Global disparities in availability of epinephrine auto-injectors

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Abstract

Background

Anaphylaxis is the most severe clinical presentation of acute systemic allergic reactions and can cause death. Given the prevalence of anaphylaxis within healthcare systems, it is a high priority public health issue. However, management of anaphylaxis – both acute and preventative – varies by region.

Methods

The World Allergy Organization (WAO) Anaphylaxis Committee and the WAO Junior Members Steering Group undertook a global online survey to evaluate local practice in the diagnosis and management of anaphylaxis across regions.

Results

Responses were received from WAO members in 66 countries. While intramuscular epinephrine (adrenaline) is first-line treatment for anaphylaxis, some countries continue to recommend alternative routes in contrast to guidelines. Epinephrine auto-injector (EAI) devices, prescribed to individuals at ongoing risk of anaphylaxis in the community setting, are only available in 60% of countries surveyed, mainly in high-income countries. Many countries in South America, Africa/Middle-East and Asian-Pacific regions do not have EAI available, or depend on individual importation. In countries where EAIs are commercially available, national policies regarding the availability of EAIs in public settings are limited to few countries (16%). There is no consensus regarding the time patients should be observed following emergency treatment of anaphylaxis.

Conclusion

This survey provides a global snapshot view of the current management of anaphylaxis, and highlights key unmet needs including the global availability of epinephrine for self-injection as a key component of anaphylaxis management.

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Most cited references 23

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Anaphylaxis: guidelines from the European Academy of Allergy and Clinical Immunology.

A Muraro, G. Roberts, M Worm … (2014)

Anaphylaxis is a clinical emergency, and all healthcare professionals should be familiar with its recognition and acute and ongoing management. These guidelines have been prepared by the European Academy of Allergy and Clinical Immunology (EAACI) Taskforce on Anaphylaxis. They aim to provide evidence-based recommendations for the recognition, risk factor assessment, and the management of patients who are at risk of, are experiencing, or have experienced anaphylaxis. While the primary audience is allergists, these guidelines are also relevant to all other healthcare professionals. The development of these guidelines has been underpinned by two systematic reviews of the literature, both on the epidemiology and on clinical management of anaphylaxis. Anaphylaxis is a potentially life-threatening condition whose clinical diagnosis is based on recognition of a constellation of presenting features. First-line treatment for anaphylaxis is intramuscular adrenaline. Useful second-line interventions may include removing the trigger where possible, calling for help, correct positioning of the patient, high-flow oxygen, intravenous fluids, inhaled short-acting bronchodilators, and nebulized adrenaline. Discharge arrangements should involve an assessment of the risk of further reactions, a management plan with an anaphylaxis emergency action plan, and, where appropriate, prescribing an adrenaline auto-injector. If an adrenaline auto-injector is prescribed, education on when and how to use the device should be provided. Specialist follow-up is essential to investigate possible triggers, to perform a comprehensive risk assessment, and to prevent future episodes by developing personalized risk reduction strategies including, where possible, commencing allergen immunotherapy. Training for the patient and all caregivers is essential. There are still many gaps in the evidence base for anaphylaxis. © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

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Undernotification of anaphylaxis deaths in Brazil due to difficult coding under the ICD-10.

K Tanno, L Bierrenbach, Cristiana Toscano … (2012)

Undernotification is well recognized as a key challenge to the study of anaphylaxis mortality, but it is seldom mentioned that one of its reasons is the difficult coding of the condition under the tenth revision of the international classification of diseases (ICD-10), given that there are no anaphylaxis-specific ICD-10, which are considered valid for coding underlying causes-of-death, and that official mortality statistics consider exclusively the underlying and disregard the contributing causes-of-death data recorded on death certificates. Brazilian mortality data were used as a case study to call attention to the inadequacy of the ICD-10 for the measurement of anaphylaxis deaths. Underlying and contributing causes-of-death data were used to estimate the rates of anaphylaxis deaths in the country over the years 2008-2010. Of 498 anaphylaxis deaths were found, of which 75% were classified as 'definite' and 25% as 'possible anaphylaxis deaths'. The average national rate for these years was 0.87 per million per year. None of these deaths would have been found had we exclusively considered information from the underlying cause-of-death field. The study of anaphylaxis mortality using secondary data requires the use of information derived from the underlying as well as from the contributing causes-of-death fields. Coding definitions should be standardized with a view of enabling trend analyses and international comparisons. The ICD-11 revision is a unique opportunity to improve the coding system so as to facilitate epidemiological studies of anaphylaxis mortality. Educational interventions targeted at improving the quality of death certificate completion are urgently needed. © 2012 John Wiley & Sons A/S.

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Categorization of allergic disorders in the new World Health Organization International Classification of Diseases

Luciana Tanno, Moises A. Calderon, Bruce Goldberg … (2014)

Background Although efforts to improve the classification of hypersensitivity/allergic diseases have been made, they have not been considered a top-level category in the International Classification of Diseases (ICD)-10 and still are not in the ICD-11 beta phase linearization. ICD-10 is the most used classification system by the allergy community worldwide but it is not considered as appropriate for clinical practice. The Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) on the other hand contains a tightly integrated classification of hypersensitivity/allergic disorders based on the EAACI/WAO nomenclature and the World Health Organization (WHO) may plan to align ICD-11 with SNOMED CT so that they share a common ontological basis. Methods With the aim of actively supporting the ongoing ICD-11 revision and the optimal practice of Allergology, we performed a careful comparison of ICD-10 and 11 beta phase linearization codes to identify gaps, areas of regression in allergy coding and possibly reach solutions, in collaboration with committees in charge of the ICD-11 revision. Results We have found a significant degree of misclassification of terms in the allergy-related hierarchies. This stems not only from unclear definitions of these conditions but also the use of common names that falsely imply allergy. The lack of understanding of the immune mechanisms underlying some of the conditions contributes to the difficulty in classification. Conclusions More than providing data to support specific changes into the ongoing linearization, these results highlight the need for either a new chapter entitled Hypersensitivity/Allergic Disorders as in SNOMED CT or a high level structure in the Immunology chapter in order to make classification more appropriate and usable.

