What allergy is high today in san antonio

Jeffrey S. Hallett, M.D. specializes in the comprehensive care of adults and children suffering from allergies, asthma, sinusitis, bronchitis and other respiratory problems. He takes pride in offering his patients personalized attention and state-of-the-art medical care.

Dr. Hallett has been in private practice since 1987 and is a Fellow of the American College of Allergy, Asthma and Immunology and the American Academy of Allergy, Asthma and immunology.

A native of West Virginia, Dr. Hallett graduated Magna Cum Laude and Phi Beta Kappa from West Virginia University. He received his medical degree from the West Virginia University School of Medicine.

Dr. Hallett completed his Pediatric Residency and his Allergy, Asthma and Immunology Fellowship at Wilford Hall USAF Medical Middle in San Antonio. He also served as the Chief of the Allergy and Immunology service at the USAF Regional Medical Middle at Scott AFB, Illinois.

Married with one daughter, Dr. Hallett also lectures nationally and internationally on topics including Allergy and Immunology, Asthma, Sublingual Immunotherapy (Oral Allergy Drops) and Allergy and Asthma Practice Standards.

Delayed reactions

Rarely, delayed-type hypersensitivity to a vaccine constituent (e.g.

aluminum) may cause an injection site nodule, but this is not generally a contraindication to subsequent vaccination. Delayed anaphylaxis (onset 3 to 6 h after exposure) is a concept that has recently been well described but in the context of individuals that own been bitten by the lone star tick and then develop IgE to a component of red meat, galactose-alpha-1, 3-galactose (alpha-gal) [41]. One patient with alpha gal allergy has safely received a gelatin containing vaccine and the authors found no documented published reports of alpha gal allergy resulting in anaphylaxis following vaccines in other patients with alpha gal allergy [42].

Of note, the route of exposure with red meat (ingestion) is diverse from the route of istration of vaccines (parenteral) and a delayed response due possibly to metabolic processes is more likely. Thus, vaccine-related allergic reactions including anaphylaxis should happen more quickly than seen in patients with allergy to red meat. Any vaccine-related reactions occurring more than 4 h after istration of a vaccine are unlikely to be immediate hypersensitivity reactions [43].

Limited immediate allergic reactions

Allergic reactions to vaccines may be mild and limited in the scope of symptoms and involvement of organ systems, or even localized to the site of vaccine istration.

Thus, typical signs of an allergic reaction may include bronchoconstriction, rhinoconjunctivitis, gastrointestinal symptoms, and/or characteristic skin lesions such as generalized urticaria and/or angioedema [17], occurring as a sole sign with an onset within minutes and less than 4 h post-vaccination [4] (D).

Other immunologic reactions

Possible non-IgE-mediated reactions to vaccines include a wide range of adverse events following immunization (AEFI) and are commonly listed on the package inserts. These include mild fever and local reactions to life threatening infections following live vaccines inappropriately given to patients with immune deficiencies.

Known side-effects from vaccines are detailed on the relevant Centers for Disease Control (CDC) website [44]. The Global Vaccine Safety Initiative addressing comprehensive AEFI considerations is reviewed on the WHO website [45].

Immediate allergic reactions

Immediate hypersensitivity or allergic reactions to vaccines are rare but potentially serious adverse events that require investigation and understanding of the associated risks in order to properly counsel patients regarding the risk versus benefit ratio for the istration of future vaccines. In this document, “allergy” will be used interchangeably with “immediate hypersensitivity” and “IgE-mediated reaction” as descriptors to denote a presumed underlying IgE-mediated immune mechanism for an adverse event.

We use the term “immediate” to distinguish these allergic reactions from those that may be mediated by antibodies other than IgE or by T cells (commonly seen in immunologic reactions to drugs).

Board-Certified — Adult and Pediatric Allergy and Asthma

Jeffrey S. Hallett, M.D.

What allergy is high today in san antonio

specializes in the comprehensive care of adults and children suffering from allergies, asthma, sinusitis, bronchitis and other respiratory problems. He takes pride in offering his patients personalized attention and state-of-the-art medical care.

Dr. Hallett has been in private practice since 1987 and is a Fellow of the American College of Allergy, Asthma and Immunology and the American Academy of Allergy, Asthma and immunology.

A native of West Virginia, Dr. Hallett graduated Magna Cum Laude and Phi Beta Kappa from West Virginia University.

What allergy is high today in san antonio

He received his medical degree from the West Virginia University School of Medicine. Dr. Hallett completed his Pediatric Residency and his Allergy, Asthma and Immunology Fellowship at Wilford Hall USAF Medical Middle in San Antonio. He also served as the Chief of the Allergy and Immunology service at the USAF Regional Medical Middle at Scott AFB, Illinois.

