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A population-based study on peanut, tree nut, fish, shellfish, and sesame allergy prevalence in Canada

Open AccessPublished:May 10, 2010DOI:https://doi.org/10.1016/j.jaci.2010.03.015

      Background

      Recent studies suggest an increased prevalence of food-induced allergy and an increased incidence of food-related anaphylaxis. However, prevalence estimates of food allergies vary considerably between studies.

      Objectives

      To determine the prevalence of peanut, tree nut, fish, shellfish, and sesame allergy in Canada.

      Methods

      Using comparable methodology to Sicherer et al in the United States in 2002, we performed a cross-Canada, random telephone survey. Food allergy was defined as perceived (based on self-report), probable (based on convincing history or self-report of physician diagnosis), or confirmed (based on history and evidence of confirmatory tests).

      Results

      Of 10,596 households surveyed in 2008 and 2009, 3666 responded (34.6% participation rate), of which 3613 completed the entire interview, representing 9667 individuals. The prevalence of perceived peanut allergy was 1.00% (95% CI, 0.80%-1.20%); tree nut, 1.22% (95% CI, 1.00%-1.44%); fish, 0.51% (95% CI, 0.37%-0.65%); shellfish, 1.60% (95% CI, 1.35%-1.86%); and sesame, 0.10% (95% CI, 0.04%-0.17%). The prevalence of probable allergy was 0.93% (95% CI, 0.74%-1.12%); 1.14% (95% CI, 0.92%-1.35%); 0.48% (95% CI, 0.34%-0.61%); 1.42% (95% CI, 1.18%-1.66%); and 0.09% (95% CI, 0.03%-0.15%), respectively. Because of the infrequency of confirmatory tests and the difficulty in obtaining results if performed, the prevalence of confirmed allergy was much lower.

      Conclusion

      This is the first nationwide Canadian study to determine the prevalence of severe food allergies. Our results indicate disparities between perceived and confirmed food allergy that might contribute to the wide range of published prevalence estimates.

      Key words

      Abbreviations used:

      IQR (Interquartile range), SPT (Skin prick test), UK (United Kingdom)
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      Is the prevalence of peanut allergy increasing? a five-year follow-up study on the prevalence of peanut allergy in primary school children in Montreal.
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      0% and 2% for fish,
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      • Sodergren E.
      • et al.
      The prevalence of food allergy: a meta-analysis.
      • Sicherer S.H.
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      Prevalence of seafood allergy in the United States determined by a random telephone survey.
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      • et al.
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      0% and 10% for shellfish,
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      • Zuidmeer L.
      • Sodergren E.
      • et al.
      The prevalence of food allergy: a meta-analysis.
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      • Thien F.
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      • Walters E.
      • Abramson M.
      Prevalence of food allergies in young adults and their relationship to asthma, nasal allergies, and eczema.
      • Sicherer S.H.
      • Munoz-Furlong A.
      • Sampson H.A.
      Prevalence of seafood allergy in the United States determined by a random telephone survey.
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      Prevalence of adverse reactions to food in Germany—a population study.
      and 0% and 0.79% for sesame.
      • Dalal I.
      • Binson I.
      • Reifen R.
      • Amitai Z.
      • Shohat T.
      • Rahmani S.
      • et al.
      Food allergy is a matter of geography after all: sesame as a major cause of severe IgE-mediated food allergic reactions among infants and young children in Israel.
      • Zuidmeer L.
      • Goldhahn K.
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      • Gislason D.
      • Madsen C.
      • Summers C.
      • et al.
      The prevalence of plant food allergies: a systematic review.
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      • Katz Y.
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      • et al.
      Early consumption of peanuts in infancy is associated with a low prevalence of peanut allergy.
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      • Dean T.
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      There have been a few population-based studies estimating the prevalence of peanut, tree nut, fish, and shellfish allergies in the United States,
      • Sicherer S.H.
      • Munoz-Furlong A.
      • Burks A.W.
      • Sampson H.A.
      Prevalence of peanut and tree nut allergy in the US determined by a random digit dial telephone survey.
      • Sicherer S.H.
      • Munoz-Furlong A.
      • Sampson H.A.
      Prevalence of seafood allergy in the United States determined by a random telephone survey.
      but no such studies have been conducted in Canada. Recently, our research team reported that the prevalence of peanut allergy in Montreal school children had stabilized between 2002 and 2007, although it exceeded (1.63%; 95% CI, 1.30%-2.02%)] estimates from most other countries except the United Kingdom (UK).
      • Ben-Shoshan M.
      • Kagan R.S.
      • Alizadehfar R.
      • Joseph L.
      • Turnbull E.
      • St Pierre Y.
      • et al.
      Is the prevalence of peanut allergy increasing? a five-year follow-up study on the prevalence of peanut allergy in primary school children in Montreal.
      The Surveying Canadians to Assess the Prevalence of Common Food Allergies and Attitudes towards Food LAbelling and Risk (SCAAALAR) study, launched in 2008, was designed to estimate the prevalence of food allergies responsible for the majority of severe/fatal anaphylactic reactions (peanut, tree nut, fish, shellfish, and sesame) in Canada.

