The Australian anti-Vaccination Network (AVN) in Australia has not been having a good time of late.

First, they were smacked down by the Health Care Complaints Commission. Following a 12 month investigation into the information provided on the AVN’s website, the HCCC issued a public warning stating the AVN “pose(s) a risk to public health and safety”.

The AVN was then investigated by the charity watchdog in New South Wales, the OLGR (yes you are not alone in thinking “why the hell are they a charity?”) which found that the AVN had “…breached charitable fundraising laws and potentially misled the public”. This was largely as a result of their collecting funds for one purpose and then spending the money elsewhere -  something you’re not allowed to do as a charity.

For example, in 2008 the AVN collected $11,810 for a “Fighting Fund”, an appeal set-up to raise money to support a family allegedly on the run from a court order to immunize a child. But the OLGR reported none of the funds raised were spent on this cause.

In addition, in March 2009 the AVN was seeking funds to run a Generation Rescue autism ad in the Australian press and raised $11,910 for the cause. The ad was never run – perhaps because they were gazumped by the Australian Skeptics and were subsequently knocked back by a parents’ publication – and likewise the money was spent elsewhere.

For many years the AVN was asking for funds to place its literature into Bounty Bags – the information packs for new mums – and to have vaccines independently tested for toxins and heavy metals. The money was collected, but the makers of Bounty Bags claimed they never had an agreement with the AVN. And the vaccine testing? Well, that never went ahead either.

In an e-newsletter, Meryl Dorey described the OLGR’s initial findings as;

“…from the very minor such as the fact that our collection box was the wrong size and didn’t have a lock and our receipt books were not numbered or kept in an assets register….”

Umm, methinks you have to do much more than have the wrong size cash box to lose your charity license.

But even more incredible is that the AVN operated for approximately 2 years without a valid charity license. Of this breach, Dorey explained:

“For 1 year, we were unable to find an auditor …. We finally found a firm who performed our audit but … since we were paying them a discounted rate, we were not really in a position to rush them along.”

The end result was the AVN’s authority to fundraise was revoked on October 20, 2010 meaning it can no longer conduct public fundraising appeals. Rather it can only ask existing members (of which it claims to have 2500) for money. This outcome is a savage blow for the AVN financially.

Indeed, even before its ability to publicly fundraise was revoked, auditors examining the financial report for the year ending December 31, 2009 stated “there is an inherent uncertainty whether the association will be able to continue as a going concern, without the ability to continue to generate external funding from donations and sponsorships.”

This on the back of the financial statement for December 31, 2008 where the AVN posted a loss of A$58,696.65. In fact, the AVN have been haemorrhaging money in the last few years. Just 12 months earlier (year ending December 2007) they posted a profit of A$88,007.97, meaning in the space of 2 years, they lost A$146,704.62.

As is its right, the AVN has appealed the loss of their charity license, and a hearing was set for Feb 14th 2011, but this has been postponed so the AVN can “re-frame their case” (whatever that means). Although its media spokesperson and sometimes president Meryl Dorey claims the audit conducted by the OLGR “…found no evidence of fraud in the breaches they discovered in our operations – (just) breaches of a purely administrational nature” the case has been referred higher up the bureaucratic chain to the Department of Justice (DoJ) and the Attorney General’s Department and to the Crown Solicitor. This is because the AVN is now being investigated for breaches of the Charitable Fundraising Act and if found guilty, these incur fines totaling $25,000 and 12 months jail. The findings of these departments are expected to be handed down any day.

So it appears that the “wrong size cash box” or “breaches of a purely administrational nature” may amount to much more than just loss of its charity license. Referral to the DoJ and Crown Solicitor are serious matters indeed.

And it seems the stress is beginning to show on Meryl Dorey. Let’s go back to January, when a family court matter in NSW was successful in getting the child of divorced parents vaccinated – Mom didn’t want the child vaccinated, but Dad did.

According to an article in the Sun Herald newspaper, the father said that if the girl remained unvaccinated, she would be forced to withdraw from school during outbreaks of some diseases, and that she would also be unable to spend time with any new babies he had, given she was not immunized against whooping cough.

The mother produced opposing evidence that the vaccinations were unnecessary, but was criticized in the judgment for submitting evidence from an “immunization skeptic”, who made what the magistrate described as “outlandish statements unsupported by any empirical evidence”.

