Urban Forestry & Urban Greening xxx (xxxx) xxx–xxx

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Urban Forestry & Urban Greening

journal homepage: www.elsevier.com/locate/ufug

Combined effects of air pollution and allergens in the city of Rome

⁎
Alessandro Di Menno di Bucchianicoa, , Maria Antonia Brighettib, Giorgio Cattania,
Corrado Costac, Mariacarmela Cusanoa, Vincenzo De Gironimoa, Francesca Froiod,
Raffaela Gaddia, Simone Pelosie, Ifigenia Sfikaf, Alessandro Travaglinib, Salvatore Tripodif
a
ISPRA, Italian National Institute for Environmental Protection Research, Italy
b
Department of Biology, University of Rome Tor Vergata, Rome, Italy
c
Engineering and Agri-Food Processing Research Center, Monterotondo (Rm), Italy
d
Allergology Centre, San Pietro-Fatebenefratelli Hospital, Rome, Italy
e
TPS Production srl, Italy
f
Pediatric Department & Allergology Service, Sandro Pertini Hospital, Rome, Italy

A R T I C LE I N FO A B S T R A C T

Keywords: Urban green is an important aspect in the quality of life of citizens of modern cities. Nevertheless some orna-
PM10 mental plants cause allergic diseases in sensitive subjects that may be worsened by air pollution.
Atmospheric pollution Studies on air quality are usually addressed to the evaluation of single substances and their specific effects:
Pollen little is known about the cumulative effect that different pollutants may have on human health. Even less is
Urban areas
known about possible combined action of traditional air pollutants with pollen and spores that have huge effects,
Health effects
in terms of allergies and asthma, on citizenship of the urban areas.
In this work the synergistic effect of PM10, PM2.5, NO2, O3 and airborne pollens (belonging to 4 taxa:
Cupressaceae/Taxaceae, Graminaceae, Olea and Urticaceae) was studied in the city of Rome during six years
(from 2010 to 2015).
For air pollutants, concentration values recorded by air-quality monitoring network of Rome were used.
Pollens and spores data were detected by the Aerobiological Monitoring Centre of the University of Rome Tor
Vergata. Effects on human health were evaluated on a group of 100 patients (aged between 4 and 18) by the
Allergymonitor™ã application that records daily symptoms of hay fever, bronchial asthma and the prescribed
therapies.
Data collected in the medical record were processed by 2 different Symptom Medication daily Scores and
compared with time series of air concentration of mentioned pollutants, pollen and spores.
Statistical analysis allowed highlighting when concomitant high levels of allergenic species and air pollution
occur, the influence of meteorological parameters, of the flowering calendar, of taking drugs and how these
aspects affect symptoms in patients.

1. Introduction
Atmospheric pollution, especially in urban areas, is, nowadays,
generally considered an important risk factor for human health and the
ecosystem, but the consciousness of its importance has gradually in-
creased during the last decades, following the progress of scientific
research.
The first Italian act on air pollution was the 1966 Anti-smog law n.
615 (IP, 1966), followed by the 1971 executive regulation (IG, 1971)
which provided the first concentration limits in the ambient air for
many substances.
The 1983 Decree (IG, 1983), updated in 1988 with the DPR n. 203
(IG, 1988), abrogated and replaced the previous law and introduced
limit values (or air quality standards) and guide values.
To protect human health from acute episodes of air pollution, two
1994 Ministry Decrees established attention and alert standards for the
same substances (IG, 1994a,b).
Specifically, the 25/11/94 Ministry Decree (IG, 1994b) introduced
quality objectives for the, at time so-called, unconventional pollutants
(PM10, Benzene, Benzo[a]pyrene).
Finally, a 1996 Ministry Decree introduced specific reference levels
for tropospheric ozone (IG, 1996).
In the late nineties was issued the European Framework Directive
for air quality (EC, 1996) and then a number of daughter directives

⁎
Corresponding author at: ISPRA, Italian National Institute for Environmental Protection and Research, Via Vitaliano Brancati, 48, Rome, 00144, Italy.
E-mail address: alessandro.dimenno@isprambiente.it (A. Di Menno di Bucchianico).

https://doi.org/10.1016/j.ufug.2018.04.001
Received 31 July 2017; Received in revised form 29 January 2018; Accepted 1 April 2018
1618-8667/ © 2018 Elsevier GmbH. All rights reserved.

