A. Sheikh

Decreasing the undernotification of anaphylaxis deaths in Brazil through the International Classification of Diseases (ICD)-11 revision.

In 2012, an analysis of the Brazilian mortality database demonstrated undernotification of anaphylaxis deaths due, at least in part, to difficult coding under the International Classification of Diseases (ICD)‐10. This work triggered a cascade of strategic international actions supported by the Joint Allergy Academies and the ICD World Health Organization (WHO) representatives to update the classifications of allergic disorders for the ICD‐11 revision. These efforts have resulted in the construction of the new ‘Allergic and hypersensitivity conditions’ section under the ‘Disorders of the Immune system’ chapter.

The Allergic Rhinitis and its Impact on Asthma (ARIA) score of allergic rhinitis using mobile technology correlates with quality of life: The MASK study

Mobile technology has been used to appraise allergic rhinitis control, but more data are needed. To better assess the importance of mobile technologies in rhinitis control, the ARIA (Allergic Rhinitis and its Impact on Asthma) score ranging from 0 to 4 of the Allergy Diary was compared with EQ‐5D (EuroQuol) and WPAI‐AS (Work Productivity and Activity Impairment in allergy) in 1288 users in 18 countries. This study showed that quality‐of‐life data (EQ‐5D visual analogue scale and WPA‐IS Question 9) are similar in users without rhinitis and in those with mild rhinitis (scores 0‐2). Users with a score of 3 or 4 had a significant impairment in quality‐of‐life questionnaires.

Health economic analysis of allergen immunotherapy for the management of allergic rhinitis, asthma, food allergy and venom allergy: A systematic overview

The European Academy of Allergy and Clinical Immunology (EAACI) is developing guidelines for allergen immunotherapy (AIT) for the management of allergic rhinitis, allergic asthma, IgE‐mediated food allergy and venom allergy. To inform the development of clinical recommendations, we undertook systematic reviews to critically assess evidence on the effectiveness, safety and cost‐effectiveness of AIT for these conditions. This study focusses on synthesizing data and gaps in the evidence on the cost‐effectiveness of AIT for these conditions.

Risk factors for the development of egg allergy: progress to date and future directions

A dramatic increase in prevalence of food allergy has been observed in several developed countries over the last 10– 15 years, making it an evolving public health challenge (1–5). Estimates of 6–8% have been reported for the prevalence of food allergy among children (1,2). Given that the increasing prevalence of asthma and allergic rhinitis was first observed around 50 years ago and may now have peaked in some settings (6), the recent emergence of food allergy has led some authors to suggest that we may be entering the ‘second wave’ of the allergy epidemic (3). The difference in the timing of emergence of asthma and allergic rhinitis, on the one hand, and food allergy, on the other hand, has led to suggestions that different risk factors may be at play (1,3). Among infants and young children, egg allergy is the second most common food allergy after cow’s milk allergy (7–9). Although potential risk factors have been reported for food allergy in general (4, 5, 10), to date, no populationbased study has investigated risk factors specific for the development of egg allergy. The study by Koplin et al. (11) investigating environmental and demographic risk factors for the development of egg allergy in infancy is therefore a welcome contribution to this evidence base. Involving the study of over 5000 12-month infants sampled from the general population, egg allergy was established using initial screening for allergen-specific IgE sensitization and, if present, confirmed using the gold standard of an oral food challenge. The authors found that ownership of a dog at home and having older siblings were associated with a decreased risk of egg allergy, but that a family history of allergy and having a parent born in East Asia were associated with increased risk of egg allergy. Cesarean section delivery, use of antibiotics, attendance to day care, and maternal age were not associated with egg allergy. While in one sense these results are to be expected as these factors have also been noted in previous studies regarding food allergy and other allergic diseases (12), the study is a welcome development for its large sample size and being the first populationbased study that has utilized the more objective oral food challenge to confirm the presence of egg allergy. There are, however, a number of methodological issues arising from this study that warrant further consideration both in relation to the interpretation of these results and also for informing the development of future studies. Firstly, the study design was cross-sectional, with data on the exposures of interest being collected in retrospect. Consequently, because information on the risk factors and the outcome was assessed at the same time, it is inherently difficult to conclude on the temporal relationship between the factors investigated and the development of egg allergy. The issue of reverse causality is a potentially important source of bias in cross-sectional epidemiologic investigations. The authors attempted to justify their retrospective collection of data on the risk factors by pointing to the possibility that families of potentially allergic children may modify certain lifestyle factors perceived as being important to the outcome, but this line of argument is misdirected. It is well known that, in establishing a causal relationship, a prospective framework, whereby the assessment of exposure data precedes the onset of the outcomes of interest, provides much stronger evidence than other study designs and this approach should, if possible, therefore always be pursued. There are several methods to handle the issue of outcome-related modification of exposures, and these should be explored where research teams consider this to be a potential risk. Therefore, future studies investigating the risk factors for the development of egg allergy will strengthen the evidence base by employing prospective study designs. In so doing, it must be appreciated that egg allergy has its origins early in life; thus, efforts should also be made to collect comprehensive information on potential risk factors prenatally, antenatally, as well as at birth and very early in life. Secondly, the study was also primarily exploratory in nature (i.e. there was no prior hypothesis on the particular risk factors of interest); hence, further studies are now needed to confirm the putative role of the observed factors in the development of egg allergy during infancy. Thirdly, it should be noted that a range of potential risk and confounding factors of interest were not considered in the present analysis. These include socioeconomic variables (e.g. income, education, and occupation), variables describing the home environment (e.g. dampness, mold, or other chemicals), season of birth, and being born in farming household or not. A recent review of studies investigating the role of diet in the development of asthma and allergy in children identified inadequate handling of potential confounding as a limitation to the evidence provided in these studies (13). A follow-up study to that review has proposed a comprehensive set of factors to take into account in future studies in order to enhance this evidence base (14). Although the authors made robust attempts in their statistical analysis, considering the exploratory nature of the study, a less conservative statistical approach would have been welcomed, particularly the alpha significant level (P = 0.1) used to select variables into the final multivariable