Meryl Dorey naturally wasn’t happy about this (it is unknown if she was the “immunization skeptic”) and made it clear in a most distasteful post on the AVN Facebook page, where she said this after a link to the story:

“Court orders rape of a child. Think this is an exaggeration? Think again. This is assault without consent and with full penetration too.”

Rape of a child is akin to vaccination? Wow. I don’t think anyone who has been subject to this type of sexual assault would agree with you Meryl. And as the post was discussed, it turned out that indeed, a few people did not agree with Meryl’s assessment of the situation.

Another administrator of the AVN page, “SB” said:

“I disagree with the rape analogy, but the forcible administration of a vaccine? Vaccines are not compulsory – yet.”

And then another:

“I disagree with the rape analogy too.”

Dorey responded further down the thread justifying her use of the term rape:

“Guys, I apologize if anyone was offended with the rape analogy. I take the issue of rape VERY seriously as two very close family members were raped…”

She then made a non-apology further on, where she redefined the meaning of the term rape:

“I know that the word does tend to mainly have sexual connotations nowadays, but historically, rape has meant so much more. And as I said, rape is not a crime of sex – it is a crime of violence, control and anger/hatred.

“It is an act of violence that demonstrates power over someone … who cannot defend themselves and to my mind – forcing a child to be vaccinated against the informed consent of his or her parent is exactly that – an act of violence by someone who is more powerful against someone who is less powerful.”

Not according to my dictionary.

From Dictionary dot com:

– noun?; 1. the unlawful compelling of a woman through physical force or duress to have sexual intercourse;? 2. any act of sexual intercourse that is forced upon a person; ?3. statutory rape: ?4. an act of plunder, violent seizure, or abuse; despoliation; violation: the rape of the countryside; 5. Archaic: the act of seizing and carrying off by force.

The Apple OSX dictionary defines it as:

Noun: the crime, committed by a man, of forcing another person to have sexual intercourse with him without their consent and against their will, esp. by the threat or use of violence against them; figurative – the wanton destruction or spoiling of a place or area : the rape of the Russian countryside.

Violence may be involved in sexual assault, but rape is not so without sexual assault. And if she meant an act of violence, “wanton destruction” or the archaic definition, then why did she include the phrase “with full penetration”?

So here comes Meryl’s non-apology:

“To anyone who was insulted or hurt by my comparing the forced vaccination of a child against the custodial parent’s wishes with rape, I do apologise wholeheartedly and without reservation. I looked up the definition of rape prior to posting … that comparison and in the dictionary sense of the word, it is accurate…”

See above.

Sorry Meryl, but redefining the meaning of the word rape and saying it’s okay because you know two people who were raped does not make it acceptable.

The discussion went on for 3 days and reached 57 comments before the topic dropped off the front page and people, including Meryl probably, thought it would all go away. But even one of her admins was astute enough to notice that everything on the internet stays forever and “someone somewhere will be keeping a scrapbook”.

Well, she was right. The rape comments fell into the hands of Tracey Spicer, the same journalist who hung up on Meryl Dorey on live radio just a few weeks earlier when she was discussing British Medical Journal’s fraud findings into Andrew Wakefield’s Lancet paper.

On air, Tracey discussed Dorey’s comments with Hettie Johnstone, an Australian child abuse campaigner who runs a child protection organisation called Bravehearts. Naturally, Hettie was appalled that someone would compare an injection for the purposes of protection against communicable disease with rape.

As expected, Dorey was livid and asked her followers to bombard the radio station with disapproving emails. She also asserted that she had apologized (well, kinda) and that it was a heat-of-the-moment comment. Me, well I’m skeptical this is the case. According to her defense above, she bothered to look up the definition of rape in the dictionary before she posted it:

“I looked up the definition of rape prior to posting …that comparison and in the dictionary sense of the word, it is accurate…”

In addition, she posted similar comments to her mailing list:

“This is immoral. It should be illegal. This is medical rape. Since it is illegal to force yourself on someone for the sake of having sex, why is it not illegal for society to force itself on an innocent child whose informed parent has chosen not to subject them to a potentially dangerous medical procedure?”

Posting her rape comments in two places and looking up a definition in the dictionary prior to doing so constitutes more than a ‘heat-of-the-moment’ outburst to me.

