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Shellfish allergy
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<h2 id="signs-and-symptoms">Signs and symptoms</h2> <p>Food allergy symptoms usually occur within minutes after exposure but can be delayed to hours depending on the nature of the immune system response.<a class="footnote-ref" id="fnref:8" href="#fn:8"><sup>8</sup></a> Symptoms may include rash, <a href="/facts/Hives/zMkVo9qL">hives</a>, itching of mouth, lips, tongue, throat, eyes, skin, or other areas, swelling of lips, tongue, eyelids, or the whole face, difficulty swallowing, runny or congested nose, hoarse voice, wheezing, shortness of breath, diarrhea, abdominal pain, lightheadedness, fainting, nausea, or vomiting.<a class="footnote-ref" id="fnref:9" href="#fn:9"><sup>9</sup></a> Symptoms of allergies vary from person to person and may vary from incident to incident.<a class="footnote-ref" id="fnref:10" href="#fn:10"><sup>10</sup></a> Serious danger regarding allergies can begin when the respiratory tract or blood circulation is affected. The former can be indicated by wheezing, a blocked airway and <a href="/facts/Cyanosis/V7ynzIjn">cyanosis</a>, and the latter by weak pulse, pale skin, and fainting. When these symptoms occur the allergic reaction is called <a href="/facts/Anaphylaxis/F9IDQxeL">anaphylaxis</a>.<a class="footnote-ref" id="fnref:11" href="#fn:11"><sup>11</sup></a> Anaphylaxis occurs when <a href="/facts/IgE_antibodies/76uGAl7k">IgE antibodies</a> are involved,<a class="footnote-ref" id="fnref:12" href="#fn:12"><sup>12</sup></a> and areas of the body that are not in direct contact with the food become affected and show severe symptoms.<a class="footnote-ref" id="fnref:13" href="#fn:13"><sup>13</sup></a><a class="footnote-ref" id="fnref:14" href="#fn:14"><sup>14</sup></a> Untreated, this can proceed to <a href="/facts/Vasodilation/cjzrU8Ro">vasodilation</a>, a low blood pressure situation called <a href="/facts/Anaphylactic_shock/F9IDQxeL">anaphylactic shock</a>.<a class="footnote-ref" id="fnref:15" href="#fn:15"><sup>15</sup></a> </p> <h2 id="causes">Causes</h2> <h3>Eating shellfish</h3> <p>The cause is typically the eating of shellfish or foods that contain shellfish. The shellfish types causing clinical allergy are, in decreasing incidence: </p> <ul><li>Shrimp</li> <li>Crab</li> <li>Lobster</li> <li>Clam</li> <li>Oyster</li> <li>Mussel.<a class="footnote-ref" id="fnref:16" href="#fn:16"><sup>16</sup></a></li></ul> <p>Once an allergic reaction has occurred it usually remains a lifelong sensitivity.<a class="footnote-ref" id="fnref:17" href="#fn:17"><sup>17</sup></a> The immune system overreacts to proteins found in shellfish, most commonly to <a href="/facts/Tropomyosin/pJwDRMXQ">tropomyosin</a>, but often to other proteins, such as <a href="/facts/Arginine_kinase/ctr0XgIx">arginine kinase</a>, <a href="/facts/Myosin_light_chain/b3jgBuIe">myosin light chain</a> and sarcoplasmic calcium-binding protein.<a class="footnote-ref" id="fnref:18" href="#fn:18"><sup>18</sup></a><a class="footnote-ref" id="fnref:19" href="#fn:19"><sup>19</sup></a><a class="footnote-ref" id="fnref:20" href="#fn:20"><sup>20</sup></a> The allergic reaction to fish is to a different protein, <a href="/facts/Parvalbumin/1vS6TQQB">parvalbumin</a>; there is no cross-reactivity between fish and shellfish allergy.<a class="footnote-ref" id="fnref:21" href="#fn:21"><sup>21</sup></a><a class="footnote-ref" id="fnref:22" href="#fn:22"><sup>22</sup></a><a class="footnote-ref" id="fnref:23" href="#fn:23"><sup>23</sup></a> </p> <h3>Cross-contact</h3> <p>Cross-contact, also referred to as cross-contamination, occurs when foods are being processed in factories or at food markets, or are being prepared for cooking in restaurants and home kitchens. The allergenic proteins are transferred from one food to another.<a class="footnote-ref" id="fnref:24" href="#fn:24"><sup>24</sup></a> </p> <h3>Shellfish parasite</h3> <p>The food-borne parasite <i><a href="/facts/Anisakis/P7yD3xtd">Anisakis</a></i> is a genus of <a href="/facts/Nematode/yLMJ43Eu">nematodes</a> known to be present in <a href="/facts/Squid/wFXpcNUf">squid</a>.