Malaysian Society of Allergy and Immunology (MSAI): Malaysian Allergy Day 2021

*Note: This article involves some heavy scientific terminologies and explanations…

The Malaysian Allergy Day 2021 is a webinar organized by the Malaysian Society of Allergy and Immunology (MSAI). It was broadcasted live on the Facebook page of MSAI on the 19th of June 2021 from 7 pm to 10 pm. With the theme of “anaphylaxis” which means severe allergies, this webinar aims to raise public awareness about different aspects of allergies through the valuable sharing of six experts from different fields of allergy and immunology. 

Topic 1: Managing Severe Allergies Effectively 

Topic 2: Effective management of allergic rhinitis 

Topic 3: Covid-19 vaccines and allergic reactions

Topic 4: Immunotherapy

Topic 5: Eczema care

Topic 6: All about allergy testing 

Q&A session

Topic 1: Managing Severe Allergies Effectively 

The host of the event, Dr. Kavita Reginald, first invited the first speaker of the day, Dr. Kent Woo, a resident consultant in Gleneagles Hospital Kuala Lumpur who was trained in allergy and immunology at Louisiana State University. He was certified by the American Board of Allergy and Immunology as well as the American Board of Internal Medicine. He is also the current president of MSAI. After giving an opening speech to greet the audience and thank all the organizing committee for holding this event, he started to share about anaphylaxis. 

To begin, Dr. Kent first introduced the term anaphylaxis, a severe allergic reaction that develops rapidly and may cause death without an effective emergency treatment. It can be triggered by either the action of the allergy-causing antibody IgE or non-IgE-related factors. IgE-mediated anaphylaxis can be triggered by the top three allergens including food allergens, venom by stinging insects, and medications. Non-IgE mediated anaphylaxis is relatively rare and it may be triggered by factors like exercise, heat and cold, alcohol, and so on. When anaphylaxis occurs, one may develop swollen lips and form itchy hives on the face and body. 

Drug allergy & anaphylaxis 

Next, Dr. Kent showed the audience two cases of anaphylaxis caused by drug allergy and food allergy. There was once a young lady who had fever, cough, and shortness of breath. When asked about her history of any allergies, the patient said that she would develop a generalized itchy rash after taking an antibiotic, a “white pill” in particular, but she had no idea of its name. 

This has presented a typical myth: Drug allergy can be diagnosed. In reality, there is no blood test to determine drug allergy. Hence, the most important step is to find out the name of the medication one is allergic to. It would be better if the allergic reaction and the treatment drug could  be recorded down for future reference. 

Back to the case, the patient was prescribed the antibiotic Augmentin to treat her respiratory tract infection. Ten minutes after taking the antibiotics, she developed anaphylaxis by showing hives on her body and swollen lips, and when being rushed to the emergency room, she started developing low blood pressure. This eventually led to a diagnosis of penicillin allergy. After this experience, the patient managed to remember that she may have a penicillin allergy even after 10 years.

Although having penicillin allergy, one should not be overly worried by the limitation of treatments due to penicillin, because not all drugs will have cross-reactivity with penicillin, and in most cases, penicillin allergy will eventually reduce. If a medical condition requires penicillin, Dr. Kent recommended to get an allergy test again to reduce the use of broad-spectrum antibiotics, which can kill a diverse range of bacteria but are more toxic, less effective, and more expensive. Limiting the use of broad-spectrum antibiotics would also slow down the development of antibiotic resistance.

Food allergy & anaphylaxis 

Moving on, Dr. Kent proceeded with introducing another case arising from one of the big eight food allergens – peanut allergy. A boy with a peanut allergy was observed to have rashes around his mouth at 2 years old and also some hives on his face at 6 years old after eating peanut candy. His parents treated that as a mild allergy symptom and did not treat it seriously. 

This leads to another myth about food allergy: Prior episodes can predict the severity of future reactions. Food allergies do not have any predictable pattern as they could be influenced by the dose of allergens, health conditions, medications, and other more factors. Therefore, one with allergies must always be prepared for an emergency in the future.  

Back to the case, the same boy ate a biscuit without knowing there were peanuts in it. After complaining of itchiness around his mouth, the mother provided some antihistamine to her son. However, things got worse when he started developing hives and coughing 20 minutes later.

