Anaphylaxis Campaign Health Professions' Conference 2015

Anaphylaxis Campaign
Health Professional Conference – Making Sense of Allergy – November 2015

Notes on the presentations

Menu planning for allergy – Tanya Wright

Latex allergy – is the epidemic over? – Dr Nicola Braithwaite

The LEAP study – Professor Gideon Lack
Professor Lack discussed the results and implications of the LEAP peanut study. For more on the LEAP study see here; for the trial results see here. For comment see the AAAAI here.

Allergy in adolescence – Dr Tom Marrs, Clinical Lecturer in Paediatric Allergy at St Thomas' Hospital

The Anaphylaxis Campaign's recent and extremely successful video, Take the Kit, shows how being unprepared, as an allergic adolescent, can prove fatal. Dr Marrs' talk expanded on this theme, not only from the point of view of the adolescent, but of their family and any health professionals with whom they came into contact.

To illustrate the last point he quoted the fatal case of a peanut allergic boy on an airplane where they were serving peanuts. The boy felt unwell, and his throat became tight. He was carrying adrenaline. However, the GP who happened to be travelling on the plane and came to help suggested that the attack was asthmatic not an allergic reaction and they they should use his asthma pump and not the adrenaline.

Points to remember:

• Fatal reactions peak in late adolescence so this is the period of gravest risk.

• The vast majority of cases of anaphylaxis resolve naturally with the body producing its own adrenaline.

• The vast majority of deaths occur because the adrenaline was not used early enough.

• Uncontrolled asthma is the greatest risk for those who also suffer from a potentially anaphylactic allergy.

Only 16-34% of anaphylactics actually use adrenaline when they suffer an anaphylactic shock. Why?

75% of anaphlylactics do not know how to use adrenaline
75% of doctors do not know how to administer adrenaline!
94% of allergics carry their adrenaline when travelling but only 43% when doing sport.
Most are not honest with themselves and do not risk assess thoroughly.

Learning from survivors:

80% had systemic (whole body) symptoms
73% did not use adrenaline
38% used antihistamines or other alternative medications.
Most survivors did not know how soon to use adrenaline – am I sick enough to use it? Most people find this difficult to judge as they do not remember what an anaphylactic reaction feels like, especially if they last had one as a child
Of 969 families whose family member suffered anaphylaxis, only 16% used adrenaline; most used asthma medication.

BSACI action plan for anaphylaxis:

Call an ambulance.
Do not go to your GP
Do not get in a car to try to drive to A&E
Do not go and hide in the loo and hope it will go away........

Survey of 1600 parents, 500 health care professionals and 800 teachers:

40-80% of the allergy sufferers forgot to carry their adrenaline
In 40-70% of the cases the adrenaline was out of date.
96% of teachers approved of the idea of having generic auto-injectors available in schools and elsewhere.

US food allergic parents and children, asked how happy they were about injecting adrenaline and how comfortable they felt about it, were hugely influenced by whether or not they had been trained and knew how to use their autoinjectors.

Adolescents do not think they are invincible

5% of adolescent anaphylactics think that they will die within the next year – but this is rubbish!
High risk takers knew a lot about the risk there were taking and were quite rational about that risk, but their situational knowledge (danger areas or situations, reading labels, where to access help) was often poor.
Boys have problems with carrying Epipens which are bulky and do not fit into tight jeans. Design work is on-going but it is hard to reduce the size of the injection mechanism without impairing its efficiency.

Adolescents need lots of support:

Someone to talk to face to face - peer groups discussions are particularly helpful.
On line forums
Downloadable apps
Plenty of parental monitoring but not directing or instructing.

Can adrenaline be dangerous?

Provided the adrenaline is injected into a muscle (it is almost impossible to do anything else with today's auto-injectors) it is totally safe and does not even produce any side effects. (In years gone by when it was injected directly into the blood stream it could be dangerous, especially in adults, but that is no longer relevant today.)

In Scandinavia training takes place with real life adrenaline injectors so that that the allergic person gets a feel for what getting an injection of adrenaline should be like.

Adult Allergy – Dr Isabel Skypala, Consultant Allergy Dietitian and Clinical Lead for Food Allergy at the Royal Brompton & Harefield NHS Foundation Trust.

Dr Skypala reported that her adult patients were a very 'mixed bag' in terms of allergies. Few had been allergic as children although nearly all of them had suffered from eczema as children.

Milk and egg allergies were rare; more common were allergies to nuts and peanuts, fruits, fish (especially shellfish), chocolate (to the theobromine), additives, citrus and various vegetables.

Plant food allergens

Allergies to fruit, vegetables and nuts and Oral Allergy Syndrome were very common.
Most patients have antibodies to pollen, often to birch pollen, which cross reacts with fruit and vegetables
Oral Allergy syndrome always to raw, not cooked, fruits and vegetables.
Apple, strawberry, peach, hazel nut and walnut are the most common but she would see those as being part of a pollen food syndrome.
Brazil and cashew nut allergies are usually stand alone allergies.
She is seeing more seed allergies with the growth in the use of seeds.
Legume allergies include fenugreek and guar gum.

