Allergy
Why Are Allergies
On the Rise?
A century ago, allergies were rare. Today, more than half of all Americans test
positive for an allergy. What's causing the skyrocketing rise in allergic disease?
By John Murphy, Senior Editor
A
bout a century ago, allergy
was so uncommon that it
hadn't yet been named. The
term "hay fever" had been
around since the 1800s, but the
word "allergy" wasn't coined until
1906.'
Historically, allergy appears to
have been a byproduct of the devel-
oped, industrialized world. Allergy
in pre-war, pre-industrialized,
1930s Japan, for example, had not
been recognized. But, by rhe 1980s,
the country had advanced to a for-
midable industrialized nation, and
allergy rates followed. By 1986,
more than 30% of children in very
polluted areas were identified with
allergic rhinitis due to pollen.'
Similarly, in North America dur-
ing the 1930s and 1940s, only
about 3 % of people (and up to
10% in ragweed-infested areas)
were estimated to have hay fever
(i.e., allergic rhinitis).' During the
past decades, however, the preva-
lence of allergic rhinitis has contin-
ued to increase, from 10% of the
population in 1970 to 30% of
adults and 40% of children in
2000, with severity ranging from
mild to debilitating.-
The actual prevalence of allergic
rhinitis is unknown because many
of these allergy sufferers don't seek
medical treatment. Currently, more
than 14% of adults (one in seven)
surveyed in the United States say
they've been medically diagnosed
with nasal allergies; that equates to
nearly 36 million
Americans
with allergic
rhinitis.'
Three of the
most common
allergens: grass
pollen (ahove),
ragweed pollen (left)
and dust mites (ahove right).
But, it's not just allergic rhinitis.
Many more Americans have other
or additional allergies. At last
count, more than half of all Ameri-
cans (54%) test positive to at least
one ofthe top 10 allergens.* On
average, people who test positive
have at least three allergies.
Allergies are not only
becoming more prevalent,
but also more severe and more
deadly. For instance, more than 12
million Americans have a food
allergy, such as to seafood (6.9 mil-
lion) or to peanuts or tree nuts (3.3
million), according to the Food
Allergy & Anaphylaxis Network.
Indeed, the number of children
allergic to peanuts doubled between
1997 and 2002. In the United
States, food allergy is the leading
cause of anaphylaxis (outside of
hospitals) and causes an estimated
150 to 200 deaths and 30,000
emergency room visits each year.
But, peanuts have been cultivated
for thousands of years, and pollen
has been around for millions of
years. So, what's causing the sud-
den increasing severity and explod-
ing prevalence of allergiesfrom
almost non-existent a century ago
to almost ubiquitous today?
Two Possible Causes
There are at least two basic
seemingly opposingcauses: the
dirty cause and the clean cause.
The dirty cause (or pollution
hypothesis) suggests that increased
REVIEW OF OPTOMETRY AUGUST 15, 2008 31
 Allergy
Ocular Allergies on the Rise pollution in our environment has
"In the literature, ocular allergy has clearly been underestimated and underappreciated," overburdened and hypersensitized
says Leonard J. Bielory, M.D., co-director of the Immuno-ophthaimology Service at the our immune systems.
University of Medicine and Dentistry of New Jersey. The clean cause (or hygiene
Dr. Bielorv's research (soon to be published) shows that about 80% to 90% of people hypothesis) suggests that we've
who have allergic rhinitis also have ocular allergic complaints. made our modern household envi-
That's nothing to sneeze at. ronment so clean that our bodies
Other research has shown that overreact to otherwise harmless
allergic conjunctivitis symptoms microbes and pathogens.
are at least as severe as rhinitis Let's take a closer look
symptoms in approximately at each hypothesis. ^ ^ ^
70% of people with allergic
rhinitis.' Also, isolated ocular The Pollution Hypothesis
symptoms are more prevalent There's no question that
than isolated nasal symptoms increased pollution in our environ-
during the summer months (fylay ment goes hand-in-band with
to August) in the United States.'' increased allergy. Indeed, a recent
In a notable subset of allergy study of 3,000 children in Munich,
sufferers, their ocular allergy complaints are actually worse than their nasal allergy com- Germany, confirms previous inves-
plaints, according to the Allergies in America survey.' More than half of nasal allergy suf- tigations that air pollution increases
ferers say that their red, itching eyes (53%), headache (51 %) and watering eyes (51 %) are the risk for allergy and atopic dis-
extremely or moderately bothersome. Furthermore, red, itching eyes are the most bother- eases.*' Specifically, children who
some symptom of 10% of nasal allergy sufferers, and watering eyes are the most bother- live close to high-traffic roads were
some symptom of 5% of nasal allergy sufferers. 50% more likely to have allergies.
