific IgE that has been detected correlates with the severity of
the response or can predict the severity of responsiveness.
Again,
I think the answer is probably yes. If
you recall, one of my earlier slides, I kind of put contact urticaria as one of
the syndromes that I wasn't really sure were always IgE related. The reason for that is probably that it is
IgE related, but they have very small amounts of serum-specific IgE, and at
least at the time that the study was done, they may simply not have been
detecting the specific IgE that was causative of the reaction.
Certainly,
with other allergies, with peanut allergy, for instance, there is a correlation
between the amount of peanut-specific IgE and the severity of reactivity. It is not necessarily highly predictive in
an individual patient, but certainly in a population basis, you can divide up a
population into those that are more likely to have those kinds of reactions
than not.
I
think the problem with moving from that kind of discussion into saying this
person is likely to have a restaurant reaction, this person is less likely to
have a restaurant reaction is that that assumes that we understand that the
dose that one receives in a restaurant is always going to be exquisitely low
and that therefore those individuals are always going to exquisitely sensitive.
I
don't know those data, I don't really know that. I do know that when one makes that conclusion about, for
instance, the amount of contaminating peanut protein that might be present in a
product that was made in a factory in which there were peanuts being made, that
is highly variable, and in some cases, the amount of peanut protein is trace,
and in other cases, it is substantial because we don't really know what goes on
behind those closed doors and how much the exposure is.
So,
I would worry a little bit about, even though I intuitively agree with you, the
patient that reacts to restaurant food by indirect exposure has got to be very
sensitive, I would worry a little bit without having the quantitative data as
to what the exposure really is and what the range of exposure is
DR.
DWYER: Thank you.
Are
there other questions? Dr. Hamilton has
another question.
DR.
HAMILTON: Because you won't be here
when we discuss this paper, I wanted to get your feedback on it. Back in 1998, McGadey and the group at
Philadelphia showed that you could--he took initially three in his abstract and
then he published a paper later, a couple of years later in the Canadian
Journal of Allergy where he actually administered oral latex to latex-allergic
individuals.
I
would like you to just overview for us this whole philosophy of oral tolerance
induced by high-dose oral desensitization, and within the context of low versus
high in threshold levels, and just sort of put that in context for us.
DR.
SLATER: Sure. The underlying question that you are probably getting to is, is a
small dose of latex by mouth not so bad.
This is sort of the underlying issue that is behind that kind of
question.
The
idea of tolerizing somebody to an allergen by the oral route is very attractive
conceptually. Remember, we have oral
exposure to not grams, but hundreds of kilograms of foreign proteins every
year. Our GI tract is intended to
prevent us from reacting to these proteins, and we are, in fact, highly
tolerant to proteins that we take in by mouth in general.
Food
allergies are a spectacular exception to that.
The question has been raised as to whether the oral route would be the
best way to try to tolerize people to proteins to which they are currently
allergic.
There
have been studies that have suggested that this actually works. The question then is what doses would
actually work, and the answer clinically, certainly if you look at oral
immunotherapy and sublingual immunotherapy regimens that are being studied more
and more in Europe at this point, is that it seems that in the end, you have to
reach a fairly high dose in order to really tolerize somebody to a protein.
Starting
out at a low dose is good, but working up to a relatively higher dose is what
you really need to achieve tolerance.
Contrast
that to studies of chronic allergen exposure in terms of the prevention of
allergies, and in those situations, it seems that chronic low dose allergen
exposure may well actually prevent allergies.
These don't reach very high doses, but that is actually a different
issue.
The
study to which Dr. Hamilton was referring was one in which a small number of
study subjects were given latex solutions by mouth, and they seemed to be
tolerized to latex. It is a very small
number, and it is very hard to interpret, and certainly something we don't
recommend.
DR.
HAMILTON: Could I just follow up with a
question? The fact that these
individuals didn't have any apparent systemic reactions, they started with very
low concentrations of oral latex and then increased--this was ammoniated
latex--is that significant to our discussion with regard to food contamination
and exposure for a latex-allergic individual?
DR.
SLATER: My memory of this study was
that there was no challenge arm at all, in other words, these were people that
came in with a strong history of latex allergy, but they weren't challenged on
entry into the study to see that they really did react even to any
exposure. Am I correct? They were challenged after the study.
DR.
HAMILTON: They had positive skin tests.
DR.
SLATER: They had positive skin tests,
but they didn't have clinical challenge.
So, in other words, I don't know what I am comparing their failure to
have an adverse reaction to the oral latex solution to.
In
other words, if these were people that were entered into a study, had a
positive challenge of some sort, ocular challenge, nasal challenge, or skin
challenge, and then had no reaction to the oral desensitization, then, had a
negative challenge afterwards, that would be more convincing.
If
I remember this study, it is one in which they had a very compelling history,
had a positive skin test, and were able to go back to work afterwards. That is not tight enough for me to draw
conclusions.
DR.
HAMILTON: And that was exactly the
reason they couldn't get it into the JCI was that absence of a control group.
DR.
DWYER: Dr. Taylor, did you have a
comment?
DR.
TAYLOR: I am not familiar with that
study, and I am not sure we shouldn't have that one in our packets if it might
at all be relevant to this consideration.
Jay,
does that mean that if you took an unselected group of people with latex
positivity by skin tests, that this study could be used to document that the
majority of them would not be sensitive to oral intake?
DR.
SLATER: You could do that study. We could also predict that that would be
true. That is the nature of skin
testing to allergens. It is the nature
of the predictive value of a challenge test.
Many
of us, especially those with the FDA, think that a challenge test is really the
gold standard, and it is because it is the best we have, but it's not 100
percent sensitive.
DR.
TAYLOR: But the FDA's standard of
safety, as we heard it from Dr. Pauli, is to protect the vast majority, so are
the vast majority of the sensitive population even susceptible to oral intake
of latex is my question.
Would
this study help to answer that question?
DR.
SLATER: This would be the way to
address that study, but I think you would also have to have individuals who had
a history of latex allergy plus had a positive skin test, and then you would
have to challenge them.
But
then the discussion that you and I would have is what dose would you challenge
them with.
DR.
TAYLOR: Oh, I understand how difficult
that study is. I just wanted to know if
this study has enough information in it for us to begin to get at the broader
population of latex-allergic individuals.
I
might agree with you after I read it that a subset of that population still
needs to be studied to answer the questions posed to this panel.
DR.
DWYER: Any other questions? I have about three.
The
first is which allergens are the most likely to be a problem. I was surprised to see there are probably
over a dozen of these substances. Which
are the ones--you mentioned two--but was that just because those two were the
ones in the kits?
DR.
SLATER: The allergens that are most
likely to elicit reactions may be different in different populations. Hev b 5 appears to be a significant allergen
in both children with spina bifida and in healthcare workers.
Other
allergens can be very important in certain populations and less important in
others, and actually, the numbers in that table show the prevalence data in
individual subpopulations, so you can look in that and get a sense that certain
allergens are more important among healthcare workers and others among the
children with spina bifida.
In
general, the most important allergens are the ones that are sort of early in
the list, you know, I would say Hev b 1 through Hev b 8 are the ones that have
been the most important.
DR.
DWYER: Just to follow up on that,
because you are probably one of the national experts on spina bifida and these
allergies in those patients, it would seem to me that many of those patients
might be given stool softeners like Metamucil or some other one.
Isn't
there a cross-reactivity between those?
DR.
SLATER: Between psyllium?
DR.
DWYER: Am I right about that or wrong?
DR.
SLATER: I am not aware of it.
DR.
DWYER: No? Okay.
DR.
SLATER: I mean if you told me it was
true, I would believe you.
DR.
DWYER: No, I am not telling you, I am
asking. I am asking an expert. I am certainly not an expert.
Do
the specific IgE tests have all of the allergens or only Hev b5, 1 through 8?
DR.
SLATER: That is exactly the
question. We don't really know the
answer. The fact that by adding Hev b 5
to the solid phase of the Pharmacia CAP, you could increase the sensitivity,
suggests that there is too little Hev b 5 in it.
I
would assume, and my assumption is that they are not full representative of all
the allergens because they are made with crude latex mixtures, and the amount
of a specific allergen in that mixture may or may not be adequate.
One
of the aims of identifying all the important allergens and sequencing them and
cloning them is to be able to construct a diagnostic tool that has all the
relevant allergens in it. Once you have
done that, then, you may learn that of those 13 allergens that I have put up on
the screen, only four of them are important, but that is what you need to
learn.
Certainly,
Kurup's study suggested that for spina bifida patients, you only needed three
to get 100 percent sensitivity. That
doesn't mean that the others, that they are not reacting to the other proteins,
it just means you can achieve 100 percent diagnostic sensitivity by looking at
those three indices.
DR.
DWYER: I am still puzzled, though, I
must ask you another question, and that is, the amount of the various allergens
in these diagnostic kits is not known?
Is that what you are saying?
DR.
SLATER: That is correct, because the
diagnostic kits are made with crude latex preparations.
DR.
DWYER: Thank you. What a surprise.
One
other question that came up at the coffee break is I understand that years ago,
latex was used in chewing gum. My
source for that is Dr. Taylor, who knows all about food additives. Apparently, if what you people were talking
about with respect to oral challenges was true, what is the history of what
happened in those old days when thousands of children were chewing gum with
latex in it?
DR.
SLATER: I haven't a clue.
DR.
DWYER: Dr. Taylor, do you know?
DR.
TAYLOR: I actually don't know very much
about the history of use of latex in chewing gum. I am always provoking FDA on this point, because it is actually
in the Code of Federal Regulations as an approved food additive only for
chewing gum purposes, and I pray and hope that no food company is actually
using it today, but it is actually permitted.
But
I don't know what the quality of that material was. I am guessing that we are talking decades back that it was
approved for that use and that, if anything, the latex was probably a cruder
preparation in those days than it was in the late 1980s when this other kind of
exposure began to reveal people who had reactions.
But
I am not aware that medical literature contains from the 1920s and 1930s any
great spike of concern about reactions in habitual users of chewing gum.
DR.
SLATER: Now was there was any spike
about the use of peanuts when peanuts--
DR.
TAYLOR: I know. You would think that anyone who is already
sensitized might encounter difficulties if they used a chewing gum with natural
rubber latex in it, but I don't know much about the actual history. I have looked for it, but I just haven't
ever even found a case, which is kind of curious because I assume it was
actually used in the early days because the synthetic materials that are used
today were not available then.
DR.
DWYER: Interesting.
Dr.
Downer.
DR.
DOWNER: One of the questions that the
committee is charged with is to look to see whether there is a positive
relationship which has been established between the use of the natural rubber
latex gloves, and if it exists, what is the strength of the relationship.
You
mentioned in your presentation that there is a lack of specificity to estimate
prevalence in the U.S., and I guess in the absence of adequate quantitative
data, my question is what are the evaluation parameters would you suggest this
committee to use in deliberations?
DR.
SLATER: In terms of determining the
positive relationship between indirect latex exposure in foods and the
likelihood of developing latex allergy?
DR.
DOWNER: Sensitivity. You mentioned that there is a lack of
specificity to estimate the prevalence in the U.S., and we can't tell if we
don't have enough quantitative data, and that is part of the charge of this
committee.
DR.
SLATER: I don't think the prevalence
data are going to help you there at all, because I think, you know, unless we
can show that there are certain populations that are much more likely to have
restaurant-associated latex exposure than others, I don't see how you can use
prevalence data to achieve that even if you had perfect tools.
I
suppose you might try to develop a prospective experiment of looking at
incidence, and if you are doing that and you are using the same tools as you go
along, you can circumvent the problem of the lack of specificity. I mean these are not completely unspecific
tests, specificity of 70s, 80s, low 90s.
So,
if you are following a population especially if you have serial serum samples
from individuals in a population, you can do the tests concurrently and
actually come to valid conclusions, but I don't really see how you can use
prevalence data, you can use prevalence data and try to answer that question.
DR.
DOWNER: One of the things I was looking
to do is look at not just the incidence, but the prevalence, as well, and do
some cross-checking, so that is what I was looking for.
DR.
SLATER: But I think one of the ways to
circumvent the problem is to collect all your sera and evaluate them
concurrently, and if you are looking at incidence data, then, you can
circumvent the problem somewhat.
DR.
DWYER: Thank you.
Let's
just go around the table and make sure we have got all the questions out
because you may run off after this over.
Dr.
Torres? Dr. Fischer?
DR.
FISCHER: I do have one. The Garabrant study, which showed the
prevalence of latex reaction in various groups, dental versus others, you
mentioned that the incidence of latex allergies were less--this is what
Garabrant showed, I think you said--less than program-specific allergens that
they were exposed to.
What
is your interpretation of those results?
DR.
SLATER: My interpretation is when you
are an animal care technician, you have more exposure to mouse urine proteins
than you do to latex allergens, and therefore, if you are in a program where
you are exposed to mouse urine proteins, which people in these room just inhale
in huge amounts, and latex allergens, which--you know, when you go into a mouse room, you have 50 mice
in that room. They are generating
protein. You may have one box of latex
gloves, which one glove is pulled out at a time.
I
think it is just a matter of exposure.
DR.
FISCHER: So, you are saying it is just
a matter of the incidence of exposure.
DR.
SLATER: I think it's exposure.
DR.
FISCHER: To the different allergens.
DR.
SLATER: That's right.
DR.
DWYER: Thank you, Dr. Fischer, and Dr.
Slater.
Dr.
Hamilton? Dr. Taylor?
DR.
TAYLOR: I suppose I should ask you--we
have had in our packet provided by FDA the case reports about adverse reactions
associated with residues from use of gloves in the preparation of foods.
Are
you familiar with any case reports in all of your reading of the literature of
other indirect contact between latex and foods that led to an adverse reaction
that was not glove related?
DR.
SLATER: No.
DR.
DWYER: Thank you.
Dr.
Blumberg? Dr. Gaspari?
DR.
GASPARI: A question about the changing
prevalence. Do you really believe that
the--maybe I should say incidence of latex sensitization is decreasing based on
better gloves, higher quality gloves with lower protein content and the loss of
the use of powder, cornstarch powder, and whether this would have any impact on
carryover in the foodstuffs? Can you
comment on that?
DR.
SLATER: Again, I don't know about the
carryover because I don't know about the quantification of latex allergen
acquisition by foods. I do think that
the incidence is dropping. I do think
it has to do with steps that have been taken regarding glove exposure.
Certainly,
in the population of patients that I used to take care of most intensely among
the spina bifida patients, the incidence dropped dramatically when the surgical
specialists who took care of them understood the importance of latex allergen
avoidance from birth.
It
made a huge difference in that population very rapidly. I think the data on the decreased incidence
among healthcare workers is still early, but it's impressive.
DR.
DWYER: Do you want a follow-up
question, Dr. Gaspari? Dr.
Johnson? Dr. Downer? Okay.
Any other questions?
Thank
you. We put you through the wringer,
but you have been very
informative. Thank you very much.
We
will go now after that interesting presentation to the CDRH Proposal, and Dr.
Stratmeyer from the Center for Devices and Radiologic Health will present this
talk.
Dr.
Stratmeyer.
CDRH Proposal
DR.
STRATMEYER: I have got a branch that is
a research and risk assessment. That is
what they do. The research is in the
area of toxicology and infection control, and basically, we are trying to
understand how the tissue interacts with medical device materials.
So,
how did I get into latex? Well, first
of all, I have got to say I am latex allergic, not the type allergy that you
guys are thinking of, but I developed an allergy because I thought back in 1990
that this was something that I would be through with in about two or three
months, and, let's see, this is 2003, so I have developed a real allergy to it,
let me tell you.
First
of all, I would like to just point out that the Center for Devices and
Radiological Health's mission is to ensure the safety and effectiveness of
medical devices, and this means that we look at both risk and benefit, and if I
understand right, you were asked to look only at risk.
So,
you have got to remember that there are differences in the laws under which
these various centers operate. So, as I
go through this, bear that in mind.
First
of all, I would like to sort of describe the process that we use to ensure the
safety and effectiveness of natural rubber-containing medical devices.
First
of all, problem identification, and then I will go into how once we identify
the problem, we used our advisory role to get the message out to industry, to
the medical community, to the public. I
will mention the fact that we do do research since that is the job of my group,
and then I will finally try to tell you how this led to the regulatory
initiatives that we have undertaken.
First
of all, adverse event reporting system.
This is the first sense that we had that there was a problem. We found in that adverse event reporting
system, 15 deaths were reported due to anaphylactic reactions to a barium enema
catheter that were reported in 1989 and 1990.
Originally,
our quick look at it says, well, gee, maybe there is something with the barium
solution. However, after researching
the issue, we began to believe the problem was caused by natural rubber
latex. Anaphylactic reactions had been
reported with other natural rubber devices also.
Research
on high-risk populations also pointed toward the involvement of natural latex
allergy. I won't spend any time
here. You have had an expert present
all this to you, but one of the populations was the spina bifida
population. That is where we got a lot
of our information and our clues to begin with, healthcare workers and rubber
industry workers.
Because
once we identified what we thought was the source of the problem is natural
rubber latex, the first thing we did was we put out a Medical Alert, and it was
distributed throughout the medical community in March of 1991.
We
also, at the same time, prepared and distributed a list of pertinent
publications and published a review article to inform healthcare workers and
consumers. At this point, we also sat down with industry and tried to convince
them that there was a problem, initial research in our lab had demonstrated
antibodies from latex-sensitive individuals, reacted to a number of natural
latex proteins from natural rubber latex-containing devices.
With
this data and published data from the literature, we sat down with industry and
convinced them that this was a serious problem that existed. We urged them to promote cooperative efforts
to develop standards and reduce natural latex protein levels.
I
must say, and like I say, this is very early in the game, and I must compliment
industry for working with us. Once we
convinced them, we have had very good cooperation.
Then,
in 1992, we organized an International Conference on Sensitivity to Natural
Latex and Medical Devices, and this was put together to address scientific,
clinical, manufacturing, and regulatory issues, and we got a lot of information
from this, because a lot of the Europeans had already been involved in this and
done a lot of work.
One
of the other things that I mentioned a little earlier that we talked to
industry about, and we got very involved in through the ASTM, was development
of standards.
Since
our early research efforts uncovered an unanticipated problem, that was
unreliable measurements of protein that were extracted from natural rubber
latex-containing devices, in cooperation with industry and ASTM, a standard for
measuring total extractable water-soluble protein was developed using a
chemically-based analytical method, and efforts to improve the methods for
detecting protein antigens, allergens, still continues today to develop more
sensitive methods with ASTM and, like I say, industry.
I
don't want to get into the research in any detail. I would just like to point out that active research in our lab,
in collaboration with other research in other clinical labs, has served as a
basis for risk assessment, methods development, and regulatory actions.
Again,
I will point out that as for methods developments, we have had active
participation in the development and credentialing of standard methods through
the ASTM. This includes protein antigen
and residual powder, and we are also working on and looking at an allergen test
now.
Now,
active research is still ongoing to develop new and improved methods for risk
assessment of NRL medical device products.
Let's
finally get to the regulatory initiatives.
In 1995, we came out with a protein content guidance. We put this guidance out to allow
manufacturers, if they wished, to label total extractable protein content using
the ASTM standard.
Then,
in 1997, we came out with a labeling regulation, it was finalized in 1997. This labeling regulation required statements
on medical devices containing natural rubber--and this includes natural rubber
latex and dry natural rubber products--that contacts living human tissue.
We
also required that the claim of hyperallergenicity be removed, and I am going
to go back and use a couple of old terms, that is just horrible, the main
reason because the hyperallergenicity claim on some of these products,
particularly in gloves, was that it was really tested for what I would call a
Type 4 or a delayed type of hypersensitive reaction rather than what we were
really concerned about was the Type 1 immediate type hypersensitive reaction.
Then,
in 1999, we published a proposed rule, because this is the way you have to go,
first, you have to have a proposed rule and then everybody comments on it, you
respond to the comments and try to address it and everything, and then
eventually, you make any changes that are necessary and come out with a final
rule. We are in the proposed rule
stage.
Basically,
this proposed rule was only on gloves.
The other rule that I talked about, the labeling rule, affected all
medical device products if the natural rubber contacted human tissue. This was only on gloves.
This
would reclassify them from Class I to Class II. One of the reasons to do that was because with Class II devices,
we rely, not just on what they call general controls, but also special
controls, and I hope you don't ask me too many questions about a lot of these
terms, because one of the other reasons I am allergic to latex is I got
stuck--I am a researcher--I got stuck with being in charge of developing these
regulations, so I had to learn a little bit of this legal terms, but I don't
consider myself an expert there at all, let me tell you.
Anyway,
by using special controls, a number of things could be used. We could require certain labeling that we
could not with just general controls. I
am trying to find out whether or not there is any difference in the reporting
requirements for adverse events, I am not sure there is, but there are some
differences in the way that the Office of Compliance can react to a problem
with a Class II device as opposed to a Class I device.
Anyway,
the special controls were, first of all, label caution statements that would
include recommended limits, and these would be on all natural rubber latex
gloves. The caution statement was
different for synthetic gloves, and that was only on gloves that contained
powder, because the statement included both latex and powder.
We
also would require that the protein levels that the glove contained be
labeled. In other words, they could be
over the recommended limit we had, but the consumer had to know that they were
over, because they would also have to label exactly what the glove content was.
The
same thing with powder labels, the powder level would have to be labeled on all
gloves. Again, somebody asked about
expiration dating. Expiration labeling
would be required. The reason expiration
labeling would be required is because one of the things that we wanted to see
happen was, number one, we wanted to see the protein content or the allergens
to go down; number two, we wanted to see the powder to go down, because, as you
were told, the protein adheres or the allergen adheres to the powder and can
become airborne, and is probably a very good way of dispersing the allergen.
But
one of the ways of getting rid of powder and making a powder-free glove is by
chlorinating it. If the chlorination
process is not done correctly, it can affect the life term or the life span of
the glove. Again, remember we are
interested, not just in safety, but also effectiveness. So, the expiration dating was based more on
effectiveness issues than on safety issues.
I
don't want to waste a lot of time. I
could go through and give you the caution statements and everything, and I can
do that if anybody is interested, but I won't waste your time doing it right
now.
I
would like to say that since we came out with a proposed rule, we have worked
with the ASTM, and the ASTM has also come out with recommended maximum limits
for rubber exam gloves, rubber surgical gloves, and synthetic exam gloves. These are powder and protein or these
maximum limits are very similar to the limits that were in the proposed
rule. But again, I think it is an
example of how the industrial community has worked with us, through ASTM, in
order to try to address this problem.
I
will just make a real quick mention of some of the other government agencies
that have also been involved with this whole issue, with the glove issue. For example, OSHA has a Technical
Information Bulletin that states, "When selecting NRL gloves, choose those
that have lower protein content.
Selecting powder-free gloves offers the additional benefit of reducing
systemic allergic reactions."
NIOSH
put out a Safety Alert that stated, "If you choose latex gloves, use
powder-free gloves with reduced protein content."
Again,
I already talked about the FDA medical glove proposed rule. I should point out that one of the options
that we considered and is published in the medical glove powder report that we
put out in 1997, was to ban powdered gloves at a predetermined time in the
future. This is something that we
decided was not the way to go because of concerns about the changes in
manufacturing that take place in order to produce powder-free gloves, what
changes they might have on barrier properties, durability, and the availability
and adequate supply of high-quality medical gloves.
Anyway,
let me end this up here and again state that our goals are to prevent
sensitization and to prevent adverse reactions, and we are trying to achieve
these goals by providing adequate information to the consumer, and that means
all the way from not just John Public, but the medical profession, to permit
the medical institutions and users to make informed decisions when choosing
medical gloves.
