Gloves: How Do the Pieces of the Puzzle Fit Together?

Gloves: How Do the Pieces of the Puzzle Fit Together?

By Peter B. Graves, RN, BSN, CNOR

Howdo healthcare workers (HCWs) choose a glove barrier material today? Morespecifically, how do HCWs select gloves that can be used for so many differenttasks? There are often numerous considerations when selecting the appropriateglove.

A History Lesson

In 1983, the Centers for Disease Control and Prevention (CDC) issued aguideline to all healthcare providers entitled "Acquired ImmunodeficiencySyndrome (AIDS): Precautions for Health-Care Workers and AlliedProfessionals."¹ While universal precautions were discussed asearly as 1983, the momentum for this program did not begin until 1985, withimplementation hitting full stride in 1987.

The primary goal of the CDC's universal precautions program was to"minimize the risk of parental exposure to potentially infectivematerials."² When the CDC issued its recommendations, federalorganizations such as OSHA and others issued parallel recommendations to protectworkers and other individuals.³

Jumping forward from 1988, HCWs can see in hindsight that universalprecautions created several problems for the healthcare industry. First,manufacturers were required to meet the huge demand for gloves created by thesenew recommendations. Because of the increasing number of gloves used every year,(FDA estimated about 22 billion in 1999⁴) and perhaps because ofhigher than average irritant and/or allergen levels for some gloves during yearsof high glove demand, an increase in work-related illnesses involving gloves hasbeen reported. These occupationally acquired ailments are well described in theliterature as:

• Non-allergic contact dermatitis,

• Type IV - allergic contact dermatitis

• Type I - Natural Rubber Latex Allergy (NRLA)

Occupational asthma also has begun to surface as an issue HCWs will need todeal with in the coming years as it relates to permissible exposure levels (PELS).⁵The role of USP absorbable dusting powders used in some glove production, aswell as the potential link to latex hypersensitivity is being studied bygovernment agencies.⁶ With these new personal protective equipment (PPE)issues surfacing, OSHA released its updated Bloodborne Pathogen Standards⁷that address both the problems associated with preventing pathogen exposure andNRLA control and enforcement issues.

The Right Glove for the Right Job

Armed with OSHA's bloodborne pathogen standards, recommendations from the CDCand the National Institute of Occupational Safety and Health (NIOSH), guidelinesfrom national organizations, and information supplied by support groups andlegislatures, how does one determine what is the correct level of protectionneeded for a task?

First and foremost, one must recognize that different glove requirementsexist for high-risk uses vs. uses that historically have little or norisk of exposures (table 1). A committee should be assembled from eachinstitution to determine the level of protection required for each task (table2). Once these tasks are identified, gloves that meet both the wearer's and thepatient's concerns should be chosen. Though cost concerns are omnipresent intoday's healthcare environment, clinical issues must be considered along withcost-related issues.

Personal Protective Equipment Standards

Developmentof the protective glove standards in an institution should address a wide arrayof issues. Some employees may be exposed to blood and body fluids, while othersmay be exposed to extremely hot or cold environments, electrical hazards, cuts,and abrasions, just to name some of the potential hazards within a healthcarefacility. An individual may need more than one specific type of protectiondepending upon the task.

Conducting literature searches will help design your facility's PPE program.There are several hospitals that have completed such a task and have publishedtheir data on the Internet. This would help any institution in the initialphases of developing a PPE program.⁸

Glove Materials

Fifteen years ago, HCWs had essentially two choices of medical glovematerials--latex or vinyl. Today, with the development of new synthetics, HCWshave a much wider array of materials from which to choose. When one analyzeseach type of material, it becomes obvious that institutions must re-think howthey provide optimal barrier protection. Table 3 illustrates that each materialhas benefits and weaknesses and it is important that healthcare institutionsreview the available data on different materials to determine which is best ableto meet the barrier protection needs of their facility.

While we have used PPE for years, let us review the strengths and weaknessesof each material:

Natural Rubber Latex (NRL)

Roughly 97% of all surgeon's gloves and 65% of all exam gloves⁹are made from natural rubber latex. Natural rubber latex has been considered thegold standard since the late 1890s. Latex gloves were first introduced as aprotective barrier between the wearer and the harsh chemicals used to soakinstruments or cleanse the skin of surgical patients.

The pros of natural rubber latex are: Excellent barrierprotection; highly elastic; low cost; produced from a renewable resource (H.brasiliensus tree).

