Food allergy and anaphylaxis have become an increasing public and personal health burden in developed countries over the last decade, contributing to increased demand for specialty services (1), significant economic cost of care (2), and reduced quality of life for food allergic children and their families (3). Effective strategies for primary prevention are lacking, and secondary prevention is limited to strategies to reduce the risk of unintentional exposure. Although specific immunotherapy appears promising, it remains at the investigational stage at this time and requires intense medical and nursing resources that are not currently available (4). While a number of factors have been proposed for the rise in food allergy (reviewed in 5), definitive (and potentially avoidable) risk factors remain the subject of ongoing research. While most food allergy begins in childhood, it may arise at any age, and deaths from food related anaphylaxis are most common in teenagers and young adults.
Food allergy and anaphylaxis is a world wide problem
According to a press release from the World Allergy Organisation April 2014 (WAO: www.worldallergy.org/UserFiles/WorldAllergyWeek2014Announcement.pdf) WAO is putting out a call to action for education, preparation, and resources in the treatment and prevention of anaphylaxis.
According to Lanny Rosenwasser, President of WAO, anaphylaxis does not have to be fatal. “Knowing how to respond when anaphylaxis occurs is critical, as with any emergency response procedures. Everyone should be aware of the possible symptoms, how to position the person, and how to administer adrenaline. Any individuals with allergen hypersensitivity should consult regularly with their allergists about possible risk of anaphylaxis and develop actions plans for anaphylaxis episodes and have epinephrine autoinjectors (adrenaline) with them at all times. Those at risk of severe or fatal anaphylaxis because of asthma, coronary artery disease, or blood pressure problems, should discuss the possible triggers of anaphylaxis with their physicians as well as lifestyle approaches to reduce the risk of anaphylaxis.”
Allergic disease in Australia: counting the economic cost
Australia and New Zealand have among the highest prevalence of allergic disorders in the developed world. An ASCIA-Access Economics Report estimated that in 2007 (2), 4.1 million Australians (19.6% of the population) had at least one allergic disease, with highest prevalence in the working age population, with 78% of those affected aged 15 to 64 years. It is predicted that from 2007 to 2050 the number of patients affected by allergic diseases in Australia will increase from 4.1 million (19.6% of the population) to 7.7 million (26.1% of the population). The economic cost of allergic disease was estimated to be $9.4 billion from direct and indirect cost of medical care and loss of income and reduced productivity, with an additional $21.3 billion from lost wellbeing (disability and premature death). An additional report by the Australian Institute of Health and Welfare on the cost of care for allergic rhinitis alone in 2011 estimating that 3.1 million (or 15% of the population) were affected (mainly those aged 25-44 years) with medication costs doubling from an estimated $107.8 million/year in 2001 to $226.8 million in 2010 ( http://www.aihw.gov.au/publication-detail/?id=10737420595&tab=2). While the cost of dealing with food allergy/anaphylaxis in Australia are currently unknown, on USA study estimated that in 2007 alone, direct medical costs in that country were $225 million, and indirect costs were $115 million from medical consultations, hospital treatment and medication use (1).
Allergic disease in Australia: counting the numbers
In the most accurate estimate of food allergy in Australia performed thus far and published early 2011 (6), the HealthNuts study based in Melbourne, Victoria, demonstrated food challenge proven incidence of food allergy at age 12 months to be much higher than previously suspected; food allergy overall (10%); peanut allergy (3%); raw egg (8.8%) and sesame seed (0.8%). Of those with egg allergy, 80% could eat egg baked into cake. Cow’s milk allergy was estimated at 2.7%, but this was based on history rather than challenge proven. Estimates of food allergy in older children are 3-5%. In a 2002 Australian study of adults aged 20-45 years, 1.3% were estimated to suffer from food allergy, most commonly to peanut, followed by shrimp (prawn), cow's milk and egg, based on a combination of medical history and diagnostic allergy testing (7). The risk of progression to dangerous reactions (anaphylaxis) is not easy to predict as1/3 of patients with anaphylaxis have food-induced anaphylaxis with first known exposure (8), and 80% of fatal anaphylaxis cases have had previous mild to moderate reactions without dangerous features.
The scale of the burden can be envisaged when considering the 309,582 births in Australia in 2012 alone ( http://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/3301.0Main+Features12012?OpenDocument ). If FA rates are uniform across Australia the HealthNuts FA prevalence potentially translates to 31,000 new cases of FA each year, including an estimated 9,000 new cases of peanut allergy alone, of whom only 20% are expected to resolve. The challenge for the Australian healthcare system will how best to care for increasing numbers of not only young children presenting with new cases of FA and anaphylaxis, but also the current generation of teenagers and adults at persistent risk of fatal anaphylaxis, with the limited health and educational resources currently available.
Stinging insect anaphylaxis
Australian population surveys have shown that up to 2.8% have experienced honeybee sting anaphylaxis and that 1% of the Tasmania population and 2.4% of the Victorian population have had anaphylaxis after “Jack Jumper Ant” (JJA) stings. Bee sting anaphylaxis is estimated to result in approximately 2 deaths/year in Australia, with wasp stings causing an estimated 1 death/year. In southern Tasmania, where suspicious deaths have been carefully investigated, four deaths from JJA sting anaphylaxis were identified over a 10-year period (9-15).
