Food labelling in Australia has been scrutinised closely in recent times as food allergies have been on the rise. Food Standards Australia New Zealand (FSANZ) is an independent statutory authority that lies within the Department of Health and develops and maintains food standards within Australia and New Zealand. FSANZ has undertaken several rounds of public consultation to consider ways to improve current food labelling.
Severe allergies and anaphylaxis is not well understood in the general community or across the health sector. The inquiry found that more education and training is required for all doctors, specialists and allied health care workers who work with people suffering from allergies. This approach of further education and training extends into the food service industry.
This chapter discusses the following issues:
upskilling medical experts and allied health sector workers in allergies and anaphylaxis; and
the need to make changes in the food service industry to support people with allergies and anaphylaxis.
Food labelling in Australia
The Committee received a significant amount of evidence in relation to food labelling and the difficulties that this causes for people with food allergies. A consistent theme was that food labels need to be accurate and meaningful:
As a parent of a child who has multiple food allergies, I am depending on the accuracy of the manufacturer’s food allergen statement. It can be a matter of life or death if the food allergen statement is incorrect.
Food shopping for a toddler who is anaphylactic to a number of allergens can be difficult and challenging when deciphering whether a product is safe for my child to consume as manufacturers rarely list the 7 top allergens by their common names (milk, egg, etc.). It is most common for manufacturers to list other/ name derivative names of food allergens. For example, casein and whey is another name/derivative for milk.
Witnesses also highlighted inconsistent labelling as one of the most significant issues regarding labelling:
Possibly the greatest frustration is multiple names for the same thing: sometimes labelled as the substance name, sometimes labelled as a number, sometimes labelled as group or class of substance. For example: potassium sorbate, 202, or the more general ‘contains sorbates’. Vague descriptors like ‘spices’ render foods unavailable to many unnecessarily. It would be better to have one standard required presentation of the name, and when applicable, number, on listed ingredients. It should also be required for those ingredients to be available when shopping online: some websites have ingredients listed, some do not, and some are inconsistent.
In particular, there were many reports of difficulties with identically packaged items having different formulations and ingredients.
Vigilance is required every time a product is bought from the supermarket that may contain allergens:
Over time our approach to food has become increasingly vigilant as we see more food products subject to recalls due to undeclared allergens. This has affected our level of confidence and trust across the food industry, where poor labelling and manufacturing processes are placing children and adults with anaphylaxis at high risk of life-threatening reactions.
To compound this, manufacturers change ingredients in what was previously a ‘safe’ product without warning or advice, making the product now unsafe. Due to personal experience, we now check every food label every time we purchase a product. For e.g. maltodextrin can be derived from both wheat and corn and this can alternate between different batches often depending on where the product is made.
One inquiry participant reported their child had had a reaction to ingredients which were not labelled on the package of a food item, the manufacturer refused to provide further information about the ingredients as it was ‘proprietary information’.
Another family suggested they had a triple check system for food purchases:
We have a three-point system of checking labels at the supermarket, as we put it in the cupboard and as we use them.
Australia and New Zealand were among the first countries to recognise the need to regulate food allergens with the introduction, in 2002, of mandatory declaration requirements in the Australia and New Zealand Food Standards Code. Since 2002, the food industry in Australia and New Zealand has developed a number of best practice initiatives to support companies to manage food allergen risk and provide clear information to consumers in order to assist them to make informed choices.
The Australian Institute of Food Science and Technology discussed the major challenges facing the Australian Government and the food industry:
Managing the risks associated with the presence of food allergens in ingredients and products is a major food safety challenge faced by food manufacturers at all levels of the supply chain.
Companies have a responsibility to manage both the intentional and unintentional presence of allergens in food products and to provide clear and accurate information on their allergen status. These requirements are the same whether the product or ingredients are manufactured or sourced in Australia and New Zealand or are imported.
The Australian Food and Grocery Council (AFGC) argued that ‘Food allergen management and labelling in Australia is recognised as the world’s best practice. This results from robust regulatory regimes protecting consumers combined with a voluntary, technically sophisticated, evidence-based, self-regulatory program run by the industry (the Allergen Bureau), for the industry.’
Allergies and Anaphylaxis Australia (A&AA) stated that ‘there is a great need to ensure food importers, ingredient suppliers, manufacturers, regulators, compliance officers and all working in food production understand their responsibilities in food allergen management. Accurate food labelling that is clear and consistent is critical so that consumers with food allergy can make safe and informed decisions about the foods they purchase. Unfortunately food recalls due to undeclared allergens are increasing, with allergen recalls being the reason for the majority of recalls.’
Food Standards Australia New Zealand (FSANZ)
Food Standards Australia New Zealand (FSANZ) is an independent statutory authority within the Department of Health. It was established under the Food Standards Australia New Zealand Act 1991 (FSANZ Act), and operates as an integral part of the food regulation system for Australia and New Zealand.
FSANZ develops and maintains the Australia New Zealand Food Standards Code (the Code). The Code sets out the legal requirements for food produced or imported for sale in Australia and New Zealand.
FSANZ also has other functions in Australia including coordinating food surveillance and food recall systems. It does not however have an enforcement role as food standards in Australia are enforced by the states and territories.
Current standards for food allergy labelling
FSANZ provided the Committee with the following information on sections of the code that regulate food labelling.
Standard 1.2.3- Information requirements- warning statements, advisory statements and declarations of the Code requires the mandatory declaration of the presence of certain foods or substances which can cause severe allergic and other reactions in food. The following foods and substances must be declared whenever they are present as ingredients (including when present in food additives and processing aids):
…added sulphites (in amounts of 10 mg/kg or more); cereals containing gluten (namely wheat, barley, rye, oats, spelt and their hybrids), crustacea, egg, fish, milk, peanuts, soybeans, sesame seeds, tree nuts and lupin.