Please cite this article as: Di Menno di Bucchianico, A., Urban Forestry & Urban Greening (2018), https://doi.org/10.1016/j.ufug.2018.04.001
A. Di Menno di Bucchianico et al.
addressed to specific pollutants. All these directives were gradually
transposed in Italy since 1999.
The current European Directives on ambient air quality are the
2004/107/EC (EC, 2004) and the 2008/50/EC (EC, 2008) and these
were both transposed and merged in Italy by the 2010 D. Lgs. n. 155
(IG, 2010).
The European Union adopted the 2008/50/EC Directive on ambient
air quality and cleaner air for Europe in order to protect human health
and the environment, to combat emissions of air pollutants, to identify
and implement the most effective emission reduction measures and set
appropriate objectives for ambient air quality, taking into account
WHO standards. This Directive introduced limit values for sulphur di-
oxide, nitrogen dioxide and oxides of nitrogen, particulate matter (PM10
and PM2.5), lead, benzene, carbon monoxide and ozone in ambient air,
establishing the exchange of information and data from networks and
individual stations measuring ambient air pollution within the Member
States. The 2008/50/EC Directive lays down measures aimed at de-
fining and establishing objectives for ambient air quality designed to
avoid, prevent or reduce harmful effects on human health and the en-
vironment as a whole; assessing the ambient air quality in Member
States on the basis of common methods and criteria; obtaining in-
formation on ambient air quality in order to help combat air pollution
and nuisance and to monitor long-term trends and improvements re-
sulting from national and Community measures; ensuring that such
information on ambient air quality is made available to the public;
maintaining air quality where it is good and improving it in other cases;
promoting increased cooperation between the Member States in redu-
cing air pollution.
In many cases limits and threshold values set by The EU Directive do
not coincide with the World Health Organization’s reference limit va-
lues: WHO thresholds for human health protection are lower than those
foreseen by the legislation and much of the urban population is still
exposed at higher levels than these guiding values. In addition, research
and international regulations on air pollution are still typical today for
evaluations of the individual substances and their specific effects: little
is known about the cumulative effect that more air pollutants, at high
concentration levels in the same time interval, may have on human
health.
Even less has been explored the possible combined action of tradi-
tional pollutants with the granulometric particle of biological particu-
late matter, about 10 μm or more aerodynamic diameter, consisting of
pollen and spores, which increases the consequences in terms of aller-
gies and asthma in the urban centres (D’Amato et al., 2007).
Likewise, the absence of legal limits that directly link certain con-
centrations of pollen or aerated spores and human health does not allow
absolute assessments of air quality.
The onset of symptoms occurs when pollen concentration, reaches a
defined value, called threshold; but this threshold varies not only from
individuals but also in the same individual during the season. Severe
asthma occurrence can be also triggered during thunderstorms in the
pollen season (D’Amato et al., 2016), and thunderstorm asthma can
affect individuals without prior asthma (Girgis et al., 2000; Lee et al.,
2017).
Allergy sufferers respond subjectively to allergy. The severity of the
symptoms depends not only on the pollen exposure, but also on specific
factors of the allergic person such as lifestyle, IgE antibody level, sen-
sitization and simultaneous exposure to other allergenic sources, the
target organ clinical reactivity (eyes, nose, lungs). Scientific studies
show that predisposed subjects have increased respiratory reactivity
induced by air pollution and increased bronchial responsiveness to in-
haled pollen allergens. Air pollution has been associated with hospital
admissions for respiratory disease in cities all over the world (Medina-
Ramòn et al., 2006). Atmospheric pollutants, particularly ozone, par-
ticulate matter and sulphur dioxide, have an inflammatory effect on the
airways of susceptible subjects, causing an increase in epithelial per-
meability, easier penetration of pollen allergen in the mucous
2
Urban Forestry & Urban Greening xxx (xxxx) xxx–xxx
membranes and greater interaction with immune system cells (D’Amato
et al., 2007). In addition, some air pollution components seem to have
an adjuvant immunological effect on the synthesis of immunoglobulin E
(IgE) in atopic subjects: for each increase of 10 μg/m3 of PM10 the risk
of hospitalization or first aid visits increases by 1.5% and to worsen
asthma increases by 3% (Pope et al., 1999). Another study has high-
lighted that by crossing the data from the wastewater analysis of the
average number of daily doses consumed in the city of Milan and those
made available by the ARPA Lombardia it was possible to find a direct
and statistically significant correlation between PM10 and PM2.5 levels
and the salbutamol doses used, the active ingredient present in the
drugs used to counter bronchospasm during asthma crisis. Each in-
crease in PM10 of 10 μg/m3 corresponds to a 6% increase in salbutamol
dose employed by the Milanese population (Fattore et al., 2016).
In addition, atmospheric pollution can interact both with pollen,
leading to an increase in release of antigens with modified allergenicity,
both with particles carrying allergenic of plants; these particles can
reach peripheral airways with inhaled air and induce asthma in sensi-
tive subjects.
2. Materials and methods
In this paper, for a six-year period (2010–2015), in the city of Rome,
the synergistic effect of airborne particulate matter, pollen, gaseous air
pollutants and meteorological conditions in patient sufferers has been
studied. The aim was to evaluate if also air pollution contribute to al-
lergic diseases symptom manifestation in sensitive subjects and the
possibility of using multivariate approach for application purpose in the
medical field.
2.1. Study design
While it is relatively easy to demonstrate the cause and effect re-
