Bee and Wasp Desensitization

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Bee and wasp allergies can be life threatening to pets. Animals who have had an anaphylactic reaction to a sting are at risk for worsening reactions with each future sting. In this episode, Dr. Trenton Ewing joins Dr. Lancellotti to discuss a life-saving therapy in which pets are desensitized to bee and wasp allergies. 85% of animals who have gone through this therapy will have a reduction in the severity of their reactions if they are stung in the future. This therapy saves lives. Have a listen and tell your friends.

Welcome, Dr. Trenton Ewing

[00:01:05] Dr. Lancellotti: Welcome, everyone, to today’s episode of Your Vet Wants You To Know. Today, we’re going to be talking about bee and wasp desensitization. This is for animals that have had a severe reaction to either a bee sting or a wasp sting, severe enough to require them to go to the hospital for treatment. This is going to be an episode where we talk about how to prevent those severe reactions from happening by desensitizing the animal to that specific type of venom. To help me in today’s discussion, I have a friend and colleague, Dr. Trenton Ewing, who is going to be talking about his research study and looking at all of the desensitization that’s been done over the past couple of decades here in Southern California. I’m very excited for him to share his wealth of knowledge with our listeners today. Welcome, Dr. Ewing. 

[00:01:56] Dr. Ewing: Hi. Good to be here. 

[00:01:58] Dr. Lancellotti: Tell our listeners a little bit about your background, where your education is, and why this particular topic is so important to you. 

[00:02:08] Dr. Ewing: Certainly. I’ve been practicing veterinary medicine since 2016, after graduating from Iowa State University. And I’m currently a veterinary resident in the field of dermatology. I’m just a few days away from completing the final year of my residency, and I’ll be sitting for a board examination later this year- 

[00:02:23] Dr. Lancellotti: That is very, very, very exciting! I just want to tell our listeners how hard a residency is and how much work goes into that. So for Dr. Ewing to be almost done and getting ready to sit his boards, this is a really exciting time for him. 

[00:02:39] Dr. Ewing: You say “exciting.” I say, “It’s a little bit stressful, but we’re getting there.” So I’d been interested in dermatology since, about my third year of vet school. I met Dr. Noxon, who’s well known in the veterinary community and he sells dermatology as a profession quite well, so I was on board pretty much immediately. But my official dermatology journey started with an internship at the University of Illinois in 2017, which I did after my rotating internship. After that, I moved to California, where I began working for the Animal Dermatology Clinic, a group of clinics, in their Pasadena office, where I’ve been for about three years now. Relating to today’s topic, my residency research project, as alluded to earlier, is on the safety and efficacy of venom immunotherapy. We looked at about 18 years of data from across all of our clinics, and this project was actually inspired by a patient of mine. A pet owner had asked me, during a consultation for venom immunotherapy (which we had been practicing for probably about 15 years in veterinary medicine, by that point), “How safe is this therapy? How effective is it going to be?” And I was still fairly new to the therapy at that time. As I mentioned, this was my first patient ever that I was going to start it on. And I promised the owner, even though I didn’t know that information, I was going to get back to them. So, I asked around. I asked my mentors. I even asked down in San Diego- what could they tell me about the therapy? And they said, “In general, it’s safe, but we don’t have any hard numbers for you.” And I said, “That’s fine.” I fired up my computer and started searching for the published literature, and there really was not much- one or two preliminary articles, often written by the very doctors I had just been talking to, which included a handful of patients. So, there wasn’t a concrete answer, but in that, I saw an opportunity and I decided to make my resident project reviewing all of this data and finding the answer to this question. “How often does this therapy work? How safe is it to do?” Ultimately, what started as an offhand question in a consultation with a patient of mine was instrumental to finishing my residency. 

[00:04:35] Dr. Lancellotti: That’s great. So, what happened with the pet whose owner asked you that question?

[00:04:40] Dr. Ewing: Well, they did not want to wait two years to find out the answer to that question, so they did end up pursuing the therapy. After saying, “Well, we’ve been doing it for a while. It seemed to be quite safe,” and they went on to do well. I even got an email down the road, when I was doing some follow-up for the research project, and they’d had a challenge sting and done just fine. So, it all turned out quite well in the end, even though we didn’t have the answers for them at the time.

