Allergy and Asthma Source

ROUGH TRANSITION TO A NEW ASTHMA INHALER
By Laurie Tarkan
Published: May 13, 2008
The New York Times
Millions of people with asthma and other lung diseases will have to switch inhalers by the end of the year. And for many, the transition will not be smooth.
The change — mandated by the federal government in 2005, to go into effect next Jan. 1 — is to comply with the 1987 treaty to protect the earth’s ozone layer. It bans most uses of chlorofluorocarbons, or CFCs, which are used as propellants in many inhalers.

CFC-free inhalers have been available for more than a decade. But four million to five million users have yet to switch, according to the consumer advocacy group Allergy and Asthma Network Mothers of Asthmatics.

For one thing, the old inhalers cost much less — an average of $13.50, or one-third the price of a CFC-free inhaler, which uses propellants called HFAs, for hydrofluoroalkanes. (CFC inhalers are generic; HFA inhalers are brand-name.) People with asthma use an average of three or four inhalers a year, but some patients use one a month.

Moreover, the new and old inhalers differ in feel, force and taste, and how they are primed and cleaned. Advocates for people with asthma say doctors and patients have not been educated about the changes.

“What the government failed to do is to mandate anyone to tell patients and physicians this transition was happening,” said Nancy Sander, president of the asthma group. “There is no education, no monitoring of patients, no financial assistance to patients who have to pay higher prices for the new drugs.”

As a result, she and others say, there have been unnecessary fears about the newer inhalers, preventable trips to the emergency room and even some hoarding of CFC inhalers.

Callers to a hot line run by Ms. Sander’s group have complained that when they were switched to the new inhalers, the differences between the two types were never explained. Many thought that their device was broken or that their symptoms were not being relieved by the new inhalers.

The Food and Drug Administration says that since January 2007 it has received 415 complaints about HFA inhalers’ costing too much or not working properly. After a public meeting last month in which doctors and patients said most people were unaware of the transition, the agency has been stepping up educational efforts, with several public service announcements expected by the end of this month, said Deborah Henderson, an official at the Center for Drug Evaluation and Research.

Both types of inhalers use albuterol, a short-acting medication that can prevent an asthma attack when used preventively — before exercising, for example — or at the first sign of breathing trouble.

But the cost difference has meant huge gains for drug companies. As people switched to HFA inhalers in 2006 and 2007, sales of all albuterol inhalers jumped from about $500 million to $1.1 billion, according to I.M.S. Health, a health care information company. Of the 40.5 million prescriptions written for albuterol inhalers last year, it said, about half were CFC and half were HFA inhalers.

And even though there are important differences between the four brands of HFA inhalers, some insurers cover only one of the four. Advocates say the higher cost may keep patients from buying inhalers or force them to cut back on other medications or switch to a less effective over-the-counter inhaler that uses epinephrine.

Several members of Congress are asking the Bush administration to require insurers, including the Medicare and Medicaid programs, to cover the new inhalers equally. Representative Steve Kagen, a Wisconsin Democrat who is also an allergy and asthma physician, said it was important “to make sure there’s as little co-pay as possible.”

The four HFA inhalers are Ventolin by GlaxoSmithKline, ProAir by Teva, Proventil by Schering-Plough and Xopenex by Sepracor. (Xopenex uses a different chemical, levalbuterol.) All companies have give-away programs for those in need and are providing free samples that doctors give to their patients. There is also financial assistance available through the Partnership for Prescription Assistance (1-888-477-2669).

Studies show that HFA inhalers are as effective as CFC inhalers and have the same rate of side effects. But if they are not used properly, patients will not get adequate doses. There are three critical differences.

HFA inhalers must be pumped four times to prime them — a number that was not so critical with the more forgiving CFC inhalers, said Dr. Leslie Hendeles, professor of pharmacy and pediatrics at the University of Florida. And each brand of the newer inhaler requires a different frequency of priming.

HFA inhalers have a weaker spray. “It’s very soft so people think it’s not working,” Dr. Stoloff said. Where CFC inhalers deliver a powerful force that feels as if the airway is being pushed open, the newer ones provide a warm, soft mist that also has a distinct taste.

They also require a slower inhale. “You have to take a nice slow, deep breath and hold it,” Ms. Sander said. If people worry that it’s not working, they may not take the second puff, may fail to wait the necessary 30 seconds between puffs or may take too many puffs. ,And their anxiety may rise, further constricting their airways.

HFA inhalers need to be washed with warm water and air dried once a week. The medication is stickier and will clog the hole, reducing the amount of medication the spray delivers.

There are also important differences among the brands, though some doctors simply write Albuterol HFA on the prescription, leaving the pharmacist to choose the brand. Only one, Ventalin, has a dose counter, which helps users keep track of how much medication is left. ProAir appears to be on many insurance companies’ lists of approved medications, but it has the softest spray, Dr. Stoloff said.

To read the full article, go to NY Times.com

Acknowledgement: thanks to Dr. Munitz for calling our attention to this article

Pollen Grains

From the AAAI Rhinitis Tips:
Do you have bouts of sneezing and itching, or a runny or stuffy nose that do not seem to go away? If so, you may have rhinitis.

Rhinitis is one of the most common illnesses in the United States , affecting more than 50 million people. It often coexists with other respiratory disorders, such as asthma. Rhinitis has a significant impact on the quality of life of those who suffer from it. In addition, it can contribute to other conditions such as sinus problems, ear problems, sleep problems, and learning problems. In patients with asthma, uncontrolled rhinitis seems to make asthma worse.

Allergic rhinitis
Allergic rhinitis is caused by substances that we breathe called allergens. Allergens are usually harmless substances that can cause problems only in some people. These problems are caused because the immune system of people with allergic rhinitis mistakenly identifies these substances as intruders and generates a reaction against them. During this reaction, the immune system cells release substances such as histamine and leukotrienes that cause the symptoms of allergic rhinitis; these and other substances also cause inflammation in the nasal lining that makes the nose very sensitive to irritants such as smoke and strong odors or to changes in the temperature and humidity of the air.

Causes:

1. When allergic rhinitis is caused by common outdoor allergens, such as airborne tree, grass and weed pollens or mold, it is called seasonal allergic rhinitis, or “hay fever.”
2. Allergic rhinitis is also triggered by common indoor allergens, such as animal dander (dried skin flakes and saliva), indoor mold, droppings from dust mites and cockroach particles. This is called perennial allergic rhinitis.

Symptoms

Sneezing
Stuffy nose (congestion)
Runny nose
Itching in the nose, roof of the mouth, throat, eyes and ears
Diagnosis
If you have symptoms of allergic rhinitis, an allergist/immunologist can help determine which specific allergens are triggering your illness. He or she will take a thorough health history, and then test use to determine if you have allergies. Skin tests or blood tests are the most common methods for determining your allergic rhinitis triggers.

What to Do During Pollen Season:
When outdoor pollens are high, remain indoors, particularly in the late morning. Pollen grains can cause significant allergic symptoms like asthma and allergic rhinitis, particularly during the spring and the fall. It is difficult to avoid pollen because it is windborne and can cover wide distances. Short of moving to a different location, here are some tips for avoiding pollen during the season.

