Review of Pollen Allergy: Literature, Results, Discussion

Chapter 1. Introduction

The suspended pollen grains in the air reach the human respiratory track through inhalation, triggering a type of seasonal allergy called pollen allergy. Pollen is one of the most widespread allergies of all the things that can cause an allergy (PMD, 2017).

Airborne pollen grains are important aeroallergens that may cause allergic rhinitis and asthma in human beings (D'Amato et al., 2007). Pollen grains that cause allergy are usually very small in size and can easily reach the lower respiratory tract (Ciprandi et al., 2005). Allergic rhinitis affects 10–30 % of the global population (Pawankar et al., 2011). Various studies have evidenced the correlation between the high airborne pollen count and allergy symptoms in hypersensitive individuals. (Mandal et al., 2008)

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Islamabad is among the cities with the highest pollen counts in the world. The pollen concentration is more in Islamabad as compared to other cities because of population of Paper Mulberry trees. Its population is maximum in Islamabad whereas almost negligible in other cities (PMD, 2017). A preliminary study of atmospheric pollen has been carried out by (Kazmi et al., 1984). A preliminary study of atmospheric pollen also has been carried out in Islamabad (Perveen et al., 2007).

In last five years, the Pollen count is high in Islamabad during the Period of March and April here is the Panted value of the pollen count of last five years (Fig 1).

Fig 1 (Panted value of pollen count of last five years)

Airborne pollen data varies from place to place due to floristic diversities in a geographical region. This data helps to identify the types and count of air spora present in the atmosphere of the study area. Climatic conditions of an area may also aid in increasing the incidence of bronchial allergies as plant growth, dispersion, and quantity of pollen grains are directly correlated with weather conditions of the area (D’Amatoet et al., 1998). Pollen calendar also aids in the appropriate diagnosis of aeroallergens (Puc et al., 2002).

Due to expansion of allergic plants caused by increased carbon dioxide concentration in the air (Ihler et al., 2015). This is most frequently caused by allergens such as pollens from trees and grass. Symptoms of allergic rhinitis and allergic asthma often coexist and it is postulated that they represent a response to the same allergen from upper and lower airways, together named chronic allergic respiratory syndrome (Togias et al., 2003).

Most abundant pollen types in Islamabad are from 08 trees (Paper Mulberry, Acacia, Eucalyptus, Pines, Grasses, Cannabis, Dandelion, and Alternaria). Out of all these plants Paper Mulberry shares about 97 percent of the Total Pollen Count (TPC) during spring season. This calculation was made from daily pollen count data available for the period 2003-2016. Data analysis revealed that concentration of Paper Mulberry grains in the atmosphere resulted in pollen allergy-related diseases. National Institute of Heath Islamabad (NIH) concluded that paper mulberry was the cause of widespread allergy in the city and its neighboring towns (Bennet et al., 1997).

The same inflammatory response is observed in nasal mucosa of patients with allergic rhinitis and bronchial mucosa of patients with asthma. In both of these situations, infiltration by Th2 cells is present (Togias et al., 2003). Less is known about changes in Th17 cells caused by natural seasonal allergen exposure. Systemic reaction caused by contact with allergen has been widely investigated in many studies; however, the immunological mechanisms leading to primary and secondary responses still remain unclear. T cells appear to be strongly involved in this process and its subsets may differ depending on antigen stimulation. The CD45RA marker is characteristic for naïve cells, which proliferate when stimulated with antigens, while the presence of CD45RO is characteristic for memory cells, which proliferate during re-call antigen stimulation (Plebanski et al., 1992).

Changes are also observed depending on whether stimulation is caused by perennial or seasonal allergen. Dust mite-specific cells from mite-allergic patients are mostly of the central memory phenotype, while specific T cells from birch pollen-allergic patients have features of effectors memory cells (Wambre et al., 2011). However, less is known about changes in central memory and effector memory cell subsets in these patients. In particular, studies describing the changes caused by pollen exposure in T cell subpopulations of patients suffering from allergic rhinitis are required. Interestingly, expression of surface antigens CCR4, CXCR1, and CD62L on memory cells increases during pollen season only in symptomatic atopic patients. Explaining the lack of symptoms in patients with asymptomatic skin sensitization and healthy control (Assing et al., 2006).

