This webinar was recorded on July 13, 2023

Think allergies only happen in spring? Let’s take a deeper dive and learn about different allergies that happen throughout the year


  • Dr. Angela Hogan, MD, FACAAI, FAAAAI, FAAP
    Professor of Pediatrics at Eastern Virginia Medical School in Norfolk, VA in the Allergy & Immunology Division at the Children’s Hospital of the King’s Daughters. Senior partner of Children’s Specialty Group.

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Transcript: While this transcript is believed to be accurate, errors sometimes occur. It remains your responsibility to evaluate the accuracy and completeness of the information in this transcript. This transcript is not intended to substitute for professional medical advice.

Andrea: Good afternoon. Thank you for joining us. We will wait a few seconds while everybody’s computers are connecting, so I thank you in advance for holding. Thank you for joining us today. We are waiting for a few more people to come on. We are waiting for those wheels to stop spending and for everybody to get connected. We have about 300 people registered, so thank you in advance for holding. Good afternoon and thank you for joining us today. We have a few housekeeping items before we start today’s program. I am Andrea Jensen, the education specialist for Allergy & Asthma Network and a certified asthma educator. All participants will be on mute for the webinar. We will record today’s webinar so don’t worry. We will post it on our website a few days after the webinar, so please be patient. You can find all of our recorded webinars on our website at Scroll down to the bottom of the page and you will see our upcoming webinars that will have been recorded. The webinar is one hour, including time for questions. We will take them at the end of the webinar but you can put them in the Q&A box at any time. It is at the bottom of your screen. Please, don’t put them in the chat. I can miss them when I toggle back and forth, so if you have questions for Dr. Hogan, these put them in the Q&A. If you have any questions with anything regarding webinar need any help, we will get to as many questions as you can before we conclude. This webinar does have CEU’s. This webinar series is part of our series in advances and allergy at, in partnership with the American College of allergy, asthma and immunology. They offer CME’s for this particular webinar. Look for an email, which you will receive within a few days, so please be patient. I always have people who email me after the webinar but just wait a couple of days and you should get an email that will have all the links with resources for Dr. Hogan and Information, so please be patient and watch for that. Allergy & Asthma Network also offers CNE’s and CRCE’s. We will put a link to the certificate in the chat. Today, we will talk about allergies throughout the year. Today it is my pleasure to introduce Dr. Angela Duff Hogan. Angela Hogan is professor of pediatrics at Eastern Virginia medical school in North, Virginia, in the allergy and immunology division at the Children’s Hospital of the King’s daughters and is a senior partner at the children’s specialty group. She graduated from the University of — sorry, I cannot get that pronunciation correct. And completed her pediatric residency there at the Children’s Hospital. She completed a fellowship in allergy and immunology at the University of Virginia in Charlottesville, a fellowship in clinical and laboratory immunology at Virginia Commonwealth University, medical College of Virginia and a four year post doctorate study and immunology. Dr. Hogan is a fellow of the American College of allergy, asthma and immunology, and the American Academy of allergy, asthma and immunology, and the American Academy of pediatrics. She is Vice Chair for the ACII asthma committee and the planning group member, representing allergy and pulmonology at the national meeting. Dr. Hogan is passionate about community, education and asthma and food allergies. She has been leading several courses, a CAI — ACI AAI, and nationally. Regionally, she has worked extensively to advocate for the health and safety of children, including forming a regional allergy support group Online. She has helped develop and has participated in multiple outreach programs for schools, EMTs and community positions. Her most treasured time is hanging out with her three amazing children and her dog Oliver. Currently, she is learning to play the bagpipes, and my oldest son (Dr. Hogan: I am not very good.) Andrea: It takes time, my oldest son is a geologist and a bagpiper, playing for 14 years, so everybody needs a hobby. Take it away.