Estimates of anaphylaxis incidence vary widely, from 1 episode/31,000 people per year up to 1 in 1700 people per year (16,17). In Australia age-adjusted Australian hospital admission rates for anaphylaxis in children aged 0–4 years, increased from 39.3 to 193.8 per million population per year between the financial years 1993–94 and 2004–05, increasing to 288.6 per million population per year in 2009/10. These increases were substantially greater for older age groups, or for the population as a whole (36.2 to 80.3 per million population between 1993–94 and 2004–05; 18). Even these figures are likely underestimates; one previous Australian study described that only 50% of patients with anaphylaxis ever attended hospital (19), and Australian health data collects anaphylaxis admission rates, but not data on those treated and then discharged.
Deaths from anaphylaxis are relatively rare in Australia. In an examination of coroner’s reports of deaths attributed to anaphylaxis occurring 1995-2007, 112 deaths were recorded over a 9-year period. Causes were food, 7 (6%); drugs, 22 (20%); probable drugs, 42 (38%); insect stings, 20 (18%); undetermined, 15 (13%); and other, 6 (5%). All food-induced anaphylaxis fatalities occurred between 8 and 35 years of age, despite the majority of food-induced anaphylaxis admissions occurring in children less than 5 years of age (20). Despite these relatively low rates of fatal anaphylaxis, there are a number of reasons to consider that such data may underestimate true rates of fatal anaphylaxis: (a) reliance on the reliability of hospital coding, where some cases of anaphylaxis may be coded as asthma deaths, even though asphyxia is a common mechanism of anaphylaxis death (21); (b) elevation of blood tryptase measurements in some cases of unexplained deaths (22); and a rare phenomenon known as Kounis syndrome, where anaphylaxis may results in coronary artery spasm, coronary ischaemia, abnormal heart rhythms and sudden death (24). While coronial inquests are mandated for deaths in children aged less than 16 years in the UK with the aim to “learn lessons and reduce the incidence of preventable child deaths” ( https://www.gov.uk/government/publications/child-death-overview-panels-contacts), FAA is considered to be death by “natural causes” under Australian law and coronial inquests are not mandated.
Morbidity associated with food allergy and anaphylaxis
Food allergy and anaphylaxis are ongoing conditions where the threat of reaction is chronic but the timing of an acute reaction is unpredictable (20). While official rates of anaphylaxis are relatively low, concentrating on death rates alone, however, underestimates the ongoing morbidity experienced by patients and their carers on a daily basis. There are many published studies examining the impact of food allergy on the quality of life of patients and their families and the psychological impact of such a diagnosis (3, 24-26). Given that underlying rates of food allergy appear to have increased over the last 10-15 years (8, 18, 27-31), it is conceivable that fatal reactions may also eventually become more common. Quality of life is significantly impaired, and patients need to be educated on unusual routes of accidental exposure to allergic triggers including kissing and sexual intimacy. While there is controversy over whether exposure by this route has triggered death ( www.news-medical.net/news/2006/05/14/17942.aspx), there is substantial literature evidence that allergen can remain in the mouth for some time after consumption, and that patient surveys demonstrate allergic reactions via this route (32-38).
Is food allergy increasing?
In the absence of repeated population estimates using objective measures of assessment, evidence that food allergy might be more common in Australia is indirect, derived from surrogate markers such as changing service demand (i.e. longer waiting lists, increasing proportion of patients seen being assessed for food allergy as opposed to other conditions; 19) and increased hospital admission rates for anaphylaxis, observed in Australia, the UK and USA (19, 27-29), although there is evidence that peanut allergy has increased in young children from the United Kingdom and the United States (31, 32). In an ACT-based study of peanut allergy 1995-2007, the absence of any change in the proportion of children presenting with potentially dangerous reactions (anaphylaxis) (whether by year of birth or year of assessment) suggests that it is less likely that these observations were an artefact of altered health-seeking behaviour of parents presenting with children with milder allergic symptoms (9).
Risk factors for food allergy
Possible risk factors for FA and anaphylaxis are starting to emerge and are the subject of ongoing research, with likely interactions between environmental risk factors and genetic predisposition, resulting in altered immune response to non-toxic food allergens, altered expression of immune regulatory genes and perhaps inheritable expression of gene expression, so-called epigenetic changes. Evidence in favour of the “hygiene hypothesis” includes lower risk of egg allergy by having older siblings at home or an indoor dog in the first year of life, but not caesarean section delivery, antibiotic use in infancy, childcare attendance and maternal age (39). Timing of introduction of allergenic food may also play a role, with delayed introduction of egg beyond 12 months in one Australian study associated with a non-significant increased risk compared to introduction at age 4-8 months (40). The potential influence of vitamin D status has been an area of interest in the last 5 years, given it known immunomodulatory properties and high rates of insufficiency in the Australian population (reviewed in 41). A number of ecological studies have shown higher rates of anaphylaxis admissions and prescriptions for AAI and IHF in less sunnier regions of the USA and Australia, raising the possibility that sun exposure/vitamin D status may play a role in FA pathogenesis (40). The most direct evidence in favour of the “Vitamin D hypothesis” is derived from the Melbourne HealthNuts study, which demonstrated between higher rates of challenge proven egg, or peanut allergy (odds ratios 3.79 and 11.59, respectively) in children aged 12 months with vitamin D insufficiency (defined as < 50nmol/l; 42). City living and socioeconomic status have been linked to higher FA risk (43), perhaps surrogate markers of a “westernised lifestyle”. Use of acid suppressive medication or altered exposure to gut microbiota early in life (e.g. childcare, exposure to pets or farm animals) might bias the immune response towards or away from a pro-allergic response (44,). Genetic factors such as family history of allergic disease (40), filaggrin loss of function gene mutations (perhaps increasing food sensitisation risk via non intact skin) and atopic eczema have also been linked to higher risk (45). Finally, it is conceivable that many of the environmental influences identified may cause inheritable epigenetic changes by activating or silencing genes important to immune regulation (45).
