GRF 2nd One Health Summit 2013: Presentation by Antonella Muraro, Food Allergy Centre Department of Woman and Child Health- University of Padua- Italy

1. GRF DAVOS
ONE HEALTH SUMMIT 2013
Davos , Nov.18th
EAACI
Food Allergy & Anaphylaxis
Initiative
Translating knowledge for best
practice in healthcare
Maria Antonella Muraro
Food Allergy Centre
Department of Woman and Child Health- University of Padua- Italy
muraro@pediatria.unipd.it

2. Disclosure
In relation to this presentation, I declare NO
conflicts of interest
A conflict of interest is any situation in which a speaker or immediate family members have interests, and those may cause a conflict with the
current presentation. Conflicts of interest do not preclude the delivery of the talk, but should be explicitly declared. These may include financial
interests (eg. owning stocks of a related company, having received honoraria, consultancy fees), research interests (research support by grants or
otherwise), organisational interests and gifts.

3. Food Allergy & Anaphylaxis
Clinical Practice Guidelines
Outline
WHAT IS FOOD ALLERGY ?
BURDEN OF FOOD ALLERGY
EAACI INITIATIVEOR transient v’s per
RESEARCH GAPS
NEXT STEPS
NEXT

4. FOOD ALLERGY
The Public Profile of Food Allergy
Food
Allergy
doesn’t
exist!!!
Food
Allergy is
the
cause of all
diseases!!!
JO Warner 2005 Pediatr Allergy Immunoll 16: 555
Miles S et al 2005 Allergy; 60:966-1003

5. FOOD ALLERGY
ADVERSE HEALTH EFFECT
ARISING FROM
A SPECIFIC IMMUNE RESPONSE
THAT OCCURS REPRODUCIBLY
ON EXPOSURE TO A GIVEN
FOOD
NIH-NIAID Food Allergy Guidelines JACI 2011
EAACI GUIDELINES ON FOOD ALLERGY 2013

6. ADVERSE REACTIONS TO FOODS
2 MAIN GROUPS ACCORDING TO THE
MECHANISMS
- IMMUNOLOGICAL (IgE/non IgE) =FOOD ALLERGY
- NON IMMUNOLOGICAL = INTOLERANCE
 enzimatic (lactose intolerance)
 toxic ( sgombroid syndrome)
 pharmacologic

7. FOOD ALLERGY
EAACI Task Force on Nomenclature
FOOD HYPERSENSITIVITY
NON ALLERGIC
HYPERSENSITIVITY
FOOD ALLERGY
IgE-MEDIATED
FOOD ALLERGY
NON IgE-MEDIATED
FOOD ALLERGY
Mixed
IgE & nonIgE
Allergy, 2001; 56: 813
J Allergy Clin Immunol 2004 113;832-6

8. FOOD ALLERGY
Clinical manifestations
SINGLE OR ASSOCIATED
MANIFESTATIONS
SKIN
GUT
RESPIRATORY TRACT
-
Urticaria/angioedema
Atopic Dermatitis
Gastroenteropathies
Rhinitis
Asthma
SYSTEMIC MANIFESTATIONS
Anaphylaxis

9. ANAPHYLAXIS
A GENERALIZED ALLERGIC
REACTION THAT IS RAPID IN
ONSET AND MAY PROGRESS TO
DEATH
2nd NIH-FAAN Consensus Meeting
Attended by allergists/immunologists, emergency department
physicians, anesthesiologists, primary care physicians, emergency medical
technicians, lay personnel and basic scientists representing over 15
NIH-FAAN Conference July 2005; Bethesda, MD USA
organizations
Sampson, Munoz-Furlong et al. JACI 2006
EAACI GUIDELINES ON ANAPHYLAXIS 2013

10. Which is the burden
of Food Allergy ?
Epidemiology
Management
Community

11. Burden of Food Allergy –A
Epidemiology
Perceived Prevalence
•Adverse reactions to foods: 35% of
parents 2 years old children
•38,4% school children in Germany
•11,6% to 12,4% UK teenagers
Eggesbo M et al Pediatr All Immunol 1999; 10: 122-132
Roehr CC et al Esp Allergy 2004;34:1534-41
Pereira B et al J Allergy Clin Immunol 2005; 116:884-92

