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    What 2012 allergen avoidance What 2012 allergen avoidance Presentation Transcript

    • WHAT YOU SHOULD HAVE READ BUT….2012  allergen avoidanceAttilio BonerUniversity ofVerona, Italy
    • Prevention of asthma in genetically susceptible children: A multifaceted intervention trial focussed on feasibility in general practice Maas Pediat Allergy Immunol 2011;22:794 1) The only variables that seemed to influence the development of asthma Simultaneous reduction were number of weeks a child was in the environmental breast-fed and the exposure to the exposures to inhalant- house dust mite allergen Der p1 and food allergens. above or below the group median (0.6606 μg/g of dust). 476 children susceptible 2) Breast-feeding seems to for developing asthma. significantly reduce the development of asthma (p=0.026), whereas a Diagnosis of allergic Der p1 exposure level at 4 yr of asthma at age 6 yrs. age below the group median may indicate a protective effect (p = 0.061).
    • Prevention of asthma in genetically susceptible children: A multifaceted intervention trial focussed on feasibility in general practice Maas Pediat Allergy Immunol 2011;22:794 OR for allergic asthma 2.0 – Simultaneous reduction at age 6 years in the environmental exposures to inhalant- 1.70 1.5 – and food allergens. 1.0 – 476 children susceptible for developing asthma. 0.5 – Diagnosis of allergic asthma at age 6 yrs. 0 0.25 Der p1 >0.66 Breast-feeding μ/g of dust 12-25 weeks vs 0
    • Opposite effects of allergy prevention depending on CD14 rs2569190 genotype in 3 intervention Studies Kerkhof JACI 2012;129:258• The Dutch Prevention and Incidence of Asthma and Mite Allergy (PIAMA) study investigated whether the use of mite allergen–impermeable mattress covers (IMCs) reduced the risk of asthma and allergy in high-risk children. No effect was found, despite lower allergen levels on the children’s mattresses. In the winters of 1995/1996 and 1996/1997, which but preceded and coincided with the PIAMA baseline measurements, temperatures had been extremelyLa mano de DIOS...was the PIAMA low, and precipitation had been extremely low asintervention study intervened upon? well. It is likely that these unusual winter weatherBrunekreef B, Allergy. 2005;60:1083-6. conditions affected the baseline allergen levels in the PIAMA study so that the effect of the planned intervention (mite impermeable mattress covers) was considerably smaller than it could have been.
    • Opposite effects of allergy prevention depending on CD14 rs2569190 genotype in 3 intervention Studies Kerkhof JACI 2012;129:258• Dutch Prevention of Asthma in Children (PREVASC) study and Canadian Childhood Asthma Primary Prevention Study (CAPPS) assessed the effectiveness of a multifaceted intervention program for primary prevention of asthma in high-risk children, including the use of mattress covers.• A meta-analysis of the PREVASC study, CAPPS, and the Isle of Wight study showed a decreased risk of asthma with multifaceted interventions in the first 5 years of life. Although this effect was still observed in CAPPS at 7 years of age, the prevalence of atopy was not reduced.1. Corver K,, et al. House dust mite allergen reduction and allergy at 4 yr: follow up of the PIAMAstudy. Pediatr Allergy Immunol 2006;17:329-36.2. Chan-Yeung M, et al. The Canadian Childhood Asthma Primary Prevention Study: outcomes at 7 years of age. J Allergy Clin Immunol 2005;116:49-55.3. Woodcock A, et al. Early life environmental control: effect on symptoms, sensitization, and lung function at age 3 years. Am J Respir Crit Care Med 2004;170:433-9.
    • Opposite effects of allergy prevention depending on CD14 rs2569190 genotype in 3 intervention Studies Kerkhof JACI 2012;129:258• A possible explanation might be that the interventions simultaneously reduced microbial exposure in the children’s mattresses, which are important reservoirs of bacteria and microbial products.• This would support the hypothesis that binding of microbial antigens to innate immune receptors skews the immune system toward a TH1 response, favoring a nonallergic immune response.
