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Prevalence and treatment of allergies in rural areas of Bavaria, Germany: a cross-sectional study

Prevalence and treatment of allergies in rural areas of Bavaria, Germany: a cross-sectional study Background: There is a high prevalence of allergies in Germany, with approximately 20% of the population having at least one allergy and only about 10% of these being treated adequately. We conducted a cross-sectional study in a rural area of Bavaria (Southern Germany) to evaluate the prevalence of allergies and their treatment, because research regarding this topic is currently limited. Methods: Data were collected in 10 offices of non-dermatological doctors using a self-filled questionnaire to ask participants about allergies and treatment. Results: A total of 641 questionnaires were appropriate for analysis. The prevalence of allergies in the Bavarian countryside was higher than that reported for Germany (37.3% vs. 20.0%). Furthermore, almost a third (30.4%) of allergies were not treated at all. The most frequently consulted therapist was found to be a general practitioner. Conclusions: Based on the study results, there is a need for prevention programs and establishment of treatments for certain allergies to minimize long-term health effects. Moreover, more studies are needed to analyze the prevalence of allergies in farmers who had a higher prevalence of allergies compared to previously reported prevalence in literature reviews. Trial registrations: The study was approved by the ethical review committee of the Technical University Munich (EC number 548/16S). Keywords: Allergies, Bavaria, Prevalence, Treatment, Allergy, Rural area Background food allergies, and 2.8% for insect venom allergies [3]. Allergies are a common health problem worldwide [1]. Exact According to the RKI, approximately 20% of all German figures on the prevalence are not available, estimations vary adults and 26% of all children and adolescents are affected between 20 and 40% [2]. Notonlydotheyinfluence thequal- by at least one allergy, but only 10% of the allergies are ity of life of affected patients, they also represent a significant treated appropriately [4]. According to data collected by financial burden to the health systems [3]. the European Centre for Allergy Research Foundation, the According to the position paper of the Environmental annual average costs for a patient with hay fever are as Medicine Commission of the Robert Koch Institute (RKI), high as 1545€. Furthermore, the foundation emphasizes a German federal government agency and research insti- the necessity of correct treatment of rhinitis without tute responsible for disease control and prevention, the which the risk for developing bronchial asthma will in- life time prevalence of allergic diseases in Germany in crease [4]. The costs for patients who suffer from asthma adults was 8.6% for asthma, 14.8% for hay fever, 3.5% for and rhinitis is six-fold and as high as the treatment for atopic dermatitis, 8.1% for contact dermatitis, 4.7% for only rhinitis. If allergies were treated correctly in Europe, approximately 84 million € could be saved per year [4]. Exact data regarding the prevalence of allergies and aller- * Correspondence: DanielleFranziska.Boehmer@mri.tum.de gic diseases are difficult to collect because the definition Klinik und Poliklinik für Dermatologie und Allergologie am Biederstein, Technical University of Munich, Biedersteiner Str. 29, 80802 Munich, Germany of allergy is variable and broad-based epidemiological Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Boehmer et al. World Allergy Organization Journal (2018) 11:36 Page 2 of 8 studies are hard to conduct. Furthermore, studies to com- allergies. Participants were asked to indicate whether pare the country-side and urban areas are rare [5, 6]. they self-treated their allergy or if their allergy was In the past, various researchers showed that farming treated by a general practitioner (GP), a dermatologist, and growing up on a farm in rural areas reduces the risk an ear, nose, and throat specialist (ENT), an alternative of having an allergy [5, 7–10]. Figures for rural areas in practitioner, or not treated at all. Furthermore, the ques- Germany had not been published to date. A small portion tionnaires were used to determine the age and sex of the (2.3%) of our study population were farmers; therefore, we participants and their current or former profession. This also assessed their allergies in view of this hypothesis. additional information allowed to compare the preva- There have been various theories to explain why aller- lence of allergies based on various jobs (e.g., indoor vs. gies are increasing worldwide, especially amongst the outdoor jobs. Participants were grouped into 4 age farming population. One of the theories is the hygiene groups (18–29 years, 30–44 years, 45–64 years, and ≥ hypothesis, which states that exposure to microbials at a 65 years), following the example of the “Gesundheit in young age can lead to a lower risk of developing an al- Deutschland aktuell study” conducted by the RKI [4, 14]. lergy than without exposure. Due to our modern sani- Assistance to fill in the questionnaire was provided by tized living conditions, our contact with microbials has the medical practitioners, if necessary. Filled anonymous greatly decreased. This leads to the theory that the questionnaires were sent back for digitalization with the change in the microbiome due to lifestyle might be a program EpiInfo (statistical software for epidemiology de- reason for the increasing prevalence of allergies. The un- veloped by the Centers for Disease Control and Preven- derstanding of the microbiome and the development of tion, Atlanta, Georgia, USA). Some questionnaires were treatments to influence this could significantly change randomly chosen to monitor the accuracy of digitalization. the prevalence of allergies in the future [11, 12]. The data were analyzed using descriptive statistics. The aim of this study was to evaluate the prevalence of Odds ratios (ORs) were calculated to compare the risk allergies in rural Bavaria and compare these numbers to of allergy between men and women and different age data collected across Germany [13]. Furthermore, we eval- and professional groups. To determine significance be- uated the treatment of allergies in rural areas. tween relationships, 95% confidence intervals of the ORs were determined. The data were analyzed using IBM Methods SPSS version 24 (IBM cooperation, Armonk, USA). This study was a cross-sectional study conducted using a paper-based