lationship between exposure to high concentrations of certain pollen
species and manifestation of allergic symptoms, it is harder to highlight,
using measured data, the combined effect of some traditional pollutant
(like PM, SO2, NO2 and O3) on allergic patients.
Basically there is to face a difficulty linked to the intrinsic differ-
ences in the variables describing these airborne species and for the
difficulty in measure of symptoms.
Fig. 1 shows the air quality and pollen network considered in this
study: for the evaluation of air quality in the city of Rome, time Series of
PM10, PM2.5, NO2 and O3 concentration measured in the 14 stations of
the AQ network of Rome (ARPA Lazio) were considered (Fig. 2). While,
for the evaluation of pollen concentrations, were considered time series
of Cupressaceae/Taxaceae, Gramineae, Olea, Urticaceae and total pol-
lens, measured by the Aerobiological Monitoring Centre of the Uni-
versity of Rome Tor Vergata (Fig. 3), together with data from the Tor
Vergata meteorological station (temperature, global radiation, pre-
cipitation, wind speed and direction).
The effects on human health were evaluated on a group of 100
patients (between 4 and 18 years old) followed from 2010 to 2015
through the Allergymonitor™© app that allows patients to record daily
symptoms of hay fever, bronchial asthma and any the therapies
adopted. The data collected in the clinical diary were automatically
processed in various daily Symptom Medication Scores.
The relationship between the air quality data and pollen (unique
series for each parameter completed through the estimation of missing
data) and weather data with the selected indexes (RTSS and ACS) was
evaluated with a modelling approach PLSDA (Partial Least Squares
Discriminant Analysis).
2.2. Meteorological data
The used meteorological data were recorded at the meteorological
station (SP2000, CAE Bologna, Italy) of Rome Tor Vergata, located in
A. Di Menno di Bucchianico et al.
Fig. 1. Map of Rome with air quality and pollen stations.
Fig. 2. Urban Background station of the air quality monitoring network of
Rome.
the Laboratory of Experimental Ecology and Aquaculture (LESA) of the
Department of Biology, currently managed by the Hydrographic Service
of the Lazio Region.
The following variables were considered: rain rate (mm), tempera-
ture (maximum, minimum and mean; °C), wind speed mean (Km h−1),
global radiation mean (Watt m−2).
2.3. Pollen counts
The aerobiological monitoring shows the qualitative and quantita-
tive variations of pollen of allergy interest. The instrument used is a
volumetric sampler type Hirst; and the data are set with a standardized
sampling method (UNI, 2004; Travaglini et al., 2009). Pollen counts
were recorded at the aerobiological station of the University of Rome
Tor Vergata.
The pollen data used refer to the daily concentration, expressed in
3
Urban Forestry & Urban Greening xxx (xxxx) xxx–xxx
Fig. 3. Aerobiological Monitoring Centre − Rome, Tor Vergata.
pollen grains per cubic meter, p/m3 (Mandrioli et al., 1998), of the 4
taxa, Cupressaceae, Olea, Poaceae, Urticaceae and total pollen.
Cupressaceae pollen belong to an great and important family. We
consider as Cupressaceae pollen all pollen belonging to following
genera: Cupressus, Calocedrus, Chamaecyparis, Hesperocyparis, Juniperus,
Sequoia, Sequoiadendron, Taxodium, Thuja and although belonging to
another family, Taxus. Normally these genera blossoms during winter,
Cupressus and Hesperocyparis during spring other genera while Juniperus
can blossom in spring and sometimes in autumn. All these species have
not flowers, but produce high quantity of pollen. These species were
normally used in our cities for ornamental use. For this reason, it is
possible to see them in parks, garden, parking, along avenue, in ce-
meteries. These genera have evergreen leaves, opposite or whorled and
usually paired or in threes. Adult leaves are narrow, scalelike, and
pressed against the branchlets, which themselves are often flattened.
The male reproductive structures are borne at the ends of short twigs;
the female structures (cones) are terminal, with opposite or whorled
A. Di Menno di Bucchianico et al.
scales, consisting of both a fused bract (modified leaf) and a scale. The
cones, usually woody, have erect ovules. Pollen size is about 20–30 μm,
at optical microscope pollen of these genera is very similar. For this
reason we count all Cupressaceae pollen as unique type (Pignatti, 1982;
Travaglini et al., 2014).
Olea belongs to Oleaceae or olive family. It is a woody plant native
to forested regions in Mediterranean basin. The leaves are opposite each
other on the branch. Flowers in most members of the family have four
sepals, four petals, the fruit is the fleshy olive. In recent years, olive
trees are used in our cities as ornamental plant, determining an increase
of Olea pollen in the town. Pollen size is about 20–25 μm (Pignatti,
1982; Travaglini et al., 2014).
Poaceae, formerly called Gramineae or Graminaceae, are grass fa-
mily of monocotyledonous flowering plants. Grasses are perennial or
annual and usually terrestrial and free-standing. Their flowers are very
simple, without tepals. From the anthers high quantity of pollen is
widespread. Poaceae live everywhere in the world, in all continents, in
desert, in forest, in town and so on being most important source of food.
They can form a typical ecosystem, the prairie. In Rome more than 150
species are known. Poaceae pollen is very important from allergological
point view, some species such timothy grass or Bermuda grass are very
dangerous. Poaceae pollen is monoporate, spheroidal, about 20–45 μm
size (Pignatti, 1982; Travaglini et al., 2014).
Urticaceae: to this family belong several herbaceous and shrubs
genera such as: Urtica (nettle), Parietaria (pellittory), Ramié (Boehmeria
nivea). Many species, especially the nettles (Urtica) have stinging hairs
on the stems and leaves. The leaves are varied and the sap is usually
watery. Small, greenish flowers often form clusters in the leaf axils.
Both male and female flowers may be borne on the same or different
plant. The curled stamens of the male flowers straighten quickly as the
flowers open, releasing pollen. From allergological point of view