According to the data from the U.S., food anaphylaxis is causing around 100 deaths per year mainly due to peanuts, nuts, seafood, milk, and egg. This is especially common in people who have an underlying asthma condition, who encountered severe reactions previously, who received delayed adrenaline dose after anaphylaxis, or those who denied their symptoms as a sign of food allergy.

Epinephrine: the solution for anaphylaxis 

Back to the case again, when the paramedics reached, they administered epinephrine for the boy. Epinephrine, also known as adrenaline, is the only medication to block any sudden anaphylaxis. It can help to activate the emergency response in the body and block all anaphylactic mechanism pathways in just 10 minutes. Some might ask, how about antihistamines and steroids? Since histamine is not the only player causing anaphylaxis, both drugs will have a slower onset of action and should not be used to replace epinephrine in the treatment of anaphylaxis. Antihistamine was shown to take 80 minutes to only reduce anaphylaxis by half. 

To better manage emergencies like anaphylaxis, an autoinjector is always preferred, especially for parents who are not skilled at drawing epinephrine from an ampule. Compared to a nurse or physician who generally takes around 30-60 seconds in drawing epinephrine, parents could take 2-6 minutes, which is more likely to worsen the anaphylaxis’s reaction. With the help of an autoinjector like EpiPen, one will only need to remove the cap of the injector and inject it into the thigh. 

Before he ended his talk, Dr. Kent reminded the audience again that: 

1. For drug allergy individuals, write down the name of the allergy-causing drug and inform the doctor. 
2. For food allergy individuals, do not make any conclusion about the severity of future allergic reactions based on past mild reactions and always be prepared. 
3. If anaphylaxis happens, get epinephrine as the main treatment.

Topic 2: Effective management of allergic rhinitis 

The second speaker is Prof. Salina Husain, who is currently the vice president of MSAI and a professor of Rhinology and Consultant Otorhinolaryngology (ear, nose, and throat). She is the head of Head and Neck Surgeon at the Faculty of Medicine at the National University of Malaysia (UKM). Besides specializing in Rhinology (nose) and Skull Base Surgery, Prof Salina also has a special interest in allergy, smell, and taste. 

Allergy is an abnormal response when the body is exposed to foreign substances (allergen). It is a condition that can be inherited from parents. For instance, one is 75% likely to be allergic when both parents are allergic, but only 25% likely to be allergic if only one parent is allergic. The word atopy is used to address this genetic predisposition which produces exaggerated IgE-mediated immune response to allergen exposure. Examples of atopy conditions include allergic rhinitis (nose), asthma, and atopic dermatitis (skin).

Allergic rhinitis is the inflammation disease of the mucosal lining of the nose. When the allergen comes in contact with the mucosal layer, the resulting antigen-antibody reaction triggers the production of IgE, and subsequently, the release of histamine in the body is mediated by IgE antibodies. It is estimated to affect 500 million people worldwide and 1 out of 3 children is allergic. These individuals with allergic rhinitis tend to have sleeping problems as they cannot breathe smoothly. They may also have frequent ear infections, frequent headaches, inflammation of the nasal cavity and paranasal sinuses, or may develop asthma symptoms. These conditions can ultimately affect their productivity in school or work.

The most important symptom of allergic rhinitis is nasal congestion along with runny nose, sneezing, and nasal itching. People can also develop allergic shiners, which are black circles under the eyes due to accumulated blood in the vein caused by sinus congestion. Since atopic rhinitis is a hereditary condition, Prof Saline emphasized that current 4 treatment strategies are aimed to only relieve symptoms and improve quality of life rather than to eradicate the condition. 

Allergen avoidance 

The most effective method to reduce allergic episodes is allergen avoidance. According to Prof. Salina, the most common aeroallergens in Malaysia are house dust mite, cockroach, and cat fur, while the most common food allergens are prawn and crab. 

To create a house dust mite-free environment, it is recommended to wet mop the floor instead of sweeping the floor. One should reduce the number of carpets in the house as they can be the living site of the dust mites. Besides, an allergen blocking pillow can reduce the exposure of dust mites while sleeping. Lastly, one is advised to wash the beddings weekly in hot water more than 55°C to kill any dust mites completely. 

For those who are allergic to pet dander, the best way is to avoid having pets. However, if this is not possible, the pet should not be allowed in the house or even on beds. Once having contact with animals, these individuals should wash their hands and clothes immediately to wash away the allergens. 