      Methods

       Selection of study population

      Households were chosen by purchasing, from Info-Direct, a random selection of telephone numbers and their accompanying addresses from the electronic white pages. (Info-Direct maintains an electronic listing of all Canadian household telephone numbers listed in the white pages and updates these records monthly). Households were limited to the 10 Canadian provinces; the territories were excluded because it was thought that there would be considerable cultural difference between individuals living in these regions and the rest of Canada. Interviews were conducted from May 2008 to March 2009.

       Survey methodology

      The telephone surveys were conducted by teams of similarly trained interviewers based at either McGill (Montreal, Quebec) or McMaster (Hamilton, Ontario) Universities, using Computer Assisted Telephone Interview software (WinCati 4.2; Sawtooth Technologies Inc, Northbrook, Ill). Respondents were eligible to participate if they were 18 years or older, were living in the household, and appeared to have no language-mental-hearing barriers. The initial age-eligible household respondent was invited to participate and asked whether any household member had an allergy to peanut, tree nut, shellfish, fish, or sesame. If any household member reported an allergy, the self-reported allergy was validated by querying the potentially allergic individual (or an appropriate surrogate if the allergic individual was not eligible or was unavailable at the time of the interview) on symptoms related to ingestion of the food and diagnosis and management of the allergy. If no food allergy was reported in the household, demographic data were obtained. In addition, data on attitudes toward food labeling for allergens and the societal risk associated with food allergy were also collected (results of the surveys on food labeling and risk perception will be described in subsequent articles).
      To optimize response rates and minimize bias, a maximum of 10 attempts was made to contact households during different days and times between the hours of 9:30 am and 9:00 pm (local time) Monday through Friday and 10:30 am and 5:00 pm (local time) on Saturdays and Sundays. In addition, households were advised that we were conducting a survey on food allergies a few weeks in advance by a mailed information letter.
      • Smith W.
      • Chey T.
      • Jalaludin B.
      • Salkeld G.
      • Capon T.
      Increasing response rates in telephone surveys: a randomized trial.
      The study was approved by the Institutional Review Boards of the McGill University Health Centre and McMaster University.

       Questionnaire

      We used a standardized questionnaire developed previously by Sicherer et al
      • Sicherer S.H.
      • Munoz-Furlong A.
      • Burks A.W.
      • Sampson H.A.
      Prevalence of peanut and tree nut allergy in the US determined by a random digit dial telephone survey.
      • Sicherer S.H.
      • Munoz-Furlong A.
      • Sampson H.A.
      Prevalence of seafood allergy in the United States determined by a random telephone survey.
      to determine the general population prevalence of peanut, tree nut, fish, and shellfish allergy
      • Sicherer S.H.
      • Munoz-Furlong A.
      • Burks A.W.
      • Sampson H.A.
      Prevalence of peanut and tree nut allergy in the US determined by a random digit dial telephone survey.
      • Sicherer S.H.
      • Munoz-Furlong A.
      • Sampson H.A.
      Prevalence of seafood allergy in the United States determined by a random telephone survey.
      in the United States, and modified it to incorporate questions regarding sesame allergy. In addition, in cases in which respondents reported that the allergy was diagnosed by a physician, we requested permission to obtain confirmatory information from the physician. To increase response rate among physicians, up to 3 letters were sent requesting medical information regarding the use of confirmatory tests to diagnose the food allergy.
      The participant questionnaire included questions on specific types of tree nut (eg, hazelnut, pecan, and pistachio), fish (eg, tuna, cod, and salmon), and shellfish including crustaceans (eg, shrimp and lobster) and mollusks (eg, clams and squid). Individuals were queried on the history of the most severe allergic reaction (ie, whether they experienced typical IgE-mediated symptoms such as pruritus, urticaria, flushing, rhinoconjunctivitis, angioedema, throat tightness, gastrointestinal complaints, breathing difficulties, wheeze, cyanosis, or circulatory collapse), interval between exposure and symptom onset, whether medical care was sought, whether epinephrine was administered, whether diagnosed by a physician, and whether confirmatory tests (ie, skin prick tests [SPTs], measurement of serum allergen-specific IgE, and/or food challenge) were performed. Demographic data were collected including number, age, and sex of household members; education level of the household respondent; whether the household respondent was born in Canada, and country of origin of respondent if not born in Canada, and number of years living in Canada; and household income level. The questionnaire was translated into French and back-translated to English.

