Food allergy and anaphylaxis affect millions of people globally. Here we outline some facts about food allergy and related issues from the perspective of various countries:   Australia New Zealand Canada The Netherlands Germany United Kingdom Italy United States   Australia (represented by Anaphylaxis Australia) Top three concerns: Food labeling Management of anaphylaxis throughout Australia (i.e., in doctors’ offices, emergency departments, child care facilities, and schools) Adrenaline cost for those 17 years old and over Prevalence The prevalence of food allergy in Australia is estimated to be 1 percent to 2 percent of the population. Common food allergens Milk, egg, peanut, tree nuts, shellfish, fish, sesame, and soy. Treatment In Australia, the medication prescribed to treat severe allergic reactions – anaphylaxis – is adrenaline, also known as epinephrine. It is available as an EpiPen® or a vial and syringe. EpiPens can be purchased from pharmacies on “authority prescription,” which means the Australian government subsidizes the cost as part of the Pharmaceutical Benefits Scheme (PBS). Any allergist, immunologist, pediatrician, respiratory, or emergency physician can prescribe an EpiPen on the PBS, and a general practitioner can also prescribe it on the PBS if he or she consults an allergy specialist over the phone. Those over the age of 17 can currently purchase one EpiPen on the PBS, whereas those under 17 can purchase two EpiPens on the PBS at a given time. Additional EpiPens can be purchased over the counter in a pharmacy for about $100. Antihistamines such as Telfast®, Claratyne®, Zyrtec®, and Phenergan® can be purchased over the counter from pharmacies. Emergency services In Australia, dial 000. Specify that someone is having an anaphylactic or severe allergic reaction so that an ambulance is dispatched as quickly as possible. Most ambulances carry adrenaline and officers who are able to administer it. Labeling Food Standards Australia New Zealand (FSANZ) regulates packaged and unpackaged foods in Australia and New Zealand. The FSANZ Food Standards Code 1.2.3 has been operational from December 20, 2002. Under the FSANZ Food Standards Code, crustaceans, egg, fish, milk, tree nuts, sesame seed, peanut, soy, gluten-containing cereals, and products derived from them must be named on the ingredient list at all times, without exception. The cutoff for all other component ingredients is 5 percent, and ingredients are listed in descending order of weight. Back to Top • • • • • • • • • • • • Canada (represented by Anaphylaxis Canada and Association Quebecoise des Allergies Alimentaires) Anaphylaxis Canada Top three concerns: Food labeling regulations and standards for priority allergens Development and implementation of standard anaphylaxis policies and legislation for all schools across the country Increased awareness of and education about anaphylaxis within the community, including medical professionals, educators, patients, and representatives of the food and food service industries Prevalence While the exact prevalence is unknown, it has been estimated that more than 600,000, or 1 percent to 2 percent, of Canadians are at risk for anaphylaxis from food and insect sting allergy. More recent studies suggest that nearly 4 percent of the U.S. population, or 1 in 25 Americans, is at risk for food allergy alone, a rate much higher than noted in the past. Canadian trends are thought to mirror those of the U.S., given similarities in lifestyle. Food allergy affects up to 6 percent of young children in North America. Common food allergens Peanut, tree nuts (e.g., almond, hazelnut, cashew, walnut), soy, sesame seed, wheat, milk, egg, fish, shellfish, and sulfite (an additive). Treatment Epinephrine (also known as adrenaline) is the medication prescribed in Canada to treat severe allergic reactions (anaphylaxis). EpiPen® or Twinject® can be purchased as “behind-the-counter” drugs (prescription not required) in many provinces. Antihistamines such as Reactine®, Benadryl®, and Claritin® are available over the counter in drugstores and large supermarkets; however, they are not recommended as the first line of defense to treat a severe allergic reaction. Emergency services For the most part, individuals make contact with the prehospital care system by calling 911. There are exceptions in more isolated regions, such as the Northwest Territories, where a 2222 prefix is dialed before 911 and rural parts of Newfoundland, where a local seven-digit ambulance service is required. (911 is used in urban centers in Newfoundland.) Not all ambulances in Canada carry epinephrine, and not all levels of paramedics are allowed to inject epinephrine; however, most can assist patients with self-injection. Labeling The Canadian Food Inspection Agency regulates packaged food labeling: The priority allergens