WORLD ALLERGY ORGANIZATION

WAO White Book

on Allergy 2011-2012:
Executive Summary

WAO White Book on Allergy 2011-2012

WAO White Book on Allergy 2011-2012:
Executive Summary

Ruby Pawankar
Giorgio Walter Canonica
Stephen T. Holgate
Richard F. Lockey

Copyright 2011 World Allergy Organization

WAO White Book on Allergy 2011-2012:
Executive Summary

Author Information

Prof. Ruby Pawankar, MD, PhD

WAO President Elect (2010-2011)
Allergy and Rhinology
Nippon Medical School
1-1-5 Sendagi, Bunkyo-ku
Tokyo 113-8603
JAPAN

Prof. Giorgio Walter Canonica, MD

WAO Past President (2010-2011)
Allergy & Respiratory Diseases
Department of Internal Medicine
University of Genoa
Padiglione Maragliano, Largo Rosanna Benzi 10
1-16132 Genoa
ITALY

Prof. Stephen T. Holgate, BSc, MD, DSc, FMed Sci

Member, WAO Board of Directors (2010-2011)
Medical Research Council Clinical Professor of Immunopharmacology
Infection, Inflammation and Immunity
School of Medicine
University of Southampton
Level F, South Block
Southampton General Hospital
Tremona Road
Southampton SO16 6YD
United Kingdom

Prof. Richard F. Lockey, MD

WAO President (2010-2011)
Division of Allergy & Immunology
Joy McCann Culverhouse Chair in Allergy & Immunology
University of South Florida College of Medicine
James Haley Veterans Administration Medical Center (111D)
13000 Bruce B. Downs Boulevard
Tampa, Florida 33612
USA
Acknowledgement

On behalf of the World Allergy Organization (WAO), the authors of the

WAO White Book on Allergy 2011-2012: Executive Summary express their gratitude
to the charity, Asthma, Allergy, and Inflammation Research (AAIR) for support in the
production of this publication.
 WAO White Book on Allergy 2011-2012: Executive Summary 1

Introduction to the
Executive Summary
each year. Because so little effort is made to provide clinical
Allergic Diseases as a

and Executive
services for patients who suffer from allergies, they often

Introduction

Summary
seek non-scientifically-based alternative and complementary
Global Public Health Issue diagnostic and therapeutic remedies for their ailments.
R. Pawankar, GW Canonica, ST.Holgate, RF Lockey In some countries, patients are repeatedly told that
priorities for diagnosis and treatment of allergic disease are
determined at the local governmental level, i.e., by “Primary
Care Trusts”. However, if representatives at this local level do
1. Introduction not understand the prevalence and significance of allergic

Declaration
of the WAO
diseases and their complications, what hope is there for
The prevalence of allergic diseases worldwide is rising them to choose to provide care for these clinical problems?
dramatically in both developed and developing countries. For example, it is important for a well-trained physician to
These diseases include asthma; rhinitis; anaphylaxis; drug, identify the allergens which cause an allergic disease and
food, and insect allergy; eczema; and urticaria (hives) and to provide patients with the chance to avoid them; the well-
angioedema. This increase is especially problematic in trained physician can prescribe appropriate medications,
children, who are bearing the greatest burden of the rising or allergen immunotherapy, a highly effective treatment

Conclusion
trend which has occurred over the last two decades. currently restricted to only a relatively few centres of care
In spite of this increase, even in the developed world, throughout the world, despite its proven efficacy. One of the
services for patients with allergic diseases are fragmented main aspects of good allergy practice is to find the cause
and far from ideal. Very few countries have comprehensive and prevent symptoms and disease progression, rather
services in this field of medicine. than just rely on medications to suppress the symptoms.

There are almost no specialized services for patients The mission of the World Allergy Organization (WAO) is to
in many countries, other than care delivered by organ- be a global resource and advocate in the field of allergy,
based specialists such as respiratory physicians, ear, asthma and clinical immunology, advancing excellence in
nose and throat specialists (otorhinolaryngologists), and clinical care through education, research and training as
dermatologists. While the care provided in many cases a world-wide alliance of allergy and clinical immunology
is adequate, such specialists generally view allergy only societies. The Organization presently embraces over
through their organ of interest, while the vast majority 84 regional and national allergy, asthma and clinical
of patients have allergic disease in multiple organs. For immunology society members and affiliated organizations
example, allergic rhinitis, conjunctivitis, and asthma are (see home page at www.worldallergy.org).
three problems which commonly manifest together, yet
WAO is greatly concerned about the increasing global
affect three different organ systems.
burden of allergic diseases. A major focus of the
Because the prevalence of allergy has increased to such Organization is to create global awareness of allergy and
an extent, allergy must be regarded as a major healthcare asthma as a major public health problem. The Organization
problem. According to World Health Organization (WHO) published the first State of World Allergy Report (SOWAR)
statistics, hundreds of millions of subjects in the world in 2007, and now presents the first ever global White Book
suffer from rhinitis and it is estimated that 300 million on Allergy.
have asthma, markedly affecting the quality of life of these
WAO conducts a wide range of activities to support the
individuals and their families, and negatively impacting the
global allergy community. This includes the provision of
socio-economic welfare of society.
resources and promotions such as World Allergy Week to
The provision of allergy care must be led by allergy assist the work of member societies as they lobby for the
specialists so that an adequate standard of care is achieved enhancement of services for the diagnosis and treatment
for all patients with these diseases. The lack of such care of allergic diseases. WAO offers research fellowships,
leads to avoidable morbidity and mortality and to substantial conducts numerous surveys via its member societies and
increased and unnecessary cost to health care systems emphasizes the importance of allergy as a necessary field
and national budgets. For example, it is estimated by WHO for research both in disease causation and management.
that 250,000 avoidable asthma deaths occur in the world The Organization has published position papers on allergy