In terms of exposure, the eyes actually have it worse than the nose, says Paul J. Gomes, And tbe closer they live, tbe higher
M.S.. director of allergy at ORA Clinical Research and Development, in North /^dover. the risk. "Children living closer
Mass. than 50 meters to a busy street had
"Your eyes are open the whole day, so they are these two huge pollen-collecting dish- the highest probability of getting
esthe perfect entryway for allergens," he says. "In fact, our studies have shown that if allergic symptoms, compared to
you put an allergen in the eye, not only do 80% of patients get eye allergies, but they also children living further away," wrote
get nasal allergies. But, if you put an allergen up the nose, you only get nasal allergy; you author Joachim Heinrich, Ph.D."^^
don't get ocular allergy." At tbe same time, rising carbon
Atmospheric pollution also damages the ocular surface, allowing allergens to penetrate dioxide emissions (from cars, trucks
the eye's defenses more easily, Mr. Gomes says. How it works: Air pollutants create low- and factories) are actually causing
level ozone, which results in oxidative stress on the conjunctival epithelium. This, in turn, plants to boost pollen production.
potentially diminishes the protection provided by the tear film barrier. "That one-two punch And, the worst is yet to come. Car-
makes it much easier for allergens to penetrate into the eye, exacerbating the severity of bon dioxide in the atmosphere is
allergy, and perhaps causing what would have been an occasionally mild complaint to expected to double by the end of
become a more chronic, more prolonged intense reaction," he says. this century. Such an increase
In short, "There's a huge unmet need in terms of the number of people with ocular aller- would lead to an estimated 6 1 %
gy complaints," Mr. Gomes says. And, that need will only increase. more pollen from ragweed.'
In the future, ocular therapies will likely target the mast cell itself to preventnot just Pollution not only makes
inhibitthe mast cell from degranulating. Fortunately, he says, current topical therapy more pollen, but it also makes
with antihistamine/mast cell stabilizers can provide ocular relief for most patients most of pollen more powerful as an aller-
the time. gen. In polluted areas, airborne par-
1. Wthnch, Brignoli R. Canevascini M, Gerber M. Epidemiological survey in hay lever patients' symptom prevalerice
ticles accumulate on the surface of
and severity and influence on patienl management. Schweiz Meo Wocfiensctir 1998 Jan i^\:^2&(5)^'9-'l3. pollen grains and actually change
2. Singti K, Bielorv L, el al Epidemioiogy ol ocular aliergy symploms in United States adults {igSB-lffl-i). Presented at
the American Coi lege ot Allergy, Asthma & Immunology Annuai Meeting: November 9-15,206; Philadelphia, Abstract 34,
the shape and structure of pollen.
3. AliergiBS in Ameiica: A Landmark Survey of Nasal Aliergy Sufferers: Executive Summary: Adult: 9, Available at: Also, pollution causes tbe release of
www mmcpub com/scsaia/AduitSummary.pdf. (Accessed July 21, 2008.)
4. Abelson MB, Lilyestrom L. Paving the pastures' Urban iite and aliergy. Rev Ophthaimol 2007 Fed, 14(2].86-B8.
more pollen protein on the surface
of pollen grains. So, polluted pollen

32 REVIEW OF OPTOMETRY AUGUST 1 5, 2008 Wi

 is more effective than non- j
polluted pollen in inducing ^
allergic reactions."
Pollution also damages the
body's mucosal defenses, which
allows greater access for allergens
to invade. Specifically, pollutants
aggravate the nasal mucosa, causing tell the immune system how to react
chronic inflammation and epithelial
breakdown, and even altering the
mucociliary system. This increases
the opportunity of exposure to
environmental allergens and
jumpstarts the process of allergic m response (an allergic response).
sensitization.'
Indeed, such exposure has even
led to a new diagnosis of an allergy- Tpjl arm of the immune system
like conjunctivitis, "urban eye
allergy syndrome," that is not
directly caused by allergy, but
largely by pollution.'*'
The Hygiene Hypothesis
On the other hand, the hygiene
hypothesis says that a cleaner envi-
ronment, particularly in childhood,
causes our bodies to overreact to
everyday "dirt." In other words,
using antimicrobial soap might be
causing your kid to sneeze.
