NPHR 2020 - Allergy

Northwestern Public Health Review - 2020 -

ALLERGY

Table of

Contents Cover Art

5

Advances Allergy Research in the News Advances in Allergy Treatment

14 Gupta

Food Allergy in Schools: Strides to Improving Safety and Awareness

23 pg. 2 | NPHR 2020

4 Wolniak

What is an Allergy?

9

Greal, Nordman, Patel, Salovich

Personal Narratives

18 Nowakowski, Bilaver

Assessing Allergies’ Cost

Letter from the

Editors

Dear Readers,

We are thrilled to present the 2020 edition of the Northwestern Public Health Review (NPHR). In this issue, we explore the dynamic chronic disease of allergies from both an individual and a population-based perspective. Allergic reactions impact individuals of all backgrounds. Further, they can take many forms from the runny noses of hayfever to the life-threatening anaphylactic reactions triggered by food, drug, and insect allergies. In this publication, we have curated a diverse set of voices and perspectives to shed light on the many facets of this medical problem as well as to highlight emerging areas of research.

First, Dr. Kristy Wolniak defines the term allergy. Her piece summarizes the biological interactions implicated in allergic reactions while simultaneously detailing what an allergy is NOT. This definition sets the foundation for the remainder of the publication. Our editorial staff members then highlight a variety of emerging concepts in allergy-related research and treatment. Personal narratives from individuals living with allergies complement these research-focused blurbs.

While each person’s experience is unique, a few underlying themes emerge from these stories. Perhaps most notably, access to life-saving medications - epinephrine - is critical. Dr. Ruchi Gupta not only describes her work in understanding the epidemiology of childhood food allergies but also discusses her advocacy work to ensure children have access to epinephrine auto-injectors (e.g., EpiPens) in schools. Finally, Virginia Nowakowski explores the economic impact of allergies during a discussion with Dr. Lucy Bilaver, an expert on the costs of care related to allergies. Each article, supplemental piece, and illustration helps to provide an interdisciplinary perspective on allergies.

We wish to thank all of our contributors and a special thank you to the students of the University of Illinois at Chicago Biomedical Visualization program for their beautiful illustrations to accompany the pieces throughout this issue. We thoroughly enjoyed developing this edition of the NPHR and are excited to share it with our readers.

Grace Bellinger

Margaret Walker

In Health, The NPHR Editors-in-Chief Grace Bellinger and Margaret Walker

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Cover Art

Sarah McGuinness This editorial illustration, titled “The Immunological Principles of Allergies,” features a child having an allergic reaction. Flanking him are a few of the leading culprits for allergies: a shaft of wheat, a few peanuts, and some microscopic grains of pollen. Also featured is an IgG molecule, and a basophil, both of which are involved in allergic reactions. The purpose of this painting was to depict the conglomerate of physical forms an allergic reaction can involve: as a coughing child, or an antibody, or a grain of pollen. It occupies space from the macro-scale to the nano-scale.

The first step I take when starting a new piece is to do as much research as I can on the subject matter. Next, I searched for inspiration in photographs of pollen and the paintings of Norman Rockwell and J. C. Leyendecker. Rockwell’s “slice of life” approach and Leyendecker’s pastel color palettes and unique compositional style interested me the most.

When the seed of an idea took hold, I sketched as many thumbnails as I could to chase after it. After assembling a plethora of reference images (including photos of my younger brother coughing), I began piecing together the final painting. Hopefully, my work will draw interest so that others may understand how allergies manifest, as well as the immunological principles behind this process.

About the Artist Sarah McGuinness is from Austin, Texas, and majored in Biochemistry and Genetics (minoring in Art) at Texas A&M University in College Station, Texas. While Sarah was in her undergraduate program, she realized that scientific research was not how she wanted to spend the rest of her life. She wanted a career that would incorporate her passion for both art and science, as well as fill the communication gap between the scientific and medical community and the public. For this reason, she decided to become a scientific illustrator and animator. She is currently completing her Master of Science in Biomedical Visualization at the University of Illinois in Chicago.

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What is an Allergy?

Dr. Kristy Wolniak, MD, PhD Allergies are quite common and continue to rise in prevalence in the industrialized world. A room full of people in Illinois during the fall months will invariably contain at least a few individuals with the runny nose, sneezing, and itchy eyes indicative of “hay fever� season. Approximately 8% of adults in the U.S. have hay fever, and up to 40% of the world population has IgE sensitization to foreign particles in the environment, according to the American Academy of Allergy Asthma and Immunology [1].

But what is an allergy exactly? continued on following pages...

NPHR 2020 | pg. 5

From a medical perspective, the word allergy itself encompasses a broad range of conditions ranging from irritating seasonal allergies like hay fever to lifethreatening allergic reactions to bee stings. While it’s very common for people to have true allergies, the word allergy has also been widely and inaccurately adapted to apply to essentially any negative response to a substance [2]. Merriam-Webster dictionary even includes one definition of allergy as “a feeling of antipathy or aversion” [3]. Understanding the definition of a true allergy and recognizing potential misconceptions and misunderstandings about allergies is important to help determine treatment and to avoid potentially fatal allergic reactions.

Although the medical term allergy encompasses many different conditions, all of the conditions defined as true allergies have the common underlying mechanism of an abnormal immune response to a foreign substance that would normally be harmless. This foreign substance is referred to as an allergen. The formation of a true allergy begins with the creation of Immunoglobulin E (IgE) antibodies against the allergen and the subsequent triggering of an immune response.

Antibodies are proteins formed by white blood cells in the immune system in response to a substance.

Antibodies are designed to specifically recognize and bind to certain substances such as bacterial and viral proteins, with the normal function of protecting the host from infection. Antibodies come in different types, and IgE is the type of antibody that is implicated in allergic reactions.

“... true allergies have the common underlying mechanism of an abnormal immune response to a foreign substance that would normally be harmless.”

The normal role of IgE antibodies is to protect individuals from parasitic infections, particularly helminths.

In allergic reactions, however, IgE antibodies are produced inappropriately against allergens such as food, medications, pollen, and metals. After binding its specific allergen on one end, the other end of the IgE antibody can also bind to a white blood cell called a mast cell. When multiple IgE antibodies bind to a mast cell, the mast cell releases histamine and other mediators of inflammation.

These mediators of inflammation can cause dilation and leakiness of the blood vessels and drive the recruitment of more immune cells. These changes lead to the swelling and itchiness associated with different allergies. When there is a massive release of histamines, there may potentially be an overwhelming immediate immune response called anaphylaxis which can lead to potentially life-threatening closing of the airways if left untreated. Given the common

Infographic by Joo-Young Lee

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mechanisms underlying allergic reactions, doctors can perform skin testing to identify a true allergy. The testing is performed by placing a small amount of the potential allergen under the skin and measuring the amount of swelling and redness that occurs. This response is indicative of the amount of IgE and therefore the immune response.

The wide array of true allergic reactions is due, in part, to the different routes of exposure to allergens. Often the route of exposure to the allergen will impact the effects mediated. Some allergic reactions such as hay fever are less likely to cause massive, potentially life-threatening immune responses than other types of allergic reactions such as an allergy to ingested shellfish. An allergen such as the metal nickel can be encountered on the skin and lead to a rash (i.e., contact allergy). While inhaled allergens, such as the pollen of hay fever, can lead to respiratory symptoms such as a stuffy or runny nose, sneezing, and itchy eyes (i.e., allergic rhinitis), ingested allergens, such as those from food, can have systemic effects such as a rash and possibly intestinal effects such as abdominal pain, nausea, and diarrhea. Medication allergies involve many different types of responses as medications are delivered via many routes. Orally ingested, intravenous, and topical medications can all cause allergic reactions.