must be listed on the label, or the product is subject to recall. The primary ingredients are listed by name, except for oils (only peanut oil must be specified), fats, colors, and flavors. It is proposed and recommended that the plant source be identified by the common name for each of the following foods: hydrolyzed plant protein, flour, gluten, starch, and modified starch. This is not, however, a regulation, and labeling exemptions under the Food and Drug Regulations still include seasonings, flavorings, colors, hydrolyzed plant protein, lecithin, starch, some items that compose less than 5 percent to 10 percent of the product, sources of cross-contact during processing, and sources of domestic oils (except peanut, which must be declared). New food labeling regulations are currently under review by Health Canada.   Association Quebecoise des Allergies Alimentaires (AQAA) Top three concerns: Education to promote the safe social integration of food-allergic and anaphylactic individuals (e.g., child care establishments, schools, camps, restaurants) Education of health professionals (nurses, physicians, dietitians) to encourage uniformity in their recommendations regarding prevention and treatment of anaphylactic reactions. Food industry education (allergen control, labeling, etc.). Prevalence One percent to 2 percent of the general population is considered to be at risk for anaphylaxis, and the number is higher among children (2 percent to 8 percent). It is also estimated that 3 percent to 4 percent of the general population and 6 percent to 8 percent of children suffer from food allergies. Common food allergens Peanut, tree nuts (e.g., almond, hazelnut, cashew, walnut), soy, sesame seed, wheat, gluten, milk, egg, fish, shellfish, and sulfites. Treatment Epinephrine is the medication prescribed in Canada to treat severe allergic reactions. Epinephrine is available by prescription as an EpiPen® or a Twinject® autoinjector. It is available over the counter in most provinces. Antihistamines such as Reactine®, Benadryl®, and Claritin® are available over the counter in drugstores and large supermarkets. Emergency services In most areas of Canada, dial 911. If there is no 911 service in a particular area, dial 0, and an operator will make the appropriate connection. Labeling The Canadian Food Inspection Agency regulates packaged food labeling. The priority allergens must be listed on the label or the product is subject to recall. The primary ingredients are listed by name except for oils (only peanut oil must be specified), fats, colors, and flavors. It is proposed and recommended that the plant or animal source be identified by common name for each of the following foods: hydrolyzed proteins, flour, gluten, starch, modified starch, and lecithin. This is not, however, a regulation and labeling exemptions under the Food and Drug Regulations still include: seasonings, flavorings, colors, some items that compose less than 5 percent to 10 percent of the finished product, cross-contact during processing, source of domestic oils (except peanut, which must be declared), hydrolyzed proteins, lecithin, and starch. Back to Top • • • • • • • • • • • • Germany (represented by Deutscher Allergie- und Asthmabund e.V. [DAAB]) Top three concerns: Promote awareness and understanding of anaphylaxis in health professionals – recognizing anaphylaxis, prodividing consistent treatment with epinephrine in public: schools and child care facilities at home: friends and family giving support Implement training programs for patients and their families Improve food labeling Prevalence Two percent to 3 percent of the German population has food allergies. The prevalence in children is 3 percent to 6 percent, but can be up to 30 percent in high-risk groups, such as children with eczema. Common food allergens In children: milk, egg, soy, wheat, tree nuts, peanuts, fish In adults: tree nuts, pip and stone fruits (apple, peach), vegetables (celery, carrot), fish, shellfish, peanut, soy, milk, egg, wheat Treatment For those diagnosed with food allergy and a risk of anaphylaxis, an emergency kit is prescribed that contains an epinephrine autoinjector, antihistamine, steroid, and, depending on the symptoms, ß2-mimetics. Antihistamines are also available over the counter. Emergency Services In Germany, dial 112. All ambulances carry adrenaline, as well as an emergency physician who can administer it. Labeling Germany follows the labeling regulations set by the European Union (EU) in EU Guideline 2003/89/EG. Since November 25, 2005, all packaged food that is produced in Germany has to follow the updated version of the food labeling regulations: The 13 main food allergens must be listed: gluten-containing cereals, shellfish, fish, egg, peanut, soy, milk, tree nuts, celery, mustard, sesame seed, lupine and mollusks. Products