In directing her supporters to spam the radio station with emails, Dorey attempted to project the publicity away from herself and towards the “rights of pro-choice parents”. But this issue was not about parents who choose not to vaccinate. It was about the media spokesperson (sometimes president) for “Australia’s Vaccine Watchdog” comparing vaccination to rape, which is not only offensive and distasteful, but completely inappropriate.

Even one of the commenters on Facebook pointed this out:

“On another note had you not made such a crude comparison which upset so many people this attention may not have happened. You made us all look bad on this one.”

Eighteen months ago it was a different landscape in the Australian media for the AVN. Meryl Dorey was the go-to person for comment whenever there was a story on vaccination. She would sit alongside professors of immunology and epidemiology and Gish Gallop her way through debates. She was all over morning television – of which the target audience is stay-at-home mums – spouting nonsense about vaccine safety and efficacy. She was given a forum to spread her fear and misinformation far and wide.

Not any more. The worm has turned and the false balance is shifting. She is finally being treated in a manner which she deserves – relegated to the pages of natural health media and websites rife with conspiracy theories and quackery. But importantly, she is finally being held accountable for her nonsense, not just by skeptics but by the mainstream media and government departments too. And with opinions like “vaccination = rape” , it’s about time.

Rachael A. Dunlop BSc (Hons), PhD., is a skeptic and blogger, as well as the winner of Twitter Shorty Award for Health 2010

Rachael came to science after a career in graphic design and advertising because she was “bored and needed and challenge”. She got what she wanted. Her research focuses on ageing disorders including heart and Parkinson’s disease. She is particularly interested in how cells respond to damaged proteins especially those which undergo suicide – a process known as apoptosis. Her current project examines the role of blue green algae in motor neurone disease.

Rachael is a reporter on the Skeptic Zone Podcast and a Vice President of the NSW committee of Australian Skeptics. She is also part of the Mystery Investigators show for schools and co-organises the Sydney Skeptics meet-up group, and contributes to The Sceptics’ Book of Pooh-Pooh blog. Rachael has a passion for combining her knowledge of art and science through scientific communication.

Following my recent critique here of the book Disconnect by Devra Davis, about the purported dangers of cell phones to health, David Gorski asked me to comment on a recently published “review article” on the same subject. The article is entitled “Risk of Brain Tumors from Wireless Phone Use” by Dubey et al [1] published in the J. Comput Assist Tomography. At the outset, the same question occurred to both of us: what is a “review article” about cell phones and brain tumors doing in a highly technical journal dedicated to CT scans and CT imaging? While we are both still guessing about the answer to this question, we agreed that the article itself is a hodge-podge of irrational analysis.

As you might surmise, Dubey and his Indian co-authors come to the conclusion that “that the current standard of exposure to microwave during mobile phone use is not safe for long-term exposure and needs to be revised.” But within the conclusion there is also the following: “There is no credible evidence from the Environmental Health and Safety Office (I presume in India) about the cause of cancer or brain tumors with the use of cell phones. It is illogical to believe that evidence of unusual brain tumors is only because of hundred’s of millions of people using cell phones worldwide.” What?! These are opposite and contradictory statements. The main body of the article includes a lot more instances of such inconsistency.

Dubious Sources, References, & Studies

Another highly dubious feature of this review article is the nature of its sources. Many of its references are merely news reports, not scientific articles and some even come from pseudo-scientific web sites. For example, figure 1 purports to illustrate cell phone radiation penetrating a 5 year old, 10 year old, and adult head. It purports to show that cell phone radiation penetrates a child’s head much more deeply than an adult’s. The source given for this image is http://www.environmentalhealthtrust.org — the web site of none other than Devra Davis! The main feature on this web site is the promotion of her book Disconnect!

This particular image is one that is frequently used by alarmists. The original source is a 1996 paper by Gandhi et al [2]. This paper has long been discredited and the image is simply wrong. Gandhi himself published an update in another paper in 2002 [3] with quite different results. Numerous papers have been published examining the issue of cell phone penetration of the head. The consensus is that RF absorption in children’s heads is not greater than adults and is well within exposure limits [4].