self-filled questionnaire in the Bavarian Forest Results as part of the previously published WALD (the official From January to March 2017, a total of 641 patients name of the study conducted in the past, it means forrest (59.7% women, 40.3% male; mean age and standard devi- in German as it was conducted in an area of Bavaria which ation, 50.5 ± 15.1 years; range, 18–86 years) participated. has lots of forrests) study ([4, 14]. Thedatawere collected Of these, 67.2% had indoor jobs (e.g., office jobs; n =387), during the first quarter of 2017. The anonymous question- 24, 7% were pensioners (n = 154), 14.4% were housewives/ naires were distributed in 10 offices of non-dermatological house husbands (n =83), 7.3% were construction workers doctors in rural Bavaria, Southern Germany. Locations of (n =42), 2.3% were farmers (n =13), 2.4% were students the doctors’ offices were in the Bavarian forest (rural dis- or scholars (n =14), 1.9% were unemployed (n =11), and tricts: Cham, Freyung-Grafenau, Passau, and Regen), an 5.9% had other jobs (n =38; Table 1). area officially declared as countryside by the federal gov- The response rate for this current sample is unknown. ernment of Germany [14, 15]. The doctors were general The data for this study were collected within the scope of practitioners (n = 1) and specialists in internal medicine the WALD-study (response rate, 77.8%) [14]. However, (n = 2) and orthopedics and surgery (n =7). They were only 718 of the 1007 participants of the WALD-study had chosen from throughout the region to ensure adequate rep- actively received the questionnaire regarding allergies that resentation. To minimize selection bias, both patients and was used in our current study. The number of people who their company were eligible for participation in this study. had saw the questionnaire at the doctor’soffices butdid The minimum age for participation was 18 years. Patients not complete it was unknown. In addition, participants re- had to give written consent. The study was approved by the cruited by dermatologists (n = 77) were excluded from this ethical review committee of the Technical University analysis to minimize selection bias. Munich (ethical committee (EC) number 548/16S). In the questionnaire, the participants were asked if Prevalence of allergies they suffered from an allergy, whether it was treated, Approximately 37.3% of the whole cohort had at least and what treatment was administered. The examined al- one allergy, and 28.1% and 43.2% of all questioned men lergies were pollen, animal hair, bee venom, wasp and women, respectively, stated that they had allergies. venom, contact, food, drug, house dust mite, and other Women had a significantly higher risk of allergies than Boehmer et al. World Allergy Organization Journal (2018) 11:36 Page 3 of 8 Table 1 Study population men (OR, 2; confidence interval [CI], [1.4; 2.8]). Further- more, women showed a significantly higher risk for most Number of participants 641 examined allergies, especially for food allergies (OR, 6.3; Gender CI, [1.9; 21.1]) and contact allergies (OR, 6.1; CI, [2.1; Men 40.3% (n = 258) 17.4]) compared to men (Fig. 1). However, the risk for Women 59.7% (n = 383) bee venom allergy (OR, 0.7; CI, [0.3; 1.8]) and other al- Missing information on gender > 0.1%(n = 10) lergies (OR, 0.8; CI, [0.3; 2.3]) was lower in women, and Age there was no significant difference in the risk for wasp Mean 50.5 years venom allergy (OR, 1.3; CI, [0.53; 3.3]) and house dust mite allergy (OR, 1.1; CI, [0.6; 1.9]). Standard deviation 15.1 years In the study population, the highest prevalence of allergy Range 18–86 years was amongst the young population aged 18–29 years 18–29 years 11.4% (n = 73) (45.7% had at least one allergy). The lowest prevalence 30–44 years 17.3% (n = 111) was observed in the population aged > 65 years (18.7%; 45–64 years 53.7% (n = 344) Fig. 2). The most common allergy was pollen allergy > 64 years 17.6% (n = 113) (16.0%), and the least common allergies were bee venom (3.4%) and other allergies (2.7%; Fig. 2). Pollen allergy was Missing information on age > 0.1% (n =3) a the most common allergy in the age groups 18–29 years Profession (25.7%), 30–44 years (18.3%), and 45–64 years (16.1%). In Indoor workers (office etc.) 60.4% (n = 387) contrast, the most common allergy found in participants House wives / house husbands 12.9% (n = 83) aged ≥65 years was drug allergies (6.6%). Construction workers 6.6% (n = 42) Indoor workers (OR, 1.5; CI, [1.0; 2.2]), farmers (OR, Students and scholars 2.2% (n = 14) 1.3; CI, [0.3; 4.9]) and unemployed participants (OR, 1.3; CI, [0.4; 4.5]) were affected by allergies the most. Farmers 2% (n = 13) Pensioners (OR, 0.5; CI, [0.3; 0.8)], construction workers No employment 1.7% (n = 11) (OR, 0.4; CI, [0.2; 0.9]), and hunters (OR, 0.3; CI, [0.0; Hunters 1.1% (n =7) 2.7]) were affected the least. However, only the ORs for Others 5.3%(n = 34) pensioners and construction workers proved to be sig- Missing information on profession 10.9% (n = 70) nificantly < 1. Regarding the different allergies, the only Retirement significant finding was that pensioners had a lower risk of pollen allergy (OR, 0.4; CI, [0.2; 0.8]) compared to Pensioners 24% (n = 154) participants in other occupations. Missing information on retirement > 0.1% (n = 22) 18 participants indicated having two professions, 1 reported having Treatment of allergies in rural Bavaria three professions Based on our data, 30.4% of all allergies were not treated at all. A GP was consulted most frequently to treat the allergy (39.3%), followed by a dermatologist (17.0%) and Fig. 1 Prevalence of self-reported allergies stratified by gender Boehmer et al. World Allergy Organization Journal (2018) 11:36 Page 4 of 8 Fig. 2 Prevalence of allergies according to age ENT doctor (7.8%), while 15.2% stated self-treatment of weak findings for this hypothesis was found in a study their allergy (Fig. 3). The most commonly treated allergy conducted by Hunt et al. in 2011 to evaluate whether (including self-treatment) was food allergy (79.3%), and women consult doctors more frequently for headache the least treated was contact allergy (62.2%). The most and backpain [16]. common allergies that were treated by a dermatologist, In a study conducted in 2008–2011 to examine blood ENT doctor, or GP were animal hair and wasp venom samples for specific immunoglobulin E (IgE) antibodies, allergy (both 61.9%; Fig. 4). Contact allergies (48.6%) and men were more frequently sensitized to at least one al- other allergies (43.8%) were treated the least frequently lergen than women [4, 17]. A question that does