Dose-response relationships between mouse allergen exposure and asthma morbidity among urban children and adolescents

Characterization of pesticide exposures and their associations with asthma morbidity in a predominantly low-income urban pediatric cohort in Baltimore City

BACKGROUND

Pesticides may impact respiratory health, yet evidence of their impact on pediatric asthma morbidity is limited, particularly among urban children.

OBJECTIVE

To characterize pesticide biomarker concentrations and evaluate their associations with pediatric asthma morbidity among predominantly low-income, Black children in Baltimore City, USA.

METHODS

We measured urinary concentrations of 10 biomarkers for pyrethroid insecticides (cyfluthrin:4F-3PBA, permethrin:3PBA), organophosphate insecticides (chlorpyrifos:TCPY, malathion:MDA, parathion:PNP, diazinon:IMPY), and herbicides (glyphosate:AMPA, GPS; 2,4-dicholorphenoxyacetic acid:2,4-D; 2,4,5-tricholorphenoxyacetic acid:2,4,5-T) among 148 children (5-17 years) with established asthma. Urine samples and asthma morbidity measures (asthma symptoms, healthcare utilization, lung function and inflammation) were collected every three months for a year. Generalized estimating equations were used to examine associations between pesticide biomarker concentrations and asthma morbidity measures, controlling for age, sex, race, caregiver education, season, and environmental tobacco smoke. In sensitivity analyses, we assessed the robustness of our results after accounting for environmental co-exposures.

RESULTS

Frequently detected (≥90% detection) pesticide biomarker concentrations (IMPY, 3PBA, PNP, TCPY, AMPA, GPS) varied considerably within children over the follow-up period (intraclass correlation coefficients: 0.1-0.2). Consistent positive significant associations were observed between the chlorpyrifos biomarker, TCPY, and asthma symptoms. Urinary concentrations of TCPY were associated with increased odds of coughing, wheezing, or chest tightness (adjusted Odds Ratio, aOR, TCPY:1.60, 95% Confidence Interval, CI:1.17-2.18). Urinary concentrations of TCPY were also associated with maximal symptom days (aOR:1.38, CI:1.02-1.86), exercise-related symptoms (aOR:1.63, CI:1.09-2.44), and hospitalizations for asthma (aOR:2.84, CI:1.08-7.43). We did not observe consistent evidence of associations between the pesticide exposures assessed and lung function or inflammation measures.

CONCLUSION

Among predominantly Black children with asthma, we found evidence that chlorpyrifos is associated with asthma morbidity. Further research is needed to assess the contribution of pesticide exposures to pediatric respiratory health and characterize exposure sources among vulnerable populations to inform targeted interventions against potentially harmful pesticide exposures.

A multi-city study of indoor air quality in green vs non-green low-income housing

OBJECTIVES

The condition of the home is a strong predictor of exposure to environmental contaminants, with low-income households being particularly vulnerable. Therefore, improving housing standards is a priority. Housing built to "green" standards, with improved building methods and materials, has been suggested to reduce contaminants. However, evidence is limited as to which contaminants are reduced. The Green Housing Study was conducted to address this issue. The study hypothesis was that housing built using green components has lower concentrations of environmental contaminants compared to conventional housing.

METHODS

A repeated-measures, 12-month cohort study was performed in three U.S. cities. Data were collected in the home at three time points throughout a year. The level of contaminants were estimated using air samples for particulate matter and black carbon, dust samples for aeroallergens and pesticides, and resident or study staff reporting evidence of mold. To investigate source(s) of PM2.5 and black carbon, multivariable models using stepwise variable selection were developed.

RESULTS

In adjusted generalized estimating equations (GEE) models, black carbon concentration (μg/m3) (β = -0.22, 95% CI = -0.38 to -0.06, p = 0.01), permethrin (OR = 0.28, 95% CI = 0.15-0.49, p < 0.0001), and reported mold (OR = 0.29, 95% CI = 0.13-0.68, p = 0.003) were significantly lower in green homes. Cockroach antigen was also lower in green homes (OR = 0.59, 95% CI = 0.33-1.08, p = 0.09), although not statistically significant. We found that 68% of PM2.5 was explained by dwelling type and smoking and 42% of black carbon was explained by venting while cooking and use of a gas stove.

CONCLUSIONS

This study provides quantitative data suggesting benefits of incorporating green building practices on the level of numerous environmental contaminants known to be associated with health. Occupant behavior, particularly smoking, is an important contributor to indoor air pollution.

Environmental justice and allergic disease: A Work Group Report of the AAAAI Environmental Exposure and Respiratory Health Committee and the Diversity, Equity and Inclusion Committee

Environmental justice is the concept that all people have the right to live in a healthy environment, to be protected against environmental hazards, and to participate in decisions affecting their communities. Communities of color and low-income populations live, work, and play in environments with disproportionate exposure to hazards associated with allergic disease. This unequal distribution of hazards has contributed to health disparities and is largely the result of systemic racism that promotes segregation of neighborhoods, disinvestment in predominantly racial/ethnic minority neighborhoods, and discriminatory housing, employment, and lending practices. The AAAAI Environmental Exposure and Respiratory Health Committee and Diversity, Equity and Inclusion Committee jointly developed this report to improve allergy/immunology specialists' awareness of environmental injustice, its roots in systemic racism, and its impact on health disparities in allergic disease. We present evidence supporting the relationship between exposure to environmental hazards, particularly at the neighborhood level, and the disproportionately high incidence and poor outcomes from allergic diseases in marginalized populations. Achieving environmental justice requires investment in at-risk communities to increase access to safe housing, clean air and water, employment opportunities, education, nutrition, and health care. Through policies that promote environmental justice, we can achieve greater health equity in allergic disease.

Life Course of Asthma

Asthma is a heterogeneous chronic airway disease that can vary over a lifetime. Although broad categories of asthma by severity and type have been constructed, there remains a tremendous opportunity to discover an approach to managing asthma with additional factors in mind. Many in the field have suggested and are pursuing a novel paradigm shift in how asthma might be better managed, considering the life course of exposures, management priorities, and predicted trajectory of lung function growth. This approach will require a more holistic view of prenatal, postnatal, adolescence, hormonal and gender aspects, and the aging process. In addition, the environment, externally and internally, including in one's genetic code and epigenetic changes, are factors that affect how asthma progresses or becomes more stable in individuals. This chapter focuses on the various influences that may, to differing degrees, affect people with asthma, which can develop at any time in their lives. Shifting the paradigm of thought and strategies for care and advocating for public policies and health delivery that focus on this philosophy is paramount to advance asthma care for all.

