By Dr. Paul Ehrlich
Our October interview with Dr. Robert Y. Lin, my friend and colleague at the New York Allergy and Asthma Society, entitled “Fatal Anaphylaxis: What the Numbers Tell Us” attracted a good deal of well-deserved attention. Among the noteworthy statistics over a 12-year period as published in an article he co-authored: that food was the least common cause of fatal anaphylaxis behind medication and insect stings, and that despite the doubling of the rate of hospitalizations for food, the rate remained stable except for African American males for whom there was an increase. This exception was noted with an asterisk and I said I would respond. Our correspondents are rightly concerned that there may be something genetic that puts African American males at greater risk than others.
This interests me greatly because for years I worked in inner-city New York public schools in a program called Project ERASE (which I also founded) to see if attentive mainstream asthma care provided in the schools could help worst-of-the-worst asthmatic students improve their academic performance and attendance, and spare them the burden of relying on emergency treatment. Our results were very much in line with precedent, such as a 75% reduction in trips to the ER.
The pertinent point is that despite these terrible asthma cases, I didn’t hear any reports of food allergies from the kids and their parents. During the life of this website, we have seen studies showing very high rates of food allergies among inner-city children, but they were largely self-reported. As we have previously noted, surveys like this are notoriously difficult. Having not seen evidence of this vulnerability myself in either the schools or my private practice, I decided to take a closer look at the language of Bob’s paper to figure out what is actually involved.
First, “Fatal food-induced allergic reactions are commonly caused by asthma and angioedema and are less commonly associated with shock, and in this study the diagnosis of asthma was more common in patients with food-related anaphylaxis. African American race has been reported to be a risk factor for food allergies, and in this study higher food-related fatal anaphylaxis rates were observed in African American subjects. Male sex predominated among cases of fatal food induced anaphylaxis.”
Further on it says, “African American race was a significant risk factor for all (emphasis added) anaphylaxis causes, with the exception of venom-induced anaphylaxis. Previous US reports suggested racial/ethnic disparity in atopic diseases, with African American subjects more likely to be sensitized to foods, to have self-reported allergy, or to have a clinic-based diagnosis of food allergy.”
Where to begin?
Right away I have to point out that the numbers are very small overall—2458 fatalities for all groups from all causes over a 12-year period—so that it doesn’t take large raw numbers to produce an alarming-sounding percentage. Thus, the 25% of all food-related anaphylaxis among African Americans sounds disproportionate to their numbers in the U.S. population, but it’s a total of 41 deaths—every one of them tragic, and probably preventable. Regardless, it wouldn’t take many life-saving interventions to tip the trend line.
A year ago, a group of very distinguished researchers looked at the racial and ethnic disparities in food allergy in the pages of the Journal of Allergy and Clinical Immunology (JACI) and concluded: “Limited data exist regarding racial/ethnic disparity in food allergy in the US. Available data lack a common definition for food allergy and use indirect measures of allergy, not food challenge. Several studies suggest that black children are at increased risk of food sIgE (food-specific IgE allergic antibodies) compared to white children, but further clinical context is needed to fully understand the significance of this finding.”
But what about those asthma-related anaphylaxis fatalities? There may in fact be stronger correlation between race and morbidity. A study just published in JACI reports: “We included 23,065 children living in 5,853 census tracts. The prevalence of current asthma was 12.9% in inner-city and 10.6% in non–inner-city areas, but this difference was not significant after adjusting for race/ethnicity, region, age, and sex. In fully adjusted models black race, Puerto Rican ethnicity, and lower household income but not residence in poor or urban areas were independent risk factors for current asthma. Household poverty increased the risk of asthma among non-Hispanics and Puerto Ricans but not among other Hispanics. Associations with asthma morbidity were very similar to those with prevalent asthma.”
This is where I came in.
The scandal to me boils down to the familiar problem of social disparities and the way they play out in health care. Look at that anomaly in the venom-related deaths. Could it be that inner-city children just aren’t around enough bees and wasps to make that a major risk? Regarding medication reactions, couldn’t it be that their doctors aren’t as careful as they should be in utilizing certain medications, or that their allergies are undiagnosed, or that physicians aren’t as capable at recognizing and treating anaphylaxis as we would hope?
As an asthma specialist, I know well the role individual behavior plays in keeping a chronic problem from erupting into an ambulance-worthy event or worse. If people don’t take their inhaled corticosteroids as directed, can we count on them to carry their Auvi-Q and what’s more, to use it correctly? More recent research shows us they don’t do either. A new Canadian study shows that half of patients, children and adults, were not treated with epinephrine inside or outside hospitals. I have seen similar data for the United States.
In their article Bob and his co-authors focus only on the most serious symptom of anaphylaxis, but fatalities are not the best measure of the public health challenges posed by allergies or asthma. If black people are dying in slightly greater numbers than others, you can bet it’s because their asthma and other health problems are not being addressed as well as they should be either.
*Bellevue is where Dr. Ehrlich learned to be a doctor