One of the major concerns in the practice of allergy is related to the safety of procedures for the diagnosis and treatment of allergic disease. Management (diagnosis and treatment) of hypersensitivity disorders involves often intentional exposure to potentially allergenic substances (during skin testing), deliberate induction in the office of allergic symptoms to offending compounds (provocation tests) or intentional application of potentially dangerous substances (allergy vaccine) to sensitized patients. These situations may be associated with a significant risk of unwanted, excessive or even dangerous reactions, which in many instances cannot be completely avoided. However, adverse reactions can be minimized or even avoided if a physician is fully aware of potential risk and is prepared to appropriately handle the situation. Information on the risk of diagnostic and therapeutic procedures in allergic diseases has been accumulated in the medical literature for decades; however, except for allergen specific immunotherapy, it has never been presented in a systematic fashion. Up to now no single document addressed the risk of the most commonly used medical procedures in the allergy office nor attempted to present general requirements necessary to assure the safety of these procedures. Following review of available literature a group of allergy experts within the World Allergy Organization (WAO), representing various continents and areas of allergy expertise, presents this report on risk associated with diagnostic and therapeutic procedures in allergology and proposes a consensus on safety requirements for performing procedures in allergy offices. Optimal safety measures including appropriate location, type and required time of supervision, availability of safety equipment, access to specialized emergency services, etc. for various procedures have been recommended. This document should be useful for allergists with already established practices and experience as well as to other specialists taking care of patients with allergies.

Background: Previous research has revealed that airborne pollen concentrations and phenology in allergenic plants are changing. In addition, variations in seasonal climate are known to affect pollen phenology in trees, weeds, and grasses. Objective: To investigate localized trends in pollen concentrations and pollen phenology over time and the effect of seasonal climate variations. Methods: We used daily pollen count concentrations from a National Allergy Bureau pollen counting station located in metropolitan Atlanta, Georgia, for 13 allergenic taxa. To evaluate long-term trends over time, we developed linear regression models for 6 pollen measures. To evaluate the effect of seasonal climate on phenology, we developed regression models using seasonal climate measures as independent variables and pollen measures as dependent variables. Results: For several tree pollen taxa, pollen concentrations increased over time, including oak and juniper pollen. In multiple species, pollen seasons trended toward an earlier release throughout the 27-year period. Variations in seasonal climate did have an effect on pollen counts and the timing of pollen release but varied by taxa. Generally, warmer spring temperatures were associated with an earlier pollen release. In addition, increased precipitation from the preceding fall was associated with increased pollen concentration in the spring months. Conclusion: Allergenic pollen concentrations for several types of pollen are increasing and trending toward an earlier pollen release in Atlanta, Georgia. Warmer temperatures preceding the pollen season were associated with the earlier pollen release.

Background: Seasonal pollen is a common cause of allergic respiratory disease. In the United States, pollen monitoring occurs via manual counting, a method which is both labor‐intensive and has a considerable time delay. In this paper, we report the field‐testing results of a new, automated, real‐time pollen imaging sensor in Atlanta, GA. Methods: We first compared the pollen concentrations measured by an automated real‐time pollen sensor (APS‐300, Pollen Sense LLC) collocated with a Rotorod M40 sampler in 2020 at an allergy clinic in northwest Atlanta. An internal consistency assessment was then conducted with two collocated APS‐300 sensors in downtown Atlanta during the 2021 pollen season. We also investigated the spatial heterogeneity of pollen concentrations using the APS‐300 measurements. Results: Overall, the daily pollen concentrations reported by the APS‐300 and the Rotorod M40 sampler with manual counting were strongly correlated (r = 0.85) during the peak pollen season. The APS‐300 reported fewer tree pollen taxa, resulting in a slight underestimation of total pollen counts. Both the APS‐300 and Rotorod M40 reported Quercus (Oak) and Pinus (Pine) as dominant pollen taxa during the peak tree pollen season. Pollen concentrations reported by APS‐300 in the summer and fall were less accurate. The daily total and speciated pollen concentrations reported by two collocated APS‐300 sensors were highly correlated (r = 0.93–0.99). Pollen concentrations showed substantial spatial and temporal heterogeneity in terms of peak levels at three locations in Atlanta. Conclusions: The APS‐300 sensor was able to provide internally consistent, real‐time pollen concentrations that are strongly correlated with the current gold‐standard measurements during the peak pollen season. When compared with manual counting approaches, the fully automated sensor has the significant advantage of being mobile with the ability to provide real‐time pollen data. However, the sensor’s weed and grass pollen identification algorithms require further improvement.

