Presentation at 3rd GRF One Health Summit 2015 Session Plenary II

1. Antonella Muraro
EAACI President
FOOD ALLERGY & ANAPHYLAXIS
the new epidemic of 21st
century
Global One Health Forum 2015
Davos , October 5th

2. Food Allergy and Anaphylaxis
the new epidemic of 21st
century
OUTLINE
1.Burden of food allergy
1A Methodological pitfalls
2. Burden of anaphylaxis
2A. Methodological pitfalls
3. Conclusions and Next Steps

3. Which is the burden
of food allergy and
anaphylaxis ?
Food Allergy and Anaphylaxis
the new epidemic of 21st
century

4. Prevalence of food allergic reactions is overallPrevalence of food allergic reactions is overall
poorly documentedpoorly documented
• Disease definition: clinical reaction v’sDisease definition: clinical reaction v’s
sensitization v’s self reportedsensitization v’s self reported
• Diagnostic criteria not always consistentDiagnostic criteria not always consistent
• Role of atopic dermatitisRole of atopic dermatitis
• Environment and Iatrogenic effects ?Environment and Iatrogenic effects ?
Burden of Food Allergy
Epidemiology-I

5. DIAGNOSIS AND MANAGEMENT
SYSTEMATIC REVIEWS
QUESTION
•What is the epidemiology of Cow’s
Milk in Europe?
•Epidemiology varies according to the
definition of cow’s milk allergy / food
allergy

6. EAACI
Food Allergy &Anaphylaxis
Guidelines
for Clinical Practice 2014
Translating Knowledge for
best practice in healthcare

7. Epidemiology of Cow’s Milk Protein
allergy
Allergy 2014: DOI: 10.1111/all.12423
Epidemiology of cow’s milk
allergy- Criteria
Prevalence %
Overall lifetime prevalence of
self-reported CMA
6.0% (95% CI
5.7-6.4)
Overall point prevalence of self-
reported CMA
2.3% (95% CI
2.1-2.5)
SPT positivity 0.3% (95% CI
0.03-0.6)
Specific-IgE positivity 4.7 (95% CI
4.2-5.1)
FC positivity 0.6% (95% CI
0.5-0.8)
FC or history of CMA 1.6% (95% CI
1.2-1.9)

8. Prevalence of food allergic reactions is overallPrevalence of food allergic reactions is overall
poorly documentedpoorly documented
• Disease definition: clinical reaction v’sDisease definition: clinical reaction v’s
sensitization v’s self reportedsensitization v’s self reported
• Diagnostic criteria not always consistentDiagnostic criteria not always consistent
• Role of atopic dermatitisRole of atopic dermatitis
• Environment and Iatrogenic effects ?Environment and Iatrogenic effects ?
Burden of Food Allergy
Epidemiology-I

9. 9
Prevalence

10. Prevalence of food allergic reactions is overallPrevalence of food allergic reactions is overall
poorly documentedpoorly documented
• Disease definition: clinical reaction v’sDisease definition: clinical reaction v’s
sensitization v’s self reportedsensitization v’s self reported
• Diagnostic criteria not always consistentDiagnostic criteria not always consistent
• Role of atopic dermatitisRole of atopic dermatitis
• Environment and Iatrogenic effects ?Environment and Iatrogenic effects ?
Burden of Food Allergy
Epidemiology-I

14. Prevalence of food allergic reactions is overallPrevalence of food allergic reactions is overall
poorly documentedpoorly documented
• Disease definition: clinical reaction v’sDisease definition: clinical reaction v’s
sensitization v’s self reportedsensitization v’s self reported
• Diagnostic criteria not always consistentDiagnostic criteria not always consistent
• Role of atopic dermatitisRole of atopic dermatitis
• Environment and Iatrogenic effects ?Environment and Iatrogenic effects ?
Burden of Food Allergy
Epidemiology-I

16. Guidelines for Introduction of
complementay foods
Previous recommendations
AAP 2004:
• General population should avoid:
– solid foods 4-6 months & cow’s milk 12
months
• Infants at risk should also avoid:
– egg for 2 yrs &
– peanuts, treenuts and fish 3 yrs

17. United Kingdom 5171
Israel 5615
Early consumption of peanuts in infancy
is associated with a low prevalence
of peanut allergyMediangofpeanutprotein/week
Peanut Protein Consumption 8 - 14 month
0 g/week
7.1 g/week
p < 0.001
Prevalence of Peanut Allergy in
Children 4 - 18yrs
%PAPrevalence
0.17%
p < 0.001
1.85%
Du Toit G et al. J Allergy Clin Immunol 2008; 122: 984-91.

