Journal Pre-proof

Perspectives and Gaps in the Management of Food Allergy and Anaphylaxis in the
Asia-Pacific Region

Agnes Sze Yin LEUNG, MRCPCH, Ruby PAWANKAR, MD, Punchama PACHARN,
MD, Lydia Su Yin WONG, MRCPCH, Duy Le Pham, MD, Grace Chan, MD, Iris
Rengganis, MD, Jing Zhao, MD, Jiu-Yao Wang, MD, Kent Chee-Keen Woo, MD,
Komei Ito, MD, Kyunguk Jeong, MD, Marysia Recto, MD, Michaela Lucas, MD,
Mizuho Nagao, MD, Rommel Crisenio M Lobo, MD, Sonomjamts Munkhbayarlakh,
MD, Sumadiono SpAK, MD, Syed Rezaul Huq, MD, Thushali Ranasinghe, MBBS,
Mimi TANG, MBBS, PhD, On behalf of the Asia Pacific Association of Allergy Asthma
and Clinical Immunology (APAAACI) Food allergy & Anaphylaxis and Junior Member
Committees

PII: S2772-8293(23)00127-3
DOI: https://doi.org/10.1016/j.jacig.2023.100202
Reference: JACIG 100202

To appear in: Journal of Allergy and Clinical Immunology: Global

Received Date: 25 May 2023

Revised Date: 3 October 2023
Accepted Date: 8 October 2023

Please cite this article as: LEUNG ASY, PAWANKAR R, PACHARN P, WONG LSY, Le Pham D, Chan
G, Rengganis I, Zhao J, Wang J-Y, Chee-Keen Woo K, Ito K, Jeong K, Recto M, Lucas M, Nagao
M, Crisenio M Lobo R, Munkhbayarlakh S, SpAK S, Huq SR, Ranasinghe T, TANG M, On behalf of
the Asia Pacific Association of Allergy Asthma and Clinical Immunology (APAAACI) Food allergy &
Anaphylaxis and Junior Member Committees, Perspectives and Gaps in the Management of Food
Allergy and Anaphylaxis in the Asia-Pacific Region, Journal of Allergy and Clinical Immunology: Global
(2024), doi: https://doi.org/10.1016/j.jacig.2023.100202.

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© 2023 The Author(s). Published by Elsevier Inc. on behalf of the American Academy of Allergy, Asthma
& Immunology.
Perspectives and Gaps in the Management of Food Allergy and Anaphylaxis in the Asia-

Pacific Region

#
Agnes Sze Yin LEUNG a, MRCPCH; # Ruby PAWANKAR b, MD; Punchama PACHARN c,

MD; Lydia Su Yin WONG d, MRCPCH; Duy Le Pham e, MD; Grace Chan f, MD; Iris

Rengganis g, MD; Jing Zhao h, MD; Jiu-Yao Wang i, MD; Kent Chee-Keen Woo j, MD; Komei

Ito k, MD; Kyunguk Jeong l, MD; Marysia Recto m, MD; Michaela Lucas n, MD; Mizuho Nagao
o
, MD; Rommel Crisenio M Lobo p, MD; Sonomjamts Munkhbayarlakh q, MD; Sumadiono,

f
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SpAK r, MD; Syed Rezaul Huq s, MD; Thushali Ranasinghe t, MBBS; Mimi TANG u, MBBS,

r
PhD,
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On behalf of the Asia Pacific Association of Allergy Asthma and Clinical Immunology
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(APAAACI) Food allergy & Anaphylaxis and Junior Member Committees
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a
Department of Paediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong,
HKSAR; Hong Kong Hub of Paediatric Excellence, The Chinese University of Hong Kong,
HKSAR; [email protected];
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b
Division of Allergy, Department of Pediatrics, Nippon Medical School, Tokyo, Japan;
[email protected]
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c
Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine Siriraj
Hospital, Mahidol University, Bangkok, Thailand; [email protected]
d
Department of Paediatrics, Yong Loo Lin School of Medicine, National University of
Singapore, Singapore; Khoo Teck Puat-National University Children’s Medical Institute,
National University Hospital, National University Health System, Singapore;
[email protected]
e
University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam;
[email protected]
f
Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital,
Singapore; [email protected]
g
Department of Internal Medicine, Faculty of Medicine, University of Indonesia, Cipto
Mangunkusumo National Hospital, Jakarta, Indonesia; [email protected]
h
Capital Institute of Pediatrics in China, Beijing, China; [email protected]
i
Division of Allergy and Clinical Immunology, Department of Pediatrics, College of
Medicine, National Cheng Kung University, Tainan, Taiwan; [email protected]
j
Gleneagles Hospital, Kuala Lumpur, Malaysia; [email protected]
k
Allergy And Immunology Center, Aichi Children's Health And Medical Center, Japan;
[email protected]
l
Ajou University School of Medicine, Korea; [email protected]