Copyright 2011 World Allergy Organization

2 Pawankar, Canonica, Holgate and Lockey

specialist training and service provision worldwide, and has These environmental changes will affect pollen counts,
identified the competencies required by all physicians who the presence or absence of stinging insects, and the
treat patients with allergic diseases, asthma, and other presence or absence of molds associated with allergic
clinical immunologic problems. The WAO Position Paper diseases.
on undergraduate training in allergy proposes that all •  In many countries, attempts to tackle these problems
medical students receive the fundamental knowledge and on a national basis are widely variable and fragmented,
training to recognize, diagnose, and treat these diseases resulting in decreased quality of life, increased morbidity
at the primary level and to know when to refer patients and mortality, and considerable cost to patients with
with more complex problems to an allergy/immunology allergic diseases.
specialist, and a WAO model allergy curriculum is presently
being developed to guide undergraduate training.
This White Book outlines the data which indicate that
WAO is in a unique position to provide education about the
allergy is a major global public health issue, and provides
clinical practice of allergy, synthesizing and disseminating
“high level” recommendations to:
expertise and best practice recommendations from
its member societies with well developed services to • create a more integrated approach to the diagnosis and
benefit those in underserved countries. Educational management of allergic diseases;
outreach programs, symposia, and lectureships are • increase public awareness of allergic diseases and their
offered to member societies and health care professionals prevention;
throughout the world. The WAO Emerging Societies
• provide greater education at the primary healthcare level
Program helps to create and develop new allergy societies,
and to non-allergy-oriented secondary care specialists;
conducts allergy training schools, and provides educational
• train medical students and other health care
resources in underserved countries. WAO advises allergy
professionals, including nurses and pharmacists, to
societies about the development and provision of national
an appropriate level to enable them to collaborate with
allergy services and local physician training, drawing on the
different organ-based specialists and allergy specialists
experience gained over many years by long-established
in providing integrated care for allergy patients;
member societies throughout diverse geographic regions.
• institute environmental control measures by the lowering
of indoor and outdoor air pollution, tobacco smoking,
and allergen and drug exposures, as appropriate;
PURPOSE • encourage a preventative approach to allergic diseases,
Why is it necessary to recognize allergic diseases as a emphasizing the importance of continued research both
global public health concern? in disease causation and management;

• A steady increase in the prevalence of allergic diseases • use model projects, for example the Finnish Asthma
globally has occurred with about 30-40% of the world Program, to disseminate good practice, promote
population now being affected by one or more allergic prevention and immune tolerance, and decrease the
conditions. allergy burden in future years.

• A high proportion of this increase is occurring in young

subjects; thus, as this young population reaches
adulthood, the burden of allergic diseases is expected to
increase even more.
• Complex allergies involving polysensitization and multiple
organ involvement are increasing, with a high morbidity
placing a higher demand on health care delivery services.
• It is forecast that allergic problems will increase further
as air pollution and the ambient temperature increase.

Copyright 2011 World Allergy Organization

 WAO White Book on Allergy 2011-2012: Executive Summary 3

• Initial treatment of RS is usually by a primary care

2. THE BURDEN OF ALLERGIC

and Executive
physician (PCP) and if unsuccessful, the PCP should refer

Introduction
DISEASE

Summary
either to a surgeon or to an allergist for specialized care.
• In the vast majority of cases, RS is controlled by proper
Allergic Rhinitis medical management without the need for surgery.
• Allergic rhinitis (AR) results from an IgE-mediated • Surgery should only be considered in those patients who
inflammation of the nasal mucosa. are properly managed but in whom a number of medical
• The disease currently affects between 10% and 30 % of treatment programs fail.

Declaration
the population. • The Allergist, who is trained in allergy, immunology,

of the WAO
• Studies indicate that prevalence rates are increasing microbiology, internal medicine and/or pediatrics
worldwide. combined with an expert knowledge of nasal and sinus
• The classification proposed in the Allergic Rhinitis and anatomy and appropriate pharmacology, is best suited
its Impact on Asthma (ARIA) guidelines is useful for the to manage RS.
implementation of treatment.
• AR is a risk factor for asthma.
Asthma