[00:05:05] Dr. Lancellotti: Excellent. We’re going to be talking about some of the answers that you got from your research project, later on in the episode. I’m looking forward to sharing that information because while you were doing this research project, I was waiting in the wings (very anxiously) for all the data that you were gathering, so that I could see how well these animals did and how safe this was. I always talk on the show about the benefit versus the risk, and your project definitely gave us a lot of data, as far as benefit vs. risk of this therapy. I’m so happy that, not only did you do that project, but that you’re going to come on today and talk about it. So, thank you very much. I appreciate it. 

[00:05:40] Dr. Ewing: You’re very welcome. 

What happens when a pet with allergies gets stung by a bee?

[00:05:41] Dr. Lancellotti: Can you describe what happens in animals who are allergic to bees and wasps when they get stung? 

[00:05:47] Dr. Ewing: A variety of reactions can occur, and the important thing with any hypersensitivity reaction is to remember it occurs on a spectrum of reactions. But of course, our greatest concern is anaphylaxis. And any of these reactions occur following an initial sensitization. A common history with these patients is that they got stung once and nothing happened, but that set into motion the chain of events that would lead to future stings and more and more severe reactions. The vast majority of our patients, when they come to us for this therapy, have had an episode of collapse and hospitalization. Of course, this is quite dramatic and you want to avoid it if you can. This is caused by a variety of chemical messengers that are released, which cause diffuse inflammation and other systemic effects. And in human medicine, they actually have this fairly detailed five-point grading system from local reactions leading up to lethal reactions. And as I said, this becomes concerning for our patients when we see symptoms such as a collapse due to low blood pressure or respiratory failure, or a variety of other issues. Kidney injuries, for example, have been documented in dogs, which can have lasting effects. In humans, there is some concern for delayed reactions, but that really hasn’t been reported in animals. Part of that is likely because we don’t have a lot of hard data on the incidence of occurrence in animals. When we use our information in human medicine, an average of 62 deaths per year in the United States are attributed to bee sting hypersensitivities. When you look at population data, roughly about 3% of US adults are hypersensitive to bee stings. So, if you extrapolate that to dogs, it’s not the most common thing in the world, but it is certainly not a rare event, by any means. 

[00:07:24] Dr. Lancellotti: Yeah. It’s certainly not something that we want to ignore in those patients that are extremely sensitive to bee and wasp venom. Even if it’s a very rare occurrence for those animals, it’s a very severe problem that needs to be addressed.

How can a veterinary dermatologist help pets with bee allergies?

Dr. Lancellotti: You and I are dermatologists. We’re not emergency veterinarians, so I know a lot of people wouldn’t think to seek us out for treatment of pets that have a bee sting allergy. And that’s partly correct. If your dog has been stung, and it’s having a severe reaction at that time, I do recommend going to an emergency practice instead of a dermatology practice. But to help prevent these future trips to the ER, dermatologists are going to be the best bet for these pet owners. Because most allergies in pets affect the skin, dermatologists have advanced training in the treatment of allergies. But in order for us to desensitize, we have to figure out what type of bee or wasp caused the problem for that particular animal. So, can you describe for the listeners what the testing process involves and what they should expect with their pet? 

[00:08:30] Dr. Ewing: Certainly. As you said, the testing is very important because, a lot of times, the specific stinging insect goes unidentified. So, we’re missing a part of the history there. But the process of venom allergy testing is actually very similar to what you and Dr. Levinson had discussed in your immunotherapy episode for environmental allergies. Although, fewer options exist when it comes to assessing venom hypersensitivity, and there’s very little peer-reviewed literature on the subject. The vast majority of the testing we do is the intradermal form of testing, which is based on human practices. A pet is given a mild, readily-reversible sedative medication and a square patch is shaved on their side. Then, we inject small volumes of various purified venoms underneath the surface of the skin and that’s monitored for 5 to 10 minutes. We start with a quite dilute form of the venom, and if there’s no reaction or no hive formation, we gradually increase that in ten-fold increments until a reaction is noted. Or depending on the venom, you reach a concentration above which you would expect a hive to form, regardless, because that’s what’s called the irritant concentration.

[00:09:38] Dr. Lancellotti: So, the irritant concentration is the point at which all animals, regardless of whether or not they actually have an allergy to that particular venom, will develop a hive. 

