A recent chain email said it all: The photo depicted a woman with a toilet-paper roll rigged atop her head, a MacGyver-style invention ideal for perpetual nose-blowing. The subject line read simply “Use During Allergy Season.”
It’s one of those sights that gets a quick laugh—one that Dr. H. James Wedner, chief of the allergy and immunology division at Washington University School of Medicine and medical director of The Asthma and Allergy Center, might appreciate. When he answers the phone in early summer and I ask how he is, he laughs and says, “Hanging in there.” It quickly becomes apparent why he’s so busy.
St. Louis has fallen from the No. 1 city in the nation for allergies and asthma to No. 29, according to the Asthma and Allergy Foundation of America. Are you seeing fewer cases?
This year, we’ve had more allergies than we’ve had in the last 20 years. If you look at where allergies are in the United States, every river valley in the country basically has a lot of allergies. The difference isn’t that St. Louis is losing allergies; it’s that other places are catching up.
Why is that?
The current theory is what’s called the hygiene hypothesis. That is, as we clean up our environment, the impetus to make immune responses to other things like bacteria is less, and you have an immune system that basically has to do something, so it makes responses to things that are innocuous. There are two halves to the immune system, called Th1 and Th2, and Th2 is the system that evolved to fight protozoa and parasites. Well, if you’ve looked around, there are no protozoa or parasites in St. Louis. So we have a part of our immune system that has basically nothing to do, so it misreads pollen as a parasite and makes an inappropriate immune response to it. As we clean up our environment, you don’t have the stimulus when you are a child to build up an immune response to bad bacteria and other things, so you’re kind of sitting there, waiting for something to happen, and what happens are allergies. It keeps me in business, but it doesn’t make anybody else happy.
Is climate change contributing to the problem, as rising temperatures cause plants to pollinate longer and produce more carbon dioxide?
As we change our climate, there is a change in the flora: the appearance of more and greater profusion of weeds, the things that make us have allergies, and the exclusion of other things that don’t make us have allergies. Why that is isn’t really clear… As global warming and CO2 goes up, the weeds seem to be happier, and the pretty plants don’t seem to be happy. One of the things that I tell everybody is that you can tell an allergen plant because they’re ugly.
Do you see a significant fluctuation throughout the year?
This was a rather unusual year. It was one of the longest pollen seasons that we’ve had… We had trees that started two weeks early and ended two weeks late… I stop in Forest Park about once a week just to see what the plants are doing, so I can see who will be calling with complaints about getting sick.
What suggestions do you make for minimizing allergies?
Stay indoors as much as possible when the pollen is high. Keep the windows closed. And you don’t actually need to run the air conditioner: If you look at the box on your air conditioner, there’s a switch that says “fan.” You want to flip that switch on. Remember that your air conditioner and heater only suck in about 15 percent of the air from outside, so most of the air in your house is simply recirculated. Pollen and mold particles are actually quite big from an aerodynamic standpoint, and they are well-removed by the filter on your air conditioner or furnace… Also, remember that pollen counts are much higher in the morning than in the evening. [So go outside] in the evening… There are some really good masks that will filter out the pollen.
Are you seeing a rise in asthma attacks as well?
Yes, during the last five years, the incidence of all allergic diseases has gone up. Allergic rhinoconjunctivitis, asthma, food allergies, every atopic disease has gone up and seems to be going up inexorably every year.
What do you recommend in terms of medicine? Any over-the-counter antihistamines like Claritin or Zyrtec?
Those are what we call the second generation of the nonsedating antihistamines. They’re now all available over-the-counter and generic… So you can go to some of the large stores, Sam’s Club and Costco, and if you buy them in bulk, it’s about 5 cents a pill, as opposed to $1 a pill if you buy small volumes in brand… We have intranasal steroids, one of which is generic. And Singulair is a pill that we give to patients—particularly younger patients—with asthma that will be over-the-counter in August.
Where do you see treatments going from here?
As we learn more about asthma, we learn more about the factors that seem to cause or drive it. You start off with an allergy, but something has to keep the asthma going… There are probably four or five newer drugs directed at specific parts of the immune system which are currently in testing… We talk about personalized medicine—that’s going to be true not only for diseases like cancer, but it’s going to turn out to be very important for diseases like asthma.
We haven’t yet talked about food allergies. How do they change as people grow older?
It’s clear that food allergies are much more prevalent in kids than adults, and they tend to go away… [Thirty years ago], food allergies were kind of rare. The No. 1 allergen now is peanuts. The things that we’re allergic to have changed a bit, and the number of children who are allergic has gone up. The same thing is true for adults. The number of adults we see is clearly increasing—it’s about
1 ½ to 2 ½ percent, but it’s going up. And the number of individuals with what we call the “hot allergens”—peanuts, shellfish, and fish—is going up. These are the people who go to restaurants, take two bites, and fall over with anaphylactic shock.
Why are we seeing a shift to certain foods?
Probably because of the shift in the diet. We eat the wrong kind of peanuts; we roast our peanuts, which makes them more allergenic. In places where they don’t have much peanut allergy, they boil them. Chinese, for example, like boiled peanuts, and the incidence of peanut allergy in China is much lower. We also don’t introduce foods early, and it turns out that the earlier you introduce a food, the less likely you are to be allergic to it. In Israel, all of the babies are fed a snack called Bamba, which is made of peanuts. If you compare the children in London to children in Israel, the incidence of peanut allergy is dramatically lower in Israel.
What are schools in St. Louis doing?
We have three kinds of schools: peanut-free schools, which remove the problem altogether; schools where there’s an allergy table, where all of the kids [with allergies] eat at one table and it’s then cleaned off; and schools where we’re still working on it… We recommend SunButter, because it’s made of sunflower seeds, and there’s almost no allergy whatsoever.
Any other general advice?
The main thing we hear is whether there’s a shot for food allergies, and the answer is no. There’s a ton of work being done throughout the world to see if we can give allergy shots for food, like we do for ragweed. But the basic answer right now is that it doesn’t work, so the way we treat a food allergy is very simple: Don’t eat that. The trio of quality environmental control, good medication, and allergen immunotherapy for upper-airway allergies—that’s how we treat allergies.
