WORLD ALLERGY ORGANIZATION WAOWAO WhiteWhite BookBook onon AllergyAllergy Update 2013 WAO White Book on Allergy World Allergy Organization (WAO) White Book on Allergy: Update 2013 Copyright 2013 World Allergy Organization WAO White Book on Allergy: Update 2013 Editors Prof. Ruby Pawankar, MD, PhD Prof. Giorgio Walter Canonica, MD WAO President WAO, Historian Professor of Allergy Allergy & Respiratory Diseases Department of Pediatrics Department of Internal Medicine Nippon Medical School University of Genoa 1-1-5, Sendagi IRCCS AOU S.Martino, Largo Rosanna Benzi Bunkyo-ku, 101-16132 Genoa Tokyo 113-8603 ITALY JAPAN [email protected] Prof. Richard F. Lockey, MD WAO Past President Prof. Stephen T. Holgate, BSc, MD, Division of Allergy & Immunology DSc, FMed Sci Joy McCann Culverhouse Chair in Allergy & Immunology WAO Treasurer University of South Florida College of Medicine Medical Research Council Clinical Professor of James Haley Veterans Administration Medical Center (111D) Immunopharmacology 13000 Bruce B. Downs Boulevard Infection, Inflammation and Immunity Tampa, Florida 33612 School of Medicine USA University of Southampton Level F, South Block Southampton General Hospital Prof. Michael S. Blaiss, MD Tremona Road WAO Board Member Southampton SO16 6YD Clinical Professor of Pediatrics and Medicine United Kingdom University of Tennessee Health Science Center 7205 Wolf River Blvd Germantown, Tennessee 38138 USA ISBN-10: 061592915X (print) ISBN-13: 978-0-615-92915-6 (print) ISBN-10: 0615929168 (digital) ISBN-13: 978-0-615-92916-3 (digital) Copyright 2013 World Allergy Organization (WAO). All rights reserved. No part of this publication may be reproduced in any form without the written consent of the World Allergy Organization. This book is not for sale. World Allergy Organization 555 East Wells Street Suite 1100 Milwaukee, Wisconsin 53202 United States of America Phone: +1 414 276 1791 Fax: +1 414 276 3349 Email: [email protected] Website : www.worldallergy.org World Allergy Organization (WAO) White Book on Allergy: Update 2013 Editors Ruby Pawankar Giorgio Walter Canonica Stephen T. Holgate Richard F. Lockey Michael S. Blaiss Copyright 2013 World Allergy Organization WAO White Book on Allergy: Update 2013 1 Foreword by His Excellency Dr. APJ Abdul Kalam, Former President of India Allergic diseases are increasing worldwide with unprecedented The White Book on Allergy is an important initiative by the complexity and severity. Children bear the greatest burden of World Allergy Organization calling on international and national allergic deseases. The most common allergic conditions in health care policy makers to address early identification of children are food allergies, eczema, and asthma. The precise symptoms, early diagnosis and appropriate strategies to causes of this increase in allergic diseases are not fully understood manage and control allergies to avoid worsening of severe but as the numbers of afflicted people increase, so does the allergic disease to people at risk and to improve practice in research and development, and progress is being made. this clinical field of medicine for the benefit of those suffering from the consequences of allergies. I congratulate the World Allergy should be recognized as a public health problem and Allergy Organization for initiating this timely and much needed efforts should be made towards its prevention and optimal document and wish them all success in its impact and treatment. To achieve this, public awareness should be implementation. increased and efforts should be made towards proper education and training for more integrated and holistic approach to the diagnosis and management of allergic diseases. HE. Dr. APJ Abdul Kalam Former, President of India New Delhi, India Copyright 2013 World Allergy Organization WAO White Book on Allergy: Update 2013 3 Foreword by Baroness Finlay, House of Lords, United Kingdom I am delighted to have an opportunity of adding my strongest to provide education and training courses for allergy patients; support to the principles laid out in this World Allergy Organization their families; school staff and employers; in how to prevent and White Book on Allergy. Indeed, many of the recommendations treat allergic conditions. align with those of a recent report on Allergy Services that I was 2) Because of the lack of knowledge of health professionals asked to chair in 2006 for the UK House of Lords Committee in the diagnosis and treatment of allergic diseases, we on Science Technology (http://www.publications.parliament. recommended that those responsible for medical training uk/pa/ld200607/ldselect/ldsctech/166/166i.pdf). The scope strengthen the input of clinical allergy to the undergraduate of the Report encompassed an assessment of