Anaphylaxis
Prof JO’B Hourihane
24.06.2014
Credentials
I am Jonathan Hourihane, Professor of Paediatrics and Child Health, in UCC.
I was a member of the 2012-2014 Food Allergy and Anaphylaxis Taskforce of the
European Academy of Allergy and Clinical Immunology, whose documents were
published and launched at EAACI’s Annual Congress in Copenhagen last week
(www.eaaci.net), and which form part of my submission to the Joint Committee
today. I am the co chair of EAACIs Food Allergy and Anaphylaxis meeting, the
world’s largest food allergy meeting scheduled for Dublin in October 2014. I am
Principal Investigator on a prospective study of anaphylaxis, with Professor
Ronan O’Sullivan and Dr Ioana Maris, funded by the National Children’s Research
Centre, Dublin. I am co-lead, with Dr Michael Byrne, of UCC’s Anaphylaxis
Initiative. I am chairman of the Irish Food Allergy Network www.ifan.ie, which
receives unrestricted educational grants from industry. Until last week I was
Secretary of the Irish Association of Allergy and Immunology, which also
receives such unrestricted financial aid. I am a Board Member of the Clemens
von Pirquet Foundation, an independent charity affiliated to EAACI, which
promotes the scientific study of allergy in children. I have received research
funding and travel grants from industrial sources related to infant formulae and
allergen immunotherapy. I recently visited paediatric allergy units in Boston,
USA, on a Safefood Knowledge Network Training and Mobility Programme grant
to discuss joint research opportunities with colleagues in Massachusetts General
Hospital and Harvard Medical School.
Anaphylaxis is a term coined by von Pirquet in the early 20th century to indicate
the phenomenon of lack of protection against a substance that should be
tolerated. Anaphylaxis could loosely be considered the opposite of prophylaxis.
The use of the term is now largely related to allergic reactions to allergens, which
can be foods, pollens, house dust mite or medicines. Recent European position
statements and systematic reviews recognise how difficult it is to collect data
prospectively regarding anaphylaxis as it is hard for non-familiar physicians and
nurses to recognise it. It is thought that maybe 10 to 20% of acute asthma deaths
are actually caused by anaphylaxis particularly in children.
Anaphylaxis is likely to become more common as medical care moves to gradual
introduction of allergenic foods into the diets of children and adults, trying
encouraging the development of tolerance. This was previously considered
impossible in this rapidly changing field. Immunotherapy will moving from
research protocols to more routine care in other parts of the world but caution
has been urged by expert groups both in America and Europe.
It appears that people at risk of anaphylaxis have a lack of protection against the
outcome of this condition and this could be addressed with simple legislative
measures week that would be both innovative and widely welcomed by the
public.
Anaphylaxis
Prof JO’B Hourihane
24.06.2014
While death is rare the prospect of death is a grim part of daily life for families
particularly with food and insect allergens. They feel that they are being
followed around by the Grim Reaper who will take their child if they make a
mistake with the food. This is not a nice way to have to live. It inhibits family
sharing their life with other carers and adults in loco parentis and limits normal
integration in social groups such as after-school clubs, sports clubs and social
parties. These are all manageable situations if proportionate restrictions and
precautions are in place. The handing over of adrenaline auto injectors from an
experienced but anxious family to an inexperienced and unfamiliar family can be
a huge area of stress for all concerned.
In the United States, the Executive has enacted the School Access to Emergency
Epinephrine Act (2013). It must be recognised that President Obama's
motivation may reflect his role as an allergy parent - one of his daughters has
peanut allergy. The intention of this act is to indemnify and encourage schools to
have generic adrenaline available to administer it to people who do not have
their own adrenaline kits available, or more likely to people who are not already
known to be allergic to the food before their reaction in school.
There is no reason why this administrative effort could not take place in Ireland,
with far lower levels/no on-site school medical services available. However, it
must come with appropriate training packages and renewal mandates. It is not
simply sufficient to just put these kits into restaurants and catering outlets
Anaphylaxis
Prof JO’B Hourihane
24.06.2014
without the backup of training and support from public health authorities and
allergy services.
We have far fewer allergists than American or European countries and access to
allergy services in Ireland is very difficult indeed. I run the largest allergy clinic
in the public sector in Ireland and receive twice as many referrals each week as
any other paediatric service in CUH, Cork, each resourced with 2 Consultants
(Neurology, Respiratory/ Cystic Fibrosis, Diabetes/ Endocrinology). My service’s
wait times are all in breach of HSE guidelines. Waiting times for the allergy clinic
in Cork are one year from routine appointments and 3 years for diagnostic food
challenges. The need therefore for patient empowerment and empowerment of
other partners in the social contract with families may be even more critical in
Ireland than elsewhere.
If a person who carries prescribed adrenaline needs assistance in using ther
adrenaline, this assistance is covered by a Samaritan-based legislation. The
administration of unprescribed medication by health professionals is also
covered by existing legislation. The gap in Irish legislation relates to the
administration by non-medical staff of adrenaline to people for whom that
adrenaline is not specifically prescribed. The United States was able to solve this
and there's no reason why the Oireachtas could not do the same.
In 2009-2010 UCC’s proposed pilot study group engaged in extensive training
and recruitment of 1st responders for a programme of campus wide allergy
stations, beside existing defibrillators.
Anaphylaxis
Prof JO’B Hourihane
24.06.2014
The programme was voluntarily suspended in February 2011 at the time of the
confusion about over-the-counter oral contraceptive administration by
pharmacists. It became apparent that the legislation under which we were
presuming protection would be available was now felt to be unclear. From 2011,
when we voluntarily suspended our programme, we have sought advice and
guidance from regulatory authorities. We received no assistance sequentially
from the Irish Medicines Board or the Chief Pharmacist’s Office up to January
2013, when a TD-facilitated meeting with the Secretary General occurred. No
material progress has occurred since then, either, despite multiple enquiries.
Since Emma Sloan died of anaphylaxis in Dublin in December 2013 our study has
received details of 36 more cases of survived anaphylaxis in children
nationwide. Reporting varies regionally which can only reflect varying medical
awareness of the condition. More cases are inevitable and another “avoidable”
death is also inevitable. Continuing legislative inaction could expose the State, its
ill-equipped schools, and its health-care providers to liability in such an event.
If Emma Sloan had been born Emma Obama, we would not be sitting here today,
but she might be alive and well in the USA. The wider, governed availability of
adrenaline in the community and easier access to more clinicians who
understand anaphylaxis are achievable, affordable and uncontroversial
public health care innovations that meet several of the Government’s aims to
improve patient autonomy and self care.
Jonathan OB Hourihane
June 2014