12. Burden of Food Allergy –
A
Epidemiology
US NIAID
• Reported Prevalence
Prevalence among all age group 1%10% ( meta-analysis).
• True: 8% children, 3-4% adults
EUROPE
• Reported Prevalence
EuroPrevall Meta-analysis: overall
prevalence rate of self reported: 12% in
children and 13% in adults
• True : 6% children, 3% adults
Chafen JJ et al, JAMA 2010;303(18)
Rona R et al JACI 2007 ;120: 638-46

13. Food Allergy as an antecedent to Asthma
the Atopic March
EAACI Global Atlas on Asthma 2013

14. Food allergy and Asthma
increased risk for anaphylaxis

15. Food allergy and Pollen Allergic Rhinitis
Cross reactivity

16. Burden of Food Allergy –
A Epidemiology

Reported increase in severe allergic
reactions from food
– 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)
–
1Webb
in Australia (1993-2003)
Ann Allergy 2006, 2Sampson Pediatrics 2003, 3Novembre Pediatrics 1998,
4Bock JACI 2001, 5Mehl Allergy 2005, 6Poulos JACI 2007, 7Gupta Thorax 2007

17. 1 child out of 4 in Europe suffers
from food allergy
Food Allergy is the
leading
cause
of
anaphylaxis
in
children

18. TRENDS IN HOSPITAL ADMISSION RATES FOR
ANAPHYLAXIS BY AGE IN ENGLAND DURING THE
PERIOD 1990-2004
Variazione ICD
100
10
1
0-14
15-44
45+
0-14
7 folds
Gupta et al. Thorax 2006; 1:1-6

19. TRENDS IN HOSPITAL ADMISSION RATES FOR SELECTED
ALLERGY-RELATED DISORDERS IN THE FINANCIAL
YEARS 1993-94 TO 2004-05
Mullins R. MJA 2007; 186:622-25
EAACI Epidemiology of Food Allergy
Allergy 2013 , in press
120
100
Atopic dermatitis
Food anaphylaxis
Angioedema
Total Anaphylaxis
Urticaria
80
60
40
20
0
2004-05
2003-04
2002-03
2001-02
2000-01
1999-00
1998-99
1997-98
1996-97
1995-96
1994-95
1993-94
YEAR
From Australian national hospital morbidity data. Rate per million population

20. Burden of Food Allergy –B
Management
Birthday Parties
Science Projects
Art Projects
Food
Rewards & Incentives
is
Special Events
Everywhere
Holiday Parties
Field Trips
Bus

21. Burden of Food Allergy –B
Management
1.
Proper diagnosis of food allergy
2.
Management of the elimination
diet ( avoidance) &
Immunotherapy
3.
Management of severe reactions
4. Implementation at School and in
the Community

22. AVOIDANCE OF THE
ALLERGENS
LABEL READING
Patient must learn the scientific and technical
names for foods that appear on labels
• 10% of those avoiding milk recognized “milk
words”, 54% of those avoiding peanut, 22% of
those avoiding soy
EU Commission food allergens list as
updated 2011 –UPDATE 2012
 ISSUE of Precautionary labelling

23. PSYCOSOCIAL IMPACT
Food allergies impact
Decisions about Food shopping/ Dining out/
Vacation
Socializing/Relatives/ Schools and child care/
Travel
The entire family follows the restricted diet
There is no break from worry and stress
Reactions occur frequently in/outside the home in
spite of best efforts at avoidance
Sicherer SH et al. Ann Allergy Asthma Immunol 2001; 87: 461-4
Elberink JN. Curr Opin Allergy Clin Immunol 2006; 6: 298-302

24. LABELLING Suggested changes
of importance for food allergic
consumers
Approved 2012 EU Parliament



Member States should retain the right, depending on
local practical conditions and circumstances, to lay
down rules in respect of the provision of information
concerning non-prepacked foods.
Although in such cases the consumer demand for
other information is limited, information on potential
allergens is considered very important.
Evidence suggests that most food allergy incidents
can be traced back to non-prepacked food. Therefore
such information should always be provided to the
consumer.

