Maria Said

Clinical and translational allergy • October 15, 2024

Antonella Muraro, Debra De Silva, Marcia Podesta, Aikaterini Anagnostou, Victoria Cardona, Susanne Halken, Pete Smith, Luciana Tanno, Paul Turner, Margitta Worm, Montserrat Alvaro Lozano, Stefania Arasi, Anna Asarnoj, Simona Barni, Kirsten Beyer, Lucy Bilaver, Andrew Bird, Roberta Bonaguro, Helen Brough, R Chinthrajah, Emma Cook, Céline Demoulin, Antoine Deschildre, Timothy Dribin, Motohiro Ebisawa, Montserrat Fernandez Rivas, Alessandro Fiocchi, David Fleischer, Eleanor Garrow, Jennifer Gerdts, Mattia Giovannini, Kirsi Järvinen, Mary Kelly, Edward Knol, Gideon Lack, Francesca Lazzarotto, Thuy-my Le, Stephanie Leonard, Jay Lieberman, Michael Makris, Lianne Mandelbaum, Mary Marchisotto, Gustavo Marino, Francesca Mori, Caroline Nilsson, Anna Nowak Wegrzyn, Mikaela Odemyr, H N Oude Elberink, Kati Palosuo, Nandinee Patel, Jennifer Pier, Sung Poblete, Rima Rachid, Pablo Rodríguez Del Río, Maria Said, Hugh Sampson, Angel Sánchez Sanz, Sabine Schnadt, Fallon Schultz, Alice Toniolo, Julia E Upton, Carina Venter, Brian Vickery, Berber Vlieg Boerstra, Julie Wang, Graham Roberts, Torsten Zuberbier

This Anaphylaxis Manifesto calls on communities to prioritise 10 practical actions to improve the lives of people at risk of serious allergic reactions. The Global Allergy and Asthma European Network and the European Federation of Allergy and Airways Diseases Patients' Associations (EFA) compiled patient-centric priorities. We used qualitative consensus methods, research evidence and feedback from over 200 patient groups, stakeholder organisations and healthcare professionals. We encourage healthcare, education and food organisations to collaborate with people at risk of serious allergic reactions to tackle safety, anxiety and financial burdens for individuals and societies. Key priorities for prevention include awareness-raising campaigns for the public and professionals, school and workplace initiatives and mandatory precautionary allergen labels on food. Priorities for improving immediate and long-term management include educating healthcare professionals, patients and schools about when and how to use adrenaline, funding two approved adrenaline devices for everyone at risk, and facilitating access to allergy specialists. Integrated care pathways should include clinical and non-clinical management options such as individualised risk assessment and quality of life assessment, self-management plans, dietetic and psychosocial support and peer support. Organisations around the world are committing to work together towards these priorities.

Clinical And Translational Allergy • November 20, 2024

Antoine Deschildre, Montserrat Alvaro Lozano, Antonella Muraro, Marcia Podesta, Debra De Silva, Mattia Giovannini, Simona Barni, Timothy Dribin, Mónica Sandoval Ruballos, Aikaterini Anagnostou, Alessandro Fiocchi, Alice Toniolo, Andrew Bird, Angel Sanz, Anna Asarnoj, Anna Nowak Wegrzyn, Berber Vlieg Boerstra, Brian Vickery, Carina Venter, Caroline Nilsson, Cecilia Parente, Céline Demoulin, David Fleischer, Diola Bijlhout, Edward Knol, Eleanor Garrow, Emma Cook, Fallon Schultz, Francesca Lazzarotto, Francesca Mori, Gary Wong, Gideon Lack, Graham Roberts, Gustavo Marino, H N G Elberink, Helen Brough, Hugh Sampson, Jay Lieberman, Jennifer Gerdts, Jing Zhao, Josefine Gradman, Julia E Upton, Julie Wang, Kati Palosuo, Kirsi Järvinen, Kirsten Beyer, Kunling Shen, Laura Polloni, Lianne Mandelbaum, Luciana Tanno, Lucy Bilaver, Marcus Shaker, Margitta Worm, Maria Said, Mary Kelly, Mary Marchisotto, Michael Makris, Mikaela Odemyr, Montserrat Fernandez Rivas, Motohiro Ebisawa, Nandinee Patel, Pablo Rodríguez Del Río, Pakit Vichyanond, Paul Turner, Pete Smith, Pilar Gaspar, R Chinthrajah, Rima Rachid, Roberta Bonaguro, Ruchi Gupta, Sabine Schnadt, Sakura Sato, Stefania Arasi, Stephanie Leonard, Sung Poblete, Susanne Halken, Thuy-my Le, Guillaume Pouessel, Tracey Dunn, Victoria Cardona, Torsten Zuberbier

