Publications by authors named "Edmond S Chan"

108 Publications

The Cost-Effectiveness of Preschool Peanut Oral Immunotherapy in the Real-World Setting.

J Allergy Clin Immunol Pract 2021 Mar 18. Epub 2021 Mar 18.

Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo. Electronic address:

Background: Across North America, 1.4% to 4.5% of children and families live with peanut allergy (PA). Preschool peanut oral immunotherapy (POIT) has been shown to be safe and effective in the real-world setting.

Objective: Evaluate the cost effectiveness of preschool POIT in North America.

Methods: Markov cohort analyses and microsimulation was used to evaluate simulated preschool children with PA over an 80-year time horizon. Models incorporated the natural history of PA, comparing children treated with preschool POIT with those not receiving immunotherapy. Costs were expressed in U.S. and Canadian dollars.

Results: A preschool POIT strategy was associated with cost savings while improving quality-adjusted life-years (QALY), dominating a nonimmunotherapy approach. Over the model horizon, when all costs (and effectiveness) of PA were included from a societal perspective, a POIT versus a non-POIT approach cost $82,514 (18.51 QALY) versus $84,367 (17.75 QALY) in the United States, and $40,111 (18.83 QALY) versus $53,848 (18.26 QALY) in Canada. In microsimulations, systemic reactions to POIT were less frequent than anaphylaxis from accidental exposure without POIT (United States: 3.59, SD 3.49 vs 19.53, SD 11.71; Canada: 3.63, SD 3.54 vs 4.56, SD 3.30), epinephrine use was reduced with POIT (United States: 5.85, SD 5.73 vs 9.76, SD 5.85; Canada: 0.34, SD 0.36 vs 0.53, SD 0.38), and fatalities were rare but lower in the POIT strategy (United States: 0.00005, SD 0.0071 vs 0.00015, SD 0.012; Canada: 0.00005, SD 0.0071 vs 0.00009, SD 0.0095).

Conclusions: Preschool POIT in a real-world setting improved health and economic outcomes in the United States and Canada.
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http://dx.doi.org/10.1016/j.jaip.2021.02.058DOI Listing
March 2021

Fruit-Induced Anaphylaxis: Clinical Presentation and Management.

J Allergy Clin Immunol Pract 2021 Mar 13. Epub 2021 Mar 13.

Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada.

Background: Data are sparse regarding the clinical characteristics and management of fruit-induced anaphylaxis.

Objective: To assess clinical characteristics and management of patients with fruit-induced anaphylaxis and determine factors associated with severe reactions and epinephrine use.

Methods: Over 9 years, children and adults presenting with anaphylaxis to seven emergency departments in four Canadian provinces and patients requiring emergency medical services in Outaouais, Quebec were recruited as part of the Cross-Canada Anaphylaxis Registry. A standardized form documenting symptoms, triggers, and management was collected. Multivariate logistic regression was used to identify factors associated with severe reactions and epinephrine treatment in the pre-hospital setting.

Results: We recruited 250 patients with fruit-induced anaphylaxis, median age 10.2 years (interquartile range, 3.6-23.4 years); 48.8% were male. The most common fruit triggers were kiwi (15.6%), banana (10.8%), and mango (9.2%). Twenty-three patients reported having eczema (9.3%). Epinephrine use was low in both the pre-hospital setting and the emergency department (28.4% and 40.8%, respectively). Severe reactions to fruit were more likely to occur in spring and among those with eczema (adjusted odds ratio [aOR] = 1.12, 95% confidence interval [CI], 1.03-1.23; and 1.17, 95% CI, 1.03-1.34, respectively). Patients with moderate and severe reactions (aOR = 1.23; 95% CI, 1.06-1.43) and those with a known food allergy (aOR = 1.38; 95% CI, 1.24-1.54) were more likely to be treated with epinephrine in the pre-hospital setting.

Conclusions: Severe anaphylaxis to fruit is more frequent in spring. Cross-reactivity to pollens is a potential explanation that should be evaluated further.
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http://dx.doi.org/10.1016/j.jaip.2021.02.055DOI Listing
March 2021

COVID-19 vaccine testing & administration guidance for allergists/immunologists from the Canadian Society of Allergy and Clinical Immunology (CSACI).

Allergy Asthma Clin Immunol 2021 Mar 15;17(1):29. Epub 2021 Mar 15.

Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, MN, Canada.

Background: Safe and effective vaccines provide the first hope for mitigating the devastating health and economic impacts resulting from coronavirus disease 2019 (COVID-19) and related public health orders. Recent case reports of reactions to COVID-19 vaccines have raised questions about their safety for use in individuals with allergies and those who are immunocompromised. In this document, we aim to address these concerns and provide guidance for allergists/immunologists.

Methods: Scoping review of the literature regarding COVID-19 vaccination, adverse or allergic reactions, and immunocompromise from PubMed over the term of December 2020 to present date. We filtered our search with the terms "human" and "English" and limited the search to the relevant subject age range with the term "adult." Reports resulting from these searches and relevant references cited in those reports were reviewed and cited on the basis of their relevance.

