Prehospital Care in Fatal Food Anaphylaxis: A Nationally Representative Case Series.

Separating Fact from Fiction in the Diagnosis and Management of Food Allergy

Anaphylaxis is a life-threatening reaction characterized by the acute onset of symptoms involving different organ systems and requiring immediate medical intervention. The incidence of fatal food anaphylaxis is 0.03 to 0.3 million/people/year. Most fatal food-induced anaphylaxis occurs in the second and third decades of life. The identified risk factors include the delayed use of epinephrine, the presence of asthma, the use of recreational drugs (alcohol, nicotine, cannabis, etc.), and an upright position. In the United Kingdom (UK) and Canada, the reported leading causal foods are peanuts and tree nuts. In Italy, milk seems to be the most common cause of fatal anaphylaxis in children < 18 years. Fatal food anaphylaxis in Italian children and adolescents almost always occurs outside and is characterized by cardiorespiratory arrest; auto-injectable adrenaline intramuscular was available in few cases. Mortality from food anaphylaxis, especially in children, is a very rare event with stable incidence, but its risk deeply impacts the quality of life of patients with food allergy and their families. Prevention of fatal food anaphylaxis must involve patients and their families, as well as the general public, public authorities, and patients’ associations.

BackgroundFood allergy is a common cause of anaphylaxis, but the incidence of fatal food anaphylaxis is not known. The aim of this study was to estimate the incidence of fatal food anaphylaxis for people with food allergy and relate this to other mortality risks in the general population.MethodsWe undertook a systematic review and meta-analysis, using the generic inverse variance method. Two authors selected studies by consensus, independently extracted data and assessed the quality of included studies using the Newcastle-Ottawa assessment scale. We searched Medline, Embase, PsychInfo, CINAHL, Web of Science, LILACS or AMED, between January 1946 and September 2012, and recent conference abstracts. We included registries, databases or cohort studies which described the number of fatal food anaphylaxis cases in a defined population and time period and applied an assumed population prevalence rate of food allergy.ResultsWe included data from 13 studies describing 240 fatal food anaphylaxis episodes over an estimated 165 million food-allergic person-years. Study quality was mixed, and there was high heterogeneity between study results, possibly due to variation in food allergy prevalence and data collection methods. In food-allergic people, fatal food anaphylaxis has an incidence rate of 1.81 per million person-years (95%CI 0.94, 3.45; range 0.63, 6.68). In sensitivity analysis with different estimated food allergy prevalence, the incidence varied from 1.35 to 2.71 per million person-years. At age 0–19, the incidence rate is 3.25 (1.73, 6.10; range 0.94, 15.75; sensitivity analysis 1.18–6.13). The incidence of fatal food anaphylaxis in food-allergic people is lower than accidental death in the general European population.ConclusionFatal food anaphylaxis for a food-allergic person is rarer than accidental death in the general population.

Fatal food anaphylaxis is rare, but a major concern for people with food allergy and their carers. We evaluated whether community healthcare professionals accurately estimate risk of fatal anaphylaxis for food allergic children, and whether accurate risk estimation is related to competence in recognizing and managing anaphylaxis. We enrolled 90 community healthcare professionals in a cross-sectional survey- 30 primary care nurses, 30 school first aiders, 30 community pharmacists. Participant risk estimates for fatal and non-fatal anaphylaxis, and all-cause fatalities, were measured using a risk ladder. Participant anaphylaxis knowledge was assessed by questionnaire, and practical skills using a simulated anaphylaxis scenario. In all three groups, participants significantly overestimated the risk of fatal anaphylaxis for food allergic children, by a mean factor of 13.5-fold (95% CI 5.0, 31.6), but did not overestimate non-fatal anaphylaxis risk or all-cause fatality risk. We found no evidence of a relationship between successful adrenaline administration and risk estimation. In conclusion, we have found evidence that community pharmacists, school first aiders and primary care nurses in the UK systematically overestimate the risk of fatal anaphylaxis for a food allergic child. This overestimation may result in increased patient and carer anxiety. Community practitioners who manage childhood food allergy and anaphylaxis need to be educated about the level of risk for fatal anaphylaxis in such children.

