CURRENT ALLERGY & CLINICAL IMMUNOLOGY JOURNAL OF THE ALLERGY SOCIETY OF SOUTH AFRICA
Vol 36, No 4 December 2023
- OPTIMISING HEALTHCARE DELIVERY
- Multidisciplinary management of the child with asthma not responding to treatment
- Beyond clinical guidelines: how care pathways and quality improvement methods can support better allergy care
- Considerations for the in-school physical and psychological safety of children with food allergy
- Transition of allergy healthcare
- Placebo or nocebo responses in clinical trials and practice
- Navigating the complexities of mould exposure in damp buildings
- Allergy, infection or autoimmune disease?
- Autonomy vs beneficence
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GUEST EDITORIAL: PATIENT AND CARER INVOLVEMENT: GETTING THE BASICS OF ALLERGY PRACTICE RIGHT
Author: John O Warner
Abstract: It is very tempting to plan an issue of the journal around the exciting new developments in managing allergic diseases. Because molecular approaches have been applied to allergic disease, we now have a panoply of novel diagnostic tools and an ever-expanding number of so-called biological therapies to take into account. These must be employed by adopting precise or personalised medical approaches to individual patients; however, the costs are currently prohibitive and, in most cases, unnecessary. In this editorial I have, therefore, decided to return to the basics of medicine and focus on optimising healthcare delivery. This can be achieved only by involving patients and carers in all the steps during the research cycle and the planning of clinical service delivery.
REVIEW ARTICLE
MULTIDISCIPLINARY MANAGEMENT OF THE CHILD WITH ASTHMA NOT RESPONDING TO TREATMENT
Author: Andrew Bush
Abstract: Most children with asthma respond well to low-dose inhaled corticosteroids, sometimes with the addition of a long-acting β-2 agonist. Failure to respond is usually because either the diagnosis is wrong or they are not taking their treatment. If the diagnosis truly is asthma and the child is not responding, then, instead of prescribing ever more and higher doses of medications, a complete review to determine what it is about the child and their asthma which is making treatment response suboptimal should be undertaken. The factors to be considered in such a review include adherence, adverse environmental factors and psychosocial influences, and relevant co-morbidities such as obesity and exercise-induced laryngeal obstruction. Such a review means that most children referred for the consideration of biological therapy can in fact be managed with standard treatment approaches. Adherence may be improved by simplifying the regime – for example, the single inhaler for reliever and treatment approach or a once-daily treatment combined with directly observed therapies. In the rare cases of children with true therapy-resistant asthma, a range of expensive injectable biologicals may help, but the need for these is the exception. Sadly, the most common cause of non-responsive asthma globally remains that the medications are either inaccessible or too expensive.
Keywords: adherence, atopy, eosinophil, exercise-induced laryngeal obstruction, obesity
Review article
BEYOND CLINICAL GUIDELINES: HOW CARE PATHWAYS AND QUALITY-IMPROVEMENT METHODS CAN SUPPORT BETTER ALLERGY CARE
Authors: Sophie JIM Spitters, John O Warner, Julie E Reed
Abstract: The increasing prevalence of allergic disease has resulted in the recognition of allergy as a global public health concern. Yet health services worldwide appear to be ill-equipped to deliver high-quality allergy care. Clinical guidelines have been developed to describe what high-quality care looks like for most allergic diseases. However, allergy guidelines do not describe how the delivery of such care is organised across clinicians and provider organisations with varying degrees of access to allergy expertise and clinical resources. In this article, we describe how care pathways can be used to improve the organisation and delivery of allergy care in accordance with the characteristics of allergic disease and local constraints in the health service. We then describe how quality-improvement methods can support the successful realisation of allergy care pathways in practice. Realising care pathways involves a highly complex process of changing the way care is practised and organised. This could involve developing a new service, clinical training or other interventions. Qualityimprovement methods were developed as a guide to navigate and support the process of change and improvement.