Results: Assessment by an allergist is warranted in any individual with a suspected allergy to a COVID-19 vaccine or any of its components. Assessment by an allergist is NOT required for individuals with a history of unrelated allergies, including to allergies to foods, drugs, insect venom or environmental allergens. COVID-19 vaccines should be offered to immunocompromised patients if the benefit is deemed to outweigh any potential risks of vaccination.

Interpretation: This review provides the first Canadian guidance regarding assessment of an adolescent and adult with a suspected allergy to one of the COVID-19 vaccines currently available, or any of their known allergenic components, and for patients who are immunocompromised who require vaccination for COVID-19. As information is updated this guidance will be updated accordingly.
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http://dx.doi.org/10.1186/s13223-021-00529-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7957441PMC
March 2021

An Approach to the Office-Based Practice of Food Oral Immunotherapy.

J Allergy Clin Immunol Pract 2021 Mar 5. Epub 2021 Mar 5.

Geisel School of Medicine at Dartmouth, Hanover, NH; Dartmouth-Hitchcock Medical Center, Lebanon, NH. Electronic address:

Oral immunotherapy (OIT) provides an active treatment option for patients with food allergies. OIT may improve quality of life and raise the threshold at which a patient with food allergy may react to an allergen, but it is a rigorous therapy that requires a high degree of commitment by the clinician, patients, and families. Recent guidelines from the Canadian Society for Allergy and Clinical Immunology have provided a framework for the ethical, evidence-based, and patient-oriented clinical practice of OIT, and the European Academy of Allergy, Asthma, and Immunology guidelines have also recommended that OIT can be used as a potential treatment. The recent Food and Drug Administration approval of an OIT pharmaceutical has accelerated the adoption of OIT. This review provides a summary of the recent Canadian Society for Allergy and Clinical Immunology guidelines and a consensus of practical experience of clinicians across the United States and Canada related to patient selection, office and staff preparation, the general OIT process, OIT-related reaction management, and treatment outcomes.
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http://dx.doi.org/10.1016/j.jaip.2021.02.046DOI Listing
March 2021

Reply to "Cardiovascular symptoms/signs in infants and toddlers with anaphylaxis".

J Allergy Clin Immunol Pract 2021 Feb;9(2):1046

Division of Allergy & Immunology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY. Electronic address:

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http://dx.doi.org/10.1016/j.jaip.2020.11.059DOI Listing
February 2021

Community Use of Epinephrine for the Treatment of Anaphylaxis: A Review and Meta-Analysis.

J Allergy Clin Immunol Pract 2021 Feb 4. Epub 2021 Feb 4.

Division of Pediatric Allergy and Clinical Immunology, Department of Pediatrics, McGill University Health Center, Montreal, QC, Canada.

Background: Community use of epinephrine for the treatment of anaphylaxis is low. Knowledge of rates of epinephrine use in the pre-hospital setting along with identification of barriers to its use will contribute to the development of policies and guidelines.

Objectives: A search was conducted on PubMed and Embase in April 2020. Our systematic review focused on 4 domains: (1) epinephrine use in the pre-hospital setting; (2) barriers to epinephrine use in the pre-hospital setting; (3) cost evaluation and cost-effectiveness of epinephrine use; and (4) programs and strategies to improve epinephrine use during anaphylaxis.

Methods: Two meta-analyses with logit transformation were conducted to: (1) calculate the pooled estimate of the rate of epinephrine use in the pre-hospital setting among cases of anaphylaxis and (2) calculate the pooled estimate of the rate of biphasic reactions among all cases of anaphylaxis.

Results: Epinephrine use in the pre-hospital setting was significantly higher for children compared with adults (20.98% [95% confidence interval (CI): 16.38%, 26.46%] vs 7.17% [95% CI: 2.71%, 17.63%], respectively, P = .0027). The pooled estimate of biphasic reactions among all anaphylaxis cases was 3.92% (95% CI: 2.88%, 5.32%). Our main findings indicate that pre-hospital use of epinephrine in anaphylaxis remains suboptimal. Major barriers to the use of epinephrine were identified as low prescription rates of epinephrine autoinjectors and lack of stock epinephrine in schools, which was determined to be cost-effective. Finally, in reviewing programs and strategies, numerous studies have engineered effective methods to promote adequate and timely use of epinephrine.

Conclusion: The main findings of our study demonstrated that across the globe, prompt epinephrine use in cases of anaphylaxis remains suboptimal. For practical recommendations, we would suggest considering stock epinephrine in schools and food courts to increase the use of epinephrine in the community. We recommend use of pamphlets in public areas (ie, malls, food courts, etc.) to assist in recognizing anaphylaxis and after that with prompt epinephrine administration, to avoid the rare risk of fatality in anaphylaxis cases.
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http://dx.doi.org/10.1016/j.jaip.2021.01.038DOI Listing
February 2021

Exome sequencing enables diagnosis of X-linked hypohidrotic ectodermal dysplasia in patient with eosinophilic esophagitis and severe atopy.