If one is facing pollen allergy, it is best to stay indoors during the peak pollen period. At the same time, using an air conditioner is preferred over opening the windows to keep the room ventilated, so that exposure to external pollen can be reduced.

Medications 

The intranasal spray is a recommended therapy for allergic rhinitis as it can send the drug directly to the sensitive nasal cavity. One of them is the allergen avoidance gel, which creates a barrier on the nasal mucosa to prevent contact with the allergen. An example will be the Prevalin allergy spray. Besides, steroid-based medications can also be administered through the help of an intranasal spray to reduce inflammation and reduce swelling of the mucosal lining in the nose.

Besides, antihistamines is another drug that blocks the action of histamine upon exposure to allergens; thereby, reducing the severity of allergic reactions. However, antihistamines were reported to cause certain side effects including sleepiness and drowsiness, dryness in mouth and respiratory passages, frequent urination, and pounding heart rates.

Furthermore, decongestants may be prescribed to shrink the swollen nasal mucosal membrane and reduce nasal congestion; thereby, increasing drainage of sinus secretion. It is usually sold asoral drugs like Piriton or intranasal sprays like Afrin and Otrivine. Some drugs like Clarinase and Cirrus have a combined effect of decongestants and antihistamines. However, if decongestants are used over 7 days, the congestion will recur in a more serious condition. It should also be used cautiously for those who have heart problems as it could increase blood pressure and heart rate.

Immunotherapy 

Next, sublingual immunotherapy is a 3 to 5 year-treatment that aims to increase the patient’s immune system instead of targeting the allergic symptoms. By building allergen tolerance and suppressing inflammatory cells, it can reduce the frequency and severity of allergic rhinitis and asthma in the long run, even when there are no drugs provided after the treatment is completed.

Surgical intervention 

In the case when the nasal obstruction persists despite the best medication provided, surgery can be carried out to physically reduce the swelling in the nose structure known as inferior turbinate. By shrinking the size of inferior turbinate, air can flow into the nasal cavity and allow smoother breathing. 

Lastly, to reduce allergic rhinitis, Prof Salina recommended increasing the consumption of dark green leafy vegetables, and deep yellow or orange vegetables as these vegetables contain high levels of vitamin C to enhance the immunity level of an individual.

Topic 3:  COVID-19 vaccines and allergic reactions 

Dr. Amir Latiff was invited for the following session. As the immediate past president of MSAI, he is one of the prominent figures in the area of allergy and immunology. He graduated from the University of Malaya and completed his Fellowship training as a Specialist  Registrar in Clinical Immunology & Allergy in Leeds, UK in 1998. Currently, Dr. Amir is the resident Consultant Clinical Immunologist, Allergist and Paediatrician at Pantai Hospital Kuala Lumpur. 

About Covid-19 vaccines

Like training the military forces, vaccines work by sending in components of the body’s enemy (target pathogen), which could be its protein, toxin, or even the dead body that shows the surface protein. This trains the body to react by producing an immune response and releasing specific antibodies once immune cells detect the presence of these components. After this “training”, the body will be prepared for future infections and able to react quickly when infected by the real pathogen.

With the vaccination program running these days, the three main covid-19 vaccines available currently are Pfizer, AstraZeneca, and Sinovac, while the others include CanSinoBIO, Sputnik V, and Johnson & Johnson. These vaccines can be divided into three categories based on their components. 

The mRNA vaccine uses mRNA, a short-lifespan genetic material that instructs the body to make a harmless protein (Spike protein) found on the surface of covid-19. The mRNA technology is quite new to be used for infectious disease control, and Pfizer is an example of it. Another type of vaccine is the viral vector vaccine, which uses a harmless virus that shows spike protein on its surface to trigger immune response. Examples of it include AstraZeneca, Johnson & Johnson, CanSinoBio and Sputnik V. Lastly, vaccines that use inactivated viruses are the most classical type and have been proven effective to vaccinate against polio, Japanese Encephalitis, and Rabies. An example of it is Sinovac.