Keywords: clinical guidelines, care pathways, allergy, asthma, quality improvement, integrated care
Review article
ENSURING THE PHYSICAL AND PSYCHOLOGICAL SAFETY OF CHILDREN WITH FOOD ALLERGY AT SCHOOLS: SOME CONSIDERATIONS
Author: Jennifer LP Protudjer
Abstract: An estimated 2–8% of children have either probable or confirmed food allergy; this corresponds to an average of 1–2 children in a classroom. Food-allergy training for teachers ranges from national-level guidance to variable levels of training, or even none. An estimated 8% to 18% of all food-induced anaphylaxis occurs in school settings. Adrenalin or epinephrine, the first-line medication for the treatment of anaphylaxis, is much more commonly used when reactions occur at school (including childcare centres), but compared to the use when reactions occur elsewhere adrenalin is underused. Individual health plans should be available in schools to help prevent allergic reactions and to serve as support for the use of adrenalin if a reaction does occur. To promote the psychological safety of children with food allergy at schools, a shared decision-making model may be appropriate. The family (and child, when appropriate) and teachers are encouraged to have timely discussions about food-allergy management. But at no time should children be systematically excluded because of their food allergy and zero-tolerance policies about bullying, including food-allergy bullying, are strongly encouraged. This article offers some guidance about managing food allergy in schools, which is intended to promote the physical and psychological safety of children with a food allergy.
Keywords: anaphylaxis, education, food allergy, management, safety, schools
Review article
TRANSITION OF ALLERGY HEALTHCARE
Authors: John O Warner, Marta Vazquez-Ortiz
Abstract: Because allergic diseases are long-term conditions that commonly manifest first in early life and persist in various forms well into adulthood, the transition from paediatric to adult care is an inevitable requirement. To date there has been very little focus on the requirements and wishes of young people with long-term medical problems as they transition through health services. As a consequence, there is a paucity of guidance on the way in which their transition should be conducted to optimise the outcomes and experience of these patients. The burdens encountered by patients as they are expected to develop full independence and competence to manage their own condition are superimposed on a number of physical, psychological and social challenges. Their need to achieve educational and career goals while taking control of their allergies can be overwhelming. System specialist societies and health services are beginning to resolve this problem as outcome data show that young people are particularly vulnerable to adverse events. A disproportionate number of fatalities occur in young people with severe asthma and food-induced anaphylaxis. Recommendations on the structure of this transition are being developed by national and international allergy societies. However, regional differences in health service organisation and variations in political, sociological, environmental and financial structures mean that the transition can be optimised only through locality-based implementation. The planning must involve all stakeholders, of whom young people with allergic diseases are most important. A series of recommendations are presented here which incorporate those developed by the European Academy of Allergy and Clinical Immunology together with our own additions that respond to specific challenges raised by young people.
Keywords: allergic disease healthcare transition, asthma, food allergy, patient experience, patient outcomes
Review article
PLACEBO/NOCEBO RESPONSES IN CLINICAL TRIALS AND PRACTICE
Author: JO Warner
Abstract: Clinicians have throughout the ages considered the enhancement of placebo effects to be part of the art of medicine. Studies to characterise placebo effects and those of its counterpart, nocebo, have identified several factors, most notably disease severity and efficiency of disease control during trial run-in periods. Milder disease or good disease control is associated with higher placebo benefits. Endogenous opioid and dopamine pathway activation have been associated with placebo responses, and genetic polymorphisms in these pathways may explain susceptibilities to placebo responsiveness. Trials in asthma have shown that placebo responses, while improving subjective symptoms, have much less effect on lung function. Giving a false sense of security to patients with severe asthma through the activation of endogenous opioids could lead to a lack of appreciation of its deterioration and could contribute to a proneness to fatality. The assumption that the placebo response is additive to that of active treatment is not proven, nor are there consistent placebo responders and non-responders. When interpreting the outcome of placebo-controlled clinical trials, design is paramount. Disease severity should be encompassed in power calculations. The run-in period should be long enough to titrate medications to the minimum required to maintain control. Having three concurrent treatment groups – active, placebo and non-intervention – can aid evaluation. Other designs may improve discrimination: these can include having a prolonged run-in on placebo with only placebo non-responders randomised to either continue placebo or commence active treatment.” The take-home message is that there is more to placebo/nocebo than meets the eye!