Pellittory is the most important specie, living everywhere in towns on
wall, ruins, pavements and similar environment with high quantity of
nitrates. Nowadays Pellittory in Rome flourishes all the year. Pollen size
in very small, about 10–18 μm. at optical microscope pollen of these
three genera is very similar, almost indistinguishable (Pignatti, 1982;
Travaglini et al., 2014).
The instrument used for pollen monitoring is a volumetric sampler-
type Hirst (1952), recommended in 1972 by the International Biolo-
gical Program (Benninghoff and Edmonds, 1972), Model 2000 VPPS
Lanzoni (Mandrioli, 1994); the data acquisition was carried out as re-
ported in Standard UNI (2004) and next updates, the protocol that
describes the procedure for measuring of the concentration of pollen
grains and fungal spores dispersed into the atmosphere and reported in
the Manuale di gestione e qualità della R.I.M.A. – Rete Italiana di Mon-
itoraggio in Aerobiologia (Travaglini et al., 2009). The pollen data used
refer to the daily concentration, expressed in p/m3 (Mandrioli et al.,
1998), of the pollen of the considered families registered from January
1st, 2010 to December 31th, 2015.
2.4. Air pollutants
For the evaluation of the air quality in the city of Rome the daily
levels of particulate matter, nitrogen dioxide and ozone were con-
sidered: these are the most critical air pollutants and they were selected
based on their past and recent average levels and for their interactive
effect with pollens grains on human health (D’Amato et al., 2007).
Specifically, 5 parameters that better describe the air quality status
were calculated: the daily average mass concentration of PM10 parti-
culate matter; the daily average mass concentration of PM2.5 particulate
matter; the daily average concentration of nitrogen dioxide, NO2; the
daily average concentration of ozone, O3, and the ozone daily max-
imum 8-h mean. All data were collected from the Cinecittà Urban
Background station, chosen within the ARPA air quality network after a
complete intercomparison among the air pollutants and pollen time
series from the whole network, for the proximity to the Aerobiological
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Urban Forestry & Urban Greening xxx (xxxx) xxx–xxx
monitoring centre of Tor Vergata, for its statistically good spatial and
temporal representativeness of the air quality status of the whole city
and for the simultaneous presence of the needed monitoring equipment
(not always, in an AQ network PM10, PM2.5, NO2 and O3 are sampled
and measured in the same site).
In addition, the 5 data time series were completed through a mul-
tiple linear regression with the other stations records for the estimation
of missing data.
Airborne particulate matter (PM) consists in a mixture of solid and
liquid atmospheric particles with an aerodynamic diameter (da) be-
tween 0.01 and 100 μm. Particles larger than 10 μm are generally dust
resulting from erosion or industrial processes, they settle to the ground
in a short time and are responsible for pollution phenomena on a small
spatial scale. Particles with an aerodynamic diameter less than or equal
to 10 μm and aerodynamic diameters less than or equal to 2.5 μm are
the subject of most air pollution studies and are commonly identified in
the PM10 and PM2.5 fractions. They are characterized by long periods of
stay in the atmosphere and can be transported at very large distances
from the emission source, they have a particularly complex and variable
chemical nature and are able to penetrate the human respiratory tree
and thus have negative effects on health.
Part of these substances are directly emitted into the atmosphere as
particulates (primary aerosols), others are generated in atmosphere by
chemical-physical processes that occur among gaseous pollutants (sec-
ondary aerosols).
The particulate matter can have both a natural (erosion of rocks,
volcanic eruptions, forest combustion and pollens) and anthropic origin
(for example, car emissions, tyre and road abrasion and various kinds of
combustion).
Nitrogen dioxide (NO2) is a toxic gas part of the nitrogen oxides. In
the polluted atmosphere its presence is associated with the nitrogen
monoxide (NO) and the mixture of the two gases is indicated as ni-
trogen oxides (NOX).
In the atmosphere nitrogen dioxide is mainly a secondary pollutant,
which results from the oxidation of nitrogen monoxide. It plays an
important role in the photochemical reactions of ozone; its high con-
centration, coupled with the presence of volatile hydrocarbons and
particular atmospheric conditions, such as strong solar radiation, it
produces high concentrations of tropospheric ozone.
The sources of nitrogen oxide emissions are mainly related to
human activity and to a lesser extent to natural phenomena. Anthropic
sources can be associated with combustion processes (vehicular traffic,
industry, electricity generation, domestic heating) and processes
without combustion (nitric acid production, use of nitrogen fertilizers,
etc.). Natural sources of nitrogen dioxide are represented by: volcanic
eruptions, electric shock caused by lightning and biological activity of
some bacterial species in the soil.
Nitrogen dioxide is a strong oxidant, highly reactive and corrosive.
The main toxic effects on human health, which can be acute and
chronic, are due to the respiratory system, the mucous membranes and
the eyes. Extremely high concentrations can cause death.
Environmental damage is mainly related to acidification of rainfall,
deposition in general (in the presence of water nitrogen dioxide is
converted into nitric acid) and the eutrophic effect that nitrogen com-
pounds exert on the vegetation and the water.
Tropospheric ozone is a secondary pollutant formed through pho-
tochemical processes in the presence of primary pollutants such as ni-
trogen oxides (NOx) and volatile organic compounds (VOCs). Following
the photochemical processes, a complex mixture of substances called
photochemical smog forms in the low layers of the atmosphere. Ozone,
which is the main representative, can cause serious problems to human
health and the ecosystem, as well as to agriculture and materials.
Photochemical pollution, is a transboundary phenomenon: in par-
ticular conditions photochemical pollutants can be transported for long