GA2LEN and EFA propose minimum specifications for all industrialised countries/regions to work towards to support students with food allergies in educational settings. We reviewed research and legislation and gained feedback from over 100 patient and professional groups. We built shared expectations around: 1. training all school staff about what food allergy is, the symptoms of allergic reactions, what to do in an emergency, and when and how to use and store devices that laypeople can use to administer adrenaline (epinephrine). 2. preventing allergic reactions by using clear labelling on school menus and prepacked and non-prepacked foods and regular cleaning where students eat. 3. preparing for serious allergic reactions, with written emergency action plans for every student with food allergies, legislation allowing schools to store adrenaline for anyone who needs it in an emergency (not just those prescribed it), and training and legal safeguards for staff administering adrenaline. 4. including affected students by discussing food allergy in the curriculum, raising awareness among all students and caregivers and reviewing school processes regularly. It is time for national and international action at the policy level. Patient groups, education networks and professional societies all play a role in campaigning for shared next steps.

The Journal Of Allergy And Clinical Immunology. Global • September 17, 2024

Merryn Netting, Briony Tyquin, Wendy Freeman, Katie Frith, Heather Roberts, Maria Said, Preeti Joshi, Sandra Vale

Anaphylaxis prevention and management in the school setting is an important health and safety issue as the rates of food allergy in children continue to increase. We describe the development and review of the Australian National Allergy Council best practice guidelines for anaphylaxis prevention and management in schools. Developed in consultation with key stakeholders in health and education settings, the best practice guidelines incorporate 7 key recommendations for anaphylaxis prevention and management: an allergy aware approach; anaphylaxis management policy and plans; allergy documentation; emergency response; staff training; community and student education; and postincident management and incident reporting. An audit of Australian state and territory education department anaphylaxis guidelines, policies, and procedures indicates that most align with best practice recommendations. Ongoing reporting and evaluation of anaphylaxis incidents across all 8 jurisdictions in Australia helps us evaluate the implementation of these measures in the school setting.

The Journal Of Allergy And Clinical Immunology. Global • May 11, 2024

Samantha Stiles, Frank Sanfilippo, Kevin Murray, Richard Loh, Maria Said, Rhonda Clifford, Sandra Vale, Sandra Salter

Anaphylaxis is increasing in Australia involving all levels of the health care system. Although guidelines recommend calling an ambulance and 4-hour observation, knowledge gaps exist regarding where people experiencing anaphylaxis receive care. We sought to examine care pathways for anaphylaxis in Western Australia and factors associated with seeking care from ambulance versus the emergency department (ED), and subsequent hospital admission. A cross-sectional study was undertaken using linked ambulance, ED, hospital, and mortality data. The proportion of anaphylaxis events following each care pathway from 2010 to 2017 was examined. Multivariable logistic regression was used to determine factors associated with ambulance versus ED as the first point of care, with additional models to determine risk of admission. Most of the 16,456 anaphylaxis events followed 6 distinct care pathways. ED was first point of care in 9,713 (59.0%) events; ambulance in 5,926 (36.0%); and hospital in 817 (5.0%). Factors associated with ambulance attendance compared with ED were metropolitan region (odds ratio [OR], 3.00; 95% CI, 2.70-3.34), age more than 65 years (OR, 2.98; 95% CI, 2.54-3.50), and anaphylaxis occurring during the day (OR, 1.31; 95% CI, 1.21-1.42). Risk of subsequent hospitalization was associated with food trigger in ED (OR, 1.52; 95% CI, 1.11-2.07), age more than 65 years (OR, 1.48; 95% CI, 1.24-1.77), children younger than 5 years (OR, 1.24; 95% CI, 1.08-1.41), and history of cancer (OR, 1.36; 95% CI, 1.18-1.56). Most people experiencing anaphylaxis present directly to ED; however, ambulance care is still substantial and around half the events involved observation in the hospital. Discrepancies in recording of anaphylaxis across linked data sets highlight gaps in current burden data, supporting the need for improved reporting.

