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Berlin/SOSA 29.9.2012

Four years of the Finnish Allergy Programme – we can reduce the burden! Allergy 2009

Professor Tari Haahtela Skin and Allergy Hospital Helsinki University Hospital


Hypersensitivity – Allergy - Atopy

allergy

- long-term immune dysfunction

Asthma

Allergic

Drug allergy

Insect allergy

Atopic eczema

Urticaria

Food allergy

rhinoconjunctivitis

Anaphylaxis

Other allergies (contact dermatitis, allergic alveolitis etc.)


Asthma co-morbidities increased days off work 2000-2005 66 000 employees in Finland, mean age 45 years

4.0 Risk of lost work days/year

RR 3,5 Long-term disability, 3 months or more

Risk Ratio

3.0

2.0

RR 1,7 RR 1,5 RR 1,3

1.0

RR 1.0

0 No Asthma or R

Rhinitis

Asthma

Asthma+R

Asthma+Depression

Kauppi P, et al. Resp Med 2011


No law of symptom escalation! 5.0

Risk Ratio

4.0

3.0

RHINASTHMA Quality-of-Life Index measured only after 20 years: SPT pos. = 17.4 SPT neg. = 20.7 (scale 0-100)

Mean subjective symptom score 20 years apart (scale 0-5)

Skin Prick Test pos. Skin Prick Test neg.

2.0

1.0 0 Baseline

20 years

Baseline

20 years Teppo H, et al. Allergy 2011


Key messages ► Endorse health, not allergy ► Strenghten tolerance

► Adopt a new attitude to allergy. Avoid allergens only if mandatory

► Recognize and treat severe allergies early. Prevent attacks/exacerbations

► Improve air quality. Stop smoking

Allergy Health!


Allergy Health! What professionals think of the messages? Nurses

Doctors

► Endorse health, not allergy

8,8

9,2

► Strenghten tolerance

8,7

9,1

► Adopt a new attitude to allergy.

8,7

9.3

9,2

9,5

9,6

9,6

Avoid allergens only if mandatory

► Treat severe allergies early. Prevent attacks/exacerbations

► Improve air quality. Stop smoking

Scale 4-10 Kauppi, P, et al. Finnish Medical Journal 2010


Allergy Health!

How do the treatment chains (processes) work?

Nurses

Doctors

Asthma

7,8

6,6

Asthma in children

7,7

6,8

Food allergy.

7,2

5,9

Specific immunotherapy

7,6

5,4

9,1

9,0

► Need

of allergy training

Scale 4-10

Kauppi, P, et al. Finnish Medical Journal 2010


Allergy Programme Goals ► Prevent allergies. – Indicator: prevalence of asthma, allergic rhinitis and atopic dermatitis reduces by 20 %.

► Increase tolerance to allergens in the population. – Indicator: avoidance diets to foods decrease by 50 %.

► Improve allergy diagnostics. – Indicator: all patients are tested in a quality certified allergy-testing centre.

► Reduce work related allergies. – Indicator: Their numbers reduce by 50 %.

► Focus to severe allergies and reduce attacks. – Indicator: ”Good Allergy Care” employed in the country, asthma attacks reduced by 40 %.

► Reduce costs caused by allergies. – Indicator: total costs of allergic diseases reduced by 20 % in 10 years. ■ Haahtela T, et al. Finnish Allergy Programme 2008-2018 – time to act and change the course. Allergy 2008 ■ von Hertzen L, et al. Scientific rationale of the Finnish Allergy Programme 2008-2018. Allergy 2009 ■ Bousquet J, et al. In Allergy, ”A new day has begun”. Allergy 2008, Editorial


Educational Programme 2008-2018 1. Opinion leaders, specialists, health care and other professionals: 3-step education 2008-2012: > 8000 participants ►

launch for 21 Central Hospitals (5 Univ. Hospitals), 2 hours

large Health Centres, half a day

back to Central Hospitals, Allergy Day

2. Allergic people, with the help of patient organisations (allergy & asthma, skin, lung health) – survey 2011 3. General population

Allergy Health!


Handbook Quality Skin Prick Testing - 9 testing centres audited and certified in 2009-2012


Haahtela T, et al. GA2LEN-manuscript, in preparation

Tools for professionals – SPT Reading Keys Table 1. Univariate logistic regression analysis for clinical relevance in STP positive patients (wheal size 3 mm or larger) and 80% PPV for each of the18 allergens. ND=not done. Allergen

Odds Ratio* (95 % CI)

P-value

80% PPV for SPT Wheal diameter,mm

Hazel Alder Birch Plane Cypress Grass Olive Artemisia Ambrosia Alternaria Cladosporium

1.36 (1.25 to 1.48) 1.43 (1.29 to 1.60) 1.45 (1.32 to 1.60) 1.50 (1.13 to 2.00) 2.70 (1.38 to 5.27) 1.62 (1.45 to 1.82) 1.40 (1.21 to 1.63) 1.37 (1.24 to 1.51) 1.58 (1.36 to 1.82) 1.27 (1.10 to 1.45) 1.30 (1.00 to 1.68)

