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Chomyn A, Chan ES, Yeung J, Cameron S, Chua GT, Vander Leek TK, Williams BA, Soller L, Abrams EM, Mak R, Wong T. Safety and effectiveness of the Canadian food ladders for children with IgE-mediated food allergies to cow's milk and/or egg. Allergy Asthma Clin Immunol 2023; 19:94. [PMID: 37932826 PMCID: PMC10629013 DOI: 10.1186/s13223-023-00847-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 10/05/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND Food ladders are tools designed to facilitate home-based dietary advancement in children with food allergies through stepwise exposures to increasingly allergenic forms of milk and egg. Several studies have now documented safety and efficacy of food ladders. In 2021, we published a Canadian adaptation of the previously existing milk and egg ladders originating in Europe using foods more readily available/consumed in Canada. Our study adds to the growing body of evidence supporting food ladder use and provides safety and effectiveness data for our Canadian adaptation of the milk and egg ladders. METHODS Surveys were distributed to families of children using the Canadian Milk Ladder and/or the Canadian Egg Ladder at baseline, with follow up surveys at 3 months, 6 months, and 12 months. Data were analyzed using REDCap and descriptive and inferential statistics are presented. RESULTS One hundred and nine participants were started on milk/egg ladders between September 2020 and June 2022. 53 participants responded to follow up surveys. Only 2 of 53 (3.8%) participants reported receiving epinephrine during the study. Severe grade 4 reactions (defined according to the modified World Allergy Organization grading system) were not reported by any participants. Minor cutaneous adverse reactions were common, with about 71% (n = 10/14) of respondents reporting cutaneous adverse reactions by 1 year of food ladder use. An increasing proportion of participants could tolerate most foods from steps 2-4 foods after 3, 6, and 12 months of the food ladder compared to baseline. CONCLUSION The Canadian food ladders are safe tools for children with cow's milk and/or egg allergies, and participants tolerated a larger range of foods with food ladder use compared to baseline.
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Affiliation(s)
- Alanna Chomyn
- Department of Pediatrics, Division of Clinical Immunology & Allergy, University of British Columbia, BC Children's Hospital, Room 1C31B 4480 Oak Street, V5Z 4H4, Vancouver, BC, Canada.
| | - Edmond S Chan
- Department of Pediatrics, Division of Clinical Immunology & Allergy, University of British Columbia, BC Children's Hospital, Room 1C31B 4480 Oak Street, V5Z 4H4, Vancouver, BC, Canada
| | - Joanne Yeung
- Department of Pediatrics, Division of Clinical Immunology & Allergy, University of British Columbia, BC Children's Hospital, Room 1C31B 4480 Oak Street, V5Z 4H4, Vancouver, BC, Canada
| | - Scott Cameron
- Department of Pediatrics, Division of Clinical Immunology & Allergy, University of British Columbia, BC Children's Hospital, Room 1C31B 4480 Oak Street, V5Z 4H4, Vancouver, BC, Canada
| | - Gilbert T Chua
- Department of Paediatrics and Adolescent Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Timothy K Vander Leek
- Pediatric Allergy & Asthma, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Brock A Williams
- Department of Pediatrics, Division of Clinical Immunology & Allergy, University of British Columbia, BC Children's Hospital, Room 1C31B 4480 Oak Street, V5Z 4H4, Vancouver, BC, Canada
- Food, Nutrition, and Health, Faculty of Land and Food Systems, University of British Columbia, Vancouver, BC, Canada
| | - Lianne Soller
- Department of Pediatrics, Division of Clinical Immunology & Allergy, University of British Columbia, BC Children's Hospital, Room 1C31B 4480 Oak Street, V5Z 4H4, Vancouver, BC, Canada
| | - Elissa M Abrams
- Department of Pediatrics, Division of Clinical Immunology & Allergy, University of British Columbia, BC Children's Hospital, Room 1C31B 4480 Oak Street, V5Z 4H4, Vancouver, BC, Canada
- Department of Pediatrics and Child Health, Section of Allergy and Immunology, University of Manitoba, Winnipeg, Canada
| | - Raymond Mak
- Department of Pediatrics, Division of Clinical Immunology & Allergy, University of British Columbia, BC Children's Hospital, Room 1C31B 4480 Oak Street, V5Z 4H4, Vancouver, BC, Canada
| | - Tiffany Wong
- Department of Pediatrics, Division of Clinical Immunology & Allergy, University of British Columbia, BC Children's Hospital, Room 1C31B 4480 Oak Street, V5Z 4H4, Vancouver, BC, Canada.
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Chua GT, Greenhawt M, Shaker M, Soller L, Abrams EM, Cameron SB, Cook VE, Erdle SC, Fleischer DM, Mak R, Vander Leek TK, Chan ES. Real-world data are critical for the implementation of preschool food allergen immunotherapy. J Allergy Clin Immunol Pract 2023; 11:2624-2625. [PMID: 37558366 DOI: 10.1016/j.jaip.2023.05.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 05/23/2023] [Indexed: 08/11/2023]
Affiliation(s)
- Gilbert T Chua
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China; Allergy Centre, Union Hospital, Hong Kong SAR, China.
| | - Matthew Greenhawt
- Section of Allergy and Clinical Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Marcus Shaker
- Section of Allergy and Clinical Immunology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Lianne Soller
- British Columbia Children's Hospital Research Institute, Vancouver, BC, Canada; Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Elissa M Abrams
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada; Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, Man, Canada
| | - Scott B Cameron
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada; Community Allergy Clinic, Victoria, BC, Canada
| | - Victoria E Cook
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada; Community Allergy Clinic, Victoria, BC, Canada
| | - Stephanie C Erdle
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - David M Fleischer
- Section of Allergy and Clinical Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Raymond Mak
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Timothy K Vander Leek
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, Alta, Canada
| | - Edmond S Chan
- British Columbia Children's Hospital Research Institute, Vancouver, BC, Canada; Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
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Greenhawt M, Dribin TE, Abrams EM, Shaker M, Chu DK, Golden DBK, Akin C, Anagnostou A, ALMuhizi F, Alqurashi W, Arkwright P, Baldwin JL, Banerji A, Bégin P, Ben-Shoshan M, Bernstein J, Bingemann TA, Bindslev-Jensen C, Blumenthal K, Byrne A, Cahill J, Cameron S, Campbell D, Campbell R, Cavender M, Chan ES, Chinthrajah S, Comberiati P, Eastman JJ, Ellis AK, Fleischer DM, Fox A, Frischmeyer-Guerrerio PA, Gagnon R, Garvey LH, Grayson MH, Isabwe GAC, Hartog N, Hendron D, Horner CC, Hourihane JO, Iglesia E, Kan M, Kaplan B, Katelaris CH, Kim H, Kelso JM, Khan DA, Lang D, Ledford D, Levin M, Lieberman JA, Loh R, Mack DP, Mazer B, Mody K, Mosnaim G, Munblit D, Mustafa SS, Nanda A, Nathan R, Oppenheimer J, Otani IM, Park M, Pawankar R, Perrett KP, Peter J, Phillips EJ, Picard M, Pitlick M, Ramsey A, Rasmussen TH, Rathkopf MM, Reddy H, Robertson K, Rodriguez Del Rio P, Sample S, Sheshadri A, Sheik J, Sindher SB, Spergel JM, Stone CA, Stukus D, Tang MLK, Tracy JM, Turner PJ, Vander Leek TK, Wallace DV, Wang J, Wasserman S, Weldon D, Wolfson AR, Worm M, Yacoub MR. Updated guidance regarding the risk of allergic reactions to COVID-19 vaccines and recommended evaluation and management: A GRADE assessment and international consensus approach. J Allergy Clin Immunol 2023; 152:309-325. [PMID: 37295474 PMCID: PMC10247143 DOI: 10.1016/j.jaci.2023.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/08/2023] [Accepted: 05/11/2023] [Indexed: 06/12/2023]
Abstract
This guidance updates 2021 GRADE (Grading of Recommendations Assessment, Development and Evaluation) recommendations regarding immediate allergic reactions following coronavirus disease 2019 (COVID-19) vaccines and addresses revaccinating individuals with first-dose allergic reactions and allergy testing to determine revaccination outcomes. Recent meta-analyses assessed the incidence of severe allergic reactions to initial COVID-19 vaccination, risk of mRNA-COVID-19 revaccination after an initial reaction, and diagnostic accuracy of COVID-19 vaccine and vaccine excipient testing in predicting reactions. GRADE methods informed rating the certainty of evidence and strength of recommendations. A modified Delphi panel consisting of experts in allergy, anaphylaxis, vaccinology, infectious diseases, emergency medicine, and primary care from Australia, Canada, Europe, Japan, South Africa, the United Kingdom, and the United States formed the recommendations. We recommend vaccination for persons without COVID-19 vaccine excipient allergy and revaccination after a prior immediate allergic reaction. We suggest against >15-minute postvaccination observation. We recommend against mRNA vaccine or excipient skin testing to predict outcomes. We suggest revaccination of persons with an immediate allergic reaction to the mRNA vaccine or excipients be performed by a person with vaccine allergy expertise in a properly equipped setting. We suggest against premedication, split-dosing, or special precautions because of a comorbid allergic history.