Conclusion
• Asthma is a life-long chronic inflammatory disorder
• Other co-morbidities of AR include: sinusitis, nasal
of the airways, associated with variable structural
polyposis, conjunctivitis, otitis media with effusion, upper
changes, that affects children and adults of all ages. It is
respiratory infections, breathing through the mouth, and
associated with airway hyperresponsiveness and airflow
sleep disorders.
obstruction that is often reversible either spontaneously
• AR has a significant impact on patients based on or with treatment.
the degree of the severity of their symptoms. It has
• When uncontrolled, asthma can cause death, and
psychological effects, interferes with social interactions,
can markedly interfere with normal activities, seriously
and creates an economic burden not only for the affected
impacting an individual’s quality of life.
subject, but for the family and for the society at large.
• Because of under-diagnosis and inadequate treatment,
• Management is based on patient education,
asthma presents a serious public health problem
environmental control measures, pharmacotherapy and
throughout the world; especially in low and middle
specific immunotherapy.
income countries.
• Atopy - the genetic predisposition to develop IgE-
Allergic Conjunctivitis
mediated sensitivity to common aeroallergens, is
• Allergic conjunctivitis is an increasingly prevalent allergic
the strongest identifiable predisposing factor to the
disease, with the same clinical gravity as allergic asthma
development of asthma, especially in children.
and allergic rhinitis.
• There was a sharp increase in the prevalence, morbidity,
• The umbrella term “allergic conjunctivitis” includes
and mortality associated with asthma beginning in
distinct clinical entities, from mild but disturbing
the 1960s and 1970s in the so-called “Westernized”
forms due to IgE sensitization to aeroallergens; to
countries of the world.
forms of keratoconjunctivitis where the severe allergic
inflammation, with corneal involvement, is more difficult • The prevalence of asthma in different countries varies
to diagnose and treat, and may lead to permanent widely, but the disparity is narrowing due to rising
ocular damage and even loss of vision. prevalence in low and middle income countries as they
adopt a more Western-type lifestyle. It is plateauing in
high income countries.
Rhinosinusitis
• Rhinosinusitis (RS) is one of the most common and • Inhaled corticosteroids are currently the most effective
expensive medical conditions. anti-inflammatory medications to treat persistent asthma.

• RS occurs in a number of forms, the most common of • The monetary costs of asthma are substantial and
which are either acute or chronic. include both direct medical costs and the indirect costs,
the latter associated with time lost from work and
premature deaths.

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4 Pawankar, Canonica, Holgate and Lockey

• National efforts to tackle asthma as a public health Food Allergy

problem, such as the program introduced in Finland, • Globally, 220 – 520 million people may suffer from
produce remarkable benefits that are reflected in food allergy.
dramatic reductions in deaths and hospital admissions. • Food allergy significantly affects the quality of life of
• Many barriers exist to a reduction in the worldwide sufferers (mainly children).
burden of asthma. • Stakeholders must be prepared to meet the needs
• There are unmet diagnostic, therapeutic, educational of patients by enhancing the diagnostic process, the
and financial needs to achieve better worldwide control traceability of responsible foods, and the availability of
of asthma. substitute foods, assisting hospitalized patients, and
• More effort is needed to focus on ways to improve the preventing mortality.
management of asthma by focusing on disease control • Large areas in the world lack legislation on food labelling.
rather than treating acute episodes. This concept has to • As diagnostic and therapeutic decision strategies are
be embedded in healthcare programs. not clear-cut, evidence-based guidelines are necessary
for clinicians, patients, governments and industry to
Atopic Eczema deal with the challenge of food allergy. Such guidelines,
• An increase in the worldwide prevalence of atopic eg, the WAO recommendation on the Diagnosis and
eczema has been observed. Rationale Against Cow’s Milk Allergy (DRACMA) are
• Atopic eczema is the most common chronic inflammatory available and are ready to be implemented.
skin disease with a varied clinical spectrum. • Epidemiologic studies are necessary, in particular, in less
• Atopic eczema is often the first manifestation of the developed areas of the world.
atopic patient and early intervention may offer an • Oral desensitization represents a promising approach to
opportunity to impede or stop the atopic march. reduce the burden of disease caused by food allergy.
• Atopic eczema represents an important public health
issue due to its impact on quality of life and its socio- Urticaria and Angioedema
economic burden. • Urticaria is a heterogeneous group of disease sub-types
characterised by wheals (fleeting elevations of the skin
Anaphylaxis lasting approximately 24 hours) and/or angioedema
• Epinephrine, at appropriate doses, is the drug of choice (deeper swellings of skin and mucus membranes).
to treat anaphylaxis. • Three major categories exist: a) spontaneous occurrence
• There is lack of consensus about the definition of of wheals, associated with acute and chronic urticaria;
anaphylaxis and this lack of consensus in definition b) wheals and angioedema elicited by particular stimuli,
contributes to the variability in its identification, treatment and in particular physical urticarias: and c) other urticarial
and the use of epinephrine. disorders such as exercise-induced urticaria.
• The variability and severity of anaphylaxis is somewhat • Urticaria occurs frequently with a lifetime prevalence
dependent on the route by which the allergen or above 20%.
inciting agent is delivered, i.e. parenteral versus oral • Except for acute urticaria, diagnostic and therapeutic
administration; the former is commonly associated with procedures can be complex and referral to a specialist is
more severe reactions. often required.
• There is a variety of other terms which describe • Untreated, chronic urticaria has a severe impact on
anaphylaxis which cause confusion, especially with its quality of life and impairs productivity by up to 30%.
definition and treatment. These include: generalized
• The socio-economic impact of urticaria is great,
systemic reaction; systemic allergic reaction; constitutional
since it is a disease which primarily occurs in people of
reaction; and serious hypersensitivity reaction.
working age.
• Anaphylaxis includes both allergic and non-allergic
• Moderate to severe urticaria requires specialist
etiologies.
treatment. In many health care systems worldwide,
• The term “anaphylactoid” is outdated. access to specialty care is insufficient.