To understand the importance of vaccines, Dr. Amir brought up the explanation about Covid-19 infection stages. During the early infection stage, an individual at Stage 1 will appear asymptomatic, while at Stage 2, mild symptoms will appear without the need of hospitalization. Entering the pulmonary phase, an individual at stage 3 will start to develop pneumonia, and in stage 4 one will need oxygenation support in the Intensive Care Unit (ICU). At stage 5, the body enters a hyper-inflammation state where ventilation is required and high chances of mortality are reported. 

Among the population, the high-risk groups are advised to be vaccinated as soon as possible. This includes individuals with diabetes type 1 or 2, obesity, hypertension, high blood cholesterol, heart disease, lung disease, cancer, chronic kidney disease, and also pregnant women. 

Besides, vaccination is also recommended for mild allergy sufferers, stable HIV patients, and lactating mothers. If a person had just received another vaccine, he or she would need to wait for at least two weeks before getting their covid-19 vaccine. Even patients who had recovered from covid-19 itself are strongly recommended to get vaccinated at least after 90 days. Furthermore, the latest news has announced that teenagers above 12 years old are now eligible for vaccination. 

Vaccines & allergies 

To differentiate the two side effects of vaccinating, Dr. Amir showed the audience the comparison table between fainting and anaphylaxis.

Some may ask: What is the risk of anaphylaxis for vaccination?. Using the data from the Vaccine Safety Datalink, a previous study in the US showed that out of the 25,173,965 vaccination provided, 1117 potential anaphylaxis cases were identified based on electronic data, and only 33 confirmed anaphylaxis cases were associated with vaccination. In other words, the rate of post vaccination anaphylaxis is about 1.31 cases per million vaccine doses. 

Some vaccines contain a non-active ingredient known as polyethylene glycol (PEG) or its derivatives, poloxamer and polysorbate 80. People can be allergic to these components but the exact mechanism is still unknown. In January 2021, it was reported that the mRNA vaccines have a slightly higher risk of anaphylaxis than the other vaccines, which is 4 cases per million doses. This is because PEG was used in developing mRNA vaccines. 

Although Polysorbate 80 is also found in viral vector vaccines, It had been used in other vaccines previously such as influenza vaccines or pneumococcal vaccines. Hence, the risk of developing anaphylaxis in the viral vector covid-19 vaccines should be lower in individuals without prior anaphylaxis history towards any previous vaccines. Lastly, Sinovac and CanSinoBio do not include PEG or any derivatives in them, so this can be the simplest option for people who developed allergic reactions. 

Nonetheless, Dr. Amir pointed out that it is better to stratify individuals with allergies and assess their risk before confirming the contraindication of vaccines. Based on the allergy risk stratification grouping, patients can be categorized into high risk, medium risk, and low risk.  

Firstly, individuals will be grouped under the high-risk category if there is a history of potential anaphylaxis towards injectable medication or vaccines with PEG or polysorbate. These people may not be eligible for the mRNA vaccines. Contrarily, an individual will be grouped under the medium-risk group if there is a history of potential anaphylaxis to injectable medications or vaccines without PEG or polysorbate, whereas one who only shows a history of mild allergy reaction will fall under the low-risk group. These people can receive any three vaccines provided in the country with 30 minutes of post-vaccination observation. Ultimately, it is best to consult advice from doctors if one has any concerns about the contraindication of vaccines. 

Dr. Amir noted that instead of getting out of this pandemic, Covid-19 may eventually develop into an endemic like dengue fever that persists and be regularly found in certain areas. However, vaccination must go on as the three covid-19 vaccines are showing equal effectiveness to prevent the progression of severe infection and death. The protection provided will greatly outweigh the rare side effects like anaphylaxis and blood clot formation (AstraZeneca vaccines). Despite getting immune protection from vaccines, one should always remain the practice of social distancing and double masking to prevent the transmission of the virus. 

To end the session, Dr. Amir shared some interesting questions that scientists are still researching, including the effectiveness of the vaccines to combat covid-19 variants, the effectiveness of it to prevent people from spreading the disease, and the protection period the vaccine can provide people. 

Topic 4: Immunotherapy

The next speaker, Dr. Kavita, graduated with a PhD in the area of Allergy and Immunology from the National University of Singapore and subsequently did post-doctoral training in several reputable institutions in Austria and France. She is currently a Senior Lecturer and Programme Leader for the Biomedicine programme in Sunway University. 

She began her talk with a short introduction of the topics she will be discussing which are allergic diseases and trigger factors, management of allergy and immunotherapy. 