1
m
Division of Adult and Pediatric Allergy and Immunology, University of the Philippines
College of Medicine, Philippine General Hospital, Manila, the Philippines;
[email protected]
n
WA Health and University of Western Australia, Australia; [email protected]
o
National Hospital Organization Mie National Hospital, Japan; [email protected]
p
Fe del Mundo Medical Center, Metro Manila, Philippines; [email protected]
q
Department of Pulmonology and Allergology, School of Medicine, Mongolian National
University of Medical Sciences, Ulaanbaatar, Mongolia; [email protected]
r
Allergy Immunology Working Group of Indonesian Pediatric Society;
[email protected]
s
National Institute of the Chest Disease & Hospital NIDCH. Mohakhali, Dhaka, Bangladesh;
[email protected]
t
Allergy, Immunology and Cell Biology Unit, University of Sri Jayewardenepura;
[email protected]
u
Allergy Immunology, Murdoch Children's Research Institute, Melbourne, Australia;

f
Department of Paediatrics, University of Melbourne, Melbourne, Australia; Department of

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Allergy and Immunology, Royal Children's Hospital, Melbourne, Australia;
[email protected]

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#
Corresponding authors
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1. Dr. Agnes Sze-yin Leung, Assistant Professor, Department of Paediatrics, Prince of

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Wales Hospital, The Chinese University of Hong Kong, HKSAR. Tel: +852-35052859,

Email: [email protected]
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2. Prof. Ruby Pawankar, Professor, Division of Allergy, Department of Pediatrics, Nippon

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Medical School, Tokyo, Japan. Tel/Fax: +81-3-5802-

8177, Email: [email protected]

FUNDING: None

CONFLICT OF INTEREST: All authors do not have any conflict of interest to declare.

2
1. What is already known about this topic?

Due to the life-long implications of a food allergy diagnosis on a significant proportion

of patients, the propensity to endanger life, and the negative impact on the quality of

life of food allergic-individuals, it is important to understand how food allergy is

currently being managed.

2. What does this article add to our knowledge?

f
The article identified a lack of reliable data on FA epidemiology, a scarcity of allergists

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in the area, the lengthy wait times for OFCs, and the dearth of adrenaline autoinjectors

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in Asia-Pacific countries. -p
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3. How does this study impact current management guidelines?
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This study urges for enhanced allergy care, improved accessibility and affordability of
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adrenaline autoinjectors, and more robust epidemiological studies on food allergy in

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the Asia-Pacific region.

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ABSTRACT

Background: Food allergy (FA), a condition with no effective cure and can result in severe

life-threatening allergic reactions, remains a global public health concern, but little is known

about how they are currently managed in the Asia-Pacific region.

Objective: The main objective of this survey was to evaluate the epidemiology of FA,

availability of resources, and management practices of FA and anaphylaxis by healthcare

providers across Asia.

Methods: A questionnaire-based survey comprising 66 questions was electronically sent out

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to member societies of APAAACI using Survey Monkey® from June 2022 to September 2022.

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Results: Twenty responses were received from 15 member countries/territories. Compared to
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the pediatric data, there was a lack of prevalence data for FA in adults. Except for Australia
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and Japan, most regions had between 0.1 and 0.5 allergists per 100,000 population, and some
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had fewer than 0.1 allergists per 100,000 population. The perceived rate of FA was high in
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regions with a short supply of allergists. Although specific IgE tests and oral food challenges

(OFCs) were available in all regions, the median wait time for OFCs at government facilities
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was 37 days (IQR 10.5-60 days). Seven regions still relied on prescriptions of ampules and
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syringes of injectable adrenaline, and adrenaline autoinjectors were not accessible in four

regions. Oral immunotherapy as FA treatment was available in half of the surveyed

countries/territories.

Conclusions: Our study offers a cross-sectional evaluation of the management practices for

FA in each APAAACI member country/territory. Urgent actions are required to enhance

allergy services, improve the accessibility and affordability of adrenaline autoinjectors, and

conduct robust epidemiological studies.

