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JENNI MIDDLETON, EDITOR

'Welcome to the new look Nursing

Times'

Factors that impact on the infection control

capability of gloves
1 MAY, 2003

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Widespread faith has been placed in the protective capability of gloves as barriers against disease. However, there are many factors that impact on the degree of barrier
protection a glove can provide in use. To optimise sta and patient protection, it is necessary to understand these factors and incorporate them into institutional practices and
educational training programmes.

Widespread faith has been placed in the protective capability of gloves as barriers against disease. However, there are
many factors that impact on the degree of barrier protection a glove can provide in use. To optimise staff and patient
protection, it is necessary to understand these factors and incorporate them into institutional practices and

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Although testing is routinely performed on gloves during their production to ensure the absence of holes or tears, it is
the maintenance of this barrier integrity during use that determines the actual effectiveness of the glove. Preservation
of barrier integrity requires proper glove selection, storage conditions, and in-use practices.

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There are attributes of gloves in addition to overt barrier protection that can thwart many infection control efforts characteristics
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Base material
The material from which a glove is made can have a profound effect on the barrier protection of a glove during the

REGISTERED GENERAL NURSE

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course of a procedure. Before the 1990s, latex and vinyl were the only choices for examination gloves. A few surgeons
used neoprene gloves, but the cost of neoprene was far too prohibitive for examination glove use.

Natural rubber latex still maintains its reputation for excellent barrier performance due primarily to a combination of

Registered Nurse Mental Health

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REGISTERED GENERAL NURSE

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structural attributes. These include molecular coiling, which provides the stretch and rebound (elasticity)
characteristics for which latex is well known. The elastic coils are held together with sufficient double-bonded side

Registered General Nurse

22.00 - 28.00 per hour

chains to provide strength. The molecular construction of latex enables it to be more flexible and resistant to fatigue
and breakthrough than vinyl (Rego and Roley, 1999). Sulphur vulcanisation provides natural rubber latex with the
ability to maintain flexibility and strength over a wide range of temperatures with an extended shelf life (thermal
stability) (Sussman and Beezhold, 1996).

Vinyl, often selected as an alternative for latex-sensitive individuals, is very rigid at the molecular structure level.
Molecules of this polyvinyl chloride (PVC) material are linked extensively with a dense random network of inflexible
branches suspended in plasticisers (for example phthalates). This creates a material that cracks, breaks or separates
at the molecular level when stressed or challenged (Rego and Roley, 1999).

Because vinyl is an inherently weaker material than latex, it was necessary to develop separate, less stringent
requirements for vinyl glove performance. Inequities in physical requirements are specified by the American Society
for Testing and Materials (ASTM) (ASTM, 2001a; 2001b; 2000). The differences noted in these ASTM requirements are
quite significant when it is realised that in-use barrier performance or durability is a result of the combined interaction
of these characteristics.

When vinyl is snagged by instruments, repeatedly jabbed at the tips by fingernails, or is pulled apart where stretch is
required, molecular branch attachments are disrupted, creating structural breaks. Consequently, vinyl loses its barrier
integrity rapidly when performing rigorous procedures or when challenged by sharp implements. This type of
breakdown is often not visibly apparent, but can be demonstrated in performance studies.

Recently, vinyl gloves with more stretch or elongation capacity have entered the market. Although more flexible, the
normally lower tensile strength and unchanged brittle microstructure of these gloves remain issues. Vinyl is
appropriate for tasks and procedures where there is no risk of contact with potentially infectious agents (food
handling, pushing wheelchairs and so on) (Korniewicz and Garzon, 1994; Korniewicz et al, 1990).

Nitrile has a material molecular structure very similar to that of latex. Acrylonitrile butadiene has been substituted for
the poly-cis-isoprene 'coils' in natural rubber latex. Thus, the strength and elongation (or snag resistance) are much
closer to that of natural rubber latex than is vinyl.

Box 1 provides a guide to the evolution of hand hygiene and glove use in medicine/nursing.

Barrier performance in use

Based on the differences in physical standards required by ASTM, it is reasonable to expect different gloves to
withstand the challenges of work, or in-use conditions, differently; and they do. Several barrier studies have been
performed on examination gloves over the past decade (Korniewicz and Garzon, 1994; Douglas et al, 1997;
Korniewicz et al, 1994; Korniewicz et al, 1993; Olsen et al, 1993; Merchant et al, 1992). It is important to note that
little has changed regarding barrier capability in use over a decade of testing. Natural rubber latex is still far more
protective than vinyl. Nitrile, however, demonstrated barrier durability equal to latex in use. No in-use studies on
polyurethane have yet been published.

