Issue 36

Summer 2021

Issue 36

The official newsletter of the British Society for Allergy and Clinical Immunology

Managing suspected allergy to COVID vaccine Page 6

COVID innovations​ Page 16

Launch of the primary care Adrenaline Auto-Injector Guideline Page 23

A tribute to Barry Kay Page 26

Allergic Rhinitis is underestimated and undertreated

fluticasone propionate/ azelastine hydrochloride

Dymista® is indicated for the relief of symptoms of moderate to severe seasonal and perennial allergic rhinitis if monotherapy with either intranasal antihistamine or glucocorticoid is not considered sufficient.

52%

70-90%

of moderate to severe persistent allergic rhinitis patients do not feel rested after sleep (n=2,305)1

of patients with asthma also have allergic rhinitis2

2 in 3

patients are still uncontrolled, despite having multiple treatments3

13%

of these uncontrolled patients visited their doctor 5 or more times in the previous year, due to their allergic rhinitis3

74%

of perennial allergic rhinitis sufferers have moderate to severe symptoms (n=392)4

Meeting patient and HCP needs Recommended by BSACI guidelines for patients uncontrolled with monotherapy6 Associated with less asthma medication use and improved asthma control in comorbid patients7

Suitable for long term use5

Fixed dose combination provides a simple regime which may increase compliance6

5 minute onset of action5

Substantial relief across entire rhinitis symptom spectrum8,9

Suitable for perennial and seasonal AR5

Shown to improve QoL10

References: 1. Valovirta E et al. The voice of the patients: allergic rhinitis is not a trivial disease. Curr. Opin Allergy Clin Immunol. 2008;8:1-9. 2. https://www.worldallergy.org/education-and-programs/education/ allergic-disease-resource-center/professionals/combinedallergic- rhinitis-and-asthma-syndrome [accessed March 2019] 3. Klimek L et al. Effectiveness of MP29-02 for the treatment of allergic rhinitis in real-life: Results from a non interventional study. Allergy Asthma Proc. 2015;36:40–47. 4. Canonica GW et al. A survey of the burden of allergic rhinitis in Europe. Allergy.

2007;62(Suppl. 85):17-25. 5. Dymista SPC. 6. Scadding GK, et al. BSACI guideline for the diagnosis and management of allergic and non-allergic rhinitis (Revised Edition 2017;First edition 2007). Clin Exp Allergy. 2017;47:856-889.. 7. De Jong HJI et al. Evaluating the real-life effect of MP-AzeFlu on asthma outcomes in patients with allergic rhinitis and asthma in UK primary care. World Allergy Organ J. 2020;13(12):100490. 8. Meltzer E et al. Clinically relevant effect of a new intranasal therapy (MP29-02) in allergic rhinitis assessed by responder analysis. Int Arch Allergy Immunol.

2013;161(4):369–77. 9. Carr W et al. A novel intranasal therapy of Azelastine with Fluticasone for the treatment of Allergic Rhinitis. J Allergy Clin Immunol. 2012;129(5):1282-89. 10. Price D et al.

Allergic rhinitis and asthma symptoms in a real-life study of MP-AzeFlu to treat multimorbid allergic rhinitis and asthma. Clin Mol Allergy. 2020;18:15.

Dymista® Nasal Spray, Suspension (azelastine hydrochloride/ fluticasone propionate) Prescribing Information Presentation: Nasal spray suspension. Each gram of suspension contains 1000 micrograms of azelastine hydrochloride and 365 micrograms of fluticasone propionate.

Indications: Relief of symptoms of moderate to severe seasonal and perennial allergic rhinitis if treatment with intranasal antihistamine or glucocorticoid alone is not considered sufficient. Dosage and administration: Adults and adolescents (12 years and older): One actuation into each nostril twice daily. Children below 12 years: not recommended as safety and efficacy has not been established in this age group. Contra-indications: Hypersensitivity to azelastine hydrochloride or fluticasone propionate or any of the other ingredients in this medicine. Warnings and precautions: Avoid concomitant use with ritonavir. Systemic effects of nasal corticosteroids may occur. Systemic exposure in severe liver disease may be increased. Dymista® may result in clinically significant adrenal suppression. Patients may experience blurred vision or other visual disturbances. Monitor patients who experience changes in vision or have a history of ocular pressure, glaucoma and/or cataract. If adrenal function is impaired, take care when changing medication to Dymista®. In patients with infections, recent surgery or injury to nose or mouth, weigh benefits against risks of use.

Contains benzalkonium chloride. Long term use may cause oedema of the nasal mucosa. Experience of use in pregnancy and lactation is limited. Dymista® should only be used if the potential benefit justifies the potential risk. Dymista® has minor influence on ability to drive and use machines. Undesirable Effects: Epistaxis, headache, dysgeusia, unpleasant smell, hypersensitivity reactions including anaphylactic reactions, angioedema, bronchospasm, glaucoma, increased intraocular pressure, cataract, blurred vision, septal perforation, nasal irritation, nasal ulcers, throat irritation, nausea, dizziness, sleepiness, fatigue, rash, dry mouth, growth retardation may be possible in adolescents receiving prolonged treatment and growth should be monitored regularly. Consult the Summary of Product Characteristics for other side effects. Package Quantities and Basic Price (UK): £14.80 for 23g bottle. Each spray (0.14 g) contains 137 mcg of azelastine hydrochloride and 50 mcg of fluticasone propionate. Legal category: POM. Product Licence Holder: Mylan Products Ltd, Station Close, Potters Bar, Hertfordshire, EN6 1TL, United Kingdom. Tel 0845 460 0000. Marketing Authorisation Number: PL 46302/0162. Date of preparation of prescribing information: February 2021 DYM-2021-0153 Adverse Drug Reactions should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store. Adverse events should be reported to UK Pharmacovigilance, Mylan, Building 4, Trident Place, Hatfield Business Park, Mosquito Way, Hatfield, Hertfordshire, AL10 9UL, on phone no. +44 (0) 800 121 8267, Email: pv.uk@viatris.com

DYM-2021-0437

Date of preparation May 2021.

Editorial

Allergy update

I

am delighted to present this issue of Allergy Update in its new digital format – my thanks go to Louise Colonnese and Ben King for their hard work in transforming the magazine and I hope you enjoy the new design.

Dr Erika Harnik Specialist Registrar in Paediatric Allergy, Evelina London Children’s Hospital

We celebrate the achievements of Professor Adam Fox during his tenure as BSACI president, and in his message overleaf he reflects on his aims and aspirations during his presidency. One of his objectives was for the society to focus on inclusivity, and Dr Makesh Katre from the equality, diversity and inclusivity working group gives us an update on the group’s recent activities.

Shuaib Nasser and Sophie Farooque from the BSACI Vaccine Allergy working group have written our feature article this issue - “Managing suspected allergy to COVID vaccines”. I would thoroughly recommend the FAQs, which also discuss the management of patients with a history of allergy prior to COVID-19 vaccination.

Following a hugely successful digital conference last year, Georgios Gkimpas and his team have been working hard to arrange for us to safely meet again in Harrogate at our BSACI Annual Meeting in October and he gives us a sneak peek of the scientific programme.

Leanne Goh and Ed Gaynor showcase the work of the GastroAllergy in Paediatrics (GAP) network, founded to support healthcare professionals in caring for children with complex presentations.

We also take a moment to celebrate the lives of Professor Barry Kay and Dr John Mullins, both of whom will be dearly missed.

I hope you enjoy this issue - if you have any comments about Allergy Update or would like to contribute to the magazine, please do not hesitate to contact me at erika.harnik@nhs.net

Contributions should be e-mailed to: info@bsaci.org Editor of Allergy Update Dr Erika Harnik Layout INQ Design Ltd (020 7737 5775) BSACI Trustees BSACI President Professor Adam Fox President Elect Professor Graham Roberts Secretary Dr Nicola Brathwaite Treasurer Dr Susan Leech Co-Editors of Clinical and Experimental Allergy Dr Robert Boyle & Dr Mohamed Shamji

Elected Council Members Dr Sophie Farooque Dr Andrew Whyte (Chair) Dr Rubaiyat Haque Professor Adnan Custovic Dr Zaraquiza Zolkipli Dr Mich Lajeunesse (Chair) Professor Judith Holloway Ex-Officio Members: Chairs of BSACI Committees Dr David Luyt – Standards of Care Committee: Dr Pamela Ewan – Allergy Services Dr George Gkimpas – Meetings Committee Dr Tomaz Garcez – Clinical Immunology Committee Dr Matt Doyle – Primary Care Committee Ms Lucy Common – Nurses Committee Dr Paul Turner – Paediatric Committee Dr Andrew Whyte – Adult Allergy Committee Dr Mich Lajeunesse – BSACI Register of Immunotherapy Committee (BRIT) Co-opted Members Ms Hannah Hunter – Dietetic Representative Dr Elizabeth Griffiths – Chair of the Specialist Advisory Committee for Allergy Professor Helen Smith – BSACI Ethics Lead Professor Michael Rudenko – EAACI Representative Trainee Representative – Dr Natasha Gunawardana

Contents Message from the President

4

Managing suspected allergy to Covid vaccines

6

Equality, Diversity, Inclusivity 10 Clinical & Experimental Allergy 11 Annual Conference 2021

12

Mind the GAP Network

14

BRIT Registry first report

15

Pandemic diagnostics

16

Anaphylaxis Guideline 2021

18

IQAS accreditation programme 21 UK Anaphylaxis Registry

22

AAI guidance

23

Committee and group news

24

Obituaries

26

BSACI team Chief Executive: Fiona Rayner fiona@bsaci.org

Clinical Guidelines Research Officer: Erinn Gallagher erinn@bsaci.org Finance & Administration Officer: Sandie Campbell sandie@bsaci.org Membership Officer: Ben King ben@bsaci.org Marketing & Communications Officer: Louise Colonnese louise@bsaci.org Training & Education Coordinator: Marie Gibbs marie@bsaci.org Managing Editor, Clinical & Experimental Allergy: Catherine Hyland catherine@bsaci.org

BSACI Studio 16, Cloisters House 8 Battersea Park Road London SW8 4BG info@bsaci.org 0207 501 3910 0207 627 2599 www.bsaci.org Registered charity no: 1069199

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President’s message

Handing over the reins I t was with real surprise that I realised, with the reduced schedule of Allergy Update, that this would be the final message of my Presidency. I would like to start by congratulating Prof Graham Roberts on his successful election as President Elect and wish him the very best for his term, which will begin at the Annual Meeting in October. I have no doubt at all that Graham will do a fantastic job. I also Professor Adam Fox wanted to pay respects to Prof Barry President Kay, a past BSACI president, who sadly passed away at the end of December.

