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Dust mite and Cockroach : Biology and Avoidance Suparat Sirivimonpan, MD.
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Dust mite and Cockroach
Biology and Avoidance
Suparat Sirivimonpan MD
CONTENTS
bull Introduction bull Dust mite
ndash Biologyndash Avoidance measures
bull Cockroachndash Biologyndash Avoidance measures
bull Conclusions
Introductionbull The average child or adult spends at least 23 hday indoors
at home in a school or at work little time outdoors
bull This pattern has consequences for many chronic diseases but has special significance for allergic disease
bull The only diseases that have been associated statistically with exposure to dust mite or the other indoor allergens are chronic rhinitis asthma and atopic dermatitis
bull Rarely cases of conjunctivitis urticaria and even anaphylaxis are associated with dust mite sensitization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Introduction
bull In addition because of the length of time spent indoors cumulative allergen exposure inside may be more important than outdoor exposure
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
bull -
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
-House Dust complex mixture of everything found in home-Variable quantities of many allergen- Monoclonal antibody assays capable of measuring individual allergens in the complex mix present in homes
Dust mite
bull Biology And Characteristic
bull Pyroglyphid mites dominate (Dpteronyssinus D farinae Euroglyphus maynei) Dust mite
bull Tropical areas Blomia tropicalis
bull Occasionally storage mites Lepidoglyphus destructor Tyrophagus putrescentior
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Dust mite bull In most humid areas of the world house dust mites are the
major source of allergens in house dust
bull Pyroglyphid mites are eight-legged and sightless (microscopic arthropods) (03 mm in length)
bull Live on skin scales and other debrisbull Very precarious water balance
bull Mites growth dependent on
1048708 water in ambient air (not capable of searching for or drinking liquids)
1048708 relative humidity gt50
1048708 absolute humidity ge6 gkg
1048708 temperature of 65-80 F (183-267 C)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552Immunol Allergy Clin N Am 31 (2011) 493ndash507
Dust mite bull As humidity fallsit may take months for mites to die and
longer for allergen levels to decrease in carpets sofas or mattresses
bull Fecal particles ndash 10-35 μm in size (similar to pollen grains)
ndash particles contain digestive enzymesndash surrounded by a chitinous peritrophic membranendash lsquomembranersquo is not waterproof and allergens elute
from fecal particles rapidly
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
bull Mite bodies and fecal pellets are the major sources of allergensbull Settle out of air quickly so airborne levels depend upon disturbance in
room
Dust mite
bull Dust mite allergen bed roombull Cockroach allergen kitchen
bull A major problem with any assessment of exposure to dust mite antigens is that patients often sleep or sit with their heads very close to mite-infested material (eg sofas blankets pillows carpet)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
wwwallergenorg18 Feb 2013
wwwallergenorg18 Feb 2013
Dust mitebull mite allergens are now referred to as
ndash group 1 (Der p 1 and Der f 1) ndash group 2 (Der p 2 and Der f 2)
bull Der f 1 and Der p 1 are highly cross-reactive as are Der f 2 and Der p 2bull Der fp 10 (tropomyosin) cross reacts with other invertebrate
tropomyosins such as shrimp
bull Antibodies to B tropicalis cross-react partially with other dust mites
bull dust levels of mite allergen (Der p 1 + Der p 2) ndash sensitization at 2-10 μgg of dustndash For nonallergic children higher ldquothresholdrdquo of 20 μgg
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Dust mite
bull Avoidance measures
Otolaryngol Clin N Am 44 (2011) 711ndash725
Avoidance
bull standard part of the treatment of allergic disease bull difficult to achieve particularly in home environments
bull Many patients despite being skin test positive were not aware that dust related to their symptoms
bull sources and nature of indoor allergens were not well understood advice offered on avoidance was often inadequate or even wrong
bull The complexity and nonlinearity of dose response relationships also makes such evaluations of the effectiveness of allergen avoidance difficult
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552Immunol Allergy Clin N Am 31 (2011) 493ndash507
Br Med J 1998 3171105
2001 29 trials (939 patients)
2004 49 trials (2733 patients) 2008 54 trials (3002 patients)
2011 55 trials (3121 patients)
26 trials physical 10 trials chemical methods 8 trials combination
Cochrane Library 2011 Issue 10
Cochrane Library 2011 Issue 10
Cochrane Library 2011 Issue 10
bull The variability applies to the evaluation of patients the intervention used and the assessment of outcome
bull Meta-analysis is only valid when the studies are comparable and this may not be true for the successful studies on allergen avoidance
J Allergy Clin Immunol 2008122694-6
very different designs and engage different subjects time frames controls seasons and methods of intervention
J Allergy Clin Immunol 2011128723-7
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
longer than 6 months
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull most professional guidelines for asthma management advocate the avoidance of acute allergen lsquolsquotriggersrsquorsquo
bull there is a diversity of views about the role of allergen avoidance practices in long-term disease management
bull 2007 National Heart Lung and Blood Institute EPR3 (US) reportndash advises that the first and most important step in controlling
allergen induced asthma is to reduce exposure
J Allergy Clin Immunol 2011128723-7
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull Finnish Allergy Program 2008-2018 ndash promotes holistic lsquolsquoallergy healthrsquorsquo through diet and physical
activity and advocates allergen avoidance only lsquolsquoin mandatory situationsrsquorsquo
bull Both the 2009 Global Initiative for Asthma and the British Thoracic Society guidelines reflect (Cochrane review)
ndash no consistent evidence for allergen avoidance in preventing asthma
ndash only tenuous evidence that reducing allergen exposure can reduce asthma morbidity
J Allergy Clin Immunol 2011128723-7
ICON pediatric asthmabull some ambiguity with respect to the role of allergen avoidance
bull JGCA NAEPP3 and PRACTALL ndash specific recommendations for the reduction in allergen exposure
for sensitized patients with asthma
bull AAMH GINA and SIGNndash unproven effectiveness of current avoidance strategies on
asthma control
bull a multifaceted comprehensive approach is prerequisite for clinical benefit
Allergy 2012 67 976ndash997
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
bull 9 trials involving 501 participants bull 2 studies investigating the effectiveness of mite impermeable
bedding covers were of good qualitybull 7 studies were small and of poor qualitybull 2 trials investigated the efficacy of acaricidesbull 2 trials investigated the role of high-efficiency particulate air (HEPA)
filtersbull 1 trial using a factorial design investigated the efficacy of both
acaricide and house dust mite impermeable bedding covers in isolation and combination
bull Remaining 4 trials investigated the efficacy of bedroom environmental control programmes involving use of house dust mite impermeable bedding covers
Cochrane Database of Systematic Reviews 2010 Issue 7
bull Trials to date small and of poor methodological qualitybull difficult to offer any definitive recommendations on the role
bull use of acaricides and extensive bedroom-based environmental control programmes may be of some benefit in reducing rhinitis symptoms but the evidence is not strong
bull Isolated use of house dust mite impermeable bedding is unlikely to prove effective
bull More research is needed
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
METHODS OFMITE ALLERGEN AVOIDANCE
Method
bull Physical methodndash Encasing of beddingndash Vacuums cleanersndash Floor coveringsndash Laundryndash Air filtration
bull Chemical methodndash Acaricide
Encasingsbull In the bedroom covering mattresses and pillows with impermeable
covers is effectivebull This effect may be large variable and persist for a couple of
months
bull Encasings differ widely in their qualityndash some cheap brands have large pores other multilayered encasings delaminate
and others harbor mites
bull Tightly woven synthetic or cotton fabrics are preferred
bull Most trials of encasings have failed to regularly wash them (difficult with some encasings) which renders them ineffective as allergens build up on the outer surface within several weeks
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Curr Allergy Asthma Rep 20088126-32
J Allergy Clin Immunol 20061181164-8
16 tightly woven 9 United States3 Japan2 Thailand1 Germany1 France
laminate-coated and loosely woven cover molting among nonwoven fibers
dead mites on an acaricide-coated and nonwoven cover group of mites in the matrix of a nonwoven cover
J Allergy Clin Immunol 20061181164-8
Nonwoven
J Allergy Clin Immunol 20061181164-8
before after
easy access for mites to readily penetrate into the substrate of the material
J Allergy Clin Immunol 20061181164-8
tightly woven fabric with systematized regular fibers allowing little space for penetration
bull Woven nonwovenndash pore size between 2 and 10 um (average 6 um) blocking most
mite allergens
bull Plasticndash pore free best barrier in terms of blockingndash but the least comfortable zero ventilation ndash tendency to become a haven for mold spores
bull For acaricide-coated materialsndash pore size is usually not a major factor ndash mites are eradicated on contact with the chemicalsndash still allow the passage of allergens ndash prevent penetration through the fabrics but allow colonization
J Allergy Clin Immunol 20061181164-8
Asian Pac J Allergy Immunol 201028155-61
Sensitized level
Symptomatic level
sponge-like polyurethane lowest rate Synthetic fibers and kapok mattresses highest rate
A combination of the following choosing new sponge-like polyurethane or coconut fiber mattresses with mite-impermeable covers and washing sheets pillowcases blankets and mattresses pad at least weekly in hot water should be the best method of prevention in HDM allergen sensitive allergic patients
Laundrybull Both dust and cat and mite allergens are effectively removed by
laundryndash physical removal of both dust and mites by the multiple wash
and rinse cycles ndash effects of detergents additivesndash subsequent drying procedures
bull McDonald LGTovey E ndash All mites were killed by water temperatures 55 degrees C or
greaterndash Killing at lower temperatures was not enhanced by any of the
pure detergents or laundry products tested
J Allergy Clin Immunol 2011128723-7
J Allergy Clin Immunol 199290599-608
Floor coveringsbull Designing the house with polished floors and wooden or
vinylleather furniture so as to limit the sites where mites can grow
bull carpets fitted onto unventilated floors water can accumulate growth of both fungi and mites
bull hard floors are likely to be preferred as they are more easily kept in a state that minimizes aeroallergen reaerosolization in the long term
bull the little available data of aeroallergens in houses suggest that the difference may be small and the effects complex
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552J Allergy Clin Immunol 2011128723-7
Vacuum cleaners
bull Vacuum cleaners are heavily promoted
bull Probably all cleaners cause a brief increase in personal aeroallergen exposure under normal domestic conditions and high-efficiency particulate arrest (HEPA) filters make little difference
bull Thus the benefits of HEPA filtration on exposure may have been exaggerated and all cleaners probably provide a brief increase in exposure
J Allergy Clin Immunol 2011128723-7
Allergy 200661119-23
Air management
bull indoor relative humidity is kept below 50 (absolute humidity below 6 gkg)
bull In some areas of the world this can be done by increasing ventilation
bull in other areas it is necessary to use air conditioning during the most humid months of the summer
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Air filtration
bull The role of air filtration continues to be debatedbull There is some consensus that small benefits exist mainly for pet
allergens
J Allergy Clin Immunol 2011128723-7
Acaricidesbull variety of acaricides have been used to treat carpets or furniturebull pyrethroids natamycin (an antifungal) pirimiphos methyl and
benzyl benzoate bull killing mites
bull Acaricides proved largely ineffective because the mite populations return shortly after their application and they may also cause skin and respiratory irritation
bull No data on clinical benefit exist and concerns about human health and environmental toxicity remain
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
J Allergy Clin Immunol 2011128723-7
Acaricidesbull 1 or 3 tannic acid
ndash method of denaturing mite allergensndash reduction of mite allergen can be achievedndash does not kill mitesndash so the effect can only be temporary approximately 6 weeks to 3
months
bull may be recommended when it is not possible to remove the carpets or change the furniture
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
CONTENTS
bull Introduction bull Dust mite
ndash Biologyndash Avoidance measures
bull Cockroachndash Biologyndash Avoidance measures
bull Conclusions
Introductionbull The average child or adult spends at least 23 hday indoors
at home in a school or at work little time outdoors
bull This pattern has consequences for many chronic diseases but has special significance for allergic disease
bull The only diseases that have been associated statistically with exposure to dust mite or the other indoor allergens are chronic rhinitis asthma and atopic dermatitis
bull Rarely cases of conjunctivitis urticaria and even anaphylaxis are associated with dust mite sensitization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Introduction
bull In addition because of the length of time spent indoors cumulative allergen exposure inside may be more important than outdoor exposure
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
bull -
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
-House Dust complex mixture of everything found in home-Variable quantities of many allergen- Monoclonal antibody assays capable of measuring individual allergens in the complex mix present in homes
Dust mite
bull Biology And Characteristic
bull Pyroglyphid mites dominate (Dpteronyssinus D farinae Euroglyphus maynei) Dust mite
bull Tropical areas Blomia tropicalis
bull Occasionally storage mites Lepidoglyphus destructor Tyrophagus putrescentior
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Dust mite bull In most humid areas of the world house dust mites are the
major source of allergens in house dust
bull Pyroglyphid mites are eight-legged and sightless (microscopic arthropods) (03 mm in length)
bull Live on skin scales and other debrisbull Very precarious water balance
bull Mites growth dependent on
1048708 water in ambient air (not capable of searching for or drinking liquids)
1048708 relative humidity gt50
1048708 absolute humidity ge6 gkg
1048708 temperature of 65-80 F (183-267 C)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552Immunol Allergy Clin N Am 31 (2011) 493ndash507
Dust mite bull As humidity fallsit may take months for mites to die and
longer for allergen levels to decrease in carpets sofas or mattresses
bull Fecal particles ndash 10-35 μm in size (similar to pollen grains)
ndash particles contain digestive enzymesndash surrounded by a chitinous peritrophic membranendash lsquomembranersquo is not waterproof and allergens elute
from fecal particles rapidly
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
bull Mite bodies and fecal pellets are the major sources of allergensbull Settle out of air quickly so airborne levels depend upon disturbance in
room
Dust mite
bull Dust mite allergen bed roombull Cockroach allergen kitchen
bull A major problem with any assessment of exposure to dust mite antigens is that patients often sleep or sit with their heads very close to mite-infested material (eg sofas blankets pillows carpet)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
wwwallergenorg18 Feb 2013
wwwallergenorg18 Feb 2013
Dust mitebull mite allergens are now referred to as
ndash group 1 (Der p 1 and Der f 1) ndash group 2 (Der p 2 and Der f 2)
bull Der f 1 and Der p 1 are highly cross-reactive as are Der f 2 and Der p 2bull Der fp 10 (tropomyosin) cross reacts with other invertebrate
tropomyosins such as shrimp
bull Antibodies to B tropicalis cross-react partially with other dust mites
bull dust levels of mite allergen (Der p 1 + Der p 2) ndash sensitization at 2-10 μgg of dustndash For nonallergic children higher ldquothresholdrdquo of 20 μgg
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Dust mite
bull Avoidance measures
Otolaryngol Clin N Am 44 (2011) 711ndash725
Avoidance
bull standard part of the treatment of allergic disease bull difficult to achieve particularly in home environments
bull Many patients despite being skin test positive were not aware that dust related to their symptoms
bull sources and nature of indoor allergens were not well understood advice offered on avoidance was often inadequate or even wrong
bull The complexity and nonlinearity of dose response relationships also makes such evaluations of the effectiveness of allergen avoidance difficult
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552Immunol Allergy Clin N Am 31 (2011) 493ndash507
Br Med J 1998 3171105
2001 29 trials (939 patients)
2004 49 trials (2733 patients) 2008 54 trials (3002 patients)
2011 55 trials (3121 patients)
26 trials physical 10 trials chemical methods 8 trials combination
Cochrane Library 2011 Issue 10
Cochrane Library 2011 Issue 10
Cochrane Library 2011 Issue 10
bull The variability applies to the evaluation of patients the intervention used and the assessment of outcome
bull Meta-analysis is only valid when the studies are comparable and this may not be true for the successful studies on allergen avoidance
J Allergy Clin Immunol 2008122694-6
very different designs and engage different subjects time frames controls seasons and methods of intervention
J Allergy Clin Immunol 2011128723-7
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
longer than 6 months
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull most professional guidelines for asthma management advocate the avoidance of acute allergen lsquolsquotriggersrsquorsquo
bull there is a diversity of views about the role of allergen avoidance practices in long-term disease management
bull 2007 National Heart Lung and Blood Institute EPR3 (US) reportndash advises that the first and most important step in controlling
allergen induced asthma is to reduce exposure
J Allergy Clin Immunol 2011128723-7
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull Finnish Allergy Program 2008-2018 ndash promotes holistic lsquolsquoallergy healthrsquorsquo through diet and physical
activity and advocates allergen avoidance only lsquolsquoin mandatory situationsrsquorsquo
bull Both the 2009 Global Initiative for Asthma and the British Thoracic Society guidelines reflect (Cochrane review)
ndash no consistent evidence for allergen avoidance in preventing asthma
ndash only tenuous evidence that reducing allergen exposure can reduce asthma morbidity
J Allergy Clin Immunol 2011128723-7
ICON pediatric asthmabull some ambiguity with respect to the role of allergen avoidance
bull JGCA NAEPP3 and PRACTALL ndash specific recommendations for the reduction in allergen exposure
for sensitized patients with asthma
bull AAMH GINA and SIGNndash unproven effectiveness of current avoidance strategies on
asthma control
bull a multifaceted comprehensive approach is prerequisite for clinical benefit
Allergy 2012 67 976ndash997
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
bull 9 trials involving 501 participants bull 2 studies investigating the effectiveness of mite impermeable
bedding covers were of good qualitybull 7 studies were small and of poor qualitybull 2 trials investigated the efficacy of acaricidesbull 2 trials investigated the role of high-efficiency particulate air (HEPA)
filtersbull 1 trial using a factorial design investigated the efficacy of both
acaricide and house dust mite impermeable bedding covers in isolation and combination
bull Remaining 4 trials investigated the efficacy of bedroom environmental control programmes involving use of house dust mite impermeable bedding covers
Cochrane Database of Systematic Reviews 2010 Issue 7
bull Trials to date small and of poor methodological qualitybull difficult to offer any definitive recommendations on the role
bull use of acaricides and extensive bedroom-based environmental control programmes may be of some benefit in reducing rhinitis symptoms but the evidence is not strong
bull Isolated use of house dust mite impermeable bedding is unlikely to prove effective
bull More research is needed
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
METHODS OFMITE ALLERGEN AVOIDANCE
Method
bull Physical methodndash Encasing of beddingndash Vacuums cleanersndash Floor coveringsndash Laundryndash Air filtration
bull Chemical methodndash Acaricide
Encasingsbull In the bedroom covering mattresses and pillows with impermeable
covers is effectivebull This effect may be large variable and persist for a couple of
months
bull Encasings differ widely in their qualityndash some cheap brands have large pores other multilayered encasings delaminate
and others harbor mites
bull Tightly woven synthetic or cotton fabrics are preferred
bull Most trials of encasings have failed to regularly wash them (difficult with some encasings) which renders them ineffective as allergens build up on the outer surface within several weeks
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Curr Allergy Asthma Rep 20088126-32
J Allergy Clin Immunol 20061181164-8
16 tightly woven 9 United States3 Japan2 Thailand1 Germany1 France
laminate-coated and loosely woven cover molting among nonwoven fibers
dead mites on an acaricide-coated and nonwoven cover group of mites in the matrix of a nonwoven cover
J Allergy Clin Immunol 20061181164-8
Nonwoven
J Allergy Clin Immunol 20061181164-8
before after
easy access for mites to readily penetrate into the substrate of the material
J Allergy Clin Immunol 20061181164-8
tightly woven fabric with systematized regular fibers allowing little space for penetration
bull Woven nonwovenndash pore size between 2 and 10 um (average 6 um) blocking most
mite allergens
bull Plasticndash pore free best barrier in terms of blockingndash but the least comfortable zero ventilation ndash tendency to become a haven for mold spores
bull For acaricide-coated materialsndash pore size is usually not a major factor ndash mites are eradicated on contact with the chemicalsndash still allow the passage of allergens ndash prevent penetration through the fabrics but allow colonization
J Allergy Clin Immunol 20061181164-8
Asian Pac J Allergy Immunol 201028155-61
Sensitized level
Symptomatic level
sponge-like polyurethane lowest rate Synthetic fibers and kapok mattresses highest rate
A combination of the following choosing new sponge-like polyurethane or coconut fiber mattresses with mite-impermeable covers and washing sheets pillowcases blankets and mattresses pad at least weekly in hot water should be the best method of prevention in HDM allergen sensitive allergic patients
Laundrybull Both dust and cat and mite allergens are effectively removed by
laundryndash physical removal of both dust and mites by the multiple wash
and rinse cycles ndash effects of detergents additivesndash subsequent drying procedures
bull McDonald LGTovey E ndash All mites were killed by water temperatures 55 degrees C or
greaterndash Killing at lower temperatures was not enhanced by any of the
pure detergents or laundry products tested
J Allergy Clin Immunol 2011128723-7
J Allergy Clin Immunol 199290599-608
Floor coveringsbull Designing the house with polished floors and wooden or
vinylleather furniture so as to limit the sites where mites can grow
bull carpets fitted onto unventilated floors water can accumulate growth of both fungi and mites
bull hard floors are likely to be preferred as they are more easily kept in a state that minimizes aeroallergen reaerosolization in the long term
bull the little available data of aeroallergens in houses suggest that the difference may be small and the effects complex
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552J Allergy Clin Immunol 2011128723-7
Vacuum cleaners
bull Vacuum cleaners are heavily promoted
bull Probably all cleaners cause a brief increase in personal aeroallergen exposure under normal domestic conditions and high-efficiency particulate arrest (HEPA) filters make little difference
bull Thus the benefits of HEPA filtration on exposure may have been exaggerated and all cleaners probably provide a brief increase in exposure
J Allergy Clin Immunol 2011128723-7
Allergy 200661119-23
Air management
bull indoor relative humidity is kept below 50 (absolute humidity below 6 gkg)
bull In some areas of the world this can be done by increasing ventilation
bull in other areas it is necessary to use air conditioning during the most humid months of the summer
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Air filtration
bull The role of air filtration continues to be debatedbull There is some consensus that small benefits exist mainly for pet
allergens
J Allergy Clin Immunol 2011128723-7
Acaricidesbull variety of acaricides have been used to treat carpets or furniturebull pyrethroids natamycin (an antifungal) pirimiphos methyl and
benzyl benzoate bull killing mites
bull Acaricides proved largely ineffective because the mite populations return shortly after their application and they may also cause skin and respiratory irritation
bull No data on clinical benefit exist and concerns about human health and environmental toxicity remain
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
J Allergy Clin Immunol 2011128723-7
Acaricidesbull 1 or 3 tannic acid
ndash method of denaturing mite allergensndash reduction of mite allergen can be achievedndash does not kill mitesndash so the effect can only be temporary approximately 6 weeks to 3
months
bull may be recommended when it is not possible to remove the carpets or change the furniture
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
Introductionbull The average child or adult spends at least 23 hday indoors
at home in a school or at work little time outdoors
bull This pattern has consequences for many chronic diseases but has special significance for allergic disease
bull The only diseases that have been associated statistically with exposure to dust mite or the other indoor allergens are chronic rhinitis asthma and atopic dermatitis
bull Rarely cases of conjunctivitis urticaria and even anaphylaxis are associated with dust mite sensitization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Introduction
bull In addition because of the length of time spent indoors cumulative allergen exposure inside may be more important than outdoor exposure
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
bull -
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
-House Dust complex mixture of everything found in home-Variable quantities of many allergen- Monoclonal antibody assays capable of measuring individual allergens in the complex mix present in homes
Dust mite
bull Biology And Characteristic
bull Pyroglyphid mites dominate (Dpteronyssinus D farinae Euroglyphus maynei) Dust mite
bull Tropical areas Blomia tropicalis
bull Occasionally storage mites Lepidoglyphus destructor Tyrophagus putrescentior
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Dust mite bull In most humid areas of the world house dust mites are the
major source of allergens in house dust
bull Pyroglyphid mites are eight-legged and sightless (microscopic arthropods) (03 mm in length)
bull Live on skin scales and other debrisbull Very precarious water balance
bull Mites growth dependent on
1048708 water in ambient air (not capable of searching for or drinking liquids)
1048708 relative humidity gt50
1048708 absolute humidity ge6 gkg
1048708 temperature of 65-80 F (183-267 C)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552Immunol Allergy Clin N Am 31 (2011) 493ndash507
Dust mite bull As humidity fallsit may take months for mites to die and
longer for allergen levels to decrease in carpets sofas or mattresses
bull Fecal particles ndash 10-35 μm in size (similar to pollen grains)
ndash particles contain digestive enzymesndash surrounded by a chitinous peritrophic membranendash lsquomembranersquo is not waterproof and allergens elute
from fecal particles rapidly
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
bull Mite bodies and fecal pellets are the major sources of allergensbull Settle out of air quickly so airborne levels depend upon disturbance in
room
Dust mite
bull Dust mite allergen bed roombull Cockroach allergen kitchen
bull A major problem with any assessment of exposure to dust mite antigens is that patients often sleep or sit with their heads very close to mite-infested material (eg sofas blankets pillows carpet)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
wwwallergenorg18 Feb 2013
wwwallergenorg18 Feb 2013
Dust mitebull mite allergens are now referred to as
ndash group 1 (Der p 1 and Der f 1) ndash group 2 (Der p 2 and Der f 2)
bull Der f 1 and Der p 1 are highly cross-reactive as are Der f 2 and Der p 2bull Der fp 10 (tropomyosin) cross reacts with other invertebrate
tropomyosins such as shrimp
bull Antibodies to B tropicalis cross-react partially with other dust mites
bull dust levels of mite allergen (Der p 1 + Der p 2) ndash sensitization at 2-10 μgg of dustndash For nonallergic children higher ldquothresholdrdquo of 20 μgg
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Dust mite
bull Avoidance measures
Otolaryngol Clin N Am 44 (2011) 711ndash725
Avoidance
bull standard part of the treatment of allergic disease bull difficult to achieve particularly in home environments
bull Many patients despite being skin test positive were not aware that dust related to their symptoms
bull sources and nature of indoor allergens were not well understood advice offered on avoidance was often inadequate or even wrong
bull The complexity and nonlinearity of dose response relationships also makes such evaluations of the effectiveness of allergen avoidance difficult
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552Immunol Allergy Clin N Am 31 (2011) 493ndash507
Br Med J 1998 3171105
2001 29 trials (939 patients)
2004 49 trials (2733 patients) 2008 54 trials (3002 patients)
2011 55 trials (3121 patients)
26 trials physical 10 trials chemical methods 8 trials combination
Cochrane Library 2011 Issue 10
Cochrane Library 2011 Issue 10
Cochrane Library 2011 Issue 10
bull The variability applies to the evaluation of patients the intervention used and the assessment of outcome
bull Meta-analysis is only valid when the studies are comparable and this may not be true for the successful studies on allergen avoidance
J Allergy Clin Immunol 2008122694-6
very different designs and engage different subjects time frames controls seasons and methods of intervention
J Allergy Clin Immunol 2011128723-7
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
longer than 6 months
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull most professional guidelines for asthma management advocate the avoidance of acute allergen lsquolsquotriggersrsquorsquo
bull there is a diversity of views about the role of allergen avoidance practices in long-term disease management
bull 2007 National Heart Lung and Blood Institute EPR3 (US) reportndash advises that the first and most important step in controlling
allergen induced asthma is to reduce exposure
J Allergy Clin Immunol 2011128723-7
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull Finnish Allergy Program 2008-2018 ndash promotes holistic lsquolsquoallergy healthrsquorsquo through diet and physical
activity and advocates allergen avoidance only lsquolsquoin mandatory situationsrsquorsquo
bull Both the 2009 Global Initiative for Asthma and the British Thoracic Society guidelines reflect (Cochrane review)
ndash no consistent evidence for allergen avoidance in preventing asthma
ndash only tenuous evidence that reducing allergen exposure can reduce asthma morbidity
J Allergy Clin Immunol 2011128723-7
ICON pediatric asthmabull some ambiguity with respect to the role of allergen avoidance
bull JGCA NAEPP3 and PRACTALL ndash specific recommendations for the reduction in allergen exposure
for sensitized patients with asthma
bull AAMH GINA and SIGNndash unproven effectiveness of current avoidance strategies on
asthma control
bull a multifaceted comprehensive approach is prerequisite for clinical benefit
Allergy 2012 67 976ndash997
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
bull 9 trials involving 501 participants bull 2 studies investigating the effectiveness of mite impermeable
bedding covers were of good qualitybull 7 studies were small and of poor qualitybull 2 trials investigated the efficacy of acaricidesbull 2 trials investigated the role of high-efficiency particulate air (HEPA)
filtersbull 1 trial using a factorial design investigated the efficacy of both
acaricide and house dust mite impermeable bedding covers in isolation and combination
bull Remaining 4 trials investigated the efficacy of bedroom environmental control programmes involving use of house dust mite impermeable bedding covers
Cochrane Database of Systematic Reviews 2010 Issue 7
bull Trials to date small and of poor methodological qualitybull difficult to offer any definitive recommendations on the role
bull use of acaricides and extensive bedroom-based environmental control programmes may be of some benefit in reducing rhinitis symptoms but the evidence is not strong
bull Isolated use of house dust mite impermeable bedding is unlikely to prove effective
bull More research is needed
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
METHODS OFMITE ALLERGEN AVOIDANCE
Method
bull Physical methodndash Encasing of beddingndash Vacuums cleanersndash Floor coveringsndash Laundryndash Air filtration
bull Chemical methodndash Acaricide
Encasingsbull In the bedroom covering mattresses and pillows with impermeable
covers is effectivebull This effect may be large variable and persist for a couple of
months
bull Encasings differ widely in their qualityndash some cheap brands have large pores other multilayered encasings delaminate
and others harbor mites
bull Tightly woven synthetic or cotton fabrics are preferred
bull Most trials of encasings have failed to regularly wash them (difficult with some encasings) which renders them ineffective as allergens build up on the outer surface within several weeks
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Curr Allergy Asthma Rep 20088126-32
J Allergy Clin Immunol 20061181164-8
16 tightly woven 9 United States3 Japan2 Thailand1 Germany1 France
laminate-coated and loosely woven cover molting among nonwoven fibers
dead mites on an acaricide-coated and nonwoven cover group of mites in the matrix of a nonwoven cover
J Allergy Clin Immunol 20061181164-8
Nonwoven
J Allergy Clin Immunol 20061181164-8
before after
easy access for mites to readily penetrate into the substrate of the material
J Allergy Clin Immunol 20061181164-8
tightly woven fabric with systematized regular fibers allowing little space for penetration
bull Woven nonwovenndash pore size between 2 and 10 um (average 6 um) blocking most
mite allergens
bull Plasticndash pore free best barrier in terms of blockingndash but the least comfortable zero ventilation ndash tendency to become a haven for mold spores
bull For acaricide-coated materialsndash pore size is usually not a major factor ndash mites are eradicated on contact with the chemicalsndash still allow the passage of allergens ndash prevent penetration through the fabrics but allow colonization
J Allergy Clin Immunol 20061181164-8
Asian Pac J Allergy Immunol 201028155-61
Sensitized level
Symptomatic level
sponge-like polyurethane lowest rate Synthetic fibers and kapok mattresses highest rate
A combination of the following choosing new sponge-like polyurethane or coconut fiber mattresses with mite-impermeable covers and washing sheets pillowcases blankets and mattresses pad at least weekly in hot water should be the best method of prevention in HDM allergen sensitive allergic patients
Laundrybull Both dust and cat and mite allergens are effectively removed by
laundryndash physical removal of both dust and mites by the multiple wash
and rinse cycles ndash effects of detergents additivesndash subsequent drying procedures
bull McDonald LGTovey E ndash All mites were killed by water temperatures 55 degrees C or
greaterndash Killing at lower temperatures was not enhanced by any of the
pure detergents or laundry products tested
J Allergy Clin Immunol 2011128723-7
J Allergy Clin Immunol 199290599-608
Floor coveringsbull Designing the house with polished floors and wooden or
vinylleather furniture so as to limit the sites where mites can grow
bull carpets fitted onto unventilated floors water can accumulate growth of both fungi and mites
bull hard floors are likely to be preferred as they are more easily kept in a state that minimizes aeroallergen reaerosolization in the long term
bull the little available data of aeroallergens in houses suggest that the difference may be small and the effects complex
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552J Allergy Clin Immunol 2011128723-7
Vacuum cleaners
bull Vacuum cleaners are heavily promoted
bull Probably all cleaners cause a brief increase in personal aeroallergen exposure under normal domestic conditions and high-efficiency particulate arrest (HEPA) filters make little difference
bull Thus the benefits of HEPA filtration on exposure may have been exaggerated and all cleaners probably provide a brief increase in exposure
J Allergy Clin Immunol 2011128723-7
Allergy 200661119-23
Air management
bull indoor relative humidity is kept below 50 (absolute humidity below 6 gkg)
bull In some areas of the world this can be done by increasing ventilation
bull in other areas it is necessary to use air conditioning during the most humid months of the summer
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Air filtration
bull The role of air filtration continues to be debatedbull There is some consensus that small benefits exist mainly for pet
allergens
J Allergy Clin Immunol 2011128723-7
Acaricidesbull variety of acaricides have been used to treat carpets or furniturebull pyrethroids natamycin (an antifungal) pirimiphos methyl and
benzyl benzoate bull killing mites
bull Acaricides proved largely ineffective because the mite populations return shortly after their application and they may also cause skin and respiratory irritation
bull No data on clinical benefit exist and concerns about human health and environmental toxicity remain
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
J Allergy Clin Immunol 2011128723-7
Acaricidesbull 1 or 3 tannic acid
ndash method of denaturing mite allergensndash reduction of mite allergen can be achievedndash does not kill mitesndash so the effect can only be temporary approximately 6 weeks to 3
months
bull may be recommended when it is not possible to remove the carpets or change the furniture
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
Introduction
bull In addition because of the length of time spent indoors cumulative allergen exposure inside may be more important than outdoor exposure
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
bull -
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
-House Dust complex mixture of everything found in home-Variable quantities of many allergen- Monoclonal antibody assays capable of measuring individual allergens in the complex mix present in homes
Dust mite
bull Biology And Characteristic
bull Pyroglyphid mites dominate (Dpteronyssinus D farinae Euroglyphus maynei) Dust mite
bull Tropical areas Blomia tropicalis
bull Occasionally storage mites Lepidoglyphus destructor Tyrophagus putrescentior
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Dust mite bull In most humid areas of the world house dust mites are the
major source of allergens in house dust
bull Pyroglyphid mites are eight-legged and sightless (microscopic arthropods) (03 mm in length)
bull Live on skin scales and other debrisbull Very precarious water balance
bull Mites growth dependent on
1048708 water in ambient air (not capable of searching for or drinking liquids)
1048708 relative humidity gt50
1048708 absolute humidity ge6 gkg
1048708 temperature of 65-80 F (183-267 C)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552Immunol Allergy Clin N Am 31 (2011) 493ndash507
Dust mite bull As humidity fallsit may take months for mites to die and
longer for allergen levels to decrease in carpets sofas or mattresses
bull Fecal particles ndash 10-35 μm in size (similar to pollen grains)
ndash particles contain digestive enzymesndash surrounded by a chitinous peritrophic membranendash lsquomembranersquo is not waterproof and allergens elute
from fecal particles rapidly
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
bull Mite bodies and fecal pellets are the major sources of allergensbull Settle out of air quickly so airborne levels depend upon disturbance in
room
Dust mite
bull Dust mite allergen bed roombull Cockroach allergen kitchen
bull A major problem with any assessment of exposure to dust mite antigens is that patients often sleep or sit with their heads very close to mite-infested material (eg sofas blankets pillows carpet)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
wwwallergenorg18 Feb 2013
wwwallergenorg18 Feb 2013
Dust mitebull mite allergens are now referred to as
ndash group 1 (Der p 1 and Der f 1) ndash group 2 (Der p 2 and Der f 2)
bull Der f 1 and Der p 1 are highly cross-reactive as are Der f 2 and Der p 2bull Der fp 10 (tropomyosin) cross reacts with other invertebrate
tropomyosins such as shrimp
bull Antibodies to B tropicalis cross-react partially with other dust mites
bull dust levels of mite allergen (Der p 1 + Der p 2) ndash sensitization at 2-10 μgg of dustndash For nonallergic children higher ldquothresholdrdquo of 20 μgg
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Dust mite
bull Avoidance measures
Otolaryngol Clin N Am 44 (2011) 711ndash725
Avoidance
bull standard part of the treatment of allergic disease bull difficult to achieve particularly in home environments
bull Many patients despite being skin test positive were not aware that dust related to their symptoms
bull sources and nature of indoor allergens were not well understood advice offered on avoidance was often inadequate or even wrong
bull The complexity and nonlinearity of dose response relationships also makes such evaluations of the effectiveness of allergen avoidance difficult
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552Immunol Allergy Clin N Am 31 (2011) 493ndash507
Br Med J 1998 3171105
2001 29 trials (939 patients)
2004 49 trials (2733 patients) 2008 54 trials (3002 patients)
2011 55 trials (3121 patients)
26 trials physical 10 trials chemical methods 8 trials combination
Cochrane Library 2011 Issue 10
Cochrane Library 2011 Issue 10
Cochrane Library 2011 Issue 10
bull The variability applies to the evaluation of patients the intervention used and the assessment of outcome
bull Meta-analysis is only valid when the studies are comparable and this may not be true for the successful studies on allergen avoidance
J Allergy Clin Immunol 2008122694-6
very different designs and engage different subjects time frames controls seasons and methods of intervention
J Allergy Clin Immunol 2011128723-7
