key: cord-1014378-krw4k5md
authors: Cianferoni, Antonella; Votto, Martina
title: COVID‐19 and allergy: How to take care of allergic patients during a pandemic?
date: 2020-11-24
journal: Pediatr Allergy Immunol
DOI: 10.1111/pai.13367
sha: 2bcaab5e000489353a5159d6c91ba6962bd3e0bc
doc_id: 1014378
cord_uid: krw4k5md

Severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), also known as COVID‐19, is a new strain of coronavirus that has not been previously identified in humans. SARS‐CoV‐2 is recognized as a highly contagious respiratory virus with severe morbidity and mortality, especially in vulnerable populations. Being a novel disease, everyone is susceptible, there are no vaccine and no treatment. To contain the spread of the disease, health authorities throughout the world have restricted the social interactions of individuals in various degrees. Allergists, like other physicians, are faced with the challenge of providing care for their patients, while protecting themselves and patients from getting infected, with strategies that are in continuous evolution as states work through the different stages of social distance. Allergist provides care for patients with the most common non‐communicable disease in the world: asthma, allergic rhinitis, food allergy, venom allergy, drug allergy atopic dermatitis, and urticarial syndromes. Some of these diseases are not only considered risk factors for severe reactions but also have symptoms such as cough and sneezing that are in differential diagnosis with COVID‐19. As we move forward, allergy symptoms may prevent patients from working, go to school, or access medical services that increasingly are allowing only asymptomatic individuals. In this review, we will outline how to take care safety of different allergic patients during the pandemic.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), also known as COVID-19, is a new strain of coronavirus that has not been previously identified in humans and is thought to have originated in chrysanthemum bats in Wuhan City, Hubei Province. 1 Since December 2019, when Chinese public health authorities noticed several cases of acute respiratory syndrome in Wuhan City, SARS-CoV-2 outbreaks and clusters of the disease have since been observed in Asia, Europe, Australia, Africa, and the Americas and WHO declared a pandemic on March 11, 2020. SARS-CoV-2 is now recognized as a highly contagious respiratory virus. SARS-CoV-2 has multiple clinical presentations from asymptomatic to severe lung injury and multiorgan disease, especially in older individuals and those with chronic comorbidities. This polyhedric presentation makes it difficult to predict which health consequence the virus will have on the single individual and make it challenging to contain the spread. 2 while developing drugs, vaccines, and hospital/healthcare preparedness, health authorities throughout the world have restricted social interactions of individuals in various degrees. Typically, the most restrictive measures are taken in the "red zone" or "phase 1" when full quarantine measures are recommended for all citizens. In such a phase, only life-sustaining businesses are open, schools are closed, and there are government-imposed social distancing rules.

These extreme mitigation strategies are followed by a progressive reopening approach with different phases such as "orange zone," "yellow zone," "green zone," or phase 2 and phase 3 that ease the restrictions as the virus becomes less prevalent in the community and healthcare systems are more prepared to treat the infected individuals ( Figure 1 ). 3 Allergists, like other physicians, face the challenge of providing care for their patients while protecting themselves and patients from getting infected. To achieve this goal, they use tactics that are in continuous evolution, adjusting work practices to state-mandated restrictions, without clear guidelines but largely guided by fragmented recommendations given by local, national, and international organizations. 4 Allergists provide care for patients with the most common non-communicable disease in the world: asthma, allergic rhinitis, food allergy, venom allergy, drug allergy atopic dermatitis, and urticarial syndromes. Some of these diseases are not only considered risk factors for severe reactions but also have symptoms, such as cough and sneezing, which are in differential diagnosis with COVID-19. Taking care of the atopic patients is therefore essential not only to reduce severe outcomes of COVID-19 infections, but also to prevent symptoms that may preclude allergy patients from working, go to school, or access medical services if they are suspected of carrying the novel virus. To take care of those patients, allergists use procedures that require close contact with patients and can aerosolize the virus, and many therapeutic approaches that modulate the immune system. Risk and benefit for the single patients and the staff need to be carefully evaluated before doing them. 4,5

