Fish Allergy Finned fish can cause severe allergic reactions (such as anaphylaxis). Therefore it is advised that people with fish allergy have quick access to an epinephrine auto-injector (such as an EpiPen®, Auvi-Q® or Adrenaclick®) at all times. This allergy usually is lifelong. Approximately 40 percent of people with fish allergy experienced their first allergic reaction as adults.1 To prevent a reaction, strict avoidance of fish and fish products is essential. Always read ingredient labels to identify fish ingredients. Salmon, tuna and halibut are the most common kinds of finned fish to which people are allergic. More than half of all people who are allergic to one type of fish also are allergic to other fish, so allergists often advise their fish-allergic patients to avoid all fish. If you are allergic to a specific type of fish but want to have other fish in your diet, talk to your doctor about the possibility of allergy testing for specific fish. Finned fish and shellfish do not come from related families of foods, so being allergic to one does not necessarily mean that you must avoid both. Avoiding Fish The federal Food Allergen Labeling and Consumer Protection Ac (FALCPA) requires that all packaged food products sold in the U.S. that contains fish as an ingredient must list the specific fish used on the label. Read all product labels carefully before purchasing and consuming any item. Ingredients in packaged food products may change without warning, so check ingredient statements carefully every time you shop. If you have questions, call the manufacturer. As of this time, the use of advisory labels (such as “May Contain”) on packaged foods is voluntary, and there are no guidelines for their use. However, the FDA has begun to develop a long-term strategy to help manufacturers use these statements in a clear and consistent manner, so that consumers with food allergies and their caregivers can be informed as to the potential presence of the eight major allergens. Read more about food labels> It has been estimated that there are upwards of 20,000 species of fish. Although this is not an exhaustive list, allergic reactions have been commonly reported to: • Anchovies • Bass • Catfish • Cod • Flounder • Grouper • Haddock • Hake • Halibut • Herring • Mahi Mahi • Perch • Pike • Pollock • Salmon • Scrod • Swordfish • Sole • Snapper • Tilapia • Trout • Tuna Some Unexpected Sources of Fish* • Caesar salad and Caesar dressing • Worcestershire sauce • Bouillabaisse • Imitation or artificial fish or shellfish (surimi, also known as “sea legs” or “sea sticks,” is one example) • Meatloaf • Barbecue sauce • Caponata, a Sicilian eggplant relish *Note: This list highlights examples of where fish has been unexpectedly found (e.g., on a food label for a specific product, in a restaurant meal, in creative cookery). This list does not imply that fish is are always present in these foods; it is intended to serve as a reminder to always read the label and ask questions about ingredients before eating a food that you have not prepared yourself. Keep the following in mind: • Fish protein can become airborne in the steam released during cooking and may be a risk. Stay away from cooking areas. • If you have seafood allergy, avoid seafood restaurants. Even if you order a non- seafood item off of the menu, cross-contact with fish is possible. • Ethnic restaurants (e.g., Chinese, African, Indonesian, Thai and Vietnamese) are considered high-risk because of the common use of fish and fish ingredients and the possibility of cross-contact, even if you do not order fish. • Avoid foods like fish sticks and anchovies. Some individuals with fish allergy make the mistake of thinking that such foods don’t “count as real fish.” • Many people who are allergic to fish or shellfish are allergic to more than one kind. Get tested and have your allergies confirmed by a physician so that you know for sure which foods to avoid. • The protein in the flesh of fish most commonly causes the allergic reaction; however, it is also possible to have a reaction to fish gelatin, made from the skin and bones of fish. Although fish oil does not contain protein from the fish from which it was extracted, it is likely to be contaminated with small molecules of protein and therefore should be avoided. • Carrageenan, or "Irish moss,” is not fish. It is a red marine algae that is used in a wide variety of foods, particularly dairy foods, as an emulsifier, stabilizer and thickener. It appears safe for most individuals with food allergies. • Allergy to iodine, allergy to radiocontrast material (used in some radiographic procedures), and allergy to fish are not related. If you have an allergy to fish, you do not need to