For most ingested or intravenous medications, the allergic response is systemic and involves skin rash/hives, itchiness, and sometimes difficulty breathing. Allergic reactions range from mild to life-threatening, but the underlying mechanisms are similar and treatments include avoidance of the allergen, antihistamines, antiinflammatory drugs, and in urgent situations, drugs that can dilate the airways.

The term allergy is sometimes inappropriately used to refer to an intolerance or a sensitivity, particularly when referring to food. How is food allergy different than food intolerance or sensitivity? Intolerance to food is typically due to a deficiency of an enzyme that aids in digestion of the food, such as lactose intolerance.

Both food allergy and food intolerance can present with similar symptoms such as stomach pain, nausea, and diarrhea. However, a food intolerance does not lead to a systemic response such as hives or difficulty breathing. If a person has a food intolerance they may be able to ingest the food in limited quantities to avoid the negative response, but in the setting of true allergy, even a quantity of the food that is not visible to the human eye can trigger an immediate allergic reaction.

Differentiating between a food allergy and food intolerance is very helpful in treatment and prevention of the negative consequences.

Understanding the mechanisms underlying true allergies helps to clarify some common misconceptions.

One is that a previously mild allergic reaction means all subsequent reactions will be mild. The immune system has memory, and every exposure to the allergen can increase the amount of IgE that can potentially bind to the allergen. A mild allergic reaction after someone eats peanuts can sometimes be followed by an immediate severe allergic reaction the next time they eat peanuts, even a very tiny amount. Another common misconception is that if an individual has eaten something before without a problem, that individual will never be allergic to that substance. The inappropriate production of IgE that is able to bind a substance actually requires that there was a prior exposure and an immune response to that substance or a substance that is structurally similar. The first exposure to an allergen that generates an immune response may not cause any symptoms. In reality, an abnormal immune response to an allergen could develop at any time after exposure, and it is not possible to predict the first incidence of a symptomatic allergic reaction.

As medical science begins to uncover the mechanisms behind the development of true allergies, clues have begun to emerge about how to prevent the development of allergies. The hygiene hypothesis of allergy development proposed that early exposure in life to certain microbes could modify the development of allergies [4]. There is currently a large body of research exploring this hypothesis and the potential implications in preventing allergy development. Many studies have begun to focus on the role of the microbiome (the

Artist’s biography on next page...

NPHR 2020 | pg. 7

Allergies are common and commonly misunderstood.

There are still many components of allergies that are not understood by doctors and researchers. Understanding how allergy is defined and how allergies develop can help provide insight into the appropriate treatment and prevention of allergic responses.

References [1] American Academy of Allergy Asthma and Immunology. Allergy statistics. 2019. www.aaaai.org/about-aaaai/newsroom/allergystatistics. Accessed 5 July 2019.

[2] Cummins, Eleanor. “You’re almost certainly using the word ‘allergies’ wrong.” 1 May, 2018. www.popsci.com/what-is-an-allergy/.

Accessed 5 July, 2019.

[3] Merriam-Webster’s Unabridged Dictionary. 2019. www.merriamwebster.com/dictionary. Accessed 5 July, 2019.

[4] Liu, A. H. (2015). Revisiting the hygiene hypothesis for allergy and asthma. Journal of Allergy and Clinical Immunology, 136(4), 860-865.

[5] [General Citation for Complete Article] Murphy, Kenneth M., et al. Janeways Immunobiology. GS, Garland Science, Taylor & Francis Group, 2017.

About the Artist

microbes within the body) and the effect of a person’s microbiome on the development of allergies [4]. These studies are beginning to provide the mechanisms that the environment and cleanliness behaviors of a person shape and influence the immune response to allergens.

As a current graduate student at the University of Illinois at Chicago’s Biomedical Visualization program, Rachel Poli started her journey in Wauwatosa, Wisconsin where she found the field of Medical Illustration.

With her long-term goals in sight, she graduated from Macalester College in St. Paul, Minnesota in 2018. She received a BS in Studio Art and an honors BS in Biology by conducting research in the immunology of allergies under Dr. Devavani Chatterjea.

During her first year in UIC’s BVIS program Rachel has begun research with Dr. Paul Sereno in his paleontology lab at the University of Chicago. She has also begun teaching an undergraduate level biology class where she has seen the need for her craft exemplified.

You can follow Rachel through LinkedIn or through Instagram. Her Instagram handle is @polirama where you can find a selection of the work she has completed during her stay at UIC.

About the Author Kristy Wolniak, MD, PhD, is an assistant professor in Hematopathology with a particular interest in clinical flow cytometry and education. She is the Phase I curriculum director of the Northwestern University Feinberg School of Medicine as well as the leader of the Pathology curriculum content, the coleader of the Immunology/Microbiology Foundations module, and the co-leader of the Diagnostic Testing thread. At the graduate medical education level, she is the residency associate program director (Clinical Pathology) and she has been involved in improving the laboratory medicine rotations in pathology to enhance the trainee experience and learning outcomes. Her education interests are in the use of technology in instruction at all levels (medical students, pathology trainees, faculty, and technologists) to increase learner engagement and the meaningful integration of basic science education into the clinical curriculum. She is the chair of the ASCP Specialist in Cytometry examination committee and helped to design and deploy an international specialist certification program for cytometrists. Her clinical research interest is in the design and optimization of clinical flow cytometry assays for leukemia and lymphoma evaluation.

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ADVANCES Advances in our understanding of allergic reactions have led to exciting discoveries and new treatments. With earlier and better treatments, we may begin to dampen the impact of allergies on public health. However, as with all new treatments and information, we must consider the safety and larger public health impact of new discoveries and treatments. Below, we have highlighted a few of the many exciting advances as well as some of the potential public health implications.

Allergy Research in the News What is Eosinophilic Esophagitis?

You may be familiar with the burning sensation associated with gastric acid reflux, commonly known as heartburn. As acid backs up into the esophagus (your food pipe) from the stomach, it causes inflammation and irritation, or esophagitis. This clinical condition may be common, but its lesser known cousin, eosinophilic esophagitis (EE), first described in the mid-1990s, is starting to gain press [1].

Eosinophilic esophagitis has little to do with gastric acid and is, instead, a reaction to commonly ingested allergenic foods. While this is not a classic anaphylactic-type reaction, it is a specific food-related reaction akin to an allergy. Those living with EE commonly experience food getting “stuck” in their chest and learn to eat small bites and drink excess water to “wash food down.” On the cellular level, tissue biopsies of these patients’ esophagi display an excess number of eosinophils (a specialized immune cell). The current proposed mechanism of disease suggests that food allergens trigger specific IgEindependent immune reactions in the

esophagus which result in recruitment of eosinophils to the esophagus wall (for more information on IgEdependant allergies, see the article “What is an Allergy?”). Continued inflammation and immune activation in the esophagus leads to chronic inflammation and a breakdown in the esophagus wall barrier leading to the symptoms described above [1].

Interestingly, these patients’ symptoms improve with specialized diets. When individuals eliminated the six most commonly allergenic foods (wheat, milk, soy, nuts, eggs, and seafood) from their diet, a large number of patients felt better, and their biopsies contain fewer eosinophils.