1. The pollen count is usually highest in the late morning and early afternoon particularly during sunny, windy days. The pollen count measures the concentration of a specific pollen like birch tree pollen, in the area in a specific area and time. A pollen count is a useful guide for when it is advisable to stay indoors and avoid contact with pollen.
2. Keep the windows and doors closed during the allergy season.
3. Install a room air conditioner with a special filter.The special filter (High Efficiency Particulate Air or HEPA filter) traps airborne allergens. If the house does not have central air, the best spot to put the air conditioner and filter would be the bedroom. Change the filters frequently. An allergic person should also use the car air conditioner to decrease pollen exposure when commuting. Pollen allergic persons should not have a window fan blowing into their bedroom as this will maintain outdoor pollen exposure all night.
4. Avoid working outdoors, if you must wear a special face mask. The face mask is designed to filter pollen out of the air and keep it from reaching the nasal passages.
5. Consider taking a vacation at the height of the pollen season. Preferably at a location where the pollen exposure is minimal, like the seashore.

Links: Allergy Medications
Info on Allergy Shots

from the FDA

This information reflects FDA’s current analysis of available data concerning these drugs. Posting this information does not mean that FDA has concluded there is a causal relationship between the drug product and the emerging safety issue. Nor does it mean that FDA is advising health care professionals to discontinue prescribing this product. FDA is considering, but has not reached a conclusion about whether this information warrants any regulatory action. FDA intends to update this document when additional information or analyses become available.

FDA is investigating a possible association between the use of Singulair and behavior/mood changes, suicidality (suicidal thinking and behavior) and suicide. Singulair is a medicine in the drug class known as leukotriene receptor antagonists. Singulair is used to treat asthma and the symptoms of allergic rhinitis (sneezing, stuffy nose, runny nose, itching of the nose) and to prevent exercise-induced asthma.

Over the past year, the maker of Singulair, Merck & Co, Inc., has updated the prescribing information and patient information for Singulair to include the following post-marketing adverse events: tremor (March 2007), depression (April 2007), suicidality (suicidal thinking and behavior) (October 2007), and anxiousness (February 2008).

In February 2008, FDA and Merck discussed how best to communicate these labeling changes to prescribers and patients. Merck plans to highlight the recent changes in the prescribing information in face-to-face interactions with prescribers and provide prescribers with patient information leaflets about Singulair. The Singulair website includes the most current prescribing information and patient information for Singulair (www.singulair.com).

FDA is working with Merck to further evaluate a possible link between the use of Singulair and behavior/mood changes, suicidality and suicide in response to inquiries received by FDA. FDA has requested that Merck evaluate Singulair study data for more information about suicidality and suicide. FDA is reviewing the postmarketing reports it has received of behavior/mood changes, suicidality and suicide in patients who took Singulair.

Due to the complexity of the analyses, FDA anticipates that it may take up to 9 months to complete the ongoing evaluations. As soon as this review is complete, FDA will communicate the conclusions and recommendations to the public.

Singulair is an effective medicine that is indicated for the treatment of asthma and symptoms of allergic rhinitis. Patients should not stop taking Singulair before talking to their doctor if they have questions about this new information. Until further information is available, healthcare professionals and caregivers should monitor patients taking Singulair for suicidality (suicidal thinking and behavior) and changes in behavior and mood.

Other leukotriene modifying medications include zafirlukast (Accolate), which is also a leukotriene receptor antagonist and zileuton (Zyflo and Zyflo CR), which is a leukotriene synthesis inhibitor. FDA is reviewing postmarketing reports it has received of behavior/mood changes, suicidality and suicide in patients who took Accolate, Zyflo, and Zyflo CR and will assess whether further investigation is warranted.

This early communication is in keeping with FDA’s commitment to inform the public about its ongoing safety reviews of drugs.

The FDA urges both healthcare professionals and patients to report side effects from the use of Singulair, Accolate, Zyflo, and Zyflo CR to the FDA’s MedWatch Adverse Event Reporting program

on-line at [www.fda.gov/medwatch/report.htm];
by returning the postage-paid FDA form 3500 [available in PDF format at [www.fda.gov/medwatch/getforms.htm] to 5600 Fishers Lane, Rockville, MD 20852-9787;
faxing the form to 1-800-FDA-0178; or
by phone at 1-800-332-1088

PUBLIC HEALTH RISK SEEN AS PARENTS REJECT VACCINES
article by JENNIFER STEINHAUER
New York Times
Published: March 21, 2008
SAN DIEGO — In a highly unusual outbreak of measles here last month, 12 children fell ill; nine of them had not been inoculated against the virus because their parents objected, and the other three were too young to receive vaccines.

The parents who objected to their children being inoculated are among a small but growing number of vaccine skeptics in California and other states who take advantage of exemptions to laws requiring vaccinations for school-age children.

The exemptions have been growing since the early 1990s at a rate that many epidemiologists, public health officials and physicians find disturbing.

Children who are not vaccinated are unnecessarily susceptible to serious illnesses, they say, but also present a danger to children who have had their shots — the measles vaccine, for instance, is only 95 percent effective — and to those children too young to receive certain vaccines.

Measles, almost wholly eradicated in the United States through vaccines, can cause pneumonia and brain swelling, which in rare cases can lead to death. The measles outbreak here alarmed public health officials, sickened babies and sent one child to the hospital.

Every state allows medical exemptions, and most permit exemptions based on religious practices. But an increasing number of the vaccine skeptics belong to a different group — those who object to the inoculations because of their personal beliefs, often related to an unproven notion that vaccines are linked to autism and other disorders.

Twenty states, including California, Ohio and Texas, allow some kind of personal exemption, according to a tally by the Johns Hopkins University.

“I refuse to sacrifice my children for the greater good,” said Sybil Carlson, whose 6-year-old son goes to school with several of the children hit by the measles outbreak here. The boy is immunized against some diseases but not measles, Ms. Carlson said, while his 3-year-old brother has had just one shot, protecting him against meningitis.

“When I began to read about vaccines and how they work,” she said, “I saw medical studies, not given to use by the mainstream media, connecting them with neurological disorders, asthma and immunology.”

Ms. Carlson said she understood what was at stake. “I cannot deny that my child can put someone else at risk,” she said.

In 1991, less than 1 percent of children in the states with personal-belief exemptions went without vaccines based on the exemption; by 2004, the most recent year for which data are available, the percentage had increased to 2.54 percent, said Saad B. Omer, an assistant scientist at the Johns Hopkins Bloomberg School of Public Health.

While nationwide over 90 percent of children old enough to receive vaccines get them, the number of exemptions worries many health officials and experts. They say that vaccines have saved countless lives, and that personal-belief exemptions are potentially dangerous and bad public policy because they are not based on sound science.

“If you have clusters of exemptions, you increase the risk of exposing everyone in the community,” said Dr. Omer, who has extensively studied disease outbreaks and vaccines.

It is the absence, or close to it, of some illnesses in the United States that keep some parents from opting for the shots. Worldwide, 242,000 children a year die from measles, but it used to be near one million. The deaths have dropped because of vaccination, a 68 percent decrease from 2000 to 2006.