The declaration must be made on the label of foods for retail sale and foods sold to caterers. For food not in a package or where it is not required to be labelled (for example, food prepared at and sold from a cafe or takeaway), Standard 1.2.1 - Requirements to have labels or otherwise provide information requires the declaration of the presence of allergens to either be displayed in connection with the food, or provided to the purchaser on request.
Standard 1.2.3 also exempts certain highly refined foods and ingredients (e.g. glucose syrup refined from wheat, alcohol distilled from milk whey) from the declaration requirements as these foods were found to be safe for food allergic individuals.
The Food and Controlled Drugs Branch (FCDB), South Australian Health, commented that allergens are not specifically named in Standard 3.2.2 of the Code as a risk that food businesses must manage, however it is specified in the labelling standards of Chapter 1 (foods that are required to bear a label, and foods that are required to have labelling information available).
FCDB suggested that ‘Having a dedicated section within Chapter 3 of the Code would mean that there would be no confusion as to the requirement for allergens to be managed by food service businesses and to be assessed during routine inspections.’
FCDB continued by stating:
Chapter 3 of the Code is planned for review by Food Standards Australia New Zealand (FSANZ), and this presents the perfect opportunity to incorporate allergens specifically as a risk that must be managed by food businesses. Dedicating a clause to allergen management, rather than incorporating it into ‘contamination’ may give weight to the severity of this issue.
Plain English Allergen Labelling (PEAL)
FSANZ told the Committee it is currently working on Proposal P1044 - Plain English Allergen Labelling (PEAL) which would make changes to the Code to make allergen labelling clearer and more consistent. It sought public comment on this proposal through 2019.
FSANZ estimates that the proposed changes would be considered by September 2020, and then the Food Ministers’ forum will be notified.
The AFGC was supportive of the work being done by FSANZ in relation to PEAL, noting that the changes:
… should result in regulatory changes leading to better allergen labelling of food products which will be clearer, more consistent across food products, and more useful for consumers with allergies in identifying the food products they can eat, and those they must avoid.
FSANZ established the Allergen Collaboration in 2011 with the purpose of strengthening engagement and collaboration amongst key stakeholders in food allergy management with the view to help consumers with a food allergy make safer choices. FSANZ is a member and the Chair of the Allergen Collaboration, as well as providing secretariat support to the group. Members of the Collaboration represent food manufacturing, food service, allergy support groups, health professionals and government.
The Allergen Collaboration maintains an Allergen Portal website which provides links to best practice food allergen resources and key messages that can be promoted in different sectors of the community.
The Allergen Bureau is the peak industry body representing food industry allergen management in Australia and New Zealand. The overall objective of the Allergen Bureau is to share information and experience within the food industry on the management of food allergens to ensure consumers receive relevant, consistent and easy to understand information on food allergens.
The Allergen Bureau informed the Committee about the Global Food Safety Initiative:
In addition to mandatory requirements, food industry may elect to implement food allergy management requirements and recommendations in various industry standards and best-practice guidance resources. The Global Food Safety Initiative (GFSI) is a collaboration between some of the world's leading food safety experts from retail, manufacturing and food service industry, as well as service providers associated with the food supply chain. Food companies that choose to implement a GFSI-recognized scheme do so with the knowledge that they are using an internationally recognized, credible, and comprehensive food safety program. The GFSI mission is to “provide continuous improvement in food safety management systems to ensure confidence in the delivery of safe food to consumers worldwide”.
Precautionary Allergen Labelling (PAL)
Many submitters raised Precautionary Allergen Labelling (PAL) as an issue that caused a lot of frustration and anxiety. The Committee heard from FSANZ what PAL was used for and how it was regulated.
FSANZ commented that PAL is used to inform food allergic consumers of the possible presence of food allergens in a product when the allergen was not intentionally added but may have occurred due to cross contact. Food manufacturers may voluntarily use PAL statements (for example, 'May contain ... ') if they are concerned about allergen cross-contact that may have occurred in the supply chain including growing and harvesting of crops, storage and transport of food, or via processing equipment at the manufacturing plant. FSANZ commented:
The Code does not contain any requirements relating to the use of PAL on food labels because there is no agreement in the scientific and medical literature on the allergen threshold for most food allergens. An allergen threshold is usually reported as an allergen intake level (e.g. mg of peanut protein) below which most allergic individuals (except for the most sensitive in the allergic population) will not develop a clinical reaction.
Although, the science is still evolving, FSANZ is aware there has been recent progress on determining allergen thresholds for some food allergens, as well as recently commenced work at an international level to achieve consensus on when and how to use PAL. FSANZ is therefore monitoring scientific and regulatory developments internationally, with a view to considering whether future changes to the regulatory arrangements for PAL are needed.
The AFGC made the following comment on PAL:
Today’s supply chains are sophisticated and much is done to maintain the integrity of raw materials (ingredients, additives etc.) as they come down the supply chain and are incorporated into food products. On occasion common equipment for material handling, production lines and facilities is used for the production of different food products resulting in the chance of ‘cross contact’ and the incidental presence of an allergen at trace levels. One of the more challenging issues for the food processing industry is how best to alert consumers to the possible presence of an allergen in a food product arising from cross-contact during production of the food and this may include the use of a precautionary allergen labelling (PAL) statement. Such statements alert consumers to the possible presence of an allergen by stating the food product may contain the allergen. Alternatively there may be a statement indicating the food was produced in a facility where the allergen was also present. Such statements have been controversial and their use by the food industry criticised on the basis that they restrict consumers choosing foods, when the allergen may not be present at all.
Dr Zurzolo, Postdoctoral Fellow, Centre for Food and Allergy Research; Melbourne School of Population and Global Health, University of Melbourne, discussed the main issues of food labelling. He commented that PAL presents the biggest problem to consumers due to confusing labelling:
Labelling is a very confusing issue. We have mandatory labelling, which basically covers any ingredient intentionally added to a food product. The food manufacturing industry, I believe, does it quite well. There are some hiccups with plain English, but FSANZ is looking into that and will hopefully provide some recommendations through that.