Word Count (abstract): 261

4
Keywords: food allergy, anaphylaxis, allergy service, allergist, adrenaline autoinjector

Abbreviations:

APAAACI: Asia Pacific Association of Allergy Asthma and Clinical Immunology

COVID-19: coronavirus disease of 2019

FA: food allergy

Hong Kong SAR: Hong Kong Special Administrative Region of the People's Republic of

China

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IQR: Interquartile Range

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OIT: Oral immunotherapy

sIgE: Specific IgE

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USD: United States Dollars
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TGA: Therapeutic Goods Administration

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1. Introduction

Food allergy is a condition with no effective cure and can result in potentially fatal allergic

responses. Up to 1 in 10 adults1 and 1 in 12 children2 are food-allergic, of which more than a

third of these allergic individuals have attended the emergency department for food-allergic

reaction at least once in their lifetime. Avoidance of the food allergen and emergency treatment

with adrenaline in the event of accidental consumption remain the mainstay of food allergy

management. Complete allergen avoidance is however difficult, and inadvertent unintentional

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allergen exposure is known to occur in half of the children who develop food allergy during

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the next two years3. Although active introduction below a patient's reaction threshold is gaining

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favor among practitioners,4 such practice is often impractical in regions where allergy service
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provision and resources are limited. Furthermore, fatal anaphylaxis continued to occur as a
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result of the delay in recognizing and administering life-saving adrenaline therapy.5, 6

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When it comes to examining the burden of food allergies across different countries, much of

the attention has been placed on identifying variations in the prevalence rates between different
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regions. While this is certainly an important aspect to consider, it is equally crucial to take into
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account other factors relating to a region's health delivery systems and socio-economic status

that can contribute to the disease burden. This includes the study of the availability of allergy

services and the time it takes for a possibly food-allergic child to be examined by a specialist

and undergo allergy testing, which are crucial aspects of an effective healthcare delivery model.

Besides allergy physicians who play a leading role in food allergy management, a

multidisciplinary model involving primary care doctors and emergency physicians is critical

as they are often the initial contact point when patients experience acute allergic reactions; as

with support from specialist allergy nurses, dieticians, and clinical psychologist who represent

the link between clinical setting and the community. Administration of adrenaline, which is the

6
only effective treatment option for anaphylaxis, is still not available in the form of autoinjectors

in some parts of the world. The availability of oral immunotherapy (OIT) in Asia, as a

promising treatment modality to increase an allergic patient’s threshold of reactivity to a given

allergen, has not been well reported.

To provide insight into current perspectives and gaps in food allergy management, it is

important to study the health service provision in Asia, which consists of a rich tapestry of

economies, encompassing a broad spectrum of development levels, from the most advanced

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and established nations to those still in the process of development. In a previous survey that

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provided a global overview of food allergy prevalence, substantial disparities in health service
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provision have been identified, even among developed countries.7 However, the scarcity of
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published literature on food allergy management practices and health service provision in Asia
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may impede a systematic review’s effectiveness. Therefore, the Asia Pacific Association of
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Allergy Asthma and Clinical Immunology (APAAACI) conducted a structured survey of

representative experts from its member societies, with the objectives of evaluating the
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epidemiology, resources, and practices relating to food allergy management in the Asia-Pacific
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region.

2. Methods

This cross-sectional survey was initiated by the APAAACI to capture the current disease

burden, availability of resources, and management practices of food allergy by healthcare

providers in the region. APAAACI is Asia’s regional allergy organization, and its members are

Asian Societies, each of which has a good representation of the local allergy specialists. Three

junior APAAACI members interested in food allergy research collaborated with the Chair of

the APAAACI Food Allergy & Anaphylaxis Committee to design the study and survey

7
instrument. A questionnaire comprising 66 questions was electronically sent out to 16 member

countries of APAAACI using Survey Monkey ® from 10th June 2022 to 7th September 2022.

The electronic questionnaire was sent out by the APAAACI Secretariat to the presidents of

member societies, who nominated their society members to participate in this survey. The

nominated respondent was either a national or regional representative actively engaged in

allergy clinical practices at his/her institutional, member society, or professional society level.