distances. Ozone pollution is, therefore, a phenomenon that is spread
over large spatial scales and the high concentration levels found in a
A. Di Menno di Bucchianico et al.
certain area are not always attributable to emission sources located
close to the sampling point.
The higher ozone concentrations are recorded in the warm months
of the year and during the hours of maximum solar irradiation. In urban
areas, ozone is formed and transformed rapidly, with a very different
behaviour than that observed for other pollutants.
The main sources of emissions of ozone precursors are road trans-
port, industrial activities, civil sector and energy production.
2.5. Clinical data
The methods for assessing and monitoring allergic symptoms are
based on online diaries compiled by patients. This practice begins to be
widespread in some European states such as Germany, Switzerland,
Austria (Berger et al., 2013; de Weger et al., 2013; Voukantsis et al.,
2013). In Italy, since 2010, the Allergymonitor™© app can be down-
loaded, accessible for free for mobile device, with Android or iOS op-
erating system. This tool is an easy-to-use and well-accepted web
platform for patients because it is very useful for improving their ad-
herence to therapy (Tripodi et al., 2012; Pizzulli et al., 2014). This is an
online diary, in which every patient, upon informed written consent of
the parents, is invited to record daily, generally in the evening, any
medications taken and allergic symptoms through the smile symbolism,
answering questions about the quality of life Inherent in Allergic pa-
thology, evaluating their state of mind or daily malaise with an Ana-
logic Visual Scale, whose score ranges from 0 (very good) to 10 (bad).
The severity of the symptoms is recorded with the use of four different
emoticons, each of which represents a degree of severity (absent, mild,
moderate and severe). The innovative aspect of the system is in the
possibility of bi-directional interaction between physician and patient
via e-mail, chat and SMS (text message). Patients (or their parents) not
entering their data for two consecutive days received an automatic alert
SMS on their mobile phone or by e-mail. In this way, it establishes a
direct and constant relationship between patient and physician, while
improving both the medical management of the disease and the ad-
herence of the patient to the doctor’s prescriptions.
The full process followed local, national and European laws on
protection of privacy and sensitive personal data.
Allergymonitor™© transforms patient data and automatically calcu-
lates SMS indices, generating a database that can be used for statistical
analysis. The study population consisted of 100 children patients
seeking care for pollen-AR at the paediatric allergy outpatient Unit of
the Sandro Pertini Hospital in Rome.
Patients registered ocular (itching, tear flow, and redness), nasal
(sneezing, itching, running, and blockage), and bronchial (cough,
wheezing, and dyspnea) symptoms. The allergic responses are set
considering RTSS (Rhinoconjuntivitis Symptom Total Score). The RTSS
includes six individual symptoms: four nasals (sneezing, rhinorrhoea,
itching, and congestion) and two ocular (itching and tearing). The in-
tensity of each symptom can be expressed with a value from 0 to 3:
0 = absent (no sign/symptom evident); 1 = mild (sign/symptom
clearly present, but minimal awareness; easily tolerated); 2 = moderate
(definite awareness of sign/symptom that is bothersome, but tolerable);
3 = severe (sign/symptom that is hard to tolerate; causes interference
with activities of daily living and/or sleeping). The daily total of six
symptoms combined can reach a score between 0 and 18 (6 symptoms
×3 point scale).
The use of drug is an additional variable. For this reason, Symptom
Medication Scores – SMS (Grouin et al., 2011; Häfner et al., 2011) will be
introduced to modulate the value of the RTSS. The SMS considered in
this study is: ACS – Average Combined Score, an index derived from the
combination of the RTSS and the RMS (Rescue Medication Score adopts a
scale based on the type of drug taken); RMS:0 = no rescue medication;
1 = antihistamines; 2 = nasal corticosteroids; 3 = oral corticosteroids
(the RMS for a given day is equal to the highest score recorded for that
day). The ACS score varies between 0 and 3) according to the formula:
5
Urban Forestry & Urban Greening xxx (xxxx) xxx–xxx
(RTSS/6 + RMS)/2.
Inclusion criteria were the following: A) allergy sufferers children
between 4 and 18 years old; B) a diagnosis of pollen-AR (Bousquet
et al., 2007, 2008); C) IgE sensitization to one or more of the following
four pollen sources: cypress, grass, olive, pellitory, i.e. the most relevant
ones in Rome between April and June (Travaglini et al., 2002) and for
their principal molecular allergens; D) positive skin prick test (SPT) four
pollen sources: cypress, grass, olive, pellitory, i.e. the most relevant
ones in Rome between April and June (Travaglini et al., 2002); E) the
intention to stay in Rome for the whole study period; F) a number of
symptoms and medications recordings per patient ≥20 consecutive
days at least during 2 years. IgE sensitization was also considered by
introducing IgE correction – IgE-pc, an index obtained by multiplying
the pollen concentration with the specific activity was also created and
defined “IgE-pc” (Pollen concentration multiplied by the Specific Ac-
tivity, SA), considered positive values are > 0.35 (Di Lorenzo et al.,
2009). The SA correction values of IgE were calculated using the ratio
between the values of molecular IgE and total IgE for each patient. IgE
molecules considered are: T222 (Cupressaceae), g205 + g215 (Grami-
neae), t224 (Oleaceae), w211 (Urticaceae). The value of IgE against
rCup a1, rPhlp1 and rPhlp 5b, nOle e1, and rPar j2 has been multiplied
by the value of the daily pollen concentration of the corresponding
pollen type (Cupressaceae for rCup a1, Poaceae for rPhl p1 + rPhl p5b,
Olea for nOle e1, Urticaceae for rPar j2) (Costa et al., 2014).
2.6. The multivariate time lag modelling
A multivariate predictive modelling approach was used. This ap-
proach is based on PLSDA (Partial Least Squares Discriminant Analysis)