One particularly dubious reference is to a book by the notorious industry gadfly George Carlo that even Devra Davis treats with caution. A number of the scientific papers that are listed are of dubious quality and/or have failed to be reproduced in follow up studies. For example one of the sections is entitled “Male fertility damaged by radiation.” Orac has written a critique on this hypothesis in which he takes apart one of the studies cited by Dubey et al. Male fertility is also one of the principle subjects in the book Disconnect, which I rebutted in my review on SBM. To summarize the three papers cited by Dubey et al. are of poor quality and/or have failed attempts at replication. The authors do not list or comment on the negative studies that contradict the one’s they listed.

Other statements and references that have been contradicted by follow up studies include claims that:

• “The RF emissions from cell phones have been shown to damage genetic material in blood cells”
• “Long-term cell phone use can increase the likelihood of being hospitalized for migraines and vertigo by 10% to 20%”
• “Cell phone radiation damages DNA, an undisputed cause of cancer”
• “Cell phone radiation has been shown to cause the blood-brain barrier to leak”

The fact that each one of these “findings” has failed replication attempts in rigorous follow up studies is not even mentioned.

In the conclusion, Dubey et al. makes the bold claim that: “Moreover it was repeatedly confirmed that the radiation from base stations is harmful to health. The existing ICNIRP and FCC exposure limits are based on a false premise that only thermal effects cause harm.” Here they are referring to cellular telephone base stations. But no references are provided to support either of these assertions.

Industry Funding

Figure 2 in the article is a chart that purports to show industry bias in brain tumor research. This establishes the principle theme of this article: the claim that most of the studies on brain cancer and cell phones with negative results have been funded by industry. This is not a scientific argument, it is a conspiracy theory. Other posts on SBM have observed that conspiracy theories are a favorite tactic of purveyors of pseudo-science. This “industry funding” theory is also the main thesis of the book Disconnect and alarmist cell phone web sites. The source given for this “industry funding bias” chart is the web site http://www.psrast.org/mobileng/mobilstarteng.htm. The organization behind this web site is a group called:  “Physicians and Scientists for Responsible Application of Science and Technology (PSRAST).” This web page is full of references to the usual unscientific alarmist material found throughout the Internet.

Dubey et al. do not mention the generally accepted alternative explanation for the dichotomy in positive vs. negative studies. First there is the issue of publication bias [5]. If a researcher makes an initial positive finding, he is more likely to rush his results to publication. An initial negative finding is less likely to ever be published. Rigorous studies with all necessary controls and a large number of trials are more expensive to conduct. It is important to note that virtually all such follow-up replication studies have been negative.

An extremely important fact that is not discussed by Dubey et al. is that expert reviews by virtually all of the industrialized world’s public health organizations have come to the same conclusion as the World Health Organization “that current evidence does not confirm the existence of any health consequences from exposure to low level electromagnetic fields.” One presumes that they have also been either co-opted or duped by this industry funded conspiracy.

Hardell vs. Interphone

By far the largest and most important case control study on the possible link between cell phones and brain cancer was the Interphone study [6]. The Interphone study was an international collaboration involving 13 countries which was coordinated by the International Agency for Research on Cancer (IRAC) which is part of the WHO. The conclusion of Interphone was “Overall, no increase in risk of glioma or meningioma was observed with use of mobile phones. There were suggestions of an increased risk of glioma at the highest exposure levels, but biases and error prevent a causal interpretation. The possible effects of long-term heavy use of mobile phones require further investigation.”

Dubey et al. characterize the important Interphone study as follows: “This nonblinded, interview-based, substantially wireless industry-funded case-control study….” They are clearly discounting Interphone with the “industry funding” conspiracy theory. They compare the Interphone studies with another set of case control studies conducted by the Swedish researcher Lennart Hardell.  “The 2 sets are the industry-funded Interphone studies and the independently funded Swedish studies reported by Hardell team.” Dubey et al. make a number of additional dubious criticisms of Interphone. To support these criticisms they list a number of letters to a journal including a couple by Hardell. Much of this criticism boils down to splitting hairs over who did a better job of controlling for “recall bias.”

Those of you who are regular readers of SBM may have seen a post by David Gorski commenting on another cell phone cancer review article in which the work of Hardell was given prominence. Gorski had this to say about Hardell: “Whenever one group of researchers keeps finding a result that no other group seems able to replicate or that otherwise disagrees with what everyone else is finding, that’s a huge red flag for me. Remove those studies, and even the wisp of a hint of a shadow of the association between cell phone use and cancer found in this study disappears. I’d have a lot more confidence in this seeming association in “high quality” studies if the association didn’t depend upon a single researcher and if this researcher was not also known for being an expert witness in lawsuits against mobile phone companies.” It would appear the Hardell himself has a conflict of interest.