18. Prevalence of immediate allergic reactions isPrevalence of immediate allergic reactions is
poorly documentedpoorly documented
•Lack of agreed working definitionLack of agreed working definition
•Uncommon disorder, rapid in onsetUncommon disorder, rapid in onset
• International Codes of Disease underusedInternational Codes of Disease underused
Sampson HA et al J Allergy Clin Immunol 2006;117: 391-397Sampson HA et al J Allergy Clin Immunol 2006;117: 391-397
Burden of Anaphylaxis
Epidemiology-II

19. •Mortality registries
•Hospital admission
•ER visits/admissions
• GP case records
•Allergists
•Patients alliances/Voluntary reporting
•Expenditure for Self-injectable- epinephrine
H
ER
A
P
P
P
P
P
P
P
P
P
P
P
P
LHU
GP
H
ER
A
P
P
P
P
P
P
P
P
P
P
P
P
LHU
GPH
ER
A
P
P
P
P
P
P
P
P
P
P
P
P
LHU
GP
H
ER
A
P
P
P
P
P
P
P
P
P
P
P
P
LHU
GP
IFFERENCE 2SOURCE OF INFORMATION

20. Local Health
Unit
GP
Allergist
Emergency Room
Hospital
WHO KNOWS
THE ANSWER?
Different stakeholders have a different
perception of the disease on:
•Prevalence
•Incidence
•Severity
•Natural history
•Management
Peephole view

21. H
ER
A
P
Regulatory
Bodies
P
P
P
P
P
P
P
P
P
P
LHU
GP Food
Industry
SOURCE OF INFORMATION

22. Type of StudiesType of Studies
• Cross-sectional ( public health records ,Cross-sectional ( public health records ,
other diseases registry , commercialother diseases registry , commercial
insurancesinsurances
• Retrospective chart review ( singleRetrospective chart review ( single
centre, multicentre)centre, multicentre)
77
Burden of Anaphylaxis
Epidemiology-II
Yu JE et al 2015 Clinic Rev Allerg ImmunolYu JE et al 2015 Clinic Rev Allerg Immunol

23. Type of StudiesType of Studies
• Population studies ( telephone surveys,Population studies ( telephone surveys,
patient’s questionnaire)patient’s questionnaire)
• Systematic reviews, meta-analysisSystematic reviews, meta-analysis
• Cohort, case controlCohort, case control
Yu JE et al 2015 Clinic Rev Allerg ImmunolYu JE et al 2015 Clinic Rev Allerg Immunol
Burden of Anaphylaxis
Epidemiology-II

24. Incidence of anaphylaxis
(per 100 000 person-years) in different
series from the general population (primary care
databases or DB of large health maintenance
organizations).
Clinical & Experimental Allergy,2014; 45 : 1027–1039

25. Incidence rates of anaphylaxis subtypes
according to age.
Clinical & Experimental Allergy 2014 , 45 : 1027–1039

26. Distribution of incidence rates of anaphylaxis
according to age group and sex.
Clinical & Experimental Allergy 2014, 45 : 1027–1039

27. Turner P et al JACI 2014

28. Turner et al., J Allergy Clin Immunol, Vol 135, n. 4, 956-963

29. Turner et al., J Allergy Clin Immunol, Vol 135, n. 4, 956-963

30. Prescriptions of
self-injectable epinephrine
Burden of Anaphylaxis
Epidemiology-II

31. Turner et al., J Allergy Clin Immunol, Vol 135, n. 4, 956-963

32. Recurrence Rates
Burden of Anaphylaxis
Epidemiology-II

33. Percentage of recurrence of anaphylaxis in
different series.
These percentages are cumulative incidence
(follow-up of 1.5 years to 25 years).
Clinical & Experimental Allergy 2014, 45 : 1027–1039