arise is by GPs, dermatologists, and ENT doctors (Fig. 4). whether men tend to ignore or are less aware of their al- lergies than women. Furthermore, women may not ne- Discussion cessarily have an allergy but think that they do [18]. According to the study results, allergies are common in Previous researchers have emphasized the influence of the rural areas of Southern Germany, and a large pro- the relationship between female steroid sex hormones portion of these allergies is not appropriately treated. and the existence of allergies. The fact that the preva- We found that women had a higher prevalence of aller- lence of allergies is usually higher in men before puberty gies than men, and similar findings were also found in and higher in females after puberty, underlines the pos- various studies conducted in the past [4]. A reason for sible relationship between female hormones and aller- this might be that women tend to consult doctors more gies. Reasons for this might be that estrogen receptors frequently than men do. Although this association has are found on numerous immunoregulatory cells [19]. It not been directly mentioned in the literature, there are has been suggested that estrogen can act to move the assumptions regarding this. However, inconsistent and immune response towards an allergic response directly Fig. 3 Display of consulted doctors or methods of treatment of allergies (at least one method of treatment) Boehmer et al. World Allergy Organization Journal (2018) 11:36 Page 5 of 8 Fig. 4 Treatment of allergies by GPs (general practitioners), dermatologists and ENTs (ear nose throat specialists) or via the modulation of immunologic pathways [20]. of the immune system can determine a complicated im- Estrogen can influence immune cells to favor an allergic munological profile in the elderly population [24]. Fur- response by promoting Th2 polarization, which can lead thermore, patients who are older often take many to class switching of B cells to then produce IgE. Never- medications, which can also interfere with allergies and theless, the roles of the hormones have not fully been allergic reactions. Nevertheless, the literature still lacks elucidated and further studies are needed [21]. sufficient information regarding allergies and their Another interesting finding was that allergies were prevalence in the elderly population. Due to our increas- more common in the younger population. The younger ing understanding of the molecular and genetic basis of generation is often better informed than the elderly, human senescence, the field of allergic diseases in the which could explain a higher prevalence of allergies (e.g., elderly should be expanded to possibly find new diag- histamine intolerance) in that group. The older gener- nostic and therapeutic opportunities [25]. ation might not know that an allergy could be an ex- A large proportion of patients (30.4%) with allergies planation for their symptoms. Furthermore, another did not receive any treatment in this current study. reason could be that individuals who are aware that they Furthermore, a large percentage of participants did not have a certain allergy may avoid the allergen (e.g., food have their allergies treated by a dermatologist or an that causes allergic symptoms) during most of their life, ENT doctor, who are usually specialized in allergology. which can result in less pronounced allergic episodes. The most frequently consulted therapist was a GP Another approach to explain this is that the current (39.3%), which could be explained by the fact that there younger generation is living in an environment that is are more GPs than other specialists across the lower re- different to that lived by the older generation many years gion of Bavaria. GPs are often the only available doctors ago. The hygiene hypothesis, which was established a for patients, especially in rural areas [26, 27]. few years ago, suggests that allergies develop easily when Out of the 13 farmers who answered the question about there is less contact with microbials. Dr. von Mutius allergies, 6 (44.4%) stated that they had an allergy. In con- found that the development of asthma and allergies was trast, it was previously observed that farmers suffered significantly lower in children who were exposed to the from less allergies and farming was recognized as a pro- microbial environment compared to those who were not tective factor [14]. The specific role of modern agriculture exposed [22, 23]. Furthermore, there are many factors for this relationship is not known. In another study, chil- that can influence allergic diseases during aging, such as dren living on very traditional farms had no hay fever or genetic, epigenetic, immunosenescence, external risk fac- allergies. Children living on Hutterite farms, which use in- tors, internal diseases, and medications. Immunosenes- dustrial farming practices, showed a high prevalence of cence is the change in immune function with aging. asthma (> 15%) and allergic sensitization [28]. A possible Immunosenescence involves modification and remodel- explanation for why the protective factor of farming might ing of tissue structure. Many functions decline with no longer be present is because modern agriculture uses aging, while other functions can become more active. A far more chemical substances, which also kill bacteria [23, senescent immune system can show impaired interac- 29]. Due to the small number of farmers participating in tions between the innate and adaptive immune re- our study, we were unable to make any conclusions or sponses. Interaction between the different components comparisons to previous studies regarding the link Boehmer et al. World Allergy Organization Journal (2018) 11:36 Page 6 of 8 between farming and allergies. However, we emphasize probably be different to the findings that were observed that additional studies are necessary to support this in this current study. In addition, this was one of the finding. first studies conducted to provide a comprehensive over- According to our results, there remains a large de- view about the prevalence and treatment of allergies in mand for diagnostics and therapies [30, 31] for allergies the Bavarian countryside. Medical care in rural areas in rural Bavaria and many other parts of Europe [32]. have many challenges due to demographic changes and An untreated insect or other allergies, such as certain urbanization [26], and therefore, determining the need food allergies (e.g., peanut), can lead to anaphylaxis and for treatment in rural areas is crucial. death [33–37]. In addition to allergic symptoms, a falsely There