Allergy Asthma Clin Immunol 2021 Jan 14;17(1). Epub 2021 Jan 14.

BC Children's Hospital, University of British Columbia, 950 W 28th Ave, Vancouver, BC, V5Z 4H4, Canada.

X-linked hypohidrotic ectodermal dysplasia (XLHED) is the most common form of ectodermal dysplasia. Clinical and genetic heterogeneity between different ectodermal dysplasia types and evidence of incomplete penetrance and variable expressivity increase the potential for misdiagnosis. We describe a family with X-linked hypohidrotic ectodermal dysplasia (XLHED) presenting with variable expressivity of symptoms between affected siblings. In addition to the classical signs of hypohidrosis, hypotrichosis and hypodontia, the index patient-a 5 year old boy, also presented with a severe atopy phenotype that was not observed in the other two affected brothers. Exome sequencing in the index and the mother identified a pathogenic nonsense variant in EDA (NM_001399.4: c.766 C>T; p. Gln256Ter). This study highlights how exome sequencing was crucial in establishing a precise molecular diagnosis of XLHED by enabling us to rule out other differential diagnoses including NEMO deficiency syndrome, that was initially presented as a clinical diagnosis to the family.
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http://dx.doi.org/10.1186/s13223-021-00510-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7809757PMC
January 2021

Food-Induced Anaphylaxis in Infants: Can New Evidence Assist with Implementation of Food Allergy Prevention and Treatment?

J Allergy Clin Immunol Pract 2021 Jan;9(1):57-69

Division of Allergy & Immunology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY. Electronic address:

Previous guidance on infant anaphylaxis largely relied on data from older children and adults. Infants are a unique subgroup, which presents specific challenges because infants are unable to verbalize symptoms, although the magnitude of underrecognition is not well studied. Data show that strict avoidance of allergens is difficult to achieve in the infant age group and a source of stress and anxiety for their caregivers. Recent studies suggest that infant anaphylaxis is less severe than in older children, which could greatly assist with implementation of food allergy prevention and treatment. New evidence from clinical trials and observational and real-world studies show that infant anaphylaxis is rare on first ingestion of a new food and typically not severe when it occurs, which parents may not be aware of when preparing to introduce peanut or other common food allergens to infants for the purpose of prevention. The better safety and efficacy of oral immunotherapy in infants and preschoolers could help prevent undesired psychosocial consequences of longstanding food allergy such as anxiety, bullying, and poor quality of life. Evidence from recent years on the lower risk of infant anaphylaxis and its severity could move allergy practice toward the confidence that regular, long-term ingestion provides.
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http://dx.doi.org/10.1016/j.jaip.2020.09.018DOI Listing
January 2021

Should we continue to counsel families to use hydrolyzed formulas as a means of allergy prevention in high-risk infants?

Paediatr Child Health 2020 Mar 29;25(2):79-81. Epub 2019 Jul 29.

Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia.

The prevalence of food allergy in North America is high, and has increased over time. As a result, focus has shifted from treatment to allergy prevention. Previous studies have suggested that hydrolyzed formula may prevent atopic dermatitis in high-risk infants. As a result, multiple international guidelines including the Canadian Paediatric Society (CPS) position statement on allergy prevention recommend the use of hydrolyzed formula as a means of allergy prevention in mothers who are not breastfeeding or using donor breastmilk. However, a recent systematic review has not supported an association between use of hydrolyzed formula and allergy prevention. In addition, studies are emerging supporting the use of early and regular cow's milk formula as a means of cow's milk allergy prevention.
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http://dx.doi.org/10.1093/pch/pxz098DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7757771PMC
March 2020

A High Proportion of Canadian Allergists Offer Oral Immunotherapy but Barriers Remain.

J Allergy Clin Immunol Pract 2020 Dec 29. Epub 2020 Dec 29.

Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, CHU Sainte-Justine, Montréal, QC, Canada.

Background: Limited data on clinical implementation of oral immunotherapy (OIT) have been reported with incomplete evaluation of barriers.

Objective: To survey Canadian allergists on their current practice of OIT and barriers to implementation and expansion of OIT.

Methods: A survey investigating current practice and logistical and clinical barriers to offering or expanding OIT was distributed to all Canadian Society of Allergy and Clinical Immunology allergists.

Results: Of 90 responding allergists, 52.2% reported offering OIT, most commonly to peanut. Food sublingual immunotherapy was offered by 7% of allergists. Having received training for OIT was associated with currently performing OIT (P = .008); 44.7% of allergists offering OIT had received training on OIT, and 81.4% not offering OIT had no training. A total of 87% of allergists performing OIT reported lack of efficacy data and lack of support staff and clinic space, and concerns about increased oral challenges (84%) were "moderately" to "extremely" important barriers to expanding OIT. For clinicians not offering OIT, concerns about safety (95%), after-hours support (95%), efficacy (93%), medicolegal risk (93%), and long-term practice implications (93%) were prioritized as significant barriers. Qualitative assessment suggested concerns about the practical challenges associated with OIT, the need for increased safety and efficacy data, and a desire for OIT guidelines and training.