Barrier durability needs

Given the differences in in-use barrier durability, it is evident that health-care personnel should select gloves with the
barrier durability appropriate for the task at hand. Indeed, the National Institute of Occupational Safety and Health
(NIOSH) emphasises the need for appropriate glove protection around infectious materials. The June 1997 NIOSH
Alert recommends non-latex gloves for activities unlikely to involve contact with infectious materials (such as food
preparation) as latex proteins can be transferred via food, routine housekeeping, maintenance, and so on). The alert
continues by emphasising: 'appropriate barrier protection is necessary when handling infectious materials.' It stresses
to employer and employee that latex gloves should be 'powder-free, with reduced protein content as the cornstarch in
the glove powder carries latex proteins' (NIOSH, 1997).

The physical requirements of tasks performed in the hospital range from low to high, as do the risks of exposure to
infectious substances or even toxic drugs (such as chemotherapy). Separating tasks into barrier durability needs can
facilitate the decision-making process on the level of barrier protection. It is often helpful to request a full utilisation
analysis by your vendor's glove representative who should be able to incorporate additional critical needs
requirements.

Many chemicals in frequent use in hospitals and in other health-care settings can be detrimental to gloves made of
different base materials and sometimes thinner gloves of the same base material. This is potentially serious if the
chemical is hazardous or if degradation of the glove results in exposure to infectious substances. Potential degradative
or penetrating chemicals include glutaraldehyde, formaldehyde, xylene, hypochlorite solutions, alcohols (Korniewicz et
al, 1989), chemotherapeutic drugs, oils, petroleum salves, unpolymerised bone cement and many other disinfectants,
sterilants and general chemicals. Ask the manufacturer for chemical compatibility.

As a very general guideline there are indications of barrier breakdown when incompatible chemicals begin to degrade
the glove. These indicators of degradation include those listed in Box 2 (Mausser, 1995; Korniewicz and Rabussay,
1997).

These indicators of barrier breakdown also occur when gloves are stored improperly. Although base materials and
manufacturer's formulations render some gloves more or less susceptible to environmental storage conditions, gloves
should generally be stored away from the sources listed in Box 3.

Gloves are much more susceptible to degradation by adverse storage conditions when packages are open and gloves
are exposed.

Another form of barrier breakdown occurs when tapes, labels, ECG leads or other adhesive substances stick to gloves
and do not readily release when removal is attempted. Forced removal can tear gloves or force frustrated individuals
to remove their gloves when using adhesives, further exposing the person and putting the facility at OSHA noncompliance risk.

Slippery gloves may compromise procedures and safety. Sharps, glass tubes, vacutainers, specimen vials and metal
instruments may slip, especially during wet procedures, increasing the risk of glove puncture errors in patient
treatment and possible spread of infectious organisms. Gloves with textured surfaces and without slippery lubricants
may offer firmer grip. As in the evaluation of all glove selection characteristics, grip efficacy should be evaluated for
the diagnostic laboratory in addition to hospital ward use. In some departments, such as phlebotomy, individual
preference may call for a smooth, non-tack glove for procedures, such as palpation, which require added tactile
sensitivity.

Everyday practices
Regardless of the care taken in selection and the implementation of proper storage tactics, the best glove barrier
protection may be compromised by inappropriate wearer practices. Several frequently encountered problems include
the following.

Lotions that contain oils

Oils, including mineral, lanolin, coconut, palm or jojoba oils, as well as Vaseline and other petroleum-based products,
should not be worn under latex gloves. These products break down chemical bonds in the material, thereby
weakening the barrier properties. Through chemical-mechanical means the oils disrupt the protective molecular bonds
within the glove, compromising protection. These lotions are fine when not under gloves. If worn during the day when
barehanded, wash hands before donning gloves. It should be noted that anti-inflammatory creams are usually
suspended in an oil base. Water or glycerine-based lotions will not compromise the glove barrier integrity and are
acceptable if the use of lotion is an acceptable practice in the department.

It is possible that lotions that contain oil as a very minor component may be compatible. Ask the manufacturer for
data or perform your own evaluation (Box 4).

When 'milking' tubing with oiled hands or handling substances known to break down the glove, choose a glove of
another material (for example nitrile is resistant to oils) (Taylor and Leow, 2000) or double glove, shedding the outer
glove after handling the oil.

Long fingernails and jewellery

These can tear and rip gloves, in addition to providing a 'safe harbour' for infectious agents (Earl, 1996). Moderation
in fingernail length and the removal of jewellery should be standard practice while wearing gloves. Breakthrough may
not be visible to the naked eye, but gloves may still leak water, dye or micro-organisms when challenged.