Dr. Hogan: My disclosures are here on this slide and have been mitigated through this speaking arrangement, too. Our objectives today, I am really excited to talk with you all. It is an exciting thing to think about how the seasons change outside and also how it impacts how we deal with our allergies and asthma. We will talk a little bit about each of the changes and what we know is that it is something that we see and hear a lot on the news. I have three headlines one it’s a grab first to see today, and the first one was from a recent publication that says smoke from wildfires may increase violent crime and also asthma attack, and another headline here is that the fog of Holland performance allergy — fog of pollen torments the fog of allergy on the day. You can see this beautiful explosion of pollen from this particular pollen tree, and then, also, you are not imagining it, seasonal allergies are getting worse. Certainly in our public forum, there is a lot of interest in season one allergies. What I would like to do is talk with you a little bit about some seasonal things we see with allergies and asthma and how those triggers change throughout the seasons. Let’s get started. First thing I like to do is think about the prevalence of allergy. It is important for us to think that 27% of U.S. children are allergic, and 20% of kids actually have seasonal allergies, things that change throughout the year. Nearly 5 million children have been diagnosed with asthma and 60% of those asthmatic children actually have allergies, also. We know that if you are a child with allergies, you are more likely to have asthma, and we know that being allergic is an important risk factor for asthma and allergic laryngitis. We know if you have asthma, it significantly impacts the quality of life and there are parameters that have been measured, but we know it impacts your sleep. In addition, it can impact your lifestyle. There are medications, treatments, you can miss school or work, and there are social and financial impacts, so knowing what triggers it can be important. Equally, what triggers allergic rhinitis should be addressed because it also impacts your quality of life. We know from a recent burden of rhinitis in America survey, that many adults and children have sleep disruption because of their nasal symptoms, and we also know that there is an association between nasal allergies and mood, and we also know that even something as simple as your sense of smell can significantly impact your quality of life, where you may not be able to taste food or there may be health concerns if you are not able to small things that might be threatening. So, we know that if we can address triggers for rhinitis and asthma, we can improve audio like. — improve quality of life. It is important that we find out what are the allergy seasons and what we see each season. The first thing we need to think about are actually what are in those seasons. There are different particles that are out in the air, and commonly we call those particle allergens. And ae robiology is the study of airborne particles of biological origin and an allergen can cause an antibody response. They can be indoor or outdoors, and those levels of allergens change during the season indoor and outdoors. We call them airborne allergens, aeroallergens. They are like little feathers, they float her out the air, they are different sizes and sometimes they are airborne longer and other times they float down and wait for some kind of parent to carry them higher again. There are lots and lots of sources of airborne particles. It can be a viral cell. It can be an intact or broken apart pollen grain. It can be from a fungus, the spores from a fungus, or the hyphal. It can be a protein dissolved in water droplet. We know that insect species like dust mites can be allergens. We know that insects, other body parts, for example, can’t purchase, we know their body parts can be a significant allergen. There can also be bird material associated with allergies. We also know in the cats and dogs, their dander, there’s a library or their year and can be sources — their urine can be attached to allergens. And these could impact our airway. So what size of particle is a really important concept. Many particles that we breathe into our nose are really big. If they are particles that are greater than 10 micrometers in size, they actually get trapped. They get trapped in our nose, our throat, and then weeks needs them out, low them out, cough them out or swallow them, and they are not a particle size that in general tends to bother us. When the particle gets smaller, between 2.5 micrometers and 10 micrometers, then those particles can travel down further into our airway and may make it into our upper airway or our bronchus. It is those exposures over a longer time that actually can exacerbate things like asthma or bronchitis. But the most worrisome particles are those that are 2.5 micrometers in size. We call that the PM 2.5, and those particulate articles can go really far down in our lungs, so they can go all the way down to the level of alveoli. Particles that small are generated often times by pollutants, so things like vehicle emissions, industrial pollutants, or maybe even smoke from wildfires have really small particle size, so they can go really low in the airway and while they are there, they can cause a lot of increased inflammation and association with that small particle size has been increased risk for respiratory infections, reduced lung function, and in some studies, it has been associated to premature death, so understanding particle size is important. Particle size alone is not all of it. We know what is also in the particle can be important, so sometimes the actual chemicals carried in those particles can impact our health, and then the individual, is that individual allergic or sensitized to a particle that might be carried low? Or do they have underlying problems, perhaps maybe they are a tobacco smoker or they worked in a mine, or something else that also might be increasing the inflammation in their lungs, and then how long are the exposed and what is the overall quality of air that they are breathing every day? All of those things come together to make an impact on the underlying allergen sensitivity and what is going on. Let’s start with spring. For Spring, we know the most common allergen, that we seek sensitization to, a street. From a recent study in 2021, he said there are approximately 81 million people in the U.S. who have been diagnosed with allergic rhinitis, about 26% of adults and 19% of children. And we know that pollen from trees, at different times during the year occur, but most happens during spring. Most common tree pollens are oak, birch, maple, cedar, pine, which can be early pollens. It is interesting to know that a virtual tree can release about 5.5 alien grains of pollen over a year, and in alder tree does more, 7.2 billion, and an oak tree about .6 billion, so it is a lot of pollen that can come from one tree, so imagine a whole forest. We know in the U.S. there are different pollination periods that people think about, and there are also different zones, so in North America, there are eight to 10 major zones where we see trees, grasses and weight start and stop during different periods. I listed on the graph from today some different regions in the country where we see different pollen patterns and we know that some tree pollen starts early. For example, mountain cedar in Texas can start in December, but for me here in Virginia, we see it starting around Valentine’’s Day and lasting until about Mother’s Day. I remind my patients that you can remember spring pollen season because you love your mother. That is sometimes helpful. But we know that not only do trees pollinate during certain times but sometimes some of the weeds can be perennial, which means all year, and some in some regions, like planting and sorrel. In general, the wind carries the pollen and some can be carried hundreds of miles. Usually, they are carried only a few hundred meters because they are heavier particle. So what we know by seeing this graph year, showing you different regions that we see for pollen, and we know, again, that is like wind speed, humidity, atmospheric factors and rainfall, I’ll determine how far the pollen goes. In general, when I tell most people, it does not matter which tree is in your yard. You don’t have to cut down any particular trees because you are allergic. What you actually do is realize that those trees are going to be in everybody’s yard because the wind is a factor. And then we also know that pollen does increase on the climate is warmer, and when we have colder climates, that is a pollen that must go down. In general, what I tell most people, is most trees pollinate for three weeks to four weeks and then they move on to another tree. If you are