Inevitably, this impending change leads me to reflect on my own term as President, which began in what feels like another lifetime – October 2018.

When I was first elected, I had a shopping list of

Allergy update

aims and aspirations but they focussed on a small number of themes. These were communication, education and inclusivity. There were some things that I had felt needed to change and a number of new paths I wanted the BSACI to take. Of course, things did not turn out as any of us expected but I think there is still much to look back on and be proud of.

We were able to come together and articulate our society’s values – ‘trusted, connected and forward thinking’ and this has since influenced the development of all our policies, as well as a review of all our existing ones. For example, as part of being ‘trusted’, we have developed a new policy that clearly lays out how we interact with industry. This included the decision to no longer accept direct funding from infant milk formula (IMF) companies, despite their long-standing support for BSACI activity. Whilst this has required significant changes to the way we have run our annual meeting, it also means we can be a strong and independent voice in the critical area of infant feeding.

Our review of the Terms of reference for all of our committees has meant that all positions within the BSACI are open to everybody to apply to, through a fair, open and transparent process.

Over time I very much hope this will change the leadership of the society and ensure that it better reflects the whole membership. Our new working group on Equality, Diversity and Inclusion will hold us to account on this and ensure that these values remain central to our work going forward.

In the last part of my Presidency, we will be reviewing the senior leadership structure of the

We will be reviewing the senior leadership structure of the society to offer more opportunity for members to be involved and for the society to benefit from its greatest asset – our members.

Professor Graham Roberts, President Elect

4

society to offer more opportunity for members to be involved and for the society to benefit from its greatest asset – our members. A key part of this journey is improving engagement between the society and its members and we have done our best to be more open and communicative. I have been delighted to see that out of the depths of the COVID challenges we have all faced, we now have

President’s message

Allergy update

Professor Adam Fox speaking at the BSACI Annual Conference 2019

3 ongoing webinar programmes – for paediatrics, adult allergists and trainees – dramatically enhancing the educational opportunities for members who wish to develop their allergy knowledge. This represents just one strand of a comprehensive National Allergy Education Strategy that has been brilliantly led

by Prof Judith Holloway, who has succeeded in developing a true community of practice that I have no doubt will continue to grow and expand beyond the development phase of the strategy and into its implementation. It has also been great to see some real strides in our external engagement with a range of governmental agencies such as the Food Standards Agency and the Department of Education – this has been well illustrated with the allergy related issues with the new COVID-19 vaccines, with BSACI directly inputting into the national advice offered by Public Health England.

I very much hope that I have left the society in a stronger place than when I started – more communicative, more inclusive and better suited to face the many challenges that we face ahead. I am really excited to see what is next for the society and delighted to be leaving it in such safe hands. I would also like to thank the many people who have been so supportive during these 3 years – especially BSACI trustees, Susan Leech and Nicola Brathwaite as well as our excellent CEO, Fiona Rayner, along with all BSACI staff who work tirelessly behind the scenes to make the society work as well as it does.

Whilst on the subject of BSACI staff, our Finance &

I very much hope that I have left the society in a stronger place than when I started – more communicative, more inclusive and better suited to face the many challenges that we face ahead.

I am really excited to see what is next for the society and delighted to be leaving it in such safe hands.

Administration Officer Ethlyn Johnson-Bellot recently left BSACI and we have appointed Sandie Campbell who has now taken up this position. After six years at BSACI Maryam Shayeghi has left to pursue an exciting opportunity in Public Health England around long COVID. We have appointed Erinn Gallagher as Maryam’s successor and wish both Ethlyn and Maryam all the best in the future and thank them both for their enormous contributions over the years.

As the need to increase our communications have grown, we also decided to appoint a temporary Marketing and Communications Officer, Louise Colonnese, who joined the team in February.

Lastly, I would also urge you to consider becoming more involved in the society yourself – there are always roles coming up and the chairs of every sub-committee would be delighted to hear from you. There has never been a more exciting time to be involved in the BSACI.

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Feature

Allergy update

Managing suspected allergy to Covid vaccines

Report on behalf of the BSACI Vaccine Allergy Working Group

T

Dr Shuaib Nasser Consultant in Allergy and Asthma, Cambridge University Hospitals NHS Foundation Trust

Dr Sophie Farooque Consultant in Allergy, Imperial College Health NHS Trust

he Pfizer Covid mRNA vaccine containing polyethylene glycol (PEG) /macrogol was first administered on the 8th of December. By the end of the day two anaphylactic reactions had been reported in women; one with a history of food anaphylaxis and the other with anaphylactic reactions to multiple classes of drugs. Allergy to PEG was suspected as the cause as there were no other known allergens in the vaccine. Alternative mechanisms postulated included complement activation by the vaccine or non-IgE mediated anaphylaxis.

Polyethylene glycols (PEGs) or macrogols are hydrophilic polyether compounds widely used as stabilising and bulking agents in pharmaceuticals, dental products, cosmetics and household products.

Their molecular mass ranges from 200 to 35,000 Da. Higher molecular weights are more allergenic with lower molecular weights often tolerated.

Both Pfizer BioNTech and Moderna mRNA vaccines against SARS-CoV-2, contain polyethylene glycol with molecular weight 2000 Da (PEG 2000).

Polysorbate 80 (polyoxyethylene20sorbitan mono-oleate) is an excipient in AstraZeneca ChAdOx1 SARS-CoV-2 vaccine at a concentration of <100μg per dose. Polysorbate 80 (molecular weight 1310 Da) is a PEG derivative widely used as a food emulsifier (E433). It is postulated that polysorbates are less allergenic compared to PEG as they have a lower molecular weight.

BSACI Vaccine Allergy Working Group Members

• • • • • • • • 6

Shuaib Nasser – Chair Dinusha Chandatilleke Matt Doyle Pam Ewan Sophie Farooque Adam Fox Liz Griffiths Rubaiyat Haque

• • • • • • •

Mich Lajeunesse Joanna Lukawska Susanna Marinho Alla Nakonechna Chris Rutkowski Stephen Till Paul Turner

Supported by Ben King from BSACI and Tom Dymond

Increasingly, PEG has been recognised as a hidden allergen triggering anaphylaxis typically to multiple classes of drugs. Undiagnosed patients remain at risk of repeated episodes of anaphylaxis.

PEG is found in many cosmetics and bathroom products and therefore allergy to PEG can also present with contact urticaria in sensitised individuals.

Severe allergic reactions to the Covid-19 vaccines are rare. Despite raised awareness since the Covid vaccination programme started, only one patient has been described with PEGinduced anaphylaxis following vaccination with an mRNA Covid vaccine. The majority of reactions to the Covid vaccines have not been confirmed as anaphylaxis and we are not aware of anyone with an immediate increase in serum mast cell tryptase.

Between 8th December 2020 and 14th March 2021, more than 24 million first and more than 1.6 million second vaccine doses were administered in the UK. For the same period, MHRA received 237 reports of unconfirmed anaphylactic reactions associated with the Pfizer vaccine and 326 for the AstraZeneca vaccine. Therefore >25 million doses have been given without an allergic reaction. As with any vaccine, the Covid-19 vaccines will cause side-effects in some people. According to MHRA, the total number and the nature of Yellow Cards reported so far are not unusual for a new vaccine where members of the public and healthcare professionals are encouraged to report any suspected adverse reaction.

It has also become apparent that almost everyone presenting to allergy services following suspected anaphylaxis to the Covid vaccines has tolerated a second dose of the same vaccine under antihistamine cover.

Therefore, the BSACI Vaccine Allergy Working Group has developed a series of FAQs which should allow first or repeat vaccination in the majority of those presenting to allergy services without the need for detailed allergy investigation. Those who develop anaphylaxis with objective signs following vaccination should be investigated by skin testing to the vaccines and their excipients in specialised drug allergy units. An algorithm describing the pathway for allergy specialists is shown.

Immediate cutaneous local reactions, cough and metallic taste after vaccination are common

Feature and if easily managed with oral antihistamines then the second dose of the same vaccine can be recommended under antihistamine cover.

Symptoms that are delayed >2h after vaccination are almost always due to the immunogenic effect of the vaccine and some of these can also be managed with AH cover and patients advised that they may develop similar symptoms with subsequent injections of the same vaccine.

VACCINE ALLERGY FAQs for GPs My patient is anxious about their vaccination, can they have antihistamines beforehand?

If your patient has a history of symptoms that would be helped by taking an antihistamine such as urticaria and they are anxious, then they could take 20mg cetirizine (Cetirizine 10mg x 2 tablets), 1 hour before their vaccination. However, if they have no such history then antihistamines will not help.

My patient is worried about reacting to the vaccine. Can they be tested for allergy to the vaccine and for allergy to polyethylene glycol (PEG) and polysorbate 80?

