WAO consensus on DEfinition of Food Allergy SEverity (DEFASE)

Stefania Arasi; Ulugbek Nurmatov; Audrey Dunn-Galvin; Graham Roberts; Paul J Turner; Sayantani B Shinder; Ruchi Gupta; Philippe Eigenmann; Anna Nowak-Wegrzyn; Ignacio J Ansotegui; Montserrat Fernandez Rivas; Stavros Petrou; Luciana K Tanno; Marta Vazquez-Ortiz; Brian Vickery; Gary Wong; Montserrat Alvaro-Lozano; Miqdad Asaria; Philippe Begin; Martin Bozzola; Robert Boyle; Helen Brough; Victoria Cardona; R Sharon Chinthrajah; Antonella Cianferoni; Antoine Deschildre; David Fleischer; Flavio Gazzani; Jennifer Gerdts; Marilena Giannetti; Matthew Greenhawt; Maria Antonieta Guzmán; Elham Hossny; Paula Kauppi; Carla Jones; Francesco Lucidi; Olga Patricia Monge Ortega; Daniel Munblit; Antonella Muraro; Giovanni Pajno; Marcia Podestà; Pablo Rodriguez Del Rio; Maria Said; Alexandra Santos; Marcus Shaker; Hania Szajewska; Carina Venter; Cristopher Warren; Tonya Winders; Motohiro Ebisawa; Alessandro Fiocchi

doi:10.1016/j.waojou.2023.100753

WAO consensus on DEfinition of Food Allergy SEverity (DEFASE)

World Allergy Organ J. 2023 Mar 2;16(3):100753. doi: 10.1016/j.waojou.2023.100753. eCollection 2023 Mar.

Authors

Stefania Arasi¹, Ulugbek Nurmatov², Audrey Dunn-Galvin³, Graham Roberts^{4

5

6}, Paul J Turner⁷, Sayantani B Shinder^{8

9}, Ruchi Gupta^{10

11}, Philippe Eigenmann¹², Anna Nowak-Wegrzyn^{13

14}, Ignacio J Ansotegui¹⁵, Montserrat Fernandez Rivas¹⁶, Stavros Petrou^{17

18

19}, Luciana K Tanno^{20

21

22}, Marta Vazquez-Ortiz²³, Brian Vickery²⁴, Gary Wong²⁵, Montserrat Alvaro-Lozano^{26

27

28}, Miqdad Asaria²⁹, Philippe Begin^{30

31}, Martin Bozzola³², Robert Boyle³³, Helen Brough^{34

35}, Victoria Cardona^{36

37}, R Sharon Chinthrajah³⁸, Antonella Cianferoni³⁹, Antoine Deschildre^{40

41}, David Fleischer⁴², Flavio Gazzani⁴³, Jennifer Gerdts⁴⁴, Marilena Giannetti⁴³, Matthew Greenhawt⁴⁵, Maria Antonieta Guzmán⁴⁶, Elham Hossny⁴⁷, Paula Kauppi⁴⁸, Carla Jones⁴⁹, Francesco Lucidi⁵⁰, Olga Patricia Monge Ortega⁴³, Daniel Munblit^{51

52

53}, Antonella Muraro⁵⁴, Giovanni Pajno⁵⁵, Marcia Podestà⁵⁶, Pablo Rodriguez Del Rio⁵⁷, Maria Said⁵⁸, Alexandra Santos⁵⁹, Marcus Shaker^{60

61

62

63}, Hania Szajewska⁶⁴, Carina Venter⁶⁵, Cristopher Warren⁶⁶, Tonya Winders⁶⁷, Motohiro Ebisawa⁶⁸, Alessandro Fiocchi⁶⁹