The biggest issue is what we call precautionary allergy labelling, which is basically providing the statement 'may contain traces' on a food product to alert the consumer that it may or may not have cross-contamination or cross-contact with a food allergen—which may happen during the manufacturing process, during shipping or during the cleaning of the manufacturing lines. These are statements are voluntary; they are not regulated; they are not standardised by any system at all. And it is the same worldwide, not just here within Australia.
Within a supermarket setting, approximately 65 per cent of processed goods carry a precautionary statement. That makes it incredibly difficult for a food allergic consumer to decide whether a food is actually safe.
Dr Zurzolo commented that his research has found that ‘approximately 60 per cent of consumers are ignoring the PAL statements. That is most likely because of how many they are, or because they are becoming complacent with them or because they have eaten them before and they haven't reacted to them. And about 90 per cent of consumers believe the statements are there just to protect the manufacturers from litigation anyway.’
A&AA emphasised that one of the main difficulties caused by PAL is that it is voluntary and unregulated:
Precautionary allergen labels (e.g. ‘May contain …’ statements) are voluntary, unregulated and cause confusion for people with food allergy and health professionals. Most products contain a precautionary allergen label without any risk assessment being undertaken and therefore, the information is meaningless.
Other products where there may be real risk, do not contain precautionary allergen labels and the individual is unaware of the risk. Further to this, if an individual with food allergy has an allergic reaction to a packaged food, it is critical that an investigation is undertaken, and the food product removed from the market place if the food is incorrectly labelled.
There is no universal terminology used to communicate cross contamination (when an allergen is unintentionally part of a food product). PAL statements vary widely. Some of the terms used by packaged food manufacturers include ‘may contain traces’, ‘may contain’, ‘contains traces’, ‘may be present’, ‘made in a facility’, ‘processed on a production line’ etc. Consumers wrongly believe each term is related to a level of risk. There remains much confusion in the community around labelling requirements, with a Melbourne study recording that up to 80% of parents whose children are at-risk of anaphylaxis thought PAL was unhelpful, with many ignoring such statements.
Many inquiry participants gave evidence of their frustration with PAL which often uses ‘may contain traces’ labelling, describing it as unhelpful and too broad.
The Allergen Bureau has developed and provides key best practice allergen management and labelling guidance for the food industry, particularly the globally recognised VITAL® (Voluntary Incidental Trace Allergen Labelling) Program - a standardised allergen risk assessment process for food industry. The VITAL Program is considered a world leading initiative in food allergen management and labelling to ensure consumers receive relevant, consistent and easy to understand information on food allergens.
The NAS suggested the introduction of standardised precautionary allergen labels, such as the Voluntary Incidental Trace Allergen Labelling (VITAL) program:
Mandate the requirement for food manufacturers to undertake an appropriate risk assessment (e.g. Voluntary Incidental Trace Allergen Labelling (VITAL) to determine whether a product requires a precautionary allergen label and standardisation of the wording used for precautionary allergen labels).
Training in the VITAL Program, developed by the Allergen Bureau, is delivered in Australia and New Zealand and internationally by endorsed Training Providers. A&AA suggested that ‘if the new VITAL symbol IS on pack this will improve confidence in the information on pack whether it has a PAL statement or not.’
Imported foods in Australia
All imported foods into Australia must comply with the FSANZ Code. This means all imported foods must label the ingredients in English and include allergen labelling.
The Department of Agriculture, Water and the Environment (DAWE) advised the Committee that Section 34 of the Imported Food Control Act 1992 (IFC Act) appoints laboratories to conduct food testing under the Imported Food Inspection Scheme (IFIS). To be an appointed analyst, a laboratory must meet stipulated conditions including National Association of Testing Authorities (NATA) accreditation. Accredited laboratories are located within major cities nationally (e.g. Sydney, Melbourne, Brisbane, Adelaide, Perth).
The Committee was interested to hear if rigorous food testing was carried out on Australian borders in relation to imported foods. DAWE made the following statement:
Food importers are legally responsible for ensuring the foods they import comply with Australian food standards and do not pose a risk to human health. The role of the department under the IFC Act is to monitor the compliance and safety of imported food at the border through the IFIS, a risk based inspection scheme.
All foods referred for inspection under the IFIS are subject to a visual and label assessment. The labelling check includes an assessment of whether mandatory declarations (as required for food allergens) are labelled correctly based on the product’s list of ingredients.
DAWE commented on the process that occurs when imported foods are referred to the IFIS:
Foods referred to IFIS are checked to ensure there is a label printed in English that includes all necessary information (e.g. description of the food, ingredient list, nutrition panel, importer name and address, lot coding and allergen information, as appropriate).
DAWE will test foods where intelligence is available for specific imports, it is not practical or feasible to routinely test imported food for the presence of undeclared allergens to determine whether the food allergen labelling on the product is appropriate.
DAWE undertakes the following activities to identify and manage the risk of undeclared allergens:
it monitors international recalls and incidents to identify foods traded internationally that may be non-compliant and whether they are imported into Australia. For example it was recently identified that spring roll wrappers produced in Singapore and recalled in New Zealand and the United Kingdom for undeclared dairy were also imported into Australia. These products were then recalled in Australia and will now be targeted for inspection at the border to ensure future imports include the presence of dairy on the label;
it implements measures at the border in response to non-compliance identified post border by the state and territory food regulators. For example, imported coconut drinks are tested for the presence of dairy allergens, if not declared on the label, following the report of a death and severe allergic reaction in Australians consuming these drinks in 2015. (see case study below); and
it responds to alerts received through international food safety networks, including the European Union’s Rapid Alert System for Food and Feed (RASFF). Earlier this year RASFF notified Australia that pesto products exported to Australia from Italy contained undeclared peanut due to cross contamination of raw ingredients. Food importers and food regulatory agencies have been working together on this issue to ensure potentially affected product has been recalled and appropriate allergen labelling is now applied.
