Latex allergy and its clinical features among healthcare workers at Mankweng Hospital, Limpopo Province, South Africa

BACKGROUND AND OBJECTIVES. Latex allergy, caused by sensitisation in atopic individuals, is a common occupational disease among healthcare workers who use latex gloves. It may be present in non-atopic individuals as well. The main objective of this study was to document the prevalence and disease spectrum of latex allergy at Mankweng Hospital, Limpopo Province, South Africa. The secondary objective was to determine clinical presentation of the disease. METHODS. A cross-sectional descriptive study, with an analytical component, was conducted among healthcare workers who worked in high-risk areas for latex sensitisation. ImmunoCAP testing was performed and followed by a skin-prick test (SPT) in those who tested negative to the blood test. RESULTS. Two hundred screening questionnaires were distributed to healthcare workers at the hospital. Of these 158 (79.0%) were returned, with 59 participants meeting the inclusion criteria (experiencing symptoms due to wearing latex gloves). The mean age of the participants was 39.6 years (standard deviation 9.8 years, range 20 - 60 years). There were more females (98.1%) than males (1.9%). Glove-related symptoms were present in 59 subjects (37.1%), in 7 (11.9%) of whom the ImmunoCAP was positive to latex (95% confidence interval 4.2 - 22.9%). Fourteen participants were lost to follow-up before the SPT was performed. Thirty-eight of the participants with negative ImmunoCAP tests underwent SPT. Positive SPTs were reported in 5 of these 38 workers (13.2%), indicating that the ImmunoCAP test missed 11.1% (5/45) of latex-allergic individuals. The prevalence of latex allergy in this study was 8.3% (12/144). A denominator of 144 was used, as there is a possibility that some of the 14 individuals lost to follow-up could have tested positive to latex sensitisation by SPT. The symptoms experienced by latex-sensitised workers were rhinitis (100.0%), asthma (50.0%), dermatitis (25.0%), severe anaphylaxis (8.3%), abdominal pain (8.3%) and angio-oedema (8.3%). CONCLUSION. Our findings reveal that latex allergy is a problem at our hospital. The prevalence of 8.3% is comparable to findings in other South African centres. We recommend a latex-free protocol for high-risk areas and healthcare workers.http://www.samj.org.zaam2014ay201

HIV-related bronchiectasis in children : an emerging spectre in high tuberculosis burden areas

BACKGROUND: Human immunodeficiency virus (HIV) infected children have an eleven-fold risk of acute lower respiratory tract infection. This places HIV-infected children at risk of airway destruction and bronchiectasis. OBJECTIVE: To study predisposing factors for the development of bronchiectasis in a developing world setting. METHODS: Children with HIV-related bronchiectasis aged 6–14 years were enrolled. Data were collected on demographics, induced sputum for tuberculosis, respiratory viruses (respiratory syncytial virus), influenza A and B, parainfluenza 1–3, adenovirus and cytomegalovirus), bacteriology and cytokines. Spirometry was performed. Blood samples were obtained for HIV staging, immunoglobulins, immunoCAP®-specific immunoglobulin E (IgE) for common foods and aeroallergens and cytokines. RESULTS: In all, 35 patients were enrolled in the study. Of 161 sputum samples, the predominant organisms cultured were Haemophilus influenzae and parainfluenzae (49%). The median forced expiratory volume in 1 second of all patients was 53%. Interleukin-8 was the predominant cytokine in sputum and serum. The median IgE level was 770 kU/l; however, this did not seem to be related to atopy; 36% were exposed to environmental tobacco smoke, with no correlation between and CD4 count. CONCLUSION: Children with HIV-related bronchiectasis are diagnosed after the age of 6 years and suffer significant morbidity. Immune stimulation mechanisms in these children are intact despite the level of immunosuppression.This study was funded by the Research Development Program Fund of the University of Pretoria awarded to RM.http://www.theunion.org/about-the-journal/about-the-journal.htm

The bronchiolitis season is upon us – recommendations for the management and prevention of acute viral bronchiolitis

Despite being so common, bronchiolitis remains poorly diagnosed and managed. This article is intended as an update on issues pertaining to this condition.http://www.samj.org.zaam201