There is no indication for allergy testing to the vaccines or their ingredients unless your patient has a previous history suggestive of allergic reactions to any of these. Allergy to these excipients may present as a history of anaphylaxis to multiple unrelated drugs (containing PEG) and in such cases, seeking advice from your local allergy service would be appropriate.

My patient is reporting multiple drug allergies; which Covid vaccine can I give them?

If your patient has reported anaphylaxis within minutes of different drugs containing polyethylene glycol (PEG), then this patient should avoid the Covid mRNA vaccines (currently Pfizer and Moderna). PEG is sometimes also called macrogol on the patient information leaflet.

If your patient has a confirmed PEG allergy, but has tolerated an influenza vaccine or other parenteral drug containing polysorbate 80, then the Astra Zeneca vaccine could be administered.

However, if the reaction is non-immediate (>2 hours after vaccination) or non-allergic symptoms (such as dizziness, headaches), then this would not be a contraindication to receiving ANY of the vaccines.

My patient has a history of chronic urticaria/ angioedema; do I need to take any precautions?

Their urticaria/angioedema should be controlled prior to vaccination and your patient should remain on regular treatment maintaining control. If control is poor then adjust the medication well ahead of vaccination. If the urticaria is in remission and your patient is not on antihistamines, you may wish

Allergy update to consider antihistamine cover. Pre-dose with antihistamine eg Cetirizine 20 mg (Cetirizine 10mg x 2 tablets) one hour before vaccination and continue with Cetirizine 10 mg twice daily for 3 days.

My patient has a history of idiopathic anaphylaxis and the green book tells me to contact you for advice. What should we do?

Idiopathic anaphylaxis is a diagnosis of exclusion by an allergist. This means that the patient has had anaphylaxis (usually with hypotensive collapse) and with no identifiable trigger. If this diagnosis has been confirmed by an allergist, then there is no contraindication to any of the vaccines. However, if the patient has had anaphylaxis within minutes of drugs (containing PEG) and they have not been seen in an allergy clinic, then they should be reviewed prior to vaccination.

Is the Covid vaccine safe in patients with a history of Steven’s Johnson Syndrome? Do I need to take any precautions?

Presently there are no reports that the Covid vaccines (Pfizer/Moderna/Astra Zeneca) have triggered Stevens-Johnson syndrome (SJS). If the cause of your patient’s SJS is not secondary to a vaccination, then they can be vaccinated with any of the vaccines. SJS following a vaccination is extremely rare with MMR the most frequently reported trigger (Su et al. 2020). If there is a history of SJS following vaccination, then please discuss with an allergist.

REACTIONS TO PREVIOUS VACCINATIONS: My patient developed a rash after their influenza vaccine several years ago. Which vaccine should I give them?

They can receive any of the Pfizer, Moderna or Astra Zeneca vaccines. We would recommend they take 20mg cetirizine (cetirizine10mg x 2 tablets) one hour prior to vaccination and then continue with Cetirizine 10mg twice daily for 3 days or longer depending on their clinical history e.g. if the rash persisted for a week, then they could take Cetirizine 10mg bd for one week.

My patient collapsed after their influenza vaccine and taken to hospital. Can they be seen in the allergy clinic and have their first Covid vaccination hospital?

That depends on the cause of the collapse. If the collapse was felt to be due to a non-allergic cause (e.g. vaso-vagal), then Covid-19 vaccination can proceed in a community setting using standard protocols.

If there were any features of an allergic reaction such as anaphylaxis (e.g. immediate-onset urticaria, angioedema, hypotension, shortness of breath) then: 1. Do you know which Influenza vaccine they received?

7

Feature 2. Have they had medication since containing polysorbate 80 (in a parenteral drug) or PEG as an excipient?

Depending on the above:

•

If they have had medication containing PEG or parenteral polysorbate 80 since the episode then they can have the vaccine locally.

• If their collapse was after an influenza vaccine

containing polysorbate 80 or the name of the influenza vaccine they received is unknown and they have not received polysorbate 80 in a parenterally-administered medication or PEG since, then their Covid vaccination should be undertaken under medical supervision.

My patient developed severe swelling of their arm after the influenza vaccine. Which vaccine should I give them?

Your patient can receive any Covid vaccination.

My patient collapsed after receiving the DTP/ MMR/Pneumococcal/Hepatitis B vaccine. Can they receive a Covid vaccine in the community?

If anaphylaxis is suspected as a cause of their collapse then please follow the advice as follows: Diptheria, Typhoid and Pertussis Vaccinations

• If Repevax was administered it contains

polysorbate 80. If your patient has since taken medications containing PEG your patient could receive Pfizer or Moderna vaccinations. If they have received an influenza vaccine or other parenteral drug containing polysorbate 80 then they could have any Covid vaccine. But if they have not then they should be referred for advice.

• Infanrix hexa powder and suspension for

injection and Infanrix-diphtheria tetanus pertussis (acellular), poliomyelitis and hib vaccine do not contain polysorbate 80 or PEG. Your patient can receive any Covid vaccination.

MMR:

• MMR Vax Pro, Priorix, Vaxelix, do not contain

polysorbate 80 or PEG. Your patient can receive any Covid vaccination.

Pneumococcal:

• Pneumococcal Polysaccharide Vaccine (MSD), Pneumovax 23, do not contain polysorbate 80 or PEG. Your patient can receive any Covid vaccination

• Prevenar 13: contains polysorbate 80. If your

patient has taken medication containing PEG then they can have Pfizer or Moderna vaccinations. If they have received an influenza vaccine or other parenteral drug containing polysorbate 80 then they could have any Covid

8

Allergy update vaccine. But if they have not then they should be referred for advice.

Hepatitis B Vaccine:

• Engerix, Hendrix, HBVax pro do not contain

polysorbate 80 or PEG. Your patient can receive any Covid vaccination

FOLLOWING THE VACCINE: My patient began to cough and developed throat tightness shortly after their Covid vaccination.

What should I do next?

If there were no other signs of allergic reaction (rash, visible swelling) and the cough settled either spontaneously or after oral antihistamines then they can have the second dose after pre-dosing with antihistamines continued for 3 days or longer if required.

If there were objective signs of an allergic reaction then the cough was likely due to anaphylaxis and the patient referred for further investigation My patient began to feel short of breath shortly after their Covid vaccination but did not need hospital admission. What should I do next?

If there were no other signs of allergic reaction (rash, visible swelling) and the SOB settled either spontaneously or after oral antihistamines then they can have the second dose after pre-dosing with antihistamines and continued for 3 days or longer if required. If however, there were other objective signs of an allergic reaction then the cough was likely due to anaphylaxis and the patient should be referred for further investigation My patient developed tingling of their mouth and tongue and skin after their Covid vaccination.

About an hour later they developed mild swelling of their lip which settled with an antihistamine.

What should I do next?

Consider pre-dosing with cetirizine 20mg (Cetirizine 10mg x 2 tablets), one hour before their next vaccination. Check their baseline observations prior to vaccination, so that if they feel unwell, you will have a baseline for comparison. Observe for 60 minutes after the vaccine.

My patient developed urticaria/angioedema the night after their Covid vaccination and had to go to hospital. What should I do about their next vaccine?

Delayed urticarial rashes or angioedema to the Covid vaccines are not due to allergy but rather due to the immunogenic effect of vaccination. Therefore, testing for allergy is unnecessary. Your patient may develop a similar reaction after the next dose and therefore pre-dosing with antihistamine such as cetirizine is recommended - for example with cetirizine 20mg (Cetirizine 10mg x 2 tablets) before and cetirizine 10mg

Feature

Allergy update

bd for 3 days or longer after vaccination.

My patient developed urticaria/angioedema the day after their Covid vaccination. It has lasted now for 2 weeks. Can you test them and organize their next vaccine in hospital?

Delayed reactions to the Covid vaccines are not due to allergy but rather due to the immunogenic effect of vaccination. Therefore, testing for allergy is unnecessary. Your patient may develop a similar reaction after the next dose and therefore pre-dosing with antihistamine such as cetirizine is recommended - for example with cetirizine 20mg (Cetirizine 10mg x 2 tablets) before and Cetirizine 10mg twice daily for up to 2 weeks after vaccination.

My patient developed a large area of swelling at the site of their Covid vaccination. It took a week to resolve. Can they have allergy testing and their next vaccination in hospital?

Mild pain and tenderness are common side-effects of the vaccine. Some patients will also develop redness and swelling local to the site of the vaccination within 48 hours. Delayed swelling and redness developing 4-11 days after the vaccine and lasting for more than a week, has been described in a small proportion of patients receiving the Moderna vaccine (Blumenthal et al., N Engl J Med 2021; 384:1273-1277). Treatment is symptomatic: antihistamine for itch, paracetamol for

pain and ice packs for discomfort. Patients can still get their second dose in the community but should be observed for 30 minutes after vaccination. Allergy testing is not needed.

OTHER ALLERGIES: My patient is allergic to wasp/bee stings, can they have their Covid vaccination in hospital?

Allergy to venom is not a risk factor for anaphylaxis to any of the vaccines. The vaccines can be given in the community and no special precautions are needed My patient has allergic rhinitis, asthma, eczema and food allergies; is the Astra Zeneca vaccine the best one?

They can receive any of the Covid vaccinations.

My patient is allergic to alcohol; can they have the Covid vaccine?

Allergy to alcohol is rare and not usually to the alcohol itself as in most patients some types of alcohol are tolerated. The Pfizer and Moderna vaccines do not contain alcohol. The Oxford/AstraZeneca vaccine contains ethanol (alcohol) as an excipient. Your patient may have the Pfizer or the Moderna vaccine.