The Committee heard that DAWE has ‘published an Imported Food Notice on food allergen management to remind importers of the importance of understanding their supply chains to ensure appropriate allergen labelling.’
The Allergen Bureau highlighted the issue that currently exists with imported foods with the following case study.
Box 4.1: Case Study: Mislabelled imported goods resulting in anaphylactic death in Australia
The consequence of an allergic reaction to a food can be tragic – in late 2013, a young boy died after becoming ill after dinner one evening. The child had an known allergy to cow’s milk and consumed a coconut drink which was subsequently found to be incorrectly labelled, as the product contained an undeclared cow’s milk ingredient.
This tragic death was investigated by the Coroner’s Court of Victoria and the findings handed down in June 2016. The coroner found that:
“On the evidence available to me, I find that [name], who was highly allergic to dairy milk, died after ingesting ‘Brand X Natural Coconut Drink’, a product that has been imported from Taiwan and mislabelled, so as not to declare that it contained dairy.”
There have since been multiple recalls of imported coconut drinks and coconut milk powders that contained undeclared milk in Australia, New Zealand, and throughout the world.
The Committee received evidence suggesting that a national approach to drug allergy labelling and management is required. Currently medicine labels are being improved however the change is occurring slowly over several years. As allergies are on the rise this issue of drug labelling may become more important as people with allergies require medicines to treat illness.
The TGA commented that unlike foods most medicines are not required to list all the ingredients on the label:
Some medicines may contain substances that might cause allergic reaction in some people. Unlike foods, most medicines are not required to list all the ingredients that are included in the medicine label. The active ingredient will always be on the medicine label, but only some inactive ingredients, also called excipients, must be on the label. Also, some potential allergens, such as impurities from manufacturing, may not be on the label.
The Western Australia Child and Adolescent Health Service suggested a national approach was needed to drug allergy management.
We would recommend a national approach to drug allergy management, with increased education about drug allergies, recognition and management of drug allergy and the development of national guidelines for drug allergy confirmation.
The Western Australian Child and Adolescent Health Services commented that:
Unexpected and adverse drug reactions (ADR) to medicines experienced by consumers may lead them to suspect drug allergy, however, true allergy is uncommon. This is especially relevant for antibiotics of which penicillin is the most commonly reported drug allergy by patients (18 per cent of Australian adult patients and five to seven per cent of children). These patients have increased morbidity and mortality and most are avoiding the medications unnecessarily.
The Australian and New Zealand Anaesthetic Allergy Group (ANZAAG) commented that there was a great deal of room for improvement for drug labelling:
In a case we know well, the new Aimovig injections, which have provided such a life changing benefit for many living with migraine, were initially not labelled as having a latex component in the injection pen mechanism. This has been corrected, but the product was rolled out globally and significant reactions occurred before the labelling was revised.
In 2010 specialists from fields such as anaesthetists, immunologists, pathologists and allergists, came together to form the Australian and New Zealand Anaesthetic Allergy Group (ANZAAG). Its aim is to foster critical inquiry and research into perioperative anaphylaxis within Australia and New Zealand in order to develop best practice in relation to the prevention, treatment and investigation of perioperative anaphylaxis.
ANZAAG raised the concern that the number of cases of chlorhexidine anaphylaxis is increasing:
The labelling of chlorhexidine containing products is often poor. Examples of this include the use of small font sizes and the use of the abbreviation CHG, for chlorhexidine, an abbreviation that is not universally recognised. Anaphylaxis to chlorhexidine can result from minimal exposure; such as the use of chlorhexidine containing alcohol wipes to clean intravenous ports prior to drug administration. The use of chlorhexidine containing products has been mandated by numerous health authorities, sometimes with limited evidence of benefit. This includes the requirement to use chlorhexidine containing alcohol wipes to clean intravenous ports prior to drug administration and the short-term use of chlorhexidine coated central venous catheters. The ubiquitous presence of chlorhexidine as a result of the above policies and often inadequate labelling has contributed to the phenomenon of repeated episodes of anaphylaxis to chlorhexidine both before and after a diagnosis of chlorhexidine allergy is made.
Education and training for allergies and anaphylaxis
The Committee heard that a broad range of education and training was required throughout the health sector to improve the understanding of allergies and recognition of symptoms and appropriate treatment for anaphylaxis. It was told that the Australian community would also benefit from a national allergy and anaphylaxis educational campaign.
Many people reported difficulties in receiving a diagnosis, often having to see several doctors and specialists before their or their child’s symptoms could be diagnosed.
This seemed to be a particular problem for sufferers of emerging allergic diseases, such as EoE and FPIES. One inquiry participant reported that it took four years to receive an EoE diagnosis for their child.
Of particular concern was the number of mothers of young children who reported that their concerns about their children were dismissed by medical professionals, these women often being described as ‘anxious’ or ‘overly concerned.’
Because my son was little and he was a first child and for whatever other reason I was considered a very anxious mother. I remember when I finally went to see the gastroenterologist he kind of got angry with me and said, 'Why have you waited so long to bring a child with these symptoms here?' I just looked at him. I said, 'Because everyone kept telling me I'm anxious.' He said, 'You are anything but anxious.'
ASCIA has developed a range of reliable evidence-based allergy and anaphylaxis educational resources for patients, carers, consumers, school staff, early childhood education/care staff, first aid providers and health professionals. These resources include action plans, e-training courses and documents that are accessible online, that can be downloaded and printed. However ASCIA stressed to the Committee that providing, updating and promoting these resources requires ongoing funding.
The NAS agreed that quality education and training on allergies and anaphylaxis is needed for many health professionals:
Quality education and training for health professionals about allergic diseases and anaphylaxis is often lacking and much needed. With the growing number of young adults with food allergies moving from paediatric to adult care, this will also become an issue for health professionals who manage adult patients.