[00:09:49] Dr. Ewing: Yes. And that actually varies venom to venom. So a lot of your wasps, hornets, etc. have a lower irritant concentration than (for example) your Honeybee venom, which goes to our highest test concentration before we truly consider that a negative result. This testing can be affected by both topical and oral formulations of steroids and anti-histamines, so it is worth discussing specific drug withdrawal times prior to testing. Essentially, it’s identical to what you would consider for environmental allergies. For our listeners who have heard that immunotherapy episode, you may recall there was another way to do allergy testing- serum allergy testing. And those tests do exist for the venom proteins, but there hasn’t really been a whole lot of research done to assess the validity of that testing. There was a recent report that came out just earlier this year (I believe January 2021) from some of our European colleagues, where they’d done both the skin testing and the serum allergy testing. The serum allergy testing had more positive results to some insects that the dog didn’t really have a known exposure to. So, you might argue that there could be some cross-reactivity and perhaps a tendency to over-diagnose. That really does mean we have to assess that a little more closely, before we rely on it in the same way as the intradermal testing. 

Three hives from reactions to venomous insects during skin testing.

How are pets desensitized to bees and wasps?

[00:11:13] Dr. Lancellotti: I know you mentioned the withdrawal times for different medications. I think that is important to reiterate because a lot of these animals, who have been stung by bees or wasps, will continue on medications like Benadryl after they have been discharged from the hospital. So, we want to make sure that they are off all of those medications for enough time, so that when we do this testing, we’re actually going to be able to accurately interpret what concentration it is that the animal has a reaction to, so that we can formulate our immunotherapy appropriately. So once we know what type of bee or wasp that the pet is allergic to, then we have to work on retraining their immune system, so that if the pet does get stung again, they won’t have this severe reaction. And we hope this will help us to avoid a trip to the emergency room. There’s a lot of different specific protocols for how to desensitize a pet to bee and wasp allergies, but can you walk the listeners through this general process and what they should expect with desensitization? 

[00:12:23] Dr. Ewing: Certainly. This is another area where we lag behind human medicine somewhat. There is a variety of protocols, from ‘traditional’ to ‘rush’ to ‘ultra rush,’ mainly focused on decreasing the duration of that induction period. But our patients tend to receive weekly induction injections, and depending on a combination of the manufacturer and preference of the supervising veterinarian, it’s between a 15 to 20 injection course, assuming there are no reactions along the way (which might alter that timeline). If there is a reaction, you tend to drop the dose and slowly increase it again. This process (15 to 20 weekly injections) is termed our induction phase. After that time, the vast majority of patients will transition to monthly maintenance injections. And all of these treatments are given under the supervision of a veterinarian. The patients are observed for multiple hours, to ensure that there’s not a reaction to the venom. The monitoring is not hugely intensive. They’re not hooked up to a lot of machines or monitoring equipment. It mainly comes down to temperature checks, making sure they’re still bright and alert and feeling good, and we try and make it as positive of an experience as we can. And a lot of our long-term pets that we see become kind of like little celebrities, you know? “Oh, today’s the day they’re coming into the clinic.” They get little costumes and little capes and we try and make it a fun time for them. 

[00:13:48] Dr. Lancellotti: Yeah. The animals that come in for bee and wasp desensitization are frequent flyers in the clinic. We see them quite a bit. Oftentimes, the animals get really excited because they’re mostly just ‘loved on’ most of the day, so it’s kind of an easy process for them, once they get used to coming in and being around the staff every week

What are the benefits to desensitizing a pet to bees and wasps?

Dr. Lancellotti: I always like to talk about the benefits and risks of different treatment options on the show. This process is certainly very involved- 15 to 20 weekly injections. The animal has to stay in the hospital for a few hours during each one of those injections, so it requires a commitment from the pet owner. Let’s talk about the benefits and risks associated with desensitizing a pet to bee and wasp allergies, so that the pet owners who are considering this can have more information on whether or not this is something their family should undergo. 

[00:14:45] Dr. Ewing: What we’re really trying to avoid is a progression of that sensitivity. The concern is that an untreated pet may have a more severe reaction with subsequent stings. Ultimately, as we discussed earlier, that can be a potentially lethal reaction, so we’re really trying to avoid that. In our research, we found that no pets that successfully completed this therapy, or even just went through induction, had a more severe reaction. And that was true, whether or not they were actively receiving injections at the time. So some of those pets that had stopped injections may have had a reaction of equal severity, but there’s evidence to say we halted the progression of that. There were no lethal reactions. And that’s the point I would like to underline. After undergoing this therapy, we did not record any lethalities.