It is unlikely the small amount of alcohol in the AZ vaccine would cause a problem.

Algorithm for allergy specialists for patients with a history of anaphylaxis prior to COVID-19 vaccination Is this the patient’s first dose?

Yes

No

Any history of unexplained anaphylaxis1 or anaphylaxis to excipients of COVID vaccines or to multiple drug classes

No

Uneventful first dose or nonallergic reaction2 to first dose?

No

Yes

Yes

Has tolerated drug containing high molecular3 weight PEG since anaphylaxis4

Systemic allergic reaction5/ anaphylaxis within 2hrs of first dose

No Has tolerated Polysorbate 80 in parenteral drug / vaccine since anaphylaxis3 Yes

Give first dose.

Can have any COVID vaccine

Administer polysorbate containing vaccine

No

Mild urticaria/ angioedema or delayed6 systemic reaction to first dose?

Yes

Yes

No

Do not give Covid-19 vaccine.

Skin test to available vaccines, PEG and Polysorbate 80.

Then, consider administration of suitable vaccine under medical supervision with an extended observation period

Administer the second dose after predosing with cetirizine 20mg with an extended observation period, if urticaria/ angioedema was localised to the injection site OR if symptoms were systemic and easily managed with antihistamines.

If symptoms were severe consider for further investigation

Give second dose

1. Only anaphylaxis occurring after PEG containing medication 2. Vasovagal episodes, non-urticarial skin reaction or non-specific symptoms. 3. Molecular weight ≥ 2000 4. Refer to SPC section 6.1 for excipient contents of current or recent drugs. 5. Including immediate onset anaphylaxis. 6. Delayed is >2hrs post-dose. PEG – Polyethylene glycol S Nasser, T Dymond

Algorithm for allergy specialists for patients with a history of anaphylaxis prior to Covid-19 vaccination

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News

Allergy update

Equality, Diversity, Inclusivity I

Dr Mahesh Katre Paediatric Specialist Registrar, Leicester Royal Infirmary

n the last decade, the UK population has become increasingly diverse and is multicultural and multi-ethnic in nature. The National Health Service (NHS) is a fantastic organisation that provides a variety of services, including allergy and immunology. The COVID-19 pandemic shows evidence of disproportionate mortality and morbidity amongst the non-White population, including NHS staff, who have contracted COVID-19. These issues have not been discussed in depth until the year 2020 when the pandemic brought forward health inequality as a glaring reality. Allergy and immunology services are not immune to this either.

It is vital to understand the reasons underpinning disparate access and clinical outcomes from an allergy and immunology viewpoint. The British Society for Allergy & Clinical Immunology (BSACI) has taken an allimportant initiative to address issues pertinent to Equality, Diversity and Inclusion (EDI) amongst our communities. The EDI working group was established recently to focus on these issues at an institutional level, which is a welcome step taken by the BSACI.

“A journey of a thousand miles begins with a single step.”

Across the country, we have seen a gradual rise in allergic conditions over the last few decades, with recent research pointing to a greater incident risk of allergic conditions with poorer clinical outcomes amongst the non-White British population.

There is a lot of work to be done to provide equitable access and improved clinical care in the non-White population. A multi-pronged and multi-professional approach in collaboration with patients from ethnic minority groups and patient organisations is needed. In addition to gaining better insight into differences in sensitisation patterns and disease presentation, it is critical to understand social, cultural and religious factors to develop a robust approach to patient-centred management. This should include development of ‘fit for purpose’ patient education tools in multiple languages and training of healthcare professionals.

Since its inception, the EDI working group has had brainstorming sessions to address the gaps in allergy care in the non-White British population and drafted a program of work with short, medium- and long-term objectives.

The EDI working group will also aim to improve equity and fairness ‘for all’ within the BSACI and beyond. We provided feedback to “National Allergy Education Strategy” document which helps improving allergy care through education. The EDI working group also reviewed and provided feedback on documents from Advisory Committee on Clinical Excellence Awards (ACCEA) and Standards of Care Committee modus operandi.

We plan to conduct a survey of allergy centres to learn more about currently available education tools in foreign languages that could be adapted and standardised at a national level.

As a member of the EDI working group, I am thankful to the BSACI for this opportunity.

BSACI Office is back open for business!!!

It was a while ago that the BSACI staff packed their work items and left the office thinking they would be back soon, that was 15 months ago!

Since then some staff have been working out of the office on occasions when needed, but now the plan is to return to the office in June, once the screens arrive and the office risk assessment has been implemented to make the office as safe as possible for those staff returning. However staff will not be spending all their contracted hours in the office as this will be mixed for now with home working and we shall see how this evolves over time.

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On a very positive note, moving back into the office will mean that we can resume face to face meetings one again in the BSACI boardroom. For all those who are involved in BSACI work who have had enough of zooming and want to meet fellow colleagues in a safe environment then please do email sandie@bsaci.org to book the meeting room. We can have up to 8 people spaced out at any one time.

We look forward to welcoming you back!

Fiona Rayner BSACI Chief Executive

News

Allergy update

Clinical and Experimental Allergy T he first four months of new leadership at CEA have been very busy. We have been fortunate that the Wiley editorial and production teams have been really engaged with our initiatives. This has allowed us to make some significant changes to the journal already. We have worked with Wiley’s production team to improve the quality of published Figures, introduce Graphical Abstracts and improve timeliness and reliability of issue production and, where relevant, open access availability. We have simplified and overhauled the author guidelines, changed to ‘free format’ submission so that authors only need to format their article for CEA after they receive a ‘Revision’ decision, and decision times have already significantly shortened. .

We have invited a new Editorial Board of internationally recognised experts to help drive up the profile of our BSACI journal. We launched our first special collection, on COVID-19, which includes a world-first report from the Addenbrookes allergy team identifying PEG as a proven cause of anaphylaxis to the Pfizer-BioNTech vaccine.

July sees the launch of a new Cochrane Corner series in CEA. These are brief summaries of recent Cochrane reviews relevant to clinical practice in allergic conditions.

They are an excellent opportunity for trainees to get a peer-reviewed publication and very useful overviews of the evidence for busy clinicians working in allergy.

Cochrane Corners will be published every two months in CEA, and our July edition will cover Biologics for Chronic Rhinosinusitis. If you would like to author a Cochrane Corner, please get in touch with Cherry Alviani (cherryalviani@ gmail.com), who is coordinating author groups for these. Together with BSACI, we have agreed on a new ‘Trusted Evidence in Allergy’ focus for the journal, meaning that we aim to publish rigorous, transparently reported work relevant to the understanding of allergic conditions to allergy practice. Please send us your best papers and discover our worldbeating author experience!

Dr Robert Boyle Reader in Paediatric Allergy and Dr Mohamed Shamji Reader in Immunology and Allergy Imperial College

The The latest from Clinical & Experimental Allergy latest from Clinical & Experimental Allergy

Editors Choice Editors Choice Covid-19 and Allergy Covid-19 and Allergy Did you know we've simplified Did you know we've simplified formatting requirements? formatting requirements?

Learn MoreMore Learn

Coming in Cochrane July Cochrane Corner Coming in July Corner

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BSACI Annual Conference

Allergy update

Welcoming you back to Harrogate in 2021 F

ollowing on from a successful Annual Conference in 2020, we are now preparing for the BSACI 2021 Conference which will take place on 7th-9th October at Harrogate Conference Centre. The 2021 Conference is envisaged to be a face-to-face event, with the priority being the safety of our delegates.

We shall be working closely with the conference centre and our agency, Dr Georgios Medivents, to put measures in Gkimpas place to ensure your safety. We will Consultant continue to monitor the coronavirus Allergist, Royal Preston Hospital situation, and, if appropriate, revert to an online event. BSACI successfully conducted the 2020 Conference online and there is significant experience to support this year, if needed.

The 2021 Conference will be focused on the development and presentation of allergy throughout life, with a number of exciting paediatric and adult sessions, and further touches upon transition and unified practice issues for paediatric and adult allergy. It will therefore cater for clinicians, scientists and

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allied health professionals who work with children and adults alike. This year, we have also put Allergy Education under the spotlight by introducing novel sessions that include showcasing educational projects across the UK, and expert panels discussing implementation of these projects. Allergy Education throughout the pandemic has been, as most things, a challenge, and successful efforts will be highlighted and discussed.

For this Conference we have focused on collaborations, reflecting the importance of input from all parts of society and stakeholders. There is a dedicated session with the collaboration of the Food Standards Agency which gives a platform to the Natasha Allergy Research Foundation (NARF) to discuss updates in protecting the allergic public. There is also a session with the collaboration of the Health Research Authority (HRA), which focuses on conducting Allergy & Immunology Research, an issue which is even more relevant during the pandemic. There are also plans for a Joint session with BPAIIG, where Allergy, Immunology and Infection will be discussed and highlighted.

Following the very well-received ‘Diversity’ talks

BSACI Annual Conference

Allergy update

last year, this year’s Conference again underscores Equality, Diversity and Inclusivity in Healthcare, which sit at the very top of BSACI priorities.

This has been an extraordinary year in our lives and practice, and this could not have gone unnoticed in this Conference. The effects of COVID in our everyday life, work and wellbeing will be showcased and discussed. Allergy to the vaccine, the changes we made to accommodate remote working and the important issue of limited vaccine uptake in the population will be highlighted. Mental health will also be put under the spotlight, an issue that affects not only our patients, but also ourselves, in the midst of the pandemic.