If the patients resume eating trigger foods, however, they will relapse [1].

Approximately 56 out of 100,000 U.S. citizens are currently living with EE [2]. Some theorize that a change in our environmental exposures cleaner environments, less population crowding, and more C-sections - have led to an increase in prevalence [1].

That said, it is unclear if the true prevalence of EE is rising or if we are now more equipped to recognize the condition thus more people are being diagnosed. Whatever the root

cause may be, EE is a newly-described entity rooted in the concept of allergic reactions with a unique biochemical mechanism.

References [1] Noel, Richard J., Philip E. Putnam, and Marc E. Rothenberg. "Eosinophilic esophagitis." New England Journal of Medicine351, no. 9 (2004): 940-941.

[2] Dellon, Evan S., Elizabeth T. Jensen, Christopher F. Martin, Nicholas J. Shaheen, and Michael D. Kappelman. "Prevalence of eosinophilic esophagitis in the United States."

Clinical Gastroenterology and Hepatology 12, no. 4 (2014): 589-596.

Illustration by Jennie Chen

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Sleep and Allergies Is your nose keeping you up at night?

It may seem obvious, but when you’re dealing with allergies it can be hard to get a good night’s rest. Allergic rhinitis, better known as “hay fever,” is a major culprit. Individuals with hay fever often struggle to breathe through their nose when their symptoms are acting up, and that’s frequently just when the sun has gone down and people are getting ready for bed. Add in the challenge of keeping the body’s airways open while lying down, and you lose quality sleep. Individuals with allergies may experience snoring, sleep apnea, and even difficulty using the machines that help with sleep apnea. Researchers found that the worse an individual’s hay fever symptoms, the harder it was to get quality sleep. Some studies also noted that treatments dedicated to fixing allergy, sinus, and nasal issues don’t always improve sleep quality. However, there is still hope!

Researchers recommend medically or surgically reducing obstructions in the nose to find sound sleep and ultimately achieve a better quality of life.

References [1] Kent, D. T., & Soose, R. J. (2014).

Environmental Factors That Can Affect Sleep and Breathing. Clinics in Chest Medicine, 35(3), 589–601. doi: 10.1016/j. ccm.2014.06.013 Accessed from https:// www.sciencedirect.com/science/article/abs/ pii/S0272523114000513

Allergies and C-Sections Could the reason why you can’t eat shellfish be linked to how you came into the world? To find some answers, researchers investigated the association between different types of birth and the development of wheeze and allergies. Previously, scientists hypothesized that children born via C-section missed receiving vital bacteria from their mothers’ birth canals that, if they had been born vaginally, would have served as a foundation for their microbiome.

Without these protective bacteria, according to the hypothesis, the children were more likely to develop food allergies or wheeze.

To test the theory, researchers examined longitudinal data from more than 5,000 children from the Upstate KIDS cohort. They tracked kids’ allergies and wheeze and compared reports from children born via C-section, both planned and emergency, to children born vaginally.

Interestingly, after controlling for several factors such as prepregnancy BMI, the researchers found that children born via emergency C-section were more likely to also develop wheeze and food allergies compared to children born vaginally.

Those born via a planned C-section were not more likely to develop a food allergy. The findings seem to diverge from the theory that receiving the mother’s bacteria seeds the infant’s microbiome and protects the infant from developing allergies or wheeze. In many situations leading

Morgan Marshalll is a Chicago-born artist who has dabbled in many different medias of illustrations and visualization. She obtained her Bachelor of Science from Lake Forest College in 2016. After graduating, Morgan worked at Northwestern Medicine as a research technologist and mouse colony manager for two years. In 2018, she was accepted in various Master of Science programs for Medical Illustrations, for a prospective graduation date of 2020. She is currently completing her Master of Science in Biomedical Visualization at the University of Illinois at Chicago, under rigorous training.

to an emergency C-section, the fetal membranes may break, allowing some bacteria from the mother’s vagina to reach the fetus. This spread of bacteria would not be as common in a planned C-section. If the proposed hypothesis was correct, children born through emergency C-sections should be less likely to develop allergies or wheeze, given that they would be more likely to receive some of their mothers’ bacteria compared to those born through planned C-sections. The researchers suggested that the findings may disagree with the theory because the data could include incorrectly labeled emergency or planned C-sections and because the study included twins— which are typically delivered via planned C-section.

Another important finding from this study: breastfeeding mediated the association between emergency C-section delivery and wheeze. So, regardless of how you were born, whether or not your mother breastfed you may play an important role in whether you can safely eat that plate of shellfish or not.

References [1] Adeyeye, T. E., Yeung, E. H., Mclain, A. C., Lin, S., Lawrence, D. A., & Bell, E. M. (2018). Wheeze and Food Allergies in Children Born via Cesarean Delivery.

American Journal of Epidemiology, 188(2), 355–362. doi: 10.1093/aje/kwy257.

Accessed from: https://academic.oup.com/ aje/article/188/2/355/5210258?casa_ t o k e n = _ D X 7 V i h L u 7 YA A A A A : g b y E o N F P d O C X v I m h S V- 6 O _ T3P1vbNcGvY_Fuj2eVDp8J3u5pIOgcufwXNlSv731Wh_aY1pF0edew

About the Artist

NPHR 2020 | pg. 11

Advances in Allergy Treatment Summarizing Popular Media - Will new immunotherapy tablets fight off allergies?

More than 50 million people in the United States suffer from allergies making them the sixth leading cause of chronic illness in the country.

There are two traditional allergy treatment options: medication to reduce or block symptoms, or immunotherapy to change the body’s immune response to an allergen.

Immunotherapy allergy treatment is conducted through shots that occur during scheduled visits to a doctor’s office, typically once a week for up to 12 months. These shots alter the body’s immune response by providing increasing doses of a specific allergen to build up immunotolerance to that allergen.

Now, a new form of allergy immunotherapy has emerged in the form of a tablet that allergy victims can take at home. The tablets are seen as a breakthrough treatment that can change the body’s response to allergens without a weekly visit to the doctor. While the at-home availability of allergy tablets offers increased convenience, the tablets require strict adherence to a prescribed dosage plan which could include daily use

for a number of years. If the dosage schedule is not properly followed, a visit to a physician is required to reset the schedule. An exact timeline for how long an individual would need to continue allergy tablet treatment to receive desired effects has yet to be established. While safe for most individuals to use from home, allergy tablets are not safe for home-use by those with severe asthma. Unlike allergy shots that can be used to combat multiple allergens simultaneously, each allergy tablet is only capable of combating one allergen at a time. To affect the body’s response to multiple allergens, multiple allergy tablets are required. accompanying table is shown below...

References [1] Thorbecke, Catherine. “What to know about the new immunotherapy allergy tablets treatment.” Good Morning America, Navjot Sobti (ABC News Medical Unit).

April 11, 2019. Retrieved from https:// www.goodmorningamerica.com/wellness/ stor y/immunotherapy-allerg y-tabletstreatment-62315324 [2] “Allergy Tablets (Sublingual Immunotherapy).” American College of Allergy, Asthma & Immunology. December 28, 2017. Retrieved from https://acaai. org/allergies/allergy-treatment/sublinguali m m u n o t h e r a py - s l i t / a l l e r g y - t a b l e t s sublingual-immunotherapy

American Academy of Pediatrics Endorses Early Introduction to Peanuts The American Academy of Pediatrics (AAP) released research suggesting early introduction to peanuts may reduce an infant’s risk of developing a peanut allergy. In its 2019 clinical report communicating updates of infant and child atopic disease prevention, the AAP details infantsafe methods of introducing peanuts to high risk children 4 months or older.

