Allergy treatment – nothing to sneeze at

New biological treatments and ways of getting babies exposed to allergens early are revolutionizing the field of clinical immunology.

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December 18, 2016 03:28
sneeze

A woman blowing her nose into a tissue, possibly after or sneeze or while sick. (photo credit: INGIMAGE)

 
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More than four out of every 10 people reading this story have at least one family member who suffers from an allergy. It could be to food, such as cheese and other milk products, fish, peanuts, eggs, nuts, avocado or kiwi. They may be allergic to other things, such as dust mites, pollen, molds, metal, latex, insect stings, antibiotics or other drugs.

Allergies are no joke. Some 30,000 Israelis, including young children, suffer from them. While some allergens can cause red eyes, runny nose, skin rashes or sneezing, others can result in asthmatic reactions including throat swelling, shortness of breath and low blood pressure.

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The most serious reaction is anaphylaxis – a life-threatening allergic reaction in which the immune system overreacts by producing chemicals that raise havoc in the body and can lead to multiple organ failure.

To head off anaphylactic shock that can lead to death, an immediate injection of epinephrine (adrenalin) in an EpiPen is required. Magen David Adom crews keep them on their ambulances.

Although there have been well-publicized tragedies in which people have died from anaphylactic shock after eating food they didn’t know contained an allergen, only now has the Ministerial Committee for Legislation approved a private member’s bill proposed by Likud MK Yehudah Glick that would require restaurants, cafes and schools to be equipped at all times with up-to-date EpiPens for adults and children.

A gamut of subjects relating to allergies and related subjects was discussed at the recent three-day World Allergy Organization (WAO) International Scientific Conference, held at the Jerusalem International Convention Center. More than 700 delegates from 25 countries around the world attended the conference, whose local organizer was the Israel Association for Allergy and Clinical Immunology.

The word “allergy” was first used in 1906, when Austrian scientist and pediatrician Dr. Clemens von Pirquet noted in his children’s clinic that patients who had previously gotten injections of smallpox vaccine or horse serum had quicker, more severe reactions to a second injection. He, along with Hungarian-born American pediatrician Dr. Bela Schick coined the word from the Greek allos meaning “other” and ergon meaning “reaction”) to describe this reaction.



Antibodies produced by the immune system that are called immunoglobulin E (IgE) stand behind allergies. If you have an allergy, your body overreacts to an allergen by producing and moving antibodies to cells that release chemicals, thus causing an allergic reaction.

ALLERGIES HAVE become much more common around the world, Prof. Nancy Agmon-Levin, the head of the Israeli association and head of the local organizing committee told The Jerusalem Post during the conference. A senior lecturer at Tel Aviv University’s Sackler Faculty of Medicine, she graduated from the Hebrew University- Hadassah Medical School and completed her residency in internal medicine and fellowship in allergy and clinical immunology at Rehovot’s Kaplan Medical Center. She is an allergy specialist at Sheba Medical Center and a scientist at its Zabludowicz Center for Autoimmune Diseases.

There is a shortage of allergy specialists in the country, she said. A variety of factors, including climatic changes, have changed the types of plants and trees. Even olive pollen that is common in the Middle East has reached Denmark. In addition, people are mostly raised in cities rather than in farms, whose domesticated animals and their microbes strengthen children’s immune systems at a young age.

The “hygiene theory” was suggested to explain the fact the skin allergy eczema and hay fever are less common in children in larger families who are probably exposed to more bacteria, viruses and other pathogens from their brothers and sisters than in children from very small families.

The idea that youngsters are “too clean” is widely accepted by allergy specialists. City children could benefit from being raised with a cat, dog or other pet to strengthen their immune systems. People eat out more, and those with food allergies may consume a dish adulterated with products to which they are allergic without them – or waiters – being aware of it.

About one in 10 Israelis suffers from allergic asthma. Air pollution is on the rise, raising the risk of asthma. Even lightning storms can increase the number of allergens in the air. In addition, there are more than 80 different autoimmune diseases from type I diabetes to Sjogren’s disease in which the body’s immune system mistakenly recognizes tissues or organs as foreign and attacks it. These affect 8% to 10% of the population. In kindergartens, 2% to 5% of all children suffer from food allergies, requiring supervision by an adult to ensure that they do not eat what they shouldn’t.

Nursery and kindergarten facilities increasingly bar peanuts or other nuts from being brought inside, she said.

But Israeli children have a much lower rate of peanut allergy than in most places in the world, she said, because most babies and toddlers are given Bamba and other puffedcorn- and-peanut snacks. A well-known published study by a British researcher on early exposure of infants to peanuts has proven that it is very beneficial to reducing the prevalence of peanut allergy, thus countering the now-rejected policy for many years of not exposing babies to peanuts until after their first birthday.

Some well-baby centers, noted Agmon- Levin, now recommend that infants as young as three or four months be allowed to lick these snacks or peanut butter itself to avoid peanut allergies. Thus, by the time they get to nursery school and kindergarten, there will be little or no danger of peanut allergies among the children.

Agmon-Levin also recommends that babies that breastfeed should from time to time be given a bit of baby formula to drink from a bottle, as these contain processed cow’s milk; early exposure to this can minimize or eliminate milk allergies later.

