Talking Allergies

[I edited this post after rereading the relevant sections of the magazine and realizing that I had misread the editor's statement. She states in reference to a letter about reactions to the smell of peanut butter: "the latest research [. . . ] shows that touch or ingestion is required to that food product"---i.e. she is referring specifically to peanut butter (on which a study has been done) and not making a general comment about inhalation reactions. Apologies for the mistake! Still, I would point out researchers do not have a definitive answer to questions about inhalation reactions.]
----------------------------------------
I very much enjoyed reading the most recent edition of _Allergic Living_ magazine, and I learn important facts about allergies in each issue–more on this in another post. But first, I'd like to raise a contentious issue. The editor’s note in the ‘letter to the editor’ section reads: "the latest research [. . .] show[s] that touch or ingestion is required to react" to peanut butter. I am assuming that this study is the same one to which Dr. Wade Watson refers later in the magazine. While he does not provide a citation, I would guess that he is describing the article published in the July 2003 (vol. 112, issue 1) edition of the _Journal of Allergy and Clinical Immunology_ entitled “Relevance of casual contact with peanut butter in children with peanut allergy” (pages 180-2). I would caution, however, that this study is not conclusive.

Although people definitely react to proteins that become airborne while cooking, as far as I’ve heard, inhalation reactions from smelling an allergen have never been observed in a clinical setting. (On the former topic, see the AAAI (American Academy of Allergy Asthma and Immunology) position statement on “Anaphylaxis in schools and other child-care settings.” http://www.aaaai.org/media/resources/academy_statements/position_statements/ps34.asp

According to the AAAI,
)

Dr. Watson describes a study in which researchers attempted to measure the amount of protein in the air from shelling peanuts or consuming peanut butter and discovered that the amount is so small as to be unmeasurable. (I would be interested in reading this study. Does anyone know where he is getting this from?) There is a difference, however, between claiming that a reaction is unlikely based on the studies that have been done thus far and claiming that this reaction is shown not to happen. I would point out that the study which Dr. Watson cites in which peanut allergic children were exposed to the smell of peanuts concludes merely that statistically speaking inhalation reactions from peanut butter are rare if in fact they do occur. (See the July 2003 (vol. 112, issue 1) edition of Journal of Allergy and Clinical Immunology.) The researchers conclude that: While it is reassuring to know that (according to this study) 90% of peanut allergic children are not likely to have reactions to the smell of peanut butter (and some of these children thought that they did react to peanut butter but did not react during the test), this study cannot say anything one way or the other about the other 10%. Also, the researchers cannot make any conclusions about airborne peanut reactions in general as neither peanut flours or roasted peanuts were tested. In fact, they note that on airplane flights, “filters in these commercial airlines contain measurable amounts of peanut protein.” (There was a study done on this which was reported in a 1996 issue of the same journal. Researchers tested air filters on a plane before they were changed and found that there was in fact an appreciable amount of peanut protein which had evidently had become airborne after peanut snacks were served on board.)
---------------------------
I'd like also to address the related issue of inhalation reactions in general even though this is a separate issue from that addressed in this month's AL magazine which refers specifically to peanut butter. One reason why I have an issue with this is that in my experience reports of 'inhalation reactions' are usually not regarded seriously. On their website, Anaphylaxis Canada implies that the potential severity of inhalation reactions is one of the ‘myths’ dispelled by a study of 32 food-related deaths in Ontario. I have an issue with the way in which this information is presented because this one study is not enough to dispel a ‘so-called’ myth. See: http://www.anaphylaxis.org/content/whatis/myths.asp)

At AllergyExpo, a conference held in Toronto in the spring of this year, Dr. Peter Vadas explained that because of the inherent limitations of clinical studies, we may never know the minimum amount of protein required to set off an allergic reaction. He commented that there is anecdotal evidence that people react from inhaling airborne particles and that this type of reaction would suggest that the threshold level of protein required for a reaction is low indeed. While Dr. Vadas was not necessarily saying that inhalation reactions occur, to my mind his comment suggests that there have been enough reports of these reactions for the medical community to wonder about the possible risks of the inhalation route of exposure.