were several limitations for the interpretation of treated case of hay fever can lead to the development of our study results. There was a selection bias because the asthma, which will consequently lead to additional de- study questionnaires were only distributed in doctors’ mand for therapy and increased healthcare costs [4]. offices, and therefore, we only included participants who In our study, the examined population lived in rural had already consulted a doctor. Therefore, a direct com- areas (i.e., countryside) of Bavaria, which would create the parison between our results and that of the RKI survey, assumption that there are less allergies compared to the which had randomly selected participants, was not pos- past in the United States [28]. Unexpectedly, the preva- sible. Self-filled questionnaires may lead to social desir- lence of allergies in this current study was higher than the ability and recall bias, which can also influence the prevalence of allergies found by the RKI in 2016 for results. In addition, the information for this study was Germany [4]. A major difference between our study and obtained from only the participant responses and we did that conducted by the RKI was that the RKI had investi- not conduct any blood or skin tests concerning their gated the German population as a whole rather than fo- diagnosis or have access to information regarding their cusing on the rural population. In total, 30.0% of the treatment from the doctor, which may have contributed population of the RKI survey and 37.3% of our study to further biases in this study. However, in a study con- group had at least one allergy. Furthermore, there were ducted by the RKI in the 1990s, questionnaires answered some differences in the findings regarding the prevalence by patients can identify the prevalence of allergies more of different allergies between the RKI survey and our accurately than interviews conducted by treating doctors study (contact dermatitis, 8.1% vs. 6.5%; insect venom al- [38]. A reason for this is that patients only consult their lergy, 2.8% vs. 4.8%; food allergies, 4.7% vs. 5.2%). There doctor when they require treatment for their allergies. are many possible explanations for these differences. The The presence of an allergy is not always communicated best explanation for the higher prevalence of allergies was and can be determined more easily by a questionnaire. the fact that only people who consulted doctors partici- An additional limitation was the duration of the study. pated in this current study, whereas the population for the The questionnaires were only distributed for 3 months RKI health survey was randomly chosen [4]. Another very (January–March), which might not be a sufficient period important difference is that our study sample was smaller, because pollen allergies are most common during this resulting in non-representative results. Furthermore, the period anyway. The participants might therefore tend to higher prevalence might be explained by the lifestyle, age, emphasize answers for pollen allergies because this allergy and profession of the participants in rural Bavaria, which was more common during the time of the questionnaire. differs from other areas and cities across Germany. The small number of participating farmers did limit the Epidemiological studies regarding the health of an en- significance of our finding that farmers have a higher inci- tire population of a country have not been performed dence of allergies than previously assumed. To support frequently in the past because they are difficult to con- our results and findings, future studies should focus on the duct. We were unable to identify any previous studies prevalence of allergies amongst farmers, be conducted in a that were conducted to evaluate different allergy treat- wider population range (i.e., not only in doctors’ offices), ments in a general population; therefore, this study is and also address the treatment of allergies nationwide. the first to shed light on the way patients treat their al- lergies. Although the study population was not represen- Conclusion tative of the entire German population, we were able to The two main conclusions of our study were that the find that the most frequently consulted doctor for the prevalence of allergies was high in rural areas and that treatment of allergies was a GP (39.3%), and that a large most cases of allergies are not adequately treated. In order number of allergies were not treated at all (30.4%). to reach more patients and increase their awareness re- However, the high number of GP consultations in rural garding allergies and possible treatments, awareness and areas of Bavaria could also be due to the unavailability of information campaigns may represent a possible solution. other specialties in that area. Figures concerning the An improvement of patient-centered-care in allergology availabity of specialities in larger cities would most could lead to a reduction in the burden of allergic disease. Boehmer et al. World Allergy Organization Journal (2018) 11:36 Page 7 of 8 As already used in other areas of dermatology, telemedi- 8. Ober C, Sperling AI, von Mutius E, Vercelli D. Immune development and environment: lessons from Amish and Hutterite children. Curr Opin cine might be a useful method for the treatment of aller- Immunol. 2017;48:51–60. gies in rural areas in the future [38, 39]. 9. MacNeill SJ, Sozanska B, Danielewicz H, Debinska A, Kosmeda A, Boznanski A, Illi S, Depner M, Strunz-Lehner C, Waser M, et al. Asthma and allergies: is Abbreviations the farming environment (still) protective in Poland? The GABRIEL CI: Confidence interval; ENT: Ear, nose, and throat specialist; GP: General Advanced Studies. Allergy. 2013;68(6):771–9. practitioner; IgE: Immunoglobulin E; OR: Odds ratio; RKI: Robert Koch Institute 10. Gassner M. Farmers and their environment: protective influences of the farming environment against the development of allergies. Chem Immunol Acknowledgements Allergy. 2014;100:278–86. Not applicable. 11. Campbell BRC, Lodge CJ, Lowe AJ, Gislason T, Heinrich J, Sunyer J, Gómez Real F, Norbäck D, Matheson MC, Wjst M, Dratva J, de Marco R, Jarvis D, Funding Schlünssen V, Janson C, Leynaert B, Svanes C. The effects of growing up on No funding was received. a farm on adult lung function and allergic phenotypes: an international population-based study. 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Prevalence and treatment of allergies in rural areas of Bavaria, Germany: a cross-sectional study

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Copyright © 2018 by The Author(s).