25. FOOD ALLERGY BURDEN
Impact Social Identity
Global Health
Perception
Social
Burden
Diagnosis
&
treatment
Disease

26. Food Allergy and Anaphylaxis Public
Campaign
June 2012 – June 2014
• PUBLIC DECLARATION ON
FOOD ALLERGY &
ANAPHYLAXIS at the EU
Parliament
• FOOD ALLERGY &
ANAPHYLAXIS GUIDELINES
• INTERNATIONAL MINIMUM
STANDARDS FOR THE
ALLERGIC CHILD AT SCHOOL
• FOOD ALLERGY & ANAPHYLAXIS
MEETING – 3 rd FAAM
• Dublin October 7-9,2014
26

27. PUBLIC DECLARATION
www.eaaci.net
27

28. PUBLIC DECLARATION
KEY ASPECTS
Education campaigning on the disease: risks and
treatment options
• Increased access needed to adrenaline autoinjectors to save lives focusing on school
• Clear food labelling policies that will help
patients better manage their condition
• Availability to research funds to find a cure for
food allergy and anaphylaxis

29. EAACI GUIDELINES
AIM
Development of comprehensive guidelines on
FOOD ALLERGY & ANAPHYLAXIS ,
not only for diagnosis
embracing all the different stake -holders
ie. Clinicians, Immunologists, Epidemiologist, Food
Technologists, Food Industry Research Dept.
Representatives, Regulatory Bodies, Allied Health
Representatives, Patient Organisations

30. work place
School
H
P
ER
leisure
time
A
LHU
GP
other
networks

31. GUIDELINES
Research Gaps (i)
Mechanisms of oral tolerance
Possible effects of modified food allergens for
tolerance
The effect of supplementation with probiotic
strains on food allergy
Timing of introduction of the allergenic food in
the infant
Biomarkers to identify patients at risk of severe
reactions

32. GUIDELINES
Research Gaps (ii)
Immunotherapy for food allergy
Whether biologicals in food allergen- specific
immunotherapy
(a) enhance the effectiveness of treatment
and/or
(b) reduce the risks of severe adverse
reactions?
Food allergen specific immunotherapy:
(a) effectiveness; (b) risks; (c) cost
effectiveness and (d) long-term benefits

33. Next steps -Guidelines
PASSIVE
THE PLAN
DISSEMINATION (i)
INCLUDES
Translation in national
languages
Distribution across
ACTIVE DISSEMINATION (ii)
Europe
Inclusion of Local
Conferences
Professionals(20 countries
Campaigns
represented)
EDUCATION
Patient’s organizations
mediated intervention

34. FOOD ALLERGY & ANAPHYLAXIS
PLATFORM
Government Specific
Policies for Food Allergy
Regulatory Bodies &
Patient Organisations
Food Industry Health
& Patient
Professionals
Organisations
Patient

35. Food Allergy & Anaphylaxis
EAACI _ Translating knowledge
for best practice in healthcare
THANK YOU !

38. Centres of Excellence
Centres of Excellence
Centres of Excellence
Centres of Excellence
THIS WILL PROMOTE
Changes in
public
health
policies
creating
vertical and
horizontal
networks
Primary Care Networks
Primary Care Networks Primary Care Networks
Primary Care Networks

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

40. WHY do we need
Guidelines?

Education needs at Primary Care level

Difficulty to recognise the symptoms of food allergy
and anaphylaxis

Lack of standardised treatment throughout Europe

Need to raise awareness at a political level

41. P
P
H
P
A
P
P
P
P
P
ER
Regulatory
Bodies LHU
GP Food
P
P
Industry
P

42. WHY ? (iii)
INDIVIDUAL
& LOCAL FACTORS
Different NHSs organization
Different health needs
Different habits
WHERE
i.E .
WHO
Different guidelines for each stakeholder?