Up to 5% of the US population has suffered anaphylaxis. Fatal outcome is rare, such that even for people with known venom or food allergy, fatal anaphylaxis constitutes less than 1% of total mortality risk. The incidence of fatal anaphylaxis has not increased in line with hospital admissions for anaphylaxis. Fatal drug anaphylaxis may be increasing, but rates of fatal anaphylaxis to venom and food are stable. Risk factors for fatal anaphylaxis vary according to cause. For fatal drug anaphylaxis, previous cardiovascular morbidity and older age are risk factors, with beta-lactam antibiotics, general anesthetic agents, and radiocontrast injections the commonest triggers. Fatal food anaphylaxis most commonly occurs during the second and third decades. Delayed epinephrine administration is a risk factor; common triggers are nuts, seafood, and in children, milk. For fatal venom anaphylaxis, risk factors include middle age, male sex, white race, cardiovascular disease, and possibly mastocytosis; insect triggers vary by region. Upright posture is a feature of fatal anaphylaxis to both food and venom. The rarity of fatal anaphylaxis and the significant quality of life impact of allergic conditions suggest that quality of life impairment should be a key consideration when making treatment decisions in patients at risk for anaphylaxis.

ObjectiveTo describe time trends for hospital admissions due to food anaphylaxis in the United Kingdom over the past 20 years.DesignAnalysis of national data, 1998-2018.SettingData relating to hospital admissions for anaphylaxis...

People with food allergies may experience food allergic reactions due to accidental exposure. These reactions are commonly categorised as non-severe, fatal food anaphylaxis and near-fatal food anaphylaxis. Non-severe allergic reactions to food are more common with an incidence of up to 1,000 times greater than fatal food-related anaphylaxis. However, obtaining accurate data relating to the circumstances under which these reactions occurred is challenging under the current diagnosis coding system used in the National Health Service (NHS). This project addressed two key questions: 1. What are the trends in the occurrence of food hypersensitivity (FHS) reactions and their consequences in terms of healthcare encounters (both to hospital and primary care)? 2. What are the circumstances surrounding severe, life-threatening reactions to food? Approach The researchers used existing NHS datasets (relating to Hospital Admissions, Accident &amp; Emergency visits, Critical Care admissions and Primary care visits) to evaluate healthcare encounters due to food hypersensitivity over the study period. Patient pathways through the healthcare system were also assessed by linking these different datasets. Key Results • Food-induced anaphylaxis represented 29.4% of reported anaphylaxis. admissions, and increased significantly from 1.23 to 4.02 admissions per 100,000 population per annum over the study period. • However, despite an annual increase of 5.7% in hospitalisation for food-induced anaphylaxis between 1998 and 2018, the case fatality rate (proportion of hospital admissions associated with a fatal outcome) more than halved, from 0.7% in 1998 to less than 0.3% in 2018. • 152 deaths were identified during the study period where the cause was very likely to have been food-induced anaphylaxis. • At least 86 (46%) fatalities were triggered by peanut or tree nuts. • Cows’ milk was reported to be the most common cause of fatal anaphylaxis in children aged under 16 years. • Using data from England for the period 2008-2018, the prevalence of food allergy ranged from 4% in preschool-aged children (under 5 years), 1-2% in school-aged children and young people (5 to 20 years) and 0.9% in adults. Although the same methods were used throughout the study period, the statistics presented may be prone to limitations such as miscoding and incomplete datasets. • Prescription of adrenaline auto-injector devices (AAI) are an important risk management intervention in people at risk of food-induced anaphylaxis. However, there is significant under-prescribing of AAI. Data showed that 40% of individuals with prior food-induced anaphylaxis were not prescribed AAI and at least 59% did not have AAI on repeat prescription. • Most healthcare visits for food allergy occurred in general practice. Less than 3% of individuals with a diagnosis of food allergy attended Accident and Emergency during the study period, 2008-2018. Therefore, using hospital data in isolation to analyse patterns of health service utilisation with respect to FHS may not provide a comprehensive overview.