As always, the BSACI Conference will provide a platform to British and foreign speakers of international calibre who sit at the cutting edge of their respective fields, supporting the Conference with high-quality talks for all issues around Allergy & Immunology. All facets of clinics and science will be showcased with a variety of talks including asthma, food/drug/skin allergy, clinical disease, laboratory/transitional allergy & immunology and research. Such talks include ‘the effect of pollution on asthma’, delivered by Professor Sir Stephen Holgate and Rosamund Kissi-Debrah, the mother of nine-year-old Ella who was the first person in the

UK whose death was listed to have been caused by air pollution, the ‘new Resuscitation Council UK Anaphylaxis Guideline’, ‘Biologics in severe asthma’, ‘PFS and LTP updates’, ‘Virome & microbiome in allergy & asthma’,’ Food avoidance for eczema’, and other exciting issues.

As expected for every BSACI Annual Conference, there will be several informative workshops where the cutting edge of allergy and immunology will be discussed, and where practical issues of our everyday practice will be highlighted in an engaging environment.

We are looking forward to welcoming you at BSACI 2021 in Harrogate. www.bsacimeeting.org

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News

Allergy update

Mind the GAP Network G

Dr Leanne Goh Consultant in Paediatric Allergy, University College London Hospital

Dr Ed Gaynor Consultant in Paediatric Gastroenterology, Great Ormond Street Hospital

astrointestinal allergic disease (GI-Allergy) is an exciting and rapidly evolving area within medicine.

First reports are thought to trace back to ancient times - Hippocrates (460375 BC) described gastrointestinal symptoms including diarrhoea, vomiting and failure to thrive in infants that only resolved on dietary elimination of cow’s milk. Despite avid research interest and ongoing scientific development, for many of these disorders, there remains no reliable diagnostic test and clinical presentations can be non-specific.

This can lead to a patient journey fraught with diagnostic delay, as well as the risk of overdiagnosis.

Contributing to the significant impact on quality of life of patients and families, professionals in the area, often experience uncertainty around complex management decisions and sometimes have to carefully negotiate ethical and safeguarding thresholds.

The GAP (Gastro-Allergy in Paediatrics) network founded in 2019, is a multi-professional group of individuals working with children and young people with GI-Allergy.

The group has recently expanded to

Steering group members Dr Osvaldo Borrelli Consultant in Paediatric Gastroenterology, Great Ormond Street Hospital Dr Jenny Epstein Consultant in Paediatric Gastroenterology, Chelsea & Westminster Hospital Dr Ed Gaynor Consultant in Paediatric Gastroenterology, Great Ormond Street Hospital Dr Leanne Goh Consultant in Paediatric Allergy, University College London Hospital Dr Sharon Hall Consultant in Paediatric Allergy, St Mary’s Hospital

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include professionals, expert in transition to young adult services. Our aim is to develop a proactive culture of learning about the evidence base underpinning the diagnosis and management of GI-Allergy and in so doing decrease professional isolation, provide support regarding opinions reached and benefit from the experience of peers who are working in this area. We provide a forum for discussion of difficult and interesting cases in a relaxed non-threatening and non-hierarchical atmosphere. Endeavouring to minimise bias, and in doing so provide assurance and increase confidence that clinical management meets a high standard.

Our members feedback that this network has not only been a valuable support to continuing professional development, but has also provided emotional support particularly through learning when things go wrong, and to celebrate management success and pathway development. To this end we have completed regional audits providing unique insight into the real-life management of GI-Allergy; and are also developing resources for professionals such as a formulary for the drugs used in GI-Allergy; and patient information multimedia resources.

We use the opinion of members to guide future direction, which includes working towards guideline development with the BSACI SOCC and BSPGHAN EoE working group, and are keen to expand are membership to interested professionals.

Our membership has steadily grown to 120 professionals, including gastroenterologists, allergists, safeguarding leads, nurses, dietitians, social workers and psychologists. If you are interested to find out more, or to join the network, please contact info@bsaci.org

BSPGHAN EoE Survey The BSPGHAN Eosinophilic oesophagitis (EoE) working group would be grateful if any members looking after children and young people with EoE would complete this nationwide survey on the management of paediatric EoE in the UK and ROI. Access using this QR code, it will take a maximum of 20 minutes of your time.

BRIT

Allergy update

Registry launches its first report T his month I’m delighted to announce the publication of the first report of data from the immunotherapy registry. The BSACI Registry for Immunotherapy (BRIT) has been active since October 2018 and this report is a snapshot of the first 18 months of registry data.

At the time of the report there were 101 registered consultant users Dr Mich from 65 different centres. There were Lajeunesse 580 participants on the registry and Consultant in an overwhelming 96% had agreed Paediatric Allergy to participate through direct email & Immunology contact with the registry: so that Southampton they can complete online quality Children’s of life questionnaires both during Hospital and after treatment. Sublingual immunotherapy accounted for 84% of the 455 participants receiving airborne allergen treatment with the rest having subcutaneous injections. There were very few side effects reported that were severe enough to warrant changing or stopping treatment, with only one case of anaphylaxis related to SCIT. Venom immunotherapy had 103 participants with more wasp than bee treatments recorded. The registry uses a field sting report by participants to measure effectiveness of treatment. Omalizumab for CSU is also recorded and had relatively few participants compared to allergen immunotherapy. This might be because it is in competition with other national and international registries for biologic therapies.

BRIT is fundamentally different from these other registries, in that the service users have access to their data at the touch of a button.

It’s taken a little time to put this report together.

Since the snapshot was taken for the report, the registry has continued to grow – currently we have 986 participants, so the registry has almost doubled in size in a year. Now that we have a framework, future reports should be easier. We also have data on real world effectiveness to analyse, both during and after treatment, and in addition will report on access to services later this year.

What you can do to get involved in the registry project From Tuesday 25th May you can download the report to see how BRIT could help your practice.

Its free to download from the BSACI website. We have also dedicated the next BSACI webinar to the registry – join us on 24th May at 5pm for an update on equality of access, standards of care, real-world effectiveness and safety with a patient viewpoint

in mind. Members can register for this free event at https://www.bsaci.org/education-and-events/ webinars/immunotherapy-and-the-brit-registry The registry has grown since the report snapshot was taken but it’s not too late to join in.

Although we now have 111 consultant users only 42 of them are active and have enrolled a participant.

So, if you are one of those dormant users, and you have an account but haven’t taken the next step, find out more at https://www.bsaci.org/ professional-resources/immunotherapy-registry.

BRIT will be very helpful for your service evaluations and departmental audit. You can also see how your individual patients are responding to treatment!

If you need further encouragement BRIT is approved by RCP-IQAS and is being used as part of the centre accreditation process. In the future we plan to make a quality dashboard to facilitate this process so that your IQAS report can be downloaded from the registry directly, and we will also publish data so that you can benchmark your centre against national trends.

Lastly many thanks to all of you who are already using the registry, and also to the steering committee who are working hard to make the project flourish. Let us know how we can help to meet your data needs, and how we can improve what is already offered. I hope that you will agree that the report shows that we are heading in the right direction.

Immunotherapy and the BRIT Registry - Monday 24th May, 5pm https://www.bsaci.org/education-andevents/webinars/immunotherapy-and-thebrit-registry/ Introduction Dr Rubaiyat Haque Headlines from the first BRIT registry report Dr Mich Lajeunesse, Chair BRIT Steering Group Access to immunotherapy services – equality and diversity Prof MT Krishna, Chair RCP – IQAS scheme and BSACI EDI committee chair Patient perspective on allergen immunotherapy Amena Warner, Allergy UK Setting up an immunotherapy service Dr Jenny Rowley – Basingstoke Final questions and Close

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Pandemic diagnostics

Allergy update

Home allergy blood testing A

s a result of the COVID-19 pandemic in 2020, many departments including paediatric allergy services were pushed to adapt patient consultations to more remote settings. A reduction in patient capacity and staff availability to conduct routine allergy diagnostic tests (i.e. skin prick tests (SPT) or Dr Ru-Xin Foong hospital specific-IgE (sIgE) blood Specialist tests) resulted in our department Registrar in finding alternative solutions to test Paediatric Allergy patients. We developed a pathway Evelina London to use a home allergy blood testing Children’s kit to collect blood samples from Hospital age-appropriate children (>6 years old) at home via fingerprick sampling which was then posted to a named laboratory for analysis using ALEX2 ®Macro Array Diagnostics. A guideline was developed to helped clinicians select appropriate patients during telephone consultations and following return of the laboratory results, a second telephone consultation was made with parents to discuss them.

Over half of the patients (52%) who were sent the testing kits were able to successfully collect a blood sample. The reasons for unsuccessful samples included: the child became distressed during collection (5%), there was insufficient blood collected (16%) or the family/child changed their mind and did not perform the test despite receiving the kit (27%). Of the 26.8% who provided feedback, 82% reported the instructions were easy to follow and they had no problems collecting the sample.

They reported that the test was particularly helpful if they lived a long distance from the hospital and for avoiding travel during the pandemic.

Clinicians found the test easy to request and helpful in confirming or excluding allergies. The main disadvantage of using the ALEX2 test was that for some patients’ additional sensitisations were identified as the test checks for sIgE to 156 extracts and 126 allergen molecules. Eight patients required further investigations such as a food challenge and/or SPT in person and six patients were advised to exclude new foods.

Home allergy testing offers a suitable alternative for hospital-based allergy diagnostics although more in-depth criteria to help clinicians select the most appropriate patients for this type of testing would be beneficial.

A YouTube video of Rebecca Batt demonstrating how to use the blood sampling kit is available here: https://www.youtube.com/ watch?v=LfbBLSGm2qM

Rebecca Batt demonstrating how to use the blood sampling kit

Improving allergy knowledge in Primary Care One of BSACI strategic aims is to improve the allergy knowledge within Primary Care, and part of this initiative involves organising allergy training days for Primary Care healthcare professionals. A BSACI allergy centre is invited to submit an application which, if approved, is funded by BSACI. Since the scheme started in 2011, BSACI allergy services have funded over 75 training days with meetings taking place all over the UK, providing training for over 3000 Primary Care professionals.