However, the AAP also cautions that the data for early introduction to eggs remains ambiguous. The report also reaffirms the lack of evidence for delaying the introduction of common allergenic foods to prevent atopic diseases such as food allergies.

The 2019 report further addresses other maternal and early infant dietary strategies for preventing atopic diseases such as asthma, dermatitis, and food allergies in infants and children. Of note, the report reinforces the lack of evidence to suggest prenatal and lactationperiod maternal dietary restriction or any breastfeeding duration prevents or delays atopic disease, including food allergies. Additionally, the AAP rescinds the position that hydrolyzed formulas prevent atopic disease in infants fed formula for 3 to 4 months, indicating that research in the years since the previous 2008 report shows no compelling evidence of atopic disease prevention even in high risk infants.

References [1] Greer, F. R., Sicherer, S. H., & Burks, A. W. (2008). Effects of Early Nutritional Interventions on the Development of Atopic Disease in Infants and Children: The Role of Maternal Dietary Restriction, Breastfeeding, Timing of Introduction of Complementary Foods, and Hydrolyzed Formulas. Pediatrics, 121(1), 183–191. doi: 10.1542/peds.20073022. Retrieved from: https://www.ncbi.nlm. nih.gov/pubmed/30886111

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Illustration by Jennie Chen

in a controlled environment so as to ease the immune system into an attenuated response to the allergen. This desensitization requires daily maintenance doses of the allergen and is not an all out cure for peanut allergy.

Patients who successfully complete the build up phase of OIT, that is increasing doses until a benchmark “accidental exposure” threshold is tolerated, are still affected by large exposures to peanuts. The effect is simply moderated to be manageable at low dose with the tools peanut allergy sufferers are already familiar: albuterol, diphenhydramine, and epinephrine [2].

OIT has shown to be effective in achieving the desired peanut desensitization in clinical trials over the past decade, with OIT participants 12.42 times more likely to pass a food challenge, designed to mock an out-of-clinic accidental exposure, without anaphylactic incident [3].

However, those who participated in OIT were at a 3.12 times greater risk to experience an anaphylactic reaction than those who avoided peanuts altogether. Additionally, evidence of an increase in quality of life for those participating in OIT was lacking [3]

OIT for Peanut Allergies - A Cost-Benefit Decision Peanut allergy is one of the most common food allergies, affecting a seemingly increasing number of children worldwide [1]. Subcutaneous immunotherapy, colloquially known as allergy shots, used to manage inhaled allergen and insect sting sensitivities are unavailable for food allergies. Traditionally, those suffering from peanut allergies avoid contact with peanuts, and in more recent years, carry auto-injector epinephrine in case of emergencies. These precautions are effective when peanut allergy sufferers and their caregivers are strict in monitoring and preventing potential peanut exposure. With this vigilance comes daily stress and unease of an accidental exposure. Especially when the peanut allergy sufferer is a small child, caregivers can feel helpless and as though this “avoid and react when necessary” method of managing the peanut allergy is analogous to “doing nothing” and simply waiting for an anaphylactic reaction to occur.

Oral immunotherapy (OIT) is an active form of food allergy therapy which has received growing attention and investigation over the past decade. OIT aims to desensitize the immune system with small and increasing doses of the allergen in question until the subject can tolerate low dose exposure to the allergen. The concept is familiar: similar to allergy shots, expose the immune system to the allergen

With the potential FDA approval of Aimmune Therapeutic “peanut capsules” arriving in 2020, OIT for peanut allergy may garner even more attention [4].

Physicians and insurance companies largely considered OIT to be investigational and not medically necessary for peanut allergy [5]. However, these peanut capsules have the potential to make OIT at home easier and an FDA approval may give credence to the therapy. As OIT becomes more familiar among the community of peanut allergy sufferers, individuals and their physicians will have to weigh the risks and benefits in attempting OIT. References [1] Prescott, S. L., Pawankar, R., Allen, K. J., Campbell, D. E., Sinn, J., Fiocchi, A., … Lee, B. W. (2013). A global survey of changing patterns of food allergy burden in children. The World Allergy Organization journal, 6(1), 21. doi:10.1186/1939-4551-6-21 [2] Jones, S. M., Pons, L., Roberts, J. L., Scurlock, A. M., Perry, T. T., Kulis, M., … Burks, A. W. (2009). Clinical efficacy and immune regulation with peanut oral immunotherapy. The Journal of allergy and clinical immunology, 124(2), 292–300.e3097. doi:10.1016/j. jaci.2009.05.022 [3] Chu, D., Wood, R., French, S., Fiocchi, A., Jordana, M., Waserman, S., . . . Schünemann, H. (2019). Oral immunotherapy for peanut allergy (PACE): A systematic review and meta-analysis of efficacy and safety. The Lancet, 393(10187), 2222-2232.

[4] Aimmune Therapeutics to Present AR101, OIT and Peanut Allergy Data at 2019 AAAAI Annual Meeting. (2019, February 4).

Retrieved from http://ir.aimmune.com/news-releases/news-releasedetails/aimmune-therapeutics-present-ar101-oit-and-peanut-allergydata.

[5] Landhuis, E., Roberts, J., & Roberts, J. (2019, September 30).

Why Parents Are Turning to a Controversial Treatment for Food Allergies. Retrieved September 9, 2019, from https://undark. org/2019/08/05/oral-immunotherapy-food-allergies/.

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Nicole Greal

Personal Narratives I have lifelong experiences with both environmental and food allergies. I received allergy shots for my allergies that are environmentally based for a few years during middle school and early high school, which helped with maintenance and overall symptoms. My food allergies are more prominent in my everyday life as far as exercising preventative measures. I am allergic to tree nuts, which are a fairly common ingredient in a lot of health foods, desserts, and snack-type foods. Being that I am a vegetarian, I have to be considerate of the fact that many vegetarian products include tree nuts as a source of protein. I also learned from a young age—I became aware of my tree nut allergy around 11 years of age—that it is important to ask for confirmation of ingredients before consuming any food given to me by someone else. In the early years of being aware of my tree nut allergy, I accidentally consumed tree nuts on a few occasions and learned that it is better to be safe and politely decline food if someone is unsure of all of the ingredients. I have also made a habit of carrying an Epi-Pen with me at all times since becoming aware of my food allergy. While I am fortunate that I have never had a severe allergic reaction thus far, I am aware that preventative care and having a line of defense in the form of my Epi-Pen is important to maintaining my health and wellness. While my allergies do not have a significant impact on my everyday life, they are something I am aware of on a daily basis and give consideration to around meal times, especially if I am eating something I didn’t cook. In my eyes, these small preventative efforts help to mitigate the potential for a greater health crisis as a result of my allergies.

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“My food allergies are more prominent in my everyday life as far as exercising preventative measures.�

About the Artist Brianna Monroe is a Chicago-based medical illustrator. She received her Bachelor of Arts at Iowa State University in biological/pre-medical illustration (BPMI) with minors in anthropology and biology in 2018.

She is currently completing her Master of Science degree in Biomedical Visualization at the University of Illinois at Chicago. Attending the BPMI 30th anniversary her freshman year at Iowa State opened her eyes to all of the possibilities this career has to offer in the medical, veterinary, and natural sciences. Brianna aims to use her passion to educate others through visually communicating complex scientific topics to a broad range of audiences.

