Major Environmental Allergens

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3 Disclosures

4 Major Environmental Allergens Indoor Outdoor Grass pollen Weed pollen Tree pollen Mold

5 Guidelines and Indoor Allergens In asthma patients who are sensitized: Allergen exposure increases asthma symptoms. Persistent exposures may increase bronchial hyper-reactivity, thereby increasing asthma exacerbation with other triggers (e.g. infections). For patients with persistent asthma: Evaluate the potential role of allergens, particularly indoor inhalant allergens. Expert Panel Report 3 (EPR3): Guidelines for the Diagnosis and Management of Asthma

6 Importance of Allergic Sensitization in Asthma Arbes S et al, JACI 2007 Nov 120: Gergen PJ et al, JACI 2009 Sept 124: Carroll WD et al, Arch Dis Childhood 2006 May 91:

7 Indoor Allergen Exposure: A Therapeutic Target?

8 Ecological Considerations Furred Pets Fungi Food Sources Food Sources HUMIDITY Domestic Mites Rodents Food Sources Cockroaches Food Sources

9 Microscopic creatures. House Dust Mites Live in bedding, upholstered furniture, stuffed animals and carpet. Feed on human skin scales. Grow best in relative humidity above 50-70%. Exposure related to allergic sensitization. Increased asthma morbidity among sensitized individuals. Arlian LG et al. J Med Entomology 1998;35:46-53.

10 Reducing Dust Mite Allergens First Line Mattress, pillow covers Wash bedding Control humidity Second Line Remove stuffed animals, carpets, and upholstered furniture HEPA or double bag vacuum cleaners Acaricides in fabrics Tannic acid Air filters unlikely to help Mattress encasing alone may be ineffective.

11 Cockroach Allergen Major factor for U.S. inner cities. Distributed throughout home. Allergens found in cockroach feces. Integrated pest management approach: Sealing cracks and crevices, removal of food and water sources, thorough cleaning. Reductions in cockroach allergen in inner city asthmatic children leads to improved asthma symptoms. Cohn et al., Environmental Health Perspectives, 114: , 2006

12 Cockroach Allergen Exposure and Asthma Morbidity in Inner City Children 0.4 Hospitalizations p= Unscheduled Medical Visits p<0.001 Hospitalizations in Past Year No. of Visits in Past Year Days With Changed Plans in Past Year Change in Care Giver s Plans p=0.006 neg skin test, low allergen exposure neg skin test, high allergen exposure* pos skin test, low allergen exposure pos skin test, high allergen exposure* Rosenstreich et al., N Eng J Med, 336: , 1997

13 Inner City Asthma Study (ICAS) Multi-component Intervention Reductions in cockroach and dust mite allergens correlated with reduced asthma morbidity. Morgan et al., N Eng J Med, 351: , 2004

14 Cat and Dog Allergens The major allergens are Cat - Fel d 1: Sebaceous and salivary glands. Dog - Can f 1: Dander and saliva. Ubiquitously found in homes and public buildings. Homes with pets have increased (~100x) allergen levels. Direct and indirect cat exposure associated with asthma symptoms and morbidity. The association between pet ownership and the development of sensitization and asthma is mixed in the literature, with increased, decreased and no risk reported.

15 Reduction Measures for Pet Dander Air filters Mixed results on effectiveness. Washing cats and dogs Washing cats and dogs can significantly reduce airborne cat allergen, but the decrease is not maintained for more than a few days. Removal of pet from home significantly decreases allergen exposure and it is associated with improvement of symptoms. Wood et al, AJRCCM 1998;158:115-20] Van der Heide et al., JACI 1999;104:447-51]

16 Recommendations for Allergen Avoidance for Pet Allergic Patients First Line Do not have pets. Find existing pet a new home. Second line Keep the pet outside at all times. Isolate the pet from the bedroom. Air cleaners. Wash pet regularly.

17 Rodent Allergens Mouse allergen is widespread in occupational and home settings, with higher levels occurring in urban areas and low income, multi-family dwellings. Exposure to high levels of mouse/rat allergen is associated with excess asthma morbidity in inner city children who are sensitive to mouse/rat allergen. Effective mouse allergen mitigation involves basic principles of integrated pest management. Reductions in mouse allergen in the environments of inner city asthmatic children may improve asthma symptoms. Phipatanakul W, Matsui E, Portnoy J, et al. Environmental assessment and exposure reduction of rodents: a practice parameter. Ann Allergy Asthma Immunol 109; 2012:

18 Damp Indoor Environments and Respiratory Health Institute of Medicine (U.S.). Committee on Damp Indoor Spaces. Board on health Promotion and Disease Prevention. Accessed

19 Mold Exposure in the Home Associates with Asthma Increasing levels of the mold, Alternaria, correlate with asthma, independent of sensitization. Salo PM et al. J Allergy Clin Immunol. 2005; 116: Salo PM et al. J Allergy Clin Immunol. 2006; 118:

20 2007 NAEPP Guidelines Recommend Controlling Dampness and Mold Mold growth indoors can be inhibited by reducing moisture and humidity. Proper building maintenance, dehumidification, air conditioning, and increased ventilation with use of kitchen and bathroom ventilation fans. Humidifiers and vaporizers increase indoor humidity and can become contaminated with mold. Therefore, they should not be used in homes of asthmatics.