Background: Shared learnings from the early use of novel therapies can aid in their optimization. The recent introduction of peanut oral immunotherapy (peanut OIT; Palforzia [Peanut (Arachis hypogaea) Allergen Powder-dnfp]) for peanut allergy addresses a significant unmet need but also highlights the requirement for consideration of several factors by both prescribers and patients. Objective: To provide guidance for prescribers of licenced peanut OIT to facilitate treatment delivery and improve outcomes. Methods: Clinicians with experience of licenced peanut OIT (United States n = 6, United Kingdom n = 1) participated in a series of interviews and group discussions designed to elicit tips for successful implementation. Results: Clinicians identified 8 tips that were considered the most relevant, practical, and impactful for prescribers of Peanut (Arachis hypogaea) Allergen Powder-dnfp: (1) preparing to provide treatment, (2) assessing the medical indication for treatment and (3) shared decision making, (4) staff education, (5) establishing office processes, (6) managing patient expectations and using anticipatory guidance, (7) optimising adherence and (8) maintaining flexibility throughout the treatment process. In addition, a range of supporting materials (e.g., checklists and action plans) are provided. Conclusion: The introduction of a novel therapy often requires healthcare providers to modify or adopt practices to effectively employ the treatment. The provision of guidance based upon early real-world experiences of licenced peanut OIT may help inform clinical practice and improve treatment outcomes.

In patients with mastocytosis, vaccination has been reported to cause exacerbation of symptoms of mast cell (MC) activation, including anaphylaxis. Anaphylactic reactions to the Pfizer-BioNTech messenger RNA (mRNA) COVID-19 vaccine have been reported. An approach to the safe administration of COVID-19 mRNA vaccine in 2 patients with mastocytosis and MC activation symptoms is described.

For this edition of From the Pages of AllergyWatch, I have selected reviews from the July to August 2021 issue. The first article, with comments from Dr Lee, presents data from patients with mastocytosis who were able to receive their coronavirus disease 2019 (COVID-19) vaccinations after premedication. The next article, with comments from Dr Joshi, outlines a study investigating the risk of airborne peanut allergy triggering reactions in patients with peanut sensitivity. The third, with comments from Dr Hernandez-Trujillo, presents data from laboratory specimens illustrating that alpha-gal allergy is an increasing problem, especially in the South. Stanley Fineman, MD, Editor-in-Chief, Allergy Watch

For this issue of “From the Pages of AllergyWatch,” I have selected 2 articles related to coronavirus disease 2019 (COVID-19) and asthma. The first review by Dr Lee from the November-December AllergyWatch postulates that the angiotensin-converting enzyme 2 (ACE2) receptors may be protective in our patients with allergic asthma and reduce the risk for hospitalization with COVID-19. The next article, reviewed by Dr Mahr from the September-October AllergyWatch, warns about stepping down controllers in pediatric patients with asthma during the pandemic. The last article, reviewed by Dr Chipps, evaluated the role of exhaled nitric oxide (eNO) as a guide to inhaled corticosteroid (ICS) stepdown decisions for our patients with asthma

Vaccines against COVID-19 (and its emerging variants) are an essential global intervention to control the current pandemic situation. Vaccines often cause adverse events; however, the vast majority of adverse events following immunization (AEFI) are a consequence of the vaccine stimulating a protective immune response, and not allergic in etiology. Anaphylaxis as an AEFI is uncommon, occurring at a rate of less than 1 per million doses for most vaccines. However, within the first days of initiating mass vaccination with the Pfizer-BioNTech COVID-19 vaccine BNT162b2, there were reports of anaphylaxis from the United Kingdom and United States. More recent data imply an incidence of anaphylaxis closer to 1:200,000 doses with respect to the Pfizer-BioNTech vaccine. In this position paper, we discuss the background to reactions to the current COVID-19 vaccines and relevant steps to mitigate against the risk of anaphylaxis as an AEFI. We propose a global surveillance strategy led by allergists in order to understand the potential risk and generate data to inform evidence-based guidance, and thus provide reassurance to public health bodies and members of the public.

Anaphylaxis is the most severe clinical presentation of acute systemic allergic reactions. The occurrence of anaphylaxis has increased in recent years, and subsequently, there is a need to continue disseminating knowledge on the diagnosis and management, so every healthcare professional is prepared to deal with such emergencies. The rationale of this updated position document is the need to keep guidance aligned with the current state of the art of knowledge in anaphylaxis management. The World Allergy Organization (WAO) anaphylaxis guidelines were published in 2011, and the current guidance adopts their major indications, incorporating some novel changes. Intramuscular epinephrine (adrenaline) continues to be the first-line treatment for anaphylaxis. Nevertheless, its use remains suboptimal. After an anaphylaxis occurrence, patients should be referred to a specialist to assess the potential cause and to be educated on prevention of recurrences and self-management. The limited availability of epinephrine auto-injectors remains a major problem in many countries, as well as their affordability for some patients.

Allergic and hypersensitivity reactions such as anaphylaxis and asthma exacerbations may occur during air travel. Although the exact incidence of in-flight asthma and allergic emergencies is not known, we have concerns that this subject has not received the attention it warrants. There is a need to provide passengers at risk and airlines with the necessary measures to prevent and manage these emergencies. A review of the epidemiology, management and approaches to prevention of allergic and asthma emergencies during air travel is presented with the goal of increasing awareness about these important, potentially preventable medical events