Impact of weather and climate change with indoor and outdoor air quality in asthma: A Work Group Report of the AAAAI Environmental Exposure and Respiratory Health Committee.

Weather and climate change are constant and ever-changing processes that affect allergy and asthma. The purpose of this report is to provide information since the last climate change review with a focus on asthmatic disease. PubMed and Internet searches for topics included climate and weather change, air pollution, particulates, greenhouse gasses, traffic, insect habitat, and mitigation in addition to references contributed by the individual authors. Changes in patterns of outdoor aeroallergens caused by increasing temperatures and amounts of carbon dioxide in the atmosphere are major factors linked to increased duration of pollen seasons, increased pollen production, and possibly increased allergenicity of pollen. Indoor air pollution threats anticipated from climate changes include microbial and mold growth secondary to flooding, resulting in displacement of persons and need for respiratory protection of exposed workers. Air pollution from indoor burning of mosquito repellants is a potential anticipatory result of an increase in habitat regions. Air pollution from fossil fuel burning and traffic-related emissions can alter respiratory defense mechanisms and work synergistically with specific allergens to enhance immunogenicity to worsen asthma in susceptible subjects. Community efforts can significantly reduce air pollution, thereby reducing greenhouse gas emission and improving air quality. The allergist's approach to weather pattern changes should be integrated and anticipatory to protect at-risk patients.

Impact of Climate Change on Pollen and Respiratory Disease.

PURPOSE OF REVIEW: A warming world will impact everyone and everything. The practice of allergic and respiratory disease will not be excepted. All the impacts will be impossible to anticipate. This review is intended to discuss significant factors related to individuals with allergic and respiratory disease. RECENT FINDINGS: Recent findings include the increased growth of allergenic plants in response to higher carbon dioxide levels and warmer temperatures. This also contributes to the increased production of pollen as well as the appearance of allergenic species in new climactic areas. Stinging insects will extend their ranges into northern areas where they have not previously been a problem. The shift and extension of pollen seasons with warmer springs and later frosts have already been observed. Recent severe hurricanes and flooding events may be just the harbinger of increasing damp housing exposure related to sea level rise. Evidence is accumulating that indicates the expected higher number of ozone alert days and increased pollution in populated areas is bringing increases in pollen potency. Finally, increased exposure to smoke and particles from wild fires, resulting from heat waves, will contribute to the general increase in respiratory disease. The practice of allergy being closely aligned with environmental conditions will be especially impacted. Allergists should consider increasing educational activities aimed at making patients more aware of air quality conditions.

Something new in the air: Paying for community-based environmental approaches to asthma prevention and control.

Despite the recommendation in national asthma guidelines to target indoor environmental exposures, most insurers generally have not covered the outreach, education, environmental assessments, or durable goods integral to home environmental interventions. However, emerging payment approaches offer new potential for coverage of home-based environmental intervention costs. These opportunities are becoming available as public and private insurers shift reimbursement to reward better health outcomes, and their key characteristic is a focus on the value rather than the volume of services. These new payment models for environmental interventions can be divided into 2 categories: enhanced fee-for-service reimbursement and set payments per patient that cover asthma-related costs. Several pilot programs across the United States are underway, and as they prove their value and as payment increasingly becomes aligned with better outcomes at lower cost, these efforts should have a bright future. Physicians should be aware that these new possibilities are emerging for payment of the goods and services needed for indoor environmental interventions for their patients with asthma.

DNA methylation levels associated with race and childhood asthma severity.

OBJECTIVE: Asthma is a common chronic childhood disease worldwide. Socioeconomic status, genetic predisposition and environmental factors contribute to its incidence and severity. A disproportionate number of children with asthma are economically disadvantaged and live in substandard housing with potential indoor environmental exposures such as cockroaches, dust mites, rodents and molds. These exposures may manifest through epigenetic mechanisms that can lead to changes in relevant gene expression. We examined the association of global DNA methylation levels with socioeconomic status, asthma severity and race/ethnicity. METHODS: We measured global DNA methylation in peripheral blood of children with asthma enrolled in the Kansas City Safe and Healthy Homes Program. Inclusion criteria included residing in the same home for a minimum of 4 days per week and total family income of less than 80% of the Kansas City median family income. DNA methylation levels were quantified by an immunoassay that assessed the percentage of 5-methylcytosine. RESULTS: Our results indicate that overall, African American children had higher levels of global DNA methylation than children of other races/ethnicities (p = 0.029). This difference was more pronounced when socioeconomic status and asthma severity were coupled with race/ethnicity (p = 0.042) where low-income, African American children with persistent asthma had significantly elevated methylation levels relative to other races/ethnicities in the same context (p = 0.006, Hedges g = 1.14). CONCLUSION: Our study demonstrates a significant interaction effect among global DNA methylation levels, asthma severity, race/ethnicity, and socioeconomic status.