Phthalate biomarkers and associations with respiratory symptoms and healthcare utilization among low-income urban children with asthma

BACKGROUND

Phthalates are synthetic chemicals present in building materials, personal care products and other consumer goods. Limited studies link phthalates to pediatric asthma incidence; however, their effects on respiratory-related outcomes among those with pre-existing asthma remains unclear.

OBJECTIVE

We examined associations between phthalates and asthma symptoms, healthcare use, lung function, and lung inflammation among children with asthma.

METHODS

We collected repeated measures of urinary biomarkers for select phthalates and phthalate replacements (MBzP, MCINP, MCIOP, MCPP, MECPTP, MEHHTP, molar sum of DEHP biomarkers [MECPP, MEHHP, MEHP, MEOHP], MEP, MiBP, MnBP) and asthma symptoms, healthcare utilization, lung function, and inflammation among 148 predominantly low-income Black children (5-17 years) with persistent asthma every 3 months for one year. We used generalized estimating equations to assess associations between biomarker concentrations and asthma-related measures adjusting for age, sex, race/ethnicity, caregiver's education level, presence of smokers in the home, and season. We also considered co-exposures to other contaminants previously associated with asthma morbidity.

RESULTS

We observed consistent positive associations with individual DEHP biomarkers, the molar sum of DEHP, and BBzP with increased odds of asthma symptoms and with healthcare utilization (adjusted Odds Ratio for general asthma symptoms: ΣDEHP:1.49,95% Confidence Interval, CI:1.08-2.07; BBzP:1.34, CI:1.04-1.73). We observed similar associations between the DEHP phthalate replacement biomarker MEHHTP and most asthma symptoms evaluated; and with select low molecular weight phthalates (DiBP, DBP) and healthcare utilization. Results were similar when controlling for other environmental exposures (e.g., PM2.5, BPA). No associations were observed with lung function or inflammation, and overall, we did not observe consistent evidence of sexually dimorphic effects.

CONCLUSION

In the present study, we found evidence to suggest that exposure to select phthalates may be associated with asthma symptoms and healthcare utilization. These findings warrant confirmation given the high asthma burden and widespread and disparate phthalate exposures reported among select populations of color.

The influence of urban exposures and residence on childhood asthma

Children with asthma who live in urban neighborhoods experience a disproportionately high asthma burden, with increased incident asthma and increased asthma symptoms, exacerbations, and acute visits and hospitalizations for asthma. There are multiple urban exposures that contribute to pediatric asthma morbidity, including exposure to pest allergens, mold, endotoxin, and indoor and outdoor air pollution. Children living in urban neighborhoods also experience inequities in social determinants of health, such as increased poverty, substandard housing quality, increased rates of obesity, and increased chronic stress. These disparities then in turn can increase the risk of urban exposures and compound asthma morbidity as poor housing repair is a risk factor for pest infestation and mold exposure and poverty is a risk factor for exposure to air pollution. Environmental interventions to reduce in-home allergen concentrations have yielded inconsistent results. Population-level interventions including smoking bans in public places and legislation to decrease traffic-related air pollution have been successful at reducing asthma morbidity and improving lung function growth. Given the interface and synergy between urban exposures and social determinants of health, it is likely population and community-level changes will be needed to decrease the excess asthma burden in children living in urban neighborhoods.

Allergen Management in Children with Type 2-High Asthma

Children exposed to various indoor and outdoor allergens are placed at an increased risk of developing asthma in later life, with sensitization in these individuals being a strong predictor of disease morbidity. In addition, aeroallergen exposure influences asthma outcomes through an interplay with adverse determinants of health. The goal of this review is to provide an introductory overview of factors related to aeroallergen exposure in type 2-high childhood asthma. These include the relevance of exposure in asthma exacerbations and severity, and the evidence-base for avoidance and treatment for sensitization to these allergens. This review will focus on both indoor aeroallergens (house dust mite, pet, cockroach, mold, and rodent) and outdoor aeroallergens (pollens and molds). Treatment of aeroallergen sensitization in children with asthma includes avoidance and removal measures, although there is limited evidence of clinical benefit especially with single-strategy approaches. We will also address the interplay of aeroallergens and climate change, adverse social determinants, and the current COVID-19 pandemic, when we have seen a dramatic reduction in asthma exacerbations and emergency department visits among children. While there are many factors that are hypothesized to contribute to this reduction, among them is a reduced exposure to outdoor seasonal aeroallergens.

Associations between sensitisation to allergens and allergic diseases: a hospital-based case-control study in China

OBJECTIVES

To assess the associations of sensitisation to common allergens with atopic dermatitis, allergic rhinitis and allergic asthma in adults.

DESIGN

Case-control study.

SETTING

Data were collected from the First Affiliated Hospital of Harbin Medical University in Harbin, China.

PARTICIPANTS

Cases were 5111 patients with physician-diagnosed atopic dermatitis (n=2631), allergic asthma (n=1320) and allergic rhinitis (n=1160) recruited from the department of allergy from March 2009 to December 2017. Controls were 2576 healthy adults who underwent physical examination at the same hospital during the same period.

MAIN OUTCOME MEASURES

Specific IgE levels to 16 common food, indoor and outdoor allergens were assessed in all participants. Adjusted ORs and 95% CIs for the association between allergen sensitisation and allergic diseases were estimated using multivariate logistic regression.

RESULTS

The prevalence of allergen sensitisation was higher in patients with atopic dermatitis (indoor=17.14%, outdoor=12.85%, food=21.44%), allergic rhinitis (indoor=23.18%, outdoor=26.81%, food=8.94%) and allergic asthma (indoor=24.65%, outdoor=16.46%, food=14.31%) compared with controls (indoor=11.03%, outdoor=6.84%, food=5.83%). After adjustment for potential confounding variables, there was a dose-response relevance between the levels of allergen-specific IgE and allergic diseases (p trend <0.0001). The number of allergens to which a patient was sensitised increased the risk of allergic diseases (atopic dermatitis: highest adjusted OR=4.28, 95% CI 2.57 to 7.11; allergic rhinitis: highest adjusted OR=13.00, 95% CI 3.76 to 45.00; allergic asthma: OR=2.37, 95% CI 1.67 to 3.37).

CONCLUSION

There was a dose-response relevance between levels of allergen-specific IgE and allergic diseases' prevalence, and multiple sensitisations increased the risk of allergic diseases. This study provides evidence for the prophylaxis of allergic diseases.