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
longer than 6 months
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull most professional guidelines for asthma management advocate the avoidance of acute allergen lsquolsquotriggersrsquorsquo
bull there is a diversity of views about the role of allergen avoidance practices in long-term disease management
bull 2007 National Heart Lung and Blood Institute EPR3 (US) reportndash advises that the first and most important step in controlling
allergen induced asthma is to reduce exposure
J Allergy Clin Immunol 2011128723-7
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull Finnish Allergy Program 2008-2018 ndash promotes holistic lsquolsquoallergy healthrsquorsquo through diet and physical
activity and advocates allergen avoidance only lsquolsquoin mandatory situationsrsquorsquo
bull Both the 2009 Global Initiative for Asthma and the British Thoracic Society guidelines reflect (Cochrane review)
ndash no consistent evidence for allergen avoidance in preventing asthma
ndash only tenuous evidence that reducing allergen exposure can reduce asthma morbidity
J Allergy Clin Immunol 2011128723-7
ICON pediatric asthmabull some ambiguity with respect to the role of allergen avoidance
bull JGCA NAEPP3 and PRACTALL ndash specific recommendations for the reduction in allergen exposure
for sensitized patients with asthma
bull AAMH GINA and SIGNndash unproven effectiveness of current avoidance strategies on
asthma control
bull a multifaceted comprehensive approach is prerequisite for clinical benefit
Allergy 2012 67 976ndash997
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
bull 9 trials involving 501 participants bull 2 studies investigating the effectiveness of mite impermeable
bedding covers were of good qualitybull 7 studies were small and of poor qualitybull 2 trials investigated the efficacy of acaricidesbull 2 trials investigated the role of high-efficiency particulate air (HEPA)
filtersbull 1 trial using a factorial design investigated the efficacy of both
acaricide and house dust mite impermeable bedding covers in isolation and combination
bull Remaining 4 trials investigated the efficacy of bedroom environmental control programmes involving use of house dust mite impermeable bedding covers
Cochrane Database of Systematic Reviews 2010 Issue 7
bull Trials to date small and of poor methodological qualitybull difficult to offer any definitive recommendations on the role
bull use of acaricides and extensive bedroom-based environmental control programmes may be of some benefit in reducing rhinitis symptoms but the evidence is not strong
bull Isolated use of house dust mite impermeable bedding is unlikely to prove effective
bull More research is needed
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
METHODS OFMITE ALLERGEN AVOIDANCE
Method
bull Physical methodndash Encasing of beddingndash Vacuums cleanersndash Floor coveringsndash Laundryndash Air filtration
bull Chemical methodndash Acaricide
Encasingsbull In the bedroom covering mattresses and pillows with impermeable
covers is effectivebull This effect may be large variable and persist for a couple of
months
bull Encasings differ widely in their qualityndash some cheap brands have large pores other multilayered encasings delaminate
and others harbor mites
bull Tightly woven synthetic or cotton fabrics are preferred
bull Most trials of encasings have failed to regularly wash them (difficult with some encasings) which renders them ineffective as allergens build up on the outer surface within several weeks
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Curr Allergy Asthma Rep 20088126-32
J Allergy Clin Immunol 20061181164-8
16 tightly woven 9 United States3 Japan2 Thailand1 Germany1 France
laminate-coated and loosely woven cover molting among nonwoven fibers
dead mites on an acaricide-coated and nonwoven cover group of mites in the matrix of a nonwoven cover
J Allergy Clin Immunol 20061181164-8
Nonwoven
J Allergy Clin Immunol 20061181164-8
before after
easy access for mites to readily penetrate into the substrate of the material
J Allergy Clin Immunol 20061181164-8
tightly woven fabric with systematized regular fibers allowing little space for penetration
bull Woven nonwovenndash pore size between 2 and 10 um (average 6 um) blocking most
mite allergens
bull Plasticndash pore free best barrier in terms of blockingndash but the least comfortable zero ventilation ndash tendency to become a haven for mold spores
bull For acaricide-coated materialsndash pore size is usually not a major factor ndash mites are eradicated on contact with the chemicalsndash still allow the passage of allergens ndash prevent penetration through the fabrics but allow colonization
J Allergy Clin Immunol 20061181164-8
Asian Pac J Allergy Immunol 201028155-61
Sensitized level
Symptomatic level
sponge-like polyurethane lowest rate Synthetic fibers and kapok mattresses highest rate
A combination of the following choosing new sponge-like polyurethane or coconut fiber mattresses with mite-impermeable covers and washing sheets pillowcases blankets and mattresses pad at least weekly in hot water should be the best method of prevention in HDM allergen sensitive allergic patients
Laundrybull Both dust and cat and mite allergens are effectively removed by
laundryndash physical removal of both dust and mites by the multiple wash
and rinse cycles ndash effects of detergents additivesndash subsequent drying procedures
bull McDonald LGTovey E ndash All mites were killed by water temperatures 55 degrees C or
greaterndash Killing at lower temperatures was not enhanced by any of the
pure detergents or laundry products tested
J Allergy Clin Immunol 2011128723-7
J Allergy Clin Immunol 199290599-608
Floor coveringsbull Designing the house with polished floors and wooden or
vinylleather furniture so as to limit the sites where mites can grow
bull carpets fitted onto unventilated floors water can accumulate growth of both fungi and mites
bull hard floors are likely to be preferred as they are more easily kept in a state that minimizes aeroallergen reaerosolization in the long term
bull the little available data of aeroallergens in houses suggest that the difference may be small and the effects complex
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552J Allergy Clin Immunol 2011128723-7
Vacuum cleaners
bull Vacuum cleaners are heavily promoted
bull Probably all cleaners cause a brief increase in personal aeroallergen exposure under normal domestic conditions and high-efficiency particulate arrest (HEPA) filters make little difference
bull Thus the benefits of HEPA filtration on exposure may have been exaggerated and all cleaners probably provide a brief increase in exposure
J Allergy Clin Immunol 2011128723-7
Allergy 200661119-23
Air management
bull indoor relative humidity is kept below 50 (absolute humidity below 6 gkg)
bull In some areas of the world this can be done by increasing ventilation
bull in other areas it is necessary to use air conditioning during the most humid months of the summer
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Air filtration
bull The role of air filtration continues to be debatedbull There is some consensus that small benefits exist mainly for pet
allergens
J Allergy Clin Immunol 2011128723-7
Acaricidesbull variety of acaricides have been used to treat carpets or furniturebull pyrethroids natamycin (an antifungal) pirimiphos methyl and
benzyl benzoate bull killing mites
bull Acaricides proved largely ineffective because the mite populations return shortly after their application and they may also cause skin and respiratory irritation
bull No data on clinical benefit exist and concerns about human health and environmental toxicity remain
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
J Allergy Clin Immunol 2011128723-7
Acaricidesbull 1 or 3 tannic acid
ndash method of denaturing mite allergensndash reduction of mite allergen can be achievedndash does not kill mitesndash so the effect can only be temporary approximately 6 weeks to 3
months
bull may be recommended when it is not possible to remove the carpets or change the furniture
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
bull -
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
-House Dust complex mixture of everything found in home-Variable quantities of many allergen- Monoclonal antibody assays capable of measuring individual allergens in the complex mix present in homes
Dust mite
bull Biology And Characteristic
bull Pyroglyphid mites dominate (Dpteronyssinus D farinae Euroglyphus maynei) Dust mite
bull Tropical areas Blomia tropicalis
bull Occasionally storage mites Lepidoglyphus destructor Tyrophagus putrescentior
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Dust mite bull In most humid areas of the world house dust mites are the
major source of allergens in house dust
bull Pyroglyphid mites are eight-legged and sightless (microscopic arthropods) (03 mm in length)
bull Live on skin scales and other debrisbull Very precarious water balance
bull Mites growth dependent on
1048708 water in ambient air (not capable of searching for or drinking liquids)
1048708 relative humidity gt50
1048708 absolute humidity ge6 gkg
1048708 temperature of 65-80 F (183-267 C)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552Immunol Allergy Clin N Am 31 (2011) 493ndash507
Dust mite bull As humidity fallsit may take months for mites to die and
longer for allergen levels to decrease in carpets sofas or mattresses
bull Fecal particles ndash 10-35 μm in size (similar to pollen grains)
ndash particles contain digestive enzymesndash surrounded by a chitinous peritrophic membranendash lsquomembranersquo is not waterproof and allergens elute
from fecal particles rapidly
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
bull Mite bodies and fecal pellets are the major sources of allergensbull Settle out of air quickly so airborne levels depend upon disturbance in
room
Dust mite
bull Dust mite allergen bed roombull Cockroach allergen kitchen
bull A major problem with any assessment of exposure to dust mite antigens is that patients often sleep or sit with their heads very close to mite-infested material (eg sofas blankets pillows carpet)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
wwwallergenorg18 Feb 2013
wwwallergenorg18 Feb 2013
Dust mitebull mite allergens are now referred to as
ndash group 1 (Der p 1 and Der f 1) ndash group 2 (Der p 2 and Der f 2)
bull Der f 1 and Der p 1 are highly cross-reactive as are Der f 2 and Der p 2bull Der fp 10 (tropomyosin) cross reacts with other invertebrate
tropomyosins such as shrimp
bull Antibodies to B tropicalis cross-react partially with other dust mites
bull dust levels of mite allergen (Der p 1 + Der p 2) ndash sensitization at 2-10 μgg of dustndash For nonallergic children higher ldquothresholdrdquo of 20 μgg
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Dust mite
bull Avoidance measures
Otolaryngol Clin N Am 44 (2011) 711ndash725
Avoidance
bull standard part of the treatment of allergic disease bull difficult to achieve particularly in home environments
bull Many patients despite being skin test positive were not aware that dust related to their symptoms
bull sources and nature of indoor allergens were not well understood advice offered on avoidance was often inadequate or even wrong
bull The complexity and nonlinearity of dose response relationships also makes such evaluations of the effectiveness of allergen avoidance difficult
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552Immunol Allergy Clin N Am 31 (2011) 493ndash507
Br Med J 1998 3171105
2001 29 trials (939 patients)
2004 49 trials (2733 patients) 2008 54 trials (3002 patients)
2011 55 trials (3121 patients)
26 trials physical 10 trials chemical methods 8 trials combination
Cochrane Library 2011 Issue 10
Cochrane Library 2011 Issue 10
Cochrane Library 2011 Issue 10
bull The variability applies to the evaluation of patients the intervention used and the assessment of outcome
bull Meta-analysis is only valid when the studies are comparable and this may not be true for the successful studies on allergen avoidance
J Allergy Clin Immunol 2008122694-6
very different designs and engage different subjects time frames controls seasons and methods of intervention
J Allergy Clin Immunol 2011128723-7
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
longer than 6 months
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull most professional guidelines for asthma management advocate the avoidance of acute allergen lsquolsquotriggersrsquorsquo
bull there is a diversity of views about the role of allergen avoidance practices in long-term disease management
bull 2007 National Heart Lung and Blood Institute EPR3 (US) reportndash advises that the first and most important step in controlling
allergen induced asthma is to reduce exposure
J Allergy Clin Immunol 2011128723-7
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull Finnish Allergy Program 2008-2018 ndash promotes holistic lsquolsquoallergy healthrsquorsquo through diet and physical
activity and advocates allergen avoidance only lsquolsquoin mandatory situationsrsquorsquo
bull Both the 2009 Global Initiative for Asthma and the British Thoracic Society guidelines reflect (Cochrane review)
ndash no consistent evidence for allergen avoidance in preventing asthma
ndash only tenuous evidence that reducing allergen exposure can reduce asthma morbidity
J Allergy Clin Immunol 2011128723-7
ICON pediatric asthmabull some ambiguity with respect to the role of allergen avoidance
bull JGCA NAEPP3 and PRACTALL ndash specific recommendations for the reduction in allergen exposure
for sensitized patients with asthma
bull AAMH GINA and SIGNndash unproven effectiveness of current avoidance strategies on
asthma control
bull a multifaceted comprehensive approach is prerequisite for clinical benefit
Allergy 2012 67 976ndash997
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
bull 9 trials involving 501 participants bull 2 studies investigating the effectiveness of mite impermeable
bedding covers were of good qualitybull 7 studies were small and of poor qualitybull 2 trials investigated the efficacy of acaricidesbull 2 trials investigated the role of high-efficiency particulate air (HEPA)
filtersbull 1 trial using a factorial design investigated the efficacy of both
acaricide and house dust mite impermeable bedding covers in isolation and combination
bull Remaining 4 trials investigated the efficacy of bedroom environmental control programmes involving use of house dust mite impermeable bedding covers
Cochrane Database of Systematic Reviews 2010 Issue 7
bull Trials to date small and of poor methodological qualitybull difficult to offer any definitive recommendations on the role
bull use of acaricides and extensive bedroom-based environmental control programmes may be of some benefit in reducing rhinitis symptoms but the evidence is not strong
bull Isolated use of house dust mite impermeable bedding is unlikely to prove effective
bull More research is needed
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
METHODS OFMITE ALLERGEN AVOIDANCE
Method
bull Physical methodndash Encasing of beddingndash Vacuums cleanersndash Floor coveringsndash Laundryndash Air filtration
bull Chemical methodndash Acaricide
Encasingsbull In the bedroom covering mattresses and pillows with impermeable
covers is effectivebull This effect may be large variable and persist for a couple of
months
bull Encasings differ widely in their qualityndash some cheap brands have large pores other multilayered encasings delaminate
and others harbor mites
bull Tightly woven synthetic or cotton fabrics are preferred
bull Most trials of encasings have failed to regularly wash them (difficult with some encasings) which renders them ineffective as allergens build up on the outer surface within several weeks
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Curr Allergy Asthma Rep 20088126-32
J Allergy Clin Immunol 20061181164-8
16 tightly woven 9 United States3 Japan2 Thailand1 Germany1 France
laminate-coated and loosely woven cover molting among nonwoven fibers
dead mites on an acaricide-coated and nonwoven cover group of mites in the matrix of a nonwoven cover
J Allergy Clin Immunol 20061181164-8
Nonwoven
J Allergy Clin Immunol 20061181164-8
before after
easy access for mites to readily penetrate into the substrate of the material
J Allergy Clin Immunol 20061181164-8
tightly woven fabric with systematized regular fibers allowing little space for penetration
bull Woven nonwovenndash pore size between 2 and 10 um (average 6 um) blocking most
mite allergens
bull Plasticndash pore free best barrier in terms of blockingndash but the least comfortable zero ventilation ndash tendency to become a haven for mold spores
bull For acaricide-coated materialsndash pore size is usually not a major factor ndash mites are eradicated on contact with the chemicalsndash still allow the passage of allergens ndash prevent penetration through the fabrics but allow colonization
J Allergy Clin Immunol 20061181164-8
Asian Pac J Allergy Immunol 201028155-61
Sensitized level
Symptomatic level
sponge-like polyurethane lowest rate Synthetic fibers and kapok mattresses highest rate
A combination of the following choosing new sponge-like polyurethane or coconut fiber mattresses with mite-impermeable covers and washing sheets pillowcases blankets and mattresses pad at least weekly in hot water should be the best method of prevention in HDM allergen sensitive allergic patients
Laundrybull Both dust and cat and mite allergens are effectively removed by
laundryndash physical removal of both dust and mites by the multiple wash
and rinse cycles ndash effects of detergents additivesndash subsequent drying procedures
bull McDonald LGTovey E ndash All mites were killed by water temperatures 55 degrees C or
greaterndash Killing at lower temperatures was not enhanced by any of the
pure detergents or laundry products tested
J Allergy Clin Immunol 2011128723-7
J Allergy Clin Immunol 199290599-608
Floor coveringsbull Designing the house with polished floors and wooden or
vinylleather furniture so as to limit the sites where mites can grow
bull carpets fitted onto unventilated floors water can accumulate growth of both fungi and mites
bull hard floors are likely to be preferred as they are more easily kept in a state that minimizes aeroallergen reaerosolization in the long term
bull the little available data of aeroallergens in houses suggest that the difference may be small and the effects complex
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552J Allergy Clin Immunol 2011128723-7
Vacuum cleaners
bull Vacuum cleaners are heavily promoted
bull Probably all cleaners cause a brief increase in personal aeroallergen exposure under normal domestic conditions and high-efficiency particulate arrest (HEPA) filters make little difference
bull Thus the benefits of HEPA filtration on exposure may have been exaggerated and all cleaners probably provide a brief increase in exposure
J Allergy Clin Immunol 2011128723-7
Allergy 200661119-23
Air management
bull indoor relative humidity is kept below 50 (absolute humidity below 6 gkg)
bull In some areas of the world this can be done by increasing ventilation
bull in other areas it is necessary to use air conditioning during the most humid months of the summer
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Air filtration
bull The role of air filtration continues to be debatedbull There is some consensus that small benefits exist mainly for pet
allergens
J Allergy Clin Immunol 2011128723-7
Acaricidesbull variety of acaricides have been used to treat carpets or furniturebull pyrethroids natamycin (an antifungal) pirimiphos methyl and
benzyl benzoate bull killing mites
bull Acaricides proved largely ineffective because the mite populations return shortly after their application and they may also cause skin and respiratory irritation
bull No data on clinical benefit exist and concerns about human health and environmental toxicity remain
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
J Allergy Clin Immunol 2011128723-7
Acaricidesbull 1 or 3 tannic acid
ndash method of denaturing mite allergensndash reduction of mite allergen can be achievedndash does not kill mitesndash so the effect can only be temporary approximately 6 weeks to 3
months
bull may be recommended when it is not possible to remove the carpets or change the furniture
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
bull -
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
-House Dust complex mixture of everything found in home-Variable quantities of many allergen- Monoclonal antibody assays capable of measuring individual allergens in the complex mix present in homes
Dust mite
bull Biology And Characteristic
bull Pyroglyphid mites dominate (Dpteronyssinus D farinae Euroglyphus maynei) Dust mite
bull Tropical areas Blomia tropicalis
bull Occasionally storage mites Lepidoglyphus destructor Tyrophagus putrescentior
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Dust mite bull In most humid areas of the world house dust mites are the
major source of allergens in house dust
bull Pyroglyphid mites are eight-legged and sightless (microscopic arthropods) (03 mm in length)
bull Live on skin scales and other debrisbull Very precarious water balance
bull Mites growth dependent on
1048708 water in ambient air (not capable of searching for or drinking liquids)
1048708 relative humidity gt50
1048708 absolute humidity ge6 gkg
1048708 temperature of 65-80 F (183-267 C)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552Immunol Allergy Clin N Am 31 (2011) 493ndash507
Dust mite bull As humidity fallsit may take months for mites to die and
longer for allergen levels to decrease in carpets sofas or mattresses
bull Fecal particles ndash 10-35 μm in size (similar to pollen grains)
ndash particles contain digestive enzymesndash surrounded by a chitinous peritrophic membranendash lsquomembranersquo is not waterproof and allergens elute
from fecal particles rapidly
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
bull Mite bodies and fecal pellets are the major sources of allergensbull Settle out of air quickly so airborne levels depend upon disturbance in
room
Dust mite
bull Dust mite allergen bed roombull Cockroach allergen kitchen
bull A major problem with any assessment of exposure to dust mite antigens is that patients often sleep or sit with their heads very close to mite-infested material (eg sofas blankets pillows carpet)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
wwwallergenorg18 Feb 2013
wwwallergenorg18 Feb 2013
Dust mitebull mite allergens are now referred to as
ndash group 1 (Der p 1 and Der f 1) ndash group 2 (Der p 2 and Der f 2)
bull Der f 1 and Der p 1 are highly cross-reactive as are Der f 2 and Der p 2bull Der fp 10 (tropomyosin) cross reacts with other invertebrate
tropomyosins such as shrimp
bull Antibodies to B tropicalis cross-react partially with other dust mites
bull dust levels of mite allergen (Der p 1 + Der p 2) ndash sensitization at 2-10 μgg of dustndash For nonallergic children higher ldquothresholdrdquo of 20 μgg
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Dust mite
bull Avoidance measures
Otolaryngol Clin N Am 44 (2011) 711ndash725
Avoidance
bull standard part of the treatment of allergic disease bull difficult to achieve particularly in home environments
bull Many patients despite being skin test positive were not aware that dust related to their symptoms
bull sources and nature of indoor allergens were not well understood advice offered on avoidance was often inadequate or even wrong
bull The complexity and nonlinearity of dose response relationships also makes such evaluations of the effectiveness of allergen avoidance difficult
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552Immunol Allergy Clin N Am 31 (2011) 493ndash507
Br Med J 1998 3171105
2001 29 trials (939 patients)
2004 49 trials (2733 patients) 2008 54 trials (3002 patients)
2011 55 trials (3121 patients)
26 trials physical 10 trials chemical methods 8 trials combination
Cochrane Library 2011 Issue 10
Cochrane Library 2011 Issue 10
Cochrane Library 2011 Issue 10
bull The variability applies to the evaluation of patients the intervention used and the assessment of outcome
bull Meta-analysis is only valid when the studies are comparable and this may not be true for the successful studies on allergen avoidance
J Allergy Clin Immunol 2008122694-6
very different designs and engage different subjects time frames controls seasons and methods of intervention
J Allergy Clin Immunol 2011128723-7
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
longer than 6 months
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull most professional guidelines for asthma management advocate the avoidance of acute allergen lsquolsquotriggersrsquorsquo
bull there is a diversity of views about the role of allergen avoidance practices in long-term disease management
bull 2007 National Heart Lung and Blood Institute EPR3 (US) reportndash advises that the first and most important step in controlling
allergen induced asthma is to reduce exposure
J Allergy Clin Immunol 2011128723-7
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull Finnish Allergy Program 2008-2018 ndash promotes holistic lsquolsquoallergy healthrsquorsquo through diet and physical
activity and advocates allergen avoidance only lsquolsquoin mandatory situationsrsquorsquo
bull Both the 2009 Global Initiative for Asthma and the British Thoracic Society guidelines reflect (Cochrane review)
ndash no consistent evidence for allergen avoidance in preventing asthma
ndash only tenuous evidence that reducing allergen exposure can reduce asthma morbidity
J Allergy Clin Immunol 2011128723-7
ICON pediatric asthmabull some ambiguity with respect to the role of allergen avoidance
bull JGCA NAEPP3 and PRACTALL ndash specific recommendations for the reduction in allergen exposure
for sensitized patients with asthma
bull AAMH GINA and SIGNndash unproven effectiveness of current avoidance strategies on
asthma control
bull a multifaceted comprehensive approach is prerequisite for clinical benefit
Allergy 2012 67 976ndash997
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
bull 9 trials involving 501 participants bull 2 studies investigating the effectiveness of mite impermeable
bedding covers were of good qualitybull 7 studies were small and of poor qualitybull 2 trials investigated the efficacy of acaricidesbull 2 trials investigated the role of high-efficiency particulate air (HEPA)
filtersbull 1 trial using a factorial design investigated the efficacy of both
acaricide and house dust mite impermeable bedding covers in isolation and combination
bull Remaining 4 trials investigated the efficacy of bedroom environmental control programmes involving use of house dust mite impermeable bedding covers
Cochrane Database of Systematic Reviews 2010 Issue 7
bull Trials to date small and of poor methodological qualitybull difficult to offer any definitive recommendations on the role
bull use of acaricides and extensive bedroom-based environmental control programmes may be of some benefit in reducing rhinitis symptoms but the evidence is not strong
bull Isolated use of house dust mite impermeable bedding is unlikely to prove effective
bull More research is needed
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
METHODS OFMITE ALLERGEN AVOIDANCE
Method
bull Physical methodndash Encasing of beddingndash Vacuums cleanersndash Floor coveringsndash Laundryndash Air filtration
bull Chemical methodndash Acaricide
Encasingsbull In the bedroom covering mattresses and pillows with impermeable
covers is effectivebull This effect may be large variable and persist for a couple of
months
bull Encasings differ widely in their qualityndash some cheap brands have large pores other multilayered encasings delaminate
and others harbor mites
bull Tightly woven synthetic or cotton fabrics are preferred
bull Most trials of encasings have failed to regularly wash them (difficult with some encasings) which renders them ineffective as allergens build up on the outer surface within several weeks
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Curr Allergy Asthma Rep 20088126-32
J Allergy Clin Immunol 20061181164-8
16 tightly woven 9 United States3 Japan2 Thailand1 Germany1 France
laminate-coated and loosely woven cover molting among nonwoven fibers
dead mites on an acaricide-coated and nonwoven cover group of mites in the matrix of a nonwoven cover
J Allergy Clin Immunol 20061181164-8
Nonwoven
J Allergy Clin Immunol 20061181164-8
before after
easy access for mites to readily penetrate into the substrate of the material
J Allergy Clin Immunol 20061181164-8
tightly woven fabric with systematized regular fibers allowing little space for penetration
bull Woven nonwovenndash pore size between 2 and 10 um (average 6 um) blocking most
mite allergens
bull Plasticndash pore free best barrier in terms of blockingndash but the least comfortable zero ventilation ndash tendency to become a haven for mold spores
bull For acaricide-coated materialsndash pore size is usually not a major factor ndash mites are eradicated on contact with the chemicalsndash still allow the passage of allergens ndash prevent penetration through the fabrics but allow colonization
J Allergy Clin Immunol 20061181164-8
Asian Pac J Allergy Immunol 201028155-61
Sensitized level
Symptomatic level
sponge-like polyurethane lowest rate Synthetic fibers and kapok mattresses highest rate
A combination of the following choosing new sponge-like polyurethane or coconut fiber mattresses with mite-impermeable covers and washing sheets pillowcases blankets and mattresses pad at least weekly in hot water should be the best method of prevention in HDM allergen sensitive allergic patients
Laundrybull Both dust and cat and mite allergens are effectively removed by
laundryndash physical removal of both dust and mites by the multiple wash
and rinse cycles ndash effects of detergents additivesndash subsequent drying procedures
bull McDonald LGTovey E ndash All mites were killed by water temperatures 55 degrees C or
greaterndash Killing at lower temperatures was not enhanced by any of the
pure detergents or laundry products tested
J Allergy Clin Immunol 2011128723-7
J Allergy Clin Immunol 199290599-608
Floor coveringsbull Designing the house with polished floors and wooden or
vinylleather furniture so as to limit the sites where mites can grow
bull carpets fitted onto unventilated floors water can accumulate growth of both fungi and mites
bull hard floors are likely to be preferred as they are more easily kept in a state that minimizes aeroallergen reaerosolization in the long term
bull the little available data of aeroallergens in houses suggest that the difference may be small and the effects complex
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552J Allergy Clin Immunol 2011128723-7
Vacuum cleaners
bull Vacuum cleaners are heavily promoted
bull Probably all cleaners cause a brief increase in personal aeroallergen exposure under normal domestic conditions and high-efficiency particulate arrest (HEPA) filters make little difference
bull Thus the benefits of HEPA filtration on exposure may have been exaggerated and all cleaners probably provide a brief increase in exposure
J Allergy Clin Immunol 2011128723-7
Allergy 200661119-23
Air management
bull indoor relative humidity is kept below 50 (absolute humidity below 6 gkg)
bull In some areas of the world this can be done by increasing ventilation
bull in other areas it is necessary to use air conditioning during the most humid months of the summer
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Air filtration
bull The role of air filtration continues to be debatedbull There is some consensus that small benefits exist mainly for pet
allergens
J Allergy Clin Immunol 2011128723-7
Acaricidesbull variety of acaricides have been used to treat carpets or furniturebull pyrethroids natamycin (an antifungal) pirimiphos methyl and
benzyl benzoate bull killing mites
bull Acaricides proved largely ineffective because the mite populations return shortly after their application and they may also cause skin and respiratory irritation
bull No data on clinical benefit exist and concerns about human health and environmental toxicity remain
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
J Allergy Clin Immunol 2011128723-7
Acaricidesbull 1 or 3 tannic acid
ndash method of denaturing mite allergensndash reduction of mite allergen can be achievedndash does not kill mitesndash so the effect can only be temporary approximately 6 weeks to 3
months
bull may be recommended when it is not possible to remove the carpets or change the furniture
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
Dust mite
bull Biology And Characteristic
bull Pyroglyphid mites dominate (Dpteronyssinus D farinae Euroglyphus maynei) Dust mite
bull Tropical areas Blomia tropicalis
bull Occasionally storage mites Lepidoglyphus destructor Tyrophagus putrescentior
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Dust mite bull In most humid areas of the world house dust mites are the
major source of allergens in house dust
bull Pyroglyphid mites are eight-legged and sightless (microscopic arthropods) (03 mm in length)
bull Live on skin scales and other debrisbull Very precarious water balance
bull Mites growth dependent on
1048708 water in ambient air (not capable of searching for or drinking liquids)
1048708 relative humidity gt50
1048708 absolute humidity ge6 gkg
1048708 temperature of 65-80 F (183-267 C)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552Immunol Allergy Clin N Am 31 (2011) 493ndash507
Dust mite bull As humidity fallsit may take months for mites to die and
longer for allergen levels to decrease in carpets sofas or mattresses
bull Fecal particles ndash 10-35 μm in size (similar to pollen grains)
ndash particles contain digestive enzymesndash surrounded by a chitinous peritrophic membranendash lsquomembranersquo is not waterproof and allergens elute
from fecal particles rapidly
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
bull Mite bodies and fecal pellets are the major sources of allergensbull Settle out of air quickly so airborne levels depend upon disturbance in
room
Dust mite
bull Dust mite allergen bed roombull Cockroach allergen kitchen
bull A major problem with any assessment of exposure to dust mite antigens is that patients often sleep or sit with their heads very close to mite-infested material (eg sofas blankets pillows carpet)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
wwwallergenorg18 Feb 2013
wwwallergenorg18 Feb 2013
Dust mitebull mite allergens are now referred to as
ndash group 1 (Der p 1 and Der f 1) ndash group 2 (Der p 2 and Der f 2)
bull Der f 1 and Der p 1 are highly cross-reactive as are Der f 2 and Der p 2bull Der fp 10 (tropomyosin) cross reacts with other invertebrate
tropomyosins such as shrimp
bull Antibodies to B tropicalis cross-react partially with other dust mites
bull dust levels of mite allergen (Der p 1 + Der p 2) ndash sensitization at 2-10 μgg of dustndash For nonallergic children higher ldquothresholdrdquo of 20 μgg
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Dust mite
bull Avoidance measures
Otolaryngol Clin N Am 44 (2011) 711ndash725
Avoidance
bull standard part of the treatment of allergic disease bull difficult to achieve particularly in home environments
bull Many patients despite being skin test positive were not aware that dust related to their symptoms
bull sources and nature of indoor allergens were not well understood advice offered on avoidance was often inadequate or even wrong
bull The complexity and nonlinearity of dose response relationships also makes such evaluations of the effectiveness of allergen avoidance difficult
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552Immunol Allergy Clin N Am 31 (2011) 493ndash507
Br Med J 1998 3171105
2001 29 trials (939 patients)
2004 49 trials (2733 patients) 2008 54 trials (3002 patients)
2011 55 trials (3121 patients)
26 trials physical 10 trials chemical methods 8 trials combination
Cochrane Library 2011 Issue 10
Cochrane Library 2011 Issue 10
Cochrane Library 2011 Issue 10
bull The variability applies to the evaluation of patients the intervention used and the assessment of outcome
bull Meta-analysis is only valid when the studies are comparable and this may not be true for the successful studies on allergen avoidance
J Allergy Clin Immunol 2008122694-6
very different designs and engage different subjects time frames controls seasons and methods of intervention
J Allergy Clin Immunol 2011128723-7
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
longer than 6 months
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull most professional guidelines for asthma management advocate the avoidance of acute allergen lsquolsquotriggersrsquorsquo
bull there is a diversity of views about the role of allergen avoidance practices in long-term disease management
bull 2007 National Heart Lung and Blood Institute EPR3 (US) reportndash advises that the first and most important step in controlling
allergen induced asthma is to reduce exposure
J Allergy Clin Immunol 2011128723-7
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull Finnish Allergy Program 2008-2018 ndash promotes holistic lsquolsquoallergy healthrsquorsquo through diet and physical
activity and advocates allergen avoidance only lsquolsquoin mandatory situationsrsquorsquo
bull Both the 2009 Global Initiative for Asthma and the British Thoracic Society guidelines reflect (Cochrane review)
ndash no consistent evidence for allergen avoidance in preventing asthma
ndash only tenuous evidence that reducing allergen exposure can reduce asthma morbidity
J Allergy Clin Immunol 2011128723-7
ICON pediatric asthmabull some ambiguity with respect to the role of allergen avoidance
bull JGCA NAEPP3 and PRACTALL ndash specific recommendations for the reduction in allergen exposure
for sensitized patients with asthma
bull AAMH GINA and SIGNndash unproven effectiveness of current avoidance strategies on
asthma control
bull a multifaceted comprehensive approach is prerequisite for clinical benefit
Allergy 2012 67 976ndash997
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
bull 9 trials involving 501 participants bull 2 studies investigating the effectiveness of mite impermeable
bedding covers were of good qualitybull 7 studies were small and of poor qualitybull 2 trials investigated the efficacy of acaricidesbull 2 trials investigated the role of high-efficiency particulate air (HEPA)
filtersbull 1 trial using a factorial design investigated the efficacy of both
acaricide and house dust mite impermeable bedding covers in isolation and combination
bull Remaining 4 trials investigated the efficacy of bedroom environmental control programmes involving use of house dust mite impermeable bedding covers
Cochrane Database of Systematic Reviews 2010 Issue 7
bull Trials to date small and of poor methodological qualitybull difficult to offer any definitive recommendations on the role
bull use of acaricides and extensive bedroom-based environmental control programmes may be of some benefit in reducing rhinitis symptoms but the evidence is not strong
bull Isolated use of house dust mite impermeable bedding is unlikely to prove effective
bull More research is needed
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
METHODS OFMITE ALLERGEN AVOIDANCE
Method
bull Physical methodndash Encasing of beddingndash Vacuums cleanersndash Floor coveringsndash Laundryndash Air filtration
bull Chemical methodndash Acaricide
Encasingsbull In the bedroom covering mattresses and pillows with impermeable
covers is effectivebull This effect may be large variable and persist for a couple of
months
bull Encasings differ widely in their qualityndash some cheap brands have large pores other multilayered encasings delaminate
and others harbor mites
bull Tightly woven synthetic or cotton fabrics are preferred
bull Most trials of encasings have failed to regularly wash them (difficult with some encasings) which renders them ineffective as allergens build up on the outer surface within several weeks
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Curr Allergy Asthma Rep 20088126-32
J Allergy Clin Immunol 20061181164-8
16 tightly woven 9 United States3 Japan2 Thailand1 Germany1 France
laminate-coated and loosely woven cover molting among nonwoven fibers
dead mites on an acaricide-coated and nonwoven cover group of mites in the matrix of a nonwoven cover
J Allergy Clin Immunol 20061181164-8
Nonwoven
J Allergy Clin Immunol 20061181164-8
before after
easy access for mites to readily penetrate into the substrate of the material
J Allergy Clin Immunol 20061181164-8
tightly woven fabric with systematized regular fibers allowing little space for penetration
bull Woven nonwovenndash pore size between 2 and 10 um (average 6 um) blocking most
mite allergens
bull Plasticndash pore free best barrier in terms of blockingndash but the least comfortable zero ventilation ndash tendency to become a haven for mold spores
bull For acaricide-coated materialsndash pore size is usually not a major factor ndash mites are eradicated on contact with the chemicalsndash still allow the passage of allergens ndash prevent penetration through the fabrics but allow colonization
J Allergy Clin Immunol 20061181164-8
Asian Pac J Allergy Immunol 201028155-61
Sensitized level
Symptomatic level
sponge-like polyurethane lowest rate Synthetic fibers and kapok mattresses highest rate
A combination of the following choosing new sponge-like polyurethane or coconut fiber mattresses with mite-impermeable covers and washing sheets pillowcases blankets and mattresses pad at least weekly in hot water should be the best method of prevention in HDM allergen sensitive allergic patients
Laundrybull Both dust and cat and mite allergens are effectively removed by
laundryndash physical removal of both dust and mites by the multiple wash
and rinse cycles ndash effects of detergents additivesndash subsequent drying procedures
bull McDonald LGTovey E ndash All mites were killed by water temperatures 55 degrees C or
greaterndash Killing at lower temperatures was not enhanced by any of the
pure detergents or laundry products tested
J Allergy Clin Immunol 2011128723-7
J Allergy Clin Immunol 199290599-608
Floor coveringsbull Designing the house with polished floors and wooden or
vinylleather furniture so as to limit the sites where mites can grow
bull carpets fitted onto unventilated floors water can accumulate growth of both fungi and mites
bull hard floors are likely to be preferred as they are more easily kept in a state that minimizes aeroallergen reaerosolization in the long term
bull the little available data of aeroallergens in houses suggest that the difference may be small and the effects complex
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552J Allergy Clin Immunol 2011128723-7
Vacuum cleaners
bull Vacuum cleaners are heavily promoted
bull Probably all cleaners cause a brief increase in personal aeroallergen exposure under normal domestic conditions and high-efficiency particulate arrest (HEPA) filters make little difference
bull Thus the benefits of HEPA filtration on exposure may have been exaggerated and all cleaners probably provide a brief increase in exposure
J Allergy Clin Immunol 2011128723-7
Allergy 200661119-23
Air management
bull indoor relative humidity is kept below 50 (absolute humidity below 6 gkg)
bull In some areas of the world this can be done by increasing ventilation
bull in other areas it is necessary to use air conditioning during the most humid months of the summer
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Air filtration
bull The role of air filtration continues to be debatedbull There is some consensus that small benefits exist mainly for pet
allergens
J Allergy Clin Immunol 2011128723-7
Acaricidesbull variety of acaricides have been used to treat carpets or furniturebull pyrethroids natamycin (an antifungal) pirimiphos methyl and
benzyl benzoate bull killing mites