The Western Australia Child and Adolescent Health Service agreed that education and training of health professionals is key to improving services to allergy management in Australia:
There is a need to inform patients, the public and all health professionals about allergy and how to recognise and respond to allergic reactions including anaphylaxis. This education and advice needs to be evidence based, up to date, easily accessible and consistent. This will require standardisation of the education and training for all personnel including schools, childcare, first responders and health professionals with regular mandated upskilling as recommended by the Australasian Society of Clinical Immunology and Allergy.
Professor O’Hehir commented that it is important to improve both doctors’ and the general community’s awareness of allergies and anaphylaxis:
We have packages such as Up-to-date that most physicians have access to, and under 'Adverse events' it clearly lists certain drugs that may cause angioedema, tongue swelling, cough et cetera. So it comes back to education…But I think it's important that there's community awareness as well as doctor awareness.
The Committee was told that it is difficult to include training in universities when there is only one Professor of Allergy and Immunology in Australia. Professor Douglass described a workforce issue that Australia currently has in relation to allergies and anaphylaxis:
I think the tsunami of allergic disease, which is a First World problem, has caught many First World countries and health systems off guard in terms of workforce capacity. Professor Robyn O’Hehir is the first professor of allergy and immunology in Australia. What teaching do you get in medical schools if you don't have professors who can teach it? Even at that level there is a lack of workforce capacity that's been evident for some time.
Post graduate training for General Practitioners, immunologists and paediatricians
There is currently a lack of broad-based training in allergic disorders amongst the health workforce at the undergraduate and post graduate level.
ASCIA told the Committee that medical education in relation to allergies and anaphylaxis was inadequate in Australia:
Medical education in the area of allergies and anaphylaxis, both undergraduate and postgraduate, has been inconsistent and inadequate in Australia. This has resulted in the majority of general practitioners, paediatricians, other medical specialists and other health professionals having inadequate training or experience in the management of allergic disease.
This has a flow on effect to patient care, when advice given to patients may be incorrect, inappropriate, inadequate and at times dangerous. Even in 2019, most general paediatrician trainees will qualify with no exposure or training in allergic diseases and will be ill equipped to manage children with allergies.
The Women’s and Children’s Health Network commented:
There is limited training for those with more general needs such a general practitioners, general paediatricians, child health nurses, and dietitians. This lack of training in what is now a very common health concern, results in misdiagnosis, incorrect and potentially harmful advice, and inappropriate (both failure to under and over refer) referral to specialist allergy care. This in turn increases the burden of illness and cost of care for the consumer/family and community.
The Western Australia Child and Adolescent Health Service stated that:
…paediatric immunology is highly specialised, with very few paediatric trained specialists in WA. We would advocate for allergy to be included in the curriculum for all Australian Health professional education programs, with a special focus on general practitioners (GPs) and general paediatricians.
Ms Carly Morton, who lost her husband to bee sting anaphylaxis, commented that there is a poor understanding of anaphylaxis even in the medical field:
In our experience anaphylaxis is often poorly identified and often incompletely managed, including at times in our own institution. Once again, this is related primarily to a lack of education and training. While there are state-based clinical pathways for anaphylaxis management, these appear poorly accessed. Worryingly, many of these episodes go unrecognised and risk being repeated. Furthermore, there is poor documentation of allergen triggers (both food and drugs) within hospital medical records. Because of long waits to see an Allergist, those at risk of anaphylaxis remain so, often without basic emergency plans such provision of an adrenaline auto-injector. State and national KPls around anaphylaxis management are lacking and a lack of data on this makes planning in this area difficult.
Dr Hew discussed the limitation in workforce training for allergy specialists in Victoria:
For those close-to-seven-million people, we have two registrar training positions—one at Royal Melbourne and one at the Alfred. It takes about three years to train someone, so that is about one specialist produced a year or sometimes none. I provide specialist services in two specialties—allergy and respiratory medicine. In respiratory medicine, there are 26 training positions in Victoria and one in Tasmania. That is 27. That means nine specialists produced per year, less than one for allergy per year in Victoria. This is a dire state of affairs.
The funding of specialist training in public hospitals depends on the hospital's willingness to fund that position. Again, allergy is predominantly an outpatient specialty. It does not deal with most of the KPIs that individual hospitals are focused on to do with inpatient stay and that therefore makes it difficult for hospitals to initiate training.
The Committee was informed there is one post graduate course available, the Graduate Certificate in Allergy, run out of the University of Western Sydney. In addition there is the Professional Certificate in Allergy Nursing, University of South Australia, catering for those with a special interest in allergy.
The NAS scoping report recommended that allergic diseases be a more significant component of all health professional (including university and where relevant, post graduate) training. This includes collaboration with the Deans of major medical schools and with the Royal Australian College of General Practitioners (RACGP) and Royal Australasian College of Physicians (RACP) to help provide credible education.
Allied health professionals
The Committee received evidence suggesting that allied health care support such as psychologists, counsellors and dieticians have an important role in caring for people with allergies and anaphylaxis. However it was clear that these support areas required specific training for the management of allergies and anaphylaxis.
The Allergy Support Hub commented:
Dieticians are incredibly valuable in providing daily management and nutritional advice to those with allergies, those with multiple and complex allergic conditions. Psychologists can assist with the social and emotional aspects of managing allergic conditions and help families through challenging times such as food challenges, social isolation, entry to school, subsequent children, childhood anxiety, food avoidance/fear and assist the psychological impact for adults with severe allergic condition.
Dietitians are often at the forefront of nutritional management of non-IgE-mediated food allergies such as food protein induced proctocolitis and food protein induced enteropathy, which in many cases requires manipulation of the maternal diet during breastfeeding. A thorough understanding of the nutritional requirements of breastfeeding, appropriate food substitution, and when and how to reintroduce allergens to the maternal and/or infant diet is required.
Dr Merryn Netting told the Committee that ‘currently basic undergraduate training for dietitians includes limited information regarding food allergy management. In addition, dietitians working in food service management require specialist training in allergen handling.’