<a class="footnote-ref" id="fnref:25" href="#fn:25"><sup>25</sup></a> <i>Anisakis</i> are directly infective to humans whenever infected squid (or marine fish) are consumed raw or slightly processed, causing a condition called anisakiasis. Symptoms from consuming live nematodes include severe abdominal pain, <a href="/facts/Nausea/dyhkcbeD">nausea</a>, and vomiting.<a class="footnote-ref" id="fnref:26" href="#fn:26"><sup>26</sup></a> In addition, there can be an allergic reaction to <i>Anisakis</i> proteins, even if the food in question was frozen or cooked before being consumed, killing the nematodes, as some of the nematode proteins are resistant to cold and heat.<a class="footnote-ref" id="fnref:27" href="#fn:27"><sup>27</sup></a> Allergic reactions can include hives, asthma and true anaphylactic reactions.<a class="footnote-ref" id="fnref:28" href="#fn:28"><sup>28</sup></a><a class="footnote-ref" id="fnref:29" href="#fn:29"><sup>29</sup></a> </p> <h3>Occupational exposure</h3> <p>An industry review conducted in 1990 estimated that 28.5 million people worldwide were engaged in some aspect of the seafood industry: fishing, aquaculture, processing and industrial cooking.<a class="footnote-ref" id="fnref:30" href="#fn:30"><sup>30</sup></a> Men predominate in fishing, women in processing facilities.<a class="footnote-ref" id="fnref:31" href="#fn:31"><sup>31</sup></a> Exposure to shellfish allergenic proteins includes inhalation of wet <a href="/facts/Aerosol/X1jXFLp2">aerosols</a> from fresh shellfish handling, and dermal contact through skin breaks and cuts.<a class="footnote-ref" id="fnref:32" href="#fn:32"><sup>32</sup></a><a class="footnote-ref" id="fnref:33" href="#fn:33"><sup>33</sup></a> Prevalence of seafood-induced adult asthma is reported as in the range of 7% to 36% (higher for <a href="/facts/Crustaceans/PBobIVJP">crustaceans</a> and lower for bony fish).<a class="footnote-ref" id="fnref:34" href="#fn:34"><sup>34</sup></a> Prevalence of skin allergy reactions, often characterized by itchy rash (hives), range from 3% to 11%.<a class="footnote-ref" id="fnref:35" href="#fn:35"><sup>35</sup></a> The shellfish-induced health outcomes are mainly due to the protein <a href="/facts/Tropomyosin/pJwDRMXQ">tropomyosin</a> causing an IgE mediated immune system response.<a class="footnote-ref" id="fnref:36" href="#fn:36"><sup>36</sup></a><a class="footnote-ref" id="fnref:37" href="#fn:37"><sup>37</sup></a> </p> <h3>Cross-reactivity to non-shellfish</h3> <p><a href="/facts/Tropomyosin/pJwDRMXQ">Tropomyosin</a>, the major allergen in shellfish allergy, is also found in <a href="/facts/House_dust_mites/CwyrgWSA">dust mites</a> and <a href="/facts/Cockroach/mKJP7W6j">cockroaches</a>.<a class="footnote-ref" id="fnref:38" href="#fn:38"><sup>38</sup></a><a class="footnote-ref" id="fnref:39" href="#fn:39"><sup>39</sup></a> Exposure to inhaled tropomyosins from dust mites is thought to be the primary sensitizer for shellfish allergy, an example of inhalant-to-food cross-reactivity.<a class="footnote-ref" id="fnref:40" href="#fn:40"><sup>40</sup></a> Epidemiological surveys have confirmed correlation between shellfish and dust mite sensitizations.<a class="footnote-ref" id="fnref:41" href="#fn:41"><sup>41</sup></a> An additional confirmation was seen in Orthodox Jews with no history of shellfish consumption, in that skin tests confirming <a href="/facts/Dust_mite_allergy/vJd79gES">dust mite allergy</a> were also positive for shellfish tropomyosin.<a class="footnote-ref" id="fnref:42" href="#fn:42"><sup>42</sup></a><a class="footnote-ref" id="fnref:43" href="#fn:43"><sup>43</sup></a> In addition to tropomyosin, arginine kinase and <a href="/facts/Hemocyanin/kCxIlQW9">hemocyanin</a> seem to have a role in cross-reactivity to dust mites.<a class="footnote-ref" id="fnref:44" href="#fn:44"><sup>44</sup></a> </p> <h3>Exercise as contributing factor</h3> <p>Exercise can be a contributing factor to an allergic food response. There is a condition called food-dependent, exercise-induced anaphylaxis.<a class="footnote-ref" id="fnref:45" href="#fn:45"><sup>45</sup></a><a class="footnote-ref" id="fnref:46" href="#fn:46"><sup>46</sup></a> For people with this condition, exercise alone is not sufficient, nor is consumption of a food to which they are mildly allergic, but when the food in question is consumed within a few hours before high-intensity exercise, the result can be anaphylaxis. Shellfish are specifically mentioned as a causative food.