Avoidance of allergens and air pollutants in respiratory allergy

[The effects of season at time of birth on asthma and pneumonia in childhood and adulthood in a birth cohort in southern Brazil]

This study evaluated the effects of seasonal weather at time of birth and ambient temperature during the first six months of life on hospitalizations due to asthma and pneumonia in preschool children and on diagnosis of asthma in adulthood among individuals from the 1982 birth cohort in Pelotas, Rio Grande do Sul, Brazil. The cohort included 5,914 live births, of which 77% were followed up until adulthood (23-24 yr). The risk of hospitalization due to pneumonia and asthma among children born from April to June (autumn) was 1.31 (95%CI: 0.99-1.73) to 2.4 (95%CI: 1.11-4.99) times higher than that of children born from January to March (summer). For temperature in the first six months of life, risk of hospitalization was 1.64 (95%CI: 1.26-2.13) to 3.16 (95%CI: 1.63-6.12) times higher for children born in the coldest as compared to the hottest temperature tertile. The effects of seasonality decreased with age, and the association with asthma in adulthood was weak. Hospitalizations in poor children were more frequent, but the effects of seasonality on pneumonia were more evident among the wealthiest.

Cockroach allergen biology and mitigation in the indoor environment

For nearly a half century, cockroaches have been recognized as a major cause of asthma morbidity in the urban, inner-city environment. Several cockroach-produced allergens have been identified and characterized, and a few have been produced as recombinant proteins. Recent research has moved beyond clinical, patient-based investigations to a more entomological perspective that addresses the production, physiological regulation, and developmental expression of cockroach allergens, thus providing insight into their functional biology and their relationship to current cockroach control strategies. Although successful removal of cockroach allergens from the infested environment has been difficult to accomplish with remedial sanitation, large-scale reductions in cockroach allergens below clinically relevant thresholds have recently been realized through suppression of cockroach populations. Here we review the current understanding of cockroach allergen biology and the demographics associated with human exposure and sensitization. We also critically evaluate allergen mitigation studies from an entomological perspective, highlighting disparities between successful and failed attempts to lessen the cockroach allergen burden in homes.

Decrease in the allergenicity of Japanese cedar pollen allergen by treatment with positive and negative cluster ions

BACKGROUND

Japanese cedar pollinosis is a severe allergic disease in Japan. The most effective means of decreasing allergic inflammation reactions is still avoidance of the aeroallergen. Recently, a novel air purification system using positively and negatively charged cluster ions was developed to create comfortable living environments. We aimed to assess the ability of existing technology to lower allergenicity of Japanese cedar pollen.

METHODS

A Japanese cedar pollen extract was nebulized from the top of a cylindrical container with 2 or 4 ion-generating devices. The extract in a mist was passed through the space filled with or without plasma cluster ions for 90 s, and the ion-treated or nontreated extract was then collected in a Petri dish at the bottom of the container.

RESULTS

The ion-exposed extract was significantly diminished in its reactivities to anti-Cry j 1 or anti-Cry j 2 antiserum and to human allergic sera IgE on ELISA. SDS-PAGE analysis revealed that ion exposure induced protein degradation in the pollen extract. Similarly, the ion treatment impaired about 80% of the binding to pooled sera IgE from patients allergic to Japanese cedar pollen on ELISA inhibition. Furthermore, intracutaneous and conjunctival reaction tests showed a remarkable diminution in the allergenicity of the ion-irradiated extract.

CONCLUSION

Ion irradiation resulted in a remarkable decrease in in vitro and in vivo allergenicities of atomized Japanese cedar pollen extracts.

Asthma prevalence in Hispanic and Asian American ethnic subgroups: results from the California Healthy Kids Survey

OBJECTIVES

Asthma prevalence for different ethnic groups in the United States, beyond white, black and Hispanic, is seldom reported. We compared the prevalence of asthma diagnosis among various Hispanic and Asian American ethnic subgroups using data collected from the school-based California Healthy Kids Survey.

METHODS

The California Healthy Kids Survey was administered to 462 147 public school students in the seventh, ninth, and 11th grades throughout California during the 2001-2002 and 2002-2003 school years. Prevalence of lifetime asthma diagnosis was calculated for 11 Asian American Pacific Islander subgroups and 8 Hispanic subgroups.