Innate Immune Responses to Fungal Allergens.

PURPOSE OF REVIEW: In this review, we describe innate immunity to fungi and the ability of pattern recognition receptors (PRRs) to recognize fungal-associated molecular patterns (FAMPs) and danger-associated molecular patterns (DAMPs). RECENT FINDINGS: Protective responses against fungal antigens can be divided into two parts: innate immunity and adaptive immunity. Detection of foreign substance by the innate immune system is mediated by a variety of genetically encoded receptors known as pattern recognition receptors (PRRs). These PRRs bind to PAMPs (pathogen-associated molecular patterns) and more specifically to fungal-associated molecular patterns or FAMPs on target microorganisms. They also bind to DAMPs (damage-associated molecular patterns) which are substances released due to tissue and cell damage. PRRs can be divided into several families including Toll-like receptors (TLRs), nucleotide-oligomerization domain (NOD)-like receptors (NLRs), and C-type lectin receptors. Fungal PRRs can respond to internal and external components found in fungi. In addition, a number of fungal products, including some fungal allergens, seem to mimic or represent DAMPs. Collectively, activation of these fungal PRRs alerts the innate immune system to the presence of fungal exposure and can promote both innate and adaptive immune responses.

Measurement of aeroallergens from furnace filters.

BACKGROUND: Exposure assessment is an important component of allergic disease diagnosis and management. Analysis for allergen content in vacuumed dust has been used traditionally. OBJECTIVE: To study allergen levels of dust taken from high-efficiency furnace filters in Midwestern homes. METHODS: Furnace filters used were FQT12 1-inch disposable filters with high-efficiency media placed in homes enrolled in the Kansas City Safe and Healthy Homes Project. Dust was removed from the filters by vacuuming. Fungal culture was used to obtain counts of viable spores. Aeroallergens Fel d1, Can f1, Mus m1, Der f1, Der p1, and Bla g2 and antigenic material from Alternaria, Aspergillus, Cladosporium, and Penicillium species were measured using commercially available immunoassay materials. RESULTS: Sixty filters were recovered from 56 homes after an average 135 days in situ. Mean weight of dust recovered was 2.43 g and correlated well with the time the filter was in place. Viable spore counts ranged to 4.8 × 10(7) per gram of dust. Mean fungal antigenic material ranged to 42 µg per gram for Cladosporium species. Mean aeroallergen material ranged to 7 µg per gram for Fel d1. Aeroallergen measurements were above the level of detection in 100% of houses for Fel d1 and 89% of houses for Bla g2. Levels of Fel d1 and Can f1 were strongly positively correlated. CONCLUSION: Allergens from 5 common aeroallergen species and antigenic material from 4 common fungal taxa can be measured in dust taken from high-efficiency furnace filters.

Secondhand tobacco smoke exposure in low-income children and its association with asthma.

Secondhand tobacco smoke (SHS) is a common indoor environmental exposure that is particularly prevalent in low-income families. It has been found to be associated with asthma in some studies; however, across all relevant studies, results have been conflicting. This study aimed to determine the prevalence of SHS exposure in the home environment in a low-income, minority population and to determine the association of exposure with childhood asthma, wheeze, and oral corticosteroids use. This retrospective study analyzed self-reported data collected as part of the Kansas City Safe and Healthy Homes Partnership to determine prevalence of SHS exposure. A logistic regression model was then used to assess the association between exposure and asthma, oral steroid use, and wheeze. Overall, 40% of children lived with at least one smoker and 15% of children lived with at least one smoker who smoked inside the house. No significant association was found between asthma or oral corticosteroid use and SHS exposure. Children who lived with a smoker had a 1.54 increased odds of wheeze in the past year. A large percentage of low-income children in the Kansas City area continue to suffer the adverse effects of SHS. These data support the need for innovative public policy to protect children from such exposure in their home environment.

Homes of low-income minority families with asthmatic children have increased condition issues.

The home is increasingly associated with asthma. It acts both as a reservoir of asthma triggers and as a refuge from seasonal outdoor allergen exposure. Racial/ethnic minority families with low incomes tend to reside in neighborhoods with low housing quality. These families also have higher rates of asthma. This study explores the hypothesis that black and Latino urban households with asthmatic children experienced more home mechanical, structural condition-related areas of concern than white households with asthmatic children. Participant families (n = 140) took part in the Kansas City Safe and Healthy Homes Program, had at least one asthmatic child, and met income qualifications of no more than 80% of local median income; many were below 50%. Families self-identified their race. Homes were assessed by environmental health professionals using a standard set of criteria and a specific set of on-site and laboratory sampling and analyses. Homes were given a score for areas of concern between 0 (best) and 53 (worst). The study population self-identified as black (46%), non-Latino white (26%), Latino (14.3%), and other (12.9%). Mean number of areas of concern were 18.7 in Latino homes, 17.8 in black homes, 13.3 in other homes, and 13.2 in white homes. Latino and black homes had significantly more areas of concern. White families were also more likely to be in the upper portion of the income. In this set of 140 low-income homes with an asthmatic child, households of minority individuals had more areas of condition concerns and generally lower income than other families.