A study published in the February 1999 issue of the _Journal of Allergy and Clinical Immunology_ indicates that there have been a number of self-reported inhalation reactions to peanut dust on airplane flights. I would suspect that the concentration of peanut protein on flights when a number of people open bags of peanuts all at once would be much higher than the situation described in the “Ask the Allergist” question, but this study does signal that reports of inhalation reactions need to be taken seriously.

See the abstract of the article here:
http://www.ncbi.nlm.nih.gov/entrez/quer ... t=Abstract

I realize that fear conditioning can lead to extreme anxiety or a panic attack which could mimic an allergic reaction. For this reason, allergists might hesitate to suggest that any particular ‘inhalation’ reaction is an immune system response. At the same time, inhalation reactions seem to be getting the attention of the medical community, and members of our own online community at Allergic Living have had inhalation reactions. I do believe that these reactions occur because they happen to my sister. She has reacted before knowing that the allergen was present so her respiratory symptoms cannot be chalked up to fear conditioning. My 'inhalation reactions' to nuts on the other hand might in fact be caused by anxiety. I'm still working on this one, but I believe I have a valid concern. I hope that someday inhalation reactions will be more widely accepted as an allergic response so that it will be easier for people who suffer from these types of reactions to negotiate an allergen free work space and allergen free living space.

Thanks Lisa!!!!! I've been meaning to react to this since I got my magazine yesterday, but just couldn't write it while remaining polite... and actually closed the magazine and stopped reading after reading the "Ask the Allergist"

This is what I have to face everyday of my life! Airborne reactions to fish have been proven in many studies (my old computer died... I can't quote any for now but have read many over the last 5 years!!!). I have heard what I thought to be reliable source people talk about airborne allergies over the years as nothing more than anxiety or the fact that it cannot cause more than mild asthma! My 5 previous reactions have proven these sayings wrong! I have been lucky in the last 4 as the only symptom was mild swelling of the throat and moderate to severe asthma, but these symptoms all appeared before investigating and finding that there was fish present! And when I first started reacting to airborne protein, my parents did many "blind tests" to make sure I was not kidding them... and these "tests" proved me right.

So please have a little respect with people that have to fight everyday to keep safe in their workplace and anywhere else outside of the house by not generalizing everything based on a single research!!!! And add a large BUT at the end to say that this is not generalized to all allergens if you believe that peanuts would be safe (which I don't think...).

Thanks anyways!

Mylène

I have yet to receive my winter 2006 issue. Is there anyone else who has not received a copy? Does anyone know when it was distributed? My fall issue was late and had hoped this one would be out shortly after the email announcing it. Maybe the Atlantic provinces are the last on their mailing list. All I know is I do not have mine yet.
SusieQ

I also have not received mine yet. I am assuming that Ontario and Quebec get theirs first due to the snail mail having to travel further anywhere else.

I havn't received mine yet either, and I am in Ontario. Maybe the people who already got the magazine live in the city where it is published?

Soccermom

Given the time of year, it doesn't surprise me that not everyone has gotten their copy yet. But they only started arriving late last week, so if you haven't received yours by now, you should expect it soon.

Dory
AL Associate Editor

It seems Gwen and I responded to this at the same time! She's much more succinct than I am.

Folks who haven't yet received Allergic Living - It is in the mail.

Postal delivery dates vary, especially at this time of year. Frankly, we've been surprised to hear that some subscribers have already received the magazine. It was scheduled to arrive shortly after Christmas.

happy holidays all, Gwen

Lisa, Just read your initial post. Yes, Dr. Watson would be referring to the study by Dr. Scott Sicherer and colleagues, published in the July '03 issue of JACI. It is the one that many allergists cite today in regard to peanut butter contact or inhalation.

Just to be completely clear to fellow forum-goers - the answer Dr. Watson gives in Ask the Allergists is in response to a specific question about whether an allergic child would have broken into hives in a grocery store because she thought she smelled peanut butter. He was not addressing inhalation and other food allergen, such as fish.

You raise the question of the dispersal of peanut proteins into the air on airplanes. My understanding is that this is a somewhat different issue. I'm going on memory here, but I believe the other JACI-published study you refer to noted not only the presence of peanut protein in the aircraft air filters, but also explained that the proteins would have become airborne through the action of many people unsealing a great number of vacuum packs simultaneously on an airplane.