A pair of review articles on cell phone brain cancer studies in the journal Epidemiology [7, 8] had this to say about Hardell: “One notable feature of the literature to date is that authorship by Lennart Hardell is associated with finding an adverse effect of mobile telephone use for several different endpoints. The discrepancy between the findings of Hardell and those of other scientists was striking enough that Ahlbom et al presented some of their summary findings in 2 forms, including and excluding the studies by Hardell and colleagues.”

Case control studies such as those conducted by Hardell and Interphone involve recruiting subjects who have been diagnosed with brain cancer. The subjects respond to a questionnaire in which they are asked to recall – purely from memory – how much they had used their cell phones over the years. The cancer patients are matched with a healthy control group who respond to the same questionnaire. If the study shows that people who have brain cancer used cell phones more that the controls, the conclusion is that cell phone use increases the risk of brain cancer.

But case control studies such as this suffer from a number of limitations, the most serious being “recall bias.” Brain cancer patients are certainly aware of the theory that cell phone use may lead to brain cancer. This theory has been in the news for years. Such patients are likely to over report past cell phone use when completing a questionnaire. Memory is notoriously unreliable, and it becomes more so over time. I don’t know about you, but I could only make a wild guess about how much I used my cell phone 10 years ago. This simple fact alone makes it hard to interpret conflicting studies.

Dubey et al. seem to acknowledge the issue of recall bias, but their treatment of the issue is inconsistent and contradictory. The authors even discount one of Hardell’s studies with the following: “this finding is probably explained by recall bias, with patients with glioma systematically overreporting use on the same side as their tumor and consequently underreporting use on the opposite side.” Yet despite this admission, Dubey et al. accept all of the Hardell studies and include them in their meta-analysis. They give greater credence to Hardell than Interphone and conclude: “The meta-analysis shows that long-term cell phone use can approximately double the risk of developing a glioma or an AN (acoustic neuroma) in the more exposed brain hemisphere.” This opposite to the conclusion of mainstream scientists as reflected in papers such as Ahlbom et al. [8].

What about incidence rates?

Perhaps the simplest and most compelling argument against any possible cell phone brain cancer association is the fact that brain cancer incidence rates have remained unchanged since the introduction of cell phones. Dubey et al. dismiss this evidence with a one sentence section entitled: “Outdated Central Brain Tumor Registry of the United States Tumor Data” and the statement that “the most recent data are already at least 4 years outdated.” The authors reference only a couple of older studies, and ignore the most recent ones from Europe, the US, and the UK that show no increase in brain cancer incidence up to 2003, 2006, and 2007 respectively [9, 10 11]. Furthermore, the data in the US & UK studies are more recent than any of Hardell’s studies!

Conclusion

The Dubey et al. review article is sprinkled with statements such as:

• “Most studies have not found any association between cell phone use and the development of head tumors”
• “There is generally a lack of convincing and consistent evidence of any effect of exposure to RF field on risk of cancer”
• “Although some positive findings have been reported, so far the totality of epidemiological evidence (meningioma) does not demonstrate an increase in risk of meningiomas related to mobile phone use”
• “There was no association between the use of cellular or cordless phones and salivary gland tumors found, although few studies reported for long-term heavy use”

As I wrote at the beginning of this review: these statements are opposite and contradictory to the overall conclusion of Dubrey et al. One supposes that the authors are trying to give the appearance of “balance.” However they reconcile these contradictory findings not with a scientific weight of evidence approach, but with their “industry funding” conspiracy theory. This brings me to add an additional question on top of our original query about what an article about cell phones is doing in a specialized journal on CT imaging. How did an article that promotes Internet conspiracy theories with a hodge-podge of irrational analysis even get published at all?

About the Author

Lorne Trottier is a co-founder of Matrox Ltd. and holds B. Eng., M. Eng., and Doctorate (honoris causa) degrees from McGill University. He has had a lifelong passion for science and technology and believes in the importance of combating pseudoscience. He is President of the Board of the Montreal Science Center Foundation, and is also a board member of a number of science outreach organizations including the NCSE, CFI Canada, and The Planetary Society. Trottier sponsors the annual Trottier Symposium at McGill University that deals with a variety of science topics of interest to the public, such as Confronting Pseudoscience. Trottier also maintains a web site on the subject of EMF and Health.