“The very success of immunizations has turned out to be an Achilles’ heel,” said Dr. Mark Sawyer, a pediatrician and infectious disease specialist at Rady Children’s Hospital in San Diego. “Most of these parents have never seen measles, and don’t realize it could be a bad disease so they turn their concerns to unfounded risks. They do not perceive risk of the disease but perceive risk of the vaccine.”

Dr. Sawyer and the vast majority of pediatricians believe strongly that vaccinations are the cornerstone of sound public health. Many doctors view the so-called exempters as parasites, of a sort, benefiting from the otherwise inoculated majority.

Most children get immunized to measles from a combined measles, mumps and rubella vaccine, a live virus.

While the picture of an unvaccinated child was once that of the offspring of poor and uneducated parents, “exempters” are often well educated and financially stable, and hold a host of like-minded child-rearing beliefs.

Vaccine skeptics provide differing explanations for their belief that vaccines may cause various illnesses and disorders, including autism.

Recent news that a federal vaccine court agreed to pay the family of an autistic child in Georgia who had an underlying mitochondrial disorder has led some skeptics to speculate that vaccines may worsen such conditions. Again, researchers say there is no evidence to support this thesis.

Alexandra Stewart, director of the Epidemiology of U.S. Immunization Law project at George Washington University, said many of these parents are influenced by misinformation obtained from Web sites that oppose vaccination.

“The autism debate has convinced these parents to refuse vaccines to the detriment of their own children as well as the community,” Ms. Stewart said.

While many parents meet deep resistance and even hostility from pediatricians when they choose to delay, space or reject vaccines, they are often able to find doctors who support their choice.

“I do think vaccines help with the public health and helping prevent the occasional fatality,” said Dr. Bob Sears, the son of the well-known child-care author by the same name, who practices pediatrics in San Clemente. Roughly 20 percent of his patients do not vaccinate, Dr. Sears said, and another 20 percent partially vaccinate.

“I don’t think it is such a critical public health issue that we should force parents into it,” Dr. Sears said. “I don’t lecture the parents or try to change their mind; if they flat out tell me they understand the risks I feel that I should be very respectful of their decision.”

Some parents of unvaccinated children go to great lengths to expose their children to childhood diseases to help them build natural immunities.

In the wake of last month’s outbreak, Linda Palmer considered sending her son to a measles party to contract the virus. Several years ago, the boy, now 12, contracted chicken pox when Ms. Palmer had him attend a gathering of children with that virus.

“It is a very common thing in the natural-health oriented world,” Ms. Palmer said of the parties.

She ultimately decided against the measles party for fear of having her son ostracized if he became ill.

In the late 1960s and 1970s, measles outbreaks in Alaska and California triggered strong enforcement of vaccine mandates by states, and exemption laws followed.

While the laws vary from state to state, most allow children to attend school if their parents agree to keep them home during any outbreak of illnesses prevented by vaccines. The easier it is to get an exemption — some states require barely any paperwork — the more people opt for them, according to Dr. Omer’s research, supported by other vaccine experts.

There are differences within states, too. There tend to be geographic clusters of “exempters” in certain counties or even neighborhoods or schools. According to a 2006 article in The Journal of The American Medical Association, exemption rates of 15 percent to 18 percent have been found in Ashland, Ore., and Vashon, Wash. In California, where the statewide rate is about 1.5 percent, some counties were as high as 10 percent to 19 percent of kindergartners.

In the San Diego measles outbreak, four of the cases, including the first one, came from a single charter school, and 17 children stayed home during the outbreak to avoid contracting the illness.

There is substantial evidence that communities with pools of unvaccinated clusters risk infecting a broad community that includes people who have been inoculated.

For instance, in a 2006 mumps outbreak in Iowa that infected 219 people, the majority of those sickened had been vaccinated. In a 2005 measles outbreak in Indiana, there were 34 cases, including six people who had been vaccinated.

Here in California, six pertussis outbreaks infected 24 people in 2007; only 2 of 24 were documented as having been appropriately immunized.

A surveillance program in the mid ’90s in Canada of infants and preschoolers found that cases of Hib fell to between 8 and 10 cases a year from 550 a year after a vaccine program was begun, and roughly half of those cases were among children whose vaccine failed.

Gardiner Harris contributed reporting from Washington.

Video: How Physicians View Parents Who Refuse to Vaccinate a Child
]

from Reuters

By Will Dunham

WASHINGTON (Reuters) Mar 07 - Federal health officials said on Thursday the government has not conceded that vaccines cause autism even after a Georgia girl won federal compensation in a case arguing a vaccine led to her autistic condition.

Hannah Poling, 9, had a rare mitochondrial disorder and a federal court ruling said regular childhood vaccinations may have contributed to some of her autism-like symptoms. She was awarded compensation under the National Vaccine Injury Compensation Program in a case that became public this week.

Some activists who argue vaccines can trigger autism jumped on the case as vindication of their cause, but Dr. Julie Gerberding, director of the U.S. Centers for Disease Control and Prevention (CDC), denied this.

“Let me be very clear that (the) government has made absolutely no statement about indicating that vaccines are a cause of autism,” Dr. Gerberding told reporters in a telephone briefing.

“That is a complete mischaracterization of the findings of the case, and a complete mischaracterization of any of the science that we have at our disposal today. So I think we need to set the record straight on that.”

The vaccine injury program is a no-fault system that has a $2.5 billion fund built up from a 75-cent-per-dose tax on vaccines. It was set up to ensure companies would not be afraid to make vaccines, and to provide injured children an easier way to seek compensation.

Thousands of lawsuits have been filed by parents who argue their children have autism caused by vaccines.

The Institute of Medicine, an independent organization set up to inform U.S. policy, has found there is no evidence that vaccines can cause autism. Many recent studies have come to the same conclusion.

Some autism advocacy groups argue that the mercury-containing thimerosal preservative in vaccines can cause autism. Republican presidential candidate Sen. John McCain entered the debate last week, saying there is “strong evidence” linking autism to a thimerosal.

Dr. Edwin Trevathan, director of the CDC’s National Center on Birth Defects and Developmental Disabilities, said the Poling case did not demonstrate any link between vaccines and autism.

“I think it’s also worth noting that most children with autism do not seem to have a mitochondrial problem,” he told the briefing.

“So this association between mitochondrial disorders and autism is actually probably relatively rare. But the association between mitochondrial disorders and severe brain damage and dysfunction is one that is not as rare and is actually quite important.”

Dr. Trevathan said it is not clear whether a fever caused by a vaccine might further stress a child with such a condition, causing autism-like symptoms.

The CDC estimates that about one in every 150 children has autism or a related disorder such as Asperger’s syndrome — 560,000 people up to age 21 in the United States.

“Our message to parents is that immunization is life-saving. There’s absolutely nothing changed in the adamant recommendations that we are making to get children vaccinated,” Dr. Gerberding said.

LINKS:
Vaccine- Autism Link Unproven

Experts Find No Vaccine Autism Link

Research Reaffirms No Vaccine Autism Link

Questions and Answers:
from the CDC

The 2007-2008 Flu Season

What sort of flu season is expected this year?
Flu seasons are unpredictable in a number of ways. Although epidemics of flu happen every year, the timing of the flu season and its severity depend on many factors, including what influenza viruses are circulating and how well viruses in the vaccine match circulating influenza viruses.