Abundance and Stability as Common Properties of Allergens

There have been many attempts to identify common biophysical properties which differentiate allergens from their non-immunogenic counterparts. This review will focus on recent studies which examine two such factors: abundance and stability. Anecdotal accounts have speculated that the elevated abundance of potential allergens would increase the likelihood of human exposure and thus the probability of sensitization. Similarly, the stability of potential allergens dictates its ability to remain a viable immunogen during the transfer from the source to humans. This stability could also increase the resilience of potential allergens to both gastric and endosomal degradation, further skewing the immune system toward allergy. Statistical analyses confirm both abundance and stability as common properties of allergens, while epidemiological surveys show a correlation between exposure levels (abundance) and allergic disease. Additional studies show that changes in protein stability can predictably alter gastric/endosomal processing and immunogenicity, providing a mechanistic link between stability and allergenicity. However, notable exceptions exist to both hypotheses which highlight the multifaceted nature of immunological sensitization, and further inform our understanding of some of these other factors and their contribution to allergic disease.

Environmental Health-Related Policies and Practices of Oklahoma Licensed Early Care and Education Programs: Implications for Childhood Asthma

Little is known about the environmental health-related policies and practices of early care and education (ECE) programs that contribute to childhood asthma, particularly in Oklahoma where child asthma rates (9.8%) and rates of uncontrolled asthma among children with asthma (60.0%) surpass national rates (8.1% and 50.3%, respectively). We conducted a cross-sectional survey with directors of Oklahoma-licensed ECE programs to assess policies and practices related to asthma control and to evaluate potential differences between Centers and Family Childcare Homes (FCCHs). Surveyed ECEs (n = 476) included Centers (56.7%), FCCHs (40.6%), and other program types (2.7%). Almost half (47.2%) of directors reported never receiving any asthma training. More Center directors were asthma-trained than FCCH directors (61.0% versus 42.0%, p < 0.0001). Most ECEs used asthma triggers, including bleach (88.5%) and air fresheners (73.6%). Centers were more likely to use bleach daily than were FCCHs (75.6% versus 66.8%, p = 0.04). FCCHs used air fresheners more than did Centers (79.0% versus 61.0%, p < 0.0001). The majority of ECEs (74.8%) used pesticides indoors. Centers applied indoor pesticides more frequently (i.e., monthly or more often) than did FCCHs (86.0% versus 58.0%, p < 0.0001). Policy, educational, and technical assistance interventions are needed to reduce asthma triggers and improve asthma control in Oklahoma ECEs.

The Impact of Social Determinants of Health on Children with Asthma

SzAsthma is the most common chronic disease of childhood. Disparities in asthma outcomes have led to international attention on the biologic, social, economic, and other factors that impact the health of children with asthma. Studies indicate that social determinants of health such as housing, neighborhood safety, and access to care significantly impact the health of children with asthma. However, screening for socioeconomic and environmental factors that impact asthma can be difficult to integrate into clinical practice. In addition, it is not yet clear which interventions to address these factors are most effective. This article will review recent studies of determinants and social determinants of health and propose a framework for identifying and addressing them in the care of children with asthma in a clinical setting.

The Role of Environmental Controls in Managing Asthma in Lower-Income Urban Communities

Children living in lower-income urban communities are at much greater risk of developing asthma, going to the emergency department for an asthma attack and being hospitalized for asthma than children living in upper- and middle-income communities. For many asthmatic children living in urban communities, especially those with greater morbidity, the allergic pathway is important in the etiology of the disease. The stages of developing allergic disease can be divided into the onset of allergic sensitization, development of allergic disease and subsequent exacerbations, and it is useful to consider the relevance of interventions at each of these stages. Indoor allergens and environmental exposures are a major contributor to allergic disease, particularly among lower socioeconomic status, urban, minority communities. These exposures include allergens, environmental tobacco smoke, combustion by-products, and mold, all of which can play an important role in asthma progression as well as morbidity. These exposures are often not found in isolation and thus these concomitant exposures need to be considered when conducting environmental interventions. There have been numerous studies looking at both primary and tertiary prevention strategies and the impact on allergic sensitization and asthma with varied results. While the outcomes of these studies have been mixed, what has emerged is the need for tertiary interventions to be targeted to the individual and to reduce all relevant exposures to which an asthmatic child is exposed and sensitized. In addition, effective intervention strategies must also consider other social determinants of asthma morbidity impacting low socioeconomic, urban communities.

Inner-City Asthma in Childhood

The inner-city is a well-established and well-studied location that includes children at high risk for high asthma prevalence and morbidity. A number of intrinsic and extrinsic risk factors contribute to asthma in inner-city populations. This review seeks to explore these risk factors and evaluate how they contribute to increased asthma morbidity. Previous literature has identified risk factors such as race and ethnicity, prematurity, obesity, and exposure to aeroallergens and pollutants. Environmental and medical interventions aimed at individual risk factors and specific asthma phenotypes have contributed to improved outcomes in the inner-city children with asthma.

New Directions in Pediatric Asthma

Childhood asthma affects many children placing them at significant risk for health care utilization and school absences. Several new developments relevant to the field of pediatric asthma have occurred over the last 5 years; yet, there is much more to learn. It is poorly understood how to prevent the disease, optimally address environmental challenges, or effectively manage poor adherence. Moreover, it is not clear how to customize therapy by asthma phenotype, age group, high risk groups, or severity of disease. Highlights of advances in pediatric asthma are reviewed and multiple essential areas for further exploration and research are discussed.

Indoor Environmental Interventions for Furry Pet Allergens, Pest Allergens, and Mold: Looking to the Future

Over the last 2 to 3 decades, significant advances have been made in understanding the role that indoor allergen exposures play with regard to respiratory health. Multiple studies have confirmed that sensitization and exposure to indoor allergens can be a risk factor for asthma morbidity. Environmental interventions targeting key indoor allergens have been evaluated with the aims of examining their causal effects on asthma-related outcomes and identifying clinically efficacious interventions to incorporate into treatment recommendations. Historically, it appeared that the most successful intervention, as performed in the Inner-City Asthma Study, was individually tailored, targeting multiple allergens in a predominantly low-income, minority, and urban pediatric population. Recent studies suggest that single-allergen interventions may be efficacious when targeting the most clinically relevant allergen for a population. In this article, we review recent literature on home environmental interventions and their effects on specific indoor allergen levels and asthma-related outcomes.

Airborne Rodent Allergen Levels in Dutch Households: A Pilot Study

Little research has been conducted in Europe regarding indoor exposure to airborne rodent allergens. The aims of this study were to gain insight into the prevalence of rodent allergens in airborne dust in Dutch households, to assess whether there is a relationship between rodent sightings and detectable allergens, and to identify risk factors associated with the presence of rodent allergens. Airborne dust was collected from the living rooms of 80 households distributed around central Netherlands by passive sampling using electrostatic dust collectors (EDCs). Samples were analysed for mouse (Mus m 1) and rat (Rat n 1) allergens. Participants completed a questionnaire on household and building characteristics, household pets, cleaning habits and ventilation. Mouse allergen was more prevalent than rat allergen and mouse sightings within the past year more than doubled the odds of detectable mouse allergen. Proximity to green areas, ventilation through an open window and insulation under the living room floor were determinants for detectable mouse allergen. Conversely, proximity to surface water was protective. No significant association was found between asthma and detectable mouse allergen. The passive EDC sampling method was used successfully to detect mouse and rat allergens in homes. The presence of mouse allergen was associated with previous mouse sightings. Risk factors and protective factors associated with the presence and levels of mouse allergen were identified.