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Luke Nordman

In my experience, people have recently become very conscious of food allergies and the fact that, for many people, an allergic reaction can be life-threatening. When I explain that the reason I’m not eating any of the home-made pastries brought into work is because of a food allergy, I’m nearly always asked, “what are you allergic to?” and, “is it okay to have this food around you?” I am rarely asked, “what does that mean?”

As someone with a peanut/tree nut food allergy that results in anaphylaxis (swelling of the throat) when I consume – not inhale – food containing my allergen, I usually reply, “It’s fine to have it around here! So long as I don’t eat it, I should be fine, and I carry several Epi-Pens in case of an emergency.” The fact that the majority of people are aware of food allergies and only need to be informed of what I’m allergic to and how sensitive I am to my allergen makes communicating my allergy very simple on my end.

The biggest challenge to managing my allergy is simply the uncertainty of what foods could contain peanuts or tree nuts. If it is a store-bought dessert, for example, there may be allergy information listed—but the most common phrase I see on labels is “processed in a facility that handles peanuts or tree nuts.” There is a level of uncertainty that exists when such food is being made and processed alongside desserts that do contain peanuts or tree nuts. If it is a homemade good, it depends on the circumstance. If the person who made the food is present and able to remember the ingredients, it can be fairly easy to determine whether or not the food is safe to eat. However, if they are not available, I have to default to not eating whatever tasty treat has been brought into work or a classroom. Ultimately, the uncertainty with what can be safe to eat, typically with homemade and store-bought desserts, means I often have to do without, or eat something I personally brought. However, when I compare my dietary restrictions with someone who has a gluten intolerance or allergy, not being able to eat desserts frequently seems far less difficult to deal with on a day-to-day basis than giving up things like bread entirely!

“So when you meet someone with a food allergy, instead of saying how sad it is, be a friend and make sure they feel supported enough to ask about their allergens in any setting.”

Kreena Patel

When I tell people that I’m allergic to nuts, their first response is something like “Oh, that’s so sad!

You can’t eat any nuts? I love almonds, I wouldn’t be able to live without them!” But I’m not actually sad that I can’t eat nuts. I’ve never been able to eat them, so I don’t know what I’m missing. What is more taxing about having a food allergy is the constant vigilance it takes to avoid having a reaction. As a kid, I would have to turn down free sweets and snacks at school parties because I didn’t know what was in them. The occasional temptations to try something sometimes ended fine, but other times sent me into a terrifying reaction. Even knowing the consequences, it took me a long time to become comfortable with advocating for myself at restaurants by letting the server know about my allergies. I felt embarrassed, like I was burdening the nice restaurant with a pesky food restriction, rather than a life-threatening allergy. I often adopted the “it probably doesn’t have nuts in it,” mentality, because I didn’t want to ask. Having food allergies can make you feel like a burden, and for some of us, it takes a while to be confident about advocating for ourselves. For me, it took a recent trip to the emergency room for anaphylaxis and the accompanying several-thousand dollar bill to finally push me to always ask at restaurants. So when you meet someone with a food allergy, instead of saying how sad it is, be a friend and make sure they feel supported enough to ask about their allergens in any setting.

pg. 16 | NPHR 2020

Nikita Salovich

It’s a strange feeling being told that something the size of your fingernail can kill you. It’s an even worse feeling knowing that the only way to stop it is something that you cannot do yourself.

When I was twelve years old I was mowing the lawn –– one of my household chores –– when I accidentally ran over a wasp nest in the ground. I was stung several times on my arms and legs and within minutes I was struggling to breathe. I remember being more confused than anything; I cried, but I couldn’t gasp enough air to sob. I don’t remember the paramedics injecting the Epi-Pen, just that there was a hole in my favorite jeans after. The next day was my first day of sixth grade. I spent it in the hospital.

From then on I had to make room in my pencil case for my Epi-Pen. Testing determined that I had a life-threatening allergy to bees, wasps, yellow jackets, and hornets (basically anything that stings). “Look on the bright side,” my doctor joked. “At least you don’t have to worry about telling them apart.” Having an allergy may seem trivial, but it quickly became part of my daily life and identity: I carried my Epi-Pen and oral steroids with me everywhere I went; I took a bus to my doctor’s office every Wednesday after soccer practice to get a shot as part of my allergy immunotherapy so I could be cleared by my doctor to study abroad; one year my mom had to choose between buying my family Christmas presents and buying me a new set of Epi-Pens; and, of course, I memorized the steps I needed to take if I ever got stung again. I did everything I could to prepare and protect myself, but when the day came when I was stung again, all of my preparation wasn’t enough to save my own life.

I was walking home from class in college when I felt the all too familiar burn of a bee sting radiate from my arm. I calmly sat down on the curb and pulled out my Epi-Pen from my backpack, ready to carry out the rehearsed steps: pull out the blue safety cap, angle it above my thigh, press for 10 seconds. Instead, my hands began to shake thinking about the needle inside the pen and the pain that would follow; I felt nauseous and horrified realizing that I couldn’t do it. I couldn't save myself.

I looked up to see another college student walking down the street and waved my hands to get his attention. When he pulled off his headphones I asked him without pause, “excuse me, do you think you could save my life?” At first he looked startled, as most people would being beckoned by a half-hysterical stranger sitting on the side of the road. But after I explained my situation he accepted and kneeled down next to me on the grass. As I coached him through how to use my Epi-Pen (he had never seen one before) I could feel my throat starting to itch. My arms wrapped tight around my backpack, he counted down from three and pushed the Epi-Pen into my leg. We waited together for an ambulance (after I politely declined his offer to call an Uber or borrow his roommate’s moped). He was confused but courteous, and, above all else, he was calm. In a cloud of delirium, I thanked him, vaguely remember saying goodbye, and never saw the man who saved my life again.

Six years later, I often think of how fortunate I was to be able to catch a stranger’s attention, and that the person I asked was willing to stop and offer me help. There could have been an incredible amount of barriers: timing, language, location, fear. So many people are affected by severe and deathly allergies, and although they may be equipped with the knowledge and tools to save themselves, the awareness, patience, and initiative of strangers to support them in that process can be extremely valuable. Even if you feel like you may not know what to do, you can always ask how you can help. As was my case, you could even save a life.

NPHR 2020 | pg. 17

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pg. 18 | NPHR 2020

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When I began practicing as a pediatrician and researcher over 15 years ago, I met a family committed to improving food allergy (FA) awareness and management. They had two sons with severe food allergies and came to Lurie Children’s for support and to advocate for more research on the condition. As a junior faculty member conducting related research, I was called into the meeting to see if I could help. I instantly connected with the family as their passion to improve children’s lives was contagious, and their support and excitement for our strides in FA research continues to this day.

As I was primarily researching asthma at the time, I was incredibly surprised by the dearth of scientific data on food allergy and recommendations for families like theirs. The only major clinical recommendations in place were to avoid their children’s allergenic foods and carry epinephrine in case of an emergency. There were few (if any) policies or precautions taken in schools and other public places to keep children with FAs safe, and parents were left navigating a brand new lifestyle with this potentially life-threatening condition, mostly on their own. After gathering as much information as I could about the disease, I noticed that even basic prevalence numbers were lacking. I felt that I could contribute to this area of research and help make a difference for affected families, thus began my journey into the food allergy world.