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Medicine & Public Health; Allergology; Immunology
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Abstract

Background: There is a high prevalence of allergies in Germany, with approximately 20% of the population having at least one allergy and only about 10% of these being treated adequately. We conducted a cross-sectional study in a rural area of Bavaria (Southern Germany) to evaluate the prevalence of allergies and their treatment, because research regarding this topic is currently limited. Methods: Data were collected in 10 offices of non-dermatological doctors using a self-filled questionnaire to ask participants about allergies and treatment. Results: A total of 641 questionnaires were appropriate for analysis. The prevalence of allergies in the Bavarian countryside was higher than that reported for Germany (37.3% vs. 20.0%). Furthermore, almost a third (30.4%) of allergies were not treated at all. The most frequently consulted therapist was found to be a general practitioner. Conclusions: Based on the study results, there is a need for prevention programs and establishment of treatments for certain allergies to minimize long-term health effects. Moreover, more studies are needed to analyze the prevalence of allergies in farmers who had a higher prevalence of allergies compared to previously reported prevalence in literature reviews. Trial registrations: The study was approved by the ethical review committee of the Technical University Munich (EC number 548/16S). Keywords: Allergies, Bavaria, Prevalence, Treatment, Allergy, Rural area Background food allergies, and 2.8% for insect venom allergies [3]. Allergies are a common health problem worldwide [1]. Exact According to the RKI, approximately 20% of all German figures on the prevalence are not available, estimations vary adults and 26% of all children and adolescents are affected between 20 and 40% [2]. Notonlydotheyinfluence thequal- by at least one allergy, but only 10% of the allergies are ity of life of affected patients, they also represent a significant treated appropriately [4]. According to data collected by financial burden to the health systems [3]. the European Centre for Allergy Research Foundation, the According to the position paper of the Environmental annual average costs for a patient with hay fever are as Medicine Commission of the Robert Koch Institute (RKI), high as 1545€. Furthermore, the foundation emphasizes a German federal government agency and research insti- the necessity of correct treatment of rhinitis without tute responsible for disease control and prevention, the which the risk for developing bronchial asthma will in- life time prevalence of allergic diseases in Germany in crease [4]. The costs for patients who suffer from asthma adults was 8.6% for asthma, 14.8% for hay fever, 3.5% for and rhinitis is six-fold and as high as the treatment for atopic dermatitis, 8.1% for contact dermatitis, 4.7% for only rhinitis. If allergies were treated correctly in Europe, approximately 84 million € could be saved per year [4]. Exact data regarding the prevalence of allergies and aller- * Correspondence: DanielleFranziska.Boehmer@mri.tum.de gic diseases are difficult to collect because the definition Klinik und Poliklinik für Dermatologie und Allergologie am Biederstein, Technical University of Munich, Biedersteiner Str. 29, 80802 Munich, Germany of allergy is variable and broad-based epidemiological Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Boehmer et al. World Allergy Organization Journal (2018) 11:36 Page 2 of 8 studies are hard to conduct. Furthermore, studies to com- allergies. Participants were asked to indicate whether pare the country-side and urban areas are rare [5, 6]. they self-treated their allergy or if their allergy was In the past, various researchers showed that farming treated by a general practitioner (GP), a dermatologist, and growing up on a farm in rural areas reduces the risk an ear, nose, and throat specialist (ENT), an alternative of having an allergy [5, 7–10]. Figures for rural areas in practitioner, or not treated at all. Furthermore, the ques- Germany had not been published to date. A small portion tionnaires were used to determine the age and sex of the (2.3%) of our study population were farmers; therefore, we participants and their current or former profession. This also assessed their allergies in view of this hypothesis. additional information allowed to compare the preva- There have been various theories to explain why aller- lence of allergies based on various jobs (e.g., indoor vs. gies are increasing worldwide, especially amongst the outdoor jobs. Participants were grouped into 4 age farming population. One of the theories is the hygiene groups (18–29 years, 30–44 years, 45–64 years, and ≥ hypothesis, which states that exposure to microbials at a 65 years), following the example of the “Gesundheit in young age can lead to a lower risk of developing an al- Deutschland aktuell study” conducted by the RKI [4, 14]. lergy than without exposure. Due to our modern sani- Assistance to fill in the questionnaire was provided by tized living conditions, our contact with microbials has the medical practitioners, if necessary. Filled anonymous greatly decreased. This leads to the theory that the questionnaires were sent back for digitalization with the change in the microbiome due to lifestyle might be a program EpiInfo (statistical software for epidemiology de- reason for the increasing prevalence of allergies. The un- veloped by the Centers for Disease Control and Preven- derstanding of the microbiome and the development of tion, Atlanta, Georgia, USA). Some questionnaires were treatments to influence this could significantly change randomly chosen to monitor the accuracy of digitalization. the prevalence of allergies in the future [11, 12]. The data were analyzed using descriptive statistics. The aim of this study was to evaluate the prevalence of Odds ratios (ORs) were calculated to compare the risk allergies in rural Bavaria and compare these numbers to of allergy between men and women and different age data collected across Germany [13]. Furthermore, we eval- and professional groups. To determine significance be- uated the treatment of allergies in rural areas. tween relationships, 95% confidence intervals of the ORs were determined. The data were analyzed using IBM Methods SPSS version 24 (IBM cooperation, Armonk, USA). This study was a cross-sectional study conducted using a paper-based self-filled questionnaire in the Bavarian Forest Results as part of the previously published WALD (the official From January to March 2017, a total of 641 patients name of the study conducted in the past, it means forrest (59.7% women, 40.3% male; mean age and standard devi- in