Food allergy and travel Is it time to establish best practice parameters?

The incidence of food allergy (FA) has continued to increase on a worldwide scale, with reports of lifetime FA prevalence up to 10%, depending on study population and geography.1Spolidoro GCI Amera YT Ali MM Nyassi S Lisik D Ioannidou A et al.Frequency of food allergy in Europe: an updated systematic review and meta-analysis.Allergy. 2023; 78: 351-368Crossref PubMed Scopus (4) Google Scholar,2Gupta RS Warren CM Smith BM Jiang J Blumenstock JA Davis MM et al.Prevalence and severity of food allergies among US adults.JAMA Netw Open. 2019; 2e185630Crossref Scopus (442) Google Scholar Similarly, accessible global travel continues to expand and raises important clinical considerations for the practicing allergist regarding safety measures and guidance for individuals with FA traveling both locally and internationally. Certainly, it is imperative for allergists to counsel patients and their loved ones on best practices to live safely with FA. Given the growing interconnected world, our practice as allergists should also include guidance on FA safety during travel. In the current issue of Annals of Allergy, Asthma & Immunology, Bjelac et al3Bjelac J Abrams EM Iglesia EG Food allergies on vacation- there and back again.Ann Allergy Asthma Immunol. 2023; 130: 438-443Abstract Full Text Full Text PDF Scopus (2) Google Scholar reviewed current literature on FA considerations during travel. After a Medline and Embase database search of articles related to FA and travel published within the last 20 years, 23 articles were reviewed to formulate this clinically focused and practical review. Overall, the authors’ work is comprehensive, summarizing both rates and risks of allergic reactions because of foods during travel but also compiling practical strategies and patient resources that can be used in preparing families to manage FA while away from home. Common challenges associated with travel are well outlined. Among these challenges are language barriers, inconsistent labeling regulations, variability in the training of food-service employees to recognize and treat FA, limited ability of travelers to prepare their own food, and unequal global distribution of FA leading to regional unfamiliarity. These, along with variability in access to emergency care in a foreign place of travel, all contribute to increased risk of severe reactions and the associated burden of anxiety that patients and families face when considering travel. The past few years have seen encouraging progress in labeling laws associated with FA domestically, notably with passage of the FA Safety, Treatment, Education, and Research Act in 2021 and the addition of sesame as the ninth major food allergen subject to food labeling regulations of the FA Labeling and Consumer Protection Act of 2004.4Food Allergen Labeling and Consumer Protection Act of 2004. 21 USC 301 note. PublicLaw. 108--282.23.Google Scholar,5S.578 - 117th Congress. FASTER Act of 2021, S.578, 117th Cong. (2021). Available at:https://www.congress.gov/bill/117th-congress/senate-bill/578. Accessed December 29, 2022.Google Scholar This is especially important given considerable sesame-related reaction burden, specifically attributable to inconsistent allergen labeling.6Nguyen K Greenthal E Sorscher S Lurie P Spergel JM Kennedy K. Adverse events and labeling issues related to suspected sesame allergy reported in an online survey.Ann Allergy Asthma Immunol. 2022; 128: 279-282Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar Despite this, travelers, especially those used to mandatory reporting of the “top nine” allergens, may face unanticipated risk from food products containing allergens in countries where such regulations do not exist. The authors also note a lack of standardization of food labeling and handling across airlines particularly with nonpackaged foods, which may be similarly problematic in hotels and restaurants, where allergens can often be “hidden” or difficult to identify.7Sánchez-Borges M Cardona V Worm M Lockey RF Sheikh A Greenberger PA et al.In-flight allergic emergencies.World Allergy Organ J. 2017; 10: 15Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar Air travel has long been associated with the prospect of accidental FA reactions, with some concerns holding more validity than others. This topic was also recently reviewed, and fortunately, in-flight reactions requiring epinephrine occur very infrequently (1 in every 12.5 million passengers).8Kodoth SM Alves P Convers K Davis K Chang C Infectious Diseases and International Travel Committee of the ACAAI. The frequency and characteristics of epinephrine use during in-flight allergic events.Ann Allergy Asthma Immunol. 