|Year : 2020 | Volume
| Issue : 1 | Page : 5-7
Recommendations for allergy practice during COVID-19 pandemic in India
Mahendra K Agarwal1, Anand B Singh2, Shailendra N Gaur3, PC Kathuria4, VK Jain5, Mahesh Goyal6, KV Nagendra Prasad7
1 Respiratory Allergy and Immunology Section, Metro Center for Respiratory Diseases, Metro Hospitals and Heart Institute, NOIDA, Uttar Pradesh, India
2 Ex-Emeritus Scientist, Aerobiology and Allergy Unit, CSIR Institute of Genomics and Integrative Biology, Delhi, India
3 Department of Respiratory Medicine, School of Medical Sciences and Research, Sharda University, Greater Noida, Uttar Pradesh, India
4 Department of Allergy and Asthma, B. L. Kapoor Superspeciality Hospital, Pusa Road, New Delhi, India
5 Department of Respiratory Medicine, Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan, India
6 Department of Allergy, Asthma and Sleep, CKS Hospitals, Jaipur, Rajasthan, India
7 Bengaluru Allergy Centre, Bengaluru, Karnataka, India
|Date of Submission||02-Jun-2020|
|Date of Acceptance||02-Jun-2020|
|Date of Web Publication||6-Jul-2020|
Dr. Shailendra N Gaur
Department of Respiratory Medicine, School of Medical Sciences and Research, Sharda University, Greater Noida, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
We are living in an unprecedented difficult time due to the infectious COVID-19 pandemic, a global emergency. During the on-going pandemic, most allergy/immunology care could be postponed/delayed or handled through virtual care. Seven experts from different parts of India deliberated on this subject in 3 weekly webinars (May 10, 17, and 24, 2020) charted out consensus-based approach for diagnosis and management of patients suffering with allergic respiratory diseases in India during this COVID-19 pandemic. This publication includes these recommendations.
Keywords: Allergic rhinitis, bronchial asthma, COVID-19, skin prick test
|How to cite this article:|
Agarwal MK, Singh AB, Gaur SN, Kathuria P C, Jain V K, Goyal M, Nagendra Prasad K V. Recommendations for allergy practice during COVID-19 pandemic in India. Indian J Allergy Asthma Immunol 2020;34:5-7
|How to cite this URL:|
Agarwal MK, Singh AB, Gaur SN, Kathuria P C, Jain V K, Goyal M, Nagendra Prasad K V. Recommendations for allergy practice during COVID-19 pandemic in India. Indian J Allergy Asthma Immunol [serial online] 2020 [cited 2020 Aug 11];34:5-7. Available from: http://www.ijaai.in/text.asp?2020/34/1/5/289068
| Introduction|| |
At present, we are living in an unprecedented difficult time due to the infectious COVID-19 pandemic caused by SARS-CoV-2, which is a global emergency requiring new strategies for providing effective medical care. During this pandemic, most allergy/immunology care could be postponed/delayed or handled through virtual care. To chart out consensus-based approach for diagnosis and management of patients suffering with allergic respiratory diseases in India during this COVID-19 pandemic, seven experts from different parts of India deliberated on this subject in 3 weekly webinars (May 10, 17, and 24, 2020). The following recommendations were made unanimously.
| Diagnosis of Allergic Respiratory Diseases|| |
1. Provisional clinical diagnosis and management of allergic diseases should be made, on the basis of present symptoms, past history and family history of atopy, through telehealth/virtual care, including video conferencing as per the guidelines of the Medical Council of India (MCI) (now known as National Medical Council (NMC))
2. Face-to-face physicians and patients interaction should be avoided. If unavoidable, the patient should be diagnosed and treated in a tertiary care hospital with advanced hospital facilities. Further, postpone face-to-face routine follow-up visits with mild-to-moderate or well-controlled allergic diseases. Consider virtual care/telehealth, to ensure continuity of care
3. If the patient has to be examined by the physician, sanitization of the clinic/hospital should be done before visit of the patient. The patient should be instructed to follow all the preventive measures before coming to the clinic as per the Director General of Health Services (DGHS) guidelines. The patient should wear a mask without valve, preferably N95 to cover nose and mouth. He/she should wash the hands with soap and/or apply sanitizer, should maintain a safe distance of 1 m from each person, and should not touch the papers on the table or the case sheet. The patient should be advised to speak to the bare minimum and should answer only what is asked by the doctor or the clinic staff. Temperature should be recorded at the entrance of the clinic using nontouch infrared thermometer, and if sufficient seating accommodation is available, one attendant may be permitted. He/she should also follow the protocol followed by the patient
4. Doctor should take minimum time in examining the patient to check his/her signs and symptoms. Examination of the throat should be done strictly after covering the mouth and nose by standard mask. Always auscultate the chest from back. Never use the aerosol-generating equipment, such as peak flow meter, spirometer, and nebulizer. Use Metered-dose Inhaler (MDI) with spacer, if necessary
5. If it is necessary to do peak expiratory flow rate (PEFR) measurement, a written and informed consent for doing PEFR should be taken from the patient, and written instructions for using the peak flow meter at home should be given to the him/her. The patient should be instructed to take following precautions – (a) peak flow meter at home should be used in a room preferably facing a window. (b) Ensure that while blowing in the peak flow meter, no other person is present nearby in the room and near the window.