From October 2007 through early January 2008, the United States experienced low levels of flu activity. Beginning in January, influenza activity began increasing. By the week ending February 2, 2008, 31 states were reporting widespread influenza activity.

CDC’s Influenza Division collects, compiles and analyzes information on influenza activity in the United States each week from October through May. New surveillance information is posted weekly at: Flu Activity & Surveillance.

What recommendations are CDC making about flu this season?
To reduce the substantial burden of influenza on the U.S., CDC recommends a three-pronged approach:

Take time to get a vaccine. Vaccination now can still provide protection against influenza this season since different influenza viruses can circulate as late as May.
Take everyday preventive steps like frequent hand washing and covering your cough to help keep germs from spreading.
Take antiviral drugs if your doctor says to. Antiviral drugs are an important second line of defense against influenza and they can be used to treat or prevent influenza virus infection.
Information and materials on these measures, including downloadable flyers and audio announcements, as well as information on how to locate available influenza vaccine for purchase, are available at: Preventing Seasonal Flu.

What can we expect this season in terms of bacterial co-infections, including Staphylococcus aureus, with flu?
Bacterial infections can occur as co-infections with influenza or occur following influenza infection. Last year, CDC noted an increase in flu and Staphylococcus aureus (S. aureus) co-infections among children who had died or were hospitalized with influenza infection. Some of those infections were with methicillin-resistant S. aureus (MRSA). CDC is working with state and local public health authorities to monitor and investigate flu-S. aureus co-infections, including pneumonias and other types of S. aureus infections. On January 30, 2008 CDC issued a Health Advisory on Influenza-Associated Pediatric Mortality and Staphylococcus aureus co-infection. For more information about flu and staph infections visit Seasonal Flu and Staph Infection.

Vaccination remains the best method for preventing flu and its potentially severe secondary complications. Influenza antiviral medications are also available for the treatment of influenza. For more information about treatment, visit Treatment and Prevention: Influenza Antiviral Drugs.

Are new strains of influenza circulating so far this season?
Influenza viruses are constantly changing so it’s common for new strains of influenza viruses to appear each year. For more information about how influenza viruses change, visit How the Flu Virus Can Change. Although influenza A (H1N1) viruses predominated early in the season, an increasing proportion of influenza viruses subtyped have been influenza A (H3N2) viruses. H3N2 viruses are typically associated with more severe illness. An H3N2 virus called A/Brisbane has been detected among the H3N2 viruses in the U.S. that have been tested this season. A/Brisbane is the virus strain that predominated in Europe and the southern hemisphere during their last flu season. The A/Brisbane strain is related to, but is a “drifted” variant from the A/Wisconsin strain included in the 2007-08 vaccine. It is too early to tell how widely A/Brisbane will circulate in the U.S. or how well this year’s vaccine will protect against this strain. However, previous influenza studies have found that while a less than ideal match between the viruses in the vaccine and circulating viruses can reduce the vaccine’s effectiveness, the vaccine can still protect enough to make illness milder and prevent flu-related complications.

How effective is the flu vaccine?
The effectiveness of the vaccine depends in part on the match between the viruses in the vaccine and influenza viruses that are circulating in the community. If these are closely matched, vaccine effectiveness is higher. If they are not closely matched, vaccine effectiveness can be reduced. However, it’s important to remember that even when the viruses are not closely matched, the vaccine can still protect many people and prevent flu-related complications. Such protection is possible because antibodies made in response to the vaccine can provide some protection (called cross-protection) against different, but related strains of influenza viruses. For more information about vaccine effectiveness, visit How Well Does the Seasonal Flu Vaccine Work?

Will this season’s vaccine be a good match for circulating viruses?
It’s not possible to predict with certainty which influenza viruses will predominate during a given season or what the severity, timing, or duration of a flu season will be. Influenza viruses are constantly changing (called drift) – they can change from one season to the next or they can even change within the course of one flu season. Experts must pick which viruses to include in the vaccine many months in advance in order for vaccine to be produced and delivered on time. (For more information about the vaccine virus selection process visit, Selecting the Viruses in the Influenza (Flu) Vaccine.) Because of these factors, there is always the possibility of a less than optimal match between circulating viruses and the viruses in the vaccine.

Over the course of a flu season CDC studies samples of influenza viruses circulating during that season to evaluate how close a match there is between viruses in the vaccine and circulating viruses. In addition, CDC conducts vaccine effectiveness studies to determine the vaccine’s effectiveness.
As of February 2, 2008, nearly all H1N1 viruses tested to date at CDC were well-matched to the H1N1 vaccine strain. However, most of the H3N2 and B virus strains were different from those contained in the vaccine, suggesting that protection against circulating H3N2 and B virus strains may not be optimal. However, it’s important to remember that even when the viruses are not closely matched, the vaccine can still protect many people and prevent flu-related complications. Such protection is possible because antibodies made in response to the vaccine can provide some protection (called cross-protection) against different, but related strains of influenza viruses. Weekly updates on circulating influenza strains are available.

Can the vaccine provide protection even if the vaccine is not a “good” match?
Yes, antibodies made in response to vaccination with one strain of influenza viruses can provide protection against different, but related strains. A less than ideal match may result in reduced vaccine effectiveness against the variant viruses, but it still can provide enough protection to prevent or lessen illness severity and prevent flu-related complications. In addition, it’s important to remember that the influenza vaccine contains three virus strains so the vaccine can also protect against the other two viruses. For these reasons, even during seasons when there is a less than ideal match, CDC continues to recommend influenza vaccination. This is particularly important for people at high risk for serious flu complications and their close contacts.

How often are the vaccine and circulating virus strains well matched?
In recent years the match between the vaccine viruses and those identified during the flu season has usually been good. In 16 of the last 19 U.S. influenza seasons, the viruses in the influenza vaccine have been well matched to the predominant circulating viruses. Since 1988, in fact, there has only been one season (1997-9 when there was very low cross-reaction between the viruses in the vaccine and the predominate circulating virus and two seasons (2003-04 and 1992-93) when there was low cross-reaction.

What actions can I take to protect myself and my family against the flu this season?
A flu vaccine is the first and best defense against influenza. However, antiviral drugs are an important second line of defense against the flu. They can be used to treat the flu or to prevent infection with flu viruses. Treatment with antiviral drugs should begin within 48 hours of getting sick, and can reduce your symptoms and shorten the time you are sick. When used for prevention, antiviral drugs are 70% to 90% effective in preventing infection with influenza viruses. Two FDA-approved influenza antiviral agents are recommended for use in the United States to treat or prevent flu during the 2007-08 influenza season: oseltamivir and zanamivir.

In addition, you can take everyday preventive steps like frequent hand washing to decrease your chances of getting the flu. If you are sick with flu, reduce your contact with others and cover your cough to help keep germs from spreading.