<a class="footnote-ref" id="fnref:47" href="#fn:47"><sup>47</sup></a><a class="footnote-ref" id="fnref:48" href="#fn:48"><sup>48</sup></a><a class="footnote-ref" id="fnref:49" href="#fn:49"><sup>49</sup></a> One theory is that exercise is stimulating the release of mediators such as histamine from IgE-activated mast cells.<a class="footnote-ref" id="fnref:50" href="#fn:50"><sup>50</sup></a> Two of the reviews postulate that exercise is not essential for the development of symptoms, but rather that it is one of several augmentation factors, citing evidence that the culprit food in combination with alcohol or aspirin will result in a respiratory anaphylactic reaction.<a class="footnote-ref" id="fnref:51" href="#fn:51"><sup>51</sup></a><a class="footnote-ref" id="fnref:52" href="#fn:52"><sup>52</sup></a> </p> <h2 id="mechanisms">Mechanisms</h2> <h3>Allergic response</h3> <p>Conditions caused by food allergies are classified into three groups according to the mechanism of the allergic response:<a class="footnote-ref" id="fnref:53" href="#fn:53"><sup>53</sup></a> </p> <ol><li>IgE-mediated (classic) – the most common type, manifesting acute changes that occur shortly after eating, and may progress to <a href="/facts/Anaphylaxis/F9IDQxeL">anaphylaxis</a></li> <li>Non-IgE mediated – characterized by an immune response not involving <a href="/facts/Immunoglobulin_E/76uGAl7k">immunoglobulin E</a>; may occur hours to days after eating, complicating diagnosis</li> <li>IgE and non-IgE-mediated – a hybrid of the above two types</li></ol> <p><a href="/facts/Allergic_reactions/dYAVosh8">Allergic reactions</a> are hyperactive responses of the immune system to generally innocuous substances, such as food proteins.<a class="footnote-ref" id="fnref:54" href="#fn:54"><sup>54</sup></a> Why some proteins trigger allergic reactions while others do not is not entirely clear. One theory holds that proteins which resist digestion in the stomach, therefore reaching the small intestine relatively intact, are more likely to be allergenic, but studies have shown that digestion may abolish, decrease, have no effect, or even increase the allergenicity of food allergens.<a class="footnote-ref" id="fnref:55" href="#fn:55"><sup>55</sup></a> The heat of cooking structurally degrades protein molecules, potentially making them less allergenic.<a class="footnote-ref" id="fnref:56" href="#fn:56"><sup>56</sup></a><a class="footnote-ref" id="fnref:57" href="#fn:57"><sup>57</sup></a> </p><p>The <a href="/facts/Pathophysiology/Tp3Dny0c">pathophysiology</a> of allergic responses can be divided into two time periods: The first is an <a href="/facts/Acute_(medical)/jvxNdA6B">acute response</a> that occurs within minutes after exposure to an allergen.<a class="footnote-ref" id="fnref:58" href="#fn:58"><sup>58</sup></a> This phase can either subside or progress into a "late-phase reaction" which can substantially prolong the symptoms of a response, and result in more tissue damage hours later.<a class="footnote-ref" id="fnref:59" href="#fn:59"><sup>59</sup></a> In the early stages of acute allergic reaction, <a href="/facts/Lymphocyte/pS2pv2Ma">lymphocytes</a> previously sensitized to a specific protein or protein fraction react by quickly producing a particular type of antibody known as secreted IgE (sIgE), which circulates in the blood and binds to IgE-specific receptors on the surface of other kinds of immune cells called <a href="/facts/Mast_cell/szfXss5q">mast cells</a> and <a href="/facts/Basophil/FRN1ugHk">basophils</a>. Both of these are involved in the acute inflammatory response.<a class="footnote-ref" id="fnref:60" href="#fn:60"><sup>60</sup></a> Activated mast cells and basophils undergo a process called <a href="/facts/Degranulation/0KMNbq2p">degranulation</a>, during which they release <a href="/facts/Histamine/Vfjda665">histamine</a> and other inflammatory chemical mediators called (<a href="/facts/Cytokine/SdWpWABH">cytokines</a>, <a href="/facts/Interleukin/a8qBzb0E">interleukins</a>, <a href="/facts/Leukotriene/PxNEg3IS">leukotrienes</a>, and <a href="/facts/Prostaglandin/kIKw0gDj">prostaglandins</a>) into the surrounding tissue causing several systemic effects, such as vasodilation, <a href="/facts/Mucous_membrane/oIw0vyel">mucous</a> secretion, <a href="/facts/Nerve/q7GsAfYV">nerve</a> stimulation, and <a href="/facts/Smooth_muscle/mpcpTsHp">smooth-muscle</a> contraction.