Throughout the survey period, we sent regular email reminders to member societies until we

received all responses from societies that accepted the invitation. The questions covered the

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following areas: the respondents’ demographic profile, the regional prevalence of food allergy,

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the availability of allergy services, and the management of food allergy including prescription
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of adrenaline and food OIT. Additional inquiries were made on the management of food allergy
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and anaphylaxis in the respondents' own practices both before and during the COVID-19 period.
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Some questions had single-best responses, while others allowed multiple responses. Therefore,
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the total responses for multi-response questions may not add up to 100%. Estimation of the

number of allergists per 100,000 population was based on Worldometers' population statistics.8
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Results were compiled and reported using a denominator of the number of respondents or
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member societies who answered each question. The denominator for each question differed as

some respondents or societies did not answer specific questions. A similar methodology was

used for the previous surveys conducted by APAAACI. 9, 10

Results

3.1 Demographic profile of respondents

Out of the 16 member societies that were contacted, only India did not provide a response. The

respondents were from Australia, Bangladesh, China, Hong Kong SAR, Indonesia, Japan,

Korea, Malaysia, Mongolia, Philippines, Singapore, Sri Lanka, Taiwan, Thailand, and Vietnam.

8
In certain countries, allergists treated both pediatric and adult patients, while in others they

treated children and adults separately. To ensure a more comprehensive representation of

patients across different age groups, certain member societies nominated more than one

individual to participate in the survey. On average, 1.3 respondents per member society

participated in the survey (Table E4). Of the 21 responses received, one was excluded as a

duplicate. Among the 20 valid responses, three respondents (15%) looked after adult patients

only, seven (35%) cared for pediatric patients only, and ten (50%) cared for both adult and

pediatric patients. Respondents’ median years of experience in the allergy & immunology

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specialty was 20 years (Interquartile range [IQR] 9.8, 23) years.

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3.2 Epidemiology of Food Allergy in the Asia-Pacific Region
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Fourteen member societies provided answers on the prevalence of food allergy in their
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respective regions. Regarding the prevalence data among the pediatric population, nine (64%)
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were based on published research, three (21%) were based on institutional/ hospital databases,

and one (7%) on school-based data (Table E1). Three respondents (21%) indicated that no
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prevalence data on immediate food allergy was available. Nine regions indicated that
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prevalence data based on published literature were available, of which five (56%) were oral

food challenge data. The burden of food allergy in descending order of prevalence was 10% in

Australian infants, 7.7% in Chinese infants and toddlers, 5% in Australian school-age children

aged 10 to 14 years, 4% in Korean school-age children aged 6 to 16 years, 0.5% in Singaporean

infants, and 0.45% in Thai pre-school children. Prevalence data based on institutional/ hospital

databases with IgE sensitization results available suggested that prevalence was higher in

Indonesia (10-15%) followed by Japan (5-10%), Philippines (5%) and Vietnam (1-5%). Data

on self-reporting showed that food allergy prevalence was 7.4% in Taiwan and 5% in Hong

Kong. The most common food allergens affecting children less than 5 years of age included

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cow’s milk (83%) and egg white (78%); common food allergens in children aged 5-12 years

included shellfish (61%), peanuts (39%), tree nut and egg white (33%); and food allergens

predominantly reported in children aged 13-17 years were shellfish (78%), peanuts (44%), tree

nut and fish (33%) (Figure 1). Food allergens including egg yolk and soy were more prevalent

in younger children than adolescents, while wheat allergy was similar across different pediatric

age groups. Fruits were reported as a common food allergen in school-age children in Japan

and China, while buckwheat was an important allergen in Korea and beef in Bangladesh,

Mongolia, and Sri Lanka.

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Concerning the prevalence data among the adult population, four (29%) were based on
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published research and three (21%) on institutional/ hospital databases (Table E1). None were
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prevalence data based on OFC. Prevalence data were not available in seven (50%) regions.
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Prevalence from either source varied considerably between regions and within regions. Food
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allergy prevalence in adults was reported to range from 1 to 10% in Vietnam, and 6 to 10% in

Indonesia. Prevalence, mostly self-reported, was around 5% in Japan and Taiwan, 2-4% in
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Australia, and 1% in Singapore. Seafood including fish and shellfish (69%) was consistently
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the most common food allergen in adults, while other common food allergens included wheat,

fruits, peanuts, tree nuts, Hilsha Fish (herring), and Brinjal (eggplant).

3.3 Food Allergy Service Provision in the Asia-Pacific Region

Food-allergic patients were predominantly cared for by allergists/immunologists (81%) and

general pediatricians (75%) in their regions (Figure 2; Table E2). General practitioners (50%)

also played a major role in looking after food-allergic patients in some regions, while internists

and respiratory physicians (31%), and gastroenterologists (13%) were less commonly involved.