    • Opposite effects of allergy prevention depending on CD14 rs2569190 genotype in 3 intervention Studies Kerkhof JACI 2012;129:258• A common functional single nucleotide polymorphism in the innate receptor CD14 (rs2569190) has been shown to interact with the level of microbial exposure in the development of atopy.• Therefore we studied whether the rs2569190 genotype modifies the intervention effects on the development of asthma and allergy in the PIAMA, CAPPS, and PREVASC birth cohoorts.
    • Opposite effects of allergy prevention depending on CD14 rs2569190 genotype in 3 intervention Studies Kerkhof JACI 2012;129:258 Intervention measures aimed at preventing CC/CT versus the development of atopy by TT genotype reducing the amount of exposure of rs2569190. to inhalant allergens in high-risk children might have Outcomes were opposite effects in subgroups of measured at children with specific CD14 ages 8. genotypes, possibly because of the simultaneous reduction of exposure to microbial products.
    • Opposite effects of allergy prevention depending on CD14 rs2569190 genotype in 3 intervention Studies Kerkhof JACI 2012;129:258 What will be Intervention measures aimed at preventing CC/CT effect of the versus the development of atopy by allergen TT genotype reducing the amount of exposure avoidance of rs2569190. to inhalant allergens togheter with in high-risk children might have Outcomes were the simultanaous opposite effects in subgroups of measured at children with specific CD14 administration of ages 8. genotypes, possibly because of the bacterial simultaneous reduction of exposure products? to microbial products.
    • Effect of freezing, hot tumble drying and washing with eucalyptus oil on house dust mites in soft toys Chang Pediat Allergy Immunol 2011;22:638 % reduction in living mites 36 toys (12 in each Freezing Hot tumble Washing with treatment group). drying eucalyptus oil 90 Live HDM by the 10 – heat escape method 20 – 4.25 before and after 30 – freezing 40 – overnight, hot 50 – tumble drying for 60 – 1 h and washing in 70 – 0.2% to 0.4% 80 – -95% -89% -95% eucalyptus oil. 90 – 100 –
    • Effect of freezing, hot tumble drying and washing with eucalyptus oil on house dust mites in soft toys Chang Pediat Allergy Immunol 2011;22:638 % reduction in living mites 36 toys (12 in each Freezing Hot tumble Washing with Additionally, washing treatment group). drying eucalyptus oil with eucalyptus oil 90 Live HDM by the a resulted in 10 – heat escape method significant reduction 20 – 4.25 before and after as in HDM allergens 30 – freezing a geometric well from 40 – overnight, hot μg/g mean of 9.12 50 – tumble drying μg/g to 0.37 for 60 – (p = 0.033). 1 h and washing in 70 – 0.2% to 0.4% 80 – -95% -89% -95% eucalyptus oil. 90 – 100 –
    • Nocturnal temperature controlled laminar airflow for treating atopic asthma: a randomized controlled trial Boyle, Thorax 2012;67:215Background:• In patients with atopic asthma, the abnormal immune response to inhalant allergens is an important contributor to symptoms.• Studies undertaken at high altitude suggest that long-term avoidance of allergens and other exposures can lead to reduced asthma symptoms.• A new device has recently been shown to markedly reduce levels of inhaled allergen and other particles using temperature controlled laminar airflow (TLA).• We undertook a multicentre randomized controlled trial of nocturnal TLA treatment in atopic asthmatic patients.
    • Nocturnal temperature controlled laminar airflow for treating atopic asthma: a randomized controlled trial Boyle, Thorax 2012;67:215 Treatment response rate in patients treated with temperature controlled laminar airflow (TLA) or a placebo device for 1 year, defined as an increase in Asthma Quality of Life Questionnaire score of either ≥0.5 or ≥ 1.0 point. 312 patients aged 7-70 with inadequately controlled persistent atopic asthma. Proportion of patients with an increase of ≥ 0.5 pts in asthma quality of life score after 1 yr of treatment. *p<0.05, **p<0.01 relative to placebo.