What have we seen so far during the 2007-2008 season in terms of antiviral resistance monitoring or surveillance in the United States?
CDC laboratory surveillance has indicated continued high resistance among influenza virus isolates to the adamantanes (amantadine and rimantadine) in the United States. As of February 2, 2008, 99% of influenza A (H3N2) viruses and 8.3% of influenza A (H1N1) viruses were resistant to the adamantanes.

In addition, as of February 2, 2008, CDC has detected 8.1% of H1N1 viruses were resistant to the antiviral drug oseltamivir (brand name Tamiflu®). No oseltamivir resistant influenza A (H3N2) or B viruses have been found in the United States this season and resistance to zanamivir has not been detected. CDC continues to track this information and updated antiviral resistance figures are available in the Weekly U.S. Influenza Surveillance Report, FluView.

As of February 2, 2008, 4.5% of all influenza viruses analyzed by CDC this season have been found to be resistant to oseltamivir. Of those, 8.1% of H1N1 viruses and 0% of H3N2 viruses have been resistant to the antiviral drug oseltamivir. Because influenza activity in the U.S. is just beginning to increase, relatively few viruses have been studied so far. CDC continues to track this information and updated antiviral resistance figures are available in the Weekly U.S. Influenza Surveillance Report, FluView.

Has there been antiviral resistance to oseltamivir before?
Yes, laboratory surveillance during last season showed that 0.7% of H1N1 viruses isolated and studied at CDC were resistant to oseltamivir.

What does this mean?
At this time, only a small number of viruses have been tested, and it is unknown whether antiviral resistance will increase as influenza activity increases and more viruses are tested.

Is CDC recommending any changes to the current guidance on the use of antivirals for the 2007-08 influenza season?
No, CDC is not recommending any changes to the current guidance on the use of influenza antivirals. CDC and the Advisory Committee on Immunization Practices (ACIP) recommend that oseltamivir (brand name Tamiflu®) or zanamivir (brand name Relenza®) can be used for the treatment and prevention of flu in the United States this season. Although amantadine and rimantadine (two other influenza antiviral drugs) also are FDA-approved for treatment or prevention of influenza, these two drugs are NOT recommended for use in the United States during the 2007-08 flu season because many recent flu viruses are resistant to these drugs. This guidance can be found in Prevention & Control of Influenza - Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2007 Jul 13;56(RR06):1-54. Also available as PDF.

CDC will continue to monitor the situation as additional information is collected.

Preventing Seasonal Flu
What can I do to protect myself against the flu?
By far, the single best way to prevent the flu is for individuals, especially people at high risk for serious complications from the flu, to get a vaccination each fall. To learn more, see Key Facts about Flu Vaccine.

What are other steps that can be taken to prevent the flu?
There are other good health habits that can help prevent the flu. These are:

Avoid close contact with people who are sick. When you are sick, keep your distance from others to protect them from getting sick too.

If possible, stay home from work, school, and errands when you are sick. You will help prevent others from catching your illness.

Cover your mouth and nose with a tissue when coughing or sneezing. It may prevent those around you from getting sick.

Washing your hands often will help protect you from germs.

Avoid touching your eyes, nose or mouth. Germs are often spread when a person touches something that is contaminated with germs and then touches his or her eyes, nose, or mouth.

Also, antiviral medications may be used to prevent the flu. See Questions and Answers: Antiviral Medications.

Can herbal, homeopathic or other folk remedies protect against the flu?
There is no scientific evidence that any herbal, homeopathic or other folk remedies have any benefit against influenza.

How long can human influenza viruses remain viable on inanimate items (such as books and doorknobs)?
Studies have shown that human influenza viruses generally can survive on surfaces for between 2 and 8 hours.

What kills influenza virus?
Influenza virus is destroyed by heat (167-212°F [75-100°C]). In addition, several chemical germicides, including chlorine, hydrogen peroxide, detergents (soap), iodophors (iodine-based antiseptics), and alcohols are effective against influenza viruses if used in proper concentration for sufficient length of time. For example, wipes or gels with alcohol in them can be used to clean hands. The gels should be rubbed until they are dry.

Antiviral Drugs for Seasonal Flu
What are flu antiviral drugs?
Flu antiviral drugs are drugs that decrease the ability of flu viruses to reproduce. While getting a flu vaccine each year is the best way to protect you from the flu, antiviral drugs can be used as a second line of defense to treat the flu or to prevent flu infection.

What are the treatment benefits of flu antiviral drugs?
For treatment, antiviral drugs should be started within 2 days after becoming sick. When used this way, these drugs can reduce the severity of flu symptoms and shorten the time you are sick by 1 or 2 days. They also may make you less contagious to other people.

How effective are antiviral drugs at preventing the flu?
When used to prevent the flu, antiviral drugs are about 70% to 90% effective. It’s important to remember that flu antiviral drugs are not a substitute for getting a flu vaccine.

What flu antiviral drugs does CDC recommend for use in the United States for the 2007-08 season?
CDC and the Advisory Committee on Immunization Practices (ACIP) recommend that oseltamivir (brand name Tamiflu®) or zanamivir (brand name Relenza®) should be used for the treatment and prevention of flu in the United States this season. Although amantadine and rimantadine (two other influenza antiviral drugs) also are FDA-approved for treatment or prevention of influenza, these two drugs are NOT recommended for use in the United States during the 2007-08 flu season because recent flu viruses are resistant to these drugs. When viruses are resistant to drugs, the drugs don’t work or don’t work as well.

Who should take antiviral drugs for flu?
CDC has provided guidelines for health care professionals on the use of antiviral drugs (see Information for Health Care Professionals: Using Antiviral Agents for Seasonal Influenza). In general, antiviral drugs can be offered to anyone who wants to avoid and/or treat the flu, people who are at high risk of serious flu-related complications may benefit most from these drugs. Also, close contacts of people with the flu who are at high risk of serious flu-related complications may benefit from antiviral drugs to protect them from getting sick.

How can I get an antiviral drug for flu?
Antiviral drugs must be prescribed by a health care professional.

How long should antiviral drugs be taken?
The length of time antiviral drugs should be taken depends on how they are being used. To prevent flu, antiviral drugs should be taken for as long as flu viruses are circulating in a given setting. To treat flu, oseltamivir and zanamivir are taken for 5 days. See Treatment & Prevention: Influenza Antiviral Drugs for more information.

What side effects can occur with flu antiviral drugs?
Side effects differ for each drug. If an antiviral drug has been prescribed for you, ask your doctor to explain how to use the drug and any possible side effects. Health care professionals prescribing flu antiviral drugs should alert patients about adverse events that can occur. For more information about side effects, see Antiviral Drugs: Summary of Side Effects.

Can flu antiviral drugs help with other illnesses such as the common cold?
No. Flu antiviral drugs only work against flu viruses. They will not help reduce symptoms from the common cold or any other flu-like illnesses caused by viruses other than flu viruses. Many other viruses cause winter illnesses besides the flu.

Can people who are not in a high-risk group receive antiviral drugs?
Yes. Consult with your doctor to determine if you should take antiviral drugs this season.

Can antiviral drugs be helpful for people unable to take the flu vaccine?
Yes. CDC and ACIP recommend use of antiviral drugs for people allergic to eggs (which can cause them to have an allergic reaction to the vaccine) or for people who previously have encountered complications from Guillain-Barre syndrome (GBS) associated with influenza vaccination. In addition, taking antiviral drugs may be recommended among persons that may not have a good immune response to the flu vaccine.