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The availability of allergists/ immunologists in the Asia-Pacific region was generally low and

varied substantially by region (Table 1). Pediatric allergists were relatively more abundant in

Japan (1.5 per 100,000 population) but in most Asia-Pacific regions, including Hong Kong,

Philippines, Singapore, and Thailand, availability of allergists was between 0.1-0.5 per 100,000

population. In Bangladesh, Indonesia, Malaysia, Mongolia, and Vietnam, there were no more

than 0.1 pediatric allergists per 100,000 population. For adult allergists, the availability of

allergists was relatively higher in Australia (1 per 100,000 population, followed by Singapore

(0.4 per 100,000 population). However, in most other regions, adult allergists were severely

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lacking, with availability below 0.1 per 100,000 population in Hong Kong, Indonesia, Japan,

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Malaysia, Mongolia, Philippines, and Vietnam.
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In most regions, allergists (81.3%), and pediatricians (18.8%) to a lesser extent, provided
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follow-up care, including annual reviews for food-allergic patients. Support from allergy nurses

was “always” and “frequently” available in half of the respondents’ clinical practice, and was
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only available “sometimes” and “rarely” in the other half. Only 12.5% of respondents reported
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having access to allied health services, such as dietetic counseling, whereas most respondents
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(31.3%) reported having access to dieticians "rarely".

The government was mainly responsible for covering the cost of allergy consultations in

Australia, Hong Kong SAR, Thailand, and Taiwan, while in Japan, the fee for allergy

consultations was paid entirely by the insurance. In Indonesia, Mongolia, Singapore, and

Vietnam, allergy consultations were subsidized almost equally by the government and the

insurance. The cost of private allergy consultations varied considerably in the Asia-Pacific

region with the highest fee reported in Singapore (USD 100-500 per consultation), Hong Kong

(USD 200-350 per consultation), and Australia (USD 150-300 per consultation). However, the

cost of allergy consultation was considerably lower at USD 10-80 per consultation in Mongolia,

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the Philippines, Indonesia, and Taiwan (Figure E1). Skin prick tests, specific IgE (sIgE) tests,

and oral food challenges were available in all regions. Nine (60%) member societies provided

information about the waiting time for their allergy services. The wait time for a patient to

obtain a subsidized skin prick or sIgE test at a government facility ranged from one week to

one month (median 10.5 days [IQR 2.5-32.6 days]) from the time of referral for allergy

evaluation, and mostly within a week (median 3.5 days [IQR 0-5 days]) following the initial

consultation (Table 2). However, the wait time for a patient to undergo an oral food challenge

at a government facility varied significantly between countries/territories and the median wait

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time was 37 days (IQR 10.5-60 days).

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3.4 Practices on Food Allergy & Anaphylaxis Management
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The availability of adrenaline autoinjectors which are essential for the immediate management
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of anaphylaxis, is limited in the Asia-Pacific region. Adrenaline autoinjectors were not

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accessible in 4 out of the 13 regions (31%) that supplied information regarding the clinical

practice of prescribing the drug, including Bangladesh, Indonesia, Mongolia, and Vietnam
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(Table 3). Ampules and injectable adrenaline syringes remained commonly prescribed in seven
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(54%) regions. In regions with the distribution of adrenaline autoinjectors, Epipen was the

most common brand available in eight (62%) member countries/territories, followed by

Anapen and Jext (7.7%). More than half of the member societies (62%) indicated that no

specific guideline on the prescription of adrenaline was followed in their respective regions,

and nurses (73%) and pharmacists (53%) were involved in educating patients on the usage of

adrenaline devices. Standardized national / regional anaphylaxis or allergy action plans were

available in 63% of respondents’ respective regions, and was lacking or non-standardized in

Bangladesh, Indonesia, Malaysia, Mongolia and Philippines. In Australia, a separate action

plan for food-allergic individuals who were not prescribed an adrenaline autoinjector was

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available, but not for the other regions. Only half (52%) of eligible patients received an

anaphylaxis action plan, and only 46% of those patients followed the plan's directions,

suggesting only fair compliance.

When asked how likely they were to admit anaphylactic patients to the hospital before and after

the COVID epidemic, respondents generally stated that their practices had not changed much

and that such occurrences only happened "sometimes" (Figure E2A). The likelihood that

respondents would observe patients experiencing anaphylaxis at home after having their

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adrenaline doses was also assessed, and once more, most respondents indicated their practices

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had not changed significantly and that such instances happened "rarely" (Figure E2B).