<a class="footnote-ref" id="fnref:61" href="#fn:61"><sup>61</sup></a> This results in <a href="/facts/Rhinorrhea/DJxxlKqs">runny nose</a>, itchiness, <a href="/facts/Dyspnea/1jBfFzxU">shortness of breath</a>, and potentially <a href="/facts/Anaphylaxis/F9IDQxeL">anaphylaxis</a>.<a class="footnote-ref" id="fnref:62" href="#fn:62"><sup>62</sup></a> Depending on the individual, the allergen, and the mode of introduction, the symptoms can be system-wide (classical anaphylaxis), or localized to particular body systems; <a href="/facts/Asthma/7GkJvxn3">asthma</a> is localized to the respiratory system while hives and eczema are localized to the skin.<a class="footnote-ref" id="fnref:63" href="#fn:63"><sup>63</sup></a> In addition to reacting to oral consumption, skin and asthma reactions can be triggered by inhallation or contact if there are skin abrasions or cuts.<a class="footnote-ref" id="fnref:64" href="#fn:64"><sup>64</sup></a><a class="footnote-ref" id="fnref:65" href="#fn:65"><sup>65</sup></a> </p> <p>After the chemical mediators of the acute response subside, late-phase responses can often occur due to the migration of other <a href="/facts/White_blood_cells/vsDunUK0">white blood cells</a> such as <a href="/facts/Neutrophil/KL6oTt8b">neutrophils</a>, <a href="/facts/Lymphocyte/pS2pv2Ma">lymphocytes</a>, <a href="/facts/Eosinophil/yhIKA8bE">eosinophils</a>, and <a href="/facts/Macrophage/z7hkQu3o">macrophages</a> to the initial reaction sites. This is usually seen 2–24 hours after the original reaction.<a class="footnote-ref" id="fnref:66" href="#fn:66"><sup>66</sup></a> Cytokines from mast cells may also play a role in the persistence of long-term effects. Late-phase responses seen in asthma are slightly different from those seen in other allergic responses, although they are still caused by release of mediators from eosinophils.<a class="footnote-ref" id="fnref:67" href="#fn:67"><sup>67</sup></a> </p><p>In addition to IgE-mediated responses, shellfish allergy can manifest as <a href="/facts/Atopic_dermatitis/DvmdVwWu">atopic dermatitis</a>, especially in infants and young children.<a class="footnote-ref" id="fnref:68" href="#fn:68"><sup>68</sup></a> Some will display both, so that a child could react to an oral food challenge with allergic symptoms, followed a day or two later with a flare up of atopic dermatitis and/or gastrointestinal symptoms, including allergic <a href="/facts/Eosinophilic_esophagitis/SkQ9kXek">eosinophilic esophagitis</a>.<a class="footnote-ref" id="fnref:69" href="#fn:69"><sup>69</sup></a> </p> <h3>Shellfish allergenic proteins</h3> <p>Several proteins from shellfish are either clearly involved in allergenic reactions or suspected to be. Tropomyosin, arginine kinase, myosin light chain and sarcoplasmic calcium-binding protein are widely present across shellfish species.<a class="footnote-ref" id="fnref:70" href="#fn:70"><sup>70</sup></a><a class="footnote-ref" id="fnref:71" href="#fn:71"><sup>71</sup></a><a class="footnote-ref" id="fnref:72" href="#fn:72"><sup>72</sup></a><a class="footnote-ref" id="fnref:73" href="#fn:73"><sup>73</sup></a> <a href="/facts/Troponin/gQdzvCCb">Troponin</a>, <a href="/facts/Actin/Hu3qIUL9">actin</a>, <a href="/facts/Triosephosphate_isomerase/9dsKLNp0">triosephosphate isomerase</a> and <a href="/facts/Hemocyanin/kCxIlQW9">hemocyanin</a> are also identified as allergenic proteins.<a class="footnote-ref" id="fnref:74" href="#fn:74"><sup>74</sup></a><a class="footnote-ref" id="fnref:75" href="#fn:75"><sup>75</sup></a> As of a 2016 review, only three (tropomyosin, arginine kinase and sarcoplasmic calcium-binding protein) were available for routine diagnostic skin testing.<a class="footnote-ref" id="fnref:76" href="#fn:76"><sup>76</sup></a> Shellfish do not manifest the proteins β-parvalbumin (found in bony fishes) or α-parvalbumin (found in cartilaginous fishes such as sharks and rays), so there is not cross-reactivity of shellfish allergy to fish allergy.