Surprisingly, about three years into my research, my professional and personal worlds collided when my one-year-old daughter had a severe allergic reaction to peanut butter. I experienced firsthand what the families of my allergy patients were feeling. Everything that I learned through my research up to that point could never have prepared me for the daily impact of food allergy. My daily experiences only further cemented my drive to do as much as possible to keep her and all children with food allergies safe at every stage of life.

Therefore, our research team set out to create and distribute a survey to over 40,000 households nationwide to shed some light on the gravity of food allergy in the United States. The data from this study, published in 2011, determined that an estimated 8% of children (1 in 13) in the U.S. were affected by food allergy [1].

As food allergy became a more widely-discussed public health epidemic, we decided to re-distribute this survey to 40,000 children and adults, respectively, and the results were published in 2018 and early 2019 [2]. Our results still found that an estimated 8% of children in the U.S. had a convincing food allergy, though more

than 11% reported having one. We also found the most commonly reported allergies in children are to peanuts, milk, shellfish, tree nuts, eggs, fin fish, wheat, soy, and sesame. Among these children with food allergy, 42.3% report a history of severe reactions, and 39.9% have multiple food allergies. Additionally, one in five children have sought emergency care for a food allergic reaction in the past year [3].

Understanding the prevalence and severity of food allergy in the United States has thankfully prompted conversation surrounding prevention strategies, management, treatments, and policies, and we have made major strides in improving safety and awareness.

This shift in conversation has been especially important in schools, where children spend so much of their young lives under the care and supervision of their teachers and school staff. As many as a quarter (25%) of first time allergic reactions occur in school due to young children trying foods for the first time or accidental ingestion. The development of inclusive and protective school policies has been critical [4].

About 10 years ago, the Illinois Public Act 96-0349 was passed, and the Illinois State Board of Education (ISBE) and the Illinois Department of Public Health (IDPH) released the guidelines for managing life-threatening food allergies in Illinois schools and required that each school board implement a comprehensive policy based on these guidelines. This prompted Chicago Public Schools’ first draft of their Food Allergy Management Policy which included protections such as requiring parent report of FA and establishing legal documentation such as 504 plans or IEP plans for students to meet their unique needs [5]. Though these policies laid a solid foundation in promoting food allergy awareness and safety in schools, there was still more work to be done. At the time, schools were not authorized to keep an emergency supply of epinephrine for children who did not have a diagnosed food allergy or their own auto-injector, and further, school health personnel were not permitted to administer any lifesaving medication to these children due to fear of liability. With these barriers, schools were instructed to call 911 and wait for help to arrive. In cases of anaphylaxis, this delay in treatment can be fatal.

Unfortunately, a major shift to improve these policies did not come about until 2010 after a 7th grade student passed away from anaphylaxis while attending a Chicago Public School. Following this heartbreaking tragedy, CPS worked tirelessly to ensure all students were completely protected if a sudden anaphylactic

NPHR 2020 | pg. 19

Data from FARE website on school guidelines on stock epinephrine

reaction occurred on school grounds. I was granted the opportunity to help with this initiative. The amendment to the Administration of Medication policy allowed all schools in the district to stock undesignated epinephrine for nurses to administer to children or staff in case of an emergency. Thankfully, the Illinois Attorney General officially passed the School Access to Emergency Epinephrine Act in 2012 and CPS became the first large urban school district in the country with this life-saving medication widely and readily available for all students and staff [5].

This victory for CPS was just the first step in protecting all students with food allergy, the next step was to see how this policy was received and utilized. Our research team collaborated with CPS to evaluate the use of this policy during the first year and found that undesignated stock epinephrine auto-injectors were administered about 38 times to students and/ or staff, and more than half of these administrations were to individuals who did not have any previous history of life-threatening food allergies [6]. This data demonstrated the importance of having this life-saving medication available in schools and led to the development of guidelines and policies by school

pg. 20 | NPHR 2020

districts nationwide. It was incredible to be part of this experience and today, 49 states either have laws/ guidelines allowing schools to stock epinephrine or actually require schools to stock epinephrine to keep their children safe, and the 50th is on its way [7].

While highlighting the need for life-saving medication in schools, we also wanted to continue to improve safety by assessing how CPS schools reported and managed food allergy in general. As part of the Improving Chronic Disease Verification and Medication Access in the Chicago Public Schools Initiative, our research team collected data on how many children with a documented food allergy had the appropriate health plans (Food Allergy Action Plan) readily available at school. We found that only half of students with a documented food allergy had a health management plan on file with the school, and these numbers were significantly lower among minority and low-income students. These findings paved the way for more education in schools for students and parents about the importance of having an action plan on file with the school for their child’s safety and helped in overcoming the barriers to chronic disease reporting with the CPS administration [8, 9].

Although safety in school has always been the number one priority for children with food allergy, we have also been trying to improve awareness and inclusivity among their classmates to allow these students to feel empowered and connected with one another. Living with a food allergy can be difficult and sometimes scary for children to manage on their own, and many students feel like they always have to educate others and be their own health advocates. Therefore, to help facilitate a more open dialogue and normalize food allergy in schools, we surveyed students on what they would want their peers to know, developed age appropriate videos and teacher guides and conducted pre-post knowledge surveys [10]. The peer-to-peer food allergy educational videos for elementary school, middle school, and high school help peers better understand and support their classmates with food allergies and are available for free on our website or in the form of a USB. They have been distributed nationally to schools and have been incredibly well received by teachers and students alike.

While it is abundantly clear that food allergy has become a major public health concern worldwide, the strides to improve policy and care for all children with the condition are unparalleled. Additionally, students living with food allergy are some of the most empowered and resilient children I have ever met, and being a health advocate for them has been nothing but rewarding. I have been so grateful to contribute to the research being done to improve the lives of children and their families and will continue to do my best to spread awareness, eliminate disparities, and find answers until we have a cure!

To watch our student-produced food allergy educational videos, please visit: https://www.feinberg.northwestern.edu/sites/cfaar/education/ video-library.html Contact our team: cfaar@northwestern.edu

Prevalence Data on adults and kids from 2018-2019 studies

NPHR 2020 | pg. 21

About the Author Ruchi Gupta, MD, MPH, has more than 15 years of experience as a board-certified pediatrician and health researcher and currently serves as the director of the Center for Food Allergy and Asthma Research at Northwestern University Feinberg School of Medicine and Ann & Robert H. Lurie Children’s Hospital of Chicago. Dr. Gupta completed her undergraduate and medical education at the University of Louisville and completed her medical residency at Children’s Hospital & Regional Medical Center, University of Washington in Seattle. She completed her pediatric health services research fellowship at Boston Children’s Hospital and Harvard Medical School, and went on to receive her Master of Public Health from the Harvard School of Public Health.

Dr. Gupta is nationally recognized for her groundbreaking research in food allergy and asthma epidemiology, specifically for her research on the prevalence of pediatric and adult food allergy in the United States. She is the author of the Food Allergy Experience, has written and co-authored over 100 peer-reviewed research manuscripts, and has had her work featured on major TV networks and in print media. She strives to improve the lives of children and their families through her epidemiological, clinical, and community-based research and hopes to continue finding answers and shaping policies surrounding food allergy and asthma.

pg. 22 | NPHR 2020

About the Artist

References [1] Gupta, R. S., Springston, E. E., Warrier, M. R., Smith, B., Kumar, R., Pongracic, J., & Holl, J. L. (2011). The prevalence, severity, and distribution of childhood food allergy in the United States. Pediatrics, 128(1), e9-e17.