References

1. Risk of Brain Tumors from Wireless Phone Use J Comput Assist Tomogr Vol 4 No 6,Nov/Dec 10. doi: 10.1097/RCT.0b013e3181ed9b54
2. Gandhi O P, Lazzi G and Furse CM. Electromagnetic absorption in the human head and neck for mobile telephones at 835 and 1900 MHz IEEE Trans. Microw. Theory Tech. 44:1884–97, 1996. doi: 10.1109/22.539947
3. Gandhi O and Kang G. Some present problems and a proposed experimental phantom for SAR compliance testing for cellular telephones at 835 and 1900 MHz Phys. Med. Biol. 47:1501–18, 2002. doi: 10.1088/0031-9155/47/9/306
4. Beard et al. Comparisons of Computed Mobile Phone Induced SAR in the SAM Phantom to That in Anatomically Correct Models of the Human Head, IEEE Trans. Electro Comp, Vol. 48, No. 2, May 2006. doi: 10.1109/TEMC.2006.873870
5. Vijayalaxmi et al. Genetic Damage in Mammalian Somatic Cells Exposed to Radiofrequency Radiation: A Meta-analysis of Data from 63 Publications Radiation Research 169, 561–574, 2008 doi: 10.1667/RR0987.1
6. Cardis et al. Brain tumour risk in relation to mobile telephone use: results of the INTERPHONE international case-control study Int’l Journal of Epidemiology 2010; 1–20. doi: 10.1093/ije/dyq079
7. Rothman. Health Effects of Mobile Phones Epidemiology Vol 20 No 5, Sept 2009. doi: 10.1097/EDE.0b013e3181aff1f7
8. Ahlbom et al. Epidemiologic Evidence on Mobile Phones and Tumor Risk Epidemiology Vol 20 No 5, Sept 2009. doi: 10.1097/EDE.0b013e3181b0927d
9. Inskip et al. Brain cancer incidence trends in relation to cellular telephone use in the United States, Neuro Oncol 12(11): 1147-1151 , 2010. doi: 10.1093/neuonc/noq077
10. Deltour et al. Time Trends in Brain Tumor Incidence Rates in Denmark, Finland, Norway, and Sweden, 1974–2003, J Natl Cancer Inst,101(24):1721–4, . 2009 Dec 16. doi: 10.1093/jnci/djp415
11. Vocht et al. Time Trends (1998–2007) in Brain Cancer Incidence Rates in Relation to Mobile Phone Use in England Article first published in Bioelectromagnetics online 28 Jan 2011. doi: 10.1002/bem.20648

As a pharmacist, when I dispense medication, it’s my responsibility to ensure that the medication is safe and appropriate for the patient. There are numerous checks we go through including verifying the dose, ensuring there are no interactions with other drugs, and verifying the patient has no history of allergy to the product prescribed. Asking about allergies is a mandatory question for every new patient.

Penicillin is one of the oldest antibiotics still in use despite widespread bacterial resistance. Multiple analogs of penicillin have been developed to change its effectiveness, or improve its tolerability. And other classes of antibiotics (e.g., cephalosporins) share some structural features with penicillin. These products are widely used for both routine and serious bacterial infections. Unfortunately, allergies to penicillin are widely reported. Statistically, one in ten of you reading this post will respond that you’re allergic to penicillin. Yet the incidence of anaphylaxis to penicillin is estimated to be only 1 to 5 per 10,000. So why do so many people believe they’re allergic to penicillin? Much of it comes down to how we define “allergy.”

Adverse Events, Reactions, and Allergies

There are a number of confounders when it comes to evaluating allergies. A big one is terminology. While different groups vary in their definitions, the term “adverse drug event” typically means that an undesirable event has occurred, but isn’t causally linked to the consumption of a drug. In contrast, “adverse drug reaction” is usually reserved to where a causal link to the drug has been established, or is fairly certain. Adverse drug reactions can occur under completely normal use of a drug. And they’re not uncommon, as I’ve pointed out before. An allergic reaction to a drug is an adverse drug reaction that is mediated by an immune response. If there is no immune response, it’s not an allergic reaction. So if you take codeine and it makes you drowsy and constipated, that’s not an allergic reaction—that’s an effect of the drug. Erythromycin commonly causes stomach upset, so if you vomit, that’s not an allergy either. So, to sum:

