MODIFICATIONS FOR ADULT ALLERGY SERVICES DURING COVID-19 PANDEMIC
MODIFICATIONS FOR ADULT
ALLERGY SERVICES DURING COVID-19 PANDEMIC
Advice to Adult Allergy Services regarding COVID-19
This document provides suggestions for changes to service provision during the COVID-19 pandemic. Suggestions for adjustments to paediatric allergy service and immunodeficiency service provision have been developed separately.
The COVID-19 pandemic has placed significant additional pressures on the NHS, with specific effects differing between Trusts. However, the impact will become even greater over the coming weeks and months and will likely result in long-term changes once the acute phase of the pandemic has resolved.
Individuals health professionals and patients should follow the advice of Public Health England, Health Protection Scotland, Public Health Wales, and Public Agency Northern Ireland. Patient information is also available from Allergy UK and Anaphylaxis Campaign, along with many other organisations. Individual departments will already have been asked to make some changes in service provision, including conducting almost all consultations by telephone. However, such advice is necessarily general and does not provide any guidance regarding specialist allergy and immunology service provision during this crisis.
It is important for allergists and immunologists to have a shared understanding of what adjustments can be made to allow continuation of important activities in the early stages of local pressures, as well as what constitutes minimum acceptable service provision to define essential activity that must continue throughout.
It should be emphasised that many departments will have already had to divert time, space, and staff to covering COVID-19 related workload. In these cases, direct transition to the minimum acceptable service provision is recommended.
General measures – detail and extent may vary between Trusts
- New and follow-up face-to-face appointments to be converted to telephone, unless face-to-face review is necessary to avoid adverse clinical outcome.
- Provide advice and guidance in response to new referrals, requesting re-referral if symptoms persist after government restrictions are lifted
- Suspend research visits and recruitment if possible, to minimise traffic in the healthcare facility
- Direct patients to government websites to obtain up-to-date information regarding public and personal health measures in place
- For patients where review will be required but is not urgent, if local policy allows consider keeping an open appointment and ask the patient to contact the department once restrictions are lifted. Where this is not possible consider copying GP advice and guidance to patients, leaving the responsibility with the patient to seek re-referral if appropriate once government measures are lifted.
- Avoid ENT examination where possible, including direct nasal and throat examination and nasendoscopy, as there are some reports that these may be an aerosol-generating procedure and a means of contracting the virus. Local Trust policies should be followed.
- When reviewing peak flow in asthma consider the risk benefit of using a handheld peak flow meter (unfiltered) versus a spirometry (filtered).
Initial practice adjustments. Not all of these will be applicable to every unit at all times, but can be considered as circumstances change locally.
- Ensure patients are provided with adrenaline autoinjectors when appropriate. BSACI guidelines that provide detailed information regarding anaphylaxis and adrenaline autoinjectors are available.
- Ensure patients have received appropriate education regarding appropriate administration technique; information regarding ordering training devices and education in the use of the three available devices can be found on the Anaphylaxis Campaign website.
- Ensure sufficient space is available to provide at least 2 metres between patients in waiting rooms and clinics.
- In the majority of adult patients, the clinical history is sufficient to make a diagnosis of food allergy. Skin testing and phlebotomy can be deferred, with investigations limited to individual cases if clinically urgent.
Rhinosinusitis and asthma
- Ensure patients with rhinosinusitis are managed with maximal therapy according to the BSACI guidelines for rhinosinusitis and nasal polyposis. Patients with rhinosinusitis may touch their face and nose more frequently, and ensuring appropriate management may help avoid this.
- Defer all skin testing to aeroallergens until COVID-19 restrictions are lifted.
- Defer commencement of subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT) for aeroallergens.
- Reduce the post-dose observation period for aeroallergen SCIT (e.g. Allergovit, Alutard) to 30 minutes, except in patients with asthma and those with a history of type 1 hypersensitivity related to doses.