    • Nocturnal temperature controlled laminar airflow for treating atopic asthma: a randomized controlled trial Boyle, Thorax 2012;67:215 Change in FeNO (ppb) 4 - 312 patients aged 7-70 3 – with inadequately controlled 2 – +2.82 persistent atopic asthma. 1 – 0 ACTIVE Proportion of patients -1 – Placebo with an increase of ≥ 0.5 pts -2 – in asthma quality of life score -3 – p=0.03 after 1 yr of treatment. -4 – -4.88 -5 –
    • Nocturnal temperature controlled laminar airflow for treating atopic asthma: a randomized controlled trial Boyle, Thorax 2012;67:215 Change in FeNO (ppb) Inhalant exposure 4 - 312 patients aged 7-70 reduction with TLA 3 – with inadequately controlled improves quality of 2 – +2.82 persistent atopic asthma. life, airway inflammation 1 – ACTIVE Proportion of and 0 patients Placebo systemic allergy -1 – with an increase of ≥ 0.5 pts in patients with -2 – in asthma quality of life score p=0.03 persistent -3 – after 1 yr of treatment. atopic asthma. -4 – -4.88 -5 –
    • Feather bedding and childhood asthma associated with house dust mite sensitisation: a randomised controlled trial. Glasgow Arch Dis Child 2011;96:541IntroductionObservational studies report inverse associations between the use offeather upper bedding (pillow and/or quilt) and asthma symptoms but thereis no randomised controlled trial evidence assessing the role of featherupper bedding as a secondary prevention measure.ObjectiveTo determine whether, among children not using feather upper bedding,a new feather pillow and feather quilt reduces asthma severity among housedust mite (HDM) sensitised children with asthma over a 1-year periodcompared with standard dust mite avoidance advice, and giving children a newmite-occlusive mattress cover.
    • Feather bedding and childhood asthma associated with house dust mite sensitisation: a randomised controlled trial. Glasgow Arch Dis Child 2011;96:541 % children with frequent wheeze 70 – (≥4 episodes) 197 children with HDM sensitisation and moderate 60 – 63.8% ns to severe asthma. 50 – 55.3% New upper bedding duck 40 – feather pillow and quilt and a mite-occlusive 30 – mattress cover (feather) 20 – Standard care and a mite- occlusive mattress cover 10 – (standard). 0 Feather Standard bedding care
    • Feather bedding and childhood asthma associated with house dust mite sensitisation: a randomised controlled trial. Glasgow Arch Dis Child 2011;96:541 197 children with HDM sensitisation and moderate % children with to severe asthma. speech-limiting wheeze New upper bedding duck feather pillow and quilt 30 – ns and a mite-occlusive 22.6% mattress cover (feather) 20 – 20.2% Standard care and a mite- 10 – occlusive mattress cover (standard). 0 Feather Standard bedding care
    • Feather bedding and childhood asthma associated with house dust mite sensitisation: a randomised controlled trial. Glasgow Arch Dis Child 2011;96:541 % children with sleep disturbed because of wheezing 197 children with HDM 60 – sensitisation and moderate ns to severe asthma. 50 – 55.3% New upper bedding duck 50.0% 40 – feather pillow and quilt and a mite-occlusive 30 – mattress cover (feather) 20 – Standard care and a mite- occlusive mattress cover 10 – (standard). 0 Feather Standard bedding care
    • Feather bedding and childhood asthma associated with house dust mite sensitisation: a randomised controlled trial. Glasgow Arch Dis Child 2011;96:541 % children with sleep disturbed because of wheezing 197 children with HDM 60 – sensitisation and moderate ns to severe asthmapillow No cover . 50 – 55.3% New upper bedding duck 50.0% or cover quilt feather pillow and quilt 40 – was provided. and a mite-occlusive 30 – mattress cover (feather) 20 – Standard care and a mite- occlusive mattress cover 10 – (standard). 0 Feather Standard bedding care
    • Feather bedding and childhood asthma associated with house dust mite sensitisation: a randomised controlled trial. Glasgow Arch Dis Child 2011;96:541but•A quarter (27 of 94) of feather group children reported usingsynthetic pillows at trial end and one-third were not sleeping withthe feather pillow and quilt.•Analysis by compliance rather than intention to treat raised thepossibility that feather bedding use was associated with reducedrespiratory symptoms and better lung function, a result in line withthe observational epidemiological findings.•No regular laundry were used and thus in the high miteenvironment of Sydney, surface allergen may have accumulatedsimilarly from non-bedding sources onto both types of bedding.