Married with one daughter, Dr. Hallett also lectures nationally and internationally on topics including Allergy and Immunology, Asthma, Sublingual Immunotherapy (Oral Allergy Drops) and Allergy and Asthma Practice Standards.

What allergy is high today in san antonio

Immediate reactions that are not allergic (Immediate non-allergic reactions)

Local, injection site reactions (swelling, redness, and/or soreness) and constitutional symptoms, especially fever, are common after the istration of numerous vaccines and are not contraindications to subsequent vaccination [16] (D).

Anaphylaxis

Differential diagnosis of anaphylaxis

There are a number of immediate adverse events following immunization that could be misdiagnosed as anaphylaxis. For example, sudden events such as syncope following immunization may be confused with anaphylaxis.

Numerous of these adverse events happen more commonly than vaccine related anaphylaxis and alternative diagnoses should be considered when a case definition for anaphylaxis is not met.

Anaphylaxis (all causes) generally presents with characteristic and predictable multi-system findings; less than 10 % of episodes present with sudden onset of hypotension (manifest as collapse/unresponsiveness) without concomitant respiratory manifestations and/or cutaneous signs (erythema, urticaria or angioedema). When sudden collapse or acute respiratory symptoms happen without skin changes following immunization, anaphylaxis should be considered.

Adverse events, other than anaphylaxis, that commonly result in sudden collapse and unresponsiveness following immunization include, in an baby, a Hypotonic Hyporesponsive Episode (HHE).

HHE is characterized by the sudden onset of unresponsiveness, hypotonia and pallor, and generally presents 1-to-6 h after immunization [32]. Cardiovascular compromise and specifically hypotension does not happen in HHE. Vasovagal syncope can happen at every ages and is now a frequently reported adverse event since adolescents are at increased risk and adolescent vaccination is widely promoted in some countries [33]. In vasovagal syncope, hypotension is transient and associated with bradycardia rather than tachycardia as would happen typically in anaphylaxis. Sudden unresponsiveness due to a febrile seizure following immunization is frequently associated with tonic-clonic motor movements and no cardiovascular compromise.

Acute respiratory distress with cough and stridor may happen following minor unintentional aspiration of an oral vaccine (oral polio or rotavirus vaccine) and may be mistaken for anaphylaxis.

In extremely rare instances, an error in vaccine istration may result in acute collapse and unresponsiveness that is neither HHE or vasovagal syncope. For example, inadvertent injection of a medication (for example a muscle relaxant) rather than the vaccine or following injection of staphylococcal toxin from a contaminated vial leading to Toxic Shock Syndrome [34, 35].

The oculo-respiratory syndrome (ORS) is defined by the onset within 24 h of immunization of at least one of the following symptoms: bilateral red eyes or respiratory symptoms (cough, sore throat, difficulty swallowing, wheeze, difficulty breathing, chest tightness) or facial edema [36].

The condition was primarily associated with two Influenza vaccines which contained high amounts of aggregated viron particles that triggered the signs and symptoms that were not a Type I hypersensitivity reaction [37, 38]. Refinements in manufacturing resulted in marked reductions in the incidence of this problem. Although ORS symptoms generally start several hours after vaccination [37], making the symptoms less likely to be due to immediate hypersensitivity, a detailed assessment, including skin testing, may be required to differentiate ORS from anaphylaxis.

Definition of Anaphylaxis

Anaphylaxis is the most severe form of an IgE-mediated reaction, encompassing a spectrum of symptoms and involvement of several organ systems.

For the majority of instances, anaphylaxis occurs within minutes following an exposure to an allergen. The International Consensus on (ICON) Anaphylaxis published in 2014 reviewed definitions proposed by WAO; the Joint Task Force on Practice Parameters, representing the AAAAI, the ACAAI, and the Joint Council of Allergy, Asthma, and Immunology (JCAAI); and the EAACI. In this consensus document, every organizations own agreed upon the concept that anaphylaxis is a “serious, generalized or systemic, allergic or hypersensitivity reaction that can be life-threatening or fatal” [18] (D).