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Affiliation(s)
- Matthew Greenhawt
- Section of Allergy and Clinical Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo.
| | - Timothy E Dribin
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Elissa M Abrams
- Department of Pediatrics and Child Health, Section of Allergy and Immunology, The University of Manitoba, Winnipeg, Canada
| | - Marcus Shaker
- Dartmouth-Hitchcock Medical Center, Section of Allergy and Immunology, Lebanon, NH; Dartmouth Geisel School of Medicine, Hanover, NH
| | - Derek K Chu
- Faculty of Medicine, and the Department of McMaster University, Hamilton, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada; The Research Institute of St. Joe's Hamilton, Hamilton, Canada; Evidence in Allergy Group, McMaster University Medical Centre, Hamilton, Canada
| | - David B K Golden
- Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, Bethesda
| | - Cem Akin
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, University of Michigan School, Ann Arbor, Mich
| | - Akterini Anagnostou
- Section of Immunology, Allergy, and Retrovirology, Department of Pediatrics, Baylor College of Medicine, Houston, Tex; Section of Immunology, Allergy and Retrovirology, Department of Pediatrics, Texas Children's Hospital, Houston, Tex
| | - Faisal ALMuhizi
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, Security Forces Hospital Program, Riyadh, Arabia
| | - Waleed Alqurashi
- Department of Pediatrics and Emergency Medicine, University of Ottawa, Ottawa, Canada
| | - Peter Arkwright
- Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, United Kingdom
| | - James L Baldwin
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, University of Michigan School, Ann Arbor, Mich
| | - Aleena Banerji
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Philippe Bégin
- Centre Hospital Universitaire Sainte-Justine, Montreal, Canada
| | - Moshe Ben-Shoshan
- Division of Allergy, Immunology, and Dermatology, Department of Pediatrics, McGill University Health Center-Montreal Children's Hospital, Montreal, Canada
| | - Jonathan Bernstein
- Division of Immunology, Department of Internal Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Theresa A Bingemann
- Division of Allergy, Immunology, and Rheumatology, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Carsten Bindslev-Jensen
- Department of Dermatology and Allergy Center, Odense Research Centre for Anaphylaxis, Odense, Denmark
| | - Kim Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Aideen Byrne
- Department of Paediatrics, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Julia Cahill
- University of Alberta, Faculty of Medicine, Calgary, Canada
| | - Scott Cameron
- Allergy Victoria, Victoria, British Columbia, Canada
| | | | - Ronna Campbell
- Department of Emergency Medicine, Mayo Clinic, Rochester
| | | | - Edmond S Chan
- Division of Allergy and Immunology, BC Children's Hospital, The University of British Columbia, Vancouver, Canada
| | - Sharon Chinthrajah
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, Stanford University School of Medicine, Palo Alto, Calif; Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, Calif; Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Palo Alto, Calif
| | - Pasquale Comberiati
- Department of Clinical and Experimental Medicine, Section of Pediatrics, University of Pisa, Pisa, Italy
| | - Jacqueline J Eastman
- Corewell Health Allergy and Immunology, Grand Rapids, Mich; Michigan State University College of Human Medicine, Grand Rapids, Mich
| | - Anne K Ellis
- Division of Allergy and Immunology, Department of Medicine, Queen's University, Kingston, Canada
| | - David M Fleischer
- Section of Allergy and Clinical Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Adam Fox
- Guys's and St Tomas's Hospital National Health Service Foundation Trust, London, Mass
| | - Pamela A Frischmeyer-Guerrerio
- Laboratory of Allergic Diseases, Food Allergy Research Section, National Institutes of Allergy and Infectious Diseases, the National Institutes of Health, Bethesda, Md
| | - Remi Gagnon
- Clinique Spécialisée en Allergie de la Capitale, Québec, Canada
| | - Lene H Garvey
- Allergy Clinic, Department of Dermatology and Allergy, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Mitchell H Grayson
- Division of Allergy and Immunology, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Ghislaine Annie Clarisse Isabwe
- Division of Allergy, Immunology, and Dermatology, Department of Pediatrics, McGill University Health Center-Montreal Children's Hospital, Montreal, Canada
| | - Nicholas Hartog
- Corewell Health Allergy and Immunology, Grand Rapids, Mich; Michigan State University College of Human Medicine, Grand Rapids, Mich
| | - David Hendron
- Access Health Care Physicians LLC, New Port Richey, Fla
| | - Caroline C Horner
- Division of Allergy and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St Louis, Mo
| | | | - Edward Iglesia
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | | | - Blanka Kaplan
- Division of Allergy and Immunology, Northwell Health, New York, NY
| | | | - Harold Kim
- Faculty of Medicine, and the Department of McMaster University, Hamilton, Canada; Division of Clinical Immunology and Allergy, Department of Medicine, Western University, St Joseph's Health Care, London (Canada), Mass
| | - John M Kelso
- Division of Allergy, Asthma, and Immunology, Scripps Clinic, San Diego, Calif
| | - David A Khan
- Division of Allergy and Immunology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Tex
| | - David Lang
- Department of Allergy and Clinical Immunology, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Dennis Ledford
- Division of Allergy and Immunology, Department of Medicine, University of South Florida Morsani College of Medicine, Tampa, Fla
| | - Michael Levin
- Division of Paediatric Allergology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Jay A Lieberman
- Division of Allergy and Immunology, The University of Tennessee, Memphis, Tenn
| | - Richard Loh
- Immunology Department, Perth Children's Hospital, Perth, Australia
| | - Douglas P Mack
- Department of Pediatrics, McMaster University, Hamilton, Canada; Halton Pediatric Allergy, Burlington, Canada
| | - Bruce Mazer
- Division of Allergy, Immunology, and Dermatology, Department of Pediatrics, McGill University Health Center-Montreal Children's Hospital, Montreal, Canada
| | - Ketan Mody
- Elite Sports Medicine Institute Ltd, Westmont, Ill
| | - Gisele Mosnaim
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, NorthShore University Health System, Evanston, Ill
| | - Daniel Munblit
- Inflammation, Repair and Development Section, National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, Mass
| | - S Shahzad Mustafa
- Rochester Regional Health, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Anil Nanda
- Division of Allergy and Immunology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Tex; Asthma and Allergy Center, Lewisville and Flower Mound, Dallas, Tex
| | | | - John Oppenheimer
- University of Medicine and Dentistry of New Jersey, Rutgers University School of Medicine, New Brunswick, NJ
| | - Iris M Otani
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California San Francisco, San Francisco, Calif
| | - Miguel Park
- Division of Allergic Diseases, Mayo Clinic, Rochester
| | - Ruby Pawankar
- Department of Pediatrics, Nippon Medical School, Tokyo, Japan
| | - Kirsten P Perrett
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, NorthShore University Health System, Evanston, Ill; Population Allergy Group and the Centre for Food and Allergy Research, Murdoch Children's Research Institute, University of Melbourne, University of Melbourne, Royal Children's Hospital, Parkville, Australia; Department of Paediatrics, University of Melbourne, Parkville, Australia
| | - Jonny Peter
- Division of Allergy and Clinical Immunology, Department of Medicine, University of Cape Town and the Allergy and Immunology Unit, University of Cape Town Lung Institute, Cape Town
| | - Elizabeth J Phillips
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn; Center for Drug Safety and Immunology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Matthieu Picard
- Hôspital Maisonneuve-Rosemont, Université de Montréal, Montreal, Canada
| | | | - Allison Ramsey
- Rochester Regional Health, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Trine Holm Rasmussen
- Department of Dermatology and Allergy Center, Odense Research Centre for Anaphylaxis, Odense, Denmark
| | | | - Hari Reddy
- Allergy, Asthma and Immunology Center of Alaska, Anchorage, Alaska; Department of Pediatrics, University of Washington School of Medicine, Seattle, Wash
| | - Kara Robertson
- Division of Clinical Immunology and Allergy, St Joseph's Health Care, London (Canada), Mass; Schulich School of Medicine and Dentistry, Western University, St Joseph's Health Care, London (Canada), Mass
| | | | | | - Ajay Sheshadri
- Department of Pulmonary Medicine, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Javed Sheik
- Kaiser Permanente Los Angeles Medical Center, Los Angeles, Calif
| | - Sayantani B Sindher
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, Stanford University School of Medicine, Palo Alto, Calif; Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, Calif; Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Palo Alto, Calif
| | - Jonathan M Spergel
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pa; Department of Pediatrics, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pa
| | - Cosby A Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - David Stukus
- Division of Allergy and Immunology, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Mimi L K Tang
- Department of Allergy Immunology, Murdoch Children's Research Institute, Melbourne, Parkville, Australia; Department of Allergy and Immunology, Royal Children's Hospital, Parkville, Australia; Department of Paediatrics, University of Melbourne, Parkville, Australia
| | - James M Tracy
- Allergy, Asthma, and Immunology Associates PC, Omaha, Neb; Department of Pediatrics, University of Nebraska School of Medicine, Omaha, Neb
| | - Paul J Turner
- Imperial College Healthcare National Health Service Trust, London, Mass; Royal Brompton and Harefield National Health Service Foundation Trust, London, Mass
| | - Timothy K Vander Leek
- Pediatric Allergy and Immunology, Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, Canada
| | - Dana V Wallace
- Nova Southeastern University College of Allopathic Medicine, Fort Lauderdale, Fla
| | - Julie Wang
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY; Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Susan Wasserman
- Division of Clinical Immunology and Allergy, Department of Medicine, McMaster University, Hamilton, Canada
| | - David Weldon
- Baylor Scott and White Clinic, College Station, Tex
| | - Anna R Wolfson
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Margitta Worm
- Division of Allergology and Immunology, Department of Dermatology, Venereology and Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Mona-Rita Yacoub
- Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Hospital, Unit of Immunology, Rheumatology, Allergy and Rare Diseases, Segrate, Milan, Italy
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Chua GT, Greenhawt M, Shaker M, Soller L, Abrams EM, Cameron SB, Cook VE, Erdle SC, Fleischer DM, Mak R, Vander Leek TK, Chan ES. Reply to "Peanut allergy prevention: A mother's perspective". J Allergy Clin Immunol Pract 2023; 11:1574-1575. [PMID: 37150549 DOI: 10.1016/j.jaip.2023.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 02/07/2023] [Indexed: 05/09/2023]
Affiliation(s)
- Gilbert T Chua
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, the University of Hong Kong, Hong Kong SAR, China; Allergy Centre, Union Hospital, Hong Kong SAR, China.
| | - Matthew Greenhawt
- Section of Allergy and Clinical Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Marcus Shaker
- Section of Allergy and Clinical Immunology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Lianne Soller
- British Columbia Children's Hospital Research Institute, Vancouver, BC, Canada; Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Elissa M Abrams
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada; Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, MB, Canada
| | - Scott B Cameron
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada; Community Allergy Clinic, Victoria, BC, Canada
| | - Victoria E Cook
- British Columbia Children's Hospital Research Institute, Vancouver, BC, Canada; Community Allergy Clinic, Victoria, BC, Canada
| | - Stephanie C Erdle
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - David M Fleischer
- Section of Allergy and Clinical Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Raymond Mak
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Timothy K Vander Leek
- Pediatric Allergy and Immunology, Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada
| | - Edmond S Chan
- British Columbia Children's Hospital Research Institute, Vancouver, BC, Canada; Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
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Chua GT, Greenhawt M, Shaker M, Soller L, Abrams EM, Cameron SB, Cook VE, Erdle SC, Fleischer DM, Mak R, Vander Leek TK, Chan ES. The Case for Prompt Salvage Infant Peanut Oral Immunotherapy Following Failed Primary Prevention. J Allergy Clin Immunol Pract 2022; 10:2561-2569. [PMID: 35752433 DOI: 10.1016/j.jaip.2022.05.040] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 05/12/2022] [Accepted: 05/25/2022] [Indexed: 05/15/2023]
Abstract
Recent guideline recommendations have shifted from recommending prolonged avoidance of allergenic foods in the first 3 years of life to a primary prevention approach involving the deliberate early introduction to infants at risk of developing food allergy. Despite this, some infants, especially those with severe eczema who are at highest risk for developing peanut allergy, fail to receive the preventative benefits of early peanut introduction due to hesitancy and other factors. Difficulty adhering to regular ingestion after introduction further reduces the effectiveness of primary prevention. As emerging real-world evidence has demonstrated that performing peanut oral immunotherapy (OIT) among infants is effective and safe, peanut OIT could be a treatment option for infants with peanut allergy. This review discusses the benefits, risks, and barriers to offering peanut OIT to infants who fail primary prevention strategies. We propose the novel concept that infants with peanut allergy be offered peanut OIT as soon as possible after failed peanut introduction through a shared decision-making process with the family, where there is a preference for active management rather than avoidance.