South African food allergy consensus document 2014

The prevalence of food allergy is increasing worldwide and is an important cause of anaphylaxis. There are no local South African food allergy guidelines. This document was devised by the Allergy Society of South Africa (ALLSA), the South African Gastroenterology Society (SAGES) and the Association for Dietetics in South Africa (ADSA). Subjects may have reactions to more than one food, and different types and severity of reactions to different foods may coexist in one individual. A detailed history directed at identifying the type and severity of possible reactions is essential for every food allergen under consideration. Skin-prick tests and specific immunoglobulin E (IgE) (ImmunoCAP) tests prove IgE sensitisation rather than clinical reactivity. The magnitude of sensitisation combined with the history may be sufficient to ascribe causality, but where this is not possible an incremental oral food challenge may be required to assess tolerance or clinical allergy. For milder non-IgE-mediated conditions a diagnostic elimination diet may be followed with food re-introduction at home to assess causality. The primary therapy for food allergy is strict avoidance of the offending food/s, taking into account nutritional status and provision of alternative sources of nutrients. Acute management of severe reactions requires prompt intramuscular administration of adrenaline 0.01 mg/kg and basic resuscitation. Adjunctive therapy includes antihistamines, bronchodilators and corticosteroids. Subjects with food allergy require risk assessment and those at increased risk for future severe reactions require the implementation of risk-reduction strategies, including education of the patient, families and all caregivers (including teachers), the provision of a written emergency action plan, a MedicAlert necklace or bracelet and injectable adrenaline (preferably via auto-injector) where necessary.http://www.samj.org.zaam2016Paediatrics and Child Healt

Severe food allergy and anaphylaxis : treatment, risk assessment and risk reduction

An anaphylactic reaction may be fatal if not recognised and managed appropriately with rapid treatment. Key steps in the management of anaphylaxis include eliminating additional exposure to the allergen, basic life-support measures and prompt intramuscular administration of adrenaline 0.01 mg/kg (maximum 0.5 mL). Adjunctive measures include nebulised bronchodilators for lower-airway obstruction, nebulised adrenaline for stridor, antihistamines and corticosteroids. Patients with an anaphylactic reaction should be admitted to a medical facility so that possible biphasic reactions may be observed and risk-reduction strategies initiated or reviewed after recovery from the acute episode. Factors associated with increased risk of severe reactions include co-existing asthma (and poor asthma control), previous severe reactions, delayed administration of adrenaline, adolescents and young adults, reaction to trace amounts of foods, use of non-selective β-blockers and patients who live far from medical care. Risk-reduction measures include providing education with regard to food allergy and a written emergency treatment plan on allergen avoidance, early symptom recognition and appropriate emergency treatment. Risk assessment allows stratification with provision of injectable adrenaline (preferably via an auto-injector) if necessary. Patients with ambulatory adrenaline should be provided with written instructions regarding the indications for and method of administration of this drug and trained in its administration. Patients and their caregivers should be instructed about how to avoid foods to which the former are allergic and provided with alternatives. Permission must be given to inform all relevant caregivers of the diagnosis of food allergy. The patient must always wear a MedicAlert necklace or bracelet and be encouraged to join an appropriate patient support organisation.http://www.samj.org.zahb201

Vaccination in food allergic patients

Important potential food allergens in vaccines include egg and gelatin. Rare cases of reactions to yeast, lactose and casein have been reported. It is strongly recommended that when vaccines are being administered resuscitation equipment must be available to manage potential anaphylactic reactions, and that all patients receiving a vaccine are observed for a sufficient period. Children who are allergic to egg may safely receive the measles-mumps-rubella (MMR) vaccine; it may also be given routinely in primary healthcare settings. People with egg allergy may receive influenza vaccination routinely; however, some authorities still perform prior skinprick testing and give two-stage dosing. The purified chick embryo cell culture rabies vaccine contains egg protein, and therefore the human diploid cell and purified verocell rabies vaccines are preferred in cases of egg allergy. Yellow fever vaccine has the greatest likelihood of containing amounts of egg protein sufficient to cause an allergic reaction in allergic individuals. This vaccine should not be routinely administered in egg allergic patients and referral to an allergy specialist is recommended, as vaccination might be possible after careful evaluation, skin-testing and graded challenge or desensitisation.http://www.samj.org.zahb201

Elimination diets and dietary interventions for the management of food allergies

The primary therapy for food allergy is strict avoidance of the offending food or foods. Dietary restriction should be tailored to meet the nutritional requirements of each patient. Patients should be educated on how to avoid allergens safely by understanding terminology for common ingredients and how to read food labels. Information regarding safe, cost-effective and freely available substitutes for the avoided foods should be provided. Patients should be re-evaluated at regular intervals to see if they have developed tolerance. Mothers of infants with cow’s milk protein allergy (CMPA) who are breastfeeding should be supported and encouraged to continue breastfeeding. Partially hydrolysed infant formulas are not hypoallergenic (tolerated by 90% of subjects with proven CMPA) and are therefore not recommended for the treatment of CMPA, but may have a role in prevention of eczema or CMPA in high-risk individuals. Some extensively hydrolysed and amino-acid-based formulas are truly hypoallergenic. The recommended feed of choice for the dietary management of mild-to-moderate CMPA in infants not breastfed is an extensively hydrolysed cow’s milk formula. The recommended formula for the dietary management of non-breastfed infants and children with known severe CMPA is an amino-acid-based formula. Soya-based formulas may be useful in infants with immunoglobulin E (IgE)-mediated CMPA with proven tolerance to soya, and some cases of mild-to-moderate non-IgE-mediated CMPA, bearing in mind the increased risk of co-reactivity between CMPA and soya allergy in non- IgE-mediated conditions. Other mammalian milks and plant-based milks, including rice and oat milks, are not suitable as sole nutrition for cow’s milk protein allergic individuals.http://www.samj.org.zahb201