derived from these allergens must be named without exception if used as an ingredient. In addition, sulfite must be listed if more than 10mg/kg is used. If the legal name of the product identifies the use of an allergen, it does not need to be listed with the ingredients. If an ingredient derived from one of the main food allergens is considered free of any allergenic protein, it does not have to be listed (every exception is assessed by the European Food Safety Authority; e.g., glucose syrup from wheat starch). Food for direct consumption and loose products are not included in labeling regulations. The unintended presence of food allergens in products via cross-contact is not covered under the labeling regulations. Manufacturers can voluntarily label these ingredients with “May contain” statements. There are no guidelines for the use of these statements so far. Back to Top • • • • • • • • • • • • Italy (represented by Food Allergy Italia) Top three concerns of Food Allergy Italia: Emergency treatment Labeling Education in school Prevalence An estimated 6 to 8% of the Italian population has food allergies. Common food allergens Cow's milk, hen's egg, wheat, fish, tree-nut, peanut; Treatment At present there aren't national guidelines for the treatment of anaphylaxis. Food Allergy Italia encourages the prescription of the self-injectable adrenaline (epinephrine) for the patients at risk of anaphylaxis. Emergency services In Italy, dial 118 or 113 anywhere in the country in order to receive emergency assistance. An ambulance, fire engine, or the police can be requested. You must specify "anaphylaxis." Back to Top • • • • • • • • • • • • The Netherlands (represented by Nederlands Anafylaxis Netwerk) Top three concerns: Educating primary care physicians on the mechanisms and social impact of food allergies and anaphylaxis Improving food labeling and increasing awareness in the food industry Providing education to schools, day care centers, restaurants Prevalence In the Netherlands, approximately 800,000 people suffer from food allergies. Anaphylaxis is believed to affect 25,000 persons. Common food allergens Peanut, milk, egg, wheat, tree nuts (e.g., almond, hazelnut, cashew, walnut), soy, fish, shellfish, and sesame seed. Treatment In the Netherlands, patients at risk for anaphylaxis are prescribed an epinephrine autoinjector (EpiPen® or Anapen®). These autoinjectors are available only with a physician’s prescription. Some antihistamines are available over the counter, and others are available through prescription. Emergency services In the Netherlands, dial 112. Specify that someone is having an anaphylactic reaction, and ask for an ambulance (indicate if the reaction was due to latex, because the equipment is not always latex-free). Generally, ambulances will arrive within 15 minutes and will have epinephrine on board. Labeling The Netherlands follows labeling regulations set by the European Union (EU): All ingredients must be listed in descending order of weight, unless they are exempt processing aids whose presence in the food is due solely to the fact that it was contained in an ingredient of the food and has no specific function in the finished product. Ingredients must be declared by their legal name. If there is no legal name, a customary name or a name that accurately describes the ingredient must be used. Additives are listed by name, serial number (“E” number), or both. Ingredients in flavorings are not required to be listed individually unless they are derived from the allergenic foods mentioned in Annex II of the labeling regulation. Back to Top • • • • • • • • • • • • New Zealand (represented by Allergy New Zealand) Top three concerns: Food labeling Dearth of allergy specialists outside of main centers Access to EpiPen(r)s Prevalence: Data is not available. Common food allergens: Eggs, wheat, soy, milk, peanuts, tree nuts, fish, and shellfish. These eight foods account for 90 percent of all food allergies. However, almost any food can cause an allergy. Treatment: Adrenaline (also known as epinephrine) is the medication prescribed in New Zealand to treat severe allergic reactions (anaphylaxis). Adrenaline injection kits for personal use are available as EpiPen®s. Antihistamines such as Zyrtec®, Claratyne®, Phenergan®, Telfast®, Benadryl®, Periactin®, and Hismanal® are available over the counter at chemists (drugstores). Emergency services: In New Zealand, dial 111. State "Ambulance" to be connected to the ambulance service. Specify that someone is having an anaphylactic reaction and that adrenaline/epinephrine is needed. Not all ambulances carry epinephrine, and only paramedics are authorized to administer it. The closest ambulance unit is usually dispatched first, and a paramedic unit will be dispatched to meet the first ambulance. In parts of rural New