super allergic to birch pollen, then you will have about four weeks of significant suffering here are some beautiful pictures, I think, of pollen grains. Pollen grains are identifiable from every single individual pollinating. This is what a scanning electron microscope. If you were an allergist, you would have to remember for your exam which pollen is from which tree, but I will not do that today because I have forgotten. I think they are always a cool picture and this would be nice artwork for somebody’s house or something. I will cover some of my favorite trees for a moment. In our area, the oak tree is pretty significant, it is that yellow crap all over your car, and as you can see here, there is active pollen from the oak tree. We also know that in our top of the region, this is what a birch tree looks like. And when we look at fault trees when they are pretty, they are already over there pollen stage. The pollen is when you see the flowers on the trees. Also, you have probably seen many of these in your neighborhood. This is the maple tree. And what we know is that we actually can do pollen counts. Pollen counts can be very helpful. It tells us how much pollen is in the air, so there are special sampler devices that are on the roof of a building or in some open area where the pollen can get access to it, and the pollens are connected and then experts you recognize what all the grains are, how many pollen grains in a particular sample, and they do higher math to be able to tell us what the actual pollen count is, and when you watch it on TV and it tells you with the pollen count is locally, they are actually telling you with the pollen count was yesterday, not today because they have to have had at least 24 hours accountable and decide which particular species of pollens are out there. In general, pollen counts are displayed as low, moderate, high, or very high. What they are trying to tell you on the TV is if you are exposed because you are allergic or sensitized, then that represents the relative risk that you will have allergy symptoms when that pollen level is high, and it can be helpful to follow pollen levels, especially if you are sensitized, but you should know that the wind and humidity can be impacted, so pollen count from yesterday may not truly be the pollen count today. We know in general that hot, dry and windy days means more pollen but don’t forget mold counts. Mold levels can also be impacted regionally, and you have a seasonal pattern? For tree pollen, peak pollen times are usually between about 2:00 p.m. and 9:00 p.m., so if you are super tree pollen allergic, you may want to go for the run first thing in the morning before the trees have a chance to warm up and start dumping out there pollen. We do know that rain also impacts pollen levels, and the pollen levels do in fact improve often times when we have a rain. My grandmother used to say, we need a rain, the pollen levels are so high, and people talk about the rain, air scrubbing the pollen out of the air. That actually does happen in some cases. We know that smaller raindrops and more light rain is better than cleansing the air then larger downpour droplets are, and we know that a prolonged rain shower actually can improve air quality, but there is a little more to that story, and we will come to that in a little bit. I want you to remember that not only do we see high tree pollen levels in the spring but we also see hi mold levels. Mold loves moisture, and we can see increased mold spores endorse and outdoors, so if there are damp basements, we will see a particular prevalence of a certain kind of mold and if there are outdoor areas that water has been collecting more snow has melted, in particular areas may be outside the home that have stayed moist, those are prime opportunities for molds to grow, so we see a lot around in the spring, also. So, let’s move ahead to summer. In summer, the predominant pollen we see is grass pollen, but there are other things that are allergens in the summer, also. Let’s not forget the importance of insect allergies, we are outdoors more, and also lots of stinging insects are outdoors more during the summer. Not only do we have these, but we have things like Yellowjackets, Hornets, wasps, and they have a lot more activity in the warmer season and also there may be more food sources available for them to have more opportunities to sting you in the right circumstances. As I mentioned, in summer, we see increasing amounts of humidity, more so than what we saw in the spring, so it promotes a lot more mold growth, and we know that mold can exacerbate both allergic rhinitis and asthma symptoms. The predominant pollen in summer is grass pollen, and grass pollen can be year-round if you are in a particularly warm climate, like the West Coast. Of all the outdoor allergens that there are opportunities to become allergic to, sensitization to grass is what we see the greatest number of nations allergic to any U.S. Most studies say that about 40% of individuals in the U.S. may be sensitized to a grass allergen. We also know that we are seeing an encroachment of certain grasses, as we see warmer and warmer areas or perhaps some areas due to global warming or climate change, some of those types of pollens and foliage are moving out, so there has been a general trend, for example, of Bermuda grass to extend northward if we look at the last 50 years. We also know that grass pollen not only causes allergic rhinitis and asthma but it has been elated to dermatitis, eczema flares and some people get very allergic — get urticaria to grass, where extra select traps pollen and that leads to hives. And there is also contact dermatitis that can happen. What we know about grass is that there are basically three main families of grass, there are the northern pastor grasses, which Timothy is probably the most important one. We see a lot of perennial and Kentucky bluegrass also. There is the Johnson grass family, where bahia is in that, and we also see the Bermuda grass family, which is more of the southern rest families. There is a lot of crossbreed activity among these families, so when we are doing particular immunotherapy to people who are allergic to one of these families, we only need to pick one representative grass from those families in order to be able to treat them. Timothy grass we have a whole lot where I live. It is kind of a northern grass, better suited for colder climates and a temperature range that it likes, with more seven grass where we see a lot more Bermuda grass, the one that kind of goes Brown in the winter months if it is in the colder climate. It goes dormant instead of dying during the winter months. So there are lots of different kinds of grasses that we can see. And there are lots of rings that that grass allergy has been associated with. One of the things I found most fascinating when I looked at grass pollen is that there has been an association of grass, pollen and food allergy, so there was a recent publication called the HealthNet study — healthNuts study, a cohort of about 5000 infants in Australia. They looked at rest pollen exposure during pregnancy and also in the first six months of life for each of the infants that were in the cohort. What they also did was measure grass pollen counts every day, and they said that if there was a significant increase in pollen during a particular day, then they would consider that to be a higher risk day. Then I took those infants and tested them for food allergies. They looked at egg, payment, Sesame — peanut, sesame seed, or shrimp, and they did this by skin pretest. Those with positive skin prick tests, which means sensitization, they did oral food challenge is to confirm they had allergy. They came up with three types of people, the people not sensitized, those people who were sensitized and tolerate the food, and then people who were actually sensitized and had proven food challenge positive allergies. What they found is that if there was a high level of grass exposure between the 10th and 12th weeks of pregnancy, then those infants were at increased risk for egg and peanut sensitization, so what was happening to mom while she was pregnant actually impacted sensitization rate of kids. They also found that if there were high pollen exposures, first seven days of life, there was an increased risk of peanut sensitization and those kids. Equally interesting, if there was a prolonged elevated exposure with multiple points during the first four months to six months of life, there was an increased risk of egg sensitization. And that if mom had a history of food allergy, she had a high exposure during her 10th to 12th week of pregnancy, and there was a high pollen exposure in performance to six months and the baby, then those kids were more likely to have true egg and peanut allergy confirmed by challenges. This was independent of whether or not the