Further funds have been obtained to run virtual meetings in 2021.

BSACI would like to thank ALK and ThermoFisher for supporting the scheme.

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BSACI Selection Process Your application will be considered by a panel selected by BSACI comprising of GPs and allergy specialists in both primary and secondary care.

The decision will be based on the criteria shown in the bullet points opposite:

Pandemic diagnostics

Allergy update

Mobile Allergy Clinic (MAC)

T

he Bristol Children’s Allergy Clinic embraced Attend Anywhere with gusto in March 2020 but it didn’t take long for a backlog of children awaiting diagnostic skin prick testing to start to build up. With no idea of when faceto-face appointments would resume, the search was on to find alternative accommodation for our clinic. We Dr Deb Marriage approached a number of companies Consultant Nurse including retail units, an empty Post in Allergy Office and the Spire Hospital, but Bristol Children’s the first to come to our rescue was Hospital Bristol Ambulance with their Mobile Treatment Vehicle. It came with its own generator, was fully stocked with emergency equipment and occupied a 10m square space when set up.

We performed the usual risk assessments, bought a camping table and ordered some large flags to help patients locate the clinic. Each weekly clinic was delivered by two Allergy CNS’ with patient electronic hospital records accessible via laptop. Having a senior nurse present enabled most patients to be discharged from their appointment, or diverted in to a food challenge appointment if necessary (being set up at the Bristol Nightingale Hospital). 125 patients were seen over the summer and 96% of parents reported preferring the MAC to attending Children’s OPD; parking was easier, they had a reduced waiting time and most patients were pleased to avoid the hospital.

Our hospital charity used their contacts to find us parking both north and south of the city centre, in a shopping mall and at Ashton Gate football stadium. Patients were offered 30 minute

• Producing a Primary Care focused programme with both adult and paediatric components • Priority will be given to centres with limited exposure to allergy training • Priority will be given to centres with limited funding opportunities to hold similar events Feedback from primary care practitioners who have attended an allergy training day has been positive and they are proving to be extremely beneficial in the day-to-day allergy management of patients in Primary Care.

appointments and were able to wait in their cars.

It was easy to clean between patients to create a COVID-secure environment, and we were able to play Aardman’s iconic films on repeat on a large dropdown screen to keep children entertained.

Trips into the driver’s cockpit were also popular!

By the autumn, we were able to return to full face-to-face capacity in a temporary home at the Bristol Spire Hospital and we are now back in the Children’s Hospital embracing more creative ways of working.

How to apply for a grant If you are an allergy service and would like to apply for a grant of £500 to host a virtual training day for Primary Care practitioners in 2021, please submit an application to Marie Gibbs, Training and Education Coordinator marie@bsaci.org. All applications will be assessed by the panel and you will be notified of the outcome by email.

Application forms are available from the BSACI website: https://www.bsaci.org/educationand-events/primary-care-education/primarycare-allergy-training-days/ Marie Gibbs

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Guidelines

Allergy update

Resuscitation Council UK Anaphylaxis Guideline 2021

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adrenaline after 5 minutes and giving an IV fluid bolus if Airway/Breathing/ Circulation problems persist.

– A new algorithm for the treatment of refractory anaphylaxis, defined as anaphylaxis where there is no improvement in respiratory or cardiovascular symptoms despite two appropriate doses of IM adrenaline.

• IV fluids are recommended for refractory anaphylaxis, and must be given early if hypotension or shock is present.

• Antihistamines are considered a third-line

intervention and should not be used to treat Airway/Breathing/Circulation problems during initial emergency treatment.

SAVE THE DATE

The guideline itself underwent extensive public and stakeholder consultation, with the draft document 2021 Annual accessed 6057 times, resulting in 130 submissions 7th - 9th from individuals and organisations. Key changes from the 2008 Guideline include:

•

Greater emphasis on intramuscular adrenaline to treat anaphylaxis, repeated after 5 minutes if Airway/Breathing/ Circulation problems persist.

– Non-sedating oral antihistamines, in Conference preference to chlorphenamine, may

October be given following initial stabilisation

especially in patients with persisting skin symptoms (urticaria and/or angioedema).

SAVE THE DATE 2021 Annual Conference

are no • Corticosteroids (e.g. hydrocortisone) 7th - 9th October

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– Initial treatment of anaphylaxis, with emphasis on repeating the dose of

SAVE THE DATE

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• There are 2 algorithms:

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avoiding sudden changes in posture and maintaining a supine position (or semirecumbent position if that makes breathing easier for the patient) during treatment.

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longer advised for the routine emergency treatment of anaphylaxis, due to a lack of C data LINas to efficacy and emerging concerns IC over safety A in the context of non-severe anaphylaxis.

LERGY & C BRITISH SOC IET Y

Paul Turner Reader and Consultant in Paediatric Allergy and Immunology, Imperial College London

he Resuscitation Council UK (RCUK) has undertaken an extensive review and update of its 2008 Anaphylaxis Guideline.

The updated guideline has been developed according to the GRADE Evidence to Decision (EtD) frameworks for adoption, adaptation, and de novo development of trustworthy recommendations (GRADEADOLOPMENT). In order to maintain full transparency, the evidence tables and process have been peer-reviewed and published in Resuscitation ( h t t p s : // d o i . o r g / 1 0 . 1 0 1 6 / j . resuscitation.2021.04.010)

www.bsacimeeting.org

Guidelines

Allergy update

Anaphylaxis Anaphylaxis?

A = Airway

B = Breathing

C = Circulation

D = Disability

E = Exposure

Diagnosis – look for: • Sudden onset of Airway and/or Breathing and/or Circulation problems1 • And usually skin changes (e.g. itchy rash)

Call for HELP

Call resuscitation team or ambulance • Remove trigger if possible (e.g. stop any infusion) • Lie patient flat (with or without legs elevated) – A sitting position may make breathing easier – If pregnant, lie on left side

Inject at anterolateral aspect – middle third of the thigh

Give intramuscular (IM) adrenaline2 • Establish airway • Give high flow oxygen • Apply monitoring: pulse oximetry, ECG, blood pressure

If no response: • Repeat IM adrenaline after 5 minutes • IV fluid bolus3

If no improvement in Breathing or Circulation problems1 despite TWO doses of IM adrenaline: • Confirm resuscitation team or ambulance has been called • Follow REFRACTORY ANAPHYLAXIS ALGORITHM

1. Life-threatening problems

2. Intramuscular (IM) adrenaline

Airway Hoarse voice, stridor

Adult and child >12 years: 500 micrograms IM (0.5 mL) Child 6–12 years: 300 micrograms IM (0.3 mL) Child 6 months to 6 years: 150 micrograms IM (0.15 mL) Child <6 months: 100–150 micrograms IM (0.1–0.15 mL)

Breathing ↑work of breathing, wheeze, fatigue, cyanosis, SpO2 <94% Circulation Low blood pressure, signs of shock, confusion, reduced consciousness

Use adrenaline at 1 mg/mL (1:1000) concentration

3. IV fluid challenge Use crystalloid Adults: 500–1000 mL Children: 10 mL/kg

The above doses are for IM injection only.

Intravenous adrenaline for anaphylaxis to be given only by experienced specialists in an appropriate setting.

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PALFORZIA WEBINAR SERIES Aimmune Therapeutics will be hosting a series of webinars to facilitate learning on the use of the treatment.

These webinars will focus on the sharing of practical experience regarding PALFORZIA treatment adoption into clinic, the identification of suitable patients for PALFORZIA, how to manage patients on treatment, how to support patient adherence, as well as sharing the treatment experience of both patients and caregivers.

THE FIRST WEBINAR IN THE THREE-PART SERIES WILL TAKE PLACE ON FRIDAY JUNE 18TH FROM 19:00 BST – 20:00 BST AND WILL BE CHAIRED BY PROFESSOR GEORGE DU TOIT (KING’S COLLEGE LONDON AND GUY’S AND ST THOMAS’ NHS TRUST).

Professor Du Toit contributed to the PALFORZIA clinical development programme that supported the marketing authorisation approval by the European Commission in December 2020.

“As a principal investigator in two pivotal trials of PALFORZIA, I have first-hand experience in how to manage treatment which I look forward to sharing with you.”

PROFESSOR GEORGE DU TOIT

TO REGISTER PLEASE VISIT:

https://aimmuneinstitute.org/uk-home/ This series of events are for UK healthcare professionals only

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The Aimmune team will be exhibiting at the British Society for Allergy & Clinical Immunology (BSACI) Conference in October and we look forward to meeting you there.

For more information, please visit www.aimmune.co.uk.

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AIMT-PM-UK-0029 | May 2021

News

Allergy update

IQAS accreditation programme • I t has been six years since the improving quality in allergy services programme (IQAS) was launched by the Royal College of Physicians. The programme designed to support allergy services in the UK and Ireland, has gone from strength to strength over the last few years. The programme currently has 30 services registered throughout the UK, with 6 currently accredited. A list of these services can be found on the IQAS accreditation website: www.iqas. org.uk/ The accreditation unit at the Royal College of Physicians has over 25 years’ experience in accreditation. Accreditation has played a pivotal role in driving change in many aspects of healthcare, including mental health and diagnostics. In addition to improving quality and providing assurance to patients, managers, referrers and commissioners about the service provided, the programme aims to achieve equity and standardisation.

During the last year, the IQAS team have been working remotely, in line with government guidelines.

This has led to some temporary changes in modus operandi with assessments being conducted remotely and IQAS training sessions being organised for registered services virtually.

