Allergenic Pollen in Europe and in the Mediterranean Area

Pollen allergy in Europe

Celso Pereira

Coimbra University Hospital

Apartado 9057

3001-301 Coimbra / Portugal

e.mail: celsopereira@netcabo.pt
The first historical report related to pollens was in the 16th century, by Botal describing a patient with “aversion to roses”. It was only 200 years later that the seasonal disease was described by Hebergen. The methodology of Backley in 1873 was the ancestor of the pollen diagnosis and since that, it has been an increasing interest in these matter ¹.

The advances on aeropallinology, pollen counts, and pollen calendars are now widespread throughout Europe. There is much data available concerning pollen concentration of different species with a methodology that permit to compare the distinct national networks in Europe ².

It is very difficult to compare the different clinical studies available on literature, because of the heterogeneity of the design, the very discrepant samples, and the different aeroallergens tested. The Position paper published in 1998 is a relevant document that extensively analyses all the studies concerning pollen sensitisation in Europe ³.

The EFA study, performed in 2000 ⁴, showed the impact of the allergic diseases in 10 countries, and this information was consistent with the European Allergy White Paper contents ⁵. Pollen allergy is increasing throughout Europe in spite off a decrease in the grassland and tree land. It is also important to stress the changes related to the forest fires, the desertification, the agricultural methods and cultivation, the demographic pressure, the importation of non-natives species, etc.

There are obvious differences concerning pollen allergy in Europe. In the 5 main geographic areas defined by G D´Amato, birch is the main pollen inducing sensitisation in the Artic and Scandinavia; birch, grasses and pollen from trees of deciduous forests in the Central area; grasses, mugwort and ragweed in the Eastern countries; grasses and pollen trees in the Central Mountainous areas; finally in the Mediterranean area the main pollens inducing allergic diseases are grasses, Parietaria, Olea and Cupressus ³.

The ECRHS performed in 12 countries on individuals ranging from 20 to 44 years showed specific IgE levels to Phleum pratensis ranging from 3.8% in Ireland to 15.6% in Switzerland ⁶. In this country a large study performed in 9651 individuals, from 1991 to 1993, revealed similar values ⁷. The skin sensitisation to grasses was similar in adults and in children, 12.7% and 12.4% respectively.

In an interesting study of a cohort including 1456 subjects, in the Isle of Wight (UK) from 1989 to 1990 the children were submitted to skin prick tests at the age of 4 years ⁸. Sensitisation to grasses was 7.8% (981 out of 1218 individuals), and 40% of the children presented the diagnosis of bronchial asthma.

Pollen allergy sensitisation was demonstrated in 1101 random children aged 8 to 11 years from Freiburg school (Germany). 19.7% were sensitised and the allergic rhinitis diagnosis was present in 8.7% of the sample ⁹. The rates of sensitisation were low in Sosnowiec, Poland, on a random sample of 2000 children, 10.3-10.8% ¹⁰.

In the allergic population attending an Allergy outpatient department, the values of pollen sensitisation are obviously higher. The allergic sensitisation are higher in urban than in rural areas. This issue depends on several factors, mainly the pollution, particularly vehicle emissions, and the increased concentration of ozone in the air ¹². The risk is also increased in people living in towers at higher levels, and in urban areas with wide greenland zones ¹³.

In patients allergic to pollen living in Budapest, the sensitisation to grasses and Ambrosia was respectively 67.6% and 59% ¹⁴, whereas in Warsaw, Poland, the major sensitisation was due to grasses (89%) and Artemisia (42%), respectively ¹⁵.

Concerning asthma patients from Germany, the allergic sensitisations to grasses were higher in Hamburg (north) than in Erfurt, 24% and 19% respectively. Birch allergy was also higher in Hamburg (19%) than in Erfurt (8%) ¹⁶.

There was an increase in Cupressus allergy in coastal region of Imperia (north Italy) besides the stabilization on pollen counts ¹⁸. The allergic patients from Rome, showed a similar pattern of sensitisation with an increased rate from 9.3% from 1994 to 1996 to 30.4% in 1999 ^19,20.

The sensitisation to Cupressus pollen is more frequent in the Mediterranean area and is responsible for an increase of clinical symptoms of allergy such as conjunctivitis and cough, but can also be related to rhinitis and/or bronchial asthma ²¹.

Parietaria is a widespread pollen in the south of Europe, mainly in the coastal areas reaching the highest ratios of allergic sensitisation, and inducing bronchial symptoms usually severe in adolescent and young adult patients. However, there is an obvious increase in children ²¹.

Olea sensitisation is also common in the south of Europe,However,in a Swiss study performed in Locarno,53.9% of the pollen allergic patients were positive to this specie ²².

Consecutive patients evaluation is one of the strategies that can permit to obtain the prevalence of aeroallergens in specific areas or countries with samples defined by the clinical epidemiology. The performance of SPT with a wide number of different allergens, according to pollen counts and geographical particularities, allow obtaining a better vision of the sensitisation in specific populations.