worry about cross reactions with radiocontrast material or iodine. Avoiding Cross-Contact Cross-contact happens when one food comes into contact with another food and their proteins mix. As a result, each food then contains small amounts of the other food. These amounts are so small that they usually can’t be seen. Even this tiny amount of food protein has caused reactions in people with food allergies! The term “cross-contact” is fairly new. Some people may call this “cross-contamination.” Download a one-page summary about cross-contact > Understanding the difference between Cross-Contamination vs. Cross- Contact When dining at a restaurant, you will need to have a discussion about cross-contact with one of the restaurant employees. Even though food allergies are commonly understood, the term cross-contact is fairly new. You may know the term and how to safely prepare an allergen- free meal, but this term is still not universally used in the food service industry. The commonly used term is cross-contamination. Foodservice employees are trained to prevent foods from being contaminated by biological contaminates. Once you know the difference it will be easier to discuss this at the restaurant. Cross-contamination is a common factor in the cause of foodborne illness. Microorganisms such as bacteria and viruses from different sources can contaminate foods during preparation and storage. Proper cooking of the contaminated food in most cases will reduce or eliminate the chances of a foodborne illness. Cross-contact occurs when an allergen is inadvertently transferred from a food containing an allergen to a food that does not contain the allergen. Cooking does not reduce or eliminate the chances of a person with a food allergy having a reaction to the food eaten. As you can see, many food service employees will hear you say cross-contact, and may think this is the same thing as cross-contamination. It is your responsibility to explain the difference to them. Examples of Cross-Contact and How to Avoid It A knife that has been used to spread peanut butter is only wiped clean before being used to spread jelly. There could be enough peanut protein remaining on the knife to cause a reaction in a person who has a peanut allergy. All equipment and utensils must be cleaned with hot, soapy water before being used to prepare allergen-free food. Even a trace of food on a spoon or spatula that is invisible to us can cause an allergic reaction. Talking to Restaurant Personnel about Cross-Contact It is important to be aware of cross-contact when dining out. A good example of this is the use of a flattop grill. During breakfast the grill may be used to scramble eggs and cook French toast, so the grill would contain egg, milk, and wheat proteins. During lunch, the grill may be used to cook meats. These items may not contain egg, milk, or wheat proteins, but if the grill was not properly cleaned before lunch, the allergens would still be present. These meats would now come in contact with these proteins and be contaminated. Be sure to speak to a manager about their procedures for cooking allergen-free meals. Do not be nervous about calling a restaurant you would like to dine at. The chef and managers appreciate your call. They do not want to do anything to cause you an allergic reaction. The best time to call is between 2:00 pm and 4:00 pm, when most restaurants are not as busy. If the chef or manager is not available, ask for the chef or manager’s name and the best time to call back. Questions to ask the chef or manager about cross-contact • Do you have a separate area to prepare foods for special diets? • Do you have separate cutting boards and utensils to prepare my meal on? • Do you use a shared grill and/or fryer for cooking regular meals and allergen-free meals? If the answer to this question is yes, the restaurant does not understand food allergies. • Who will be preparing my meal? Servers should not prepare any part of your meal. Ladles and tongs used for serving soups and salad ingredients can be inadvertently placed back with the wrong food. This could cause your meal to come in contact with other foods you may be allergic to. • How will my meal be labeled and delivered? It should be delivered separately, preferably by the chef or manager. Many servers balance several plates on their arms, or set several plates overlapping on a tray. You do not want your plate next to another plate that might contain an allergen. • Can my table be sanitized? Read more tips for dining out> Effective Cleaning To effectively remove food protein from surfaces, wash the surfaces with soap and water. Simply wiping the crumbs from spatulas, cookie sheets, cutting boards, or surfaces is not enough.