Allergy in the World: A Guide for Physicians and Travelers 9780824886950

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ALLERGY IN THE WORLD

in the World* A Guide for Physicians and Travelers

edited by

Alexander Roth, M . D .

The University Press of Hawaii X Honolulu

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Copyright © 1978 by The University Press of Hawaii All rights reserved. No part of this work may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying and recording, or by any information storage or retrieval system, without permission in writing from the publisher. Manufactured in the United States of America

Library of Congress Cataloging in Publication Data Main entry under title: Allergy in the world. Includes bibliographies. 1. Allergy. 2. Allergens. 3. Medical geography. 1. Roth, Alexander, 1919,DNLM: 1. Allergens. 2. Pollen. 3. Hypersensitivity—Occurrence. QW900 A436, RC585.A447 616.9'7'009 77-11666 ISBN 0-8248-0521-6

Contents

Foreword Preface Wind-pollinated Plants of Proven Allergenicity and Greatest Clinical Importance Molds of Clinical Importance Countries and Areas Argentina Australia Brazil Canada Chile Colombia Cuba Dominican Republic Ecuador Egypt Finland France Georgian Soviet Socialist Republic German Democratic Republic (East Germany) Germany, Federated Republic (West Germany) Great Britain Greece

vii ix xiii xv 1 4 20 25 29 33 34 35 38 40 41 44 49 52 53 57 61

vi Hawaiian Islands Hungary Iceland India Iran Ireland Israel Italy Japan Lebanon Mexico Netherlands New Zealand Norway Okinawa Peru Philippines Poland Portugal Puerto Rico Romania South Africa Spain Sweden Switzerland Thailand Turkey United States of America Venezuela Yugoslavia Contributors

Contents 64 67 71 73 85 88 90 94 100 109 112 115 118 120 121 122 123 126 129 132 134 138 141 144 148 149 151 155 161 163 167

Foreword

With pleasure and some nostalgia, I have accepted Dr. Roth's invitation to introduce Allergy in the World. More than twenty years have gone by since Oren C. Durham and I made the first hesitant attempt to compile a practical text of what was then known about pollen and spores in the United States and her immediate neighbors. Neither our book nor any book on the aerobiology of allergenic plants would have been possible without Mr. Durham's extraordinary contributions to the field. I am writing these few paragraphs in his honor and memory. What kind of man was Oren C. Durham w h o , singlehandedly, moved "aerobiology" from a hobby to an integral component of clinical allergy? Born on April Fools' Day, 1889, on a farm at the western edge of Kansas, Oren C. Durham did not become a botanist by irresistable force, but by happy accident. He had been a salesman, teacher, carpenter, tinsmith, painter, and physiotherapist when he happened to identify a pollen grain, rough marsh elder, for his wife's uncle, a practicing physician. He continued the collection of pollen as an extracurricular activity until 1923. From then on, he devoted all of his t i m e — w i t h the assistance of W. W . Duke, Karl K. Koessler, Samuel M. Feinberg, and other pioneers in allergy—to the systematic development of his specialty. A few years later, he joined Swan-Myers Cor-

