Global strategy for asthma management and prevention

Allergic rhinitis is a symptomatic disorder of the nose induced after allergen exposure by an IgE-mediated inflammation of the membranes lining the nose. It is a global health problem that causes major illness and disability worldwide. Over 600 million patients from all countries, all ethnic groups and of all ages suffer from allergic rhinitis. It affects social life, sleep, school and work and its economic impact is substantial. Risk factors for allergic rhinitis are well identified. Indoor and outdoor allergens as well as occupational agents cause rhinitis and other allergic diseases. The role of indoor and outdoor pollution is probably very important, but has yet to be fully understood both for the occurrence of the disease and its manifestations.

In 1999, during the Allergic Rhinitis and its Impact on Asthma (ARIA) WHO workshop, the expert panel proposed a new classification for allergic rhinitis which was subdivided into 'intermittent' or 'persistent' disease.

This classification is now validated. The diagnosis of allergic rhinitis is often quite easy, but in some cases it may cause problems and many patients are still under-diagnosed, often because they do not perceive the symptoms of rhinitis as a disease impairing their social life, school and work.

The management of allergic rhinitis is well established and the ARIA expert panel based its recommendations on evidence using an extensive review of the literature available up to December 1999. The statements of evidence for the development of these guidelines followed WHO rules and were based on those of Shekelle et al. A large number of papers have been published since 2000 and are extensively reviewed in the 2008 Update using the same evidence-based system. Recommendations for the management of allergic rhinitis are similar in both the ARIA workshop report and the 2008 Update. In the future, the GRADE approach will be used, but is not yet available.

Another important aspect of the ARIA guidelines was to consider co-morbidities. Both allergic rhinitis and asthma are systemic inflammatory conditions and often co-exist in the same patients. In the 2008 Update, these links have been confirmed.

The ARIA document is not intended to be a standard-of-care document for individual countries. It is provided as a basis for physicians, health care professionals and organizations involved in the treatment of allergic rhinitis and asthma in various countries to facilitate the development of relevant local standard-of-care documents for patients.

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Allergic rhinitis and its impact on asthma (ARIA) 2008 update (in collaboration with the World Health Organization, GA(2)LEN and AllerGen)

Authors Jan L. Brozek, MD, PhD – Department of Clinical Epidemiology & Biostatistics and Medicine, McMaster University, Hamilton, Canada Jean Bousquet, MD, PhD – Service des Maladies Respiratoires, Hopital Arnaud de Villeneuve, Montpellier, France, INSERM, CESP U1018, Respiratory and Environmental Epidemiology Team, France, and WHO Collaborating Center for Rhinitis and Asthma Carlos E. Baena-Cagnani, MD – Faculty of Medicine, Catholic University of Cordoba, Cordoba, Argentina Sergio Bonini, MD – Institute of Neurobiology and Molecular Medicine – CNR, Rome, Italy and Department of Medicine, Second University of Naples, Naples, Italy G. Walter Canonica, MD – Allergy & Respiratory Diseases, DIMI, Department of Internal Medicine, University of Genoa, Genoa, Italy Thomas B. Casale, MD – Division of Allergy and Immunology, Department of Medicine, Creighton University, Omaha, Nebraska, USA Roy Gerth van Wijk, MD, PhD – Section of Allergology, Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, the Netherlands Ken Ohta, MD, PhD – Division of Respiratory Medicine and Allergology, Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan Torsten Zuberbier, MD – Department of Dermatology and Allergy, Charite Universitatsmedizin Berlin, Berlin, Germany Holger J. Schunemann, MD, PhD, MSc – Department of Clinical Epidemiology & Biostatistics and Medicine, McMaster University, Hamilton, Canada

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Allergic Rhinitis and Its Impact on Asthma

Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma

Probiotics in primary prevention of atopic disease: a randomised placebo-controlled trial

Background
The prevalence of atopic diseases is on the rise. Traditional lifestyles may be associated with a reduced risk of atopy.

Objectives
To test the hypothesis that children living on a farm have lower prevalences of atopic diseases. To identify differences in living conditions between farmers and other families which are associated with the development of atopic conditions.

Design
Cross-sectional survey among children entering school (aged 5–7 years). A written questionnaire including the ISAAC core questions and asking for exposures on a farm and elsewhere was administered to the parents. Setting: School health entry examination in two Bavarian districts with extensive farming activity. Subjects: 10 163 children.

Main outcome measures
The prevalence of doctor's diagnoses and symptoms of hay fever, asthma and eczema as assessed by parental report.