Keywords: placebo, nocebo, clinical trials, asthma, trial design, mechanisms
Allergies in the Workplace
NAVIGATING THE COMPLEXITIES OF MOULD EXPOSURE IN DAMP BUILDINGS: A CASE REPORT ON CHALLENGES AND POTENTIAL SOLUTIONS
Authors: Dikeledi O Matuka, Edith Ratshikhopha, Munyadziwa Muvhali, Lufuno Muleba, Tanusha Singh
Abstract: The increasing presence of moulds in workplaces poses significant occupational health risks, particularly in poorly maintained structures. Insufficient attention is given to dealing with this emerging issue; therefore, it is imperative to understand mould-related health effects and remediation strategies to ensure a safe and healthy work environment. This case investigation aimed to establish an association between employee symptoms and moulds in a damp building. An environmental assessment was undertaken to identify visible signs of water damage and identify mould species in air and surface samples. Information on mould exposure, building-related symptoms and predisposing factors was gathered through an online self-administered questionnaire. Serum samples were collected from the index cases and controls to determine possible atopy and hypersensitivity reactions to moulds. The walkthrough revealed water-damaged walls, visible mould growth and suboptimal maintenance of the plumbing system. Environmental mould species, including Cladosporium, Aspergillus and Penicillium, were identified. The most common symptom reported was headache, followed by a pressing sensation on the scalp, a lack of concentration and fatigue. Most of the workers were atopic, and specific IgE tests yielded negative results for all workers except one positive for Alternaria alternata. Elevated sIgG antibody levels were detected for Cladosporium and A alternata species, linking exposure to at least one mould species identified in the work environment. This case highlights the importance of employing appropriate serological tools to investigate mould exposure. Furthermore, it underscores the challenge of interpreting laboratory results without standardised reference values, which may have an impact on accurate diagnosis and case management, in turn emphasising the need to establish local IgG reference ranges. The investigation also raises awareness of effective case management to prevent adverse health effects related to mould sensitisation in occupational settings.
Keywords: indoor air quality, bio-aerosols, mould sensitisation, water-damaged building, atopy, exposure assessment
Case Report
ALLERGY, INFECTION OR AUTOIMMUNE DISEASE? A POLYMORPHOUS SKIN RASH IN A YOUNG WOMAN
Author: Shaunagh Emanuel
Abstract: Coronavirus disease-19 (COVID-19) is an ongoing global contagious viral pandemic caused by the ‘severe acute respiratory syndrome coronavirus 2’ (SARS-CoV-2) that was first reported in December 2019 following a cluster of pneumonia cases in Wuhan, China. Pulmonary manifestations of the illness predominate; however, of the extrapulmonary signs associated with COVID-19, a variety of dermatological manifestations have increasingly been reported. These cutaneous manifestations may be due to the effect of the viral infection on tissues, effects on the coagulation system, the effects of medication or dysregulated immune responses. This case report describes a polymorphous rash that took several weeks to evolve, posing a diagnostic dilemma for clinicians. It presented in a young woman as a possible allergy, then progressed into a ‘post-viral’- looking generalised exanthem; finally, it developed into a disease of immune dysregulation.
Keywords: COVID-19, guttate psoriasis, immune dysregulation, polymorphous rash
DR SPUR’S MYSTERY CASE
Allergy, atopic dermatitis, abnormal FBC and elevated IgE: What do you see??
Authors: Miguel Jose Teixeira, Sylvia van den Berg, André van Niekerk
Abstract: The patient presented with the triad of infections, low platelets and atopic dermatitis. This has raised the concern that we are dealing with a patient with an inborn error of immunity (IEI), most probably Wiskott-Aldrich syndrome (WAS). The differential diagnosis includes hyper-IgE syndrome, in particular DOCK8 deficiency, Omenn’s syndrome, immune dysregulation, polyendocrinopathy, enteropathy, X-linked (IPEX) syndrome, Comèl- Netherton syndrome and other combined immunodeficiencies.
Congress report
2023 ANNUAL CONGRESS REPORT
Abstract: The Allergy Society of South Africa (ALLSA) joined forces with the South African Immunology Society (SAIS) to plan and host the 2023 conference held at the Century City Convention Centre from 28 September to 1 October. The leaders behind this event were professors Jonny Peter (ALLSA) and Theresa Rossouw (current President of SAIS), who expertly coordinated the scientific programme. This year we were truly blessed by having our immunologically trained colleagues present – once again highlighting the importance of merging and overlapping the fields of allergy and immunology.
Congress report
REPORT ON THE FIRST NIGERIAN ALLERGY CONFERENCE
Abstract: The Allergy & Clinical Immunology Society (ACIS) of Nigeria with the organisational support of the UCT African Paediatric Fellowship Programme and funded by the EAACIClemens von Pirquet Foundation, organised the first Nigerian Allergy Conference. It was held in Lagos, Nigeria, on 21 and 22 September 2023. Fifty medical doctors from Lagos and the close surroundings attended the meeting entitled ‘Current trends in allergy diagnosis and management’. The attendees specialised in and represented a variety of disciplines, including dermatology, pulmonology, general practice and paediatrics.