    • Feather bedding and childhood asthma associated with house dust mite sensitisation: a randomised controlled trial. Glasgow Arch Dis Child 2011;96:541 OR for frequent wheeze (≥4 episodes) The association of feather upper 2.0 – bedding use (pillow and quilt) and 1.5 – 1.88 respiratory outcomes, with 1.0 – further consideration 0.5 – of child’s usual 0.61 sleeping position. 0 0 Non-supine Supine children children Feather bedding use
    • Feather bedding and childhood asthma associated with house dust mite sensitisation: a randomised controlled trial. Glasgow Arch Dis Child 2011;96:541 The association of feather upper OR for speech-limiting wheeze bedding use (pillow and quilt) and 1.5 – respiratory outcomes, with 1.0 – further consideration 0.5 – 0.90 of child’s usual 0.0 sleeping position. 0 0 Non-supine Supine children children Feather bedding use
    • Feather bedding and childhood asthma associated with house dust mite sensitisation: a randomised controlled trial. Glasgow Arch Dis Child 2011;96:541 The association of feather upper OR for sleep disturbed because of wheezing (≥1 nights per week) bedding use (pillow and quilt) and 1.5 – respiratory outcomes, with 1.0 – further consideration 0.5 – of child’s usual 0.57 0.0 sleeping position. 0 0 Non-supine Supine children children Feather bedding use
    • Feather bedding and childhood asthma associated with house dust mite sensitisation: a randomised controlled trial. Glasgow Arch Dis Child 2011;96:541 Intervention The association ofrisk reduced the feather upper being of sleep OR for sleep disturbed because of wheezing (≥1 nights per week) bedding use (pillow disturbed because and quilt) and of wheezing and 1.5 – respiratory wheeze to severe outcomes, witha 1.0 – further consideration greater extent for 0.5 – of child’s usual slept children who 0.57 0.0 sleeping position. supine. 0 0 Non-supine Supine children children Feather bedding use
    • House dust mite avoidance measures for perennialallergic rhinitis: an updated Cochrane systematic review Nurmatov, Allergy 2012;67:158 HDM (house dust mite) control measures 7 of the 9 trials reported vs placebo. that, when compared with control, Patients with the interventions studied clinically proven resulted in significant reduction allergic rhinitis. in HDM load. 9 trials involving 501 participants.
    • House dust mite avoidance measures for perennialallergic rhinitis: an updated Cochrane systematic review Nurmatov, Allergy 2012;67:158 Interventions that achieve substantial reductions in HDM load may HDM (house dust mite) offer some benefit in reducing control measures rhinitis symptoms. vs placebo. Patients with Isolated use of HDM clinically proven impermeable bedding allergic rhinitis. is unlikely to prove effective. 9 trials involving Education is also neededd 501 participants.
    • Do young adults with childhood asthma avoid occupational exposures at first hire? Dumas ERJ 2011;37:1043 % subjects exposed in their first job 298 children examined 50 – (1991-1995). Job at follow-up in 2003-2007 40 – 47% 30 – (aged 17-29 yrs). Exposure to dust, gases 20 – and/or fumes in their 10 – first occupation. 0
    • Do young adults with childhood asthma avoid occupational exposures at first hire? Dumas ERJ 2011;37:1043 OR to be exposed1.0 – 0.980.5 – 0.67 0.55 0 0.27 Pre-hire Severe University Not onset asthma in degree university asthmatics childhood degree
    • Do young adults with childhood asthma avoid occupational exposures at first hire? Dumas ERJ 2011;37:1043 OR to besuggest a Results exposed healthy worker hire1.0 – effect in subjects with more severe or more symptomatic asthma in chilhood. Education may modulate self-selection. 0.980.5 – 0.67 0.55 0 0.27 Pre-hire Severe University Not onset asthma in degree university asthmatics childhood degree
    • Complianceeducation
    • EAACI Position Paper: Prevention of work-relatedrespiratory allergies among pre-apprentices or apprentices and young workers Moscato G, Allergy 2011;66:1164 Students starting career programs with exposure to high molecular weight allergens have a substantial frequency of specific sensitization to work-related allergens that is related to atopy and bronchial hyperresponsiveness (BHR). The incidence of work-related symptoms is higher in the first 2–3 years after starting exposure and decrease afterward. Work-related rhinitis and asthma are more common in those with pre-existing allergic rhinitis and/or BHR.