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Affiliation(s)
- Gilbert T Chua
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, the University of Hong Kong, Hong Kong SAR, China; Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong SAR, China; Department of Paediatrics, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China.
| | - Matthew Greenhawt
- Section of Allergy and Clinical Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Marcus Shaker
- Dartmouth-Hitchcock Medical Center, Section of Allergy and Clinical Immunology, New Hampshire, Lebanon, NH
| | - Lianne Soller
- British Columbia Children's Hospital Research Institute, Vancouver, BC, Canada; Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Elissa M Abrams
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada; Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, MB, Canada
| | - Scott B Cameron
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada; Community Allergy Clinic, Victoria, BC, Canada
| | - Victoria E Cook
- British Columbia Children's Hospital Research Institute, Vancouver, BC, Canada; Community Allergy Clinic, Victoria, BC, Canada
| | - Stephanie C Erdle
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - David M Fleischer
- Section of Allergy and Clinical Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Raymond Mak
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | | | - Edmond S Chan
- British Columbia Children's Hospital Research Institute, Vancouver, BC, Canada; Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
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Chua GT, Chan ES, Yeung J, Cameron SB, Soller L, Williams BA, Chomyn A, Vander Leek TK, Abrams EM, Mak R, Wong T. Patient selection for milk and egg ladders using a food ladder safety checklist. Allergy Asthma Clin Immunol 2022; 18:51. [PMID: 35692059 PMCID: PMC9188637 DOI: 10.1186/s13223-022-00696-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 05/30/2022] [Indexed: 11/29/2022] Open
Abstract
A food ladder is a form of home-based dietary advancement therapy that gradually increases exposure to an allergenic food through the gradual introduction of egg or milk containing food with increasing quantity and allergenicity from extensively heated forms, such as baked goods, to less processed products. While widely considered safe, the food ladder is not risk-free and most of the egg and milk ladder studies only included preschoolers with mild egg and milk allergies, and with no or well-controlled asthma. We propose a Food Ladder Safety Checklist to assist with patient selection using “4 A's” based on available evidence for food ladders, including Age, active or poorly controlled Asthma, history of Anaphylaxis, and Adherence.
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Affiliation(s)
- Gilbert T Chua
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, 1/F, New Clinical Building, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong,, SAR, China. .,Department of Paediatrics and Adolescent Medicine, The Hong Kong Children's Hospital, Hong Kong, SAR, China. .,Department of Paediatrics, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China.
| | - Edmond S Chan
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada.,British Columbia Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Joanne Yeung
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Scott B Cameron
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada.,Community Allergy Clinic, Victoria, BC, Canada
| | - Lianne Soller
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada.,British Columbia Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Brock A Williams
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada.,Food, Nutrition, and Health, Faculty of Land and Food Systems, University of British Columbia, Vancouver, BC, Canada
| | - Alanna Chomyn
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Timothy K Vander Leek
- Department of Pediatrics, Pediatric Allergy & Asthma, University of Alberta, Edmonton, AB, Canada
| | - Elissa M Abrams
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada.,Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, Canada
| | - Raymond Mak
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Tiffany Wong
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada.,British Columbia Children's Hospital Research Institute, Vancouver, BC, Canada
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7
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Abrams EM, Watson W, Vander Leek TK, Atkinson A, Primeau MN, Francoeur MJ, McHenry M, Lavine E, Orkin J, Cummings C, Blair B, Chan ES. Dietary exposures and allergy prevention in high-risk infants. Allergy Asthma Clin Immunol 2022; 18:36. [PMID: 35501827 PMCID: PMC9063186 DOI: 10.1186/s13223-021-00638-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/07/2021] [Indexed: 11/10/2022]
Abstract
Infants at high risk for developing a food allergy have either an atopic condition (such as eczema) themselves or an immediate family member with such a condition. Breastfeeding should be promoted and supported regardless of issues pertaining to food allergy prevention, but for infants whose mothers cannot or choose not to breastfeed, using a specific formula (i.e., hydrolyzed formula) is not recommended to prevent food allergies. When cow's milk protein formula has been introduced in an infant's diet, make sure that regular ingestion (as little as 10 mL daily) is maintained to prevent loss of tolerance. For high-risk infants, there is compelling evidence that introducing allergenic foods early-at around 6 months, but not before 4 months of age-can prevent common food allergies, and allergies to peanut and egg in particular. Once an allergenic food has been introduced, regular ingestion (e.g., a few times a week) is important to maintain tolerance. Common allergenic foods can be introduced without pausing for days between new foods, and the risk for a severe reaction at first exposure in infancy is extremely low. Pre-emptive in-office screening before introducing allergenic foods is not recommended. No recommendations can be made at this time about the role of maternal dietary modification during pregnancy or lactation, or about supplementing with vitamin D, omega 3, or pre- or probiotics as means to prevent food allergy.
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Affiliation(s)
- Elissa M Abrams
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, FE125-685 William Avenue, Winnipeg, MB, R2A 5L9, Canada.
| | - Wade Watson
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, FE125-685 William Avenue, Winnipeg, MB, R2A 5L9, Canada
| | - Timothy K Vander Leek
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, FE125-685 William Avenue, Winnipeg, MB, R2A 5L9, Canada
| | - Adelle Atkinson
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, FE125-685 William Avenue, Winnipeg, MB, R2A 5L9, Canada
| | - Marie-Noel Primeau
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, FE125-685 William Avenue, Winnipeg, MB, R2A 5L9, Canada
| | - Marie-Josee Francoeur
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, FE125-685 William Avenue, Winnipeg, MB, R2A 5L9, Canada
| | - Mary McHenry
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, FE125-685 William Avenue, Winnipeg, MB, R2A 5L9, Canada
| | - Elana Lavine
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, FE125-685 William Avenue, Winnipeg, MB, R2A 5L9, Canada
| | - Julia Orkin
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, FE125-685 William Avenue, Winnipeg, MB, R2A 5L9, Canada
| | - Carl Cummings
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, FE125-685 William Avenue, Winnipeg, MB, R2A 5L9, Canada
| | - Becky Blair
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, FE125-685 William Avenue, Winnipeg, MB, R2A 5L9, Canada
| | - Edmond S Chan
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, FE125-685 William Avenue, Winnipeg, MB, R2A 5L9, Canada
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8
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Soller L, Carr S, Kapur S, Rex GA, McHenry M, Cook VE, Leo S, Wong T, Vander Leek TK, Gerstner TV, Yeung J, Abrams EM, Mak R, Hildebrand KJ, Erdle SC, Cameron SB, Chan ES. Real-world peanut OIT in infants may be safer than non-infant preschool OIT and equally effective. J Allergy Clin Immunol Pract 2022; 10:1113-1116.e1. [PMID: 34954121 DOI: 10.1016/j.jaip.2021.12.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 12/06/2021] [Accepted: 12/07/2021] [Indexed: 02/08/2023]
Affiliation(s)
- Lianne Soller
- Allergy Clinic, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Stuart Carr
- Snö Asthma and Allergy Clinic, Abu Dhabi, United Arab Emirates
| | - Sandeep Kapur
- Division of Allergy, Department of Pediatrics, Dalhousie University/IWK Health Centre, Halifax, Nova Scotia, Canada; Halifax Allergy and Asthma Associates, Halifax, Nova Scotia, Canada
| | - Gregory A Rex
- Division of Allergy, Department of Pediatrics, Dalhousie University/IWK Health Centre, Halifax, Nova Scotia, Canada; Halifax Allergy and Asthma Associates, Halifax, Nova Scotia, Canada
| | - Mary McHenry
- Division of Allergy, Department of Pediatrics, Dalhousie University/IWK Health Centre, Halifax, Nova Scotia, Canada; Halifax Allergy and Asthma Associates, Halifax, Nova Scotia, Canada
| | - Victoria E Cook
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada; Community Allergy Clinic, Victoria, British Columbia, Canada
| | - Sara Leo
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada; West Coast Allergy and Immunology Clinic, Vancouver, British Columbia, Canada
| | - Tiffany Wong
- Allergy Clinic, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Thomas V Gerstner
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, Manitoba, Canada; Meadowood Medical Center, Winnipeg, Manitoba, Canada
| | - Joanne Yeung
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada; Vancouver Kids Allergy, Vancouver, British Columbia, Canada
| | - Elissa M Abrams
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada; Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, Manitoba, Canada; Meadowood Medical Center, Winnipeg, Manitoba, Canada
| | - Raymond Mak
- Allergy Clinic, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kyla J Hildebrand
- Allergy Clinic, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Stephanie C Erdle
- Allergy Clinic, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Scott B Cameron
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada; Community Allergy Clinic, Victoria, British Columbia, Canada
| | - Edmond S Chan
- Allergy Clinic, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
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9
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Greenhawt M, Abrams EM, Shaker M, Chu DK, Khan D, Akin C, Alqurashi W, Arkwright P, Baldwin JL, Ben-Shoshan M, Bernstein J, Bingemann T, Blumchen K, Byrne A, Bognanni A, Campbell D, Campbell R, Chagla Z, Chan ES, Chan J, Comberiati P, Dribin TE, Ellis AK, Fleischer DM, Fox A, Frischmeyer-Guerrerio PA, Gagnon R, Grayson MH, Horner CC, Hourihane J, Katelaris CH, Kim H, Kelso JM, Lang D, Ledford D, Levin M, Lieberman J, Loh R, Mack D, Mazer B, Mosnaim G, Munblit D, Mustafa SS, Nanda A, Oppenheimer J, Perrett KP, Ramsey A, Rank M, Robertson K, Sheikh J, Spergel JM, Stukus D, Tang ML, Tracy JM, Turner PJ, Whalen-Browne A, Wallace D, Wang J, Waserman S, Witry JK, Worm M, Vander Leek TK, Golden DB. The Risk of Allergic Reaction to SARS-CoV-2 Vaccines and Recommended Evaluation and Management: A Systematic Review, Meta-Analysis, GRADE Assessment, and International Consensus Approach. J Allergy Clin Immunol Pract 2021; 9:3546-3567. [PMID: 34153517 PMCID: PMC8248554 DOI: 10.1016/j.jaip.2021.06.006] [Citation(s) in RCA: 138] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 06/01/2021] [Accepted: 06/11/2021] [Indexed: 01/26/2023]
Abstract
Concerns for anaphylaxis may hamper severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) immunization efforts. We convened a multidisciplinary group of international experts in anaphylaxis composed of allergy, infectious disease, emergency medicine, and front-line clinicians to systematically develop recommendations regarding SARS-CoV-2 vaccine immediate allergic reactions. Medline, EMBASE, Web of Science, the World Health Organizstion (WHO) global coronavirus database, and the gray literature (inception, March 19, 2021) were systematically searched. Paired reviewers independently selected studies addressing anaphylaxis after SARS-CoV-2 vaccination, polyethylene glycol (PEG) and polysorbate allergy, and accuracy of allergy testing for SARS-CoV-2 vaccine allergy. Random effects models synthesized the data to inform recommendations based on the Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) approach, agreed upon using a modified Delphi panel. The incidence of SARS-CoV-2 vaccine anaphylaxis is 7.91 cases per million (n = 41,000,000 vaccinations; 95% confidence interval [95% CI] 4.02-15.59; 26 studies, moderate certainty), the incidence of 0.15 cases per million patient-years (95% CI 0.11-0.2), and the sensitivity for PEG skin testing is poor, although specificity is high (15 studies, very low certainty). We recommend vaccination over either no vaccination or performing SARS-CoV-2 vaccine/excipient screening allergy testing for individuals without history of a severe allergic reaction to the SARS-CoV-2 vaccine/excipient, and a shared decision-making paradigm in consultation with an allergy specialist for individuals with a history of a severe allergic reaction to the SARS-CoV-2 vaccine/excipient. We recommend further research to clarify SARS-CoV-2 vaccine/vaccine excipient testing utility in individuals potentially allergic to SARS-CoV2 vaccines or their excipients.