[00:15:34] Dr. Lancellotti: That’s great. In these animals that have undergone the therapy, when they get stung again, we’re not at an increased risk of the animal dying from this reaction. 

[00:15:46] Dr. Ewing: Exactly. When we consider the challenge stings, as a whole, 85% of those stings in which patients had received the therapy had a reduced severity of reaction. The important point there is reduced severity is not no reaction. Some pets had no reaction, some just had a little local swelling and they were fine, but none of those pets went on to require hospitalization. The only group that was uniformly protected in this way (a reduced severity of reaction at all challenged stings) was the group that was actively receiving maintenance injections at the time of the sting. So that does suggest that there is a benefit to these ongoing maintenance therapy injections on roughly a monthly basis, for most patients moving forward. That reduced severity of reaction is what I would consider the primary benefit- that medical benefit. But there is a secondary benefit, and I think it actually applies more to our pet owners rather than the pets themselves- and that is mental. A lot of our pet owners have expressed to us how stressful it is to see their pet suddenly collapse and have to be rushed to the hospital. Sometimes, they might even be there for multiple days if it’s a really severe reaction. The other side of that coin is, when we have pets that have experienced these challenge stings (and more or less shrugged off that reaction, or just had hives, and maybe gotten an antihistamine and were okay), that really does build the confidence and comfort of our pet owners. I have had many tell me that they have felt safer going to the park and doing those normal day-to-day activities with their dogs and have not felt that sort of sense of dread that some of them didn’t even realize they had. So I think the mental benefit of that feeling of security can’t be understated either.

[00:17:37] Dr. Lancellotti: I love that so much- that peace of mind that we’re giving to pet owners to reassure them that we are working on retraining your animal’s immune system, so that you will not have this emergency situation occur. It just allows them to be able to do the things with their dogs that they want to do. They want to be able to take them to the park, like you said. They want to be able to have the animal hang out in the backyard with them or be by the pool. Those are all areas where you worry, “Okay, maybe there’s a bee around.” If that’s the case, having this immunotherapy help to retrain the immune system, it really does provide a lot of peace of mind for those pet owners who have gone through traumatic experiences. This really helps to heal that emotional trauma that they’ve suffered. I love this therapy as a way to, not only help the pets, but to help the pet owner as well. I think that’s fantastic. I also wanted to mention a particular case of mine. Actually, I think you had done the testing on this dog, Chewbacca. You did Chewbacca’s testing, right? 

[00:18:43] Dr. Ewing: Oh yeah. I remember Chewy. 

[00:18:45] Dr. Lancellotti: Yeah! Chewbacca had been so severe in his reaction, that he required several days of hospitalization. He required a plasma transfusion, in order to help with the severely low blood pressure that he experienced. This dog was as severe as you could possibly get. He underwent testing and immunotherapy, and several months after starting, he did have a challenge sting occur. The owner wasn’t quite sure that he had been stung by a bee. She didn’t see the actual sting occur, but he experienced same clinical signs that she had seen with prior stings. So she brought him to the hospital, they found a stinger and took it out. And he did require an injection of anti-histamines and an injection of steroids, but he was able to go home that next morning. He didn’t require several days of hospitalization, nor a plasma transfusion. The critical care doctor that was working with him, on both occasions, was just amazed at the difference that she saw in that animal. So to know that challenge sting can occur and not have the severity of the reaction is just a huge relief for everybody- not only the pet owner, but the veterinarians that treat these animals as well. I love the benefit of this therapy. I wish more people were aware that it’s available as something that we can use to save these animals lives, essentially. 

[00:20:26] Dr. Ewing: Yeah. It’s really remarkable to me that a patient that had that severe of an initial reaction, made it to the emergency clinic with the stinger still in them, because that is continuous exposure to the venom. In emergency, I always hated (probably more than any other issue), those severe hypersensitivity reactions, because it felt like you were just racing this dog’s hyperactive immune system, and you really had to move. So the fact that we were able to buy Chewy that extra time to get the therapy and all of those things, I can imagine (even for the emergency doctors) a sense of relief that, “Oh, he’s come in, he’s stable, and we just have to work through this.”

What are the risks of bee and wasp desensitization?

[00:21:06] Dr. Lancellotti: Yeah. That’s great. So we talked a little bit about the benefits. What about some of the risks? This was a big thing that your study looked at. Tell me a little bit about the data that you found there. 