recent trends and postgraduate training of internists and primary care of allergy prevalence, the social and economic burdens that physicians as well of those of nurses. allergic disorders cause, current allergy treatments and research strategies, and policies which impact upon allergy 3) Although high quality research into cellular and molecular patients such as housing standards, food labelling and the mechanisms of allergy is advancing, the factors contributing work and school environments. As with the White Book, our to allergy development and the “allergy epidemic,” are poorly report came at a time when the prevalence of allergic disorders understood. It is imperative that further research should in this country has been claimed to have reached epidemic focus on the environmental factors, such as early allergen proportions. Although it is unlikely that a cure for all forms of exposure, which may contribute to the inception, prevention allergy will be found in the near future, we have made a number or exacerbation of allergic disorders. We were concerned of recommendations which we believe will contribute to the that the knowledge gained from cellular and molecular prevention, treatment and management of allergic disorders. research in allergy was not being translated into clinical Our main conclusions and recommendations were: practice and was identified as an area of unmet need that required greater priority. 1) There is a need for Allergy centres where specialist, high quality diagnostic and treatment services that are accessible Immunotherapy is a valuable resource in the prophylactic to the public. Once a diagnosis is obtained and a treatment treatment of patients with life-threatening allergies, or whose plan developed at the allergy centre, the patient’s disease allergic disease does not respond to other medication. can often be managed back in primary or general secondary Although initially expensive, immunotherapy can prevent care. However, patients with severe or complex allergic a symptomatic allergic response for many years, and may conditions may need long-term follow-up from specialists in prevent the development of additional allergic conditions, so the allergy centre. its wider use could potentially result in significant long-term savings for health services. Full cost-benefit analyses of the Allergen immunotherapy by injection should always be carried potential health, social and economic value of immunotherapy out by specialists within the allergy centre because of the risk treatment needs to be conducted so the case for its use and of anaphylaxis. Collaboration between clinicians in primary, funding can be strengthened. secondary and tertiary care is key to improving the diagnosis and management of people with allergic conditions. Once 4) We recognised the appreciable impact that allergic rhinitis established, the allergy centre in each geographical region has on student performance in schools and examinations. should encourage and co-ordinate the training of local GPs Indeed, we wished to encourage health professionals to and other healthcare workers in allergy. In a “hub and spokes” interface more closely with schools to ensure children with model, the allergy centre, or “hub,” would act as a central allergic disease receive optimal care. We support the use point of expertise with outreach clinical services, education of individual care plans for children with medical needs. and training provided to doctors and nurses in primary and However, we were concerned that many teachers and secondary care, the “spokes.” In this way, knowledge regarding support staff within schools are not appropriately educated in the diagnosis and management of allergic conditions would be how to deal with allergic emergencies and should take urgent disseminated throughout the region. remedial action to improve this training where required. We were especially concerned about the lack of clear guidance The allergy centre should also act as a lead in providing public regarding the use of autoinjectors of adrenaline on children information and advice. Specialists at the centre should work in with anaphylactic shock in the school environment. collaboration with allergy charities, schools and local businesses Copyright 2013 World Allergy Organization 4 Pawankar, Canonica, Holgate, Lockey and Blaiss 5) We considered that controlled trials should be conducted 9) We were also concerned that the results of allergy self-testing involving multiple interventions to examine the effect of kits available to the public are being interpreted without the ventilation, humidity and mite-reduction strategies on advice of appropriately trained healthcare personnel, and that allergy development and control. As climate change and air