Long before antimicrobial soap,
purified water and dust-filtering air
conditioning came along, humans
(particularly children) were exposed children in Eastern Germany
to all kinds of dirt and microorgan-
isms. (Of course, in poorer areas
and underdeveloped countries, they
still are.) The hygiene hypothesis
holds that in dirtier environments,
microbial exposure (to viruses, bac-
teria and parasites) effectively edu-
cates the body's immune system,
teaching it how to defend itself.
Take that "education" away (by
creating a much cleaner environ-
ment), and it alters the immune sys-
tem's development. Now, the body
is more likely to mistake a relatively genic pollen in early life does not
harmless allergen for an invasive
pathogen, such as bacteria or a par-
asite. This, in turn, stimulates an
34 REVIEW OF OPTOMETRY AUGUST 15, 2008
overreactionan allergic reaction.
More specifically, an allergic
reaction is an immunological hyper-
sensitivity reaction that causes an
immediate inflammatory response.
In the immune system, T helper
cells act as the traffic copsthey
to an invader. Bacteria and viruses
generally elicit a T^]!-mediated
immune response. But when the
immune system detects a greater
^ danger, it fights back with a Tyil
" The hygiene hypothesis suggests
that insufficient stimulation of the
leads to an overactive T H 2 arm,
which in turn causes allergic dis-
ease.
The hygiene hypothesis has
plenty of support. It started with a
study that found that allergic rhini-
tis and eczema are less common in
children from larger familieswho
presumably expose each other to
more infectious agentsthan in
families with only one child." Like-
wise, growing up with a dog or a
cat in the home appears to reduce
the risk of developing allergies.''
Another classic example: Before
the fall of the Berlin Wall in 1989,
where living conditions were poorer
and dirtierhad lower prevalence
of allergic rhinitis. Following unifi-
cation, and the resulting surge in
Western lifestyle, allergy rates in
East German children began to
catch up to their West German
counterparts." k f r
Similarly, people who grow |Rk
up in rural areas, particularly
those who grow up on farms, tend
to have lower risk for allergic rhini-
tis and asthma. "Exposure to aller-
appear to increase the risk of
acquiring symptoms of respiratory
allergy, and may even give some
protection against them," wrote the
investigators of the International
Study of Asthma and Allergies in
Childhood (ISAAG)r
So, does the hygiene hypothesis
mean than we can reduce allergies
by reverting to a less hygienic
lifestyle? Should we get rid of the
antibacterial soap?
No Clear Answer
Unfortunately, neither the pollu-
tion hypothesis nor the hygiene
hypothesis provides all the answers.
Many questions remain.
Pollution, for instance, may not
directly cause allergy. Instead, it
may act as an adjuvantsomething
that influences the course of an
immune responseto exacerbate
the reaction to an allergen.'^
The hygiene hypothesis has some
holes in it, too. For one, the inner-
city poor, who are exposed to
greater allergens and microbes (and
would presumably benefit from the
hygiene hypothesis), actually have
higher rates of asthma and respira-
tory allergies."^
Also, according to the hygiene
hypothesis, viral infections prevent
the development of allergic disease.
But, the influenza virus now
appears to enhance, rather than
inhibit, the development of
asthma and allergic responses.'^
Another curious anomaly:
While the rates of allergic j|k
rhinitis and asthma have
increased throughout the 20th
century, they appear to have
reached a peak among children in
the early 1990sand may now be
on a decline.'" The hygiene hypothe-
sis doesn't explain such an anom-
aly, since concurrent environmental
exposure certainly hasn't declined.
Also, allergies aren't all environ-
mental. Genetics play a role as well.
For instance, if one parent suffers
from allergies, the child is 40%
more likely to have allergies; if both
parents have allergies, their children
are 75% more likely to have aller-
gies., according to the American
College of Allergy, Asthma &
Immunology.
In other words, don't toss out
that antibacterial soap just yet.
ARE YOU^SEEING
^ ^
I. Jackson M. Allergy: The History ot a ^
Modern Malady. 1st ed. London: Reaktion __
Books: 2007:10,24,25 1 %
^ 2 Dykewic; MS. Fineman S, Skoner DP, et
1 | ^ al Diagnosis and management ot rhinitis: complete
guidelines ot the Joint Task Force on Practice Parame-
ters in Aiietgy, Asthma and Immunology. American Academy
ol Ailergy. Asthma, and Immunology, Ann Allergy Asthma
Immunol 1998 Nov;81(5 R 2):478-518.