Do Baseline Asthma and Allergic Sensitization Characteristics Predict Responsiveness to Mouse Allergen Reduction?

BACKGROUND

Mouse allergen reduction is associated with improvements in asthma among sensitized and exposed children, but whether clinical characteristics predict responsiveness to allergen reduction is unclear.

OBJECTIVE

To examine the effects of clinical characteristics on relationships between mouse allergen reduction and asthma outcomes.

METHODS

We performed a secondary analysis of data from a randomized clinical trial of a mouse allergen intervention, examining the effects of atopy, demographic characteristics, lung function, asthma control, and asthma severity on relationships between mouse allergen reduction and asthma outcomes.

RESULTS

Participants were predominantly low-income and minority (78% black, 22% Hispanic), and had persistent asthma. Among less atopic participants (<6 positive skin prick test results), each 50% reduction in mouse allergen was associated with fewer symptoms (incidence rate ratio [95% CI]: maximal symptoms: 0.94 [0.92-0.96]). There was little effect of mouse allergen reduction on symptoms among more atopic participants (P > .05). The interactions between atopic status and mouse allergen reduction were statistically significant for all symptom outcomes; however, there was no evidence that atopic status influenced the effect of mouse allergen reduction on exacerbation-related outcomes. Older children (≥9 years) tended to experience greater improvement in some asthma outcomes with reduction in mouse allergen exposure than younger children. There was no evidence that either mouse-specific IgE or lung function influenced the effect of mouse allergen reduction on any asthma outcomes.

CONCLUSIONS

Although there may be variability in the clinical response to mouse allergen reduction among low-income, minority children with asthma, there were no clinical characteristics that clearly identified a subgroup at which the intervention should be targeted.

Inner-City Asthma in Children

Asthma in inner-city children is often severe and difficult to control. Residence in poor and urban areas confers increased asthma morbidity even after adjusting for ethnicity, age, and gender. Higher exposure to household pests, such as cockroaches and mice, pollutants and tobacco smoke exposure, poverty, material hardship, poor-quality housing, differences in health care quality, medication compliance, and heath care access also contribute to increased asthma morbidity in this population. Since 1991, the National Institutes of Allergy and Infectious Diseases established research networks: the National Cooperative Inner-City Asthma Study (NCICAS), the Inner-City Asthma Study (ICAS), and the Inner-City Asthma Consortium (ICAC), to improve care for this at risk population. The most striking finding of the NCICAS is the link between asthma morbidity and the high incidence of allergen sensitization and exposure, particularly cockroach. The follow-up ICAS confirmed that reductions in household cockroach and dust mite were associated with reduction in the inner-city asthma morbidity. The ICAC studies have identified that omalizumab lowered fall inner-city asthma exacerbation rate; however, the relationship between inner-city asthma vs immune system dysfunction, respiratory tract infections, prenatal environment, and inner-city environment is still being investigated. Although challenging, certain interventions for inner-city asthma children have shown promising results. These interventions include family-based interventions such as partnering families with asthma-trained social workers, providing guidelines driven asthma care as well as assured access to controller medication, home-based interventions aim at elimination of indoor allergens and tobacco smoke exposure, school-based asthma programs, and computer/web-based asthma programs.

Time for Allergists to Consider the Role of Mouse Allergy in Non-Inner City Children with Asthma

Mouse allergen is endemic in the inner cities of the United States, with research predominantly in the Northeastern United States. A recent practice parameter notes the effect of mouse exposure in asthma in inner cities. However, studies are emerging that find a role of mouse allergen in non-inner cities as well. Mouse sensitization is associated with mouse allergen exposure and has been linked with adverse asthma outcomes including increased asthma symptoms, poorer lung function, and increased risk of exacerbations. There are commercially available extracts for testing for mouse sensitization although they are not standardized. Pest management studies have had varying results, but with decreased allergen exposure, there is a trend toward improved asthma outcomes. Physicians should be aware of the potential for rodent exposure and sensitization and consider screening for mouse allergy in asthmatic children, especially if they are located in the inner city, have poorly controlled asthma, or have a history of mouse infestation in their location. Evidence is emerging that this allergen should be considered in non-inner-city asthmatics as well. Finally, advocacy efforts are necessary to ensure that removal of this allergen is accomplished, when possible, in the environments of asthmatic children sensitized to mouse.

Sampling Devices for Indoor Allergen Exposure: Pros and Cons

PURPOSE OF REVIEW

To review current indoor allergen sampling devices, including devices to measure allergen in reservoir and airborne dust, and personal sampling devices, with attention to sampling rationale and major indoor allergen size and characteristics.

RECENT FINDINGS

While reservoir dust vacuuming samples and airborne dust volumetric air sampling remain popular techniques, recent literature describes sampling using furnace filters and ion-charging devices, both which help to eliminate the need for trained staff; however, variable correlation with reservoir dust and volumetric air sampling has been described. Personal sampling devices include intra-nasal samples and personal volumetric air samples. While these devices may offer better estimates of breathable allergens, they are worn for short periods of time and can be cumbersome. Reservoir dust sampling is inexpensive and is possible for families to perform. Airborne dust sampling can be more expensive and may better quantify cat, dog, and mouse allergen exposure. Personal sampling devices may offer a better representation of breathable air.

Perceived Versus Actual Aeroallergen Sensitization in Urban Children

BACKGROUND

Individuals often report allergy to specific aeroallergens, but allergy testing can reveal disparate sensitization.

OBJECTIVE

To characterize the agreement between perceived and actual sensitization to individual aeroallergens in an urban pediatric population.

METHODS

A total of 253 children were enrolled from pediatric clinics in New York, NY. Detailed questionnaires regarding perceived sensitization and serum specific IgE measurements to 10 common aeroallergens were completed. Agreement between perceived and actual sensitization (sIgE ≥ 0.35 kU_A/L) to individual aeroallergens was assessed by Cohen's kappa. Multivariable logistic regression models adjusted for potential confounders were used to test for associations between perceived and actual sensitization.