(Swierenga et al., 1998) and statistical modelling libraries were written
in the MATLAB 7.1 R14 environment by the Research Centre for en-
gineering and agro-food processing at CREA (Italy). The PLSDA ap-
proach (Sjöström et al., 1986; Sabatier et al., 2003; Costa et al.,
2013a,b,2014; Taiti et al., 2015) was used in order to predict the pre-
sence or the absence of symptoms; the Y variable is represented by
threshold 6 for the scores RTSS (RTSS ≥ 6), and threshold 1 for ACS
(ACS ≥ 1). The partitioning design consists, for each patient, in using
the data from the year with the larger number of records to build and
cross-validate the dataset (hereafter labelled as the “model year”), and
the other year as independent test (hereafter labelled as the “test year”).
The prediction ability of PLSDA and the different number of models also
depends on the number of latent vectors (LV, used up to 19) used in the
model. The x-block (25 variables) was pre-processed using a first au-
toscale algorithm (centres columns to zero mean and scales to unit
variance). Followed by a second pre-processing step applying seven
different algorithms: none, baseline (Weighted Least Squares), detrend
(remove a linear trend), mean centring, MSC (multiplicative scatter
correction with offset), normalize (normalization of the rows) and snv
(Standard Normal Deviate). The best models were extracted at 5 dif-
ferent forecast levels (time lag) ranging from 0 to 4 days (Brighetti
et al., 2014). A summary of the relative importance of the X-variables is
given by Variable Importance in the Projection (VIP) (Febbi et al., 2015;
Infantino et al., 2015; Taiti et al., 2015). VIP scores estimate the im-
portance of each variable in the PLS-based models. VIP scores were
calculated according to Chong and Jun (2005).
The forecast model is constructed by considering two sets of data:
data for all years of available recordings, except for one, 2015, are used
in the calibration phase, while data for the year 2015 are used for the
test and validation of the model.
3. Results and discussion
3.1. Air quality and pollen allergens in Rome
The first step of this study was the evaluation of the average levels
of air pollutants and pollens in the city of Rome: what is the current
A. Di Menno di Bucchianico et al.
Fig. 4. PM10, PM2.5, NO2 and O3 2010–2015 time series from the Cinecittà Urban Background station, Rome.
status and the time trend of these two different forms of air pollution?
There are periods in which emissions and dispersion episodes lead them
to be present together in the air or the total diversity of sources makes
them out of phase?
In the period of study, the considered air quality pollutants (PM10,
PM2.5, NO2 and O3) showed their typical seasonal pattern (higher levels
during the cold months for PM10, PM2.5, NO2, higher levels during the
warm months for O3) and a general decrease, except for the ozone, in
the number of exceedances of limit values (Fig. 4)
On the other side, the pollen families considered as representative of
pollen emission in the city of Rome (Cupressaceae/Taxaceae,
Gramineae, Olea and Urticaceae) showed concentration picks strictly
related with their blooming season (Fig. 5, please note that in other
periods of the year concentration go to zero).
During the period of study, the pollen families showed generally
stationary levels, except for the Urticaceae and this is probably caused
by a reduced care of public green areas in recent years.
A clear difference between PM10 (the thoracic fraction) and pollen
aerosol time patterns is well showed considering specific threshold
values (Table 1) to extract PM10 exceedances and pollen events (ex-
ceedances is the legal term referred to the European Directive on air
quality). PM10 daily exceedances of EU limit value 50 μg/m3 follow the
typical seasonal pattern, even as pollen events (Travaglini et al., 2009)
that are strictly linked to the blooming period, because of the short
permanence in the atmosphere of pollen grains (Fig. 6).
To investigate the potential cumulative effect that these different
pollutants may have on human health it is fundamental to point out the
number and the period of possible common events. During the period of
study, based on the abovementioned threshold values, the worst
months for the contemporary presence of high levels of air pollutants
and pollen, in the city of Rome, were February and March. (Table 2).
6
Urban Forestry & Urban Greening xxx (xxxx) xxx–xxx
3.2. The multivariate time lag modelling
A total number of 100 patients were recruited, but only 65 com-
pleted the study (Table 3). Reason for drop-out are too short period of
registration (< 20 days of registration).
The Table 4 shows the registration years number per patients
number.
Some of the 65 patients had no variability in the allergic response:
the recorded values were all lower or higher than the threshold value.
Therefore, the number of patients included in PLSDA was 45 for ACS
and 59 for RTSS.
The system has generated 68,181 models in total: 39,960 models for
ACS and 28,221 models for RTSS (Table 5).
Therefore, for best model selection the following modelling para-
meters were considered: time lag (from 0 to 4), number of LVs (from 1
up to 19) and x-block second pre-processing (7).
For each patient, the best models obtained for ACS (222 models)
and for RTSS (278 models) at different time lag (from 0 to 4 days) and
up to 19 LVs, have been selected.
RTSS models generally resulted better than ACS models (Tables 6
and 7) in terms of percentage of correct classification.
The best results are observed at time lag 1 for RTSS (Table 8) and at
time lag 4 for ACS (Table 9). This delay may be due to the drug: the ACS
index also includes drug use, which results in an improvement in per-
ception of the symptoms. It is possible to observe high performances of
mean correct classification about 70% (from 69,09% to 79,76%). These
values indicate a relative high accuracy in predicting symptoms when
present.
The Table 10 shows the percentage VIP scores of patients in order to
evaluate the impact of x-block variables.
Fig. 7 shows the VIP scores of 4 patients taken as cases for example
among the 68 analyzed, for the two SMS, ACS and RTSS: the values of
A. Di Menno di Bucchianico et al. Urban Forestry & Urban Greening xxx (xxxx) xxx–xxx