       Definitions of food allergy

      We developed 3 definitions of food allergy.
      • 1.
        Perceived food allergy. This includes all cases of self-reported food allergy, regardless of history or presence of supporting confirmatory tests.
      • 2.
        Probable food allergy. This refers to those self-reporting food allergy who have a convincing history of food allergy or who report a physician confirmed food allergy. A convincing clinical history of an IgE-mediated reaction to a specific food was defined as a minimum of 2 mild signs/symptoms or 1 moderate or 1 severe sign/symptom that was likely IgE-mediated and occurred within 120 minutes after ingestion or contact (or inhalation in the case of fish and shellfish). Reactions were considered mild if they involved pruritus, urticaria, flushing, or rhinoconjunctivitis; moderate if they involved angioedema, throat tightness, gastrointestinal complaints, or breathing difficulties (other than wheeze); and severe if they involved wheeze, cyanosis, or circulatory collapse.
        • Ben-Shoshan M.
        • Kagan R.S.
        • Alizadehfar R.
        • Joseph L.
        • Turnbull E.
        • St Pierre Y.
        • et al.
        Is the prevalence of peanut allergy increasing? a five-year follow-up study on the prevalence of peanut allergy in primary school children in Montreal.
        • Hourihane J.O.
        • Kilburn S.A.
        • Dean P.
        • Warner J.O.
        Clinical characteristics of peanut allergy.
        • Brown S.G.
        Clinical features and severity grading of anaphylaxis.
        • Sicherer S.H.
        • Burks A.W.
        • Sampson H.A.
        Clinical features of acute allergic reactions to peanut and tree nuts in children.
      • 3.
        Confirmed food allergy. Participants were considered to have a confirmed allergy only if one of the following was fulfilled:
        • a.
          They had a convincing clinical history of an IgE-mediated reaction attributed to food and their physician provided confirmation of a positive SPT defined as a wheal diameter at least 3 mm larger than that elicited by the negative control within 10 to 15 minutes of placement
          • Eigenmann P.A.
          • Sampson H.A.
          Interpreting skin prick tests in the evaluation of food allergy in children.
          OR a serum food-specific IgE ≥0.35 kU/L OR a positive food challenge.
        • b.
          They were never exposed to the food or had an uncertain clinical history (ie, any history other than convincing) of an IgE-mediated reaction and their physician provided confirmation of a positive SPT AND a food-specific IgE above previously published thresholds (ie, ≥15 kU/L for peanut and tree nut and ≥20 kU/L for fish
          • Sampson H.A.
          Utility of food-specific IgE concentrations in predicting symptomatic food allergy.
          ) OR a positive SPT AND a positive food challenge OR a positive food challenge alone. It should be noted, however, that for peanut allergy, a SPT ≥8 mm in those ≥2 years and a SPT ≥4 mm in those <2 years were considered sufficient diagnostic criteria in those never exposed or with an uncertain history. It has been reported that these thresholds are highly predictive of peanut allergy.
          • Sporik R.
          • Hill D.J.
          • Hosking C.S.
          Specificity of allergen skin testing in predicting positive open food challenges to milk, egg and peanut in children.
          • Hill D.J.
          • Heine R.G.
          • Hosking C.S.
          The diagnostic value of skin prick testing in children with food allergy.
          It should be noted that although these thresholds are widely used among allergists in different countries including Canada,
          • Ben-Shoshan M.
          • Kagan R.
          • Primeau M.N.
          • Alizadehfar R.
          • Turnbull E.
          • Harada L.
          • et al.
          Establishing the diagnosis of peanut allergy in children never exposed to peanut or with an uncertain history: a cross-Canada study.
          they are not universally accepted,
          • Pucar F.
          • Lim H.
          • Clarke A.E.
          Peanut oral challenge: a retrospective study of 140 patients.
          and there are physicians who would use a higher threshold of 13 mm.
          • Kagan R.S.
          • Hayami D.
          • Joseph L.
          • St-Pierre Y.
          • Clarke A.E.
          The predictive value of a positive prick skin test to peanut in atopic, peanut-naïve children.

       Statistical analysis

      Preliminary point estimates and 95% CIs for the overall prevalence of perceived and probable food allergy were calculated, accounting for the fact that households were the primary sampling units in this survey data, rather than individuals.
      • Cochrane W.
      Sampling techniques.
      Given that sufficient confirmatory test data were not available for all participants, a third estimate was computed, based on the data provided, as a tentative lower bound for the prevalence of confirmed food allergy in all participants.
      • Kmetic A.
      • Joseph L.
      • Berger C.
      • Tenenhouse A.
      Multiple imputation to account for missing data in a survey: estimating the prevalence of osteoporosis.
      • Rubin D.
      Multiple imputation for nonresponse in surveys.
      However, with no results of food challenges having been obtained, a proportion of true negatives among self-reported cases could not be established. Hence, the lower end of a 1-sided binomial 97.5% CI for the proportion of confirmed cases was first calculated, with a value that decreases as the number of confirmed observations gets smaller. As an example, if for a given allergy, 15 of 15 cases providing test results were confirmed, the lower end of the interval would be 78%, whereas it would only be 48% if only 5 of 5 cases were confirmed. This percentage was then multiplied by the proportion of all responders who reported a comparable history to that of confirmed cases. Pursuing the same example, if 15 cases were confirmed among patients with a convincing history, and 5 among those with an uncertain history, the prevalence estimate for confirmed allergy would be the sum of 78% of the proportion of convincing histories plus 48% of that of uncertain histories. Relevant 95% CIs were also adjusted to account for the multilevel aspect of this data.