egg and P Nick got introduced between four months and six months — peanut got introduced between four months and six months, so I think that is interesting to see that grass pollen could be a figure. A recent case report studied a four-year-old with a documented peanut allergy, and they were on peanut OIT, and they did have a 10 millimeter skin test grasp. During their gold up and maintenance phases of OIT, there were four episodes of anaphylaxis and two of the episodes were in the name and ends — were in the maintenance phase and not related to missing a dose, a concurrent illness, physical activities, the doses were not given on an empty stomach. They were not able to find any reason why the child should have anaphylaxis to their OIT, other than they were grass allergic and grass pollen levels were high at that time. What they stated was the case, stated the importance of considering seasonal timing of anaphylaxis while on OIT, and that grass pollen sensitization and exposure could possibly be an additional extrinsic cofactor for the risk of anaphylaxis. Likewise, some of us worry about patients who have EOE, and when they are sensitized to particular pollen, and they are in pollen season. Sometimes there EOE is worse during the pollen season or perhaps if they get an endoscopy during that pollen season, even though they may be avoiding them, we may also see increased amounts because of their previous sensitization. This raises questions about grass pollen sensitization and food allergy Association. We also know that grass pollen and asthma tend to run very closely together. There was a recent systematic review on the relationship of vast pollen exposure to asthma exacerbations, and this meta-analysis shows the strongest associations were found between asthma attack’s, asthma ED visits or hospitalizations when grass concentrations were high the previous two days in children who were less than 18, and it showed when you were sensitized, pollen levels were high, that you also had lower lung function. In Australian study, they show readmission to the hospital was associated with higher levels of grass pollen with a significant incidence ratio. I want to tell you a recent story. This is a recent story from November 2016. It is in Melbourne, Australia, they were experiencing an unprecedented heat wave. Temperatures on this day climbed 95 degrees, and it was one of the hottest reported during that particular year. The pollen counts there were extremely high. They were predominantly ryegrass. Between 7:00 and 8:30 p.m., the temperature dropped below 60 suddenly, and a thunderstorm erupted with severe wind gusts. Within one hour, the emergency received hundreds of also people who were in acute respiratory distress and having breathing difficulties. By midnight, they had received over 1300 phone calls, more cases than they could actually send their ambulances out to. Within 30 hours of the thunderstorm, there were over 3000 respiratory related ER visits and 476 hospital admissions. in total, there were 10,000 people who needed treatment in the hospital emergency department for asthma attack within a short time of the thunderstorm. 10 people died, and six of them were within one week of the storm area so it is up with that? This is called thunderstorm asthma. While we can see it locally, there can also be epidemic levels of thunderstorm asthma in certain locations, but thunderstorm asthma is an asthma exacerbation or attack that immediately follows that thunderstorm during a pollen season. These have been reported across the world during pollen season. They first started reporting it in the 1980’s read every time there is a high pollen count and a summer thunderstorm, it does not always trigger asthma, but there are certain factors that need to line up and make that particular place more susceptible to it. When we look at what happened in Melbourne, it is important to remember that, first of all, ryegrass pollen, which is their number one pollen there, is a very large particle. If you remember what I told you, 35 micrometer pollen particles are going to get trapped probably in the nose or bronchi, but or nose and throat, and probably will not make it to the bronchi. In this particular case, there was very high humidity. With that high humidity, the pollen actually ruptured and released a lot of much smaller particles, and those much smaller particles, less than three might meters, were easily inhaled the to the lungs. What I think is most interesting about this story is the fact that it was not asthmatics who were having asthma, although, all the mortality was in patients with asthma already and were predisposed because they were sensitized, but 28% of the people who had an asthma attack in Melbourne actually only had allergic rhinitis. So being sensitized to allergic rhinitis, that one airway theory, being sensitized, having the right sized particle that got low enough in their lungs, they had a significant asthma attack, and they previously had not had a physician’s diagnosis of asthma, so that is scary when you think about it. When we think about thunderstorm asthma in this other schematic, what happens in meteorological simple terms is that pollen or mold spores kind of get swept up into the clouds, and that extra moisture can actually put those — split particles into smaller particles but the lighting is also a factor because the ionic charge can also help split the product, so we get — split the particles, so we get smaller fragments that are able to penetrate the lower parts of the long. With the current thinking is and why I put thunderstorms in summer is that we do think thunderstorms are more present in summer, but also climate change and air pollution have become an important cofactor for the development of pollen related disease and thunderstorm asthma. Let’s go there and spend a minute to talk about climate change. Is climate change in fact impacting that element of allergy and what we see? Just a side comment, global warming and climate change are not necessarily the same thing. Although, a lot of people use them the same grasp. Global warming has to do with the increasing of the temperature of the earth, and climate change has to do with things that are changing, like colder air might be getting colder and warmer areas might be getting warmer, dry areas might be getting dryer, etc. What we have seen is over the past 50 years, the average global temperature has increased at the fastest rate in recorded history, and we think that global warming is related to greenhouse gas. And what we are seeing is that this greenhouse effect is changing precipitation patterns. It makes it wetter areas wetter, it can make drier areas drier, and it changes insect and rodent borne activity and diseases. A changes ozone levels, which can in fact respiratory ailments. Potentially, it can contaminate drinking water due to flooding, and we also see climate change driven droughts and floods that can affect our agriculture, which ultimately can impact food and securities. What we are also seen, it is increasing the prevalence of allergies as one of our early slides did in fact tell us. So why is it changing things? It has to do with CO2. The collation is — the correlation has been shown between CO2 prevalence and asthma and rhinitis. CO2 has a big impact on pollen. It makes plants grow faster and bigger. They produce more pollen, and then the pollen they do produce has more allergenic proteins, and they start pollinating earlier and the growing season is longer than it used to be. When we look at something like ragweed, for example, there are differences in how well the ragweed grows in the garden or out on a farm, away from the city, so we know that there is a lot more ragweed pollen in urban areas than there are in rural areas. That is thought to be partly due to increased CO2 in the urban areas that make the ragweed plants much happier so they grow bigger and tolerant and have more pollen. The ragweed plans that are in the city than the ones out in the side of the road in a little area. There is one study that showed an association between the actual increase in outdoor temperature and emergency room visits for asthma, and there is another study for birch pollen that shows higher ozone levels that increased the allergen a nicity of birch pollen. So the effects of CO2 are impacting the pollen levels and the plants in our environment. So, how many of you remember the week of June 13 this year? It was not that long ago. If you remember, the headlines were –“none of your patients are safe from wildfires.” We should spend a moment and talk about wildfires because it looks like we are going to have a few more wildfires but the summer is over. Wildfires are generally more common in the summer, and they are particularly in regions that experience hot and dry conditions. There are several factors that contribute to increasing