To address this knowledge gap, ASCIA offers free online e-training in food allergy. However this does not make a dietitian competent in allergy management. ASCIA commented:
We have sought to address this need by development of a two-day, evidence based, peer reviewed face to face ASCIA training course in association with the Dietitians Association of Australia Centre for Advanced Learning, however this course comes at a cost to the individual which limits its accessibility.
Vocational Education Training - Hospitality
The Committee received evidence advocating for improved practices in hospitality and training in relation to allergies.
The NAS advocated for accredited food allergy training to be incorporated in hospitality courses. The NAS called for the ‘inclusion of an accredited food allergen management training course that meets the National Allergy Strategy Minimum standards for food allergen management training, in all hospitality training courses.’
The Allergen Bureau told the Committee that they believe a gap currently exists in the institutional education for food manufacturing professionals:
Many of the current TAFE and University courses, for general manufacturing workers through to food science graduates, do not adequately address food allergens and their management. To address this gap, a review of the Cert I, II and III in Food Processing is currently underway, led by Skills Impact, and subject matter experts in food allergen management have been consulted in this area.
Food science degrees in university also do not all address food allergens and their management in food industry – being knowledge which is traditionally obtained once working in the industry.
Several submitters suggested a certificate to serve food safely with regard to allergies, similar to the Responsible Service of Alcohol (RSA) certificate:
Given the increasing prevalence of anaphylaxis and the risk to life if hospitality staff inadvertently serve a person food containing that person’s allergen, I would like to see a mandatory ‘Allergies and Anaphylaxis’ training program that servers of food are required to undertake, similar to how servers of alcohol are required to undertake a ‘Responsible Service of Alcohol’ program.
In relation to education and training, the Restaurant and Catering Industry Association (R&CA) suggested that allergen and anaphylaxis training be incorporated into food safety and handling training nationwide:
Currently, there are three levels of training available to employees within food businesses, a safe food handling certificate (both back and front of house) which is issued by state food regulation agencies as well as a single food safety supervisor who is responsible for management of food safety practices across the business. Also, a single staff member (usually the front of house restaurant manager) will hold a full first aid certificate. The food safety supervisor may have some allergen training, but this is an optional competency in certain states and not common across food service businesses.
R&CA has long held the view that mandating training for food handlers under a nationally consistent system is good public policy.
Currently in Australia only NSW, ACT, QLD and VIC require businesses to have a food safety supervisor. In the jurisdictions where a food safety supervisor is required, there are differences with regards to:
Which businesses are required to have a food safety supervisor and the reasoning behind why they need to have a food safety supervisor;
The training requirements for food safety supervisors;
Whether a period of currency applies to the training required; and
Regulation of training provided to food safety supervisors.
NSW is the only jurisdiction that regulates the training for food safety supervisors and NSW has included food allergen management in this training.
The Committee received a submission from the Food and Controlled Drugs Branch, South Australian Health that suggested that food service businesses who choose to offer allergen free foods may be required to have a dedicated ‘allergen free zone’ or a separate equipment and utensils or thorough cleaning process before preparing allergen free food.
The management of schools is a state and territory issue. However the Committee received significant evidence from individuals regarding the inconsistent management practices of allergies and anaphylaxis across many Australian schools.
Inquiry participants reported mixed experiences with their children in schools. Several witnesses noted that each state and territory has different guidelines for the management of allergies within schools. In addition there seems to be a great deal of variance between schools as to how well these guidelines are followed.
Some parents reported working with their schools to develop management plans for their child’s circumstances and being disappointed to find out after reactions or anaphylactic episodes that these guidelines were ignored. As an example, one parent wrote about their child being sent to the toilet alone after a reaction which was directly against their allergy management plan.
Other people reported gaps in care for children with allergies, such as children being served food with allergens during school camps.
Many parents reported feeling like they are troublesome and a burden to the school. Others reported being rejected from schools because of their child’s severe allergies.
Many parents of children with allergies reported bullying of their children at school, as well as children being excluded from activities or food-based rewards or special events.
In terms of education and training for schools the Committee was impressed with the evidence received from the NSW Anaphylaxis Education Program (NSWAEP). This program:
… is unique in both NSW and Australia and was established in 2004 to improve and support state wide anaphylaxis education in response to the growing need in the community and in response to the death of Hamidur Rahman on a high school camp in NSW in 2002.
In 2017-2018, it has enabled the training of over 120 000 school staff across the Department of Education in schools in NSW. The purpose of the NSWAEP is to disseminate high quality, evidence-based training and to educate individuals and groups in the recognition and management of anaphylaxis with a particular focus on schools.
NSWAEP works closely with ASCIA to develop school programs for anaphylaxis:
The NSWAEP is recognised as the peak training body for recognition and management of anaphylaxis for the school and children’s service sectors across NSW. The specialist allergy nurses who work for the NSWAEP all hold post graduate qualifications in Allergy Nursing and are active members of ASCIA.
First aid training
Several submitters called for the inclusion of allergies and anaphylaxis training in all first aid courses delivered across Australia. Including an allergies module in first aid training would gradually increase the understanding and awareness of allergies and anaphylaxis within the broader community in Australia.
Dr Michelle Warton suggested that like training for defibrillators, adrenaline auto-injectors could also be included in first aid training.
Asthma Australia noted that there was a need to incorporate anaphylaxis first aid training into various settings.
The food service industry workforce has a high turnover of staff that receives little to no training in some cases. Several witnesses made suggestions on possible improvements to systems and training of staff in the food service sector.
The NAS commented that allergic reactions to food purchased from the food service sector remains an issue for people with food allergy. Severe allergic reactions, including fatalities, continue to occur.
The NAS suggested prompt and standardised investigations should be carried out in response to reported food allergy reactions in food service:
Prompt environmental health officer investigation of food service premises using standardised protocols in response to a reported food allergic reaction in food service. Where deaths have occurred, the investigation is carried out by the environmental health officer alongside police.