Following changes to the accreditation standards in 2019, registration is now open to general and specialist allergy services throughout the UK and Ireland.

We strongly encourage all allergy services to register.

what accreditation is and how it can add value to your service

• the process and logistics involved in accreditation

• the benefits of registering

Registered services have access to the following:

• The full accreditation standards • Access to the IQAS website and selfassessment web-tool

• Regular virtual training session on the accreditation process and standards

• Online repository of best practice templates and documents

• Regular newsletters on the programme with updates

• Support from the IQAS office team

To register to these sessions, please contact the IQAS team. If you have any questions about the programme, contact us at askiqas@rcp.ac.uk or 020 3075 1508.

Rumneet Ghumman Project Coordinator IQAS and QPIDS Royal College of Physicians

Opportunities for non-registered services If your service has not yet registered with IQAS and is considering registration, the IQAS programme will be hosting regular introductory sessions led by the IQAS clinical lead, Professor Thirumala Krishna.

This virtual session is specifically designed for non-registered services to learn more, including:

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News

Allergy update

UK Anaphylaxis Registry

New national reporting platform for allergic reactions and anaphylaxis in the community

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t is extremely difficult to obtain accurate data on food and nonfood related anaphylaxis reactions in the community. Existing NHS data Is limited by incomplete or incorrect coding, and a current lack of ability to define the allergen in NHS datasets.

Dr Alessia Baseggio Conrado Clinical Project Manager, Children’s CRF - NHLI, Imperial College London

The Food Standards Agency is funding a UK register to report unintended allergic reactions, triggered by both food and non-food triggers, in collaboration with the BSACI and Paediatric Emergency Research in the United Kingdom & Ireland (PERUKI).

The UK Anaphylaxis Registry aims to improve our understanding of the circumstances of allergic reactions, in the community, in order to better inform patient care and help guide public policy (for example, in terms of which food allergens cause the majority of reactions in the UK).

The Registry is fully integrated into the European Anaphylaxis Registry platform (NORA), that has been collecting worldwide online data for more than 10 years.

Our objective is to collect data relating to adults and children having unintended accidental reactions to both food and non-food triggers, either at the time of presentation to an Accident & Emergency department, or within 12 months of reaction at outpatient clinic. We hope all UK allergists will sign up to have access to the Registry and enter data online. Contributors will have full access to their data for local audit and education purposes, and be invited to participate in outputs from the Registry as appropriate.

Dr Paul Turner Reader and Consultant in Paediatric Allergy and Immunology, Imperial College London

The Registry has a two-step data collection process: the first is a case report form for completion by the healthcare professional, where anonymous data relating to the allergic reaction is collected (suspected trigger, timing of reaction, symptoms and treatment). Healthcare professionals will be requested to obtain verbal consent to enter the patient’s email address (or for children, their parent’s) into the system, which will trigger an electronic request for consent and

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access to a patient questionnaire which will collect additional information relating to symptoms and possible risk factors.

We are thrilled to announce that the UK Anaphylaxis Registry will be launched this summer!

We are looking for BSACI members to support this Registry and we invite you to participate in this study. The Registry will be coordinated through Imperial College London and the BSACI, who will provide healthcare professionals with passwordprotected access to the online portal.

If you are interested please contact us at anaphylaxis.registry@imperial.ac.uk

2021/22 membership renewals We rely on memberships to help sustain BSACI. Without our members we would not be able to improve allergy care for patients. Please remember your 2021/22 membership renewal is due by 1st August 2021. You can do this quickly and easily online by visiting www.bsaci.org/aboutbsaci/membership/ where you can make a one-off payment or set up a direct debit.

Online webinars (see page 12) are just one of many benefits of membership. You also have access to Clinical & Experimental Allergy news online, are able to download PDF guidelines and access to the website’s members area allows you the opportunity to become involved in Society activities (such as committees, guideline groups, external consultations and professional representation with the Royal College of Physicians).

Plus a discount at our Annual Conference (7th-9th October 2021 - see page 12). Find out all about all membership benefits at www.bsaci.org

Guidelines

Allergy update

New adrenaline auto-injectors guidance AAI prescription guidance for primary care for adults and children

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Dr Elizabeth Angier Portfolio GP, NHS Hampshire, Southampton and Isle of Wight CCG

his new guidance has been led

by GPs Dr Elizabeth Angier and Dr Deepa Choudhury with the support of the BSACI Standards of Care Committee. It has been written for a primary care healthcare professional managing a patient who has either experienced anaphylaxis or a milder allergic reaction where they may be at risk of anaphylaxis in the future. This guidance is timely as many patients have disclosed possible allergic reactions as part of the history for the COVID-19 vaccination programme or have possible historic allergies listed or on alerts in their electronic notes without clear clinical detail of anaphylaxis.

clinical cases to illustrate the guidance are also included to reflect real life scenarios.

The guidance emphasises the need for training on devices and referral to a specialist allergy clinic. It highlights how the specialist and primary care teams could work together to avoid gaps in care. Several new guidelines for anaphylaxis have recently been released and these are acknowledged. There is also a case history about a possible reaction after a vaccination which is topical for primary care with the delivery of the COVID- 19 vaccine being supported by many primary care networks.

A literature search was performed to inform the document and the following stakeholders were involved

• British Society for Allergy and Clinical

Many reports have shown that primary care physicians and other health care professionals may not feel confident in anaphylaxis recognition and risk assessment as this may not have been covered in their training.

Immunology

• Allergy UK • Anaphylaxis Campaign • Asthma UK • Pharmacy • Royal College General Practitioners • The BSACI Primary Care Group • The College of Paramedics • Medicines and Healthcare products

The document includes a desktop summary and more background and context to this area in different sections to support the patient journey. These include key clinical questions that may arise in the primary care consultation, and an algorithm to guide the prescribing of adrenaline in the community.

There is also an ideal service pathway, links to a community referral form template, and information on adrenaline dosages and the different types of AAIs. A ‘frequently asked questions’ for common enquiries, resources and signposting to patient support groups, and

Regulatory Agency

We are currently finalising the guideline and it should be published at the end of May on our website, www.bsaci.org

Online training and events for members Over the last 12 months we have been hosting regular online webinars for all our members. Covering a host of topics including Cow’s Milk Allergy and Penicillin allergy, the webinars have been organised by BSACI Council with the aim of offering high quality, conveniently accessible education on key allergy topics. The speakers are all experts in their field and the webinars have been a huge success. You can attend the live webinars or access them after the event. Take a look: www.bsaci.org/education-and-events/webinars/

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Committee and group news

Allergy update

Junior Members

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Dr. Natasha Gunawardana ST7 Allergy, Royal Brompton Hospital

he change to virtual training has massively increased the attendance of recent BSACI training days. This year, training days have been held in Guy’s and St. Thomas’s and Southampton with excellent feedback. The next training day is scheduled for the 27th May hosted

by Leicester with a further day hosted by the Royal Nose Throat and Ear hospital in June (TBC). Please contact Marie Gibbs if you are interested in attending.

We have recently started adult allergy monthly lunchtime teaching, aimed primarily at allergy trainees but open to all BSACI members. These are

run by the different adult allergy teaching centres and complement paediatric allergy grand rounds and immunology regional training. Recordings will soon be available on the BSACI website.

RECENT ACTIVITIES: • Expanded virtual training • New curriculum for training days from Sept 2021 • BSACI SOCC patient information leaflets and ‘Cochrane Corner’ for CEA Junior members have formed two separate groups to assist the BSACI SOCC committee in writing patient information leaflets and assist the editors of CEA in starting a Cochrane corner.

Both of these are great opportunities for juniors to gain experience in writing and working with future colleagues and patient groups.

If you have any questions regarding any matters concerning junior members please get in touch: juniormembers@bsaci.org

Standards of Care Committee

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Dr David Luyt Consultant in Paediatric Allergy, Leicester Royal Infirmary

his report will focus on people rather that products as, since our last report, the SOCC has undergone great changes in personnel in keeping with guidance from the new terms of reference which recommends limiting individual tenures and encourages wider representation from the society. We called for applications from the society and were heartened by the interest shown – sadly too many applicants to include all in the committee. We welcomed Judith Clayton, Jose Costa, Helen Fisher, Nasreen Khan, Ellie Minshall, Prathap Pillai, Liz Powell, Nicola Rew, Emily Staples and Leonard Siew.

We also said farewell (and a huge thank you for their amazing contributions over many years) to Rubaiyat Haque, Shuaib Nasser and Stephen Till and to Stephen Durham and TK Krishna, although will continue to have access to their experience and wise guidance in our newly formed wider advisory committee; and have further appointed to this group Katherine Anagnostou, Chris Corrigan

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and Chris Rutkowski. Members can see their biogs on the BSACI website.

The committee also said a sad farewell in April to Maryam Shayeghi our chief scientific officer. Maryam announced that after 6 years in the post she was ready to take on fresh challenges. We are delighted to welcome in her place Erinn Gallagher. Erinn moved to the UK 1 year ago from Sydney, Australia. She has a diverse employment background in histopathology as a Scientific Officer for Sonic Healthcare as well as in business consulting for private hospitals and pharmaceutical companies as an Associate at Ernst & Young. She previously studied a Bachelor of Medical Science and is currently studying a Master of Public Health, specialising in communicable disease control.

Lastly, two final mentions in the theme of this report on people in SOCC: Andy Clark has taken on the role of audit lead, and Natasha Gunawardana, BSACI Junior Members representative, supported

by Liz Powell who is the trainee representative on the core committee, is leading a new project to develop information leaflets.

Committee and group news

Allergy update

Food Allergy Specialist Group

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Hannah Hunter Specialist Adult Allergy Dietitians, Guy’s and St Thomas’ Hospital

hroughout the pandemic, we have been delivering free webinars to our members and since they have been successful we plan to continue these as restrictions ease.