- Extend the interval between doses to 8-10 weeks in patients established on maintenance treatment.
- Stop SCIT in vulnerable people and those over 70, in order to facilitate the stringent social distancing and shielding measures advocated by the government by minimising visits to healthcare facilities.
Stinging insect allergy
- Defer skin and specific IgE testing for venoms until COVID-19 restrictions are lifted
- Ensure patients with a history of systemic reaction are provided with a written action plan, adrenaline autoinjectors and advice regarding avoidance of stings, in line with BSACI guidance. Patients can order training devices and find information on correct use on the Anaphylaxis Campaign website.
- Defer commencement of venom immunotherapy (VIT) until COVID-19 restrictions are lifted. The risk of insect sting is low in most cases, and provided the patient has an action plan, adrenaline autoinjectors, and advice regarding avoidance, the risk of fatal systemic reaction is very small. In contrast, the risk of contracting COVID-19 is rising, and with a mortality rate of up to 4-5% the risk of attending a healthcare facility increasingly outweighs the benefit of VIT.
Reduce the post-dose observation period for Alutard Bee and Wasp VIT to 30 minutes as specified in the product information. Consider reducing the post-dose observation period for Pharmalgen Bee and Wasp VIT to 30 minutes (shorter than the 60 minutes specified in the product information), unless there is a history of type 1 hypersensitivity related to VIT doses.
- Extend beyond the licensed interval to 10-12 weeks (for Alutard Bee and Wasp) or 8-10 weeks (for Pharmalgen Bee and Wasp) in patients established on maintenance treatment. It may be appropriate to continue administering VIT despite reduction or unavailability of intensive care unit support, provided the patient has never had type 1 hypersensitivity symptoms following VIT doses. In high risk patients (eg mastocytosis) if VIT is continued it should remain at the licensed interval, and there should be a low threshold for stopping VIT if there is no intensive care support available.
- Stop VIT in vulnerable people and those over 70, in order to facilitate the stringent social distancing and shielding measures advocated by the government by minimising visits to healthcare facilities.
- Defer drug allergy skin testing, specific IgE testing, and challenges until COVID-19 restrictions are lifted, except in cases where there is clear and urgent need for a specific drug and where rapid desensitisation when required is either not possible or not feasible.
- Consider providing a generic “To Whom It May Concern” letter with the contact details of the allergy/immunology service for future treating clinicians to discuss desensitisation or alternatives if required.
Urticaria and angioedema
- Defer commencement of omalizumab in new patients until COVID-19 restrictions are lifted.
- Administer home omalizumab therapy earlier than the fourth dose specified in the product information, by administering training at the second dose and transitioning to home therapy for the third dose. While home therapy is not licensed where there is a history of anaphylaxis of any cause, in cases where there is a clear trigger and no association with omalizumab doses home therapy could be used. In this case consider provision of a written anaphylaxis action plan and adrenaline autoinjectors, if not already done.
- If alternative immunosuppressive medications (e.g. prednisolone, ciclosporin, azathioprine etc) are
being used in place of omalizumab, ensure appropriate advice is given with regard to social
distancing and shielding according to government advice.
Minimum acceptable service provision. These activities will jeopardise patient safety if stopped
- Drug or general anaesthetic allergy investigation when required immediately, there is no option, and desensitisation acutely is not an option.
- Provision of advice regarding options when one class of drug is excluded due to suspected/confirmed allergy.
- Facilitation of rapid drug desensitisation either directly or remotely where appropriate.
- Ensure appropriate arrangements for patients on medications prescribed by the immunology/allergy department which require monitoring. The British Association of Dermatologists has developed guidance regarding immunosuppressed patients.
Contributors: Dr A Whyte, Dr C Rutkowski, Dr S Nasser, Dr T Garcez, Prof MT Krishna,
J Edmonds, Dr L Angier, Dr A Clark, Prof G Roberts
Contact Dr Andrew Whyte via the BSACI office with any feedback or concerns.