<a class="footnote-ref" id="fnref:77" href="#fn:77"><sup>77</sup></a><a class="footnote-ref" id="fnref:78" href="#fn:78"><sup>78</sup></a><a class="footnote-ref" id="fnref:79" href="#fn:79"><sup>79</sup></a> </p> <h2 id="diagnosis">Diagnosis</h2> <p>Diagnosis of shellfish allergy is based on the person's history of allergic reactions, <a href="/facts/Skin_prick_test/qX6p7Ea0">skin prick test</a> and measurement of shellfish-specific serum <a href="/facts/Immunoglobulin_E/76uGAl7k">immunoglobulin E</a> (IgE or sIgE). Confirmation is by double-blind, placebo-controlled food challenges.<a class="footnote-ref" id="fnref:80" href="#fn:80"><sup>80</sup></a> Self-reported shellfish allergy often fails to be confirmed by food challenge.<a class="footnote-ref" id="fnref:81" href="#fn:81"><sup>81</sup></a> </p> <h2 id="prevention">Prevention</h2> <p>Reviews of food allergens in general stated that introducing solid foods at 4–6 months may result in the lowest subsequent allergy risks for eczema, allergic rhinitis and more severe reactions.<a class="footnote-ref" id="fnref:82" href="#fn:82"><sup>82</sup></a> The evidence is best for peanuts, eggs and milk.<a class="footnote-ref" id="fnref:83" href="#fn:83"><sup>83</sup></a> The literature is sparse for consequences of early introduction of shellfish.<a class="footnote-ref" id="fnref:84" href="#fn:84"><sup>84</sup></a> </p> <h2 id="treatment">Treatment</h2> <p>Treatment for accidental ingestion of shellfish products by allergic individuals varies depending on the sensitivity of the person. An <a href="/facts/Antihistamine/HuMC25lt">antihistamine</a> such as <a href="/facts/Diphenhydramine/XbbIg1Nv">diphenhydramine</a> may be prescribed. Sometimes <a href="/facts/Prednisone/eGgPIauI">prednisone</a> will be prescribed to prevent a possible late phase <a href="/facts/Type_I_hypersensitivity/fSqwUhBH">Type I hypersensitivity</a> reaction.<a class="footnote-ref" id="fnref:85" href="#fn:85"><sup>85</sup></a> Severe allergic reactions (anaphalaxis) may require treatment with an <a href="/facts/Epinephrine_pen/BEE2FaUv">epinephrine pen</a>, which is an injection device designed to be used by a non-healthcare professional when emergency treatment is warranted.<a class="footnote-ref" id="fnref:86" href="#fn:86"><sup>86</sup></a> Unlike for egg allergy, for which there is active research on trying <a href="/facts/Oral_immunotherapy/y38xes3E">oral immunotherapy</a> (OIT) to desensitize people to egg allergens,<a class="footnote-ref" id="fnref:87" href="#fn:87"><sup>87</sup></a> reviews mention that there are no published clinical trials evaluating oral immunotherapy for shellfish allergy.<a class="footnote-ref" id="fnref:88" href="#fn:88"><sup>88</sup></a><a class="footnote-ref" id="fnref:89" href="#fn:89"><sup>89</sup></a> </p> <h2 id="prognosis">Prognosis</h2> <p>Unlike milk and egg allergies,<a class="footnote-ref" id="fnref:90" href="#fn:90"><sup>90</sup></a><a class="footnote-ref" id="fnref:91" href="#fn:91"><sup>91</sup></a> shellfish allergy usually persists into adulthood.<a class="footnote-ref" id="fnref:92" href="#fn:92"><sup>92</sup></a><a class="footnote-ref" id="fnref:93" href="#fn:93"><sup>93</sup></a> </p> <h2 id="epidemiology">Epidemiology</h2> <p>Incidence and prevalence are terms commonly used in describing disease <a href="/facts/Epidemiology/wgTmxoMA">epidemiology</a>. Incidence is newly diagnosed cases, which can be expressed as new cases per year per million people. Prevalence is the number of cases alive, expressible as existing cases per million people during a period of time.<a class="footnote-ref" id="fnref:94" href="#fn:94"><sup>94</sup></a> Worldwide, the prevalence of shellfish allergy is increasing because shellfish consumption is increasing,<a class="footnote-ref" id="fnref:95" href="#fn:95"><sup>95</sup></a> and among adults shellfish is the most common anaphylaxis-eliciting food.<a class="footnote-ref" id="fnref:96" href="#fn:96"><sup>96</sup></a> Reviews cite self-reported shellfish allergy in range of 0.5 to 2.5 percent in the general population.