      Results

       Participation rate

      Of 10,596 households contacted, 3666 responded (34.6% participation rate), of which 3613 completed the entire interview, representing 9667 individuals.
      Compared with the general Canadian population, immigrants within the last 10 years as well as those with lower household income are underrepresented in our study population (Table I).
      Table IDemographic characteristics
      SCAAALAR populationCanadian population
      College/university/professional degree or diploma60.5%32.9% (as of 2001)
      High school diploma90.7%68.7% (as of 2001)
      Born in Canada85.6%80.6% (as of 2006)
      Immigrated to Canada in the last 10 years1.9%6.3% (as of 2006)
      Married/cohabitation70.3%72.5% (as of 2006)
      Dwelling owned82.1%68.0% (as of 2006)
      Median annual household income$70,000$63,600 (as of 2006)
      Household income under low-income cutoff
      Among respondents who provided income-related information, representing 61% of our household sample.
      Low income cutoffs, defined as income levels at which families or unattached individuals spend at least 70% of before tax income on food, shelter, and clothing and is determined according to family size and geographic location.
      8.9%14.5% (as of 2006)
      Rural (based on postal code) location15.5%13.7% (as of 2001)
      Rural
      Residing outside Canadian metropolitan areas or in Canadian metropolitan areas with a population ≤100,000.
      39.0%32.4% (as of 2007)
      Residing in Atlantic Canada5.4%6.9% (as of 2006)
      Quebec39.5%23.4%
      Ontario32.6%38.9%
      Prairies12.2%17.5%
      British Columbia10.3%13.2%
      SCAAALAR,Surveying Canadians to Assess the Prevalence of Common Food Allergies and Attitudes towards Food LAbelling and Risk.
      Among respondents who provided income-related information, representing 61% of our household sample.
      Low income cutoffs, defined as income levels at which families or unattached individuals spend at least 70% of before tax income on food, shelter, and clothing and is determined according to family size and geographic location.
      Residing outside Canadian metropolitan areas or in Canadian metropolitan areas with a population ≤100,000.

       Prevalence estimates

      The prevalence of perceived peanut allergy was 1.00% (95% CI, 0.80%-1.20%); tree nut, 1.22% (95% CI, 1.00%-1.44%); fish, 0.51% (95% CI, 0.37%-0.65%); shellfish, 1.60% (95% CI, 1.35%-1.86%); and sesame, 0.10% (95% CI, 0.04%-0.17%; Fig 1, Fig 2, Fig 3, Fig 4, Fig 5; Table II).
      Figure thumbnail gr1
      Fig 1Algorithm for the diagnosis of confirmed peanut allergy. The number of participants eligible for SPTs, measurement of PN-specific IgE levels, or FCs exceeds the number of available test results because participants did not have the tests done, participants refused to release medical information from the treating physician, or physicians did not provide test results. †Data provided not sufficient to establish the diagnosis of allergy. ‡For those below 2 years, the cutoff is 4 instead of 8 mm.
      Figure thumbnail gr2
      Fig 2Algorithm for the diagnosis of confirmed tree nut allergy. The number of participants eligible for SPTs, measurement of TN-specific IgE levels, or FCs exceeds the number of available test results because participants did not have the tests done, participants refused to release medical information from the treating physician, or physicians did not provide test results. †Data provided not sufficient to establish the diagnosis of allergy.
      Figure thumbnail gr3
      Fig 3Algorithm for the diagnosis of confirmed fish allergy. The number of participants eligible for SPTs, measurement of fish-specific IgE levels, or FCs exceeds the number of available test results because participants did not have the tests done, participants refused to release medical information from the treating physician, or physicians did not provide test results. †Data provided not sufficient to establish the diagnosis of allergy.
      Figure thumbnail gr4
      Fig 4Algorithm for the diagnosis of confirmed shellfish allergy. The number of participants eligible for SPTs, measurement of shellfish-specific IgE levels, or FCs exceeds the number of available test results because participants did not have the tests done, participants refused to release medical information from the treating physician, or physicians did not provide test results. †Data provided not sufficient to establish the diagnosis of allergy.
      Figure thumbnail gr5