RESULTS

A total of 161 (63.6%) of 253 children reported perceived sensitization to 1 or more aeroallergen, and 203 (80.2%) were actually sensitized to 1 or more aeroallergen. Agreement between perceived and actual aeroallergen sensitization was fair for most aeroallergens, with greatest agreement for cat dander (κ, 0.42; 95% CI, 0.32-0.53) and dust (κ, 0.32; 95% CI, 0.20-0.44). Models adjusted for potential confounders showed nearly 6-fold odds of sensitization to cat dander given perceived cat allergy (adjusted odds ratio, 5.82; 95% CI, 2.91-11.64), and over 2-fold odds of sensitization to Dermatophagoides pteronyssinus, Dermatophagoides farinae, dog dander, or grass pollen given perceived sensitization to their respective allergens. Among children with no perceived sensitization, actual sensitization ranged from 5.4% to 30.4%, and was more common for indoor versus outdoor allergens, including cockroach.

CONCLUSIONS

Children who perceive allergen sensitization to cat, dog, dust, or grass are likely to demonstrate actual sensitization to these individual allergens. Children with no perceived sensitization to allergens are nonetheless frequently sensitized.

The Exposome and Asthma

This article on exposome and asthma focuses on the interaction of patients and their environments in various parts of their growth, development, and stages of life. Indoor and outdoor environments play a role in pathogenesis via levels and duration of exposure, with genetic susceptibility as a crucial factor that alters the initiation and trajectory of common conditions such as asthma. Knowledge of environmental exposures globally and changes that are occurring is necessary to function effectively as medical professionals and health advocates.

Bedroom Allergen Exposure Beyond House Dust Mites

PURPOSE OF REVIEW

The review provides insight into recent findings on bedroom allergen exposures, primarily focusing on pet, pest, and fungal exposures.

RECENT FINDINGS

Large-scale studies and improved exposure assessment technologies, including measurement of airborne allergens and of multiple allergens simultaneously, have extended our understanding of indoor allergen exposures and their impact on allergic disease. Practical, streamlined methods for exposure reduction have shown promise in some settings, and potential protective effects of early-life exposures have been further elucidated through the investigation of specific bacterial taxa. Advances in molecular allergology have yielded novel data on sensitization profiles and cross-reactivity. The role of indoor allergen exposures in allergic disease is complex and remains incompletely understood. Advancing our knowledge of various co-exposures, including the environmental and host microbiome, that interact with allergens in early life will be crucial for the development of efficacious interventions to reduce the substantial economic and social burden of allergic diseases including asthma.

At-risk children with asthma (ARC): a systematic review

Introduction

Asthma attacks are responsible for considerable morbidity and may be fatal. We aimed to identify and weight risk factors for asthma attacks in children (5–12 years) in order to inform and prioritise care.

Methods

We systematically searched six databases (May 2016; updated with forward citations January 2017) with no language/date restrictions. Two reviewers independently selected studies for inclusion, assessed study quality and extracted data. Heterogeneity precluded meta-analysis. Weighting was undertaken by an Expert Panel who independently assessed each variable for degree of risk and confidence in the assessment (based on study quality and size, effect sizes, biological plausibility and consistency of results) and then achieved consensus by discussion. Assessments were finally presented, discussed and agreed at a multidisciplinary workshop.

Results

From 16 109 records, we included 68 papers (28 cohort; 4 case-control; 36 cross-sectional studies). Previous asthma attacks were associated with greatly increased risk of attack (ORs between 2.0 and 4.1). Persistent symptoms (ORs between 1.4 and 7.8) and poor access to care (ORs between 1.2 and 2.3) were associated with moderately/greatly increased risk. A moderately increased risk was associated with suboptimal drug regimen, comorbid atopic/allergic disease, African-American ethnicity (USA), poverty and vitamin D deficiency. Environmental tobacco smoke exposure, younger age, obesity and low parental education were associated with slightly increased risk.

Discussion

Assessment of the clinical and demographic features identified in this review may help clinicians to focus risk reduction management on the high-risk child. Population level factors may be used by health service planners and policymakers to target healthcare initiatives.

Trial registration number

CRD42016037464.

Indoor allergen levels in settled airborne dust are higher in day-care centers than at home

BACKGROUND

Early-life sensitization to indoor allergens predicts asthma development. The aim of this study was to compare allergen concentrations in day-care centers (DCC) with those in private homes.

METHODS

Settled airborne dust was collected 4 times a year from 20 German DCC (620 samples) and from the homes of children and day-care workers (602 samples) using electrostatic dust collectors (EDC). The samples were analyzed with fluorescence enzyme immunoassays recognizing domestic mite allergens (DM), Fel d 1, Can f 1, and Mus m 1. Pet allergen thresholds that discriminate samples from homes with cats or dogs from those without were calculated using receiver-operating characteristics. Influences on allergen levels were analyzed using multilevel models.

RESULTS

Allergen loads were on average higher in DCC than in homes. In DCC, 96% of the samples were positive for DM, 95% for Can f 1, 90% for Fel d 1, and 83% for Mus m 1. In homes, 84% contained DM, 48.5% Can f 1, 33% Fel d 1, and 43% Mus m 1. The threshold level for homes with dogs was 75 ng/m² Can f 1 (96.8% sensitivity, 96% specificity), and the threshold level for homes with cats was 46 ng/m² Fel d 1 (92% sensitivity, 94.9% specificity). In DCC, Can f 1 and Fel d 1 loads were higher than these thresholds in 37% and 54% of the samples, respectively. Allergen levels were significantly influenced by the season and room type; however, carpets on floors had no influence.

CONCLUSIONS

Mite, mouse, cat, and dog allergens were mostly higher in DCC than in homes. Exposure to dog and cat allergens in DCC often reached levels of households with pets.

IL-21 alleviates allergic asthma in DOCK8-knockout mice

Patients with DOCK8 deficiency are at increased susceptibility to develop allergic diseases such as food allergy and asthma. Here, we aimed to analyze the pathogenesis of asthma in DOCK8-deficient patients. In our mouse model, DOCK8-knockout (KO) mice sensitized with low-dose OVA were challenged with 1.5% OVA to induce allergic asthma. As compared to that in WT mice, remarkable airway hyperresponsiveness was observed in KO mice. Increased inflammatory cells and eosinophils infiltrated in airway lumen in KO mice especially around bronchi. KO mice showed higher levels of serum IgE and OVA-specific IgE and significantly elevated IgE-producing B cells in blood and in spleen. Surprisingly, nasal administration with rmIL-21 significantly reduced the airway hyperresponsiveness, inflammatory infiltration, as well as the serum IgE and IgE-producing B cells. DOCK8-knockout mice are susceptible to low-dose OVA induced allergic airway inflammation and airway hyperresponsiveness. Supplementary nasal administration of rmIL-21 alleviates allergic asthma in this mouse model.