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Author and article information

Contributors

Luciana Kase Tanno

Journal

Journal ID (nlm-ta): World Allergy Organ J

Journal ID (iso-abbrev): World Allergy Organ J

Title: The World Allergy Organization Journal

Publisher: World Allergy Organization

ISSN (Electronic): 1939-4551

Publication date PMC-release: 20 October 2023

Publication date Collection: October 2023

Publication date (Electronic): 20 October 2023

Volume: 16

Issue: 10

Electronic Location Identifier: 100821

Affiliations

[a ]Division of Allergy, Department of Pulmonology, Allergy and Thoracic Oncology, University Hospital of Montpellier, Montpellier, France

[b ]Desbrest Institute of Epidemiology and Public Health, UMR UA11 University of Montpellier - INSERM, France

[c ]WHO Collaborating Centre on Scientific Classification Support, Montpellier, France

[d ]Department of Pulmonology, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, 371, av. du Doyen Gaston Giraud, 34295 Cedex 5, Montpellier, France

[e ]Allergie-Centrum-Charité, Klinik für Dermatologie, Venerologie und Allergologie, Campus Charité Mitte, Universitätsmedizin Berlin, Germany

[f ]Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Sagamihara, Japan

[g ]Department of Allergy and Immunology, Hospital Quironsalud Bizkaia, Bilbao, Spain

[h ]Department of Medicine, Allergy Asthma and Clinical Immunology Section, University of Verona, Verona, Italy

[i ]Atlanta Allergy & Asthma, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA

[j ]Section of Medicine of the Brazilian Academy of Medicine of Rio de Janeiro, Rio de Janeiro, Brazil

[k ]Division of Allergy, Asthma and Clinical Immunology, Department of Medicine, Mayo Clinic, Scottsdale, AZ, USA

[l ]The University of Sydney, New South Wales, Australia

[m ]The Chinese University of Hong Kong, Department of Pediatrics, Prince of Wales Hospital, Hong Kong Special Administrative Region of China

[n ]Department of Mother and Child Health University of Padua Padua, Italy

[o ]Division of Paediatric Allergology, University of Cape Town, Cape Town, South Africa

[p ]Department of Immunology, Universidad Autónoma del Estado de Hidalgo, Pachuca, Hidalgo, Mexico

[q ]Department of Medicine, University of Verona, Verona, Italy

[r ]Institute of Allergology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany

[s ]Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany

[t ]Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Viet nam

[u ]Department of Dermatology and Venereology, Acibadem City Clinic Tokuda Hospital Sofia, 51B Nikola Vaptsarov Blvd., 1407, Sofia, Bulgaria

[v ]Department of Dermatology and Venereology, Trakia University-Stara Zagora, Stara Zagora, Bulgaria

[w ]Department of Allergy, Hospital General de Villalba, Madrid, Spain

[x ]Allergology Section, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain

[y ]University Hospital Dr Dragisa Misovic, Serbia

[z ]Division of Allergic Diseases, Mayo Clinic, Rochester, MN, USA

[aa ]Division of Rheumatology, Allergy and Clinical Immunology, Department of Medicine, University of Florida, USA

[ab ]Phoenix Children's Hospital, Phoenix, AZ, USA

[ac ]Hospital Infantil de México Federico Gómez, Mexico

[ad ]Center for Molecular Biomedicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Viet nam

[ae ]Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Ill, USA

[af ]National Heart & Lung Institute, Imperial College London, London, UK

[ag ]Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore

[ah ]Medicine and Pediatrics, The Ohio State University in Columbus, Ohio, USA

[ai ]Allergy Section, Department of Internal Medicine, Hospital Vall d'Hebron, and ARADyAL Research Network, Spain

Author notes

[∗ ]Corresponding author. Division of Allergy, Department of Pulmonology, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, 371, av. du Doyen Gaston Giraud, 34295 cedex 5, Montpellier, France. luciana.tanno@ 123456gmail.com

Article

Publisher Item ID: S1939-4551(23)00081-9 Publisher ID: 100821

DOI: 10.1016/j.waojou.2023.100821

PMC ID: 10616381

PubMed ID: 37915955

SO-VID: 9eb3fe78-1d0e-4e3a-a4f2-7dbb4297f6f6

License:

This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

History

Date received : 6 June 2023

Date revision received : 5 September 2023

Date accepted : 11 September 2023

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Global disparities in availability of epinephrine auto-injectors

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Abstract

Background

Methods

Results

Conclusion

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Most cited references 23

Anaphylaxis: guidelines from the European Academy of Allergy and Clinical Immunology.

Undernotification of anaphylaxis deaths in Brazil due to difficult coding under the ICD-10.

Categorization of allergic disorders in the new World Health Organization International Classification of Diseases

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Cited by 4

Most referenced authors 293