1. Allergic Diseases and Trigger Factor

Allergic diseases can manifest in many forms and the common ones are listed in the picture above. The risk factors of allergies are dependent on genetic factors as well as environment factors or also known as allergens such as dust mites, cockroaches, food, pollen and more. 

2. Management of Allergy

Dr. Kavita pointed out that allergy management should start with identification of the trigger factor which can be done in various ways including the skin prick test, blood test and a patch test. Once a trigger factor is identified, patients need to be educated to understand what trigger factors are and therefore learn how to avoid and minimise exposure to the allergen. Next, patients should also communicate this information to others, especially those they live with to further prevent any exposure to the allergen and possibly limit exposure to related allergens. Finally, clinical management such as symptomatic relief using antihistamines and steroids, biologicals and the highlight of Dr. Kavita’s talk – Immunotherapy.

Allergen avoidance is the simplest and most effective way of managing the allergy and best for managing easily avoidable allergens such as pet dander and food allergens. Dust mite management is a little bit tricky because it is harder to completely avoid it but it is possible to minimise it by using items such as impermeable bed covers, choosing upholstery that can be easily wiped down and reducing carpeting. Reducing humid areas will also reduce mold in the house. To minimise airborne allergen exposure, one can use air filters and a face mask when exposed to it.

Moving on, pharmacological treatment is suitable for mild-to moderate allergy intensity. The pharmacological treatments include Antihistamines and Corticosteroids, and have the effect of rapid improvement of allergic symptoms by reducing the excess mucus, itchiness and wheezing. However, it is not long lasting so it needs to be taken at regular intervals.

3. Immunotherapy

What is immunotherapy? 

It is a vaccination program that increases immunity to allergens that trigger allergic reactions. It aims to generate tolerance to allergens by modifying the immune response. The way it works can be seen in the following picture:

What are the pros and cons of this type of Immunotherapy?

Dr. Kavita explained the pros beginning with a decreased dependence on medication, which will result in a decrease of cost in the long term. It also treats the underlying cause of allergies, not merely the symptoms in contrast to pharmacological therapy which treats the symptoms alone. Immunotherapy can also treat multiple allergies at once and provide long-term allergy relief. That being said, similar to every other medication, Immunotherapy comes with some cons. There is higher up-front cost and can result in redness, swelling and tenderness at the injection site. It also needs time commitment in that one needs to go to the doctor’s office to get the injection. At the beginning of the therapy, the allergy symptoms can worsen initially in some individuals. It does not work on every type of allergy, the current products available are suitable for some allergies only such as pet dander, pollen, dust and general insect allergies. Immunotherapy to some food allergens are available but very strict patient evaluation is required. Lastly, there is a low risk of anaphylaxis which is treated with a 30 minutes observation in the doctor’s office. Despite its cons, Immunotherapy can prevent development of new allergies and prevent the progression of allergic rhinitis to asthma in children.

What is Immunotherapy recommended for?

It is recommended for individuals with:

• Allergic asthma 
• Allergic rhinitis, allergic sinusitis 
• Allergic conjunctivitis
• Pet allergy
• Stinging insect allergy 

It can only be provided and administered upon a sustainability assessment by an allergy specialist

There are 2 main modes of Immunotherapy which are Sublingual Immunotherapy(“Allergy Drops/Tablets”) and Subcutaneous Immunotherapy(“Allergy Shots”).

What to expect for Sublingual Immunotherapy(“Allergy Drops/Tablets”) and Subcutaneous Immunotherapy(“Allergy Shots”).

In summary, Immunotherapy is the only therapy that can modify the allergic immune response. It also has long term benefits of reducing patient’s allergic symptoms, and improving their quality of life. Suitability to receive immunotherapy must be carefully assessed by an allergy specialist. With that informative summary, Dr. Kavita ended her talk. 

Topic 5: Eczema Care

Dr. Kavita proceeded to invite Dr. Nazirin to give a talk on eczema care. Dr. Nazirin graduated from the royal college of surgeons in Ireland in 1997 and later obtained a Masters in Clinical Dermatology from St John’s Institute of Dermatology, St Thomas’ Hospital in London in 2007. She is now a Consultant Dermatologist that practices at Pantai Hospital KL and Nazarin Skin Clinic in Midvalley KL. 