Affiliations

¹ Allergy Diseases Research Area, Pediatric Allergology Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy.
² Division of Population Medicine, School of Medicine, Cardiff University, Wales, UK.
³ Applied Psychology and Paediatrics and Child Health, University College Cork, Cork, Ireland.
⁴ Faculty of Medicine, University of Southampton, Southampton, UK.
⁵ The David Hide Asthma and Allergy Research Centre, St Mary's Hospital, Isle of Wight, UK.
⁶ NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK.
⁷ National Heart & Lung Institute, Imperial College London, London, UK.
⁸ Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Stanford University, Stanford, CA, USA.
⁹ Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford University, Stanford, CA, USA.
¹⁰ Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
¹¹ Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
¹² Department of Pediatrics, Gynecology and Obstetrics, University Hospital of Geneva, Geneva, Switzerland.
¹³ Allergy and Immunology, Department of Pediatrics, New York University School of Medicine, Langone Health, New York, NY, USA.
¹⁴ Department of Pediatrics, Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland.
¹⁵ Department of Allergy and Immunology, Hospital Quironsalud Bizkaia, Bilbao, Spain.
¹⁶ Allergy Department, Hospital Clinico San Carlos, Instituto de Investigacion Sanitaria San Carlos (IdISSC), Universidad Complutense, Madrid, Spain.
¹⁷ Nuffield Department of Primary Care Health Sciences, University of Oxford.
¹⁸ Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.
¹⁹ Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, England, UK.
²⁰ Division of Allergy, Department of Pulmonology, University Hospital of Montpellier, France.
²¹ Desbrest Institute of Epidemiology and Public Health, UA-11, INSERM University of Montpellier, France.
²² WHO Collaborating Centre on Scientific Classification Support, Montpellier, France.
²³ Section of Inflammation, Repair and Development, National Heart and Lung Institute, Imperial College London, London, United Kingdom.
²⁴ Department of Pediatrics, Emory University, Atlanta, GA, USA.
²⁵ Department of Paediatrics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong.
²⁶ Pediatric Allergy and Clinical Immunology Department, Hospital Sant Joan de Deu, Barcelona, Spain.
²⁷ Institut de Recerca Sant Joan de Deu, Barcelona, Spain.
²⁸ Universitat de Barcelona, Spain.
²⁹ Department of Health Policy, London School of Economics and Political Science, UK.
³⁰ Allergy, immunology and Rheumatology Division, Department of Pediatrics, CHU Sainte-Justine, Montreal, QC, Canada.
³¹ Allergy and Clinical immunology Division, Department of Medicine, Centre Hospitalier de l'Université de Montréal, QC, Canada.
³² Hospital Britanico de Buenos Aires Buenos Aires, Argentina.
³³ National Heart and Lung Institute, Imperial College London, UK.
³⁴ Children's Allergy Service, Evelina Children's Hospital, Guy's and St. Thomas' Hospital, London, UK.
³⁵ Paediatric Allergy Group, Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK.
³⁶ Allergy Section, Department of Internal Medicine, Hospital Vall D'Hebron, Barcelona, Spain.
³⁷ ARADyAL Research Network, Spain.
³⁸ Sean N Parker Center for Allergy and Asthma Research, Stanford University.
³⁹ The Children's Hospital of Philadelphia, The University of Pennsylvania, Philadelphia, PA, United States.
⁴⁰ CHU Lille, Univ Lille, Pediatric Allergy and Pulmonology Unit, Hôpital Jeanne de Flandre, 59000 Lille, France.
⁴¹ Section of Pediatric Allergy & Immunology, Children's Hospital Colorado, USA.
⁴² University of Colorado School of Medicine, USA.
⁴³ Departement of Economics and Law, University of Rome La Sapienza, Italy.
⁴⁴ Executive Director, Food Allergy Canada, Toronto, Ontario, Canada.
⁴⁵ Section of Allergy and Immunology, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA.
⁴⁶ Immunology and Allergy Service, Clinical Hospital University of Chile, Santiago, Chile.
⁴⁷ Pediatric Allergy, Immunology and Rheumatology Unit, Children's Hospital, Ain Shams University, Cairo, Egypt.
⁴⁸ University of Helsinki and Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland.
⁴⁹ Chief Executive of Patient Organisation, Allergy UK, London, UK.
⁵⁰ Allergology Unit of the San Juan de Dios Hospital, San José, Costa Rica.
⁵¹ Department of Paediatrics and Paediatric Infectious Diseases, Institute of Child's Health, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
⁵² Inflammation, Repair and Development Section, National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom.
⁵³ Research and Clinical Center for Neuropsychiatry, Moscow, Russia.
⁵⁴ Food Allergy Centre Department of Woman and Child Health Padua University Hospital, Padua Italy.
⁵⁵ Pediatric Unit- Policlinico Hospital, University of Messina, Messina, Italy.
⁵⁶ Food Allergy Italia, Italy.
⁵⁷ Hospital Universitario Infantil Niño Jesus, Madrid, Spain.
⁵⁸ CEO Allergy & Anaphylaxis Australia, Sydney, Australia.
⁵⁹ Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom.
⁶⁰ Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom.
⁶¹ Children's Allergy Service, Evelina London Children's Hospital, Guy's and St Thomas' Hospital, London, United Kingdom.
⁶² Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom.
⁶³ Dartmouth Geisel School of Medicine and Dartmouth-Hitchcock Medical Center, Lebanon.
⁶⁴ Department of Paediatrics, The Medical University of Warsaw, Warsaw, Poland.
⁶⁵ Section of Allergy and Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA.
⁶⁶ Center for Food Allergy and Asthma Research, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, USA.
⁶⁷ Allergy & Asthma Network (AAN), President and CEO, Allergy and Asthma Network, Vienna, VA, USA.
⁶⁸ Clinical Research Center for Allergy and Rheumatology, National Hospital Organization, Sagamihara National Hospital, Sagamihara Japan.
⁶⁹ Translational Research in Paediatric Specialities Area, Division of Allergy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.

Abstract

Background: While several scoring systems for the severity of anaphylactic reactions have been developed, there is a lack of consensus on definition and categorisation of severity of food allergy disease as a whole.

Aim: To develop an international consensus on the severity of food allergy (DEfinition of Food Allergy Severity, DEFASE) scoring system, to be used globally.

Methods phase 1: We conducted a mixed-method systematic review (SR) of 11 databases for published and unpublished literature on severity of food allergy management and set up a panel of international experts.

Phase 2: Based on our findings in Phase 1, we drafted statements for a two-round modified electronic Delphi (e-Delphi) survey. A purposefully selected multidisciplinary international expert panel on food allergy (n = 60) was identified and sent a structured questionnaire, including a set of statements on different domains of food allergy severity related to symptoms, health-related quality of life, and economic impact. Participants were asked to score their agreement on each statement on a 5-point Likert scale ranging from "strongly agree" to "strongly disagree". Median scores and percentage agreements were calculated. Consensus was defined a priori as being achieved if 70% or more of panel members rated a statement as "strongly agree" to "agree" after the second round. Based on feedback, 2 additional online voting rounds were conducted.

Results: We received responses from 92% of Delphi panel members in round 1 and 85% in round 2. Consensus was achieved on the overall score and in all of the 5 specific key domains as essential components of the DEFASE score.

Conclusions: The DEFASE score is the first comprehensive grading of food allergy severity that considers not only the severity of a single reaction, but the whole disease spectrum. An international consensus has been achieved regarding a scoring system for food allergy disease. It offers an evaluation grid, which may help to rate the severity of food allergy. Phase 3 will involve validating the scoring system in research settings, and implementing it in clinical practice.

Keywords: Consensus; Definition; Food allergy; Severity; e-Delphi study.