This was to determine whether natural seasonal allergen exposure causes changes in the percentage and immunological status of T cell subsets in patients with allergic respiratory syndrome. Further, characterize activation of T cells in this condition; production of cytokines by these cells was assessed (Assing et al., 2006).

Haroon and Rasul (2008) reported that the paper mulberry tree has been the focus of attention ever since pollen allergy was first recognized as a threat to human health in Islamabad. Most of the people who suffer from severe allergy symptoms, like asthma attacks, are allergic to the pollen of paper mulberry (Haroon et al., 2008). According to the World Conservation Union, paper mulberry is one of the worst plant invaders in Pakistan (IUCN, 2004).

Chapter 2. Review of literature

Allergic rhinitis (AR) is among the most common diseases globally and ranks first in Europe (over 25percent of the European population). Along with the rapid economic growth and urbanization, the severe and deteriorating regional haze has smothered the eastern region of China. The health effects caused by outdoor air pollution have become a sensitive topic for the public, media, and even the government of China and adjacent countries. The need for a better comprehension to the role of ambient air pollution on human health and implementing of suitable protective policies has fueled related studies in the past decade. A number of adverse health effects, including non-accidental death, respiratory diseases (such as rhinitis, asthma, tracheids, pneumonia), cardiovascular diseases (such as stroke, arrhythmia, ischemic heart disease, cerebrovascular disease), cardiopulmonary diseases (chronic obstructive pulmonary disease, COPD) and, more rarely, conjunctivitis, dermatological disorders, skin allergy and exacerbated cough are associated with ambient air pollution (Zhang et al., 2015).

Most studies regarding respiratory diseases have addressed asthma and COPD, and only limited studies have focused on allergic rhinitis (AR) in China. As a typical respiratory illness, AR affects 20–40percent of the population worldwide, although the prevalence varies with age and region (Greiner et al., 2011-2013). Although it is usually a minor respiratory disease, AR frequently presented with symptoms that affect work performance and quality of daily life and consumes health recourses (Schoenwetter et al., 2004).

According to the Allergies in Asia-Pacific Survey, one of the largest studies of AR on adults and children in Asia, the prevalence of AR was 8.7% in Asia. The prevalence of self-reported AR in adults is much lower in China than in many Western and developed/developing countries (such as Japan and Korea). The age- and gender-adjusted incidence of AR was approximately 14percent in China, ranging from 8.7 percent (Beijing) to 24.1percent (Urumqi). The prevalence of AR for adults was 11.2percent and 15.7percent in Changchun and Shenyang of northeastern China, respectively (Katelaris et al., 2012).

Many plant species are responsible in aggravating pollens allergy by producing pollen that includes Broussonetia papyrifera, Alternanthera pungens, Cannabis sativa, Eucalyptus globules, Grasses, and Pinus sp. It is revealed that percentage of woody taxa in the atmosphere results in pollen allergy-related diseases (Parveen et al., 2012; Ozturk et al., 2013)

In India study have shown that Mulberry tree pollen is a major aeroallergen in northern regions of India(Singh et al., 2003). Already in the early seventies, mulberry tree pollen was considered to cause respiratory allergy in the US (Targow, 1971). Ozone was also associated with AR in children who reside in industrial areas of China (Kim et al., 2011). Moreover, the short-term effects of air pollutants on human health showed seasonal variations with the change of human activity and meteorological factors (Peng et al., 2005).

Chapter 3. Materials and methods

Collection of data

For the Collection of data, I visited Pakistan Meteorological Department Islamabad (PMD). Pakistan Institute of Medical Sciences (PIMS); National Institute of Health (NIH); Federal Government Services Hospital (FGSH). Pakistan Meteorological Department Islamabad (PMD) provides me the information about pollen allergy

The questionnaire contained a separate set of specific questions for those who claimed to have had suffered from allergy symptoms. Questions were asked in view of the availability of the skin tests carried out at the Allergy Center at the National Institute of Health (NIH).