bull Acaricides proved largely ineffective because the mite populations return shortly after their application and they may also cause skin and respiratory irritation
bull No data on clinical benefit exist and concerns about human health and environmental toxicity remain
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
J Allergy Clin Immunol 2011128723-7
Acaricidesbull 1 or 3 tannic acid
ndash method of denaturing mite allergensndash reduction of mite allergen can be achievedndash does not kill mitesndash so the effect can only be temporary approximately 6 weeks to 3
months
bull may be recommended when it is not possible to remove the carpets or change the furniture
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
bull Pyroglyphid mites dominate (Dpteronyssinus D farinae Euroglyphus maynei) Dust mite
bull Tropical areas Blomia tropicalis
bull Occasionally storage mites Lepidoglyphus destructor Tyrophagus putrescentior
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Dust mite bull In most humid areas of the world house dust mites are the
major source of allergens in house dust
bull Pyroglyphid mites are eight-legged and sightless (microscopic arthropods) (03 mm in length)
bull Live on skin scales and other debrisbull Very precarious water balance
bull Mites growth dependent on
1048708 water in ambient air (not capable of searching for or drinking liquids)
1048708 relative humidity gt50
1048708 absolute humidity ge6 gkg
1048708 temperature of 65-80 F (183-267 C)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552Immunol Allergy Clin N Am 31 (2011) 493ndash507
Dust mite bull As humidity fallsit may take months for mites to die and
longer for allergen levels to decrease in carpets sofas or mattresses
bull Fecal particles ndash 10-35 μm in size (similar to pollen grains)
ndash particles contain digestive enzymesndash surrounded by a chitinous peritrophic membranendash lsquomembranersquo is not waterproof and allergens elute
from fecal particles rapidly
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
bull Mite bodies and fecal pellets are the major sources of allergensbull Settle out of air quickly so airborne levels depend upon disturbance in
room
Dust mite
bull Dust mite allergen bed roombull Cockroach allergen kitchen
bull A major problem with any assessment of exposure to dust mite antigens is that patients often sleep or sit with their heads very close to mite-infested material (eg sofas blankets pillows carpet)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
wwwallergenorg18 Feb 2013
wwwallergenorg18 Feb 2013
Dust mitebull mite allergens are now referred to as
ndash group 1 (Der p 1 and Der f 1) ndash group 2 (Der p 2 and Der f 2)
bull Der f 1 and Der p 1 are highly cross-reactive as are Der f 2 and Der p 2bull Der fp 10 (tropomyosin) cross reacts with other invertebrate
tropomyosins such as shrimp
bull Antibodies to B tropicalis cross-react partially with other dust mites
bull dust levels of mite allergen (Der p 1 + Der p 2) ndash sensitization at 2-10 μgg of dustndash For nonallergic children higher ldquothresholdrdquo of 20 μgg
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Dust mite
bull Avoidance measures
Otolaryngol Clin N Am 44 (2011) 711ndash725
Avoidance
bull standard part of the treatment of allergic disease bull difficult to achieve particularly in home environments
bull Many patients despite being skin test positive were not aware that dust related to their symptoms
bull sources and nature of indoor allergens were not well understood advice offered on avoidance was often inadequate or even wrong
bull The complexity and nonlinearity of dose response relationships also makes such evaluations of the effectiveness of allergen avoidance difficult
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552Immunol Allergy Clin N Am 31 (2011) 493ndash507
Br Med J 1998 3171105
2001 29 trials (939 patients)
2004 49 trials (2733 patients) 2008 54 trials (3002 patients)
2011 55 trials (3121 patients)
26 trials physical 10 trials chemical methods 8 trials combination
Cochrane Library 2011 Issue 10
Cochrane Library 2011 Issue 10
Cochrane Library 2011 Issue 10
bull The variability applies to the evaluation of patients the intervention used and the assessment of outcome
bull Meta-analysis is only valid when the studies are comparable and this may not be true for the successful studies on allergen avoidance
J Allergy Clin Immunol 2008122694-6
very different designs and engage different subjects time frames controls seasons and methods of intervention
J Allergy Clin Immunol 2011128723-7
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
longer than 6 months
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull most professional guidelines for asthma management advocate the avoidance of acute allergen lsquolsquotriggersrsquorsquo
bull there is a diversity of views about the role of allergen avoidance practices in long-term disease management
bull 2007 National Heart Lung and Blood Institute EPR3 (US) reportndash advises that the first and most important step in controlling
allergen induced asthma is to reduce exposure
J Allergy Clin Immunol 2011128723-7
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull Finnish Allergy Program 2008-2018 ndash promotes holistic lsquolsquoallergy healthrsquorsquo through diet and physical
activity and advocates allergen avoidance only lsquolsquoin mandatory situationsrsquorsquo
bull Both the 2009 Global Initiative for Asthma and the British Thoracic Society guidelines reflect (Cochrane review)
ndash no consistent evidence for allergen avoidance in preventing asthma
ndash only tenuous evidence that reducing allergen exposure can reduce asthma morbidity
J Allergy Clin Immunol 2011128723-7
ICON pediatric asthmabull some ambiguity with respect to the role of allergen avoidance
bull JGCA NAEPP3 and PRACTALL ndash specific recommendations for the reduction in allergen exposure
for sensitized patients with asthma
bull AAMH GINA and SIGNndash unproven effectiveness of current avoidance strategies on
asthma control
bull a multifaceted comprehensive approach is prerequisite for clinical benefit
Allergy 2012 67 976ndash997
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
bull 9 trials involving 501 participants bull 2 studies investigating the effectiveness of mite impermeable
bedding covers were of good qualitybull 7 studies were small and of poor qualitybull 2 trials investigated the efficacy of acaricidesbull 2 trials investigated the role of high-efficiency particulate air (HEPA)
filtersbull 1 trial using a factorial design investigated the efficacy of both
acaricide and house dust mite impermeable bedding covers in isolation and combination
bull Remaining 4 trials investigated the efficacy of bedroom environmental control programmes involving use of house dust mite impermeable bedding covers
Cochrane Database of Systematic Reviews 2010 Issue 7
bull Trials to date small and of poor methodological qualitybull difficult to offer any definitive recommendations on the role
bull use of acaricides and extensive bedroom-based environmental control programmes may be of some benefit in reducing rhinitis symptoms but the evidence is not strong
bull Isolated use of house dust mite impermeable bedding is unlikely to prove effective
bull More research is needed
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
METHODS OFMITE ALLERGEN AVOIDANCE
Method
bull Physical methodndash Encasing of beddingndash Vacuums cleanersndash Floor coveringsndash Laundryndash Air filtration
bull Chemical methodndash Acaricide
Encasingsbull In the bedroom covering mattresses and pillows with impermeable
covers is effectivebull This effect may be large variable and persist for a couple of
months
bull Encasings differ widely in their qualityndash some cheap brands have large pores other multilayered encasings delaminate
and others harbor mites
bull Tightly woven synthetic or cotton fabrics are preferred
bull Most trials of encasings have failed to regularly wash them (difficult with some encasings) which renders them ineffective as allergens build up on the outer surface within several weeks
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Curr Allergy Asthma Rep 20088126-32
J Allergy Clin Immunol 20061181164-8
16 tightly woven 9 United States3 Japan2 Thailand1 Germany1 France
laminate-coated and loosely woven cover molting among nonwoven fibers
dead mites on an acaricide-coated and nonwoven cover group of mites in the matrix of a nonwoven cover
J Allergy Clin Immunol 20061181164-8
Nonwoven
J Allergy Clin Immunol 20061181164-8
before after
easy access for mites to readily penetrate into the substrate of the material
J Allergy Clin Immunol 20061181164-8
tightly woven fabric with systematized regular fibers allowing little space for penetration
bull Woven nonwovenndash pore size between 2 and 10 um (average 6 um) blocking most
mite allergens
bull Plasticndash pore free best barrier in terms of blockingndash but the least comfortable zero ventilation ndash tendency to become a haven for mold spores
bull For acaricide-coated materialsndash pore size is usually not a major factor ndash mites are eradicated on contact with the chemicalsndash still allow the passage of allergens ndash prevent penetration through the fabrics but allow colonization
J Allergy Clin Immunol 20061181164-8
Asian Pac J Allergy Immunol 201028155-61
Sensitized level
Symptomatic level
sponge-like polyurethane lowest rate Synthetic fibers and kapok mattresses highest rate
A combination of the following choosing new sponge-like polyurethane or coconut fiber mattresses with mite-impermeable covers and washing sheets pillowcases blankets and mattresses pad at least weekly in hot water should be the best method of prevention in HDM allergen sensitive allergic patients
Laundrybull Both dust and cat and mite allergens are effectively removed by
laundryndash physical removal of both dust and mites by the multiple wash
and rinse cycles ndash effects of detergents additivesndash subsequent drying procedures
bull McDonald LGTovey E ndash All mites were killed by water temperatures 55 degrees C or
greaterndash Killing at lower temperatures was not enhanced by any of the
pure detergents or laundry products tested
J Allergy Clin Immunol 2011128723-7
J Allergy Clin Immunol 199290599-608
Floor coveringsbull Designing the house with polished floors and wooden or
vinylleather furniture so as to limit the sites where mites can grow
bull carpets fitted onto unventilated floors water can accumulate growth of both fungi and mites
bull hard floors are likely to be preferred as they are more easily kept in a state that minimizes aeroallergen reaerosolization in the long term
bull the little available data of aeroallergens in houses suggest that the difference may be small and the effects complex
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552J Allergy Clin Immunol 2011128723-7
Vacuum cleaners
bull Vacuum cleaners are heavily promoted
bull Probably all cleaners cause a brief increase in personal aeroallergen exposure under normal domestic conditions and high-efficiency particulate arrest (HEPA) filters make little difference
bull Thus the benefits of HEPA filtration on exposure may have been exaggerated and all cleaners probably provide a brief increase in exposure
J Allergy Clin Immunol 2011128723-7
Allergy 200661119-23
Air management
bull indoor relative humidity is kept below 50 (absolute humidity below 6 gkg)
bull In some areas of the world this can be done by increasing ventilation
bull in other areas it is necessary to use air conditioning during the most humid months of the summer
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Air filtration
bull The role of air filtration continues to be debatedbull There is some consensus that small benefits exist mainly for pet
allergens
J Allergy Clin Immunol 2011128723-7
Acaricidesbull variety of acaricides have been used to treat carpets or furniturebull pyrethroids natamycin (an antifungal) pirimiphos methyl and
benzyl benzoate bull killing mites
bull Acaricides proved largely ineffective because the mite populations return shortly after their application and they may also cause skin and respiratory irritation
bull No data on clinical benefit exist and concerns about human health and environmental toxicity remain
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
J Allergy Clin Immunol 2011128723-7
Acaricidesbull 1 or 3 tannic acid
ndash method of denaturing mite allergensndash reduction of mite allergen can be achievedndash does not kill mitesndash so the effect can only be temporary approximately 6 weeks to 3
months
bull may be recommended when it is not possible to remove the carpets or change the furniture
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
Dust mite bull In most humid areas of the world house dust mites are the
major source of allergens in house dust
bull Pyroglyphid mites are eight-legged and sightless (microscopic arthropods) (03 mm in length)
bull Live on skin scales and other debrisbull Very precarious water balance
bull Mites growth dependent on
1048708 water in ambient air (not capable of searching for or drinking liquids)
1048708 relative humidity gt50
1048708 absolute humidity ge6 gkg
1048708 temperature of 65-80 F (183-267 C)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552Immunol Allergy Clin N Am 31 (2011) 493ndash507
Dust mite bull As humidity fallsit may take months for mites to die and
longer for allergen levels to decrease in carpets sofas or mattresses
bull Fecal particles ndash 10-35 μm in size (similar to pollen grains)
ndash particles contain digestive enzymesndash surrounded by a chitinous peritrophic membranendash lsquomembranersquo is not waterproof and allergens elute
from fecal particles rapidly
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
bull Mite bodies and fecal pellets are the major sources of allergensbull Settle out of air quickly so airborne levels depend upon disturbance in
room
Dust mite
bull Dust mite allergen bed roombull Cockroach allergen kitchen
bull A major problem with any assessment of exposure to dust mite antigens is that patients often sleep or sit with their heads very close to mite-infested material (eg sofas blankets pillows carpet)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
wwwallergenorg18 Feb 2013
wwwallergenorg18 Feb 2013
Dust mitebull mite allergens are now referred to as
ndash group 1 (Der p 1 and Der f 1) ndash group 2 (Der p 2 and Der f 2)
bull Der f 1 and Der p 1 are highly cross-reactive as are Der f 2 and Der p 2bull Der fp 10 (tropomyosin) cross reacts with other invertebrate
tropomyosins such as shrimp
bull Antibodies to B tropicalis cross-react partially with other dust mites
bull dust levels of mite allergen (Der p 1 + Der p 2) ndash sensitization at 2-10 μgg of dustndash For nonallergic children higher ldquothresholdrdquo of 20 μgg
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Dust mite
bull Avoidance measures
Otolaryngol Clin N Am 44 (2011) 711ndash725
Avoidance
bull standard part of the treatment of allergic disease bull difficult to achieve particularly in home environments
bull Many patients despite being skin test positive were not aware that dust related to their symptoms
bull sources and nature of indoor allergens were not well understood advice offered on avoidance was often inadequate or even wrong
bull The complexity and nonlinearity of dose response relationships also makes such evaluations of the effectiveness of allergen avoidance difficult
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552Immunol Allergy Clin N Am 31 (2011) 493ndash507
Br Med J 1998 3171105
2001 29 trials (939 patients)
2004 49 trials (2733 patients) 2008 54 trials (3002 patients)
2011 55 trials (3121 patients)
26 trials physical 10 trials chemical methods 8 trials combination
Cochrane Library 2011 Issue 10
Cochrane Library 2011 Issue 10
Cochrane Library 2011 Issue 10
bull The variability applies to the evaluation of patients the intervention used and the assessment of outcome
bull Meta-analysis is only valid when the studies are comparable and this may not be true for the successful studies on allergen avoidance
J Allergy Clin Immunol 2008122694-6
very different designs and engage different subjects time frames controls seasons and methods of intervention
J Allergy Clin Immunol 2011128723-7
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
longer than 6 months
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull most professional guidelines for asthma management advocate the avoidance of acute allergen lsquolsquotriggersrsquorsquo
bull there is a diversity of views about the role of allergen avoidance practices in long-term disease management
bull 2007 National Heart Lung and Blood Institute EPR3 (US) reportndash advises that the first and most important step in controlling
allergen induced asthma is to reduce exposure
J Allergy Clin Immunol 2011128723-7
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull Finnish Allergy Program 2008-2018 ndash promotes holistic lsquolsquoallergy healthrsquorsquo through diet and physical
activity and advocates allergen avoidance only lsquolsquoin mandatory situationsrsquorsquo
bull Both the 2009 Global Initiative for Asthma and the British Thoracic Society guidelines reflect (Cochrane review)
ndash no consistent evidence for allergen avoidance in preventing asthma
ndash only tenuous evidence that reducing allergen exposure can reduce asthma morbidity
J Allergy Clin Immunol 2011128723-7
ICON pediatric asthmabull some ambiguity with respect to the role of allergen avoidance
bull JGCA NAEPP3 and PRACTALL ndash specific recommendations for the reduction in allergen exposure
for sensitized patients with asthma
bull AAMH GINA and SIGNndash unproven effectiveness of current avoidance strategies on
asthma control
bull a multifaceted comprehensive approach is prerequisite for clinical benefit
Allergy 2012 67 976ndash997
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
bull 9 trials involving 501 participants bull 2 studies investigating the effectiveness of mite impermeable
bedding covers were of good qualitybull 7 studies were small and of poor qualitybull 2 trials investigated the efficacy of acaricidesbull 2 trials investigated the role of high-efficiency particulate air (HEPA)
filtersbull 1 trial using a factorial design investigated the efficacy of both
acaricide and house dust mite impermeable bedding covers in isolation and combination
bull Remaining 4 trials investigated the efficacy of bedroom environmental control programmes involving use of house dust mite impermeable bedding covers
Cochrane Database of Systematic Reviews 2010 Issue 7
bull Trials to date small and of poor methodological qualitybull difficult to offer any definitive recommendations on the role
bull use of acaricides and extensive bedroom-based environmental control programmes may be of some benefit in reducing rhinitis symptoms but the evidence is not strong
bull Isolated use of house dust mite impermeable bedding is unlikely to prove effective
bull More research is needed
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
METHODS OFMITE ALLERGEN AVOIDANCE
Method
bull Physical methodndash Encasing of beddingndash Vacuums cleanersndash Floor coveringsndash Laundryndash Air filtration
bull Chemical methodndash Acaricide
Encasingsbull In the bedroom covering mattresses and pillows with impermeable
covers is effectivebull This effect may be large variable and persist for a couple of
months
bull Encasings differ widely in their qualityndash some cheap brands have large pores other multilayered encasings delaminate
and others harbor mites
bull Tightly woven synthetic or cotton fabrics are preferred
bull Most trials of encasings have failed to regularly wash them (difficult with some encasings) which renders them ineffective as allergens build up on the outer surface within several weeks
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Curr Allergy Asthma Rep 20088126-32
J Allergy Clin Immunol 20061181164-8
16 tightly woven 9 United States3 Japan2 Thailand1 Germany1 France
laminate-coated and loosely woven cover molting among nonwoven fibers
dead mites on an acaricide-coated and nonwoven cover group of mites in the matrix of a nonwoven cover
J Allergy Clin Immunol 20061181164-8
Nonwoven
J Allergy Clin Immunol 20061181164-8
before after
easy access for mites to readily penetrate into the substrate of the material
J Allergy Clin Immunol 20061181164-8
tightly woven fabric with systematized regular fibers allowing little space for penetration
bull Woven nonwovenndash pore size between 2 and 10 um (average 6 um) blocking most
mite allergens
bull Plasticndash pore free best barrier in terms of blockingndash but the least comfortable zero ventilation ndash tendency to become a haven for mold spores
bull For acaricide-coated materialsndash pore size is usually not a major factor ndash mites are eradicated on contact with the chemicalsndash still allow the passage of allergens ndash prevent penetration through the fabrics but allow colonization
J Allergy Clin Immunol 20061181164-8
Asian Pac J Allergy Immunol 201028155-61
Sensitized level
Symptomatic level
sponge-like polyurethane lowest rate Synthetic fibers and kapok mattresses highest rate
A combination of the following choosing new sponge-like polyurethane or coconut fiber mattresses with mite-impermeable covers and washing sheets pillowcases blankets and mattresses pad at least weekly in hot water should be the best method of prevention in HDM allergen sensitive allergic patients
Laundrybull Both dust and cat and mite allergens are effectively removed by
laundryndash physical removal of both dust and mites by the multiple wash
and rinse cycles ndash effects of detergents additivesndash subsequent drying procedures
bull McDonald LGTovey E ndash All mites were killed by water temperatures 55 degrees C or
greaterndash Killing at lower temperatures was not enhanced by any of the
pure detergents or laundry products tested
J Allergy Clin Immunol 2011128723-7
J Allergy Clin Immunol 199290599-608
Floor coveringsbull Designing the house with polished floors and wooden or
vinylleather furniture so as to limit the sites where mites can grow
bull carpets fitted onto unventilated floors water can accumulate growth of both fungi and mites
bull hard floors are likely to be preferred as they are more easily kept in a state that minimizes aeroallergen reaerosolization in the long term
bull the little available data of aeroallergens in houses suggest that the difference may be small and the effects complex
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552J Allergy Clin Immunol 2011128723-7
Vacuum cleaners
bull Vacuum cleaners are heavily promoted
bull Probably all cleaners cause a brief increase in personal aeroallergen exposure under normal domestic conditions and high-efficiency particulate arrest (HEPA) filters make little difference
bull Thus the benefits of HEPA filtration on exposure may have been exaggerated and all cleaners probably provide a brief increase in exposure
J Allergy Clin Immunol 2011128723-7
Allergy 200661119-23
Air management
bull indoor relative humidity is kept below 50 (absolute humidity below 6 gkg)
bull In some areas of the world this can be done by increasing ventilation
bull in other areas it is necessary to use air conditioning during the most humid months of the summer
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Air filtration
bull The role of air filtration continues to be debatedbull There is some consensus that small benefits exist mainly for pet
allergens
J Allergy Clin Immunol 2011128723-7
Acaricidesbull variety of acaricides have been used to treat carpets or furniturebull pyrethroids natamycin (an antifungal) pirimiphos methyl and
benzyl benzoate bull killing mites
bull Acaricides proved largely ineffective because the mite populations return shortly after their application and they may also cause skin and respiratory irritation
bull No data on clinical benefit exist and concerns about human health and environmental toxicity remain
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
J Allergy Clin Immunol 2011128723-7
Acaricidesbull 1 or 3 tannic acid
ndash method of denaturing mite allergensndash reduction of mite allergen can be achievedndash does not kill mitesndash so the effect can only be temporary approximately 6 weeks to 3
months
bull may be recommended when it is not possible to remove the carpets or change the furniture
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
Dust mite bull As humidity fallsit may take months for mites to die and
longer for allergen levels to decrease in carpets sofas or mattresses
bull Fecal particles ndash 10-35 μm in size (similar to pollen grains)
ndash particles contain digestive enzymesndash surrounded by a chitinous peritrophic membranendash lsquomembranersquo is not waterproof and allergens elute
from fecal particles rapidly
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
bull Mite bodies and fecal pellets are the major sources of allergensbull Settle out of air quickly so airborne levels depend upon disturbance in
room
Dust mite
bull Dust mite allergen bed roombull Cockroach allergen kitchen
bull A major problem with any assessment of exposure to dust mite antigens is that patients often sleep or sit with their heads very close to mite-infested material (eg sofas blankets pillows carpet)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
wwwallergenorg18 Feb 2013
wwwallergenorg18 Feb 2013
Dust mitebull mite allergens are now referred to as
ndash group 1 (Der p 1 and Der f 1) ndash group 2 (Der p 2 and Der f 2)
bull Der f 1 and Der p 1 are highly cross-reactive as are Der f 2 and Der p 2bull Der fp 10 (tropomyosin) cross reacts with other invertebrate
tropomyosins such as shrimp
bull Antibodies to B tropicalis cross-react partially with other dust mites
bull dust levels of mite allergen (Der p 1 + Der p 2) ndash sensitization at 2-10 μgg of dustndash For nonallergic children higher ldquothresholdrdquo of 20 μgg
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Dust mite
bull Avoidance measures
Otolaryngol Clin N Am 44 (2011) 711ndash725
Avoidance
bull standard part of the treatment of allergic disease bull difficult to achieve particularly in home environments
bull Many patients despite being skin test positive were not aware that dust related to their symptoms
bull sources and nature of indoor allergens were not well understood advice offered on avoidance was often inadequate or even wrong
bull The complexity and nonlinearity of dose response relationships also makes such evaluations of the effectiveness of allergen avoidance difficult
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552Immunol Allergy Clin N Am 31 (2011) 493ndash507
Br Med J 1998 3171105
2001 29 trials (939 patients)
2004 49 trials (2733 patients) 2008 54 trials (3002 patients)
2011 55 trials (3121 patients)
26 trials physical 10 trials chemical methods 8 trials combination
Cochrane Library 2011 Issue 10
Cochrane Library 2011 Issue 10
Cochrane Library 2011 Issue 10
bull The variability applies to the evaluation of patients the intervention used and the assessment of outcome
bull Meta-analysis is only valid when the studies are comparable and this may not be true for the successful studies on allergen avoidance
J Allergy Clin Immunol 2008122694-6
very different designs and engage different subjects time frames controls seasons and methods of intervention
J Allergy Clin Immunol 2011128723-7
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
longer than 6 months
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull most professional guidelines for asthma management advocate the avoidance of acute allergen lsquolsquotriggersrsquorsquo
bull there is a diversity of views about the role of allergen avoidance practices in long-term disease management
bull 2007 National Heart Lung and Blood Institute EPR3 (US) reportndash advises that the first and most important step in controlling
allergen induced asthma is to reduce exposure
J Allergy Clin Immunol 2011128723-7
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull Finnish Allergy Program 2008-2018 ndash promotes holistic lsquolsquoallergy healthrsquorsquo through diet and physical
activity and advocates allergen avoidance only lsquolsquoin mandatory situationsrsquorsquo
bull Both the 2009 Global Initiative for Asthma and the British Thoracic Society guidelines reflect (Cochrane review)
ndash no consistent evidence for allergen avoidance in preventing asthma
ndash only tenuous evidence that reducing allergen exposure can reduce asthma morbidity
J Allergy Clin Immunol 2011128723-7
ICON pediatric asthmabull some ambiguity with respect to the role of allergen avoidance
bull JGCA NAEPP3 and PRACTALL ndash specific recommendations for the reduction in allergen exposure
for sensitized patients with asthma
bull AAMH GINA and SIGNndash unproven effectiveness of current avoidance strategies on
asthma control
bull a multifaceted comprehensive approach is prerequisite for clinical benefit
Allergy 2012 67 976ndash997
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
bull 9 trials involving 501 participants bull 2 studies investigating the effectiveness of mite impermeable
bedding covers were of good qualitybull 7 studies were small and of poor qualitybull 2 trials investigated the efficacy of acaricidesbull 2 trials investigated the role of high-efficiency particulate air (HEPA)
filtersbull 1 trial using a factorial design investigated the efficacy of both
acaricide and house dust mite impermeable bedding covers in isolation and combination
bull Remaining 4 trials investigated the efficacy of bedroom environmental control programmes involving use of house dust mite impermeable bedding covers
Cochrane Database of Systematic Reviews 2010 Issue 7
bull Trials to date small and of poor methodological qualitybull difficult to offer any definitive recommendations on the role
bull use of acaricides and extensive bedroom-based environmental control programmes may be of some benefit in reducing rhinitis symptoms but the evidence is not strong
bull Isolated use of house dust mite impermeable bedding is unlikely to prove effective
bull More research is needed
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
METHODS OFMITE ALLERGEN AVOIDANCE
Method
bull Physical methodndash Encasing of beddingndash Vacuums cleanersndash Floor coveringsndash Laundryndash Air filtration
bull Chemical methodndash Acaricide
Encasingsbull In the bedroom covering mattresses and pillows with impermeable
covers is effectivebull This effect may be large variable and persist for a couple of
months
bull Encasings differ widely in their qualityndash some cheap brands have large pores other multilayered encasings delaminate
and others harbor mites
bull Tightly woven synthetic or cotton fabrics are preferred
bull Most trials of encasings have failed to regularly wash them (difficult with some encasings) which renders them ineffective as allergens build up on the outer surface within several weeks
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Curr Allergy Asthma Rep 20088126-32
J Allergy Clin Immunol 20061181164-8
16 tightly woven 9 United States3 Japan2 Thailand1 Germany1 France
laminate-coated and loosely woven cover molting among nonwoven fibers
dead mites on an acaricide-coated and nonwoven cover group of mites in the matrix of a nonwoven cover
J Allergy Clin Immunol 20061181164-8
Nonwoven
J Allergy Clin Immunol 20061181164-8
before after
easy access for mites to readily penetrate into the substrate of the material
J Allergy Clin Immunol 20061181164-8
tightly woven fabric with systematized regular fibers allowing little space for penetration
bull Woven nonwovenndash pore size between 2 and 10 um (average 6 um) blocking most
mite allergens
bull Plasticndash pore free best barrier in terms of blockingndash but the least comfortable zero ventilation ndash tendency to become a haven for mold spores
bull For acaricide-coated materialsndash pore size is usually not a major factor ndash mites are eradicated on contact with the chemicalsndash still allow the passage of allergens ndash prevent penetration through the fabrics but allow colonization
J Allergy Clin Immunol 20061181164-8
Asian Pac J Allergy Immunol 201028155-61
Sensitized level
Symptomatic level
sponge-like polyurethane lowest rate Synthetic fibers and kapok mattresses highest rate
A combination of the following choosing new sponge-like polyurethane or coconut fiber mattresses with mite-impermeable covers and washing sheets pillowcases blankets and mattresses pad at least weekly in hot water should be the best method of prevention in HDM allergen sensitive allergic patients
Laundrybull Both dust and cat and mite allergens are effectively removed by
laundryndash physical removal of both dust and mites by the multiple wash
and rinse cycles ndash effects of detergents additivesndash subsequent drying procedures
bull McDonald LGTovey E ndash All mites were killed by water temperatures 55 degrees C or
greaterndash Killing at lower temperatures was not enhanced by any of the
pure detergents or laundry products tested
J Allergy Clin Immunol 2011128723-7
J Allergy Clin Immunol 199290599-608
Floor coveringsbull Designing the house with polished floors and wooden or
vinylleather furniture so as to limit the sites where mites can grow
bull carpets fitted onto unventilated floors water can accumulate growth of both fungi and mites
bull hard floors are likely to be preferred as they are more easily kept in a state that minimizes aeroallergen reaerosolization in the long term
bull the little available data of aeroallergens in houses suggest that the difference may be small and the effects complex
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552J Allergy Clin Immunol 2011128723-7
Vacuum cleaners
bull Vacuum cleaners are heavily promoted
bull Probably all cleaners cause a brief increase in personal aeroallergen exposure under normal domestic conditions and high-efficiency particulate arrest (HEPA) filters make little difference
bull Thus the benefits of HEPA filtration on exposure may have been exaggerated and all cleaners probably provide a brief increase in exposure
J Allergy Clin Immunol 2011128723-7
Allergy 200661119-23
Air management
bull indoor relative humidity is kept below 50 (absolute humidity below 6 gkg)
bull In some areas of the world this can be done by increasing ventilation
bull in other areas it is necessary to use air conditioning during the most humid months of the summer
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Air filtration
bull The role of air filtration continues to be debatedbull There is some consensus that small benefits exist mainly for pet
allergens
J Allergy Clin Immunol 2011128723-7
Acaricidesbull variety of acaricides have been used to treat carpets or furniturebull pyrethroids natamycin (an antifungal) pirimiphos methyl and
benzyl benzoate bull killing mites
bull Acaricides proved largely ineffective because the mite populations return shortly after their application and they may also cause skin and respiratory irritation
bull No data on clinical benefit exist and concerns about human health and environmental toxicity remain
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
J Allergy Clin Immunol 2011128723-7
Acaricidesbull 1 or 3 tannic acid
ndash method of denaturing mite allergensndash reduction of mite allergen can be achievedndash does not kill mitesndash so the effect can only be temporary approximately 6 weeks to 3
months
bull may be recommended when it is not possible to remove the carpets or change the furniture
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
Dust mite
bull Dust mite allergen bed roombull Cockroach allergen kitchen
bull A major problem with any assessment of exposure to dust mite antigens is that patients often sleep or sit with their heads very close to mite-infested material (eg sofas blankets pillows carpet)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
wwwallergenorg18 Feb 2013
wwwallergenorg18 Feb 2013
Dust mitebull mite allergens are now referred to as
ndash group 1 (Der p 1 and Der f 1) ndash group 2 (Der p 2 and Der f 2)
bull Der f 1 and Der p 1 are highly cross-reactive as are Der f 2 and Der p 2bull Der fp 10 (tropomyosin) cross reacts with other invertebrate
tropomyosins such as shrimp
bull Antibodies to B tropicalis cross-react partially with other dust mites
bull dust levels of mite allergen (Der p 1 + Der p 2) ndash sensitization at 2-10 μgg of dustndash For nonallergic children higher ldquothresholdrdquo of 20 μgg
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Dust mite
bull Avoidance measures
Otolaryngol Clin N Am 44 (2011) 711ndash725
Avoidance
bull standard part of the treatment of allergic disease bull difficult to achieve particularly in home environments
bull Many patients despite being skin test positive were not aware that dust related to their symptoms
bull sources and nature of indoor allergens were not well understood advice offered on avoidance was often inadequate or even wrong
bull The complexity and nonlinearity of dose response relationships also makes such evaluations of the effectiveness of allergen avoidance difficult
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552Immunol Allergy Clin N Am 31 (2011) 493ndash507
Br Med J 1998 3171105
2001 29 trials (939 patients)
2004 49 trials (2733 patients) 2008 54 trials (3002 patients)
2011 55 trials (3121 patients)
26 trials physical 10 trials chemical methods 8 trials combination
Cochrane Library 2011 Issue 10
Cochrane Library 2011 Issue 10
Cochrane Library 2011 Issue 10
bull The variability applies to the evaluation of patients the intervention used and the assessment of outcome
bull Meta-analysis is only valid when the studies are comparable and this may not be true for the successful studies on allergen avoidance
J Allergy Clin Immunol 2008122694-6
very different designs and engage different subjects time frames controls seasons and methods of intervention
J Allergy Clin Immunol 2011128723-7
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
longer than 6 months
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull most professional guidelines for asthma management advocate the avoidance of acute allergen lsquolsquotriggersrsquorsquo
bull there is a diversity of views about the role of allergen avoidance practices in long-term disease management
bull 2007 National Heart Lung and Blood Institute EPR3 (US) reportndash advises that the first and most important step in controlling
allergen induced asthma is to reduce exposure
J Allergy Clin Immunol 2011128723-7
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull Finnish Allergy Program 2008-2018 ndash promotes holistic lsquolsquoallergy healthrsquorsquo through diet and physical
activity and advocates allergen avoidance only lsquolsquoin mandatory situationsrsquorsquo
bull Both the 2009 Global Initiative for Asthma and the British Thoracic Society guidelines reflect (Cochrane review)
ndash no consistent evidence for allergen avoidance in preventing asthma
ndash only tenuous evidence that reducing allergen exposure can reduce asthma morbidity
J Allergy Clin Immunol 2011128723-7
ICON pediatric asthmabull some ambiguity with respect to the role of allergen avoidance
bull JGCA NAEPP3 and PRACTALL ndash specific recommendations for the reduction in allergen exposure
for sensitized patients with asthma
bull AAMH GINA and SIGNndash unproven effectiveness of current avoidance strategies on
asthma control
bull a multifaceted comprehensive approach is prerequisite for clinical benefit
Allergy 2012 67 976ndash997
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
bull 9 trials involving 501 participants bull 2 studies investigating the effectiveness of mite impermeable
bedding covers were of good qualitybull 7 studies were small and of poor qualitybull 2 trials investigated the efficacy of acaricidesbull 2 trials investigated the role of high-efficiency particulate air (HEPA)
filtersbull 1 trial using a factorial design investigated the efficacy of both
acaricide and house dust mite impermeable bedding covers in isolation and combination
bull Remaining 4 trials investigated the efficacy of bedroom environmental control programmes involving use of house dust mite impermeable bedding covers
Cochrane Database of Systematic Reviews 2010 Issue 7
bull Trials to date small and of poor methodological qualitybull difficult to offer any definitive recommendations on the role
bull use of acaricides and extensive bedroom-based environmental control programmes may be of some benefit in reducing rhinitis symptoms but the evidence is not strong
bull Isolated use of house dust mite impermeable bedding is unlikely to prove effective
bull More research is needed
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
METHODS OFMITE ALLERGEN AVOIDANCE
Method
bull Physical methodndash Encasing of beddingndash Vacuums cleanersndash Floor coveringsndash Laundryndash Air filtration
bull Chemical methodndash Acaricide
Encasingsbull In the bedroom covering mattresses and pillows with impermeable
covers is effectivebull This effect may be large variable and persist for a couple of
months
bull Encasings differ widely in their qualityndash some cheap brands have large pores other multilayered encasings delaminate
and others harbor mites
bull Tightly woven synthetic or cotton fabrics are preferred
bull Most trials of encasings have failed to regularly wash them (difficult with some encasings) which renders them ineffective as allergens build up on the outer surface within several weeks
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Curr Allergy Asthma Rep 20088126-32
J Allergy Clin Immunol 20061181164-8
16 tightly woven 9 United States3 Japan2 Thailand1 Germany1 France
laminate-coated and loosely woven cover molting among nonwoven fibers
dead mites on an acaricide-coated and nonwoven cover group of mites in the matrix of a nonwoven cover
J Allergy Clin Immunol 20061181164-8
Nonwoven
J Allergy Clin Immunol 20061181164-8
before after
easy access for mites to readily penetrate into the substrate of the material
J Allergy Clin Immunol 20061181164-8
tightly woven fabric with systematized regular fibers allowing little space for penetration
bull Woven nonwovenndash pore size between 2 and 10 um (average 6 um) blocking most
mite allergens
bull Plasticndash pore free best barrier in terms of blockingndash but the least comfortable zero ventilation ndash tendency to become a haven for mold spores
bull For acaricide-coated materialsndash pore size is usually not a major factor ndash mites are eradicated on contact with the chemicalsndash still allow the passage of allergens ndash prevent penetration through the fabrics but allow colonization
J Allergy Clin Immunol 20061181164-8
Asian Pac J Allergy Immunol 201028155-61
Sensitized level
Symptomatic level
sponge-like polyurethane lowest rate Synthetic fibers and kapok mattresses highest rate
A combination of the following choosing new sponge-like polyurethane or coconut fiber mattresses with mite-impermeable covers and washing sheets pillowcases blankets and mattresses pad at least weekly in hot water should be the best method of prevention in HDM allergen sensitive allergic patients
Laundrybull Both dust and cat and mite allergens are effectively removed by
laundryndash physical removal of both dust and mites by the multiple wash
and rinse cycles ndash effects of detergents additivesndash subsequent drying procedures
bull McDonald LGTovey E ndash All mites were killed by water temperatures 55 degrees C or
greaterndash Killing at lower temperatures was not enhanced by any of the
pure detergents or laundry products tested
J Allergy Clin Immunol 2011128723-7
J Allergy Clin Immunol 199290599-608
Floor coveringsbull Designing the house with polished floors and wooden or
vinylleather furniture so as to limit the sites where mites can grow
bull carpets fitted onto unventilated floors water can accumulate growth of both fungi and mites
bull hard floors are likely to be preferred as they are more easily kept in a state that minimizes aeroallergen reaerosolization in the long term