Management of food allergy and anaphylaxis
Management involves patient and carer education, addressing issues such as situations of higher risk, underlying psychological concerns, provision of an action plan how to recognise and respond to an allergic reaction (including anaphylaxis), and in those at higher risk of dangerous allergic reactions, provision of injectable adrenaline. ASCIA’s recommendations are consistent with world best practice, as described in a recent WAO consensus statement: www.ncbi.nlm.nih.gov/pmc/articles/PMC3500036/
The need for education on food allergy and anaphylaxis
The demand for evidence-based education on how best to care for increasing numbers of children presenting with food allergy and anaphylaxis continues to outstrip the current resources available for face-to-face training by community and hospital-based food allergy and anaphylaxis trainers. Australia is a large country, and with most specialist services located in our major cities, it has become clear that regional areas will suffer if alternative models for delivery of educational content are not developed.
ASCIA’s educational resources
Over the last decade, ASCIA has developed a number of hard copy and online resources to assist in food allergy/anaphylaxis management including national standardised emergency action plans, as well as patient and health professional educational material ( www.allergy.org.au/health-professionals/anaphylaxis-resources). Educational material is reviewed on a cyclical basis, generally at least once every 2-3 years (sometimes more often), and distributed for peer review by ASCIA membership before finalisation and publication.
In addition over the last 5 years, ASCIA, with the assistance of unrestricted educational grants* has partnered with the Western Australian and New South Wales departments of Health, Education and Training and Community Care to develop evidence based and standardised educational modules on food allergy and anaphylaxis to be available for national use. These departments have provided financial and logistical support for this long running project, which has emerged after extensive consultation and has now been endorsed by relevant state education and health departments. Online anaphylaxis education is available without charge through the ASCIA website (www.allergy.org.au). Face-to-face and online courses have been developed in modular format, which facilitates content revision, content consistency and legislative variability across multiple regions, and enhances access to educational material independent of geographical location.
ASCIA courses have been developed for school and, childcare staff, parents, health professionals, first aid providers and the general community. Over the past 3 months almost 80,000 teachers have registered for ASCIA’s anaphylaxis e-training for schools, developed to provide accurate and consistent anaphylaxis education across Australia and New Zealand, available without charge. ASCIA anaphylaxis training for childcare was recently approved by the Australian Children's Education and Care Quality Authority (ACECQA). Over 150,000 school and childcare staff have undergone ASCIA online training since the program was first launched.
ASCIA e-training courses for health professionals (anaphylaxis; food allergy; allergic rhinitis; and immunotherapy) have been combined to form a single 6 hour Active Learning Module (ALM) titled ASCIA Allergy and Anaphylaxis e-training for Health Professionals ALM. This Active Learning Module has been approved by the RACGP QI&CPD Program. Total points: 40 (Category 1).
Current ASCIA education courses available:
- Anaphylaxis training for schools and childcare
- Anaphylaxis training for first aid (community)
- Anaphylaxis training for health professionals
- Anaphylaxis training for pharmacists
- Food allergy training for dietitians and other health professionals
- Allergic rhinitis training for health professionals
- Allergen immunotherapy training for health professionals
- Allergy and anaphylaxis e-training for health professionals ALM – available from mid April 2014.
*Important note regarding ASCIA activities and funding
ASCIA is a not-for-profit professional medical society. As a non-government organisation, ASCIA does not receive government funding. ASCIA’s educational activities are underpinned by members donating their time for resource development, and funding derived from membership fees and unrestricted educational grants. Providers of unrestricted grants have no input into resource content or development.
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© ASCIA 2014
The Australasian Society of Clinical Immunology and Allergy (ASCIA) is the peak professional body of Clinical Immunologists and Allergists in Australia and New Zealand.
Postal address: PO Box 450 Balgowlah NSW 2093 Australia
This document has been developed and peer reviewed by ASCIA members and is based on expert opinion and the available published literature at the time of review. Information contained in this document is not intended to replace medical advice and any questions regarding a medical diagnosis or treatment should be directed to a medical practitioner. The development of this document is not funded by any commercial sources and is not influenced by commercial organisations.
Content updated April 2014