German as it was conducted in an area of Bavaria which ation, 50.5 ± 15.1 years; range, 18–86 years) participated. has lots of forrests) study ([4, 14]. Thedatawere collected Of these, 67.2% had indoor jobs (e.g., office jobs; n =387), during the first quarter of 2017. The anonymous question- 24, 7% were pensioners (n = 154), 14.4% were housewives/ naires were distributed in 10 offices of non-dermatological house husbands (n =83), 7.3% were construction workers doctors in rural Bavaria, Southern Germany. Locations of (n =42), 2.3% were farmers (n =13), 2.4% were students the doctors’ offices were in the Bavarian forest (rural dis- or scholars (n =14), 1.9% were unemployed (n =11), and tricts: Cham, Freyung-Grafenau, Passau, and Regen), an 5.9% had other jobs (n =38; Table 1). area officially declared as countryside by the federal gov- The response rate for this current sample is unknown. ernment of Germany [14, 15]. The doctors were general The data for this study were collected within the scope of practitioners (n = 1) and specialists in internal medicine the WALD-study (response rate, 77.8%) [14]. However, (n = 2) and orthopedics and surgery (n =7). They were only 718 of the 1007 participants of the WALD-study had chosen from throughout the region to ensure adequate rep- actively received the questionnaire regarding allergies that resentation. To minimize selection bias, both patients and was used in our current study. The number of people who their company were eligible for participation in this study. had saw the questionnaire at the doctor’soffices butdid The minimum age for participation was 18 years. Patients not complete it was unknown. In addition, participants re- had to give written consent. The study was approved by the cruited by dermatologists (n = 77) were excluded from this ethical review committee of the Technical University analysis to minimize selection bias. Munich (ethical committee (EC) number 548/16S). In the questionnaire, the participants were asked if Prevalence of allergies they suffered from an allergy, whether it was treated, Approximately 37.3% of the whole cohort had at least and what treatment was administered. The examined al- one allergy, and 28.1% and 43.2% of all questioned men lergies were pollen, animal hair, bee venom, wasp and women, respectively, stated that they had allergies. venom, contact, food, drug, house dust mite, and other Women had a significantly higher risk of allergies than Boehmer et al. World Allergy Organization Journal (2018) 11:36 Page 3 of 8 Table 1 Study population men (OR, 2; confidence interval [CI], [1.4; 2.8]). Further- more, women showed a significantly higher risk for most Number of participants 641 examined allergies, especially for food allergies (OR, 6.3; Gender CI, [1.9; 21.1]) and contact allergies (OR, 6.1; CI, [2.1; Men 40.3% (n = 258) 17.4]) compared to men (Fig. 1). However, the risk for Women 59.7% (n = 383) bee venom allergy (OR, 0.7; CI, [0.3; 1.8]) and other al- Missing information on gender > 0.1%(n = 10) lergies (OR, 0.8; CI, [0.3; 2.3]) was lower in women, and Age there was no significant difference in the risk for wasp Mean 50.5 years venom allergy (OR, 1.3; CI, [0.53; 3.3]) and house dust mite allergy (OR, 1.1; CI, [0.6; 1.9]). Standard deviation 15.1 years In the study population, the highest prevalence of allergy Range 18–86 years was amongst the young population aged 18–29 years 18–29 years 11.4% (n = 73) (45.7% had at least one allergy). The lowest prevalence 30–44 years 17.3% (n = 111) was observed in the population aged > 65 years (18.7%; 45–64 years 53.7% (n = 344) Fig. 2). The most common allergy was pollen allergy > 64 years 17.6% (n = 113) (16.0%), and the least common allergies were bee venom (3.4%) and other allergies (2.7%; Fig. 2). Pollen allergy was Missing information on age > 0.1% (n =3) a the most common allergy in the age groups 18–29 years Profession (25.7%), 30–44 years (18.3%), and 45–64 years (16.1%). In Indoor workers (office etc.) 60.4% (n = 387) contrast, the most common allergy found in participants House wives / house husbands 12.9% (n = 83) aged ≥65 years was drug allergies (6.6%). Construction workers 6.6% (n = 42) Indoor workers (OR, 1.5; CI, [1.0; 2.2]), farmers (OR, Students and scholars 2.2% (n = 14) 1.3; CI, [0.3; 4.9]) and unemployed participants (OR, 1.3; CI, [0.4; 4.5]) were affected by allergies the most. Farmers 2% (n = 13) Pensioners (OR, 0.5; CI, [0.3; 0.8)], construction workers No employment 1.7% (n = 11) (OR, 0.4; CI, [0.2; 0.9]), and hunters (OR, 0.3; CI, [0.0; Hunters 1.1% (n =7) 2.7]) were affected the least. However, only the ORs for Others 5.3%(n = 34) pensioners and construction workers proved to be sig- Missing information on profession 10.9% (n = 70) nificantly < 1. Regarding the different allergies, the only Retirement significant finding was that pensioners had a lower risk of pollen allergy (OR, 0.4; CI, [0.2; 0.8]) compared to Pensioners 24% (n = 154) participants in other occupations. Missing information on retirement > 0.1% (n = 22) 18 participants indicated having two professions, 1 reported having Treatment of allergies in rural Bavaria three professions Based on our data, 30.4% of all allergies were not treated at all. A GP was consulted most frequently to treat the allergy (39.3%), followed by a dermatologist (17.0%) and Fig. 1 Prevalence of self-reported allergies stratified by gender Boehmer et al. World Allergy Organization Journal (2018) 11:36 Page 4 of 8 Fig. 2 Prevalence of allergies according to age ENT doctor (7.8%), while 15.2% stated self-treatment of weak findings for this hypothesis was found in a study their allergy (Fig. 3). The most commonly treated allergy conducted by Hunt et al. in 2011 to evaluate whether (including self-treatment) was food allergy (79.3%), and women consult doctors more frequently for headache the least treated was contact allergy (62.2%). The most and backpain [16]. common allergies that were treated by a dermatologist, In a study conducted in 2008–2011 to examine blood ENT doctor, or GP were animal hair and wasp venom samples for specific immunoglobulin E (IgE) antibodies, allergy (both 61.9%; Fig. 4). Contact allergies (48.6%) and men were more frequently sensitized to at least one al- other allergies (43.8%) were treated the least frequently lergen than women [4, 17]. A question that does arise is by GPs, dermatologists, and ENT doctors (Fig. 4). whether men tend to ignore or are less aware of their al- lergies than women. Furthermore, women may not ne- Discussion cessarily have an allergy but think that they do [18]. According to the study results, allergies are common in Previous researchers have emphasized the influence of the rural areas of Southern Germany, and a large pro- the relationship between female steroid sex hormones portion of these allergies