Fig. 5. Main Pollen allergens 2010–2015 time series from the Aerobiological monitoring Centre of Tor Vergata, Rome.

Table 1 total IgE are higher than 300 kU/L for 2 patients (patient #27: IgE
2008/50/EC PM10 daily limit value and A.I.A. – Aerobiology Italian Association – tot = 847 kU/L, patient #31: IgE tot = 381 kU/L) and less than
pollen standards. 300 kU/L in the case of other two patients (patient #92: IgE tot = 294
Adopted threshold values kU/L, patient #127: IgE tot = 168 kU/L). The results of percentage of
correct classification in the model are high for patients #27 and #31
PM10 50 μg/m3 (respectively 96.9% and 100.0%), lower for patient #92 and #127
Cupressaceae/Taxaceae 90 p/m3 (respectively 46.7% and 63,1%); same result for the test: patient
Graminae 30 p/m3
Olea 25 p/m3
#27 = 81.0%, patient #31 = 96.4%; patient #92 = 12.1%, patient
Urticaceae 70 p/m3 #127 = 12.2% (Table 11). The 2 pie plots shows the values of IgE SA
sensitization of each of the 4 patients: Patient #27 is sensitive to rPhl

80 160
PM10 - exceedance days per year Pollens - events per year
70 140

60 120
N. of exceedance days

50 100
N. of events

40 80

30 60

20 40

10 20

0 0
2010 2011 2012 2013 2014 2015 2010 2011 2012 2013 2014 2015

20 30
PM10 - average number of exceedance days Pollens - average number of events
18
25
16
N. of exceedance days

14
20
N. of events

12
10 15
8
10
6
4
5
2
0 0

Fig. 6. PM10 and pollen concentrations in Rome: comparing time patterns.

7
A. Di Menno di Bucchianico et al. Urban Forestry & Urban Greening xxx (xxxx) xxx–xxx

Table 2 Table 7
PM10 and pollen concentrations in Rome: 2010–2015 common events. Mean of percentages of correct classification: comparison between ACS and
RTSS models.
Month/year 2010 2011 2012 2013 2014 2015 Tot
SMS % Correct Classification
January 0 1 0 1 1 0 3
February 2 9 5 2 2 1 21 mean test mean models
March 9 4 5 3 7 5 33
April 0 0 0 0 1 1 2 ACS 66.46 76.23
May 0 0 0 0 0 0 0 RTSS 73.85 79.32
June 0 0 1 0 0 0 1
July 0 0 0 0 0 0 0
August 0 0 0 0 0 0 0
Table 8
September 0 0 0 0 0 0 0
October 0 0 0 0 0 0 0
RTSS: influence of the time lag on the algorithm prediction performance in the
November 0 0 0 0 0 0 0 patients. In bold the best values at time lag 1.
December 0 0 0 0 0 0 0
Time lag Mean%
Tot 11 14 11 6 11 7 60
Correct Classification Correct Mean Mean Test
Model Classification Test Model
Table 3
Characteristics of the population samples. 0 79.11 70.64 72.24 76.92
1 80.91 74.97 72.51 77.02
n. of patients 2 78.62 75.69 70.78 77.60
100 3 79.17 73.70 71.53 77.99
n. of selected patients 4 78.75 74.36 69.09 78.48
65
Males Females
35 30
Average age (2010)
Table 9
12 y ACS: influence of the time lag on the algorithm prediction performance in the
min age max age patients. In bold the best values at time lag 4.
6y 18 y
Time lag Mean%

Correct Classification Correct Mean Mean Test

Table 4 Model Classification Test Model
Patients number vs observation years.
0 77.99 70.20 76.37 75.05
N. of years N. of patients 1 79.04 72.35 76.34 75.23
2 76.60 68.43 76.02 75.35
2 27 3 77.34 71.77 71.18 74.59
3 12 4 79.76 71.91 76.75 76.26
4 20
5 5
6 1
Table 10
Percentage VIP scores. xn = number X-block variables.
Table 5 pollen meteoclimatic pollutant
Total models for ACS and RTSS. (xn = 13) (xn = 6) (xn = 5)

Models ACS RTSS ACS 63.1 19.1 17.8

RTSS 64.3 12.9 22.8
TOTAL 39960 28221
selected 222 278
n. of patients 45 59
are due: for patient #27 to Graminaceae; for patient #31 to Olea; for
patient #92 to Olea; for patient #127 to Olea without IgE correction.
Table 6 The patients #27, #31 and #127 show also an important variables
Number of models (m) with different percentages of correct classification (pcc). pollutant contribute (in order NO2, O3max and PM10).