    • EAACI Position Paper: Prevention of work-related respiratory allergies among pre-apprentices or apprentices and young workers Moscato G, Allergy 2011;66:1164 At least for several allergens, sensitization to common inhalant allergens is associated with the development of sensitization to occupational allergens and the development of work-related respiratory symptoms. Atopy may interact with exposure-response relationships. A baseline health assessment should be performed before starting a vocational school or work that includes exposure to respiratory sensitizers, to identify personal determinants for the development of sensitization and respiratory allergy, and/or to identify pre-existing respiratory diseases susceptible to worsening with workplace exposure.
    • EAACI Position Paper: Prevention of work-relatedrespiratory allergies among pre-apprentices or apprentices and young workers Moscato G, Allergy 2011;66:1164 Adolescents with asthma and allergy often do not consider these conditions in their career choices and may not be aware of the effects that work may have on asthma. There is a need for improved education of adolescents and young adults with asthma as to the potential effects of work on asthma. Environmental control is the cornerstone for prevention, and every effort should be made to keep the workplaces as healthy places.
    • EAACI Position Paper: Prevention of work-relatedrespiratory allergies among pre-apprentices or apprentices and young workers Moscato G, Allergy 2011;66:1164 The physician in charge for the baseline health assessment should discuss the results with the young adult helping her/him in making the professional choice. The young adult should be educated to adopt all preventive measures to limit occupational exposure to potential allergens and respiratory irritants and to recognize and report immediately all possible symptoms suggestive of onset of work-related respiratory allergies or work-related exacerbations. Medical surveillance should be prioritized in the first 2–3 years of exposure and scheduled according to the clinical profile, exposure details, and reliability of available tests.
    • Management of occupational asthma: cessation or reduction of exposure? A systematic review of available evidence Vandenplas ERJ 2011;38:804 OR for reduction of exposure compared with complete avoidance for 10 – 10.23 09 – Reduction 08 – or cessation 07 – of exposure 06 – in 9 and 5 05 – 5.6 studies, respe 04 – ctively. 03 – 02 – 01 – 0.16 0.30 00 Improvement Recovery Symptoms BHR of asthma symptoms worsening
    • Management of occupational asthma: cessation or reduction of exposure? A systematic review of available evidence Vandenplas ERJ 2011;38:804 OR for reduction of exposure compared with complete avoidance for 10 – These findings 10.23 09 – indicate that the Reduction of 08 reduction – or cessation 07 exposure – of exposure 06 cannot be – in 9 and 5 routinely 05 – 5.6 studies, respean advocated as 04 – alternative to ctively. 03 – the cessation of exposure. 02 – 01 – 0.16 0.30 00 Improvement Recovery Symptoms BHR of asthma symptoms worsening
    • Pet shop workers: exposure, sensitization, and work-related symptoms. Renström A, Allergy 2011;66:1081 % subjects presenting 60 - 53% 50 – Subjects (n = 59) from 40 – 24 pet shops. Questionnaire and lung 30 – 34% function tests and skin prick tests. 20 – 22% 10 – 0 nasal eye asthma symptoms
    • Pet shop workers: exposure, sensitization, and work-related symptoms. Renström A, Allergy 2011;66:1081 % subjects presenting 60 - 53% 50 – However,only Subjects (n = 59) from 40 – 24 pet shops. (7%) 4 workers were previously 30 – 34% Questionnaire and lung diagnosed with function tests and skin asthma prick tests 20 – 22% 10 – 0 nasal eye asthma symptoms
    • Pet shop workers: exposure, sensitization, and work-related symptoms. Renström A, Allergy 2011;66:1081 % subjects sensitized to work-related allergens 30 – Subjects (n = 59) from 24 pet shops. 29% 20 – Questionnaire and lung function tests and skin prick tests 10 – 0
    • Pet shop workers: exposure, sensitization, and work-related symptoms. Renström A, Allergy 2011;66:1081 % subjects sensitized to work-related allergens The findings stress 30 – the importance of Subjects (n = 59) from 24 pet shops. the improving 29% knowledge of 20 – health risks and Questionnaire and lung allergen avoidance function tests and skin measures among prick tests 10 – pet shop staff 0
    • Takehome