key: cord-0742433-g2qxgyca
authors: Zhang, Shouling; Sicherer, Scott H.; Bakhl, Katrina; Wang, Kelly; Stoffels, Guillaume; Oriel, Roxanne C.
title: Restaurant takeout practices of food-allergic individuals and associated allergic reactions in the COVID-19 era
date: 2021-10-08
journal: J Allergy Clin Immunol Pract
DOI: 10.1016/j.jaip.2021.09.041
sha: 5ff10af0d5fbdc22a8d6252b05aefa09a9a1cf4f
doc_id: 742433
cord_uid: g2qxgyca

nan

Individuals with food allergies face challenges when ingesting food prepared in restaurants. Allergic reactions can be severe or even fatal. In a US national registry study, 19% of food-associated fatalities occurred in restaurants. 1, 2 Although restaurant staff may feel comfortable providing allergen-safe meals, deficits exist in staff training and knowledge of food allergies. 3, 4 A recent analysis of national survey data showed that the home accounts for 51% of food-allergic reactions in children. 5 Some of these reactions could result from restaurant takeout, but takeout was not specifically assessed. Dining out accounted for 13% of reactions. 5 Allergic reactions to restaurant takeout has not been previously evaluated.

With social distancing implemented during the coronavirus-19 (COVID-19) pandemic, takeout has become more common. We sought to characterize takeout preferences among US families with a food-allergic child before and during the COVID-19 pandemic. As a secondary objective, we characterized any associated allergic reactions. We created a survey of parents ordering takeout with data before and during the pandemic, allergic reactions, and demographics. The study was approved by the institutional review board. From November to December 2020, a Research Electronic Data Capture online survey was distributed via the Mount Sinai Jaffe Food Allergy Institute listserv and social media. Listserv subscribers include foodallergic individuals, their parents, and individuals interested in food allergy. Individuals aged 18 years or older with at least one child with a physician-diagnosed food allergy were sent the survey after we obtained informed consent. Deidentified, parental-reported data were collected. Descriptive statistics, McNemar, Wilcoxon signed rank sum, chi-square, Fisher exact, and Cochran-Armitage trend tests were used for analyses, all performed using SAS software (version 9.4, (SAS Institute, Cary, NC). Statistical significance was set at P less than .05.

A total of 206 individuals participated. Children with food allergy were mostly male (56.3%), White (87.9%), non-Hispanic (83.5%), and from the northeast (New York, 60.7%; New Jersey, 21.4%; and Connecticut, 6.8%). Table E1 (in this article's Online Repository at www.jaci-inpractice.org) lists demographics. Before the pandemic, defined as before March 2020, most families reported ordering takeout in varying frequencies (77.7%). Table E2 (in this article's Online Repository at www.jaci-inpractice.org) lists takeout preferences and practices. Overall, there were no differences in takeout practices among food-allergic individuals before and during the COVID-19 pandemic. Figure 1 shows pre-COVID precautions taken by food allergic individuals who order takeout and reasons why respondents avoided takeout. Other mitigation efforts (11.2%) included only ordering from restaurants previously visited or that do not cook with avoided ingredients. There were no differences in these responses pre-/during COVID-19; however, during COVID-19, 11.2% indicated that the pandemic was a reason to avoid takeout.

Allergic reactions from restaurant takeout were reported by 16.8% (n ¼ 29) of 173 respondents. Thirty-three participants did not answer. Most children who had an allergic reaction were school-aged children or adolescents: 6 to 12 years (37.9%), 13 to 17 years (37.9%), and 18 years or older (13.8%). Allergic reactions varied from one (44.8%) to two (34.5%) and three or more (20.7%). One allergic reaction was excluded from analyses owing to delayed symptom onset; all other reported reactions occurred within 2 hours. Symptoms typically occurred within 30 minutes (69.0%), or from 31 minutes to 2 hours (27.6%); 28.6% reported emergency room evaluation. Treatment included oral antihistamines (86.2%), epinephrine autoinjector use (27.6%), steroids (20.7%), bronchodilators (6.9%), none (6.9%), and antacids (3.4%). The source of allergic reaction was often unknown. When identified, milk (24.1%), peanut (20.7%), and wheat (6.9%) were most common. Restaurant cuisines most often implicated in allergic reactions included Chinese (25.0%), American (14.3%), and Indian, Korean, Thai, Italian, vegan, or hotel restaurants (each 7.1%). There were no significant differences in takeout precautions or methods for ordering among those who had reactions. A statistically higher risk for reaction was noted for those ordering Mexican, Chinese, or Asian cuisine not specified by the survey participant (Table I) .