34. Fatal Anaphylaxis
Mortality registries
Hospital databases
Burden of Anaphylaxis
Epidemiology-II

35. Incidence of deaths from
anaphylaxis in international
series.
Clinical & Experimental Allergy 2014 , 45 : 1027–1039

36. Turner et al., J Allergy Clin Immunol, Vol 135, n. 4, 956-963

37. Turner et al., J Allergy Clin Immunol, Vol 135, n. 4, 956-963

38. Turner et al., J Allergy Clin Immunol, Vol 135, n. 4, 956-963

39. Turner et al., J Allergy Clin Immunol, Vol 135, n. 4, 956-963

40. J ALLERGY CLIN IMMUNOL VOLUME 136, NUMBER 2
Burden of Anaphylaxis
Epidemiology-II

41. Cause of anaphylaxis admission by age
group: 1998-1999 to 2011-2012. A,
Anaphylaxis admissions
by attributed cause and age group.
Mullins R et al JACI 2015

42. Cause of anaphylaxis admission by age
group: 1998-1999 to 2011-2012. B, Time
trends for food-associated anaphylaxis
as a proportion of total admissions by
age group.
Mullins R et al JACI 2015

43. Australian hospital morbidity data: 1998-
1999 to 2011-2012.
Age-specific admission rates to
Australian hospitals (per 100,000
population per year) for total anaphylaxis (A)
Mullins R et al JACI 2015

44. Australian hospital morbidity data: 1998-1999 to
2011-2012. Relative rates of admission (per
100,000 total
admissions) for food-related anaphylaxis
(B)
Mullins R et al JACI 2015

45. Australian hospital morbidity data: 1998-1999 to
2011-2012. Relative rates of admission (per
100,000 total
admissions) for asthma
Mullins R et al JACI 2015

46. Conclusions (i)
•The prevalence is overall increasing mainly
in the pediatric age
•Food anaphylaxis appears on the rise and
the leading cause
•Data vary hugely depending on the source
and type of study
Food Allergy and Anaphylaxis
the new epidemic of 21st
century

47. Conclusions (ii)
•Need of common agreement on diagnostic
criteria across health professionals and
community
•Need good quality data
•Need of real-time study population
capturing acute episodes
Food Allergy and Anaphylaxis
the new epidemic of 21st
century

48. • Conclusions (iii)
Educational efforts to improve networking
among stakeholders
Networks of Research Consortia for real
–time surveillance studies
AND
for developing biomarkers risk of
recurrences and fatalities
Food Allergy and Anaphylaxis
the new epidemic of 21st
century

49. EAACI Anaphylaxis Guidelines
Implementation
Next Steps
•Anaphylaxis Severity Score TF
•Anaphylaxis project for GPs and patients
•Research Consortia platforms
Food Allergy and Anaphylaxis
the new epidemic of 21st
century

51. Antonella Muraro
EAACI President
THANK YOU
Global One Health Forum 2015
Davos , October 5th

53. Thank you

54. Changes in age-specific anaphylaxis
admission rates
Mullins R JACI 2015

55. Burden of Food Anaphylaxis
Epidemiology -III
• Food-induced anaphylaxis is a leading cause
of outpatient anaphylaxis
• Food-related anaphylaxis increased 13% per
year in a 12-year period
• Food-induced anaphylaxis admissions have
increased in the UK (1990-2004) and in
Australia (1993-2003)
1
Webb Ann Allergy 2006, 2
Sampson Pediatrics 2003, 3
Novembre Pediatrics
1998, Bock JACI 2001, 5
Mehl Allergy 2005, 6
Poulos JACI 2007, 7
Gupta Thorax
2007 Decker WW, Campbell RL, Manivannan V, et al.
J Allergy Clin Immunol. 2008;122:1161–5.

56. Ordered logistic regression model: probability of
experiencing
a recurrence of anaphylaxis
Clinical & Experimental Allergy 2014, 45 : 1027–1039

57. Ordered logistic regression model: probability of
experiencing
a recurrence of anaphylaxis
Clinical & Experimental Allergy 2014, 45 : 1027–1039