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Affiliation(s)
- Matthew Greenhawt
- Section of Allergy and Clinical Immunology, Food Challenge and Research Unit, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo,Corresponding author: Matthew Greenhawt, MD, MBA, MS, Section of Allergy and Clinical Immunology, Food Challenge and Research Unit, Children’s Hospital Colorado, University of Colorado School of Medicine, 13123 E. 16th Ave., Aurora, CO 80045
| | - Elissa M. Abrams
- Department of Pediatrics and Child Health, Section of Allergy and Immunology, The University of Manitoba, Winnipeg, Man, Canada
| | - Marcus Shaker
- Dartmouth-Hitchcock Medical Center, Section of Allergy and Immunology, Lebanon; Dartmouth Geisel School of Medicine, Hanover, NH
| | - Derek K. Chu
- Department of Medicine, McMaster University Department of Health Research Methods, Evidence and Impact, McMaster University; The Research Institute of St. Joe's Hamilton; Evidence in Allergy Group, McMaster University, Hamilton, Ont, Canada
| | - David Khan
- Division of Allergy and Immunology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Cem Akin
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, University of Michigan School, Ann Arbor, Mich
| | - Waleed Alqurashi
- Department of Pediatrics and Emergency Medicine, University of Ottawa, Ottawa, Ont, Canada
| | - Peter Arkwright
- Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK
| | - James L. Baldwin
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, University of Michigan School, Ann Arbor, Mich
| | - Moshe Ben-Shoshan
- Division of Allergy, Immunology, and Dermatology, Department of Pediatrics, McGill University Health Center–Montreal Children’s Hospital, Montreal, Quebec, Canada
| | - Jonathan Bernstein
- Division of Immunology, Department of Internal Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Theresa Bingemann
- Division of Allergy, Immunology, and Rheumatology, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Katharina Blumchen
- Department of Paediatric and Adolescent Medicine, Paediatric Pneumology, Allergology, and Cystic Fibrosis, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Aideen Byrne
- Children’s Health Ireland at Crumlin, Crumlin, Ireland
| | - Antonio Bognanni
- Department of Health Research Methods, Evidence and Impact, Evidence in Allergy Group, McMaster University, Hamilton, Ont, Canada
| | - Dianne Campbell
- The Children’s Hospital at Westmead, Sydney, New South Wales, Australia
| | - Ronna Campbell
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minn
| | - Zain Chagla
- Division of Infectious Diseases, Department of Medicine, McMaster University, Hamilton, Ont, Canada
| | - Edmond S. Chan
- BC Children’s Hospital, Division of Allergy and Immunology, The University of British Columbia, Vancouver, BC, Canada
| | - Jeffrey Chan
- Department of Emergency Medicine, Southlake Regional Medical Center, Newmarket, Ont, Canada
| | - Pasquale Comberiati
- Department of Clinical and Experimental Medicine, Section of Pediatrics, University of Pisa, Pisa, Italy, Department of Clinical Immunology and Allergology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Timothy E. Dribin
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Anne K. Ellis
- Division of Allergy and Immunology, Department of Medicine, Queen’s University, Kingston, Ont, Canada
| | - David M. Fleischer
- Section of Allergy and Clinical Immunology, Food Challenge and Research Unit, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Adam Fox
- Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Pamela A. Frischmeyer-Guerrerio
- Laboratory of Allergic Diseases, Food Allergy Research Section, National Institutes of Allergy and Infectious Diseases, the National Institutes of Health, Bethesda, Md
| | - Remi Gagnon
- Clinique Spécialisée en Allergie de la Capitale, Quebec, Quebec, Canada
| | - Mitchell H. Grayson
- Division of Allergy and Immunology, Department of Clinical Pediatrics, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Caroline C. Horner
- Division of Allergy and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, Mo
| | | | | | - Harold Kim
- Western University, Londo, McMaster University, Hamilton, Ont, Canada
| | - John M. Kelso
- Division of Allergy, Asthma, and Immunology, Scripps Clinic, San Diego, Calif
| | - David Lang
- Department of Allergy and Clinical Immunology, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Dennis Ledford
- Division of Allergy and Immunology, Department of Medicine, University of South Florida Morsani College of Medicine, Tampa, Fla
| | - Michael Levin
- Division of Paediatric Allergology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Jay Lieberman
- Division of Allergy and Immunology, The University of Tennessee, Memphis, Tenn
| | - Richard Loh
- Immunology Department, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Doug Mack
- McMaster University Hamilton, Halton Pediatric Allergy, Burlington, Ont, Canada
| | - Bruce Mazer
- Division of Allergy, Immunology, and Dermatology, Department of Pediatrics, McGill University Health Center–Montreal Children’s Hospital, Montreal, Quebec, Canada
| | - Giselle Mosnaim
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, NorthShore University Health System, Evanston, Ill
| | - Daniel Munblit
- Department of Paediatrics and Paediatric Infectious Diseases, Institute of Child’s Health, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia, Inflammation, Repair, Development Section, National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
| | - S. Shahzad Mustafa
- Rochester Regional Health, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Anil Nanda
- Asthma and Allergy Center, Lewisville and Flower Mound, Texas, Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Kirsten P. Perrett
- Murdoch Children’s Research Institute, Department of Paediatrics, University of Melbourne, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Allison Ramsey
- Rochester Regional Health, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Matthew Rank
- Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic, Scottsdale, Division of Pulmonology, Phoenix Children’s Hospital, Phoenix, Ariz
| | - Kara Robertson
- Division of Clinical Immunology and Allergy, St. Joseph’s Health Care, the Schulich School of Medicine and Dentistry, Western University, London, Ont, Canada
| | - Javed Sheikh
- Kaiser Permanente Los Angeles Medical Center, Los Angeles, Calif
| | - Jonathan M. Spergel
- Division of Allergy and Immunology, Children’s Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pa
| | - David Stukus
- Division of Allergy and Immunology, Department of Clinical Pediatrics, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Mimi L.K. Tang
- Murdoch Children’s Research Institute, University of Melbourne, Royal Children’s Hospital, Department of Allergy and Immunology, Royal Children's Hospital, Parkville, Victoria, Australia
| | - James M. Tracy
- Allergy, Asthma, and Immunology Associates, PC, Associate Professor of Pediatrics, University of Nebraska School of Medicine, Omaha, Neb
| | - Paul J. Turner
- Imperial College Healthcare NHS Trust and Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Anna Whalen-Browne
- Division of Clinical Immunology and Allergy, Department of Medicine, Evidence in Allergy Group, McMaster University, Hamilton, Ont, Canada
| | - Dana Wallace
- Nova Southeastern University College of Allopathic Medicine, Fort Lauderdale, Fla
| | - Julie Wang
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, the Jaffe Food Allergy Institute, New York, NY
| | - Susan Waserman
- Department of Medicine, Clinical Immunology, and Allergy, McMaster University, Hamilton, Ont, Canada
| | - John K. Witry
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Margitta Worm
- Division of Allergology and Immunology, Department of Dermatology, Venereology, and Allergology, Charité- Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Timothy K. Vander Leek
- Pediatric Allergy and Asthma, Department of Pediatrics, University of Alberta, Edmonton, Alta, Canada
| | - David B.K. Golden
- Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, Md
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Chua GT, Chan ES, Soller L, Cook VE, Vander Leek TK, Mak R. Home-Based Peanut Oral Immunotherapy for Low-Risk Peanut-Allergic Preschoolers During the COVID-19 Pandemic and Beyond. Front Allergy 2021; 2:725165. [PMID: 35387028 PMCID: PMC8974914 DOI: 10.3389/falgy.2021.725165] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 08/23/2021] [Indexed: 12/03/2022] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has led to the deprioritization of non-emergency services, such as oral food challenges and the initiation of oral immunotherapy (OIT) for food-allergic children. Recent studies have suggested that home-based peanut OIT could be a safe and effective option for low-risk peanut-allergic children. In the period between September 1, 2020, and January 31, 2021, nine preschoolers with a history of mild allergic reactions to peanut underwent home-based peanut OIT. Eight of them (88.9%) completed the build-up phase at home in 11–28 weeks, tolerating a daily maintenance dose of 320 mg peanut protein. During the build-up, six patients (75.0%) reported urticaria, three (33.3%) reported gastrointestinal tract symptoms, and one (14.3%) reported oral pruritis. None of the patients developed anaphylaxis, required epinephrine, or attended emergency services related to OIT. One or two virtual follow-up visits were completed per patient during the build-up phase. Our case series shows that home-based OIT could be offered to the low-risk preschoolers during the COVID-19 pandemic when non-emergency services are limited and could be considered beyond the pandemic, especially for the families living in the rural or remote areas that may otherwise be unable to access OIT.