[00:21:16] Dr. Ewing: Oh yeah, and it’s very positive findings overall. I think we had a total of 82 patients and nearly 2000 total treatments, and just under 3% of those treatments resulted in an adverse reaction of any kind- a very safe treatment, all things considered. Most of those reactions did occur during the induction period, when those patients are first being re-exposed to this venom- and most often, in the first three treatments- roughly in the first three weeks of therapy. Across the board, you’re talking about 3% of patients experiencing an adverse event at some point. And usually, that was one or maybe two. So you might say to yourself, “Even though that’s a pretty low number, it does leave out an important point- what were those adverse reactions?” It doesn’t matter if it was just 3% of patients, if that was a considerably severe reaction. There’s more good news there- none of these reactions were particularly severe. You may see things like injection site discomfort, or maybe some hives pop-up, or a little bit of itch. Occasionally, we recorded some facial swelling, but none of these reactions required hospitalization. Far and away, accounting for nearly half of reactions was just digestive upset (vomiting at the time of the injection or maybe a little bit of diarrhea once they got home). A difficulty there is, it is not possible for us to say, “Was that truly the injection?” If a dog develops hives after you give an injection, that was probably the injection. But if a dog spends a day in the clinic with us, and then they have diarrhea when they get home, that could have been due to stress or a variety of other factors. But even if you say, “All of that was due to the injection,” that is still quite a mild reaction, all things considered. When you look at the benefits of the therapy, I think it’s safe to say that there’s a wide margin of safety, and it passes my own personal ‘Would I do this for my own dog?’ test. I certainly would, if I had a venom hypersensitive dog in my home. When you look at accidental overdoses and things along those lines- looking through this data, there was a record of one patient that inadvertently received the wrong concentration of venom. They wound up receiving about 100 times the dose that they were supposed to receive that day. And they were totally fine. No reaction occurred. They walked out the door totally unaware that this had occurred, until the next week, when somebody noted it on the log that somebody had administered the incorrect concentration. That was the only time that had occurred, but it does further support the idea that this is quite a safe therapy. If you can inadvertently dose at 100 times the dose you’re meant to give and the patient does just fine, I feel quite comfortable with it at a personal level. 

[00:24:03] Dr. Lancellotti: Yeah, I totally agree. For the severity of reactions that these animals are experiencing when they get stung by a bee or a wasp, the benefit to desensitization far outweighs the risks that you were able to find in these thousands of treatments that you looked at. So if this was something that I was dealing with in my own pet, I would have absolutely no hesitations in performing desensitization, so that I would have the benefit of the animal not having a severe reaction, but also that secondary benefit- the peace of mind that I would get from knowing that my animal is much safer.

What should pet owners know about bee desensitization?

Dr. Lancellotti: What are some of the big takeaway points that you want pet owners to remember, as far as what we talked about today? 

[00:24:50] Dr. Ewing: I would say that the biggest take-home for me is- I just want people to know that the therapy exists. I think that’s an important point you touched on earlier. A lot of the clients that come to us just heard about it in passing at the ER or something along those lines. So, just a greater acknowledgement of this therapy that’s been well-used in human medicine for quite some time. The venom allergy can be frightening and it can feel overwhelming, but there is a treatment option out there that is suitable for the vast majority of pets. It allows you to be proactive, rather than reactive. It allows you to take some of that power back and take a measure of control of your pet’s health. So I would encourage anyone with a venom-allergic pet to consult with a veterinary dermatologist, if you’re able to see if they offer that immunotherapy. And I’d be happy to speak with any veterinarians who may have questions or concerns about the therapy, or would like a little more detail in that regard. 

[00:25:45] Dr. Lancellotti: That’s excellent. Thanks for being a great resource for everybody. 

[00:25:49] Dr. Ewing: Happy to help. 