Should people use antiviral drugs before or after receiving the live attenuated influenza vaccine (LAIV) called FluMist®?
LAIV is one of two types of flu vaccine. It is given as a nasal spray and contains weakened, live virus. Flu antiviral drugs taken from 48 hours before through 2 weeks after getting LAIV can lower or prevent the vaccinated person from responding to the vaccine and the person may not get immune protection from the vaccine.

Antiviral drugs can be taken with the inactivated (i.e. killed) flu vaccine.

Can antiviral drugs be given even if a person is not tested for flu or if a flu test does not indicate that they have influenza?
Yes. For individual patients, influenza testing is not required for antiviral drugs to be prescribed. Testing is done based on health care provider recommendations.

Tests are available that can test for flu viruses in as little as 30 minutes or less. Flu testing can be used to rapidly confirm the flu as the cause of outbreaks. However, results from these rapid tests are not 100% accurate; the test may indicate that a person does not have influenza even though they really do have the flu. So, other information in addition to influenza test results, if done, need to be factored into decisions about using antiviral drugs. One consideration will be information about influenza circulating in the community in general.

What are Tamiflu® (oseltamivir) and Relenza® (zanamivir)?
Tamiflu® and Relenza® are chemically related antiviral drugs known as neuraminidase inhibitors that fight against both influenza A and B viruses.

Oseltamivir (brand name Tamiflu ®) is approved to both treat and prevent flu in people one year of age and older.

Zanamivir (brand name Relenza ®) is approved to treat flu in people 7 years and older and to prevent flu in people 5 years and older.

What are the possible side effects of Tamiflu® (oseltamivir)?
Tamiflu® has been in use since 1999. The most common side effects are nausea and vomiting which usually happen in the first 2 days of treatment. Taking Tamiflu® with food can reduce the chance of getting these side effects. On November 13, 2006, a new precaution about Tamiflu® was added. The precaution warns that people with the flu, mostly children, may be at an increased risk of self-injury and confusion shortly after taking Tamiflu® and should be closely monitored for signs of unusual behavior. This precaution was added after the FDA received post marketing reports (mostly from Japan) about persons (primarily among children and adolescents) who had purposefully injured themselves or been delirious while using Tamiflu® (oseltamivir) to treat influenza. The reports appear to be uncommon. For more information, visit the Food & Drug Administration’s MedWatch page.

What should be done if complications while taking Tamiflu® (oseltamivir) occur?
Contact a health care professional immediately if someone taking Tamiflu® shows any signs of unusual behavior.

What are the possible side effects of Relenza® (zanamivir)?
Relenza® has been in use since 1999. The most common side effects are diarrhea, nausea, sinusitis, runny or stuffy nose, bronchitis, cough, headache, dizziness, and ear, nose and throat infections. Some persons, mostly those who already had a chronic lung disease such as asthma, have reported serious breathing problems such as wheezing or shortness of breath after taking Relenza® (zanamivir). In rare cases, people have had an allergic reaction to the drug, including rashes and edema (a build up of fluid in body-tissue) of the face and throat.

Who is at risk for complications from Relenza® (zanamivir)?
Persons with chronic lung diseases such as asthma or chronic obstructive pulmonary disease are not recommended to use Relenza® (zanamivir), as some patients have reported difficulty breathing after inhaling the drug.

What should be done if complications while taking Relenza® (zanamivir) occur?
If you have side effects while taking Relenza® (zanamivir) talk to your health care provider immediately.

Can influenza antiviral drugs be used in pregnant women?
Oseltamivir and zanamivir are both “Pregnancy Category C” medications, indicating that no studies have been conducted to assess the safety of these drugs for pregnant women. Because of the unknown effects of these drugs on pregnant women and their unborn children, these two drugs should be used during pregnancy only if the potential benefit justifies the potential risk to the unborn child. Physicians considering using one of these drugs in a pregnant woman should consult that drug package insert.

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LINKS:
The Whole Foods Allergy Free Cookbook by Cybele Pascal

Divvies Allergy Free Goodies (Made to Share)

THIS POST HAS BEEN MARKED PRIVATE BY WORDPRESS.COM STAFF IN RESPONSE TO A COPYRIGHT VIOLATION COMPLAINT.

In the article below, Ms. Broussard alleges that the current perception of increased incidence in food allergies is all a big conspiracy propagated by the Food Allergy and Anaphylaxis Network and the pharmaceutical companies that benefit from the public’s “paranoia”. She dismisses the severity of fatal food related anaphylaxis and displays shallow understanding of the research and the issues in this field.
It is disappointing to say the least that Harper’s magazine and WNYC allowed this article to make it to press and on the air without doing the requisite research on such an important topic.
Ms. Broussard’s article is merely another manifestation of the “backlash” to the media attention to food allergies (see “Mean Grownups” post in this blog). These articles would be useful if they were well-researched and well- informed on the issues, instead of merely just cashing in on a hot topic by trying to be controversial and in the process, making the lives of many truly food allergic patients more difficult.

“Everyone’s Gone Nuts”
The Exaggerated Threat of Food Allergies
by Meredith Broussard
in Harpers Jan 2008

Of little concern to most parents or educators only a generation ago,food allergies are now seen as a childhood epidemic. The American Academy of Pediatrics recently began recommending that peanuts be withheld until a child turns three; hundreds of food-allergy non profitsand local parents groups have formed; and six states have passed laws requiring food-allergy safety measures in their schools, with similar legislation currently being considered in Congress. Children are even being recruited to help battle this supposed threat, as in this Food Allergy & Anaphylaxis Network (FAAN) brochure, which enjoins young students to “Be a PAL” and protect the lives of their classmates. But the rash of fatal food allergies is mostly myth, a cultural hysteria cooked up with a few key ingredients: fearful parents in an age of increased anxiety, sensationalist news coverage, and a coterie of wellplaced advocates whose dubious science has fed the frenzy.

One of the first and most influential of the food-allergy non profits, FAAN has successfully passed off as fact its message that food allergies have become more prevalent and dire. Since 2005, more than 400 news stories have used FAAN’s estimates that allergic reactions to food send 30,000 Americans to emergency rooms each year and that 150 to 200 ultimately die. The group derived these figures from a 1999 study of a rural Minnesota community,in which 133 people over a five-year period were determined to have suffered anaphylaxis-an allergic reaction that can mean everything from going into shock to developing an itchy mouth. Yet only nine people in the study ever required hospitalization for anaphylaxis from any cause. As for
the death estimate, just one person died of anaphylactic shock, prompted not by food allergies but by exercise. The Centers for Disease Control and Prevention, in its most up-to-dare figures, recorded only 12deaths from food allergies in all of 2004. When asked about these statistical discrepancies, FAAN founder and CEO Anne Munoz-Furlong said focusing on any number
misses the point: “One child dying from food allergies is too many.”