Dr. Nazirin thanked Dr. Kavita for the kind introduction and proceeded to share the slides she had prepared for the day. The points covered in her talk are listed below:

Dr Nazarin highlighted point 4 which is the Basic Daily Routine Management of Eczema as the most important point. 

1. What is eczema?

Eczema is a long-standing, itchy, scaly, inflamed skin rash which sometimes blisters and weeps. Although it is most commonly found in children, it is not uncommon to find it in adults too. Those who have eczema in adulthood have it as a late onset eczema or it’s carried on from childhood.

In infants, the most common areas affected are the scalp, cheek, elbows and knees. As the child grows it affects the neck, front part of the elbows, around the ankles and the back of the knees. In adulthood, areas around the eyes are mostly affected too. Eczema appears as dark patches instead of red patches for patients with darker skin tone. 

2. What is the goal of eczema care?

• Reduce the number and severity of flares
• Reduce itchiness and improve quality of life
• Maintain normal activities of daily living
• Maximize disease-free periods
• Prevent infectious complications
• Avoid/Minimize side effects of therapy

3. Why is it so important to have good control of eczema?

Because the impact of eczema affects people differently at different ages. From age 0-3, common impacts include parental exhaustion and emotional distress which might lead to an impaired mother-child attachment. Whereas from 3-10 years of age, most patients go through teasing, bullying and an avoidance of social interactions and sports. As the patients grow into adulthood, they face low self-esteem.

4. What is the Basic Daily Routine Management of Eczema?

a) Keep fingernails short so that when patients accidentally scratch themselves, their skin won’t be damaged too much, lowering the possibility of infection.

b) Use gentle, non-drying, low/neutral pH, hypoallergenic, fragrance-free, non-soap cleansers.

• Oatmeal soap can help control itching
• Short, luke-warm(not hot) bath or shower daily
• Do not scrub skin
• Pat skin slightly dry. While skin is still damp, apply moisturizer within 3 minutes to seal in the hydration

c) Keep skin moisturized

• Moisturizers can be in the form of ointment, cream or lotion, the choice depends on dryness of skin. If one’s skin is very dry, it’s better to use creamier, richer moisturizers. 
• Apply moisturizer in downward motion to reduce the possibility of blockage of hair follicle which might cause inflammation or infection of hair follicle.
• Use moisturizer frequently: twice or more times per day.

d) Dress in smooth texture, loose-fitting clothes and make sure it doesn’t get overheated

• Avoid wool or mohair clothing and other scratchy clothing
• Avoid scratchy bed sheets

e) Avoid triggers

• Such as pet dander, pollen, soaps and shampoos, dust mites, wool and more

5. What to do if my eczema flares up?

a) Use of steroids

Doctors will usually prescribe steroids in the form of creams, lotions, gels and ointments should a flare up of eczema cannot be controlled by moisturizers alone. Apply steroids after applying moisturiser so that one will not forget to apply the moisturiser and it helps with absorption of steroid cream. Steroids should be used for short periods of time – few days to few weeks only. 

One shouldn’t be afraid of using steroids, however, one should use it with respect of care to avoid side effects such as inflamed hair follicles (folliculitis), thinning of skin, stretch marks and Hypopigmentation(lighter skin color).

b) Tacrolimus ointment or Pimecrolimus cream

These ointments and creams block production of proinflammatory cytokines and other inflammatory mediators. These can be used in mild eczema and for patients who have to rely a lot on steroid creams. 

c) See one’s doctor

Other treatments that can be prescribed include oral steroids, oral antibiotics, oral antihistamines and more.

6. Why is my eczema not better?

• Wrong diagnosis
• Non compliance to the Basic Daily Routine Management of Eczema
• Possibility of persistent exposure to an irritant or allergen
  • Allergens can be identified with Patch test, Prick test and lgE specific Blood test
• Concomitant infection
• Very severe eczema

7. When do I need to see the doctor for my eczema?

• To get a right diagnosis
• To get the right advice
• When eczema flares up despite practicing Basic Daily Routine Management of Eczema
• Possibility of skin infection
• uncontrolled/widespread eczema

8. Will I ever totally grow out of my eczema?

Most children do grow out of eczema, however, the later the age of onset, the more persistent the eczema will be.