Thank
you.
DR.
DWYER: Thank you, Dr. Stratmeyer.
Does
the committee have questions? Dr.
Torres and then Dr. Blumberg, Dr. Gaspari.
Questions of Clarification
DR.
TORRES: My question is whether you know
whether the industry is using all this labeling about protein content,
non-powder, et cetera, et cetera, also on gloves that have been sold to the
food industry applications. You spoke
of medical applications.
DR.
STRATMEYER: Unfortunately, I am not an
expert in what is used in the food handling industry, so I can't tell you.
DR.
BLUMBERG: I have the same question
about the medical gloves versus food handlers' gloves, but you also mentioned
earlier on about the adverse event reporting system, and our document has a
comment that the CFSAN Adverse Event Reporting System, on page 10 of our
report, it says, "To date, FDA has received one report through the CAERS
Reporting System of an allergic reaction to food that was believed to be due to
NRL."
I
was wondering, over what time period was this Adverse Event Reporting System in
effect.
DR.
STRATMEYER: I will let somebody here
talk about that, because again, our Adverse Event Reporting System, we look
only at medical device adverse reports. Somebody from the Center for Foods will
address that.
Again,
as you are seeing, there is some real differences between how various products
are handled based on what part of the law they are regulated by. In fact, you will be able to probably get
some answers. I believe that the
manufacturers have a speaker this afternoon or tomorrow, and you can probably
ask the manufacturers your question about food-handling gloves.
DR.
DWYER: Thank you, Dr. Stratmeyer.
We
have two questions, Mr. Bonnette, that we need answered with someone from the
agency today. One is medical gloves
versus food handlers' gloves. Could you
please get someone who can talk about that.
The
second is the issue of the CAERS and how long this Adverse Event Reporting
System was in place to produce one.
Dr.
Torres, you will be at the end after the others. Dr. Gaspari, I think is the next speaker.
DR.
GASPARI: My question is related to the
prevention issue. The goal is to
prevent sensitization, and there is it looks like three different agencies are
recommending the same thing - NIOSH, OSHA, and your agency also, are all
recommending decreased protein content and avoiding the use of cornstarch.
This
recommendation seems to be somewhat intuitive in that if patients become
allergic to polypeptides in natural rubber latex, if you decrease the antigen
content, you are decreasing their potential exposures below the threshold of
sensitization.
But
my question is, this recommendation, is this based on intuition or is there a
prospective study comparing low protein latex gloves to the older form of high
protein versus the cornstarch-free versus the cornstarch-containing gloves over
the 48-month period as was described earlier, and is it based on science or is
it based on intuition in terms of that recommendation?
DR.
STRATMEYER: Bob may be able to speak to
this, too, but my reaction is that it
is based on intuition more than--it is very difficult to get these data in a
controlled fashion. That is one of the
problems that you see, the argument about the prevalence or the incidence of
the allergy.
DR.
DWYER: Our next question is from Mr.
Scholz.
MR.
SCHOLZ: Maybe this is more of a
follow-up to Dr. Torres' question, but on the proposed rule, did it deal at all
with retail, the retail food side, or was it healthcare field only?
DR.
STRATMEYER: We don't deal with the--if
it were sold on the retail, you mean in a drugstore?
MR.
SCHOLZ: Drugstore, restaurant, grocery
store.
DR.
STRATMEYER: If it were sold as a
medical glove, it would--Wava, would you agree, if it's sold as a medical
glove, even though it is sold in a drugstore, it would be considered a medical
device?
MR.
SCHOLZ: So, the rule did not deal at
all with use of the glove in those establishments?
DR.
STRATMEYER: Well, the use of the
glove--all right, no, I see what you are saying.
MR.
SCHOLZ: What I am trying to find out is
if there are any comments on the rule proposed in '99 from the retail food
sector.
DR.
STRATMEYER: No.
DR.
DWYER: The answer is that there were no
comments in '99 from the retail food sector.
DR.
STRATMEYER: No.
DR.
DWYER: Dr. Torres.
DR.
TORRES: In your list of research
ongoing, you mentioned that there were more work on methodology. So, my question is whether all this labeling
in terms of levels that are recommended for protein content, are those based on
science or in the sense of this is the detection limit of our method, or they
are based on what is the protein level that would require for an allergic
reaction.
DR.
STRATMEYER: In other words, what the
recommended levels were based on.
DR.
TORRES: Right.
DR.
STRATMEYER: They were based on as low
as reasonably achievable. In other
words, I think it is very difficult to put the threshold level which would
cause sensitization. In fact, for some
individual, it might be down to molecules for all I know, it would be very low.
So,
as a result, this was something that rather than raising the price of an exam
glove up to $5.00 a glove, which we could put in requirements, that the cost of
manufacturing would go so high, that would be a disaster also. So, it was just as low as was reasonably
achievable, and then again, that is sitting down with industry and trying to
battle it out.
DR.
DWYER: Thank you. What protein is it, please?
DR.
STRATMEYER: Pardon?
DR.
DWYER: What protein is it, is it a mix
of proteins?
DR.
STRATMEYER: In the proposed rule, it's
a mix of proteins, it is just a general protein test. Now, ASTM has come out with tests and some levels for also
antigens and I believe also allergens, or looking at allergens.
DR.
DWYER: Thank you.
Dr.
Johnson has a question.
DR.
JOHNSON: You stated at the end that
your goal is to provide adequate information to the consumer, so they can make
informed decisions to avoid sensitization and adverse reactions.
I
am just wondering if you have a view on whether that adequate information
includes information to the consumer if their food has come in contact with
latex during its processing, preparation, or service.
DR.
STRATMEYER: I don't feel confident
enough of my immunology to know. I
haven't looked at the oral side of it, so I wouldn't feel very comfortable
trying to say whether or not--I don't know whether there is a problem, in other
words.
We
came to the conclusion with respect particularly to healthcare workers, that
there was a problem and that we wanted to make that information available to
them. That is sort of what you are trying
to do, is decide whether or not there is enough information to say that there
is a risk.
DR.
DWYER: Dr. Torres has another question,
and then Dr. Hamilton.
DR.
TORRES: So, the target for the
information that you are generating, it is the healthcare worker. So, a patient going to a dentist or any
other medical service, as a patient, there is no information disputed to you?
DR.
STRATMEYER: We have web sites and
everything, and I think that if you go to an awful lot of the medical
facilities now, you will see that this is a non-latex, you know, a latex-free
area, or if you take a look at the glove box, you can tell exactly what it is.
Like
I say, one of the things with patients is we saw a lot less problems in the
Adverse Event Reporting System simply because of the fact they aren't exposed
that much unless they have multiple surgeries, whereas, the healthcare worker
can be exposed on a daily basis.
DR.
DWYER: Thank you, Dr. Stratmeyer.
Dr.
Hamilton had a question.
DR.
HAMILTON: I would like to step back and
ask the question, is there in the United States a distinction between medical
gloves and all other gloves, are they called consumer gloves? I mean I hear of food handlers' gloves, I
hear--do we have a terminology that defines it, because in Australia, they call
them consumer gloves and medical gloves.
DR.
STRATMEYER: When I talk about a medical
glove, I am talking about something that is defined in the bylaw as a medical
glove. You could sell that latex glove
and not call it a medical glove, and you could sell it for home cleaning, you
could sell it for I guess food handling or whatever. It doesn't have to be labeled as a medical glove, but if it is
labeled by a medical glove, it is affected by Center for Devices and
Radiological Health's regulations.
DR.
HAMILTON: So, is there anything
stopping a dentist from using a consumer glove?
DR.
STRATMEYER: Now you are getting into--
DR.
HAMILTON: Practice?
DR.
STRATMEYER: --the practice of medicine
or dentistry, and that is not part of FDA's role. I think that most dentists would not do that because, first of
all, the reason they are doing it is to protect themselves, and I think they
would want the satisfaction that they are using something that has been tested
and approved.
DR.
HAMILTON: So, we can safely say there
is a consumer glove entity and a medical glove entity, and they are distinct,
but they can cross over just based on the user's preference.
DR.
STRATMEYER: Yes.
DR.
HAMILTON: If I could, I would like to
address the question that Dr. Gaspari brought up, which is the issue of do we
have actual data that supports the validity of the use of powder-free versus
powdered latex gloves, and their use in terms of reducing exposure.
I
think we have several levels of studies that have been done based on what I
have gleaned from the literature. In
1994, John Yunginger initially started by measuring allergenic levels in powder
and powder-free latex gloves by extracting them and doing in vitro testing with
RAST inhibition analysis.
He
showed very clearly in his paper, in 1994, that while there are exceptions,
that the general rule is that powdered latex gloves tend to have higher level
of allergen extractable than powder-free gloves, but there were the exceptions.
Then,
as time went on, there are a variety of clinical studies that, as Dr.
Stratmeyer said, are very difficult to do in terms of documentation of
exposure, that have looked at populations that have been exposed to powder-free
and powdered latex gloves, either small studies where they have looked at a
dental office, like Charous' study, or the study in Canada with Tarlow, where
they have looked at hospital with powder-free versus powdered latex gloves,
and, in general, the gestalt is that in the environment where powder-free latex
gloves have been used, there has been less tendency to develop latex allergy
than in environments where powdered latex gloves have been used, but that is a
soft set of studies because there are a lot of difficulties with interpretation
of those studies. They are very
difficult to do.
DR.
GASPARI: So, it is evidence, but it's
not the highest quality evidence in support, in terms of scientific data to
support a rationale. The other question
that I had attached to that was the protein content. You didn't address that yet.
DR.
HAMILTON: We will hear from Dr. Tomazac
on this issue next, but, yes, there are definitive studies that looked at
general allergenic potency by RAST inhibition analysis back in the early '90s.
Most
recently, we have more sophisticated methods for measuring allergenic content
of rubber products that are extractable.
I am not sure I answered your question.
DR.
GASPARI: Really, what I was getting at
was the prevention issue, prevention of sensitization and lowering the
incidence by using higher quality gloves, and that is really the heart of my
question was again related to whether these two measures have been proven to
lower the rate of sensitization in a prospective study.
That
would be the highest quality of outcome and also the most difficult kind of
study to do, time and large number of patients, but that would be the best
evidence, in my mind, the scientific evidence that there is a benefit to these
measures.
DR.
HAMILTON: In our packet, we don't have
those papers, but there are a whole cadre of papers that have looked at those
questions. Some of them have flaws,
aren't perfect, but as a group, they speak to the issue of powder-free latex is
the direction that we should move at least in my opinion.
DR.
DWYER: Are there specific papers that
you wish the committee to have distributed?
DR.
HAMILTON: Tomorrow, I can bring some
and give them to the Secretary.
DR.
DWYER: It will be helpful.
DR.
HAMILTON: As at least suggested model
papers in this area.
DR.
DWYER: I have one last question and
then I would like Dr. Johnson, and then we will go all around the table.
I
am puzzled because if you powder a latex glove, the powder apparently sort of
absorbs compounds from the glove, so it would seem to me the ideal, and then it
could get in the air and you could breathe it or it could get into food or the
catheter that you showed us, and so forth, but it seems to me that the glove
itself, if you got rid of the powder, should therefore have less of those
proteins, because they have been leached out or absorbed.
So,
the ideal would be a glove where you put a lot of powder on it, get all of the
proteins leached out, rinse the proteins off, and then went about your
business. To a naive nutritionist, that
would seem logical.
What
is wrong with the logic there? How does
this work, is it an inhalation that we are talking about with the powder, or is
it simply both?
DR.
STRATMEYER: It depends on whether you
are talking about the patient or the healthcare worker. With the healthcare worker, it would
probably be inhalation. With the
patient, that is a different matter.
That would be tissue contact.
The
issue of what you are talking about, you can do the same thing by washing the
glove without adding, and then add the powder later, you know, because that is
one of the things that we thought perhaps had happened, when all of a sudden
glove production went from a few billion up to, you know, 20 billion in a very
short period of time, because universal precautions, that is when we started
noticing a lot of things, and it could be that they were just running lines
faster, not emptying the water as fast, because remember how these things are
made, they are dipped and then a mandrel goes through a wash. If you don't clean that water out, you are
going to get a lot of protein there, and it is going to end up coming off with
the glove.
Like
I say, we have seen the levels--and Vesna will be getting into this, this
afternoon--we have seen the levels of protein go down.
DR.
DWYER: Thank you.
Dr.
Johnson.
DR.
JOHNSON: My question is probably
equally as naive, but I am just wondering anecdotally, if you ask workers to
use the powder-free gloves, is there any evidence that they then powder it
themselves? I mean if they are
difficult to get on, it seems as if the workers are constantly putting them on.
DR.
STRATMEYER: There are ways to make the
gloves easier to get on without powder.
A lot of it is going to be preference, so anything I have is anecdotal. I think there are still a lot of surgeons
that still like powdered gloves because they can get a nice, thin glove with a
lot o tactile sensation, and surgeons' gloves are longer and tighter, they are
harder to get on.
But
again, if you want good, solid information, I don't have any. I don't know, Wava Truscott, do you have any
solid information?
DR.
DWYER: I am sorry, you will have to
come up to the microphone and identify yourself if you wish to speak.
DR.
TRUSCOTT: I am sorry, I am Dr. Wava
Truscott, Kimberly Clark.
DR.
DWYER: Go ahead.
DR.
TRUSCOTT: As far as reports, there are
some hospitals where surgeons in preference to having a powdered glove, will
add their own powder. Basically, all
gloves do start off as powdered because they just stick together and crumple in
manufacturing. So, then, you take off
the powder and you are almost right, because you start off with powder and that
washing takes the protein down.
They
are adding, as Dr. Stratmeyer was indicating, other things, like lubricant type
things, to make it easier and easier to put on than the other types of gloves,
or coatings, and thus to facilitate it.
Unfortunately, there are still some people that want more of the
ball-bearing type effect of a powder, so they will add it after it has been
removed.
DR.
DWYER: Thank you for your informative
comment.
Dr.
Gaspari.
DR.
GASPARI: I had a couple of comments
related to local effects of powder on the skin that are potentially of
relevance. First of all, the cornstarch
powder or really any kind of particulate material, when held against the skin,
will damage the stratum corneum, which really supplies the barrier function to
the skin. When held under occlusion for
a prolonged period of times, like under a rubber glove, this is theoretically a
basis for enhanced percutaneous exposure, percutaneous penetration of
polypeptides that are stuck onto those cornstarch particles.
So,
that is one issue, enhanced penetration of things that are sticking to the
cornstarch because of the alterations in barrier function.
Secondly,
there has been a couple studies that suggested that--these are animal model
studies--that if you co-administer an antigen with cornstarch particles, that
it is acting like an immunologic adjuvant, so there is an immunologic basis for
potentially adjuvancy of the cornstarch particles themselves.
So,
an adjuvant means that it induces inflammation and enhances the immune response
to a foreign antigen, boosting, like an IgE response, and alters the way the
immune system sees an antigen.
So,
those are two issues related to cornstarch particles.
DR.
DWYER: Thank you. More good news.
Could
we now go around the table, just finish, and have lunch. Remember that this gentleman may not be here
tomorrow, so this is your chance to get your shots in.
Dr.
Torres, any more questions? Dr.
Fischer. Dr. Hamilton. Dr. Taylor, you have been
uncharacteristically silent today. Dr.
Blumberg.
DR.
BLUMBERG: It is really a question and
it relates to some of the issue about the availability of the protein to
deliver that antigenic stimulus. The
reports that we were given by Beezhold, they said that there is more protein
inside the glove and it may have to do with some of this issue of occlusion and
the powder, and so on.
In
his study, he actually turned the glove inside-out to get more protein when
they delivered it. Now, that is not how
a food handler presumably would use it if they are using medical gloves and
those regulations, so I guess my question is--maybe you can address that
manufacturing issue--is there a difference between the availability of the
protein on the inside and the outside of the glove, or does it have to do with
the fact that you just have your hand inside the glove and there is the contact
that is involved, because that is going to affect it.
DR.
STRATMEYER: Again, I think the
manufacturers can probably this better than me, but there is a difference I
think because of the fact of the way, again, a mandrel is dipped in there, and
then it's pulled off, so what you have got, it is turned inside-out when it
comes off.
So,
the side that was next to the tank that it was going through, the latex it was
going through, would then be the inside of the glove.
DR.
BLUMBERG: Thank you for clarifying
that.
DR.
DWYER: Thank you.
Dr.
Gaspari. Dr. Johnson. Dr. Downer.
Dr. Scholz.
Well,
we have learned more about this particular product's manufacture than we ever
thought we would know.
DR.
STRATMEYER: So did I.
DR.
DWYER: At this point, I think we are
going to adjourn for lunch. Is that
appropriate for the committee, adjourning now and coming back at 1:30? Is that your pleasure or do you want to
start at 1 o'clock?
I
think the committee prefers, unless I hear otherwise, to reunite at 1 o'clock.
Thank
you.
[Whereupon,
at 12:10 p.m., the meeting was recessed, to reconvene at 1:00 p.m., this same
day.]
AFTERNOON SESSION
[1:00 p.m.]
DR.
DWYER: Over the lunch, it became
apparent that two committee members may have to leave tomorrow evening,
therefore, if the committee is willing, we would like to plow ahead today and
we would hope to try to go until 5 o'clock or thereabouts, 5:00, 5:15, and then
what we are trying to do, and we should know in about an hour, is to get two
speakers to move up, so that more speakers will be today, and we will have
fewer speakers tomorrow.
There
are some people who are not here and there are other people who cannot be
changed, the public comment time cannot be changed, but we will try to move up
those who can be moved up, and then Mr. Bonnette and I will work together to
see if we can move up some of the other things in the afternoon tomorrow to
give us enough time to finish in a deliberative and considered fashion by
tomorrow evening, so we have the benefit of the entire committee.
Is
there anyone on the committee who will find it a hardship to work until 5:00
tonight? Yes.
DR.
DOWNER: I may, I will have to make a
call.
DR.
DWYER: Very good. Anyone else?
With
that, if you will let us know, Dr. Downer, that will be nice.
Let's
get started then and resume our deliberations with those questions, those key
three questions. That is what we are
expected to do and what we will have to do tomorrow is to answer those three
questions, not everything about latex and latex allergy, but those three
specific questions must be answered by tomorrow. So, it is a good idea to just keep them at top of mind as we go
through the rest of the discussion.
For
more substance now, we are turning to Dr. Shanklin, who is at the Office of
Food Additive Safety at the Food and Drug Administration. She is going to speak to us on Safety
Assessment of Food Additives.
We
are grateful, Dr. Shanklin, for your presence.
Safety Assessment of Food Additives
DR.
SHANKLIN: Thank you.
Good
afternoon. As was stated, my name is
Anna Shanklin. I am from the U.S. Food
and Drug Administration, FDA.
FDA's
mission, pure and simple, is to promote and protect the public health by
helping safe and effective products reach the marketplace and monitoring those
substances while they are still on the market.
Today,
we will discuss a very important aspect of our agency's mission, food
additives, and today's presentation, Safety Assessment of Food Additives, how
FDA regulates food additives.
Additives
provide a variety of useful functions, as you are aware, in foods, such as
keeping them wholesome and appealing in transport. Additives also help to improve food's taste, texture,
consistency, color, and even nutritional value.
In
this presentation, we will review aspects of the food and drug law, to learn
about the legal framework in place for food additive approvals. We will discuss the food additive review
process outlined in the law, and gain more understanding on the safety
evaluation of food additives and how we should apply these provisions in the
law to evaluate natural rubber latex, a food additive, and its implications in
food mediated latex allergic reactions.
As
you have heard earlier, CFSAN's mission is to promote and protect the public
health by ensuring that the food supply is safe and wholesome and that
cosmetics are safe, and that food and cosmetic products are honestly and
accurately labeled.
The
Office of Food Additive Safety within CFSAN has the task of ensuring that the
use of food ingredients is safe.
In
review of OFAS's vast universe of food ingredients covered by Dr. Pauli this
morning, for the purposes of today's presentation, we want to focus on food
packaging and food contact substances for deliberation.
Now,
foods and food ingredients, as well as substances for use in, on, or in contact
with food, fall under the jurisdiction of the Federal Food, Drug, and Cosmetic
Act, often referred to as "The Act" or the FFDCA. It is the basic food and drug law of the
United States.
The
FDA is the federal agency mainly responsible for administering the main part of
the FFDCA. The law gives FDA authority
over foods and food ingredients, and is intended to assure the consumer that
foods are pure and wholesome, safe to eat, and produced under sanitary
conditions.
The
Office of Food Additive Safety is mainly responsible for administering the food
additive provisions of the Act, found in Section 409. Our administration of Section 409 focuses on the evaluation of
the proposed uses and safety information of the new food additive, and once a
safety determination has been made, writing regulations stipulating safe
conditions of use for the food additive.
Now,
regulations are not law, but a regulation is the standard requirement based on
the law. However, a regulation does
have full force of the law. U.S.
federal regulations are compiled in the Code of Federal Regulations, CFR, and
specifically Part 21 contains FDA regulations.
Although
our food additive regulations are not law, they are intended to be written such
that noncompliance with the regulation would violate some section of the law,
and in our case, the FFDCA.
The
law provides a framework for assuring the safe use of these additives or
chemicals on or in food. Under this
framework, the agency must approve new food additives before they can be used
in a manner and whereby they may be become components of foods.
This
is in accordance with the 1958 Food Additives Amendment to the Act, which
requires FDA approval of new food additives prior to their inclusion of food,
thus, the term "pre-market approval."
What
i a food additive? You have also
visited this definition earlier. In
Section 201(s) of the Act, a food additive is any substance, the intended use
of which results or may reasonably be expected to result, directly or
indirectly, in its becoming a component or otherwise affecting any
characteristics of any food.
This
includes any substance intended for use in producing, manufacturing, packing,
processing, preparing, treating, packaging, transporting, or holding food if
such use is not generally recognized as safe.
Yes, even food contact articles or food packaging is considered to be a
food additive if it is expected to become a component or migrate into food.
The
definition excludes substances that are generally recognized as safe, or GRAS,
by qualified experts. Examples of these would be items, such as salt, glass,
and stainless steel, among a few.
In
short, in the broadest sense, a food additive is any substance that is
reasonably expected to become a component of food as a result of its intended
use, if such use is not generally recognized as safe.
In
addition to the definition of food additive found in the Act, there are also
other important provisions provided in the law relating to how we regulate food
additives.
Section
409 defines an unsafe food additive. "The use of a food additive is
unsafe, unless that use conforms to a regulation, notification, or an exemption
issued by FDA under Section 409."
Section
402 speaks about adulterated food.
"A food is adulterated if it is or if it contains any food additive
that is unsafe."
Section
301 defines prohibited acts. "The
introduction or delivery into interstate commerce of any food that is
adulterated or misbranded."
Together,
these mechanisms or these provisions provide a mechanism for FDA to enforce the
law. Let's look at an example.
The
presence of an unsafe food additive renders a food adulterated, and when that
food enters into interstate commerce, a violation of the FFDCA occurs. FDA can then proceed with enforcement
actions under the law against the person introducing the adulterated food into
interstate commerce.
The
same applies for food packaging. Here,
we have the example of a candy bar wrapper using or containing a new
antioxidant that is not approved. If
that antioxidant then migrates into the candy bar, that is an adulterated
food. When that food enters into
interstate commerce, a violation of the Act occurs and FDA can take enforcement
measures.
Again,
food additives are regulated because the Act prohibits the interstate distribution
in the U.S. or importation of any food or articles that are adulterated.