Our resources now comprise of 30 diet sheets, the latest addition being milk, egg, wheat and soya (MEWS) free. In the pipeline we have an FPIES weaning leaflet and our EoE diet sheets are under review.

This year our members raised concerns over the recent marketing of SpoonfulOne in the UK, an early allergen introduction product for babies. In conjunction with BSACI, Allergy UK and the Anaphylaxis

Campaign, we voiced our concerns to Nestle through a formal letters and virtual meetings. We are pleased with the outcome that the launch has been suspended by Nestle.

There has been increasingly interest over the past year of the management of long-COVID. One such strategy brought to our attention was that a

RECENT ACTIVITIES: • Programme of free webinars for BDA Food Allergy Specialist Group (FASG) members • Engagement with Nestle to discontinue marketing of Spoonful One in the UK, in conjunction with BSACI • Statement and survey on long-COVID and low histamine diets low histamine diet may alleviate the symptoms.

As there is no evidence to support this approach and following a low histamine diet without support is potentially harmful, we produced a statement to this effect through the BDA and supported by BSACI (contact Hannah if you would like a copy).

We urge BSACI members to seek dietetic support if you have patients who are following a low histamine diet or plan to initiate one. Our plan is to conduct a members’ survey to capture experience so far with patients.

Twitter: @BDA_FASG

Nurses in Allergy

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e continue to reach out to nurse and allied health members of the society to bring us together virtually and support each other during the COVID-19 Pandemic. We held a series of successful Zoom support meetings in 2020 and into 2021 with excellent presentations and discussions generated.

We are continuing our committee meetings over Zoom and keeping up the valuable work of this experienced and supportive group. Recent discussions have included work on the Education Strategy, BSACI conference planning, results of our Year of the Nurse survey (including plans of how to disseminate findings) and engagement and organisation of communications to the nurse members of BSACI.

Lucy Common Advanced Clinical Nurse Specialist (Salford) and Chair of the Nurses in Allergy Committee

Please look out for communications for expressions of interest in joining the group when committee places become available. We are particularly interested in hearing from our nursing colleagues working with Immunology and Allergy patients in primary care and adult nursing from across the UK in all nations to increase diversity in the group.

Further support can be provided via e-mail and looking at our resources on the new BSACI website. We have recently updated the Sub-lingual Immunotherapy Standard Operating Procedure (SOP) and it will be available online soon.

Our current e-mail address is bsacinurses@ gmail.com which will become nurses@bsaci.org later this year to make our communications with the nurse and allied health members of BSACI even more accessible, centralised and responsive.

We also have an active Twitter account so please follow us for support and information: #BSACInurses

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Obituaries

Allergy update

A tribute to my friend Barry Kay I first met Barry quite by Divine providence. I had just completed my medical training after many years first at Oxford and then at King’s College Hospital School of Medicine in Camberwell (this was before it was part of the GKT behemoth). I had no idea what I wanted to do with my life except that it had to involve basic, scientific medical research.

I had met some very clever and Professor eminent scientists while in Oxford Chris Corrigan who inspired me with this goal. I Professor of flicked though the BMJ appointments Asthma, Allergy supplement (in those days there was & Respiratory no internet) and came across, quite Medicine by chance, an advertisement for a King’s College, Clinical Research Fellow in Asthma London at the Cardiothoracic Institute at the Royal Brompton Hospital in the Allergy & Clinical Immunology Department (hence the infamous ACID bunch). Owing to Barry’s insight and generosity this was as far as I needed to go.

I met Barry for the first time in his office which was a floor up from the corridor in which his laboratories were situated. Barry was very polite and chatted to me like a colleague. I was mildly surprised that it was he alone doing the interviewing. I had to admit to him that, despite my first class degree from Oxford and my theoretical expertise in immunology, I barely knew one end of a test tube from the other. He didn’t seem daunted.

I can’t really remember what we discussed. I was afforded this unique research opportunity because Alan Bennett (with whom I had undertaken some research) was a keen saxophonist as well as a Professor of Pharmacology and played in our student rock band.

Anyway, Barry gave me the job. I believe that my lifelong friends and colleagues Andy Wardlaw

The team photographed outside the Cardiothoracic Institute

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Dr Barry Kay (1939 – 2020)

and Robyn O’Hehir had a similar experience.

Another lifelong friend and colleague who started as a clinical research fellow with Barry about this time (1985) was Tony Frew. It was the start of a unique and invaluable, mutually stimulating collaboration which has never ended. He told me that he thought T cells and eosinophils were likely important in asthma, which was revolutionary since asthma was seen in those days as episodic spasm of bronchial smooth muscle caused by the release or mediators from IgE-sensitised mast cells (and ignoring the fact that clinical atopy is neither necessary not sufficient for the development of asthma). He believed that allergen-activated T cells secreted factors which attracted eosinophils to the bronchial mucosa in asthma. Our tasks were assigned.

My first task was to see whether helper T cells are activated in the blood of patients with asthma using this new-fangled flow cytometry.

Andy was given the task of seeing how eosinophils ticked, and especially what made them migrate.

Tony was tasked with taking biopsies of skin latephase allergic reactions to look for evidence of T cell activation and eosinophil recruitment. Robyn was to generate allergen-specific T cell clones.

What a vision! How could we have known then what a revolutionary vision this would prove to be!

Tony, Andy and Robyn were my constant companions in the laboratory in those days, as were two overseas visiting clinical research fellows, Jaw-Ji Tsai (a consultant physician in his native Taiwan) and Piero Maestrelli, a consultant specialising in occupational lung disease from Padua in Italy (if you go there, be sure to see the Giottos in the chapel and the ancient anatomy demonstration lecture theatre in the University).

These two characters are still my friends: in fact, Jaw-Ji’s daughter is now training in medicine over

Obituaries here and it has been a pleasure to help her: one particularly memorable incident was helping her cope with a patient’s Geordie accent!

Since my laboratory expertise was limited, to say the least, I was completely indebted to the technical scientists in Barry’s lab to help me, most notably Oliver Cromwell, who was in charge of all technical facilities, Redwan Moqbel, Gary Walsh, Adele Hartnell and Andrea Champion. These kind people smiled at my pathetic incompetence and showed me how to isolate blood lymphocytes by centrifugation on Ficoll (20 minutes, 20°C, no brake), while Adele very patiently showed me how to use our flow cytometer (which was an early, 2 channel only model driven by a bicycle light bulb) without breaking it. She was very patient, especially when I tried to use it on Friday afternoons after a lunchtime visit to the local pub (regrettably, Barry was not generally invited to these).

I also had to venture onto the wards at the Brompton and ask asthmatic patients if they’d donate blood.

Barry was passionate about research, and passionate in his support for his team: I’m sure we will never forget the famous Friday Morning Meetings at which we all presented our latest advances: a struggle for our foreign visitors at times who couldn’t keep up with Barry’s “constructive criticism” (I remember Jaw-Ji bursting into tears one morning because he couldn’t make out what “caveat” meant).

He was ecstatic when I started to produce evidence that T cells from asthmatics expressed CD25, one of the few T cell markers described at that time (nothing was known then about Th1 and Th2 T cells and cytokines). When Andy reported to Barry at one meeting that PAF attracted eosinophils, he was so astonished by this that he sneaked into the laboratory the following day and checked for himself….

Meanwhile Robyn was looking for these newfangled cytokines in her clone supernatants and Tony was collecting biopsies of skin late-phase reactions from human volunteers which – surprise, surprise – showed a T cellular infiltrate. With his inspiration I was able to win an MRC Clinician Scientist award which was renewed following a 2 year probation period for a further 5 years. I remember Barry telling me about it in the car park at work. He approached, all stern and po-faced. “I suppose you want to know if you got your grant from the MRC?” (It was very harrowing, speaking to a panel of about 12 scientists and clinicians pestering me with questions: perhaps you have been there….). “Yes please”, I said. “Well you did, and that’s a great honour for the Department.” A friendly tap on the back and that was that.

To read more of this tribute and Barry Kay’s full obituary, please visit the BSACI website. An ‘in memoriam’ site has also been created for those who wish to share their memories or to leave messages.

Allergy update

John Mullins BSc (Hons), PhD (1948-2020) BSACI members will be saddened to learn of the death of retired member, Dr John Mullins in November 2020 after a long illness. He was well known both in the UK and internationally for his work on Aeroallergens. John graduated from Cardiff University, and in 1974, was awarded a PhD for his research on the Genus Aspergillus. In addition, John studied many other types of fungi and airborne pollen which led him to work on numerous national and international research programmes in aerobiology and allergy.

Dr Mullins worked at the Asthma and Allergy Unit Sully Hospital, South Glamorgan and later at Cardiff Hospital. While at these posts, John was responsible for the pollen and fungal spore monitoring site at Cardiff for over 30 years. The site has a continuous year-round daily record of volumetric pollen counts dating from 1954, and of daily fungal spore counts for many decades. This record is the longest in the world.

It has been the subject of many research projects and has been used in numerous clinical trials. Dr Mullins has an extensive list of peer reviewed publications.

These include analyses of long-term trends in pollen counts in relation to climate changes and the implications of these for hay fever and asthma, and trends in respiratory and cardiovascular health in relation to changes in aeroallergens and air pollution.

John helped the careers of many people in the fields of Aerobiology and Medicine through providing training, by giving research supervision and by participating in joint projects. He will be sadly missed by many friends and colleagues, not only for his major contribution to the knowledge of aeroallergens but also for his personal qualities of tremendous kindness, positive attitude, a great sense of humour and the willingness to always help others.

Dr Jean Emberlin

Dr John Mullins

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