Epidemiology of IgE-mediated food allergy

Despite the large number of foods that may cause immunoglobulin E (IgE)-mediated reactions, most prevalence studies have focused on the most common allergenic foods, i.e. cow’s milk, hen’s egg, peanut, tree nut, wheat, soya, fish and shellfish. Food allergy peaks during the first two years of life, and then diminishes towards late childhood as tolerance to several foods develops. Based on meta-analyses and large population-based studies, the true prevalence of food allergy varies from 1% to >10%, depending on the geographical area and age of the patient. The prevalence of food allergy in South Africa (SA) is currently being studied. The prevalence of IgE-mediated food allergy in SA children with moderate-to-severe atopic dermatitis is 40%; however, this represents a high-risk population for food allergy. Preliminary data from the South African Food Sensitisation and Food Allergy (SAFFA) study, which is investigating food allergy in an unselected cohort of 1 - 3-year olds, show a prevalence of 11.6% sensitisation to common foods. Food allergy was most common to egg (1.4%) and peanut (1.1%). Food allergy appears to be the most common trigger of anaphylactic reactions in the community, especially in children, in whom food is responsible for ≥85% of such reactions. In adults, shellfish and nut, and in children, peanut, tree nut, milk and egg, are the most common triggers of food-induced anaphylaxis.http://www.samj.org.zahb201

Diagnosis of food allergy : history, examination and in vivo and in vitro tests

One cannot depend on one single test to diagnose food allergy. A detailed history is an essential initial step in cases of suspected food allergy. Aspects of the history should be gathered separately for each food being considered, as a patient may experience different types of reactions with various foods, each of which requires individual diagnostic and management strategies. History alone is not diagnostic and additional measures of sensitisation or food challenges are often required. In suspected immunoglobulin E (IgE)-mediated allergy, skin-prick tests (SPTs) and/or measurement of serum specific IgE antibodies (ImmunoCAP) to suspected foods is used to prove sensitisation. Sensitisation does not, however, confirm clinical food allergy as these tests indicate an immunological response to the specific allergen, but the diagnosis requires a clear correlation between the test result and clinical reaction (by positive history or food challenge). The magnitude of the test result (SPT mean wheal size or ImmunoCAP level in kU/L) correlates with the likelihood of clinical allergy, but not the severity of a reaction. Choice of the allergens tested should be guided by the history, but limited to the lowest necessary number to avoid false-positive results. Tests for sensitisation to foods should not be performed when the history indicates that such foods are tolerated. Ninety-five per cent positive predictive values (where a clinical reaction can be predicted in 95% of cases) have been described for immediate reactions, but may be population specific. There are no validated tests to confirm non-IgE- or mixed IgE- and non-IgE-mediated food allergies. Diagnosis of this group of allergies depends on elimination of the suspected food, clearance of symptoms, and recurrence of symptoms on re-introduction of the food.http://www.samj.org.zahb201

Exclusion diets and challenges in the diagnosis of food allergy

Instituting an exclusion diet for 2 - 6 weeks, and following it up with a planned and intentional re-introduction of the diet, is important for the diagnosis of a food allergy when a cause-and-effect relationship between ingestion of food and symptoms is unclear. Food may be re-introduced after (short-term) exclusion diets for mild-to-moderate non-immunoglobulin E (IgE)-mediated conditions in a safe clinical environment or cautiously at home. However, patients who have had an IgE-mediated immediate reaction to food, a previous severe non-IgE-mediated reaction or a long period of food exclusion should not have a home challenge, but rather a formal incremental food challenge protocol in a controlled setting. An incremental oral food challenge (OFC) test is the gold standard to diagnose clinical food allergy or demonstrate tolerance. It consists of gradual feeding of the suspected food under close observation. It should be done by trained practitioners in centres that have experience in performing the procedure in an appropriate setting. An OFC must be performed in a setting where resuscitation equipment is available in the event of a severe anaphylactic reaction. OFCs are terminated when a reaction becomes apparent. Standardised and pre-set criteria are available on when to discontinue challenges. Patients who tolerate the full dose ‘pass’ the challenge and are advised to eat a full portion of the food at least twice a week to maintain tolerance. Those who have reactions have ‘failed’ the challenge, should avoid the food, receive education and implement risk-reduction strategies where appropriate. Patients should be observed for a minimum of 2 hours following a negative challenge and for 4 hours after a positive one.http://www.samj.org.zahb201