Points
to Remember. An unsafe food additive in
a food renders that food adulterated.
An unapproved additive is the same as an unsafe food additive. Therefore, the presence of an unapproved
food additive renders a food adulterated.
The
1958 Amendment to the Act, in addition to defining the food additive and
establishing pre-market review of food additives, also established two key
concepts we want to focus on today - the standard of review and the standard of
safety for food additive approvals.
The
Amendment also published formal rulemaking procedures. Under the general safety standard of the
Act, a food additive cannot be approved for a particular use unless a fair
evaluation of the data available to FDA establishes that the additive is safe
for that use.
Thus,
the Standard of Review criterion requires a fair evaluation of the data, and
not infiltration of personal attitudes or preferences or beliefs of
administrative officials.
The
1958 report states that, "The committee has endeavored to prescribe a new
criterion requiring a high standard of fairness be observed in administrative
rulemaking, and again that personal attitudes or preferences of administrative
officials could not prevail on the basis of being supported by substantial
evidence picked from the record without regard to other evidence of value in
the record."
Furthermore,
the House of Representatives report from 1958 states that, "The committee
feels that the Secretary's findings of fact and orders should not be based on
isolated evidence in the record, which evidence in and of itself may be
considered substantial without taking account of the contradictory evidence of
equal or greater substance." Thus,
there must be a fair evaluation of all the available data.
The
Standard of Safety relies on the concept of reasonable certainty of no
harm. You have heard that also
earlier. "Reasonable certainty of
no harm," with equal emphasis on each word, as stated by Commissioner
David Kessler of 1995.
"Safe"
is defined in the Code of Federal Regulations as a "Reasonable certainty
in the minds of competent scientists that the additive or substance is not
harmful under its intended conditions of use." This is the standard.
"Harm,"
what is harm? Harm refers to health of
man or animal.
The
Standard of Safety set forth by the law requires the petitioner to demonstrate
a reasonable certainty of no harm from the intended use of its substance. FDA
will then assess whether it has received adequate documentation to appropriate
questions regarding the safety of the proposed use of the additive.
It
is very clear from the legislative history what the concept of reasonable
certainty means. From the 1958
congressional report, it states that, "The concept of safety used in this
legislation involves the question of whether a substance is hazardous to the
health of man or animal. Safety then
requires proof of a reasonable certainty that no harm will result from the
proposed use of an additive."
In
prescribing these standards, Congress recognized that absolute certainty of any
substance can never be proven, and in the report it indicates that the concept
of safety as outlined in the legislative history does not, and cannot, require
proof beyond any possible doubt that no harm will result under any conceivable
circumstance.
In
Section 409, the law provides a legal framework for regulating the safe use of
food additives. Let's review this legal
framework more closely.
Under
Section 409, any person may petition FDA to issue a regulation prescribing safe
conditions of use of an additive, and this is formally known as the Food
Additive Petition Process.
Keeping
in mind our Standard of Review, fair evaluation of the data, and our Standard
of Safety, reasonable certainty of no harm, let's clarify or examine the
petition process more intimately.
Our
safety decision regarding the approval of food additives is solely a safety
decision. Our evaluation is not
intended to ensure, nor is it possible to ensure, safety with absolute
certainty. Our standard is the
reasonable certainty of no harm rather than a certainty of no theoretical
possibility of harm.
Our
evaluation is not a risk-benefit analysis relative to other available
options. Our evaluation is not intended
to enforce or limit consumer choices.
However, our decision does, in fact, ensure safety.
It
is a consensus decision made with residual certainty that provides a fair
evaluation of all the data of record.
It must protect the public health, and this data of record will be able
to withstand scientific, procedural, and legal challenges from all sides.
Thus,
our evaluation is a science-based decision in a well-documented record.
So,
the approval of food additives again are solely based on safety, under the
safety standard, reasonable certainty of no harm where harm refers to health of
man or animal. The Standard of Review
is the fair evaluation of the entire record, and benefits are not to be weighed
in our safety decision.
Let's
review the process and the key players.
With the submission of a petition, the safe use of a substance is
determined through a series of reviews of the relevant scientific data and
information submitted by the petitioner.
A
typical submission will undergo chemistry, toxicology, and environmental
science reviews, and the review is managed and coordinated by a consumer safety
officer.
In
order for FDA's key players to evaluate the safety of a substance under its
proposed use, certain scientific information is needed - the complete identity
of the chemical substance, conditions of proposed use, the intended technical
effect with the petitioner submitting to FDA, data establishing the minimum
amount required to achieve this technical effect, the method for quantifying
how much of the additive is available, full reports of safety studies,
manufacturing methods, as well as environmental information in accordance with
the National Environmental Policy Act.
We
want to stop and emphasize here that a full-blown, exhaustive safety evaluation
of all the appropriate studies with agency ownership of the safety decision
occurs under the safety evaluation of a food additive.
We
also want to emphasize that in the safety evaluation of a substance, an
important requirement is the estimation of the food additive's probably human
exposure under its proposed conditions of use to determine whether its use or
presence in food at a certain concentration is safe.
The
key determinant in the evaluation of the substance in or added to the diet is
the relation of its human exposure to a level at which no adverse effects are
observed in toxicological studies, or as a popular coined phrase states,
"The dose makes the poison."
The
technical review process is very thorough.
FDA scientists provide free filing consultations to help
petitioners. FDA scientists review the
data and evaluate the petitioner's safety argument.
FDA
communicates with the petitioner to resolve any questions and/or additional
data needs it has. FDA reviews the
documentation and then FDA reaches a scientific conclusion and makes a
recommendation.
Section
409 also stipulates other required actions on food additive petitions after it
has been submitted. FDA must complete
the review and establish a regulation or deny the petition and inform the
petitioner.
The
FFDCA legal framework outlined in Section 409 also speaks to other provisions
pertaining to the response of actions on food additive petitions. FDA must allow for objections to the actions
filed by any person and honor requests for public hearing.
The
Act also allows for judicial review of the objections that have been
filed. The requirement we want to focus
on today is agency-initiated amendment or repeal of regulations.
In
amending or repeal of regulation, it is essential to understand that the
process is equivalent to that of food additive approvals. In the process of food additive approvals,
there is a fair evaluation of the data under the Safety Standard, reasonable
certainty of no harm, and an issuance of a regulation.
In
the process for amending or repealing a regulation, there should be a fair
evaluation of the data under the Safety Standard, reasonable certainty of no
harm, and the issuance of a regulation.
Simply put, if it comes in as a regulation, it goes out as a
regulation. It is FDA's responsibility
under the law.
So,
the legal framework for food additive approvals provide that food additives
again are unsafe until FDA makes a decision, and if FDA decides that the food
additive is safe under its conditions of use, we write regulations stipulating
an identify, specifications and conditions of safe use. The detailed specifications may include
types of food that the additive is permitted in, the manner of use, and any
other special labeling requirements.
FDA
regulations do not provide for specific product approvals. This process for review of additives is for
those added directly into food, as well as for food contact substances, such as
packaging.
Specifically,
the food additive regulations for indirect regulations are listed in Part 174
through 178 of the Code of Federal Regulations.
We
want to touch briefly on the fact that in 1997, the Food and Drug
Administration and Modernization Act amended the Act more commonly referred to
as FDAMA to establish a food contact notification process as the primary
process by which FDA regulates food additives that are food contact
substances. The FCS process is outlined
in Section 409 of the Act.
FDAMA
also gave us the statutory definition of a food contact substance. And what is a food contact substance? It is any substance intended for use as a
component of materials used in manufacturing, packing, packaging, transporting,
or holding food if such use is not intended to have any technical effect in the
food, also known as indirect food additives.
Thus,
for the purposes of today's meeting, it is important to emphasize that under
the legal framework established by the Act, a food additive that is the subject
of an effective notification is also a safe food additive.
So,
food additive approvals in brief.
Section 409 gives FDA all the necessary tools for assuring the safe use
of food additives regardless of whether FDA is petitioned or notified, the safe
use of a substance is determined through a series of reviews of the relevant
scientific data and information submitted.
We
review the safety of each substance under its proposed conditions of use, and
this review is carried out by qualified and competent scientists.
The
safety assessment of the food additive is concluded by writing a regulation,
allowing a notification to become effective or by granting an exemption.
In
reviewing roles and responsibility, the petitioner is responsible for
demonstrating safety, and FDA is responsible for conducting a full and fair
evaluation of the data and information, and issuing a regulation only if FDA
scientists conclude that the requested use is safe.
Now
that we are well versed on how FDA evaluates the safety of food additives and
the regulatory process for food additive approvals, let's examine a specific
food additive, an indirect food additive, a food contact material, natural
rubber.
Let's
review it based on the Act in Section 409 and the Standards of Review and
Safety previously discussed. First, I would like to point out that natural
rubber latex is approved in several places throughout the Code of Federal
Regulations in Part 21.
As
we talked about earlier, a direct use is in 21 CFR 172.615, chewing gun
base. So, that is one of the regulated
uses that Dr. Taylor mentioned earlier.
For indirect use, it is also listed in adhesives, pressure-sensitive
adhesives, resinous and polymeric coatings, acrylic and modified acrylic
plastics, both semirigid and rigid, cellophane, closures with sealing gaskets
for food containers, and the one that we are concerned about, rubber articles
intended for repeated use.
So,
natural rubber latex is listed along with its conditions of safe use in Section
177.2600, and this regulation was issued in 1963. Therefore, it is an acceptable indirect food additive. It is used in the production of latex food
service gloves, thus, it is a food contact substance.
FDA's
current position is that provided that the compositional requirements of the
regulation and its limitations and specifications are met, the use of natural
rubber as a component of food service gloves is in compliance with 21 CFR
177.2600, and it is not an unsafe food additive.
But
we know that we have issues with natural rubber latex, and what are these
issues? As previously discussed,
exposure to natural rubber latex has been shown to elicit a range of responses
in sensitized people. Of specific
concerns are various allergic reactions responding to the natural rubber latex
usually as a result of prolonged cumulative exposure to natural rubber latex.
These
allergic reactions have been linked to latex proteins.
FDA
has received reports of latex allergenic individuals, those who are already
sensitized to latex, displaying allergic reactions to foods believed to have
been handled by food service workers wearing natural rubber latex gloves. Thus, the problem becomes food mediated
latex allergic reactions.
Remembering
that part of our agency's mission, to monitor substances while they are still
on the market, post-market surveillance, FDA understands, as Dr. Tarantino
said, that since the approval of natural rubber latex in 1963, things have
changed, and we want to state that we are dedicated to promoting and protecting
the public health.
With
that, CFSAN has been gathering information relating to food mediated latex
allergy in an effort to determine if there are data to support the claim that
latex proteins are transferred to food as a result of the use of latex food
service gloves, and if such use may trigger an allergic response in
hypersensitive consumers, and if there is sufficient evidence to propose a
regulatory action, such as amending or repealing the regulation currently in 21
CFR 177.2600.
Let's
look at the glove. We know that latex
food service gloves are used by the food service industry as a barrier to
infectious agents that may be present on the hands of food service
workers. Thus, gloves are considered a
food contact material, and they are subject to the law.
Under
the approval process, natural rubber latex was evaluated for use in repeat use
articles with a fair evaluation of data, under the Safety Standard of
reasonable certainty of no harm.
However,
it has been suggested that the latex food service gloves are responsible for
introducing natural rubber latex allergens to food, thus rendering the food
adulterated. The proteins are
components of food contact articles, the gloves, that may migrate to food as a
result of their intended use in the food service gloves, thus, they are
constituents of the food additives. As
such, they are subject to the safety requirements in the law, and their
assessment of safety should be based on the law.
So,
evaluation and any regulatory actions on the use of natural rubber latex in
food service gloves and other food contact articles should be based on the
general safety standard.
Again,
the Safety Standard is reasonable certainty of no harm. Our decision and actions regarding the use
of NRL in contact with food has to be focused on this standard - does it or
does it not meet the standard. That is
the question.
So,
food mediated latex allergic reactions, how do we address the problem from a
public health standpoint? In addressing
the problem of food mediated latex allergic reactions, we must consider that
safety is our first priority. Before we
act again, we must ask the question if the use of the additive would result in
the production of unsafe food.
FDA
just operate under the law. We must
consider that food additive approvals result in the issuance of a regulation
and that there is a legal framework in place.
We must remember that food additive regulations are issued based solely
on safety data relating to the additive itself, that food additive provisions
do not provide a mechanism for FDA to consider risk-benefit relative to other
options when reviewing the safe use of a particular substance.
In
other words, we cannot ban latex for use in food service gloves based on the
fact that there are other options available.
We
also want to remember that there is a legal framework in place for approvals
and also for amending and repealing regulations, and that end with an issuance
of a regulation.
So,
what did we learn regarding how FDA regulates food additives? We learned again that there is a legal
framework in place, and this is found in Section 409 of the Act, that this
framework provides for a solid review process conducted by competent
scientists, and that the Standard of Review is fair evaluation of data, and our
Standard of Safety is reasonable certainty or no harm, remember safe meaning a
reasonable certainty in the minds of competent scientists that no harm will
result from the intended use of the additive, and harm again referring to harm
to health.
Also,
currently, natural rubber latex is a safe food additive under Section 21 CFR
177.2600 as long as it is compliance with that regulation.
Finally,
we have reviewed the legal framework in place for food additive approvals, and
we have reviewed the food additive process and the safety evaluation of food
additives as outlined in the law.
We
have also reviewed the issue of food mediated latex allergic reactions, and
hopefully, have gained a greater understanding of how to address the problem
from a public health standpoint, understanding FDA's responsibility to operate
under the law, promoting and protecting the public health.
Are
there any questions?
DR.
DWYER: Thank you.
Questions of Clarification
DR.
DWYER: While the committee deliberates,
Dr. Hamilton, did you have a question?
DR.
HAMILTON: Yes. Could you, as a point of information for me,
clarify whether powdered versus non-powdered gloves ever entered into the
approval process with regard to this 21 CFR 177.2600? In other words, there was no discussion of discriminating
powdered versus non-powdered, it was just latex gloves were reviewed, right?
DR.
SHANKLIN: Not that I am aware of, and
in the regulation, it just says natural rubber latex.
Would
someone else from the agency care to comment on that?
DR.
PAULI: Let me add a little bit, that
when that regulation was issued, I think what people were mostly thinking about
were hoses in factories, use of rubber in general, because cornstarch itself
would be considered safe, and if natural rubber latex was safe, we often get
mixes and matches in ways that one wouldn't have contemplated.
DR.
HAMILTON: Thank you.
DR.
DWYER: Dr. Taylor, you had a comment?
DR.
TAYLOR: So, I asked this question once
before this morning, but is our advisory committee restricted to the debate
about natural rubber latex as approved under 21 CFR 177.2600?
DR.
SHANKLIN: Yes.
DR.
TAYLOR: So, we are not to comment
upon--I mean it seems incredulous to me that we are being asked to comment on
the use of latex gloves, when there is direct food additive approval for latex. It seems very inconsistent.
DR.
SHANKLIN: Dr. Tarantino wishes to
comment on that.
DR.
DWYER: Dr. Tarantino.
DR.
TARANTINO: Again, I think as you have
seen most of the information presented to us was about gloves, but as George
said, the regulation is about natural rubber.
If you have any evidence that it is the hoses and the belts and the
other things as opposed to gloves, we would be very interested in hearing that.
It
is clear that most of the information that came to us--and this is why the
questions were phrased that way--pointed at gloves, but we are interested in
hearing if you have something else to say about other forms of natural rubber
latex used in food contact.
DR.
DWYER: Dr. Taylor.
DR.
TAYLOR: Does not the FDA also have
authority to regulate the safety in food contact materials being applied to
meat and poultry products under the purview of the U.S. Department of
Agriculture?
DR.
TARANTINO: The USDA defers to us about
doing the safety review, and we coordinate with them.
DR.
TAYLOR: So, it seems to me as though
there may be some uses under Section 9 of the Code of Federal Regulations
regarding meat and poultry applications, in particular, the netting materials
that are used on corned beef and ham, and things like that, have a latex core. That is what I am familiar with. I don't know that there might not be others.
DR.
TARANTINO: That is an issue, as well,
in and of itself, but I think the underlying regulation that we are involved
with here is the natural rubber latex per se in contact with food.
DR.
DWYER: Dr. Gaspari.
DR.
GASPARI: I have a question related to
one of your slides with the quotation, "The dose makes the poison,"
and in terms of evaluating dosing with natural rubber latex exposures, number
one, we don't know what the dose is that would elicit allergic response or
allergic signs and symptoms in an NRL-allergic individual, and, two, we don't
know the actual dose range of natural rubber latex that is carried over into
the food that could potentially elicit, and what a safe level would be in an
at-risk population.
That
is one question. I guess the other
question I have is in terms of what is a reasonable level of risk of this type
of phenomenon occurring. Obviously,
there is millions of exposures of people in restaurants that food is prepared
with handlers using natural rubber latex gloves, and there is probably,
although I guess this is totally unknown, how much latex they are actually
exposed to, and if basically, all we have is a handful of reports of severe
reactions, it seems like a very rare event although we don't know what the
exact denominator is.
The
other question, what is an acceptable rate of a very extremely rare reaction
even though it may be potentially very serious to even fatal?
So,
those are my two questions.
DR.
DWYER: Let's make sure we have got the
questions. One is what is an acceptable
rate under the law of an adverse reaction, the kinds that have been described
in the case reports for natural rubber latex, and the other question I had you
ask is what dose elicits an allergic response.
Could
you speak to those?
DR.
SHANKLIN: He wants to take it.
DR.
DWYER: Okay, fine.
DR.
PAULI: We want somebody near retirement
to take a question like that.
DR.
DWYER: Are you planning on identifying
yourself?
DR.
PAULI: This is George Pauli. Actually, this is one of those questions we
have to turn back, and that is why we are giving very general terms. What is reasonable in terms of the real
world? That is where we are looking for
your judgment and how much scientific data do you need to stand up to
scrutiny. That is where we are asking
your input because our guidance is very general.
As
I mentioned this morning, we think of common food as the gold standard. On the other hand, we don't want to see
peanuts mixed in the chili as happened several years back and having someone
die from it.
This
is a context where we are looking for wisdom, and we will give you the facts we
have, and as you noticed, the questions, they were put together in a charge, had
contingency clauses in there, because we don't know which can be answered. But, frankly, this is what we are throwing
to you to give us your best guidance in this area.
DR.
DWYER: Thank you.
Don't
sit down, because we have another question. You didn't answer the question
about what dose elicits an allergic response.
DR.
PAULI: Then, again, I would say we
don't know. We don't know what amount
would be transferred to food, we don't have any information on that. You saw the papers that were given out. That's all the information we have.
Those
are very legitimate questions, and it might point to a need for further
quantification, but as you will also hear later, in reflecting from this
morning, the framework is changing, too, of what was the amount that would have
transferred 10 years ago compared to now may be different, so the exposure may
be differing.
I
think for those of you in the allergy field, you know, one of the hot areas is
how do you set a threshold and a threshold for whom, because there may be
thresholds that vary with the individual, and just don't have answers on that,
we are looking for feedback.
DR.
DWYER: Thank you.
One
other question is, is the regulation really concerning natural rubber or
natural rubber latex?
DR.
SHANKLIN: Natural rubber latex.
DR.
DWYER: Thank you.
Dr.
Hamilton.
DR.
HAMILTON: I have one more
question. One of your slides you showed
that candy wrapper adulterating a candy bar, and then it being transported with
a truck across state lines, and then the FDA going after it.
Is
there a requirement to actually measure the adulterating component in the food
before the FDA actually takes action, or is it just based on--
DR.
SHANKLIN: In this case, since the
antioxidant was unapproved, then, that automatically renders the food
adulterated, and when it enters into interstate commerce, that is just a
violation.
DR.
HAMILTON: So, just the presence.
DR.
SHANKLIN: Just the presence.
DR.
HAMILTON: One doesn't have to quantify
its absolute transfer to the food or anything of that nature?
DR.
SHANKLIN: No.
DR.
HAMILTON: Thank you.
DR.
DWYER: Dr. Torres, Fischer?
DR.
FISCHER: I would like to ask about
chewing gum, because you brought that back up again. Tell me what is in chewing gum, is it natural rubber or natural
latex?
DR.
SHANKLIN: Let's look it up right
here. I think it's natural rubber, if I
am not mistaken, but I have the regulation right here. It speaks to natural rubber, smokesheet and
latex solids.
DR.
FISCHER: Well, that helps.
[Laughter.]
DR.
DWYER: No wonder the teachers told us
not to chew it.
DR.
FISCHER: My next question, to follow
that up, would be are there any reports of allergies from chewing gum?
DR.
SHANKLIN: Not that I am aware of.
DR.
FISCHER: So, nobody has ever questioned
that.
DR.
TAYLOR: Is the FDA aware of whether any
chewing gum manufacturers are actually using this material as chewing gum based
today?
DR.
SHANKLIN: I think Dr. Stratmeyer may
want to comment on that question.
DR.
STRATMEYER: I don't know about whether
they are using it for chewing gum, but actually, what you are talking about is
really not natural rubber latex, and I don't know for sure. There are some people out here that can
probably answer that, but one of the problems you have got is definitions.
We
ran into that when we wrote our first rule on labeling natural
rubber-containing medical devices. So,
in the rule, we put down definitions for everything that there was. We considered natural rubber to cover two
different things, natural rubber latex and dry natural rubber.
There
is a lot of difference in how the proteins that are available from dry natural
rubber are a lot less than the proteins that are available from natural rubber
latex. We also defined natural latex,
and we had trouble doing this, because you could go to different places and
find it.
We
worked with ASTM and some of the people in V-11, which is the rubber group, and
we got definitions and nailed them down, and without those definitions, it is
very difficult to identify what material you were talking about, particularly
when you go back several years.
Do
you want to say something about the chewing gum?
DR.
DWYER: Shall we recognize this person,
and would the person please come up and identify themselves.
DR.
BOREL: I am Dr. Lisa Borel of Consumer
Advocates, Latex Allergy. Over seven
years we have investigated many products for natural rubber content or natural
rubber latex content. Chewing gum does
not contain natural rubber which is made here in the United States. It is all synthetics at this point and makes
bigger bubbles, I was told.
DR.
DWYER: Thank you.
Dr.
Blumberg, any questions? How about Dr.
Downer?
DR.
DOWNER: Thank you for a very
interesting presentation. You mentioned
with respect to food additives, amendment and repeal, that regulations in
equals regulations out. Can you tell me
what happens within that process, because it seems as if there is no need for
discussion or deliberations then?
DR.
SHANKLIN: What I mean by that is that
under the food additive approval process, there is a formal regulation or
formal regulatory process, whereas, the data is submitted, FDA reviews the
data, and it issues a regulation. So,
in order to have an amendment or a change to the regulation or repeal a
regulation, that data or information has to be submitted and reviewed under the
same standards and a regulation issued.
DR.
DOWNER: Thank you.
DR.
DWYER: Any others? Dr. Hamilton.
DR.
HAMILTON: May I make a recommendation
that this committee use the definitions that have been already defined in the
document that Dr. Stratmeyer just described because I got a little puzzled and
confused when natural rubber and natural rubber latex were used all of a
sudden, and it wasn't really well defined.
It was defined just a moment ago, but I think if we use the definitions
that already have been through scrutiny, it would be helpful to all of us.
DR.
DWYER: Does the committee agree to
that? If so, it might be helpful for
the agency to provide us with the definitions if they are not already
provided. Could we get that maybe by
the break? Perhaps it's in our
materials and we just don't know it.