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Foreword

poration in Indianapolis as director of aerobiological research and professional services. When Swan-Myers merged with Abbott Laboratories, he moved to North Chicago, but his responsibilities remained about the same. I remember my first meeting with Mr. Durham very clearly. He met me at the gate. On the way to his office, he stopped at a spectacular tree in bloom and asked me if I knew what it was. I did not know, of course; it was a tree of heaven. Abbott Laboratories gave him the opportunities he needed. I treasure the booklets he prepared while he was there, but I am afraid that his Hay Fever Holiday, which has guided thousands of families to enjoyable vacations, and his weightier booklets and books will become collectors' items before long. It is inspiring to record how this Seventh-day Adventist, a missionary at heart, humble, serious, and tireless, initiated and guided research on the incidence of pollen at all levels of ground and air, and on techniques for their accurate measurement. He enlisted the help of individual physicians, professional societies, airlines, and the meteorological services of the United States, Canada, and Mexico to achieve his objectives. His stature continued to grow. In 1946 he was appointed lecturer in aerobiology at the University of Illinois. Oren C. Durham was an astronomer, an ornithologist, an entomologist. He was at ease and one with nature, and would have excelled in any of these fields. He chose aerobiology, and I am fond of thinking that, even if all of us are replaceable, the painstaking science of defining, recognizing, and classifying "aeroallergens" would probably be a generation behind if Oren C. Durham had not decided to change his life at the age of twenty-three years, and taught all of us what devotion and tenacity can do. I looked forward to seeing him in front of his exhibits at the annual meetings of the American Academy of Allergy, the eyes behind the glasses in his strong, stern, often inscrutable face lighting up with a shy smile of recognition. I miss him. He died on February 7, 1967. Allergy in the World is the second volume on airborne pollens and spores which has appeared since his death. He would be pleased. Max Samter, M.D.

Preface

Samter and Durham's book on Allergy in the United States (1) has been a favorite of mine since it was published in 1955. It came at a time when Americans were increasingly on the move, and therefore became exposed to aeroallergens in different parts of our country. It became important for physicians and patients alike to know what pollens were significant in the various regions of the United States, and in the adjoining countries of Canada and Mexico. During the years since that time, as I have watched the numbers of travelers and distances traveled expand enormously, it has occurred to me that it would be helpful to have a reference work with similar information for countries all over the world. I suggested this to Dr. Samter, but he was occupied with other projects, and proposed that I give it a try. It seemed an overwhelming task, but eventually I decided to go ahead. I began by writing to allergists who had published articles on the subject in their countries and others who were knowledgeable in the field. The amount of correspondence this required was staggering, and unforeseen obstacles many, but within two years most of the chapters that were promised had arrived. It was my original intention to make as few changes in the original contributions as possible, in order to preserve the in-

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dividual flavor, but the various reviewers felt that for the sake of clarity and uniformity, editing was essential. I must confess that I did this with regret, since it eliminated the individual style of the contributor, and made it necessary to omit some interesting, albeit not vital, information. The book is organized so as to make its use as simple as possible. The countries and areas appear in alphabetical order. The information is arranged the same way in each chapter. After a brief review of geographic and climatic conditions, aeroallergens are discussed—the pollens of trees, grasses, and weeds. Molds and other allergens are discussed next. A brief section on clinical observations and available medications follows. Wherever possible, pollen and mold calendars are appended. A list of references is also included when available. In addition there are brief summaries of allergy problems in several countries, based on personal communications to the editor. The largest number of contributions come from the Americas and Europe. Unfortunately, large areas of the globe are still terrae incognitae as far as allergy is concerned. Newmark (2, 3) published an excellent map showing those areas that had been surveyed so far, and points out that progress is being made. No information could be obtained from the People's Republic of China, and the U.S.S.R. is represented by only the Republic of Georgia. A similar situation exists on the continent of Africa. I hope, however, that these gaps in our knowledge will be filled in soon. The chapter on the United States is relatively brief, since Samter's book continues to serve as the primary reference. It was originally planned to list medications for asthma and hay fever in use in the various countries. The recent trend toward the use of very effective single drugs which are now available internationally makes this unnecessary. Disodium cromoglycate (Intal, Arane), the new beta-2 agonists (albuterol, terbutaline), and oral and inhaled steroids are now available almost everywhere, and replace the fixed-dose multiple drug prescriptions. The old reliable standbys, the theophyllins and antihistamines, can be purchased in all countries surveyed. I would like to thank all contributors for providing their chapters and for their patience, and I ask their indulgence for

Preface

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the editing that had to be done to get this book into print. I am also grateful to the anonymous reviewers for their helpful suggestions.