Allergies tend to run in families due to genetic components; most identical twins with allergies react to the same allergen, and the children of allergic parents are likely to have allergies. If you have an allergy, you are better off staying calm, as chronic stress can make the body’s reactions more severe.

PROF. MARIO Sanchez Borges of Venezuela is president of the WOA, which has member societies in 97 countries around the world, including Israel. He told the Post that it was his first visit to Israel and that he found the level of doctors in the field, including their research, very high.

“We have some 35,000 member allergy and clinical immunology specialists around the world and send them news and information every month,” he said. “Depending on the country, doctors who become allergy and clinical immunology specialists first have to study internal medicine or pediatrics,” added Borges, who now has a private practice in Caracas in the 120-bed Centro Medico Docente la Trinidad hospital. He treats both adults and children.

Where he lives in the tropics, he said, there is a large amount of dust mites that cause allergies, especially asthma. Pollen is spreading rapidly and causing hay fever.

He also encounters a lot of food allergies.

“There isn’t a single food to which no one is allergic,” he noted.

Borges had much praise for Israeli health professionals for their significant reduction of peanut allergies by encouraging parents to give peanut snacks at a young age.

“We around the world are learning from you.”

PROF. LANNY Rosenwasser at the University of Missouri at Kansas City’s medical school felt at home here, as he has cousins in Ramat Hasharon, and one of his relatives was a founder of the city. The Bronx-born allergy specialist said many of his other relatives were wiped out in the Holocaust or left Europe in time and survived.

“I have been here five or six times to visit them and see the country,” he said.

The US has some 5,000 specialists in the field.

“Our manpower is lower than we need. It may be because many doctors are now retiring and are not being replaced by young doctors. The cost of studying medicine in the US, unlike in Israel where it is subsidized, is very high,” he noted.

“When I went to medical school in 1968, tuition was just $2,000. Today, it is $70,000 in my school. Graduates spend many years paying off their loans.” Doctors are also more likely to be employees of hospitals and clinics today rather than working independently.

There are also too few doctors because many are women who also meet their obligations to their children and don’t work full time. The gap is partially filled by nurse practitioners and physician assistants.

He studied allergy and clinical immunology at the US National Institutes of Health in Maryland.

“I was a basic immunologist there, and immunology is the cornerstone of all knowledge of allergies.” He is pleased with his career, as he was the discoverer of interleukin 1 – a group of 11 cytokines – which plays a vital role in the regulation of immune and inflammatory responses to infections.

“I have also had a very good teaching and clinical career and been active in many professional organizations, including as president of the American Academy of Allergy, Asthma and Immunology.”

Rosenwasser, who said he is allergic to dust mites, cats and grass, is optimistic that many of his patients will in the coming years benefit from new drugs and treatments.

PROF. RUBY PAWANKER, a former president of the WOA (2012-2013) – the first woman and the first person born in India to head it – also attended the conference. She studied medicine in her native country, was invited for a short-term project in Tokyo in 1989 and then decided to stay in Japan, a country very different from her own. Today she speaks, writes and reads Japanese almost like a native. She is president-elect of the Asian Association for Allergy and Clinical Immunology.
 
Pawanker's appointment broke barriers faced by women while working in a university hospital, mostly treating children, teaching and doing research. Besides her clinical and teaching assignments in allergy, her research has focused on the cellular and molecular mechanisms of allergy, impact of environmental pollutants and novel therapies.

It was her first visit to Israel, an experience that she found very exciting and moving, especially because “my ancestors were Cochin Jews. Today, I am an Orthodox Christian.”

When asked if she had allergies, she answered in the affirmative. “Yes, to crustaceans like shrimps and lobsters. In fact,” she said, seeming to think about it for the first time, “maybe my genes are getting back at me” for these forbidden foods.

Working with allergies is very interesting, she said, “because every patient is different.”

Pollen, especially from cedar trees, is a very common allergen. Hay fever, she said, is a “national disease.”

Like Israelis, Indian children have a very low rate of peanut allergy – because they eat boiled peanuts at a young age.

Among the major allergy treatments that have begun to be used are biologicals, such as anti-IgEs that bind with IgE. There is also intensive study of biomarkers in asthma and consideration is being given to the use of probiotics to restore balance in the body.

EpiPens became available in Japan only in 2003, while they were introduced in the US three decades ago. She advocates putting EpiPens and automatic defibrillators (to resuscitate heart attack patients) in every public place. She said she will never forget saving the life of a Filipino nurse in a flight from Dubai to Singapore.

“She ate some noodles and became red in the face and all over and was wheezing I could see she had anaphylaxis. The airline had an EpiPen and i treated her for her anaphylaxis. By the time we landed, she had stabilized and was feeling well. She was so grateful.” It was her first episode.

MANY OF the conference lectures involved biological treatments that block cytokines, which allow eosinophils – white blood cells involved in the pathogenesis of allergic disease – to proliferate. These new treatments are “changing the rules of the game and opening a new era in the treatment of allergies,” concluded Agmon-Levin.

In the field of food allergies, oral immunotherapies are being introduced to induce immune tolerance to foods; it may lead to allergic people losing their fear of anaphylaxis, without the need to carry EpiPens.

Some sufferers may eventually be able to benefit from skin patches or under-tongue tablets to relieve their condition.

Things are looking up for those suffering from allergies and yearning for a normal life.


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