<0.001 <0.001 <0.001 0.005 0.004 <0.001 <0.001 <0.001 <0.001 0.001 0.049

5 4 3 7 4 3 6 5 5 8 7

Aspergillus

1.05 (0.75 to 1.46)

0.78

ND

Parietaria Cat Dog Derm. pteron. Derm.farinae

1.31 (1.11 to 1.56) 1.19 (1.10 to 1.29) 1.24 (1.13 to 1.35) 1.32 (1.20 to 1.45)

0.002 <0.001 <0.001 <0.001

3 7 10 3

1.29 (1.15 to 1.44)

<0.001

3

Blatella

1.69 (1.19 to 2.38)

0.003

7


Allergen Component Diagnostics â&#x20AC;&#x201C; stable vs. labile components

Arachis hypogaea (Ara h)

Lipid transfer protein Ara h 1 Lipid transfer protein Ara h 2 Lipid transfer protein Ara h 3 PR-10 birch-homolog Ara h 8

Gallus domesticus (Gal d)

Ovomukoid Gal d 1 Ovalbumin Gal d 2 Ovotransferrin Gal d 3 Lysotsyme Gal d 4


Erik (12 years) – fruits, vegetables cause throat symptoms – strict elimination diet. Is there a real risk of anaphylaxis ?

Microchip ISAC 103 Positive responses: Bet v 1, and Bet v 1 homologes – labile allergen components

 risk of anaphylaxis is small

MS598

birch pollen Bet v 1


Allergy Health Allergy Programme Goals in 3 Steps 1. Short-term goal

patients recover, have less symptoms

â&#x2013;ş detect and treat inflammation effectively - hit early and hit hard

2. Mid-term goal

burden is reduced, patient and societal level

(days off work, disability, emergencies, hospital days, unscheduled visits, costs) â&#x2013;ş guided self-management to stop attacks/exacerbations proactively

3. Long-term goal

incidence of new cases levels off, a step from treatment to prevention is taken

â&#x2013;ş practical advice to increase immunological tolerance


Asthma Barometer Study in Pharmacies 2001 vs. 2010 Astma has become a milder disease in 10 years

62%

2010

Mild Liev채

45%

2001

2010

Keskivaikea MMModerate

Vaikea Severee

2001

34%

45%

4% 10%

Kauppi P, Peura S, Haahtela T. 2012


Allergy Health Allergy Programme Goals in 3 Steps 1. Short-term goal

patients recover, have less symptoms

â&#x2013;ş detect and treat inflammation effectively - hit early and hit hard

2. Mid-term goal

burden is reduced, patient and societal level

(days off work, disability, emergencies, hospital days, unscheduled visits, costs) â&#x2013;ş guided self-management to stop attacks/exacerbations proactively

3. Long-term goal

incidence of new cases levels off, a step from treatment to prevention is taken

â&#x2013;ş practical advice to increase immunological tolerance


Lahdensuo A, et al. Guided self-management in asthma BMJ 1996,1998; GINA 2009, modified, Haahtela T, et al. Finnish Allergy Programme 2008-2018. Allergy 2008

Adult asthma Control Card/Stamp + Net/Mobile-version

Doctor – Nurse (Pharmacist) Ask patient – is he/she doing 1. Reliever max 2 dose/wk 2. Symptoms max 2 day/wk 3. Symptoms max 1 night/wk 4. No activity restrictions 5. PEF-var. max 50 l/min/wk

OK?

Ask yourself - is the treatment 1. Reliever need minimal 2. Controller dose adequate 3. Adherent to treatment 4. Correct inhalation 5. Exacerbation plan exists ► Good morning PEF______

OK?

Patient - guided self-management Notice symptom increase 1. Needing more reliever? 2. Feeling cold, flu? 3. Coughing Wheezing 4. Exercise tolerance 5. Morning-PEF ► PEF-decreases from____to____ Stop attack (exacerbation) 1. Increase controller 2-4 fold (2-4 wk),

YES

or start a course of controller (4 wk)

2. 3. 4. 5. 6.

Start to use reliever regularily (2-4 wk) If on Combi, double the dose (2 wk) Prednisolon tabl. 20mg/day (1-2 wk) Go to emergency, if no help Later, check controller treatment

Doctor/Nurse uses the check-list to assure asthma control, and guide the patient to self-management. Zero tolerance to asthma attacks


Guided self-management - Tools for patients 1) Asthma, 2) Childhood asthma, 3) Rhinoconjunctivitis, 4) Atopic dermatitis, 5) Urticaria, 6) Food allergy, 7) Anaphylaxis

ARIA Principle!


Emergency visits caused by asthma or anaphylaxis Finland 1998-2007 Asthma emergencies

Benchmarking!