is not appropriately treated. and the existence of allergies. The fact that the preva- We found that women had a higher prevalence of aller- lence of allergies is usually higher in men before puberty gies than men, and similar findings were also found in and higher in females after puberty, underlines the pos- various studies conducted in the past [4]. A reason for sible relationship between female hormones and aller- this might be that women tend to consult doctors more gies. Reasons for this might be that estrogen receptors frequently than men do. Although this association has are found on numerous immunoregulatory cells [19]. It not been directly mentioned in the literature, there are has been suggested that estrogen can act to move the assumptions regarding this. However, inconsistent and immune response towards an allergic response directly Fig. 3 Display of consulted doctors or methods of treatment of allergies (at least one method of treatment) Boehmer et al. World Allergy Organization Journal (2018) 11:36 Page 5 of 8 Fig. 4 Treatment of allergies by GPs (general practitioners), dermatologists and ENTs (ear nose throat specialists) or via the modulation of immunologic pathways [20]. of the immune system can determine a complicated im- Estrogen can influence immune cells to favor an allergic munological profile in the elderly population [24]. Fur- response by promoting Th2 polarization, which can lead thermore, patients who are older often take many to class switching of B cells to then produce IgE. Never- medications, which can also interfere with allergies and theless, the roles of the hormones have not fully been allergic reactions. Nevertheless, the literature still lacks elucidated and further studies are needed [21]. sufficient information regarding allergies and their Another interesting finding was that allergies were prevalence in the elderly population. Due to our increas- more common in the younger population. The younger ing understanding of the molecular and genetic basis of generation is often better informed than the elderly, human senescence, the field of allergic diseases in the which could explain a higher prevalence of allergies (e.g., elderly should be expanded to possibly find new diag- histamine intolerance) in that group. The older gener- nostic and therapeutic opportunities [25]. ation might not know that an allergy could be an ex- A large proportion of patients (30.4%) with allergies planation for their symptoms. Furthermore, another did not receive any treatment in this current study. reason could be that individuals who are aware that they Furthermore, a large percentage of participants did not have a certain allergy may avoid the allergen (e.g., food have their allergies treated by a dermatologist or an that causes allergic symptoms) during most of their life, ENT doctor, who are usually specialized in allergology. which can result in less pronounced allergic episodes. The most frequently consulted therapist was a GP Another approach to explain this is that the current (39.3%), which could be explained by the fact that there younger generation is living in an environment that is are more GPs than other specialists across the lower re- different to that lived by the older generation many years gion of Bavaria. GPs are often the only available doctors ago. The hygiene hypothesis, which was established a for patients, especially in rural areas [26, 27]. few years ago, suggests that allergies develop easily when Out of the 13 farmers who answered the question about there is less contact with microbials. Dr. von Mutius allergies, 6 (44.4%) stated that they had an allergy. In con- found that the development of asthma and allergies was trast, it was previously observed that farmers suffered significantly lower in children who were exposed to the from less allergies and farming was recognized as a pro- microbial environment compared to those who were not tective factor [14]. The specific role of modern agriculture exposed [22, 23]. Furthermore, there are many factors for this relationship is not known. In another study, chil- that can influence allergic diseases during aging, such as dren living on very traditional farms had no hay fever or genetic, epigenetic, immunosenescence, external risk fac- allergies. Children living on Hutterite farms, which use in- tors, internal diseases, and medications. Immunosenes- dustrial farming practices, showed a high prevalence of cence is the change in immune function with aging. asthma (> 15%) and allergic sensitization [28]. A possible Immunosenescence involves modification and remodel- explanation for why the protective factor of farming might ing of tissue structure. Many functions decline with no longer be present is because modern agriculture uses aging, while other functions can become more active. A far more chemical substances, which also kill bacteria [23, senescent immune system can show impaired interac- 29]. Due to the small number of farmers participating in tions between the innate and adaptive immune re- our study, we were unable to make any conclusions or sponses. Interaction between the different components comparisons to previous studies regarding the link Boehmer et al. World Allergy Organization Journal (2018) 11:36 Page 6 of 8 between farming and allergies. However, we emphasize probably be different to the findings that were observed that additional studies are necessary to support this in this current study. In addition, this was one of the finding. first studies conducted to provide a comprehensive over- According to our results, there remains a large de- view about the prevalence and treatment of allergies in mand for diagnostics and therapies [30, 31] for allergies the Bavarian countryside. Medical care in rural areas in rural Bavaria and many other parts of Europe [32]. have many challenges due to demographic changes and An untreated insect or other allergies, such as certain urbanization [26], and therefore, determining the need food allergies (e.g., peanut), can lead to anaphylaxis and for treatment in rural areas is crucial. death [33–37]. In addition to allergic symptoms, a falsely There were several limitations for the interpretation of treated case of hay fever can lead to the development of our study results. There was a selection bias because the asthma, which will consequently lead to additional de- study questionnaires were only distributed in doctors’ mand for therapy and increased healthcare costs [4]. offices, and therefore, we only included participants who In our study, the examined population lived in rural had already consulted a doctor. Therefore, a direct com- areas (i.e., countryside) of Bavaria, which would create the parison between our results and that of the RKI survey, assumption that there are less allergies compared to