Copyright 2011 World Allergy Organization

 WAO White Book on Allergy 2011-2012: Executive Summary 5

Allergy to Drugs and Biological Agents • Fatal reactions occur in up to 50% of individuals who

and Executive
Introduction
• Adverse drug reactions (ADR) may affect up to 1/10 have no documented history of a previous systemic

Summary
of the world’s population and affect up to 20% of all reaction.
hospitalized patients. • HVA impairs long-term quality of life (QOL) and is the
• More than 10% of all ADR are unpredictable drug cause of substantial socio-economic problems.
hypersensitivity reactions (DHR). • A subject’s QOL is negatively affected when appropriate
• Both under-diagnosis and over-diagnosis are common. diagnosis and education are not achieved and when
• The most common DHR involve antibiotics such as venom immunotherapy (VIT) (a series of injections of

Declaration
the venom to which the subject is allergic and which

of the WAO
penicillins, cephalosporins, and sulfonamides, and
aspirin and other non steroidal anti-inflammatory drugs. essentially cures their disease) is not utilized.

• The clinical spectrum of DHR involves various organs, • HVA can be effectively treated with VIT and appropriate
timing and severity. venom therapies.

• DHR can be severe, even life threatening, and are • HVA poses a problem in occupational settings,
associated with significant mortality rates. Drugs may be especially in bee keepers and greenhouse workers.
responsible for up to 20% of fatalities due to anaphylaxis. • HVA has important adverse consequences in terms of

Conclusion
• DHR have a significant socio-economic impact on employment, earning capacity and leisure and sporting
both direct costs (management of reactions and activities.
hospitalizations) and indirect costs (missed work/school • HVA has a substantial adverse financial impact on
days; alternative drugs). healthcare costs.
• Diagnostic procedures for DHR should also attempt to
identify the underlying mechanisms causing the DHR. Occupational Allergy
• Occupational allergic diseases represent an important
• Diagnosis is critical for DHR management and
public health issue due to their high prevalence and their
prevention. Selection of an alternative drug and
socio-economic burden.
desensitization is necessary in some cases.
• Occupational asthma (OA) contributes significantly to the
Insect Allergy global burden of asthma, since the condition accounts
• Hymenoptera venom allergy (HVA) is a common global for approximately 15% of asthma amongst adults.
medical problem and refers to subjects who have • Allergic contact dermatitis (ACD) is one of the most
a sting-induced large local (LL) or systemic allergic common occupational diseases.
reaction (anaphylaxis). A LL reaction is defined as a • Occupational allergic diseases remain largely under-
reaction larger than 10 cm in diameter which lasts over recognized by physicians, patients, and occupational
24 hours in which the signs and symptoms are confined health policy makers.
to tissues contiguous with the sting site. Systemic • Occupational allergic diseases can result in long-term
reactions cause generalized signs and symptoms and health impairment, especially when the diagnostic and
include a spectrum of manifestations, ranging from avoidance measures are delayed.
mild to life-threatening. Mild systemic reactions may be
• Occupational allergic diseases lead to important adverse
limited only to the skin and consist of flushing, urticaria,
consequences in terms of healthcare resources,
and angioedema. More severe systemic reactions
employment, earning capacity and quality of life.
can involve bronchospasm, laryngeal edema, and
hypotension. HVA can cause fatal anaphylaxis. • Occupational allergic diseases are associated with a
substantial adverse financial impact for affected workers,
• The morbidity rate is underestimated; fatal reactions
insurance or compensation schemes, health services,
may not be appropriately recorded, accounting for this
and employers.
underestimation.
• Occupational allergic diseases are, by definition,
• The incidence of positive specific IgE antibodies to
preventable diseases and their burden should be
venom is high in the general population, but only a
minimized by appropriate preventative strategies.
fraction of such individuals develop a systemic reaction.

