mx food allergy 2026 - anaphylaxis campaign · product with pal product without pal to s 1. product...

Paul Turner

MRC Clinician Scientist & Honorary Consultant in Paediatric Allergy & Immunology,

Imperial College London; Honorary Clinical Lecturer, University of Sydney

How will we manage food allergy in 2026

Will we all be out of a job?

Du T

oit

et

al, J

AC

I 2

01

6


>50% allergic

@ age 5 yrs


15.3%

>50% allergic

@ age 5 yrs


8.5% already allergic

@ 4-6 months of age

• Food allergy is likely to continue to remain a

significant healthcare issue

… although new prevention strategies are

likely to have some impact

• Infant eczema likely to remain a significant

risk factor…


Adrenaline auto-injector devices

0

50

100

150

200

250

300

200

0

200

1

200

2

200

3

200

4

200

5

20

06

200

7

200

8

200

9

201

0

201

1

201

2

150mcg

300+mcg

TOTAL

Thousa

nds o

f pre

scriptions

Data: NHS Prescription Cost Analysis for England, 2000-2012

Hospital admissions

2000 2005 20100

2

4

6

8

Adm

issio

ns p

er

100,0

00 p

opula

tion Age 0-14

Age 15-59

Age 60+

FOOD

Hospital admissions

2000 2005 20100

2

4

6

8

Adm

issio

ns p

er

100,0

00 p

opula

tion Age 0-14

Age 15-59

Age 60+

FOOD

?

Impact of a Food Allergy Diagnosis

• 39% longer to shop

• Significantly greater expense

• Quality of life scores worse than Type 1 DM

• Risk of compromised nutrition

• Risk of fatal reaction

Avery NJ, Assessment of quality of life in children with peanut allergy. Ped All Immunol 2003;14:378-82.

Fox AT et al. Food Allergy as a risk factor for Nutritional Rickets. Ped All Immunol 2004 Dec;15 (6):566-9.

Bock SA et al Fatalities due to anaphylactic reactions to food. J Allergy Clin Immunol. 2001;107(1):191-3.

IS

ANAPHYLAXIS

ALWAYS

SEVERE

?

Risk of food-induced anaphylaxis

Umasunthar et al, Clin Exp Allergy. 2013;43:1333-41.

83% of (245) teenagers with anaphylaxis

don’t use their AAI

Anaphylaxis is not uncommon,

but death from anaphylaxis is very rare…

Brown et al., MJA (2007)

Turner et al, Allergy (2016

Anaphylaxis is not uncommon,

but death from anaphylaxis is very rare…

…but also unpredictable

Perceptions…

Fatal anaphylaxis

rare but unpredictable

Perceptions…

• Food allergy common

• Allergen labelling

widespread

Fatal anaphylaxis

rare but unpredictable

“You might tell me that the chance

of dying is 1 in a million…

“You might tell me that the chance

of dying is 1 in a million…

“…my child is that 1 in a million”

Management vs treatment

There is currently no treatment for food

allergy in routine clinical practice

Management ≠ Treatment

Current management… NOW & THEN

• Dietary Avoidance

• Rescue treatment

• Immunotherapy

Dietary avoidance…

Allergen disclosure required under law:

• key allergens in ingredients of prepacked foods

Allergen Labelling

Allergen Labelling

Allergen disclosure required under law:Australia & NZ UK and Europe USA

Wheat Wheat Wheat

Other gluten: rye, barley,

oats, spelt

Other gluten: rye, barley,

oats, spelt, kamut

Egg Egg Egg

Milk Milk Milk

Peanuts Peanut Peanut

Tree nuts Tree nutsTree nuts

and coconut (!)

Soy Soy Soy

Fish Fish Fish

Crustaceans Crustaceans Crustaceans

Molluscs

Celery

Mustard

Sesame Sesame

Lupin

Sulphur dioxide (>10ppm) Sulphur dioxide (>10ppm)

Allergen Labelling



Mandatory disclosure applies only to allergens in

ingredients

Allergen Labelling



Mandatory disclosure applies only to allergens in

ingredients

Since December 2014, there are now statutory

requirements in terms of labelling:

… but not for potential allergen presence due to

cross-contamination

Turner et al, 2011Turner et al, BMJ 2011

Unnecessary avoidance?

• Sensitisation is a poor marker of clinical reactivity:

Osborne et al. JACI 2011; 127:668–676.

Ball et al. PAI 2011; 22:808-12.

Unnecessary avoidance?

• Sensitisation is a poor marker of clinical reactivity:

• Should peanut-allergic patients avoid all nuts?

