EHJ October 2002, pages 304-307 The importance of EHOs in allergen management has generally been overlooked in favour of more highly -publicised food-related issues. But allergies can, and do, kill, and as Nick Warburton explains, EHOs have a key role in raising awareness

In June 1999, Ross Baillie, Scottish senior record holder and finalist in the 110m hurdles at the 1998 Commonwealth Games, was rushed to hospital after suffering a severe allergic reaction. Earlier that day, Mr Baillie, who was considered by many to be the natural successor to Colin Jackson, had been at a training session when he made the fatal decision to eat a sandwich with coronation chicken filling for lunch. Minutes after biting into the sandwich, he realised that it contained peanuts as his tongue started to swell and he began coughing.

The incident has particular relevance because Mr Baillie had not realised that the coronation chicken filling on this occasion contained nuts as an ingredient. His untimely death highlights the importance of raising awareness of allergens in all food that is sold to the public.

WHAT ARE FOOD ALLERGIES?

As Hazel Gowland, food adviser to the Anaphylaxis Campaign, and a nut allergy sufferer points out, food allergy "is now such a fashionable term that it is often borrowed by those who suffer, or believe that they suffer, from other food-triggered symptoms". However, unlike those who may experience food-triggered symptoms that are unpleasant (but are not incapacitating or potentially life threatening), the effect on a "true allergy" sufferer is far more serious. A true allergy affects a person's immune system and is described as IgE-mediated (IgE is a type of anti-body called Reagin).

"Those who are at life-threatening risk may experience IgE-mediated symptoms which can lead to anaphylaxis or potentially fatal asthma," says Ms Gowland. These symptoms can, as in Ross Baillie's case, become fatal within minutes or hours. Reactions can even be triggered by minute (trace) amounts. While the symptoms may vary, they include the swelling of the throat and mouth, difficulty in breathing, a dramatic drop in blood pressure (which can stop the heart), collapse, unconsciousness and death.
The symptoms of an allergic reaction can sometimes be reversed or suppressed (to buy time to get the patient to hospital) by the rapid administration of adrenaline by intra-muscular injection. However, according to Dr Ian Leitch, senior environmental health officer (food safety) at Omagh DC, "there are many documented cases of people who died because they failed to receive the adrenaline shortly after they took the initial reaction".

The most common types of foods to cause life-threatening reactions include peanuts and tree nuts (such as walnuts, almonds, Brazil nuts, hazelnuts and pistachios), shellfish and sesame seeds. While sesame seeds appear to be on the rise as an allergen, due to their increasing use on burger buns for example, nuts and peanuts are two of the major trigger allergens to cause severe anaphylactic reactions. As Dr Leitch points out, "most fatalities occur when food that intentionally contains peanuts or nuts is consumed accidentally".

People who have a nut allergy have died from eating a range of products in which they were not expecting to find nuts. These include coronation chicken sandwiches, lemon meringue pie, bread with hidden walnuts, Italian ice cream and chicken korma, among others. The rising popularity of multi-cultural dishes, new recipes and fancy terms for dishes that disguise nut content are, according to Ms Gowland, some of the factors behind an increase in the number of allergy reactions.

Speaking at this year's CIEH conference, she said that the most susceptible group was that between the ages of 13-30. This is due to a wide range of factors; for example, this age group is the most sociable, the most metabolically susceptible to having serious symptoms and many young sufferers have not been properly diagnosed.

CHANGING EATING TRENDS

The main reason behind the rise in the number of allergy sufferers meanwhile is a change in eating trends - people are dining out more and relying on others to prepare the food they consume. According to a national study of fatal anaphylactic reactions, by Dr Richard Pumphrey, clinical manager in the immunology department at St Mary's Hospital, Manchester, 76 per cent of food-related fatal reactions have been linked with commercial catering, with approximately five food-related deaths per year from 1992 to 1998.¹

Ms Gowland cites a number of factors, which could account for this. To begin with, staff are often temporary and, in some circumstances, do not share a common language with the customer. Furthermore, cultural differences can play an important factor. Awareness of food allergy is low and not always widely understood. Not all staff are trained, even in basic hygiene practices, so it is unlikely that many would be able to recognise an allergy enquiry or know how to manage it. And an additional problem is that packaging, ingredients lists, menus and signs can sometimes be misleading, are not always consistent, and/or available for the consumer to make an informed choice.