We know that SARS-CoV-2 spreads mainly from person to person, for interaction below 6 feet (1.8 m) via large droplets, produced when an infected person coughs, sneezes, or talks. Those droplets can land in the mouth, nose, or eyes of people nearby and can be inhaled. Symptomatic and asymptomatic individuals can spread the disease very easily and sustainably between people. The virus can also spread in other ways, from touching surfaces or objects, feces, animals to people, and people to animals, but these are not thought to be the main ways the virus spreads. 3 Information from the ongoing COVID-19 pandemic suggests that this virus is spreading more efficiently than influenza (R 0 = 1-2), but not as efficiently as measles (R 0 = 12-18), which is highly contagious. 1 We know that the way to reduce person-to-person spreads are to maintain good social distance (about 6 feet); cover your face with a mask; wash your hands often with soap and water or use a hand sanitizer with at least 60% alcohol; and routinely clean and disinfect frequently touched surfaces. 3 While organizing the office space, it is very important that when possible, staff will maintain 6-feet distance from each other, and also healthcare providers will maintain when possible such distance from patients. shown to reduce transmission in healthcare setting. 5 Furthermore, while the vaccine is not available, the CDC and ECDC have recommended the healthcare providers to use personal protective equipment (PPE) typical for standard, contact, and airborne precautions and use eye protection (Table 2) . Therefore, to take care of COVID-infected or potentially infected patients, gowns, gloves, and either an N95 respirator (in the USA) or FFP3/FFP2 (in Europe) plus face shield and goggles or a powered air-purifying respirator (PAPR) should be used. However, there is a worldwide shortage of N95 and PARP; therefore, allergists may need to use a face mask

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), also known as COVID-19, poses a new threat for the communities. Allergists serve patients, who are affected by chronic disease and need continuity of care during the pandemic. The level of community spread of the virus will likely fluctuate during the coming years until either a universal vaccine or herd immunity is achieved.

Allergists need to be ready to operate safely with appropriate modifications of their practice tailored on community circulation. To reduce the risk of exposure, the allergist can decide to visit only asymptomatic patients, by strict screening phone call prior to the visit. Patients should be asked whether they have been exposed to COVID-19 infected individuals, whether they have traveled to areas of high transmission, and whether they have any of the typical symptoms ( Figure 2 ). Telehealth can be used instead of an in-person visit. Furthermore, procedures such as spirometry and nebulizers should be avoided. 3

To reduce the spread of the virus, policies in the office should be present in the office to self-quarantine asymptomatic healthcare providers that have been directly exposed to sick patients or in the community ( Figure 2 and Table 2 ).

For certain periods, allergist may be asked to reduce the visit to only essential ones, in order to reduce the physical contact among people and to preserve PPE and resources.

It is important to note that many allergy/immunology services are elective and can be managed without face-to-face interaction or deferred outright for short periods. Prioritizing certain services may be required when countries go in the red zone to prevent disease spread or based on the availability of adequate PPE for healthcare providers (Table 1 and Table 2 ). 4, 5 We will here review how to treat specific conditions in the allergy office.

Skin testing may require prolonged contact with the patients, and

there is a risk of fluid body contamination, especially in children that may cry or cough while doing the procedure.

In the red zone, such a procedure can be delayed as often information is not essential for the immediate treatment of the patient.

Skin tests can be resumed in yellow/orange zone (phase 2/3) if appropriate PPE is available for healthcare providers such as a mask, eye protection, gowns, and gloves. 4,5

Food challenges represent the gold standard for the diagnosis of food allergy, as in vitro and in vivo testing has not enough specificity and sensitivity to predict tolerance of food in patients with Patients at low risk of reaction (higher doses of oral immunotherapy, never reacted before) should be restarted first followed by those patients at increased risk of reactions as conditions improve. For highest risk patients requiring essential testing, lung function should be carried out in a negative pressure room and using equipment only for high risk or infected patients. These should be discarded afterward.

Exercise testing, nebulization, bronchial challenge tests, and

other aerosol-generating procedures should be postponed during the pandemic until the green phase is reached.

Asthma is one of the most common lung diseases globally, and its incidence is still increasing in developing country. It is listed as a risk factor for severe disease by the CDC in the case of COVID-19

infection. 3 This recommendation is largely based on the fact that SARS-CoV-2 is a coronavirus and can cause asthma exacerbation.