The World Allergy Organization Journal • February 15, 2024

Antonio Bognanni, Ramon Firmino, Stefania Arasi, Derek Chu, Alexandro W Chu, Siw Waffenschmidt, Arnav Agarwal, Piotr Dziechciarz, Andrea Horvath, Hanako Mihara, Yetiani Roldan, Luigi Terracciano, Alberto Martelli, Anna Starok, Maria Said, Raanan Shamir, Ignacio Ansotegui, Lamia Dahdah, Motohiro Ebisawa, Elena Galli, Rose Kamenwa, Gideon Lack, Haiqi Li, Ruby Pawankar, Amena Warner, Gary Wing Wong, Martin Bozzola, Amal Assa'ad, Christophe Dupont, Sami Bahna, Jonathan Spergel, Carina Venter, Hania Szajewska, Anna Nowak Wegrzyn, Yvan Vandenplas, Nikolaos Papadopoulos, Susan Waserman, Alessandro Fiocchi, Holger Schünemann, Jan Brożek

Cow's milk allergy (CMA) is the most complex and common food allergy in infants. Elimination of cow's milk from the diet and replacement with a specialized formula for infants with cow's milk allergy who cannot be breastfed is an established approach to minimize the risk of severe allergic reactions while avoiding nutritional deficiencies. Given the availability of multiple options, such as extensively hydrolyzed cow's milk-based formula (eHF-CM), aminoacid formula (AAF), hydrolyzed rice formula (HRF), and soy formula (SF), there is some uncertainty regarding which formula might represent the most suitable choice with respect to health outcomes. The addition of probiotics to a specialized formula has also been proposed as a potential approach to possibly increase the benefit. We systematically reviewed specialized formulas for infants with CMA to inform the updated World Allergy Organization (WAO) DRACMA guidelines. To systematically review and synthesize the available evidence about the use of specialized formulas for the management of individuals with CMA. We searched from inception PubMed, Medline, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), and the websites of selected allergy organizations, for randomized and non-randomized trials of any language investigating specialized formulas with or without probiotics. We included all studies irrespective of the language of the original publication. The last search was conducted in January 2024. We synthesized the identified evidence quantitatively or narratively as appropriate and summarized it in the evidence profiles. We conducted this review following the PRISMA, Cochrane methods, and the GRADE approach. We identified 3558 records including 14 randomized trials and 7 observational studies. Very low certainty evidence suggested that in infants with IgE-mediated CMA, eHF-CM, compared with AAF, might have higher probability of outgrowing CMA (risk ratio (RR) 2.32; risk difference (RD) 25 more per 100), while showing potentially lower probability of severe vomiting (RR 0.12, 95% CI 0.02 to 0.88; RD 23 fewer per 100, 95% CI 3 to 26) and developing food protein-induced enterocolitis syndrome (FPIES) (RR 0.15, 95% CI 0.03 to 0.82; RD 34 fewer per 100, 95% CI 7 to 39). We also found, however, that eHF-CM might be inferior to AAF in supporting a physiological growth, with respect to both weight (-5.5% from baseline, 95%CI -9.5% to -1.5%) and length (-0.7 z-score change, 95%CI -1.15 to -0.25) (very low certainty). We found similar effects for eHF-CM, compared with AAF, also in non-IgE CMA. When compared with SF, eHF-CM might favor weight gain for IgE CMA infants (0.23 z-score change, 95%CI 0.01 to 0.45), and tolerance acquisition (RR 1.86, 95%CI 1.03 to 3.37; RD 27%, 95%CI 1%-74%) for non-IgE CMA (both at very low certainty of the evidence (CoE)). The comparison of eHF-CM vs. HRF, and HRF vs. SF, showed no difference in effect (very low certainty). For IgE CMA patients, low certainty evidence suggested that adding probiotics (L. rhamnosus GG, L. casei CRL431 and B. lactis Bb-12) might increase the probability of developing CMA tolerance (RR 2.47, 95%CI 1.03 to 5.93; RD 27%, 95%CI 1%-91%), and reduce the risk of severe wheezing (RR 0.12, 95%CI 0.02 to 0.95; RD -23%, 95%CI -8% to -0.4%). However, in non-IgE CMA infants, the addition of probiotics (L. rhamnosus GG) showed no significant effect, as supported by low to very low CoE. Currently available studies comparing eHF-CM, AAF, HRF, and SF provide very low certainty evidence about their effects in infants with IgE-mediated and non-IgE-mediated CMA. Our review revealed several limitations in the current body of evidence, primarily arising from concerns related to the quality of studies, the limited size of the participant populations and most importantly the lack of diversity and standardization in the compared interventions. It is therefore imperative for future studies to be methodologically rigorous and investigate a broader spectrum of available interventions. We encourage clinicians and researchers to review current World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) Guidelines for suggestions on how to use milk replacement formulas in clinical practice and what additional research would be the most beneficial.