Mimosas in bloom well before Women’s Day, spring days as early as February, winter weeks with temperatures a few degrees higher than average. Flowers bloom, i pollini are raging and it now seems certain that the sneezing season is irremediably longer and more annoying. This year, however, there is a new element, the almost ubiquitous use of the masks to protect themselves from the infection of Sars-CoV-2. Thus, as Riccardo Asero, president of the Association of Italian Territorial and Hospital Allergologists and Immunologists (AAIITO) observes, we expect a reduction in daily exposure and symptoms, because the masks filter the virus and therefore also the pollen. Of course, if you are on the terrace of the house without wearing it, the possible positive anti-allergy effect vanishes.

Adverse reactions

Allergy sufferers, however, do not seem relieved of this good news as their thoughts are now monopolized by fear of Covid vaccines: the reporting of some cases of serious anaphylactic reactions to the first administrations in the United Kingdom and the United States has created some alarm and also for this reason AAIITO and SIAAIC have created guidelines for the management of allergy sufferers at risk of severe reactions. They will be updated as the vaccination campaign continues and more and more clinical data will be collected with the aim of standardizing behavior throughout the country. The main message? Being allergic is not in itself a contraindication to the vaccine. Asero explains: Analyzing the data of severe anaphylaxis cases it was not possible to find a common denominator and therefore an element of certain risk; on the other hand due to the danger of serious reactions, even if it is higher than that of the anti-flu, in any case very low. Based on what is known we have drawn up recommendations for the evaluation of patients before the vaccine and for the efficient and safe management of those with elements of risk. For example, it is hypothesized that polyethylene glycol or PEG, an excipient in vaccines but also in other drugs and products, may play a role in anaphylaxis: the compound may have different molecular weights (the molecules can be more or less large, ed

) and thus have different allergenic capacities. We still do not have certainties and even the preliminary skin tests with PEG at different molecular weights that can be performed in those we know are allergic to this compound are not always clearly predictive. Allergy sufferers should undergo a survey more in-depth allergological assessment than usual before the vaccine to consider, for example, any previous reactions to vaccines or to excipients such as PEG or polysorbates, thus allowing to stratify the risk of anaphylaxis.

Risk categories

The document therefore indicates the four categories of patients with a higher probability, who can be vaccinated but require additional precautions. Specific Gianenrico Senna, president of the Italian Society of Allergy, Asthma and Clinical Immunology (SIAAIC), These are those who had reactions prior to the first administration of the vaccine for Covid-19, those suffering from mastocytosi (condition in which there are many cells rich in histamine and which therefore increases the frequency of anaphylaxis, ed), those who have had more than one anaphylactic reaction in the past, especially if the cause has not been identified, and those who have severe uncontrolled asthma. The latter are 2-3 percent of asthmatics and precautionary protected vaccination: there is no certain data that they are at greater risk, but if the respiratory disease is very unstable, a concomitant and unexpected anaphylaxis could be more dangerous.

Protected environment

What happens if you belong to one of these four categories? Maria Antonella Muraro, head of the Center for the study and treatment of food allergies in the Veneto Region, explains: If you are considered to be at high risk, vaccination must take place in a protected environment, ie in the hospital in the presence of an anesthetist available for rapid resuscitation; if you are at medium or low allergic risk in the clinic there must in any case be trained staff ready to intervene in the event of anaphylaxis, in addition, emergency devices must be present or adrenalin, fluids, a defibrillator. The ideal would be to have adrenaline with auto-injector at hand, because the correct dose is ready to use, very simple to administer by any operator even in a moment of inevitable agitation such as the appearance of an anaphylactic reaction. The protocol also provides for aprolonged observation: Most of the anaphylactic reactions recorded so far appear within the first 15 minutes, but in high-risk patients, for example asthmatics with unstable disease, it is recommended to be observed for up to one hour after inoculation. The appearance of even mild symptoms such as itching in the hands and feet, a feeling of closed throat, swelling indicate the need for very close monitoring; if there is a worsening within five to ten minutes, especially respiratory, adrenaline must be administered immediately, Muraro specifies. The paper emphasizes the importance of recognizing and treating the signs of anaphylaxis by placing the patient in the supine position, injecting adrenaline intramuscularly and administering a crystalloid solution intravenously to keep the fluids in the blood vessels constant. Cortisone or antihistamine would just be a waste of time, Muraro notes. Moreover, the risks associated with an excess of zeal, or the use of adrenaline in those who have not progressed towards anaphylaxis, are minimal compared to the danger of not doing it in time: you can have tachycardia and excitability, nothing serious compared to the possible death if the anaphylactic reaction cannot be stopped as soon as possible. However, there is still no certain scientific evidence of the efficacy of pre-medication for high-risk allergy sufferers with cortisone drugs for a few days. Allergy sufferers should not be afraid if they are vaccinated in the presence of those who know how to recognize alarm bells, if they are monitored and if the adrenaline auto-injector is available, Muraro concludes.

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