• 31% of 94 peanut-allergic children were ‘sensitised’ to a

tree nut

• Only 7 (of 29) were allergic at formal OFC

Osborne et al. JACI 2011; 127:668–676.

Ball et al. PAI 2011; 22:808-12.

Improved diagnostics?

New in vitro diagnostics:

• Component resolved

diagnostics (CRD)

• Basophil activation test




diagnostics (CRD)

Dang et al. JACI 2012;129:1056-63.




diagnostics (CRD)

• Basophil activation test

Don’t underestimate the power of a food challenge…

-10 0 10 20

Change in HRQL pre- and post challenge

Self-efficacy assessment

In child,

reportedby parent

In child,self-reported

Improvement in self-efficacy

-40

-30

-20

-10 0 10 20

Food Allergy Quality of Life

In child,reported by parent

In parent

In child,

self-reported

Reduced adverse impact

Diagnosis: The future ?

Turner et al, 2011Turner et al, BMJ 2011

Back to avoidance…

Turner et al, BMJ 2011

Product with PAL Product without PALH

elp

ful to

all

erg

ic c

on

su

me

rs1. Product with PAL with a real risk of

inducing an allergic reaction

i.e. unsafe to consume

• Proper risk assessment by the food

manufacturer

• Conclusion that the allergen may be

present in the product (despite

allergen management and Good

Manufacturing Practice).

4. Product without PAL with low or

no risk of inducing an allergic

reaction

i.e. safe to consume

• Proper risk assessment by the food

manufacturer

• Conclusion that the allergen is not

present in the product at a level that

is likely to cause an allergic reaction

No

t h

elp

ful to

all

erg

ic c

on

su

me

rs

2. Product with PAL with unknown

risk of inducing an allergic reaction

i.e. may be safe or unsafe to eat

• No proper risk assessment

• No conclusion about allergen

presence can be drawn

5. Product without PAL, with

unknown risk of inducing an

allergic reaction

i.e. may be safe or unsafe to

consume

• No proper risk assessment



3. Product with PAL with low or no

risk of inducing an allergic reaction

i.e. safe to consume

• Proper risk assessment undertaken

• Manufacturer uses PAL nonetheless



Do foods with PAL contain allergen?

0 10 20 30 40 50 60

Hefle et al, 2007 (n=179) USA

Pele et al, 2007(n=569) Europe

Ford et al, 2010(n=228) USA

Crotty et al, 2010 (n=81) USA

FSAI, 2011(n=108) Eire

Remington et al, 2013 (n=352) USA

Zurzolo et al, 2013 (n=43) Australia

Robertson et al, 2013 (n=38) Eire

FSA, 2014(n=508) UK

% pre-packed food products with PAL containing allergen

Peanut

Hazelnut

Soya

Milk

Egg

} 0%

So…

Most foods with PAL don’t contain the allergen

• … but some do, and enough to trigger reactions

• Snack/confectionery items at particular risk

(nut contamination)

Some foods without PAL do contain the allergen

UK FSA Survey

(2014)

508 products

2012-2014

Remington et al.

Allergy. 2015;70:813-9.

The reality:

• Wide inconsistencies in labelling

• Significant increase in awareness of the

hazards posed by food allergens …but understanding is still far from complete

• Foods can become contaminated with residues

of allergenic foods at multiple points:

• Harvesting on farms

• Storage & transportation

• Manufacture: shared equipment

• Measures to reduce cross-contamination not

uniform across manufacturers

The future…

The future: Aids to avoidance…

Hypoallergenic foods

Not a novel concept: e.g. hydrolysed cow’s milk-based formula




• Immunotherapy

Accidental/inadvertent reactions are common:

• 1 in 8 peanut-allergic children experienced at least

one accidental reaction every year1

• Over 50% of 512 infants had at least one reaction

over 3 years follow-up2

Avoidance is, therefore, inadequate on its own

1Nguyen-Luu et al, PAI 2012; 23:133–139. 2Fleischer et al. Pediatrics 2012; 130:e25–32.

Accidental/inadvertent reactions are common:

• 1 in 8 peanut-allergic children experienced at least

one accidental reaction every year1

• Over 50% of 512 infants had at least one reaction

over 3 years follow-up2

Avoidance is, therefore, inadequate on its own

All food-allergic children need:

• Personalised Allergy Management Plan

• Rescue treatment (which may include AAI)1Nguyen-Luu et al, PAI 2012; 23:133–139. 2Fleischer et al. Pediatrics 2012; 130:e25–32.