[00:25:51] Dr. Lancellotti: So if you would like to find a dermatologist near you to consult about venom immunotherapy, there is a link on the Your Vet Wants You To Know website under the resources tab. So you can consult with them to find out whether or not they perform bee and wasp desensitization.  If your pet has had a reaction to bee stings, or if you’ve gone through and done the desensitization, I would love for you to join the Facebook group and share your experience with bee stings and what your pet went through, to help reassure them that they’re not alone and join in this community of pet owners who are looking for evidence-based answers and information. I did want to mention one thing that I think might be a good tool for some pet owners who have pets that have had a bee or wasp reaction- and that would be the Outfox Field Guard. The Outfox Field Guard is something that was created to help decrease the risk of foxtails, which are pretty common here in southern California (grass awns going up the nose and in the ears- basically anywhere on the face, when an animal is out hiking or running around in the grass). It’s also really good for those animals that like to eat bees. So for dopey Boxers that just see that the bees are around, and then they snap one up and they’re (all of a sudden) having an allergic reaction, the Outfox Field Guard is this protective mesh hood that goes over the animal’s face (which makes it very easy for them to see through the mesh) and stops them from eating anything. That’s a really good preventative tool that people can use to help to decrease the animals’ risk of actually ingesting those bees and getting stung in their mouths. 

[00:27:57] Dr. Ewing: Yeah, I think that’s an excellent tool. And another one worth mentioning is- a lot of these pets come into contact with the bees by walking on them. So, if you’re quite concerned, training your pet to wear shoes or little boots when you’re out and about, that can reduce that risk as well. 

[00:28:12] Dr. Lancellotti: That’s a great suggestion. Thank you.

boxer dog wearing outfox field guard
A pet allergic to bees wears the Outfox Field Guard to prevent him from eating bees.

Scratching the Itch

Dr. Lancellotti: I like to end each episode with a short segment called Scratching The Itch. It’s a segment that is designed to highlight something, whether it’s a human interest story, a product, or a website- just something that provides relief or makes you feel good. Hence, scratching the itch. Dr. Ewing, do you have a ‘scratching the itch’ for us today? 

[00:28:35] Dr. Ewing: I do. For today’s ‘Scratching The Itch’ segment, I’d like to recommend a short video from a YouTube channel called CatPusic. And the title is, “Reducing hole for the cat. When will he stop?” Pusic is a very well-trained cat from Belarus. He was found abandoned on his owner’s doorstep in a cardboard box and they took to training him. The YouTube channel is a lot of, “What can we get our cat to do? Can he navigate a laser maze?” -those sorts of things. But this one, in particular, is seeing how small of a hole he will go through (in a barrier made of cardboard) to get a treat. There are a lot of good videos to check out on that channel, but this is one of my favorites. 

[00:29:16] Dr. Lancellotti: I have to tell you- I was watching this with my four-year-old daughter and the two of us were howling laughing at this video of this cat trying to get himself through the tiniest hole. It was hysterical. So, I highly recommend that people go and check this out. If you are in need of a good chuckle, this cat is absolutely adorable. 

[00:29:39] Dr. Ewing: And I’ve got to say, the results… surprising! 

[00:29:42] Dr. Lancellotti: It is. I mean, he gave that last hole quite an effort. It was very good. Thank you very much for an adorable ‘scratching the itch,’ and thank you so much for taking the time to talk to pet owners today about what bee and wasp desensitization entails. And I hope that people will go and find a dermatologist and seek out this therapy, as it could potentially be a life-saving treatment. Thank you, Dr. Ewing. 

[00:30:06] Dr. Ewing: You’re very welcome. Thank you for having me on. 

[00:30:09] Dr. Lancellotti: And for everyone out there listening, I look forward to your next visit with Your Vet Wants You To Know.

References:

  1. Boord, Mona J. “Venomous Insect Hypersensitivity.” Veterinary Allergy, by Chiara Noli et al., Wiley Blackwell, 2014, pp. 191–194.
  2. Buckley GJ, Corrie C, Bandt C, et al. Kidney injury in a dog following bee sting-associated anaphylaxis. Can Vet J 2017; 58: 265-269.
  3. Casale TB, Burks AW. Clinical practice. Hymenoptera-sting hypersensitivity. N Engl J Med 2014; 370: 1432-1439.
  4. Cox L, Larenas-Linnemann D, Lockey RF, et al. Speaking the same language: The World Allergy Organization Subcutaneous Immunotherapy Systemic Reaction Grading System. J Allergy Clin Immunol 2010; 125: 569-574.e7.
  5. QuickStats: Number of Deaths from Hornet, Wasp, and Bee Stings, Among Males and Females — National Vital Statistics System, United States, 2000–2017. MMWR Morb Mortal Wkly Rep 2019; 68:649.
  6. Rostaher A, Mueller RS, Meile L, et al. Venom immunotherapy for Hymenoptera allergy in a dog. Vet Dermatol 2021; Epub ahead of print.

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