I came across a very interesting and powerful editorial that summarized many issues dealing with the worldwide problem of allergy.

Allergy is a major health problem-clearly not in everyone and not in the majority of the population. Worldwide allergy affects 10-30% of people. As far as a single chronic clinical condition, that is a significant number. Also, the prevalence has increased.

The impact of an allergy can be life-threatening (acute severe episodes) or chronic (daily symptoms). The allergic condition does have a major socioeconomic burden and allergy also has the obvious effect on a patient or a family’s quality of life.

Despite advances in research on causes, associations, risk factors, and treatment of allergy there are many inadequacies and unanswered questions. This editorial shares those concerns.

This is a consensus statement from a group of 40 noted researchers and clinicians from four continents who met in Switzerland last year. The banner for the meeting was simply ‘Allergy and Allergic Diseases: Barriers to Cure’.

Allergic conditions deal with many broad areas of medicine. Allergy affects a wide range of organ systems; eyes, respiratory tract, gastrointestinal tract, and skin. The conditions vary in severity and their course.

Listed are the concerns and needs (these come from the experts and are my summations of their summation);

• The cause(s) for the increase in allergy prevalence is unknown. Environmental considerations    include; air quality, diet, climate, UV radiation, direct skin contact, and psycho-social interactions.
• A specific environment may protect or put someone at risk if they have the genetic predisposition towards allergy.
• Interactions between bacteria, pollutants, and the immune system are marginally understood.
• There is inadequate understanding of those natural mechanisms that lead to acute vs. chronic suffering with allergy or resolution of allergy.
• There needs to be a better classification system for severity/types of allergy.
• New therapies need to work on the pathways that lead to an allergic response.
• Better translational research is needed (taking what is learned in the laboratory to the bedside).
• Better tools are needed to analyze the information or data regarding allergy.
• There needs to be a plan for prevention of allergy.
• We need better tools for diagnosis and prediction of a response to treatment.

The article also noted the gap between what we know about allergy and the application of that knowledge to those who struggle with allergy.

• There is a shortage of well-trained allergists in most countries
• Education and training efforts regarding allergy need to start with the medical students, especially for a condition that affects so many people
• Awareness campaigns are needed for targeted groups such as nurses and school teachers
• There needs to be close cooperation with patient organizations
• Decision makers for developing and approving health policies and administration must be made more aware of the issues and problems of allergic diseases

Reviewer’s note-

It scary what we do not know and it is even scarier that we are not doing much about a few things when we can.

Allergy is a public health problem.

The editorial challenges us to make a change.

This year Dr. Vitalpur and I will be offering clinical teaching about the immune system and allergy in particular to first year medical students.

I have always wondered why allergy is not a required resident rotation – a requirement by the governing board of residencies. The condition affects so many children and is thought to affect so many more. I can easily see the impact of having at least a few weeks of exposure to the specialty in our allergy clinic.

We are most happy to speak at support groups or schools and we have done that many times. I am concerned that we are not asked more frequently to go out in the community.

We get involved with patient organizations and are willing to be involved with more.

It is unfortunate that we are not asked about policy or design. More often we have a reactive role in this regard.

The challenge is before us.

FEL (2-2-2012)

During a career you hear many words of wisdom from your mentors who are with you seeing children in the office and from meetings, curbside conversations/consultations, and from the literature. The adage that allergic children get sick easier, more frequently, and have more severe illnesses has been out there for many years. There are a number of theories for this contention. Children with allergy tend to remedy their itchy nose with internal manipulation, otherwise known as nose-picking. The finger serves as the vector for direct inoculation of viral particles onto the respiratory tract. Also, a number of years ago a publication reported that allergic noses actually had more receptors for the cold virus than non-allergic noses.

The May issue of the  Journal of Allergy, Asthma, and Immunology (Volume 125 No 5.) has an article by Jaime Olenec, ‘Weekly monitoring of children with asthma for infections and illness during common cold seasons’ concluded that atopic (showing IgE antibodies) children with asthma do have more frequent and more severe asthma exacerbations due to the common cold. The bottom line for me is the impact that the specialty of allergy and the determination of sensitization to allergens can make on children with asthma. The study did not address allergen control measure effects on frequency/severity of asthma symptoms.

My review of the study-

The group who did this is excellent and has a long established research track record and publication record regarding the role of viruses and allergy in pediatric asthma.

The journal in which this was published is peer-reviewed and a top-notch allergy journal. Also of note is that the manuscript was submitted in September, 2010 and was accepted for publication four months later.

The support for the work was from the National Institutes of Health.

The purpose of the study was to look at the impact of viral infections and allergic sensitization on the loss of asthma control during the peak ‘cold’ season.

The study involved 58 children between the ages of 6-8 years who were known to have asthma. These children were followed for three years. Skin testing and specific IgE testing was performed on all. Nasal samples were collected and analyzed for human rhinovirus infection. Diary cards were kept for symptoms. Cold and asthma symptom scores were collected along with peak flow value recordings and notations of the frequency albuterol (rescue inhaler) usage.

There were 42 children who had at least one season of complete data. The average age was 6.5 years and there were 30 boys and 12 girls. In this group 50% had one or more positive skin prick test for an allergen. Of note is that 69% had one or more positive blood tests for an allergen. Additional baseline information included; daily asthma controller medications used by 88%, and oral corticosteroids were used by 57% in the past year. Fifty five percent of the mothers and 40% of the fathers had allergy.

The number of viral illnesses per season was higher in the allergen sensitized group; 47% more virus-associated illness per season. During documented viral infections (viral cultures were frequently performed), the non-atopic children commonly reported no or mild cold symptoms. In the sensitized (atopic) children symptoms tended to be more moderate or severe. Also, almost half of the viral infections in the sensitized children caused moderate or severe asthma symptoms.

The author’s conclusions were that respiratory tract illnesses (asthma symptoms) due to viruses were more severe and were more frequent in children who are atopic.

These were children with asthma who had a positive allergy test. The terms sensitized and atopy were used to describe the group. Asthma frequency and asthma severity was increased in those who have made at least one IgE antibody to something.

This was a small study which was done in only one site. Larger studies in a variety of populations need to be done to confirm these observations.

This work re-affirms my practice of being aggressive with my allergic asthmatic children when the first signs of a cold occur. I advocate stepping-up the treatment program and continuing it for up to 14 days. One of the charts shows that the average duration of cold symptoms was 8.1 +/- 5.6 days and the average duration of asthma symptoms was 7.2 +/- 7.8 days in those who had a documented rhinovirus infection. For me this fits nicely with what I advise- on the average cold symptoms may begin the day prior to asthma symptoms and at the extremes of the range, asthma symptoms may last 14 days in some children.

FEL