Copyright 2011 World Allergy Organization

6 Pawankar, Canonica, Holgate and Lockey

Sports and Allergies • The genetic epidemiological observations for

• Moderate and controlled exercise is beneficial for allergic specific candidate genes in atopy and allergic
subjects and should be part of their management. disease require careful replication, enhanced by
• Vigorous exercise may trigger or exacerbate several international collaboration and the availability of
allergy syndromes such as bronchospasm, rhinitis, large, well-characterized case-control populations for
urticaria-angioedema and anaphylaxis. genotyping. The only way to achieve this is to promote
greater cooperation among researchers and create
• Allergy diagnosis should be part of the routine medical
multidisciplinary teams including researchers from
examination in all professional and amateur athletes, in
academia, industry and clinical practice.
order to adopt adequate preventative and therapeutic
measures for controlling the disease, while avoiding
potential symptoms occurring on exercise.
Allergens as Risk Factors for Allergic
Diseases
• Sensitization (IgE antibodies) to foreign proteins in the
environment is present in up to 40% of the population.
• Such sensitization is strongly associated with exposure
for proteins derived from pollens, molds, dust mites and
3. RISK FACTORS FOR ALLERGIC cockroaches.
DISEASE • For asthma, rhinitis and atopic eczema there is a strong
and consistent association between disease and
The Potential of Genetics in Allergic sensitization.
Diseases • The association between sensitization to grass pollens
• Allergic disorders are heterogeneous and involve and symptoms of hay fever occurring during the grass
important gene-environmental interactions. pollen season provides strong evidence for a causal role
• Human genetics has a role to play in understanding of grass pollen in the disease.
susceptibility for disease onset, phenotypes and sub-
phenotypes, severity, response to treatments and natural Environmental Risk Factors: Indoor and
history. Outdoor Pollution
• Epidemiological studies show that indoor and outdoor
• Although candidate gene association studies have
pollution affects respiratory health, including an
provided some insight into the role of genes in disease
increased prevalence of asthma and allergic diseases.
susceptibility, most new information is emerging from
hypothesis-free approaches such as genome-wide • Outdoor pollution is associated with substantial
association studies. mortality; for example in China, outdoor pollution is
associated with more than 300,000 deaths annually.
• Many early gene association studies were under-
powered and the results have not been confirmed in • Conservative estimates show that exposure to indoor air
different populations. pollution may be responsible for almost 2 million deaths
per annum in developing countries.
• Genetic factors that influence the expression of
atopy are different from those that influence disease • Exposure to outdoor/indoor pollutants is associated with
manifestations or its severity in specific organs. new onset of asthma, asthma exacerbations, rhinitis,
rhinoconjunctivitis, acute respiratory infections, increase
• Poymorphism of a single gene usually accounts for only
of anti-asthmatic drug use, and hospital admissions for
a small proportion of the disease phenotype.
respiratory symptoms.
• Epigenetic influences involving multiple mechanisms,
• Abatement of the main risk factors for respiratory
including methylation of CpG islands in gene promoters,
disease and, in particular, environmental tobacco
histone acetylation, phosphorylation and methylation
smoke, indoor biomass fuels and outdoor air pollution,
and a large number of micro RNAs, explain a proportion
will achieve huge health benefits.
of the gene-environmental interactions and
trans-generational effects.

Copyright 2011 World Allergy Organization

 WAO White Book on Allergy 2011-2012: Executive Summary 7

Socio-economic Factors and • Atopy and asthma are more prevalent in developed and

and Executive
Environmental Justice industrialized countries compared with undeveloped and

Introduction

Summary
• The global prevalence, morbidity, mortality and economic less affluent countries.
burden of asthma have increased over the last 40 years. • Migration studies provide information on the role of
• However, the growth and burden of the disease is not environmental factors on the development of atopy
uniform. Disparities in asthma morbidity and mortality, and asthma.
with an inverse relationship to social and economic • Physicians should be aware that environmental and
status, are increasingly documented around the world. climate changes may enhance the development of
allergic diseases and asthma.

Declaration
• Asthma and other atopic disorders may be more

of the WAO
concentrated among those of lower socio-economic • Physicians should be aware that migrants, especially
status because they also bear a disproportionate burden from developing to more developed countries, are at
of exposure to suboptimal, unhealthy environmental increased risk to acquire allergic diseases and asthma
conditions (e.g. physical, social, and psychological and that the effect is age and time-dependent. Early age
conditions). and longer time increase the likelihood of developing
• Future research needs to pay increased attention to atopy and asthma.

Conclusion
the social, political, and economic forces that result in
marginalization of certain populations in disadvantaged
areas of the world which may increase exposure to
known environmental risk factors contributing to the
rising asthma burden.
4. EVIDENCE BASED APPROACHES
Climate Change, Migration and Allergy TO DIAGNOSIS AND MANAGEMENT
• The Earth’s temperature is increasing as illustrated by
rising sea levels, glaciers melting, warming of the oceans Diagnosis and Identification
and diminished snow cover in the northern hemisphere. of Causative Allergens
• Climate change coupled with air pollutant exposures may • Confirmation of allergy and identification of causative
have potentially serious adverse consequences especially allergens are crucial to correctly manage allergic
for human health in urban and polluted regions. diseases.
• High summer temperatures have an impact on rates of • Precise diagnosis allows the implementation of therapies
acute exacerbation and hospital admission for elderly oriented to the etiologic factors of allergic diseases, such
patients with breathing problems and may cause as environmental measures and immunotherapy.
unexpected death. • Diagnosis begins with a detailed medical history and
• Pollen allergy is frequently used to study the physical examination.
interrelationship between air pollution and respiratory • The identification of a temporal association between
allergy. Climatic factors (temperature, wind speed, symptoms and allergen exposure constitutes the basis
humidity, thunderstorms, etc.) can affect both biological for further testing.
and chemical components of this interaction. • Clinical suspicion is confirmed by means of investigation
• Changes in the weather such as thunderstorms during of IgE antibodies in vivo (skin tests) or in vitro.
pollen seasons may induce hydration of pollen grains • Skin tests should include relevant allergens and the use
and their fragmentation which generates atmospheric of standardized allergen extracts.
biological aerosols carrying allergens. As a consequence
• In vitro testing is especially useful when skin test results
asthma outbreaks can be observed in pollinosis patients.
do not correlate with the history or cannot be performed.
• Migration from one country to another involves exposure
• In vitro tests can be applied to “probability of disease”
to a new set of pollutants and allergens as well as
prediction in food allergy.
changes in housing conditions, diet and accessibility to
medical services which may affect migrants’ health.