Dr. Nazarin ended her insightful talk on eczema with a word of thanks for the audience’s attention. 

Topic 6: All about allergy testing 

The last speaker of the day, Dr. Shahjahan was invited to take over the “zoom mic”. Dr. Shah received his Post Graduate Degree in the Field of Allergy from Imperial College, London. He currently has his private practice which is focused on allergy diagnosis, prevention, treatment and allergy treatment at a primary care level.

He opened his talk by giving a rough outline of his talk where he will be talking about common allergies, primary care on a general practitioner (GP) level, tests done on the GP level and more.

What is an allergy?

When someone is in contact with dust mite, the immune cells under the skin will release some chemicals to fight the allergens. The effect of this on the skin is redness, itchiness, swelling or even runny nose.

What are the common allergies?

They are Eczema, Asthma, Allergic Rhinitis, Food Allergy and Chemical Allergy. These allergies can be developed at any age and could sometimes be genetic. It could also be related to the type of work done, habits such as smoking and drinking alcohol and exposure to chemicals. 

What are common allergy tests?

Skin Prick Testing(APT) in Primary Care

APT is done in clinics and is very accessible to people. Results also can be obtained within 20 minutes. Should patients show serious reactions to tests, they are advised to do the test in the hospital. To prepare the patient, doctors speak to the patients to understand their clinical history, the kind of reaction they have and medications taken. Most people take the allergy test to understand what they are allergic to so that they can avoid it. After understanding the patients’ history, consent will be taken. The doctor will proceed to explain the steps of APT. After the test, patients will be observed in case of serious side effects.

Process of conducting SPT

Doctors will obtain the result based on the reaction of the skin to the allergen. 

Specific IgE Test

It is a blood test with results given in a few days. Benefits of this test is that it can be done with many allergens. However, this comes with higher cost. 

Patch Test

It is a skin test where reagents are applied to the skin, most of the time at the back of the patient. Patient leaves it on for 24-48 hours and returns to the clinic, then the doctor will check the reaction of the skin. A variety of chemicals/metals/VOC can be tested.

Q&A session 

After the end of all sharings, the speakers gathered together on Zoom to address some questions collected from the audience. From the questions, almost half of the questions are regarding concerns about receiving covid-19 vaccines as below: 

Q1: Will there be any allergy reaction if a mix and match of vaccine types are used?

Dr. Amir clarified that the vaccine mix and match may be referring to the case like taking AstraZeneca for the first dose and taking Pfizer for the second dose of covid-19 vaccine. The mix and match should not increase the risk of anaphylaxis, but one should be assessed by stratifying the risk of getting anaphylaxis for the PEG-carrying vaccines, especially Pfizer and AstraZeneca.

Q2: Can I take the vaccines if 

1. I have eczema caused by autoimmune skin conditions/ autoimmune rheumatoid arthritis?

Patients with autoimmune disease can be vaccinated. However, those with higher risks forming blood clots (eg. antiphospholipid syndrome) may not be advisable to receive the AstraZeneca jab. If one is worried, he or she can also stay at the vaccination center for 15-30 minutes for further observation. 

Additionally, Dr Nazirin pointed out that there are differences between allergy and autoimmune disease, and people might have been confused between the two based on the question statement. 

2. I am taking oral steroids?

Oral steroids help to reduce inflammation and stop histamine production by suppressing the body’s immune response. Despite the limited immune response, one should still get vaccinated to at least get partial protection towards Covid-19. 

These individuals must not stop their daily medication for the vaccine. Instead, they can consult their doctor to take the minimum dosage to reduce the suppression of their immunity. 

3. I have Steven Johnson syndrome and am allergic to fresh water shrimp?

Dr. Kent stated that the Malaysian guideline does not consider Stevens Johnson Syndrome, a rare but serious reaction to drugs, as a contraindication for vaccination. For shrimp allergy, Dr Kent recommended this individual to get assessed and stratified based on the risk and carry EpiPen along as a safeguard measure.

4. I developed rashes after the first vaccine dose?

Similarly, this individual should be assessed for the actual cause of rashes as it can be easily triggered by different allergens. Dr. Kent and Dr. Nazirin both hypothesized that hand sanitizers and high histamine level due to over worrying could trigger rashes. 