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Affiliation(s)
- Gilbert T. Chua
- Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong, Hong Kong, SAR China
- *Correspondence: Gilbert T. Chua
| | - Edmond S. Chan
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
- British Columbia Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Lianne Soller
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
- British Columbia Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Victoria E. Cook
- British Columbia Children's Hospital Research Institute, Vancouver, BC, Canada
- Community Allergy Clinic, Victoria, BC, Canada
| | - Timothy K. Vander Leek
- Pediatric Allergy and Asthma, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Raymond Mak
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
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11
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Chomyn A, Chan ES, Yeung J, Vander Leek TK, Williams BA, Soller L, Abrams EM, Mak R, Wong T. Canadian food ladders for dietary advancement in children with IgE-mediated allergy to milk and/or egg. Allergy Asthma Clin Immunol 2021; 17:83. [PMID: 34353372 PMCID: PMC8340453 DOI: 10.1186/s13223-021-00583-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 07/15/2021] [Indexed: 12/16/2022] Open
Abstract
Food ladders are clinical tools already widely used in Europe for food reintroduction in milk- and egg-allergic children. Previously developed milk and egg ladders have limited applicability to Canadian children due to dietary differences and product availability. Herein we propose a Canadian version of cow’s milk and egg food ladders and discuss the potential role that food ladders may have in the care of children with IgE-mediated allergies to cow’s milk and/or egg, as either a method of accelerating the acquisition of tolerance in those who would outgrow on their own, or as a form of modified oral immunotherapy in those with otherwise persistent allergy.
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Affiliation(s)
- Alanna Chomyn
- Department of Pediatrics, Division of Clinical Immunology & Allergy, University of British Columbia, BC Children's Hospital, Room 1C31B, 4480 Oak Street, Vancouver, BC, V5Z 4H4, Canada.
| | - Edmond S Chan
- Department of Pediatrics, Division of Clinical Immunology & Allergy, University of British Columbia, BC Children's Hospital, Room 1C31B, 4480 Oak Street, Vancouver, BC, V5Z 4H4, Canada
| | - Joanne Yeung
- Department of Pediatrics, Division of Clinical Immunology & Allergy, University of British Columbia, BC Children's Hospital, Room 1C31B, 4480 Oak Street, Vancouver, BC, V5Z 4H4, Canada
| | - Timothy K Vander Leek
- Pediatric Allergy & Asthma, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Brock A Williams
- Department of Pediatrics, Division of Clinical Immunology & Allergy, University of British Columbia, BC Children's Hospital, Room 1C31B, 4480 Oak Street, Vancouver, BC, V5Z 4H4, Canada.,Food, Nutrition, and Health, Faculty of Land and Food Systems, University of British Columbia, Vancouver, BC, Canada
| | - Lianne Soller
- Department of Pediatrics, Division of Clinical Immunology & Allergy, University of British Columbia, BC Children's Hospital, Room 1C31B, 4480 Oak Street, Vancouver, BC, V5Z 4H4, Canada
| | - Elissa M Abrams
- Department of Pediatrics, Division of Clinical Immunology & Allergy, University of British Columbia, BC Children's Hospital, Room 1C31B, 4480 Oak Street, Vancouver, BC, V5Z 4H4, Canada.,Department of Pediatrics and Child Health, Section of Allergy and Immunology, University of Manitoba, Winnipeg, Canada
| | - Raymond Mak
- Department of Pediatrics, Division of Clinical Immunology & Allergy, University of British Columbia, BC Children's Hospital, Room 1C31B, 4480 Oak Street, Vancouver, BC, V5Z 4H4, Canada
| | - Tiffany Wong
- Department of Pediatrics, Division of Clinical Immunology & Allergy, University of British Columbia, BC Children's Hospital, Room 1C31B, 4480 Oak Street, Vancouver, BC, V5Z 4H4, Canada.
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Shaker MS, Phillips E, Blumenthal KG, Abrams EM, Banerji A, Oppenheimer J, Vander Leek TK, Mack DP, Wickner PG, Singer AG, Khan DA, Greenhawt M. Reply to "How important is the second dose of the COVID-19 mRNA vaccine?". J Allergy Clin Immunol Pract 2021; 9:2537-2539. [PMID: 34112481 PMCID: PMC8181594 DOI: 10.1016/j.jaip.2021.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 03/02/2021] [Indexed: 11/22/2022]
Affiliation(s)
- Marcus S Shaker
- Dartmouth-Hitchcock Medical Center, Section of Allergy and Immunology, Lebanon, NH; Geisel School of Medicine at Dartmouth, Hanover, NH.
| | - Elizabeth Phillips
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass; Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital, Boston, Mass
| | - Elissa M Abrams
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, MB, Canada
| | - Aleena Banerji
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | | | - Timothy K Vander Leek
- Pediatric Allergy and Asthma, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Douglas P Mack
- McMaster University, Hamilton, ON, Canada; Halton Pediatric Allergy, Burlington, ON, Canada
| | - Paige G Wickner
- Harvard Medical School, Boston, Mass; Division of Allergy and Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Alexander G Singer
- Department of Family Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - David A Khan
- Division of Allergy & Immunology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Matthew Greenhawt
- Department of Pediatrics, Section of Allergy and Immunology, Children's Hospital Colorado, University of Colorado Denver School of Medicine, Denver, Colo
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13
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Shaker M, Phillips E, Blumenthal KG, Abrams EM, Banerji A, Oppenheimer J, Vander Leek TK, Mack DP, Wickner PG, Singer AG, Khan DA, Greenhawt M. The Importance of a Timely Second Dose of the 2021 COVID-19 mRNA Vaccine Depends on the Protection Afforded by a First Dose and Subsequent Risk of Anaphylaxis. J Allergy Clin Immunol Pract 2021; 9:2556-2561. [PMID: 33892171 PMCID: PMC8056986 DOI: 10.1016/j.jaip.2021.04.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 03/23/2021] [Accepted: 04/15/2021] [Indexed: 12/16/2022]
Abstract
Vaccination against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) represents our greatest hope to combat the devastating coronavirus disease 2019 (COVID-19) pandemic. Amid ongoing global vaccination efforts, rare cases of severe allergic reactions to COVID-19 mRNA vaccines have received significant attention. Although the exact nature of these reactions may be heterogeneous, various approaches exist to engage with patients, communities, public health departments, primary care providers, and other clinicians in a multidisciplinary approach to advance population health. Whereas it is optimal for patients to receive COVID-19 vaccination as outlined in emergency use authorizations, second-dose deferral of mRNA vaccines may be a consideration within a shared decision-making paradigm of care in select circumstances characterized by high durable first-vaccine–dose protection and significant elevations of vaccine anaphylaxis risk. Still, the durability of protection afforded by a single dose of a COVID-19 mRNA vaccine is uncertain, and alternative approaches to complete vaccination, including precautionary use of a COVID-19 viral vector vaccine, also remain patient-preference–sensitive options. There is an urgent need to define correlates of COVID-19 immunity and the level of longer-term protection afforded by COVID-19 vaccination.
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Affiliation(s)
- Marcus Shaker
- Dartmouth-Hitchcock Medical Center, Section of Allergy and Immunology, Lebanon, NH; Geisel School of Medicine at Dartmouth, Hanover, NH.
| | - Elizabeth Phillips
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass; Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital, Boston, Mass
| | - Elissa M Abrams
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Aleena Banerji
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | | | - Timothy K Vander Leek
- Pediatric Allergy and Asthma, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Douglas P Mack
- McMaster University, Hamilton, and Halton Pediatric Allergy, Burlington, Ontario, Canada
| | - Paige G Wickner
- Harvard Medical School, Boston, Mass; Division of Allergy and Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Alexander G Singer
- Department of Family Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - David A Khan
- Division of Allergy and Immunology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Matthew Greenhawt
- Department of Pediatrics, Section of Allergy and Immunology, Children's Hospital Colorado, University of Colorado Denver School of Medicine, Denver, Colo
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Vander Leek TK, Chan ES, Connors L, Derfalvi B, Ellis AK, Upton JEM, Abrams EM. COVID-19 vaccine testing & administration guidance for allergists/immunologists from the Canadian Society of Allergy and Clinical Immunology (CSACI). Allergy Asthma Clin Immunol 2021; 17:29. [PMID: 33722299 PMCID: PMC7957441 DOI: 10.1186/s13223-021-00529-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 02/19/2021] [Indexed: 03/03/2023]
Abstract
BACKGROUND Safe and effective vaccines provide the first hope for mitigating the devastating health and economic impacts resulting from coronavirus disease 2019 (COVID-19) and related public health orders. Recent case reports of reactions to COVID-19 vaccines have raised questions about their safety for use in individuals with allergies and those who are immunocompromised. In this document, we aim to address these concerns and provide guidance for allergists/immunologists. METHODS Scoping review of the literature regarding COVID-19 vaccination, adverse or allergic reactions, and immunocompromise from PubMed over the term of December 2020 to present date. We filtered our search with the terms "human" and "English" and limited the search to the relevant subject age range with the term "adult." Reports resulting from these searches and relevant references cited in those reports were reviewed and cited on the basis of their relevance. RESULTS Assessment by an allergist is warranted in any individual with a suspected allergy to a COVID-19 vaccine or any of its components. Assessment by an allergist is NOT required for individuals with a history of unrelated allergies, including to allergies to foods, drugs, insect venom or environmental allergens. COVID-19 vaccines should be offered to immunocompromised patients if the benefit is deemed to outweigh any potential risks of vaccination. INTERPRETATION This review provides the first Canadian guidance regarding assessment of an adolescent and adult with a suspected allergy to one of the COVID-19 vaccines currently available, or any of their known allergenic components, and for patients who are immunocompromised who require vaccination for COVID-19. As information is updated this guidance will be updated accordingly.