      Fig 5Algorithm for the diagnosis of confirmed sesame allergy. The number of participants eligible for SPTs, measurement of sesame-specific IgE levels, or FCs exceeds the number of available test results because participants did not have the tests done, participants refused to release medical information from the treating physician, or physicians did not provide test results. †Data provided not sufficient to establish the diagnosis of allergy. FC, Food challenge; Hx, history; PN, peanut; TN, tree nut.
      Table IIPrevalence estimates for perceived, probable, and confirmed food allergy
      ParticipantsPeanutTree nutFishShellfishSesame
      Children (%) (95% CI)
       Perceived1.77 (1.21-2.33)1.73 (1.16-2.30)0.18 (0.00-0.36)0.55 (0.21-0.88)0.23 (0.03-0.43)
       Probable1.68 (1.14-2.23)1.59 (1.04-2.14)0.18 (0.00-0.36)0.50 (0.18-0.82)0.23 (0.03-0.43)
       Confirmed1.03 (0.67-1.39)0.69 (0.40-0.97)00.06 (0.01-0.10)0.03 (0.00-0.06)
      Adults (%) (95% CI)
       Perceived0.78 (0.58-0.97)1.07 (0.84-1.30)0.60 (0.43-0.78)1.91 (1.60-2.23)0.07 (0.01-0.13)
       Probable0.71 (0.52-0.90)1.00 (0.78-1.23)0.56 (0.39-0.73)1.69 (1.39-1.98)0.05 (0.00-0.11)
       Confirmed0.26 (0.18-0.34)0.35 (0.27-0.44)0.12 (0.08-0.16)0.71 (0.58-0.84)0.01 (0.00-0.02)
      Entire study population (%) (95% CI)
       Perceived1.00 (0.80-1.20)1.22 (1.00-1.44)0.51 (0.37-0.65)1.60 (1.35-1.86)0.10 (0.04-0.17)
       Probable0.93 (0.74-1.12)1.14 (0.92-1.35)0.48 (0.34-0.61)1.42 (1.18-1.66)0.09 (0.03-0.15)
       Confirmed0.61 (0.47-0.74)0.68 (0.54-0.83)0.10 (0.07-0.14)0.73 (0.59-0.86)0.03 (0.01-0.06)
      The prevalence of probable peanut allergy was 0.93% (95% CI, 0.74%-1.12%); tree nut, 1.14% (95% CI, 0.92%-1.35%); fish, 0.48% (95% CI, 0.34%-0.61%); shellfish, 1.42% (95% CI, 1.18%-1.66%); and sesame, 0.09% (95% CI, 0.03%-0.15%; Fig 1, Fig 2, Fig 3, Fig 4, Fig 5; Table II).
      Although most participants self-reporting food allergy had testing performed (Table III), only 56.7%, 55.9%, 51.0%, 34.2%, and 70.0% of those self-reporting peanut, tree nut, fish, shellfish, and sesame allergy allowed us to contact their physician to obtain confirmatory test results. In over 50% of cases, these physicians failed to provide results, and in only 21.6%, 10.2%, 6.1%, 4.5%, and 40.0% of those self-reporting food allergy were these results sufficient to establish the diagnosis (Table III). None of the patients reported a food challenge. Confirmatory tests for peanut, tree nut, and shellfish were performed less often in adults (Table III). Based on the results obtained, the prevalence of confirmed peanut allergy was 0.61% (95% CI, 0.47%-0.74%), and the prevalence of confirmed tree nut, fish, shellfish and sesame allergy was 0.68% (95% CI, 0.54%-0.83%), 0.10% (95% CI, 0.07%-0.14%), 0.73% (95% CI, 0.59%-0.86%), and 0.03% (95% CI, 0.01%-0.06%), respectively (Fig 1, Fig 2, Fig 3, Fig 4, Fig 5; Table II).
      Table IIINumber and percentage of participants with reported and sufficient confirmatory tests
      Among those reporting food allergy.
      ParticipantsPeanutTree nutFishShellfishSesame
      Children, N (%
      Among those reporting food allergy.
      )
       Self-report of tests
      Including those who did not know whether tests were done.
      35 (89.7)33 (86.8)3 (75.0)11 (91.7)4 (80.0)
       Consent to contact MD30 (76.9)30 (78.9)2 (50.0)9 (75.0)3 (60.0)
       Results provided by MD16 (41.0)16 (42.1)1 (25.0)5 (41.7)2 (40.0)
       Results sufficient to confirm allergy16 (41.0)8 (21.1)0 (0.0)2 (16.7)2 (40.0)
      Adults, N (%
      Among those reporting food allergy.
      )
       Self-report of tests
      Including those who did not know whether tests were done.
      42 (72.4)56 (70.0)34 (75.6)69 (48.3)5 (100.0)
       Consent to contact MD25 (43.1)36 (45.0)23 (51.1)44 (30.8)4 (80.0)
       Results provided by MD8 (13.8)9 (11.3)6 (13.3)8 (5.6)2 (40.0)
       Results sufficient to confirm allergy5 (8.6)4 (5.0)3 (6.7)5 (3.5)2 (40.0)
      Entire study population N (%
      Among those reporting food allergy.
      )
       Self-report of tests
      Including those who did not know whether tests were done.
      77 (79.4)89 (75.4)37 (75.5)80 (51.6)9 (90.0)
       Consent to contact MD55 (56.7)66 (55.9)25 (51.0)53 (34.2)7 (70.0)
       Results provided by MD24 (24.7)25 (21.2)7 (14.3)13 (8.4)4 (40.0)
       Results sufficient to confirm allergy21 (21.6)12 (10.2)3 (6.1)7 (4.5)4 (40.0)
       Difference in reported tests percentages in children versus adults (%)17.3 (2.4, 32.3)16.8 (2.1, 31.6)−0.6 (−44.8, 43.7)43.4 (25.8, 61.1)−20 (−55.1, 15.1)
      MD, Medical doctor.
      Among those reporting food allergy.
      Including those who did not know whether tests were done.