bull the little available data of aeroallergens in houses suggest that the difference may be small and the effects complex
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552J Allergy Clin Immunol 2011128723-7
Vacuum cleaners
bull Vacuum cleaners are heavily promoted
bull Probably all cleaners cause a brief increase in personal aeroallergen exposure under normal domestic conditions and high-efficiency particulate arrest (HEPA) filters make little difference
bull Thus the benefits of HEPA filtration on exposure may have been exaggerated and all cleaners probably provide a brief increase in exposure
J Allergy Clin Immunol 2011128723-7
Allergy 200661119-23
Air management
bull indoor relative humidity is kept below 50 (absolute humidity below 6 gkg)
bull In some areas of the world this can be done by increasing ventilation
bull in other areas it is necessary to use air conditioning during the most humid months of the summer
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Air filtration
bull The role of air filtration continues to be debatedbull There is some consensus that small benefits exist mainly for pet
allergens
J Allergy Clin Immunol 2011128723-7
Acaricidesbull variety of acaricides have been used to treat carpets or furniturebull pyrethroids natamycin (an antifungal) pirimiphos methyl and
benzyl benzoate bull killing mites
bull Acaricides proved largely ineffective because the mite populations return shortly after their application and they may also cause skin and respiratory irritation
bull No data on clinical benefit exist and concerns about human health and environmental toxicity remain
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
J Allergy Clin Immunol 2011128723-7
Acaricidesbull 1 or 3 tannic acid
ndash method of denaturing mite allergensndash reduction of mite allergen can be achievedndash does not kill mitesndash so the effect can only be temporary approximately 6 weeks to 3
months
bull may be recommended when it is not possible to remove the carpets or change the furniture
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
wwwallergenorg18 Feb 2013
wwwallergenorg18 Feb 2013
Dust mitebull mite allergens are now referred to as
ndash group 1 (Der p 1 and Der f 1) ndash group 2 (Der p 2 and Der f 2)
bull Der f 1 and Der p 1 are highly cross-reactive as are Der f 2 and Der p 2bull Der fp 10 (tropomyosin) cross reacts with other invertebrate
tropomyosins such as shrimp
bull Antibodies to B tropicalis cross-react partially with other dust mites
bull dust levels of mite allergen (Der p 1 + Der p 2) ndash sensitization at 2-10 μgg of dustndash For nonallergic children higher ldquothresholdrdquo of 20 μgg
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Dust mite
bull Avoidance measures
Otolaryngol Clin N Am 44 (2011) 711ndash725
Avoidance
bull standard part of the treatment of allergic disease bull difficult to achieve particularly in home environments
bull Many patients despite being skin test positive were not aware that dust related to their symptoms
bull sources and nature of indoor allergens were not well understood advice offered on avoidance was often inadequate or even wrong
bull The complexity and nonlinearity of dose response relationships also makes such evaluations of the effectiveness of allergen avoidance difficult
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552Immunol Allergy Clin N Am 31 (2011) 493ndash507
Br Med J 1998 3171105
2001 29 trials (939 patients)
2004 49 trials (2733 patients) 2008 54 trials (3002 patients)
2011 55 trials (3121 patients)
26 trials physical 10 trials chemical methods 8 trials combination
Cochrane Library 2011 Issue 10
Cochrane Library 2011 Issue 10
Cochrane Library 2011 Issue 10
bull The variability applies to the evaluation of patients the intervention used and the assessment of outcome
bull Meta-analysis is only valid when the studies are comparable and this may not be true for the successful studies on allergen avoidance
J Allergy Clin Immunol 2008122694-6
very different designs and engage different subjects time frames controls seasons and methods of intervention
J Allergy Clin Immunol 2011128723-7
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
longer than 6 months
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull most professional guidelines for asthma management advocate the avoidance of acute allergen lsquolsquotriggersrsquorsquo
bull there is a diversity of views about the role of allergen avoidance practices in long-term disease management
bull 2007 National Heart Lung and Blood Institute EPR3 (US) reportndash advises that the first and most important step in controlling
allergen induced asthma is to reduce exposure
J Allergy Clin Immunol 2011128723-7
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull Finnish Allergy Program 2008-2018 ndash promotes holistic lsquolsquoallergy healthrsquorsquo through diet and physical
activity and advocates allergen avoidance only lsquolsquoin mandatory situationsrsquorsquo
bull Both the 2009 Global Initiative for Asthma and the British Thoracic Society guidelines reflect (Cochrane review)
ndash no consistent evidence for allergen avoidance in preventing asthma
ndash only tenuous evidence that reducing allergen exposure can reduce asthma morbidity
J Allergy Clin Immunol 2011128723-7
ICON pediatric asthmabull some ambiguity with respect to the role of allergen avoidance
bull JGCA NAEPP3 and PRACTALL ndash specific recommendations for the reduction in allergen exposure
for sensitized patients with asthma
bull AAMH GINA and SIGNndash unproven effectiveness of current avoidance strategies on
asthma control
bull a multifaceted comprehensive approach is prerequisite for clinical benefit
Allergy 2012 67 976ndash997
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
bull 9 trials involving 501 participants bull 2 studies investigating the effectiveness of mite impermeable
bedding covers were of good qualitybull 7 studies were small and of poor qualitybull 2 trials investigated the efficacy of acaricidesbull 2 trials investigated the role of high-efficiency particulate air (HEPA)
filtersbull 1 trial using a factorial design investigated the efficacy of both
acaricide and house dust mite impermeable bedding covers in isolation and combination
bull Remaining 4 trials investigated the efficacy of bedroom environmental control programmes involving use of house dust mite impermeable bedding covers
Cochrane Database of Systematic Reviews 2010 Issue 7
bull Trials to date small and of poor methodological qualitybull difficult to offer any definitive recommendations on the role
bull use of acaricides and extensive bedroom-based environmental control programmes may be of some benefit in reducing rhinitis symptoms but the evidence is not strong
bull Isolated use of house dust mite impermeable bedding is unlikely to prove effective
bull More research is needed
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
METHODS OFMITE ALLERGEN AVOIDANCE
Method
bull Physical methodndash Encasing of beddingndash Vacuums cleanersndash Floor coveringsndash Laundryndash Air filtration
bull Chemical methodndash Acaricide
Encasingsbull In the bedroom covering mattresses and pillows with impermeable
covers is effectivebull This effect may be large variable and persist for a couple of
months
bull Encasings differ widely in their qualityndash some cheap brands have large pores other multilayered encasings delaminate
and others harbor mites
bull Tightly woven synthetic or cotton fabrics are preferred
bull Most trials of encasings have failed to regularly wash them (difficult with some encasings) which renders them ineffective as allergens build up on the outer surface within several weeks
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Curr Allergy Asthma Rep 20088126-32
J Allergy Clin Immunol 20061181164-8
16 tightly woven 9 United States3 Japan2 Thailand1 Germany1 France
laminate-coated and loosely woven cover molting among nonwoven fibers
dead mites on an acaricide-coated and nonwoven cover group of mites in the matrix of a nonwoven cover
J Allergy Clin Immunol 20061181164-8
Nonwoven
J Allergy Clin Immunol 20061181164-8
before after
easy access for mites to readily penetrate into the substrate of the material
J Allergy Clin Immunol 20061181164-8
tightly woven fabric with systematized regular fibers allowing little space for penetration
bull Woven nonwovenndash pore size between 2 and 10 um (average 6 um) blocking most
mite allergens
bull Plasticndash pore free best barrier in terms of blockingndash but the least comfortable zero ventilation ndash tendency to become a haven for mold spores
bull For acaricide-coated materialsndash pore size is usually not a major factor ndash mites are eradicated on contact with the chemicalsndash still allow the passage of allergens ndash prevent penetration through the fabrics but allow colonization
J Allergy Clin Immunol 20061181164-8
Asian Pac J Allergy Immunol 201028155-61
Sensitized level
Symptomatic level
sponge-like polyurethane lowest rate Synthetic fibers and kapok mattresses highest rate
A combination of the following choosing new sponge-like polyurethane or coconut fiber mattresses with mite-impermeable covers and washing sheets pillowcases blankets and mattresses pad at least weekly in hot water should be the best method of prevention in HDM allergen sensitive allergic patients
Laundrybull Both dust and cat and mite allergens are effectively removed by
laundryndash physical removal of both dust and mites by the multiple wash
and rinse cycles ndash effects of detergents additivesndash subsequent drying procedures
bull McDonald LGTovey E ndash All mites were killed by water temperatures 55 degrees C or
greaterndash Killing at lower temperatures was not enhanced by any of the
pure detergents or laundry products tested
J Allergy Clin Immunol 2011128723-7
J Allergy Clin Immunol 199290599-608
Floor coveringsbull Designing the house with polished floors and wooden or
vinylleather furniture so as to limit the sites where mites can grow
bull carpets fitted onto unventilated floors water can accumulate growth of both fungi and mites
bull hard floors are likely to be preferred as they are more easily kept in a state that minimizes aeroallergen reaerosolization in the long term
bull the little available data of aeroallergens in houses suggest that the difference may be small and the effects complex
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552J Allergy Clin Immunol 2011128723-7
Vacuum cleaners
bull Vacuum cleaners are heavily promoted
bull Probably all cleaners cause a brief increase in personal aeroallergen exposure under normal domestic conditions and high-efficiency particulate arrest (HEPA) filters make little difference
bull Thus the benefits of HEPA filtration on exposure may have been exaggerated and all cleaners probably provide a brief increase in exposure
J Allergy Clin Immunol 2011128723-7
Allergy 200661119-23
Air management
bull indoor relative humidity is kept below 50 (absolute humidity below 6 gkg)
bull In some areas of the world this can be done by increasing ventilation
bull in other areas it is necessary to use air conditioning during the most humid months of the summer
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Air filtration
bull The role of air filtration continues to be debatedbull There is some consensus that small benefits exist mainly for pet
allergens
J Allergy Clin Immunol 2011128723-7
Acaricidesbull variety of acaricides have been used to treat carpets or furniturebull pyrethroids natamycin (an antifungal) pirimiphos methyl and
benzyl benzoate bull killing mites
bull Acaricides proved largely ineffective because the mite populations return shortly after their application and they may also cause skin and respiratory irritation
bull No data on clinical benefit exist and concerns about human health and environmental toxicity remain
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
J Allergy Clin Immunol 2011128723-7
Acaricidesbull 1 or 3 tannic acid
ndash method of denaturing mite allergensndash reduction of mite allergen can be achievedndash does not kill mitesndash so the effect can only be temporary approximately 6 weeks to 3
months
bull may be recommended when it is not possible to remove the carpets or change the furniture
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
wwwallergenorg18 Feb 2013
Dust mitebull mite allergens are now referred to as
ndash group 1 (Der p 1 and Der f 1) ndash group 2 (Der p 2 and Der f 2)
bull Der f 1 and Der p 1 are highly cross-reactive as are Der f 2 and Der p 2bull Der fp 10 (tropomyosin) cross reacts with other invertebrate
tropomyosins such as shrimp
bull Antibodies to B tropicalis cross-react partially with other dust mites
bull dust levels of mite allergen (Der p 1 + Der p 2) ndash sensitization at 2-10 μgg of dustndash For nonallergic children higher ldquothresholdrdquo of 20 μgg
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Dust mite
bull Avoidance measures
Otolaryngol Clin N Am 44 (2011) 711ndash725
Avoidance
bull standard part of the treatment of allergic disease bull difficult to achieve particularly in home environments
bull Many patients despite being skin test positive were not aware that dust related to their symptoms
bull sources and nature of indoor allergens were not well understood advice offered on avoidance was often inadequate or even wrong
bull The complexity and nonlinearity of dose response relationships also makes such evaluations of the effectiveness of allergen avoidance difficult
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552Immunol Allergy Clin N Am 31 (2011) 493ndash507
Br Med J 1998 3171105
2001 29 trials (939 patients)
2004 49 trials (2733 patients) 2008 54 trials (3002 patients)
2011 55 trials (3121 patients)
26 trials physical 10 trials chemical methods 8 trials combination
Cochrane Library 2011 Issue 10
Cochrane Library 2011 Issue 10
Cochrane Library 2011 Issue 10
bull The variability applies to the evaluation of patients the intervention used and the assessment of outcome
bull Meta-analysis is only valid when the studies are comparable and this may not be true for the successful studies on allergen avoidance
J Allergy Clin Immunol 2008122694-6
very different designs and engage different subjects time frames controls seasons and methods of intervention
J Allergy Clin Immunol 2011128723-7
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
longer than 6 months
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull most professional guidelines for asthma management advocate the avoidance of acute allergen lsquolsquotriggersrsquorsquo
bull there is a diversity of views about the role of allergen avoidance practices in long-term disease management
bull 2007 National Heart Lung and Blood Institute EPR3 (US) reportndash advises that the first and most important step in controlling
allergen induced asthma is to reduce exposure
J Allergy Clin Immunol 2011128723-7
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull Finnish Allergy Program 2008-2018 ndash promotes holistic lsquolsquoallergy healthrsquorsquo through diet and physical
activity and advocates allergen avoidance only lsquolsquoin mandatory situationsrsquorsquo
bull Both the 2009 Global Initiative for Asthma and the British Thoracic Society guidelines reflect (Cochrane review)
ndash no consistent evidence for allergen avoidance in preventing asthma
ndash only tenuous evidence that reducing allergen exposure can reduce asthma morbidity
J Allergy Clin Immunol 2011128723-7
ICON pediatric asthmabull some ambiguity with respect to the role of allergen avoidance
bull JGCA NAEPP3 and PRACTALL ndash specific recommendations for the reduction in allergen exposure
for sensitized patients with asthma
bull AAMH GINA and SIGNndash unproven effectiveness of current avoidance strategies on
asthma control
bull a multifaceted comprehensive approach is prerequisite for clinical benefit
Allergy 2012 67 976ndash997
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
bull 9 trials involving 501 participants bull 2 studies investigating the effectiveness of mite impermeable
bedding covers were of good qualitybull 7 studies were small and of poor qualitybull 2 trials investigated the efficacy of acaricidesbull 2 trials investigated the role of high-efficiency particulate air (HEPA)
filtersbull 1 trial using a factorial design investigated the efficacy of both
acaricide and house dust mite impermeable bedding covers in isolation and combination
bull Remaining 4 trials investigated the efficacy of bedroom environmental control programmes involving use of house dust mite impermeable bedding covers
Cochrane Database of Systematic Reviews 2010 Issue 7
bull Trials to date small and of poor methodological qualitybull difficult to offer any definitive recommendations on the role
bull use of acaricides and extensive bedroom-based environmental control programmes may be of some benefit in reducing rhinitis symptoms but the evidence is not strong
bull Isolated use of house dust mite impermeable bedding is unlikely to prove effective
bull More research is needed
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
METHODS OFMITE ALLERGEN AVOIDANCE
Method
bull Physical methodndash Encasing of beddingndash Vacuums cleanersndash Floor coveringsndash Laundryndash Air filtration
bull Chemical methodndash Acaricide
Encasingsbull In the bedroom covering mattresses and pillows with impermeable
covers is effectivebull This effect may be large variable and persist for a couple of
months
bull Encasings differ widely in their qualityndash some cheap brands have large pores other multilayered encasings delaminate
and others harbor mites
bull Tightly woven synthetic or cotton fabrics are preferred
bull Most trials of encasings have failed to regularly wash them (difficult with some encasings) which renders them ineffective as allergens build up on the outer surface within several weeks
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Curr Allergy Asthma Rep 20088126-32
J Allergy Clin Immunol 20061181164-8
16 tightly woven 9 United States3 Japan2 Thailand1 Germany1 France
laminate-coated and loosely woven cover molting among nonwoven fibers
dead mites on an acaricide-coated and nonwoven cover group of mites in the matrix of a nonwoven cover
J Allergy Clin Immunol 20061181164-8
Nonwoven
J Allergy Clin Immunol 20061181164-8
before after
easy access for mites to readily penetrate into the substrate of the material
J Allergy Clin Immunol 20061181164-8
tightly woven fabric with systematized regular fibers allowing little space for penetration
bull Woven nonwovenndash pore size between 2 and 10 um (average 6 um) blocking most
mite allergens
bull Plasticndash pore free best barrier in terms of blockingndash but the least comfortable zero ventilation ndash tendency to become a haven for mold spores
bull For acaricide-coated materialsndash pore size is usually not a major factor ndash mites are eradicated on contact with the chemicalsndash still allow the passage of allergens ndash prevent penetration through the fabrics but allow colonization
J Allergy Clin Immunol 20061181164-8
Asian Pac J Allergy Immunol 201028155-61
Sensitized level
Symptomatic level
sponge-like polyurethane lowest rate Synthetic fibers and kapok mattresses highest rate
A combination of the following choosing new sponge-like polyurethane or coconut fiber mattresses with mite-impermeable covers and washing sheets pillowcases blankets and mattresses pad at least weekly in hot water should be the best method of prevention in HDM allergen sensitive allergic patients
Laundrybull Both dust and cat and mite allergens are effectively removed by
laundryndash physical removal of both dust and mites by the multiple wash
and rinse cycles ndash effects of detergents additivesndash subsequent drying procedures
bull McDonald LGTovey E ndash All mites were killed by water temperatures 55 degrees C or
greaterndash Killing at lower temperatures was not enhanced by any of the
pure detergents or laundry products tested
J Allergy Clin Immunol 2011128723-7
J Allergy Clin Immunol 199290599-608
Floor coveringsbull Designing the house with polished floors and wooden or
vinylleather furniture so as to limit the sites where mites can grow
bull carpets fitted onto unventilated floors water can accumulate growth of both fungi and mites
bull hard floors are likely to be preferred as they are more easily kept in a state that minimizes aeroallergen reaerosolization in the long term
bull the little available data of aeroallergens in houses suggest that the difference may be small and the effects complex
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552J Allergy Clin Immunol 2011128723-7
Vacuum cleaners
bull Vacuum cleaners are heavily promoted
bull Probably all cleaners cause a brief increase in personal aeroallergen exposure under normal domestic conditions and high-efficiency particulate arrest (HEPA) filters make little difference
bull Thus the benefits of HEPA filtration on exposure may have been exaggerated and all cleaners probably provide a brief increase in exposure
J Allergy Clin Immunol 2011128723-7
Allergy 200661119-23
Air management
bull indoor relative humidity is kept below 50 (absolute humidity below 6 gkg)
bull In some areas of the world this can be done by increasing ventilation
bull in other areas it is necessary to use air conditioning during the most humid months of the summer
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Air filtration
bull The role of air filtration continues to be debatedbull There is some consensus that small benefits exist mainly for pet
allergens
J Allergy Clin Immunol 2011128723-7
Acaricidesbull variety of acaricides have been used to treat carpets or furniturebull pyrethroids natamycin (an antifungal) pirimiphos methyl and
benzyl benzoate bull killing mites
bull Acaricides proved largely ineffective because the mite populations return shortly after their application and they may also cause skin and respiratory irritation
bull No data on clinical benefit exist and concerns about human health and environmental toxicity remain
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
J Allergy Clin Immunol 2011128723-7
Acaricidesbull 1 or 3 tannic acid
ndash method of denaturing mite allergensndash reduction of mite allergen can be achievedndash does not kill mitesndash so the effect can only be temporary approximately 6 weeks to 3
months
bull may be recommended when it is not possible to remove the carpets or change the furniture
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
Dust mitebull mite allergens are now referred to as
ndash group 1 (Der p 1 and Der f 1) ndash group 2 (Der p 2 and Der f 2)
bull Der f 1 and Der p 1 are highly cross-reactive as are Der f 2 and Der p 2bull Der fp 10 (tropomyosin) cross reacts with other invertebrate
tropomyosins such as shrimp
bull Antibodies to B tropicalis cross-react partially with other dust mites
bull dust levels of mite allergen (Der p 1 + Der p 2) ndash sensitization at 2-10 μgg of dustndash For nonallergic children higher ldquothresholdrdquo of 20 μgg
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Dust mite
bull Avoidance measures
Otolaryngol Clin N Am 44 (2011) 711ndash725
Avoidance
bull standard part of the treatment of allergic disease bull difficult to achieve particularly in home environments
bull Many patients despite being skin test positive were not aware that dust related to their symptoms
bull sources and nature of indoor allergens were not well understood advice offered on avoidance was often inadequate or even wrong
bull The complexity and nonlinearity of dose response relationships also makes such evaluations of the effectiveness of allergen avoidance difficult
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552Immunol Allergy Clin N Am 31 (2011) 493ndash507
Br Med J 1998 3171105
2001 29 trials (939 patients)
2004 49 trials (2733 patients) 2008 54 trials (3002 patients)
2011 55 trials (3121 patients)
26 trials physical 10 trials chemical methods 8 trials combination
Cochrane Library 2011 Issue 10
Cochrane Library 2011 Issue 10
Cochrane Library 2011 Issue 10
bull The variability applies to the evaluation of patients the intervention used and the assessment of outcome
bull Meta-analysis is only valid when the studies are comparable and this may not be true for the successful studies on allergen avoidance
J Allergy Clin Immunol 2008122694-6
very different designs and engage different subjects time frames controls seasons and methods of intervention
J Allergy Clin Immunol 2011128723-7
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
longer than 6 months
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull most professional guidelines for asthma management advocate the avoidance of acute allergen lsquolsquotriggersrsquorsquo
bull there is a diversity of views about the role of allergen avoidance practices in long-term disease management
bull 2007 National Heart Lung and Blood Institute EPR3 (US) reportndash advises that the first and most important step in controlling
allergen induced asthma is to reduce exposure
J Allergy Clin Immunol 2011128723-7
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull Finnish Allergy Program 2008-2018 ndash promotes holistic lsquolsquoallergy healthrsquorsquo through diet and physical
activity and advocates allergen avoidance only lsquolsquoin mandatory situationsrsquorsquo
bull Both the 2009 Global Initiative for Asthma and the British Thoracic Society guidelines reflect (Cochrane review)
ndash no consistent evidence for allergen avoidance in preventing asthma
ndash only tenuous evidence that reducing allergen exposure can reduce asthma morbidity
J Allergy Clin Immunol 2011128723-7
ICON pediatric asthmabull some ambiguity with respect to the role of allergen avoidance
bull JGCA NAEPP3 and PRACTALL ndash specific recommendations for the reduction in allergen exposure
for sensitized patients with asthma
bull AAMH GINA and SIGNndash unproven effectiveness of current avoidance strategies on
asthma control
bull a multifaceted comprehensive approach is prerequisite for clinical benefit
Allergy 2012 67 976ndash997
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
bull 9 trials involving 501 participants bull 2 studies investigating the effectiveness of mite impermeable
bedding covers were of good qualitybull 7 studies were small and of poor qualitybull 2 trials investigated the efficacy of acaricidesbull 2 trials investigated the role of high-efficiency particulate air (HEPA)
filtersbull 1 trial using a factorial design investigated the efficacy of both
acaricide and house dust mite impermeable bedding covers in isolation and combination
bull Remaining 4 trials investigated the efficacy of bedroom environmental control programmes involving use of house dust mite impermeable bedding covers
Cochrane Database of Systematic Reviews 2010 Issue 7
bull Trials to date small and of poor methodological qualitybull difficult to offer any definitive recommendations on the role
bull use of acaricides and extensive bedroom-based environmental control programmes may be of some benefit in reducing rhinitis symptoms but the evidence is not strong
bull Isolated use of house dust mite impermeable bedding is unlikely to prove effective
bull More research is needed
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
METHODS OFMITE ALLERGEN AVOIDANCE
Method
bull Physical methodndash Encasing of beddingndash Vacuums cleanersndash Floor coveringsndash Laundryndash Air filtration
bull Chemical methodndash Acaricide
Encasingsbull In the bedroom covering mattresses and pillows with impermeable
covers is effectivebull This effect may be large variable and persist for a couple of
months
bull Encasings differ widely in their qualityndash some cheap brands have large pores other multilayered encasings delaminate
and others harbor mites
bull Tightly woven synthetic or cotton fabrics are preferred
bull Most trials of encasings have failed to regularly wash them (difficult with some encasings) which renders them ineffective as allergens build up on the outer surface within several weeks
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Curr Allergy Asthma Rep 20088126-32
J Allergy Clin Immunol 20061181164-8
16 tightly woven 9 United States3 Japan2 Thailand1 Germany1 France
laminate-coated and loosely woven cover molting among nonwoven fibers
dead mites on an acaricide-coated and nonwoven cover group of mites in the matrix of a nonwoven cover
J Allergy Clin Immunol 20061181164-8
Nonwoven
J Allergy Clin Immunol 20061181164-8
before after
easy access for mites to readily penetrate into the substrate of the material
J Allergy Clin Immunol 20061181164-8
tightly woven fabric with systematized regular fibers allowing little space for penetration
bull Woven nonwovenndash pore size between 2 and 10 um (average 6 um) blocking most
mite allergens
bull Plasticndash pore free best barrier in terms of blockingndash but the least comfortable zero ventilation ndash tendency to become a haven for mold spores
bull For acaricide-coated materialsndash pore size is usually not a major factor ndash mites are eradicated on contact with the chemicalsndash still allow the passage of allergens ndash prevent penetration through the fabrics but allow colonization
J Allergy Clin Immunol 20061181164-8
Asian Pac J Allergy Immunol 201028155-61
Sensitized level
Symptomatic level
sponge-like polyurethane lowest rate Synthetic fibers and kapok mattresses highest rate
A combination of the following choosing new sponge-like polyurethane or coconut fiber mattresses with mite-impermeable covers and washing sheets pillowcases blankets and mattresses pad at least weekly in hot water should be the best method of prevention in HDM allergen sensitive allergic patients
Laundrybull Both dust and cat and mite allergens are effectively removed by
laundryndash physical removal of both dust and mites by the multiple wash
and rinse cycles ndash effects of detergents additivesndash subsequent drying procedures
bull McDonald LGTovey E ndash All mites were killed by water temperatures 55 degrees C or
greaterndash Killing at lower temperatures was not enhanced by any of the
pure detergents or laundry products tested
J Allergy Clin Immunol 2011128723-7
J Allergy Clin Immunol 199290599-608
Floor coveringsbull Designing the house with polished floors and wooden or
vinylleather furniture so as to limit the sites where mites can grow
bull carpets fitted onto unventilated floors water can accumulate growth of both fungi and mites
bull hard floors are likely to be preferred as they are more easily kept in a state that minimizes aeroallergen reaerosolization in the long term
bull the little available data of aeroallergens in houses suggest that the difference may be small and the effects complex
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552J Allergy Clin Immunol 2011128723-7
Vacuum cleaners
bull Vacuum cleaners are heavily promoted
bull Probably all cleaners cause a brief increase in personal aeroallergen exposure under normal domestic conditions and high-efficiency particulate arrest (HEPA) filters make little difference
bull Thus the benefits of HEPA filtration on exposure may have been exaggerated and all cleaners probably provide a brief increase in exposure
J Allergy Clin Immunol 2011128723-7
Allergy 200661119-23
Air management
bull indoor relative humidity is kept below 50 (absolute humidity below 6 gkg)
bull In some areas of the world this can be done by increasing ventilation
bull in other areas it is necessary to use air conditioning during the most humid months of the summer
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Air filtration
bull The role of air filtration continues to be debatedbull There is some consensus that small benefits exist mainly for pet
allergens
J Allergy Clin Immunol 2011128723-7
Acaricidesbull variety of acaricides have been used to treat carpets or furniturebull pyrethroids natamycin (an antifungal) pirimiphos methyl and
benzyl benzoate bull killing mites
bull Acaricides proved largely ineffective because the mite populations return shortly after their application and they may also cause skin and respiratory irritation
bull No data on clinical benefit exist and concerns about human health and environmental toxicity remain
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
J Allergy Clin Immunol 2011128723-7
Acaricidesbull 1 or 3 tannic acid
ndash method of denaturing mite allergensndash reduction of mite allergen can be achievedndash does not kill mitesndash so the effect can only be temporary approximately 6 weeks to 3
months
bull may be recommended when it is not possible to remove the carpets or change the furniture
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
Dust mite
bull Avoidance measures
Otolaryngol Clin N Am 44 (2011) 711ndash725
Avoidance
bull standard part of the treatment of allergic disease bull difficult to achieve particularly in home environments
bull Many patients despite being skin test positive were not aware that dust related to their symptoms
bull sources and nature of indoor allergens were not well understood advice offered on avoidance was often inadequate or even wrong
bull The complexity and nonlinearity of dose response relationships also makes such evaluations of the effectiveness of allergen avoidance difficult
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552Immunol Allergy Clin N Am 31 (2011) 493ndash507
Br Med J 1998 3171105
2001 29 trials (939 patients)
2004 49 trials (2733 patients) 2008 54 trials (3002 patients)
2011 55 trials (3121 patients)
26 trials physical 10 trials chemical methods 8 trials combination
Cochrane Library 2011 Issue 10
Cochrane Library 2011 Issue 10
Cochrane Library 2011 Issue 10
bull The variability applies to the evaluation of patients the intervention used and the assessment of outcome
bull Meta-analysis is only valid when the studies are comparable and this may not be true for the successful studies on allergen avoidance
J Allergy Clin Immunol 2008122694-6
very different designs and engage different subjects time frames controls seasons and methods of intervention
J Allergy Clin Immunol 2011128723-7
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
longer than 6 months
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull most professional guidelines for asthma management advocate the avoidance of acute allergen lsquolsquotriggersrsquorsquo
bull there is a diversity of views about the role of allergen avoidance practices in long-term disease management
bull 2007 National Heart Lung and Blood Institute EPR3 (US) reportndash advises that the first and most important step in controlling
allergen induced asthma is to reduce exposure
J Allergy Clin Immunol 2011128723-7
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull Finnish Allergy Program 2008-2018 ndash promotes holistic lsquolsquoallergy healthrsquorsquo through diet and physical
activity and advocates allergen avoidance only lsquolsquoin mandatory situationsrsquorsquo
bull Both the 2009 Global Initiative for Asthma and the British Thoracic Society guidelines reflect (Cochrane review)
ndash no consistent evidence for allergen avoidance in preventing asthma
ndash only tenuous evidence that reducing allergen exposure can reduce asthma morbidity
J Allergy Clin Immunol 2011128723-7
ICON pediatric asthmabull some ambiguity with respect to the role of allergen avoidance
bull JGCA NAEPP3 and PRACTALL ndash specific recommendations for the reduction in allergen exposure
for sensitized patients with asthma
bull AAMH GINA and SIGNndash unproven effectiveness of current avoidance strategies on
asthma control
bull a multifaceted comprehensive approach is prerequisite for clinical benefit
Allergy 2012 67 976ndash997
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
bull 9 trials involving 501 participants bull 2 studies investigating the effectiveness of mite impermeable
bedding covers were of good qualitybull 7 studies were small and of poor qualitybull 2 trials investigated the efficacy of acaricidesbull 2 trials investigated the role of high-efficiency particulate air (HEPA)
filtersbull 1 trial using a factorial design investigated the efficacy of both
acaricide and house dust mite impermeable bedding covers in isolation and combination
bull Remaining 4 trials investigated the efficacy of bedroom environmental control programmes involving use of house dust mite impermeable bedding covers
Cochrane Database of Systematic Reviews 2010 Issue 7
bull Trials to date small and of poor methodological qualitybull difficult to offer any definitive recommendations on the role
bull use of acaricides and extensive bedroom-based environmental control programmes may be of some benefit in reducing rhinitis symptoms but the evidence is not strong
bull Isolated use of house dust mite impermeable bedding is unlikely to prove effective
bull More research is needed
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
METHODS OFMITE ALLERGEN AVOIDANCE
Method
bull Physical methodndash Encasing of beddingndash Vacuums cleanersndash Floor coveringsndash Laundryndash Air filtration
bull Chemical methodndash Acaricide
Encasingsbull In the bedroom covering mattresses and pillows with impermeable
covers is effectivebull This effect may be large variable and persist for a couple of
months
bull Encasings differ widely in their qualityndash some cheap brands have large pores other multilayered encasings delaminate
and others harbor mites
bull Tightly woven synthetic or cotton fabrics are preferred
bull Most trials of encasings have failed to regularly wash them (difficult with some encasings) which renders them ineffective as allergens build up on the outer surface within several weeks
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Curr Allergy Asthma Rep 20088126-32
J Allergy Clin Immunol 20061181164-8
16 tightly woven 9 United States3 Japan2 Thailand1 Germany1 France
laminate-coated and loosely woven cover molting among nonwoven fibers
dead mites on an acaricide-coated and nonwoven cover group of mites in the matrix of a nonwoven cover
J Allergy Clin Immunol 20061181164-8
Nonwoven
J Allergy Clin Immunol 20061181164-8
before after
easy access for mites to readily penetrate into the substrate of the material
J Allergy Clin Immunol 20061181164-8
tightly woven fabric with systematized regular fibers allowing little space for penetration
bull Woven nonwovenndash pore size between 2 and 10 um (average 6 um) blocking most
mite allergens
bull Plasticndash pore free best barrier in terms of blockingndash but the least comfortable zero ventilation ndash tendency to become a haven for mold spores
bull For acaricide-coated materialsndash pore size is usually not a major factor ndash mites are eradicated on contact with the chemicalsndash still allow the passage of allergens ndash prevent penetration through the fabrics but allow colonization
J Allergy Clin Immunol 20061181164-8
Asian Pac J Allergy Immunol 201028155-61
Sensitized level
Symptomatic level
sponge-like polyurethane lowest rate Synthetic fibers and kapok mattresses highest rate
A combination of the following choosing new sponge-like polyurethane or coconut fiber mattresses with mite-impermeable covers and washing sheets pillowcases blankets and mattresses pad at least weekly in hot water should be the best method of prevention in HDM allergen sensitive allergic patients
Laundrybull Both dust and cat and mite allergens are effectively removed by
laundryndash physical removal of both dust and mites by the multiple wash
and rinse cycles ndash effects of detergents additivesndash subsequent drying procedures
bull McDonald LGTovey E ndash All mites were killed by water temperatures 55 degrees C or
greaterndash Killing at lower temperatures was not enhanced by any of the
pure detergents or laundry products tested
J Allergy Clin Immunol 2011128723-7
J Allergy Clin Immunol 199290599-608
Floor coveringsbull Designing the house with polished floors and wooden or
vinylleather furniture so as to limit the sites where mites can grow
bull carpets fitted onto unventilated floors water can accumulate growth of both fungi and mites
bull hard floors are likely to be preferred as they are more easily kept in a state that minimizes aeroallergen reaerosolization in the long term
bull the little available data of aeroallergens in houses suggest that the difference may be small and the effects complex
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552J Allergy Clin Immunol 2011128723-7
Vacuum cleaners
bull Vacuum cleaners are heavily promoted
bull Probably all cleaners cause a brief increase in personal aeroallergen exposure under normal domestic conditions and high-efficiency particulate arrest (HEPA) filters make little difference
bull Thus the benefits of HEPA filtration on exposure may have been exaggerated and all cleaners probably provide a brief increase in exposure
J Allergy Clin Immunol 2011128723-7
Allergy 200661119-23
Air management
bull indoor relative humidity is kept below 50 (absolute humidity below 6 gkg)
bull In some areas of the world this can be done by increasing ventilation
bull in other areas it is necessary to use air conditioning during the most humid months of the summer
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Air filtration
bull The role of air filtration continues to be debatedbull There is some consensus that small benefits exist mainly for pet
allergens
J Allergy Clin Immunol 2011128723-7
Acaricidesbull variety of acaricides have been used to treat carpets or furniturebull pyrethroids natamycin (an antifungal) pirimiphos methyl and
benzyl benzoate bull killing mites
bull Acaricides proved largely ineffective because the mite populations return shortly after their application and they may also cause skin and respiratory irritation
bull No data on clinical benefit exist and concerns about human health and environmental toxicity remain
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
J Allergy Clin Immunol 2011128723-7
Acaricidesbull 1 or 3 tannic acid
ndash method of denaturing mite allergensndash reduction of mite allergen can be achievedndash does not kill mitesndash so the effect can only be temporary approximately 6 weeks to 3
months
bull may be recommended when it is not possible to remove the carpets or change the furniture
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
Otolaryngol Clin N Am 44 (2011) 711ndash725
Avoidance
bull standard part of the treatment of allergic disease bull difficult to achieve particularly in home environments
bull Many patients despite being skin test positive were not aware that dust related to their symptoms
bull sources and nature of indoor allergens were not well understood advice offered on avoidance was often inadequate or even wrong
bull The complexity and nonlinearity of dose response relationships also makes such evaluations of the effectiveness of allergen avoidance difficult
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552Immunol Allergy Clin N Am 31 (2011) 493ndash507
Br Med J 1998 3171105
2001 29 trials (939 patients)
2004 49 trials (2733 patients) 2008 54 trials (3002 patients)
2011 55 trials (3121 patients)
26 trials physical 10 trials chemical methods 8 trials combination
Cochrane Library 2011 Issue 10
Cochrane Library 2011 Issue 10
Cochrane Library 2011 Issue 10
bull The variability applies to the evaluation of patients the intervention used and the assessment of outcome
bull Meta-analysis is only valid when the studies are comparable and this may not be true for the successful studies on allergen avoidance
J Allergy Clin Immunol 2008122694-6
very different designs and engage different subjects time frames controls seasons and methods of intervention
J Allergy Clin Immunol 2011128723-7
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
longer than 6 months
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull most professional guidelines for asthma management advocate the avoidance of acute allergen lsquolsquotriggersrsquorsquo
bull there is a diversity of views about the role of allergen avoidance practices in long-term disease management
bull 2007 National Heart Lung and Blood Institute EPR3 (US) reportndash advises that the first and most important step in controlling