In 1995 the Spanish Allergologica study evaluated the allergic sensitisation in 10 regions ²³. Grass pollen was the major allergen inducing allergic complaints with a prevalence ranging within 22% to 77%. Olea europea allergy was more frequent in the southern areas, related to the olive tree culture, being irrelevant on the north. Parietaria sensitisation ranged from 0.9% to 43.1%, being more frequent in the coastal southern areas. Allergy to Compositae (Artemisia vulgaris) and Chaenopodium pollen was reported to the southern regions and the continental northern area of Aragon.
An interesting study in Liguria, Italy, evaluated during 10 years the airborne pollen concentration and the skin sensitisation to aeroallergens ¹⁸. Parietaria, grass and Olea pollen allergy were the most prevalent in the sensitised patients, but there were no differences between the individuals living in the coastal areas and those living on the inland areas. Cupressaceae and Compositae sensitisation was also relevant, mainly in the coastal regions, probably related to the higher population density and the higher levels of particle pollutants ¹².

In Thessalonic, Greece, the Compositae sensitisation is frequent and corresponds to the 3 and 5 most prevalent pollen allergies, Chaenopodium (18.3%) and Artemisia (15.1%). Plantago was also a relevant pollen in this area and was responsible for 14.6% of sensitisations ²⁵.

An interesting prospective study was conducted in 5 centres (Isle of Wight, Vienna, Freiburg, Athens, and Kaunas) showed high sensitisation rates in Austria and UK and relatively low in Greece ²⁶. Grass pollen was strongly associated with hay fever in all centers and with birch pollen in Austria and with Parietaria in Greece.

Portugal is characterized by different geographical conditions associated to distinct patterns of the flora distribution and different botanical species. In allergic patients the grass pollen allergy ranges from 18.7% in Setúbal, (south coastal area), to 53.9% in Cova da Beira, in the inland central country ²⁶. In pollen allergic patients the grass pollen is also the most important pollen in all studies. In Coimbra, a study performed in 100 patients allergic to grass pollen, revealed that the allergen that induced higher skin reactivity was Agrophyron repens, followed by Agrostis alba, Cynosurus c., Anthoxanthum, Poa pratensis and Lolium perenne.

Madeira had the highest Parietaria sensitisation prevalence in Portugal, corresponding to 53.4% of a consecutive 100 allergic rhinitis patients. Most of them were also positive to grass pollen, the most prevalent allergen (61.3%) ²⁷.

Cova da Beira is an inland central region of Portugal, characterized by a dry hot summer and a cold rainy winter ²⁶. This area had the highest pollen counts in Portugal and pollen allergy is frequent in allergic patients. Grasses, Parietaria and Olea were the 3 most prevalent allergens in urban areas, 54.6%, 34.6% and 33.3% respectively. In opposite, in the rural areas, a significant decrease on the same pollen sensitisation was observed, 42.6%, 16.6% and 27.5%, respectively. Compositae and Chaenopodiaceae sensitisation was also observed: Artemisia vulgaris (13.4%), Chaenopodium album (6.7%) rectively. Plantago lanceolata was responsible for 12.7% of positive SPT in all patients. Sensitisation to pollens tree allergens, such as Robinia pseudoacacia, Platanus acerifolia, Tilia cordata, Pinus radiata and Betula pubescens had the following results: 6.4%, 5,8%, 4.9%, 4.4% and 4.3% respectively.

In these area, sensitisation to pollens was also the most prevalent in children ²⁸. Besides grasses, Parietaria judaica and Olea europeae were the most relevant pollen sensitisation even in children younger than 5 years: 43.5%, 23.4% and 19.8% respectively.

Platanus allergy has an enormous importance in Madrid, Spain, ²⁹ but this sensitisation can increase in other areas of the south of Europe, because it is being implemented as an ornamental tree in a lot of urban areas, as well as other highly allergenic species. Compositae and Plantaginacea are other families that are increasingly relevant in the allergic patients and could be important allergens in the next years.
There is an highly heterogeneity of sensitisation throughout Europe. The genetic, the climate, the geography, the native and the imported flora, the pollution and the demography are responsible for these different patterns. It is very important to design studies that could be compared and could be representative of the different countries or regions.

The increase in allergic diseases in all Europe, particularly pollen allergy, must be an incentive to these kinds of studies. The Iberian Chapter of SLAAI will perform a study concerning the prevalence of aeroallergens sensitisation with the same methodology and representative for 2 countries: Portugal and Spain. It is highly recommendable that this kind of strategy could be enhanced and developed in a large number of Countries in Europe in order to obtain a better knowledge of the allergic sensitisation and reinforce the targets of interest implementing measures that could reduce the high risk of exposure to allergens.

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