Management of accidental reactions…

Allergy Action Plan

Name:

DOB:

Parent / Carer details:

1) ! 2) !

THIS CHILD HAS THE FOLLOWING ALLERGIES:

AIRWAY: Persistent cough, hoarse voice, difficulty swallowing, swollen tongue

BREATHING: Difficult or noisy breathing, wheeze or persistent cough

CONSCIOUSNESS: Persistent dizziness / Pale or floppy Suddenly sleepy, collapse, unconscious

If ANY ONE of these signs are present:

1. Lie child flat. If breathing is difficult, allow to sit 2. Give EpiPen® or EpiPen® Junior 3. Dial 999 for an ambulance* and say

ANAPHYLAXIS (“ANA-FIL-AX-IS”)

If in doubt, give EpiPen®

After giving Epipen: 1. Stay with child, contact parent/carer

2. Commence CPR if there are no signs of life

3. If no improvement after 5 minutes, give a further EpiPen® or alternative adrenaline autoinjector device, if available

Photo

Keep your EpiPen device(s) at room temperature, do not refrigerate. For more information and to register for a free

reminder alert service, go to www.epipen.co.uk Patient support groups:

http://www.allergyuk.org or www.anaphylaxis.org.uk

! The British Society for Allergy & Clinical Immunology

w w w . b s a c i . o r g

*You can dial 999 from any phone, even if there is no credit left on a mobile.

Medical observation in hospital is recommended after anaphylaxis.

Watch for signs of ANAPHYLAXIS (life-threatening allergic reaction):

Child’s Weight: Kg

Mild-moderate allergic reaction: · Swollen lips, face or eyes

· Itchy / tingling mouth

· Hives or itchy skin rash

ACTION: · Stay with the child, call for help if necessary

· Give antihistamine:

· Contact parent/carer

· Abdominal pain or vomiting

· Sudden change in behaviour

(if vomited, can repeat dose)

This is a medical document that can only be completed by the patient's treating health professional and cannot be altered without their permission.

This plan has been prepared by:

Hospital/Clinic:

! Date:

British Society for Allergy and Clinical Immunology

Additional instructions:

Clinic details

We need:

1. Recognition

2. Appropriate management in community

3. Appropriate management by healthcare

professionals

1) Recognition

• Symptoms of anaphylaxis (DIB, LOC, pharyngeal

swelling) are poorly recognized by adolescents1

• One in 7 report difficulty in knowing when to use

their AAI in a US survey (n=1885)3

1Sampson et al. JACI 2006: 117: 1440–5.2Simons et al JACI 2009: 124: 301–6.

2) Appropriate Management

• 83% of (204) teenagers

with anaphylaxis don’t

use their AAI1

1Noimark et al. CEA 2012: 42:284–92

Allergy Action Plan

Name:

DOB:

Parent / Carer details:

1) ! 2) !

THIS CHILD HAS THE FOLLOWING ALLERGIES:

AIRWAY: Persistent cough, hoarse voice, difficulty swallowing, swollen tongue

BREATHING: Difficult or noisy breathing , wheeze or persistent cough

CONSCIOUSNESS: Persistent dizziness / Pale or floppy Suddenly sleepy, collapse, unconscious

If ANY ONE of these signs are present:

1. Lie child flat. If breathing is difficult, allow to sit 2. Dial 999 for an ambulance* and say

ANAPHYLAXIS (“ANA-FIL-AX-IS”) 3. Stay with child, contact parent/carer 4. Commence CPR if there are no signs of life

Photo

This BSACI Action Plan for Allergic Reactions is for children with mild to moderate allergies, who need

to avoid certain allergens. For people with severe allergies (and at risk of

anaphylaxis) there are BSACI Action Plans which include adrenaline autoinjector instructions. These are available at our website, www.bsaci.org

For further information consult NICE Clinical Guidance CG116 Food allergy in children and young

people at http://guidance.nice.org.uk/CG116 Patient support groups:

http://www.allergyuk.org or www.anaphylaxis.org.uk

! The British Society for Allergy & Clinical Immunology

w w w . b s a c i . o r g

*You can dial 999 from any phone, even if there is no credit left on a mobile.

Medical observation in hospital is recommended after anaphylaxis.

Watch for signs of ANAPHYLAXIS (life-threatening allergic reaction):

Mild-moderate allergic reaction: · Swollen lips, face or eyes

· Itchy / tingling mouth

· Hives or itchy skin rash

· Abdominal pain or vomiting

· Sudden change in behaviour

ACTION: · Stay with the child, call for help if necessary

· Give antihistamine:

· Contact parent/carer

(if vomited, can repeat dose)

Child’s Weight: Kg

This is a medical document that can only be completed by the patient's treating health professional and cannot be altered without their permission.