REFERENCES 1

United S a m t e r , M . , a n d D u r h a m , 0 . C.: Regional Allergy of the States, Canada, Mexico, and Cuba. S p r i n g f i e l d , III.: T h o m a s , 1955.

2 3

Newmark, F. M.: Pollen aerobiology. Ann. Allergy 358:26, 1968. Newmark, F. M.: Recent developments in pollen aerobiology Ann Allergy 149:28, 1970.

Wind-pollinated Plants of Proven Allergenicity and of Greatest Clinical Importance TREES Birch family Alder Birch Hazel

Betulaceae

Beech family Beech Oak

Fagaceae

Elm family Elm Hackberry

Ulmaceae

Maple family Box elder Maple

Aceraceae

Sycamore family Plane tree (sycamore)

Platanaceae

Poplar-willow family Aspen Cottonwood Poplar Willow

Salicaceae

Walnut-hickory family Hickory Pecan Walnut

Juglandaceae

Olive family Ash Olive

Oleaceae

Casuarina (beefwood) family Australian pine

Casuarinaceae

A/nus Betula Corylus Fagus Quercus U/mus Ce/tis Acer Acer

negundo

P/atanus Populus Popu/us Populus Sa/ix Carya Carya Jug/ans Fraxinus Olea Casuarina

xiv

Allergenic Wind-pollinated Plants GRASSES Gramineae Cynodon dactylon Poa pratensis Dactylis glomerata Agrostis alba Lolium spp. Anthoxanthum odoratum Holcus lanatus

Grass family Bermuda grass Bluegrass Orchard grass Red top Rye grass Sweet vernal grass Velvet grass WEEDS Sunflower family Ragweeds Marsh elder Cocklebur Sagebrush and wormwood Pigweed (carelessweed) family Goosefoot family Saltbush Plantain family Plantain Hemp family Hemp Knotweed family Sorrel Dock

Compositae Ambrosia Iva Xanthium Artemisia Amaranthaceae Chenopodiaceae Atrip/ex Plantaginaceae Plantago Cannabinaceae Cannabis Polygonaceae Rumex Rumex

Molds of Clinical Importance Class Zygomycetes Mucor Rhizopus

Class Ascomycetes Chaetomium

Fungi Imperfecti Order Moniliales Family Moniliaceae Aspergillus Botrytis Moni/ia Mycogone Paeciiomyces Pénicillium

Family Dematiaceae Alternaria Cladosporium Helminthosporium Pullularia (Aureobasidium) Stemphylium

Family Tuberculariaceae Epicoccum Fusarium

Order Sphaeropsidales Phoma

Class Basidiomycetes Subclass Heterobasidiomycetes Rusts Smuts

ALLERGY IN THE WORLD

Argentina

(Summary Notes) Pollinosis is not a big problem. Grasses and house dust are the major allergens. Short ragweed has been reported from some areas. Alternaria and Aspergillus are the most common molds. Source: Baena Cagnani, C.: Personal communication. IX International Congress of Allergology, Buenos Aires, Argentina, 1976.

Australia Ion C.

Morrison

Geography and Climate The Australian Commonwealth, which includes the island continent of Australia and the island of Tasmania, is situated in the Southern Hemisphere, just south of the equator, and has an area of 8 million square kilometers, almost as great as that of the continental United States. Australia has six states and two mainland territories, and a population of 14 million. Traversing the continent from east to west, there is first a narrow coastal plain, well watered by rivers, with an average width of 65 to 80 kilometers. Bordering this plain is the Great Dividing Range, which extends from the north of Queensland to the south of New South Wales, and is about 244 kilometers wide. This range rises often abruptly from the plain, but the descent on its western slopes is gradual, until the country, to the north of Spencer's Gulf, is at or even below sea level. Thence? there is another almost imperceptible rise until the mountain ranges of Western Australia are reached, and beyond these lies another coastal plain. The mountains of Australia are relatively low; the highest peak, Mount Kosciusko in New South Wales, is only 2,200 meters. Three-quarters of the landmass is a huge plateau between 185 and 455 meters high with rolling hills and mountains.