Association of tobacco smoke exposure and atopic sensitization.

BACKGROUND: Forty million children are regularly exposed to environmental tobacco smoke (ETS) each year, increasing their risk for premature death and middle ear and acute respiratory infections. Early life exposure to ETS also is clearly associated with wheezing. However, there is no clear understanding of the influence of ETS on the development of allergic sensitization. OBJECTIVE: To determine the association of combined exposure to ETS and indoor allergens on IgE sensitization to aeroallergens in children. METHODS: This case-control study enrolled 116 cases and 121 controls from low-income families from Kansas City, Missouri. The adjusted odds ratio was calculated using a logistic model to assess the association between ETS and allergic sensitization using dust allergen levels as a covariate. RESULTS: Thirty-six percent of atopic children and 39% of controls were exposed to ETS (P < .05). Unadjusted analyses showed no significant influence of ETS on IgE sensitization to indoor allergens. Logistic regression analyses also showed no significant influence of ETS on sensitization when adjusted for levels of allergens in the home dust and family history of allergic rhinitis. CONCLUSION: These data suggest that ETS exposure was not associated with IgE sensitization to indoor allergens, even when home allergen levels were taken into consideration. Further understanding of how components of tobacco smoke influence the immune response is necessary to interpret the disparate findings across studies.

Airborne concentrations of peanut protein.

Food allergy to peanut is a significant health problem, and there are reported allergic reactions to peanuts despite not eating or having physical contact with peanuts. It is presumed that an allergic reaction may have occurred from inhalation of airborne peanut allergens. The purpose of this study was to detect the possible concentrations of airborne peanut proteins for various preparations and during specific activities. Separate Ara h 1 and Ara h 2 monoclonal enzyme-linked immunosorbent assays and a polyclonal sandwich enzyme immunoassay for peanuts were used to detect the amount of airborne peanut protein collected using a Spincon Omni 3000 air collector (Sceptor Industries, Inc., Kansas City, MO) under different peanut preparation methods and situations. Air samples were measured for multiple peanut preparations and scenarios. Detectable amounts of airborne peanut protein were measured using a whole peanut immunoassay when removing the shells of roasted peanut. No airborne peanut allergen (Ara h 1 or Ara h 2) or whole peanut protein above the LLD was measured in any of the other peanut preparation collections. Ara h 1, Ara h 2, and polyclonal peanut proteins were detected from water used to boil peanuts. Small amounts of airborne peanut protein were detected in the scenario of removing shells from roasted peanuts; however, Ara h 1 and Ara h 2 proteins were unable to be consistently detected. Although airborne peanut proteins were detected, the concentration of airborne peanut protein that is necessary to elicit a clinical allergic reaction is unknown.

Reduced clinic, emergency room, and hospital utilization after home environmental assessment and case management.

Allergists often suspect home environmental conditions are contributors to allergic disease. Case management can be an effective tool in managing asthmatic patients. To describe the impact of home environmental assessments and case management on the medical care utilization of patients with allergic disease the following studies were conducted. This study was designed to retrospectively examine health care utilization of pediatric patients that had a home environmental assessment recommended by a pediatric allergist as part of a comprehensive case management program. Subjects were chosen from pediatric patients who received home assessment after referral for case management by pediatric allergy specialists in a hospital-based clinic as indicated by high emergency room (ER) and hospital utilization. Case management included education, clinic visits, environmental assessment, and a single person responsible for following the subject's care. Home assessment included airborne spore collections, surface collections, and dust collection for evaluation of antigens. There were 25 subjects. Seventy-two percent were asthmatic and 12% were diagnosed with allergic rhinitis. In the year before entering the study these subjects experienced 47 ER visits, 22 hospitalizations, and 279 clinic visits. In the subsequent year they underwent 18 ER visits, 3 hospitalizations, and 172 clinic visits. Penicillium/Aspergillus levels were above 100 spores/m(3) of air in 94% of homes and above 1000 spores/m(3) in 74% of homes. Thirty-six percent of homes had Stachybotrys above 100 spores/m(3). Home environmental assessment and case management may reduce medical care utilization for children suffering from allergic rhinitis and asthma.