Artificial fingernails present several problems. Of primary concern is the harbouring of fungi and bacteria that cannot
be effectively removed even with nailbrushes. Micro-organisms can dwell and even thrive between the natural and
artificial nail. This situation may be compounded by the fact that the moist, warm, occlusive environment under a
glove supports microbial growth. Of somewhat less importance, but noteworthy nonetheless, artificial nails tend to
cling to the glove surface (especially powder-free gloves), making donning more difficult (Larson, 1996).

Everyday good practice

The following good practices are essential for all health-care staff using gloves.

Double gloving
This has been shown to significantly reduce wearer risk of hazard exposure. If double gloving is to be practised in
specific procedures (such as chemotherapy or bone marrow aspiration), gloves should be evaluated for ease of
donning one over another (Thomas et al, 2001).

Handwashing
Handwashing is essential. Regardless of the gloves selected and their apparent barrier efficacy, hands must be
thoroughly washed, rinsed and dried, or appropriate hand sanitisers used, immediately after gloves are removed. If
liners are used for irritation or there are Type IV concerns (Knowledge Network, 2001) they must also be removed
with each glove change because they may harbour contaminants.

Preventing transference of micro-organisms

Stay conscious of what contaminated gloves may be touching. Straightening of the hair, touching one's face and/or
clothing may leave behind micro-organisms that can be transferred to another.

Change gloves
Gloves should be changed between tasks and procedures on the same patient, after contact with potentially infectious
areas of the body or substances and before touching mucous membranes. Remove gloves promptly after use, before
touching non-contaminated items and environmental surfaces, and before attending another patient. Wash hands or
use appropriate hand sanitisers immediately to avoid transfer of micro-organisms to other patients or environments.

Do not reuse disposable gloves. Microbial contamination cannot be adequately removed by washing (ICNA, 1999), nor
are disposable gloves constructed to withstand re-sterilisation.

Removal
Infectious organisms may contaminate the exterior surface of gloves during use. It is important to follow proper glove
removal techniques. The gloves should then be dropped, not tossed, into the appropriate disposal container (ICNA,
1999). A perfect barrier is meaningless if the contamination on the outside of the glove is spread throughout the
environment as a result of poor removal technique.

Length of glove wear

The length of time a glove is worn may make it more vulnerable to barrier compromise (Hansen et al, 1998). Rigorous
manipulation and contact with various chemicals can affect glove fatigue. Length of wear may also be a factor in the
transmission of bacteria; therefore, changing gloves between procedures is strongly encouraged.

Rapid identification of glove type

This is important. When you or your staff reach for a glove, is it readily apparent which type of material you are
donning? Is the base glove material labelled generically as 'synthetic' or does it specify vinyl, nitrile or other synthetic
material? It does little good to understand the difference in barrier capability among glove materials if the material of
the glove you are grabbing is not readily apparent.

If gloves break down due to physical or chemical breach, potentially infectious micro-organisms can pass through the
intended barrier. This can result in exposure from the patient to the wearer or from the hands of the health-care
professional to the patient. This is especially a concern if:

- The health-care provider has compromised skin (for example dermatitis - see Box 5)

- The patient has a highly infectious, virulent or drug-resistant infection

- The patient is at increased risk of infection (immuno-compromised).

Powder
Powder serves three purposes:

- As a manufacturing aid by preventing gloves from sticking to themselves or other gloves during processing and
packaging

- To facilitate donning

- To absorb perspiration. This characteristic can also result in negative consequences, including the absorption of
natural lipids, and over-drying the skin, leading to the chapped, cracked hands of irritant dermatitis (Box 5).

Articles have been published that describe the adherence of proteins from the surface of latex gloves onto powder
particles (Edlich et al, 2001). It has been demonstrated that, when the protein-laden particles are aerosolised, the
protein allergens they carry increase aeroallergen levels (Tarlo et al, 1994). It has also been shown that there is no
significant difference in aeroallergen (latex protein) levels when using powder-free latex gloves or using no gloves at
all (Heilman et al, 1996). However, it should be emphasised again that latex protein-sensitive individuals (Type I)
should wear only synthetic gloves and work in a powder-free environment.

Just as proteins have been reported to be absorbed from the glove surface to the powder particles, so may chemicals.
Non-glove chemicals - such as glutaraldehyde, formaldehyde-based disinfectants, chemotherapeutic agents, and
medications - may be absorbed by the powder and potentially aerosolised. This can cause dermatitis not only of the
hands, but also on parts of the body where the powder may land.

