The economic costs of severe anaphylaxis in France: an inquiry carried out by the Allergy Vigilance Network.

BACKGROUND: The prevalence of severe anaphylaxis, between 1 and 3 per 10,000, has increased sharply over recent years, with a rate of lethality of 1%. The economic burden is unknown. OBJECTIVE: The aim of this study was to estimate the economic costs of anaphylaxis, including direct costs of treatment, hospitalization, preventive and long-care measures, and the indirect cost: absenteeism. METHODS: Analysis of 402 patients of anaphylaxis declared by 384 allergists was reported to the Allergy Vigilance Network. The global cost was estimated from the national data of hospital admissions: ICD-10 coding available for 2003, 2004 and 2005. RESULTS: Three work/classroom days were lost per patient. Diagnosis required oral challenge with hospitalization in 18% of cases. The estimated mean total cost was 1895 euros for food- and drug-related anaphylaxis (5610 euros for the most severe), and 4053 euros for Hymenoptera anaphylaxis. National statistics recorded 2575 patients in 2005; 22% more than in 2003. The estimated annual cost was 4,789,500 euros. The possible reasons for this being an under-estimate include: data coming only from hospitalized patients, poor identification by medical teams unfamiliar with ICD-10 codes, peri-operative anaphylaxis being insufficiently declared, rush-immunotherapy and maintenance treatments for Hymenoptera anaphylaxis. Similarly, the extra cost of cow milk substitutes, as well as insurance costs where deaths are followed by litigation were not taken into account. CONCLUSIONS: The mean cost of anaphylaxis was 1895-5610 euros in nonfatal patients. The prevalence was under-estimated because of many biases, leading to under-estimation of the national cost. Further studies would be necessary to evaluate the value of preventive strategies.

Oral desensitization in children with milk and egg allergies obtains recovery in a significant proportion of cases. A randomized study in 60 children with cow's milk allergy and 90 children with egg allergy.

BACKGROUND: Food allergy is treated by avoidance diets in order to prevent anaphylactic reactions and to cure chronic associated symptoms. However, the natural history is left unchanged. OBJECTIVE: To search for a beneficial effect of an oral desensitization protocol to allergenic foods in IgE-dependent milk or egg allergies in children. METHODS: 60 children with documented cow's milk allergy (13 months-6.5 years), and 90 children with egg allergy (12 months-8 years), were consecutively included after 6-12 months of avoidance diet, if a SBPCFC to 60 ml milk (60 ml) or to 965 mg of raw egg white was negative. They were randomized for uninterrupted avoidance or oral desensitization (group A or OD). Six months later, a new SBPCFC was performed with, up to 200 ml of milk or 7g of raw egg white. Prick tests and specific IgE levels were carried out simultaneously. RESULTS: Data were obtained for 57 children with CMA (30 A and 27 OD), and 84 children with EA (35 A and 49 OD). The two groups (AD or OD group) were similar with regard to means of ages, the size of PT wheals and the level of IgEs at baseline. MILK ALLERGY: A SBPCFC to milk was positive in 11.1% of those following OD vs. 40% after A (p < .025). The size of PT decreased after OD and increased after A (-3.4 mm vs. +0.84 mm; p < .002). EGG ALLERGY: The SBPCFC to egg was positive in 30.6% after OD vs. 48.6% after A (p < .1). After 6 months, in the OD group, the mean size of the PT and the level of specific IgE were significantly reduced compared to the A group. In the A group, the threshold of reactivity was often lower, or more serious symptoms were observed. CONCLUSION: Oral desensitization helps the egg and milk allergic children to overcome their allergies. Since the avoidance of these foods is likely to increase sensitization as well as to lower the threshold of reactivity, an active treatment is required. Further attempts to standardize the procedures of oral desensitization are expected.

The risk of systemic reactions to skin prick-tests using food allergens: CICBAA data and literature review.

Prick-tests to foods are usually carried out as the first step in the diagnosis of food allergy. Severe anaphylaxis accounts for 4.9 % of allergies in children and occurs more frequently in adults, raising the possibility of systemic reactions to prick-tests in highly sensitized people. Several studies published in the literature have used commercial extracts. As for airborne allergens, concentrations causing a skin reaction of 15 mm do not present a risk of systemic reactions. Prick-tests to native foods--prick-in-prick tests--have been less extensively studied. The CICBAA1 data, from 1,138 food allergic patients of all ages, cover 34,905 prick-in-prick tests to foods. The wheal of these prick-tests has been regulary registered. The risk of systemic reactions can be evaluated at 0.008 %. There were no severe reactions and anti-histamine and corticosteroid therapy were sufficient. These results are similar to those of the large study in 2000 carried out by Devenney in neonates (0.005%). A review of the literature reveals only a few severe reactions in adults. The authors draw attention to the necessary precautions: temporary contra-indication for skin prick-tests in children and adults with grade 3 or 4 asthma, with particular attention to such foods as all kinds of nuts, fish, etc.