National clinical practice guidelines for food allergy and anaphylaxis: an international assessment

BackgroundClinical practice guidelines are important tools to promote evidence-based clinical care, but not all countries have the capacity or infrastructure to develop these in-house. The European Academy of Allergy and Clinical Immunology has recently developed guidelines for the prevention, diagnosis and management of food allergy and the management of anaphylaxis. In order to inform dissemination, adaptation and implementation plans, we sought to identify countries that have/do not have national guidelines for food allergy and anaphylaxis.MethodsTwo reviewers independently searched PubMed to identify countries with guidelines for food allergy and/or anaphylaxis from the inception of this database to December 2016. This was supplemented with a search of the Agency for Healthcare Research and Quality’s National Guideline Clearinghouse in order to identify any additional guidelines that may not have been reported in the peer-reviewed literature. Data were descriptively and narratively synthesized.ResultsOverall, 5/193 (3%) of countries had at least one guideline for food allergy or anaphylaxis. We found that one (1%) country had a national guideline for the prevention of food allergy, three (2%) countries had a guideline for the diagnosis of food allergy and three (2%) countries had a guideline for the management of food allergy. Three (2%) countries had an anaphylaxis guideline.ConclusionsThis study concludes that the overwhelming majority of countries do not have any national clinical practice guidelines for food allergy or anaphylaxis.

Influenza burden, prevention and treatment in asthma – a scoping review by the EAACI Influenza in Asthma Task Force

To address uncertainties in the prevention and management of influenza in people with asthma, we performed a scoping review of the published literature on influenza burden; current vaccine recommendations; vaccination coverage; immunogenicity, efficacy, effectiveness, and safety of influenza vaccines; and the benefits of antiviral drugs in people with asthma. We found significant variation in the reported rates of influenza detection in individuals with acute asthma exacerbations making it unclear to what degree influenza causes exacerbations of underlying asthma. The strongest evidence of an association was seen in studies of children. Countries in the European Union currently recommend influenza vaccination of adults with asthma; however, coverage varied between regions. Coverage was lower among children with asthma. Limited data suggest that good seroprotection and seroconversion can be achieved in both children and adults with asthma and that vaccination confers a degree of protection against influenza illness and asthma‐related morbidity to children with asthma. There were insufficient data to determine efficacy in adults. Overall, influenza vaccines appeared to be safe for people with asthma. We identify knowledge gaps and make recommendations on future research needs in relation to influenza in patients with asthma.

MASK 2017: ARIA digitally-enabled, integrated, person-centred care for rhinitis and asthma multimorbidity using real-world-evidence

AbstractmHealth, such as apps running on consumer smart devices is becoming increasingly popular and has the potential to profoundly affect healthcare and health outcomes. However, it may be disruptive and results achieved are not always reaching the goals. Allergic Rhinitis and its Impact on Asthma (ARIA) has evolved from a guideline using the best evidence-based approach to care pathways suited to real-life using mobile technology in allergic rhinitis (AR) and asthma multimorbidity. Patients largely use over-the-counter medications dispensed in pharmacies. Shared decision making centered around the patient and based on self-management should be the norm. Mobile Airways Sentinel networK (MASK), the Phase 3 ARIA initiative, is based on the freely available MASK app (the Allergy Diary, Android and iOS platforms). MASK is available in 16 languages and deployed in 23 countries. The present paper provides an overview of the methods used in MASK and the key results obtained to date. These include a novel phenotypic characterization of the patients, confirmation of the impact of allergic rhinitis on work productivity and treatment patterns in real life. Most patients appear to self-medicate, are often non-adherent and do not follow guidelines. Moreover, the Allergy Diary is able to distinguish between AR medications. The potential usefulness of MASK will be further explored by POLLAR (Impact of Air Pollution on Asthma and Rhinitis), a new Horizon 2020 project using the Allergy Diary.