I think the part about how the protein got into the air is important. If you have it handy, feel free to cite.

Thanks for expressing your views. And safe and happy holidays to you if I don't have time to post again pre-Christmas. cheers, Gwen

I received mine yesterday...haven't had time to read it all, but what I have read looks great! Just wondering why the AL Home Page doesn't reflect the current issue as yet?

The reason the new issue is not up yet on the homepage:

As mentioned, you're actually receiving the issue early. ahead of our schedule. The Post Office was really efficient in some areas, delivering publication mail as quickly as first-class mail.

The site will be updated over the holidays.

Coming soon - podcasts! A redesign too, but that will take a little longer. We're never sitting on our hands here at AL HQ.

Gwen

Gwen,
thanks for the response, and happy holidays to you too. Yes, the authors of the original article under discussion (by Simonte, Sicherer and others) do note in reviewing the literature that the situation on the plane is quite different from the situation they are testing--in the "discussion" section they note that "reactions to airborne peanut protein have been reported when many packets of roasted peanuts are opened simultaneously, " and they cite two articles on this. (I don't recall if that article which I cited by Jones, Stark, Sussman, and Yunginger actually said much about this--it was a brief abstract, and I think they just concluded that the protein in the filter came from the snacks served on board.) Sicherer et al. were really just studying the effects of casual exposure to the amount of peanut butter one would be exposed to in, say, sitting next to someone eating a peanut butter and jam sandwich.

They emphasize that conclusions about reactions to peanut products can only be drawn in relation to an exposure to a limited amount of peanut butter: "Larger exposures were not investigated," they note, "[and] indeed, many of the self-reported reactions to casual exposures are described to occur with larger exposures (eg a classroom, in which most of the children are constructing products with peanut butter. In addition, exposure to peanut in other forms (eg, flour and dust from roasted peanuts) was not investigated. As discussed above, dust from roasted peanut might be more likely to become airborne and induce reactions."

This study is reassuring, and they note that self-reported airborne reactions to the smell of peanuts are rare---1% of 4685 people in a national (US) registry of peanut allergic individuals claim to react. As they say, in all of these cases it is difficult to rule out ingestion as the route of exposure. And they note that reports of inhalation reactions to other types of food (milk, egg, fish, peas) are "almost always associated with active cooking of the food." (but I would stress....they didn't say "always.") So it would seem that most people don't have to worry so much about inhalation reactions. But I don't think we can know for sure based on this study that reactions to airborne peanut butter do not occur as this as a preliminary study (it was the first one on peanut butter and only 30 children were in the study).

Mylene, I'm glad that you have shared your experiences with us---this sounds counterintuitive, but I'm actually calmer about the possibility of having an inhalation reaction because other people other than people in my family have had them and I'm convinced that it is something that some people have to be concerned about. Reading up on these studies has helped too---I do feel justified now in asking people I know not to eat peanuts around me.

I was also going to write in about the article on biphasic reactions. I found that really helpful because while I knew about them, I didn't know the facts--but I think I'll leave that post to another day.

Lisa

FYI, homepage has been updated - excerpts from the Winter issue are now there for viewing.

And if you didn't subscribe in time to receive this issue, you can order it online under "Current/Back Issues".

I liked the Winter edn.--especially the cover The article on dealing with family members was helpful--and timely given the problems with allergies, family and Christmas. Also, it's useful to know how those hepa filters actually work.

The article on biphasic reactions really helped me a lot. I knew about biphasic reactions, but I wasn't clear on how long one had to worry about them after the initial reaction. This was a major cause of anxiety after my major anaphylactic event many years ago---I asked about why I had to continue to take Benadryl and the doctor in emergency told me I could have another reaction. That was the first I had heard about biphasic reactions. I wasn't sure whether the Benadryl would actually prevent a second reaction or how long I had to worry about a reaction coming back. And I didn't have an epi. at that time.

Since that time, I've been concerned that the fact that it took more than one dose of adrenaline to control that reaction might mean that there was less of a chance that I could get the next reaction to nuts under control. So I was majorly relieved to find out it is quite common for people to need a second dose. I'm feeling much more safe with those epis by my side! And if another reaction does arise, I'll feel better prepared to deal with a possible biphasic reaction.