The questionnaires were given in to the following medical centers and related institutions: Pakistan Institute of Medical Sciences (PIMS); National Institute of Health (NIH); Federal Government Services Hospital (FGSH); and Pakistan Meteorological Department (PMD).

From the three major hospitals, responses were attained from PIMS and FGSH, and NIH. Doctors who provided incomplete information or required further elaboration on any particular question were further contacted in person face to face or on telephone. Thus, information was obtained on the factors associated with pollen allergies, as well as, possible solutions for its eradication, including both preventive and curative measures. A separate detailed record of the patients who sought medical advice for purposes of allergy treatment could not be obtained. Therefore, information on variables like the sex of the patient, age, or place of residents is not available from the data collected from the medical centers. In addition, Pakistan Meteorological Department was contacted to provide any information pertaining to the association between the prevailing environmental conditions and pollen allergies.

Test for diagnosis of allergies

Knowing exactly what you are allergic to can help you lessen or prevent exposure and treat your reactions. There are several tests to pinpoint allergies:

Allergy skin testing

Allergy skin testing is considered the most sensitive testing method and provides rapid results. The most common test is the “prick test,” which involves pricking the skin with the extract of a specific allergen, then observing the skin’s reaction.

Serum-specific IgE antibody testing

These blood tests provide information similar to allergy skin testing

How to perform a test

The test used to ascertain the source of allergies is a standard skin test used at the NIH and involves the placement of a drop of a mixture of 25 pollen antigens, prepared at the NIH, on the skin surface under the forearm. Using a sterile needle the antigen is scratched into the surface of the skin and the excess is removed using tissue paper. The patient is kept under observation for 20 minutes. Those positive for pollen allergies are confirmed by signs of erythematic or urticaria in the inoculated area.

Chapter 4. Results and discussion

Results

Analysis of the data collected from the people reveals that of the total 60 patients respondents included in my research, 42 (70%) informed having suffered from one or more of the symptoms associated with some form of pollen allergy during the months of January to April (Pie Chart 1). The medical report of each respondent was seen by the interviewer, to confirm that the respondent had suffered from pollen allergy symptoms.

Pie Chart 1: Percentage symptom distribution

• Variables
• No of Patients and Percentage (%)
• Age of respondent

1. 10-19 years
2. 8(13.33)
3. 20-29 years
4. 26(43.33)
5. 30-39 years
6. 12(20)
7. 40 plus
8. 14(23)

• Gender of respondent
• Male

1. 24(40%)

• Female

1. 34(60%)

• Previous place of residence
• Lived in other parts of Islamabad

1. 28

• Always lived at present place
• 20

1. Live in outside Islamabad

• 12

1. Occupation
2. Private

• 25

1. Public

• 5

1. Housewife

• 10

1. Students/Others

• 20

Table No 1: Allergy distribution sex, gender, age, and occupation vise.

The percentage distribution of the respondents suffering from allergy symptoms by age shows that persons aged 25 years or above were at the highest risk of contracting the allergies. This finding is supported by a senior doctor at the allergy clinic, PIMS, who also found that older persons were more susceptible to contracting pollen allergies compared to young children. However, as is known allergies are not infectious but a disease of the immune system, implying that the older persons included in this study, which were suffering from allergies, were perhaps those who may have had a weekend immune system.

Sex-wise, the percentage distribution of morbidity shows that 60% of the allergy patients were females compared to 40% of males (Table1). Many of these respondents, as indicated above, were older and shared the belief that these illnesses were a recent phenomenon. They were of the opinion that the pervasiveness of the illness was increasing by every year regardless of age and sex. On inquiring about what in their opinion were the causes of these illnesses, most perceived unhygienic living conditions, lack of clean water, and impure food to be the major contributory factors. A few also spoke of the widely propagated opinion that greenery in Islamabad was spreading allergies, a claim refuted by older respondents who said Islamabad was always this green without any allergies in the past.

