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1 s2.0 S2772829323001273 Main
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
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
oo
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]
r
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#
Corresponding authors
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Wales Hospital, The Chinese University of Hong Kong, HKSAR. Tel: +852-35052859,
Email: [email protected]
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FUNDING: None
CONFLICT OF INTEREST: All authors do not have any conflict of interest to declare.
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1. What is already known about this topic?
of patients, the propensity to endanger life, and the negative impact on the quality of
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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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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
Objective: The main objective of this survey was to evaluate the epidemiology of FA,
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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
countries/territories.
Conclusions: Our study offers a cross-sectional evaluation of the management practices for
allergy services, improve the accessibility and affordability of adrenaline autoinjectors, and
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Keywords: food allergy, anaphylaxis, allergy service, allergist, adrenaline autoinjector
Abbreviations:
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
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1. Introduction
Food allergy is a condition with no effective cure and can result in potentially fatal allergic
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
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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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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
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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
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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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
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
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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
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
Results
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.
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In certain countries, allergists treated both pediatric and adult patients, while in others they
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
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,
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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).
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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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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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
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
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,
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
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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 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
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
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
In Bangladesh, Malaysia and Vietnam, food-allergic patients were not primarily evaluated by
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
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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
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,
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
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autoinjectors, with most offering 2 and some up to 4 brands.31 Reasons contributing to the
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
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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
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of Asia’s most populous areas, notably China, lacked information about allergy care supply.
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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
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
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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
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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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20
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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21
Table 1: Availability of adult and pediatric allergists in each country
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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
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
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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
2
Table 3: Type of adrenaline device in each country/ region
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
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SINGAPORE √ Epipen No
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%