Anaphylaxis emergencies

Kauppi P, ym. Finnish Medical Journal 2010


National Anaphylaxis Register 2000 - 2011 insect 11 %

other 3%

insect 8%

allergen preparation 13 %

drug 7%

other 6%

food 36 %

allergen preparation 13 %

food 66 %

children

drug 37 %

adults

Allergen Laboratory, Skin and Allergy Hospital, Helsinki University Hospital SMK


Asthma emergency visits in children Helsinki capital area 2000-2009 (population 1,3 million) Number of emergency visits

3000

diagnoses J20, J21, J45, J46

- 6% 2756 2584

2000

2009

1500 - 62% 380 143

2000

2009

0 0-6

7-14 Age group Kauppi P, et al. 2012, in preparation


Asthma and COPD Hospital Days in Finland 2000-2010

Number of patients on regular medication 2000=191 268 2010=233 218 (+22%)

Asthma 2000=32 321 2010=14 979 (-54%)

+ 22%

COPD 2000=46 671 2010=23 387 (-46%)

- 46%

- 54%

Kauppi P, et al. Thorax 2012


Total asthma costs in Finland 1987-2007 800 000 000 €

90,00 % 80,00 % 70,00 % 60,00 % 50,00 % 40,00 % 30,00 % 20,00 % 10,00 % 0,00 %

Scenario (Max) Scenario (Min) Realized costs Use of drugs

700 000 000 €

600 000 000 € 500 000 000 €

400 000 000 € 300 000 000 €

200 000 000 € 100 000 000 €

0€ 1987

1991

1995

1999

2003

2007

Reissell E, et al. Asthma costs in Finland. A public health model to indicate cost effectiveness during 20 years. Finnish Medical Journal 2010.


Allergy Health Allergy Programme Goals in 3 Steps 1. Short-term goal

patients recover, have less symptoms

â&#x2013;ş detect and treat inflammation effectively - hit early and hit hard

2. Mid-term goal

burden is reduced, patient and societal level

(days off work, disability, emergencies, hospital days, unscheduled visits, costs) â&#x2013;ş guided self-management to stop attacks/exacerbations proactively

3. Long-term goal

incidence of new cases levels off, a step from treatment to prevention is taken

â&#x2013;ş practical advice to increase immunological tolerance


Tools for professionals New Guidelines for Allergy in Children “Have less fear and more happiness” (The Allergy Police is Gone!)

Mika J. Mäkelä, ym. The challenge of relaying the right public health messages in allergy. PAI 2012, Editorial Anna Pelkonen, ym. Allergy in children: practical recommendations of the Finnish Allergy Programme 2008 -2018 for prevention, diagnosis and treatment. PAI 2012

MeDALL = Mechanisms of Development of Asthma. EU-funded Programme


Practical advice to build-up and improve tolerance Finnish Allergy Programme 2008-2018

Primary prevention • •

• • •

Support breastfeeding. Solid foods from 4-6 mo. Do not avoid environmental exposure unnecessarily (e.g. foods, pets). Strenghten immunity by increasing connection to natural environments. Strenghten immunity by regular physical exercise. Strenghten immunity by healthy diet

Secondary and tertiary prevention • •

(Mediterranean or Baltic type of diet improves asthma control).

• •

(e.g. traditional Mediterranean or Baltic type).

• • •

Use antibiotics with care. Majority of microbes are useful and support health. Probiotic bacteria in fermented food or other preparations may strenghten immunity. Do not smoke.

Regular physical exercise is antiinflammatory. Healthy diet is anti-inflammatory

Fermented food or other preparations, including probiotic bacteria, are antiinflammatory. Allergen specific immunotherapy: – allergens as is (foods) – sublingual tablets or drops (e.g. timothy, birch pollen, mites?) – subcutaneous injections Hit early and hit hard respiratory/skin inflammation with anti-inflammatory medication. Find maintenance treatment for long-term control. Do not smoke.


What are the trends among military conscripts 2004-2012?

â&#x2013; Haahtela T, et al. Prevalence of asthma in Finnish young men. BMJ 1990. â&#x2013;  Latvala J, et al. Trends in prevalence of asthma and allergy in Finnish young men: nationwide study, 19662003. BMJ 2005.


What do patients think?

The information gap: how to get the message to the people?


Campaign for the general public 2011


Freedom!

Are we reaching the goals? ► Prevent allergies. – Indicator: prevalence of asthma, allergic rhinitis and atopic dermatitis reduces by 20 %.

No data yet, but

several follow-ups ongoing (military conscripts, FinEsS-study)

► Increase tolerance to allergens in the population. – Indicator: avoidance diets to foods decrease by 50 %. Allergy

diets in schools -20 %, in day-care

centres -25 %, large variation in the country

► Improve allergy diagnostics. – Indicator: all patients are tested in a quality certified allergy-testing centre. Yes,

we are half a way

► Reduce work related allergies. – Indicator: Their numbers reduce by 50 %. No,

still no clear decrease

► Focus to severe allergies and reduce attacks. – Indicator: ”Good Allergy Care” employed in the country, asthma attacks reduced by 40 %.

Yes, looks good!

► Reduce costs caused by allergies. – Indicator: total costs of allergic diseases reduced by 20 % in 10 years. Yes in asthma, all major allergic conditions are taken into account in the new estimates

Tari Haahtela  
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