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8 Pawankar, Canonica, Holgate and Lockey

• There is a need for increased accessibility to allergy • The additional effects of allergen specific
diagnosis and therapies and improved diagnostic immunotherapy, that are lacking with pharmacological
methodologies that can substitute in vivo provocation treatment, are the long-lasting clinical effects and
tests for drug and food allergy. the alteration of the natural course of the disease.
• The use of unproven tests increases the unnecessary This prevents the new onset of asthma in patients
costs of allergy diagnosis. with allergic rhinitis and prevents the onset of new
sensitizations.
Pharmacotherapy of Allergic Diseases • The mechanisms of action of specific immunotherapy
• Subjects from all countries, ethnic and socioeconomic are multiple and complex, and result in a modification
groups, and ages suffer from allergies. of the immunological responses to allergens, with
subsequent reduction of the allergic inflammatory
• Asthma and allergic rhinitis are common health problems
reaction. The mechanisms of action of SCIT and SLIT
that cause major illnesses and disability worldwide.
are similar.
• The strategy to treat allergic diseases is based on:
• SCIT maintains its beneficial effects for years after it has
(i) patient education, (ii) environmental control and
been discontinued. This long-term or carry over effect
allergen avoidance, (iii) pharmacotherapy, and (iv)
also occurs with SLIT.
immunotherapy.
• SCIT indications, contraindications, limits and practical
• Pharmacotherapy is the mainstay of treatment for
aspects are defined in numerous guidelines.
allergic diseases because it not only controls symptoms
but improves the quality of life. • SLIT is considered a viable alternative to SCIT and is
used in clinical practice in many countries. A 2009 World
• Primary care physicians play an important role in first
Allergy Organization Position Paper further details the
line management of allergies. They have to make the
indications, contraindications, and methodology of using
initial clinical diagnosis, begin treatment, and monitor the
SLIT.
patient.
• New forms of immunotherapy, allergen products, and
• Allergy specialists are trained to make a specific
approaches to food allergy and atopic eczema are under
diagnosis and treat patients with allergies, particularly
investigation.
those with moderate/severe disease.
• The chronic nature of allergies makes it essential to
Biological Agents
propose and explain long-term management strategies
• Research in allergy and immunology has led to a variety
to patients, health care policy makers, and government
of novel therapeutic approaches; some agents are
authorities.
already utilized in clinical practice and more are in
• In recent decades, a substantial improvement has
clinical trials.
been made in the efficacy and safety of allergy
• New therapeutic approaches include toll-like receptor
pharmacotherapy.
agonists, cytokine blockers, specific cytokine receptor
• Disease management using evidenced-based practice
antagonists and transcription factor modulators targeting
guidelines has been shown to yield better patient
syk kinase, peroxisome proliferator-activated receptor
outcomes.
gamma, and nuclear factor kappa B.
• The anti-IgE mAb omalizumab is effective to treat allergic
Allergen Specific Immunotherapy asthma, but the criteria to select patients for this type of
• Allergen specific immunotherapy is recognized as
therapy are not well-defined.
an effective treatment for respiratory allergy and
Hymenoptera venom allergy.
• Subcutaneous Immunotherapy (SCIT) represents
the standard modality of treatment. Sublingual
Immunotherapy (SLIT) which is now accepted as an
alternative to injection immunotherapy, has recently been
introduced into clinical practice.

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 WAO White Book on Allergy 2011-2012: Executive Summary 9

Allergy Education for Patients and

5. PREVENTION OF ALLERGIC

and Executive
Families

Introduction
DISEASES

Summary
• The provision of appropriate training and education for
patients and families is fundamental to the management
of allergic disease. • The rise in prevalence of allergic diseases has continued
• The evidence base for the efficacy of education and in the industrialized world for more than 50 years.
training is relatively weak but it is effective in asthma and, • Sensitization rates to one or more common allergens
to a lesser extent, eczema and anaphylaxis. among school children are currently approaching 40%-

Declaration
• Different age and ethnicity populations require different 50%.

of the WAO
educational approaches. • Strategies used to tackle these problems are thus far
• Modern information technology is valuable, especially to ineffective.
educate younger subjects. • Primary prevention is difficult because the reasons for
• Education and training programs should contain a increased sensitization rates are unknown. Also, the
written self management action plan. mechanisms involved in the progression of sensitization
in increasing numbers of individuals resulting in allergic