People with food allergies may experience food allergic reactions due to accidental exposure. These reactions are commonly categorised as non-severe, fatal food anaphylaxis and near-fatal food anaphylaxis. Non-severe allergic reactions to food are more common with an incidence of up to 1,000 times greater than fatal food-related anaphylaxis. However, obtaining accurate data relating to the circumstances under which these reactions occurred is challenging under the current diagnosis coding system used in the National Health Service (NHS). This project addressed two key questions: 1. What are the trends in the occurrence of food hypersensitivity (FHS) reactions and their consequences in terms of healthcare encounters (both to hospital and primary care)? 2. What are the circumstances surrounding severe, life-threatening reactions to food? Approach • A UK arm of NORA was established using the same online platform as the existing European Registry. • Participation of healthcare professionals and/or patients to enter relevant information was co-ordinated by BSACI in conjunction with the Paediatric Emergency Research in the United Kingdom Ireland (PERUKI) network. • Different versions of the questionnaire were developed to increase response rates: (1) a comprehensive form mapped to existing NORA data fields for completion by Healthcare Professionals in the non-acute setting; (2) a shorter form with key data fields to increase data reporting in more pressured, acute healthcare settings; and (3) a form for completion by patients or their parent/guardian. Key Results The launch of the UK anaphylaxis registry faced delays and was impacted by significant pressures on NHS services due to the COVID-19 pandemic. This led to a lower than anticipated uptake of the Registry by clinics and Accident &amp; Emergency departments. As a result, only a minority of accidental reactions (less than 5%) were captured in the registry, almost all in children and young people under age 18 years. Some indicative results of this analysis are the following: • 213 cases reported to be due to a food trigger and of these, 208 occurred in children/young people aged 18 years or under. • Common food triggers were peanut, tree nuts (especially cashew), cow’s milk/dairy and hen’s egg. • 47% of reactions occurred after consumption of prepacked food products and in at least 59% of these cases, the allergen was declared as an actual ingredient. Further work would be needed to understand how to optimise reporting of data, for example by reducing the time burden for completion by clinicians and patients.

Gaining a better understanding of the risk factors for severe anaphylaxis represents a crucial challenge for physicians. This survey aimed to analyse cases of severe food anaphylaxis and assess potential risk factors for severity. We retrospectively analysed food anaphylaxis cases recorded by the French-speaking Allergy-Vigilance Network (2002-2021) and compared the main characteristics of grade 3 (Ring classification) and grade 4 cases using univariate and multivariate statistical analyses. Of the 2621 food anaphylaxis cases reported, 731 (27.9%) were considered severe (grade 3, n = 687 [94%] and grade 4, n = 44 [6%]; 19 deaths). Overall, 56.1% of cases were adults (mean age: 28.3 years) and 53.7% were male. The most frequent triggers were peanut (13.9%), wheat (9.4%), cashew (5.8%), shrimp (5.3%), and cow's milk (4.6%). More grade 4 anaphylaxis cases occurred in children than in adults (26 vs. 18; p = 0.01). In univariate analysis, individuals with grade 4 anaphylaxis were more likely to have a history of allergy to the culprit food (71.1% vs. 42.1%; p < 0.001), asthma diagnosis (59.5% vs. 30.4%; p < 0.001), and peanut as the culprit food (34.1% vs. 12.6%; p < 0.001). In multivariate analysis, factors predictive of grade 4 anaphylaxis were asthma diagnosis (OR [95% CI]: 3.41 [1.56-7.44]; p = 0.002) and peanut as the culprit trigger (OR [95% CI]: 3.46 [1.28-9.34]; p = 0.014). Our data highlight the risk factors for severe food anaphylaxis, notably a history of asthma and peanut as the culprit food. These individuals should benefit from personalised management strategies.

