Prof Antonella Muraro | University of Padua and University Hospital of Padua, Padua, Italy
Chair of the EAACI Guidelines Committee
EAACI Past-President (2015–2017)
Your term as President of EAACI was during 2015–2017. What was the most rewarding aspect of this position?
The possibility to build strong partnerships among immunologists, clinicians, allied health, and patients, who all share the same vision and work together for the same goals. This model of collaboration was implemented both in the scientific activities, such as the guidelines, and in the academy policy decisions, including the patient’s representative in the Executive Committee. It represented a cultural change which gave EAACI a credibility at the general-public level and a leadership role worldwide.
As the Chair of the EAACI Guidelines Committee, please could you tell us about your role, the committee, and the committee’s goals.
As Chair, I ensure that the committee fulfils its main aim: to oversee that the generation of EAACI Guidelines is implemented successfully across the membership. I had the privilege of starting the guidelines initiative in EAACI in 2012, with the first guidelines on food allergy and anaphylaxis published in 2014. This initiative shaped a new cultural approach moving from consensus statements, based on experts’ opinion, to evidence-based guidelines following the requirements for evidence-based healthcare and healthcare outcomes according to the Institute of Medicine (IOM) and the Guidelines International Network (GIN). In this regard, guidelines can serve also to guide the decisions of policy makers and payers. Transparency is paramount. Everybody can comment on the final draft guideline forwarded to the public via the EAACI website, and the funding body EAACI should not have any influence on the final content.
In order to ensure that all groups and relevant areas are equally represented, the Guidelines Committee includes an epidemiologist, an allied-health representative, a junior member, two patient representatives, and the Ethics chair as an adjunct member. I would like to take this opportunity to thank all the members of the committee for their hard work and dedication.
Specifically, the committee is responsible for four aspects of EAACI Guidelines: 1) assisting EAACI members in developing proposals for new guidelines and updated guidelines for review and approval by the EAACI Executive Committee; 2) overseeing the consistency of the process and its adequate progress; 3) ensuring the appropriate dissemination of EAACI Guidelines; and, most importantly, 4) facilitating the implementation of EAACI Guidelines.
Collaboration is of massive importance for scientific progression. Who are the Guidelines Committee currently collaborating with, and what are the associated projects?
The Guidelines Committee has a continuous collaboration with the EAACI groups and members to evaluate the gaps in disease management that should prioritise a new guideline or speed-up revision of an old one. In this regard, we are now launching the revision of the prevention of food allergy guidelines which will be available on the EAACI website in mid-May. The revision of the anaphylaxis guidelines is ongoing. Due to the exciting developments in the area, we are going to revise the guidelines for food allergy diagnosis, which will include the role of molecular allergology, as well as the food allergy management guidelines with in-depth evaluation of the immunotherapy for food allergy.
The closest collaboration is with the methodologists in order to obtain the support from them for the evidence-based appraisal and the systematic review of the studies. The mutual exchange of expertise between clinicians and methodologists is further hugely promoted downstream in any new guideline project to achieve the most comprehensive perspective. However, the most accredited methodological approaches, such as GRADE, are complex and the guideline recommendations are not always well appraised by the ultimate users. The new challenge is now to develop a novel concept of user-friendly guidelines that could facilitate getting the feeling of ownership by the readers and their implementation in daily practice.
One of your research interests is the prevention of childhood allergies. In your opinion, what have been the most interesting developments in this field over the recent years?
The crucial change has been the shift from the concept that avoiding a food could prevent the onset of food allergy to actively administering the food with the aim to facilitate achieving oral tolerance. The failure of the avoidance theory, which resulted in an increase of the prevalence of food allergy, has also been recently demonstrated in a pivotal study in the UK LEAP study. Identifying that the skin, especially the eczematous skin, could open the door to food sensitisation and that there is an age-based ‘window of opportunity’ for introducing complementary food would ultimately lead clinicians to properly modulate the introduction of the right food at the right time. We have revised all the studies in the systematic review on prevention of food allergy, which has recently been published online.1
You were recently involved in the publication of an EAACI position paper about the association between diet diversity and allergy outcomes. What was the rationale for publishing this paper, and what are the main take-home messages?
In the last decade, there has been increasing interest in the role of nutrition on the onset of diseases or maintenance of well-being. Many studies have been conducted on the role of some nutrients, for example fish oil and vitamin D, as well as on the interplay between an early diversification of the diet and the development of allergic manifestations in children and women who are pregnant. Results have been, however, inconclusive, mainly due to the lack of agreed definitions in most of the studies. The aim of this statement is to provide some recommendation by evaluating the association between diet diversity and allergy outcomes (food sensitisation, asthma, allergic rhinitis, atopic dermatitis) in a systematic analysis. According to the knowledge available so far, the paper concluded that diet diversity is recommended for any infant or child, given no evidence of harm and some potential association of benefit in the prevention of allergic symptoms.2 In addition, we hope that the effort to harmonise definitions and set standards for research would serve as basis for collecting good quality data and allow progress in the field.
Support has been gaining for the potential relationship between the microbiome and allergic diseases. What are your thoughts on this hypothesis?
Our germs are shaping our immune response and many research steps have been performed in elucidating the details involved. During my term as President, EAACI promoted a joint article with the American Academy of Allergy, Asthma and Immunology (AAAAI) on the role of the microbiome in modulating the immune system and influencing onset and severity of clinical manifestations such as asthma, atopic dermatitis, and food allergy.3 This PRACTALL manuscript intends to provide shared evidence-based recommendations on cutting-edge topics in allergy. Actually, it served also to establish research outcomes for future investigations. I believe that at this stage, however, only networks of big data could provide definite results and possibility of intervention through manipulation of the microbiota.
The COVID-19 pandemic has impacted numerous clinical therapeutic areas, in particular immunology. Are EAACI putting together guidelines or resources to help educate and advise clinicians with how to either treat COVID-19 or continue treatment of their existing patients?
EAACI has put in place an effort to provide articles with free access at the EAACI COVID-19 resource centre.4 In addition, the EAACI Section on Pediatrics has recently published a very useful practical guide for managing allergies and immunodeficiencies in children in daily practice.5
In the UK, a law that will require prepackaged foods to be labelled with allergens in more detail will come into effect from October 2021. What impact do allergen labelling laws such as this have on those who have a food allergy?
This will be a landmark step. All patients with food allergies will have the opportunity to check the full list of the ingredients and allergens of prepackaged food. According to the current law, it is mandatory to include in the list of the ingredients only 14 food allergens acknowledged by the European Commission. Patients who are allergic to allergens different from the 14 have still the risk of an inadvertent reaction by accidental ingestion not being able to detect their specific food allergen. This law would reduce the burden for the patients and their families, hopefully preventing anaphylactic reactions and saving lives.