Conclusion: The implementation of OIT faces many barriers, both clinical and logistical. Increasing high-quality safety and efficacy data may support those hesitant to offer OIT, and improving funding may address the practical infrastructure challenges. In addition, training will help expand access for allergists interested in performing OIT.
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http://dx.doi.org/10.1016/j.jaip.2020.12.025DOI Listing
December 2020

First pediatric electronic algorithm to stratify risk of penicillin allergy.

Allergy Asthma Clin Immunol 2020 Dec 4;16(1):103. Epub 2020 Dec 4.

Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, Canada.

Beta-lactam allergy is reported in 5-10% of children in North America, but up to 94-97% of patients are deemed not allergic after allergist assessment. The utility of standardized skin testing for penicillin allergy in the pediatric population has been recently questioned. Oral drug challenges when appropriate, are preferred over skin testing, and can definitively rule out immediate, IgE-mediated drug allergy. To our knowledge, this is the only pediatric study to assess the reliability of a penicillin allergy stratification tool using a paper and electronic clinical algorithm. By using an electronic algorithm, we identified 61 patients (of 95 deemed not allergic by gold standard allergist decision) as low risk for penicillin allergy, with no false negatives and without the need for allergist assessment or skin testing. In this study, we demonstrate that an electronic algorithm can be used by various pediatric clinicians when evaluating possible penicillin allergy to reliably identify low risk patients. We identified the electronic algorithm was superior to the paper version, capturing an even higher percentage of low risk patients than the paper version. By developing an electronic algorithm to accurately assess penicillin allergy risk based on appropriate history, without the need for diagnostic testing or allergist assessment, we can empower non-allergist health care professionals to safely de-label low risk pediatric patients and assist in alleviating subspecialty wait times for penicillin allergy assessment.
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http://dx.doi.org/10.1186/s13223-020-00501-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7716490PMC
December 2020

A Consensus Approach to the Primary Prevention of Food Allergy Through Nutrition: Guidance from the American Academy of Allergy, Asthma, and Immunology; American College of Allergy, Asthma, and Immunology; and the Canadian Society for Allergy and Clinical Immunology.

J Allergy Clin Immunol Pract 2021 Jan 26;9(1):22-43.e4. Epub 2020 Nov 26.

Section of Allergy & Immunology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo. Electronic address:

Recently published data from high-impact randomized controlled trials indicate the strong potential of strategies to prevent the development of food allergy in high-risk individuals, but guidance in the United States at present is limited to a policy for only the prevention of peanut allergy, despite other data being available and several other countries advocating early egg and peanut introduction. Eczema is considered the highest risk factor for developing IgE-mediated food allergy, but children without risk factors still develop food allergy. To prevent peanut and/or egg allergy, both peanut and egg should be introduced around 6 months of life, but not before 4 months. Screening before introduction is not required, but may be preferred by some families. Other allergens should be introduced around this time as well. Upon introducing complementary foods, infants should be fed a diverse diet, because this may help foster prevention of food allergy. There is no protective benefit from the use of hydrolyzed formula in the first year of life against food allergy or food sensitization. Maternal exclusion of common allergens during pregnancy and/or lactation as a means to prevent food allergy is not recommended. Although exclusive breast-feeding is universally recommended for all mothers, there is no specific association between exclusive breast-feeding and the primary prevention of any specific food allergy.
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http://dx.doi.org/10.1016/j.jaip.2020.11.002DOI Listing
January 2021

First Real-World Effectiveness Analysis of Preschool Peanut Oral Immunotherapy.

J Allergy Clin Immunol Pract 2021 Mar 19;9(3):1349-1356.e1. Epub 2020 Nov 19.

British Columbia Children's Hospital, Vancouver, BC, Canada; Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada.

Background: We previously described safety of preschool peanut oral immunotherapy (P-OIT) in a real-world setting; 0.4% of patients experienced a severe reaction, and 4.1% received epinephrine, during build-up.

Objective: To determine the effectiveness of preschool P-OIT after 1 year of maintenance.

Methods: Preschoolers (9-70 months) with at least 1 objective reaction to peanut (during baseline oral food challenge (OFC) or P-OIT build-up) received a follow-up OFC to cumulative 4000 mg protein after 1 year on 300 mg peanut daily maintenance. Effectiveness of desensitization was defined as proportion of patients with a negative follow-up OFC. Symptoms and treatment at follow-up OFC were recorded.