However, other previous severe pandemic coronaviruses (SARS-CoV and MERS-CoV) have not been associated with asthma.

Similarly, during this current pandemic, there are little data to demonstrate a specific increased risk of COVID-19 from asthma.

Data from China, Korea, and the United States note that asthma is not a strong risk factor for severe COVID-19 disease, and actually, severe patients appear to be less likely to have asthma or COPD than the general population. 1,2 However, these data are based on hospitalized patients and may have significant limitations due to selection and reporting bias. It is also possible that asthma may use more caution and increased social distancing to avoid infections.

Nonetheless, there is no evidence that anti-inflammatory medication taken regularly to prevent inflammatory diseases is putting patients at increased risk of severe COVID-19-related disease. 7 On the other hand, we know that patients with asthma during the pandemic continue to have a risk of exacerbation not only related to SARS-CoV-2 but also related to other infectious and allergy triggers with well-known morbidity and mortality. Asthma exacerbation requiring medical emergency treatment may increase the risk of exposure to COVID-19 due to visits to healthcare facilities. 4 Allergen immunotherapy can be considered the following recommendation outlined before l. 6 One challenge during pandemic is to find food allergen-free or of a particular brand that patients are accustomed to; therefore, referral to nutrition to address the nutritional needs of patients may be warranted. 9

For allergic skin disorder, specific recommendations on service reduction are as follows:

In patients with urticaria, angioedema, and atopic dermatitis, the majority of visits can be considered under the non-urgent category

where face-to-face care can be postponed or conducted via phone with digital photographs triage or telehealth. 3,10

Patients who are doing biologics for any of the above diseases can continue to receive those during the pandemic. For patients with known hereditary angioedema who develop an acute episode, visiting local urgent or emergency healthcare facilities is appropriate.

Also, every effort should be made to obtain on-demand therapy for home administration. 4, 5 All visits can be postponed desensitization in the hospital setting for essential antibiotics can be done. 6 For venom allergy, being VIT of patients with a history of a systemic reaction to the venom, as this is a life-threatening condition, is considered an essential service, as discussed before.

Patients with immunodeficiency are at high risk of complication for COVID-19, so balance for prompt face-in-face service and risk that those services pose need to be carefully evaluated. Those patients can be continued on IVIG per regular therapy, although the IVIG products are unlikely to cover for the current virus, given the still low prevalence in the general population. Consideration to switch to subcutaneous vs IV formulation should be considered as well as at home vs. in hospital/office administration. Telehealth can be continued for those encounters that do not require in-person visit. 4,5

A pandemic response is likely and once in a lifetime event, making challenging to reorganize clinical practice and continue to adapt those changes based on viral infection level in the community.

Any suggestions may, therefore, change rapidly based on the evolving situation on the territory. Limiting in-person visit may have significant financial consequences, and also at a certain point, delay of procedure may represent a more significant risk for patient than the potential risk of being exposed to COVID-19 and should be taken under consideration. 

Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72314 Cases From the Chinese Center for Disease Control and Prevention

Novel Coronavirus-Important Information for Clinicians

COVID-19: Pandemic Contingency Planning for the Allergy and Immunology Clinic

Managing childhood allergies and immunodeficiencies during respiratory virus epidemics -the 2020 COVID-19 pandemic

Administration of subcutaneous allergen immunotherapy during the COVID-19 outbreak: A Work Group Report of the AAAAI Immunotherapy, Allergen Standardization and Allergy Diagnostics (IASAD) Committee

Covid-19 in Immune-Mediated Inflammatory Diseases -Case Series from New York

Acute At Home Management of Anaphylaxis During the Covid-19 Pandemic

Dietary Management of Food Protein-Induced Enterocolitis Syndrome during COVID-19 Pandemic

Considerations on Biologicals for Patients with allergic disease in times of the COVID-19 pandemic

Medical Advisory Board of the International FPIES Association. Managing food protein-induced enterocolitis syndrome during the coronavirus disease 2019 pandemic: Expert recommendations

COVID-19 and allergy: How to take care of allergic patients during a pandemic?