key: cord-0697263-408ek3ha authors: Hagemann, Jan; Onorato, Gabrielle L.; Jutel, Marek; Akdis, Cezmi A.; Agache, Ioana; Zuberbier, Torsten; Czarlewski, Wienczyslawa; Mullol, Joaquim; Bedbrook, Anna; Bachert, Claus; Bennoor, Kazi S.; Bergmann, Karl‐Christian; Braido, Fulvio; Camargos, Paulo; Caraballo, Luis; Cardona, Victoria; Casale, Thomas; Cecchi, Lorenzo; Chivato, Tomas; Chu, Derek K.; Cingi, Cemal; Correia‐de‐Sousa, Jaime; del Giacco, Stefano; Dokic, Dejan; Dykewicz, Mark; Ebisawa, Motohiro; El‐Gamal✝, Yehia; Emuzyte, Regina; Fauquert, Jean‐Luc; Fiocchi, Alessandro; Fokkens, Wytske J.; Fonseca, Joao A.; Gemicioglu, Bilun; Gomez, René‐Maximiliano; Gotua, Maia; Haahtela, Tari; Hamelmann, Eckard; Iinuma, Tomohisa; Ivancevich, Juan Carlos; Jassem, Ewa; Kalayci, Omer; Kardas, Przemyslaw; Khaitov, Musa; Kuna, Piotr; Kvedariene, Violeta; Larenas‐Linnemann, Desiree E.; Lipworth, Brian; Makris, Michael; Maspero, Jorge F.; Miculinic, Neven; Mihaltan, Florin; Mohammad, Yousser; Montefort, Stephen; Morais‐Almeida, Mario; Mösges, Ralph; Naclerio, Robert; Neffen, Hugo; Niedoszytko, Marek; O’Hehir, Robyn E.; Ohta, Ken; Okamoto, Yoshitaka; Okubo, Kimi; Panzner, Petr; Papadopoulos, Nikolaos G.; Passalacqua, Giovanni; Patella, Vincenzo; Pereira, Ana; Pfaar, Oliver; Plavec, Davor; Popov, Todor A.; Prokopakis, Emmanuel P.; Puggioni, Francesca; Raciborski, Filip; Reijula, Jere; Regateiro, Frederico S.; Reitsma, Sietze; Romano, Antonino; Rosario, Nelson; Rottem, Menachem; Ryan, Dermot; Samolinski, Boleslaw; Sastre, Joaquin; Solé, Dirceu; Sova, Milan; Stellato, Cristiana; Suppli‐Ulrik, Charlotte; Tsiligianni, Ioanna; Valero, Antonio; Valiulis, Arunas; Valovirta, Erkka; Vasankari, Tuula; Ventura, Maria Teresa; Wallace, Dana; Wang, De Yun; Williams, Siân; Yorgancioglu, Arzu; Yusuf, Osman M.; Zernotti, Mario; Bousquet, Jean; Klimek, Ludger title: Differentiation of COVID‐19 signs and symptoms from allergic rhinitis and common cold: An ARIA‐EAACI‐GA(2)LEN consensus date: 2021-05-14 journal: Allergy DOI: 10.1111/all.14815 sha: 81b67c161a96739fbe738c597624ef04b04d9688 doc_id: 697263 cord_uid: 408ek3ha BACKGROUND: Although there are many asymptomatic patients, one of the problems of COVID‐19 is early recognition of the disease. COVID‐19 symptoms are polymorphic and may include upper respiratory symptoms. However, COVID‐19 symptoms may be mistaken with the common cold or allergic rhinitis. An ARIA‐EAACI study group attempted to differentiate upper respiratory symptoms between the three diseases. METHODS: A modified Delphi process was used. The ARIA members who were seeing COVID‐19 patients were asked to fill in a questionnaire on the upper airway symptoms of COVID‐19, common cold and allergic rhinitis. RESULTS: Among the 192 ARIA members who were invited to respond to the questionnaire, 89 responded and 87 questionnaires were analysed. The consensus was then reported. A two‐way ANOVA revealed significant differences in the symptom intensity between the three diseases (p < .001). CONCLUSIONS: This modified Delphi approach enabled the differentiation of upper respiratory symptoms between COVID‐19, the common cold and allergic rhinitis. An electronic algorithm will be devised using the questionnaire. Although there are many asymptomatic patients, one of the problems of COVID-19 is early recognition of the disease. Premedical visit screening and symptom evaluation have to be implemented quickly to minimise the risk of seeing COVID-19 patients unprepared. Furthermore, testing for coronavirus is still widely restricted due to the shortage of available PCR tests in many countries. 1 Testing capacities have improved dramatically since the beginning of the pandemic, with the recent addition of antigen-based testing. Some of these tests are home-based and have only just obtained FDA approval. However, they still represent a bottleneck, 2 with the subsequent waiting periods leading to large groups of people at risk of infection requiring quarantine. To prevent unnecessary closure of critical facilities, for example schools and public services, triage requires further improvement in terms of speed and accuracy. COVID-19 symptoms are polymorphic. Typically, induces shortness of breath, cough, fever, nasal congestion and general malaise. 3 However, SARS-coronavirus-2 (SARS-CoV-2) infection has been linked to a number of other symptoms afflicting several organ systems, including muscle and joint pain, sore throat, headache, nausea, vomiting and diarrhoea, as well as coagulopathy. 4 Impaired sense of smell and taste has emerged as an alarming symptom of SARS-CoV-2 infection in the West, but not so much in Asia. [5] [6] [7] [8] [9] Presentation in the upper respiratory tract has also been described as extremely variable across age groups, 10 making it difficult to distinguish COVID-19 from common upper respiratory infections (e.g. croup in children 10 ). Therefore, besides the management of severe COVID-19, one of the major problems of the infection is how to screen citizens with possible COVID-19 and distinguish them from patients with similar symptoms caused by allergic rhinitis 11, 12 distinction is needed for this approach and may be of great importance during the winter with the co-existence of COVID-19, flu, common cold or other respiratory viral infections and house dust mite-induced rhinitis. Systematic reviews and meta-analyses have been produced for many COVID-19 symptoms including differentiation between flu and COVID-19. 