allergen induced asthma is to reduce exposure
J Allergy Clin Immunol 2011128723-7
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull Finnish Allergy Program 2008-2018 ndash promotes holistic lsquolsquoallergy healthrsquorsquo through diet and physical
activity and advocates allergen avoidance only lsquolsquoin mandatory situationsrsquorsquo
bull Both the 2009 Global Initiative for Asthma and the British Thoracic Society guidelines reflect (Cochrane review)
ndash no consistent evidence for allergen avoidance in preventing asthma
ndash only tenuous evidence that reducing allergen exposure can reduce asthma morbidity
J Allergy Clin Immunol 2011128723-7
ICON pediatric asthmabull some ambiguity with respect to the role of allergen avoidance
bull JGCA NAEPP3 and PRACTALL ndash specific recommendations for the reduction in allergen exposure
for sensitized patients with asthma
bull AAMH GINA and SIGNndash unproven effectiveness of current avoidance strategies on
asthma control
bull a multifaceted comprehensive approach is prerequisite for clinical benefit
Allergy 2012 67 976ndash997
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
bull 9 trials involving 501 participants bull 2 studies investigating the effectiveness of mite impermeable
bedding covers were of good qualitybull 7 studies were small and of poor qualitybull 2 trials investigated the efficacy of acaricidesbull 2 trials investigated the role of high-efficiency particulate air (HEPA)
filtersbull 1 trial using a factorial design investigated the efficacy of both
acaricide and house dust mite impermeable bedding covers in isolation and combination
bull Remaining 4 trials investigated the efficacy of bedroom environmental control programmes involving use of house dust mite impermeable bedding covers
Cochrane Database of Systematic Reviews 2010 Issue 7
bull Trials to date small and of poor methodological qualitybull difficult to offer any definitive recommendations on the role
bull use of acaricides and extensive bedroom-based environmental control programmes may be of some benefit in reducing rhinitis symptoms but the evidence is not strong
bull Isolated use of house dust mite impermeable bedding is unlikely to prove effective
bull More research is needed
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
METHODS OFMITE ALLERGEN AVOIDANCE
Method
bull Physical methodndash Encasing of beddingndash Vacuums cleanersndash Floor coveringsndash Laundryndash Air filtration
bull Chemical methodndash Acaricide
Encasingsbull In the bedroom covering mattresses and pillows with impermeable
covers is effectivebull This effect may be large variable and persist for a couple of
months
bull Encasings differ widely in their qualityndash some cheap brands have large pores other multilayered encasings delaminate
and others harbor mites
bull Tightly woven synthetic or cotton fabrics are preferred
bull Most trials of encasings have failed to regularly wash them (difficult with some encasings) which renders them ineffective as allergens build up on the outer surface within several weeks
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Curr Allergy Asthma Rep 20088126-32
J Allergy Clin Immunol 20061181164-8
16 tightly woven 9 United States3 Japan2 Thailand1 Germany1 France
laminate-coated and loosely woven cover molting among nonwoven fibers
dead mites on an acaricide-coated and nonwoven cover group of mites in the matrix of a nonwoven cover
J Allergy Clin Immunol 20061181164-8
Nonwoven
J Allergy Clin Immunol 20061181164-8
before after
easy access for mites to readily penetrate into the substrate of the material
J Allergy Clin Immunol 20061181164-8
tightly woven fabric with systematized regular fibers allowing little space for penetration
bull Woven nonwovenndash pore size between 2 and 10 um (average 6 um) blocking most
mite allergens
bull Plasticndash pore free best barrier in terms of blockingndash but the least comfortable zero ventilation ndash tendency to become a haven for mold spores
bull For acaricide-coated materialsndash pore size is usually not a major factor ndash mites are eradicated on contact with the chemicalsndash still allow the passage of allergens ndash prevent penetration through the fabrics but allow colonization
J Allergy Clin Immunol 20061181164-8
Asian Pac J Allergy Immunol 201028155-61
Sensitized level
Symptomatic level
sponge-like polyurethane lowest rate Synthetic fibers and kapok mattresses highest rate
A combination of the following choosing new sponge-like polyurethane or coconut fiber mattresses with mite-impermeable covers and washing sheets pillowcases blankets and mattresses pad at least weekly in hot water should be the best method of prevention in HDM allergen sensitive allergic patients
Laundrybull Both dust and cat and mite allergens are effectively removed by
laundryndash physical removal of both dust and mites by the multiple wash
and rinse cycles ndash effects of detergents additivesndash subsequent drying procedures
bull McDonald LGTovey E ndash All mites were killed by water temperatures 55 degrees C or
greaterndash Killing at lower temperatures was not enhanced by any of the
pure detergents or laundry products tested
J Allergy Clin Immunol 2011128723-7
J Allergy Clin Immunol 199290599-608
Floor coveringsbull Designing the house with polished floors and wooden or
vinylleather furniture so as to limit the sites where mites can grow
bull carpets fitted onto unventilated floors water can accumulate growth of both fungi and mites
bull hard floors are likely to be preferred as they are more easily kept in a state that minimizes aeroallergen reaerosolization in the long term
bull the little available data of aeroallergens in houses suggest that the difference may be small and the effects complex
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552J Allergy Clin Immunol 2011128723-7
Vacuum cleaners
bull Vacuum cleaners are heavily promoted
bull Probably all cleaners cause a brief increase in personal aeroallergen exposure under normal domestic conditions and high-efficiency particulate arrest (HEPA) filters make little difference
bull Thus the benefits of HEPA filtration on exposure may have been exaggerated and all cleaners probably provide a brief increase in exposure
J Allergy Clin Immunol 2011128723-7
Allergy 200661119-23
Air management
bull indoor relative humidity is kept below 50 (absolute humidity below 6 gkg)
bull In some areas of the world this can be done by increasing ventilation
bull in other areas it is necessary to use air conditioning during the most humid months of the summer
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Air filtration
bull The role of air filtration continues to be debatedbull There is some consensus that small benefits exist mainly for pet
allergens
J Allergy Clin Immunol 2011128723-7
Acaricidesbull variety of acaricides have been used to treat carpets or furniturebull pyrethroids natamycin (an antifungal) pirimiphos methyl and
benzyl benzoate bull killing mites
bull Acaricides proved largely ineffective because the mite populations return shortly after their application and they may also cause skin and respiratory irritation
bull No data on clinical benefit exist and concerns about human health and environmental toxicity remain
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
J Allergy Clin Immunol 2011128723-7
Acaricidesbull 1 or 3 tannic acid
ndash method of denaturing mite allergensndash reduction of mite allergen can be achievedndash does not kill mitesndash so the effect can only be temporary approximately 6 weeks to 3
months
bull may be recommended when it is not possible to remove the carpets or change the furniture
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
Avoidance
bull standard part of the treatment of allergic disease bull difficult to achieve particularly in home environments
bull Many patients despite being skin test positive were not aware that dust related to their symptoms
bull sources and nature of indoor allergens were not well understood advice offered on avoidance was often inadequate or even wrong
bull The complexity and nonlinearity of dose response relationships also makes such evaluations of the effectiveness of allergen avoidance difficult
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552Immunol Allergy Clin N Am 31 (2011) 493ndash507
Br Med J 1998 3171105
2001 29 trials (939 patients)
2004 49 trials (2733 patients) 2008 54 trials (3002 patients)
2011 55 trials (3121 patients)
26 trials physical 10 trials chemical methods 8 trials combination
Cochrane Library 2011 Issue 10
Cochrane Library 2011 Issue 10
Cochrane Library 2011 Issue 10
bull The variability applies to the evaluation of patients the intervention used and the assessment of outcome
bull Meta-analysis is only valid when the studies are comparable and this may not be true for the successful studies on allergen avoidance
J Allergy Clin Immunol 2008122694-6
very different designs and engage different subjects time frames controls seasons and methods of intervention
J Allergy Clin Immunol 2011128723-7
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
longer than 6 months
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull most professional guidelines for asthma management advocate the avoidance of acute allergen lsquolsquotriggersrsquorsquo
bull there is a diversity of views about the role of allergen avoidance practices in long-term disease management
bull 2007 National Heart Lung and Blood Institute EPR3 (US) reportndash advises that the first and most important step in controlling
allergen induced asthma is to reduce exposure
J Allergy Clin Immunol 2011128723-7
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull Finnish Allergy Program 2008-2018 ndash promotes holistic lsquolsquoallergy healthrsquorsquo through diet and physical
activity and advocates allergen avoidance only lsquolsquoin mandatory situationsrsquorsquo
bull Both the 2009 Global Initiative for Asthma and the British Thoracic Society guidelines reflect (Cochrane review)
ndash no consistent evidence for allergen avoidance in preventing asthma
ndash only tenuous evidence that reducing allergen exposure can reduce asthma morbidity
J Allergy Clin Immunol 2011128723-7
ICON pediatric asthmabull some ambiguity with respect to the role of allergen avoidance
bull JGCA NAEPP3 and PRACTALL ndash specific recommendations for the reduction in allergen exposure
for sensitized patients with asthma
bull AAMH GINA and SIGNndash unproven effectiveness of current avoidance strategies on
asthma control
bull a multifaceted comprehensive approach is prerequisite for clinical benefit
Allergy 2012 67 976ndash997
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
bull 9 trials involving 501 participants bull 2 studies investigating the effectiveness of mite impermeable
bedding covers were of good qualitybull 7 studies were small and of poor qualitybull 2 trials investigated the efficacy of acaricidesbull 2 trials investigated the role of high-efficiency particulate air (HEPA)
filtersbull 1 trial using a factorial design investigated the efficacy of both
acaricide and house dust mite impermeable bedding covers in isolation and combination
bull Remaining 4 trials investigated the efficacy of bedroom environmental control programmes involving use of house dust mite impermeable bedding covers
Cochrane Database of Systematic Reviews 2010 Issue 7
bull Trials to date small and of poor methodological qualitybull difficult to offer any definitive recommendations on the role
bull use of acaricides and extensive bedroom-based environmental control programmes may be of some benefit in reducing rhinitis symptoms but the evidence is not strong
bull Isolated use of house dust mite impermeable bedding is unlikely to prove effective
bull More research is needed
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
METHODS OFMITE ALLERGEN AVOIDANCE
Method
bull Physical methodndash Encasing of beddingndash Vacuums cleanersndash Floor coveringsndash Laundryndash Air filtration
bull Chemical methodndash Acaricide
Encasingsbull In the bedroom covering mattresses and pillows with impermeable
covers is effectivebull This effect may be large variable and persist for a couple of
months
bull Encasings differ widely in their qualityndash some cheap brands have large pores other multilayered encasings delaminate
and others harbor mites
bull Tightly woven synthetic or cotton fabrics are preferred
bull Most trials of encasings have failed to regularly wash them (difficult with some encasings) which renders them ineffective as allergens build up on the outer surface within several weeks
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Curr Allergy Asthma Rep 20088126-32
J Allergy Clin Immunol 20061181164-8
16 tightly woven 9 United States3 Japan2 Thailand1 Germany1 France
laminate-coated and loosely woven cover molting among nonwoven fibers
dead mites on an acaricide-coated and nonwoven cover group of mites in the matrix of a nonwoven cover
J Allergy Clin Immunol 20061181164-8
Nonwoven
J Allergy Clin Immunol 20061181164-8
before after
easy access for mites to readily penetrate into the substrate of the material
J Allergy Clin Immunol 20061181164-8
tightly woven fabric with systematized regular fibers allowing little space for penetration
bull Woven nonwovenndash pore size between 2 and 10 um (average 6 um) blocking most
mite allergens
bull Plasticndash pore free best barrier in terms of blockingndash but the least comfortable zero ventilation ndash tendency to become a haven for mold spores
bull For acaricide-coated materialsndash pore size is usually not a major factor ndash mites are eradicated on contact with the chemicalsndash still allow the passage of allergens ndash prevent penetration through the fabrics but allow colonization
J Allergy Clin Immunol 20061181164-8
Asian Pac J Allergy Immunol 201028155-61
Sensitized level
Symptomatic level
sponge-like polyurethane lowest rate Synthetic fibers and kapok mattresses highest rate
A combination of the following choosing new sponge-like polyurethane or coconut fiber mattresses with mite-impermeable covers and washing sheets pillowcases blankets and mattresses pad at least weekly in hot water should be the best method of prevention in HDM allergen sensitive allergic patients
Laundrybull Both dust and cat and mite allergens are effectively removed by
laundryndash physical removal of both dust and mites by the multiple wash
and rinse cycles ndash effects of detergents additivesndash subsequent drying procedures
bull McDonald LGTovey E ndash All mites were killed by water temperatures 55 degrees C or
greaterndash Killing at lower temperatures was not enhanced by any of the
pure detergents or laundry products tested
J Allergy Clin Immunol 2011128723-7
J Allergy Clin Immunol 199290599-608
Floor coveringsbull Designing the house with polished floors and wooden or
vinylleather furniture so as to limit the sites where mites can grow
bull carpets fitted onto unventilated floors water can accumulate growth of both fungi and mites
bull hard floors are likely to be preferred as they are more easily kept in a state that minimizes aeroallergen reaerosolization in the long term
bull the little available data of aeroallergens in houses suggest that the difference may be small and the effects complex
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552J Allergy Clin Immunol 2011128723-7
Vacuum cleaners
bull Vacuum cleaners are heavily promoted
bull Probably all cleaners cause a brief increase in personal aeroallergen exposure under normal domestic conditions and high-efficiency particulate arrest (HEPA) filters make little difference
bull Thus the benefits of HEPA filtration on exposure may have been exaggerated and all cleaners probably provide a brief increase in exposure
J Allergy Clin Immunol 2011128723-7
Allergy 200661119-23
Air management
bull indoor relative humidity is kept below 50 (absolute humidity below 6 gkg)
bull In some areas of the world this can be done by increasing ventilation
bull in other areas it is necessary to use air conditioning during the most humid months of the summer
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Air filtration
bull The role of air filtration continues to be debatedbull There is some consensus that small benefits exist mainly for pet
allergens
J Allergy Clin Immunol 2011128723-7
Acaricidesbull variety of acaricides have been used to treat carpets or furniturebull pyrethroids natamycin (an antifungal) pirimiphos methyl and
benzyl benzoate bull killing mites
bull Acaricides proved largely ineffective because the mite populations return shortly after their application and they may also cause skin and respiratory irritation
bull No data on clinical benefit exist and concerns about human health and environmental toxicity remain
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
J Allergy Clin Immunol 2011128723-7
Acaricidesbull 1 or 3 tannic acid
ndash method of denaturing mite allergensndash reduction of mite allergen can be achievedndash does not kill mitesndash so the effect can only be temporary approximately 6 weeks to 3
months
bull may be recommended when it is not possible to remove the carpets or change the furniture
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
Br Med J 1998 3171105
2001 29 trials (939 patients)
2004 49 trials (2733 patients) 2008 54 trials (3002 patients)
2011 55 trials (3121 patients)
26 trials physical 10 trials chemical methods 8 trials combination
Cochrane Library 2011 Issue 10
Cochrane Library 2011 Issue 10
Cochrane Library 2011 Issue 10
bull The variability applies to the evaluation of patients the intervention used and the assessment of outcome
bull Meta-analysis is only valid when the studies are comparable and this may not be true for the successful studies on allergen avoidance
J Allergy Clin Immunol 2008122694-6
very different designs and engage different subjects time frames controls seasons and methods of intervention
J Allergy Clin Immunol 2011128723-7
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
longer than 6 months
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull most professional guidelines for asthma management advocate the avoidance of acute allergen lsquolsquotriggersrsquorsquo
bull there is a diversity of views about the role of allergen avoidance practices in long-term disease management
bull 2007 National Heart Lung and Blood Institute EPR3 (US) reportndash advises that the first and most important step in controlling
allergen induced asthma is to reduce exposure
J Allergy Clin Immunol 2011128723-7
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull Finnish Allergy Program 2008-2018 ndash promotes holistic lsquolsquoallergy healthrsquorsquo through diet and physical
activity and advocates allergen avoidance only lsquolsquoin mandatory situationsrsquorsquo
bull Both the 2009 Global Initiative for Asthma and the British Thoracic Society guidelines reflect (Cochrane review)
ndash no consistent evidence for allergen avoidance in preventing asthma
ndash only tenuous evidence that reducing allergen exposure can reduce asthma morbidity
J Allergy Clin Immunol 2011128723-7
ICON pediatric asthmabull some ambiguity with respect to the role of allergen avoidance
bull JGCA NAEPP3 and PRACTALL ndash specific recommendations for the reduction in allergen exposure
for sensitized patients with asthma
bull AAMH GINA and SIGNndash unproven effectiveness of current avoidance strategies on
asthma control
bull a multifaceted comprehensive approach is prerequisite for clinical benefit
Allergy 2012 67 976ndash997
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
bull 9 trials involving 501 participants bull 2 studies investigating the effectiveness of mite impermeable
bedding covers were of good qualitybull 7 studies were small and of poor qualitybull 2 trials investigated the efficacy of acaricidesbull 2 trials investigated the role of high-efficiency particulate air (HEPA)
filtersbull 1 trial using a factorial design investigated the efficacy of both
acaricide and house dust mite impermeable bedding covers in isolation and combination
bull Remaining 4 trials investigated the efficacy of bedroom environmental control programmes involving use of house dust mite impermeable bedding covers
Cochrane Database of Systematic Reviews 2010 Issue 7
bull Trials to date small and of poor methodological qualitybull difficult to offer any definitive recommendations on the role
bull use of acaricides and extensive bedroom-based environmental control programmes may be of some benefit in reducing rhinitis symptoms but the evidence is not strong
bull Isolated use of house dust mite impermeable bedding is unlikely to prove effective
bull More research is needed
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
METHODS OFMITE ALLERGEN AVOIDANCE
Method
bull Physical methodndash Encasing of beddingndash Vacuums cleanersndash Floor coveringsndash Laundryndash Air filtration
bull Chemical methodndash Acaricide
Encasingsbull In the bedroom covering mattresses and pillows with impermeable
covers is effectivebull This effect may be large variable and persist for a couple of
months
bull Encasings differ widely in their qualityndash some cheap brands have large pores other multilayered encasings delaminate
and others harbor mites
bull Tightly woven synthetic or cotton fabrics are preferred
bull Most trials of encasings have failed to regularly wash them (difficult with some encasings) which renders them ineffective as allergens build up on the outer surface within several weeks
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Curr Allergy Asthma Rep 20088126-32
J Allergy Clin Immunol 20061181164-8
16 tightly woven 9 United States3 Japan2 Thailand1 Germany1 France
laminate-coated and loosely woven cover molting among nonwoven fibers
dead mites on an acaricide-coated and nonwoven cover group of mites in the matrix of a nonwoven cover
J Allergy Clin Immunol 20061181164-8
Nonwoven
J Allergy Clin Immunol 20061181164-8
before after
easy access for mites to readily penetrate into the substrate of the material
J Allergy Clin Immunol 20061181164-8
tightly woven fabric with systematized regular fibers allowing little space for penetration
bull Woven nonwovenndash pore size between 2 and 10 um (average 6 um) blocking most
mite allergens
bull Plasticndash pore free best barrier in terms of blockingndash but the least comfortable zero ventilation ndash tendency to become a haven for mold spores
bull For acaricide-coated materialsndash pore size is usually not a major factor ndash mites are eradicated on contact with the chemicalsndash still allow the passage of allergens ndash prevent penetration through the fabrics but allow colonization
J Allergy Clin Immunol 20061181164-8
Asian Pac J Allergy Immunol 201028155-61
Sensitized level
Symptomatic level
sponge-like polyurethane lowest rate Synthetic fibers and kapok mattresses highest rate
A combination of the following choosing new sponge-like polyurethane or coconut fiber mattresses with mite-impermeable covers and washing sheets pillowcases blankets and mattresses pad at least weekly in hot water should be the best method of prevention in HDM allergen sensitive allergic patients
Laundrybull Both dust and cat and mite allergens are effectively removed by
laundryndash physical removal of both dust and mites by the multiple wash
and rinse cycles ndash effects of detergents additivesndash subsequent drying procedures
bull McDonald LGTovey E ndash All mites were killed by water temperatures 55 degrees C or
greaterndash Killing at lower temperatures was not enhanced by any of the
pure detergents or laundry products tested
J Allergy Clin Immunol 2011128723-7
J Allergy Clin Immunol 199290599-608
Floor coveringsbull Designing the house with polished floors and wooden or
vinylleather furniture so as to limit the sites where mites can grow
bull carpets fitted onto unventilated floors water can accumulate growth of both fungi and mites
bull hard floors are likely to be preferred as they are more easily kept in a state that minimizes aeroallergen reaerosolization in the long term
bull the little available data of aeroallergens in houses suggest that the difference may be small and the effects complex
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552J Allergy Clin Immunol 2011128723-7
Vacuum cleaners
bull Vacuum cleaners are heavily promoted
bull Probably all cleaners cause a brief increase in personal aeroallergen exposure under normal domestic conditions and high-efficiency particulate arrest (HEPA) filters make little difference
bull Thus the benefits of HEPA filtration on exposure may have been exaggerated and all cleaners probably provide a brief increase in exposure
J Allergy Clin Immunol 2011128723-7
Allergy 200661119-23
Air management
bull indoor relative humidity is kept below 50 (absolute humidity below 6 gkg)
bull In some areas of the world this can be done by increasing ventilation
bull in other areas it is necessary to use air conditioning during the most humid months of the summer
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Air filtration
bull The role of air filtration continues to be debatedbull There is some consensus that small benefits exist mainly for pet
allergens
J Allergy Clin Immunol 2011128723-7
Acaricidesbull variety of acaricides have been used to treat carpets or furniturebull pyrethroids natamycin (an antifungal) pirimiphos methyl and
benzyl benzoate bull killing mites
bull Acaricides proved largely ineffective because the mite populations return shortly after their application and they may also cause skin and respiratory irritation
bull No data on clinical benefit exist and concerns about human health and environmental toxicity remain
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
J Allergy Clin Immunol 2011128723-7
Acaricidesbull 1 or 3 tannic acid
ndash method of denaturing mite allergensndash reduction of mite allergen can be achievedndash does not kill mitesndash so the effect can only be temporary approximately 6 weeks to 3
months
bull may be recommended when it is not possible to remove the carpets or change the furniture
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
2001 29 trials (939 patients)
2004 49 trials (2733 patients) 2008 54 trials (3002 patients)
2011 55 trials (3121 patients)
26 trials physical 10 trials chemical methods 8 trials combination
Cochrane Library 2011 Issue 10
Cochrane Library 2011 Issue 10
Cochrane Library 2011 Issue 10
bull The variability applies to the evaluation of patients the intervention used and the assessment of outcome
bull Meta-analysis is only valid when the studies are comparable and this may not be true for the successful studies on allergen avoidance
J Allergy Clin Immunol 2008122694-6
very different designs and engage different subjects time frames controls seasons and methods of intervention
J Allergy Clin Immunol 2011128723-7
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
longer than 6 months
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull most professional guidelines for asthma management advocate the avoidance of acute allergen lsquolsquotriggersrsquorsquo
bull there is a diversity of views about the role of allergen avoidance practices in long-term disease management
bull 2007 National Heart Lung and Blood Institute EPR3 (US) reportndash advises that the first and most important step in controlling
allergen induced asthma is to reduce exposure
J Allergy Clin Immunol 2011128723-7
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull Finnish Allergy Program 2008-2018 ndash promotes holistic lsquolsquoallergy healthrsquorsquo through diet and physical
activity and advocates allergen avoidance only lsquolsquoin mandatory situationsrsquorsquo
bull Both the 2009 Global Initiative for Asthma and the British Thoracic Society guidelines reflect (Cochrane review)
ndash no consistent evidence for allergen avoidance in preventing asthma
ndash only tenuous evidence that reducing allergen exposure can reduce asthma morbidity
J Allergy Clin Immunol 2011128723-7
ICON pediatric asthmabull some ambiguity with respect to the role of allergen avoidance
bull JGCA NAEPP3 and PRACTALL ndash specific recommendations for the reduction in allergen exposure
for sensitized patients with asthma
bull AAMH GINA and SIGNndash unproven effectiveness of current avoidance strategies on
asthma control
bull a multifaceted comprehensive approach is prerequisite for clinical benefit
Allergy 2012 67 976ndash997
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
bull 9 trials involving 501 participants bull 2 studies investigating the effectiveness of mite impermeable
bedding covers were of good qualitybull 7 studies were small and of poor qualitybull 2 trials investigated the efficacy of acaricidesbull 2 trials investigated the role of high-efficiency particulate air (HEPA)
filtersbull 1 trial using a factorial design investigated the efficacy of both
acaricide and house dust mite impermeable bedding covers in isolation and combination
bull Remaining 4 trials investigated the efficacy of bedroom environmental control programmes involving use of house dust mite impermeable bedding covers
Cochrane Database of Systematic Reviews 2010 Issue 7
bull Trials to date small and of poor methodological qualitybull difficult to offer any definitive recommendations on the role
bull use of acaricides and extensive bedroom-based environmental control programmes may be of some benefit in reducing rhinitis symptoms but the evidence is not strong
bull Isolated use of house dust mite impermeable bedding is unlikely to prove effective
bull More research is needed
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
METHODS OFMITE ALLERGEN AVOIDANCE
Method
bull Physical methodndash Encasing of beddingndash Vacuums cleanersndash Floor coveringsndash Laundryndash Air filtration
bull Chemical methodndash Acaricide
Encasingsbull In the bedroom covering mattresses and pillows with impermeable
covers is effectivebull This effect may be large variable and persist for a couple of
months
bull Encasings differ widely in their qualityndash some cheap brands have large pores other multilayered encasings delaminate
and others harbor mites
bull Tightly woven synthetic or cotton fabrics are preferred
bull Most trials of encasings have failed to regularly wash them (difficult with some encasings) which renders them ineffective as allergens build up on the outer surface within several weeks
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Curr Allergy Asthma Rep 20088126-32
J Allergy Clin Immunol 20061181164-8
16 tightly woven 9 United States3 Japan2 Thailand1 Germany1 France
laminate-coated and loosely woven cover molting among nonwoven fibers
dead mites on an acaricide-coated and nonwoven cover group of mites in the matrix of a nonwoven cover
J Allergy Clin Immunol 20061181164-8
Nonwoven
J Allergy Clin Immunol 20061181164-8
before after
easy access for mites to readily penetrate into the substrate of the material
J Allergy Clin Immunol 20061181164-8
tightly woven fabric with systematized regular fibers allowing little space for penetration
bull Woven nonwovenndash pore size between 2 and 10 um (average 6 um) blocking most
mite allergens
bull Plasticndash pore free best barrier in terms of blockingndash but the least comfortable zero ventilation ndash tendency to become a haven for mold spores
bull For acaricide-coated materialsndash pore size is usually not a major factor ndash mites are eradicated on contact with the chemicalsndash still allow the passage of allergens ndash prevent penetration through the fabrics but allow colonization
J Allergy Clin Immunol 20061181164-8
Asian Pac J Allergy Immunol 201028155-61
Sensitized level
Symptomatic level
sponge-like polyurethane lowest rate Synthetic fibers and kapok mattresses highest rate
A combination of the following choosing new sponge-like polyurethane or coconut fiber mattresses with mite-impermeable covers and washing sheets pillowcases blankets and mattresses pad at least weekly in hot water should be the best method of prevention in HDM allergen sensitive allergic patients
Laundrybull Both dust and cat and mite allergens are effectively removed by
laundryndash physical removal of both dust and mites by the multiple wash
and rinse cycles ndash effects of detergents additivesndash subsequent drying procedures
bull McDonald LGTovey E ndash All mites were killed by water temperatures 55 degrees C or
greaterndash Killing at lower temperatures was not enhanced by any of the
pure detergents or laundry products tested
J Allergy Clin Immunol 2011128723-7
J Allergy Clin Immunol 199290599-608
Floor coveringsbull Designing the house with polished floors and wooden or
vinylleather furniture so as to limit the sites where mites can grow
bull carpets fitted onto unventilated floors water can accumulate growth of both fungi and mites
bull hard floors are likely to be preferred as they are more easily kept in a state that minimizes aeroallergen reaerosolization in the long term
bull the little available data of aeroallergens in houses suggest that the difference may be small and the effects complex
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552J Allergy Clin Immunol 2011128723-7
Vacuum cleaners
bull Vacuum cleaners are heavily promoted
bull Probably all cleaners cause a brief increase in personal aeroallergen exposure under normal domestic conditions and high-efficiency particulate arrest (HEPA) filters make little difference
bull Thus the benefits of HEPA filtration on exposure may have been exaggerated and all cleaners probably provide a brief increase in exposure
J Allergy Clin Immunol 2011128723-7
Allergy 200661119-23
Air management
bull indoor relative humidity is kept below 50 (absolute humidity below 6 gkg)
bull In some areas of the world this can be done by increasing ventilation
bull in other areas it is necessary to use air conditioning during the most humid months of the summer
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Air filtration
bull The role of air filtration continues to be debatedbull There is some consensus that small benefits exist mainly for pet
allergens
J Allergy Clin Immunol 2011128723-7
Acaricidesbull variety of acaricides have been used to treat carpets or furniturebull pyrethroids natamycin (an antifungal) pirimiphos methyl and
benzyl benzoate bull killing mites
bull Acaricides proved largely ineffective because the mite populations return shortly after their application and they may also cause skin and respiratory irritation
bull No data on clinical benefit exist and concerns about human health and environmental toxicity remain
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
J Allergy Clin Immunol 2011128723-7
Acaricidesbull 1 or 3 tannic acid
ndash method of denaturing mite allergensndash reduction of mite allergen can be achievedndash does not kill mitesndash so the effect can only be temporary approximately 6 weeks to 3
months
bull may be recommended when it is not possible to remove the carpets or change the furniture
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
26 trials physical 10 trials chemical methods 8 trials combination
Cochrane Library 2011 Issue 10
Cochrane Library 2011 Issue 10
Cochrane Library 2011 Issue 10
bull The variability applies to the evaluation of patients the intervention used and the assessment of outcome
bull Meta-analysis is only valid when the studies are comparable and this may not be true for the successful studies on allergen avoidance
J Allergy Clin Immunol 2008122694-6
very different designs and engage different subjects time frames controls seasons and methods of intervention
J Allergy Clin Immunol 2011128723-7
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
longer than 6 months
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull most professional guidelines for asthma management advocate the avoidance of acute allergen lsquolsquotriggersrsquorsquo
bull there is a diversity of views about the role of allergen avoidance practices in long-term disease management
bull 2007 National Heart Lung and Blood Institute EPR3 (US) reportndash advises that the first and most important step in controlling
allergen induced asthma is to reduce exposure
J Allergy Clin Immunol 2011128723-7
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull Finnish Allergy Program 2008-2018 ndash promotes holistic lsquolsquoallergy healthrsquorsquo through diet and physical
activity and advocates allergen avoidance only lsquolsquoin mandatory situationsrsquorsquo
bull Both the 2009 Global Initiative for Asthma and the British Thoracic Society guidelines reflect (Cochrane review)
ndash no consistent evidence for allergen avoidance in preventing asthma
ndash only tenuous evidence that reducing allergen exposure can reduce asthma morbidity
J Allergy Clin Immunol 2011128723-7
ICON pediatric asthmabull some ambiguity with respect to the role of allergen avoidance
bull JGCA NAEPP3 and PRACTALL ndash specific recommendations for the reduction in allergen exposure
for sensitized patients with asthma
bull AAMH GINA and SIGNndash unproven effectiveness of current avoidance strategies on
asthma control
bull a multifaceted comprehensive approach is prerequisite for clinical benefit
Allergy 2012 67 976ndash997
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
bull 9 trials involving 501 participants bull 2 studies investigating the effectiveness of mite impermeable
bedding covers were of good qualitybull 7 studies were small and of poor qualitybull 2 trials investigated the efficacy of acaricidesbull 2 trials investigated the role of high-efficiency particulate air (HEPA)
filtersbull 1 trial using a factorial design investigated the efficacy of both
acaricide and house dust mite impermeable bedding covers in isolation and combination
bull Remaining 4 trials investigated the efficacy of bedroom environmental control programmes involving use of house dust mite impermeable bedding covers
Cochrane Database of Systematic Reviews 2010 Issue 7
bull Trials to date small and of poor methodological qualitybull difficult to offer any definitive recommendations on the role
bull use of acaricides and extensive bedroom-based environmental control programmes may be of some benefit in reducing rhinitis symptoms but the evidence is not strong
bull Isolated use of house dust mite impermeable bedding is unlikely to prove effective
bull More research is needed
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
METHODS OFMITE ALLERGEN AVOIDANCE
Method
bull Physical methodndash Encasing of beddingndash Vacuums cleanersndash Floor coveringsndash Laundryndash Air filtration
bull Chemical methodndash Acaricide
Encasingsbull In the bedroom covering mattresses and pillows with impermeable
covers is effectivebull This effect may be large variable and persist for a couple of
months
bull Encasings differ widely in their qualityndash some cheap brands have large pores other multilayered encasings delaminate
and others harbor mites
bull Tightly woven synthetic or cotton fabrics are preferred
bull Most trials of encasings have failed to regularly wash them (difficult with some encasings) which renders them ineffective as allergens build up on the outer surface within several weeks
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Curr Allergy Asthma Rep 20088126-32
J Allergy Clin Immunol 20061181164-8
16 tightly woven 9 United States3 Japan2 Thailand1 Germany1 France
laminate-coated and loosely woven cover molting among nonwoven fibers
dead mites on an acaricide-coated and nonwoven cover group of mites in the matrix of a nonwoven cover
J Allergy Clin Immunol 20061181164-8
Nonwoven
J Allergy Clin Immunol 20061181164-8
before after
easy access for mites to readily penetrate into the substrate of the material
J Allergy Clin Immunol 20061181164-8
tightly woven fabric with systematized regular fibers allowing little space for penetration
bull Woven nonwovenndash pore size between 2 and 10 um (average 6 um) blocking most
mite allergens
bull Plasticndash pore free best barrier in terms of blockingndash but the least comfortable zero ventilation ndash tendency to become a haven for mold spores
bull For acaricide-coated materialsndash pore size is usually not a major factor ndash mites are eradicated on contact with the chemicalsndash still allow the passage of allergens ndash prevent penetration through the fabrics but allow colonization
J Allergy Clin Immunol 20061181164-8
Asian Pac J Allergy Immunol 201028155-61
Sensitized level
Symptomatic level
sponge-like polyurethane lowest rate Synthetic fibers and kapok mattresses highest rate
A combination of the following choosing new sponge-like polyurethane or coconut fiber mattresses with mite-impermeable covers and washing sheets pillowcases blankets and mattresses pad at least weekly in hot water should be the best method of prevention in HDM allergen sensitive allergic patients
Laundrybull Both dust and cat and mite allergens are effectively removed by
laundryndash physical removal of both dust and mites by the multiple wash
and rinse cycles ndash effects of detergents additivesndash subsequent drying procedures
bull McDonald LGTovey E ndash All mites were killed by water temperatures 55 degrees C or
greaterndash Killing at lower temperatures was not enhanced by any of the
pure detergents or laundry products tested
J Allergy Clin Immunol 2011128723-7
J Allergy Clin Immunol 199290599-608
Floor coveringsbull Designing the house with polished floors and wooden or
vinylleather furniture so as to limit the sites where mites can grow
bull carpets fitted onto unventilated floors water can accumulate growth of both fungi and mites
bull hard floors are likely to be preferred as they are more easily kept in a state that minimizes aeroallergen reaerosolization in the long term
bull the little available data of aeroallergens in houses suggest that the difference may be small and the effects complex
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552J Allergy Clin Immunol 2011128723-7
Vacuum cleaners
bull Vacuum cleaners are heavily promoted
bull Probably all cleaners cause a brief increase in personal aeroallergen exposure under normal domestic conditions and high-efficiency particulate arrest (HEPA) filters make little difference
bull Thus the benefits of HEPA filtration on exposure may have been exaggerated and all cleaners probably provide a brief increase in exposure
J Allergy Clin Immunol 2011128723-7
Allergy 200661119-23
Air management
bull indoor relative humidity is kept below 50 (absolute humidity below 6 gkg)
bull In some areas of the world this can be done by increasing ventilation
bull in other areas it is necessary to use air conditioning during the most humid months of the summer
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Air filtration
bull The role of air filtration continues to be debatedbull There is some consensus that small benefits exist mainly for pet
allergens
J Allergy Clin Immunol 2011128723-7
Acaricidesbull variety of acaricides have been used to treat carpets or furniturebull pyrethroids natamycin (an antifungal) pirimiphos methyl and
benzyl benzoate bull killing mites
bull Acaricides proved largely ineffective because the mite populations return shortly after their application and they may also cause skin and respiratory irritation
bull No data on clinical benefit exist and concerns about human health and environmental toxicity remain
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
J Allergy Clin Immunol 2011128723-7
Acaricidesbull 1 or 3 tannic acid
ndash method of denaturing mite allergensndash reduction of mite allergen can be achievedndash does not kill mitesndash so the effect can only be temporary approximately 6 weeks to 3
months
bull may be recommended when it is not possible to remove the carpets or change the furniture
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
Cochrane Library 2011 Issue 10
Cochrane Library 2011 Issue 10
bull The variability applies to the evaluation of patients the intervention used and the assessment of outcome
bull Meta-analysis is only valid when the studies are comparable and this may not be true for the successful studies on allergen avoidance