Symptoms of Allergies

Analysis of the data on various symptoms of allergies shows that of the 33% of respondents suffering from one or more allergy symptoms, 70% experienced the common and simultaneous symptoms of sneezing, running nose and watery, red itchy eyes, followed by constant running and itchy nose (Graph 2). Amongst the symptoms, the more severe cases were found to be those suffering from asthma, other breathing problems, or congestion in the chest (14%).

Graph 2 Percentage symptoms Distribution

As the graphical presentation shows, the figures are high for each allergy, indicating that most of the allergy patients suffered from more than one type of allergy symptom. Results show that about 30% of the respondents suffered from other symptoms along with those already mentioned. The most common problems identified in the category of 'others' were headaches, cough, and tiredness.

A variety of non-genetic factors may also play an important role, such as the quantity of exposure, nutritional status of the individual, and the presence of chronic underlying infections or acute viral illnesses9. This factor may also be true for our study where the incidence of allergies was reported to be higher among females. Rural girls/women often work for hours in the fields where the quantity of exposure may be high. In addition, the nutritional status, especially among children, in developing countries like Pakistan is rather poor.

Duration of illness and medical advice sought

Graph 3 presents the incidence of illness by each month of the year and confirms the finding that allergy-related illnesses are at its peak during the months of February and March. As many as 42% of the respondents reported having contracted one or more spring allergies during the month of March alone.

Graph 3 Percentage distribution of the incidence of illness by months

The percentage of the patients declines to a little more than half (29%) during the month of April, followed by a sharp decline in May, leading to negligible cases thereafter. Statistics obtained on allergies in Islamabad indicate a sharp rise in the incidence this year compared to last year. More than half (58%) of the study population suffering from pollen allergies had experienced the symptoms either a season before or the spring this year. Fifteen percent and 18% continued to suffer from allergies, during the spring season.

Pie Chart 2 Allergy symptoms appear season vise

About 66% are suffered in spring season, 4% are suffered in autumn season, 11% in the Winter season, and approx 2% in the summer season are suffered from allergies. From these people, about 17% are those who are suffered all year around.

Discussion

Results of the study conducted in Islamabad, show that of the total 60 respondents, 82% suffered from pollen allergies during the study period of January through April 2017. The findings indicate that most of the patients contracted more than one symptom of allergy and that, more interestingly, the pattern of the symptoms of allergies varied by place of residence. Analysis shows the incidence of pollen allergies to be comparatively more widespread amongst residents of Islamabad with the highest percentage of patients suffering from asthma, difficult breathing, or tightness in the chest. Overall, the most common symptoms of pollen allergies were sneezing/running nose/and itchy, watery eyes, and as high as 70% of the study population suffered from these illnesses. Another important finding of this study reveals that a substantially greater number of females contracted pollen allergies compared to men.

The time of release of pollen grains and identification of their type is useful information for patients suffering from allergic diseases (Scevkova et al., 2010). Broussonetia papyrifera was found to be vulnerable in causing sensitization amongst residents of Islamabad city. Vegetation-covered area correlates significantly with the prevalence of allergies (Khan et al., 2010).

Stratification of the illnesses contracted by age shows that persons at the highest risk of developing allergy-related illnesses belonged to the age bracket of 40 years. Most of the patients developed allergies in the months of March and April and 35 to 50% of them continued to suffer from the illnesses for more than 2 months.

In particular, modifications in pollen and allergen production related to climate change has increased the incidence of illnesses related to asthma and allergies (Shea et al., 2008). On the causes of this widespread morbidity in Islamabad, very few investigations has been conducted so far, primarily leading to inconclusive identification of the allergens or other factors contributing to the pervasiveness of the illnesses. However, many doctors conclude that specific plants and trees which have been identified to trigger pollen allergies are not the only sources. There can be multiple allergens in the environment leading to a high incidence and allergies can occur due to other environmental factors. While the research carried out by PIMS and presented at the International Environment Conference in Islamabad, specifically identified 3 major allergens for most allergies, namely, Bermuda/American Grass (67%), followed by pollens of Bhung (Cannabis sativa) and Paper Mulberry pollen, with the severity of the allergy being in the reverse order.