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Oral immunotherapy was clinically available in half of the regions including Hong Kong, Japan,
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Malaysia, Singapore, Thailand, and Taiwan (Table E3). In all of these regions where clinical
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OIT was provided, the OIT items were unregistered and given as non-prescription treatment.
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The region with the highest availability of OIT was Japan, where more than 100 allergy centers

provided OIT for the treatment of food allergies. In other regions, OIT was offered in the range
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of 2 to 8 centers within the country/territory. The most common food OIT prescribed was eggs,
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peanuts, milk, wheat, tree nut and soy. In these regions that offered OIT, no national / regional

guidelines regarding OIT as a treatment were available. The only region where such guideline

was available was Australia11, in which only OIT approved by the Therapeutic Goods

Administration (TGA) or those administered as part of a clinical research trial can be offered

to food-allergic patients.

4. Discussion

This survey, distributed to APAAACI member countries, sought information on the level of

allergy care across the Asia-Pacific region. Such information is required for engagement with

13
stakeholders and policymakers at the national and international levels in order to strengthen

the discipline of allergology. Our study highlighted a number of unmet needs in the Asia-

Pacific region in terms of food allergy research and management, including the paucity of

reliable data on food allergy epidemiology, the lack of allergists in the area, the lengthy wait

times for diagnostic oral food challenges, and lastly the dearth of adrenaline autoinjectors in

the Asia-Pacific countries/territories.

The true prevalence of food allergy in Asia remains elusive, especially among adults. In our

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study, 27% and 53% of the regions evaluated lacked prevalence data on IgE-mediated food

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allergy in children and adults, respectively. Only 5 regions provided challenge-confirmed data

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on the prevalence of food allergies, and none of them included data from adults. The prevalence
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of food allergies from self-reporting data, however, represented the "perceived" rate of food
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allergy in a region, which is a good surrogate marker on the quality of life and financial burden

that food allergy imposes. In most regions, the prevalence of “perceived” food allergy was
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around 5%, which was similar to the situation in Europe, where it was reported that one in 20
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children had a food allergy to one or more foods ever12. However, in some regions the rate
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could be as high as 10% such as in Indonesia and Vietnam. In these regions where the self-

reported food allergy prevalence was high, the availability of allergist was low (<0.1 per

100,000 population), suggesting that a high rate of “perceived” food allergy might have been

contributed by the low level of allergy service provision. It is imperative that patients who were

perceived to have a food allergy received appropriate specialist evaluation as food allergy has

a significant impact on the psychological well-being and quality of life (QoL) of allergic

individuals and their families13.

In comparison to the United States14 and Europe15, which had 1 allergist per 100,000 population

and 1.8 allergists per 100,000 population, respectively, the availability of allergy physicians

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was generally low in Asia (<0.5 per 100,000 population) except for Australia and Japan. In

Australia, where a government-funded National Allergy Strategy to support the improvement

in allergy care has been in place since 201516, allergists / clinical immunologists were available

at around 1 in 100,000 adult population.29,30 As for Japan, where the country's Basic Law on

Measures Against Allergic Diseases has also been in effect since June 201417, the availability

of pediatric allergists was relatively higher at 1.5 per 100,000 population, but the number of

adult allergists remained low (<0.1 per 100,000 population). Several regions were involved in

a previous global survey that evaluated allergy services provision18, 19, compared to this 2005

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survey there was at least a 2-fold rise in the allergist number in Malaysia (from 0.004 to 0.02-

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0.06 per 100,000 population), Mongolia (0.04 to 0.1 per 100,000 population) and Bangladesh
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(from zero to a few). The advances were slow compared to that in Germany, where the yearly
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allergy specialist registration rate was up to 140 per year15. Most other European countries also
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reported a steadily growing specialty. A recent article reviewed that Germany had a high ratio
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of 6.5 allergists per 100,000 population, but not all allergy specialists managed food allergies.31

Some might be in different fields like dermatology or respiratory, highlighting the challenges
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in comparing allergy service provision across regions. To ensure that there are enough allergy
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specialists to meet the rising demand for allergy care, it is critical to continue advancing the

allergy discipline across the Asia-Pacific region. This is especially relevant in areas where the

prevalence of allergic diseases is rising, such as China.

In Bangladesh, Malaysia and Vietnam, food-allergic patients were not primarily evaluated by

allergists/ immunologists, but by general practitioners, pediatricians or respiratory physicians.

In other regions, although allergy/ immunology consultation services were available, general

pediatricians (75%) and general practitioners (50%) also played a key role in the care of food-

allergic patients. According to a survey, over 40% of the respondents representing different

countries claimed that allergy/ immunology was not recognized as a separate specialty in their

15
country, with the Asia-Pacific area having the lowest recognition. Over 70% of respondents

reporting such findings in the Asia-Pacific region20. The diagnosis and management of allergic

diseases often require a multidisciplinary approach, including collaboration with other

healthcare providers such as primary care physicians, gastroenterologists, dermatologists, etc.