Australia

The northern third of Australia is tropical; the rest lies in the temperate zone. Generally, the climate is very dry, and only 11 percent of the country has rain exceeding 1,000 mm annually. Of all the continents (excluding Antarctica), Australia receives the least rainfall, and also "has the least runoff from its rivers into oceans. Only in relatively small areas of the continent could the rainfall be described as abundant. The vegetation of the continent depends a great deal on the distribution of rainfall. Plants vary from the desert and saltbush type of the interior to the tropical forest of the southwest coast. A state-by-state summary of allergy problems follows.

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Australia

QUEENSLAND (BRISBANE) Sources of Airborne Allergens Trees. Dense rain forest covers part of the coastal area. In the drier areas, eucalyptus and acacia predominate. Grass. The state is well known for its great grasslands. The most important allergenic species are Rhodes grass, paspalum, Sudan grass, Bermuda grass, foxtail, kangaroo grass, and red Natal. Weeds. Plantain is common, and ragweed is also present. Molds. Most important as allergens are Cladosporium, Pénicillium, Epicoccus, Aspergillus, and Rhizopus.

Clinical Observations Pollen allergy in persons under the age of 10 years is rare. House dust is an important allergen, and in combination with molds, causes many cases of asthma. Inland on the Downs, pollen hay fever is more common than along the coast. A survey of 16,000 first-grade school children showed that 5 percent were asthmatic, and in some areas this figure approached 10 percent. The total asthmatic population in Queensland is estimated at 70,000. Asthma tends to occur in waves, one peaking in May, the other in October. Allergy to stinging insects is on the increase. Of interest is a reaction to "side-winders," a sugarcane leaf hopper. Animal danders, feathers, goat hair (a very popular carpet is made of goats' hair), and wool are occasional offenders.

Grasses Wild oats Yorkshire fog Couch grass Rhodes grass Cocksfoot Barley grass Rye grass Maize Paspalum Pennisetum Kangaroo grass Weeds Cape weed Wattle Plantain Dock Goosefoot family

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Trees Bead tree Australian pine Pepper tree Pine Murray pine

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Pollen Calendar QUEENSLAND

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Australia

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NEW SOUTH WALES New South Wales is the most populous and industrialized state. Sydney and the rest of the coastal area has a dry sunny climate, but inland summers are hot, and winters cold.

Sources of Airborne Allergens Trees. The most important tree is the eucalyptus. The cypress pine is f o u n d on the western slopes, and the hoop pine and red cedar in the north. Also c o m m o n are pepper tree, Australian pine, river oak, and belah. Grasses. The most important species are barley, brome, canary, Bermuda, cocksfoot, paspalum, prairie, Rhodes, rye, summer, wild oats, winter, Yorkshire fog, and stink grass. Less important are buffalo, Johnson, Sudan, kangaroo, and Kentucky bluegrass. Weeds. Most important are capeweed, dock, plantain, western ragweed, pigweed, and fat hen weed. Less important are noogoora burr, Bathurst burr, sorrel, Paterson's curse, wild mustard, fennel, saltbush, and ferns. Molds. A/ternaria, Cladosporium, Stemphylium, and Phoma.

Clinical Observations Ragweed is becoming more c o m m o n and causing more symptoms w i t h each passing year.

Pollen Calendars

z PLANT


o

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NEW SOUTH WALES Trees Bead tree Australian pine Pepper tree Cypress Murray pine Grasses Wild oats Yorkshire fog Couch grass Rhodes grass Cocksfoot Barley grass Rye grass Maize Paspalum Pennisetum Canary grass Weeds Capeweed Wattle Plantain Dock Goosefoot family

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SYDNEY, NEW SOUTH WALES Grasses Brome grass Barley Couch grass Paspalum Prairie grass Rye grass Summer grass Winter grass Weeds Capeweed Dock Fat hen weed Pigweed Plantain Western ragweed

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Australia

VICTORIA Victoria is the most southerly state on the eastern seaboard of Australia and the second most populous.