Mr Newling of Maurice Blackburn Lawyers, commented on the lack of education and training available to staff working in the hospitality industry. He stated:
Where the system seems to fall down seems to be the line of communication between kitchen staff and wait staff. We're concerned that education and training on the double-checking mechanisms that would make it impossible for the wrong plate to be served to the wrong person may be missing. This is just as relevant in restaurants as it is in hospitals, childcare facilities, aged-care homes…
Maurice Blackburn Lawyers suggested that:
…all food service providers must have a system or policy in place to ensure that the right person gets the right meal. There should be a requirement that the existence of such a system or policy is compulsory and therefore should be reinforced by regular inspections and audits; that there are documented consequences for breaching that requirement; and that the curriculum of relevant certificate courses reflects such workplace systems or policies that must be in place and adhered to.
Many people with severe allergies reported not eating out or doing so rarely due to safety concerns. Some of these people reported being turned away from restaurants or being told to eat outside when they attempted to bring their own food from home for a child with severe allergies.
Inquiry participants reported that in general food servers and kitchen staff had little training or understanding of allergies.
Despite these issues, the inquiry did receive some reports of restaurants expending extra effort to ensure the safety of patrons with allergies.
Numerous inquiry participants highlighted their frustration with speciality food stores such as bakeries or butchers not listing ingredients for their products and employees being unable to advise what allergens were in the food they were selling.
The Committee received evidence from people with allergies and anaphylaxis who had difficulties flying on airline carriers both within Australia and overseas due to their food allergies.
Dr Hew discussed public policy relating to airlines and their policies for food allergy. He informed the Committee that A&AA surveyed 33 airlines to find out what their general policies were with regard to food allergies:
Of 33 Airlines, 40 per cent did not have information available on their website and 40 per cent had no availability of information by telephone contact. If you put that together, 20 per cent had no information available by either telephone contact or by website at that time.
Only one of 33 airlines was willing to say that they had an adrenaline supply in the emergency boxes on every flight. That means 32 out of 33 airlines either did not or were not willing to commit to that. We would suggest that this is really important.
Dr Hew advocated for airlines to carry adrenaline auto-injectors as he said it is possible that some passengers may develop anaphylaxis for the first time in the air:
Passengers are, in general, responsible for their own medical management but if you forget to bring the adrenaline injectors, or the adrenaline injector is insufficient to treat the anaphylaxis event, or individuals may develop anaphylaxis for the first time in the air. It is possible to die from anaphylaxis in less time than it takes to land an airplane.
One submitter commented that ‘some international airlines offer ‘nut exclusion zones’ which are safe for families with kids with allergies to sit. In addition, some airports in international destinations have adrenaline auto-injectors on display on walls next to defibrillators.
Another submitter told the Committee that she had difficulties taking her own allergen free food on an international flight:
On both of my experiences in travelling overseas, I have had immense trouble with security letting ice packs onto the plane so that my food can remain cold. As I cannot eat any of the airline provided meals because of allergy, I must take my own food for the duration of the flight. When going through security, officials are extremely persistent that ice is only allowed onto the plane for individuals traveling with baby formula/breast milk and medication. My medical needs that therefore require me to take my own food are apparently not satisfactory despite the fact that I provide up to date doctors’ letters explaining my situation. This was sustained by multiple levels of supervisors.
On the most recent trip (December 2018/January 2019) the only reason ice packs for my food were allowed onto the plane was because my mum had, at the last minute decided to throw in some probiotics. The probiotics were considered ‘medication’ and so ice packs were allowed to keep the bottle cold. These experiences have caused me much anxiety and distress in a situation (overseas travel) that is already uncomfortable and anxiety provoking for many. I do not think that border security protocol is inclusive of those who have allergy.
The Committee recognises that hospitals fall under the direction of states and territories. However the Committee received evidence about the lack of assistance when patients with severe food allergies were admitted to hospital throughout Australia.
There were many reports of very poor food service in hospitals for people with allergies. Many people reported being served food with allergens in it despite informing the hospital before admission of food allergies.
Others reported hospitals being unable to provide them with allergen free food, or being offered incomplete meals such as a banana for an adult man’s dinner.
Many parents of children with food allergies stated that after several days of being served food with allergens in it, they started bringing pre-made food into the hospital for their child to eat. This was an added stress to an already stressful time.
Mr Simon Tate and Ms Gabrielle Catan’s son Louis died in hospital in 2015. He was admitted to hospital for an asthma attack. During Louis’ time in hospital, his parents commented on the lack of food and safety policies within the hospital. Being fed food in hospital which contained allergens led to Lewis’ death:
Louis died on the 23rd of October 2015. Louis was admitted to Frankston Hospital, Victoria, for an asthma attack. On admission the hospital were notified of his food allergies and the fact that he carried an EpiPen. Louis was served a hospital breakfast that resulted in anaphylaxis and died due to the severity of the anaphylaxis and a subsequent reaction to general anaesthetics.
Our experience has been that there are no consistent food safety policies and procedures in hospitals across Australia in respect to food allergens. Hospitals seem to develop their own protocols, with different interpretation of the Food Safety Act and industry practice.
Mr Tate and Ms Catan recommended that:
…there should be a National Safety and Quality Health Service (NSQHS) standard set by the Australian Commission on Safety and Quality in Health Care in respect to food safety for patients with food allergies. Food safety is currently not seen as a clinical matter in hospital and as such there is an apparent lack of ownership and accountability across the healthcare sector and various government departments.
The NSWEAP commented on hospital incident reporting showing evidence of how easily children can be fed foods they are allergic to while they are in hospital. It found that screening and documentation of food allergies was inconsistent within the hospital setting, with staff reporting that allergy documentation tools are confusing and misused.
Confusion in relation to access and use of adrenaline auto-injectors (EpiPen) is another concern. NSWAEP pointed out that ‘EpiPens are often not brought to hospital by families, however when they are, hospital staff have no clear guidelines about their roles and responsibilities and the prescribing of EpiPens on inpatient medical charts.’