Allergists frequently play a central role in encouraging cross-disciplinary care such that the

quality of care for patients with complex allergic disease can be improved. In addition, the

proportion of pediatric allergists was generally higher compared to adult allergists in most

regions, likely contributed by the fact that food allergies mostly present in the first few years

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of life and allergens like eggs and cow’s milk tend to outgrow with time21. However, since

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other allergic conditions such as asthma and allergic rhinitis tend to develop later in life and
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severe eczema and food allergies such as peanut and tree nut persist throughout life22, training
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capacity for adult allergists should be enhanced. It will also be challenging to implement oral
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immunotherapy as a standard food allergy treatment in areas lacking adequate allergy service
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provision. Promoting the allergy specialty is therefore essential for improving patient outcomes,

encouraging interdisciplinary collaboration and raising awareness of allergy management.

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Our study also revealed that adrenaline autoinjector was not available in 4 of the 13 regions

that responded to the survey, and in half of the regions, adrenaline was still provided in ampules

together with 1 ml syringes and needles or 1 ml tuberculin syringes prefilled with the

appropriate adrenaline dose. Issues with these method was that caregivers or patients are likely

to be slower in drawing up an accurate dose of adrenaline from the ampule than healthcare

professionals at emergency. Prefilled syringes that contained adrenaline also have a short half-

life and need to be exchanged every 3 months23 in contrast to adrenaline autoinjectors, which

usually have a shelf-life of a minimum of 12 months24 and can last for as long as 30 months25.

In contrast to findings from our study, a global review of IgE-mediated food allergy

management showed that all surveyed countries but Brazil had access to adrenaline

16
autoinjectors, with most offering 2 and some up to 4 brands.31 Reasons contributing to the

unavailability of adrenaline autoinjectors included high costs, lack of regionally produced

autoinjectors, and the lack of guidelines on the prescription of adrenaline at a national/ regional

level in most examined regions. Based on the most recent guidelines, it is recommended that

adrenaline autoinjectors be used as the primary treatment for anaphylaxis.26-28 Therefore, public

health measures to ensure the widespread availability of adrenaline autoinjectors should be a

priority to avoid unnecessary morbidity and mortality.

f
These findings should be interpreted in light of several limitations. On average 1.3 respondents

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per region/country participated in the survey. Sampling bias, a limitation inherent in survey

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study, should be taken into consideration, although respondents were encouraged to consult
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with relevant experts of their respective societies before completing the questionnaires. Also
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the responses might reflect the opinion of the respondent and not the nationally representative

data. While surveys are low-quality methodological design for epidemiologic data, it is a
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feasible strategy especially when reliable data from the Asia-Pacific region is lacking. Some
ur

of Asia’s most populous areas, notably China, lacked information about allergy care supply.
Jo

Figures on food allergy prevalence and allergist availability have not been validated, thus the

data collected is better viewed as qualitative rather than quantitative. The accuracy of

anaphylaxis referrals to the allergy clinic and hospital admissions can be improved by gathering

information from both emergency medicine providers and allergy/immunology specialists.

Besides, data on the wait time to receive allergy care and the cost of allergy consultation are

also subjected to respondents’ primary affiliation and the healthcare delivery system of each

country.

In conclusion, our study provides a cross-sectional assessment of the pattern of food allergies,

the resources that are available, and the ways that each member country/territory of APAAACI

17
in the Asia-Pacific area manage food allergies and anaphylaxis at the time of the survey. There

is an urgent call for robust epidemiological studies in Asia to produce accurate and reliable

incidence and prevalence of food allergy across time, to breach the gap between the demand

and supply of allergy services and to enhance the availability and accessibility of adrenaline

autoinjector and allergen-specific immunotherapy.

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ACKNOWLEDGEMENTS: We thank all APAAACI member countries for participating in

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this survey.
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AUTHORS’ CONSENT FOR PUBLICATION: All authors have given their consent for
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publication
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AUTHORS CONTRIBUTIONS: ASYL and RP conceived the idea for the survey,
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contributed to the writing of the survey questions, oversaw the dissemination of the survey and
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collation of survey results as well as writing and review of this manuscript. PP, LSYW

contributed to writing of the survey questions, analysis of the results and writing and review of

the manuscript. The remaining authors oversaw the administration of the survey in their

respective countries including engaging the appropriate experts involved in food allergy and

anaphylaxis management, reviewed the final results and the final manuscript

AVAILABILITY OF DATA AND MATERIALS: The authors confirm that the data

supporting the findings of this study are available within the article and its supplementary

materials.