J Allergy Clin Immunol 2008122694-6
very different designs and engage different subjects time frames controls seasons and methods of intervention
J Allergy Clin Immunol 2011128723-7
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
longer than 6 months
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull most professional guidelines for asthma management advocate the avoidance of acute allergen lsquolsquotriggersrsquorsquo
bull there is a diversity of views about the role of allergen avoidance practices in long-term disease management
bull 2007 National Heart Lung and Blood Institute EPR3 (US) reportndash advises that the first and most important step in controlling
allergen induced asthma is to reduce exposure
J Allergy Clin Immunol 2011128723-7
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull Finnish Allergy Program 2008-2018 ndash promotes holistic lsquolsquoallergy healthrsquorsquo through diet and physical
activity and advocates allergen avoidance only lsquolsquoin mandatory situationsrsquorsquo
bull Both the 2009 Global Initiative for Asthma and the British Thoracic Society guidelines reflect (Cochrane review)
ndash no consistent evidence for allergen avoidance in preventing asthma
ndash only tenuous evidence that reducing allergen exposure can reduce asthma morbidity
J Allergy Clin Immunol 2011128723-7
ICON pediatric asthmabull some ambiguity with respect to the role of allergen avoidance
bull JGCA NAEPP3 and PRACTALL ndash specific recommendations for the reduction in allergen exposure
for sensitized patients with asthma
bull AAMH GINA and SIGNndash unproven effectiveness of current avoidance strategies on
asthma control
bull a multifaceted comprehensive approach is prerequisite for clinical benefit
Allergy 2012 67 976ndash997
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
bull 9 trials involving 501 participants bull 2 studies investigating the effectiveness of mite impermeable
bedding covers were of good qualitybull 7 studies were small and of poor qualitybull 2 trials investigated the efficacy of acaricidesbull 2 trials investigated the role of high-efficiency particulate air (HEPA)
filtersbull 1 trial using a factorial design investigated the efficacy of both
acaricide and house dust mite impermeable bedding covers in isolation and combination
bull Remaining 4 trials investigated the efficacy of bedroom environmental control programmes involving use of house dust mite impermeable bedding covers
Cochrane Database of Systematic Reviews 2010 Issue 7
bull Trials to date small and of poor methodological qualitybull difficult to offer any definitive recommendations on the role
bull use of acaricides and extensive bedroom-based environmental control programmes may be of some benefit in reducing rhinitis symptoms but the evidence is not strong
bull Isolated use of house dust mite impermeable bedding is unlikely to prove effective
bull More research is needed
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
METHODS OFMITE ALLERGEN AVOIDANCE
Method
bull Physical methodndash Encasing of beddingndash Vacuums cleanersndash Floor coveringsndash Laundryndash Air filtration
bull Chemical methodndash Acaricide
Encasingsbull In the bedroom covering mattresses and pillows with impermeable
covers is effectivebull This effect may be large variable and persist for a couple of
months
bull Encasings differ widely in their qualityndash some cheap brands have large pores other multilayered encasings delaminate
and others harbor mites
bull Tightly woven synthetic or cotton fabrics are preferred
bull Most trials of encasings have failed to regularly wash them (difficult with some encasings) which renders them ineffective as allergens build up on the outer surface within several weeks
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Curr Allergy Asthma Rep 20088126-32
J Allergy Clin Immunol 20061181164-8
16 tightly woven 9 United States3 Japan2 Thailand1 Germany1 France
laminate-coated and loosely woven cover molting among nonwoven fibers
dead mites on an acaricide-coated and nonwoven cover group of mites in the matrix of a nonwoven cover
J Allergy Clin Immunol 20061181164-8
Nonwoven
J Allergy Clin Immunol 20061181164-8
before after
easy access for mites to readily penetrate into the substrate of the material
J Allergy Clin Immunol 20061181164-8
tightly woven fabric with systematized regular fibers allowing little space for penetration
bull Woven nonwovenndash pore size between 2 and 10 um (average 6 um) blocking most
mite allergens
bull Plasticndash pore free best barrier in terms of blockingndash but the least comfortable zero ventilation ndash tendency to become a haven for mold spores
bull For acaricide-coated materialsndash pore size is usually not a major factor ndash mites are eradicated on contact with the chemicalsndash still allow the passage of allergens ndash prevent penetration through the fabrics but allow colonization
J Allergy Clin Immunol 20061181164-8
Asian Pac J Allergy Immunol 201028155-61
Sensitized level
Symptomatic level
sponge-like polyurethane lowest rate Synthetic fibers and kapok mattresses highest rate
A combination of the following choosing new sponge-like polyurethane or coconut fiber mattresses with mite-impermeable covers and washing sheets pillowcases blankets and mattresses pad at least weekly in hot water should be the best method of prevention in HDM allergen sensitive allergic patients
Laundrybull Both dust and cat and mite allergens are effectively removed by
laundryndash physical removal of both dust and mites by the multiple wash
and rinse cycles ndash effects of detergents additivesndash subsequent drying procedures
bull McDonald LGTovey E ndash All mites were killed by water temperatures 55 degrees C or
greaterndash Killing at lower temperatures was not enhanced by any of the
pure detergents or laundry products tested
J Allergy Clin Immunol 2011128723-7
J Allergy Clin Immunol 199290599-608
Floor coveringsbull Designing the house with polished floors and wooden or
vinylleather furniture so as to limit the sites where mites can grow
bull carpets fitted onto unventilated floors water can accumulate growth of both fungi and mites
bull hard floors are likely to be preferred as they are more easily kept in a state that minimizes aeroallergen reaerosolization in the long term
bull the little available data of aeroallergens in houses suggest that the difference may be small and the effects complex
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552J Allergy Clin Immunol 2011128723-7
Vacuum cleaners
bull Vacuum cleaners are heavily promoted
bull Probably all cleaners cause a brief increase in personal aeroallergen exposure under normal domestic conditions and high-efficiency particulate arrest (HEPA) filters make little difference
bull Thus the benefits of HEPA filtration on exposure may have been exaggerated and all cleaners probably provide a brief increase in exposure
J Allergy Clin Immunol 2011128723-7
Allergy 200661119-23
Air management
bull indoor relative humidity is kept below 50 (absolute humidity below 6 gkg)
bull In some areas of the world this can be done by increasing ventilation
bull in other areas it is necessary to use air conditioning during the most humid months of the summer
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Air filtration
bull The role of air filtration continues to be debatedbull There is some consensus that small benefits exist mainly for pet
allergens
J Allergy Clin Immunol 2011128723-7
Acaricidesbull variety of acaricides have been used to treat carpets or furniturebull pyrethroids natamycin (an antifungal) pirimiphos methyl and
benzyl benzoate bull killing mites
bull Acaricides proved largely ineffective because the mite populations return shortly after their application and they may also cause skin and respiratory irritation
bull No data on clinical benefit exist and concerns about human health and environmental toxicity remain
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
J Allergy Clin Immunol 2011128723-7
Acaricidesbull 1 or 3 tannic acid
ndash method of denaturing mite allergensndash reduction of mite allergen can be achievedndash does not kill mitesndash so the effect can only be temporary approximately 6 weeks to 3
months
bull may be recommended when it is not possible to remove the carpets or change the furniture
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
Cochrane Library 2011 Issue 10
bull The variability applies to the evaluation of patients the intervention used and the assessment of outcome
bull Meta-analysis is only valid when the studies are comparable and this may not be true for the successful studies on allergen avoidance
J Allergy Clin Immunol 2008122694-6
very different designs and engage different subjects time frames controls seasons and methods of intervention
J Allergy Clin Immunol 2011128723-7
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
longer than 6 months
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull most professional guidelines for asthma management advocate the avoidance of acute allergen lsquolsquotriggersrsquorsquo
bull there is a diversity of views about the role of allergen avoidance practices in long-term disease management
bull 2007 National Heart Lung and Blood Institute EPR3 (US) reportndash advises that the first and most important step in controlling
allergen induced asthma is to reduce exposure
J Allergy Clin Immunol 2011128723-7
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull Finnish Allergy Program 2008-2018 ndash promotes holistic lsquolsquoallergy healthrsquorsquo through diet and physical
activity and advocates allergen avoidance only lsquolsquoin mandatory situationsrsquorsquo
bull Both the 2009 Global Initiative for Asthma and the British Thoracic Society guidelines reflect (Cochrane review)
ndash no consistent evidence for allergen avoidance in preventing asthma
ndash only tenuous evidence that reducing allergen exposure can reduce asthma morbidity
J Allergy Clin Immunol 2011128723-7
ICON pediatric asthmabull some ambiguity with respect to the role of allergen avoidance
bull JGCA NAEPP3 and PRACTALL ndash specific recommendations for the reduction in allergen exposure
for sensitized patients with asthma
bull AAMH GINA and SIGNndash unproven effectiveness of current avoidance strategies on
asthma control
bull a multifaceted comprehensive approach is prerequisite for clinical benefit
Allergy 2012 67 976ndash997
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
bull 9 trials involving 501 participants bull 2 studies investigating the effectiveness of mite impermeable
bedding covers were of good qualitybull 7 studies were small and of poor qualitybull 2 trials investigated the efficacy of acaricidesbull 2 trials investigated the role of high-efficiency particulate air (HEPA)
filtersbull 1 trial using a factorial design investigated the efficacy of both
acaricide and house dust mite impermeable bedding covers in isolation and combination
bull Remaining 4 trials investigated the efficacy of bedroom environmental control programmes involving use of house dust mite impermeable bedding covers
Cochrane Database of Systematic Reviews 2010 Issue 7
bull Trials to date small and of poor methodological qualitybull difficult to offer any definitive recommendations on the role
bull use of acaricides and extensive bedroom-based environmental control programmes may be of some benefit in reducing rhinitis symptoms but the evidence is not strong
bull Isolated use of house dust mite impermeable bedding is unlikely to prove effective
bull More research is needed
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
METHODS OFMITE ALLERGEN AVOIDANCE
Method
bull Physical methodndash Encasing of beddingndash Vacuums cleanersndash Floor coveringsndash Laundryndash Air filtration
bull Chemical methodndash Acaricide
Encasingsbull In the bedroom covering mattresses and pillows with impermeable
covers is effectivebull This effect may be large variable and persist for a couple of
months
bull Encasings differ widely in their qualityndash some cheap brands have large pores other multilayered encasings delaminate
and others harbor mites
bull Tightly woven synthetic or cotton fabrics are preferred
bull Most trials of encasings have failed to regularly wash them (difficult with some encasings) which renders them ineffective as allergens build up on the outer surface within several weeks
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Curr Allergy Asthma Rep 20088126-32
J Allergy Clin Immunol 20061181164-8
16 tightly woven 9 United States3 Japan2 Thailand1 Germany1 France
laminate-coated and loosely woven cover molting among nonwoven fibers
dead mites on an acaricide-coated and nonwoven cover group of mites in the matrix of a nonwoven cover
J Allergy Clin Immunol 20061181164-8
Nonwoven
J Allergy Clin Immunol 20061181164-8
before after
easy access for mites to readily penetrate into the substrate of the material
J Allergy Clin Immunol 20061181164-8
tightly woven fabric with systematized regular fibers allowing little space for penetration
bull Woven nonwovenndash pore size between 2 and 10 um (average 6 um) blocking most
mite allergens
bull Plasticndash pore free best barrier in terms of blockingndash but the least comfortable zero ventilation ndash tendency to become a haven for mold spores
bull For acaricide-coated materialsndash pore size is usually not a major factor ndash mites are eradicated on contact with the chemicalsndash still allow the passage of allergens ndash prevent penetration through the fabrics but allow colonization
J Allergy Clin Immunol 20061181164-8
Asian Pac J Allergy Immunol 201028155-61
Sensitized level
Symptomatic level
sponge-like polyurethane lowest rate Synthetic fibers and kapok mattresses highest rate
A combination of the following choosing new sponge-like polyurethane or coconut fiber mattresses with mite-impermeable covers and washing sheets pillowcases blankets and mattresses pad at least weekly in hot water should be the best method of prevention in HDM allergen sensitive allergic patients
Laundrybull Both dust and cat and mite allergens are effectively removed by
laundryndash physical removal of both dust and mites by the multiple wash
and rinse cycles ndash effects of detergents additivesndash subsequent drying procedures
bull McDonald LGTovey E ndash All mites were killed by water temperatures 55 degrees C or
greaterndash Killing at lower temperatures was not enhanced by any of the
pure detergents or laundry products tested
J Allergy Clin Immunol 2011128723-7
J Allergy Clin Immunol 199290599-608
Floor coveringsbull Designing the house with polished floors and wooden or
vinylleather furniture so as to limit the sites where mites can grow
bull carpets fitted onto unventilated floors water can accumulate growth of both fungi and mites
bull hard floors are likely to be preferred as they are more easily kept in a state that minimizes aeroallergen reaerosolization in the long term
bull the little available data of aeroallergens in houses suggest that the difference may be small and the effects complex
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552J Allergy Clin Immunol 2011128723-7
Vacuum cleaners
bull Vacuum cleaners are heavily promoted
bull Probably all cleaners cause a brief increase in personal aeroallergen exposure under normal domestic conditions and high-efficiency particulate arrest (HEPA) filters make little difference
bull Thus the benefits of HEPA filtration on exposure may have been exaggerated and all cleaners probably provide a brief increase in exposure
J Allergy Clin Immunol 2011128723-7
Allergy 200661119-23
Air management
bull indoor relative humidity is kept below 50 (absolute humidity below 6 gkg)
bull In some areas of the world this can be done by increasing ventilation
bull in other areas it is necessary to use air conditioning during the most humid months of the summer
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Air filtration
bull The role of air filtration continues to be debatedbull There is some consensus that small benefits exist mainly for pet
allergens
J Allergy Clin Immunol 2011128723-7
Acaricidesbull variety of acaricides have been used to treat carpets or furniturebull pyrethroids natamycin (an antifungal) pirimiphos methyl and
benzyl benzoate bull killing mites
bull Acaricides proved largely ineffective because the mite populations return shortly after their application and they may also cause skin and respiratory irritation
bull No data on clinical benefit exist and concerns about human health and environmental toxicity remain
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
J Allergy Clin Immunol 2011128723-7
Acaricidesbull 1 or 3 tannic acid
ndash method of denaturing mite allergensndash reduction of mite allergen can be achievedndash does not kill mitesndash so the effect can only be temporary approximately 6 weeks to 3
months
bull may be recommended when it is not possible to remove the carpets or change the furniture
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
bull The variability applies to the evaluation of patients the intervention used and the assessment of outcome
bull Meta-analysis is only valid when the studies are comparable and this may not be true for the successful studies on allergen avoidance
J Allergy Clin Immunol 2008122694-6
very different designs and engage different subjects time frames controls seasons and methods of intervention
J Allergy Clin Immunol 2011128723-7
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
longer than 6 months
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull most professional guidelines for asthma management advocate the avoidance of acute allergen lsquolsquotriggersrsquorsquo
bull there is a diversity of views about the role of allergen avoidance practices in long-term disease management
bull 2007 National Heart Lung and Blood Institute EPR3 (US) reportndash advises that the first and most important step in controlling
allergen induced asthma is to reduce exposure
J Allergy Clin Immunol 2011128723-7
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull Finnish Allergy Program 2008-2018 ndash promotes holistic lsquolsquoallergy healthrsquorsquo through diet and physical
activity and advocates allergen avoidance only lsquolsquoin mandatory situationsrsquorsquo
bull Both the 2009 Global Initiative for Asthma and the British Thoracic Society guidelines reflect (Cochrane review)
ndash no consistent evidence for allergen avoidance in preventing asthma
ndash only tenuous evidence that reducing allergen exposure can reduce asthma morbidity
J Allergy Clin Immunol 2011128723-7
ICON pediatric asthmabull some ambiguity with respect to the role of allergen avoidance
bull JGCA NAEPP3 and PRACTALL ndash specific recommendations for the reduction in allergen exposure
for sensitized patients with asthma
bull AAMH GINA and SIGNndash unproven effectiveness of current avoidance strategies on
asthma control
bull a multifaceted comprehensive approach is prerequisite for clinical benefit
Allergy 2012 67 976ndash997
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
bull 9 trials involving 501 participants bull 2 studies investigating the effectiveness of mite impermeable
bedding covers were of good qualitybull 7 studies were small and of poor qualitybull 2 trials investigated the efficacy of acaricidesbull 2 trials investigated the role of high-efficiency particulate air (HEPA)
filtersbull 1 trial using a factorial design investigated the efficacy of both
acaricide and house dust mite impermeable bedding covers in isolation and combination
bull Remaining 4 trials investigated the efficacy of bedroom environmental control programmes involving use of house dust mite impermeable bedding covers
Cochrane Database of Systematic Reviews 2010 Issue 7
bull Trials to date small and of poor methodological qualitybull difficult to offer any definitive recommendations on the role
bull use of acaricides and extensive bedroom-based environmental control programmes may be of some benefit in reducing rhinitis symptoms but the evidence is not strong
bull Isolated use of house dust mite impermeable bedding is unlikely to prove effective
bull More research is needed
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
METHODS OFMITE ALLERGEN AVOIDANCE
Method
bull Physical methodndash Encasing of beddingndash Vacuums cleanersndash Floor coveringsndash Laundryndash Air filtration
bull Chemical methodndash Acaricide
Encasingsbull In the bedroom covering mattresses and pillows with impermeable
covers is effectivebull This effect may be large variable and persist for a couple of
months
bull Encasings differ widely in their qualityndash some cheap brands have large pores other multilayered encasings delaminate
and others harbor mites
bull Tightly woven synthetic or cotton fabrics are preferred
bull Most trials of encasings have failed to regularly wash them (difficult with some encasings) which renders them ineffective as allergens build up on the outer surface within several weeks
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Curr Allergy Asthma Rep 20088126-32
J Allergy Clin Immunol 20061181164-8
16 tightly woven 9 United States3 Japan2 Thailand1 Germany1 France
laminate-coated and loosely woven cover molting among nonwoven fibers
dead mites on an acaricide-coated and nonwoven cover group of mites in the matrix of a nonwoven cover
J Allergy Clin Immunol 20061181164-8
Nonwoven
J Allergy Clin Immunol 20061181164-8
before after
easy access for mites to readily penetrate into the substrate of the material
J Allergy Clin Immunol 20061181164-8
tightly woven fabric with systematized regular fibers allowing little space for penetration
bull Woven nonwovenndash pore size between 2 and 10 um (average 6 um) blocking most
mite allergens
bull Plasticndash pore free best barrier in terms of blockingndash but the least comfortable zero ventilation ndash tendency to become a haven for mold spores
bull For acaricide-coated materialsndash pore size is usually not a major factor ndash mites are eradicated on contact with the chemicalsndash still allow the passage of allergens ndash prevent penetration through the fabrics but allow colonization
J Allergy Clin Immunol 20061181164-8
Asian Pac J Allergy Immunol 201028155-61
Sensitized level
Symptomatic level
sponge-like polyurethane lowest rate Synthetic fibers and kapok mattresses highest rate
A combination of the following choosing new sponge-like polyurethane or coconut fiber mattresses with mite-impermeable covers and washing sheets pillowcases blankets and mattresses pad at least weekly in hot water should be the best method of prevention in HDM allergen sensitive allergic patients
Laundrybull Both dust and cat and mite allergens are effectively removed by
laundryndash physical removal of both dust and mites by the multiple wash
and rinse cycles ndash effects of detergents additivesndash subsequent drying procedures
bull McDonald LGTovey E ndash All mites were killed by water temperatures 55 degrees C or
greaterndash Killing at lower temperatures was not enhanced by any of the
pure detergents or laundry products tested
J Allergy Clin Immunol 2011128723-7
J Allergy Clin Immunol 199290599-608
Floor coveringsbull Designing the house with polished floors and wooden or
vinylleather furniture so as to limit the sites where mites can grow
bull carpets fitted onto unventilated floors water can accumulate growth of both fungi and mites
bull hard floors are likely to be preferred as they are more easily kept in a state that minimizes aeroallergen reaerosolization in the long term
bull the little available data of aeroallergens in houses suggest that the difference may be small and the effects complex
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552J Allergy Clin Immunol 2011128723-7
Vacuum cleaners
bull Vacuum cleaners are heavily promoted
bull Probably all cleaners cause a brief increase in personal aeroallergen exposure under normal domestic conditions and high-efficiency particulate arrest (HEPA) filters make little difference
bull Thus the benefits of HEPA filtration on exposure may have been exaggerated and all cleaners probably provide a brief increase in exposure
J Allergy Clin Immunol 2011128723-7
Allergy 200661119-23
Air management
bull indoor relative humidity is kept below 50 (absolute humidity below 6 gkg)
bull In some areas of the world this can be done by increasing ventilation
bull in other areas it is necessary to use air conditioning during the most humid months of the summer
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Air filtration
bull The role of air filtration continues to be debatedbull There is some consensus that small benefits exist mainly for pet
allergens
J Allergy Clin Immunol 2011128723-7
Acaricidesbull variety of acaricides have been used to treat carpets or furniturebull pyrethroids natamycin (an antifungal) pirimiphos methyl and
benzyl benzoate bull killing mites
bull Acaricides proved largely ineffective because the mite populations return shortly after their application and they may also cause skin and respiratory irritation
bull No data on clinical benefit exist and concerns about human health and environmental toxicity remain
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
J Allergy Clin Immunol 2011128723-7
Acaricidesbull 1 or 3 tannic acid
ndash method of denaturing mite allergensndash reduction of mite allergen can be achievedndash does not kill mitesndash so the effect can only be temporary approximately 6 weeks to 3
months
bull may be recommended when it is not possible to remove the carpets or change the furniture
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
longer than 6 months
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull most professional guidelines for asthma management advocate the avoidance of acute allergen lsquolsquotriggersrsquorsquo
bull there is a diversity of views about the role of allergen avoidance practices in long-term disease management
bull 2007 National Heart Lung and Blood Institute EPR3 (US) reportndash advises that the first and most important step in controlling
allergen induced asthma is to reduce exposure
J Allergy Clin Immunol 2011128723-7
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull Finnish Allergy Program 2008-2018 ndash promotes holistic lsquolsquoallergy healthrsquorsquo through diet and physical
activity and advocates allergen avoidance only lsquolsquoin mandatory situationsrsquorsquo
bull Both the 2009 Global Initiative for Asthma and the British Thoracic Society guidelines reflect (Cochrane review)
ndash no consistent evidence for allergen avoidance in preventing asthma
ndash only tenuous evidence that reducing allergen exposure can reduce asthma morbidity
J Allergy Clin Immunol 2011128723-7
ICON pediatric asthmabull some ambiguity with respect to the role of allergen avoidance
bull JGCA NAEPP3 and PRACTALL ndash specific recommendations for the reduction in allergen exposure
for sensitized patients with asthma
bull AAMH GINA and SIGNndash unproven effectiveness of current avoidance strategies on
asthma control
bull a multifaceted comprehensive approach is prerequisite for clinical benefit
Allergy 2012 67 976ndash997
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
bull 9 trials involving 501 participants bull 2 studies investigating the effectiveness of mite impermeable
bedding covers were of good qualitybull 7 studies were small and of poor qualitybull 2 trials investigated the efficacy of acaricidesbull 2 trials investigated the role of high-efficiency particulate air (HEPA)
filtersbull 1 trial using a factorial design investigated the efficacy of both
acaricide and house dust mite impermeable bedding covers in isolation and combination
bull Remaining 4 trials investigated the efficacy of bedroom environmental control programmes involving use of house dust mite impermeable bedding covers
Cochrane Database of Systematic Reviews 2010 Issue 7
bull Trials to date small and of poor methodological qualitybull difficult to offer any definitive recommendations on the role
bull use of acaricides and extensive bedroom-based environmental control programmes may be of some benefit in reducing rhinitis symptoms but the evidence is not strong
bull Isolated use of house dust mite impermeable bedding is unlikely to prove effective
bull More research is needed
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
METHODS OFMITE ALLERGEN AVOIDANCE
Method
bull Physical methodndash Encasing of beddingndash Vacuums cleanersndash Floor coveringsndash Laundryndash Air filtration
bull Chemical methodndash Acaricide
Encasingsbull In the bedroom covering mattresses and pillows with impermeable
covers is effectivebull This effect may be large variable and persist for a couple of
months
bull Encasings differ widely in their qualityndash some cheap brands have large pores other multilayered encasings delaminate
and others harbor mites
bull Tightly woven synthetic or cotton fabrics are preferred
bull Most trials of encasings have failed to regularly wash them (difficult with some encasings) which renders them ineffective as allergens build up on the outer surface within several weeks
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Curr Allergy Asthma Rep 20088126-32
J Allergy Clin Immunol 20061181164-8
16 tightly woven 9 United States3 Japan2 Thailand1 Germany1 France
laminate-coated and loosely woven cover molting among nonwoven fibers
dead mites on an acaricide-coated and nonwoven cover group of mites in the matrix of a nonwoven cover
J Allergy Clin Immunol 20061181164-8
Nonwoven
J Allergy Clin Immunol 20061181164-8
before after
easy access for mites to readily penetrate into the substrate of the material
J Allergy Clin Immunol 20061181164-8
tightly woven fabric with systematized regular fibers allowing little space for penetration
bull Woven nonwovenndash pore size between 2 and 10 um (average 6 um) blocking most
mite allergens
bull Plasticndash pore free best barrier in terms of blockingndash but the least comfortable zero ventilation ndash tendency to become a haven for mold spores
bull For acaricide-coated materialsndash pore size is usually not a major factor ndash mites are eradicated on contact with the chemicalsndash still allow the passage of allergens ndash prevent penetration through the fabrics but allow colonization
J Allergy Clin Immunol 20061181164-8
Asian Pac J Allergy Immunol 201028155-61
Sensitized level
Symptomatic level
sponge-like polyurethane lowest rate Synthetic fibers and kapok mattresses highest rate
A combination of the following choosing new sponge-like polyurethane or coconut fiber mattresses with mite-impermeable covers and washing sheets pillowcases blankets and mattresses pad at least weekly in hot water should be the best method of prevention in HDM allergen sensitive allergic patients
Laundrybull Both dust and cat and mite allergens are effectively removed by
laundryndash physical removal of both dust and mites by the multiple wash
and rinse cycles ndash effects of detergents additivesndash subsequent drying procedures
bull McDonald LGTovey E ndash All mites were killed by water temperatures 55 degrees C or
greaterndash Killing at lower temperatures was not enhanced by any of the
pure detergents or laundry products tested
J Allergy Clin Immunol 2011128723-7
J Allergy Clin Immunol 199290599-608
Floor coveringsbull Designing the house with polished floors and wooden or
vinylleather furniture so as to limit the sites where mites can grow
bull carpets fitted onto unventilated floors water can accumulate growth of both fungi and mites
bull hard floors are likely to be preferred as they are more easily kept in a state that minimizes aeroallergen reaerosolization in the long term
bull the little available data of aeroallergens in houses suggest that the difference may be small and the effects complex
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552J Allergy Clin Immunol 2011128723-7
Vacuum cleaners
bull Vacuum cleaners are heavily promoted
bull Probably all cleaners cause a brief increase in personal aeroallergen exposure under normal domestic conditions and high-efficiency particulate arrest (HEPA) filters make little difference
bull Thus the benefits of HEPA filtration on exposure may have been exaggerated and all cleaners probably provide a brief increase in exposure
J Allergy Clin Immunol 2011128723-7
Allergy 200661119-23
Air management
bull indoor relative humidity is kept below 50 (absolute humidity below 6 gkg)
bull In some areas of the world this can be done by increasing ventilation
bull in other areas it is necessary to use air conditioning during the most humid months of the summer
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Air filtration
bull The role of air filtration continues to be debatedbull There is some consensus that small benefits exist mainly for pet
allergens
J Allergy Clin Immunol 2011128723-7
Acaricidesbull variety of acaricides have been used to treat carpets or furniturebull pyrethroids natamycin (an antifungal) pirimiphos methyl and
benzyl benzoate bull killing mites
bull Acaricides proved largely ineffective because the mite populations return shortly after their application and they may also cause skin and respiratory irritation
bull No data on clinical benefit exist and concerns about human health and environmental toxicity remain
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
J Allergy Clin Immunol 2011128723-7
Acaricidesbull 1 or 3 tannic acid
ndash method of denaturing mite allergensndash reduction of mite allergen can be achievedndash does not kill mitesndash so the effect can only be temporary approximately 6 weeks to 3
months
bull may be recommended when it is not possible to remove the carpets or change the furniture
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull most professional guidelines for asthma management advocate the avoidance of acute allergen lsquolsquotriggersrsquorsquo
bull there is a diversity of views about the role of allergen avoidance practices in long-term disease management
bull 2007 National Heart Lung and Blood Institute EPR3 (US) reportndash advises that the first and most important step in controlling
allergen induced asthma is to reduce exposure
J Allergy Clin Immunol 2011128723-7
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull Finnish Allergy Program 2008-2018 ndash promotes holistic lsquolsquoallergy healthrsquorsquo through diet and physical
activity and advocates allergen avoidance only lsquolsquoin mandatory situationsrsquorsquo
bull Both the 2009 Global Initiative for Asthma and the British Thoracic Society guidelines reflect (Cochrane review)
ndash no consistent evidence for allergen avoidance in preventing asthma
ndash only tenuous evidence that reducing allergen exposure can reduce asthma morbidity
J Allergy Clin Immunol 2011128723-7
ICON pediatric asthmabull some ambiguity with respect to the role of allergen avoidance
bull JGCA NAEPP3 and PRACTALL ndash specific recommendations for the reduction in allergen exposure
for sensitized patients with asthma
bull AAMH GINA and SIGNndash unproven effectiveness of current avoidance strategies on
asthma control
bull a multifaceted comprehensive approach is prerequisite for clinical benefit
Allergy 2012 67 976ndash997
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
bull 9 trials involving 501 participants bull 2 studies investigating the effectiveness of mite impermeable
bedding covers were of good qualitybull 7 studies were small and of poor qualitybull 2 trials investigated the efficacy of acaricidesbull 2 trials investigated the role of high-efficiency particulate air (HEPA)
filtersbull 1 trial using a factorial design investigated the efficacy of both
acaricide and house dust mite impermeable bedding covers in isolation and combination
bull Remaining 4 trials investigated the efficacy of bedroom environmental control programmes involving use of house dust mite impermeable bedding covers
Cochrane Database of Systematic Reviews 2010 Issue 7
bull Trials to date small and of poor methodological qualitybull difficult to offer any definitive recommendations on the role
bull use of acaricides and extensive bedroom-based environmental control programmes may be of some benefit in reducing rhinitis symptoms but the evidence is not strong
bull Isolated use of house dust mite impermeable bedding is unlikely to prove effective
bull More research is needed
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
METHODS OFMITE ALLERGEN AVOIDANCE
Method
bull Physical methodndash Encasing of beddingndash Vacuums cleanersndash Floor coveringsndash Laundryndash Air filtration
bull Chemical methodndash Acaricide
Encasingsbull In the bedroom covering mattresses and pillows with impermeable
covers is effectivebull This effect may be large variable and persist for a couple of
months
bull Encasings differ widely in their qualityndash some cheap brands have large pores other multilayered encasings delaminate
and others harbor mites
bull Tightly woven synthetic or cotton fabrics are preferred
bull Most trials of encasings have failed to regularly wash them (difficult with some encasings) which renders them ineffective as allergens build up on the outer surface within several weeks
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Curr Allergy Asthma Rep 20088126-32
J Allergy Clin Immunol 20061181164-8
16 tightly woven 9 United States3 Japan2 Thailand1 Germany1 France
laminate-coated and loosely woven cover molting among nonwoven fibers
dead mites on an acaricide-coated and nonwoven cover group of mites in the matrix of a nonwoven cover
J Allergy Clin Immunol 20061181164-8
Nonwoven
J Allergy Clin Immunol 20061181164-8
before after
easy access for mites to readily penetrate into the substrate of the material
J Allergy Clin Immunol 20061181164-8
tightly woven fabric with systematized regular fibers allowing little space for penetration
bull Woven nonwovenndash pore size between 2 and 10 um (average 6 um) blocking most
mite allergens
bull Plasticndash pore free best barrier in terms of blockingndash but the least comfortable zero ventilation ndash tendency to become a haven for mold spores
bull For acaricide-coated materialsndash pore size is usually not a major factor ndash mites are eradicated on contact with the chemicalsndash still allow the passage of allergens ndash prevent penetration through the fabrics but allow colonization
J Allergy Clin Immunol 20061181164-8
Asian Pac J Allergy Immunol 201028155-61
Sensitized level
Symptomatic level
sponge-like polyurethane lowest rate Synthetic fibers and kapok mattresses highest rate
A combination of the following choosing new sponge-like polyurethane or coconut fiber mattresses with mite-impermeable covers and washing sheets pillowcases blankets and mattresses pad at least weekly in hot water should be the best method of prevention in HDM allergen sensitive allergic patients
Laundrybull Both dust and cat and mite allergens are effectively removed by
laundryndash physical removal of both dust and mites by the multiple wash
and rinse cycles ndash effects of detergents additivesndash subsequent drying procedures
bull McDonald LGTovey E ndash All mites were killed by water temperatures 55 degrees C or
greaterndash Killing at lower temperatures was not enhanced by any of the
pure detergents or laundry products tested
J Allergy Clin Immunol 2011128723-7
J Allergy Clin Immunol 199290599-608
Floor coveringsbull Designing the house with polished floors and wooden or
vinylleather furniture so as to limit the sites where mites can grow
bull carpets fitted onto unventilated floors water can accumulate growth of both fungi and mites
bull hard floors are likely to be preferred as they are more easily kept in a state that minimizes aeroallergen reaerosolization in the long term
bull the little available data of aeroallergens in houses suggest that the difference may be small and the effects complex
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552J Allergy Clin Immunol 2011128723-7
Vacuum cleaners
bull Vacuum cleaners are heavily promoted
bull Probably all cleaners cause a brief increase in personal aeroallergen exposure under normal domestic conditions and high-efficiency particulate arrest (HEPA) filters make little difference
bull Thus the benefits of HEPA filtration on exposure may have been exaggerated and all cleaners probably provide a brief increase in exposure
J Allergy Clin Immunol 2011128723-7
Allergy 200661119-23
Air management
bull indoor relative humidity is kept below 50 (absolute humidity below 6 gkg)
bull In some areas of the world this can be done by increasing ventilation
bull in other areas it is necessary to use air conditioning during the most humid months of the summer
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Air filtration
bull The role of air filtration continues to be debatedbull There is some consensus that small benefits exist mainly for pet
allergens
J Allergy Clin Immunol 2011128723-7
Acaricidesbull variety of acaricides have been used to treat carpets or furniturebull pyrethroids natamycin (an antifungal) pirimiphos methyl and
benzyl benzoate bull killing mites
bull Acaricides proved largely ineffective because the mite populations return shortly after their application and they may also cause skin and respiratory irritation
bull No data on clinical benefit exist and concerns about human health and environmental toxicity remain
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
J Allergy Clin Immunol 2011128723-7
Acaricidesbull 1 or 3 tannic acid
ndash method of denaturing mite allergensndash reduction of mite allergen can be achievedndash does not kill mitesndash so the effect can only be temporary approximately 6 weeks to 3
months
bull may be recommended when it is not possible to remove the carpets or change the furniture
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
CURRENT MEDICAL GUIDELINES AND ALLERGEN AVOIDANCE
bull Finnish Allergy Program 2008-2018 ndash promotes holistic lsquolsquoallergy healthrsquorsquo through diet and physical
activity and advocates allergen avoidance only lsquolsquoin mandatory situationsrsquorsquo
bull Both the 2009 Global Initiative for Asthma and the British Thoracic Society guidelines reflect (Cochrane review)
ndash no consistent evidence for allergen avoidance in preventing asthma
ndash only tenuous evidence that reducing allergen exposure can reduce asthma morbidity
J Allergy Clin Immunol 2011128723-7
ICON pediatric asthmabull some ambiguity with respect to the role of allergen avoidance
bull JGCA NAEPP3 and PRACTALL ndash specific recommendations for the reduction in allergen exposure
for sensitized patients with asthma
bull AAMH GINA and SIGNndash unproven effectiveness of current avoidance strategies on
asthma control
bull a multifaceted comprehensive approach is prerequisite for clinical benefit
Allergy 2012 67 976ndash997
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
bull 9 trials involving 501 participants bull 2 studies investigating the effectiveness of mite impermeable
bedding covers were of good qualitybull 7 studies were small and of poor qualitybull 2 trials investigated the efficacy of acaricidesbull 2 trials investigated the role of high-efficiency particulate air (HEPA)
filtersbull 1 trial using a factorial design investigated the efficacy of both
acaricide and house dust mite impermeable bedding covers in isolation and combination
bull Remaining 4 trials investigated the efficacy of bedroom environmental control programmes involving use of house dust mite impermeable bedding covers
Cochrane Database of Systematic Reviews 2010 Issue 7
bull Trials to date small and of poor methodological qualitybull difficult to offer any definitive recommendations on the role
bull use of acaricides and extensive bedroom-based environmental control programmes may be of some benefit in reducing rhinitis symptoms but the evidence is not strong
bull Isolated use of house dust mite impermeable bedding is unlikely to prove effective
bull More research is needed
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
METHODS OFMITE ALLERGEN AVOIDANCE
Method
bull Physical methodndash Encasing of beddingndash Vacuums cleanersndash Floor coveringsndash Laundryndash Air filtration