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Affiliation(s)
- Timothy K Vander Leek
- Pediatric Allergy and Asthma, Department of Pediatrics, University of Alberta, 207-10430 61 Ave NW, Edmonton, AB, T6H 2J3, Canada.
| | - Edmond S Chan
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver, BC, Canada
| | - Lori Connors
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Beata Derfalvi
- Division of Immunology, Department of Pediatrics, Dalhousie University/IWK Health Centre, Halifax, NS, Canada
| | - Anne K Ellis
- Division of Allergy & Immunology, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Julia E M Upton
- Division of Immunology and Allergy, Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Elissa M Abrams
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, MN, Canada
- Department of Pediatrics, Division of Allergy and Immunology, University of British Columbia, Vancouver, BC, Canada
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15
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Greenhawt M, Abrams EM, Oppenheimer J, Vander Leek TK, Mack DP, Singer AG, Shaker M. The COVID-19 Pandemic in 2021: Avoiding Overdiagnosis of Anaphylaxis Risk While Safely Vaccinating the World. J Allergy Clin Immunol Pract 2021; 9:1438-1441. [PMID: 33529722 PMCID: PMC7847187 DOI: 10.1016/j.jaip.2021.01.022] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 01/21/2021] [Accepted: 01/22/2021] [Indexed: 12/16/2022]
Affiliation(s)
- Matthew Greenhawt
- Department of Pediatrics, Section of Allergy and Immunology, Children's Hospital Colorado, University of Colorado Denver School of Medicine, Denver, Colo.
| | - Elissa M Abrams
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, MB, Canada
| | | | - Timothy K Vander Leek
- Pediatric Allergy and Asthma, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Douglas P Mack
- McMaster University, Hamilton, ON, Canada; Halton Pediatric Allergy, Burlington, ON, Canada
| | - Alexander G Singer
- Department of Family Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Marcus Shaker
- Dartmouth-Hitchcock Medical Center, Section of Allergy and Immunology, Lebanon, NH; Geisel School of Medicine at Dartmouth, Hanover, NH
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16
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Mack DP, Soller L, Chan ES, Hanna MA, Terpstra C, Vander Leek TK, Bégin P. A High Proportion of Canadian Allergists Offer Oral Immunotherapy but Barriers Remain. J Allergy Clin Immunol Pract 2020; 9:1902-1908. [PMID: 33359585 DOI: 10.1016/j.jaip.2020.12.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 11/27/2020] [Accepted: 12/08/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Limited data on clinical implementation of oral immunotherapy (OIT) have been reported with incomplete evaluation of barriers. OBJECTIVE To survey Canadian allergists on their current practice of OIT and barriers to implementation and expansion of OIT. METHODS A survey investigating current practice and logistical and clinical barriers to offering or expanding OIT was distributed to all Canadian Society of Allergy and Clinical Immunology allergists. RESULTS Of 90 responding allergists, 52.2% reported offering OIT, most commonly to peanut. Food sublingual immunotherapy was offered by 7% of allergists. Having received training for OIT was associated with currently performing OIT (P = .008); 44.7% of allergists offering OIT had received training on OIT, and 81.4% not offering OIT had no training. A total of 87% of allergists performing OIT reported lack of efficacy data and lack of support staff and clinic space, and concerns about increased oral challenges (84%) were "moderately" to "extremely" important barriers to expanding OIT. For clinicians not offering OIT, concerns about safety (95%), after-hours support (95%), efficacy (93%), medicolegal risk (93%), and long-term practice implications (93%) were prioritized as significant barriers. Qualitative assessment suggested concerns about the practical challenges associated with OIT, the need for increased safety and efficacy data, and a desire for OIT guidelines and training. CONCLUSION The implementation of OIT faces many barriers, both clinical and logistical. Increasing high-quality safety and efficacy data may support those hesitant to offer OIT, and improving funding may address the practical infrastructure challenges. In addition, training will help expand access for allergists interested in performing OIT.
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Affiliation(s)
- Douglas P Mack
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada.
| | - Lianne Soller
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Edmond S Chan
- Division of Allergy & Immunology, Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver, BC, Canada
| | - Mariam A Hanna
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Collin Terpstra
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | | | - Philippe Bégin
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, CHU Sainte-Justine, Montréal, QC, Canada
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Soller L, Abrams EM, Carr S, Kapur S, Rex GA, Leo S, McHenry M, Vander Leek TK, Yeung J, Cook VE, Wong T, Hildebrand KJ, Mak R, Gerstner TV, Cameron SB, Chan ES. First Real-World Effectiveness Analysis of Preschool Peanut Oral Immunotherapy. J Allergy Clin Immunol Pract 2020; 9:1349-1356.e1. [PMID: 33221274 DOI: 10.1016/j.jaip.2020.10.045] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 09/22/2020] [Accepted: 10/12/2020] [Indexed: 01/12/2023]
Abstract
BACKGROUND We previously described safety of preschool peanut oral immunotherapy (P-OIT) in a real-world setting; 0.4% of patients experienced a severe reaction, and 4.1% received epinephrine, during build-up. OBJECTIVE To determine the effectiveness of preschool P-OIT after 1 year of maintenance. METHODS Preschoolers (9-70 months) with at least 1 objective reaction to peanut (during baseline oral food challenge (OFC) or P-OIT build-up) received a follow-up OFC to cumulative 4000 mg protein after 1 year on 300 mg peanut daily maintenance. Effectiveness of desensitization was defined as proportion of patients with a negative follow-up OFC. Symptoms and treatment at follow-up OFC were recorded. RESULTS Of the 117 patients who successfully completed 1 year of P-OIT and subsequently underwent a cumulative 4000-mg follow-up OFC, 92 (78.6%) had a negative OFC and 115 (98.3%) tolerated a cumulative dose of greater than or equal to 1000 mg. For the 25 (21.4%) who reacted, their threshold increased by 3376 mg (95% CI, 2884-3868) from baseline to follow-up; 17 (14.5%) patients experienced grade 1 reactions, 7 (6.00%) grade 2, and 1 (0.85%) grade 3. Two patients (1.71%) received epinephrine associated with P-OIT, and 1 (0.85%) went to the emergency department. CONCLUSIONS Our data demonstrate that real-world preschool P-OIT is effective after 1 year of maintenance for those who received a follow-up OFC. For those who reacted, their threshold increased sufficiently to protect against accidental exposures. P-OIT should be considered for preschoolers as an alternative to current recommendations to avoid peanut.
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Affiliation(s)
- Lianne Soller
- British Columbia Children's Hospital, Vancouver, BC, Canada; Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada.
| | - Elissa M Abrams
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada; Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, MB, Canada; Meadowood Medical Center, Winnipeg, MB, Canada
| | - Stuart Carr
- Pediatric Allergy & Asthma, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Sandeep Kapur
- Division of Allergy, Department of Pediatrics, Dalhousie University/IWK Health Centre, Halifax, NS, Canada; Halifax Allergy & Asthma Associates, Halifax, NS, Canada
| | - Gregory A Rex
- Division of Allergy, Department of Pediatrics, Dalhousie University/IWK Health Centre, Halifax, NS, Canada; Halifax Allergy & Asthma Associates, Halifax, NS, Canada
| | - Sara Leo
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada; West Coast Allergy and Immunology Clinic, Vancouver, BC, Canada
| | - Mary McHenry
- Division of Allergy, Department of Pediatrics, Dalhousie University/IWK Health Centre, Halifax, NS, Canada; Halifax Allergy & Asthma Associates, Halifax, NS, Canada
| | - Timothy K Vander Leek
- Pediatric Allergy & Asthma, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada; Pediatric Allergy & Immunology, Edmonton, AB, Canada
| | - Joanne Yeung
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada; Vancouver Pediatric and Allergy Centre, Vancouver, BC, Canada
| | - Victoria E Cook
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada; Community Allergy Clinic, Victoria, BC, Canada
| | - Tiffany Wong
- British Columbia Children's Hospital, Vancouver, BC, Canada; Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Kyla J Hildebrand
- British Columbia Children's Hospital, Vancouver, BC, Canada; Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Raymond Mak
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Thomas V Gerstner
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, MB, Canada; Meadowood Medical Center, Winnipeg, MB, Canada
| | - Scott B Cameron
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada; Community Allergy Clinic, Victoria, BC, Canada
| | - Edmond S Chan
- British Columbia Children's Hospital, Vancouver, BC, Canada; Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
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Searing DA, Dutmer CM, Fleischer DM, Shaker MS, Oppenheimer J, Grayson MH, Stukus D, Hartog N, Hsieh EWY, Rider NL, Vander Leek TK, Kim H, Chan ES, Mack D, Ellis AK, Abrams EM, Bansal P, Lang DM, Lieberman J, Golden DB, Wallace D, Portnoy J, Mosnaim G, Greenhawt M. A Phased Approach to Resuming Suspended Allergy/Immunology Clinical Services. J Allergy Clin Immunol Pract 2020; 8:2125-2134. [PMID: 32450236 PMCID: PMC7242939 DOI: 10.1016/j.jaip.2020.05.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 05/12/2020] [Accepted: 05/14/2020] [Indexed: 01/09/2023]
Abstract
In early 2020, the first US and Canadian cases of the novel severe acute respiratory syndrome coronavirus 2 infection were detected. In the ensuing months, there has been rapid spread of the infection. In March 2020, in response to the virus, state/provincial and local governments instituted shelter-in-place orders, and nonessential ambulatory care was significantly curtailed, including allergy/immunology services. With rates of new infections and fatalities potentially reaching a plateau and/or declining, restrictions on provision of routine ambulatory care are lifting, and there is a need to help guide the allergy/immunology clinician on how to reinitiate services. Given the fact that coronavirus disease 2019 will circulate within our communities for months or longer, we present a flexible, algorithmic best-practices planning approach on how to prioritize services, in 4 stratified phases of reopening according to community risk level, as well as highlight key considerations for how to safely do so. The decisions on what services to offer and how fast to proceed are left to the discretion of the individual clinician and practice, operating in accordance with state and local ordinances with respect to the level of nonessential ambulatory care that can be provided. Clear communication with staff and patients before and after all changes should be incorporated into this new paradigm on continual change, given the movement may be forward and even backward through the phases because this is an evolving situation.
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Affiliation(s)
- Daniel A Searing
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Cullen M Dutmer
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - David M Fleischer
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Marcus S Shaker
- Dartmouth-Hitchcock Medical Center, Section of Allergy and Immunology, Lebanon, NH; Dartmouth Geisel School of Medicine, Hanover, NH
| | | | - Mitchell H Grayson
- Nationwide Children's Hospital, The Ohio State University School of Medicine, Columbus, Ohio
| | - David Stukus
- Nationwide Children's Hospital, The Ohio State University School of Medicine, Columbus, Ohio
| | - Nicholas Hartog
- Spectrum Health Helen DeVos Children's Hospital, Grand Rapids, Mich
| | - Elena W Y Hsieh
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo; Department of Immunology and Microbiology, University of Colorado School of Medicine, Denver, Colo
| | - Nicholas L Rider
- The Texas Children's Hospital, Section of Immunology, Allergy, and Retrovirology and the Baylor College of Medicine, Houston, Texas
| | - Timothy K Vander Leek
- Pediatric Allergy and Asthma, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Harold Kim
- Western University, London, ON, Canada; McMaster University, Hamilton, ON, Canada
| | - Edmond S Chan
- BC Children's Hospital, Division of Allergy & Immunology, The University of British Columbia, Vancouver, BC, Canada
| | - Doug Mack
- McMaster University, Hamilton, ON, Canada; Halton Pediatric Allergy, Burlington, ON, Canada
| | - Anne K Ellis
- Division of Allergy and Immunology, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Elissa M Abrams
- Department of Pediatrics and Child Health, Section of Allergy and Immunology, The University of Manitoba, Winnipeg, MB, Canada
| | - Priya Bansal
- Asthma and Allergy Wellness Center, St Charles, Ill
| | - David M Lang
- Department of Allergy and Clinical Immunology, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jay Lieberman
- Division of Allergy and Immunology, The University of Tennessee, Memphis, Tenn
| | - David Bk Golden
- Division of Allergy and Clinical Immunology, John Hopkins University School of Medicine, Baltimore, Md
| | - Dana Wallace
- Nova Southeastern University College of Allopathic Medicine, Fort Lauderdale, Fla
| | - Jay Portnoy
- Children's Mercy, University of Missouri-Kansas City School of Medicine, Kansas City, Mo
| | - Giselle Mosnaim
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, NorthShore University Health System, Evanston, Ill
| | - Matthew Greenhawt
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo.