The National Institutes of Allergy and Infectious Diseases (NIAID) / Food Allergy and Anaphylaxis Network (FAAN) criteria developed in 2006 by an NIH meeting of experts in the fields of allergy and immunology defined anaphylaxis as one of three scenarios: 1) The acute onset of an illness within minutes or hours with involvement of: skin and/or mucosa (pruritus, flushing, hives, angioedema), and either respiratory compromise (dyspnea, wheeze/bronchospasm, decreased peak expiratory flow, stridor, hypoxemia) OR decreased blood pressure/end organ dysfunction (collapse, syncope, incontinence) 2) Two or more of the following that happen rapidly after exposure to a likely allergen for that patient: skin and/or mucosa; respiratory compromise; decreased blood pressure/end organ dysfunction; persistent GI symptoms (vomiting, crampy abdominal pain, diarrhea) 3) The following within minutes or hours after exposure of a known allergen for that patient: decreased blood pressure [19] (D).

Alternative criteria include those developed by the Brighton Collaboration Working Group for case definitions [20] (D).

What allergy is high today in san antonio

These criteria are not intended to distinguish differing levels of severity of anaphylaxis, but instead denote diverse levels of diagnostic certainty, as the definition is used primarily for epidemiologic studies. A Level 1 case definition has the highest level of diagnostic certainty, with progressively lower certainty for levels 2 and 3, respectively. Because these levels do not directly define severity, it is possible for a extremely severe clinical event to be classified as a level 2 or 3, based on the available information. Furthermore, appropriate rapid treatment of an incipient immediate hypersensitivity reaction with intramuscular epinephrine may modulate the severity of the reaction [18] (D).

Although most episodes of anaphylaxis involve cutaneous symptoms of urticaria and/or angioedema, this is not universally the case.

Skin and/or mucosal signs may be absent in 10–20 % of every episodes, and hypotension in infants often remains unrecognized. Unique aspects of anaphylaxis in infants, including behavioral changes and challenges regarding recognition of cardiovascular signs has recently been reviewed [21]. In general, underreporting of anaphylaxis is likely common [22] (D).

Most episodes of anaphylaxis happen with a sudden onset and rapid progression [23] (D). Biphasic reactions are also described, in which an initial clinical presentation resolves with or without treatment, to be followed later (up to 72 h) by a recurrence [24, 25] (D). Protracted anaphylaxis (lasting up to several days without resolution) has also been described, but is unusual and the literature consists only of case reports or little series [26] (D).

What allergy is high today in san antonio

Protracted anaphylaxis has been reported following istration of vaccines [11] (D).

It is therefore not possible to assign a strict time frame (time from exposure to onset of symptoms) upon the definition of anaphylaxis in relation to a potential triggering event, such as an immunization. The AAAAI and ACAAI Joint Task Force on Practice Parameters advised considering events with onset within 4 h of vaccine istration as possibly consistent with anaphylaxis [4] (D).

Guidelines from the EAACI note that symptoms and signs of anaphylaxis generally happen within 2 h of exposure to the allergen and this is even faster following exposure to parenteral medications or insect stings (venom) [27] (D). A review of a registry of anaphylactic reactions in the UK found that the median time to respiratory or cardiac arrest for reactions to venom (a parenteral exposure) was 15 min, with the longest interval being 120 min [28] (D).

The differential diagnosis of, and the potential triggers for, anaphylaxis must be considered whenever an episode appears to coincide with vaccine istration, since assessing the likelihood of causality (i.e.

the vaccine causing anaphylaxis) is heavily dependent upon there being no alternative cause that can be implicated (Table 1) [29] (D).

The WAO has suggested removing the term “anaphylactoid” from use, and this is supported by the most recent update of anaphylaxis published by the Joint Task Force on Practice Parameters, representing the AAAAI, the ACAAI, and the JCAAI [29] (D). Historically, this term referred to the same syndrome as anaphylaxis that was caused by immune mechanisms, but not involving serum IgE specific for an allergen.

Other non-IgE-mediated immunologic mechanisms may cause anaphylaxis. For example, IgG-mediated and immune complex-mediated anaphylaxis has been reported for certain medications and biologic agents [30] (D), and non-immune activation of mast cells and basophils may happen [31]. However, it is now recognized that because anaphylaxis is a syndrome, with specific clinical features, and because the underlying immune mechanisms cannot easily be ascertained at the time of the event, it is essential to treat every episodes that drop into this category the same. Non-IgE-mediated events will not be discussed in this document except as they may be considered in the differential diagnosis for an adverse event (Table 1).

The CDC and FDA supported passive surveillance system, Vaccine Adverse Event Reporting System (VAERS), uses the term “serious” to include death, hospitalization or prolongation of hospitalization, persistent or significant disability/incapacity, or is life threatening.

What allergy is high today in san antonio

In this document, we use “serious” throughout the document in the same manner as clinicians use the term and not precisely as defined by VAERS.