wildfires during the summer months, drier weather, we also know that vegetation may tend to dry out, especially in late summer, and they get more of a fire hazard. We know that lightning can actually increase the risk for wildfires, and then people are out and about doing stuff and they are not always careful, and they can also contribute wildfires. Why are wildfires in issue and why are they something you need to discuss with your patients? We do know that climate change is increasing the vulnerability of any forest wildfires — of many forests wildfires, and wildfire smoke has small particulate matter, and other things associated with it, like carbon monoxide, nitrogen oxide, and various volatile organic compounds, but they also have small particles and they can go really small, down into the airway, where they can increase inflammation and lead to bronchospasm. We know that smoke exposure increases as for Tori hospitalizations, emergency room visits, and also with — hospitalizations, and emergency room visits, and it may make them more susceptible. We know that particle sizes are especially dangerous for children, whose lungs are still developing. There are studies that suggest exposure to small particles, especially particles in pollution, may lead to the develop mental asthma. So one of the tips I tell my patients, I tell them to pay attention to what the television is saying in terms of equality and particle size and how many parts are out there. And then the other thing I tell them is that they should stay indoors. They should keep the indoor door in — the indoor air in, and outdoor air out, and they should get an N95 mask if they have to be outside air quality is poor. If they say to evacuate an area, they need to evacuated. We need to protect the most vulnerable and those exposed to extreme climate events. Now we are to fall and the most common fall allergen is weed, prevalent during autumn months. The most common when we talk about his ragweed. It grows wild everywhere. We just mentioned it is especially prevalent on the East Coast and Midwest. Here is another schematic where you can see weed comes in. When I lived in Kentucky, we had the ragweed on August 15, and here in the coastal Virginia area, it comes in about August 1. There are other weeds, like cocklebur, lamb’s quarters and mugwort. Ragweed likes open areas and fields and roadsigns and vacant lot. You can grow super tall, up to five feet and they produce pretty greenish flowers that you can see here in this picture. What is interesting is that ragweed was not native to Europe but got introduced after about World War I, and that because of climate change, ragweed species is spreading very quickly across Europe, and they are having a significant disease burden because of ragweed exposure. They do like disturbed soil like construction sites and abandoned agricultural fields. We know one single plant can produce about a billion grains of pollen per season. They are carried in the wind, and it is a very important because of pollen related allergic rhinitis. There are different breeds or species of ragweed and the most important allergen is Amb a 1, and on the ragweed pollen, there are 12 different allergens. If you are sensitized to multiple allergens, then you have a higher risk of asthma. Asthma symptoms occur in about 25% of ragweed allergic patients, and we know that it causes asthma twice as often as other types of pollen. We also know that how much pollen is out there is associated with how many symptoms you are going to have. The highest ragweed levels are usually mid-day and the lowest levels are at about 6:00 in the morning. Nature published a recent article that suggested that there are certain levels of ragweed pollen that are associated with higher symptom levels. We do know that if we double the atmospheric CO2 concentration, we are going to make ragweed happy and they are going to grow and grow and grow, and there was a recent study that also said that if we do allergy shots to ragweed effectively, we do impact asthma and the severity of symptoms, so that is encouraging. I do want to mention fire and. They are on the move when we are involved — fire ants. They are on the move in fall, and they might migrate to warmer surfaces, such as concrete slabs or asphalt roads. They can then be easily missed if you are out and about and doing things, and if you get into a swarm of fire ants, then they can be associated with painful bites. The fire ants clamps down with his mouth, lifts his butt up and stings by twisting his abdomen. Often times, we see a circular pattern. What happens is we see blister like areas. What we also know is that about 1% to 3% of the population actually can develop IfE- mediated anaphylactic symptoms to fire ants, and we are seeing the migrate further and further north. Currently, they are as far as Virginia because we have some in this particular area, too. We know that fall is a very important exposure for mold, and the most important one is alter naria. It peaks on warm, sunny days, and levels can be very, very high. Alt a 1 is the most important allergen and really important. We know exposure has been described as most important allergenic source associated with asthma in. Areas of the world, and sensitization to it has been uncritically associated with increased asthma severity and 13% of the population is sensitized to alterneria, so it is an extreme important allergen in the fall. There is also a seasonality to dust mites. Dust mites thrive as the humidity in the house goes up, and that are studies that show the levels to be higher in the fall. Let’s spend a moment to talk about winter. Winter we move and allergen levels in doors are mostly associated with indoor allergens like dust mites, pets, cockroaches, but mold levels can significantly in race. We — increase. We also know we bring a lot of other crap entire house like unscented candles, fresheners, odor irritants, and then cold air itself can also be a trigger of asthma. And then we see an increase of respiratory attachments during winter and that can lead to — respiratory infections during winter and back, to asthma. Inter-molds are prevalent and some outdoor molds move indoors during the winter months, and we know that the higher the humidity, the more likely we are to develop mold. Mold, unlike mildew, does not die down when it freezes. It just goes dormant and it is available to come back. We also know that cold air can be a trigger of asthma. We think that is partially because the cold air strips are airways of water and those changes in osmollity and that — osmolality leads to inflammation and broncoconst riction, so we often tell people to wear a mask covering the mouth and nose. Even though we like to take it cool and cozy by the fireside, remember, the fireplace has small particles that can be irritants. It can also trigger asthma, so we need to be very careful, even though it is a desirable place that can trigger asthma in sensitive individuals. So seasonal allergies are quite common and can cause significant discomfort for those affected. Let’s review for one second what are the symptoms that we see associated with allergic rhinitis. We know it is sneezing, runny nose, obstructed nose, postnasal drip, itching, irritability, fatigue, itching of the inner eyes and ear. When asthma symptoms — asthma symptoms most commonly look like a cough associated with wheezing, shortness of breath, chest tightness, and exercise-induced bronchospasm. When we think about allergens, there are lots of available resources that tell us how to treat allergens, from staying indoors, closing windows, making sure we run the air conditioner to HEPA filters, if we have pets, we can wash them or have filters in those cases. There are things we can do to eliminate mold and reduce dust mites, and there are many resources available on the Allergy & Asthma Network that will tell you how to treat allergens you have been exposed to. Most important thing to manager allergy and asthma symptoms is remember what your triggers are — manage your allergy and symptoms is remember what your triggers are. Try to avoid contact or reduce exposure if you have allergens, and then it is important to make an effective treatment schedule with your provider so you can treat the symptoms when they occur through the seasons. From one of our recent presidents of the American College of asthma and allergy, Dr. Fonacier, she says it is important to get ahead of it. If you know that you have spring or fall time symptoms, start taking your medicine two or three weeks before those particular pollens become prevalent so that you are not trying to put the horse back in the barn and have to chase them over the hill. It is easier to shut the barn door, again, another Kentucky analogy from the Kentucky girl. Thank you. We will open it up for discussion at this point and thank you for attending.

