Original article
Asthma, lower airway disease
Mold and Alternaria skin test reactivity and asthma in children in Connecticut

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Background

Sensitivity to mold has been associated with asthma incidence, persistence, and severity.

Objective

To examine the relationship between skin test reactivity (STR) to molds and specifically to Alternaria and asthma severity in a group of ethnically diverse children in Connecticut.

Methods

Demographics and STR to 14 local allergens, including Alternaria, Penicillium, and mold mix, were obtained for 914 Puerto Rican, African American, and non-Hispanic white children.

Results

A total of 126 children (14%) had a positive skin test result to mold, and 58 (6%) demonstrated STR to Alternaria. Compared with non-Hispanic white children, there was no difference in the likelihood of being sensitized to Alternaria for Puerto Rican and African American children (odds ratio [OR], 0.7; 95% confidence interval [CI], 0.3–1.5; and OR, 0.9; 95% CI, 0.4–2.2; respectively). In an adjusted analysis, Alternaria STR was associated with severe, persistent asthma (OR, 3.4; 95% CI, 1.2–8.6) but did not predict increasing asthma severity. STR to cat (OR, 2.5; 95% CI, 1.3–4.9) and dog (OR, 2.9; 95% CI, 1.3–6.0) was also associated with severe persistent asthma. Alternaria STR was associated with severe persistent asthma independent of the total number of positive skin test results.

Conclusions

Mold and Alternaria STR were uncommon among children in Connecticut. Alternaria STR was not associated with increasing asthma severity but was associated with severe, persistent asthma independent of the total number of positive skin test results. There was no association between ethnicity and Alternaria STR.

Introduction

Asthma is a significant cause of morbidity and mortality for an estimated 9 million children in the United States.1, 2 The relationship between allergy and asthma in children is well established.3, 4, 5, 6 Among children with asthma, the rate of skin test reactivity (STR) to one or more allergens has been reported to be as high as 80%.7 One allergen with emerging interest in its relationship to asthma is the spore-forming saprophyte Alternaria alternata. STR to Alternaria has been associated with both the development and persistence of asthma symptoms.3, 7, 8, 9, 10, 11, 12, 13, 14 Alternaria STR has also been associated with greater asthma severity, acute asthma exacerbations, and hospital and intensive care unit (ICU) admissions for asthma in adults and children,9, 15, 16, 17, 18, 19, 20 an observation possibly linked to the Alternaria-induced heightened airway responsiveness reported in children.9, 21, 22

The relationship between Alternaria STR and ethnicity in children with asthma is incompletely understood. An increased prevalence of Alternaria STR in children of Hispanic and African American ethnicities has been reported.21 This result is consistent with increased prevalence of STR to other commonly tested allergens in minority children.21, 23, 24, 25, 26, 27 In Connecticut, Puerto Rican and African American children have both increased STR to environmental allergens24 and greater asthma severity compared with non-Hispanic white children.28, 29, 30, 31

In this study, we examined the relationship among Alternaria STR, ethnicity, and asthma severity in a group of 914 ethnically diverse children in Connecticut. In addition, we investigated the relationship between Alternaria STR and pulmonary function in a subset of 56 children matched by age, sex, and ethnicity with and without Alternaria STR.

Section snippets

Study Population

The study population included children with physician-diagnosed asthma who were referred for allergy skin testing (AST) between June 1, 1998, and December 1, 2007, as part of the previously described Easy Breathing Program.31, 32 All children had current respiratory symptoms (defined as cough, wheezing, and/or shortness of breath within the previous 12 months). Asthma severity was classified by the child's physician as intermittent and mild, moderate, or severe persistent asthma using a

Characteristics of the Study Population

Between June 1, 1998, and December 1, 2007, 1,149 children with physician-confirmed asthma underwent AST, of whom 914 were younger than 18 years and Puerto Rican, African American, or non-Hispanic white (Fig 1). Of the 914 children, 66% were Puerto Rican, 22% were African American, and 12% were non-Hispanic white (Table 1). Puerto Rican children referred for AST were older, more likely to have Medicaid insurance, and more likely to have a family history of asthma or allergic disease compared

Discussion

Alternaria alternata is one of the most common airborne fungi in outdoor and indoor environments. Considered an aeroallergen, Alternaria spores are thought to be more antigenic than pollen because of their smaller size, their high levels, especially in late summer and after thunderstorms and high winds, and their ability (in mice) to produce potent TH2 adjuvant effects in the airway.38, 39, 40 In this ethnically diverse group of children with asthma who reside in New England, however, Alternaria

Acknowledgments

We are grateful to the referring physicians who participate in Easy Breathing. We thank Charles B. Hall, PhD for review of the statistical methods, Autherene Grant for assistance with data management, Catherine Quirk and Gloria Jones for performing the allergy testing, and Barbara Turgeon for administrative support.

References (46)

  • R.T. Cohen et al.

    Health-care use among Puerto Rican and African-American children with asthma

    Chest

    (2006)
  • P.S. Higgins et al.

    Risk factors for asthma and asthma severity in nonurban children in Connecticut

    Chest

    (2005)
  • M.M. Cloutier et al.

    Childhood asthma in an urban community: prevalence, care system, and treatment

    Chest

    (2002)
  • C.B. Hall et al.

    Diagnosing pediatric asthma: validating the Easy Breathing Survey

    J Pediatr

    (2001)
  • T.B. Pulimood et al.

    Epidemic asthma and the role of the fungal mold Alternaria alternata

    J Allergy Clin Immunol

    (2007)
  • G.Y. Marks et al.

    It's blowing in the wind: new insights into thunderstorm-related asthma

    J Allergy Clin Immunol

    (2007)
  • P.A. Eggleston et al.

    Relationship of indoor allergen exposure to skin test sensitivity in inner-city children with asthma

    J Allergy Clin Immunol

    (1998)
  • R.S. Gruchalla et al.

    Inner City Asthma Study: relationships among sensitivity, allergen exposure, and asthma morbidity

    J Allergy Clin Immunol

    (2005)
  • A.N. Dey et al.

    Summary health statistics for U.S. children: National Health Interview Survey, 2003

    Vital Health Stat 10

    (2005)
  • W.R. Taylor et al.

    Impact of childhood asthma on health

    Pediatrics

    (1992)
  • S.H. Arshad et al.

    Sensitization to common allergens and its association with allergic disorders at age 4 years: a whole population birth cohort study

    Pediatrics

    (2001)
  • M.R. Sears et al.

    Atopy in childhood, I: gender and allergen related risks for development of hay fever and asthma

    Clin Exp Allergy

    (1993)
  • M.R. Sears et al.

    Atopy in childhood, III: relationship with pulmonary function and airway responsiveness

    Clin Exp Allergy

    (1993)
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    Disclosures: Authors have nothing to disclose.

    Funding Sources: This work was supported by grant U18 HS11147 from the Agency for Healthcare Research and Quality (Michelle M. Cloutier, principal investigator) and grant RO1 HL68201-A101 from the National, Heart Lung and Blood Institute (A. David Paltiel, PhD, principal investigator).

    Dr Lyons is currently with Children's Hospital Boston and Boston Medical Center, Boston, Massachusetts.

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