Airway, Breathing or Circulation Failure in Fatal Food Anaphylaxis: A Nationally Representative Case Series.

The observed increase in incidence of allergic disease in many regions over the past 3 decades has intensified interest in understanding the epidemiology of severe allergic reactions. We discuss the issues in collecting and interpreting these data and highlight current deficiencies in the current methods of data gathering. Anaphylaxis, as measured by hospital admission rates, is not uncommon and has increased in the United Kingdom, the United States, Canada, and Australia over the last 10-20 years. All large datasets are hampered by a large proportion of uncoded, 'unspecified' causes of anaphylaxis. Fatal anaphylaxis remains a rare event, but appears to be increasing for medication in Australia, Canada, and the United States. The rate of fatal food anaphylaxis is stable in the United Kingdom and the United States, but has increased in Australia. The age distribution for fatal food anaphylaxis is different to other causes, with data suggesting an age-related predisposition to fatal outcomes in teenagers and adults to the fourth decade of life. The increasing rates of food and medication allergy (the latter exacerbated by an ageing population) has significant implications for future fatality trends. An improved ability to accurately gather and analyse population-level anaphylaxis data in a harmonized fashion is required, so as to ultimately minimize risk and improve management.

Background The risk of fatal anaphylaxis in a food allergic person is very low, yet the possibility of this catastrophic event is a major focus for both patients and healthcare professionals. It is unclear how healthcare professionals perceive risk of fatal or non-fatal anaphylaxis in the context of food allergy, and whether their perception of risk influences their management of food allergy. We investigated whether school nurses/first aiders could accurately estimate fatal anaphylaxis risk in children/young people with food allergy, and whether their assessment of risk correlated with their knowledge and management of food allergy in children/young people. Methods Interview-based surveys completed in 30 schools over 6 months included assessment of risk perception in relation to childhood food allergy using a novel risk assessment tool, an assessment of their knowledge of when to administer adrenaline and assessment of their practical ability to use an adrenaline autoinjector. Results Risk perception varied widely but all participants overestimated fatal food anaphylaxis risk more than they overestimated all-cause mortality risk in young people [median log-fold overestimate for all-cause mortality 0.51 (IQR 0.00, 1.48); food anaphylaxis death 1.20 (IQR 0.06, 2.10) p=0.018]. We did not find any association between estimation of anaphylaxis/fatal anaphylaxis risk in a food allergic child, and practical ability to use an adrenaline autoinjector in a simulated scenario. We did however find that participants who state that they would (unnecessarily) dial emergency services for a non-anaphylactic reaction, also significantly overestimated risk of anaphylaxis in a food allergic person (median log-fold overestimate 1.76 (IQR 0.92, 2.33) vs. 0.72 (IQR -1.51, 1.59) for those who would not dial emergency services for a non-anaphylactic reaction (p=0.009). Multivariate analyses showed weak evidence that personal or previous medical experience of allergic disease correlates with increased overestimation of fatal food anaphylaxis risk. Conclusion School nurses/first aiders overestimate fatal food anaphylaxis risk more than overestimating other fatality risks in children. The data suggests that this overestimation of risk is not associated with improved ability to recognise/manage anaphylaxis. These data suggest that correcting any risk misperception among healthcare providers, in relation to risk of anaphylaxis in food allergy, is unlikely to be harmful.

Age As a Risk Factor For Fatal Food-Induced Anaphylaxis: An Analysis Of UK and Australian Fatal Food Anaphylaxis Data

A new approach to epinephrine deficiency and fatal food anaphylaxis

Fatal Food Anaphylaxis in Children: A Statutory Review in England.