       Characteristics of reactions

      Initial allergic reactions in children with probable peanut, tree nut, and sesame allergy occurred at a median age of 2 years (interquartile range [IQR], 1-4), 7 years (IQR, 2-12), and 2 years (IQR, 1-4), respectively (Table IV). Initial reactions in participants 18 years and older with probable peanut, tree nut, and sesame allergy occurred at a median age of 11 years (IQR, 2-30), 20 years (IQR, 10-40) and 10 years (IQR, 2-15), respectively. Initial reactions to fish and shellfish occurred in children at a median age of 4 years (IQR, 2.5-5) and 6.5 years (IQR, 4-9) and in adults, at a median age of 12 years (IQR, 5-25) and 25 years (IQR, 17-37; Table IV).
      Table IVCharacteristics of reactions
      ParticipantsPeanutsTree nutFishShellfishSesame
      Children
       Initial reaction median age (y) (IQR)
      Among participants with probable food allergy reporting at least 1 allergic reaction.
      2 (1-4)7 (2-12)4 (2.5-5)6.5 (4-9)2 (1-4)
       Participants with probable allergy reporting at least 1 allergic reaction (N)30264105
       % With recurrent reactions
      Among participants with probable food allergy reporting at least 1 allergic reaction.
      56.758.350.044.480.0
       % With moderate/severe reaction
      Among participants with probable food allergy reporting at least 1 allergic reaction.
      90.088.5100.090.0100.0
       % Treated with epinephrine
      Among participants with moderate/severe reactions as defined in the text.
      29.634.825.033.320.0
      Adults
       Initial reaction median age (y) (IQR)
      Among participants with probable food allergy reporting at least 1 allergic reaction.
      11 (2-30)20 (10-40)12 (5-25)25 (17-37)10 (2-15)
       Participants with probable allergy reporting at least 1 allergic reaction (N)4973371224
       % With recurrent reactions
      Among participants with probable food allergy reporting at least 1 allergic reaction.
      84.884.193.877.0100.0
       % With moderate/severe reaction
      Among participants with probable food allergy reporting at least 1 allergic reaction.
      91.895.991.993.475.0
       % Treated with epinephrine
      Among participants with moderate/severe reactions as defined in the text.
      40.040.020.613.266.7
      Entire study population
       Initial reaction median age (y) (IQR)
      Among participants with probable food allergy reporting at least 1 allergic reaction.
      4 (2-16)15.5 (6-30)8 (5-25)25 (14-35)3 (1.5-12.5)
       Participants with probable allergy reporting at least 1 allergic reaction (N)7999411329
       % With recurrent reactions
      Among participants with probable food allergy reporting at least 1 allergic reaction.
      73.777.488.974.687.5
       % With moderate/severe reaction
      Among participants with probable food allergy reporting at least 1 allergic reaction.
      91.193.992.793.288.9
       % Treated with epinephrine
      Among participants with moderate/severe reactions as defined in the text.
      36.138.721.114.637.5
      Among participants with probable food allergy reporting at least 1 allergic reaction.
      Among participants with moderate/severe reactions as defined in the text.
      Recurrent reactions were common and occurred in 73.7%, 77.4%, 88.9%, 74.6%, and 87.5% of those with peanut, tree nut, fish, shellfish, and sesame allergy, respectively (Table IV). Among those with moderate or severe reactions (defined above),
      • Ben-Shoshan M.
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      • Joseph L.
      • Turnbull E.
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      • et al.
      Is the prevalence of peanut allergy increasing? a five-year follow-up study on the prevalence of peanut allergy in primary school children in Montreal.
      • Hourihane J.O.
      • Kilburn S.A.
      • Dean P.
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      Clinical characteristics of peanut allergy.
      • Brown S.G.
      Clinical features and severity grading of anaphylaxis.
      • Sicherer S.H.
      • Burks A.W.
      • Sampson H.A.
      Clinical features of acute allergic reactions to peanut and tree nuts in children.
      to peanut, tree nut, fish, shellfish, and sesame, only 36.1%, 38.7%, 21.1%, 14.6%, and 37.5% reported receiving epinephrine treatment, respectively (Table IV).
      The most prevalent tree nut, fish, and shellfish associated with allergic reactions were reported to be hazelnut, cod/salmon, and shrimp, respectively. These were also the most common foods associated with moderate/severe reactions.