18
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new EpiPen® have before it expires? | Epipen.ca. [cited 2022Dec8]. Available from:
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World allergy organization anaphylaxis guidance 2020. World Allergy Organ J.

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Figure legends:

Figure 1: Top food allergens in the Asia-Pacific region, by age group. Cow’s milk and egg are common food allergens in children below 5 years

of age; shellfish, peanuts, tree nut and fish are more prevalent food allergens among school age children aged 5 to 12 years and adolescents aged

13 to 17 years.

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Figure 2: Health professionals who typically manage food allergy in the Asia-Pacific region (total responses). The majority of allergic patients

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(81%) were managed by allergists/ immunologists, although general pediatricians (75%), general practitioners (50%), respiratory physicians

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(31%), internists (31%), and gastroenterologists (13%) also played important roles in managing food-allergic patients in this region.

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Table 1: Availability of adult and pediatric allergists in each country

No. of adult allergists per 100,000 No. of pediatric allergists per

Country/ Region
population per region 100,000 population per region

AUSTRALIA 1 per 100,000 <1 per 100,000

BANGLADESH very few very few

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CHINA Information not available Information not available

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HONG KONG SAR 0.04 per 100,000 0.4 per 100,000

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INDONESIA 0.02 per 100,000 0.07 per 100,000

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JAPAN <0.1 per 100,000 1.5 per 100,000

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KOREA Information not available Information not available

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MALAYSIA 0.02 per 100,000 0.06 per 100,000

MONGOLIA 0.1 per 100,000

ur 0.11 per 100,000
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PHILIPPINES 0.05 per 100,000 0.26 per 100,000

SINGAPORE 0.4 per 100,000 0.4 per 100,000

SRI LANKA Information not available Information not available

THAILAND Information not available 0.2 per 100,000

TAIWAN Information not available Information not available

VIETNAM 0.005 per 100,000 0.017 per 100,000

1
Table 2: Typical waiting time (days) for a child / adult to receive sIgE/ skin prick tests and oral food challenges at a government
facility
WAITING TIME FOR A CHILD / ADULT WAITING TIME FOR A CHILD / ADULT TO WAITING TIME FOR A CHILD / ADULT
TO RECEIVE AN SIGE/ SKIN PRICK TESTS RECEIVE AN SIGE/ SKIN PRICK TESTS FROM TO RECEIVE AN ORAL FOOD
FROM ALLERGY REFERRAL INITIAL CONSULTATION CHALLENGE

AUSTRALIA 180 < 1 (done on the day of consultation) 90 to 180

BANGLADESH 10 Not available Not available

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HONG KONG SAR

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225 90 30 to 300

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INDONESIA 7 to 14 3 to 5 3

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JAPAN 0 0 (no waiting time) 30 to 60

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PHILIPPINES 7 to 14
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SINGAPORE 7 to 60 0 to 7 30 to 60

THAILAND 30 14 180

VIETNAM 1 0 (no waiting time) 3 to 5

2
Table 3: Type of adrenaline device in each country/ region

If AAInj is available, Any guidelines on the prescription of

Country/ region* Type of adrenaline device
what are the brands? AAInj in your country/region?
Adrenaline vial & syringe Adrenaline autoinjector

AUSTRALIA √ Epipen, Anapen Yes

BANGLADESH √ No

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HONG KONG SAR √ Epipen, Jext Yes

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INDONESIA √ No

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√

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JAPAN Epipen Yes

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MALAYSIA √ No

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MONGOLIA No

PHILIPPINES √ √ Epipen Yes

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SINGAPORE √ Epipen No

SRI LANKA √ √ Epipen No

THAILAND √ √ Epipen Yes

TAIWAN √ EpiPen No

VIETNAM √ No
Abbreviation: AAInj-adrenaline autoinjector
*information was not available from China and Korea

3
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4
90

80

70

60

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pr
50

-
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40

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30

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20

10

0
Cow’s milk Egg yolk Egg white Peanut Tree nut Soy Wheat Fish Shellfish

Infants and preschool < 5 years old School-age 5-12 years old Adolescents 13-17 years old
90%

80%

70%

60%

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50%

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40%

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30%

20%

10%

0%
Respiratory physician /
General practitioner General paediatrician Allergist/immunologist Internist Gastroenterologist
Pulmonologist
% 50.00% 75.00% 81.25% 31.25% 31.25% 12.50%