[Efficiency of diagnosis of latex allergy by the combined use of three latex materials for prick-tests]. / Intérêt de l'utilisation associée de trois matériels de latex pour prick-tests, dans le diagnostic de l'allergie au latex.

The diagnosis of latex allergy is mainly based on prick-tests. In order to improve the efficiency of the diagnosis, a comparative study of three latex materials is carried out in 64 controls and 29 patients allergic to latex = Stallergènes and Allerbio extracts, prepared from crude natural latex, and an ammoniated emulsion of rubber latex (AEL). No adverse reactions are recorded. The specificity is 100% for both extracts, 85% for AEL. Sensitivity is respectively 68%, 63%, 72%. The range of values of the wheal is significantly narrower for Stallergènes extract. 46% of allergic patients are reactive to the three materials. The combined use of three materials reaches an 80% efficiency similar to that of Rast Cap System and the addition of three prick-tests and Rast obtains an efficiency of 93.1%. Using several latex materials could increase the efficiency of the diagnosis, inasmuch as the extracts are generated from natural latex, whereas patients are sensitized to manufactured products originating from ammoniated latex.

[Use of an amino-acid-based formula in the treatment of cow's milk protein allergy and multiple food allergy syndrome]. / Intérêt d'une formule à base d'acide aminés dans le traitement de l'allergie au protéines du lait de vache et du syndrome des allergies alimentaires multiples.

Food allergy to cow's milk proteins (APLV) is frequently found in young infants. Treatment is by starting an elimination diet. Different substitution products have been proposed: soya milk, partial hydrolysate of the proteins of lactoserum, powdered casein hydrolysate, hydrolysed soya and pork collagen. Allergic reactions to soya milk, hydrolysates of lactoserum proteins, powdered casein hydrolysates and hydrolysates of soya have been described. The study that we present evaluates the effect on the natural development of these allergies of a formula based on amino-acids (Neocate) in 26 patients who presented a syndrome of multiple allergies one of which was a food allergy to milk. Twenty-five of them had a severe atopic dermatitis, isolated (14 cases), or associated with gastro-intestinal troubles (6) break in the growth curve (5), anaphylactic reactions (2), one asthma (1). One child had a chronic diarrhoea associated with a weight plateau. Evaluation 2 or 3 months later showed a significant improvement of the atopic dermatitis. Return of the stature-weight growth was noted in 4 children from 5, the check in one was reported as due to a initially unrecognised allergy to gluten. The recovery of the APLV was shown by double-blind oral provocation test in 20/23 children between 11 and 37 months (22 +/- 9). Duration of administration of Neonate was between 6 to 19 months (12 + 5) months. This study confirmed the beneficial effect of the amino-acid formula on weight gain, gastro-intestinal troubles and development of atopic dermatitis. The level of recovery of APLV of 86% at the age of 2 years is better than that reported in the syndrome of multiple food allergies of 22%. The influence of this diet on the development of other food allergies remains to be evaluated.

Prospective study of mustard allergy: first study with double-blind placebo-controlled food challenge trials (24 cases).

BACKGROUND: Mustard allergy accounts for 1.1% of food allergies in children. However, double-blind placebo-controlled food challenge trials (DB PCFCs) have not yet been proposed. OBJECTIVE: To carry out DB PCFCs to determine the real frequency of mustard allergy in patients sensitized to mustard. METHODS: A prospective study was conducted in 30 subjects aged 3-20 years presenting positive prick tests to ground mustard seeds (Brassica nigra), mustard flour (B. juncea), metabisulfite-free strong mustard seasoning (B. juncea) and a commercialized allergenic extract (B. nigra). Twenty-seven subjects were screened for mustard-specific immunoglobulin E (IgE). PCFCs were carried out either DB or single blind (SB) with up to 1340 mg of metabisulfite-free seasoning. RESULTS: The mean diameter of the wheal induced by prick tests with the allergenic extract was lower (n.s.) than that induced by the native mustard products: 5.8 mm (1.5-15) vs 6.9 mm (0.5-18) for B. nigra ground seeds, 7.8 mm (1-20) for B. juncea flour and 9.7 mm (3-20) for the strong mustard seasoning. The diameter of the wheal induced by the allergenic extract was significantly different from that induced by the mustard seasoning (P < 0.005). The mean of mustard specific-IgE values was 8.7 KU/l (0.35-72.4). Seven of 30 food challenges were considered positive. Mean prick test results in the positive and negative PCFC subgroups were 5.5 mm vs 5.9 mm for the commercialized extract, 10.9 mm vs 5.8 mm for B. nigra ground seeds (P < 0.01), 9.9 mm vs 7.1 mm for B. juncea flour (n.s. P > 0.25) and 11.5 mm vs 9.1 mm for the metabisulfite-free mustard seasoning (n.s. P > 0.1). Mean specific IgE values determined by CAP system radioallergosorbent test (Phadebas Pharmacia) were higher but not significantly so (P > 0.25) in the subgroup with mustard allergy (12.3 K/l vs 7.6 KU/l). CONCLUSIONS: About 23.3% of the sensitized subjects were allergic to a routine dose of mustard. Positive prick tests and the presence of specific IgE were not predictive. SB PCFC or DB PCFC is required before recommending avoidance diets.