Results: Of the 117 patients who successfully completed 1 year of P-OIT and subsequently underwent a cumulative 4000-mg follow-up OFC, 92 (78.6%) had a negative OFC and 115 (98.3%) tolerated a cumulative dose of greater than or equal to 1000 mg. For the 25 (21.4%) who reacted, their threshold increased by 3376 mg (95% CI, 2884-3868) from baseline to follow-up; 17 (14.5%) patients experienced grade 1 reactions, 7 (6.00%) grade 2, and 1 (0.85%) grade 3. Two patients (1.71%) received epinephrine associated with P-OIT, and 1 (0.85%) went to the emergency department.

Conclusions: Our data demonstrate that real-world preschool P-OIT is effective after 1 year of maintenance for those who received a follow-up OFC. For those who reacted, their threshold increased sufficiently to protect against accidental exposures. P-OIT should be considered for preschoolers as an alternative to current recommendations to avoid peanut.
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http://dx.doi.org/10.1016/j.jaip.2020.10.045DOI Listing
March 2021

Aiming for a shorter time to diagnosis: pediatric eosinophilic esophagitis in British Columbia.

Allergy Asthma Clin Immunol 2020 14;16:88. Epub 2020 Oct 14.

BC Children's Hospital Research Institute, Vancouver, BC Canada.

Longer time to diagnosis for patients with eosinophilic esophagitis can lead to adverse patient outcomes, but the length of diagnostic delay has not been quantified for patients with eosinophilic esophagitis in Canada. Our study defines the time to diagnosis (TTD) for pediatric patients with eosinophilic esophagitis in British Columbia and identifies factors that predict increased time to diagnosis. The median TTD was 21 months (1.75 years; IQR = 7, 45) with a median age at EoE diagnosis of 105 months (8.75 years; IQR = 44, 156). Caucasians experienced significantly longer TTD compared to other ethnicities (24 months (IQR = 7, 52) and 12 months (IQR = 4.5, 23) respectively,  = 0.008). Caucasian ethnicity ( = 0.037) and older age at the time of diagnosis ( = 0.006) predicted increased TTD. Our model explained 7.9% (Adjusted R = 0.079) of the total variance for our cohort.
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http://dx.doi.org/10.1186/s13223-020-00486-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7557005PMC
October 2020

Management and diagnosis of exercise-associated anaphylaxis cases in the paediatric population.

Clin Exp Allergy 2021 Jan 28;51(1):148-150. Epub 2020 Oct 28.

Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada.

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http://dx.doi.org/10.1111/cea.13763DOI Listing
January 2021

Risk of peanut- and tree-nut-induced anaphylaxis during Halloween, Easter and other cultural holidays in Canadian children.

CMAJ 2020 Sep;192(38):E1084-E1092

Division of Allergy and Clinical Immunology (Leung, Gabrielli, Ben-Shoshan), Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montréal, Que.; Division of Rheumatology (Clarke, Shand), Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Morris), Hôpital Sacré-Coeur; Division of Pediatric Emergency Medicine (Gravel), Department of Pediatrics, Centre hospitalier universitaire Sainte-Justine, Montréal, Que.; Division of Pediatric Emergency Medicine (Lim), Department of Pediatrics, Children's Hospital at London Health Sciences Centre, London, Ont.; Divisions of Allergy and Immunology (Chan) and Emergency Medicine (Goldman, Enarson), Department of Pediatrics, BC Children's Hospital, University of British Columbia, Vancouver, BC; Department of Pediatrics (O'Keefe), Faculty of Medicine, Memorial University, St. John's, NL; Food Allergy Canada (Gerdts), Toronto, Ont.; Division of Clinical Immunology & Allergy (Chu), Department of Medicine, and Department of Health Research Methods, Evidence, and Impact (Chu), McMaster University, Hamilton, Ont.; Division of Immunology and Allergy (Upton), Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ont.; Centre for Outcomes Research and Evaluation (Zhang), Research Institute of McGill University Health Centre, Montréal, Que.

Background: It is not established whether the risk of anaphylaxis induced by peanuts or tree nuts in children increases at specific times of the year. We aimed to evaluate the risk of peanut-and tree-nut-induced anaphylaxis during certain cultural holidays in Canadian children.

Methods: We collected data on confirmed pediatric cases of anaphylaxis presenting to emergency departments in 4 Canadian provinces as part of the Cross-Canada Anaphylaxis Registry. We assessed the mean number of cases per day and incidence rate ratio (IRR) of anaphylaxis induced by unknown nuts, peanuts and tree nuts presenting during each of 6 holidays (Halloween, Christmas, Easter, Diwali, Chinese New Year and Eid al-Adha) versus the rest of the year. We estimated IRRs and 95% confidence intervals (CIs) using Poisson regression.

Results: Data were collected for 1390 pediatric cases of anaphylaxis between 2011 and 2020. Their median age was 5.4 years, and 864 (62.2%) of the children were boys. During Halloween and Easter, there were higher rates of anaphylaxis to unknown nuts (IRR 1.66, 95% CI 1.13-2.43 and IRR 1.71, 95% CI 1.21-2.42, respectively) and peanuts (IRR 1.86, 95% CI 1.12-3.11 and IRR 1.57, 95% CI 0.94-2.63, respectively) compared to the rest of the year. No increased risk of peanut- or tree-nut-induced anaphylaxis was observed during Christmas, Diwali, Chinese New Year or Eid al-Adha. Anaphylaxis induced by unknown nuts, peanuts and tree nuts was more likely in children aged 6 years or older than in younger children.