Sources of Airborne Allergens Trees. Most common are birch, sycamore, oak, elm, and in the uplands, snow gum and ash. In the warmer areas grow the bean tree, acacia, and privet. Grasses. Most common species are rye, Yorkshire fog, barley, orchard, bent grass, bluegrass, prairie grass, and canary grass. Molds. Most important species are A/ternaria, Cladosporium, and Penicillium.

Clinical Observations The most important allergenic plants are the pastoral grasses; 90 percent of pollen sensitive patients are allergic to grass pollens. Native grasses are not significant. Pollination is at its peak from October through December. Paspalum pollinates from January through April but causes little trouble. Tree pollens are not clinically significant, and although ragweed is present, it is under control and of little importance. House dust is an important allergen and causes symptoms especially from February through May. Molds, on the other hand, do not cause much difficulty.

Pollen Calendar VICTORIA PLANT

< K i S a - S - ) : D = > i ± j O Q i u T B : 5 < 5 T T < ( / > 0 2 0

Trees Bead tree Australian pine Pepper tree Cypress Murray pine

x x

Grasses Wild oats Yorkshire fog Couch grass Rhodes grass Cocksfoot Barley grass Rye grass Prairie grass Paspalum Canary grass Bluegrass Weeds Capeweed Wattle Plantain Dock Goosefoot family Coprosma Privet

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Australia

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SOUTH AUSTRALIA South Australia is largely pastoral, with main cities on the Southern Ocean, and the remainder mostly desert. More than three-fourths of the state has less than 250 mm of rainfall a year. The great majority of the population lives in the capital, Adelaide.

Sources of Airborne Allergens Trees. Main species are eucalyptus, pine, and ash. Grasses. Species are the same as those found in Victoria. Most frequently encountered are perennial rye, Bermuda, and phalaris. Weeds. Weeds are not too prominent. Plantain, capeweed, and echium are found. Molds. A/ternaria, Periicillium, C/adosporium, Monilia, and Sporobo/omyces have been identified.

Clinical Observations Most of the patients studied reacted to grass pollen and house dust. Sensitivity to weeds and molds was not as frequent.

Pollen Calendar SOUTH A U S T R A L I A PLANT Trees Bead tree Australian pine Pepper tree Cypress Olive tree Grasses Wild oats Yorkshire fog Couch grass Rhodes grass Cocksfoot Barley grass Rye grass Canary grass Paspalum Pennisetum Veldt grass Weeds Capeweed Wattle Plantain Dock Goosefoot family Paterson's curse

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Australia

WESTERN AUSTRALIA This is the largest state, comprising one-third of the continent. It embraces a wide range of climates, as it stretches from latitude 13° to 35° S. Rainfall is scant except in the south and the north; most of the inhabitants of the state live near Perth, the capital.

Sources of Airborne Allergens Trees. Trees, mainly various species of eucalyptus, are not considered clinically important. Grasses. Buffel grass predominates in the northwest (Kimberley region). In the southwest, Wimmera rye grass, wild oats, and veldt grass are abundant. Weeds. From latitude 25° to 31° the most interesting plants are the everlastings, members of the daisy family, which cover the ground like a large carpet. These plants are related to the pyrethrums of central Africa. Molds. No information available.

Clinical Observations In the northwest, rains occur in late summer (January, February), with pollination of grasses following in early fall. Below latitude 31°, the main allergens are those of the native and cultivated plants and trees of the agricultural area. Food allergy is more common here than along the eastern seaboard of the continent.