<a class="footnote-ref" id="fnref:97" href="#fn:97"><sup>97</sup></a><a class="footnote-ref" id="fnref:98" href="#fn:98"><sup>98</sup></a><a class="footnote-ref" id="fnref:99" href="#fn:99"><sup>99</sup></a> Prevalence is higher in coastal southeast Asian countries, where shellfish consumption is more common.<a class="footnote-ref" id="fnref:100" href="#fn:100"><sup>100</sup></a><a class="footnote-ref" id="fnref:101" href="#fn:101"><sup>101</sup></a><a class="footnote-ref" id="fnref:102" href="#fn:102"><sup>102</sup></a><a class="footnote-ref" id="fnref:103" href="#fn:103"><sup>103</sup></a> Self-reported allergy prevalence is always higher than food-challenge confirmed allergy, which one review put at 0% to 0.9% (the higher value in southeast Asia).<a class="footnote-ref" id="fnref:104" href="#fn:104"><sup>104</sup></a> </p> <h2 id="regulation">Regulation</h2> <p>Whether food allergy prevalence is increasing or not, food allergy awareness has increased, with impacts on the quality of life for children, their parents and their immediate caregivers.<a class="footnote-ref" id="fnref:105" href="#fn:105"><sup>105</sup></a><a class="footnote-ref" id="fnref:106" href="#fn:106"><sup>106</sup></a><a class="footnote-ref" id="fnref:107" href="#fn:107"><sup>107</sup></a><a class="footnote-ref" id="fnref:108" href="#fn:108"><sup>108</sup></a> In the United States, the <a href="/facts/Food_Allergen_Labeling_and_Consumer_Protection_Act/CyJGXYPJ">Food Allergen Labeling and Consumer Protection Act</a> (FALCPA), made law in August 2004, effective January 1, 2006,<a class="footnote-ref" id="fnref:109" href="#fn:109"><sup>109</sup></a> causes people to be reminded of allergy problems every time they handle a food package. Although not regulated under FALCPA, restaurants have added allergen warnings to menus. The <a href="/facts/Culinary_Institute_of_America/Igxt0LdN">Culinary Institute of America</a>, a premier school for chef training, has courses in allergen-free cooking and a separate teaching kitchen.<a class="footnote-ref" id="fnref:110" href="#fn:110"><sup>110</sup></a> School systems have protocols about what foods can be brought into the school. Despite all these precautions, people with serious allergies are aware that accidental exposure can easily occur at other peoples' houses, at school or in restaurants.<a class="footnote-ref" id="fnref:111" href="#fn:111"><sup>111</sup></a> </p> <h3>Regulation of labeling</h3> <p>In response to the risk that certain foods pose to those with food allergies, some countries have responded by instituting labeling laws that require food products to clearly inform consumers if their products contain major allergens or byproducts of major allergens among the ingredients intentionally added to foods. Laws and regulations passed in the US and by the European Union recommend labeling but do not require mandatory declaration of the presence of trace amounts in the final product as a consequence of unintentional cross-contamination.<a class="footnote-ref" id="fnref:112" href="#fn:112"><sup>112</sup></a><a class="footnote-ref" id="fnref:113" href="#fn:113"><sup>113</sup></a><a class="footnote-ref" id="fnref:114" href="#fn:114"><sup>114</sup></a> </p> <h4>Ingredients intentionally added</h4> <p>FALCPA requires companies to disclose on the label whether a packaged food product contains any of these eight major food allergens, added intentionally: cow's milk, peanuts, eggs, shellfish, fish, tree nuts, soy and wheat.<a class="footnote-ref" id="fnref:115" href="#fn:115"><sup>115</sup></a> This list originated in 1999 from the World Health Organisation Codex Alimentarius Commission.<a class="footnote-ref" id="fnref:116" href="#fn:116"><sup>116</sup></a> To meet FALCPA labeling requirements, if an ingredient is derived from one of the required-label allergens, then it must either have its "food sourced name" in parentheses, for example "Casein (milk)," or as an alternative, there must be a statement separate but adjacent to the ingredients list: "Contains milk" (and any other of the allergens with mandatory labeling).