Interpretation: We found an increased risk of anaphylaxis induced by unknown nuts and peanuts during Halloween and Easter among Canadian children. Educational tools are needed to increase awareness and vigilance in order to decrease the risk of anaphylaxis induced by peanuts and tree nuts in children during these holidays.
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http://dx.doi.org/10.1503/cmaj.200034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7532006PMC
September 2020

Increasing Awareness of the Low Risk of Severe Reaction at Infant Peanut Introduction: Implications During COVID-19 and Beyond.

J Allergy Clin Immunol Pract 2020 Nov - Dec;8(10):3259-3260. Epub 2020 Sep 4.

Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada.

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http://dx.doi.org/10.1016/j.jaip.2020.08.044DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7473022PMC
November 2020

Prevalence of Physician-Reported Food Allergy in Canadian Children.

J Allergy Clin Immunol Pract 2021 Jan 6;9(1):193-199. Epub 2020 Aug 6.

Department of Family Medicine, University of Manitoba, Winnipeg, MB, Canada; Department of Pediatrics, Division of Allergy and Immunology, University of British Columbia, Vancouver, BC, Canada. Electronic address:

Background: Food allergy prevalence data have largely been derived from self-report, and estimates vary.

Objective: Determine the prevalence of physician-reported food allergy in children using electronic medical record data from the Canadian Primary Care Sentinel Surveillance Network (CPSSN).

Methods: This was a retrospective cohort study using the CPCSSN repository, Canada's only primary care practice-based surveillance system. Machine learning algorithms were applied to assess for food allergy documentation. Demographic information, chronic diseases of interest, prescribed medications, and health behaviors from the CPCSSN repository were identified.

Results: The prevalence of physician-reported food allergy in Canadian children was 2.53% (95% CI, 2.48%-2.59%). The most common food allergies documented were peanut (0.8% of children), tree nut (0.6%), cow's milk (0.4%), egg (0.3%), fruit (0.2%), finned fish (0.2%), and shellfish (0.2%). Among children with food allergy, only 33.7% had an epinephrine autoinjector prescription. In logistic regression analysis, children with food allergy were more likely to have an atopic comorbidity (odds ratio [OR], 2.20; 95% CI, 2.06-2.35) and less likely to be obese than children without food allergies (OR, 0.84; 95% CI, 0.78-0.90). In the age- and sex-adjusted models, patients with food allergy were significantly more likely to have a psychiatric morbidity, specifically: attention deficit/hyperactivity disorder (OR, 1.81; 95% CI, 1.66-1.96), autism (OR, 1.89; 95% CI, 1.63-2.19), and depression (OR, 1.17; 95% CI, 1.02-1.35).

Conclusions: Our study is the first to estimate national physician-reported prevalence of food allergy, and demonstrates a lower rate than that based on self-report. Further studies into the association of food allergy and psychiatric comorbidities (attention deficit/hyperactivity disorder, autism, depression) and the association of food allergy and obesity are needed.
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http://dx.doi.org/10.1016/j.jaip.2020.07.039DOI Listing
January 2021

One-year sustained impact of supervised epinephrine autoinjector administration during food challenge on parent confidence.

Ann Allergy Asthma Immunol 2020 12 31;125(6):705-707. Epub 2020 Jul 31.

Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.

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http://dx.doi.org/10.1016/j.anai.2020.07.028DOI Listing
December 2020

Novel Approaches to Food Allergy Management During COVID-19 Inspire Long-Term Change.

J Allergy Clin Immunol Pract 2020 10 25;8(9):2851-2857. Epub 2020 Jul 25.

Section of Allergy and Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo.

The SARS-CoV2 pandemic has prompted a re-evaluation of our current practice of medicine. The seemingly abrupt worldwide spread of this disease resulted in immediate changes and a reduction in many allergy-focussed services and procedures. The reality of the long-term circulation of this virus in our communities requires us to evolve as a specialty. In this article, we outline current and future challenges in the management of food allergy in light of coronavirus disease 2019 (COVID-19). We focus on infant food allergy prevention, management of anaphylaxis, accurate diagnosis with oral food challenges, and active management of food allergy with oral immunotherapy. This article identifies the challenges of conflicting guidelines, shortcomings of acute management approaches, and inherent system deficiencies. We offer perspectives and strategies that can be implemented now, including an evaluation of virtual care and telemedicine for the management of food allergy. The use of a shared decision-making model results in novel approaches that can benefit our patients and our specialty for years to come. COVID-19 has forced us to re-evaluate our current way of thinking about food allergy management to better treat our patients.
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http://dx.doi.org/10.1016/j.jaip.2020.07.020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7382335PMC
October 2020

Managing Food Allergy in Schools During the COVID-19 Pandemic.