In 2005, every major American media outlet covered the story of a teenager who died after kissing a boy who earlier in the day had eaten a peanut-butter sandwich. This “kiss of death” confirmed for countless nervous parents their worst fears: food-allergic children were in constant danger-they could “even die!” as FAAN warns here-from any sort of secondhand exposure to certain foods. (In a press release soon after the girl’s death, FAAN instructed food-allergic teens to tell “thatspecial someone that you can die …. Don’t wait for the first kiss.”) But there is simply no evidence that a food allergen can do serious harm if not ingested. Nicholas Pawlowski, an allergist at Children’s Hospital of Philadelphia, says he occasionally has to spread peanut butter on a patient’s arm to demonstrate to parents that their child will not die from casual contact with a nut. In the case of the peanut-butter kiss, a coroner later ruled, to no fanfare, that the girl had smoked pot

In addition to offering certificates to “PAL Heroes,” FAAN presents individuals and businesses with a service award named after Mufioz-Furlong’s daughter, a former food-allergic child who, like most people, grew out of her allergies. Anne Munoz-Furlong says she founded FAAN when her community didn’t seem to believe the threat to her child was real. Her organization
and others have certainly helped to change the perception of food allergies. (A recent Newsweek cover showing a pigtailed girl in a gas mask with a carton of milk in one hand and a peanut-butter sandwich in the other is typical of much recent coverage.) But all we know for certain now is that more parents think their children suffer from food allergies. Indeed, even the best allergy tests produce high rates of false positives, and most studies of childhood
prevalence interview no one under the age of eighteen. Ken Kochanek, a CDC statistician, says there are far too few recorded incidents of anaphvlactic shock triggered by food allergies to draw any sound epidemiological conclusions:”We can’t find any hard data that supports the severity.”

These hugging forms evoke a better world in which we all look out for our food-allergic friends. Such chumminess already exists within the world of food-allergy advocacy. The FAAN children’s website was built using a donation from Dey, the distributor of the Epipen adrenaline in,
jector; Dey and Verus Pharmaceuticals, the maker of Epilpen’s chief competitor, sponsor FAAN’s major annual fundraising event. (As part of its safety guidelines, FAAN suggests carrying an adrenaline injector at all times and regularly renewing the prescription.) Just about all the
leading food allergists also have ties to FAAN or the Food Allergy Initiative (FAI), an organization prone to even more extreme rhetoric. This intimacy helps explain why suspect statistical findings get published. For instance, the coauthors of an oft-cited study on the dangers facing food-allergic children at restaurants were Anne Mufioz-Furlong’s husband, who serves as a top FAAN executive, and a FAAN medical,board member whose research is funded in part by FAl. The latter isalso an editor at the leading allergy journal where the study appeared;the journal’s editor-in-chief is head of FAl’s medical board.

There is no question that food allergies are real. Yet instead of creating the healthy, happy children shown here, exaggerating the threat may actually do as much harm as the allergies themselves. The peril is now perceived as so great that psychosomatic reactions to foods and their odors are not uncommon. Recent surveys have also shown that children thought to have food allergies feel more overwhelmed by anxiety, more limited in what they believe they can safely accomplish, than even children with diabetes and rheumatological disease. One study documented how food-allergic youths become terror-stricken when inside places like supermarkets and restaurants,since they know that allergens are nearby. Such psychological distress is exacerbated by parents, who report keeping their children away from birthday parties and sending them to school in “No Nuts” Tshirts. Having been fed a steady diet of fear for more than two decades, we have become, it appears, what we eat.

LINKS:
Interview with Meredith Broussard on WNYC

Ms. Broussard’s blog on Failed Relationships (and apparently, Food Allergies)

In response to the Harper’s article, I am posting an excerpt of an interview with Dr. Michael Pistiner, an Allergy- Immunology fellow at Harvard conducted by Sloane Miller originally posted on MyAllergy.com
DR. MICHAEL PISTINER: According to Broussard, the 150 to 200 deaths and 30,000 episodes of anaphylaxis in the United States each year were based on a 5-year study (1983 to 1987) by Yocum and colleagues in Olmsted County, Minnesota (a population that is similar in demographics to the white American population).

This study was published in the well respected Journal of Allergy and Clinical Immunology in 1999. (Yocum et al. JACI. 1999;104:452)

This was a groundbreaking study. Though it’s 20 years old, the information continues to be useful and, for some statistical facts, unmatched. Its uniqueness and usefulness is that all of the medical records (clinic, hospital, ER, etc.) from all of the residents of this county were collected and reviewed, giving the author of the study and his colleagues the rare opportunity to identify even cases of anaphylaxis that were misdiagnosed, mislabeled and would have otherwise not been reported (Weiler. JACI. 1999; 104:271-3).

It is common that researchers and clinicians use the results of studies such as this one to estimate how many people in the nation’s population as a whole suffer from a disease. Based on the 2007 population estimated numbers, one could predict that there would be 32,523 cases of food-induced anaphylaxis and 211 related deaths. FAAN and the many reputable investigators who derive numbers from this study are not misrepresenting or exaggerating the statistics, they are using the available data.

SM: Remember the now famous story of a peanut-allergic teen that supposedly died from kissing her boyfriend who had eaten peanuts? The coroner later proved that she died from an asthma attack.

Can asthma be part of an allergic or anaphylactic reaction?
MP: Yes. Anaphylaxis can trigger asthma attacks that are notoriously difficult to treat. Wheezing, cough, chest tightness, and shortness of breath commonly occur during an asthma attack but are also life threatening symptoms seen during anaphylaxis (Wang. Clinical and Experimental Allergy, 37, 651-660). In some cases, respiratory symptoms can be the only manifestation (Moneret-Vautrin et al. Allergy. 2005: 60: 443-451). Anaphylaxis presenting in this way must be quickly treated with epinephrine. Prior to the advent of albuterol, epinephrine was the drug of choice for asthma exacerbation. When in doubt, use your epinephrine and call 911.

SM: How real is the threat from so-called “second-hand exposure,” like a kiss, to an allergen?

MP: Allergens can be transferred through saliva, so the second-hand exposure threat is real but entirely avoidable. Rosemary Hallett and colleagues at the University of California Davis School of Medicine reviewed data collected on 379 subjects with self-reported immediate nut or seed allergy and found that 20 subjects (5.3%) reported that they experienced reactions from kissing. Most of these reactions were mild but 20% did experience respiratory symptoms (Hallett et al. N Engl J Med 2002; 346:1833-4). Studies in other countries showed that people with food allergies reported that they experienced allergic symptoms after having “close physical contact (for example, kissing) with someone who recently ate something they were hypersensitive to (Eriksson et al. Journal of Investigational Allergology and Clinical Immunology. 2003 13(3):149-154).

In 2006, Maloney and colleagues conducted a study measuring the amount of peanut protein in 1 ml of saliva at certain times after eating a peanut butter sandwich and following various interventions. The study showed that soon after eating peanut butter salivary levels of peanut protein were high enough in some to cause a reaction. Additionally, 13% of subjects had detectable peanut protein in the saliva after 1 hour. No subjects had detectable salivary peanut protein several hours later and after eating a peanut-free meal. This study supports the reports of patients experiencing symptoms after kissing and demonstrates that oral contact with saliva, such as from sharing utensils or cups, can contain significant amounts of allergen and should be avoided. Additionally this study gives some guidance as far as interventions that can reduce the risk of a reaction other than complete avoidance (Maloney et al. JACI. V 118, (3) 719-724).