For pre-packed foods, the main source of information is the ingredients list. If this is misleading or inconsistent, and is not supported by additional information detailing the presence of allergens as ingredients or potential contaminants, the consequences can be catastrophic.

The greatest risk to allergy sufferers however, comes from foods that are sold loose or in catering outlets, as in both cases there is not always a requirement to label foods for sale. In addition, there is a greater opportunity for cross-contamination, both by staff and inadvertently by customers themselves, for example by mixing foods sold on a salad bar, delicatessen or a self-service in-store bakery display.

Foods that are sold labelled and pre-packed from supermarkets are relatively well managed. In fact, some of the main high street supermarkets even provide customers with warnings about certain products and their suitability for allergy sufferers.

However, food allergy campaign groups argue that much more could be done to improve the standard of labelling on products. "It's hardly rocket science, but people would like to see what's in the ingredients list," says Ms Gowland. "We also want ingredients that allergy suffers can read."

A recent study by the Anaphylaxis Campaign for the Food Standards Agency (FSA) entitled "'May contain' labelling - The consumer's perspective", carried out a survey in which consumers had to identify a range of products from leading supermarkets for a nut allergic consumer. The research found that even in cases where nut trace contamination had been clearly labelled, some consumers had missed the warning.

WHAT ACTION IS BEING TAKEN?

While there has been a notable increase in the number of people who suffer from a serious food allergy (research suggests around one person in 100 is at risk)², some action has been taken to tackle the problem.

In some areas of the food industry, there have been improvements. Most major food factories are experienced at applying good manufacturing practice and Haccp principles. Furthermore, manufacturers and retailers increasingly have recognised the need to control the use of allergens as ingredients or trace contaminants along with all other risks.

A number of initiatives have been introduced over the years to "integrate the assessment, management and communication of allergy risks into food service". In 1995, allergen management was included as a requirement for all S/NVQ food preparation and foodservice units.³ Two years later, the Ministry of Agriculture, Fisheries and Food (MAFF) distributed "Be allergy aware" posters and leaflets to over 300,000 food outlets.

The FSA recently revised this policy by publishing a free informative A5 booklet and A3 poster, which is available in eight community languages and is aimed at the catering industry. The role of the EHO will be key to its success, providing caterers with copies during inspections and explaining any issues relating to the booklet.

In August, the FSA also published a commissioned report by the British Nutrition Foundation, which looks at the provision of information with regard to non-prepacked foods. The report makes a number of recommendations to the FSA regarding allergy awareness. These include:

• working with interested parties to define minimum training requirements in relation to allergy awareness for food sector staff. The aim would be to minimise cross-contamination and to facilitate the provision of accurate information to the consumer;
• working with interested parties to develop an agreed list of common allergen-containing foods or food groups;
• lending its support to approaches which help establish good operating practices with regard to allergens, particularly with regard to nuts, peanuts and seeds; and
• considering the support of an allergy awareness scheme that could be constructed along similar lines to the "Heart beat award scheme".

THE TANDRIDGE AWARD SCHEME

Surrey County Council Trading Standards, recently set up an innovative pilot scheme in Tandridge DC, which offers information and advice to businesses relating to the risk posed to food allergy sufferers and the necessary steps that can be taken to avoid any potential life-threatening incidents. The project, known as the responsible retailer allergy awareness scheme, was established with assistance from Tandridge environmental health department, the Anaphylaxis Campaign and the British Nutrition Foundation.
"It had come to our attention that consumers who suffer from such allergies were sometimes unsure as to what foods were safe to eat because menu descriptions were not always detailed enough or staff were not able to provide the additional information requested," says Claire Wilman, senior enforcement officer at Surrey Trading Standards. "The main aim of the scheme is to enhance trader awareness about potential allergens contained within the food they serve."

In addition to enhancing trader knowledge about food allergies, the pilot scheme also encourages businesses to follow a code of practice. The code of practice includes areas such as compliance with food safety and trading standards laws, undertaking the voluntary labelling of foods that contain harmful allergens and the recognition of consumer rights. Since its inception in August, the council has sent out letters to around 270 businesses inviting catering premises in Tandridge to join the scheme. So far the take-up has been low, but it is still early days, and Ms Wilman hopes that once advertising spreads, the take-up will increase.