Wheat and milk rarely seen as allergens in adults although often implicated in other food related conditions.

Seafoods

2-5% of patients allergic to crustaceans, usually to prawns but there is little cross over with molluscs.
With increased farming of prawns, king prawns have now overtaken shrimps.
Tropomysin is the main allergen but there are others.

Non IgE reactions

Wheat, barley and rye
Lactose intolerance
Fermentable carbohydrates
Sulphites
Biogenic amines - histamine
Scombroid poisoning

Diagnosis

History is crucial - including medications and co-factors such as alcohol or drugs.
Tests are useful but only when combined with a history – they are of poor predictive value.
Skin prick tests for pollen, seafood, fruits, vegetables, cereals and seeds are the most used.
Component Resolved Diagnosis (CRD) – molecular testing – is of some use but is very expensive.
Exclusion diets should show results within 2-4 weeks for IgE allergies, but may need to be followed for 6 weeks if for non-IgE allergies.
Positive skin prick tests are not always confirmed by challenge tests.

Menu planning – Tanya Wright, Specialist allergy dietitian

Tanya suggested that one should be aiming for easy, tasty, inclusive food – building on one's existing knowledge of food however great or small that might be.

One needs to learn to become an avid and informed label reader and to read every label as apparently similar product can be very different. She once logged 7 different varieties of hot dogs, each with different ingredients!

Be aware of 'naturally freefrom' foods and also be aware that having a 'freefrom' tag does not mean that a food is 'freefrom' all allergens, only the ones specified.

You also need to be aware of the extent your own or your child's allergies. For example, if they are egg allergic, can they tolerate cooked egg? In which case, be aware of which food contain cooked egg (baked good etc) and which contain raw egg (mayonnaise, royal icing, lemon curd etc.)

Also be aware of the many different names under which flours, legumes etc may be sold, especially in ethnic shops.

Living with allergy – Hazel Gowland of Allergy Action

Allergy is a whole package of atopies – but the connections between sensitivities are not always made.

There are 178 pages covering 50 threads on allergy on Mumsnet...

Childhood allergy creates huge stress and guilt for parents – even though no blame is attached.
Childhood allergy stresses include the time and the extra expense involved in caring for an allergic child.
Sensitisation is often via non food items such as face creams, shampoos or washing powders (Ecover, for example, includes both wheat and milk.)

Allergic child care involves management plans:

In schools – how are children fed and exercised? Can staff us autoinjectors? Are they on top of potential bullying and exclusion issues?
As teenagers: This is the transition moment but the health service offers little support. Are they aware of the dangers of living in student flats, going to parties, travelling etc?

Latex allergy – is the epidemic over? Dr Nicola Braithwaite, Consultant Paediatric Allergist at King's College Hospital, London

1927 saw the first case of latex allergy.

Dramatic rise in the incidence of latex allergy between 1980s and 2000, especially among healthcare workers and children with spina bifida.

1990s – USA – incidence:

General population – 1–5%
Healthcare workers – 2–17%
Children with spina bifida – 20–68% (Possibly because they underwent so many operations so came into contact with surgical gloves much more frequently.)
Incidence of intra-operative anaphylaxis – 17%

Latex surgical gloves

First introduced in 1834
1920s – in common use for surgical procedures. Usually washed and re-used thus reducing allergenicity.
1960s – single use glove introduced – encourage wider use of gloves throughout the healthcare industry.
Addition of cornstarch powder to make them easier to put on. But cornstarch leaches the proteins from the latex and then made it airborne when the gloves were removed.
1980s – HIV epidemic. Rapid increase in the use of gloves for all healthcare needs, not just for surgery.
High rise in demand led to poor production processes and higher levels of allergenicity.

Clinical picture

Contact dermatitis
More common in atopic individuals and can predispose to IgE allergy.
Latex can cross react with fruits and vegetables – avocado, bananas, kiwi, chestnuts, nightshades
Treatment – as for all other allergies – avoidance although this is not easy as although latex has now been removed from most healthcare products it is still ubiquitous – knicker elastic, trainers, seals on chocolate bars and hundreds of other everyday products.

1990s– 2015

Epidemic seems to be over in developed countries where exposure to latex in healthcare products has been hugely reduced – although it remains an issue in developing countries where latex healthcare products are still more widely used.

Between 1990 and 2005 there were approximately 300 papers on latex allergy on PubMed every year; now it is down to 30–40.
Figures from Denmark suggest that incidence has reduced from 6% to 1.2% over this period.
Amongst spina bifida children sensitisation has reduced from 55% to 5%; allergy from 37% to 0.8%.
Most sufferers now appear to be in older age group who became sensitised in the 1980s/90s.

However, when latex was taken out of healthcare products, it was introduced into catering and is still used in condoms.....

First published December 2015

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