43. WHY ? (iv)
5 MAJOR PURPOSES
1. Assisting clinical decision making by
patients and practitioners
2. educating individual or groups
3. assessing and assuring the quality of
care
4. guiding allocation of resources for health
care;
5. reducing the risk of legal liability for
negligent care

44. WHY ? (v)
HARMONIZE PRACTICE
FROM «CURE»
SHIFTING
TO CARE

45. CARING
CARING
CARING
CARING
CARING
CARING
CARING
CARING
CARING
CARING
CARING
CARING
CARING
CARING
CARING
CARING
CARING
CARING
CARING
CARING
CARING
CARING
CARING
CARING
CARING
means
SHARING
SHARING
SHARING
SHARING
SHARING
SHARING
SHARING
SHARING
SHARING
SHARING
SHARING
SHARING
SHARING
SHARING
SHARING
SHARING
SHARING
SHARING
SHARING
SHARING
SHARING
SHARING
SHARING
SHARING
SHARING

46. WHO are the
Guidelines aimed at?
Allergist
Food Industry Research
Departments
Immunologist
Patient Organisations
Epidemiologist
Emergency Dept
Physician
Food
Technologist
Paediatrician
Regulatory
Bodies
Politicians

47. Structure of the Project
 Steering Committee
 8 Working Groups
 Methodologist’s Group lead by Aziz Shiekh
 Experts Group for Peer –Review
 Extended Panel: Representatives of Scientific
Societies
involved
gastroenterology,
in
the
dermatology,
field
(i.e.
emergency
physicians)
 Representatives from Patient’s Organizations

48. 2013 April
Guideline chapters sent
to Peer Review for
comments
2012 SeptemberDecember
literature research for
the systematic reviews
2011Sept- January
2012 Zurich
workshop with all the
Guidelines members
with AGREE
methodologist
1
2013 February
Face-to-face meeting
3
2
2012 JuneSeptember
the questions for the
systematic Review
2013 May
collection of comments
and review of
guidelines chapters
7
5
4
6
8
9
2013 February–April
1st draft of the
Guidelines chapters
2012 December
workshop and evaluation
of the systematic
reviews- refining of the
systematic reviews
2013 June: Publication
on EAAI Website

49. Food Allergy Clinical Practice Guidelines
Prevention, Diagnosis &
Management, Anaphylaxis, Co
mmunity, Quality of Life
7 systematic review
protocols published in CTA
7 systematic review ready
for submission
5 guidelines on the EAACI
website for review

50. http://www.eaaci.org/resources/foodallergy-and-anapyhlaxis-campaign.html
1. FOOD ALLERGY DIAGNOSIS AND
MANAGEMENT
2. FOOD ALLERGY QUALITY OF LIFE
3. FOOD ALLERGY IN THE COMMUNITY
4. FOOD MANUFACTURERS ISSUES
5. PREVENTION OF FOOD ALLERGY
6. ANAPHYLAXIS
Chapters 3 and 4 on line from Oct.2013

51. EAACI WEBSITE
http://www.eaaci.org/resources/foodallergy-and-anapyhlaxis-campaign.html

52. GUIDELINES Systematic reviews
QUESTIONS (i)
DIAGNOSIS & MANAGEMENT
What is the epidemiology of FA in Europe?
What is the diagnostic accuracy of tests in
supporting the clinical diagnosis?
What the effectiveness of pharmacological / non –
pharmacological interventions in acute and long
term management ?
http://www.eaaci.org/resources/food-allergyand-anapyhlaxis-campaign.html

53. GUIDELINES Systematic reviews
QUESTIONS (ii)
Prevention
What is the effectiveness of
approaches for the primary
prevention of food allergy?
http://www.eaaci.org/resources/food-allergyand-anapyhlaxis-campaign.html