Zealand, ambulance officers are often volunteer first-aiders and don't have paramedic qualifications. In these situations, an on-call general practitioner will be contacted and they will give instructions for treatment via radio. The general practitioner may also arrange to meet the ambulance en-route to the nearest hospital. Back to Top • • • • • • • • • • • • United Kingdom (represented by the Anaphylaxis Campaign) Top three concerns: Food labeling and information Medical advice and services for people with allergies Research Prevalence Research suggests that one in 50 children is potentially at risk of severe allergic reactions to peanuts, tree nuts, or both. A small number are affected by other foods. Common food allergens Peanut, tree nuts (e.g, almond, hazelnut, cashew, walnut), sesame seed, fish, shellfish, egg, and milk. Treatment Adrenaline (the common term in the U.K. for epinephrine) is the medication prescribed to treat severe allergic reactions (anaphylaxis). Adrenaline injection kits for personal use are available as EpiPen® and Anapen®. Antihistamines are available over the counter in pharmacies and large supermarkets. Emergency services In the U.K., dial 999 and request an ambulance. Tell them that the patient is suffering from anaphylaxis and needs adrenaline. Labeling The U.K. follows labeling regulations set by the European Union (EU). All ingredients must be listed in descending order of weight, unless they are exempt processing aids whose presence in the food is due solely to the fact that it was contained in an ingredient of the food and has no specific function in the finished product. Ingredients must be declared by their legal name. If there is no legal name, a customary name or a name that accurately describes the ingredient must be used. Additives are listed by name, serial number (“E” number), or both. Ingredients of flavorings are not required to be listed individually. Single-ingredient foods, such as fresh fruits and vegetables, and foods sold for immediate consumption do not have to list an ingredient statement. The EU has created the following list of allergens that must be declared when they appear in packaged food: Cereals containing gluten Crustaceans Egg Fish Peanut Tree nuts Soybean Milk Celery Mustard Sesame seed Sulfur dioxide and sulfites at concentrations of more than 10 mg/kg or 10 mg/liter expressed as SO2 Lupine Mollusks Back to Top • • • • • • • • • • • • United States (represented by the Food Allergy & Anaphylaxis Network [FAAN]) Top three concerns: Clear, consistent, reliable food labeling Epinephrine availability and administration by emergency medical services School management of food allergy Prevalence: Approximately 12 million Americans suffer from food allergy. Food-induced anaphylaxis is believed to cause 50,000 emergency room visits and about 150 deaths annually. Common food allergens: Milk, eggs, peanuts, tree nuts (almonds, hazelnuts, cashews, walnuts, etc.), fish, shellfish, soy, and wheat Treatment: Epinephrine, also called adrenaline, is the medication of choice for controlling a severe reaction. It is available by prescription as an EpiPen® or Twinject® auto-injector. Emergency services: In the United States, dial 911. Specify that someone is having an anaphylactic reaction and that epinephrine is needed. In many parts of the United States, certain levels of emergency medical technicians (EMTs) are not authorized to carry and administer epinephrine. As a result, specifying that epinephrine is needed will help ensure that the proper type of EMT will arrive at the scene. Labeling: In the United States, the Food and Drug Administration (FDA) regulates packaged food. FDA regulations require that protein-containing ingredients derived from the top eight allergens (milk, egg, wheat, peanut, soy, tree nut, fish, and crustacean shellfish) be identified by their common or usual name. When scientific ingredient names are used, the law requires manufacturers to list the common term in parentheses next to the scientific term, for example “casein (milk),” or to provide a “Contains” statement of each major allergen in the product directly after or adjacent to the ingredient list. Such ingredients must be listed even if they are present in colors, flavors, or spice blends. Additionally, manufacturers must list the specific nut or seafood that is used (e.g., almond, walnut, cashew; or tuna, salmon, shrimp, or lobster). The law makes an exception for highly refined oils, such as peanut oil and soybean oil. Highly refined oils are not labeled as allergens. Allergy warnings such as “May contain…” or “Manufactured in a facility…” are voluntarily used by some food manufacturers. There are no regulations for the use of these statements. However, the intent of the messages is to alert you to a risk. Avoid products with these warnings. Back to Top