Allergies, including food allergies have increased over the last 20 years. This
is partly due to increased public awareness, and a genuine increase, the cause of
which we are not entirely certain. The public awareness has been heightened by several
reports on food Anaphylaxis in public places & a recent (in the last 2 years)
death on an aircraft due to food Anaphylaxis.
The most recent media release last week: "Passengers settle claim with Alitalia
and KLM in Peanut Allergy case", confirms the point. This is a story about
an Australian woman, a sufferer of Peanut Anaphylaxis, and her travelling companion
had booked to fly to Ireland in November 1998 and were cancelled days before they
were due to fly out on the basis of the womans medical condition.
The shock came for the woman who was an established international traveller with
no previous problems based on her condition. Neither Alitalia nor KLM had a formal
policy in place at the time of the incident to deal with passengers who suffer from
peanut allergies on their flights.
It is obvious that the only way to deal with Life-threatening food Allergies is
to increase the awareness to the general public, especially people working in the
service Industry. Since there is no cure, or even a drug that can prevent this feared
reaction, the only way to deal with it is Prevention & Preparedness.
Food Allergy is estimated to affect between 2 to 2.5% of the general population.
A recent survey of the prevalence of peanut & tree nut allergy in the US estimates
that 1.14% or close to 3 million Americans is affected.
Despite food Allergy being a fairly common illness, food allergies are among the
most frequently misunderstood & misdiagnosed illness especially among children.
Part of this confusion stems from the term "food allergy" is often used
very loosely, to mean anything from "I dont like the taste of this food
to Anaphylaxis & potential Death.
Adverse Reaction to Foods: A clinically abnormal response believed
due to an ingested food or food additive.
Food Intolerance: A physiologic response to an ingested food or
food additive, which is not proven to be immunologic in nature. This category includes
idiosyncratic, pharmacologic (caffeine), metabolic (lactose intolerance) or toxic
(scromboid fish poisoning).
Food Hypersensitivity (Allergy): An immunologic hypersensitivity
or truly "allergic" reaction resulting from the ingestion of food or food
additive. This reaction involves IgE antibodies & is diagnosed with a Skin Prick
Test or RAST test.
A psychologically based food intolerance, where a conditioned response is elicited
by the recognition, appearance, smell or taste of a particular food. Panic attack
is an example of food aversion presenting as Anaphylaxis
- About 2% of adults & 6% of children get food allergies
- About 33% of all Anaphylaxis attending ER is due to foods
In US 100 150 people die each year from foods, compared to 50 dying from
bee & wasp sings.
Manifestations of IgE mediated (true) food Allergy:
- Atopic Dermatitis
- Urticaria / Angioedema
- Oral Allergy Syndrome
- Rhino conjunctivitis
- Systemic Anaphylaxis
Life-Threatening Food Allergies
Anaphylaxis: rapid, generalized, often unanticipated, immunologically
mediated reaction that occurs after exposure to a food in a previously sensitised
Reaction can affect virtually any organ in the body.
Common Foods implicated in Life-Threatening Food Allergy:
Foods most often implicated:
- Peanut, Tree nuts, Fish, Shellfish
Other foods less often implicated:
- Cows milk, egg, Fruits, Seeds (sesame), cereal grains
Food additives & spices may be implicated
Prevalence of Life-Threatening Food Allergy
- 1-2% of the general population
- US estimates 1000 cases & 100-150 deaths per year
How is Anaphylaxis diagnosed?
To classify as anaphylaxis we require:
- One symptom of generalized mediator release (flushing, itching, urticaria)
And at least one of the following:
- Oral & Gastro-Intestinal: swelling of tongue, vomiting, diarrhoea
- Respiratory: Rhinitis, wheeze, stridor
- Cardiovascular: low blood pressure, irregular or rapid pulse, faint or shock
The only exception is isolated laryngeal oedema or shock / syncope after injection.
Fatal Food Anaphylaxis: Risk Factors
- Peanut or Nut sensitivity
- Previous episode of anaphylaxis with incriminated food(s)
- Food eaten away from home
- Accidental ingestion
- Denial of symptoms, delay Treatment
- Lack of use of Adrenaline
- History of Asthma plus food Allergy
Emergency Treatment of Anaphylaxis
- Adrenaline is the only life saving drug in the treatment of Anaphylaxis
- 0.3-0.5 mg 1:1000, i.m.
- Adrenaline is rapidly Metabolised, may need to be given every 12-14 minutes
- I.V. Fluids: colloids or crystalloids
- Other: (Secondary) Antihistamine, Steroids
Beware of Relapse (Bi-phasic response), Therefore observe for 4-6 hours
When should Adrenaline be given?
"3 D Rule of giving Adrenaline":
- Definite reaction to nuts
- Death a possibility
Only 2 things threaten life. The "2 D Rule":
- Difficulty Breathing (either due to swelling or asthma)
The 1 "1 D Rule":
Do give Adrenaline if in Doubt
In mid 1998 the Department of Transport (DOT) issued a proposal mandating that the
10 major US Airlines must provide "peanut-free zones" for passengers with
This met with great resistance with the Air Transport Association
. the mandate was never implemented.
Why banning Peanuts wont work:
- No such thing as a peanut-free flight. Will they do a body search?
"Peanut-free" gives everyone a feeling of false security, which in turn
When a ban goes in place the emphasis moves from education & raising awareness
to enforcing the ban
There are lots of other life-threatening food triggers such as sesame, milk, eggs,
fish & wheat. Where do we stop?
Education of patients (so that they can take responsibility for themselves) and
the general public so they can assist in avoiding deaths due to accidents is a more
Peanut Allergic Reactions on Commercial Airlines
A recent study done in Feb 99 (& Published in the American Journal of
Asthma, Allergy and Clinical Immunology) addressed the subject as to wether aerosolised
peanut does cause allergic reactions in planes.
The study involved 3,704 people from the Peanut & Tree nut Allergy Registry.
They answered a questionnaire & had follow-up consultations.
Severe reactions to peanut on flights are primarily due to ingestion, but respiratory
reactions occurred from inhalation when passengers are consuming peanuts. These
inhalation reactions were not life threatening. They would occur on the same mechanism
as a cat allergic person who gets rhinitis, watery eyes & wheezing on entering
a room where there is a cat.
What can Airlines do to reduce anxiety & deaths amongst food allergic patients?
- Educate all staff on Food Anaphylaxis to alleviate passenger anxiety
- Flight Attendants should be knowledgeable on Anaphylaxis and how to treat it.
All airlines should carry Adrenaline, which can be easily used by the staff on board
eg Epi-Pen. Several of these should be on board Obtain indemnity if necessary
Since all fatalities from foods are accidents, the staff on board should be equipped
to deal with emergencies arising from foods served on board & foods taken on