54. GUIDELINES Systematic reviews
QUESTIONS (ii)
Quality of life
Which disease-specific , validated
instruments can be employed to
enable assessment of the impact of
,and investigations and
interventions, for food allergy on
HRQL?
http://www.eaaci.org/resources/food-allergyand-anapyhlaxis-campaign.html

55. GUIDELINES Systematic reviews
QUESTIONS (iii)
ANAPHYLAXIS
What is the epidemiology of Anaphylaxis in Europe?
What is the effectiveness of interventions for the
acute management of anaphylaxis?
What the effectiveness of interventions for the long
term management of those at high risk of further
episodes of aanaphylaxis ?
http://www.eaaci.org/resources/food-allergyand-anapyhlaxis-campaign.html

56. GUIDELINES
Recommendations
KEY MESSAGES
MULTIDISCIPLINARY &
MULTIFACETED APPROACH
DIETARY AVOIDANCE
PROACTIVE TREATMENT
EDUCATION
CENTRES OF EXCELLENCE &
NETWORKING

57. DIAGNOSIS
OF FOOD ALLERGY
1
Recommendation (Boxes)
•
To ensure correct avoidance of the
correct allergens
To ensure timely recognition of
subjects at high risk of anaphylaxis
To avoid unneccessary diets
To avoid delay in proper diagnosis of
a different disease

58. Primary Care Networks
Centres of Excellence
Centres of Excellence
Centres of Excellence
Centres of Excellence
THIS WILL PROMOTE
Primary Care Networks
Changes in
public health
policies in order
to create
vertical and
horizontal
networks
Primary Care Networks
Primary Care Networks

59. 2013 April
Guideline chapters sent
to Peer Review for
comments
2012 SeptemberDecember
literature research for
the systematic reviews
2011Sept- January
2012 Zurich
workshop with all the
Guidelines members
with AGREE
methodologist
1
2013 February
Face-to-face meeting
3
2
2012 JuneSeptember
the questions for the
systematic Review
2013 May
collection of comments
and review of
guidelines chapters
4
I
7
5
6
8
9
2013 February–April
1st draft of the
Guidelines chapters
2012 December
workshop and evaluation
of the systematic
reviews- refining of the
systematic reviews
JUNE 23
JULY 10
PUBLIC
COMMENT
2013 June: Publication
on EAAI Website

61. Thank you!!
Antonella Muraro
Graham Roberts
Thomas Werfel
Karin Hoffman-Sommergruber
Susanne Halken
Vicky Cardona
Nikos Papadopoulos
Phillippe Eigenmann
Ronald Van Ree
Berber Vlieg–Boerstra
Pascal Demoly
Anthony Dubois
Lars Poulsen
Carsten Bindslev Jensen
Gideon Lack
Andrew Clark
Bodo Niggeman
Philippe Eigenmann
Margitta Worm
Montserrat Fernandez Rivas
Holger Mosbech
Knut Brockow
Vicky Cardona
Pascal Demoly
Beatrice Bilo
Frans Timmermans
Laurie Harada
Abdel Bellou
Aziz Sheikh
Quiza Zolkipli - Junior
Audrey DunnGalvin
Franziska Reuff
Alexandra Figueira Santos
Berber Vlieg–Boerstra
Valérie Verhasselt
Liam o Mahony
Anthony Dubois
Andrey DunnGalvin
Jonathan Hourihane
Bertine Flokstra-de Blok
Jacquelien Saleh- Langenberg
Breda Flood
Lynne Regent
Nicolette De Jong
Kirsten Beyer
Carina Venter
Andrea von Berg
Syed Hasan Arshad
Mikael Kuitunen
Susan Prescott
Gideon Lack
Susanne Lau
Nicolette De Jong
Yanne Boloh
Harald Renz
Ulrich Wahn
Arne Host
Bright Nwaru
Sarah Salvilla
Sangeeta Dhami
Karla Soares-Weiser
Sukhmeet panesar
Debra de Silva
Lennart Hickstein
Cezmi Akdis

62. School
work
place
H
P
ER
leisure
time
A
LHU
GP
other
networks