the which had randomly selected participants, was not pos- past in the United States [28]. Unexpectedly, the preva- sible. Self-filled questionnaires may lead to social desir- lence of allergies in this current study was higher than the ability and recall bias, which can also influence the prevalence of allergies found by the RKI in 2016 for results. In addition, the information for this study was Germany [4]. A major difference between our study and obtained from only the participant responses and we did that conducted by the RKI was that the RKI had investi- not conduct any blood or skin tests concerning their gated the German population as a whole rather than fo- diagnosis or have access to information regarding their cusing on the rural population. In total, 30.0% of the treatment from the doctor, which may have contributed population of the RKI survey and 37.3% of our study to further biases in this study. However, in a study con- group had at least one allergy. Furthermore, there were ducted by the RKI in the 1990s, questionnaires answered some differences in the findings regarding the prevalence by patients can identify the prevalence of allergies more of different allergies between the RKI survey and our accurately than interviews conducted by treating doctors study (contact dermatitis, 8.1% vs. 6.5%; insect venom al- [38]. A reason for this is that patients only consult their lergy, 2.8% vs. 4.8%; food allergies, 4.7% vs. 5.2%). There doctor when they require treatment for their allergies. are many possible explanations for these differences. The The presence of an allergy is not always communicated best explanation for the higher prevalence of allergies was and can be determined more easily by a questionnaire. the fact that only people who consulted doctors partici- An additional limitation was the duration of the study. pated in this current study, whereas the population for the The questionnaires were only distributed for 3 months RKI health survey was randomly chosen [4]. Another very (January–March), which might not be a sufficient period important difference is that our study sample was smaller, because pollen allergies are most common during this resulting in non-representative results. Furthermore, the period anyway. The participants might therefore tend to higher prevalence might be explained by the lifestyle, age, emphasize answers for pollen allergies because this allergy and profession of the participants in rural Bavaria, which was more common during the time of the questionnaire. differs from other areas and cities across Germany. The small number of participating farmers did limit the Epidemiological studies regarding the health of an en- significance of our finding that farmers have a higher inci- tire population of a country have not been performed dence of allergies than previously assumed. To support frequently in the past because they are difficult to con- our results and findings, future studies should focus on the duct. We were unable to identify any previous studies prevalence of allergies amongst farmers, be conducted in a that were conducted to evaluate different allergy treat- wider population range (i.e., not only in doctors’ offices), ments in a general population; therefore, this study is and also address the treatment of allergies nationwide. the first to shed light on the way patients treat their al- lergies. Although the study population was not represen- Conclusion tative of the entire German population, we were able to The two main conclusions of our study were that the find that the most frequently consulted doctor for the prevalence of allergies was high in rural areas and that treatment of allergies was a GP (39.3%), and that a large most cases of allergies are not adequately treated. In order number of allergies were not treated at all (30.4%). to reach more patients and increase their awareness re- However, the high number of GP consultations in rural garding allergies and possible treatments, awareness and areas of Bavaria could also be due to the unavailability of information campaigns may represent a possible solution. other specialties in that area. Figures concerning the An improvement of patient-centered-care in allergology availabity of specialities in larger cities would most could lead to a reduction in the burden of allergic disease. Boehmer et al. World Allergy Organization Journal (2018) 11:36 Page 7 of 8 As already used in other areas of dermatology, telemedi- 8. Ober C, Sperling AI, von Mutius E, Vercelli D. Immune development and environment: lessons from Amish and Hutterite children. Curr Opin cine might be a useful method for the treatment of aller- Immunol. 2017;48:51–60. gies in rural areas in the future [38, 39]. 9. MacNeill SJ, Sozanska B, Danielewicz H, Debinska A, Kosmeda A, Boznanski A, Illi S, Depner M, Strunz-Lehner C, Waser M, et al. Asthma and allergies: is Abbreviations the farming environment (still) protective in Poland? The GABRIEL CI: Confidence interval; ENT: Ear, nose, and throat specialist; GP: General Advanced Studies. Allergy. 2013;68(6):771–9. practitioner; IgE: Immunoglobulin E; OR: Odds ratio; RKI: Robert Koch Institute 10. Gassner M. Farmers and their environment: protective influences of the farming environment against the development of allergies. Chem Immunol Acknowledgements Allergy. 2014;100:278–86. Not applicable. 11. Campbell BRC, Lodge CJ, Lowe AJ, Gislason T, Heinrich J, Sunyer J, Gómez Real F, Norbäck D, Matheson MC, Wjst M, Dratva J, de Marco R, Jarvis D, Funding Schlünssen V, Janson C, Leynaert B, Svanes C. The effects of growing up on No funding was received. a farm on adult lung function and allergic phenotypes: an international population-based study. Thorax. 2017;72:236–44. 12. Wlasiuk G, Vercelli D. The farm effect, or: when, what and how a farming Availability of data and materials environment protects from asthma and allergic disease. Curr Opin Allergy The data can be available upon contact. Clin Immunol. 2012;12(5):461–6. 13. Liu AH. Revisiting the hygiene hypothesis for allergy and asthma. J Allergy Authors’ contributions Clin Immunol. 2015;136:860–5. Conception and design of study: KJ, ZA. Acquisition of data: BD, SB, KJ, ZA. 14. Krause JTL, Scheler E, Schielein M, Biedermann T, Zink A. Dermatologischer Analysis and interpretation of data: BD, SB, KJ, DU, BT, ZA. Drafting manuscript: Versorgungsbedarf und Zugang zur medizinischen Versorgung im Bayerischen BD, ZA. Critically revising manuscript for important intellectual content: SB, KJ, Wald (WALD-Studie 2016/2017). J Dtsch Dermatol Ges. 2017;15:127. DU, BT. Final approval of the version to be published: BD, SB, KJ, DU, BT, ZA. 15. 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Journal

World Allergy Organization JournalSpringer Journals

Published: Nov 19, 2018

References