Andrea: Thank you, Dr. Hogan. That was a wealth of information. Hopefully you did not hear me clacking away as I was taking notes. Let me turn my camera on. I liked what the last quote you had about the allergy meds, about getting ahead of them before the season starts. One thing my kids joke about, they are all adults but when they come back to visit, I give them an Easter basket, and I go to a certain warehouse store and stock up on all the allergy meds and that is what they get in their Easter basket. I will put a little chocolate, but that is about the time of year. Like you say, we have to look ahead and get going before. Do not wait until you start sneezing and then start taking whatever your allergy meds are. I love that quote, fantastic. We have a couple of questions. Let me read those off. I got COVID in January in 2019 but had allergies my entire life. Until recently, I never had an issue with air quality but now I have to wear a KN95, regardless of air quality. Can allergies get worse from COVID-19 and make your body more sensitive to air quality?

Dr. Hogan: Excellent question. And, in general, COVID has changed our immune system in 101 ways. It has turned off some things that we thought maybe protective features, and it has turned on other things and sort of run with them. I do think COVID has been associated with increased allergies and some individuals, so, it makes perfect sense to me that you may have been perfectly fine and now post-COVID, you are seeing changes in your immune system. Although, naturally, sometimes even without COVID, we do see natural changes in our immune system. In general, we see outdoor allergies started about the age of three and they peek usually about the age of 15. And then somewhere around that age of 65 or 70, we start to see those allergies start to decrease and diminish, assuming we do not do anything to change our allergy immune system with any kind of immunotherapy.