[2] Gupta RS, Warren CM, Smith BM, et al. Prevalence and Severity of Food Allergies Among US Adults. JAMA Netw Open. 2019;2(1):e185630. doi:https:// doi.org/10.1001/jamanetworkopen.2018.5630 [3] Gupta, R. S., Warren, C. M., Smith, B. M., Blumenstock, J. A., Jiang, J., Davis, M. M., & Nadeau, K. C. (2018). The public health impact of parent-reported childhood food allergies in the United States. Pediatrics, 142(6), e20181235.

[4] Sicherer, S. H., & Mahr, T. (2010). Management of food allergy in the school setting. Pediatrics, 126(6), 1232-1239.

[5]Zadikoff, E. H., Whyte, S. A., DeSantiago‐Cardenas, L., Harvey‐Gintoft, B., & Gupta, R. S. (2014). The development and implementation of the Chicago public schools emergency EpiPen® policy. Journal of School Health, 84(5), 342-347.

[6] DeSantiago-Cardenas, L., Rivkina, V., Whyte, S. A., Harvey-Gintoft, B. C., Bunning, B. J., & Gupta, R. S. (2015). Emergency epinephrine use for food allergy reactions in Chicago Public Schools. American journal of preventive medicine, 48(2), 170-173.

[7]https://www.foodallergy.org/education-awareness/advocacy-resources/ advocacy-priorities/school-access-to-epinephrine-map [8] Rivkina, V., Tapke, D. E., Cardenas, L. D., Harvey-Gintoft, B., Whyte, S. A., & Gupta, R. S. (2014). Identifying barriers to chronic disease reporting in Chicago Public Schools: a mixed-methods approach. BMC public health, 14(1), 1250.

[9] Gupta, R. S., Rivkina, V., DeSantiago-Cardenas, L., Smith, B., HarveyGintoft, B., & Whyte, S. A. (2014). Asthma and food allergy management in Chicago Public Schools. Pediatrics, 134(4), 729-736.

[10] Jiang, J., Gallagher, J. L., Szkodon, J. W., Syed, M., Gobin, K. S., Gupta, R. S., & Bilaver, L. A. (2019). The development and evaluation of peer food allergy education videos for school-age youth. Annals of Allergy, Asthma & Immunology.

Madison Rice is currently a BVIS graduate student at the University of Illinois at Chicago.

She is originally from Dallas, Texas, and received a Bachelor of Science in Microbiology from Mississippi State University. Her current work at UIC focuses on cellular and molecular 3D modeling and animation.

Virginia Nowakowski, MPH with Dr. Lucy Bilaver, PhD

Assessing Allergies’

COST

If the warming weather has ever made your nose run or your eyes water, you are not alone. Millions of Americans suffer from allergic symptoms like these each year. In many cases, taking a simple antihistamine is enough to clear up any problems, but not all allergies are the same. While spring weather may cause sneezing or a slight rash for individuals with seasonal allergies, eating the wrong meal can send people with peanut allergies into a state of anaphylactic shock.

Regardless of the severity of the allergy, there is no doubt that allergies are widespread in the United States. Between allergic rhinitis, respiratory allergies, skin allergies, and food allergies, more than 50 million Americans suffer from some kind of allergy, and many will deal with this problem their whole lives, making allergies the sixth leading cause of chronic illness [1].

While allergies may seem like an individual’s problem, the prevalence of allergies is actually a major public health concern. Allergies, especially among the 5.6 million children who deal with food allergies, require extensive management in order to protect individuals’ health. That management comes at a cost to both families and society. Northwestern’s Dr. Lucy Bilaver, PhD, was one of the first researchers to quantify the economic burden of children’s food allergies when she worked with a team to examine caregivers’ reports of costs related to allergy care [2].

The researchers’ 2013 analysis provided a clearer look into how families manage allergies as well as how much allergies actually cost.

“We didn't really have an estimate prior to that study of the scope of the economic burden,” Bilaver says.

“We found in adding up all these different types of costs that the total economic burden of food allergy was just under $25 billion – spent annually.”

The researchers measured costs that would typically be part of managing an allergy, including both direct medical costs to the healthcare system, as well as indirect medical costs that were borne by the family.

Most of the direct medical costs included what one might expect in caring for any chronic condition – for one, more visits to the doctor.

“A family might initially discuss an allergic reaction or concern of a food allergy with a pediatrician, but usually there is some more specialized testing, such as skin testing, that would happen in a special allergy visit,” Bilaver says. “Usually an allergist would recommend a yearly visit – seeing an allergist on a regular basis would be an important part of standard care.”

In addition to regular doctors’ visits, families dealing with allergies may need to consider medications for daily management or for rescue, in cases of accidental exposure to the allergen. Epinephrine auto-injectors are a common, quite expensive treatment individuals keep on hand for occasions when a serious allergic reaction like anaphylaxis develops. However, Bilaver

NPHR 2020 | pg. 23

notes that with the use of epinephrine often comes another direct medical expense: an emergency room visit.

“It could be the case that one epinephrine auto-injector would be enough to stop the reaction, but there could be continued reactions that would require medical care,” Bilaver says. “Certainly, if there is an accidental exposure, the recommendation would be to go to the ER to make sure that that reaction is under control.”

Emergency room visits for an allergic reaction are more frequent than one might hope. Recent research by Dr. Ruchi Gupta found that one in five children with a food allergy received care at an emergency room in the last year [3]. Should an individual with allergies require more care after an emergency room visit, such as an in-patient hospitalization, the cost increases even more.

Between outpatient visits, emergency room visits, and inpatient hospitalizations, the 2013 Northwestern study found that America’s healthcare system paid $4.3 billion annually in allergy care for children with food allergies [2]. Though substantial, the number explained less than a quarter of the total costs for food allergies that caregivers reported in the study. Other crucial elements to consider in allergy care economics are what things families forgo or seek out to make sure that their child stays healthy. Caregivers may lose pay for a day of work if they have to use the time to drive their child to an appointment. Families may have to pay for medications not fully covered by insurance.

For families dealing with food allergies specifically, there is a challenge to buy and cook food that will be safe for their affected family member to eat. Congress made the task a little easier in 2004 by passing the Food Allergen Labeling and Consumer Protection Act (FALCPA) [4].

The act, which came into full effect in 2006, requires consumer packaged food companies to clearly note if their product contains any of the “top eight” food allergens: milk, eggs, fish, crustacean shellfish, tree nuts, peanuts, wheat, or soybeans [5]. If a product contains any of these ingredients, the ingredient must either be written in bold in the main ingredient list or listed separately in a “Contains: allergen” statement [5].

Similar rules exist for agricultural foods, such as meat, poultry, and egg products that fall under the USDA’s inspection [6]. Of course, many individuals react to allergens outside of these lists, demanding they more carefully scan ingredient labels. Additionally, FALCPA does not require companies to include advisory

pg. 24 | NPHR 2020

statements about potential cross-contamination of their products, which may occur in facilities where companies make some foods with allergens and other foods without them [5]. These warnings indicating that a food was made on shared equipment that also processed allergencontaining products can be lifesaving for individuals with very severe food allergies – but companies include them at their own discretion.

“In the way in which food is produced, there are issues of cleaning equipment and using shared production lines for allergen-free foods and allergen-containing foods,” Bilaver says. “There is an opportunity for changes in policy around food precautionary labels in order to make them a more effective tool for families who deal with food allergies.”