So, someone from the agency will provide that to the committee by the
break.
Thank
you very much, Dr. Shanklin, appreciate your help.
Just
recap, at the break, we should know how many speakers we can get moved up, but
it is my intention as chair, unless the committee objects, to continue this
meeting until 5 o'clock tonight. Is
that all right with everybody? Dr.
Downer is going to check and make sure that her other engagement can be
changed.
The
purpose of this is to get the benefit of all committee in the discussion
because two members may have to leave tomorrow night. Thank you.
Let's
go on then to the next speaker, who is Dr. Hepp. Dr. Hepp is at the Office of Food Additive Safety, and his topic
is the Specific Background on Food Mediated Latex Reactions. This should be some interesting science.
Specific Background on Food Mediated
Latex Reactions
DR.
HEPP: Good afternoon and thank you for
the introduction.
The
information presented so far was, for the most part, background in that it was
describing latex allergy as a problem that exists in the clinical setting. It also described the steps that FDA's
Center for Devices and Radiologic Health have taken to address that problem in
the clinical setting, and as Anna just described, FDA's authority as it relates
to the regulation of food additives.
The
purpose of bringing this Additives and Ingredients Subcommittee together is to
provide you with all the information that relates latex allergy directly to
food safety, and another reason is to collect any additional information that
FDA may not be aware of from people participating in the meeting, and then to
get independent consideration from this committee about all of the information.
DR.
TORRES: Are there any slides in the
handouts? I don't see it in my set.
DR.
DWYER: Is there a handout?
DR.
HEPP: There is no handout at the
moment. We will provide that later.
DR.
DWYER: Good. It would be helpful before the end of the day.
DR.
HEPP: Okay. The third reason for getting the committee together is to get
some independent consideration of all the data that we have collected or that
we can collect at this meeting, and to get answers to the questions that we
have presented the committee with in the charging questions.
So,
to that end, I intend to highlight the Center for Food Safety and Applied
Nutrition's involvement with this issue and then catalog all the information
that we found that relates latex allergy directly to food safety.
As
Dr. Slater pointed out this morning, there is a number of adverse reactions
that can happen as a result of wearing latex gloves. One is irritant contact dermatitis. Irritant contact dermatitis is a breakdown of the skin that is
exposed to the NRL. It is confined to
the area of contact with the NRL glove, and it is not mediated by the immune
system.
Delay
type hypersensitivity reactions are T-cell mediated reactions. They are usually caused by chemicals in the
glove that are used in the compounding of the rubber into a useful product, for
example, it is not uncommon for people to react to the accelerators that are
used to hasten the vulcanization or the cross-linking of the rubber polymer in
the natural rubber matrix.
Now,
although together, these two reactions comprise perhaps 80 to 90 percent of all
the adverse reactions associated with latex gloves, they are not the reactions
that are the subject of this meeting.
The
reactions that are the subject of this meeting are the immediate type
hypersensitivity reactions. Immediate
type hypersensitivity reactions are IgE mediated and therefore they are
systemic reactions. They are a reaction
to certain proteins that are found in the natural rubber, and they present with
symptoms such as urticaria or hives, rhinoconjunctivitis, asthma, and sometimes
anaphylaxis.
They
require previous sensitization, usually prolonged cumulative exposure to the
natural rubber latex proteins, although genetic predisposition does play a role
in sensitization.
So,
for the rest of this meeting, anytime we refer to latex allergy, it is these
immediate type hypersensitivity reactions that we are referring to.
Now,
because FDA's involvement or Center for Food Safety and Applied Nutrition's
involvement with this issue begins with the food code, I am going to describe
briefly what the food code is.
The
food code contains FDA's recommendations for safe food handling and sanitation
procedures that FDA offers for use in the retail food industry. It is offered to state and local agencies as
guidance in the hopes that they will adopt it.
This guidance is neither federal law, nor is it federal regulation,
however, FDA does encourage the states to adopt the food code as part of their
state codes.
The
food code is developed in cooperation with state and local governments,
consumers, industry, and academia at the Conference for Food Protection. The Conference for Food Protection has in
place, procedures that ensure that everyone who has a stake in setting food
safety standards has a chance to be heard before any changes are made to the
food code.
Now,
FDA's involvement probably begins in 1993 or the Center for Food Safety's
involvement begins in '93, when FDA added Section 3-301.11 to the food
code. This section of the food code
recommends that bare hands contact with most ready-to-eat foods be
prohibited. It further states that
suitable utensils should be used instead of bare hands.
This
provision was added to the food code as a result of a number of outbreaks of
foodborne illnesses that resulted from the transmission of pathogens from the
food worker's hands to the food, and was intended to address that issue.
This
provision was not adopted or accepted by many states initially, but in time,
more and more states began to adopt it, and by 1997, many states had adopted
the provision as state law, and this resulted in a noticeable increase in the
number or in the use of all kinds of food service gloves. Latex happened to be an alternative to other
materials for food service gloves.
The
Center for Food Safety, this should say, first learned that latex food service
gloves were a concern to many people who have been sensitized to latex allergy
in the occupational setting.
We
learned that the concerns centered around the possible migration of allergenic
proteins to food as a result of contact with these food service gloves, and the
subsequent possibility that such proteins could cause an allergic reaction in
consumers when that food is consumed by someone who is latex allergic.
By
this time, however, the subject of latex allergy, as it relates to medical
gloves, had been the subject of review in the Center for Devices and Radiologic
Health, as you know.
They
made several findings which are important and relevant. Those include that certain NRL proteins can
be allergenic, NRL proteins bind to the cornstarch that is used as donning
powder, and that aerosolized donning powder is allergenic and may be an agent
for sensitization of non-allergic individuals, although again, usually,
prolonged chronic exposure is required for sensitization.
So,
as a result of the expressed concern about the use of latex food service
gloves, the findings of the Center for Devices and Radiologic Health, and the
recommendations of the National Institute for Occupational Safety and Health,
the Occupational Safety and Health Administration, the American Academy of
Allergy, Asthma, and Immunology, who all recommended that food service workers
not use latex food service gloves, FDA published a caution in the food code
that basically stated that information relating to latex allergy should be
considered by those retail food establishments who were choosing food service
gloves.
At
the same time, FDA began gathering information that relates latex allergy
directly to food safety.
In
2002, FDA reported its findings to the Conference for Food Protection, and the
findings that we reported at the Conference for Food Protection won't be
different from the findings that we are reporting here today, so I won't tell
you exactly what we said to them, we will get to that soon enough.
FDA
also indicated to the Conference that natural rubber is the subject of federal
food additive regulation, and therefore, the safety of such use is most
appropriately reviewed under Section 409 of the Federal Food, Drug, and
Cosmetic Act, and not within the context of the food code.
Now,
we get to the interesting part, data that relates latex allergy directly to
food safety. This does not include
several things. One, it is important to
acknowledge that there is an enormous body of information, scientific
information relating to latex allergy, and one author was able to show that the
number of publications, scientific publications relating to latex allergy
increased exponentially during the 1990s.
However,
most of that relates to occupational use of latex gloves in the clinical
setting, and for our purposes, it is important to separate those uses from the
food safety issues, so I won't be presenting the bulk of that information that
relates to worker exposure and occupational safety.
In
addition, when we review the safety of a food additive use, as Dr. Shanklin
stated, under Section 409 of the Federal Food, Drug, and Cosmetic Act, we are
required to consider the safety of the additive itself, and we don't have
authority to consider risks and benefits relative to alternative materials.
If
an alternative material is safe, if we have evaluated it and determined it to
be safe, and latex is safe, one can't be more safe than the other. They both meet the safety standard. So, information relating to risks and
benefits associated with alternative materials really won't answer any
questions about the safety of latex in this use, so I won't be presenting any
information about vinyl gloves or nitrile gloves, just the information that
relates to latex.
We
have a number of publications from the literature. Most of them are Letters to the Editor describing either case
reports or experiments that were done that are not exactly the quality in terms
of design and control of the experiments that you would like in a study that
you would use for a decisionmaking process.
However,
this is one paper that is a full research report. It is reported in Allergy Asthma Proceedings in the year
2000. Dr. Beezhold is in the audience
today, and I think he will talk more about this later on today.
The
authors reported study to determine whether natural rubber proteins can be
transferred to foods following contact with latex gloves. The results of this study were that the
direct transfer of natural rubber protein to cheese was visualized using a
modified immunoblot method. That is, they
took a latex glove and they applied it to a slice of cheese, and then used an
immunoblot method to lift the fingerprint and visualize the fingerprints that
represented the latex protein that was transferred to the cheese.
Another
thing that they did in this paper was they measured the direct transfer of
natural rubber protein to lettuce, and they quantified that using an inhibition
ELISA specific to natural rubber.
The
results of their study, one of the conclusions was that an average of 50
nanograms of protein was found to transfer per finger contact. These are the authors' results, and the nice
thing about a full research paper is that you get to see the context by which
they arrived at those results.
The
context is shown on this slide. The
authors report using a specific lot of gloves with an expiration date of 1993,
which means that they were manufactured well before 1993. During the 1990s, it is important to note
that the protein content in such gloves dramatically decreased.
This
is evidenced by, among other things, Table 1 in that publication, which shows
the most recent powdered latex gloves that were examined by the authors had 33
times less protein in it than the gloves that they used for the transfer
experiments.
The
newest powder-free gloves, that had an expiration date of 2003, had a total
antigenic protein content below the detection limit of the method. In addition, the authors report that 80
percent of the total protein was on the inside of the glove.
This
is not unusual to have most of the protein on the inside of the glove for two
reasons. One, as the glove is being
cured on the mold, the aqueous part of the latex is being driven to the outside
of the mold, and that is going to carry the water-soluble proteins with it.
In
addition, of those proteins aren't removed from the glove by extraction before
the donning powder slurry is applied, the proteins can accumulate in the
donning powder slurry. Then, when you
apply the powder, it is possible for you to apply additional proteins at the
same time.
Well,
the outside of the glove on the mold is the inside of the glove as you use the
glove. The author reports that the
experiments were done with such gloves turned inside-out to make it easier to
detect the protein that transferred.
These
experiments demonstrate the physical possibility of detecting a transfer under
certain circumstances, but those circumstances are different from what would be
encountered in the use of a food service glove today.
The
next bit of information we found was published in the Journal of Allergy and
Clinical Immunology. It was an abstract
and subsequently published in the European Journal of Allergy as a Letter to
the Editor.
The
authors described a double-blind, placebo-controlled challenge study with latex
glove extract on patients allergic to NRL.
The purpose of the study was to determine if latex-contaminated food can
provoke an allergic symptom in an NRL-sensitized individual.
The
protocol was at 30-minute intervals, the subjects being identified as being
latex allergic receive 10 ml of sugar water followed by 0.2 or 0.5 ml of an
aqueous solution NRL glove extracts.
The
results were that three of the test subjects experienced reactions to the
challenge, and those reactions were pharyngeal itching and congestion, and one
subject experienced dysphonia.
That
was all that was reported. Dysphonia
could be anything from a generalized sensation of hearing impairment to a loss
of hearing, but it wasn't explained in the report.
They
also reported that none of the four in the control group reacted to the
challenge. Now, the four in the control
group were four people who were not latex allergic.
The
positive responses were found at doses of 5 micrograms, 50 micrograms, and 20
milligrams, and it would be interesting to compare the nature of these
reactions and the dose with what could be arguably an exaggerated dose from the
experiment that tried to quantify the amount of protein that does transfer to
food. That is, these doses are, at the
lowest, 100 times higher than what was found in the previous paper.
It
is also important to note here that three of the subjects who were latex
allergic did not respond to an oral challenge of up to 50 milligrams of latex
glove extract.
The
next paper is the paper that came up earlier today. Printed as an abstract in the Journal of Allergy and Clinical
Immunology, and subsequently in the Canadian Journal of Allergy and Clinical
Immunology is a report on the oral desensitization experiments in NRL allergic
patients.
The
patients were subjected to oral challenges beginning at does of 1/10,000th, the
lowest skin prick positive concentration, doubling those doses every 15 minutes
until the patients received the 2 mg dose of latex extract.
Thereafter,
the subjects ingested 1 mg two or three times a day. The authors reported diminished skin prick test response, and
they also reported that all subjects returned to their jobs involving heavy NRL
exposure without symptoms. They didn't
say what heavy NRL exposure meant, but they did say that the workers were
healthcare workers, so they were in a healthcare environment.
The
information may suggest that the ingestion of allergen does not necessarily
induce systemic reactions in latex allergic subjects. One of the authors on this report is also Dr. Beezhold, so he may
be able to comment more directly on that.
Also,
reported in the Journal of Allergy and Clinical Immunology in 2002, a case
report of a patient who had anaphylactic reaction 10 minutes after eating a
doughnut at a shop that used latex food service gloves.
The
patient had previously eaten similar doughnuts at a shop that did not use latex
food service gloves, and never had an adverse reaction to those doughnuts. The patient was then diagnosed with latex
allergy, and he was also tested for the major ingredients in cream-filled
doughnuts.
The
authors reported administering with consent piece of doughnuts obtained from
the shop using latex gloves every 30 minutes until the patient experienced
urticaria, conjunctivitis, and lip edema.
They report that the patient experienced no symptoms upon consuming a
doughnut obtained from the shop that did not use latex gloves.
Based
on this result, the authors conclude that the latex contaminating the doughnut
was the cause of the original anaphylactic reaction. However, they did not measure latex in the doughnut that the
subject reacted to, and other than testing for the major components that are
generally in a cream-filled doughnut, they didn't establish that there wasn't
there some other ingredient in the doughnut from the shop that used the latex
glove that the child may have been allergic to.
In
the New England Journal of Medicine, 1999, healthcare was reported to have
developed latex allergy after five years of using latex gloves in her
work. The authors conducted
double-blind tests where the patient was asked to drink orange juice that was
stirred with a latex glove and on another occasion drink orange juice that was
not stirred with a latex glove.
The
patient experienced allergenic symptoms within 35 minutes of drinking the
orange juice stirred with the glove, and she was treated and the symptoms
cleared. No symptoms were experienced
after drinking orange juice that was not stirred with the latex glove.
Howard
Schwartz reported in the Journal of Allergy and Clinical Immunology in 1995,
two patients who experienced severe reactions to food eaten at
restaurants. In both cases, food
handlers were said to have been wearing latex gloves.
Both
patients had long histories of allergies and both tested positive to skin prick
tests with a crude latex preparation, and one had been previously diagnosed
with latex allergy. The authors
conclude that although the clinical experiences of the two patients could not
be confirmed, it is suggestive that latex may be a hidden food allergen in this
food.
Nixon
and Lee reported in the Medical Journal of Australian 2001, a healthcare worker
with a history of eczema, hay fever, and asthma developed angioedema,
bronchospasm within 10 minutes of eating in a restaurant. The patient was treated and had an
uncomplicated recovery. The cause of
the episode remained unknown.
Several
months later, she was diagnosed with latex allergy on the basis of a positive
RAST, and after developing a skin reaction to latex gloves at work. Subsequent inquiry confirmed that the
restaurant generally used latex gloves to handle salad, vegetables, and
seafood.
Adverse
event reports. What I am going to say
here is going to differ from what you got in your background report, because
there was a mistake in your background report, so this is the part you need to
pay attention to.
CFSAN
began receiving some adverse event reports of food mediated latex allergic
reactions from consumers in 1999. A
total of 79 consumers contacted FDA in 2000 following placement of the name and
address of an FDA contact on a web site run by the National Latex Allergy
Network.
Approximately
12 additional reports were received after 2001. This is the total of all the adverse event reports that we have
gotten from any channel, so the question about how long our Adverse Event
Monitoring System has been in place, I guess gets to the point were there
adverse event reports that we missed in that system.
That
system had a predecessor. That system
is relatively new, but it had a predecessor, and not all of the adverse events
that FDA receives came in through those channels. This basically documents all the adverse event reports that we
have received.
The
consumers reported their recollection of allergenic reactions followed by
consumption of foods purportedly handled by food workers wearing latex
gloves. These reported allergic
reactions occurred over a wide period of time, most having taken place in the
past 10 years, and all consumers reported developing latex allergy prior to
experiencing what they believed was their first food mediated latex allergic
reaction.
Finally,
there is the issue of cross-reacting food allergies. The appendix to your background report lists an awful lot of
foods that have cross-reacting potential with latex-specific IgE.
The
cross-reactivity issue raises two very important questions. One is the possibility that the reaction was
due to food that has cross-reacting potential to latex specific IgE.
The
second issue is to what extent could the reaction be due to food that has been
contaminated by proteins from a different food that either has cross-reacting
potential to latex specific IgE or to which the individual may already be
allergic.
Contamination
with another food protein could simply result from handling one type of food
that the consumer might have been allergic to before preparing that consumer's
food, and then transferring that protein to the food prepared for the consumer
who reacted.
This
brings us back to the charging questions.
The questions that we are asking the committee to consider in light of
that information are: Does this
information establish a positive relationship between the use of natural rubber
latex gloves in food service and allergenic reactions to food served in food
establishments or sold at food markets?
If
that relationship does exist, what is the strength of it, and can it be shown
to be causative? If a positive
relationship has been established here in No. 1, and shown to be causative, can
you suggest science-based options to mitigate food mediated latex allergy risks?
If
the current evidence is not sufficient to establish a relationship, what
additional questions need to be addressed to adequately understand this issue?
I
will be happy to take questions.
DR.
DWYER: Thank you very much for your
presentation.
Questions of Clarification
DR.
DWYER: I have a question to lead
off. I was puzzled in going through the
list that you so kindly provided us of the various foods that seem to
cross-react. I am not clear as to the
botanical families of these various things, like celery, loquat, kumquat, kiwi,
and so forth.
I
wonder if you or someone at the agency could give us a list of the botanical
families of these various foods, so that we could see if they fall in any
pattern.
DR.
HEPP: We can try to generate that
information.
DR.
DWYER: Dr. Gaspari.
DR.
GASPARI: I have a question about the
consumer reports to your office during 2000 and 2001. You said there were a total of 91 reports from consumers that
they self-reported. They had knowledge
of a registry? Tell me a little bit
more about your registry for the consumer self-reporting of the food reactions
that are postulated to be related to latex.
DR.
HEPP: At one point, the name of an FDA
contact was put on the web site of the National Latex Allergy Network, and
adverse event reports that people wanted to report would go directly to that
contact person rather than through the Adverse Event Reporting System.
Does
that answer your question?
DR.
GASPARI: The next question, was there
any follow-up interactions with those patients to verify whether they had been
to an allergist or whether they were really latex allergic or not, or just
whether they thought they are latex allergic, or whether they thought that
latex gloves were being used in the restaurant? In other words, what follow-up contacts happened after these
self-reported incidents came in to the Bureau, what kind of verification was
done, and were any site visits made to restaurants to find out whether there
were latex gloves actually being used in the restaurants or not?
DR.
HEPP: I think we have Carl Klontz in
the audience. Carl was the contact
person on the web site. He is probably
the best person to answer that question.
DR.
DWYER: Would the committee be willing
to have this gentleman come up and answer this question?
DR.
KLONTZ: My name is Carl Klontz. I am a medical officer, epidemiologist at
the Center for Food Safety and Applied Nutrition.
A
little bit of history on this. As Mark
said, about late 1999, we began receiving reports spontaneously at the Food and
Drug Administration from consumers who reported experiencing reactions that
they attributed to food eaten at retail food establishments wherein latex
gloves had been used.
There
was some frustration and concern among these people that there was no single
reporting site in the Center for Food Safety where these reports could be sent,
so I had volunteered to have my name and contact information put on the web
site you have seen there.
So,
in 2000, about 79 reports came in directly to me as a result of my name and
contact information being placed on that web site, and in about 2001, about 12
more. No, we did not follow up with site visits to the food
establishments. This was strictly a
system of receiving spontaneous reports or reports that came in as a result of
the posting on the web site.
I
will say, though, that 88 percent of the 79 individuals, 88 percent had
indicated they had a positive RAST test, that they had IgE, that a physician
had diagnosed not only latex allergy, but IgE antibodies to latex through the
RAST test.
There
were a few that just had a clinical history compatible with latex allergy and
then a couple with a positive skin prick test.
DR.
DWYER: Thank you.
DR.
GASPARI: Could I ask one more question?
DR.
DWYER: Yes, one.
DR.
GASPARI: When you analyzed those
reports after you had information from these consumers, did you analyze them
individually and draw some kind of conclusion as to whether this is feasible
versus this patient is totally mistaken and this self-report has no
validity? Did you place any value to
their reports based on the information that you were able to get from them, and
any medical records or basically whatever information that you had, or did you
just record the reports and leave it as that?
DR.
KLONTZ: You have several complements to
your question there. Number one is no
medical records were obtained. We did
not go back and obtain medical records.
We did not verify, in fact, that physicians had made the diagnosis of
latex allergy. We took what we received
in the reports.
Now,
having said that, let me tell you about the population that reported to us,
because I personally put a lot of credibility into this group, this cohort of
individuals. A highly educated group of
individuals. Most of them were
healthcare workers. They understand the
biology of allergies in general and latex allergy in specific.
About
half of them were R.N.'s. They were
dentists, they were physicians, allied healthcare workers composed about 85
percent of the cohort, so a highly educated group of individuals.
The
other thing I would like to say is that we have to qualify these results. This is a case series. In the world of epidemiology, that is at the
bottom in terms of persuasiveness. We
don't have case-controlled studies, we don't have clinical trials, that's for
sure, don't even have cohort studies.
Nevertheless, my own opinion is that this is a highly believable groups
of individuals.
Can
I prove it? No, I don't have the kinds
of studies, but I put a fair amount of merit into this group.
DR.
DWYER: Thank you.
Dr.
Torres had a question. I think it was
for Dr. Hepp, though.
DR.
TORRES: On the study report from
Beezhold, I haven't read the full paper, but you said it was lettuce and
cheese, there was the same amount, it didn't matter what the substrate was?
DR.
HEPP: I think with the experiments on
cheese, they used a method that they didn't quantify the amount of protein that
transferred. The method that they used
to detect the protein on the lettuce, that transferred to lettuce, they could
quantify the amount. So, 50 nanograms
per finger touch would refer to the amount of protein that transferred in his
experiments to the lettuce.
DR.
TORRES: The same study, you said that
reversing the glove was required to do the study meaning that if they had done
it the other way around, it would have given no response?
DR.
HEPP: There is a good chance that the
amount of transfer would have been below the detection limit. I don't know that for sure, but you are
going to be approaching the detection limit of the method. In the paper, it states that he did it to
facilitate detecting the protein.
DR.
DWYER: Thank you.
Mr.
Scholz, you had a question?
MR.
SCHOLZ: Yes, thanks. Back to the self-reporting, you had cases in
'99 and 2000 and 2001, there is nothing in 2002?
DR.
KLONTZ: The web site, as I understand
it, was disbanded in 2002 because of a lack of funding, so, no, that current
channel does not exist for further reports.
MR.
SCHOLZ: Was there any follow-up
inquiries to where they said they were at restaurants or where they thought--I
mean on your end, did you follow up to confirm where they were, or it was just
on their recall?
DR.
KLONTZ: No. Again, all the information was on their recall. The vast majority indicated that the
reactions had occurred in association with consuming food at restaurants.
DR.
DWYER: Thank you.
Dr.
Johnson had a question.
DR.
JOHNSON: I just wanted to clarify about
the web site, it wasn't clear to me.
Your name and contact information was on the Latex Allergy Network.
DR.
KLONTZ: Yes.
DR.