3 Aiiergies in America: A Landmark Sun/ey ot Nasal Allergy
Sulterers: Executive Summary: Adult:4 Available at:
www.mmcpub.com/scsaia/AdultSummaiyptlt, (Accessed
July 21,2008.)
4. t^athan RA. Meltzer EO, Seiner JC, et al. Prevalence ot
ailergic rhinitis in the United States. J Allergy Clin Immunol
1997,99:S808-S14
5. Arbes SJ Jr. Gergen PJ, Elliott L, Zeldin DC. Prevaiences
ot positive skin test responses to 10 common allergens in the
US population: results liom the third National Healtti and
Nutrition Examination Survey. J Ailefgy Clin Immunol. 2005
Aug;116(2):377-83.
6. Morgenstern V, Zutavern A, Cyrys J, et al.: GINI Study ASL0WA9 '
Group: LISA Study Group, Atopic diseases, aliergic sensitiza-
tion, and exposure to traffic-related air poliution in children.
AmJ Respir Crit Care Med 2t)08 Jun 15;l77{12):1331-7,
O PER PAIR
7. Wayne P, Foster S, Connolly J, et ai. Production ot aller-
genic poilen by ragweed {Ambrosiaarlemisiifoli3i.) is
increased in C02-enriched atmospheres. Ann Ailergy Asthma
Immunol 2002 Mar;88(3):279-82.
8. Chehregani A, Majde A, Moin M, et al. Increasing allergy
potency ot Zinnia poilen grains in polluted areas. Ecotoxicol
You're seeing perfectly. The
Environ Sat 2004 Jun;58(2):267-72
9. Passaii 0, Lauriello M, Mezzedimi C, Beliussi L. Nasai Parasol' punctal occluder is
allergy and atmospheric poilution. Inl J Pediatr Otorhino-
iaryngol 1999 Oct 5;49 Suppi 1:S257-60 available for as low as 3D
10. Leonardi A, Lanier 8. Urhan eye allergy syndrome: a new
clinical entity? Curr Med Res Opin 2008 Jun 28. [Epub atiead per pair. And every Parasol
o! print.]
includes Odyssey's 30-day
II, Strachan DP. Hay tever, hygiene, and household size.
BMJ 1989 Nov 18:299(6710)-1259-60. pop out guarantee. Which
12 Ownby DR. Johnson CC, Peterson EL Exposure to dogs
and cats in tfie tirst yeaf ot iite and risk ot ailergic sensitiza- means there's never been a
tin al 6 te 7 years ot age, JAMA 2002 Aug 2e;286[8):963-72.
13. von Mutius E, Weiiand SK, Fritzsch C, el al. Increasing better time to try the Parasol.
prevaience ot hay tever and atopy among children in Leipzig,
It's risk free, so call and order today.
EastGermany. Lancet 1998 Mar21;351(9106):862-6.
14. Burr ML, Emberlin JC, Treu R, et al; ISAAC Phase One
Study Group. Poilen counts in relation to the prevalence ot
aliergic rhinoconjunctivilis, asthma and atopic eczema in ttie
International Study ot Asttima and Allergies in Childtiood HE PARASOL PUNCTi
(ISAAC] Clin Exp Aliergy 2003 Dec:33( 12): 1675-80.
15 Takatuji S, Suzuki S, Muranaka M, Miyamoto T. Influence EASY TO INSERT SIMPLE SIZING POP-OUT GUARANTEE
ol environmental taclors on IgE production. Ciba Found
Sympt989:147:l88-2O1: discussion 201-4, Reviev*.
16. Matricardi PM, Bouygue GR, Tripodi S. Inner-city asthmii
and the hygiene hypothesis. Ann Allergy Asthma Immun!
20C2 Dec;89(6 SuppI 1 }:69-74. Review.
17. Umetsu OT. Flu strikes the hygiene hypothesis. Nat Med
2004 Mar;10(3):232-4.
18. Zllner IK, Weiland SK, Piechotowski I, et al. No increase
in the prevalence ol asthma, allergies, and atopic sensitisa-
DYSSEY
tion among children in Germany: 1992-2001. Thorax 2005
Jul:60(7):545-8.
Iby Oaks Dr I Mdmphis TN 38134 888.905.7770 odysseymed.coffl