National clinical practice guidelines for food allergy and anaphylaxis: an international assessment

Background Clinical practice guidelines are important tools to promote evidence-based clinical care, but not all countries have the capacity or infrastructure to develop these in-house. The European Academy of Allergy and Clinical Immunology has recently developed guidelines for the prevention, diagnosis and management of food allergy and the management of anaphylaxis. In order to inform dissemination, adaptation and implementation plans, we sought to identify countries that have/do not have national guidelines for food allergy and anaphylaxis. Methods Two reviewers independently searched PubMed to identify countries with guidelines for food allergy and/or anaphylaxis from the inception of this database to December 2016. This was supplemented with a search of the Agency for Healthcare Research and Quality’s National Guideline Clearinghouse in order to identify any additional guidelines that may not have been reported in the peer-reviewed literature. Data were descriptively and narratively synthesized. Results Overall, 5/193 (3%) of countries had at least one guideline for food allergy or anaphylaxis. We found that one (1%) country had a national guideline for the prevention of food allergy, three (2%) countries had a guideline for the diagnosis of food allergy and three (2%) countries had a guideline for the management of food allergy. Three (2%) countries had an anaphylaxis guideline. Conclusions This study concludes that the overwhelming majority of countries do not have any national clinical practice guidelines for food allergy or anaphylaxis.


Background
The increase in the prevalence of allergic diseases seen over recent decades has resulted in food allergy and anaphylaxis emerging as important clinical conditions globally [1][2][3][4]. Concerns have been expressed about the clinical care patients with these conditions receive [5][6][7]. In an attempt to improve clinical care and outcomes, a number of professional and national organizations have developed clinical practice guidelines for a range of communicable and non-communicable disorders. Much of this activity has however been undertaken in highincome country settings, this reflecting the relative lack of infrastructure, capacity and financial resources available in many low-and middle-income countries (LMICs) to develop their own national guidelines. One way of bridging this gulf is to adapt and customize existing international guidelines for use in countries that do not have their own clinical guidelines [8].
The European Academy of Allergy and Clinical Immunology (EAACI) has recently produced international clinical practice guidelines on the primary prevention [9], diagnosis and management of food allergy [10] and the management of anaphylaxis [11]. In order to inform deliberations on the global dissemination, adaptation and implementation of these EAACI guidelines, we sought to

Open Access
Clinical and Translational Allergy

Search strategy
We searched PubMed database using the search terms "(guideline OR practice parameter) AND (food allergy OR anaphylaxis)". In addition, we searched the Agency for Healthcare Research and Quality's (AHRQ) National Guideline Clearinghouse to identify any guidelines that may not have been reported in the peer-reviewed literature [12]. There was no time limit on the searches. Our searches were originally undertaken in June 2016 and were then refreshed in December 2016.

Guideline selection
Two reviewers independently screened the search results to identify documents that were formally labelled as national guidelines. From these, we selected publications that were directed towards healthcare professionals, had a clear methods section and assigned strength of evidence to recommendations. Duplicate entries were removed and, in cases where there were updates of national guidelines, we selected the most comprehensive and/or most recent version of the guideline. Discrepancies were resolved through discussion or arbitration by a third person if agreement could not be reached.

Data extraction
We independently extracted data on the body that produced these guidelines, the year of publication and the domain(s) of interest in relation to food allergy and/or anaphylaxis. Discrepancies were resolved through discussion or independent arbitration, if necessary.

Data synthesis
We undertook a descriptive analysis to identify the number and percentage of countries that had guidelines for food allergy and/or anaphylaxis. The denominator for the number of countries in the world (n = 193) was taken from the list of the United Nations (UN) Member States [13]. We then divided the food allergy guidelines into sub-domains focusing on aspects of prevention, diagnosis and management.

Results
Our searches of PubMed identified a total of 855 hits from which we selected 60 papers for detailed analysis. Of these, seven satisfied our inclusion criteria. Searching the AHRQ website failed to identify any additional guidelines. We in addition found 11 pan-national guidelines for food allergy prevention (n = 5) [9,[14][15][16][17], diagnosis (n = 2) [10,14] and management (n = 3) [10,14,18], and anaphylaxis (n = 3) [11,19,20]. "Appendix" details documents that appeared not to meet our inclusion criteria, but which we were unable to fully assess.

Overall findings
We found that 5/193 (3%) countries had at least one guideline on food allergy or anaphylaxis (Table 1).

Food allergy
Four (2%) countries had guidelines on some aspect of food allergy (see Table 1). These comprised of one (1%) covering aspects of food allergy prevention, three (2%) dealing with diagnosis, and three (2%) dealing with food allergy management ( Table 2).

Anaphylaxis
Three (2%) of countries has guidelines dealing with anaphylaxis (see Table 3).

Summary of principal findings
This analysis of the international literature has found that only a minority of countries have any formally produced clinical practice guidelines for food allergy and anaphylaxis with the major gaps being in African and Asian countries. This is a concern considering that food allergy and anaphylaxis now affect people globally and furthermore they are associated with significant morbidity and, in some cases, mortality [21,22].

Strengths and limitations
The key strengths of this study are that we formally searched the principal biomedical database, namely Pub-Med using established systematic search techniques and that these searches were from the inception of this database and were not restricted by language. Furthermore, we cross-checked the results with AHRQ's National Guideline Clearinghouse, which is the foremost repository of clinical guidelines.

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The main limitation is that we may have missed some guidelines that were either not formally published in the peer-reviewed literature and/or were not available in English. We may also have missed guidelines that are in development.

Interpretation in the light of previous published research
This is, as far as we are aware, the first truly international overview of guidelines available for both food allergy and anaphylaxis. It builds on a recent comparison of food allergy guidelines [23] and our earlier study focused on  anaphylaxis, both of which found a more limited number of guidelines and considerable variation in the recommendations contained in these guidelines [24]. This work subsequently contributed to the creation of an International Consensus statement on anaphylaxis [25].

Conclusions
The findings of this study point to considerable gaps in the availability of national guidelines for food allergy and anaphylaxis. EAACI and other international guideline bodies should consider working with the countries that currently have no national guidelines to produce clinical practice guidelines on food allergy and anaphylaxis that are language specific and tailored to their local needs. Furthermore we suggest compiling an online database on the EAACI website which logs adapted versions of the guideline and also proactively sending details of these adapted guidelines for listing on the AHRQ's National Guideline Clearinghouse: https:// www.guideline.gov/.