      Discussion

      We have conducted the first nationwide study on food allergy prevalence that attempts to confirm participant self-report of allergy by obtaining physician records of diagnostic testing. However, retrieving such information proved to be challenging because all participants did not undergo such testing, and of those who did, many participants or physicians refused to provide results. Hence, our prevalence estimates of confirmed allergy are very conservative, and we have therefore also provided estimates for perceived and probable allergy, which likely better approximate true prevalence. The difference between perceived and confirmed estimates certainly contributes to the wide range of published values for food allergy prevalence.
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      Although we tried to increase the participation rate through the use of an introductory letter and by calling on different days and different times of the day, it is still relatively low. This is consistent with recently reported trends of low participation rates in telephone surveys, especially among persons with lower education.
      • Feveile H.
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      This low participation rate is also in line with the most recent food allergy telephone survey conducted by Sicherer et al
      • Sicherer S.
      • Munoz-Furlong A.
      • Sampson H.
      Prevalence of self-reported peanut, tree nut and sesame allergy in the US determined by a random nationwide telephone survey: results from 1997, 2002 and 2008.
      in 2008 (42% participation rate). In addition, although digital telephone surveys using white pages sampling (through Info-direct) are suitable to collect information for prevalence on most common self-reported health conditions in the population including minorities,
      • Dal G.E.
      • Taylor A.
      • Wilson D.
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      Optimizing telephone-based population sampling.
      • Ngo-Metzger Q.
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      they may result in selection bias because of exclusion of unlisted numbers,
      • Dal G.E.
      • Taylor A.
      • Wilson D.
      Is there a difference in health estimates between people with listed and unlisted telephone numbers?.
      persons who are primary or exclusive cell-phone users, ethnic minorities, immigrants,
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      and lower socioeconomic groups.
      • Stang A.
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      • Dragano N.
      • Beck E.M.
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      • et al.
      Baseline recruitment and analyses of nonresponse of the Heinz Nixdorf Recall Study: identifiability of phone numbers as the major determinant of response.
      Accordingly, these latter 2 groups are relatively underrepresented in our study. Further, our low response rate may have led to a higher participation rate among those with food allergies. However, we believe that our estimates for the prevalence of perceived and probable food allergy are valid given that these estimates for peanut allergy in Canadian and Quebec children (Canada, perceived 1.77% and probable 1.68%; Quebec, 1.69% and 1.69%, respectively) are consistent with our estimates for confirmed peanut allergy in Montreal school children (1.63%), in whom the participation rate was 64.2%.
      • Ben-Shoshan M.
      • Kagan R.S.
      • Alizadehfar R.
      • Joseph L.
      • Turnbull E.
      • St Pierre Y.
      • et al.
      Is the prevalence of peanut allergy increasing? a five-year follow-up study on the prevalence of peanut allergy in primary school children in Montreal.
      Our results demonstrate that there is substantial misconception on behalf of both health care providers and patients regarding the diagnosis and management of food allergy. In our study, physicians underused the confirmatory tests required to establish or refute the diagnosis of food allergy, supporting our recent observation on the underuse of confirmatory tests in children never exposed to peanut or with an uncertain history.
      • Ben-Shoshan M.
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      Establishing the diagnosis of peanut allergy in children never exposed to peanut or with an uncertain history: a cross-Canada study.
      Underuse of confirmatory tests was most frequent in adults reporting shellfish allergy and cannot be entirely attributed to recall bias, given that shellfish allergy usually develops in adulthood.
      • Roehr C.C.
      • Edenharter G.
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      Food allergy and non-allergic food hypersensitivity in children and adolescents.
      Inadequate use of confirmatory tests can have substantial consequences, with some mislabelled allergic and burdened with a lifetime of unnecessary dietary vigilance, whereas others may be falsely reassured that they are not at risk for fatal anaphylaxis. Furthermore, most of our participants with food allergy had experienced at least 1 repeat reaction, and few reactions were managed appropriately with epinephrine.
      It is possible that some participants deemed to have a convincing history for tree nut or fish allergy did not actually experience an IgE-mediated reaction with the potential to develop into anaphylaxis. Tree nut allergy was the most prevalent food allergy reported in our study, and our estimates exceed most others.
      • Sicherer S.H.
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      • Sampson H.A.
      Prevalence of seafood allergy in the United States determined by a random telephone survey.
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      It is possible that the 4.5% of participants with probable tree nut allergy who reported symptoms limited to itching/swelling of the mouth immediately after oral contact with a specific nut have a pollen-food allergy syndrome
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      and are less likely to experience severe anaphylactic reactions. It is also possible that patients reporting fish allergy may have had scombroid fish poisoning because of bacterial contamination of fish and production of histamine
      • Lavon O.
      • Lurie Y.
      • Bentur Y.
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      or an IgE-mediated reaction to Anisakis simplex associated with consumption of raw fish.
      • Choi S.J.
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      • Couture C.
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      However, given that all participants reporting fish allergy had either multiple reactions or a positive SPT to fish, the diagnosis of scombroid fish poisoning or Anisakis allergy is unlikely.
      It is possible that a small percentage of children who did not experience a recent reaction had actually developed tolerance. Although we had data only on the date of the most severe reaction and not the most recent, if we assume that the most severe reaction is actually the most recent, 15% of children not having a reaction to peanut in the past 2 years,
      • Rangaraj S.
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      9% not experiencing a reaction to tree nut in the past year,
      • Fleischer D.M.
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      17.2% not experiencing a reaction to fish in the past 2 years,
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      and 20% not experiencing a reaction to sesame in the past 2.3 years
      • Aaronov D.
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      • Cohen A.
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      might have outgrown their allergy. Thus, our probable prevalence estimates in participants with peanut, tree nut, fish, and sesame allergy would decrease to 0.88% (95% CI, 0.71%-1.09%), 1.11% (95% CI, 0.91%-1.34%), 0.47% (95% CI, 0.34%-0.63%) and 0.09% (95% CI, 0.04%-0.17%), respectively. This clearly represents a lower bound because some of the participants might have experienced a more recent but less severe reaction. Given that there are no reports on the rate of resolution of shellfish allergy, we were unable to conduct a similar sensitivity analysis.