An Integrated Pest Management Intervention Improves Knowledge, Pest Control, and Practices in Family Child Care Homes

To reduce young children’s exposure to pesticides when attending family child care homes (FCCHs), we developed an integrated pest management (IPM) intervention for FCCH directors. First, we developed IPM educational materials and resources to provide the foundation for an IPM educational intervention for FCCHs. Next, we conducted and evaluated a six-month nurse child care health consultant (CCHC)-led education and consultation IPM intervention to increase IPM knowledge, IPM practices, IPM policies, and decrease the presence or evidence of pests. The pilot intervention study was conducted by three CCHCs in 20 FCCHs in three counties in California. Pre- and post-intervention measures were completed by the FCCH directors and observation measures were completed by the CCHCs. Results indicated significant increases in IPM knowledge, (t-statistic (degrees of freedom), (t(df) = 2.55(10), p < 0.05), increases in IPM practices (t(df) = −6.47(17), p < 0.05), and a 90% reduction in the prevalence of pests. There were no significant differences in changes in IPM practices based on director education, FCCH county, or IPM intervention intensity or duration. A nurse-led IPM education and consultation intervention can reduce exposures of young children attending family child care homes to harmful chemicals.

Environmental determinants of allergy and asthma in early life

Allergic disease prevalence has increased significantly in recent decades. Primary prevention efforts are being guided by study of the exposome (or collective environmental exposures beginning during the prenatal period) to identify modifiable factors that affect allergic disease risk. In this review we explore the evidence supporting a relationship between key components of the external exposome in the prenatal and early-life periods and their effect on atopy development focused on microbial, allergen, and air pollution exposures. The abundance and diversity of microbial exposures during the first months and years of life have been linked with risk of allergic sensitization and disease. Indoor environmental allergen exposure during early life can also affect disease development, depending on the allergen type, dose, and timing of exposure. Recent evidence supports the role of ambient air pollution in allergic disease inception. The lack of clarity in the literature surrounding the relationship between environment and atopy reflects the complex interplay between cumulative environmental factors and genetic susceptibility, such that no one factor dictates disease development in all subjects. Understanding the effect of the summation of environmental exposures throughout a child's development is needed to identify cost-effective interventions that reduce atopy risk in children.

Indoor Air Quality

Many health care providers are concerned with the role environmental exposures play in the development of respiratory disease. While most individuals understand that outdoor air quality is important to their health status, many are unaware of the detrimental effects indoor air pollution can potentially have on them. The Environmental Protection Agency (EPA) regulates both outdoor and indoor air quality. According to the EPA, indoor levels of pollutants may be up to 100 times higher than outdoor pollutant levels and have been ranked among the top 5 environmental risks to the public. There has been a strong correlation between air quality and health, which is why it is crucial to obtain a complete environmental exposure history from a patient. This article focuses on the effects indoor air quality has on the respiratory system. Specifically, this article will address secondhand smoke, radon, carbon monoxide, nitrogen dioxide, formaldehyde, house cleaning agents, indoor mold, animal dander, and dust mites. These are common agents that may lead to hazardous exposures among individuals living in the United States. It is important for health care providers to be educated on the potential risks of indoor air pollution and the effects it may have on patient outcomes. Health problems resulting from poor indoor air quality are not easily recognized and may affect a patient's health years after the onset of exposure.

Integrated Pest Management Intervention in Child Care Centers Improves Knowledge, Pest Control, and Practices

INTRODUCTION

To reduce young children's exposure to pests and pesticides, an integrated pest management (IPM) intervention was provided for child care center staff.

METHODS

The 7-month IPM education and consultation intervention was conducted by trained nurse child care health consultants in 44 child care centers in California. IPM knowledge surveys were completed by child care staff, objective IPM assessments were completed by research assistants pre- and postintervention, and activity logs were completed by the nurses.

RESULTS

There were significant increases in IPM knowledge for the child care staff who attended workshops. There were reductions in the prevalence of pests and increases in IPM practices at the postintervention compared with the preintervention time point. The nurses consulted an average of 5.4 hours per center.

DISCUSSION

A nurse-led IPM intervention in child care centers can reduce exposure to harmful substances for young children attending child care centers.

Indoor Environmental Control Practices and Asthma Management

Indoor environmental exposures, particularly allergens and pollutants, are major contributors to asthma morbidity in children; environmental control practices aimed at reducing these exposures are an integral component of asthma management. Some individually tailored environmental control practices that have been shown to reduce asthma symptoms and exacerbations are similar in efficacy and cost to controller medications. As a part of developing tailored strategies regarding environmental control measures, an environmental history can be obtained to evaluate the key indoor environmental exposures that are known to trigger asthma symptoms and exacerbations, including both indoor pollutants and allergens. An environmental history includes questions regarding the presence of pets or pests or evidence of pests in the home, as well as knowledge regarding whether the climatic characteristics in the community favor dust mites. In addition, the history focuses on sources of indoor air pollution, including the presence of smokers who live in the home or care for children and the use of gas stoves and appliances in the home. Serum allergen-specific immunoglobulin E antibody tests can be performed or the patient can be referred for allergy skin testing to identify indoor allergens that are most likely to be clinically relevant. Environmental control strategies are tailored to each potentially relevant indoor exposure and are based on knowledge of the sources and underlying characteristics of the exposure. Strategies include source removal, source control, and mitigation strategies, such as high-efficiency particulate air purifiers and allergen-proof mattress and pillow encasements, as well as education, which can be delivered by primary care pediatricians, allergists, pediatric pulmonologists, other health care workers, or community health workers trained in asthma environmental control and asthma education.

Child maltreatment and pediatric asthma: a review of the literature

BACKGROUND

Child maltreatment is a common problem with known adverse consequences, yet its contributions to the development and course of pediatric asthma are only poorly understood.

MAIN

This review first describes possible pathways connecting child maltreatment to pediatric asthma, including aspects of the physical home environment, health behaviors and disease management, and psychological consequences of child maltreatment. We subsequently review existing studies, which generally report an association between maltreatment experiences and asthma outcomes in childhood. However, this literature is in its early stages; there are only a handful studies, most of them rely on self-reports of both child maltreatment and asthma history, and none have investigated the physiological underpinnings of this association. Taken together, however, the studies are suggestive of child maltreatment playing a role in pediatric asthma incidence and expression that should be explored further.

CONCLUSION

Existing data are sparse and do not allow for specific conclusions. However, the data are suggestive of child maltreatment influencing asthma risk and morbidity long before the adult years. Future research should focus on understanding how child maltreatment contributes to asthma disease risk and progression in this highly vulnerable population.

Individualized Household Allergen Intervention Lowers Allergen Level But Not Asthma Medication Use: A Randomized Controlled Trial

BACKGROUND

Environmental exposures to indoor allergens are major contributors to asthma symptoms, particularly in inner cities. The effectiveness of household allergen reduction as an adjunct to National Asthma Education Prevention Program guideline-based pharmacologic therapy in asthma has not been prospectively studied.