13 However, there is insufficient knowledge on consensus across the international medical community regarding nasal symptoms that may enable differentiation between COVID-19, common cold and allergic rhinitis. An ARIA (Allergic Rhinitis and its Impact on Asthma)-EAACI (European Academy of Allergy and Clinical Immunology)-GA 2 LEN (Global Allergy and Asthma European Network) initiative was carried out to establish consensus on a set of questions aimed at distinguishing these diseases. From this consensus, an algorithm will be proposed and digitalised using a method already validated in MASK. [14] [15] [16] The current paper presents the results of the consensus. This is a new paper of the series of ARIA-EAACI papers on COVID-19. 17-21 A modified Delphi was carried out. 22 A questionnaire developed by JB, WC, LK and JM was sent to all ARIA members by GLO. Those seeing COVID-19 patients were requested to answer within a week. The questionnaire included items related to upper and lower airway symptoms for COVID-19, common cold and allergic rhinitis (Table 1 ). In the questionnaire, the respondents were asked to assess five nasal symptoms, three ocular symptoms, taste, smell, cough, wheezing and sore throat. For each question, there was a statement on frequency and severity. For this, participants were asked to grade the severity from 0 to 10. Then, they gave a global assessment from 0 to 10 according to whether they agreed on the suggested severity grading for the three diseases. A level of 6 or higher was considered as agreement. Suggestions for questions/statements were able to be added to the questionnaire. A total of 87 answer sheets were included in this analysis. Any written comments were transformed into numeric changes where possible. To determine whether the participants agreed that the symptom/item was to be included in the tool, we collected the total number of participants agreeing as well as the total percentages. The same procedure was used for disagreement and missing/invalid data, respectively. Among the 192 questionnaires sent out, 89 (46.3%) were returned within 7 days. The average monthly number of COVID-19 consultations among the participants was 16.8 ± 20. The participants were from 37 different countries ( Figure 1 ). There was a high proportion of agreeing participants, with an average of 76.3% (range 69-83). The overall data quality was acceptable, and missing values for some of the questions were below 20% (Table 2) . Participants were able to grade the maximum expected severity for each disease, and the average final VAS severity data are shown in Figure 2 . A two-way ANOVA revealed significant differences in symptom intensity between the three diseases (p < .001). Eye symptoms (7, 8) were among the most discussed statements, and the corresponding statements had relatively low levels of approval ( Figure 1 ). Nasal pain (5) was regarded as impractical by six participants, which was also reflected by a relatively low level of Missing/invalid answer n = 87 n % n % n % Figure 3 ). This was possibly caused by different interpretations of the item's description, and this issue needs to be addressed in further developments of the algorithm. Additional common COVID-19 symptoms will be considered for integration in the future algorithm development process (Table 3 ). Additional supporting information may be found online in the Supporting Information section. Lessons learnt from easing COVID-19 restrictions: an analysis of countries and regions in Asia Pacific and Europe Current status of diagnostic testing for SARS-CoV-2 infection and future developments: a review A meta-analysis of 67 studies with presenting symptoms and laboratory tests of COVID-19 patients Clinical characteristics of covid-19 in New York City Chemosensory dysfunction in COVID-19 out-patients Frequency and clinical utility of olfactory dysfunction in COVID-19: a systematic review and meta-analysis Olfactory and gustatory dysfunctions in COVID-19 patients: a systematic review and meta-analysis East-West differences in clinical manifestations of COVID-19 patients: a systematic literature review and metaanalysis The loss of smell and taste in the COVID-19 outbreak: a tale of many countries A case series of pediatric croup with COVID-19 Allergic rhinitis Treatment of allergic rhinitis during and outside the pollen season using mobile technology. 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Recto, Shereen M Elina Toskala, Massimo Triggiani, Nadja Triller, Katja Triller, Ioanna Tsiligianni, M