Low-cost interventions improve indoor air quality and children's health.

Intervention in the home environment to reduce asthma triggers theoretically improves health outcomes for asthmatic children. Practical benefit from application of these interventions has proven difficult. This single-blind study tested the effectiveness of simple low-cost home interventions in improving health scores of children with asthma. Families with at least one asthmatic child were recruited. Initial health examination, health, and home assessments were conducted and targeted interventions were implemented. Interventions included dehumidification, air filtration, furnace servicing, and high-efficiency furnace filters. When present, gross fungal contamination was remediated. Asthma education was provided along with education in healthy home practices. Follow-up assessments were conducted after 6 months. Health surveys were completed at enrollment and follow-up. This study enrolled 219 children with asthma. Home inspections and interventions were conducted in 181 homes and 83 families completed all phases. Reduction in asthma and allergy-related health scores was shown in follow-up health surveys. Health improvements were significant for cough when heating, ventilation, and air conditioning (HVAC) service and dehumidification were used. Breathing problems were significantly improved for dehumidification, HVAC service, and room air cleaners. Total dust allergen load was reduced for the dehumidification group (p < 0.05). Mold spore counts were reduced one order of magnitude in 25% of the homes. Indoor spore counts adjusted for outdoor spore levels were reduced overall (p < 0.01). Simple low-cost interventions directed to producing cleaner indoor air coupled with healthy home education improve the indoor air quality and health in asthmatic children.

Landscape Plant Selection Criteria for the Allergic Patient.

Patients with pollen-related allergies are concerned about the species within their landscape that provoke their symptoms. Allergists are often asked for guidance but few information sources are available to aid patients in the recognition of allergenic plants and strategies to avoid personal exposure to them. Landscaping and horticultural workers also have few reliable guidance references, and what is available usually extols the virtues of the plants rather than their negative features. The aim of this article was to provide the results of the Landscape Allergen Working Group that was formed by the AAAAI Aerobiology Committee, which aimed to fill these existing knowledge gaps and develop guidance on producing a low-allergenic landscape. Within the context that complete pollen avoidance is unrealistic, the workgroup introduces selection criteria, avoidance strategies, and guidance on low-allergenic plants that could be selected by patients to reduce the overall pollen burden in their landscape environment. Specific focus is placed on entomophilous plants, which require insects as dispersal vectors and generally produce lower quantities of pollen, compared with anemophilous (wind-pollinated) species. Other biological hazards that can be encountered while performing landscaping activities are additionally reviewed and avoidance methods presented with the aim of protecting gardeners, and workers in the landscape and horticulture industries. The guidance presented in this article will ultimately be a helpful resource for the allergist and assist in engaging patients who are seeking to reduce the burden of allergen in their landscape environment.

International consensus (ICON) on: clinical consequences of mite hypersensitivity, a global problem.

Since mite allergens are the most relevant inducers of allergic diseases worldwide, resulting in significant morbidity and increased burden on health services, the International Collaboration in Asthma, Allergy and Immunology (iCAALL), formed by the American Academy of Allergy, Asthma and Immunology (AAAAI), the American College of Allergy, Asthma and Immunology (ACAAI), the European Academy of Allergy and Clinical Immunology (EAACI), and the World Allergy Organization (WAO), has proposed to issue an International Consensus (ICON) on the clinical consequences of mite hypersensitivity. The objectives of this document are to highlight aspects of mite biology that are clinically relevant, to update the current knowledge on mite allergens, routes of sensitization, the genetics of IgE responses to mites, the epidemiologic aspects of mite hypersensitivity, the clinical pictures induced by mites, the diagnosis, specific immunotherapeutic approaches, and prevention.

Innate and Adaptive Immune Response to Fungal Products and Allergens.

Exposure to fungi and their products is practically ubiquitous, yet most of this is of little consequence to most healthy individuals. This is because there are a number of elaborate mechanisms to deal with these exposures. Most of these mechanisms are designed to recognize and neutralize such exposures. However, in understanding these mechanisms it has become clear that many of them overlap with our ability to respond to disruptions in tissue function caused by trauma or deterioration. These responses involve the innate and adaptive immune systems usually through the activation of nuclear factor kappa B and the production of cytokines that are considered inflammatory accompanied by other factors that can moderate these reactivities. Depending on different genetic backgrounds and the extent of activation of these mechanisms, various pathologies with resulting symptoms can ensue. Complicating this is the fact that these mechanisms can bias toward type 2 innate and adaptive immune responses. Thus, to understand what we refer to as allergens from fungal sources, we must first understand how they influence these innate mechanisms. In doing so it has become clear that many of the proteins that are described as fungal allergens are essentially homologues of our own proteins that signal or cause tissue disruptions.