JOHNSON: Not an FDA web site.
DR.
KLONTZ: That's correct, it was not an
FDA web site, it was the National Latex Allergy Network, my name, telephone
number, and address.
DR.
JOHNSON: Thanks.
DR.
DWYER: Thank you.
Dr.
Hamilton and then Dr. Taylor.
DR.
HAMILTON: Again, the
self-reporting. All the reactions that
were reported to you occurred during the short time interval after
which--occurred in that year of, what, 2000 basically or 1999, 2000. In other words, no reports came to you of
previous experiences back in the mid-1990's, because that is when the latex
allergen levels and gloves were really super-high, and it is at least a gestalt
that it began dropping down about the time that you started collecting reports.
So,
if anything, I would have expected that you probably would have gotten the tail
end of a lot of the reports that might have occurred and might have been
reported to you.
DR.
KLONTZ: Right. One of the deficiencies of the questionnaire
is that we did not ask specifically what the dates of each of the--in many
cases, multiple reactions that these individuals experienced was, so I have no
tabular list of a chronology there in terms of dates of reactions for any given
individual, however, the median number of reactions reported by this cohort was
6 in their lifetime, ranging from 1 to actually, one person more than 100
episodes, which she believed had occurred of this sort of reaction, but I don't
have the dates. It was a deficiency of
the questionnaire.
DR.
HAMILTON: Did you get information on
other allergenic specificities that the individual was sensitized to, such as
other foods, or not?
DR.
KLONTZ: Yes, we asked about food
histories both before and after development of latex allergies; prior to
developing latex allergies, about 28 percent of the cohort said they had
pre-existing food allergies.
Once
latex allergy came to their attention via diagnosis or symptoms, that number
jumped up very high, to about 70 percent indicated they had allergies to foods.
DR.
HAMILTON: How many individuals actually
went back to the restaurant to confirm or validate that they actually had latex
gloves in the restaurant?
DR.
KLONTZ: I can't tell you that. We didn't specifically ask that. The understanding on the basis of reporting
was that they attributed the reaction to consuming food at a retail foods where
latex gloves were used. A number of
them indicated in a narrative fashion that they had called back after
experiencing the reaction and documented or through a telephone call learned
that indeed latex gloves were used there.
DR.
HAMILTON: Did they specify whether they
were powdered and unpowdered?
DR.
KLONTZ: No, not to that level, no.
DR.
DWYER: Dr. Taylor.
DR.
TAYLOR: I have several questions for
Dr. Hepp actually. You made a number of
comments about various dosage levels of exposure to NRL from some of these case
reports and studies, but is there a well-validated analytical procedure that
can be used by investigators and researchers to determine the amount of natural
rubber latex proteins in foods?
I
mean can we put faith in the numbers from the analytical procedures in several
different laboratories where they have done with different methods that might
not be comparable to one another directly?
DR.
HEPP: Different methods will be
measuring different things. There are
definitely certain standard methods, and those methods don't necessarily always
measure the same thing. It is important
to know, when you are reporting a number, the method that is used to determine
that number.
DR.
TAYLOR: I just wondered if 5 micrograms
by one method could be 50 nanograms by another method.
DR.
HEPP: Sure. Dr. Tomazac is going to speak to this issue, I believe.
It
may be that they are not even measuring the same thing. In one case, they might be measuring total
protein, and in other case--
DR.
TAYLOR: Dr. Beezhold's experiment in
particular seemed to be sort of a real world experiment, you know, handling the
lettuce with gloves even though he turned them inside-out first, but the one
where they stirred the orange juice with the glove seemed to me to be a little
bit contrived because I could visualize that these proteins might have
different degrees of solubility in different kind of materials, and that that
could alter the level that might be found in the product.
DR.
HEPP: Like I said, most of the
information that we have available is not a part of a well-designed and
controlled experiment, but this is what we have.
DR.
TAYLOR: Now, I have a question about
the food codes. You mentioned the food
code pretty prominently, so I am going back to the charge to this committee
again. We are primarily charged to come
up with recommendations about the use of natural rubber latex gloves, but are
we also restricted to food service, because of the focus on the food code?
DR.
HEPP: I guess I wouldn't say that you
were even restricted to gloves. What I
have reported is information that relates to gloves because that's the
information that is available. People
are looking at gloves. But most of the
background report is not referring necessarily to gloves, but the use of
natural rubber in contact food.
DR.
TAYLOR: Gloves could be used by food
processing establishments in addition to food service establishments, so I am
wondering why the focus is on the retail segment of the industry when a
processor might use the very same gloves at a different level.
How
do I know if I am an affected individual and go to a restaurant and get sick,
that it was because the restaurant used the glove or maybe it was because the
pre-chopped lettuce came in a great big bag and the processor of that lettuce
used the latex gloves?
DR.
HEPP: You absolutely don't. The only reason I brought up the food code
is to basically the issue of latex allergies and food service gloves started
with the food code, but we are interested in any information that relates for
use of natural rubber, and it is actually natural rubber allergy, although it
is often referred to as latex allergy, that relates to food safety.
So,
yes, any way that impacts the foods processing industry, as well as the retail
food and food service industries, it is all on the table. The reason we keep focusing on food service
gloves in the retail establishments is that that is the information that we
have.
DR.
TAYLOR: I appreciate that. Thank you.
DR.
DWYER: Dr. Downer had a question.
DR.
DOWNER: Back to self-reporting. I wanted to find out if your questionnaire
addressed whether or not there were any family members that had an
allergy. I am trying to get at possible
genetic redisposition.
DR.
KLONTZ: Was the question whether there
are family members?
DR.
DOWNER: Whether or not your
questionnaires for the self-reporting indicated whether or not family members
or the persons reporting, if they had any problem with possible allergies.
DR.
KLONTZ: No, the questionnaire did not.
DR.
DOWNER: You did not ask that question.
DR.
KLONTZ: No.
DR.
DWYER: Thank you.
Let
me just go around the table one final time before we finish.
Mr.
Scholz, any questions? Dr. Johnson, Dr.
Gaspari, Dr. Blumberg.
DR.
HAMILTON: I have a question. Is it correct that Dr. Beezhold will be
giving a presentation or not?
DR.
DWYER: Yes.
DR.
HAMILTON: Excellent. I will wait until then.
DR.
DWYER: Dr. Fischer, any questions? Dr. Torres.
DR.
TORRES: I am thinking about the comment
made by Dr. Taylor about the difference between food service and food
processing. One difference I can imagine
would be that in the food service environment, the worker may use a glove on a
limited volume of food, while in a processing environment, the worker may use
on a much, much larger volume of food, therefore, whatever protein was found on
the glove get much more diluted in the mass of food, and therefore, being less
of a problem, but without having data to show it, it is just a belief at this
point.
DR.
DWYER: Dr. Hamilton.
DR.
HAMILTON: I have one last
question. How do you deal with the
issue that it has been shown, to the best of my knowledge, but bananas in the
United States are actually taken to a site where they are gassed with ethylene
gas, and in the process of maturing the bananas, a protein, cross-reactive with
natural rubber latex, Hevea, Hev b 6 related protein actually is created or
developed in the banana, whereas, the child can eat a banana from Brazil that
is not processed in this way, a latex allergic child can eat a banana from
Brazil, but not a banana from America, and a person who also has a
cross-reactive sensitivity to the components Hevean, which is cross-reactive
with banana, the component of banana.
So,
the question is how do we deal with the development or the actual production of
a cross-reactive allergenic protein by the distributor that really doesn't
relate to natural rubber latex gloves, but is clearly a problem to the latex
allergic sensitized individual.
That
is an issue we are not dealing with, of course, here, but does that fall at all
within the realm of the food code issue that we are dealing with? Am I making myself clear or not clear?
DR.
HEPP: I think you are, and I think the
place to begin dealing with a question like that is gathering information,
understanding the problem.
DR.
DWYER: Thank you. Any other questions? Is everybody finished?
What
we are going to do now, we have I think some good arrangements. We are going to take a short break, 15
minutes. We will have Dr. Tomazac and
then Dr. Beezhold has kindly agreed to speak today, so we will have them and
ask questions and then we will be finished.
Tomorrow,
what we are trying to do, Mr. Bonnette is trying very hard to move some of the
other speakers up a little bit, so that we can have some time for deliberations
when our two members, who otherwise would not be able to participate, will be
involved.
I
think that will be very helpful because we really need everybody's wisdom
around the table. So, 15 minutes, we
need to get back here in 15 minutes, which is just 3 o'clock according to my
clock.
[Recess.]
Is
it a problem tomorrow morning to start at 8:00 rather than 8:30 for
anybody? We will revisit that but,
basically, we will probably start at 8:00.
This afternoon, we will go through Dr. Tomazac who can come up to the
podium now. The second speaker will be
Dr. Beezhold. We have kindly also got
Mr. Heumann from the Oregon Department of Health Services. So this is a big help.
Now,
for dinner, you are on your own tonight.
One of the things that we need to be careful of is not to discuss
committee business except when we are here together. Some of us are going to dinner at 6:30 and if anybody wants to
come and talk about bad football teams like the University of Wisconsin or
Vermont and its various laws, whatever, if you want to talk about things other
than food and drugs, let us know, and we will arrange to make the reservation
for more. But no committee business
will be discussed so that we don't violate the Federal Committee Act, or
whatever it is called.
At
this point, we are going to turn back to our deliberations and hear about
progress in the management of natural rubber latex allergy and its impact on
food safety with Dr. Tomazac.
Thank
you for coming and doing this, Dr. Tomazac.
She is also at the Center for Devices and Radiological Health.
Progress in the Management of NRL
Allergy
DR.
TOMAZAC: Good afternoon, whoever is
still awake. It is very hard to be one
of the last speakers because it looks to me like everything has been said
already that I am planning to say. But
I hope I will be able to, even if I will be a little bit redundant, to give a
little bit different angle to what I am going to say.
You
heard a nice overview of what is latex allergy and why did it develop and how
did it develop. Also, you had a number
of presentations that clearly show you that FDA was actively involved in this
process of trying to resolve this issue.
FDA,
and actually I am really talking about CDRH at this point in time, has been
involved in various ways, as you heard, education and methods development and
guidance documents and regulations.
Certainly, that was a very important part of the progress, but the most
important progress came from clinical and basic research because they told us
what is involved in latex allergy, what are the allergens and how can we handle
that.
So
I think we are grateful that we have this huge amount of data that can be used
to make the changes because industry was also actively involved.
Now,
when we are discussing the issue of possible food contamination with latex
proteins, it is very important to keep this in mind, what has been the
situation and conditions at the time when latex allergy became a problem and
when actually, transfer of the proteins from latex glove to food became a
concern.
In
decision process making, it is very critical to include present status of the
situation, what do we have now on the market and where are we going from there.
The
main things I will be talking about protein levels and powder levels. You also heard about that, but I will give
you a little bit more details how they changed through years and, of course,
that had effect on the prevalence of NRL sensitivity, and I will show you a
little bit about that, and then also summarize technology that has been
developed and different actions that have been taken through the years to
actually help these changes to substantiate and also, among other things, the
type of the glove that is being used today is different than what has been at
the time when we didn't know anything about latex.
Protein
levels on the gloves were extremely high at the time when actually the use of
gloves skyrocketed in the few years after the Universal Precaution Act and
other things, and I tried to summarize just a few papers that actually through
the years used the same method for measuring proteins, so at least we can
compare this.
If
you look at the level that has been reported in '93, which probably includes
gloves at that time and earlier, was extremely high, and then you could see
steady trend of protein levels going down.
If you look at this two last studies where both of them are actually
reported in the ASTM minutes because it was ASTM-associated study, studies were
done in many labs on the same samples and they clearly indicate the drop in
protein level in gloves that are presently marketed.
With
powder, there was also similar situation.
At a time when the whole issue started, we had no controls of how much
powder should be or was on the gloves.
There were no methods also to measure that, and no regulations to
control it.
So,
for example, we did one survey in our laboratory in the mid-sixties, and I saw
the gloves, like some surgical gloves that had up to 600 milligrams of protein
per glove, and this is a huge amount of protein.
But
that also changed because in the meantime, what we did, I mean ASTM developed
method for measuring the powder level, and based on that, once when we had the
method, ASTM could develop specifications for what should be a limit for powder
on the gloves, and that is actually included in one of the ASTM standards.
With
this in mind, and also the large body of literature that indicated how bad
powder can be, the level decreased, and also besides the lower level,
manufacturers developed a number of technologies that can reduce or completely
eliminate donning powder and some of them were mentioned, like chlorination or
coating or whatever, but donning is there, and the powder doesn't have
necessary to be present.
With
these changes that I just mentioned and the main culprits, which is protein and
the powder, we also see clearly a decrease in the prevalence of latex
allergy. This is very hard to document
well because several people mentioned this morning the studies are done in
different ways, studies include different populations of people, and also they
use very different criteria to say what is allergy, what is not allergy.
Now,
if you notice maybe a little difference in the numbers between these and what
Jay Slater presented this morning, that is because this is true allergy. I did not include any studies where serum
antibodies was the only parameter, because that has been discussed also how
unreliable this can be as a sole criteria for determining sensitivity.
So,
we are really having a nice trend and I am sure or I hope the trend will
continue.
DR.
DWYER: Before you go on, could you
please say what that is based on then, it is based on symptoms, signs, or is it
based on--
DR.
TOMAZAC: This is only related to
healthcare workers and how this goes usually when they study healthcare
workers, the first thing is they have symptoms, so medical history is usually
number one, and then, of course, they are skin tested and then they have a
serum test, so basically, allergy is confirmed with all these three symptoms,
and then there are situations where actually you may find discrepancy between
skin test and serum antibodies.
This
is due to the mechanism of how the allergies develop and stage in which
sensitization is, so there are other tests that can apply, which is wear test
and inhalation challenge test that actually Dr. Hamilton really worked hard on
developing kind of standard procedure for that.
So,
basically, all these positively confirmed cases of latex allergy. So, now, how does that reflect to food
contamination? I think when we discuss
this issue, there are two main questions that we need to ask ourselves, how
serious the problem indeed is, and how would these improvements in gloves today
affect our thinking and our possible actions regarding to that.
Why
is the problem to know how big the problem is, the main issue is
cross-sensitivity with other allergens.
Now, you also heard a lot about that, but let me just say that most of
the NRL, I mean of the latex sensitive individuals diagnosed as sensitive, they
had other allergies, too, because as we know, genetic setup is very important
factor in developing of allergies, so frequently, when someone has an allergy,
it is actually predisposition and can easily develop other allergies.
In
latex sensitive population, there is a very high percentage of those who have a
food allergy, and Dr. Klontz said that his questionnaire indicated 70 percent,
and I think that some other studies are close to that.
So,
this is two-way street actually and most of the studies start with latex
allergy and then they detect food allergy.
I don't think that there are many studies or any that I am aware of that
look for food sensitive individuals and then test for latex allergy, but this,
too, phenomenon clearly associated with each other.
Now,
the similar thing is with reactions to supposedly contaminated food. Now, when there is a reaction, it is very
hard to say is that reaction to ordinary component of the food or it is
reaction to contaminant by handling with latex gloves.
The
only way how that possibly could be determined is to have these individuals who
experience such reactions to really test them very carefully afterwards for all
kinds of related food allergens as for latex allergen.
From
the reports that we heard from Mark Hepp and actually from Dr. Klontz, none of
them actually provides these details.
None of these patients have been tested subsequently for all kinds of
food except the only testing was that in a doughnut shop, but as Mark said,
there would have been other things besides these three basic protein sources.
So,
how hard it is I will just mention one anecdotal case, but it was highly
publicized several years ago, and it was featured on 20-20. I think that some people will remember
that. But this was a lady who I think
was a healthcare worker and was highly sensitive to latex and aware of that.
She
started to avoid latex completely, and she did that successfully, and then one
evening before going to bed, she ate a banana and experienced severe
anaphylactic shock. So I think that indicates very clearly how cross-reactivity
may be a very dangerous issue.
So,
now I would like actually to summarize things, actions, and activities that
have been already done in order to help this whole issue of latex allergy to be
reduced, minimized or resolved. There
are different kinds of documents that exist today, and some of the documents
are clearly informative and educative for consumer's safety, and besides the
Medical Alert that our center issued right in the beginning of the whole thing,
there are other documents that this is NIOSH Alert which was issued several
years ago, and then Academy of Allergy issued their own position paper, and
then OSHA issued a Technical Bulletin that I think is going to be revised and a
new version will come out shortly.
But
anyway, all these three documents are similar in the sense that they all warn
people to exercise caution when they use latex gloves and as Jay said in the
morning, for those who are latex sensitive, the only way of preventing reaction
is avoidance, avoidance, and avoidance.
But
for those who are not sensitized and they don't have clear indication that they
may be sensitized, then, all the documents recommending use of low powder or no
powder and low protein gloves, so in this respect, they are very similar.
So,
this type of a document, of course, had effect on the public, and here I tried
to summarize a little bit of the market analysis that we have been using for
our documents and for our proposed regulation.
In the first column, you see how use of gloves in the United States has
grown tremendously, and it is still going up and now with the threat of
bioterrorism, I think it is going to go up again quite a bit.
But
look at the shift, how it is occurring from powdered gloves, latex powdered to
non-powdered, and also increase in use of synthetic gloves. This is clear trend and I hope that this
trend will also continue, so that everybody can use the glove, which is safe or
relatively safe, and proper for the particular use.
Besides
this advisory document, we also have other documents that can help achieve
these goals, and this is, as I said, we develop now standard methods for both
powder and protein measurements, so there is good control of the amount there
is on the gloves.
We
also have this ASTM specifications now for both protein limits and powder
limits, so this is recommendation, of course, but we hope that it will be
followed.
Interestingly,
there are also documents that actually are specifically designed for using the
gloves in the food services and food processing, and this is a recommendation
from NSF, National Sanitary Foundation, and the other one is just being
developed by ASTM, is ASTM standard for specification for gloves in the food
service.
I
can say that both of those documents are again in a way similar. They both are recommending the high quality
gloves to be used in food service and actually they recommend that food service
gloves should meet the criteria for medical gloves.
I
hope that ASTM one will be finalized relatively soon and also, as Dr.
Stratmeyer mentioned before, in our proposed regulation, we did propose
labeling--I mean not propose--we would require the labeling, but we would
recommend also powder and protein limits in conjunction with the labeling.
So,
now, in conclusion, I think I can say that in more than the 10 years that we
are dealing with this issue and with involvement of everybody who is involved,
who actually was affected by the issue, which is consumers, manufacturers,
regulators, medical community, they all participated in one or the other way to
resolve the issue, and I can say that what we see now it is significant
improvement in the quality of gloves, and I think that it was confirmed by Jay
Slater in the morning, who said that indeed, there are less new cases of latex
allergy now, and I spoke privately with a number of clinical laboratories or
clinicians who confirmed the same thing, that the number of new cases is much
less than it used to be.
Now,
that doesn't mean that our work is finished because I think that many of the
improvements came up already in the anticipation of the new regulation, because
proposed regulation was published in 1999, and it will come out one day, I am
sure, and manufacturers wants to be ready when it comes, that they actually are
already to the level that they think will be asked from FDA.
So,
that will ensure that trend continues, but I think until it is completely
resolved, I think we should all hang in and help.
Thanks.
Questions of Clarification
DR.
DWYER: Thank you very much, Dr.
Tomazac, for a very interesting presentation.
Can you tell us the difference between--just tell us what they look like
at least--those surgical gloves and the food handler gloves.
It
seems to me they would all order the same gloves in a hospital. I work in a hospital.
DR.
TOMAZAC: This is the same question as
actually was raised this morning. If I
am talking about surgical and examination gloves in the medical environment,
then, surgical gloves are just a little bit--may be heavier in the sense of
latex. They have slightly different
requirements, and they usually have a longer cuff, and because the surgeons
have gloves on their hands for much longer time, that was tendency that they
had much more powder than examination gloves.
Now,
examination gloves, I mean inside the surgical gloves, you have a very
different glove because orthopedic gloves are so different than some other
gloves, which I don't know much since I am not in a clinical practice, but
examination gloves also vary tremendously.
It depend on the manufacture and so on, but how is that reflected to
food gloves.
Again,
this question, we cannot answer. Maybe
someone tomorrow from industry will be able to tell you a little bit more.
DR.
DWYER: It certainly would be very
helpful if someone, either at the agency or elsewhere, could show the committee
the difference between these gloves.
Perhaps everyone else on the committee knows it.
DR.
TOMAZAC: The question is if it can be
done because, see, manufacturers may send the same glove to hospital and sell
it on the consumer market. They may
sell a less good quality, but they also may make special gloves for consumer
use, and we really cannot get this information.
So,
what has been used so far, it is hard to say.
DR.
DWYER: Thank you.
Dr.
Torres.
DR.
TORRES: Have there been any surveys on
what the level of compliance with recommendations of products on the
market? Since your expertise of your
agency is on medical application, at least in the medical applications.
DR.
TOMAZAC: As far as I know, any glove
that is on the market, and it's labeled as medical glove, has to meet
requirements of the medical gloves. If
it is not, I think our compliance usually makes inspection from time to time,
and if something--
DR.
TORRES: I mean specifically about
powder and protein, because those have recommendations at this point.
DR.
TOMAZAC: Up to this point, there was no
strict recommendation. The only
recommendation that we had is if the manufacturer wanted to label a level of
protein, they can, and also because of the limitation of the standard method,
we also said in that guidance document that the lowest level they can label is
50 micrograms/gram of latex, because that was the limit of detection of the
method.
What
we have observed on the market were gloves that said this product has less than
50 micrograms, which means they could not detect any proteins on their gloves,
but any other gloves, we never saw any other number on that box, and they were
not required to label, they just get this option. But we did not propose any limits on protein or powder at the
same time.
DR.
GASPARI: I have two questions. The first one is related to the data slide
and the trend in glove use in the U.S.A.
In 1997, you have synthetic gloves representing about 10 percent of the
total number of gloves being sold in the U.S. or in use, I guess, and in 2003,
it is up to about 33 percent.
DR.
TOMAZAC: No, no, this is the billions
of gloves. The first column, right?
DR.
GASPARI: No, the total would be 33 in
2003.
DR.
TOMAZAC: Billion.
DR.
GASPARI: Thirty-three billion.
DR.
TOMAZAC: Can we have that slide back?
DR.
GASPARI: If you add up synthetic and
powder and powder-free, that is about 13.4.
13.4 over 33 is about a 33 percent of the market share. Is that right?
DR.
TOMAZAC: I don't have a slide in front
of me.
DR.
GASPARI: So, my question is, is that
one of the reasons that latex allergy is declining, because of an increased use
of synthetic gloves as opposed to a safer latex glove, or in addition to the
fact that NRL gloves that are being manufactured now because they are low
protein and low powder, or safe.
DR.
TOMAZAC: I think that this is combined
effect of everything because you have less protein and less powder on the latex
powder gloves. You have a higher
percentage of other gloves that are on the market that the people use, so when
you combine this effect, that all results in a decrease.
DR.
GASPARI: My second question is related
to why do latex gloves continue to be the dominant glove product, is it a
result of expense and glove production and barrier function, so what are all
the factors that maintain natural latex glove industry and in the medical
community as the dominant glove?
DR.
TOMAZAC: Well, I think that the
majority of glove users would agree that latex has some superior qualities that
synthetic materials only recently tried to reach. Earlier, synthetic products were extremely inferior in comparison
with latex, but now it is a slightly different situation, but ductility,
elasticity, and barrier properties were superior in latex.
DR.