Conclusion
Allergen Avoidance diseases are incompletely understood. Asthma and
• Effective allergen avoidance leads to an improvement of allergies may have their origin early in life, even in-utero.
symptoms in allergic patients. • Reliable early markers of IgE-mediated diseases are
• Several studies of comprehensive environmental unavailable.
interventions in asthmatic children report benefits. • Novel research indicates that tolerance is the key to
• There is little evidence to support the use of a simple prevention. More research about the mechanisms
single intervention, e.g., only covering bedding, to involved in the development of tolerance should be
control dust mite allergen levels. encouraged. Inadequate or lack of tolerance in allergic
individuals appears to link with immune regulatory
• Similarly, in mite allergic patients with rhinitis, single mite
network deficiencies.
avoidance measures are not beneficial.
• National asthma and allergy plans (e.g. The Finnish
• The following is a guide for a pragmatic approach to
Asthma Programme 1994-2004) have concluded that
allergen avoidance:
the burden of these community health problems can
–– Use a comprehensive environmental intervention
be reduced. The change for the better is achieved as
to achieve the greatest possible reduction in
governments, communities, physicians and other health
allergen exposure;
care professionals, and patient organizations commit
–– Tailor the intervention to the patient’s allergen to an educational plan to implement best practices for
sensitization and exposure status; prevention and treatment of allergic diseases.
–– If unable to assess the level of allergen exposure,
use the level of allergen-specific IgE antibodies or
the size of skin test wheal as an indicator;
–– Start the intervention as early as possible in the
natural course of the disease;
–– Primary prevention strategies aimed at
eliminating or reducing exposure to potentially
sensitizing agents should be developed and
evaluated.

Copyright 2011 World Allergy Organization

10 Pawankar, Canonica, Holgate and Lockey

The Cost-Effectiveness of Consulting an

6. HEALTH ECONOMICS, MEDICAL Allergist
EDUCATION AND COST-EFFECTIVE • Allergic diseases are chronic conditions with systemic
involvement that can affect multiple organs and systems
HEALTH CARE IN ALLERGY throughout the lifespan of atopic (allergic) subjects.
• In assessing the economic burden of allergic diseases,
Health Care Delivery and Health
the costs of several organ-specific diseases need to be
Economics in Allergy
aggregated, including the nose (allergic rhinitis), sinuses
• Asthma and allergic diseases are significant causes of
(rhinosinusitis); lungs (asthma); skin (atopic eczema);
morbidity on a global scale.
and others.
• Asthma disproportionately affects minorities and people
• Cost-effective analyses (CEA) assess the comparative
from lower socioeconomic groups.
effects of one health care intervention over another,
• The total global cost of care for people with asthma and under the premise that there is a need to maximize the
allergic disorders is disproportionately high despite the effectiveness relative to its cost.
relatively low cost per person mainly due to the high
• A cost-effective intervention could, if incorrectly used,
prevalence of these disorders.
generate unnecessary costs, provide no benefit and
• The most effective management for these disorders is to even cause harm.
teach patients self-management skills.
• The allergist is an expert in tailoring therapy to the
• Education should focus on training physicians to individual patient and adjusting treatment dosages
promote and foster self-management skills in their in more severe or complex cases. The main defining
patients. characteristics of allergists are their appreciation of
the importance of external triggers in causing diverse
Medical Education in Allergy diseases; their expertise in both the diagnosis and
The intended outcomes for clinician and healthcare treatments of multiple system disorders, including
professionals training in allergy are to: the use of allergen avoidance and the selection of
appropriate drug and/or immunological therapies; and
• Produce graduates equipped to further their careers in
their knowledge of allergen specific immunotherapy
healthcare and in particular to enhance the number of
practices.
individuals trained in the mechanisms and management
of allergic diseases. • Misinterpretation of the results of diagnostic tests
by non-specialists can lead to over-diagnosis and
• Develop an understanding of the processes involved
inappropriate management which can be harmful for the
in improving the management of patients with allergic
patient. It may lead to over-prescription of therapy and
disease.
costly and unnecessary allergen avoidance measures,
• Develop new areas of teaching in response to the
including exclusion diets that can lead to nutritional
advance of scholarship and the needs of vocational
deficiency and secondary morbidity. Conversely, the
training.
under-appreciation of the severity of asthma can lead
• Provide a training in research skills. to life-endangering under-treatment or the lack of
• Develop skills and understanding of the more complex potentially life-altering immunotherapy.
components of allergic disease encountered in specific • The cost-effectiveness of allergist consultation will
areas of practice. be demonstrated by improved patient outcomes and
experiences together with a reduction in unnecessary
expenditure by payer, society or patient/family.

Copyright 2011 World Allergy Organization

 WAO White Book on Allergy 2011-2012: Executive Summary 11

Declaration of the
World Allergy Organization

DECLARATION II. A
 llergens And Environmental

and Executive
Introduction
Pollutants

Summary
In its role as an umbrella organization of
national and regional allergy, asthma and
Identified Need:
clinical immunology societies worldwide, Evidence-based information about the major indoor and
the World Allergy Organization invited all outdoor allergens and pollutants responsible for causing or
exacerbating allergic diseases and asthma is either lacking
84 of its member societies to contribute to
or, when available, is not always universally accessible.

Declaration
of the WAO
the White Book by participating in an online
survey on the current status and needs of Recommendation:
the specialty in their respective country or Local indoor and outdoor allergens and pollutants which
region. The responses from the Member cause and exacerbate allergic diseases should be
identified and, where possible, mapped and quantified.
Societies along with the scientific reviews
Appropriate environmental and occupational preventative
which are included in the White Book form

Conclusion
measures should be implemented where none exist or
the basis of the World Allergy Organization as necessary. Strategies proven to be effective in disease
prevention should also be implemented.
Declaration.