On top of finding special foods, seeking medical care, paying for medications, and potentially losing days of work — the caregivers in the 2013 Northwestern study noted that in some cases their child’s allergy required seeking mental health services or changing schools, summer camps, or daycares to ensure safety from accidental exposure.

“Many families with a food allergy are not going to incur these additional costs — not every family with a food allergy is going to need a childcare change or need a change in schools or need to seek mental health services,” Bilaver says. “While the data does not show that the majority of families with a food allergy incurred those types of costs, for at least a relatively small proportion it is an issue. It is kind of a unique consequence of having food allergies.”

$4.3 billion

American healthcare system’s annual spending for food allergy care

Altogether, out-of-pocket expenses accounted for more than a quarter of food allergy costs in the 2013 analysis, about $5 billion [2]. The biggest chunk of costs in the analysis, $14 billion, came from “foregone labor market activities” [2]. These opportunity costs included the money “lost” when caregivers had to change careers or give up some career options to help manage an allergic condition – further increasing allergies’ financial burden for families.

Northwestern’s 2013 study demonstrated just how costly it can be to care for an allergy. Its findings made Bilaver wonder how individuals from limited socioeconomic backgrounds handled their allergy management. She examined the data again in a 2016 study to look at how caregivers from different socioeconomic backgrounds managed the financial burden of allergies. The research revealed that families from lower income backgrounds spent more on emergency room visits and hospitalizations than higher income individuals, and less on out-of-pocket costs [7].

It may seem strange that lower income individuals would spend more on expensive emergency room visits and hospitalizations, but for Bilaver, this trend could indicate that low income individuals are struggling to afford preventive medications and management that would help them avoid emergency care. Their difficulty to pay for regular allergy management could

$5 billion

be a crucial insight for programs seeking to improve allergy outcomes and reduce hospitalizations for allergies, highlighting the public health importance of Northwestern’s research.

As a chronic illness that places a large financial burden on individuals, families, and the country, allergies present an opportunity for members of the public health field to explore the condition’s impact on different individuals and communities. Most strategies for dealing with this issue currently rely on management. However, Bilaver points to emerging research on the prevention of allergies, noting it could present new solutions for allergy care.

“I think the most exciting thing that has happened in terms of food allergies in my research and other research is the implementation of guidelines to prevent allergies, specifically peanut allergies” Bilaver says.

$14 billion annual cost due to “forgone labor market activities” which includes money “lost” when caregivers had to change careers or give up some career options to help manage an allergic condition

annual out-of-pocket expenses for food allergy

NPHR 2020 | pg. 25

Perhaps in the future allergies will become an entirely preventable condition, reducing the financial burden for individuals, facilities, and society. Until then, research like Bilaver’s calls attention to the importance of creating effective public health strategies to manage allergies.

References [1 ]CDC. “Allergies and Hay Fever.“ 2017. https://www.cdc.gov/ nchs/fastats/allergies.htm [2] Gupta, Ruchi, Holdford, David, Bilaver, Lucy. “The Economic Impact of Childhood Food Allergy in the United States.”

2013. https://jamanetwork.com/journals/jamapediatrics/ fullarticle/1738764 [3] Lurie Children’s Hospital. “One in Five Kids with Food Allergies Treated in Emergency Department in Past Year.” 2018. https:// www.luriechildrens.org/en/news-stories/one-in-five-kids-withfood-allergies-treated-in-emergency-department-in-past-year/ [4] Roses, JB. “Food allergen law and the Food Allergen Labeling and Consumer Protection Act of 2004: falling short of true protection for food allergy sufferers.” 2011. https://www.ncbi.nlm. nih.gov/pubmed/24505841 [5] FDA. “Food Allergen Labeling And Consumer Protection Act of 2004 Questions and Answers.” 2006. https://www.fda.gov/food/ guidanceregulation/guidancedocumentsregulatoryinformation/ allergens/ucm106890.htm#q4 [6] FSIS. “Allergies and Food Safety.” 2016. https://www.fsis.usda. gov/wps/portal/fsis/topics/food-safety-education/get-answers/ food-safety-fact-sheets/food-labeling/allergies-and-food-safety/ allergies-and-food-safety [7] Bilaver, Lucy, Kester, Kristen, Smith, Bridget, Gupta, Ruchi.

“Socioeconomic Disparities in the Economic Impact of Childhood Food Allergy” 2016. https://pediatrics.aappublications.org/ content/137/5/e20153678 [8] Sicherer, Scott. “New guidelines detail use of ‘infant-safe’ peanut to prevent allergy.” 2017. https://www.aappublications. org/news/2017/01/05/PeanutAllergy010517

pg. 26 | NPHR 2020

About the Author

According to the most recent guidelines published by the American Academy of Pediatrics, introducing peanuts to infants’ diets helps decrease sensitivities to the food [8]. Similar practices to expose children to allergens early on in their lives could potentially reduce sensitivities and protect individuals from developing an allergy in the first place. The method could certainly be cost-saving, if evidence continues to support its effectiveness.

Virginia Nowakowski, MPH, graduated from Northwestern’s Program in Public Health in spring of 2019. She currently serves as an associate program manager for Bright Pink, a national nonprofit dedicated to preventing breast and ovarian cancer and improving women’s health. An alumna of the Medill School of Journalism, Virginia enjoys working at the intersection of health and communication.

Special thanks to Dr. Lucy Bilaver, PhD, whose research and expertise informed this article. Dr. Bilaver is an applied health services researcher at Northwestern University Feinberg School of Medicine. Her work focuses on pediatric health issues, specifically children with food allergies and autism spectrum disorder, producing research to improve policies related to children’s health.

ABOUT BVIS

Grace Bellinger Co-Editor-in-Chief NUIN PhD/MPH Candidate

Kaitlyn O’Shea Staff Editor MS Biostatistics Student

EDITORIAL

Margaret Walker Co-Editor-in-Chief Dual MD/MPH Candidate

Tanvi Potluri Staff Editor DGP PhD Candidate

Jennie Chen Staff Illustrator DGP PhD/MPH Candidate

DESIGN

Joo-Young Lee Design Editor MD Student

Founded in 1921 by Professor Thomas Smith Jones, the Biomedical Visualization graduate program (BVIS) at the University of Illinois at Chicago (UIC) is one of only four accredited graduate programs in North America providing professional training for careers in the visual communication of life science, medicine, and healthcare. The program’s unique curriculum attracts graduate students from a variety of disciplines such as medicine, life science, art, digital animation, and computer science.

BVIS utilizes the academic resources of multiple departments throughout the UIC campus to support its interdisciplinary studies. A recently revised curriculum strongly emphasizes effective communication and problem solving and provides a solid foundation in medical science, learning theory, and innovative visualization techniques. In addition to illustration and design, course offerings in visualization technology have been expanded to include animation, interactive media, educational gaming, virtual reality, sterography, haptics, and augmented reality.

Close relationships between UIC BVIS and other prestigious Chicago universities and medical centers provide opportunities for student immersion experiences and effective collaboration with peers. For the seventh consecutive year, BVIS students have contributed editorial illustrations to the Northwestern Public Health.

NPHR 2020 | pg. 27

Founded in 2013, the Northwestern Public Health Review endeavors to stimulate the exchange and cross-pollination of public health ideas, resources, and opportunities across the Northwestern community and beyond. Through multiple channels, the student-run NPHR offers opportunities for learning and reporting on public health issues.

Thank you to The Alumnae of Northwestern University for their support in printing this issue.