A ROLE FOR EHOs

The majority of people who suffer from severe food allergies know what foods they need to avoid, but in order for them to make an informed choice, they need help from a range of professionals, including EHOs.
The Food Safety (General Food Hygiene) Regulations 1995, place the responsibility on food business properties to identify hazards in their businesses and to operate adequate safety measures (a process of hazards analysis) so that consumers are protected. The regulations describe a food hazard as anything that has the potential to cause harm to the consumer.

Research carried out by Dr Leitch in Northern Ireland however, reveals that while EHOs consider the control of nut/peanut food allergens as important, most do not include such hazards in their analysis.⁴ Respondents claim that this is due to a lack of knowledge about allergens, which probably relates to a lack of training in that area.

The gaps in knowledge and training are assisted by a current lack of specific guidance on the subject. The Local Authorities Co-ordinator of Regulatory Services (Lacors), formerly the Local Authority Co-ordinating Body on Food and Trading Standards (Lacots) provides guidance for EHOs on the application of risk assessment principles. But as Dr Leitch points out, the notes focus on physical, chemical and microbiological hazards. "There is very little mention of food allergens as a hazard".

A NATIONAL TRAINING PROGRAMME

Dr Leitch has long supported a properly resourced Haccp-based professional training programme, which encompasses food allergen control systems. This would give EHOs the necessary knowledge and competence to provide producers and processors of food with advice on the avoidance of trigger allergens during inspections. The Anaphylaxis Campaign, working closely with a number of environmental health, trading standards and food and medical professionals, has drafted a proposal to undertake such a programme and has recently consulted with the FSA.

With greater knowledge and up-to-date training, EHOs are well-placed to play a significant role in raising awareness during the food preparation stage. In addition, EHOs can provide advice to food servers, pointing out the potential for cross-contamination or inadvertently misinforming the public. For instance, if a chef includes nuts in a meal, it is important that this information is passed on to the serving staff. In the event that a customer asks the server if a meal contains nuts, the server needs to be in a position to provide accurate information.

As Dr Leitch concludes: "EHOs are the most effective group to bring the food allergen safety message to the food trade, working on a one-to-one basis with business proprietors. "It's over to the FSA, Lacors, the universities and the training officers to provide the tools for the job."

Arguably the best strategy to protect allergic sufferers is the avoidance of trigger allergens. However, in a world in which food diversity is forecast to grow, an accurate and efficient assessment of peanut/nut hazard analysis during general food hygiene inspections can greatly enhance the level of security.

Dr Ian Leitch and Hazel Gowland's papers can be accessed at the CIEH website: www.cieh.org

For more information about the Anaphylaxis Campaign visit: www.anaphylaxis.org.uk or tel: 01252 542029.

To find out more about Tandridge DC's responsible retailer allergy awareness pilot scheme, contact: Claire Wilman at: claire.wilman@surreycc.gov.uk

The Food Standards Agency's 'Be Allergy Aware' posters and booklets and the "'May Contain' Labelling - The Consumer's Perspective" booklet are available from the FSA. Tel: 0845 606 0667 or e-mail: foodstandards@eclogistics.co.uk

The British Nutrition Foundation's report "Preparatory work on improving information in catering outlets and for foods sold loose (LSA 13/258)" is available from the FSA website. Visit: www.foodstandards.gov.uk/multimedia/pdfs/bnfreport.pdf

References:

1. Pumphrey, R.S.H., (2000). "Lessons for the management of anaphylaxis from a study of fatal reactions". Journal of Clinical and Experimental Allergy 30:1144-50.
2. Tariq, Stevens, Matthews, Ridout, Twiselton, Hide - "Cohort study of peanut and tree nut sensitisation by the age of four years", BMJ 1996, 313: 514-7.
3. Hospitality Training Foundation - Occupational Standards - National Vocational Qualifications/Scottish Vocational Qualifications for chefs and foodservice staff from January 1995.
4. Leitch, Ian, Blair, Ian, McDowell, David. "Dealing with allergy", Environmental Health Journal, October 2000, pages 335-339.