OBJECTIVE

To study the effect of individualized allergen reduction on ability to reduce asthma pharmacologic therapy over 40 weeks.

METHODS

We performed a randomized controlled trial to determine the effect of multifaceted indoor allergen avoidance measures on the ability to reduce asthma controller therapy in adults and children residing in New York City who were both sensitized and exposed to at least 1 indoor allergen. Asthma treatment and control were optimized in all subjects before randomization.

RESULTS

A total of 125 subjects were randomized to receive individualized household allergen reduction and 122 received a sham intervention. Subjects in the intervention group significantly reduced all measured allergen levels (cat, dog, dust mite allergens in the bedroom, cockroach and mouse allergens in the kitchen and bedroom); those in the control group reduced only dust mite and mouse allergens in the bedroom and cockroach allergen in the kitchen. Participants in the intervention arm reduced National Asthma Education Prevention Program-based therapy from step 4.4 at randomization to 3.50 postintervention (range, 0-6); participants in the control arm reduced medication from step 4.4 to 3.4 (P = .76). There were no differences in other measured asthma outcomes.

CONCLUSIONS

Targeted allergen avoidance measures do not allow for reduction in asthma pharmacologic therapy compared with usual care in patients already receiving optimal controller therapy.

Mouse allergen exposure and decreased risk of allergic rhinitis in school-aged children

BACKGROUND

Little is known about exposure to mouse allergen (Mus m 1) and allergic rhinitis (AR).

OBJECTIVE

To evaluate the association between mouse allergen exposure and AR in children.

METHODS

We examined the relation between mouse allergen level in house dust and AR in 511 children aged 6 to 14 years in San Juan, Puerto Rico. Study participants were chosen from randomly selected households using a multistage probability sample design. The study protocol included questionnaires, allergy skin testing, and collection of blood and dust samples. AR was defined as current rhinitis symptoms and skin test reactivity to at least one allergen.

RESULTS

In the multivariate analyses, mouse allergen level was associated with a 25% decreased odds of AR in participating children (95% confidence interval, 0.62-0.92). Although endotoxin and mouse allergen levels were significantly correlated (r = 0.184, P < .001), the observed inverse association between Mus m 1 and AR was not explained by levels of endotoxin or other markers of microbial or fungal exposure (peptidoglycan and glucan).

CONCLUSION

Mouse allergen exposure is associated with decreased odds of AR in Puerto Rican school-aged children.

Allergens on desktop surfaces in preschools and elementary schools of urban children with asthma

Desktop dust has been studied as a source of food allergen, but not as a source of potential aeroallergen exposure. Thirty-six wiped samples from desktop surfaces were collected from preschools and schools. Samples were analyzed for detectable levels of common aeroallergens including Alternaria, cockroach, dog, dust mite, cat, mouse, and rat allergens by immunoassay. Mouse allergen was the most prevalent, detectable in 97.2% of samples. Cat allergen was detectable in 80.6% of samples, and dog allergen was detectable in 77.8% of samples. Other allergens were not as prevalent. Mouse was the only allergen that was highly correlated with settled floor dust collected from the same rooms (r = 0.721, P < 0.001). This is the first study to detect aeroallergens on desktop surfaces by using moist wipes. Allergens for mouse, cat, and dog were highly detectable in wipes with mouse desktop surface levels correlating with levels in vacuumed floor dust.

The indoor environment and inner-city childhood asthma

OBJECTIVE

Exposure to indoor pollutants and allergens has been speculated to cause asthma symptoms and exacerbations and influence the risk of developing asthma. The aim of this article is to review the medical literature regarding the role of the indoor environment on inner-city childhood asthma.

DATA SOURCES

A literature search was performed in PubMed. Studies focusing on inner-city indoor allergen, childhood asthma, and environmental controls were included.

RESULTS

The prevalence of asthma in children is increasing especially in inner-city area. Exposure to high levels of indoor allergens and pollutants has been related to asthma development. Studies have shown that mouse, cockroach, pets, dust mite, mold, tobacco smoke, endotoxin and nitrogen dioxide are the important exposures. Recent studies have shown that indoor environmental control is beneficial in reducing asthma morbidity and development.

CONCLUSIONS

Inner-city children are exposed to various indoor allergens and pollutants that may lead to asthma development and exacerbation of existing asthma. Multifaceted environmental controls are beneficial in improving asthma symptom and maybe a viable prevention strategy. Further prospective studies of environmental intervention are needed to further identify effective strategies to improve and prevent asthma symptoms in inner-city children.

Environmental exposures and asthma morbidity in children living in urban neighborhoods

A substantial disparity in asthma prevalence and morbidity among urban children compared with their nonurban counterparts has been recognized for more than two decades. Because of the nature of urban neighborhoods, pest allergens, such as cockroach and mouse, are present in high concentrations in US urban housing and have both repeatedly been linked to asthma morbidity in sensitized children. In addition, there is a growing body of evidence demonstrating that concentrations of many pollutants are higher indoors than outdoors in both US and European urban communities and that exposures to indoor pollutants such as particulate matter (PM) and nitrogen dioxide (NO2 ) are independently associated with symptoms in children with asthma. Although environmental interventions are challenging to implement, when they reduce relevant indoor allergen and pollutant exposures, they are associated with clear improvements in asthma. Other modifiable risk factors in urban childhood asthma that have emerged include dietary and nutritional factors. Overweight and obese children, for example, may be more susceptible to the pulmonary effects of pollutant exposure. Insufficiency of vitamin D and folate has also emerged as modifiable risk factors for asthma morbidity in children. The identification of these modifiable risk factors for urban childhood asthma morbidity offers a ripe opportunity for intervention.

Management of rodent exposure and allergy in the pediatric population

Although rodent allergy has long been recognized as an occupational disease, it has only been in the past decade that it has been recognized as a community-based disease that affects children. Most homes in the US have detectable mouse allergen, but the concentrations in inner-city homes are orders of magnitude higher than those found in suburban homes. Home mouse allergen exposure has been linked to sensitization to mouse, and children with asthma who are both sensitized and exposed to high mouse allergen concentrations at home are at greater risk for symptoms, exacerbations and reduced lung function. Rat allergen is found primarily in inner-city homes and has also been linked to asthma morbidity among sensitized children. The objective of this review is to summarize the scientific literature on rodents and their allergens, the effects of exposure to these allergens on allergic respiratory disease, and to make recommendations, based on this evidence base, for the evaluation and management of mouse allergy in the pediatric population.

Indoor pollutant exposures modify the effect of airborne endotoxin on asthma in urban children

RATIONALE

The effect of endotoxin on asthma morbidity in urban populations is unclear.