      Our estimates of the median age of the initial reaction to peanut, tree nut, and sesame in children are similar to published estimates,
      • Cohen A.
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      • Fleischer D.M.
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      but for adults, the median age exceeds that reported in most other studies. This is likely a result of recall bias—that is, adults have difficulty recalling the date of a personal remote reaction and likely report the date of a more recent one, whereas parents usually recall the date of their child's initial reaction.
      • Moberg C.
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      The median age of the initial reaction to fish and shellfish in both children and adults is comparable to other reports, possibly because the onset of these allergies is usually at an older age.
      • Sicherer S.H.
      • Munoz-Furlong A.
      • Sampson H.A.
      Prevalence of seafood allergy in the United States determined by a random telephone survey.
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      Analysis of food-allergic and anaphylactic events in the National Electronic Injury Surveillance System.
      In addition, the age of the initial introduction of a food (for which we did not collect data) may have influenced the age of the initial reaction.
      • Du Toit G.
      • Katz Y.
      • Sasieni P.
      • Mesher D.
      • Maleki S.J.
      • Fisher H.R.
      • et al.
      Early consumption of peanuts in infancy is associated with a low prevalence of peanut allergy.
      Our definitions for food allergy differed slightly from those used previously by Sicherer et al
      • Sicherer S.H.
      • Munoz-Furlong A.
      • Burks A.W.
      • Sampson H.A.
      Prevalence of peanut and tree nut allergy in the US determined by a random digit dial telephone survey.
      • Sicherer S.H.
      • Munoz-Furlong A.
      • Sampson H.A.
      Prevalence of seafood allergy in the United States determined by a random telephone survey.
      in the United States. However, to compare our results to US estimates, we have used comparable definitions. Our 2009 nationwide estimates for the perceived prevalence of peanut allergy exceeded those published by Sicherer et al
      • Sicherer S.H.
      • Munoz-Furlong A.
      • Sampson H.A.
      Prevalence of peanut and tree nut allergy in the United States determined by means of a random digit dial telephone survey: a 5-year follow-up study.
      in 2002 by 0.27% (95% CI, 0.02%-0.52%) for all participants and by 0.88% (95% CI, 0.24%-1.52%) for children. Canadian estimates for the perceived prevalence of tree nut allergy were higher by 0.44% (95% CI, 0.18%-0.71%) for all participants and by 1.15% (95% CI, 0.55%-1.76%) for children. Canadian estimates for the prevalence of peanut and tree nut combined, based on a convincing history, exceeded US estimates by 0.31% (95% CI, 0.02%-0.60%). In contrast, our 2009 estimates for the probable prevalence of shellfish allergy were lower than US 2002 estimates by 0.69% (95% CI, 0.37%-1.01%) for all and by 0.96% (95% CI, 0.56%-1.37%) for adults. The difference between Canadian and US estimates for fish allergy was not significant (0.07%; 95% CI, –0.10% to 0.23%).
      • Sicherer S.H.
      • Munoz-Furlong A.
      • Sampson H.A.
      Prevalence of seafood allergy in the United States determined by a random telephone survey.
      The observed difference in prevalence estimates between Canada and the United States might be a result of several factors. Our study was conducted 7 years later than Sicherer's,
      • Sicherer S.H.
      • Munoz-Furlong A.
      • Sampson H.A.
      Prevalence of peanut and tree nut allergy in the United States determined by means of a random digit dial telephone survey: a 5-year follow-up study.
      and therefore, temporal trends may contribute to an increase in true prevalence as well as enhanced awareness and an attendant increase in perceived prevalence. Several studies suggest an increase in the prevalence of peanut allergy during the last decade
      • Sicherer S.H.
      • Munoz-Furlong A.
      • Burks A.W.
      • Sampson H.A.
      Prevalence of peanut and tree nut allergy in the US determined by a random digit dial telephone survey.
      • Sicherer S.H.
      • Munoz-Furlong A.
      • Sampson H.A.
      Prevalence of peanut and tree nut allergy in the United States determined by means of a random digit dial telephone survey: a 5-year follow-up study.
      • Grundy J.
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      • Dean T.
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      that has recently stabilized.
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      • Joseph L.
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      • et al.
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      The difference may also be a result of inherent differences in the 2 countries. Despite assumed similarities in Canadian and US dietary habits, studies report differences in lifestyles, food availability, and nutrition fortification between the countries that might affect the emergence of food allergies.
      • Csizmadi I.
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      Finally, some of the observed differences may be attributed to the lower response rate in our study (ie, 35% vs 67.3% in the US seafood study and 52% in the US peanut and tree nut study), which might have led to overrepresentation of those with food allergies.
      Given that there are no US estimates for sesame allergy, we were able to compare our estimates only to previously published UK and Israeli estimates.
      • Du Toit G.
      • Katz Y.
      • Sasieni P.
      • Mesher D.
      • Maleki S.J.
      • Fisher H.R.
      • et al.
      Early consumption of peanuts in infancy is associated with a low prevalence of peanut allergy.
      The prevalence of sesame allergy in Canada and Israel is similar and much lower than in the UK. This contrasts sharply with the prevalence of peanut allergy, which is similar in Canada and the UK (1.85%; 95% CI, 1.45%-2.32%) and much higher than in Israel (0.17%; 95% CI, 0.07%-0.34%).
      • Du Toit G.
      • Katz Y.
      • Sasieni P.
      • Mesher D.
      • Maleki S.J.
      • Fisher H.R.
      • et al.
      Early consumption of peanuts in infancy is associated with a low prevalence of peanut allergy.
      In conclusion, our results reveal significant disparities between perceived and confirmed food allergies. Guidelines regarding increased use of confirmatory tests in general and food challenges in particular should be disseminated and might contribute to a more accurate diagnosis in those never exposed or with an uncertain history. Research should be expanded to include vulnerable populations such as those of lower socioeconomic status and immigrants, and the role of environmental factors in the pathogenesis of food allergies should be explored.
      Clinical implications
      Guidelines regarding increased use of confirmatory tests in general and food challenges in particular should be disseminated and might contribute to a more accurate diagnosis in those reporting food allergies.
      We thank Dr Scott H. Sicherer from the Elliot and Rosyln Jaffe Food Allergy Institute, Division of Allergy and Immunology, Department of Pediatrics, Mount Sinai School of Medicine, New York, for sharing with us the food allergy telephone questionnaire.

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      • Correction
        Journal of Allergy and Clinical ImmunologyVol. 127Issue 3
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          With regard to the June 2010 article entitled “A population-based study on peanut, tree nut, fish, shellfish, and sesame allergy prevalence in Canada” (J Allergy Clin Immunol 2010;125:1327-1335), the family name of one of the authors, Susan J. Elliott, was misspelled.
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