The cons are: Should not be worn by those individuals allergicto natural rubber latex proteins; not recommended for use with certain chemicals(Table 3).

Vinyl (Polyvinyl Chloride/PVC)

Vinylhas been around for many years. It was first produced as a 'latex-alternative'material, but unfortunately it has had significantly high in-use failure rates,^10,11 as high as 68%.⁷ While we continue to see new vinyl blendscoming to market, these designer-blended vinyl gloves offer increased elasticityand comfort without addressing the high in-use failure rates. Vinyl is not beingused as a surgical glove material due its perceived poor fit and feel and highend use failure rates.¹² Additionally, vinyl gloves should not beworn for more than 30 minutes.¹³

The pros for vinyl are: Alternative for those allergic tonatural rubber latex; suitable for food service and other areas with low-risktasks; not subject to light or ozone degradation.

The cons are: Low tensile strength; stiff material; relativelyhigh-end in-use failure rate; not recommended for handling cytotoxic drugs.^14,15

Neoprene (Polychloroprene)

Neoprene is a material that was developed in 1931¹⁷ as asubstitute for natural rubber latex. It has characteristics similar to naturalrubber latex such as strength, puncture resistance, fit, and feel. In medicalgloves, neoprene is primarily used in surgical gloves.

The pros of neoprene are: Alternative for use by those allergicto natural rubber latex; excellent chemical barrier; provides good barrierprotection; less permeable to alcohol than natural rubber latex and vinyl.¹⁸

The cons are: Some neoprene formulations are slightly lesselastic than natural rubber latex; more expensive than natural rubber latex.

Special Note
Neoprene and the other synthetics often undergo manufacturing methodssimilar to those used for natural rubber latex. As such, glove manufacturers mayadd many of the same rubber chemicals that are used in the manufacturing ofnatural rubber latex gloves. These rubber chemicals may elicit a Type IVreaction in those individuals already sensitized to them. Therefore, it isimportant to verify the amount and types of chemicals used to manufacture thegloves.¹⁹

Nitrile (carboxylated butadiene-acrylonitrile)

Nitrile is a polymer of carboxylated butadiene and acrylonitrile.²⁰This material also was developed as the result of a latex shortage during WWII,but was not commercially available until 1969. The most common use of nitrile isfor examination gloves.

The pros of nitrile are: Alternative for those allergic tonatural rubber latex; resistant to hydrocarbons (oil & benzene);²¹durable (more puncture resistant).

The cons are: May be subject to ozone degradation; tears easilyonce breached.

Styrene (Butadiene Rubber (SBR))

This material is a copolymer of styrene and butadiene and does not requireaccelerators.²² It is ozone sensitive, and therefore requires theaddition of antioxidants. When antioxidants are added, the potential alwaysexists for Type IV contact dermatitis reactions to occur on the wearer's skin ifusers are sensitive to a chemical used in the glove's production.²³

The pro of SBR is: Alternative for use by those allergic tonatural rubber latex.

The cons of SBR are: Low ozone tolerance, will degrade withoutantioxidants; lower elasticity than latex; disintegrates upon contact withuncured bone cement (table 3).

Styrene Ethylene Butadiene Styrene (SEBS)

SEBS is a block polymer of styrene, ethylene, butadiene, and styrene. It isused in the manufacture of both examination and surgical gloves. The SEBSmaterial does not require the use of rubber chemicals or antioxidants.²⁴This material has a noticeable and strong odor, particularly after the producthas been sterilized, thus making one suspect that a softener has been used.²⁵

The pros of SEBS are: Alternative for use by those allergic tonatural rubber latex; resistant to ozone.

The cons of SEBS are: Strong odor from suspected softeners; lowtensile strength; disintegrates upon contact with uncured bone cement (table 3).

Special Note
As mentioned in both the SBR and SEBS materials, contact with uncuredbone cement is not advised. SBR and SEBS are chemically alike because they arecomposed of short chain polymers. When you introduce methylmethcrylate (bonecement) to the equation, the methylmethcrylate catalyst is a short chain polymersolvent. Thus, rapid breakdown of the material is likely. When usingmethylmethcrylate, gloves made of either of these materials should be avoided.²⁶

Polyurethane (PU)

Polyurethane is composed of polymeric methylene diphenyl diisocyanate.²⁷This material is very expensive in comparison to natural rubber latex.