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19
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Shaker MS, Oppenheimer J, Grayson M, Stukus D, Hartog N, Hsieh EWY, Rider N, Dutmer CM, Vander Leek TK, Kim H, Chan ES, Mack D, Ellis AK, Lang D, Lieberman J, Fleischer D, Golden DBK, Wallace D, Portnoy J, Mosnaim G, Greenhawt M. Reply to "Subcutaneous terbutaline as an alternative to aerosolized albuterol". J Allergy Clin Immunol Pract 2020; 8:2450-2452. [PMID: 32340824 PMCID: PMC7174169 DOI: 10.1016/j.jaip.2020.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 04/08/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Marcus S Shaker
- Children's Hospital at Dartmouth, Dartmouth-Hitchcock Medical Center, Section of Allergy and Immunology, Lebanon, NH; Departments of Pediatrics, Medicine, and Community and Family Medicine, Dartmouth Geisel School of Medicine, Hanover, NH.
| | - John Oppenheimer
- Department of Internal Medicine, Pulmonary, and Allergy, UMDNJ Rutgers University School of Medicine, Morristown, NJ
| | - Mitchell Grayson
- Division of Allergy and Immunology, Nationwide Children's Hospital, The Ohio State University School of Medicine, Columbus, Ohio
| | - David Stukus
- Division of Allergy and Immunology, Nationwide Children's Hospital, The Ohio State University School of Medicine, Columbus, Ohio
| | - Nicholas Hartog
- Division of Allergy and Immunology, Spectrum Health Helen DeVos Children's Hospital, Grand Rapids, Mich
| | - Elena W Y Hsieh
- Section of Allergy and Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Nicholas Rider
- The Texas Children's Hospital, Section of Immunology, Allergy, and Retrovirology and the Baylor College of Medicine, Houston, Tex
| | - Cullen M Dutmer
- Section of Allergy and Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Timothy K Vander Leek
- Division of Pediatric Allergy and Asthma, Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada
| | - Harold Kim
- Division of Clinical Immunology and Allergy, Western University, London, ON, Canada; Division of Clinical Immunology and Allergy, McMaster University, Hamilton, ON, Canada
| | - Edmond S Chan
- Division of Allergy and Immunology, BC Children's Hospital, The University of British Columbia, Vancouver, BC, Canada
| | - Doug Mack
- Division of Clinical Immunology and Allergy, McMaster University, Hamilton, ON, Canada; Halton Pediatric Allergy, Burlington, ON, Canada
| | - Anne K Ellis
- Division of Allergy and Immunology, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - David Lang
- Department of Medicine, Section of Allergy and Immunology, Cleveland Clinic, Cleveland, Ohio
| | - Jay Lieberman
- Division of Allergy and Immunology, The University of Tennessee, Memphis, Tenn
| | - David Fleischer
- Section of Allergy and Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - David B K Golden
- Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Dana Wallace
- Nova Southeastern University College of Allopathic Medicine, Fort Lauderdale, Fla
| | - Jay Portnoy
- Division of Allergy, Asthma, and Immunology, Children's Mercy, University of Missouri-Kansas City School of Medicine, Kansas City, Mo
| | - Giselle Mosnaim
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, NorthShore University Health System, Evanston, Ill
| | - Matthew Greenhawt
- Section of Allergy and Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
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20
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Shaker MS, Oppenheimer J, Grayson M, Stukus D, Hartog N, Hsieh EWY, Rider N, Dutmer CM, Vander Leek TK, Kim H, Chan ES, Mack D, Ellis AK, Lang D, Lieberman J, Fleischer D, Golden DBK, Wallace D, Portnoy J, Mosnaim G, Greenhawt M. COVID-19: Pandemic Contingency Planning for the Allergy and Immunology Clinic. J Allergy Clin Immunol Pract 2020; 8:1477-1488.e5. [PMID: 32224232 PMCID: PMC7195089 DOI: 10.1016/j.jaip.2020.03.012] [Citation(s) in RCA: 210] [Impact Index Per Article: 52.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 03/18/2020] [Indexed: 01/15/2023]
Abstract
In the event of a global infectious pandemic, drastic measures may be needed that limit or require adjustment of ambulatory allergy services. However, no rationale for how to prioritize service shut down and patient care exists. A consensus-based ad-hoc expert panel of allergy/immunology specialists from the United States and Canada developed a service and patient prioritization schematic to temporarily triage allergy/immunology services. Recommendations and feedback were developed iteratively, using an adapted modified Delphi methodology to achieve consensus. During the ongoing pandemic while social distancing is being encouraged, most allergy/immunology care could be postponed/delayed or handled through virtual care. With the exception of many patients with primary immunodeficiency, patients on venom immunotherapy, and patients with asthma of a certain severity, there is limited need for face-to-face visits under such conditions. These suggestions are intended to help provide a logical approach to quickly adjust service to mitigate risk to both medical staff and patients. Importantly, individual community circumstances may be unique and require contextual consideration. The decision to enact any of these measures rests with the judgment of each clinician and individual health care system. Pandemics are unanticipated, and enforced social distancing/quarantining is highly unusual. This expert panel consensus document offers a prioritization rational to help guide decision making when such situations arise and an allergist/immunologist is forced to reduce services or makes the decision on his or her own to do so.
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Affiliation(s)
- Marcus S Shaker
- Dartmouth-Hitchcock Medical Center, Section of Allergy and Immunology, Lebanon, NH; Dartmouth Geisel School of Medicine, Hanover, NH
| | | | - Mitchell Grayson
- Nationwide Children's Hospital, The Ohio State University School of Medicine, Columbus, Ohio
| | - David Stukus
- Nationwide Children's Hospital, The Ohio State University School of Medicine, Columbus, Ohio
| | - Nicholas Hartog
- Spectrum Health Helen DeVos Children's Hospital, Grand Rapids, Mich
| | - Elena W Y Hsieh
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Nicholas Rider
- The Texas Children's Hospital, Section of Immunology, Allergy, and Retrovirology and the Baylor College of Medicine, Houston, Texas
| | - Cullen M Dutmer
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Timothy K Vander Leek
- Pediatric Allergy and Asthma, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Harold Kim
- Western University and McMaster University, London, ON, Canada
| | - Edmond S Chan
- BC Children's Hospital, The University of British Columbia, Vancouver, BC, Canada
| | - Doug Mack
- McMaster University, Hamilton, ON, Canada; Halton Pediatric Allergy, Burlington, ON, Canada
| | - Anne K Ellis
- Division of Allergy and Immunology, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - David Lang
- Department of Medicine, Section of Allergy and Immunology, Cleveland Clinic, Cleveland, Ohio
| | - Jay Lieberman
- Division of Allergy and Immunology, The University of Tennessee, Memphis, Tenn
| | - David Fleischer
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - David B K Golden
- Division of Allergy and Clinical Immunology, John Hopkins University School of Medicine, Baltimore, Md
| | - Dana Wallace
- Nova Southeastern University College of Allopathic Medicine, Fort Lauderdale, Fla
| | - Jay Portnoy
- Children's Mercy, University of Missouri-Kansas City School of Medicine, Kansas City, Mo
| | - Giselle Mosnaim
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, NorthShore University Health System, Evanston, Ill
| | - Matthew Greenhawt
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo.
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Soller L, Abrams EM, Carr S, Kapur S, Rex GA, Leo S, Lidman PG, Yeung J, Vander Leek TK, McHenry M, Wong T, Cook VE, Hildebrand KJ, Gerstner TV, Mak R, Lee NJ, Cameron SB, Chan ES. First Real-World Safety Analysis of Preschool Peanut Oral Immunotherapy. J Allergy Clin Immunol Pract 2019; 7:2759-2767.e5. [PMID: 31002957 DOI: 10.1016/j.jaip.2019.04.010] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 03/08/2019] [Accepted: 04/04/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND In 2017, a clinical trial of 37 subjects demonstrated that preschool peanut oral immunotherapy (P-OIT) was safe, with predominantly mild symptoms reported and only 1 moderate reaction requiring epinephrine. OBJECTIVES We sought to examine whether these findings would be applicable in a real-world setting. METHODS As part of a Canada-wide quality improvement project, community and academic allergists administered P-OIT to preschool-age children who had (1) skin prick test wheal diameter greater than or equal to 3 mm or specific IgE level greater than or equal to 0.35 kU/L and history of reaction and/or positive baseline oral food challenge, or (2) no ingestion history and specific IgE level greater than or equal to 5 kU/L. Over 16 to 22 weeks, patients had biweekly clinic visits for updosing, and consumed the dose daily at home between visits. Target maintenance dose was 300 mg peanut protein. Symptoms were classified using a modified World Allergy Organization Subcutaneous Immunotherapy Reaction Grading System (1 mildest, 5 fatal). RESULTS Of 270 patients who started P-OIT in the period 2017 to 2018, 243 reached maintenance, and 27 dropped out (10.0%); 67.8% of patients experienced reactions during buildup: 36.3% grade 1, 31.1% grade 2, and 0.40% grade 4. Eleven patients (4.10%) received epinephrine (10 patients received 1 dose, 1 patient received epinephrine on 2 separate days), representing 2.23% of reactions (12 of 538) and 0.029% of doses (12 of 41,020). CONCLUSIONS We are the first group to describe preschool P-OIT in a real-world multicenter setting. The treatment appears to be safe for the vast majority of patients because symptoms were generally mild and very few reactions received epinephrine; however, life-threatening reactions in a minority of patients (0.4%) can still occur.