GASPARI: What about the cost of, say, a
surgeon's nitrile glove compared to a surgeon's natural rubber latex
powder-free glove?
DR.
TOMAZAC: If I am not wrong, I think the
nitrile gloves cost even a little bit more, a little bit more at this point in
time, but other synthetic gloves would probably cost a little bit less, but I
don't know if anyone else--I am getting yes.
But I don't think that cost was the main factor, because really, there
are some recent studies, for example, that show in-use durability of latex
versus synthetic materials, which before we didn't know really exactly how much
better they are, but durability is definitely better, and when you are talking
about the surgeon who has one glove on for several hours, certainly, that is an
important factor.
But
some nitrile gloves tend to be equally good now in durability and barrier
properties.
DR.
DWYER: Thank you.
Dr.
Blumberg.
DR.
BLUMBERG: I may have missed it, but I
am a little confused. Did you state
what the NSF or the ASTM standards were for protein content? You indicated that a 2002 figure, the number
was 140 micrograms per gram, and then you talked about standards of 50
microgram per gram or less.
DR.
TOMAZAC: I know it may be
confusing. 50 micrograms or less refers
to our first guidance that we issued in '95, which says the manufacturers are
allowed to put the level of protein on the box of the gloves, but any number
below 50 micrograms is not valid because the limit of the standard procedure
that we had then for measuring total proteins could not measure less than 50.
So,
that was that guidance document and, as I said, some of them followed
this. The number that I showed you
here, those are just by random taking gloves from the market, and right now we
do not have any other regulation that requires level of protein to be certain
number.
What
we do have, we have ASTM specification, which is actually a guidance document,
and so now what can happen in the future, you know, you or we can say, okay, we
will say that this is what it should be, or we said we do not agree with ASTM
standard, but we want this and this limits if you want, but we may not ever say that we really want
to limit.
DR.
BLUMBERG: Thank you. In terms of those standards, is it the total
protein number or is it the amount that is actually soluble or transferable,
and with that, is it again total protein, or does it really relate to the
antigenic proteins?
DR.
TOMAZAC: Numbers that showed you, it is
total protein, because this was the only standard method that existed at that
time, and if I wanted to compare, I had to use just those data, otherwise, I
cannot compare.
Also
method measures only those proteins that can be extracted, water extracted from
the glove. So, is there any protein
that can be released from the glove in some other way. I don't think that is the question, but, you
know, because the latex is pretty solid
material and the proteins from matrix usually don't come out especially in the
normal use.
DR.
BLUMBERG: Just one more question at
least from me. Again, a point of
clarification. What is the difference
between NIOSH and AAAAI and OSHA guidelines and the NSF and ASTM guidelines,
are one use and the other manufacture?
DR.
TOMAZAC: NSF is, I don't know, maybe
somebody else can tell me what the function of NF--can I just ask Mark?
DR.
HEPP: The National Sanitation
Foundation is a private certifying organization. They develop standards, and then they allow people to certify
their products against their standards, kind of like Underwriter Laboratories,
it is certified by that certifying body.
The
National Sanitation Foundation is not a government organization, it's a private
organization, however, they like to develop their standards, so that those
standards comport with any federal requirements.
DR.
BLUMBERG: But in contrast, for example,
I mean does NIOSH recommend or develop guidelines for protein content or powder
content, or is that just issues of prevention and avoiding use of the gloves?
DR.
TOMAZAC: No, NIOSH is actually
recommendation and information for the consumers, what to do and how to
do. Now, OSHA, you also heard about
OSHA before. OSHA is regulating medical practice, but also other worker practice,
whatever, and they actually are making rules, what should and should not be
done in a practice.
ASTM,
on the other side, is the organization that develops standards, any kind of
standards, so when these standards exist, it is asset that whoever needs them
can adopt them and say, you know, we want you to use this one because we want
to compare your data with someone else who uses the same method, so having a
standard method is very critical for any kind of regulations that are made.
Then,
with us, who else was there mentioned, oh, Academy also, that is also
recommendation. But when we bring a
regulation, then, that is a mandatory thing, whatever we put.
DR.
DWYER: Thank you. That is very helpful.
I
might add that 33 billion, I thought at first you meant million, but I guess
you do mean billion.
DR.
TOMAZAC: Oh, I do mean billion.
DR.
DWYER: I must say I am under on my
glove consumption this year.
DR.
TOMAZAC: Actually, I don't have, like I
think that like '89 was 2 billion, and then it went up to this number.
DR.
DWYER: It sounds like a lot of gloves.
Dr.
Torres, any question?
DR.
TORRES: Sure. Is that consumption data or production data?
DR.
TOMAZAC: Consumption, yes, what has
been sold on the market.
DR.
DWYER: Dr. Fischer, any questions? Dr. Hamilton.
DR.
HAMILTON: Could you remind us of what
the ASTM specifications are that are proposed by the ASTM for both protein and
powder?
DR.
TOMAZAC: Well, I guess I can even if
it's not final. If I remember
correctly, ASTM proposed, first of all, calculation of both protein and powder,
not per gram of latex or per device, but per surface area, because as I
mentioned before, orthopedic gloves are extremely thick and heavy, but the
surface is the same as the examination glove besides the size of the cuff.
So,
it will be very unfair if you say you have to have so much powder per gram of
latex. So, it was suggested by ASTM to
start expressing the concentration or level on surface. Proposal was in this stage, the proposal
exists already for three years, and at this point in time, the level of powder
for examination gloves is 10 microgram per decimeter squared, and for surgical
gloves, it is 15.
Then,
we also have for protein, it is also about 10.
I think maybe Ko-Kee will answer that question better.
DR.
DWYER: If the committee doesn't mind,
this gentleman speaking?
DR.
HAN: Ko-Kee Han from ASTM Subcommittee
on Consumer Rubber Products.
I
just want to clarify it's milligram, not microgram. You were saying 10 microgram, 15 microgram.
DR.
TOMAZAC: It is not 10 milligrams--oh,
for powder, yes, I am sorry. Powder is
10 milligrams for examination.
DR.
HAMILTON: So, I am totally
confused. What are the levels
again? Can you repeat them?
DR.
TOMAZAC: Say it again.
DR.
HAMILTON: What are the levels again for
both protein--
DR.
TOMAZAC: For powder, it is 10
milligrams per decimeter squared; for examination gloves, 15 milligrams; for
surgical gloves and 2 milligrams for powder-free gloves, which I did not
mention before.
DR.
DWYER: And the protein?
DR.
TOMAZAC: And the protein would be 10
micrograms, but--there we go again.
When we were talking about total protein, there was one method, the
first standard that ASTM developed, and that standard, based on this standard,
ASTM recommended 200 micrograms per gram of latex at that time.
Then,
in the meantime, there was another method developed which was immunological
method. It's ELISA assay that measures
only biologically relevant proteins, those proteins that can cause immune response
in rabbits, so we call it total antigen assay.
Now,
because it is so different in the mechanism, also, the levels are different,
and for this method, ASTM suggested 10 micrograms per decimeter squared. So, you know, this was developing standard
that included new methods and new thinking, but that is where they are right
now.
But
that doesn't mean that 200 micrograms per gram of latex is 20 times higher
value, so please do not be confused with that.
This is actually somehow equivalent value because we did study where we
compared the levels of a 30 gloves measured by this classical, old protein
method comparing with the levels that we were receiving with ELISA method, and
then determined what will be equivalent level for the new method.
DR.
DWYER: Thank you.
Dr.
Hamilton, do you have further questions?
DR.
HAMILTON: Yes. Is it safe to say, then, that the allergen
on the cornstarch is not represented in any of the measurements that we do for
extractable protein and antigen?
DR.
TOMAZAC: It is.
DR.
HAMILTON: So, therefore, what we are
dealing with in terms of transfer of allergen onto food products or onto
surfaces may not be represented in the measurements that we are doing of glove
products. So, it is very complicated.
DR.
TOMAZAC: It is very complicated and
actually I just did some studies on that, so I can say a few words. You know, the dry powder, I think maybe you
have been doing something with the dry powder and trying to determine how much
protein is when you take the powder directly from the glove.
What
I did, I took powder and the proteins away from glove, extracted everything
together, and then separated powder, and I assumed that from this powder, some
of the protein has been also extracted, not only from glove, but also from
powder.
Up
to recent time, we really didn't have any way of measuring this protein on the
powder. We only measured clear water
extract of all the proteins. So, I
tried to develop a little modification of this ELISA test, so that we could
include that powder, and, yes, even after extraction, there is protein that
remains on powder.
This
is not very uniform, like 5 percent, 10 percent. It can vary from glove to glove.
So, yes, at this point in time, that is not included in standard tests,
but it may be included in a revision if we decide to do so.
DR.
HAMILTON: So, the ASTM method or
recommendations may ultimately include also a specification for absorbed
allergenic component on donning powder basically.
DR.
TOMAZAC: Theoretically, it may because
there is a technical approach to it.
DR.
HAMILTON: Thank you.
DR.
DWYER: Thank you.
Dr.
Johnson.
DR.
JOHNSON: I have a question about the
doughnut study. It seems like a couple
of speakers have dismissed this because of the possibility that there were
different ingredients in the two doughnuts, that there was a difference other
than the fact that the one was prepared with latex gloves, and the other
wasn't, even though the authors say that they tested for every ingredient used
in the preparation of cream-filled doughnuts, and the child was negative.
So,
my question is, do you know, was this a chain type of doughnut, such that you
would anticipate that they would be using the same recipe, or was it just
two--and I realize it was done in Italy--but was it just two random doughnut
shops that they bought a cream-filled doughnut from?
DR.
TOMAZAC: As Mark said this afternoon,
all of these studies are so deficient in the details, that it is almost
impossible to--you know, you have more questions than answers in each of
these. Now, they did test for three
major components, which is egg--
DR.
JOHNSON: They tested for milk.
DR.
TOMAZAC: --wheat and milk. But there are other ingredients in
doughnuts, and we cannot discount that.
It could have been latex, but there is no proof that it was latex,
because not all the appropriate studies have been done to eliminate all the
possibilities of other things.
DR.
DWYER: But if it was an Italian
doughnut, it probably wasn't a Krispy Creme or Dunkin. We have our suspicions.
Mr.
Scholz, do you have any questions for our colleague?
Okay. Then, thank you so much. We have really put you through the wringer,
and you can go and eat a doughnut without gloves.
Thank
you so much for that.
We
will go then to our colleague from NIOSH, Dr. Beezhold, who has been asked to
comment for us from his agency's perspective.
Thank you for accommodating the committee, Dr. Beezhold, we are most
grateful to you.
Invited Comment
DR.
BEEZHOLD: Thank you and I appreciate
the invitation to come and talk to you.
I must clarify, though, as a new government employee, I am really not
here as an official NIOSH representative since I have just joined the agency in
the last couple of months, and the work that I am presenting, which you have
all seen several times already, was done prior to joining NIOSH.
So,
I am not here particularly as a NIOSH representative, but I do have NIOSH
clearance to come and speak, and in that light, my opinions probably don't
differ that much from NIOSH's opinions.
You
have seen the NIOSH Alert, I don't know if you have a copy of that. You should all get a copy of that. But I would just like to read for you the
recommendations.
They
have recommendations for employers and employees, and their first
recommendation for employers is to provide workers with non-latex gloves to use
when there is little potential for contact with infectious materials, for
example, in the food service industry.
So, they are speaking particularly to that.
Then,
to workers, they also say use non-latex gloves for activities that are not
likely to involve contact with infectious materials, for example, food
preparation.
So,
I think the NIOSH stance is fairly clear, and think I want to move on from
there to go and present what I will do.
I am going to change my comments a little bit and try to move through
because a lot of this stuff you have heard already.
But
what we are really dealing with, here is a slide that demonstrates--
DR.
DWYER: The NIOSH recommendations, I am
not sure they were included in our handouts, were they? If there is a way to get a copy of the NIOSH
recommendations xeroxed to our desks tomorrow morning, that would be helpful.
DR.
BEEZHOLD: What I am going to direct my
comments to is primarily the cross-sensitization--I mean for inadvertent
exposures. You have heard about
cross-sensitization to foods as a potential complicating issue here, but I am
really talking about inadvertent exposures, and I want to just point out the
insidious nature of this where a latex allergic person has no idea the food is
prepared and potentially contaminated with latex, so they are very
unknowledgeable in what they are being exposed to, so it is very inadvertent
and oftentimes a surprise for them.
This
is just some of the things that we came across with inadvertent exposures where
people that were wearing gloves at work and were contaminated with latex
proteins, and they actually carried them home on their clothes and on their
hands and their hair.
But
then we have also--the study I am going to present to you is the one from
transferring the allergens to the foods by food service personnel.
These
are the reports in the literature that directly look at anaphylaxis or two
latex glove contaminated food, and you have already heard some of these studies
more documented and with all of the caveats that these are deficient studies,
all of them in all of their designs and the information that they present, but
I don't think that that means that what we are looking at doesn't actually
occur. If you talk to allergists who
have patients that are very sensitive to latex, most of them will tell you that
they have had exposures in restaurants.
It
is just that physicians don't go on to document this very often in the
literature. So, what I want to do is
show you the work that we did to show the direct transfer of latex protein. This was kind of stimulated by one of my
colleague's patients, Gordon Sussman in Toronto, who has a huge patient
population of latex allergic individuals, and he has got a large number of them
that have reactions to food service gloves.
This
one was particularly severe, and this was a dental hygienist who had been
diagnosed with latex allergy, she was skin test positive, had a clear positive
history. She had no known food allergies except she was skin test positive to
potato, and potato is one of the weaker cross-reactors with latex.
She
went to a restaurant, ate a salad, a lettuce salad, and within 30 minutes, she
went into anaphylaxis. She actually
blacked out. She was given an
Epi-Pen. She was taken to the emergency
room. She recovered okay, but it was a
very severe reaction. Her eyes even
swelled shut.
So,
that stimulated us to look at can proteins really be transferred from gloves to
the food, so we embarked on this series of experiments, and we looked at a
sampling of gloves that we had in the laboratory at a time in order to do this
demonstration.
As
was pointed out, these were gloves that as the time went on, their protein
value fell, and I would only point out to
you that this is the Lowry total protein, it is an ASTM standard. This is the ASTM inhibition ELISA. We are talking about levels of less than 200
here or what should be on the market, and less than 10 here should be on the
market.
We
chose this particular glove with a value of 258 because it had a large amount
of protein on, and what we were attempting to do was going to be difficult
technically in the laboratory.
I
would also point out that you see this level of 258 back a few years ago, and
we have talked about a distinction between medical gloves and gloves in food
service. My laboratory at Guthrie had a
vast experience of testing gloves on the market, and we probably tested every
latex glove that has been manufactured or presented on the market at one point
or another.
Just
recently, in June, received a glove for testing that was labeled a food service
glove, and it had a value, a Lowry value of 10, 140 micrograms per gram, far
exceeding the level of the glove that we used in this particular experiment.
What
we do with this fingerprint assay, it's a visual assay, it is not quantitative,
but it's a visual, and it shows you what happens when you contact a surface
with a latex glove. These are the
different gloves that we used for this particular paper, and we chose--
DR.
DWYER: By the way, while you have got
this slide on, where did the glove come from, was it sent in a brown paper
envelope?
DR.
BEEZHOLD: These were gloves that we had
on store in our Testing Service. I do
have the manufacturer, and I have given you the lot number, but they were
packaged gloves. That is another thing,
that we made sure they were packaged in their original packagings, so they
weren't altered at all.
But
what this test does is just gives you a visual demonstration, and it's a
modified immunoblot. We touched the
surface of a membrane that combined protein with the glove. Each one of those touches is for 3
seconds. Then, we processed the
membrane with antibodies that detect latex proteins.
You
can as you see darker fingerprints, that means there is more latex protein that
has come off of the glove and onto that surface. We have done this with numerous gloves, and we get a very pattern
like this. You can do it with gloves on
the market today, and you will see protein transfer like this.
This
is essentially the situation that we are looking at on foods. This is a moist surface that is being
touched with the glove, and that is what is transferring and that is what is
there. You are leaving fingerprints of
protein behind when you touch.
Yes,
the lower the amount of protein on the glove, the less of a fingerprint you
will see.
To
address that point, or the criticism of our study is that we turned the gloves
inside-out, and really, the only reason we did that was so that we had enough
protein there to actually detect it on these blots.
But
this is just to look at some gloves.
You will see here we have a couple of different exam gloves that we have
done this fingerprint test with the outside of the glove, and you see protein,
and with the inside, and you see a little bit more protein.
Here
is a comparison of some surgical gloves that are on the market, that we
actually extracted either the inside or the outside surface of the glove, and
quantitated it in the ELISA assay. You
will see here that some of the gloves have more on the outside than the
inside. Some of the gloves have more on
the inside than the outside.
What
happens is it is manufactured dependent, it depends on how the manufacturer
processes the glove, how they strip it off the mold. Some strip it off and turn it inside-out, so the high protein
level goes on the inside. Some of them blow it off with air, and so the outside
stays the outside, and you have a higher protein on the outside.
So,
it is really you can't make the statement that gloves have most of their
protein on the outside, it is variable, it depends. In general, it is usually on the outside, and we looked at it,
and about, I think in the paper I report something like 65 percent of the protein
is on the outside versus the inside.
But again, it is dependent on the particular glove that is being used.
So,
a food service person doesn't know that they have got a glove with a low
protein on the outside and have all the protein on the inside.
This
is a visualization of what happens when you contact food and the reason why we
used the particular glove that we used, because what we are doing is touching a
piece of cheese, then taking that nitrocellulose membrane and putting it on the
cheese to pick up the protein, and you lose a lot of protein in each of these
steps and/or the cheese blocks the ability of the antibody to recognize it.
So,
we needed a fair amount of protein there to actually visualize it, but again,
you can see here that the protein in this lane is cheese lane, this is the
glove directly contacting the membrane, which is what has actually occurred.
This
is what we were able to pick up off of that cheese. Again, this is not quantitative, and our controls over here were
vinyl gloves that, of course, produced no fingerprints of latex protein, nor
were we able to pick any up off the cheese.
DR.
HAMILTON: Could I stop?
DR.
BEEZHOLD: Sure.
DR.
HAMILTON: Could you go back? You are saying transfer of latex
allergen. So, did you use human IgE
containing sera?
DR.
BEEZHOLD: No, not in this particular
situation. This is a rabbit polyclonal
sera.
DR.
HAMILTON: So, it really is latex
antigen instead of allergen?
DR.
BEEZHOLD: Correct. We have done this same technique with patient
sera and see the identical same thing.
It is a weaker reaction, but we have confirmed that we see the same
thing with human IgE to latex.
So,
the next step we did, we actually quantitated the amount of protein that was on
latex, and we did this just by taking a piece of lettuce and contacting it with
a gloved hand. The technician counted
the number of contacts, you see down at the bottom, number of contacts, and
this is the total amount of protein that we are detecting.
This
is done with the inhibition ELISA.
Here, we are reporting what we actually found. With 100 contacts here, we found 8.7 micrograms of protein
transferred from glove to the lettuce.
In all of these cases, that transferred to about 70 to 80 nanograms per
contact, per finger contact.
This
is glove-specific, so it depends on the amount of protein now, but in this
particular glove, we had 70 to 80 nanograms, and I have put down here, as we
reported in the paper and in other papers, we have patients that react on skin
testing to a solution containing 70 picograms per milliliter of latex protein.
So,
a drop containing 70 picograms per ml is put on a patient's skin. They are pricked through that drop, and they
have a positive reaction to the latex proteins. So, it gives you an indication of about what kind of level a
patient can react to.
Certainly,
it doesn't translate to how much you need to ingest to react to.
DR.
TORRES: This is contacted with the same
glove 100 times?
DR.
BEEZHOLD: Yes, the same glove contacted
at one piece of lettuce 100 times, just going like that. They counted how many times they did it, and
then put the lettuce in a tube and extracted the surface of the lettuce and
tested it for latex protein.
So,
the point is that we are here seeing 100 or 1,000-fold more protein per
fingerprint from this glove than a person can react to on a skin test, and with
the caveat we don't know how much a person ingesting that can react to other
than the comment that Dr. Hepp made earlier about a study we did with
desensitizing patients and having them drink latex protein.
We
did that. That is a very, very
different situation, it is really not the same thing, because what you are
doing is we skin prick tested them, found out if they reacted to a microgram or
a half a microgram or a nanogram.
Depending
on the patient's level of reactivity, we then diluted 10,000 times that, gave
that person that to drink, so you reduced 10,000-fold the amount of protein
that they react to on skin test, so you wouldn't expect a clinical reaction to
that.
Then,
every 15 minutes you give them a two-fold higher dose than that, and
immunologically, what is being done is you are hyposensitizing the patient and
theoretically, you are depleting the IgE that is present, so it really gives
you no indication whatsoever of how much protein a person can react to
mucosally.
DR.
HAMILTON: Could I stop you for a
second? In that study, because now you
are here and you participated with the guys, you selected 2 milligrams as the
target dose for escalating up, and that was based, as I understand it, on an
estimate of total, that that is the content of total protein extractable from
average latex glove?
DR.
BEEZHOLD: At the time we started the
study, we could, from a pair of gloves, we were seeing gloves at that time that
would have a milligram of protein on their surface, so we reasoned that 2
milligrams would be from both gloves, and we would have to reach that target
dose.
It
was actually a similar target dose that has worked out for some other allergens
that are used in hyposensitization techniques like that.
DR.
HAMILTON: Penicillin.
DR.
BEEZHOLD: Right. So, you try and reach a target dose that is
in the milligram range.
DR.
DWYER: Was this work done in Toronto?
DR.
BEEZHOLD: This work was done in
Philadelphia, with Steve McGadey's group.
So,
I just close with this slide and say that in my mind, in the experiments that
we have done, there is really no question that if you contact the surface with
a latex glove that has protein on the surface, that that protein is transferred
to whatever surface is contacted.
You
can pick it off of lab benches and doorknobs and telephones, and we have
actually done some of that work, and the presence of moisture increases the
ability of that protein to transfer over.
I
don't know that we have talked about this a lot, but I don't know that this
represents a route whereby people are actually being sensitized to latex. I don't think that it is. But it certainly is a route whereby people
that are allergic to latex can be exposed and can have significant and
life-threatening reactions.
I
think I have one more slide. This is
just kind of a summary slide. I had my
name on a list with actually some of the people from the FDA and ASTM, and
various other organizations regarding a movement within the ASTM to actually
ban latex or consider banning latex from food service, and this is just the
letters--I was named as one of maybe six or seven people on a list--these are
the letters that I received, or e-mails, that I received all supporting a ban
or removal of latex gloves from food service.
I
would be happy to answer any more questions that you have.
Questions of Clarification
DR.
DWYER: We have a number of
questions. Dr. Taylor and then Dr.
Hamilton.
DR.
TAYLOR: You indicated that the use of
latex gloves in food service could be a significant cause of reactions. We have also heard today that that statement
might have been more true in 1993 than it is in 2003.
Based
on your experience and your long experience with this issue, I guess I would
just like your comments about that. You
also presented us with this one result that here in June of 2003, you managed
to analyze a glove with 1,000 micrograms of protein in it.
DR.
BEEZHOLD: There is no doubt that
protein levels have come down on medical gloves. Clearly, I mean the data right there showed it to you visually
and numerically, and we have looked at gloves, and they have come down 100- to
1,000-fold. That is medical gloves.
My
concern with food service gloves is that they are not in the medical
regulation, and they are not necessarily covered by those same protein values.
DR.