Penicillin Allergies

Within that box of adverse reactions we’re calling “drug allergies” there’s a number of methods of classifying the different immune responses. The most common way is to split events into immunoglobulin E (IgE)–mediated (immediate) reactions, or non–IgE-mediated (delayed) hypersensitivity reactions. The IgE-mediated reactions are the ones we might immediately think of when we hear “penicillin allergy”: flushing, itchy skin, wheezing, vomiting, throat swelling, and even anaphylaxis. These reactions can occur immediately to a few hours after a dose. The non-IgE-mediated reactions are delayed, and can be mild or severe, ranging from serum sickness to the horrific (but fortunately rare) Stevens-Johnson syndrome.

Skin rash (morbilliform eruptions) are non-IgE reactions commonly reported with penicillin therapy, though their relationship to the penicillin itself isn’t clear. Rashes that appears several days after starting therapy (or even after finishing a course of antibiotics) may be due to a poorly-understood relationship between the antibiotic and any concurrent viral infection. These rashes are not itchy. With subsequent exposure to penicillin (or a related drug) the rash can reappear. These types of reactions do not mean that one cannot receive penicillin again, however.

It’s the structure of the penicillin molecule itself that triggers allergic reactions. Both the “parent” drug and any iterations created through metabolism can induce allergic responses. Analogs of penicillin, with different molecular side chains, can trigger selective sensitivity in some. So one could have an allergic reaction to amoxicillin or ampicillin, but be able to tolerate penicillin.

Testing for allergies

Determining if you’re actually allergic to penicillin is important to sort out, as not all reactions mean penicillin cannot be administered again. Skin testing is the standard for testing for IgE-mediated allergies, and needs to be performed under medical supervision, usually by allergy specialists, in settings where access to resuscitation medication is available. Given the unreliability of memory, skin testing is the standard when there’s any doubt all about the type of prior reaction. In cases of the severe non-Ig-E type reactions, there’s no rechallenge attempted, and those patients should never receive penicillins again.

So if you think you’re allergic to penicillin, but are not certain of the type of allergy you have, testing is something worth thinking about. Without it, you’re setting yourself up for a lifetime of risk and consequences of the avoidance of penicillin. Data show that patients considered penicillin-allergic will typically receive more broad-spectrum antibiotics, which may have more side effects, be more expensive, and in some situations, less effective. And given IgE-mediated allergy can wane over time, even significant childhood reactions may not manifest as adult allergies—but only testing can determine this for certain.

Formal evaluations of penicillin allergies support this approach. A recent paper in the Journal of Allergy and Clinical Immunology describes a prospective evaluation of children that presented to an emergency room with a delayed-onset rash from penicillin. Eighty-eight children were enrolled over two years. At the time of enrollment, they were screened for viruses. Each child returned to the hospital two months after their initial visit, where they underwent skin (patch and intradermal) as well as blood evaluations for allergy. They all had an oral challenge with the original antibiotic, too. After evaluation, none had a positive skin test, 11 children (12.5%) had a intradermal reaction, and only six (6.8%) had the rash recur after an oral challenge. Within the group that had a positive oral challenge, two had intradermal-negative, and one was intradermal-positive. Most of the children had tested positive for viral infections, too.

The authors concluded that penicillin allergies are overdiagnosed, and viral infections may be a factor leading to rashes and over-diagnosis. The authors recommended oral challenges, rather than skin, intradermal, or blood tests for all children that develop delayed-onset rashes during treatment with penicillins.

Conclusion

While penicillin allergies can be real, and can be serious, only a small percentage of people that consider themselves allergic actually cannot receive penicillin. Avoiding penicillin can mean using antibiotic alternatives that are less effective, more expensive, and have greater side effects. For this reason, confirming a penicillin allergy with a physician is warranted—before an antibiotic is needed. After all, unless it’s necessary, you don’t want to end up with someone like Mark Crislip standing over your hospital bed, being asked what his second choice of antibiotic is going to be.

Reference

Caubet JC, Kaiser L, Lemaître B, Fellay B, Gervaix A, & Eigenmann PA (2011). The role of penicillin in benign skin rashes in childhood: a prospective study based on drug rechallenge. The Journal of allergy and clinical immunology, 127 (1), 218-22 PMID: 21035175