J Allergy Clin Immunol Pract 2020 10 23;8(9):2845-2850. Epub 2020 Jul 23.

Department of Medicine, Clinical Immunology and Allergy, McMaster University, Hamilton, Ontario, Canada; Halton Pediatric Allergy, Burlington, Ontario, Canada.

In the wake of the COVID-19 pandemic and massive disruptions to daily life in the spring of 2020, in May 2020, the Centers for Disease Control (CDC) released guidance recommendations for schools regarding how to have students attend while adhering to principles of how to reduce the risk of contracting SARS-CoV-2. As part of physical distancing measures, the CDC is recommending that schools who traditionally have had students eat in a cafeteria or common large space instead have children eat their lunch or other meals in the classroom at already physically distanced desks. This has sparked concern for the safety of food-allergic children attending school, and some question of how the new CDC recommendations can coexist with recommendations in the 2013 CDC Voluntary Guidelines on Managing Food Allergy in Schools as well as accommodations that students may be afforded through disability law that may have previously prohibited eating in the classroom. This expert consensus explores the issues related to evidence-based management of food allergy at school, the issues of managing the health of children attending school that are acutely posed by the constraints of an infectious pandemic, and how to harmonize these needs so that all children can attend school with minimal risk from both an infectious and allergic standpoint.
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http://dx.doi.org/10.1016/j.jaip.2020.07.016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7375974PMC
October 2020

Long-term, open-label extension study of the efficacy and safety of epicutaneous immunotherapy for peanut allergy in children: PEOPLE 3-year results.

J Allergy Clin Immunol 2020 10 10;146(4):863-874. Epub 2020 Jul 10.

DBV Technologies, Montrouge, France; Division of Pediatric Allergy and Immunology, Icahn School of Medicine at Mount Sinai, New York, NY.

Background: The PEPITES (Peanut EPIT Efficacy and Safety) trial, a 12-month randomized controlled study of children with peanut allergy and 4 to 11 years old, previously reported the safety and efficacy of epicutaneous immunotherapy (EPIT) for peanut allergy (250 μg, daily epicutaneous peanut protein; DBV712 250 μg).

Objective: We sought to assess interim safety and efficacy of an additional 2 years of EPIT from the ongoing (5-year treatment) PEOPLE (PEPITES Open-Label Extension) study.

Methods: Subjects who completed PEPITES were offered enrollment in PEOPLE. Following an additional 2 years of daily DBV712 250 μg, subjects who had received DBV712 250 μg in PEPITES underwent month-36 double-blind, placebo-controlled food challenge with an optional month-38 sustained unresponsiveness assessment.

Results: Of 213 eligible subjects who had received DBV712 250 μg in PEPITES, 198 (93%) entered PEOPLE, of whom 141 (71%) had assessable double-blind, placebo-controlled food challenge at month 36. At month 36, 51.8% of subjects (73 of 141) reached an eliciting dose of ≥1000 mg, compared with 40.4% (57 of 141) at month 12; 75.9% (107 of 141) demonstrated increased eliciting dose compared with baseline; and 13.5% (19 of 141) tolerated the full double-blind, placebo-controlled food challenge of 5444 mg. Median cumulative reactive dose increased from 144 to 944 mg. Eighteen subjects underwent an optional sustained unresponsiveness assessment; 14 of those (77.8%) maintained an eliciting dose of ≥1000 mg at month 38. Local patch-site skin reactions were common but decreased over time. There was no treatment-related epinephrine use in years 2 or 3. Compliance was high (96.9%), and withdrawals due to treatment-related adverse events were low (1%).

Conclusions: These results demonstrate that daily EPIT treatment for peanut allergy beyond 1 year leads to continued response from a well-tolerated, simple-to-use regimen.
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http://dx.doi.org/10.1016/j.jaci.2020.06.028DOI Listing
October 2020

Parents of children with food allergy: A qualitative study describing needs and identifying solutions.

Ann Allergy Asthma Immunol 2020 12 23;125(6):674-679. Epub 2020 May 23.

Faculty of Medicine, Department of Pediatrics, University of British Columbia, British Columbia, Canada; BC Children's Hospital, Vancouver, Canada.

Background: Parents experience a wide range of emotions, specifically stress and anxiety, when their child receives a diagnosis of a food allergy. Managing this health condition and coping with emotions require professional and peer support. Currently, there is a lack of resources and a lack of awareness of the resources that are required to help assist parents in managing their child's food allergy.

Objective: To describe parental experiences when caring for a child with food allergy and to review the resources parents need to manage living with a child with food allergy and more specifically how they would want these resources delivered.

Methods: A total of 7 semistructured focus groups were conducted in British Columbia, Canada. Parents were asked to describe their experiences with managing their child's food allergy and identify helpful resources.