% Correct mean total mean test mean models

Classification test + models
4. Summary and conclusions

ACS RTSS ACS RTSS ACS RTSS Millions of people worldwide, particularly children, suffer from al-
lergic rhino-conjunctivitis (AR) induced by pollens (pollen-AR) (Asher
m < 60 pcc 25 39 57 62 26 26
60 ≤ m < 70 pcc 60 49 50 48 40 61
et al., 2006; Brozek et al., 2010). AR negatively affects patients’ per-
m ≥ 70 pcc 137 190 115 168 156 191 formance of daily activities, sleep patterns, cognitive function, work
and school productivity and quality of life (Peden and Reed, 2010).
Allergies are increasing despite, in Rome, the analysis of trends shows a
p1 + rPhl p5b (59.29 kU/L) and to rPar j2 (243,00 kU/L) and to a lesser statistically significant decrease of important atmospheric pollutants
extent nOle e1 (0,54 kU/L,); patient #31 is sensitive to rPhl p1 + rPhl such as PM10, PM2.5 and NO2, all related o anthropogenic emissions
p5b (111.78 kU/L) and to rPar j2 (23,70 kU/L) and to a lesser extent such as the road traffic (Cattani et al., 2010, 2014). Pollen concentra-
nOle e1 (0,47 kU/L); the patient #92 is sensitive to nOle e1 (9,38 kU/L) tions in Rome, on the other hand, appear stable, with the only exception
and to rPhl p1 + rPhl p5b (2,59 kU/L); patient #127 is sensitive to nOle of Urticaceae that are increasing in the last years. In general the higher
e1 (0,69 kU/L) and to rPar j2 (0,10 kU/L). The same figures (bar plots) levels of concentrations in the atmosphere of pollens and air pollutants
show the contribution of VIP score for each of the 25 variables used in occur in different seasons, this is due to the big differences in natural
the x-block; regarding pollen concentrations, the major contributions and anthropogenic sources of these substances. In the city of Rome the

8
A. Di Menno di Bucchianico et al. Urban Forestry & Urban Greening xxx (xxxx) xxx–xxx

Fig. 7. Variable Importance in Projection (VIP) scores: factors that contribute to the prediction of allergic symptoms. From top to left in clockwise direction: pz #27,
pz #31, pz #92, pz #127.

Table 11
Molecular profile of 4 patients: pz #27, pz #31, pz #92, pz #127.
patient IgE kU/L pcc

EXTRACTS MOLECULES

E TOT E CYP E PHL E OLI E PAR E Cup a 1 E Phl p 1 + E Phl p 5 E Ole e 1 E Par j 2 SA model test

#27 847.18 4.48 32.72 NR 110.90 NR 59.29 0.54 243.00 0.36 96.88 80.95
#31 381.00 0.39 60.32 NR 14.30 NR 111.78 0.47 23.70 0.36 100.00 96.43
#92 294.00 26.52 2.64 13.03 NR NR 2.59 9.38 NR 0.04 46.67 12.12
#127 168.00 NR 0.27 NR 0.66 NR NR 0.10 0.69 0.05 63.11 12.16

greatest overlap period is between February and March, when high
levels of pollens occur together with high levels of air pollutants.
Less than half of the patients regularly follow medical advice, drug
therapies generally achieve only partial control of symptoms, and pa-
tient’s adherence to therapy is often poor (Canonica et al., 2007); in
addition, allergic responses are subjective. The development of pre-
dictive models represents an important contribution to symptomatology
prevention, and this is a topic of particular interest in applied research
in various fields.
The PLSDA, based on air concentrations of atmospheric pollutants,
pollens and weather data, showed a good accuracy in the prediction of
allergic symptoms. Comparing the results with a previous study (Costa
et al., 2014), we confirm that: 1) a multivariate modelling approach can
accurately predict the presence or absence of symptoms up to 4 days

9
A. Di Menno di Bucchianico et al.
before the event; 2) the models’ predictive performance tended to im-
prove when the degree of individual allergic susceptibility was also
taken into account. Results confirm that the models performance is
highly dependent from patients: the forecast models are reliable for
patients with a value of IgE-AS > 0.15 (Costa et al., 2014), and not for
patients with low levels of IgE; in other words, the model is applicable
only to allergy sufferers. Therefore the allergic symptoms’ forecast may
aid allergy sufferers to avoid exposure to atmospheric concentrations of
allergenic pollen and help them plan in taking medication, always
under medical supervision (Berger et al., 2013).
A correct analysis must take into account all the environmental
factors that interact in the various stages of the reproductive process
and pollen release and transport. Many authors have underlined that
flowering, pollination and pollen dispersion are all closely related to
variations in meteorological variables, especially rainfall and tem-
perature, which affect the levels of pollen in the air (Annie and Liem,
1980; Spieksma and Nikkels, 1998; Silva-Palacios et al., 2000; Laaidi,
2001; Gioulekas et al., 2004; Green et al., 2004; Jato et al., 2009;
Sabariego et al., 2011; Hilaire et al., 2012; Jochner et al., 2012).
Moreover in Spain has been evaluated as an increased risk of asthma
symptoms in pollen-allergic asthmatic patients during the pollen
season, is caused by air pollution (Feo Brito et al., 2007). Also in this
study the single patients’ symptoms have been associated with the
pollutants: in 20,3% of models the main contribution of the X-block
variables to the first LV is given by the pollutants; Therefore exposure to
allergens is also influenced by environmental conditions.
Acknowledgments
The research activity of Aerobiological Monitoring Centre of the
University of Rome Tor Vergata was funded in part by Centro
Universitario Cattolico – CUC.
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