Epidemiology of anaphylaxis

Anaphylaxis following vaccine istration is a rare event, estimated to happen at a rate of approximately 1 per million vaccine doses (B) [8]. Fatalities are exceedingly rare [39] (D). More frequent acute events that happen following istration of vaccines may be confused with anaphylaxis, including vasovagal reactions, panic (anxiety) attacks, and vocal cord dysfunction (Table 1).

The correct diagnosis is critically dependent upon obtaining essential details in the history surrounding the event [40] (D). This may provide details of exposure to allergens other than vaccines, or may discern other possible alternative diagnoses (Table 1). An precise history is also essential to confirm that the timing of the event (onset in minutes to 4 h, see above) is compatible with the biologic plausibility of anaphylaxis to a vaccine.

Association versus causality

Adverse events that temporally follow immunization are often attributed to the vaccine, suggesting a causal link to a component of the vaccine or to the immunologic response to the vaccine.

What allergy is high today in san antonio

Numerous AEFI are coincidental events that are falsely attributed to vaccines because of the temporal association. Causality, particularly with rare events and/or complicated multifactorial disorders with documented delays in diagnosis (e.g. narcolepsy), can be hard to prove or disprove. For these reasons, careful analyses of numerous AEFIs own failed to substantiate or law out a causal association.

Reports of temporal associations do not provide support for causality, but may indicate a need for future careful study to collect supportive data for a causal hypothesis [46

Susan S.

Laubach, MD joined Allergy & Asthma Medical Group and Research Middle in July 2011. Originally from Stockton, California, Dr. Laubach majored in Human Biology with honors from Stanford University before undergoing her medical training at the University of California, San Francisco (UCSF) School of Medicine. She trained in pediatrics at Mount Sinai Medical Middle in New York, NY where she founded a Palliative Care service for children with life-threatening illnesses. She then completed a fellowship in Allergy and Immunology at Duke University in Durham, NC where she received extensive training in the diagnosis and management of primary immunodeficiency and food allergy. From there, she was honored to serve athletic duty, dependent, and retired military service members in the Department of Allergy/Immunology at Walter Reed Army Medical Middle in Washington, DC.

Prior to joining Allergy & Asthma Medical Group and Research Middle, Dr. Laubach conducted research on sublingual immunotherapy (SLIT) for children with peanut allergy, under the direction of Dr. Wesley Burks at Duke University. She has also published research on influenza vaccination in patients with egg allergy, and presented data on diverse build-up schedules for immunotherapy (allergy shots). Dr. Laubach is an athletic member of the American Academy of Allergy, Asthma, and Immunology; the American College of Allergy, Asthma, and Immunology; the American Academy of Pediatrics; and the American Medical Association.

Dr.

Laubach met her husband, Justin, while both volunteering at Camp Okizu, a camp for northern Californian children with cancer and their siblings. He now practices anesthesiology in San Diego. They own 2 young children and a large extended family in the San Diego area.

Click on the link under to view Dr. Laubach’s CVs

Laubach — Full CV
Laubach — Abbreviated CV

AWARDS:

  1. Nominated for the UCSF Chancellor’s Award for the Advancement of Women, 2000
  2. ACAAI Acorn Award, 2007

Back to Our Physicians

Bio

Alexander S.

Kim, MD, is a board-certified allergist/immunologist who specializes in drug allergy and allergic airway disease. He performs comprehensive evaluations on a wide spectrum of immune conditions including drug, venom, food hypersensitivity, mast cell disorders (mast cell activation and mastocytosis), eosinophilic disorders (eosinophilic esophagitis, peripheral eosinophilia), allergic skin conditions (atopic dermatitis, urticaria), allergic airway disease (asthma, sinusitis and AERD) and immunodeficiency.

Dr. Kim is involved with clinical research focused on quality improvement and patient safety, drug allergy and desensitization, chronic sinusitis and aspirin-exacerbated respiratory disease.

Dr. Kim also serves as an associate program director of the Allergy/Immunology Fellowship Program and teaches medical students at UC San Diego School of Medicine. He has several research publications in the field of allergy and immunology and has presented his research at numerous national scientific meetings.

He completed a fellowship in allergy and immunology at UC San Diego School of Medicine and a residency in internal medicine at Baylor College of Medicine in Houston, where he was elected to serve as chief resident for an additional year. Dr. Kim earned his medical degree from SUNY Downstate College of Medicine in Brooklyn, New York.

He is board-certified in internal medicine and allergy and immunology.

He is a member of the American Academy of Allergy, Asthma and Immunology and the American College of Allergy, Asthma, and Immunology.

In addition to the location listed above, Dr. Kim also sees patients in El Centro.

UC San Diego Health Links
For more information, see Allergy & Immunology.

Gender

Male

Date Joined Staff

7/1/2015


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