Andrea: Thank you. Another question, oh, we hear this all the time, is it true that children can outgrow allergies and/or asthma?

Dr. Hogan: Gosh, this would be a whole other lecture probably. In short, yes and no. We do think that sensitization for most people may in fact, what probably changes the most for kids is the actual airway. So when you are little and you have a little tiny nose, let’s say you are allergic to cats, and you have inflammation in your nose, you don’t have a lot of room to move that’s not out, — that snot out, so the cap allergen explosion may have a bigger impact. As you grow and go through puberty and your head and nose gets bigger, and you can blow your nose, and you might take your medicine, too, and there are more available medicines, the impact of those allergens sometimes become less. Sometimes people may scan test positive for one thing and then 10 years later may not be positive to. I am not sure if the first skin test was true or not. In general, we think sensitization to things sort of follows a certain lifecycle, where, you know, you remain sensitized to them but maybe your impactor exposure changes. I do not know about allergies that you specifically are said to outgrow them. Asthma, a whole different can of worms. There are different as much or directories for pollen allergies and different asthmatics, there is viral-induced asthma. Those have different endpoints, so we do see kids out there as Malta time — outgrow their as Malta time but it tends to be more of the viral asthma — there asthma all the time, but it tends to be more of the viral asthma.

Andrea: When is the best time to start allergy immunotherapy depending on the season?

Dr. Hogan: In general, and I am a moderately conservative allergist, if you are asking specifically about the season, I think if you are in or mostly allergic to grass pollen, you could still start allergy shots during grass season because you remember that the way that allergy shots work is that you start with a really small amount in the beginning and then you build up as you go along, so, there is a safety net that is built into allergy shots if you are starting a particular season and that pollen level is high. We do know that the further and further you get along and immunotherapy, we do still see local reactions when pollen levels are superhigh, and there is a low risk for systemic reaction if you are super pollen allergic and in a pollen season to read I think probably the best time to start allergy shots, if it is indicated with you and your provider, is probably when they feel like it is indicated. I probably would not worry about the season because there is built in factors in immunotherapy to help keep you safe.

Andrea: Thank you. And then another part of that, it could go along, when is the best time to get allergy tested? If somebody has to go after allergy meds for a week before they do the skin prick test, can somebody go a week in the middle of summer with high grass pollen? Do you normally have people do that year-round? I think would’ve my kids had to wait to the middle of winter because that is the only time he could go off of his medicine.