RESULTS

Asthma prevalence among Hispanic subgroups ranged from 13.2% for Mexican American students to 22.8% for Puerto Rican students and 23.0% among Cuban American students. Lifetime asthma diagnosis among the 11 Asian American Pacific Islander subgroups ranged from 10.9% among Korean American students to 23.8% among Filipino American students.

CONCLUSIONS

The survey revealed substantial variation in asthma prevalence between the different Hispanic and Asian American Pacific Islander subgroups and that Pacific Islanders, Filipinos, Cubans, and Puerto Ricans are at elevated risk for asthma. Differences in the distributions of characteristics related to country of birth, residential history, generational status, and/or degree of acculturation might account for much of the observed differences in asthma prevalence between ethnic subgroups. Previous asthma prevalence estimates for Asians or Hispanics are in part a function of the particular ethnic composition of the population under investigation. We suggest that asthma studies that include a substantial number of Asian Pacific Islander and Hispanic persons use a more detailed categorization of race/ethnicity.

New insights in allergen avoidance measures for mite and pet sensitized patients. A critical appraisal

It is widely acknowledged that avoidance of allergens such as those derived from foods, drugs, latex and stinging insects results in a complete disappearance of symptoms. By contrast, although it has been clearly shown that allergens are an important risk factor for the development of respiratory symptoms and that several avoidance measures reduce allergen levels, whether this gives clinical improvement in symptoms is debatable. Many reasons could be invoked to justify this evident discrepancy. Apart from the intrinsic methodological aspects (e.g. single or combined interventions measure, population studied, severity of respiratory symptoms, outcomes, evaluated parameters, etc.), it is important to outline that a successful approach requires that the avoided allergen is the only and real factor responsible for symptoms, the patient's education and the use of a comprehensive protocol to reduce allergen exposure. Other important factors include the involvement of the patient, the relevance of other allergens/non-specific agents, and exposure to sensitizing agents also outside patient's home. It is likely that the clinical phase of allergic airway disease and the degree of bronchial (and also nasal) remodelling, in each individual, represent relevant factors for the clinical outcome of allergen avoidance procedures. Since the management of respiratory allergy is a complex strategy (including drugs, allergen avoidance, immunological and educational interventions), it is difficult in real life to distinguish the efficacy of a single intervention in comparison to the others. A combined strategy is likely to produce better clinical results.

The effect of pet ownership on the risk of allergic sensitisation and bronchial asthma

An increasing volume of evidence suggests that early contact of children with the allergens of furred pets (especially those produced by cats) may determine a lower risk of developing allergic sensitisation to these materials. A possible explanation of this data is that an early inhalation of high levels of the major cat allergen Fel d 1 induces the production of IgG and IgG4 antibodies with a "protective" effect. Other authors have shown that the prevalence of allergic sensitisation to cats, in adults, is reduced in those patients exposed to the lowest and highest levels of the allergens. On the contrary, the risk of developing sensitisation to cats is significantly higher when the patients were exposed to intermediate levels of Fel d 1. Moreover, epidemiological studies have demonstrated a relatively low prevalence of cat allergy (about 10%) in some countries where rates of cat ownership are high. This data confirms the role of indirect exposure to pet allergens in inducing allergic sensitisation. Clothes of pet owners have been indicated as the carriers for the dispersal of these allergens in pet-free environments. However, it is important to point out that exposure of highly sensitised patients to relevant amounts of pet allergens (such as in a pet shows/shops) may determine a dramatic exacerbation of nasal and/or bronchial symptoms.

Cutaneous and serological responses to cat allergen in adults exposed or not to cats

BACKGROUND

The relationship between pet ownership and the risk of developing respiratory allergic sensitization to pet allergens is still controversial.

OBJECTIVE

To determine the degree of cutaneous immediate hypersensitivity and the levels of specific IgE and IgG4 antibodies to cat allergen in cat sensitized patients directly or indirectly exposed to this animal.