Results: A total of 40 parents (33 females) participated in the focus groups. Participant demographics were collected. The following 3 main themes emerged: (1) anxiety (an emotional roller coaster); (2) a transformational journey (the waiting game, loss of normalcy, strained relationships and mistrust, and financial challenges); and (3) the need for resources (day to day management, ages and stages, mental health supports, and "the dream").

Conclusion: An in-person allied health care team is needed to provide an integrated, patient-centered approach for how families can live and manage food allergies. Credible information and resources, such as medically reviewed websites, support groups, and counseling services, with a goal of reducing child and parental anxiety, should be provided by health care professionals.
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http://dx.doi.org/10.1016/j.anai.2020.05.014DOI Listing
December 2020

A Phased Approach to Resuming Suspended Allergy/Immunology Clinical Services.

J Allergy Clin Immunol Pract 2020 Jul - Aug;8(7):2125-2134. Epub 2020 May 22.

Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo. Electronic address:

In early 2020, the first US and Canadian cases of the novel severe acute respiratory syndrome coronavirus 2 infection were detected. In the ensuing months, there has been rapid spread of the infection. In March 2020, in response to the virus, state/provincial and local governments instituted shelter-in-place orders, and nonessential ambulatory care was significantly curtailed, including allergy/immunology services. With rates of new infections and fatalities potentially reaching a plateau and/or declining, restrictions on provision of routine ambulatory care are lifting, and there is a need to help guide the allergy/immunology clinician on how to reinitiate services. Given the fact that coronavirus disease 2019 will circulate within our communities for months or longer, we present a flexible, algorithmic best-practices planning approach on how to prioritize services, in 4 stratified phases of reopening according to community risk level, as well as highlight key considerations for how to safely do so. The decisions on what services to offer and how fast to proceed are left to the discretion of the individual clinician and practice, operating in accordance with state and local ordinances with respect to the level of nonessential ambulatory care that can be provided. Clear communication with staff and patients before and after all changes should be incorporated into this new paradigm on continual change, given the movement may be forward and even backward through the phases because this is an evolving situation.
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http://dx.doi.org/10.1016/j.jaip.2020.05.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7242939PMC
July 2020

AGA Institute and the Joint Task Force on Allergy-Immunology Practice Parameters Clinical Guidelines for the Management of Eosinophilic Esophagitis.

Gastroenterology 2020 05;158(6):1776-1786

Division of Gastroenterology and Hepatology, Veterans Affairs Northeast Ohio Healthcare System, Case Western Reserve University School of Medicine, Cleveland, Ohio.

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http://dx.doi.org/10.1053/j.gastro.2020.02.038DOI Listing
May 2020

Anaphylaxis as a presenting symptom of food allergy in children with no known food allergy.

J Allergy Clin Immunol Pract 2020 09 26;8(8):2811-2813.e2. Epub 2020 Apr 26.

Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada.

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http://dx.doi.org/10.1016/j.jaip.2020.04.033DOI Listing
September 2020

Billing fees for various common allergy tests vary widely across Canada.

Allergy Asthma Clin Immunol 2020 22;16:28. Epub 2020 Apr 22.

7Division of Allergy & Immunology, Department of Pediatrics, Faculty of Medicine, The University of British Columbia, Vancouver, BC Canada.

Background: The prevalence of food allergy in Canada is high and has increased over time. To date, there are no Canadian data on the healthcare costs of visits to allergists.

Methods: We sent an anonymous survey to allergist members of the Canadian Society of Allergy and Clinical Immunology (CSACI) between October and December 2019. Survey questions included demographic information and billing fees for various types of allergy visits and diagnostic testing.

Results: Of 200 allergists who are members of CSACI, 43 allergists responded (21.5% response rate). Billing fees varied widely. The greatest ranges were noted for oral immunotherapy (OIT; both initial consultation [mean $198.70; range $0 to $575] and follow up/build up visits [mean $125.74; range: $0 to $575]). There were significant provincial differences in billing fees, as well as significant billing fee differences between hospital versus community allergists (e.g. oral food challenge [OFC]: $256.38 vs. $134.94, p < 0.01). Billing fees were higher outside of Ontario, with the exception of specific Immunoglubulin E (sIgE) testing and OIT visits.

Conclusions: Greater standardization of billing fees across provinces and between hospital versus community allergy could result in more consistency of billing fees for OFC and OIT across Canada. Further knowledge of exact costs will help inform practice and policy in the diagnosis and management of food allergy.
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http://dx.doi.org/10.1186/s13223-020-00426-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7178720PMC
April 2020

AGA institute and the joint task force on allergy-immunology practice parameters clinical guidelines for the management of eosinophilic esophagitis.

Ann Allergy Asthma Immunol 2020 05;124(5):416-423

Division of Gastroenterology and Hepatology, Veterans Affairs Northeast Ohio Healthcare System, Case Western Reserve University School of Medicine, Cleveland, Ohio.

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http://dx.doi.org/10.1016/j.anai.2020.03.020DOI Listing
May 2020