Strong consideration should be given to restricting glove usage to that of powder-free gloves in contagious infection or
isolation wards to reduce the risk of powder-borne cross-contamination. Similar action should be considered for
immune-compromised isolation wards. Where this is not possible, precautions should be taken for proper use,
removal, and disposal of gloves, especially after contamination with bodily fluids. Proper handwashing should always
follow glove removal. Contaminated gloves should never be snapped while worn or during removal, nor should they be
thrown into waste receptacles, amplifying risks of microbial-laden powder aerosolisation (Verkuyl, 1992).

Studies have shown that the presence of powder in wounds can significantly decrease the resistance to infection
(Jaffray and Nade, 1983). Powder can interfere with local immunological protection at the site of exposed wounds. The
powder 'distracts' the immunological defence mechanisms, allowing micro-organisms to multiply that otherwise would
have been stopped and increasing the probability of infection. Add to this its potential role as a micro-organism and
there are a number of immune-compromised and infectious disease areas in hospitals or outpatient centres where
powder may increase the incidence and spread of nosocomial infections.

To produce a powder-free glove, the powder must be removed and the glove surface treated to reduce tack
(stickiness) and ease donning. Despite the added costs required for powder removal, the demand for powder-free
gloves is escalating due to a number of increasing concerns. NIOSH and OSHA (US equivalents to the National
Institute for Occupational Health and Safety and the Infection Control Nurses' Association) have placed emphasis on
the movement towards powder-free gloves in their alerts and technical bulletins (OSHA, 1999a; 1999b). Special
interest groups are also pressing for powder-free medical gloves. Several are attempting to ban the use of powdered
gloves through state legislation in the USA.

Conclusion
Gloves can greatly reduce the daily risk of cross-infection for patients and staff if selected and worn properly. Many
factors must be considered to ensure that the selection and preservation of that barrier is optimal. Once the glove
with an appropriate barrier level and functionality for the task is selected, care must be taken to ensure that proper
storage conditions are maintained and that employees comply with appropriate barrier maintenance practices during
use. Increased risk of nosocomial spread of infection associated with gloves is not limited to barrier breach but can
also be related to the presence of powder, residual chemicals, cross-contamination contact, and improper disposal.

Ignaz Semmelweis was able to decrease infant mortality by 15.55% primarily by ensuring surgeons washed their
hands. It is tragic that slipping back to the old ways resulted in a reversal of that trend. It is critical in this time of
decreased labour and funds that we continue our vigilance at minimising any opportunity for the spread of nosocomial
diseases. The proper selection and wearing of gloves is one of the cornerstone requirements in our war against
nosocomial infection.

American Society For Testing and Materials (ASTM). (1998)Standard Test Methods for Vulcanized Rubber
and Thermoplastic Elastomers: Tension (D142-98). West Conshohocken, Pa: ASTM.

American Society for Testing and Materials (ASTM). (2000)Standard Specification for Poly(vinyl Chloride
Gloves for Medical Application (D 5250-00). West Conshohocken, Pa: ASTM.

American Society For Testing and Materials (ASTM). (2001a)Standard Specification for Rubber Examination
Gloves (D 3578-01). West Conshohocken, Pa: ASTM.

American Society for Testing and Materials (ASTM). (2001b)Standard Specification for Nitrile Examination
gloves for Medical Application (D 6319-00a). West Conshohocken, Pa: ASTM.

Douglas, A., Simon, R., Goddard, M. (1997)Barrier durability of latex and vinyl medical gloves in clinical
settings. American Industrial Hygiene Association Journal 58: 672-676.

Earl, A. (1996)Operating Room (chapter 95). In: Olmsted, R.N. (ed.). APIC Infection Control and Applied
Epidemiology: Principles and practice. St Louis, Mo: Mosby.

Edlich, R.F., Woodard, C.R., Pine, S.A., Lin, K.Y. (2001)Hazards of powder on surgical and examination
gloves: a collective review. Journal of Long Term Effects of Medical Implants 11: 172, 15-27.

Hansen, K.N., Korniewicz, D.M., Hexter, D.A. et al. (1998)Loss of glove integrity during emergency
department procedures. Annals of Emergency Medicine 31: 1, 65-72.

Heilman, D., Jones, R., Swanson, M., Yunginger, J. (1996)A prospective, controlled study showing that
rubber gloves are the major contributor to latex aeroallergen levels in the operating room. Journal of Allergy and
Clinical Immunology 98: 2, 325-330.

Infection Control Nurses' Association. (1999)Glove Usage Guidelines. London: ICNA.