METHODS

We studied 112 adolescents and adults sensitized to cat allergens (43 with and 69 without a cat at home). There were also 52 control subjects, 27 atopic non-sensitized to cat and 25 non-atopic. The degree of immediate hypersensitivity was assessed by using, in duplicate, skin prick test with four five-fold dilutions of cat hair allergen extract with the content of its major allergen Fel d 1 quantified in micrograms plus positive (10 mg/ml histamine chlorhydrate) and negative (saline solution) controls. The resulting wheal areas were analysed by means of Parallel Line Assay. A blood sample was collected from every patient and control subjects for the evaluation of serological cat specific IgE and IgG4 antibodies.

RESULTS

Patients with cat at home had a lower cutaneous response than patients without this pet. The difference in the skin sensitivity was estimated in 3.4 times (P<0.01). There was no statistical difference between the levels of cat specific IgE antibodies in the two groups of patients (P=0.065). The levels of Fel d 1 specific IgG4 antibodies showed a statistically significant association with the presence of cat at home, with higher levels in patients owing cat at home than in patients without this pet (P<0.001).

CONCLUSION

The results of this study demonstrate that direct cat exposure in adolescents and adults with respiratory allergy is associated with a lower cutaneous response to cat allergenic extract, assessed by SPT and compared with indirect exposure. In patients with cat at home mean levels of specific IgE are statistically comparable whereas the levels of IgG4 are higher in comparison with subjects not exposed to cats. The role of indirect exposure to cat allergens in airways sensitization also in adults is emphasized. Moreover, patients with cat at home show a cutaneous and serological sensitization to cat allergen not higher in comparison with subjects not exposed to cats.

Causative and contributive factors to asthma severity and patterns of medication use in patients seeking specialized asthma care

STUDY OBJECTIVES

(1) To assess the prevalence of specific factors considered causative or contributive to asthma in a population of patients seen in a specialized asthma clinic, and to determine whether any of these factors were associated with more severe disease; and (2) to assess the utilization of inhaled steroids by asthma severity in this population and compare it with published guidelines of the National Heart, Lung, and Blood Institute (NHLBI). DESIGN, SETTING, AND PATIENT POPULATION: We conducted a retrospective chart review of new patients seen in a specialized asthma treatment center over a 2.5-year period and recorded the prevalence of 14 causative or contributive factors, the severity of asthma, and the intensity of treatment with inhaled corticosteroids in each patient. Patients were grouped as mild asthma vs moderate/severe asthma and compared by chi(2) analysis and stepwise logistic regression to determine whether certain factors were associated with more severe asthma.

MEASUREMENTS AND RESULTS

The average number of factors recorded was 2.9 +/- 1.8 in the mild group (+/- SD) and 3.5 +/- 1.6 in the moderate/severe asthma group. This difference was statistically significant (p = 0.014). Increasing age, male gender, symptomatic gastroesophageal reflux disease (GERD), and chronic sinusitis were independently associated with more severe asthma. Suboptimal use of inhaled corticosteroids was more common in patients with mild persistent asthma, but suboptimal dosing of inhaled corticosteroids was equally common in mild and moderate/severe asthma. No relationship was found between allergen sensitization combined with exposure to cats, dogs, dust mite, or molds and more severe asthma.

CONCLUSIONS

This study confirms earlier studies showing that symptomatic GERD and chronic sinusitis are important comorbid conditions in patients with asthma, both being associated with greater asthma severity. This study further shows that the doses of inhaled corticosteroids used for treatment of asthma fall short of NHLBI guidelines in the majority of patients regardless of asthma severity.

Focus on cat allergen (Fel d 1): immunological and aerodynamic characteristics, modality of airway sensitization and avoidance strategies

The increasing frequency of pet ownership (especially cats) in many industrialized countries has raised the level of exposure to the allergens produced by these animals. Moreover, it is likely that modern energy-saving systems and the wide use of upholstered furniture has resulted in closer contact between cats (and their allergens) and humans. Many different methods have been developed to quantify the main cat allergen (Fel d 1) in settled dust and in ambient air. The threshold levels of cat allergen inducing sensitization or triggering respiratory symptoms in sensitized patients have been calculated in settled dust, but airborne amounts of Fel d 1 probably represent a more reliable index of allergen exposure. Noticeably, the amount of Fel d 1 may be relatively high also in confined environments where cats have never been kept. It has been demonstrated that clothes of cat owners are the main source for dispersal of allergens in cat-free environments. This fact may be of relevance, because recent studies have shown that allergic sensitization to cats is more likely to develop in children exposed to moderate levels of this allergen than in children exposed to high amounts of Fel d 1. The ubiquity of cat allergen may justify the common observation that allergen avoidance is often insufficient to reduce the risk of developing allergic sensitization and/or symptom exacerbation in highly susceptible patients. Further efforts are needed to improve the efficacy of Fel d 1 avoidance strategies to try to reduce the risk of allergic sensitization to this allergen.