Dr. Hogan: Certainly winter is a lot easier to be able to come off of your allergy medicine, if you are someone who is particularly seasonally pollen allergic. Most people can tolerate coming off their medicine for a week, although it is a miserable week. I do think it depends on when you get to that threshold of like we have had enough and we would like to know what is causing our allergies and we need to have skin testing. Sometimes people just come off their medicine during the pollen season and I will say, OK, let’s shovel the medicines and national the medicines and weight of the winter — shuffle the medicines and wait till the winter. Theoretically, you could skin test during any season. If you skin test during any season, you can get your therapy started earlier if you are going to do immunotherapy. Immunotherapy might not be for everyone. It might be the importance of identifying what they are allergic to so that you know when to stop and start other medicines. So the value in skin testing is not just for allergy shots but actually to know when you’re asthma might be at risk or when you need to step up certain therapies or step down certain therapies as you go in and out of season. I would not wait to find out what you are allergic to, because you think you are allergic to grass and you are miserable and grass season.

Andrea: Another question, and this was on one of your sites about the prevalence right now for allergies, seems like decades ago it was maybe 10% of the population. I see on some slides it was closer to 30% for some people. Do you think that will continue to increase? Will it stay the same? With climate change and things change a little bit?

Dr. Hogan: I think we are going to continue to see increasing prevalence of allergy due to a host of things. You know, there are epigenetic changes, mental changes, certainly there are changes in antibiotic usage, there are changes in pollutants. There are so many factors that are all coming together. I think we are going to continue to see an increase in rise of allergen sensitization in susceptible individuals.

Andrea: Thank you. I thought I had seemed to see a lot more allergy commercials are now.

Dr. Hogan: Yes.

Andrea: A lot more people are joining our mystery club. We have another question that says, can cleaning your nose and scraping your tongue help with allergy symptoms?

Dr. Hogan: I do not know about scraping your tongue as much because you can disturb some of the protective flora there. I do not know that I would talk about scraping, but clearly wiping the pollen out of your nose. Even something as simple as nasal irrigation with a saline solution can improve the pollen. You can get it out, so it does not have to go a little bit further and be sneezed out or it is not there to cause a local reaction in your nose. I do not know that I would recommend scraping your tongue.

Andrea: OK, thank you. Sometimes we just need to leave room to flow. We are just about to the end of our time. Let me scroll through and see if there are a couple more questions. Why do immunosuppressant drugs seem to make my allergies and asthma worse? This person had a kidney transplant a few years ago.

Dr. Hogan: This is a tough question, so, immunosuppressant may suppress one part of your immune system but not another part of your immune system. So, even, for example, although this is not the exact thing in patients with HIV for example would have a significant suppression of their T cells, we see significant elevation of their IGE levels. Sometimes in people who have transplants, they actually sometimes get the pollen where the food allergy sensitization profile of their donor. So, there is a lot of very interesting concepts that happen. Even though you are immunosuppressed, we did not suppress all of your immune system. You still have the opportunity to have some allergy symptoms, depending upon which immunosuppressant sewer on, so that is something I would discuss with my immunologist. But it is not unheard of.

Andrea: OK, lots of complicated issues going on with these bodies. OU last questionR, one to to be respectful of your time, someone is asking about weird allergic reactions in the fall in there 20’s that seem to lessen to next to no reactions over the years. Sounds like there allergies are getting better.

Dr. Hogan: And that can happen. And, also, again, it may be exposure. Remember, there is a whole new view of stuff, so there may be other factors better for you. Let’s say you have severe allergies when you were little and allergic to cat. So you had that baseline cat on board and then you got the pollen on top, but now you don’t live with a cat anymore. So your glass is no longer full and just half-full, so you have to take all the environmental things together. Maybe you lived near the highway where there was diesel fuel read all of those things are cofactors that may influence what your allergies look like. It is great if you are having less allergies. That is the most important thing. We went to everybody’s quality of life to be improved. I am happy that they are not bothering U.S. much. It would be hard to retrospectively know exactly what was going on when, but I am glad you are better.

Andrea: Thank you. Lots of complicated cases here. For those of you who would like to go back and review some of the information today, this has been added and will be available on our website within a few days. Feel free to review the video, share it with friends, family members, colleagues. This has been a lot of great information, so thank you again, Dr. Hogan. For those of you who need CME’s or any continuing education credits, be patient, you’ll get an email within a couple of days. Today is Thursday, so I don’t know if it will go out tomorrow or on Monday, but in that emailed, and it will be from Zoom, with all the resources for everything Dr. Hogan talked about today. Click on the links to get your continuing education credits. And we will have the link to the recorded video. That will be coming your way, so lots of kudos coming up in our little chat here. Our next webinar, we are actually bundling these up a little bit, normally we just have one per month, but the next webinar will be on Monday, and that will also have a continuing education credit or CME’s, whatever you need, so that is allergen immunotherapy for asthma Guidelines and real-life applications. If you cannot make that, at register because you will still get the link and you can watch the recording whenever it fits around your schedule. Thank you for joining us. This is Andrea Jensen for the staff at Allergy & Asthma Network. Join us as we work every day to breathe better together and help control our allergies. Thank you everyone and have a wonderful day.