TAYLOR: I have the same question. Have you had much experience with testing
of, quote, unquote, "food service gloves," or gloves not designated
as medical gloves or examination gloves that would be covered by the other part
of FDA?
DR.
BEEZHOLD: Sure, and just like with the
examination gloves that are on the market, there is good ones and there is bad
ones, and they span the gamut. We actually
looked, after we did that study, we actually examined I think three food
service gloves that were specifically sent to us by people that had gotten them
from restaurants, and there was one that was very low protein, and there was
kind of a medium one or two medium ones, I would say, and nothing off the
charts, but they vary considerably by manufacturer.
If
all of the food service gloves came from the same place and you knew where they
came from, and you knew that people were testing them, then, that would be one
thing, but a restaurant doesn't have a particular supplier of food service
gloves. They may get them from various
sources, and you really don't know what you are getting.
The
other problem I see with food service gloves, and that is really not an issue
here, but many of them are powdered.
Those of you who are familiar with powder manufacture or the placing of
powder on gloves, it is typically done in a slurry tank, and those slurry tanks
are where large numbers of gloves get dipped into this tank, the proteins elute
off of the glove into the slurry.
They
can reach very high concentrations in that slurry. The slurry has been tested for bacteria and many different
bacteria can grow in that slurry, produce endotoxin, and then that material is
left on the surface of the glove. Then,
you are having your food contacted with that same material.
It
is just not something, personally, my own personal opinion is that it is not
food that I want to be eating.
DR.
DWYER: Could you provide some references
in the peer-reviewed literature that demonstrate those points?
DR.
BEEZHOLD: Brock Williams published a
study looking at endotoxin levels, and endotoxin levels have been tested on
gloves for a long time. In ancient
literature, you know, 20, 30 years ago, there is levels of endotoxins on
gloves.
DR.
TAYLOR: How about analytical values on
food service gloves as far as protein levels or powder levels are
concerned? We saw some data on medical
gloves, and I know that there has been a lot of literature on that, and it has
been monitored since the early '90s, and you can document the drop.
DR.
BEEZHOLD: The concern has always been
or the major concern has been medical gloves because of the outbreak of allergy
among healthcare workers.
DR.
TAYLOR: So, we don't have a heck of a
lot of published data on the food service gloves.
DR.
BEEZHOLD: No, we don't.
DR.
HAMILTON: But the real problem is what
is a food service glove. I mean that is
what I was trying to get at initially.
I mean is it a consumer glove or is it a defective medical glove,
medical examination glove? I mean we
don't know.
DR.
BEEZHOLD: Some food service gloves are
medical gloves that fail the standard, so they are passed on to the food
service.
DR.
HAMILTON: How can Don, in running a
laboratory that gets all these examination gloves, and one happens to be
labeled "food," but it could be an examination, consumer glove,
whatever. I mean it's terminology that
is so vague in the United States, that we really don't know what we are dealing
with.
I
don't think it is even possible for us to know what is considered a food
service glove, so we couldn't possibly answer that question.
DR.
TAYLOR: When I say "food service
glove," I am just meaning any analytical data on gloves that are not
labeled as medical or examination gloves.
If they are labeled in that fashion, then, they have to meet these other
specifications. So, I would assume any
glove that doesn't carry that designation isn't required to meet that standard
either.
DR.
BEEZHOLD: That is correct. I think there are some other qualifications
that they do have to meet for food services.
Wava is shaking her head yes.
But they have nothing to do with proteins. I think it is for--is it for chemical additives?
DR.
DWYER: It sounds like there is a
riffraff of the medical glove industry or something.
DR.
BEEZHOLD: Yes.
DR.
DWYER: Could we go around the table and
get more questions out here?
DR.
DOWNER: Was what you are saying true,
then, you are saying that if the medical gloves are defective, they are sent to
the food industry, is that what I heard you say?
DR.
BEEZHOLD: In some cases, that is true,
and defective for a medical glove might mean it didn't meet the whole
specification or didn't meet the length specification or something like that. It is not necessarily a defective glove, but
it didn't meet the standard for the medical glove, so it was put into the
consumer glove market.
DR.
DWYER: Mr. Scholz.
MR.
SCHOLZ: Do you have any numbers that
suggest how often that is done or how often that happens in the retail side, or
is it anecdotal evidence?
DR.
BEEZHOLD: I can tell you that that is
what manufacturers have told me is done; how often, I don't know, I have no
clue.
DR.
DWYER: I am sure the manufacturers will
be able to answer that tomorrow, because I suspect some of us will ask.
Dr.
Johnson.
DR.
JOHNSON: When you looked at the number
of times of contact with the food, did you try at all to estimate in sort of
typical or usual food handling practices?
It seems to me, you know, I have seen food service workers where they
have got their hands in the potato salad, and they likely are touching the item
numerous times.
DR.
BEEZHOLD: The purpose of the paper was
to try and demonstrate that it actually happens and sort of simulate, but we
didn't really go into a detailed analysis of all of the ways foods manipulated
with gloved hands, no. We were actually
quite surprised that we were able to do it with the minimal contact that we did
do.
DR.
DWYER: Dr. Fischer.
DR.
FISCHER: It looks like from your paper
that if you use powder-free gloves, you get no transfer to the food in the
small number of samples that you have done there. Would you say that if somebody in the food service position were
to put on powdered gloves, and then rinsed their hands with the gloves on, or
even washed them, that that would get rid of the problem?
DR.
BEEZHOLD: I think it may--it would
reduce the protein level somewhat,
certainly if they used soap. I am not
sure what that would do, what purpose that would do for the food industry
wearing--what is the difference of wearing a washed glove versus a washed hand,
for instance.
I
do know that surgeons typically use a wiping method. We tested that years ago where they are required, when they go to
surgery with a powdered glove, they are actually required to wipe the powder
off with a sterile gauze soaked in saline.
The
compliance rate with that was less than 50 percent when we tested, but we also
tested that it really didn't reduce the protein levels, and what it did do, the
only thing you really saw was a clumping of the starch particles. It would have to be a really thorough wash
to get it off.
DR.
FISCHER: I have a second quick
question. The ELISA assay that you used
to produce these results in the paper, are you still using the same ELISA assay
today?
DR.
BEEZHOLD: That's the ELISA assay that
has been standardized by the ASTM, and it is actually being used around the
world, the same reagents.
DR.
FISCHER: Do you find it very reproducible,
there is no problem?
DR.
BEEZHOLD: Yes. I mean it's not a monoclonal type assay
reproducibility, there is variability in it, but it is an assay that we have
had, we have sent out to labs around the world, and labs that haven't had a lot
of experience doing ELISA assays, and they have come up with fairly similar
results. So, it's a pretty reproducible
technique.
DR.
FISCHER: And when you strip the protein
off the lettuce, let's say, or cheese, there is no interference there?
DR.
BEEZHOLD: We tested for interference
with lettuce because of cross-reactivities.
You could potentially get lettuce proteins reacting, and we saw none of
that.
DR.
DWYER: Dr. Torres, did you have a
question?
DR.
TORRES: I am thinking about your 100
wash contact with the lettuce, then, thinking about washing your hands with the
gloves in order to remove the proteins, when you said 100, when you did 50
contacts, did you less protein?
DR.
BEEZHOLD: Yes, it was a very
dose-dependent response or contact number dependent response. I could show you the slide again, but it is
also in the paper. It was a linear
response, which means that you are continually, each time you are contacting, you
are continually releasing similar amounts of protein with each contact.
DR.
TORRES: So, every contact, you are
releasing the same amount, meaning that if you wash it once, you remove some,
if you wash it again, you love more?
DR.
BEEZHOLD: If you wash with large
volumes of water and soap, say, although some soaps I understand are not good
for latex gloves, but if you would wash large volumes of water and soap, you
would remove--I mean that is how, in manufacturing, that is how they lower the
protein levels just by washing or leaching the gloves in large leaching vat.
DR.
DWYER: Mr. Scholz, you had a question?
MR.
SCHOLZ: Are you aware or do you know
who may have done work with manufacturers to determine the different levels in
their gloves, what we saw from you, and what you have said is a wide range, is
there any research, is there any information on manufacturing process or
information that you could give us that suggest as to why it varies so much?
DR.
BEEZHOLD: From what I know of
manufacturing, and I am not a manufacturing expert, but I have toured
manufacturing plants, and I have looked at protein levels from samples stripped
off of the manufacturing line at various times.
There
is a point--I don't know if we have time to go over manufacturing--but the mold
shaped like a hand is dipped into a vat.
It then goes through some drying process. When it dries, the protein balloons to the surface, follows the
water evaporating.
It
then can go to ovens. It depends on the
manufacturer and the type of glove. If
it's a surgical glove, it will receive
a lot more processing. If it's an exam
glove, it will receive less processing.
At
one point, exam gloves, my understanding was they went from the drying oven to
the slurry tank, were dried off, and that was it. There was no leaching afterwards, and that is why we were seeing
very, very high protein levels, but you can reduce the protein levels by
washing and what is called leaching, and the glove is just dipped into a big
tank with water.
The
more leaching beds that the manufacturer has, the lower the protein is. There is a major way they reduce proteins,
is by chlorinating the glove, and that is a leach bath, in some places, a leach
bath with bleach in it, so it is chlorinated.
That
tends to destroy the protein. Then, it
has to be neutralized and rinsed, which reduces protein even more. So, depending on the manufacturer and how
many of those steps that they have in there will determine the final outcome.
Generalities,
we know that chlorinated gloves have very low proteins on them. Powder-free gloves tend to be lower protein,
and powdered gloves tend to be much higher protein.
MR.
SCHOLZ: That process, I assume it
becomes more expensive as more steps are added, and the cost of surgical gloves
versus exam gloves versus the lowest end of the gloves that the consumer could
buy, I assume that the cost--
DR.
BEEZHOLD: Yes, the manufacturers have
different lines where they will make a surgical glove on one line, an exam
glove on another line, and my understanding is they don't convert between
those.
To
add something, intuitively, it says just add a leach bath to your line, or two
leach baths to your line, you have to understand that these are huge conveyor
belts, each one with a porcelain mold, so there is thousands of porcelain molds
in this line, and it's a continuous loop, and they are just going along.
So,
my understanding is if you decide to increase the size of that line, so you can
put another leach bath in, you have got a lot of expense, because you have got
to buy more molds.
DR.
DWYER: Thank you. I think that's all we need about the
manufacturing.
How
about Dr. Gaspari, because we are really focusing on the safety.
DR.
GASPARI: In some of your slides, you
presented an estimate of how much antigen is transferred on the food, and you
gave an estimate of how much it would take to elicit positive skin prick tests
in a highly allergic individual, and I think you quoted, what, 70 picogram?
DR.
BEEZHOLD: That is what we have
calculated.
DR.
GASPARI: So, the question is, one,
based on that estimate, what spectrum of host reactivities would you expect to
elicit, in other words, patients that are very highly allergic, moderately
allergic, weakly allergic, that is one question.
The
second question is, is a skin prick test challenge dose the same as a mucosal
challenge does?
DR.
BEEZHOLD: I will answer the second
question first. I think I added that
caveat it is certainly not. You know,
the dynamics are different, how is it absorbed, is it reactive with proteases
or other things in the mucosa.
So,
we really, they are too difficult to do to get--I was just giving you kind of
numbers to kind of put some perspective to it, but as far as how much allergen
does it take to cause a mucosal reaction?
I can tell you one thing, it will be different for different people and
their level of sensitivity.
We
know that from our experience with the latex allergic individuals. We also know there are people out there that
are exquisitely sensitive to latex, it just defies reason sometimes.
DR.
DWYER: Anybody else on this side have a
question?
DR.
HAMILTON: We have a lot of experience
with oral challenges with ragweed versus skin reactions, and we know that you
have to add milligram quantities orally to get the same immune response that
you get with nanogram quantities intradermally. That is just ragweed, that is a poor example because latex is
probably more complex.
DR.
BEEZHOLD: In skin prick tests, you are
actually breaching through the stratum corneum, it is almost a direct dermal
inoculation. With a mucosal challenge,
you are basically applying it intra-orally and allowing it, or do you prick the
oral mucosa, as well?
DR.
HAMILTON: No.
DR.
BEEZHOLD: You breach the barrier. You just allow it to be absorbed--
DR.
HAMILTON: Ingestion is my understanding
of how the oral ragweed studies were done.
So, you are dealing with digestive enzymes breaking down the proteins.
Getting
back to this oral challenge study, I actually talked to Dr. McGadey yesterday,
and one question I did ask him, which sort of struck me a little, was in your
opinion, now--he has experience administering oral latex to latex allergic
individuals--in your opinion, can low levels of latex allergen elicit clinical
symptoms that are severe, and in his general experience, his impression was
that it probably did not or would not or could not.
Now,
that was the impression. Now, the
question I have is we have talked about ammoniated latex being administered
orally, but you have rightly reminded me over the years that we are dealing
with a glove that goes through a process where it is treated with heat, so the
proteins that are coming out are actually possibly even modified allergenic
proteins.
So,
therefore, is that study representative or useful in terms of us interpreting
what low levels of allergen will do orally?
DR.
BEEZHOLD: Well, actually, the material
that was given to those patients orally was ammoniated latex, it was not heat
treated, but it was broken down, peptides of the latex, so yes, there may be
some more heat-induced type release of epitopes that might be opened up there,
but we tried to use as close to the material that is on a glove as possible.
DR.
HAMILTON: Was it freshly collected,
because we know that when latex allergen sits with ammonia, that it denatures
the allergenic protein. That is, of
course, one of the theories as to how this--
DR.
BEEZHOLD: It was actually collected
from ammoniated latex that was sent to our lab, and made a film of the latex
and let it dry, and then extracted that film and lyophilized the material and
stored it in the freezer until we were ready to use it.
DR.
DWYER: Thank you.
Any
other questions on this side? Anything
else you wish to say?
DR.
BEEZHOLD: I am done.
DR.
DWYER: Thank you very much, appreciate
it.
We
are almost finished here today, gang.
We have got one more person and that's Michael Heumann from the Oregon
Department of Health Services. Thank
you for coming east to talk to us about some comments. This is a state, Oregon is a state with
latex food service glove prohibition.
We
will hear from a couple of other states tomorrow, but first, we will hear from
you. Thank you so much for coming east.
Invited Comment from a State with Latex
Food
Service Glove Prohibition
MR.
HEUMANN: Thank you very much for having
me. I would like to ask a favor of
you. You have all been sitting here a
very long time, and I don't want to give you a break, but I would like to ask
you a stand up. When I stood up, I was
as little numb, you have got to be numb, as well. Just stand up and sit back down again, please, just so that your
brains will still function a little bit.
It is pretty hard.
DR.
DWYER: Could the Secretary also get us
copies of the slides that we don't have.
There are several presentations that we don't have slides of, and we
will need them tomorrow.
MR.
HEUMANN: Do you have copies of my
slides in front of you? I presented
them to FDA this morning, so they are here.
All they need to do is hand them out.
So, they are here and present.
DR.
DWYER: Why don't you go ahead and they
will catch up.
MR.
HEUMANN: What I am going to do for the
last talk this afternoon is something completely different than what you heard
about so far today from the other speakers, and I do appreciate very much the
opportunity to be able to come here to address this group.
You
have got one heck of a decision that you are struggling with and wrestling
with, and, indeed, it is one that we have struggled with and made a decision
about.
So,
what I want to talk to you about today rather than a scientific presentation,
is rather share with you the steps that we took to apply the scientific data to
make a similar decision to what you are facing, to what we believe is a public
health problem.
To
do that, I want to talk about what it is that we did, I want to talk about how
it is that we became aware of this situation in the first place. Then, I want to continue with why did we
take the actions that we took, and then I want to conclude with the role of our
partners in developing a response. You
have already heard a lot about partnerships, but I want to go into a little bit
in greater extent. Then, I will open it
up to questions.
So,
what did we do? So, Oregon has the
administrative rules that govern a whole variety of things that government
does, and in January of 2002, Oregon's Food Code Agency, which is in my
department, finally got around to adopting the 1999 FDA Food Code Rules. In our statutes, it is the Oregon
Administrative Rule 333-150-0000.
In
that, we added a glove use limitation clause,
and it says, "Effective March 1, 2003, the use of latex gloves in
food service establishments is prohibited." A simple sentence is all we wanted to go for. So, that's what we did.
So,
how did we become aware of this in the first place? Where did we get this from?
This takes us back to the year 1992.
I manage--I should say by way of introduction--I am an epidemiologist
and I manage the environmental and occupational epidemiology programs for the
Oregon Public Health Agency. So, I have
in my bailiwick, if you will, a variety or programs that look at both workplace
exposures and hazards, as well as those hazards that exist where people live
and play. So, it is kind of the whole
gamut of people's lives.
So,
what I focus on, though, are generally non-infectious or non-communicable
disease issues. We have been partnering
with NIOSH since 1992 to look at a variety of occupational illnesses and
injuries, and most consistent during this time has been occupational skin
diseases that we have been tracking.
The
way that we track those diseases, the way we started back in 1992, was to look
at the State Worker's Compensation Claims Database. We have an open competitive state in Oregon, and that means that
a variety of private companies, as well as public companies, sell, insure
Worker's Compensation insurance to different employers, and they are required
to report a portion of their information in a standardized fashion to the State
to do their administrative work.
So,
we started looking at that and we realized that that data was very, very
limited. It only had information on
what are called "disabling" claims and also on denied claims. What was lacking from that a database was
information on what are called "non-disabling" or
"medical-only" claims, which is probably 85 percent of all of the
Worker's Comp claims that are accepted.
So,
we had a problem there, and that was that we weren't getting good information,
so we started partnering with some of the private insurance companies, so that
we could get access to their information.
So, these are administrative databases, they are not public health or
epidemiologic databases, but they still have some very useful information in
them.
In
particular, they have information on the antecedent causes of illnesses and
injuries that are available in text fields, in uncoded text fields that are
kind of just written down from the initial forms, which gives us a chance to
look at that.
So,
since 1992, we were certainly quite aware of latex allergy issues in the
healthcare industry and the healthcare field, and our response to that took the
effect that we started when we first started seeing that this was a problem,
and a very real problem in Oregon, is we started looking at the research that
science and that researchers had come up with about the issues of latex
allergy, so that we could get up to speed about it.
Once
we had done that, we began the process of educating those people who are
affected by the hazards and educating them about these hazards, as well as
alternatives.
Our
goal was to try to encourage, on a voluntary basis, the creation of latex-safe
environments. To do this work, we
developed partnerships with hospitals and other employers, as well as employees
and employee groups who were affected by this, so this is all in healthcare.
The
other partnerships were with the Worker's Compensation insurers, and then also
with NIOSH. Our funding again came from
NIOSH. The reason that Worker's
Compensation insurers were a big partner, not only were the source of the
initial information, but here were the entities that were responsible for
paying out very large claims potentially when a highly trained healthcare
provider, a physician, a nurse, a dentist may lose their career because of
latex allergy, and no longer be able to function in the environment to which
they had been trained.
Some
of the insurers in Oregon were paying out claims of $500,000, and they don't
take that very lightly, so they were a very willing partner to help find ways
to encourage alternatives.
Obviously,
the other parties, the hospitals, the other employers and the employees were
also partners willing, to one degree or another. I should say that we had been quite successful, certainly on a
national level, the change was already happening, and we played, I am sure,
just a small role in this, but we, by the late 1990s, had done a lot to help
most hospitals in Oregon become latex-safe.
One
hospital had become completely latex-free and those hospitals that first became
latex-safe agreed with us that they would serve as consultants for those other
hospitals and employers that were just starting the process, so that somebody
who had already created the wheel could share that information with others.
So,
we were pretty happy with ourselves that we were making inroads and being
successful. In late 1998, our review of
the Worker's Compensation data identified the first cluster of cases of latex
glove dermatitis among food care workers in Oregon.
Again,
this was from the Worker's Compensation data, and I mentioned to you earlier
the uniqueness of the private industry data is that it has certain text fields,
so here is an example of some of the descriptions of the accident description,
allergic reaction to wearing latex gloves.
Another one said received severe rash on both hands due to latex gloves,
and these were among workers in food service industries - cooks, chefs, food
preparers, and others.
Then,
there is also the text of the injury description itself, describing respiratory
disorders of the lungs in relation to an allergic reaction to wearing latex
gloves or dermatitis on the hands. So,
you can see there is a certain richness of data that we couldn't get when we
looked at the State summary data, which just--actually, the State summary data
would say that there was either a disabling claim or a denied claim that was
the result of clothing or glove material.
It wouldn't get any more specific than that.
So,
we sought this kind of information and indeed found something that we hadn't
seen before. This surprised us greatly
because this was a new trend. Here, the
numbers of cases of healthcare workers were going down, and all of a sudden, a
new cluster.
By
the way, by "cluster," I am saying we only saw five accepted claims
by the end of 1998, but that was five claims in an industry that we had never
seen before, so it surprised us.
Well,
we got another surprise just around that same time. As part of the training that we do, in the industry at this time,
in the healthcare industry, we would call local representatives of various
glove manufacturers and ask for samples of different kinds of gloves, so that
we could use them in our training, both the latex gloves, as well as
alternative gloves.
So,
when I did this, and this is not meant to be an endorsement of any manufacturer,
but when I did that, this is what I received when the glove representative came
to my office. I wanted medical exam
gloves, and this gentleman brought to me a product that says, Food Mates
Natural, and it was a lightly powdered latex exam glove, and the other was a
powder-free latex exam glove, both with the name on them, Food Mates Natural,
and the image that you can see there--it may be hard for some of you to see--is
a hand with a latex glove on reaching in and picking up a strawberry out of a
bowl of strawberries.
I
said what is this, I didn't ask for some other glove, I wanted medical exam
gloves. He said, well, that is what
they are because the demand for powdered latex gloves is going down, we are now
marketing them to the food service industry.
So, this was confirmation of where this trend was coming from, indeed,
there was a shift in marketing of the companies.
So,
during the first two years, that is to say, 1998 and 1999, we saw 12 cases
among workers. Not all of them were
accepted claims, some of them were denied claims, but these were all among food
service workers, and we also started to receive unsolicited reports of allergic
reactions among restaurant customers.
There
were people who, of course, as was mentioned by Dr. Klontz earlier, are people
who had a prior history of latex sensitivity, but we started getting reports
from citizens who were consumers in restaurants that started having
anaphylactic and other reactions while they were still in the restaurant. So, there was a range of symptoms certainly.
Some
only had throat tightness, some only had difficulty breathing, wheezing, and
the like. Some had tickling in their
chest and their throat, and others had an anaphylactic reaction and they needed
to call 911 and have an Epi-Pen, et cetera, and be taken to an emergency
department.
So,
we wanted to confirm what we were seeing.
This was all very new to us and while we thought we were winning in one
area, it is kind of like poking into a balloon, you push in one side and a bulge
comes out on another side.
So,
we tried to confirm the cases with the Worker's Compensation insurer, and
basically, they were as surprised as we were, because they don't review their
data the same way that we do, so we were kind of educating them, and they would
indeed go back to the employers where these cases had happened, and were
confirming with them that these were taking place in food service now.
We
also confirmed with restaurants whether or not latex gloves were actually
used. We would go out and visit and
kind of go into the kitchen and ask, even though we are not sanitarians, we are
epidemiologists, and, sure enough, we found latex gloves being used in
restaurants almost everywhere that we went.
Also,
we would try to confirm as best we could with customers, but we didn't do
anything nearly as extensive with an organized questionnaire as FDA did from
their cases, so we just were receiving the cases.