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Affiliation(s)
- Lianne Soller
- British Columbia Children's Hospital Research Institute, Vancouver, BC, Canada; Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada.
| | - Elissa M Abrams
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada; Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, MB, Canada; Meadowood Medical Center, Winnipeg, MB, Canada
| | - Stuart Carr
- Pediatric Allergy & Asthma, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Sandeep Kapur
- Division of Allergy, Department of Pediatrics, Dalhousie University/IWK Health Centre, Halifax, NS, Canada; Halifax Allergy & Asthma Associates, Halifax, NS, Canada
| | - Gregory A Rex
- Division of Allergy, Department of Pediatrics, Dalhousie University/IWK Health Centre, Halifax, NS, Canada; Halifax Allergy & Asthma Associates, Halifax, NS, Canada
| | - Sara Leo
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada; West Coast Allergy and Immunology Clinic, Vancouver, BC, Canada
| | - Per G Lidman
- Pediatric Allergy & Asthma, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Joanne Yeung
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada; Vancouver Pediatric and Allergy Centre, Vancouver, BC, Canada
| | - Timothy K Vander Leek
- Pediatric Allergy & Asthma, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Mary McHenry
- Division of Allergy, Department of Pediatrics, Dalhousie University/IWK Health Centre, Halifax, NS, Canada; Halifax Allergy & Asthma Associates, Halifax, NS, Canada
| | - Tiffany Wong
- British Columbia Children's Hospital Research Institute, Vancouver, BC, Canada; Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Victoria E Cook
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada; Community Allergy Clinic, Victoria, BC, Canada
| | - Kyla J Hildebrand
- British Columbia Children's Hospital Research Institute, Vancouver, BC, Canada; Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Thomas V Gerstner
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, MB, Canada; Meadowood Medical Center, Winnipeg, MB, Canada
| | - Raymond Mak
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Nicole J Lee
- British Columbia Children's Hospital Research Institute, Vancouver, BC, Canada; Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Scott B Cameron
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada; Community Allergy Clinic, Victoria, BC, Canada
| | - Edmond S Chan
- British Columbia Children's Hospital Research Institute, Vancouver, BC, Canada; Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
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Soller L, Carr S, Kapur S, Leo S, Rex GA, Lidman PG, Yeung J, Vander Leek TK, Wong T, McHenry M, Hildebrand K, Cook VE, Abrams EM, Lee NJ, Cameron SB, Chan ES. First ever real-world safety analysis of preschool peanut oral immunotherapy. J Allergy Clin Immunol 2019. [DOI: 10.1016/j.jaci.2018.12.799] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Anaphylaxis is an acute, potentially fatal systemic allergic reaction with varied mechanisms and clinical presentations. Although prompt recognition and treatment of anaphylaxis are imperative, both patients and healthcare professionals often fail to recognize and diagnose early signs and symptoms of the condition. Clinical manifestations vary widely; however, the most common signs are cutaneous symptoms, including urticaria, angioedema, erythema and pruritus. Immediate intramuscular administration of epinephrine into the anterolateral thigh is first-line therapy, even if the diagnosis is uncertain. The mainstays of long-term management include specialist assessment, avoidance measures, and the provision of an epinephrine auto-injector and an individualized anaphylaxis action plan. This article provides an overview of the causes, clinical features, diagnosis and acute and long-term management of this serious allergic reaction.
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Affiliation(s)
| | | | | | - Harold Kim
- 1Western University, London, ON Canada.,4McMaster University, Hamilton, ON Canada
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Hildebrand KJ, Abrams EM, Vander Leek TK, Upton JEM, Mack DP, Kirste L, McCusker C, Kapur S. Primum non nocere-first do no harm. And then feed peanut. Allergy Asthma Clin Immunol 2017; 13:7. [PMID: 28194188 PMCID: PMC5299733 DOI: 10.1186/s13223-017-0180-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Accepted: 01/18/2017] [Indexed: 01/15/2023] Open
Abstract
The Addendum Guidelines for the Prevention of Peanut Allergy in the United States—Report of the NIAID-Sponsored Expert Panel were developed to build on previous food allergy guidelines after several key studies demonstrated the benefit of early introduction of allergenic foods. These landmark studies including the Learning Early about Peanut (LEAP), LEAP-On and Enquiring about Tolerance trials created a paradigm shift in food allergy prevention. The “take home” messages of this guideline include that peanut should be introduced early in the first year of life, and for the majority of infants, peanut can be introduced at home. The only group of infants for which medical assessment is recommended is those with severe eczema, egg allergy or both. Here we summarize the Guideline recommendations, endorsed by the Canadian Society of Allergy and Clinical Immunology, and highlight important aspects relevant to Canadian practitioners.
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Affiliation(s)
- Kyla Jade Hildebrand
- Program Director Clinical Immunology & Allergy Training Program, Faculty of Medicine, Department of Pediatrics, University of British Columbia, British Columbia Children's Hospital, 4480 Oak Street, Room 1C31B, Vancouver, BC V6H 3V4 Canada
| | | | | | | | - Douglas P Mack
- McMaster University, Joseph Brant Hospital, 1230 North Shore Blvd, Burlington, ON L7S 1W7 Canada
| | - Linda Kirste
- Government of British Columbia, Dietitian & Physical Activity Services, HealthLink BC, Burnaby, Canada
| | - Christine McCusker
- McGill University, Meakins-Christie Laboratories RI-MUHC, Block E, Office EM3.2230,2155 Decarie Blvd, Montreal, QC H4A 3J1 Canada
| | - Sandeep Kapur
- Dalhousie University, 503-5657 Spring Garden Road, Halifax, NS B3J 3R4 Canada
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Chan ES, Cummings C, Atkinson A, Chad Z, Francoeur MJ, Kirste L, Mack D, Primeau MN, Vander Leek TK, Watson WT. Dietary exposures and allergy prevention in high-risk infants: a joint position statement of the Canadian Society of Allergy and Clinical Immunology and the Canadian Paediatric Society. Allergy Asthma Clin Immunol 2014; 10:45. [PMID: 25908933 PMCID: PMC4407306 DOI: 10.1186/1710-1492-10-45] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Accepted: 08/11/2014] [Indexed: 11/10/2022] Open
Abstract
Allergic conditions in children are a prevalent health concern in Canada. The burden of disease and the societal costs of proper diagnosis and management are considerable, making the primary prevention of allergic conditions a desirable health care objective. This position statement reviews current evidence on dietary exposures and allergy prevention in infants at high risk of developing allergic conditions. It revisits previous dietary recommendations for pregnancy, breastfeeding and formula-feeding, and provides an approach for introducing solid foods to high-risk infants. While there is no evidence that delaying the introduction of any specific food beyond six months of age helps to prevent allergy, the protective effect of early introduction of potentially allergenic foods (at four to six months) remains under investigation. Recent research appears to suggest that regularly ingesting a new, potentially allergenic food may be as important as when that food is first introduced. This article has already been published (Paediatr Child Health. 2013 Dec;18(10):545–54), and is being re-published with permission from the original publisher, the Canadian Paediatric Society.
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Affiliation(s)
- Edmond S Chan
- BC Children's Hospital, Department of Pediatrics, Division of Allergy & Immunology, University of British Columbia, Room 1C31B, 4480 Oak St, Vancouver, BC V6H 3V4 Canada
| | - Carl Cummings
- Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec Canada
| | - Adelle Atkinson
- The Hospital for Sick Children, Division of Allergy and Clinical Immunology, Department of Paediatrics, University of Toronto, Toronto, ON Canada
| | - Zave Chad
- Department of Pediatrics, University of Ottawa, Ottawa, ON Canada
| | - Marie-Josée Francoeur
- Hôpital Charles LeMoyne, Département de pédiatrie, Service d'allergie et immunologie clinique, Université de Sherbrooke, Greenfield Park, Québec, Canada
| | - Linda Kirste
- Allergy Nutrition Service, Dietitian Services, HealthLinkBC, Burnaby, BC Canada
| | | | - Marie-Noël Primeau
- Montreal Children's Hospital, Department of Pediatrics, Division of Allergy and Immunology, McGill University Health Centre, Montreal, QC Canada
| | - Timothy K Vander Leek
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB Canada
| | - Wade Ta Watson
- Department of Pediatrics, Dalhousie University, Division of Allergy, IWK Health Centre, Halifax, NS Canada
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Bahreinian S, Ball GDC, Vander Leek TK, Colman I, McNeil BJ, Becker AB, Kozyrskyj AL. Allostatic load biomarkers and asthma in adolescents. Am J Respir Crit Care Med 2012; 187:144-52. [PMID: 22955315 DOI: 10.1164/rccm.201201-0025oc] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Allostatic load (AL), a novel measure of the physiologically dysregulated response of the body to stress, represents a biomarker of chronic stress exposure. OBJECTIVES To determine whether preadolescent children with high AL are more susceptible to asthma as adolescents. METHODS This was a prospective evaluation of children recruited at 7 to 10 years of age in the nested case-control arm of the Study of Asthma, Genes and Environment and followed until 11 to 14 years of age. AL was measured using eight biomarkers: fasting glucose, total cholesterol, high-density lipoprotein cholesterol, dehydroepiandrosterone sulfate, cortisol, systolic and diastolic blood pressure, and waist-to-hip ratio. AL, created from the sum of biomarkers in a high-risk quartile, was related to prevalence and incidence of asthma using logistic regression. MEASUREMENTS AND MAIN RESULTS Among 352 participants followed until 11 to 14 years of age, prevalent asthma was four times more likely in boys with high (>3) versus low (≤2) AL after adjusting for current asthma/atopy, age, ethnicity, parental history of asthma, and overweight status. Similar results were observed in the analysis of new-onset asthma in boys (adjusted odds ratio, 4.35; 95% confidence interval, 1.19-15.9). In girls, there were no associations between AL and asthma. In the analysis of a subset of biomarkers, combinations of total cholesterol, glucose, and cortisol were associated with similar or greater risk of asthma prevalence or onset in boys. CONCLUSIONS AL and its biomarkers are associated with an increased likelihood of asthma in adolescent boys. The observed association between AL and asthma may be attributable to a combined subset of AL biomarkers.
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Affiliation(s)
- Salma Bahreinian
- 3-547, Edmonton Clinic Health Academy (ECHA), 11405-87 Avenue, Edmonton, AB, T6G 1C9 Canada.
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Alsaif M, Robinson JL, Lees G, Vander Leek TK. A child with lumps and bumps down on the farm. Can J Infect Dis Med Microbiol 2007; 18:203-204. [PMID: 18923718 PMCID: PMC2533548 DOI: 10.1155/2007/230729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
| | - Joan L Robinson
- Correspondence: Dr Joan Robinson, Aberhart Centre One, 11402 University Avenue, Edmonton, Alberta T6G 2J3. Telephone 780-407-1680, fax 780-407-7136, e-mail
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Leek TKV. GOAL: What Have We Learned? Allergy Asthma Clin Immunol 2005; 1:117-9. [PMID: 20529222 PMCID: PMC2877064 DOI: 10.1186/1710-1492-1-3-117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Timothy K Vander Leek
- Division of Clinical Immunology and Allergy, Department of Pediatrics, University of Alberta, Edmonton, Alberta.
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