21 Major Outdoor Allergens Pollen from grasses, trees, weeds, and mold spores. Pollen and mold counts vary geographically and by season. Seasonal peaks in pollens cause allergic rhinitis ( hay fever ) and can exacerbate asthma. The National Allergy Bureau (NAB TM ) maintains a current and user friendly website of pollen counts Pollen counts are predicted to rise with climate change Burge HA, Rogers CA. Outdoor allergens. Environ Health Perspect. 2000;108(S4):653 Shea KM, et al. Climate change and allergic disease. J Allergy Clin Immun. 2008;122(3):

22 Outdoor Allergen Exposure Trees and grasses predominate in spring and early summer. Weeds (ragweed) peak in fall months. Associations between pollen exposure and ED visits for asthma are complex, allergenspecific and modified by age 10-15% increased risk of ED visit on days with highest pollen counts for oak and grasses. Example of seasonal variation in pollen counts (Atlanta, Georgia) (Birch family) (Cypress family) (Oak family) (Pine family) (Grasses) (Ragweed) Darrow LA et al., J Allergy Clin Immunol July, 2012, 30:

23 Outdoor allergen particles Pollens grains are typically microns in diameter, too big to enter the lower respiratory tract. Allergens are also detectable in smaller sub-pollen particles that are likely more immunogenic. The precise composition of smaller pollen particles and their relationship to allergic diseases requires more study. The concentration and deposition of airborne allergen particles is enhanced following rainstorms, which helps explain thunderstorm asthma. - Schäppi GF et al, J Allergy Clin Immun. 1997; 100: Newson R et al, Thorax. 1997; 52: Anderson HR et al, Thorax. 1998; 53: Bacsi A et al, J Allergy Clin Immun. 2006; 118:844.

24 Non-Allergen Environmental Factors Affecting Allergic Diseases Pollutants Sources Automobiles, industry (summer)

25 Human Activity Produces Greenhouse Gases that Trap Heat in the Atmosphere Image provided by National Park Service

26 Other Signs of Climate Change/ Disruption Image Source: EPA

27 Source: EPA Greenhouse Gases

28 Source EPA Clean Air Act

29 CO2

30 N 2 O

31 Particulate Matter (PM)

32 PM

33 Ozone (O 3 )

34 O 3 Ozone standards were revised by EPA October, The previous standard was 75ppb set in The new standard is 70ppb. Once fully implemented would prevent annually asthma attacks in children 160,000 missed school days 28,000 missed work days 660 premature deaths Both ALA and AAP urged a lower standard of 60ppb. HR 806

35 Indoor Air Pollutants World Health Organization

36 Asthma and Air Pollution Molfino, Lancet, 1991; Peden, AJRCCM, 1995 Bernstein DI, Traffic related pollutants and wheezing in children. J Asthma Feb;49(1):5-7. * Alexis & Carlsten, 2014

37 Asthma and Air Pollution Molfino, Lancet, 1991; Peden, AJRCCM, 1995 Bernstein DI, Traffic related pollutants and wheezing in children. J Asthma Feb;49(1):5-7. * Alexis & Carlsten, 2014

38 Air Pollution And Asthma Janssen NA, et.al. Environ Health Perspect 2003;111: Venn AJ, et.al. Am J Respir Crit Care Med 2001;164: Wyler C, et.al. Epidemiology 2000;11: Nicolai T, et.al. Eur Respir J 2003:21: Schwartz, J. Pediatrics. 2004;43:113: Tomoyuki Ohtani et al, Cellular Basis of the Role of Diesel Exhaust Particles in Inducing Th2-Dominant Response J of Immun, 2005,

39 Environmental Tobacco Smoke Exposure 1 Sonnenschein-van der Voort AM, et.al. Environ Health Dec 11;11:91. 2 Herr M, J Allergy Clin Immunol Aug;130(2):

40 Role Of Pollution And Climate Change Ziska LH, et.al. J Allergy Clin Immunol 2003;111: Wayne P, et.al. Ann Allergy Asthma Immunol 2002;88: Ziska L, Proc Natl Acad Sci U S A. 2011;108:

41 Thunderstorm Asthma

42 Taking Action on Climate Change: Adaptation/Preparedness in Healthcare

43 What Should We Advise Patients With Respiratory Diseases?

44 Taking Action on Climate Disruption: Mitigation

45 AAP Recommendations Pediatricians can promote medical educational opportunities and inform policymakers on the risks climate change poses to child health. We can reduce our energy consumption at home, work and on the road We can bike, walk and use other modes of active transportation, which is good for our climate, and for our health. We can reduce, reuse, recycle Kids can get involved by learning about climate change from NASA or via Green Schools Alliance Parents can join groups such as Moms Clean Air Force to work on the local and national level to protect families We all can advocate for policies that reduce greenhouse gas emissions. Most importantly, you can let your political leaders know you care.

46 We are an important voice! Pediatric health care professionals should understand these threats, anticipate their effects on children s health, and participate as children s advocates for strong mitigation and adaptation strategies now. - American Academy of Pediatrics There s no voice more credible than public health professionals to convey that our climate crisis is a public health crisis. Gina McCarthy, EPA Administrator -

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