I. E pidemiological Studies Of III. Availability Of Allergy, Asthma

Allergic Diseases And Clinical Immunology
Services (Allergists) And
Identified Need: Appropriate Medications
In several parts of the world, there is a paucity of published
epidemiological information about the overall prevalence of
Identified Need:
allergic diseases and, in particular, about specific diseases.
There is an increasing need for more allergy specialists and
For example, there is little or no information about severe
for the existence of local and regional allergy diagnostic
asthma; anaphylaxis; food allergy; insect allergy; drug
and treatment centers in order to facilitate timely referrals
allergy; and complex cases of multi-organ allergic disease.
for patients with complex allergic diseases. Accessibility
Data concerning some of these disorders are available in a
to affordable and cost-effective therapy and to novel
few countries, but only for certain age groups.
therapies is needed. For example, adrenaline auto-injectors
for patients at risk of anaphylaxis; new and more effective
Recommendation: medications to treat severe asthma; and access to allergen
Every country should undertake epidemiological studies immunotherapy are lacking in some parts of the world.
to establish the true burden of allergic diseases; asthma;
and primary and secondary immunodeficiency diseases.
Recommendation:
This is the first essential step in ensuring the provision of
Public health officials should provide for adequate
adequate physician and healthcare professional services to
allergy/clinical immunology services, including access to
meet both current and future needs.
specialists and diagnostic and treatment centers. Allergists
should be able to prescribe the most cost-effective
medication to manage a patient’s disease. Examples
include adrenaline auto-injectors to treat anaphylaxis;
anti-IgE for severe asthma; a variety of very effective
medications to treat chronic urticaria and angioedema,
hereditary angioedema, rhinitis, conjunctivitis and asthma.

Copyright 2011 World Allergy Organization

12 Pawankar, Canonica, Holgate and Lockey

Allergen-specific immunotherapy is effective in preventing

the onset of asthma and is the only available treatment V. Recognition Of The Specialty
to prevent anaphylaxis and death from bee, wasp, yellow And Training Programs
jacket, hornet and ant induced anaphylaxis. Consultations
with allergists, timely diagnosis and treatment are Identified Need:
necessary to improve long-term patient outcomes and Globally, medical education providers need to recognize
quality of life and to reduce the unnecessary direct and allergy / clinical immunology as a specialty or sub-
indirect costs to the patient, payer and society. specialty, resulting in adequate training programs for
optimal patient care.

IV. Undergraduate And

Recommendation:
Postgraduate Education For Expertise in allergy and clinical immunology should be an
Primary Care Physicians And integral part of the care provided by all specialty clinics.
Where allergy/clinical immunology training is not presently
Pediatricians available or recognized as a specialty, training and national
accreditation programs should be instituted to enable
Identified Need: selected physicians to receive formal training and the
There is a need for undergraduate and postgraduate qualifications required to become certified allergists/clinical
training in allergy, asthma and clinical immunology for immunologists. Such programs will also enable general
general practitioners and pediatricians such that primary practitioners, including pediatricians, to enhance their
care physicians and pediatricians may appropriately assist capacity to provide for the routine care for patients with
patients with allergic diseases. allergic diseases.

Recommendation:
Allergic diseases are a major cause of morbidity and VI. Public Awareness Of
mortality. Suitable undergraduate and postgraduate Allergy, Asthma And Clinical
training for medical students, physicians, pediatricians
and other healthcare professionals will prepare them Immunology
to recognize allergy as the underlying cause of many
common diseases. It will also enable them to manage Identified Need:
mild, uncomplicated allergic disorders by targeting the In most populations around the world, there is a lack
underlying inflammatory mechanisms associated with of adequate education about, and awareness of, the
these diseases. They will learn when and how to refer the morbidity and mortality associated with allergic diseases;
more complicated cases for a specialist consultation. Such the often chronic nature of these diseases; the importance
education at the general practice level is of paramount of consulting a physician trained in allergy, asthma and
importance since the vast majority of patients with allergic clinical immunology; and the medications and treatments
diseases are cared for by primary care physicians and available to appropriately treat and prevent these diseases.
pediatricians. These clinicians will also be required to co-
manage such patients with an allergy specialist and should
Recommendation:
be aware of the role of the allergist/clinical immunologist
Public health authorities should target allergic diseases
in investigating, managing and caring for patients with
as a major cause of morbidity and potential mortality.
complex allergic problems.
They should collaborate with national allergy, asthma and
clinical immunology societies and patient support groups
to publicize the necessity for general awareness and
appropriate care for these diseases.

Copyright 2011 World Allergy Organization

 WAO White Book on Allergy 2011-2012: Executive Summary 13

Conclusion

The World Allergy Organization is a global federation of 84 national and regional allergy,

and Executive
Introduction
asthma and clinical immunology societies. These regional and national societies are an

Summary
excellent resource for knowledge and expertise. It is strongly recommended that public
health and government officials, medical school leaders and patient groups collaborate
with these societies to promote excellence in care for patients with allergic diseases.

As members of the World Allergy Organization, the regional and national allergy, asthma
and clinical immunology societies contribute to the work of the WAO Councils and are

Declaration
of the WAO
available to assist with enquiries about how best to implement these recommendations.
Information is available on the WAO website www.worldallergy.org and enquiries may be
directed to [email protected].

Conclusion

Copyright 2011 World Allergy Organization

Notes
Notes