We observed that the optimum temperature supported the highest pollen numbers in the air of Islamabad city and same is observed when spring pollen count is found highest (Recioet al., 2009).In Norway subjects in summer had higher IgE levels than in other seasons of the year (Omenaas et al., 1994). Probably due to pollen exposure during the summer season another study reported 45% patients of allergic rhinitis to be sensitive to tree pollens and 48.7% to grass pollens (Anwar and Bokhari 2002).A number of studies have attempted to evaluate the correlation between prevalence of pollen and allergic diseases(Behbehani et al., 2004). Only one case of pollinosis to Broussonetia papyrifera has been reported in Italy (Zanforlin and Incovaia, 2004)

Summary

Pollen is fine to coarse powdery substance comprising pollen grains which are male micro gemetophyte of seed plants, which produce male gametes(sperm cells) Nasal allergy to pollen is called pollinosis, and allergy specifically to grass pollen is called hay fever. Generally, pollens that cause allergies are those of anemophilous plants (pollen is dispersed by air currents.) Such plants produce large quantities of lightweight pollen.

Seasonal allergic rhinitis, or hay fever, is an allergic response to pollen. It causes inflammation and swelling of the lining of the nose and of the protective tissue of the eyes (conjunctiva). Symptoms include sneezing, congestion (feeling stuffy), and itchy, watery eyes. Treatment options include over-the-counter and prescription antihistamines, anti-leukotrienes, nasal steroids, and nasal cromolyn. Some people may have allergic asthma symptoms (wheezing, shortness of breath, chest tightness) caused by exposure to pollen.

The present study was planned to determine the effect causes and higher concentration of pollen allergy in Islamabad region. I visited the Pakistan Institute of Medical Sciences (PIMS); National Institute of Health (NIH); Benazir Bhutto Hospital (BBH). The study was conducted from February 2017 to June 2017. The data were collected from 100 people who was suffered from those symptom which are common in pollen allergy patients. The groups range according to age vise 10 to 50 years and above residing in different localities of Islamabad. Various tests were performed to for the confirmation of allergy in these hospitals. These tests are allergy skin tests, and serum-specific IgE antibody tests. On the view of these tests 60(80%) are suffered from one or more symptoms which are showing that they are allergic patients. Few questions were asked from these people for the diagnosis of cause and effect according to season vise. Results of the study conducted in Islamabad, show that of the total 60 respondents, 82% suffered from pollen allergies during the study period of January through April, 2017. . Analysis shows the incidence of pollen allergies to be comparatively more widespread amongst residents of Islamabad with the highest percentage of patients suffering from asthma, difficult breathing or tightness in the chest. Overall, the most common symptoms of pollen allergies were sneezing/running nose/and itchy, watery eyes, and as high as 70% of the study population suffered from these illnesses. Another important finding of this study reveals that a substantially greater number of females contracted pollen allergies compared to men.

Symptom Appear

• Number Of Patients

Year Around Summer Winter Autumn Spring 9 1 6 2 35

• Percentage Symptoms Distribution

Sneezing, running nose, watery, itchy eyes Nasal Congestion Asthama Breathing Problem tightness in the chest, chronic of cough Poor sense of smell headaches Ear Infection Ithicng on skin Others 42 8 3 2 5

• Percentage Symptoms Distribution

Sneezing, running nose, watery, itchy eyes Nasal Congestion Asthama Breathing Problem tightness in the chest, chronic of cough Poor sense of smell headaches Ear Infection Ithicng on skin Others 42 8 3 2 5

• Percentage distribution of the incidence of illness by months

January February March April May June July August September October November December 0.0333 0.05 0.35 0.2833 0.01 0 0.01 0.1 0.2 0 0 0 Months