Results
Farmers' children had lower prevalences of hay fever (adjusted odds ratio = 0.52, 95% CI 0.28–0.99), asthma (0.65, 0.39–1.09), and wheeze (0.55, 0.36–0.86) than their peers not living in an agricultural environment. The reduction in risk was stronger for children whose families were running the farm on a full-time basis as compared with families with part-time farming activity. Among farmers' children increasing exposure to livestock was related to a decreasing prevalence of atopic diseases (aOR = 0.41, 95% CI 0.23–0.74).

Conclusions
Factors related to environmental influences on a farm such as increased exposure to bacterial compounds in stables where livestock is kept prevent the development of allergic disorders in children.

Reduced risk of hay fever and asthma among children of farmers.

Background Atopic dermatitis (AD) is considered to be one of the first manifestations in the atopic march. However, few prospective studies on AD and its association with childhood asthma exist. Objective The aim of this study was to prospectively investigate the natural course of AD to determine factors influencing its prognosis and to analyze the relationship of AD with childhood asthma. Methods The Multicenter Allergy Study, a German birth cohort, followed 1314 children from birth to age 7 years. Physical examinations, parental interviews on atopic symptoms and diagnoses, and determination of specific IgE levels were performed regularly. Results The cumulative prevalence of AD in the first 2 years of life was 21.5%. Of these children with early AD, 43.2% were in complete remission by age 3 years, 38.3% had an intermittent pattern of disease, and 18.7% had symptoms of AD every year. Severity (adjusted cumulative odds ratio, 5.86; 95% CI, 3.04-11.29) and atopic sensitization (adjusted cumulative odds ratio, 2.76; 95% CI, 1.29-5.91) were major determinants of prognosis. Early wheeze and a specific sensitization pattern were significant predictors for wheezing at school age, irrespective of AD. Early AD without these cofactors constituted no increased risk of subsequent wheeze (adjusted odds ratio, 1.11; 95% CI, 0.56-2.20) or bronchial hyperreactivity. Conclusion AD is a common condition in infancy but disappears around age 3 years in a significant proportion of children. The prognosis is mostly determined by the severity and the presence of atopic sensitization. Early AD is associated with asthma at school age, but in many of these asthmatic children, wheezing manifests before or with the onset of AD. Children with AD and wheeze have a marked loss in lung function, suggesting a distinct phenotype rather than a progressive development from AD to asthma.

The natural course of atopic dermatitis from birth to age 7 years and the association with asthma.

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(06)69286-6.pdf

Perennial allergen sensitisation early in life and chronic asthma in children: a birth cohort study

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(00)02842-7.pdf

Early exposure to house-dust mite and cat allergens and development of childhood asthma: a cohort study

192 (52·2%) 492 (52·0%) 403 (50·8%) 33 (55·9%) 56 (59·6%) Mean ponderal index at birth (SD) 25·40 (2·39) 25·23 (2·31) 25·23 (2·30) 25·85 (2·26) 24·83 (2·25) Elevated cord blood IgE 74 (21·0%) 167 (18·4%) 142 (18·7%) 8 (13·6%) 17 (19·3%) Parental atopy 176 (48·6%) 507 (53·6%) 402 (50·8%) 30 (50·8%)* 75 (79·8%)† One or more older sibling 153 (41·6%) 440 (46·6%) 367 (46·3%) 32 (54·2%) 41 (43·6%) Maternal smoking in pregnancy 110 (33·2%)‡ 199 (22·6%) 162 (22·0%) 10 (17·5%) 27 (30·7%) Parental smoking 191 (58·8%)‡ 381 (44·0%) 313 (43·3%) 24 (40·7%) 44 (53·0%) High level of parental education 162 (48·6%)‡ 501 (55·9%) 414 (55·3%) 33 (60·0%) 54 (58·06%) Data assessed early in life Breast feeding ≥4 weeks .. .. 583 (74·3%) 46 (78·0%) 78 (83·9%)† Sensitisation to foods (≤age 3 years) .. .. 140 (20·4%) 6 (11·8%)* 49 (57·6%)†

Sabina Illi

Papers

Reduced risk of hay fever and asthma among children of farmers.

The natural course of atopic dermatitis from birth to age 7 years and the association with asthma.

Perennial allergen sensitisation early in life and chronic asthma in children: a birth cohort study

Early exposure to house-dust mite and cat allergens and development of childhood asthma: a cohort study

Perennial allergen sensitisation early in life and chronic asthma in children