Asthma Australia advised the Committee that its consumer feedback included instances where patients were not permitted to take their EpiPen with them during hospital admission, highlighting the need for greater education for consumers and health practitioners in a range of settings.
The NAS has developed a resource for food allergen management in hospitals. Developed in conjunction with Queensland Health, this resource includes best practice guidelines, policy and audit tool templates, and an ingredient substitution tool. The guide also includes a menu assessment tool which was developed with the Dietitians Association of Australia. It is freely available for use on the NAS website.
Food labelling was an issue that received significant attention throughout the inquiry. The Committee was moved by some of the accounts from individuals and families during the inquiry, about how difficult daily routines become when a person has a food allergy, let alone multiple food allergies. The Committee appreciates that our society places a great deal of importance on food sharing for socialising and celebrating many occasions. Therefore the Committee understood the difficulties and confusion people with allergies faced when scrutinising food product labels in supermarkets and food outlets.
The Committee believes that food labelling requires urgent attention in the areas of Plain English Allergen Labelling (PEAL) and Precautionary Allergen Labelling (PAL). Food Standards Australia New Zealand (FSANZ) should work to implement changes to PEAL before September 2020.
The Committee recommends that the Allergen Bureau continues to work closely with the food industry to consistently use the VITAL program for relevant food products and to develop a label to demonstrate that a product has been assessed.
It was evident that there was an urgent need to educate and upskill many health professionals in order to obtain optimal management of allergic disease in Australia. In addition to the medical profession, the Committee recognised there was a great need to educate the general community and other important industries such as food service, schools, hospitals and airline industries in allergies and anaphylaxis.
The inclusion of an allergies and anaphylaxis module in first aid training is a practical solution to improve knowledge and understanding across the community. The Committee supports the need for a national standardised first aid course that includes allergy and anaphylaxis training.
My Health Record will greatly assist the health care sector to understand the high prevalence rates of allergies. The Committee supports all policy measures that increase the confidence in and uptake of the use of the electronic My Health Record. The Committee notes the importance of individuals keeping their My Health Record up to date. Increasing the uptake of MHR will assist all medical specialists and pharmacists to understand and treat drug allergy and food allergies with more consistency.
The food service industry requires education and training in allergy and anaphylaxis management. Allergy training should be incorporated into training modules within the vocational education training sector. The Committee recognises the food service industry has a fluid workforce with people coming in and out of the casual workforce regularly. However, the Committee believes that those undertaking training in hospitality and food service should receive at least some education and training on food allergies and anaphylaxis.
Environmental health officers that attend investigations for allergen contamination in the food service industry should be trained in allergy and anaphylaxis education, in order for them to have a better understanding of sensitivities and contamination risks for people with allergies. The Committee believes that an increased awareness and understanding of allergies throughout the food sector industry and the Australian community will be beneficial for everyone living with allergies and anaphylaxis.
Hospitals are an issue for all states and territories, however the Committee urges all hospitals to reconsider funding arrangements for allergy and immunology specialist placements, including allergy nurses and specialist doctor placements, in order to alleviate long waiting lists in public hospitals. The Committee also encourages hospitals to consider implementation of the resource for food allergen management in hospitals developed by the National Allergy Strategy.
The Committee encourages all airlines to improve the safety of passengers with allergies and in particular, those passengers who are living with anaphylaxis. Australian airlines should give consideration as to how it can provide food to passengers with allergies or have a policy that allows for passengers to carry adequate food for themselves on international flights.
The Committee believes all seats of travellers who have emergency care plans for anaphylaxis should be wiped down before boarding; cabin crew should receive first aid training that includes anaphylaxis training, recognising symptoms of anaphylaxis and an understanding of how to administer an adrenaline auto-injector; and all airlines be required to carry at least two adrenaline auto-injectors in first aid kits on domestic and international flights entering and departing Australia.
The Committee recommends that the Australian Government review all work, health and safety standards within vocational education training to ensure all food service and food preparation training modules include training on allergies and anaphylaxis, including the prevention of food cross contact.
The Committee recommends that the Allergen Bureau in collaboration with Food Standards Australia New Zealand (FSANZ), work with the food industry to encourage the consistent use of the VITAL food allergen risk assessment program, including the introduction of a VITAL ‘V’ tick on packaging to inform consumers that a product has been through this process.
The Committee recommends that the Australian Government work with state and territories to mandate allergen regulations for all hospitals, to ensure that allergen free meals are made available to all patients.
The Committee recommends that Food Standards Australia New Zealand (FSANZ) expedites the finalisation of the Plain English Allergy Labelling (PEAL) process before September 2020 and informs the Committee once the process has been finalised.
The Committee recommends that Food Standards Australia New Zealand (FSANZ) prioritises work in relation to reformulation labels on products. Any product that has changed its ingredients should have either new packaging alerting consumers to the reformulation, or should have a sticker placed on the front stating clearly that new ingredients have been added.
The Committee recommends that all staff at Australian primary and secondary schools receive nationally consistent education and training for recognising and responding to anaphylaxis.
The Committee recommends that the Department of Health work with the Australasian Society of Clinical Immunology and Allergy (ASCIA) and all states and territories to ensure that treatment for anaphylaxis be incorporated into a nationally standardised first aid training course, and if necessary to provide additional funding to first aid training providers to facilitate this.
The Committee recommends that the Australian Government work with the Australasian Society of Clinical Immunology and Allergy (ASCIA) and state and territories to include information about allergies and anaphylaxis education and training into undergraduate teacher training degrees, learning support assistant training and childcare worker vocational education training.
The Committee recommends that the Australian Government requires that all airlines in and out of Australia undertake the following to assist with customers requiring anaphylaxis care:
seats of travellers who have emergency care plans for anaphylaxis should be wiped down before boarding;
cabin crew should receive first aid training that includes anaphylaxis training, recognising symptoms of anaphylaxis and an understanding of how to administer an adrenaline auto-injector; and
require all first aid kits on domestic and international flights entering and departing Australia to carry at least two adrenaline auto-injectors.