6. Skin test remains to be the gold standard for the identification of offending allergens in patients suffering with allergic diseases. However, performance of skin tests should be deferred temporarily during the lock down period in clinically diagnosed new cases of allergic diseases. Only if absolutely necessary, serological tests for allergen-specific IgE may be advised in specific conditions.
| Management of Allergic Respiratory Diseases|| |
7. Drugs suggested to use during COVID19 pandemic for allergic rhinitis are Intra Nasal Corticosteroids (INCS) with or without intranasal saline douche. Antihistamines and antileukotriene should be used depending on the severity of the disease
8. For asthmatics, inhaled corticosteroids with or without bronchodilators (Long Acting Beta Agonist (LABA) or Short Acting Beta Agonist (SABA)) or antimuscarinics (Long Acting Muscarine Antagonist (LAMA)) should be continued with MDI with spacer, and depending on the severity of symptoms of the patient, dose escalation can be done as per the Global initiative for Asthma guidelines (Global Strategy for Asthma Management and Prevention 2020. Available from: www.qinasthma.org). Oral steroids for short periods of 7–10 days may be advised, if required. Systemic parenteral corticosteroids should be avoided and should be given only in case of emergency in a hospital
9. Patients suffering with acute severe symptoms/anaphylaxis should be treated in a hospital, and if required, injection adrenaline or any other injection for the above problem can be given, as giving injections in COVID-19 patient is not a contraindication
10. Nebulization practice for medicines to be avoided
11. Use of biologicals is not advisable for new patients during the pandemic of COVID-19. However, those patients who are already using the biologicals may be allowed to continue, subject to availability of prompt emergency management as and when required
12. Allergen immunotherapy (AIT – Subcutaneous Immunotherapy (SCIT)/sublingual immunotherapy [SLIT]) should not be initiated in newly diagnosed patients of allergic respiratory diseases. However, in patients who are already on AIT (SCIT), AIT injections may be suspended till the lockdown is lifted. Injections may be restarted as per the Indian Guidelines for Immunotherapy reproduced below:
“In case of default – up to 1 month – no change in schedule; 1–2 months – continue with last lower dose; 2–4 months – continue with last dilution, and > 4 months – restart AIT. This schedule has been advised as per the current Indian practice followed for over 50 years.”
Use of SLIT has not yet been approved by the Central Drugs Controller General of India. In those patients, who are already taking SLIT (prescribed by physician based on the research license granted by the state regulatory authorities), should defer the use of SLIT till the lockdown period is over.
| Prevention of Allergic Diseases and Covid-19 Infection|| |
13. Allergens avoidance for allergic diseases practice to be followed as per the standard guidelines.
Practice of social distancing, isolation measures, and hand/home/clinic hygiene should be strictly followed.
Those patients who are known to be allergic or having intolerance to a particular disinfectant, an alternative disinfectant should be advised.
These recommendations have been prepared to help provide a logical approach to quickly adjust patient care to avoid risk to both healthcare personnel and patients. It may be clarified that the final decision with respect to the diagnosis and management of the patient is the sole autonomy of the clinician, their practice, and their healthcare system. Hence, the decision to follow any of these recommendations or not, or to follow an altered course of action, rests with the judgment of each clinician.
The authors express their sincere thanks to Dr. Puneet Komarla, Department of Respiratory Medicine, CDSIMER, Dayananda Sagar University, Ramanagara, Karnataka, for his immense contribution in organizing these Webinars.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Revised Guidelines on Clinical Management of COVID-19. Government of India, Ministry of Health and Family Welfare, DGHS (EMR Division); 31 March, 2020.
Gaur SN, Raj Kumar, Singh AB, Agarwal MK, Arora N. Guidelines for practice of allergen immunotherapy in India: 2017-An update. Indian J of Allergy Appl Immunol 2017;31:3-33.
|3.|Suggested additional readings
Shaker MS, Oppenheimer J, Grayson M, Stukus D, Hartog N, Hsieh EW, et al
. COVID-19: Pandemic contingency planning for the allergy and immunology clinic. J Allergy Clin Immunol Pract 2020;8:1477-8800.
Bousquet J, Akdis C, Jutel M, Bachert C, Klimek L, Agache I, et al
. Intranasal corticosteroids in allergic rhinitis in COVID-19 infected patients: An ARIA-EAACI statement. Allergy 2020; doi:10.1111/all.14302.(under Print)