Jaffray, D.C., Nade, S. (1983)Does surgical glove powder decrease the inoculum of bacteria required to produce
an abscess? Journal of the Royal College of Surgeons of Edinburgh 28: 4, 219-222.

Knowledge Network, Kimberly-Clark Health Care Education. (2001)First Hand Volume 2: Glove-associated
reactions. Roswell, Ga: Kimberly-Clark.

Korniewicz, D., Garzon, L. (1994)How to choose and use gloves. Nursing 24: 9, 18.

Korniewicz, D., Kirwin, M., Cresci, K. et al. (1994)Barrier protection with examination gloves: double versus
single. American Journal of Infection Control 22: 1, 12-15.

Korniewicz, D., Kirwin, M., Cresci, K., Larson, E. (1993)Leakage of latex and vinyl exam gloves in high and
low risk clinical settings. American Industrial Hygiene Association Journal 54: 1, 22-26.

Korniewicz, D., Laughon, B., Cyr, W.H. et al. (1990)Leakage of virus through used vinyl and latex
examination gloves. Journal of Clinical Microbiology 28: 4, 787-788.

Korniewicz, D., Laughon, B., Butz, A., Larson, E. (1989)Integrity of vinyl and latex procedure gloves. Nursing
Research 38: 3, 144-146.

Korniewicz, D.M., Rabussay, D. (1997)Surgical glove failures in clinical practice settings. American Operating
Room Nurses' Journal 66: 4, 660-667.

Larson, E.L. (1996)Hand washing and skin preparation for invasive procedures (chapter 19). In: Olmsted, R.N.
(ed.). APIC Infection Control and Applied Epidemiology: Principles and practice. St Louis, Mo: Mosby.

Mausser, R.F. (1995)Latex and foam rubber (chapter 19). In: Morton, M. (ed.). Rubber Technology (3rd edn).
London: Chapman and Hall.

Merchant, V., Molinari, J., Pickett, T. (1992)Microbial penetration of gloves following usage in routine dental
procedures. American Journal of Dentistry 5: 2, 95-96.

National Institute of Occupational Safety and Health (NIOSH). (1997)Preventing Allergic Reactions to
Natural Rubber Latex in the Workplace (NIOSH Alert). Washington, DC: NIOSH.

Occupational Safety and Health Administration. (OSHA). (1991)Bloodborne pathogens. Occupational Safety
and Health Standards (1910.1030). Available at www.osha.gov

OSHA. (1999a)Controlling occupational exposure to hazardous drugs. OSHA Technical Manual section VI: chapter
2, 1-37.

OSHA. (1999b)Potential for Allergy to Natural Rubber Latex Gloves and other Natural Rubber Products (OSHA
Technical Information Bulletin). Washington, DC: OSHA.

Olsen, R., Lynch, P., Coyle, M. et al. (1993)Examination gloves as barriers to hand contamination in clinical
practice. Journal of the American Medical Association 270: 3, 350-353.

Pacela, A.F. (1992)OSHA bloodborne pathogens standard includes 'medical equipment repair' workers. Journal of
Clinical Engineering 17: 1, 3.

Rego, A., Roley, L. (1999)In-use barrier integrity of gloves: latex and nitrile superior to vinyl. American Journal
of Infection Control 27: 5, 405-410.

Risse, G.B. (1980)Semmelweis, Ignaz Philipp. In: Gilespie, C.C., (ed.). Dictionary of Scientific Biography 19701980. New York, NY: Charles Scribner and Sons.

Spirling, L.I., Daniels, I.R., (2002)Historical perspectives on health. William Stewart Halstead - surgeon
extraordinaire: a story of drugs, gloves and romance. Journal of the Royal Society for the Promotion of Health 122:
2, 122-124.

Sussmann, G., Beezhold, D.H. (1996)Safe use of natural rubber latex. Allergy and Asthma Proceedings 17: 2,
101-102.

Tarlo, S., Sussman, G., Contala, A., Swanson, M. (1994)Control of airborne latex by use of powder-free latex
gloves. Journal of Allergy and Clinical Immunology 93: 6, 985-989.

Taylor, J.S., Leow, Y-H. (2000)Cutaneous reactions to rubber. Rubber Chemistry and Technology: Rubber
Reviews 73: 3, 427-485.

Thomas, S., Agarwal, M., Mehta, G. (2001)Intraoperative glove perforation - single versus double gloving in
protection against skin contamination. Postgraduate Medical Journal 77: 458-460.

Truscott., W., Stoessel, K.B. (2001)CrItical Glove barrier issues. Firsthand 1: 11.

Verkuyl, D. (1992)Glove powder introduced in the circulation by autotransfusion and severe cardiac failure.
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