SM: Broussard quotes a CDC statistician who says, “There are far too few recorded incidents of anaphylactic shock triggered by food allergies to draw any sound epidemiological conclusions: ‘We can’t find any hard data that supports the severity’.”

MP: Studies determining the rates anaphylaxis and death from anaphylaxis have been notoriously difficult to conduct. Until recently, there has been little consensus as to its definition or clinical criteria and it is widely thought that it is underreported and underdiagnosed (Lieberman et al. Annals of Allergy, Asthma & Immunology. 2007;98:519-523).

Statistical information on deaths caused by food anaphylaxis is reliant on appropriate coding, interpretation of death certificates, and the correct diagnosis of cause of death (Neugut et al. ARCH INTERN MED/VOL 161, JAN 8, 2001) .

Even with imperfect methods of data collection and reporting, it is clear from the existing studies that food-related anaphylaxis is a real and growing global issue.

The European Academy Of Allergology And Clinical Immunology recently published a position paper on the management of anaphylaxis in childhood. In this paper, they review several studies supporting an increase in cases of anaphylaxis in North America and Europe. They reference studies that support an increase in anaphylaxis and food allergies in the United Kingdom and Canada.

In looking at the literature, it is clear that food-induced anaphylaxis is very real.

These studies have additionally shown us what risk factors are associated with death:

delayed epinephrine administrationbeing an adolescence or young adultasthmapeanut allergytree nut allergyprior minor reactionsnot asking about ingredients when dining out (Bock at al. Journal of Allergy and Clinical immunology. V119 (4) 1016-1017)The studies have also shown us what we can do to prevent these tragedies.

SM: Ms. Broussard implied that FAAN’s medical board and advising doctors are in some way colluding to disseminate exaggerated evidence. Do you know anything about FAAN’s studies’ objectivity?

MP: FAAN’s medical board and advising doctors are many of the leaders in food allergy and academic allergy and have been responsible for many of the studies leading to information that has dispelled fear and has increased patient safety. The studies published by these authors have been in well respected, peer reviewed journals which are scrutinized by other allergists and experts in the field prior to their publication. This identical process goes for studies that have received funding by FAAN. This process leaves little room for the dissemination of confabulated or manipulated data for self gain.

SM: Ms. Broussard wrote, “…exaggerating the threat may actually do as much harm as the allergies themselves. The peril is now perceived as so great that psychosomatic reactions to foods and their odors are not un-common”. Are you seeing this in your practice?

MP: I have experienced fear first hand while watching my own child have a severe, life threatening allergic reaction and not having the appropriate medication that could save his life. After my son recovered and my family had time to process what had happened we put into place well thought-out strategies, based on existing literature, to attempt to prevent this from happening again (avoidance strategies) and in the event that it did, a treatment plan to save his life (allergy action plan and epinephrine). Although we have a healthy respect for his allergy and are vigilant we are no longer afraid.

**
Dr. Michael Pistiner:

Dr. Michael Pistiner is currently a fellow in Allergy and Immunology at Children’s Hospital Boston, Harvard Medical School and is in his final year of the Scholars in Clinical Science Program of Harvard Medical School (masters program in patient based research). Over the last 2 years he has developed a special interest in pediatric food allergy and in the management of food allergy in schools. Within the last 4 months he has seen first hand the critical importance of community wide education as his pre-school aged son experienced anaphylaxis (life-threatening allergic reaction) after eating a small amount of walnut. He is committed to the use of practical food allergy education to replace fear and divisiveness with empowerment, confidence, and unity. Upon completion of his fellowship in July 2008, he will return to New York State and join Allergy & Asthma Consultants of Rockland & Bergen.

For references to the articles mentioned by Dr. Pistiner, please go to the original article on MyAllergyNetwork.com

Posted by: Scott Sicherer, MD January 03, 2008
(on the WNYC response forum)
Dr. Sicherer is Asst. Professor of Allergy and Immunology at Mt. Sinai Hospital
New York
My name is Scott Sicherer. I am a pediatric allergist and researcher (government and private funded) specializing in food allergy. I am co-author on most of the studies that Ms. Broussard “quotes” in her Harpers article where she implies conspiracy and trivializes this significant medical problem. I am also a volunteer medical advisor to FAAN, an organization that she mocks but is, in my view, a non-profit that has clearly increased safety for those who suffer from this medical illness. I mention these points because by Ms. Broussard’s reasoning these personal involvements would probably disqualify me from discussing food allergy (e.g., conspiracy to exagerate). Apparently, NPR also sees some odd virtue in having a non-medical expert journalist be a spokesperson for health issues. I have never “posted” to sites like this and I am a bit reluctant to draw any additional attention to Ms. Broussard’s hurtful, confused and potentially dangerous comments, but I was obviously compelled to do so…It is easy to play “debate team” with any topic but here it has become irresponsible and, indeed, potentially dangerous. I am glad to see so many listeners have spoken up on their disappointment and made important points that I will not reiterate. I would be pleased to provide actual evidence-based educational information about food allergy on this “show”–but maybe that is too uninteresting for the media? I hope that is not the case.

Esophagitis is a general term for any inflammation, irritation, or swelling of the esophagus, the tube that leads from the back of the mouth to the stomach. Eosinophilic esophagitis patients present with gastric reflux symptoms (heartburn, chest pain, vomiting, regurgitation, abdominal pain) in addition to difficulty swallowing and/ or food impaction and are found on biopsy of the esophagus to have high number of eosinophils (greater than 15-20 per high power field) without infiltration of the rest of the gastrointestinal tract.

Eosinophils are a type of white blood cell which play an important role in immune function, mainly as a defense against against parasites, but are also involved in diseases like allergies and asthma.
People with eosinophilic esophagitis usually have a personal or family history of allergic disease such as hayfever, asthma, or eczema. They present with difficult to treat reflux symptoms, and often food impaction in teens or young adults. Upper endoscopy can show linear furrows, mucosal rings, strictures, or appear normal.

The diagnosis is established by obtaining multiple (at least 5) biopsy specimens of the esophagus which show increased eosinophils (15-20/hpf) in the mucosa only, with none in the stomach or duodenum.
The exact etiology of eosinophilic esophagitis is not yet known, but food and environmental allergies are possible contributors. Short-term studies of the natural history of the disease show no concomitant eosinophilic infiltration of stomach or duodenum, no progression to hypereosinophilic syndrome or development of malignancy.
Food Allergy testing via prick and atopy patch skin test have been used to identify relevant food allergens to guide elimination diets.

Treatment consists of elimination diets, topical corticosteroids, and systemic corticosteroids.

LINKS:

Center for Pediatric Eosinophil Disorders
Resources for Families
More Resources for Families dealing with Eosinophilic Disorders
American Partnership for Eosinophilic Disorders (APFED)
Allergy and Asthma Consultants of Rockland and Bergen
Neocate

MERRY CHRISTMAS and
REMEMBER TO ALWAYS CHECK INGREDIENTS!

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