Here, to the best of our knowledge, we report the first study evaluating restaurant takeout practices among food-allergic individuals and any associated allergic reactions. Allergic reactions to takeout food occur despite precautions taken by food-allergic individuals: 16.8% in this survey. Severe allergic reactions occurred mostly to food from Asian restaurants. These results were consistent with research citing Asian restaurants as high-risk for food-allergic reactions (up to 19%), and suggest that risk may vary by cuisine, which should be considered by restaurant patrons. 6 Our study highlights specific precautions taken by foodallergic individuals ordering takeout ( Figure 1 ). Although there was no difference in the types of precautions exercised among individuals who reacted and did not react, future studies understanding the efficacy of individual precautionary strategies are suggested to identify best practices. Most individuals who had an allergic reaction took steps to prevent one from occurring. Interestingly, only one individual experienced an allergic reaction when no precaution was taken. We hypothesize that miscommunication of allergy status from families to restaurants may explain why individuals experienced allergic reactions even when precautionary steps were taken. Moreover, certain precautionary strategies may have different levels of effectiveness compared with others. We would not encourage a dependence on the visual inspection of food (there was a trend toward risk with this strategy). Restaurant staff lack of knowledge is also likely. 3 A high percentage of restaurants had no menu allergen labeling (35.8%), and there was a borderline difference in this category between those who did and did not react (P ¼ .06), which suggests that this could be a focus area and may reflect increased allergen awareness and protocols in those establishments (ie, better communication and knowledge). Identifying potential barriers to menu allergen labeling that may exist for restaurants is recommended, so that widespread menu labeling can occur in collaboration with restaurants. Families made no major changes to takeout routines during the COVID-19 pandemic, and allergic reactions occurred in patterns seen before the pandemic. Data presented here support the need for improved communication between restaurant workers and patrons and the expansion of food allergy knowledge among restaurant staff.

Allergic reactions from takeout were high, but this should be interpreted with caution owing to study limitations, including the survey-based nature of this study, which was potentially biased by respondent experience and recall. Recall bias may exist with pre-pandemic data, because this study was conducted more than 6 months after the start of the COVID-19 pandemic. The nature of the survey did not allow us to determine whether persons with specific allergies (eg, milk vs peanut) had increased risks for reactions, nor could we determine whether restaurants that did not usually provide takeout before the pandemic were riskier than those that did. The study was based on a convenience sample, and thus it was geographically limited. However, additional analysis excluding the approximately 11% of survey participants outside New York, New Jersey, and Connecticut did not yield meaningful differences in study conclusions.

Future studies are needed examining effective ways to prevent allergic reactions from takeout food, to advance advocacy efforts. Allergists should carefully discuss risks with patients, promoting clear communication and asking and educating about crosscontact and hidden ingredients. 7, 8 Mandating the declaration of allergenic ingredients on menus, encouraging free text options for food allergies to be declared by individuals ordering takeout, and regular and effective restaurant staff training may be helpful in reducing risk. 8 Prior studies from the hospitality industry also indicate interest from restaurants in obtaining additional food allergy training. 9 Together, these efforts may improve takeout experiences among food-allergic individuals, so that food can be enjoyed safely. †Chi-square test for association and Cochran-Armitage trend tests were used to determine whether there was an association between individuals who had a reaction compared with those who did not before the pandemic among factors presented in the table. 

Fatalities due to anaphylactic reactions to foods

Further fatalities caused by anaphylactic reactions to food

Food-allergy management from the perspective of restaurant and food establishment personnel

Restaurant food allergy practices -six selected sites

Characteristics of food allergic reactions in United States restaurants

Peanut and tree nut allergic reactions in restaurants and other food establishments

Restaurant staff's knowledge of anaphylaxis and dietary care of people with allergies

Food Allergy in Restaurants Work Group Report

an association between time of delivery (before or during COVID) and the factors presented in the table. zOther (<10%) includes bakery