2023; 130: 74-79Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar,9Lieberman JA Greenhawt M. Keeping perspective at 35,000 feet: in-flight allergic reactions remain very rare events.Ann Allergy Asthma Immunol. 2023; 130: 6-7Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar In contrast, despite emergency epinephrine being required on all US flights and many international flights, there is no requirement for autoinjectors, which very well could significantly limit prompt administration during an in-flight emergency. This undoubtedly undermines families’ feelings of safety and confidence during travel and presents an opportunity for our field to continue to advocate for our patients on a national level. Despite these inconsistencies and potential areas of risk for patients with FA, we note that our national societies do not currently have dedicated established guidelines or practice parameters on travel as it relates to FA. Although web-based resources exist from both the AAAAI and ACAAI, a standardized approach for clinicians to guide patients planning to travel may prove useful. The table compiled in the article by Bjelac et al3Bjelac J Abrams EM Iglesia EG Food allergies on vacation- there and back again.Ann Allergy Asthma Immunol. 2023; 130: 438-443Abstract Full Text Full Text PDF Scopus (2) Google Scholar is both an excellent resource and a potential starting point to formulate best practices based on review of literature and expert opinion. In addition, current available resources require patients to access this information in a self-directed manner, which leaves the burden on families while they may be preparing for other aspects of their trip and importantly, does not allow questions, concerns or clarifications to be discussed in real time with their allergist. One potential solution is to develop an evidence-based standardized parameter to assist in counseling patients and families with FA for travel. Checklists have been shown to increase safety and communication in other medical specialties, such as in surgery and anesthesiology.10Haugen AS Sevdalis N Søfteland E. Impact of the World Health Organization surgical safety checklist on patient safety.Anesthesiology. 2019; 131: 420-425Crossref PubMed Scopus (39) Google Scholar A standardized checklist that an allergist can use with patients before travel may serve to mitigate the actual risk of reaction while abroad and to decrease patient anxiety. Such a checklist should include information as highlighted in the article by Bjelac et al,3Bjelac J Abrams EM Iglesia EG Food allergies on vacation- there and back again.Ann Allergy Asthma Immunol. 2023; 130: 438-443Abstract Full Text Full Text PDF Scopus (2) Google Scholar including carrying epinephrine, FA action plans, translation cards, and prepared emergency statements in the local language. Allergists should also designate time to address families’ individual specific concerns to provide accurate education where needed. For instance, as highlighted in the article by Bjelac et al,3Bjelac J Abrams EM Iglesia EG Food allergies on vacation- there and back again.Ann Allergy Asthma Immunol. 2023; 130: 438-443Abstract Full Text Full Text PDF Scopus (2) Google Scholar many families are worried about air travel owing to the common belief that inhalational or cutaneous exposure to allergens may lead to a severe life-threatening reaction. Explaining that oral ingestion, in contrast, poses a much more significant risk of systemic reactions (vs other modes of exposures) may help mitigate some level of familial anxiety before travel. A standardized guideline or practice parameter might also serve as a robust resource to provide for families directly in cases in which this might also be helpful. The very nature of travel means leaving one's familiar setting and routines. However, to those with an FA, the disruption may go beyond simple inconvenience and prove to be harmful, as outlined in the recent article by Bjelac et al.3Bjelac J Abrams EM Iglesia EG Food allergies on vacation- there and back again.Ann Allergy Asthma Immunol. 2023; 130: 438-443Abstract Full Text Full Text PDF Scopus (2) Google Scholar Any way to mitigate this risk should be a priority within the allergy community and through clinical practice. We thus encourage consideration of a guided practice parameter to consolidate resources into the most salient and accessible form to allow efficient education at the allergist's office before traveling. Food allergies on vacation—there and back againAnnals of Allergy, Asthma & ImmunologyVol. 130Issue 4PreviewFood allergy is an important public health concern that affects all facets of life, and travel is no exception. We sought to provide a scoping review regarding the literature pertaining to management of FA while traveling. Full-Text PDF