This plan has been prepared by:

Hospital/Clinic:

! Date:

British Society for Allergy and Clinical Immunology

Additional instructions:

Clinic details

NOT JUST PATIENTS….

How to use Adrenaline auto-injectors…

MAMA Study:

• Only 4 out of 10 mothers

were able to successfully

administer adrenaline in an

anaphylaxis scenario,

6 weeks after training

• 30% failed to remove cap

• 18% insufficient time

• 8% wrong end

• Only two doctors (2%) demonstrated use correctly.

• Most frequent errors:

57% - not holding pen in place for >5 seconds

21% - failure to apply pressure to activate

16% - self-injection into thumb

• 60% failed to use device correctly even after reading

instructions

• In 37% NO adrenaline would have been administered

Refractory anaphylaxis

What we do know:

• 83% of (204) teenagers with anaphylaxis don’t use their

AAI1

• Symptoms of anaphylaxis (DIB, LOC, pharyngeal

swelling) are poorly recognized by adolescents2

• One in 7 report difficulty in knowing when to use AAI in

a US survey (n=1885)3

• Adrenaline IM doesn’t always work4

1Noimark et al. CEA 2012: 42:284–92 2Sampson et al. JACI 2006: 117: 1440–5.3Simons et al JACI 2009: 124: 301–6. 4Pumphrey & Gowland, JACI 2007;119:1018-9.

Do we need to shift our focus?




• Immunotherapy

Immunotherapy to food

Nowak-Wegrzyn & Sampson. JACI 2011; 127(3):558-73

Nowak-Wegrzyn & Fiocchi, Curr Opin Allergy Clin Immunol. 2010; 10:214-9.

Studies completed or underway…

Egg Milk Peanut Other

Subcutaneous ✓

Baked, oral ✓ ✓

Native, oral ✓ ✓ ✓ ✓

SLIT ✓ ✓ ✓

Epicutaneous ✓ ✓

Tolerising peptides ✓ ✓

Safety

• Desensitisation typically achieved in >80%

• High rate of adverse events during SOTI:

• 70-80% experience adverse events

• Rates of ‘anaphylaxis’ vary

• Severity of anaphylaxis vary

• Up to 10% of patients withdraw

Desensitisation vs long term tolerance…

Nowak-Wegrzyn & Sampson. JACI 2011; 127(3):558-73

Desensitisation vs long term tolerance…

Peanut 12 (50%) of 24 children who completed

SOTI were tolerant after 2 months1

Egg 11 (37%) of 30 children who completed

SOTI were tolerant after 2 months2

Cow’s

Milk

10 (31%) of 32 children were able to

tolerate at least one portion of CM daily

1-5 years after completing SOTI3

1Vickery et al. JACI 2014 Feb;133(2):468-475.e6.2Burks et al. N Engl J Med 2012; 367:233–243.3Keet et al. JACI 2013; 132:737–739; e6.

Some clinical concerns…

• How to select those suitable for SOTI

• Risk of increasing sensitisation?

• Risk of inducing a false sense of security in

those only temporarily desensitised

• Effect on QoL of patient

• Potential for causing other problems e.g. EoE

THE FUTURE

THE FUTURE: Dietary avoidance

• Accurate diagnosis and therefore appropriate

avoidance

• Clearer food labelling

• Apps to help avoid potential allergens

• Better understanding when eating out

• Hypoallergenic foods

THE FUTURE: Rescue treatment

• Recognition of symptoms

• More intuitive AAI

• Apps to aid AAI use/emergency services

• More training for HCPs

THE FUTURE: Treatment options

• Use of baked CM / egg

• More research into SOTI:

• Safer protocols

• Better understanding of long-term

tolerance induction

• SOTI as primary prevention

THE FUTURE… is already here?

• Accurate diagnosis and therefore appropriate avoidance

• Clearer food labelling

• Apps to help avoid potential allergens

• Better understanding when eating out

• Hypoallergenic foods

• Recognition of symptoms

• More intuitive AAI

• Apps to aid AAI use/emergency services

• More training for HCPs

• Baked CM / Egg

• More research into SOTI:

• Safer protocols

• Better understanding of long-term tolerance induction

• SOTI as primary prevention

mx food allergy 2026 - anaphylaxis campaign · product with pal product without pal to s 1. product...

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