At
this point, we started to identify who are the partners that we need to work
with to address this issue, and we identified the Oregon Restaurant
Association, which is an industry representative group that probably has a
membership that represents maybe a quarter of all restaurants. There is over 30,000 restaurants in
Oregon, so this represents about a
quarter of those entities.
We
also wanted to find Labor if we could, and there was only one large union, the
United Food and Commercial Workers Union, that represents food process workers
and food industry workers.
Also,
we partnered with local health departments because they are the sanitarians
that go out and license restaurants to operate. Then, of course, our primary insurance partner continued to be
the largest carrier, which is Liberty Northwest Insurance.
So,
briefly, what happened with these relationships is that it turns out that
Liberty Northwest insured the Oregon Restaurant Association. That was convenient because we were able to
get Liberty to call a meeting with the leadership of the Oregon Restaurant
Association allowed us to come and present our findings to them, and they
immediately understood the severity of the potential issue and agreed to
collaborate and agreed that this was something that they weren't looking
forward to and didn't want to have happen.
We
also had contact with some of the large national and even some of the
international corporations that have chain restaurants in Oregon, as well as
elsewhere, and when we would bring this to their attention, they were usually
very surprised. In the beginning they
kind of said, oh, what is the issue here, why are you bothering us with this,
but when we explained it to them and showed them the information of what we
were seeing, they also recognized the importance of this and agreed to make
changes immediately.
So,
we were feeling relatively successful.
The Oregon Restaurant Association agreed to put out newsletter articles
out to their membership, and our goal here was one of voluntary change. I should say here this was similar to what
we wanted to do, and I think largely achieved, in the healthcare industry.
One
slight digression. In two different
legislative sessions--our legislature, thank goodness, only meets every other
year--but in two different sessions, we had bills that were introduced into our
state legislature that would have prohibited latex glove use in healthcare, and
we were adamantly opposed to that.
We
felt that this was a marketplace change and the industry was collaborating and
that you didn't need to go that way, and, thank goodness, I think we all prevailed
in that way.
So,
we wanted to do the same thing. Our
goal is a voluntary change here. We
would educate people, they would get on-board, and we would have no problem. Likewise, when we worked with the labor
union, they agreed to collaborate. They published an article in their union
newsletter, and the with local health departments, we ended up getting
collaboration from five counties that wanted to help us with the pilot
intervention.
We
did training for all county health departments. We have meetings with them on an annual basis, and so we did a
large training where we trained all the sanitarians about the hazards
associated with latex allergy and glove use and what were some of the
alternatives, what to look for, and how they could get the information out.
We
also developed a latex Alert for restaurants, which is on the last page of your
handout is the text of it. It is too
large to fit on a slide, so I gave it to you as the last--should be the last
page of your handout.
So,
the five counties agreed to do a pilot assessment. They agreed to gather information to find out how commonly were
latex gloves used in restaurants. They
agreed then to provide education and to distribute our flyers both in English
and in Spanish.
So,
this all seemed pretty good, so why did we need to take any action beyond
that? Here we were, we had a positive
response from restaurants. We also
contacted suppliers, restaurant supply houses to let them know of the potential
hazard in the products that they were selling to restaurants, and many of them
agreed, some of them chose not to agree, but quite frankly, what got both
suppliers and restaurant owners to make a change had less to do with what we
were seeing more of, which was worker health and safety issues, that wasn't
such a motivating factor.
The
motivating factor was the potential liability from a customer who, God forbid,
should have an anaphylactic reaction or other reaction in their restaurant,
causing a scene, and potentially leading to a lawsuit.
Around
that time, by the way, we were also getting calls from attorneys from other
states wanting to know if we would give them information about these citizens,
so that they could potentially build a lawsuit in Oregon.
Needless
to say, we don't do that, we don't give out that information, but that actually
shocked us also. We were really worried
that here was a new problem, an eminently preventable problem that could and
should be prevented, and in our mind, there was no reason whatsoever that a
lawsuit should ever have to happen in Oregon if we all acted together. We were a little naive perhaps, or
idealistic I should say.
So,
even though we were doing this and having a positive response when we would go
out and take our action, cases were still coming in, and the reality was there
are over 30,000 restaurants, and we couldn't reach everybody quick enough.
So,
around this time, we wanted to find another way to do a statewide solution to
address the problem. It needed to be
simple, that would allow us to help prevent cases. Our goal again was to protect customers, employees, and
employers, as well as suppliers. So, we
were trying to create a multiple win-win situation here.
Around
this time, in late 2001, we learned that our colleagues in the Food Protection
Office of our agency, were about to adopt a 1999 Food Code, and so that means
that they were opening the food code to amendments and to changes, and indeed
they were planning a few amendments, they didn't adopt the entire code. We are a little independent out in Oregon, I
guess.
But
we saw it as our opportunity to act, and I should mention here also that
Oregon's rules, unlike the FDA recommended rules, does not require the use of
gloves. It requires hand washing. We require that all restaurant workers wash
their hands and wash their hands frequently. They may also use other utensils,
and a glove can be seen as a utensil as it was defined earlier this morning in
FDA.
But
I think it is important because there are some states that require, in their
statutes, glove use, that mandate no hand contact with foods that are no longer
to be prepared or cooked, but are ready to serve foods. We don't do that, we are a little different.
Tomorrow,
you will hear from Rhode Island and Arizona about their bans and what they
entail and how they got there. I can't
speak for them, but you will hear from them tomorrow, but we found that their
language was far more complex and went on for pages, and as I say, we wanted to
have something simple, so we proposed that one sentence that the use of latex
gloves in food service establishment be prohibited.
The
Oregon Restaurant Association prevailed upon us to delay that by about seven
months and have it implemented on March 1st of 2003. We agreed because there should be time for everybody to make the
changeover. Suppliers need to be able to get rid of product, the restaurants
need to be able to get rid of product.
So,
the Food Code was finally adopted in August of 2002. This received major media coverage, and what received major media
coverage was the latex glove ban. The
rest of it was kind of old news and was a sleeper. But this issue received a lot of coverage in the media.
In
addition to that, which we helped foster because we wanted to get the word out,
we advised restaurants and suppliers of the change through letters, as well as
articles and a variety of methods.
We
also encouraged them to adopt the change before the March deadline, so that
they could get on-board because now that they knew about it, we wanted to head
off any potential lawsuits before the curtain came down.
Also,
the local health departments, which do routine inspections of all restaurants,
agreed to carry out the word and provide letters. So, the information went out. This resulted in many, many
questions, but, in general, we got very good support from the restaurants.
Some
of them called us very hostile and said what are you doing, why are you making
me do this, you know, my workers love latex gloves, and when we would explain
what we were doing and why, at the end they would generally say thank you for
doing this.
So,
we had a lot of collaboration. There
was really no unified opposition to this in Oregon.
So,
now I want to just switch to the concluding remarks here. From our perspective, it is important, as
you all know, and this is why you are having industry and a variety of folks
come here, to cultivate wide support among the people who are affected, indeed,
you want to bring them together and find who is it that is at stake, provide
them with information and education about the issues.
From
my perspective, it is important to involve them in the decisionmaking, to have
them on-board, to have them in agreement with what is happening as much as
possible.
So,
I want to conclude here and basically summarize what I had said, and that is
that our actions were based on initially identifying the problem through our
occupational disease tracking system, and that is how we identified a new
pattern.
By
the way, I want to say here, you are separating it out, you are kind of having
independent stove pipes, not looking at worker health and safety, but only
looking at that which happens to customers.
I
have to tell, each and every worker that converts to become latex allergic is
also a customer of restaurants, and many people are feeling that they can't go
to restaurants safely without having the risk of developing a reaction, and if
not at this restaurant, maybe another one, they always have to ask, so workers
are affected equally, and the changes that you may recommend will improve
potentially in the prevention efforts that will affect workers' health and
safety, as well as that of the consumers, and the more that we can do
activities to prevent a problem from coming to a new industry, I think the
better off we are.
We
got up to speed and then it was our effort to apply this science, tried to do
it in a voluntary way and when it wasn't happening quickly enough, we did do
the formal rule change.
I
do want to just conclude by saying that we agree with everybody I think in this
room, and that is that natural rubber latex does have an important place in the
protection against exposures to bloodborne pathogens, but this is primarily a
healthcare issue. We don't know of any
restaurants that are performing surgery or should have exposure to bloodborne
pathogens or other bodily fluids as part of the food services that they supply.
We
also, though, agree that low protein, powder-free gloves are the safest option
for people who are not yet latex allergic, however, for people who already have
a latex allergy, I think the data is showing that even a low protein,
powder-free glove, if they come in contact with it, can still trigger one level
of a reaction or another.
Also,
as you all know, there are many alternative glove materials that exist and it
is very important that we select gloves to the specific use that we have.
I
also want to mention something that was not talked about earlier. We talked about the fact that some people
can have an irritant contact dermatitis reaction to latex gloves, perhaps from
the mechanical presence of the powders that are occluded and held next to the
skin, that can abrade the skin and actually even push the powders and proteins
into the skin.
Then,
you could also have the delayed hypersensitivity reaction, and then we have,
thank goodness just the small tip of the iceberg, are those people who have the
immediate reaction.
But
there is some evidence, I think a good bit of evidence, that suggests that
people who may only begin with either an irritant reaction or a delayed
reaction, can indeed in many cases do progress on to an immediate
hypersensitivity reaction. So, we
should not exclude them out of hand as saying they don't matter. They may not matter now, but they may matter
tomorrow or the next day.
Finally,
we have found as a result of our work that we are doing that powdered natural
latex gloves are being promoted in many other settings, and we are worried, not
only about food care workers, but child care workers and children being exposed
in child care when they either eat food, when their diapers are changed, or
when their noses are wiped, being exposed to powdered latex gloves, janitorial
service, a whole variety of other occupations and industries are likewise being
exposed now because you have a large body of lesser quality gloves that are
still being manufactured and are now being just promoted for use elsewhere.
So,
my final words are latex allergies are real, but they are also preventable and
we have an opportunity.
With
that, I will be happy to take any questions.
Questions of Clarification
DR.
DWYER: Thank you so much for coming and
thank you for accommodating us. Now, we
will ask some questions.
Dr.
Gaspari.
DR.
GASPARI: I would like to know when you
started tracking the Workmen's Comp files, basically, from your slide, I see that on page 2, in 1998,
the first case reports identified with latex glove dermatitis data, and then a
second slide later on, 12 cases among workers in the first two years.
So,
what I would like to know is in those Workmen's Comp files, were those patients
evaluated by a dermatologist or an allergist to determine the etiology of their
hand dermatitis, because as you have already alluded, and we have heard
repeatedly today, that actually, there are
wide variety of causes of hand dermatitis and, of course, of the three
major causes that latex allergy is probably the least common, so please
respond.
MR.
HEUMANN: That is an excellent
question. I agree, as mentioned
earlier, few cases actually get into the Worker's Comp system for a variety of
reasons. One is because the worker may
not recognize the association; two, the worker may not go to the doctor; three,
the worker may be afraid of filing a claim because, although it's wrong, they
may be afraid that their job is in jeopardy.
The
fourth reason, and there may be even others, is the physician, who they may
actually end up going and seeing, may not either ask or recognize whether or
not this could be a work-related etiology.
So,
that's I think an important caveat to state, so, if anything, this is a major
underreporting.
But
your question as to whether or not a case is seen by a dermatologist or not,
most claims that are accepted usually are adjudicated. Worker's Comp claims, at least in Oregon,
are not easily accepted without a hard body of evidence, and, indeed, we have
seen more claims filed that are denied than we have seen that are accepted.
So,
those that we have seen that are disabling claims that are accepted, while we
have only gone back to look at some of those data, because that is a separate
database in the Worker's Comp system, we have identified a smaller number of
those cases where they actually have been confirmed by dermatologists.
Indeed,
Dr. Franz Stors, who is probably the preeminent dermatologist in Oregon at
least, sees most of those cases. She is
our only tertiary care dermatologist, so any hard case gets kind of funneled to
her from general practitioners and other dermatologists, as well. So, a number of the cases that were filed
and accepted claims have come through her, and she is actually a sentinel
provider for us. So, yes, some number
of them have been, but certainly not all.
It's a long answer.
DR.
DWYER: Other questions? Dr. Hamilton and Dr. Taylor.
DR.
HAMILTON: First, I would like to ask
you--I am a little confused because at one moment you indicated that on the
issue of the use of latex gloves in medical applications, you were opposed to
that notion, and yet I got exactly the opposite perspective when you started
dealing with food handling.
MR.
HEUMANN: Isn't that funny, yes. Do you want me to explain that?
DR.
HAMILTON: Can you clarify a little bit
on that issue?
MR.
HEUMANN: Sure. With healthcare, we believed that the change
was coming by itself. We believed that
there was motivation on the part of the medical industry, both employers and
employees, because you have highly-trained, high-end, highly-educated employees
who don't want to suffer from this allergy, because it is career threatening and
they have a lot invested in that career.
You
also have the employers, the hospitals and others, who don't want to have, one,
patients who are having problems as a result of a latex-contaminated
environment. So, there was a lot of
incentive there, a lot of awareness, a lot of momentum on the national level to
identify other glove products, to identify and push for higher quality latex
glove products in addition to the other non-latex glove products.
So,
that was happening already, I thought, by itself. When you go to make a rule change or a law change, oftentimes
what happens is you polarize an argument, and people who you could otherwise
have on your side and find ways to build agreement, tend to polarize and dig
their heels in and say you are not going to tell me what to do.
So,
in this situation where we found ourselves in food services, we initially had
the exact same attitude, this is a no-brainer.
It's clear, you know, we are seeing cases that we didn't see before,
they are matching temporally with an influx in marketing of these gloves to
food industry.
We
thought we will teach them, no problem, and indeed in the early couple of years
that we were doing this, every contact we had for the most part resulted in a
positive change. It wasn't fast enough. We were seeing more cases coming in of
workers who worked in other restaurants that we had not yet contacted.
There
is not the same unified industry within food care. You have got lots and lots and lots of small mom and pop
restaurants and food stands and catering services that don't communicate with
others and are pretty much out of the loop.
So,
because of that, we felt we were striving in a losing battle, that we were
still running into more cases of both customers, as well as workers, and that
we saw the opportunity of a rule change, which didn't have to go through the
legislature.
That's
the other thing. A rule change can
happen within the agency level, and because we had the main party to be
affected, the Oregon Restaurant Association, who would be our, quote, unquote
"enemy," already on our side, we thought that this would be easier,
and indeed it was.
We
didn't have any opposition, any real opposition from within the state. The only opposition, the Oregon Restaurant
Association wanted was that they wanted to delay in the implementation.
DR.
HAMILTON: Could you clarify for me what
role the liability issue played in this whole argument?
MR.
HEUMANN: Sure. The role of the liability issue is the Sword
of Damocles, that threat that hangs over people that, one, restaurants don't
like the idea of bad publicity, of the word of mouth getting out that somebody
went down in a restaurant and had a horrendous reaction to the food, so there
is bad publicity there.
It
becomes a news story. Then, secondly,
we were hearing of, and hopefully, you guys are also aware of the fact that
there have been numerous lawsuits in states all over the United States about
customers who have gone into restaurants and had anaphylactic reactions and
then sued.
I
should say that to date, no customer has won a lawsuit that has been finally
settled. There was one I believe in San
Diego where the customer actually did win, but, of course, that is going to be
appealed and it will be years.
But
besides the win or the loss, there is the publicity issue and there is the
tremendous dollars that go into legal cases.
DR.
HAMILTON: So, the issue of hard science
supporting the notion that latex allergen and food can actually induce a
reaction was not a consideration ultimately.
MR.
HEUMANN: Sure, it was the underlying
consideration that I think convinced the restaurant folks that the lawyers from
the other side would win the case. I
mean I think that is how the science--it played out for us way back when we
were working in the healthcare area, but it certainly played out with worker
health and safety that the science is the reason that we wanted them to make a
change. That is not the reason that they wanted to make a change.
Do
you see what I am saying? Okay.
DR.
DWYER: Any other questions? Mr. Scholz and Dr. Gaspari.
MR.
SCHOLZ: What did you do with the Oregon
Food Code in terms of requiring--the food service folks cannot wear latex
gloves--does the code require--
MR.
HEUMANN: Right, it was just that one
sentence that say you can't wear.
MR.
SCHOLZ: Right. Does the code require that they wear other
types of gloves?
MR.
HEUMANN: No. As I said earlier, our code requires them to hand wash, hand
wash, and hand wash is what our code requires of food service workers. They have the option, in addition to hand
washing, of using other utensils to augment their handling of foods that will
not be further processed before serving.
MR.
SCHOLZ: I mean did you get as specific
as saying you have to wash your hands six times a day?
MR.
HEUMANN: I am not a sanitarian, and I
don't administer those rules, but they are very specific. I can call up and find out for you by
tomorrow what the code says, but I believe that it says that when you change
from one task to another, you have to wash your hands. So, if you are making salad one minute, and
then you are going to make a sandwich, you have to wash your hands.
If
you are going to make food and then handle money, you have to wash your hands
both before and after, like going to the bathroom, those sorts of things. I don't know if it is a specified number.
DR.
GASPARI: My question was along the same
line, so I still don't understand why you decided to do away with gloves
completely and not intervene like a vinyl glove or non-latex glove. That is one question.
The
second question is perhaps related to Dr. Shanklin's presentation about--I am
getting a little foggy about some of the earlier presentations--about the
transfer of pathogens from the hands into the food, and apparently what is
happening at the Oregon State level seems to contradict what we heard from the
FDA earlier about pathogens and direct handling of foodstuffs.
Can
you comment about how this--
MR.
HEUMANN: Why don't I take a stab at it
first and then they can fill in.
DR.
GASPARI: Go ahead, sure.
MR.
HEUMANN: So, you asked two
questions. The first question, I am
trying to remember back, about non-latex gloves. Indeed, the rule says that you can use--under the other optional
utensils, they include non-latex gloves, so they do include a vinyl glove or a
nitrile glove, as well as wraps, as well as tongs, as well as other utensils.
So,
other gloves are allowable. We did not
prohibit the use of gloves per se, just prohibiting the use of latex gloves in
any way, shape, or form, which means dishwashers can't use latex gloves to wash
dishes, janitors in restaurants can't use latex gloves to clean up, that
everybody has to use a non-latex product or some other means to do their work. So, that one simple sentence was a little
broader than we had even imagined, but it was or it is.
DR.
GASPARI: But the option of the direct
hands on the foodstuffs, that is what I need to have clear.
MR.
HEUMANN: That is an option, direct hand
contact in Oregon is a voluntary option in Oregon, it is not a recommended
option at the FDA level. So, there is a
difference there, but their food code is a recommended guideline, it is not a
requirement. As I said, we do things a
little differently out in Oregon.
So,
the other question you had
DR.
GASPARI: Would you state that directly
to us for the record, as well? And you
agree with that?
DR.
TARANTINO: The people who can address
this more have left, but, in general, the food code which, as you said, is a
recommendation, says no bare hand contact.
It doesn't say you have to use gloves, it certainly doesn't say you have
to use latex gloves. You can also use
utensils, you can use tongs, but it does say no bare hands contact.
What
I am hearing here is that they are saying bare hands contact is an option, you
wash your hands.
DR.
GASPARI: Let me ask you, then, how does
the FDA respond to when a state basically doesn't follow recommendations, what
is your response to that other than saying--well, you tell me what you are
going to say.
DR.
TARANTINO: It is clearly a
recommendation, the states have the option to make their own recommendations or
requirements, and presumably, they have a justification for doing it
differently. This is an area where
there is definitely differences of opinion on what the best route to food
safety is.
MR.
HEUMANN: I don't believe that Oregon's
rate or incidence of foodborne outbreaks that are restaurant-associated is any
greater in Oregon than elsewhere, because one of the things to recall is just
because you are wearing a glove, doesn't mean that you change the glove as
often as you should, and indeed, people have observed glove users and have seen
them to from getting a bagel off the shelf to handling money without changing
gloves, to handling food again. That is
a violation. You need to change your
glove in between those activities. You
shouldn't be handling different things.
Likewise,
they have observed people going into the bathroom with the gloves on, going to
the bathroom, and coming out again with the same gloves on and going back to
work.
There
is a potential for a false sense of security in gloves. Certainly, gloves can do a great job, but it
takes the commitment of the worker to do what they need to be doing correctly
with the glove, but they shouldn't have a false sense of security, and
foodborne outbreaks still happen, folks, even in states where glove use is
required.
DR.
DWYER: Are there any other questions?
Dr.
Hamilton and then Dr. Fischer.
DR.
HAMILTON: Could I just go back to the
issue you raised at the very end? That
is, you suggested that the scientific evidence was a consideration for Oregon
initially, right?
MR.
HEUMANN: For the Public Health Agency.
DR.
HAMILTON: What data did you use to
convince yourselves that there is absolute credibility, there is a link between
the presence of allergen, latex allergen and a food, and the induction of a
reaction in an individual in that restaurant?
MR.
HEUMANN: I would say that we used the
same evidence that you have been citing today.
We certainly because we worked closely with NIOSH, we were involved with
them actively as they were developing their recommendations. We certainly appreciated and use as a
reference the AAAAI recommendations that they had, the FDA Fact Sheet or
Advisory, as well as the OSHA Advisories, as well as all of the published
literature, Dr. Beezhold's work and all of the other literature.
We
would actively go and do lit searches to find out. We would actively contact all the different glove manufacturers that
we could and invite them to come to speak with us about what the processes
were, what went into it, what was involved, what were the weaknesses, what were
the strengths, et cetera, et cetera, whether they were a latex glove
manufacturer, a vinyl glove manufacturer, nitrile glove manufacturer, or other
synthetic materials.
We
tried to absorb as much information as we could because we knew that we are a
small state, we don't have the budget and the resources nor the time to be able
to do these studies ourselves, so we have to rely on the work of others, and we
try to learn it, understand it, and see how it applies, and it was for the
reason of the literature that we decided that we needed to take action.
How
we took that action was to educate, to advise, and to build partnerships. We would try to share the science.
DR.
DWYER: Thank you. That was fine.
Anybody
else? No others?
DR.
TORRES: Is it correct, my impression is
that you made the decision, the food service worker and the food service case based
on the worker safety? That, you
emphasized the most, because you went to the Workmen's Comp files, and there
was a source of your decision data more than whether there were consumers being
affected by the transfer of allergens.
MR.
HEUMANN: Correct. That is what we learned about first. That is where we observed a cluster of
cases. The first cluster of cases were among workers, because that is part of
the surveillance or tracking that we do, and because we are so involved with
worker health and safety in our state, and we have been doing a lot in the area
of other dermatologic issues, such as poison oak and other derm issues that we
are trying to reduce that.
So,
yes, it is certainly not workers along, but we think workers are equally at
risk.
DR.
DWYER: Thank you for an interesting
presentation. I think all the questions
have been asked.
What
we plan to do tomorrow, just for the committee, is we will be starting at 8:00
a.m., there will be food there earlier, and at what point we are going to be
able to for a time certain for finishing, we are not quite sure, but we should
know early tomorrow morning because it depends on getting an arrangement for
some people who are scheduled fairly late.
I
think probably 4:00 is fairly safe. It
depends on how fast we move along, but we will try very hard to get done
tomorrow. I am going to try to get done
by about 4:00 p.m. It depends on the
deliberations, it could go until 5:00, but we will try to get some specifics to
you before the break, so we can tell
our planes, and so forth, when we are going to be coming.
Thank
you very much.
[Whereupon,
at 5:15 p.m., the meeting was recessed to reconvene at 8:00 a.m., Wednesday,
August 27, 2003.]