<a class="footnote-ref" id="fnref:117" href="#fn:117"><sup>117</sup></a><a class="footnote-ref" id="fnref:118" href="#fn:118"><sup>118</sup></a> The European Union requires listing for those eight major allergens plus molluscs, <a href="/facts/Celery/r2oRCGJw">celery</a>, mustard, lupin, sesame and <a href="/facts/Sulfite/xdppUlKA">sulfites</a>.<a class="footnote-ref" id="fnref:119" href="#fn:119"><sup>119</sup></a> In Japan, a food-labeling system for five specific allergenic ingredients (egg, milk, wheat, buckwheat, peanut) was mandated under law on April 1, 2002. Additional labeling of shrimp/prawn and crab became mandatory in 2008. This applies to packaged food, but not to restaurants.<a class="footnote-ref" id="fnref:120" href="#fn:120"><sup>120</sup></a> </p> <h2 id="see-also">See also</h2> <ul><li><a href="/facts/List_of_allergens/JTg7nscR">List of allergens</a> (food and non-food)</li></ul> <h2 id="external-links">External links</h2> <h2 id="references">References</h2> <ol> <li id="fn:1"><p>National Report of the Expert Panel on Food Allergy Research, NIH-NIAID 2003 "National Report of the Expert Panel on Food Allergy Research" (PDF). 30 June 2003. Archived from the original (PDF) on 2006-10-04. Retrieved 2006-08-07. <a href="https://web.archive.org/web/20061004001123/http://www3.niaid.nih.gov/about/organization/dait/PDF/june30_2003.pdf" target="_blank">https://web.archive.org/web/20061004001123/http://www3.niaid.nih.gov/about/organization/dait/PDF/june30_2003.pdf</a> <a href="#fnref:1" class="footnote-back-ref">↩</a></p></li> <li id="fn:2"><p>"Food Allergies" Archived 2012-10-06 at the Wayback Machine Asthma and Allergy Foundation of America <a href="http://www.aafa.org/display.cfm?id=9&sub=20&cont=286" target="_blank">http://www.aafa.org/display.cfm?id=9&sub=20&cont=286</a> <a href="#fnref:2" class="footnote-back-ref">↩</a></p></li> <li id="fn:3"><p>"Food allergy". National Health Service (England). 16 May 2016. Archived from the original on 20 July 2017. Retrieved 27 December 2020. <a href="http://www.nhs.uk/conditions/food-allergy/Pages/Intro1.aspx" target="_blank">http://www.nhs.uk/conditions/food-allergy/Pages/Intro1.aspx</a> <a href="#fnref:3" class="footnote-back-ref">↩</a></p></li> <li id="fn:4"><p>Urisu A, Ebisawa M, Ito K, Aihara Y, Ito S, Mayumi M, Kohno Y, Kondo N (September 2014). "Japanese Guideline for Food Allergy 2014". Allergol Int. 63 (3): 399–419. doi:10.2332/allergolint.14-RAI-0770. PMID 25178179. <a href="https://doi.org/10.2332%2Fallergolint.14-RAI-0770" target="_blank">https://doi.org/10.2332%2Fallergolint.14-RAI-0770</a> <a href="#fnref:4" class="footnote-back-ref">↩</a></p></li> <li id="fn:5"><p>Thalayasingam M, Lee BW (May 2015). "Fish and shellfish allergy". Chem Immunol Allergy. Chemical Immunology and Allergy. 101: 152–61. doi:10.1159/000375508. ISBN 978-3-318-02340-4. PMID 26022875. <a href="978-3-318-02340-4" target="_blank">978-3-318-02340-4</a> <a href="#fnref:5" class="footnote-back-ref">↩</a></p></li> <li id="fn:6"><p>Lopata AL, Jeebhay MF (June 2013). "Airborne seafood allergens as a cause of occupational allergy and asthma". Curr Allergy Asthma Rep. 13 (3): 288–97. doi:10.1007/s11882-013-0347-y. PMID 23575656. S2CID 1276304. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:6" class="footnote-back-ref">↩</a></p></li> <li id="fn:7"><p>Jeebhay MF, Robins TG, Lehrer SB, Lopata AL (September 2001). "Occupational seafood allergy: a review". Occup Environ Med. 58 (9): 553–62. doi:10.1136/oem.58.9.553. PMC 1740192. PMID 11511741. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1740192" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1740192</a> <a href="#fnref:7" class="footnote-back-ref">↩</a></p></li> <li id="fn:8"><p>MedlinePlus Encyclopedia: Food allergy <a href="/wiki/MedlinePlus" target="_blank">/wiki/MedlinePlus</a> <a href="#fnref:8" class="footnote-back-ref">↩</a></p></li> <li id="fn:9"><p>MedlinePlus Encyclopedia: Food allergy <a href="/wiki/MedlinePlus" target="_blank">/wiki/MedlinePlus</a> <a href="#fnref:9" class="footnote-back-ref">↩</a></p></li> <li id="fn:10"><p>MedlinePlus Encyclopedia: Food allergy <a href="/wiki/MedlinePlus" target="_blank">/wiki/MedlinePlus</a> <a href="#fnref:10" class="footnote-back-ref">↩</a></p></li> <li id="fn:11"><p>MedlinePlus Encyclopedia: Food allergy <a href="/wiki/MedlinePlus" target="_blank">/wiki/MedlinePlus</a> <a href="#fnref:11" class="footnote-back-ref">↩</a></p></li> <li id="fn:12"><p>Reber LL, Hernandez JD, Galli SJ (August 2017). "The pathophysiology of anaphylaxis". The Journal of Allergy and Clinical Immunology. 