General strategy for the management of bronchial asthma in pregnancy

Epidemiological studies showed that bronchial asthma is one of the most common diseases which can complicate pregnancy (1-7%). In about 0.05-2% of the cases, asthma occurs as a life-threatening event. In the common medical practice a waiting strategy or, even, the complete refusal for drug therapies are frequently observed. This is justified by the fear of the possible adverse effects of drugs on developing fetus. On the contrary, several studies have demonstrated that severe and uncontrolled asthma may produce serious maternal and fetal complications, such as gestational hypertension and eclampsia, fetal hypoxemia and an increased risk of perinatal death. Therefore, all pregnant women suffering from bronchial asthma should be considered as potentially at high risk of complications and adequately treated. Since asthma is a chronic disease with acute exacerbations, a continuous treatment is mandatory to control symptoms, to prevent acute episodes and to reduce the degree of airway inflammation. The global strategy for asthma management in pregnancy includes five main topics: (1) objective evaluation of maternal/ fetal clinical conditions; (2) avoidance/control of triggering factors; (3) pharmacological treatment; (4) educational support; (5) psychological support. As far as drug therapy is concerned, the International Guidelines and Recommendations suggest that the general strategy does not differ significantly from management outside pregnancy. We herein review and discuss the available data and the criteria for the management of asthma in pregnant patients.

Birch and ragweed pollinosis north of Milan: a model to investigate the effects of exposure to "new" airborne allergens

BACKGROUND

The effects of sudden and massive exposure of the general population to novel airborne allergens are not known. This study aimed to investigate the clinical effects of two "new" allergens, ragweed and birch, in an area north of Milan during the last 15 years.

METHODS

We reviewed the records of 2571 monosensitized patients seen during the last 10 years in two allergy units north of Milan. Data included age at onset of allergic symptoms, and family history of allergic diseases. In this sample, 500 were allergic to grass, mite, birch, and ragweed; 293 to pellitory; 167 to mugwort; 100 to Alternaria; and 11 to plantain.

RESULTS

Birch pollen-allergic patients and ragweed pollen-allergic patients showed a similar mean age at onset (35.3 years vs. 35.1 years; P = NS), but were significantly older than all other groups of patients (P < 0.001). Patients allergic to ragweed and birch pollen, 304 and 323 respectively, were >30 years at the onset of allergic symptoms. A family history of allergic disorders among first degree relatives was far less frequent among patients allergic to birch pollen (29%) or ragweed pollen (27%) than among patients sensitive to all other airborne allergens, except those allergic to mugwort pollen (P < 0.001). In both ragweed and birch groups, a positive family history was significantly more common among subjects < 30 years than in those > 30 years at onset of respiratory allergy (81/196 (41%) vs. 54/304 (18%), P < 0.001 for the ragweed group; 80/177 [45%]vs. 65/323 (20%), P < 0.001 for the birch group).

CONCLUSION

Exposure of the general population of this area to two new airborne allergens resulted in the onset of respiratory allergy in many older people who lacked any relevant predisposing factor. Although we cannot exclude the possibility that those who became allergic had been exposed to birch or ragweed pollen elsewhere, a more likely explanation is a specific susceptibility that remains viable until the subject encounters the "right" allergen.

Environmental controls in the management of allergic asthma

Environmental allergen control is one of the four primary goals of good asthma management. The American Academy of Allergy, Asthma, and Immunology has published a position statement [78] that endorses the National Asthma Education and Prevention Program management guidelines [23] and recommends that every patient with persistent asthma be evaluated for environmental allergen sensitivity. Patients who have sensitivities should receive practical advice on allergen avoidance. An accumulating body of knowledge indicates that such measures, when strictly applied for a sufficient period of time, can indeed reduce asthma symptoms, need for medication, and airway hyperresponsiveness. Ongoing prospective trials in large numbers of patients are being conducted and should enhance the ability to make proper recommendations to patients.