Food anaphylaxis in schools: evaluation of the management plan and the efficiency of the emergency kit.

BACKGROUND: Children with severe food allergies can benefit from a personalized care project (PCP) in schools. The usefulness of the PCP and the residual risk of allergic emergencies are poorly appreciated. The objective was to evaluate the efficiency of the management plan and the training in the use of the emergency kit. METHODS: A telephone survey using a detailed questionnaire was performed in 45 families whose children had been previously referred to the department. The distribution of disorders was as follows: asthma, 37.7%; atopic dermatitis and asthma, 28.8%; atopic dermatitis, 15.5%; angioedema and urticaria, 13.3%; and anaphylactic shock, 4.2%. Food allergy had been diagnosed in the 45 children by past history, and double-blind or single-blind, placebo-controlled food challenges (DBPCFCs, or SBPCFCs) with evidence of specific IgE. Exactly 75.5% of the children had peanut allergy. Multiple food allergies characterized 46.8% of the subjects. They had benefited from a strict elimination diet and a protocol for emergency care including a ready-to-use intramuscular epinephrine injection. A PCP had been requested by the School Public Health Service. RESULTS: Thirty-nine PCPs were implemented (86.5% of the requests). They represented 63% of the PCPs for food allergy in the eastern region of France: one per 5800 school-age children. The retrospective period of evaluation was 25 months on average. The types of meals were very diverse, and medically acceptable in 83% of cases. The place where the emergency kit was stored in the school varied. Forty reactions occurred in 33% of the children (5/6 times in the absence of a PCP), asthma in 28%, shock in 1%, and immediate skin reactions in 11%. Reactions occurred at home in 78% of the subjects, and in school in 22% of the subjects. The cause of the reactions was not specifically known in 63% of cases. Twenty-seven percent of the reactions were linked to the ingestion of food allergens. In 10% of subjects, the reaction was due to a modification of ingredients by the food industry. CONCLUSIONS: The frequency of respiratory symptoms during oral challenge tests was confirmed by the frequency of asthmatic reactions within the follow-up period. The role of hidden allergens and of misleading labeling validates the need for PCPs in the case of peanut and tree nut allergies, past history of severe reactions, multiple food allergies, reactions to a low dose in DBPCFCs, and asthmatic reactions to foods. This study provides encouraging data on the usefulness of PCPs and confirms the need for thorough instruction and training of the school staff in dealing with allergic emergencies. Addition of a beta-agonist spray to the emergency kit is suggested.

Thresholds of clinical reactivity to milk, egg, peanut and sesame in immunoglobulin E-dependent allergies: evaluation by double-blind or single-blind placebo-controlled oral challenges.

BACKGROUND: The prevalence of food anaphylaxis due to masked allergens has increased within the last 10 years. Contamination of manufactured products by food allergens is a key concern for food industries. OBJECTIVE: To determine quantities eliciting reactions in patients who have an IgE-dependent food allergy, thanks to standardized oral provocation tests. To evaluate the subsequent levels of sensitivity required for the detection tests of allergens for egg, peanut, milk and sesame. METHODS: Prick-in-prick tests, Cap system RAST, and single or double-blind placebo-controlled food challenges (SBPCFC or DBPCFC) were performed. The doses of natural food were gradually increased from 5 to 5000 mg for solid food and from 1 to 30 mL for peanut oil, sunflower oil, soy oil and sesame oil. RESULTS: Data from 125 positive oral challenges to egg, 103 to peanut, 59 to milk and 12 to sesame seeds were analysed. Haemodynamic modifications were observed in 2%, 3%, 1.7%, and 8% of the oral challenges (OCs) to egg, peanut, milk and sesame, respectively. Respiratory symptoms were observed in 12%, 20%, 10% and 42% of egg, peanut milk and sesame allergies, respectively. A cumulative reactive dose inferior or equal to 65 mg of solid food or 0.8 mL of milk characterized 16%, 18%, 5% and 8% of egg, peanut, milk and sesame allergies, respectively. 0.8% of egg allergies, 3.9% of peanut allergies, and 1.7% of milk allergies reacted to 10 mg or less of solid food or to 0.1 mL for milk. The lowest reactive threshold has been observed at less than 2 mg of egg; 5 mg of peanut, 0.1 mL of milk and 30 mg of sesame seed. Ten out of 29 OC with peanut oil, two out of two OC with soy oil and three out of six OC with sunflower oil were positive. Five out six OC with sesame oil were positive: 1 and 5 mL induced an anaphylactic shock. CONCLUSION: The risk of asthma and anaphylactic shock to sesame and peanut is confirmed. Minimal reactive quantities show that, in order to guarantee a 95% safety for patients who are allergic to egg, peanut and milk, and on the basis of consumption of 100 g of food, the detection tests should ensure a sensitivity of 10 p.p.m. for egg, 24 p.p.m. for peanut and 30 p.p.m. for milk proteins. Oil allergies being considered, the limit of sensitivity should fall to 5 p.p.m.