140 (2): 335–348. doi:10.1016/j.jaci.2017.06.003. ISSN 0091-6749. PMC 5657389. PMID 28780941. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5657389" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5657389</a> <a href="#fnref:12" class="footnote-back-ref">↩</a></p></li> <li id="fn:13"><p>MedlinePlus Encyclopedia: Food allergy <a href="/wiki/MedlinePlus" target="_blank">/wiki/MedlinePlus</a> <a href="#fnref:13" class="footnote-back-ref">↩</a></p></li> <li id="fn:14"><p>Sicherer SH, Sampson HA (February 2014). "Food allergy: Epidemiology, pathogenesis, diagnosis, and treatment". J Allergy Clin Immunol. 133 (2): 291–307. doi:10.1016/j.jaci.2013.11.020. PMID 24388012. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:14" class="footnote-back-ref">↩</a></p></li> <li id="fn:15"><p>Sicherer SH, Sampson HA (February 2014). 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S2CID 1154235. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:17" class="footnote-back-ref">↩</a></p></li> <li id="fn:18"><p>Gelis S, Rueda M, Valero A, Fernández EA, Moran M, Fernández-Caldas E (July 2020). "Shellfish Allergy: Unmet Needs in Diagnosis and Treatment". J Investig Allergol Clin Immunol. 30 (6): 409–20. doi:10.18176/jiaci.0565. PMID 32694101. <a href="https://doi.org/10.18176%2Fjiaci.0565" target="_blank">https://doi.org/10.18176%2Fjiaci.0565</a> <a href="#fnref:18" class="footnote-back-ref">↩</a></p></li> <li id="fn:19"><p>Lopata AL, Kleine-Tebbe J, Kamath SD (November 2016). "Allergens and molecular diagnostics of shellfish allergy: Part 22 of the Series Molecular Allergology". Allergo J Int. 25 (7): 210–18. doi:10.1007/s40629-016-0124-2. PMC 5306157. PMID 28239537. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5306157" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5306157</a> <a href="#fnref:19" class="footnote-back-ref">↩</a></p></li> <li id="fn:20"><p>Pedrosa M, Boyano-Martínez T, García-Ara C, Quirce S (October 2015). "Shellfish Allergy: a Comprehensive Review". Clin Rev Allergy Immunol. 49 (2): 203–16. doi:10.1007/s12016-014-8429-8. PMID 24870065. S2CID 7306395. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:20" class="footnote-back-ref">↩</a></p></li> <li id="fn:21"><p>Thalayasingam M, Lee BW (May 2015). "Fish and shellfish allergy". Chem Immunol Allergy. Chemical Immunology and Allergy. 101: 152–61. doi:10.1159/000375508. ISBN 978-3-318-02340-4. PMID 26022875. <a href="978-3-318-02340-4" target="_blank">978-3-318-02340-4</a> <a href="#fnref:21" class="footnote-back-ref">↩</a></p></li> <li id="fn:22"><p>Tong WS, Yuen AW, Wai CY, Leung NY, Chu KH, Leung PS (October 2018). "Diagnosis of fish and shellfish allergies". J Asthma Allergy. 11: 247–60. doi:10.2147/JAA.S142476. PMC 6181092. PMID 30323632. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6181092" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6181092</a> <a href="#fnref:22" class="footnote-back-ref">↩</a></p></li> <li id="fn:23"><p>Ruethers T, Taki AC, Johnston EB, Nugraha R, Le TT, Kalic T, McLean TR, Kamath SD, Lopata AL (August 2018). "Seafood allergy: A comprehensive review of fish and shellfish allergens". Mol. Immunol. 100: 28–57. doi:10.1016/j.molimm.2018.04.008. PMID 29858102. 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PMID 32191412.{{cite journal}}: CS1 maint: DOI inactive as of November 2024 (link) <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:27" class="footnote-back-ref">↩</a></p></li> <li id="fn:28"><p>Prester L (August 2016). "Seafood Allergy, Toxicity, and Intolerance: A Review". J Am Coll Nutr. 35 (3): 271–83. doi:10.1080/07315724.2015.1014120. PMID 26252073. S2CID 1154235. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:28" class="footnote-back-ref">↩</a></p></li> <li id="fn:29"><p>Audicana MT, Kennedy MW (April 2008). "Anisakis Simplex: From Obscure Infectious Worm to Inducer of Immune Hypersensitivity". Clinical Microbiology Reviews. 21 (2): 360–79. doi:10.1128/CMR.00012-07. PMC 2292572. 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