bull Chemical methodndash Acaricide
Encasingsbull In the bedroom covering mattresses and pillows with impermeable
covers is effectivebull This effect may be large variable and persist for a couple of
months
bull Encasings differ widely in their qualityndash some cheap brands have large pores other multilayered encasings delaminate
and others harbor mites
bull Tightly woven synthetic or cotton fabrics are preferred
bull Most trials of encasings have failed to regularly wash them (difficult with some encasings) which renders them ineffective as allergens build up on the outer surface within several weeks
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Curr Allergy Asthma Rep 20088126-32
J Allergy Clin Immunol 20061181164-8
16 tightly woven 9 United States3 Japan2 Thailand1 Germany1 France
laminate-coated and loosely woven cover molting among nonwoven fibers
dead mites on an acaricide-coated and nonwoven cover group of mites in the matrix of a nonwoven cover
J Allergy Clin Immunol 20061181164-8
Nonwoven
J Allergy Clin Immunol 20061181164-8
before after
easy access for mites to readily penetrate into the substrate of the material
J Allergy Clin Immunol 20061181164-8
tightly woven fabric with systematized regular fibers allowing little space for penetration
bull Woven nonwovenndash pore size between 2 and 10 um (average 6 um) blocking most
mite allergens
bull Plasticndash pore free best barrier in terms of blockingndash but the least comfortable zero ventilation ndash tendency to become a haven for mold spores
bull For acaricide-coated materialsndash pore size is usually not a major factor ndash mites are eradicated on contact with the chemicalsndash still allow the passage of allergens ndash prevent penetration through the fabrics but allow colonization
J Allergy Clin Immunol 20061181164-8
Asian Pac J Allergy Immunol 201028155-61
Sensitized level
Symptomatic level
sponge-like polyurethane lowest rate Synthetic fibers and kapok mattresses highest rate
A combination of the following choosing new sponge-like polyurethane or coconut fiber mattresses with mite-impermeable covers and washing sheets pillowcases blankets and mattresses pad at least weekly in hot water should be the best method of prevention in HDM allergen sensitive allergic patients
Laundrybull Both dust and cat and mite allergens are effectively removed by
laundryndash physical removal of both dust and mites by the multiple wash
and rinse cycles ndash effects of detergents additivesndash subsequent drying procedures
bull McDonald LGTovey E ndash All mites were killed by water temperatures 55 degrees C or
greaterndash Killing at lower temperatures was not enhanced by any of the
pure detergents or laundry products tested
J Allergy Clin Immunol 2011128723-7
J Allergy Clin Immunol 199290599-608
Floor coveringsbull Designing the house with polished floors and wooden or
vinylleather furniture so as to limit the sites where mites can grow
bull carpets fitted onto unventilated floors water can accumulate growth of both fungi and mites
bull hard floors are likely to be preferred as they are more easily kept in a state that minimizes aeroallergen reaerosolization in the long term
bull the little available data of aeroallergens in houses suggest that the difference may be small and the effects complex
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552J Allergy Clin Immunol 2011128723-7
Vacuum cleaners
bull Vacuum cleaners are heavily promoted
bull Probably all cleaners cause a brief increase in personal aeroallergen exposure under normal domestic conditions and high-efficiency particulate arrest (HEPA) filters make little difference
bull Thus the benefits of HEPA filtration on exposure may have been exaggerated and all cleaners probably provide a brief increase in exposure
J Allergy Clin Immunol 2011128723-7
Allergy 200661119-23
Air management
bull indoor relative humidity is kept below 50 (absolute humidity below 6 gkg)
bull In some areas of the world this can be done by increasing ventilation
bull in other areas it is necessary to use air conditioning during the most humid months of the summer
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Air filtration
bull The role of air filtration continues to be debatedbull There is some consensus that small benefits exist mainly for pet
allergens
J Allergy Clin Immunol 2011128723-7
Acaricidesbull variety of acaricides have been used to treat carpets or furniturebull pyrethroids natamycin (an antifungal) pirimiphos methyl and
benzyl benzoate bull killing mites
bull Acaricides proved largely ineffective because the mite populations return shortly after their application and they may also cause skin and respiratory irritation
bull No data on clinical benefit exist and concerns about human health and environmental toxicity remain
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
J Allergy Clin Immunol 2011128723-7
Acaricidesbull 1 or 3 tannic acid
ndash method of denaturing mite allergensndash reduction of mite allergen can be achievedndash does not kill mitesndash so the effect can only be temporary approximately 6 weeks to 3
months
bull may be recommended when it is not possible to remove the carpets or change the furniture
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
ICON pediatric asthmabull some ambiguity with respect to the role of allergen avoidance
bull JGCA NAEPP3 and PRACTALL ndash specific recommendations for the reduction in allergen exposure
for sensitized patients with asthma
bull AAMH GINA and SIGNndash unproven effectiveness of current avoidance strategies on
asthma control
bull a multifaceted comprehensive approach is prerequisite for clinical benefit
Allergy 2012 67 976ndash997
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
bull 9 trials involving 501 participants bull 2 studies investigating the effectiveness of mite impermeable
bedding covers were of good qualitybull 7 studies were small and of poor qualitybull 2 trials investigated the efficacy of acaricidesbull 2 trials investigated the role of high-efficiency particulate air (HEPA)
filtersbull 1 trial using a factorial design investigated the efficacy of both
acaricide and house dust mite impermeable bedding covers in isolation and combination
bull Remaining 4 trials investigated the efficacy of bedroom environmental control programmes involving use of house dust mite impermeable bedding covers
Cochrane Database of Systematic Reviews 2010 Issue 7
bull Trials to date small and of poor methodological qualitybull difficult to offer any definitive recommendations on the role
bull use of acaricides and extensive bedroom-based environmental control programmes may be of some benefit in reducing rhinitis symptoms but the evidence is not strong
bull Isolated use of house dust mite impermeable bedding is unlikely to prove effective
bull More research is needed
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
METHODS OFMITE ALLERGEN AVOIDANCE
Method
bull Physical methodndash Encasing of beddingndash Vacuums cleanersndash Floor coveringsndash Laundryndash Air filtration
bull Chemical methodndash Acaricide
Encasingsbull In the bedroom covering mattresses and pillows with impermeable
covers is effectivebull This effect may be large variable and persist for a couple of
months
bull Encasings differ widely in their qualityndash some cheap brands have large pores other multilayered encasings delaminate
and others harbor mites
bull Tightly woven synthetic or cotton fabrics are preferred
bull Most trials of encasings have failed to regularly wash them (difficult with some encasings) which renders them ineffective as allergens build up on the outer surface within several weeks
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Curr Allergy Asthma Rep 20088126-32
J Allergy Clin Immunol 20061181164-8
16 tightly woven 9 United States3 Japan2 Thailand1 Germany1 France
laminate-coated and loosely woven cover molting among nonwoven fibers
dead mites on an acaricide-coated and nonwoven cover group of mites in the matrix of a nonwoven cover
J Allergy Clin Immunol 20061181164-8
Nonwoven
J Allergy Clin Immunol 20061181164-8
before after
easy access for mites to readily penetrate into the substrate of the material
J Allergy Clin Immunol 20061181164-8
tightly woven fabric with systematized regular fibers allowing little space for penetration
bull Woven nonwovenndash pore size between 2 and 10 um (average 6 um) blocking most
mite allergens
bull Plasticndash pore free best barrier in terms of blockingndash but the least comfortable zero ventilation ndash tendency to become a haven for mold spores
bull For acaricide-coated materialsndash pore size is usually not a major factor ndash mites are eradicated on contact with the chemicalsndash still allow the passage of allergens ndash prevent penetration through the fabrics but allow colonization
J Allergy Clin Immunol 20061181164-8
Asian Pac J Allergy Immunol 201028155-61
Sensitized level
Symptomatic level
sponge-like polyurethane lowest rate Synthetic fibers and kapok mattresses highest rate
A combination of the following choosing new sponge-like polyurethane or coconut fiber mattresses with mite-impermeable covers and washing sheets pillowcases blankets and mattresses pad at least weekly in hot water should be the best method of prevention in HDM allergen sensitive allergic patients
Laundrybull Both dust and cat and mite allergens are effectively removed by
laundryndash physical removal of both dust and mites by the multiple wash
and rinse cycles ndash effects of detergents additivesndash subsequent drying procedures
bull McDonald LGTovey E ndash All mites were killed by water temperatures 55 degrees C or
greaterndash Killing at lower temperatures was not enhanced by any of the
pure detergents or laundry products tested
J Allergy Clin Immunol 2011128723-7
J Allergy Clin Immunol 199290599-608
Floor coveringsbull Designing the house with polished floors and wooden or
vinylleather furniture so as to limit the sites where mites can grow
bull carpets fitted onto unventilated floors water can accumulate growth of both fungi and mites
bull hard floors are likely to be preferred as they are more easily kept in a state that minimizes aeroallergen reaerosolization in the long term
bull the little available data of aeroallergens in houses suggest that the difference may be small and the effects complex
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552J Allergy Clin Immunol 2011128723-7
Vacuum cleaners
bull Vacuum cleaners are heavily promoted
bull Probably all cleaners cause a brief increase in personal aeroallergen exposure under normal domestic conditions and high-efficiency particulate arrest (HEPA) filters make little difference
bull Thus the benefits of HEPA filtration on exposure may have been exaggerated and all cleaners probably provide a brief increase in exposure
J Allergy Clin Immunol 2011128723-7
Allergy 200661119-23
Air management
bull indoor relative humidity is kept below 50 (absolute humidity below 6 gkg)
bull In some areas of the world this can be done by increasing ventilation
bull in other areas it is necessary to use air conditioning during the most humid months of the summer
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Air filtration
bull The role of air filtration continues to be debatedbull There is some consensus that small benefits exist mainly for pet
allergens
J Allergy Clin Immunol 2011128723-7
Acaricidesbull variety of acaricides have been used to treat carpets or furniturebull pyrethroids natamycin (an antifungal) pirimiphos methyl and
benzyl benzoate bull killing mites
bull Acaricides proved largely ineffective because the mite populations return shortly after their application and they may also cause skin and respiratory irritation
bull No data on clinical benefit exist and concerns about human health and environmental toxicity remain
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
J Allergy Clin Immunol 2011128723-7
Acaricidesbull 1 or 3 tannic acid
ndash method of denaturing mite allergensndash reduction of mite allergen can be achievedndash does not kill mitesndash so the effect can only be temporary approximately 6 weeks to 3
months
bull may be recommended when it is not possible to remove the carpets or change the furniture
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
bull 9 trials involving 501 participants bull 2 studies investigating the effectiveness of mite impermeable
bedding covers were of good qualitybull 7 studies were small and of poor qualitybull 2 trials investigated the efficacy of acaricidesbull 2 trials investigated the role of high-efficiency particulate air (HEPA)
filtersbull 1 trial using a factorial design investigated the efficacy of both
acaricide and house dust mite impermeable bedding covers in isolation and combination
bull Remaining 4 trials investigated the efficacy of bedroom environmental control programmes involving use of house dust mite impermeable bedding covers
Cochrane Database of Systematic Reviews 2010 Issue 7
bull Trials to date small and of poor methodological qualitybull difficult to offer any definitive recommendations on the role
bull use of acaricides and extensive bedroom-based environmental control programmes may be of some benefit in reducing rhinitis symptoms but the evidence is not strong
bull Isolated use of house dust mite impermeable bedding is unlikely to prove effective
bull More research is needed
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
METHODS OFMITE ALLERGEN AVOIDANCE
Method
bull Physical methodndash Encasing of beddingndash Vacuums cleanersndash Floor coveringsndash Laundryndash Air filtration
bull Chemical methodndash Acaricide
Encasingsbull In the bedroom covering mattresses and pillows with impermeable
covers is effectivebull This effect may be large variable and persist for a couple of
months
bull Encasings differ widely in their qualityndash some cheap brands have large pores other multilayered encasings delaminate
and others harbor mites
bull Tightly woven synthetic or cotton fabrics are preferred
bull Most trials of encasings have failed to regularly wash them (difficult with some encasings) which renders them ineffective as allergens build up on the outer surface within several weeks
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Curr Allergy Asthma Rep 20088126-32
J Allergy Clin Immunol 20061181164-8
16 tightly woven 9 United States3 Japan2 Thailand1 Germany1 France
laminate-coated and loosely woven cover molting among nonwoven fibers
dead mites on an acaricide-coated and nonwoven cover group of mites in the matrix of a nonwoven cover
J Allergy Clin Immunol 20061181164-8
Nonwoven
J Allergy Clin Immunol 20061181164-8
before after
easy access for mites to readily penetrate into the substrate of the material
J Allergy Clin Immunol 20061181164-8
tightly woven fabric with systematized regular fibers allowing little space for penetration
bull Woven nonwovenndash pore size between 2 and 10 um (average 6 um) blocking most
mite allergens
bull Plasticndash pore free best barrier in terms of blockingndash but the least comfortable zero ventilation ndash tendency to become a haven for mold spores
bull For acaricide-coated materialsndash pore size is usually not a major factor ndash mites are eradicated on contact with the chemicalsndash still allow the passage of allergens ndash prevent penetration through the fabrics but allow colonization
J Allergy Clin Immunol 20061181164-8
Asian Pac J Allergy Immunol 201028155-61
Sensitized level
Symptomatic level
sponge-like polyurethane lowest rate Synthetic fibers and kapok mattresses highest rate
A combination of the following choosing new sponge-like polyurethane or coconut fiber mattresses with mite-impermeable covers and washing sheets pillowcases blankets and mattresses pad at least weekly in hot water should be the best method of prevention in HDM allergen sensitive allergic patients
Laundrybull Both dust and cat and mite allergens are effectively removed by
laundryndash physical removal of both dust and mites by the multiple wash
and rinse cycles ndash effects of detergents additivesndash subsequent drying procedures
bull McDonald LGTovey E ndash All mites were killed by water temperatures 55 degrees C or
greaterndash Killing at lower temperatures was not enhanced by any of the
pure detergents or laundry products tested
J Allergy Clin Immunol 2011128723-7
J Allergy Clin Immunol 199290599-608
Floor coveringsbull Designing the house with polished floors and wooden or
vinylleather furniture so as to limit the sites where mites can grow
bull carpets fitted onto unventilated floors water can accumulate growth of both fungi and mites
bull hard floors are likely to be preferred as they are more easily kept in a state that minimizes aeroallergen reaerosolization in the long term
bull the little available data of aeroallergens in houses suggest that the difference may be small and the effects complex
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552J Allergy Clin Immunol 2011128723-7
Vacuum cleaners
bull Vacuum cleaners are heavily promoted
bull Probably all cleaners cause a brief increase in personal aeroallergen exposure under normal domestic conditions and high-efficiency particulate arrest (HEPA) filters make little difference
bull Thus the benefits of HEPA filtration on exposure may have been exaggerated and all cleaners probably provide a brief increase in exposure
J Allergy Clin Immunol 2011128723-7
Allergy 200661119-23
Air management
bull indoor relative humidity is kept below 50 (absolute humidity below 6 gkg)
bull In some areas of the world this can be done by increasing ventilation
bull in other areas it is necessary to use air conditioning during the most humid months of the summer
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Air filtration
bull The role of air filtration continues to be debatedbull There is some consensus that small benefits exist mainly for pet
allergens
J Allergy Clin Immunol 2011128723-7
Acaricidesbull variety of acaricides have been used to treat carpets or furniturebull pyrethroids natamycin (an antifungal) pirimiphos methyl and
benzyl benzoate bull killing mites
bull Acaricides proved largely ineffective because the mite populations return shortly after their application and they may also cause skin and respiratory irritation
bull No data on clinical benefit exist and concerns about human health and environmental toxicity remain
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
J Allergy Clin Immunol 2011128723-7
Acaricidesbull 1 or 3 tannic acid
ndash method of denaturing mite allergensndash reduction of mite allergen can be achievedndash does not kill mitesndash so the effect can only be temporary approximately 6 weeks to 3
months
bull may be recommended when it is not possible to remove the carpets or change the furniture
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
House dust mite avoidance measures for perennial allergic rhinitis
bull 9 trials involving 501 participants bull 2 studies investigating the effectiveness of mite impermeable
bedding covers were of good qualitybull 7 studies were small and of poor qualitybull 2 trials investigated the efficacy of acaricidesbull 2 trials investigated the role of high-efficiency particulate air (HEPA)
filtersbull 1 trial using a factorial design investigated the efficacy of both
acaricide and house dust mite impermeable bedding covers in isolation and combination
bull Remaining 4 trials investigated the efficacy of bedroom environmental control programmes involving use of house dust mite impermeable bedding covers
Cochrane Database of Systematic Reviews 2010 Issue 7
bull Trials to date small and of poor methodological qualitybull difficult to offer any definitive recommendations on the role
bull use of acaricides and extensive bedroom-based environmental control programmes may be of some benefit in reducing rhinitis symptoms but the evidence is not strong
bull Isolated use of house dust mite impermeable bedding is unlikely to prove effective
bull More research is needed
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
METHODS OFMITE ALLERGEN AVOIDANCE
Method
bull Physical methodndash Encasing of beddingndash Vacuums cleanersndash Floor coveringsndash Laundryndash Air filtration
bull Chemical methodndash Acaricide
Encasingsbull In the bedroom covering mattresses and pillows with impermeable
covers is effectivebull This effect may be large variable and persist for a couple of
months
bull Encasings differ widely in their qualityndash some cheap brands have large pores other multilayered encasings delaminate
and others harbor mites
bull Tightly woven synthetic or cotton fabrics are preferred
bull Most trials of encasings have failed to regularly wash them (difficult with some encasings) which renders them ineffective as allergens build up on the outer surface within several weeks
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Curr Allergy Asthma Rep 20088126-32
J Allergy Clin Immunol 20061181164-8
16 tightly woven 9 United States3 Japan2 Thailand1 Germany1 France
laminate-coated and loosely woven cover molting among nonwoven fibers
dead mites on an acaricide-coated and nonwoven cover group of mites in the matrix of a nonwoven cover
J Allergy Clin Immunol 20061181164-8
Nonwoven
J Allergy Clin Immunol 20061181164-8
before after
easy access for mites to readily penetrate into the substrate of the material
J Allergy Clin Immunol 20061181164-8
tightly woven fabric with systematized regular fibers allowing little space for penetration
bull Woven nonwovenndash pore size between 2 and 10 um (average 6 um) blocking most
mite allergens
bull Plasticndash pore free best barrier in terms of blockingndash but the least comfortable zero ventilation ndash tendency to become a haven for mold spores
bull For acaricide-coated materialsndash pore size is usually not a major factor ndash mites are eradicated on contact with the chemicalsndash still allow the passage of allergens ndash prevent penetration through the fabrics but allow colonization
J Allergy Clin Immunol 20061181164-8
Asian Pac J Allergy Immunol 201028155-61
Sensitized level
Symptomatic level
sponge-like polyurethane lowest rate Synthetic fibers and kapok mattresses highest rate
A combination of the following choosing new sponge-like polyurethane or coconut fiber mattresses with mite-impermeable covers and washing sheets pillowcases blankets and mattresses pad at least weekly in hot water should be the best method of prevention in HDM allergen sensitive allergic patients
Laundrybull Both dust and cat and mite allergens are effectively removed by
laundryndash physical removal of both dust and mites by the multiple wash
and rinse cycles ndash effects of detergents additivesndash subsequent drying procedures
bull McDonald LGTovey E ndash All mites were killed by water temperatures 55 degrees C or
greaterndash Killing at lower temperatures was not enhanced by any of the
pure detergents or laundry products tested
J Allergy Clin Immunol 2011128723-7
J Allergy Clin Immunol 199290599-608
Floor coveringsbull Designing the house with polished floors and wooden or
vinylleather furniture so as to limit the sites where mites can grow
bull carpets fitted onto unventilated floors water can accumulate growth of both fungi and mites
bull hard floors are likely to be preferred as they are more easily kept in a state that minimizes aeroallergen reaerosolization in the long term
bull the little available data of aeroallergens in houses suggest that the difference may be small and the effects complex
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552J Allergy Clin Immunol 2011128723-7
Vacuum cleaners
bull Vacuum cleaners are heavily promoted
bull Probably all cleaners cause a brief increase in personal aeroallergen exposure under normal domestic conditions and high-efficiency particulate arrest (HEPA) filters make little difference
bull Thus the benefits of HEPA filtration on exposure may have been exaggerated and all cleaners probably provide a brief increase in exposure
J Allergy Clin Immunol 2011128723-7
Allergy 200661119-23
Air management
bull indoor relative humidity is kept below 50 (absolute humidity below 6 gkg)
bull In some areas of the world this can be done by increasing ventilation
bull in other areas it is necessary to use air conditioning during the most humid months of the summer
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Air filtration
bull The role of air filtration continues to be debatedbull There is some consensus that small benefits exist mainly for pet
allergens
J Allergy Clin Immunol 2011128723-7
Acaricidesbull variety of acaricides have been used to treat carpets or furniturebull pyrethroids natamycin (an antifungal) pirimiphos methyl and
benzyl benzoate bull killing mites
bull Acaricides proved largely ineffective because the mite populations return shortly after their application and they may also cause skin and respiratory irritation
bull No data on clinical benefit exist and concerns about human health and environmental toxicity remain
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
J Allergy Clin Immunol 2011128723-7
Acaricidesbull 1 or 3 tannic acid
ndash method of denaturing mite allergensndash reduction of mite allergen can be achievedndash does not kill mitesndash so the effect can only be temporary approximately 6 weeks to 3
months
bull may be recommended when it is not possible to remove the carpets or change the furniture
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
bull Trials to date small and of poor methodological qualitybull difficult to offer any definitive recommendations on the role
bull use of acaricides and extensive bedroom-based environmental control programmes may be of some benefit in reducing rhinitis symptoms but the evidence is not strong
bull Isolated use of house dust mite impermeable bedding is unlikely to prove effective
bull More research is needed
Cochrane Database of Systematic Reviews 2010 Issue 7
House dust mite avoidance measures for perennial allergic rhinitis
METHODS OFMITE ALLERGEN AVOIDANCE
Method
bull Physical methodndash Encasing of beddingndash Vacuums cleanersndash Floor coveringsndash Laundryndash Air filtration
bull Chemical methodndash Acaricide
Encasingsbull In the bedroom covering mattresses and pillows with impermeable
covers is effectivebull This effect may be large variable and persist for a couple of
months
bull Encasings differ widely in their qualityndash some cheap brands have large pores other multilayered encasings delaminate
and others harbor mites
bull Tightly woven synthetic or cotton fabrics are preferred
bull Most trials of encasings have failed to regularly wash them (difficult with some encasings) which renders them ineffective as allergens build up on the outer surface within several weeks
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Curr Allergy Asthma Rep 20088126-32
J Allergy Clin Immunol 20061181164-8
16 tightly woven 9 United States3 Japan2 Thailand1 Germany1 France
laminate-coated and loosely woven cover molting among nonwoven fibers
dead mites on an acaricide-coated and nonwoven cover group of mites in the matrix of a nonwoven cover
J Allergy Clin Immunol 20061181164-8
Nonwoven
J Allergy Clin Immunol 20061181164-8
before after
easy access for mites to readily penetrate into the substrate of the material
J Allergy Clin Immunol 20061181164-8
tightly woven fabric with systematized regular fibers allowing little space for penetration
bull Woven nonwovenndash pore size between 2 and 10 um (average 6 um) blocking most
mite allergens
bull Plasticndash pore free best barrier in terms of blockingndash but the least comfortable zero ventilation ndash tendency to become a haven for mold spores
bull For acaricide-coated materialsndash pore size is usually not a major factor ndash mites are eradicated on contact with the chemicalsndash still allow the passage of allergens ndash prevent penetration through the fabrics but allow colonization
J Allergy Clin Immunol 20061181164-8
Asian Pac J Allergy Immunol 201028155-61
Sensitized level
Symptomatic level
sponge-like polyurethane lowest rate Synthetic fibers and kapok mattresses highest rate
A combination of the following choosing new sponge-like polyurethane or coconut fiber mattresses with mite-impermeable covers and washing sheets pillowcases blankets and mattresses pad at least weekly in hot water should be the best method of prevention in HDM allergen sensitive allergic patients
Laundrybull Both dust and cat and mite allergens are effectively removed by
laundryndash physical removal of both dust and mites by the multiple wash
and rinse cycles ndash effects of detergents additivesndash subsequent drying procedures
bull McDonald LGTovey E ndash All mites were killed by water temperatures 55 degrees C or
greaterndash Killing at lower temperatures was not enhanced by any of the
pure detergents or laundry products tested
J Allergy Clin Immunol 2011128723-7
J Allergy Clin Immunol 199290599-608
Floor coveringsbull Designing the house with polished floors and wooden or
vinylleather furniture so as to limit the sites where mites can grow
bull carpets fitted onto unventilated floors water can accumulate growth of both fungi and mites
bull hard floors are likely to be preferred as they are more easily kept in a state that minimizes aeroallergen reaerosolization in the long term
bull the little available data of aeroallergens in houses suggest that the difference may be small and the effects complex
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552J Allergy Clin Immunol 2011128723-7
Vacuum cleaners
bull Vacuum cleaners are heavily promoted
bull Probably all cleaners cause a brief increase in personal aeroallergen exposure under normal domestic conditions and high-efficiency particulate arrest (HEPA) filters make little difference
bull Thus the benefits of HEPA filtration on exposure may have been exaggerated and all cleaners probably provide a brief increase in exposure
J Allergy Clin Immunol 2011128723-7
Allergy 200661119-23
Air management
bull indoor relative humidity is kept below 50 (absolute humidity below 6 gkg)
bull In some areas of the world this can be done by increasing ventilation
bull in other areas it is necessary to use air conditioning during the most humid months of the summer
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Air filtration
bull The role of air filtration continues to be debatedbull There is some consensus that small benefits exist mainly for pet
allergens
J Allergy Clin Immunol 2011128723-7
Acaricidesbull variety of acaricides have been used to treat carpets or furniturebull pyrethroids natamycin (an antifungal) pirimiphos methyl and
benzyl benzoate bull killing mites
bull Acaricides proved largely ineffective because the mite populations return shortly after their application and they may also cause skin and respiratory irritation
bull No data on clinical benefit exist and concerns about human health and environmental toxicity remain
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
J Allergy Clin Immunol 2011128723-7
Acaricidesbull 1 or 3 tannic acid
ndash method of denaturing mite allergensndash reduction of mite allergen can be achievedndash does not kill mitesndash so the effect can only be temporary approximately 6 weeks to 3
months
bull may be recommended when it is not possible to remove the carpets or change the furniture
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
METHODS OFMITE ALLERGEN AVOIDANCE
Method
bull Physical methodndash Encasing of beddingndash Vacuums cleanersndash Floor coveringsndash Laundryndash Air filtration
bull Chemical methodndash Acaricide
Encasingsbull In the bedroom covering mattresses and pillows with impermeable
covers is effectivebull This effect may be large variable and persist for a couple of
months
bull Encasings differ widely in their qualityndash some cheap brands have large pores other multilayered encasings delaminate
and others harbor mites
bull Tightly woven synthetic or cotton fabrics are preferred
bull Most trials of encasings have failed to regularly wash them (difficult with some encasings) which renders them ineffective as allergens build up on the outer surface within several weeks
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Curr Allergy Asthma Rep 20088126-32
J Allergy Clin Immunol 20061181164-8
16 tightly woven 9 United States3 Japan2 Thailand1 Germany1 France
laminate-coated and loosely woven cover molting among nonwoven fibers
dead mites on an acaricide-coated and nonwoven cover group of mites in the matrix of a nonwoven cover
J Allergy Clin Immunol 20061181164-8
Nonwoven
J Allergy Clin Immunol 20061181164-8
before after
easy access for mites to readily penetrate into the substrate of the material
J Allergy Clin Immunol 20061181164-8
tightly woven fabric with systematized regular fibers allowing little space for penetration
bull Woven nonwovenndash pore size between 2 and 10 um (average 6 um) blocking most
mite allergens
bull Plasticndash pore free best barrier in terms of blockingndash but the least comfortable zero ventilation ndash tendency to become a haven for mold spores
bull For acaricide-coated materialsndash pore size is usually not a major factor ndash mites are eradicated on contact with the chemicalsndash still allow the passage of allergens ndash prevent penetration through the fabrics but allow colonization
J Allergy Clin Immunol 20061181164-8
Asian Pac J Allergy Immunol 201028155-61
Sensitized level
Symptomatic level
sponge-like polyurethane lowest rate Synthetic fibers and kapok mattresses highest rate
A combination of the following choosing new sponge-like polyurethane or coconut fiber mattresses with mite-impermeable covers and washing sheets pillowcases blankets and mattresses pad at least weekly in hot water should be the best method of prevention in HDM allergen sensitive allergic patients
Laundrybull Both dust and cat and mite allergens are effectively removed by
laundryndash physical removal of both dust and mites by the multiple wash
and rinse cycles ndash effects of detergents additivesndash subsequent drying procedures
bull McDonald LGTovey E ndash All mites were killed by water temperatures 55 degrees C or
greaterndash Killing at lower temperatures was not enhanced by any of the
pure detergents or laundry products tested
J Allergy Clin Immunol 2011128723-7
J Allergy Clin Immunol 199290599-608
Floor coveringsbull Designing the house with polished floors and wooden or
vinylleather furniture so as to limit the sites where mites can grow
bull carpets fitted onto unventilated floors water can accumulate growth of both fungi and mites
bull hard floors are likely to be preferred as they are more easily kept in a state that minimizes aeroallergen reaerosolization in the long term
bull the little available data of aeroallergens in houses suggest that the difference may be small and the effects complex
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552J Allergy Clin Immunol 2011128723-7
Vacuum cleaners
bull Vacuum cleaners are heavily promoted
bull Probably all cleaners cause a brief increase in personal aeroallergen exposure under normal domestic conditions and high-efficiency particulate arrest (HEPA) filters make little difference
bull Thus the benefits of HEPA filtration on exposure may have been exaggerated and all cleaners probably provide a brief increase in exposure
J Allergy Clin Immunol 2011128723-7
Allergy 200661119-23
Air management
bull indoor relative humidity is kept below 50 (absolute humidity below 6 gkg)
bull In some areas of the world this can be done by increasing ventilation
bull in other areas it is necessary to use air conditioning during the most humid months of the summer
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Air filtration
bull The role of air filtration continues to be debatedbull There is some consensus that small benefits exist mainly for pet
allergens
J Allergy Clin Immunol 2011128723-7
Acaricidesbull variety of acaricides have been used to treat carpets or furniturebull pyrethroids natamycin (an antifungal) pirimiphos methyl and
benzyl benzoate bull killing mites
bull Acaricides proved largely ineffective because the mite populations return shortly after their application and they may also cause skin and respiratory irritation
bull No data on clinical benefit exist and concerns about human health and environmental toxicity remain
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
J Allergy Clin Immunol 2011128723-7
Acaricidesbull 1 or 3 tannic acid
ndash method of denaturing mite allergensndash reduction of mite allergen can be achievedndash does not kill mitesndash so the effect can only be temporary approximately 6 weeks to 3
months
bull may be recommended when it is not possible to remove the carpets or change the furniture
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
Method
bull Physical methodndash Encasing of beddingndash Vacuums cleanersndash Floor coveringsndash Laundryndash Air filtration
bull Chemical methodndash Acaricide
Encasingsbull In the bedroom covering mattresses and pillows with impermeable
covers is effectivebull This effect may be large variable and persist for a couple of
months
bull Encasings differ widely in their qualityndash some cheap brands have large pores other multilayered encasings delaminate
and others harbor mites
bull Tightly woven synthetic or cotton fabrics are preferred
bull Most trials of encasings have failed to regularly wash them (difficult with some encasings) which renders them ineffective as allergens build up on the outer surface within several weeks
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Curr Allergy Asthma Rep 20088126-32
J Allergy Clin Immunol 20061181164-8
16 tightly woven 9 United States3 Japan2 Thailand1 Germany1 France
laminate-coated and loosely woven cover molting among nonwoven fibers
dead mites on an acaricide-coated and nonwoven cover group of mites in the matrix of a nonwoven cover
J Allergy Clin Immunol 20061181164-8
Nonwoven
J Allergy Clin Immunol 20061181164-8
before after
easy access for mites to readily penetrate into the substrate of the material
J Allergy Clin Immunol 20061181164-8
tightly woven fabric with systematized regular fibers allowing little space for penetration
bull Woven nonwovenndash pore size between 2 and 10 um (average 6 um) blocking most
mite allergens
bull Plasticndash pore free best barrier in terms of blockingndash but the least comfortable zero ventilation ndash tendency to become a haven for mold spores
bull For acaricide-coated materialsndash pore size is usually not a major factor ndash mites are eradicated on contact with the chemicalsndash still allow the passage of allergens ndash prevent penetration through the fabrics but allow colonization
J Allergy Clin Immunol 20061181164-8
Asian Pac J Allergy Immunol 201028155-61
Sensitized level
Symptomatic level
sponge-like polyurethane lowest rate Synthetic fibers and kapok mattresses highest rate
A combination of the following choosing new sponge-like polyurethane or coconut fiber mattresses with mite-impermeable covers and washing sheets pillowcases blankets and mattresses pad at least weekly in hot water should be the best method of prevention in HDM allergen sensitive allergic patients
Laundrybull Both dust and cat and mite allergens are effectively removed by
laundryndash physical removal of both dust and mites by the multiple wash
and rinse cycles ndash effects of detergents additivesndash subsequent drying procedures
bull McDonald LGTovey E ndash All mites were killed by water temperatures 55 degrees C or
greaterndash Killing at lower temperatures was not enhanced by any of the
pure detergents or laundry products tested
J Allergy Clin Immunol 2011128723-7
J Allergy Clin Immunol 199290599-608
Floor coveringsbull Designing the house with polished floors and wooden or
vinylleather furniture so as to limit the sites where mites can grow
bull carpets fitted onto unventilated floors water can accumulate growth of both fungi and mites
bull hard floors are likely to be preferred as they are more easily kept in a state that minimizes aeroallergen reaerosolization in the long term
bull the little available data of aeroallergens in houses suggest that the difference may be small and the effects complex
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552J Allergy Clin Immunol 2011128723-7
Vacuum cleaners
bull Vacuum cleaners are heavily promoted
bull Probably all cleaners cause a brief increase in personal aeroallergen exposure under normal domestic conditions and high-efficiency particulate arrest (HEPA) filters make little difference
bull Thus the benefits of HEPA filtration on exposure may have been exaggerated and all cleaners probably provide a brief increase in exposure
J Allergy Clin Immunol 2011128723-7
Allergy 200661119-23
Air management
bull indoor relative humidity is kept below 50 (absolute humidity below 6 gkg)
bull In some areas of the world this can be done by increasing ventilation
bull in other areas it is necessary to use air conditioning during the most humid months of the summer
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Air filtration
bull The role of air filtration continues to be debatedbull There is some consensus that small benefits exist mainly for pet
allergens
J Allergy Clin Immunol 2011128723-7
Acaricidesbull variety of acaricides have been used to treat carpets or furniturebull pyrethroids natamycin (an antifungal) pirimiphos methyl and
benzyl benzoate bull killing mites
bull Acaricides proved largely ineffective because the mite populations return shortly after their application and they may also cause skin and respiratory irritation
bull No data on clinical benefit exist and concerns about human health and environmental toxicity remain
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
J Allergy Clin Immunol 2011128723-7
Acaricidesbull 1 or 3 tannic acid
ndash method of denaturing mite allergensndash reduction of mite allergen can be achievedndash does not kill mitesndash so the effect can only be temporary approximately 6 weeks to 3
months
bull may be recommended when it is not possible to remove the carpets or change the furniture
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
Encasingsbull In the bedroom covering mattresses and pillows with impermeable
covers is effectivebull This effect may be large variable and persist for a couple of
months
bull Encasings differ widely in their qualityndash some cheap brands have large pores other multilayered encasings delaminate
and others harbor mites
bull Tightly woven synthetic or cotton fabrics are preferred
bull Most trials of encasings have failed to regularly wash them (difficult with some encasings) which renders them ineffective as allergens build up on the outer surface within several weeks
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Curr Allergy Asthma Rep 20088126-32
J Allergy Clin Immunol 20061181164-8
16 tightly woven 9 United States3 Japan2 Thailand1 Germany1 France
laminate-coated and loosely woven cover molting among nonwoven fibers
dead mites on an acaricide-coated and nonwoven cover group of mites in the matrix of a nonwoven cover
J Allergy Clin Immunol 20061181164-8
Nonwoven
J Allergy Clin Immunol 20061181164-8
before after
easy access for mites to readily penetrate into the substrate of the material
J Allergy Clin Immunol 20061181164-8
tightly woven fabric with systematized regular fibers allowing little space for penetration
bull Woven nonwovenndash pore size between 2 and 10 um (average 6 um) blocking most
mite allergens
bull Plasticndash pore free best barrier in terms of blockingndash but the least comfortable zero ventilation ndash tendency to become a haven for mold spores
bull For acaricide-coated materialsndash pore size is usually not a major factor ndash mites are eradicated on contact with the chemicalsndash still allow the passage of allergens ndash prevent penetration through the fabrics but allow colonization
J Allergy Clin Immunol 20061181164-8
Asian Pac J Allergy Immunol 201028155-61
Sensitized level
Symptomatic level
sponge-like polyurethane lowest rate Synthetic fibers and kapok mattresses highest rate