OBJECTIVES

To determine if indoor pollutant exposure modifies the relationships between indoor airborne endotoxin and asthma health and morbidity.

METHODS

One hundred forty-six children and adolescents with persistent asthma underwent repeated clinical assessments at 0, 3, 6, 9, and 12 months. Home visits were conducted at the same time points for assessment of airborne nicotine, endotoxin, and nitrogen dioxide (NO2) concentrations. The effect of concomitant pollutant exposure on relationships between endotoxin and asthma outcomes were examined in stratified analyses and statistical models with interaction terms.

MEASUREMENTS AND MAIN RESULTS

Both air nicotine and NO2 concentrations modified the relationships between airborne endotoxin and asthma outcomes. Among children living in homes with no detectable air nicotine, higher endotoxin was inversely associated with acute visits and oral corticosteroid bursts, whereas among those in homes with detectable air nicotine, endotoxin was positively associated with these outcomes (interaction P value = 0.004 and 0.07, respectively). Among children living in homes with lower NO2 concentrations (<20 ppb), higher endotoxin was positively associated with acute visits, whereas among those living in homes with higher NO2 concentrations, endotoxin was negatively associated with acute visit (interaction P value = 0.05). NO2 also modified the effect of endotoxin on asthma symptom outcomes in a similar manner.

CONCLUSIONS

The effects of household airborne endotoxin exposure on asthma are modified by coexposure to air nicotine and NO2, and these pollutants have opposite effects on the relationships between endotoxin and asthma-related outcomes.

Mouse allergen is the major allergen of public health relevance in Baltimore City

BACKGROUND

Cockroach and mouse allergens have both been implicated as causes in inner-city asthma morbidity in multicenter studies, but whether both allergens are clinically relevant within specific inner-city communities is unclear.

OBJECTIVE

Our study aimed to identify relevant allergens in Baltimore City.

METHODS

One hundred forty-four children (5-17 years old) with asthma underwent skin prick tests at baseline and had clinical data collected at baseline and 3, 6, 9, and 12 months. Home settled dust samples were collected at the same time points for quantification of indoor allergens. Participants were grouped based on their sensitization and exposure status to each allergen. All analyses were adjusted for age, sex, and serum total IgE level.

RESULTS

Forty-one percent were mouse sensitized/exposed, and 41% were cockroach sensitized/exposed based on bedroom floor exposure data. Mouse sensitization/exposure was associated with acute care visits, decreased FEV1/forced vital capacity percentage values, fraction of exhaled nitric oxide levels, and bronchodilator reversibility. Cockroach sensitization/exposure was only associated with acute care visits and bronchodilator reversibility when exposure was defined by using bedroom floor allergen levels. Mouse-specific IgE levels were associated with poor asthma health across a range of outcomes, whereas cockroach-specific IgE levels were not. The relationships between asthma outcomes and mouse allergen were independent of cockroach allergen. Although sensitization/exposure to both mouse and cockroach was generally associated with worse asthma, mouse sensitization/exposure was the primary contributor to these relationships.

CONCLUSIONS

In a community with high levels of both mouse and cockroach allergens, mouse allergen appears to be more strongly and consistently associated with poor asthma outcomes than cockroach allergen. Community-level asthma interventions in Baltimore should prioritize reducing mouse allergen exposure.

Effects of allergic phenotype on respiratory symptoms and exacerbations in patients with chronic obstructive pulmonary disease

RATIONALE

Chronic obstructive pulmonary disease (COPD) guidelines make no recommendations for allergy diagnosis or treatment.

OBJECTIVES

To determine whether an allergic phenotype contributes to respiratory symptoms and exacerbations in patients with COPD.

METHODS

Two separate cohorts were analyzed: National Health and Nutrition Survey III (NHANES III) and the COPD and domestic endotoxin (CODE) cohort. Subjects from NHANES III with COPD (n = 1,381) defined as age > 40 years, history of smoking, FEV1/FVC < 0.70, and no diagnosis of asthma were identified. The presence of an allergic phenotype (n = 296) was defined as self-reported doctor diagnosed hay fever or allergic upper respiratory symptoms. In CODE, former smokers with COPD (n = 77) were evaluated for allergic sensitization defined as a detectable specific IgE to perennial allergens. Bivariate and multivariate models were used to determine whether an allergic phenotype was associated with respiratory symptoms and exacerbations.

MEASUREMENTS AND MAIN RESULTS

In NHANES III, multivariate analysis revealed that individuals with allergic phenotype were more likely to wheeze (odds ratio [OR], 2.1; P < 0.01), to have chronic cough (OR, 1.9; P = 0.01) and chronic phlegm (OR, 1.5; P < 0.05), and to have increased risk of COPD exacerbation requiring an acute doctor visit (OR, 1.7; P = 0.04). In the CODE cohort, multivariate analysis revealed that sensitized subjects reported more wheeze (OR, 5.91; P < 0.01), more nighttime awakening due to cough (OR, 4.20; P = 0.03), increased risk of COPD exacerbations requiring treatment with antibiotics (OR, 3.79; P = 0.02), and acute health visits (OR, 11.05; P < 0.01). An increasing number of sensitizations was associated with a higher risk for adverse health outcomes.

CONCLUSIONS

Among individuals with COPD, evidence of an allergic phenotype is associated with increased respiratory symptoms and risk of COPD exacerbations.

Sensitization to rodents (mouse/rat) in urban atopic populations without occupational exposure living in Campania district (Southern Italy): a multicenter study

BACKGROUND

Up to now very few data on allergic sensitization to rodent allergens in Western Europe and Italy are available, and there are no information at district level.The aim of this report was to investigate clinical significance and characteristics of allergic sensitization to mouse/rat (M/Rt) allergens in atopic subjects living in Campania district (Southern Italy).

METHODS

Allergists from the whole Campania district were required to report the results of skin prick tests of at least 100 consecutive subjects. In 1,477 consecutive outpatients, we selected all subjects with an immediate skin reaction to M/Rt dander. Clinical history including a careful evaluation of the modality of exposure and the results of skin-prick tests (SPTs) were recorded.

RESULTS

Fifty seven patients were sensitized to M/Rt dander (5.78%). Two patients were mono-sensitized. Fourteen patients reported indoor conditions suggesting presence of rodents allergens at home. All patients exhibited low-moderate degree of SPT positivity to M/Rt. High frequency of concomitant allergic sensitization to dust mites was found.

CONCLUSIONS

Our results suggest that the role of allergic sensitization to rodents is not negligible in atopic subjects without occupational exposure living in Campania district area; these values are higher in comparison to those previously found in Naples area. Highly atopic individuals should be tested by SPTs/evaluation of serum specific IgE to rodents in the case they should begin an occupational exposure to M/Rt or keep these animals as pets.