The pro of polyurethane is: Alternative for use by thoseallergic to natural rubber latex.

The cons of polyurethane are: Can be slippery when wet; somepolyurethanes may dissolve in common alcohols (ethyl & isopropyl).²⁸

Special Note
Caution should be taken when using polyurethane gloves with certainsutures packaged in alcohol.

Polyisoprene (PIP)

Polyisoprene is a new synthetic glove material that is structurally similarto natural rubber latex, but without the allergenic proteins. It is composed ofpolyisoprene molecules, the same building blocks found in natural rubber latex

The pro of polyisoprene is: Alternative for use by thoseallergic to natural rubber latex.

The con of polyisoprene is: More expensive than natural rubberlatex.

Making Changes

So, with the data available to evaluate each material, it is important todetermine if the appropriate glove is being used in your healthcare facility.From an infection control standpoint, it is imperative to find out what glove isbeing worn within your institution. For example, assume that one uses a SEBSglove (not compatible with uncured bone cement) during a total hip procedure ona patient who is allergic to natural rubber latex. You are told the surgeon usesbone cement to secure the implant. Does this not increase the risk for acatastrophic glove failure? The potential glove failure event may put the wearerat risk for direct exposure to blood and body fluids and place the patient atrisk for acquiring an infection? This catastrophic scenario can be avoided bybecoming informed and proactive.

Peter B. Graves, RN, BSN, CNOR is a clinical nurse consultant for RegentMedical in Norcross, Ga.

1. Acquired Immunodeficiency Syndrome (AIDS): Precautions for HealthCare Workers and Allied Professionals. MMWR. Sept. 2, 1983;32(34);450-1.

2. ibid.

3. Background of bloodborne pathogen standard. www.oshaslc.gov/OshDoc/interp_data/119921026.html.

4. Federal Register: July 30, 1999: Vol. 64, No. 146, Proposed rules, page 41720.

5. PELS update. www.osha.gov/oshinfo/priorioties/pel/html6. National Occupational Research Agenda (NORA). Occupational Asthma and Chronic Obstructive Pulmonary Disease. www.cdc.gov/niosh/psacops/html.

7. OSHA guide for Healthcare Facilities. January 1999 update.

8. University of Toronto. Protective glove standard. January 1999.

9. IMS Health. Quarter 4, 2000.

10. Leakakos, T. All gloves are not created equal. Surgical Services Management. July, 1999; Vol. 5, No. 7:29-32.

11. Korniewicz, D., et al. Leakage of virus through used vinyl and examination gloves. Journal of Clinical Microbiology. April 28, 1990;787-788.

12. Muto, M.G., et al. Glove leakage rates as a function of latex content and brand. Arch Surg. August 2000, Vol 135:982-985.

13. Burt, S. What you need to know about latex allergy. Nursing Management. August 1999;20-26.

14. Roley, R. Glove use and safety issues in the laboratory. American Laboratory News. June 1996.

15. Laidlaw, JL, et al. Permeability of latex and polyvinyl chloride gloves to 20 antineoplastic drugs. AM J Hosp Pharm. 1984;41:2618-23.

16. Neoprene is a registered trademark of Dupont Dow Elastomers.

17. Zimmerman, C. Gloves in medical and nursing settings. Part 2: Materials and their properties. Legal Aspects.

18. Leakakos, T. All gloves are not created equal. Surgical Services Management. July, 1999; Vol. 5, No. 7:29-32.

19. Kanerva, L., Estlander, T., and Jolanki, R. Occupational allergic contact dermatitis caused by thiourea compounds. Contact Dermatitis. Oct. 31, 1994:(4):242-8.

20. Welker, J. and Mcdowell, C. Nitrile emerges as a solution, not just as an alternative. Infection Control Today. March 1999.

21. ibid.

22. Lecture. Alternative materials for medical gloves. Muenster, Germany. June 23, 1996.

23. ibid.

24. ibid.

25. ibid.

26. Hinsch, M. Selecting Surgical gloves. SSM. April 2000.

27. Rubber & Plastic News. August 14, 2000. Page 8.

28. Hinsch, M. Selecting surgical gloves. SSM. April 2000; Vol. 6, No. 4:36-41.

29. Association of periOperative Registered Nurses. Standards and Recommended Practices (2001). 283-285.

30. Beezhold, D. and Sussman, G. Determining the allergenic potential of latex gloves, SSM. Feb. 1997; Vol. 3, No. 2:35-41.