A combination of the following choosing new sponge-like polyurethane or coconut fiber mattresses with mite-impermeable covers and washing sheets pillowcases blankets and mattresses pad at least weekly in hot water should be the best method of prevention in HDM allergen sensitive allergic patients
Laundrybull Both dust and cat and mite allergens are effectively removed by
laundryndash physical removal of both dust and mites by the multiple wash
and rinse cycles ndash effects of detergents additivesndash subsequent drying procedures
bull McDonald LGTovey E ndash All mites were killed by water temperatures 55 degrees C or
greaterndash Killing at lower temperatures was not enhanced by any of the
pure detergents or laundry products tested
J Allergy Clin Immunol 2011128723-7
J Allergy Clin Immunol 199290599-608
Floor coveringsbull Designing the house with polished floors and wooden or
vinylleather furniture so as to limit the sites where mites can grow
bull carpets fitted onto unventilated floors water can accumulate growth of both fungi and mites
bull hard floors are likely to be preferred as they are more easily kept in a state that minimizes aeroallergen reaerosolization in the long term
bull the little available data of aeroallergens in houses suggest that the difference may be small and the effects complex
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552J Allergy Clin Immunol 2011128723-7
Vacuum cleaners
bull Vacuum cleaners are heavily promoted
bull Probably all cleaners cause a brief increase in personal aeroallergen exposure under normal domestic conditions and high-efficiency particulate arrest (HEPA) filters make little difference
bull Thus the benefits of HEPA filtration on exposure may have been exaggerated and all cleaners probably provide a brief increase in exposure
J Allergy Clin Immunol 2011128723-7
Allergy 200661119-23
Air management
bull indoor relative humidity is kept below 50 (absolute humidity below 6 gkg)
bull In some areas of the world this can be done by increasing ventilation
bull in other areas it is necessary to use air conditioning during the most humid months of the summer
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Air filtration
bull The role of air filtration continues to be debatedbull There is some consensus that small benefits exist mainly for pet
allergens
J Allergy Clin Immunol 2011128723-7
Acaricidesbull variety of acaricides have been used to treat carpets or furniturebull pyrethroids natamycin (an antifungal) pirimiphos methyl and
benzyl benzoate bull killing mites
bull Acaricides proved largely ineffective because the mite populations return shortly after their application and they may also cause skin and respiratory irritation
bull No data on clinical benefit exist and concerns about human health and environmental toxicity remain
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
J Allergy Clin Immunol 2011128723-7
Acaricidesbull 1 or 3 tannic acid
ndash method of denaturing mite allergensndash reduction of mite allergen can be achievedndash does not kill mitesndash so the effect can only be temporary approximately 6 weeks to 3
months
bull may be recommended when it is not possible to remove the carpets or change the furniture
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
J Allergy Clin Immunol 20061181164-8
16 tightly woven 9 United States3 Japan2 Thailand1 Germany1 France
laminate-coated and loosely woven cover molting among nonwoven fibers
dead mites on an acaricide-coated and nonwoven cover group of mites in the matrix of a nonwoven cover
J Allergy Clin Immunol 20061181164-8
Nonwoven
J Allergy Clin Immunol 20061181164-8
before after
easy access for mites to readily penetrate into the substrate of the material
J Allergy Clin Immunol 20061181164-8
tightly woven fabric with systematized regular fibers allowing little space for penetration
bull Woven nonwovenndash pore size between 2 and 10 um (average 6 um) blocking most
mite allergens
bull Plasticndash pore free best barrier in terms of blockingndash but the least comfortable zero ventilation ndash tendency to become a haven for mold spores
bull For acaricide-coated materialsndash pore size is usually not a major factor ndash mites are eradicated on contact with the chemicalsndash still allow the passage of allergens ndash prevent penetration through the fabrics but allow colonization
J Allergy Clin Immunol 20061181164-8
Asian Pac J Allergy Immunol 201028155-61
Sensitized level
Symptomatic level
sponge-like polyurethane lowest rate Synthetic fibers and kapok mattresses highest rate
A combination of the following choosing new sponge-like polyurethane or coconut fiber mattresses with mite-impermeable covers and washing sheets pillowcases blankets and mattresses pad at least weekly in hot water should be the best method of prevention in HDM allergen sensitive allergic patients
Laundrybull Both dust and cat and mite allergens are effectively removed by
laundryndash physical removal of both dust and mites by the multiple wash
and rinse cycles ndash effects of detergents additivesndash subsequent drying procedures
bull McDonald LGTovey E ndash All mites were killed by water temperatures 55 degrees C or
greaterndash Killing at lower temperatures was not enhanced by any of the
pure detergents or laundry products tested
J Allergy Clin Immunol 2011128723-7
J Allergy Clin Immunol 199290599-608
Floor coveringsbull Designing the house with polished floors and wooden or
vinylleather furniture so as to limit the sites where mites can grow
bull carpets fitted onto unventilated floors water can accumulate growth of both fungi and mites
bull hard floors are likely to be preferred as they are more easily kept in a state that minimizes aeroallergen reaerosolization in the long term
bull the little available data of aeroallergens in houses suggest that the difference may be small and the effects complex
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552J Allergy Clin Immunol 2011128723-7
Vacuum cleaners
bull Vacuum cleaners are heavily promoted
bull Probably all cleaners cause a brief increase in personal aeroallergen exposure under normal domestic conditions and high-efficiency particulate arrest (HEPA) filters make little difference
bull Thus the benefits of HEPA filtration on exposure may have been exaggerated and all cleaners probably provide a brief increase in exposure
J Allergy Clin Immunol 2011128723-7
Allergy 200661119-23
Air management
bull indoor relative humidity is kept below 50 (absolute humidity below 6 gkg)
bull In some areas of the world this can be done by increasing ventilation
bull in other areas it is necessary to use air conditioning during the most humid months of the summer
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Air filtration
bull The role of air filtration continues to be debatedbull There is some consensus that small benefits exist mainly for pet
allergens
J Allergy Clin Immunol 2011128723-7
Acaricidesbull variety of acaricides have been used to treat carpets or furniturebull pyrethroids natamycin (an antifungal) pirimiphos methyl and
benzyl benzoate bull killing mites
bull Acaricides proved largely ineffective because the mite populations return shortly after their application and they may also cause skin and respiratory irritation
bull No data on clinical benefit exist and concerns about human health and environmental toxicity remain
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
J Allergy Clin Immunol 2011128723-7
Acaricidesbull 1 or 3 tannic acid
ndash method of denaturing mite allergensndash reduction of mite allergen can be achievedndash does not kill mitesndash so the effect can only be temporary approximately 6 weeks to 3
months
bull may be recommended when it is not possible to remove the carpets or change the furniture
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
laminate-coated and loosely woven cover molting among nonwoven fibers
dead mites on an acaricide-coated and nonwoven cover group of mites in the matrix of a nonwoven cover
J Allergy Clin Immunol 20061181164-8
Nonwoven
J Allergy Clin Immunol 20061181164-8
before after
easy access for mites to readily penetrate into the substrate of the material
J Allergy Clin Immunol 20061181164-8
tightly woven fabric with systematized regular fibers allowing little space for penetration
bull Woven nonwovenndash pore size between 2 and 10 um (average 6 um) blocking most
mite allergens
bull Plasticndash pore free best barrier in terms of blockingndash but the least comfortable zero ventilation ndash tendency to become a haven for mold spores
bull For acaricide-coated materialsndash pore size is usually not a major factor ndash mites are eradicated on contact with the chemicalsndash still allow the passage of allergens ndash prevent penetration through the fabrics but allow colonization
J Allergy Clin Immunol 20061181164-8
Asian Pac J Allergy Immunol 201028155-61
Sensitized level
Symptomatic level
sponge-like polyurethane lowest rate Synthetic fibers and kapok mattresses highest rate
A combination of the following choosing new sponge-like polyurethane or coconut fiber mattresses with mite-impermeable covers and washing sheets pillowcases blankets and mattresses pad at least weekly in hot water should be the best method of prevention in HDM allergen sensitive allergic patients
Laundrybull Both dust and cat and mite allergens are effectively removed by
laundryndash physical removal of both dust and mites by the multiple wash
and rinse cycles ndash effects of detergents additivesndash subsequent drying procedures
bull McDonald LGTovey E ndash All mites were killed by water temperatures 55 degrees C or
greaterndash Killing at lower temperatures was not enhanced by any of the
pure detergents or laundry products tested
J Allergy Clin Immunol 2011128723-7
J Allergy Clin Immunol 199290599-608
Floor coveringsbull Designing the house with polished floors and wooden or
vinylleather furniture so as to limit the sites where mites can grow
bull carpets fitted onto unventilated floors water can accumulate growth of both fungi and mites
bull hard floors are likely to be preferred as they are more easily kept in a state that minimizes aeroallergen reaerosolization in the long term
bull the little available data of aeroallergens in houses suggest that the difference may be small and the effects complex
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552J Allergy Clin Immunol 2011128723-7
Vacuum cleaners
bull Vacuum cleaners are heavily promoted
bull Probably all cleaners cause a brief increase in personal aeroallergen exposure under normal domestic conditions and high-efficiency particulate arrest (HEPA) filters make little difference
bull Thus the benefits of HEPA filtration on exposure may have been exaggerated and all cleaners probably provide a brief increase in exposure
J Allergy Clin Immunol 2011128723-7
Allergy 200661119-23
Air management
bull indoor relative humidity is kept below 50 (absolute humidity below 6 gkg)
bull In some areas of the world this can be done by increasing ventilation
bull in other areas it is necessary to use air conditioning during the most humid months of the summer
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Air filtration
bull The role of air filtration continues to be debatedbull There is some consensus that small benefits exist mainly for pet
allergens
J Allergy Clin Immunol 2011128723-7
Acaricidesbull variety of acaricides have been used to treat carpets or furniturebull pyrethroids natamycin (an antifungal) pirimiphos methyl and
benzyl benzoate bull killing mites
bull Acaricides proved largely ineffective because the mite populations return shortly after their application and they may also cause skin and respiratory irritation
bull No data on clinical benefit exist and concerns about human health and environmental toxicity remain
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
J Allergy Clin Immunol 2011128723-7
Acaricidesbull 1 or 3 tannic acid
ndash method of denaturing mite allergensndash reduction of mite allergen can be achievedndash does not kill mitesndash so the effect can only be temporary approximately 6 weeks to 3
months
bull may be recommended when it is not possible to remove the carpets or change the furniture
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
Nonwoven
J Allergy Clin Immunol 20061181164-8
before after
easy access for mites to readily penetrate into the substrate of the material
J Allergy Clin Immunol 20061181164-8
tightly woven fabric with systematized regular fibers allowing little space for penetration
bull Woven nonwovenndash pore size between 2 and 10 um (average 6 um) blocking most
mite allergens
bull Plasticndash pore free best barrier in terms of blockingndash but the least comfortable zero ventilation ndash tendency to become a haven for mold spores
bull For acaricide-coated materialsndash pore size is usually not a major factor ndash mites are eradicated on contact with the chemicalsndash still allow the passage of allergens ndash prevent penetration through the fabrics but allow colonization
J Allergy Clin Immunol 20061181164-8
Asian Pac J Allergy Immunol 201028155-61
Sensitized level
Symptomatic level
sponge-like polyurethane lowest rate Synthetic fibers and kapok mattresses highest rate
A combination of the following choosing new sponge-like polyurethane or coconut fiber mattresses with mite-impermeable covers and washing sheets pillowcases blankets and mattresses pad at least weekly in hot water should be the best method of prevention in HDM allergen sensitive allergic patients
Laundrybull Both dust and cat and mite allergens are effectively removed by
laundryndash physical removal of both dust and mites by the multiple wash
and rinse cycles ndash effects of detergents additivesndash subsequent drying procedures
bull McDonald LGTovey E ndash All mites were killed by water temperatures 55 degrees C or
greaterndash Killing at lower temperatures was not enhanced by any of the
pure detergents or laundry products tested
J Allergy Clin Immunol 2011128723-7
J Allergy Clin Immunol 199290599-608
Floor coveringsbull Designing the house with polished floors and wooden or
vinylleather furniture so as to limit the sites where mites can grow
bull carpets fitted onto unventilated floors water can accumulate growth of both fungi and mites
bull hard floors are likely to be preferred as they are more easily kept in a state that minimizes aeroallergen reaerosolization in the long term
bull the little available data of aeroallergens in houses suggest that the difference may be small and the effects complex
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552J Allergy Clin Immunol 2011128723-7
Vacuum cleaners
bull Vacuum cleaners are heavily promoted
bull Probably all cleaners cause a brief increase in personal aeroallergen exposure under normal domestic conditions and high-efficiency particulate arrest (HEPA) filters make little difference
bull Thus the benefits of HEPA filtration on exposure may have been exaggerated and all cleaners probably provide a brief increase in exposure
J Allergy Clin Immunol 2011128723-7
Allergy 200661119-23
Air management
bull indoor relative humidity is kept below 50 (absolute humidity below 6 gkg)
bull In some areas of the world this can be done by increasing ventilation
bull in other areas it is necessary to use air conditioning during the most humid months of the summer
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Air filtration
bull The role of air filtration continues to be debatedbull There is some consensus that small benefits exist mainly for pet
allergens
J Allergy Clin Immunol 2011128723-7
Acaricidesbull variety of acaricides have been used to treat carpets or furniturebull pyrethroids natamycin (an antifungal) pirimiphos methyl and
benzyl benzoate bull killing mites
bull Acaricides proved largely ineffective because the mite populations return shortly after their application and they may also cause skin and respiratory irritation
bull No data on clinical benefit exist and concerns about human health and environmental toxicity remain
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
J Allergy Clin Immunol 2011128723-7
Acaricidesbull 1 or 3 tannic acid
ndash method of denaturing mite allergensndash reduction of mite allergen can be achievedndash does not kill mitesndash so the effect can only be temporary approximately 6 weeks to 3
months
bull may be recommended when it is not possible to remove the carpets or change the furniture
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
J Allergy Clin Immunol 20061181164-8
tightly woven fabric with systematized regular fibers allowing little space for penetration
bull Woven nonwovenndash pore size between 2 and 10 um (average 6 um) blocking most
mite allergens
bull Plasticndash pore free best barrier in terms of blockingndash but the least comfortable zero ventilation ndash tendency to become a haven for mold spores
bull For acaricide-coated materialsndash pore size is usually not a major factor ndash mites are eradicated on contact with the chemicalsndash still allow the passage of allergens ndash prevent penetration through the fabrics but allow colonization
J Allergy Clin Immunol 20061181164-8
Asian Pac J Allergy Immunol 201028155-61
Sensitized level
Symptomatic level
sponge-like polyurethane lowest rate Synthetic fibers and kapok mattresses highest rate
A combination of the following choosing new sponge-like polyurethane or coconut fiber mattresses with mite-impermeable covers and washing sheets pillowcases blankets and mattresses pad at least weekly in hot water should be the best method of prevention in HDM allergen sensitive allergic patients
Laundrybull Both dust and cat and mite allergens are effectively removed by
laundryndash physical removal of both dust and mites by the multiple wash
and rinse cycles ndash effects of detergents additivesndash subsequent drying procedures
bull McDonald LGTovey E ndash All mites were killed by water temperatures 55 degrees C or
greaterndash Killing at lower temperatures was not enhanced by any of the
pure detergents or laundry products tested
J Allergy Clin Immunol 2011128723-7
J Allergy Clin Immunol 199290599-608
Floor coveringsbull Designing the house with polished floors and wooden or
vinylleather furniture so as to limit the sites where mites can grow
bull carpets fitted onto unventilated floors water can accumulate growth of both fungi and mites
bull hard floors are likely to be preferred as they are more easily kept in a state that minimizes aeroallergen reaerosolization in the long term
bull the little available data of aeroallergens in houses suggest that the difference may be small and the effects complex
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552J Allergy Clin Immunol 2011128723-7
Vacuum cleaners
bull Vacuum cleaners are heavily promoted
bull Probably all cleaners cause a brief increase in personal aeroallergen exposure under normal domestic conditions and high-efficiency particulate arrest (HEPA) filters make little difference
bull Thus the benefits of HEPA filtration on exposure may have been exaggerated and all cleaners probably provide a brief increase in exposure
J Allergy Clin Immunol 2011128723-7
Allergy 200661119-23
Air management
bull indoor relative humidity is kept below 50 (absolute humidity below 6 gkg)
bull In some areas of the world this can be done by increasing ventilation
bull in other areas it is necessary to use air conditioning during the most humid months of the summer
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Air filtration
bull The role of air filtration continues to be debatedbull There is some consensus that small benefits exist mainly for pet
allergens
J Allergy Clin Immunol 2011128723-7
Acaricidesbull variety of acaricides have been used to treat carpets or furniturebull pyrethroids natamycin (an antifungal) pirimiphos methyl and
benzyl benzoate bull killing mites
bull Acaricides proved largely ineffective because the mite populations return shortly after their application and they may also cause skin and respiratory irritation
bull No data on clinical benefit exist and concerns about human health and environmental toxicity remain
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
J Allergy Clin Immunol 2011128723-7
Acaricidesbull 1 or 3 tannic acid
ndash method of denaturing mite allergensndash reduction of mite allergen can be achievedndash does not kill mitesndash so the effect can only be temporary approximately 6 weeks to 3
months
bull may be recommended when it is not possible to remove the carpets or change the furniture
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
bull Woven nonwovenndash pore size between 2 and 10 um (average 6 um) blocking most
mite allergens
bull Plasticndash pore free best barrier in terms of blockingndash but the least comfortable zero ventilation ndash tendency to become a haven for mold spores
bull For acaricide-coated materialsndash pore size is usually not a major factor ndash mites are eradicated on contact with the chemicalsndash still allow the passage of allergens ndash prevent penetration through the fabrics but allow colonization
J Allergy Clin Immunol 20061181164-8
Asian Pac J Allergy Immunol 201028155-61
Sensitized level
Symptomatic level
sponge-like polyurethane lowest rate Synthetic fibers and kapok mattresses highest rate
A combination of the following choosing new sponge-like polyurethane or coconut fiber mattresses with mite-impermeable covers and washing sheets pillowcases blankets and mattresses pad at least weekly in hot water should be the best method of prevention in HDM allergen sensitive allergic patients
Laundrybull Both dust and cat and mite allergens are effectively removed by
laundryndash physical removal of both dust and mites by the multiple wash
and rinse cycles ndash effects of detergents additivesndash subsequent drying procedures
bull McDonald LGTovey E ndash All mites were killed by water temperatures 55 degrees C or
greaterndash Killing at lower temperatures was not enhanced by any of the
pure detergents or laundry products tested
J Allergy Clin Immunol 2011128723-7
J Allergy Clin Immunol 199290599-608
Floor coveringsbull Designing the house with polished floors and wooden or
vinylleather furniture so as to limit the sites where mites can grow
bull carpets fitted onto unventilated floors water can accumulate growth of both fungi and mites
bull hard floors are likely to be preferred as they are more easily kept in a state that minimizes aeroallergen reaerosolization in the long term
bull the little available data of aeroallergens in houses suggest that the difference may be small and the effects complex
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552J Allergy Clin Immunol 2011128723-7
Vacuum cleaners
bull Vacuum cleaners are heavily promoted
bull Probably all cleaners cause a brief increase in personal aeroallergen exposure under normal domestic conditions and high-efficiency particulate arrest (HEPA) filters make little difference
bull Thus the benefits of HEPA filtration on exposure may have been exaggerated and all cleaners probably provide a brief increase in exposure
J Allergy Clin Immunol 2011128723-7
Allergy 200661119-23
Air management
bull indoor relative humidity is kept below 50 (absolute humidity below 6 gkg)
bull In some areas of the world this can be done by increasing ventilation
bull in other areas it is necessary to use air conditioning during the most humid months of the summer
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Air filtration
bull The role of air filtration continues to be debatedbull There is some consensus that small benefits exist mainly for pet
allergens
J Allergy Clin Immunol 2011128723-7
Acaricidesbull variety of acaricides have been used to treat carpets or furniturebull pyrethroids natamycin (an antifungal) pirimiphos methyl and
benzyl benzoate bull killing mites
bull Acaricides proved largely ineffective because the mite populations return shortly after their application and they may also cause skin and respiratory irritation
bull No data on clinical benefit exist and concerns about human health and environmental toxicity remain
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
J Allergy Clin Immunol 2011128723-7
Acaricidesbull 1 or 3 tannic acid
ndash method of denaturing mite allergensndash reduction of mite allergen can be achievedndash does not kill mitesndash so the effect can only be temporary approximately 6 weeks to 3
months
bull may be recommended when it is not possible to remove the carpets or change the furniture
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
Asian Pac J Allergy Immunol 201028155-61
Sensitized level
Symptomatic level
sponge-like polyurethane lowest rate Synthetic fibers and kapok mattresses highest rate
A combination of the following choosing new sponge-like polyurethane or coconut fiber mattresses with mite-impermeable covers and washing sheets pillowcases blankets and mattresses pad at least weekly in hot water should be the best method of prevention in HDM allergen sensitive allergic patients
Laundrybull Both dust and cat and mite allergens are effectively removed by
laundryndash physical removal of both dust and mites by the multiple wash
and rinse cycles ndash effects of detergents additivesndash subsequent drying procedures
bull McDonald LGTovey E ndash All mites were killed by water temperatures 55 degrees C or
greaterndash Killing at lower temperatures was not enhanced by any of the
pure detergents or laundry products tested
J Allergy Clin Immunol 2011128723-7
J Allergy Clin Immunol 199290599-608
Floor coveringsbull Designing the house with polished floors and wooden or
vinylleather furniture so as to limit the sites where mites can grow
bull carpets fitted onto unventilated floors water can accumulate growth of both fungi and mites
bull hard floors are likely to be preferred as they are more easily kept in a state that minimizes aeroallergen reaerosolization in the long term
bull the little available data of aeroallergens in houses suggest that the difference may be small and the effects complex
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552J Allergy Clin Immunol 2011128723-7
Vacuum cleaners
bull Vacuum cleaners are heavily promoted
bull Probably all cleaners cause a brief increase in personal aeroallergen exposure under normal domestic conditions and high-efficiency particulate arrest (HEPA) filters make little difference
bull Thus the benefits of HEPA filtration on exposure may have been exaggerated and all cleaners probably provide a brief increase in exposure
J Allergy Clin Immunol 2011128723-7
Allergy 200661119-23
Air management
bull indoor relative humidity is kept below 50 (absolute humidity below 6 gkg)
bull In some areas of the world this can be done by increasing ventilation
bull in other areas it is necessary to use air conditioning during the most humid months of the summer
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Air filtration
bull The role of air filtration continues to be debatedbull There is some consensus that small benefits exist mainly for pet
allergens
J Allergy Clin Immunol 2011128723-7
Acaricidesbull variety of acaricides have been used to treat carpets or furniturebull pyrethroids natamycin (an antifungal) pirimiphos methyl and
benzyl benzoate bull killing mites
bull Acaricides proved largely ineffective because the mite populations return shortly after their application and they may also cause skin and respiratory irritation
bull No data on clinical benefit exist and concerns about human health and environmental toxicity remain
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
J Allergy Clin Immunol 2011128723-7
Acaricidesbull 1 or 3 tannic acid
ndash method of denaturing mite allergensndash reduction of mite allergen can be achievedndash does not kill mitesndash so the effect can only be temporary approximately 6 weeks to 3
months
bull may be recommended when it is not possible to remove the carpets or change the furniture
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
Laundrybull Both dust and cat and mite allergens are effectively removed by
laundryndash physical removal of both dust and mites by the multiple wash
and rinse cycles ndash effects of detergents additivesndash subsequent drying procedures
bull McDonald LGTovey E ndash All mites were killed by water temperatures 55 degrees C or
greaterndash Killing at lower temperatures was not enhanced by any of the
pure detergents or laundry products tested
J Allergy Clin Immunol 2011128723-7
J Allergy Clin Immunol 199290599-608
Floor coveringsbull Designing the house with polished floors and wooden or
vinylleather furniture so as to limit the sites where mites can grow
bull carpets fitted onto unventilated floors water can accumulate growth of both fungi and mites
bull hard floors are likely to be preferred as they are more easily kept in a state that minimizes aeroallergen reaerosolization in the long term
bull the little available data of aeroallergens in houses suggest that the difference may be small and the effects complex
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552J Allergy Clin Immunol 2011128723-7
Vacuum cleaners
bull Vacuum cleaners are heavily promoted
bull Probably all cleaners cause a brief increase in personal aeroallergen exposure under normal domestic conditions and high-efficiency particulate arrest (HEPA) filters make little difference
bull Thus the benefits of HEPA filtration on exposure may have been exaggerated and all cleaners probably provide a brief increase in exposure
J Allergy Clin Immunol 2011128723-7
Allergy 200661119-23
Air management
bull indoor relative humidity is kept below 50 (absolute humidity below 6 gkg)
bull In some areas of the world this can be done by increasing ventilation
bull in other areas it is necessary to use air conditioning during the most humid months of the summer
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Air filtration
bull The role of air filtration continues to be debatedbull There is some consensus that small benefits exist mainly for pet
allergens
J Allergy Clin Immunol 2011128723-7
Acaricidesbull variety of acaricides have been used to treat carpets or furniturebull pyrethroids natamycin (an antifungal) pirimiphos methyl and
benzyl benzoate bull killing mites
bull Acaricides proved largely ineffective because the mite populations return shortly after their application and they may also cause skin and respiratory irritation
bull No data on clinical benefit exist and concerns about human health and environmental toxicity remain
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
J Allergy Clin Immunol 2011128723-7
Acaricidesbull 1 or 3 tannic acid
ndash method of denaturing mite allergensndash reduction of mite allergen can be achievedndash does not kill mitesndash so the effect can only be temporary approximately 6 weeks to 3
months
bull may be recommended when it is not possible to remove the carpets or change the furniture
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
Floor coveringsbull Designing the house with polished floors and wooden or
vinylleather furniture so as to limit the sites where mites can grow
bull carpets fitted onto unventilated floors water can accumulate growth of both fungi and mites
bull hard floors are likely to be preferred as they are more easily kept in a state that minimizes aeroallergen reaerosolization in the long term
bull the little available data of aeroallergens in houses suggest that the difference may be small and the effects complex
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552J Allergy Clin Immunol 2011128723-7
Vacuum cleaners
bull Vacuum cleaners are heavily promoted
bull Probably all cleaners cause a brief increase in personal aeroallergen exposure under normal domestic conditions and high-efficiency particulate arrest (HEPA) filters make little difference
bull Thus the benefits of HEPA filtration on exposure may have been exaggerated and all cleaners probably provide a brief increase in exposure
J Allergy Clin Immunol 2011128723-7
Allergy 200661119-23
Air management
bull indoor relative humidity is kept below 50 (absolute humidity below 6 gkg)
bull In some areas of the world this can be done by increasing ventilation
bull in other areas it is necessary to use air conditioning during the most humid months of the summer
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Air filtration
bull The role of air filtration continues to be debatedbull There is some consensus that small benefits exist mainly for pet
allergens
J Allergy Clin Immunol 2011128723-7
Acaricidesbull variety of acaricides have been used to treat carpets or furniturebull pyrethroids natamycin (an antifungal) pirimiphos methyl and
benzyl benzoate bull killing mites
bull Acaricides proved largely ineffective because the mite populations return shortly after their application and they may also cause skin and respiratory irritation
bull No data on clinical benefit exist and concerns about human health and environmental toxicity remain
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
J Allergy Clin Immunol 2011128723-7
Acaricidesbull 1 or 3 tannic acid
ndash method of denaturing mite allergensndash reduction of mite allergen can be achievedndash does not kill mitesndash so the effect can only be temporary approximately 6 weeks to 3
months
bull may be recommended when it is not possible to remove the carpets or change the furniture
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
Vacuum cleaners
bull Vacuum cleaners are heavily promoted
bull Probably all cleaners cause a brief increase in personal aeroallergen exposure under normal domestic conditions and high-efficiency particulate arrest (HEPA) filters make little difference
bull Thus the benefits of HEPA filtration on exposure may have been exaggerated and all cleaners probably provide a brief increase in exposure
J Allergy Clin Immunol 2011128723-7
Allergy 200661119-23
Air management
bull indoor relative humidity is kept below 50 (absolute humidity below 6 gkg)
bull In some areas of the world this can be done by increasing ventilation
bull in other areas it is necessary to use air conditioning during the most humid months of the summer
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Air filtration
bull The role of air filtration continues to be debatedbull There is some consensus that small benefits exist mainly for pet
allergens
J Allergy Clin Immunol 2011128723-7
Acaricidesbull variety of acaricides have been used to treat carpets or furniturebull pyrethroids natamycin (an antifungal) pirimiphos methyl and
benzyl benzoate bull killing mites
bull Acaricides proved largely ineffective because the mite populations return shortly after their application and they may also cause skin and respiratory irritation
bull No data on clinical benefit exist and concerns about human health and environmental toxicity remain
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
J Allergy Clin Immunol 2011128723-7
Acaricidesbull 1 or 3 tannic acid
ndash method of denaturing mite allergensndash reduction of mite allergen can be achievedndash does not kill mitesndash so the effect can only be temporary approximately 6 weeks to 3
months
bull may be recommended when it is not possible to remove the carpets or change the furniture
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
Allergy 200661119-23
Air management
bull indoor relative humidity is kept below 50 (absolute humidity below 6 gkg)
bull In some areas of the world this can be done by increasing ventilation
bull in other areas it is necessary to use air conditioning during the most humid months of the summer
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Air filtration
bull The role of air filtration continues to be debatedbull There is some consensus that small benefits exist mainly for pet
allergens
J Allergy Clin Immunol 2011128723-7
Acaricidesbull variety of acaricides have been used to treat carpets or furniturebull pyrethroids natamycin (an antifungal) pirimiphos methyl and
benzyl benzoate bull killing mites
bull Acaricides proved largely ineffective because the mite populations return shortly after their application and they may also cause skin and respiratory irritation
bull No data on clinical benefit exist and concerns about human health and environmental toxicity remain
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
J Allergy Clin Immunol 2011128723-7
Acaricidesbull 1 or 3 tannic acid
ndash method of denaturing mite allergensndash reduction of mite allergen can be achievedndash does not kill mitesndash so the effect can only be temporary approximately 6 weeks to 3
months
bull may be recommended when it is not possible to remove the carpets or change the furniture
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
Air management
bull indoor relative humidity is kept below 50 (absolute humidity below 6 gkg)
bull In some areas of the world this can be done by increasing ventilation
bull in other areas it is necessary to use air conditioning during the most humid months of the summer
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Air filtration
bull The role of air filtration continues to be debatedbull There is some consensus that small benefits exist mainly for pet
allergens
J Allergy Clin Immunol 2011128723-7
Acaricidesbull variety of acaricides have been used to treat carpets or furniturebull pyrethroids natamycin (an antifungal) pirimiphos methyl and
benzyl benzoate bull killing mites
bull Acaricides proved largely ineffective because the mite populations return shortly after their application and they may also cause skin and respiratory irritation
bull No data on clinical benefit exist and concerns about human health and environmental toxicity remain
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
J Allergy Clin Immunol 2011128723-7
Acaricidesbull 1 or 3 tannic acid
ndash method of denaturing mite allergensndash reduction of mite allergen can be achievedndash does not kill mitesndash so the effect can only be temporary approximately 6 weeks to 3
months
bull may be recommended when it is not possible to remove the carpets or change the furniture
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
Air filtration
bull The role of air filtration continues to be debatedbull There is some consensus that small benefits exist mainly for pet
allergens
J Allergy Clin Immunol 2011128723-7
Acaricidesbull variety of acaricides have been used to treat carpets or furniturebull pyrethroids natamycin (an antifungal) pirimiphos methyl and
benzyl benzoate bull killing mites
bull Acaricides proved largely ineffective because the mite populations return shortly after their application and they may also cause skin and respiratory irritation
bull No data on clinical benefit exist and concerns about human health and environmental toxicity remain
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
J Allergy Clin Immunol 2011128723-7
Acaricidesbull 1 or 3 tannic acid
ndash method of denaturing mite allergensndash reduction of mite allergen can be achievedndash does not kill mitesndash so the effect can only be temporary approximately 6 weeks to 3
months
bull may be recommended when it is not possible to remove the carpets or change the furniture
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
Acaricidesbull variety of acaricides have been used to treat carpets or furniturebull pyrethroids natamycin (an antifungal) pirimiphos methyl and
benzyl benzoate bull killing mites
bull Acaricides proved largely ineffective because the mite populations return shortly after their application and they may also cause skin and respiratory irritation
bull No data on clinical benefit exist and concerns about human health and environmental toxicity remain
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
J Allergy Clin Immunol 2011128723-7
Acaricidesbull 1 or 3 tannic acid
ndash method of denaturing mite allergensndash reduction of mite allergen can be achievedndash does not kill mitesndash so the effect can only be temporary approximately 6 weeks to 3
months
bull may be recommended when it is not possible to remove the carpets or change the furniture
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
Acaricidesbull 1 or 3 tannic acid
ndash method of denaturing mite allergensndash reduction of mite allergen can be achievedndash does not kill mitesndash so the effect can only be temporary approximately 6 weeks to 3
months
bull may be recommended when it is not possible to remove the carpets or change the furniture
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
Cockroach
bull Biology And Characteristic
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
Cockroaches
bull Phylum Arthropoda class Insecta order Blattaria bull major source of indoor allergens especially in inner citiesbull allergens can be derived from feces saliva or debris from dead
animals
bull Most common species indoors
1048708 Blattella germanica German
1048708 Periplaneta americana American
bull World wide distributionbull Highest levels usually in kitchens (mite allergen in bedding)
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
Cockroaches
bull Allergens not easily detected in undisturbed air large particles (like dust mites) gt10 μm in diameter and that consequently fall rapidly
bull Large quantities of cockroach allergens can accumulate in homes and may remain for years after cockroaches have been eradicated
bull it was the concentration of cockroach allergen in childrenrsquos bedrooms that correlated with the risk of hospitalization
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
German cockroach (Blattella germanica)
American cockroach (Periplaneta americana)
oriental cockroach (Blatta orientalis)
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
wwwallergenorg2122013
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
Cockroach
bull Avoidance Measures
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
Cockroach
bull Pest allergens appear to be particularly difficult to eliminate and require different strategies than those used for other indoor allergens
bull These interventions include initial removal of the insects rodents or both but also require long-term care to prevent a return of the infestation
J Allergy Clin Immunol 2010125575-81
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
J Allergy Clin Immunol 2010125575-81
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
Cockroaches
bull effective when applied as part of an overall avoidance plan
bull Spraying with insecticides ndash is generally ineffective ndash volatile organic substances used are often irritating to patients
with asthma
Thomas AE Platts-MillsMiddletonrsquos Allergy 7rsquoth edition 539-552
The primary strategies are (1) poison bait
Bait for killing cockroaches ranges from boric acid to a variety of chemicals including hydramethylnon abamectin and fipronil
(2) careful housekeeping to enclose all sources of food for insects(3) cleaning to remove any accumulated allergen(4) sealing all possible access points to the house
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
Cockroach
bull Once cockroaches have been eliminated from the environment bull a thorough cleaning is necessarybull not only immediately after pesticide treatmentbull but continued for long periods of time (up to several months) to
remove the allergen
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
Immunol Allergy Clin N Am 31 (2011) 493ndash507
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
Pediatr Clin N Am 54 (2007) 103ndash120
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
Summarybull Many different allergens are found indoors but dust mite cat
cockroach mouse and dog appear to be the most important bull single interventions for indoor allergens have limited effectivenessbull multifaceted comprehensive approach is prerequisite for clinical
benefit bull Complete allergen avoidance is usually impractical or impossible
and often limiting to the patientbull some measures involve significant expense and inconveniencebull tailoring environmental interventions to specific sensitization profiles
has been shown to be of added value
It is also necessary to tailor interventions to an individualrsquos living situation and patterns of disease
Thank you
Thank you