If these rashes are signs of anaphylaxis to the vaccine, one should avoid vaccines with PEG components and preferably opt for Sinovac, but if not, one should not skip the second dose of vaccine. 

The risk from getting covid-19 vaccine is similar to getting normal vaccines like flu vaccine. Avoiding vaccination leads to higher risk of severe infection, whose risk is even greater than the risk from getting vaccinated. As pointed out by Dr. Kent, if there are any concerns or doubts, it would be wiser to talk to a doctor than referring to information on social media that is less reliable and credible.

Q3: I had side effects like fever and pain on my arm after the first dose of the vaccine. What are the possible side effects for the second dose of vaccine? Will they be milder or more serious?  

Dr. Amir emphasized that the severity of side effects really depends on individuals, as everyone has different immunity levels based on the genetic factors and natural differences. Although there is no absolute method to predict the severity of side effects, one should not pre medicate for vaccine injection as it can dampen the immune response and limit the immune response.

Also, severity of side effects DOES NOT represent the strength of immunity. Strangely, people tend to compare their side effects with families and friends and make claims about having better or weaker immunity. To note, the side effects are not caused by the same immune mechanism developed after vaccination.

Q4: Can I use an EpiPen If I have anaphylaxis after receiving the vaccine? Since EpiPen is expensive, should the fee be borne by the patients themselves?

Dr. Kent brought up the fact that vaccination centers have trained medical personnel and resuscitation medication. Prior to getting vaccinated, one can notify the nurse or medical staff about possibilities of developing anaphylaxis to prepare the team for any emergencies. Without the use of EpiPen, one could be less worried about the cost of EpiPen. 

Despite the high cost of EpiPen, it is worth the investment as it can save lives in emergencies. To encourage people to bring along EpiPen, MSAI is currently working with companies to get EpiPen registered to reduce the cost and make it more affordable. 

Q5: Is there any difference between brands within the same type of vaccines? 

As Dr. Kent and Dr. Amir said, the best vaccine brand is that first jab one can get, as all brands are equally effective to prevent the serious infection stage. Once someone is vaccinated, it can provide great protection to only limit the covid-19 infection by showing mild symptoms. Besides, based on future research, people may need booster shots from a different brand to protect themselves against the variant. 

As a side note, Dr. Kent mentioned that getting vaccinated not only builds one’s own immunity, but also helps to build up herd immunity and limit the spread of Covid-19 in the population. In other words, this protects those who cannot be vaccinated, like patients with immune deficiency disorder or undergoing chemotherapy to fight cancers.

The following are some questions related to allergy in general:

Q6: Why am I allergic to the vitamin C product from factory A but not factory B?

Although both are vitamin C products, different factories may use different excipients including stabilizers or preservatives. Instead of being allergic to an active compound, the vitamin C, this individual might be allergic to the stabilizer or preservatives. 

Q7: Is Immunotherapy an expensive treatment?

According to Dr. Salina, one may need to spend at least RM400 for the spray or RM500 for the tablet per month. As the complete immunotherapy may go on for 3 to 5 years, the total cost might reach up to RM30,000. Although this seems to be a big amount, this would be cheaper if someone smokes a packet of cigarettes every day. 

Also, in the long term, immunotherapy can cut down on the cost of the antiallergic drug. A previous study conducted by Dr. Salina that compared the medical cost of patients who undergo pharmacotherapy (treatment with drugs) and immunotherapy. Since those who received immunotherapy were symptom-free after 3 to 5 years, they managed to cut down medical costs and save more money from the antiallergic drugs .

Q8: Can probiotics be used to treat eczema and other skin allergies?

Probiotics is an emerging and exciting field to be the treatment for allergic disease like skin and food allergy. Dr Nazirin stated that probiotics had shown protection in some cases, where it successfully controlled eczema or showed prevention in newborns when pregnant mothers who have eczema consumed probiotics. However, the evidence is not strong enough and more research will be required to confirm these/ such findings. 

Speaking about probiotics, Dr. Kent also advised the audience to check the probiotic strains before consuming. For instance, probiotic strains found in fermented food like yoghurt may not bring any impact for disease conditions. It is best to identify the strains in probiotics and do some research from the available literature to confirm their effectiveness. He believed that the increasing research data will help in making better recommendations to use probiotics in disease treatments in time.

Written by: Pei Zoe, Chee San

Edited by: Jamie