Pollen Calendar WESTERN AUSTRALIA K S < 5 = i = i < 0 3 O 2

PLANT Trees Bead tree Australian pine Pepper tree

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Rhodes grass Cocksfoot Barley grass Rye grass Maize Paspalum Pennisetum Veldt grass Weeds Capeweed Wattle Plantain Dock Goosefoot family

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Cypress Murray pine Grasses W i l d oats Yorkshire fog Couch grass

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Australia

16

TASMANIA Tasmania is an island state 240 km to the south of Victoria. It is mountainous, enjoys adequate rainfall (unlike most of the other Australian states), and has mild summers and winters.

Sources of Airborne Allergens Trees. Beech and myrtle are found where the rainfall is adequate. Eucalyptus grows in the drier areas. Grasses. The same species are found here as in Victoria. Rye and Yorkshire fog are common. Weeds. Plantain pollen constitutes the major weed pollen. Molds. Alternaria, C/adosporium, and Pénicillium are the most important molds.

Clinical Observations Prune trees, which flower in August, appear to cause allergic symptoms in the Hobart area. The grasses are the most common allergens in the spring. Molds are most likely to cause symptoms in late summer, January and February. The Commonwealth Serum Laboratories of Australia (a semigovernmental institution) supplies the bulk of allergen extracts for use in hyposensitization. However, British, American, and New Zealand commercial products are also used on a national basis, and some allergists prefer to manufacture their o w n extracts.

Pollen Calendar TASMANIA plant

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Molds Phoma

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Candida Aspergillus Alternaría Mucor Curvularia Fusarium Cladosporium Stemphylium Helminthosporium Rhizopus Neurospora

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Pollen and Mold Calendar JAIPUR (RAJASTHAN) (29-34) PLANT

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Grasses' Weeds Spurge family Dodonca Goosefoot family Pigweed family Castor bean Hemp Molds A/ternaria Helminthosporium Cladosporium Fusarium

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"Grasses are the most important inhalant allergens. The major grass species are Johnson grass, Bermuda grass, maize, Pennisetum, wire grass, finger grass, and sugarcane.

Pollen and Mold Calendar BIKANER (RAJASTHAN) (35-38) PLANT

z < -)

Trees Mesquite Acacia China tree Siris tree

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Grasses Bermuda grass Bur grass

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Molds Alternaria Cladosporium

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Pollen Calendar LUCKNOW (UTTAR PRADESH) PLANT

Trees Syzygium (myrtle family) Ho/opte/ea Nim tree Ailanthus family Australian pine Grasses Weeds Pigweed and goosefoot families Cocklebur Mugwort Castor bean Hemp

Z i n 5 o c > z _ i l 3 o . K > o t Œ S < 2 = I = I < Ô ) O Z Q

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India

REFERENCES AND NOTES 1

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Shivpuri, D. N.; Viswariathan, R.; and Dua, K. L.: Studies in pollen allergy in Delhi area, 1957-58, Part 1 (pollination calendar and field studies). Indian J. Med. Res. 48:15, 1960. Shivpuri, D. N.; Viswanathan, R.; and Dua, K. L.: Studies in pollen allergy in Delhi area, 1957-58, Part 2 (pollination calendar based on aero-palynology). Indian J. Med. Res. 48:21, 1960. Shivpuri, D. N.; Dua, K. L.; and Subramanian, T. A. V.: Studies in pollen allergy in Delhi area. Part 3 (collection and processing of pollens and preparation of their extracts). Indian J. Med. Res. 51:64, 1963. Shivpuri, D. N., and Dua, K. L.: Studies in pollen allergy in Delhi area, Part 4 (clinical investigations). Indian J. Med. Res. 51:68, 1963. Dua, K. L., and Shivpuri, D. N.: Atmospheric pollen studies in Delhi area in 1958-59 (aero-palynology). J. Allergy 33:507, 1962. Shivpuri, D. N.: Comparative evaluation of the sensitivity of c o m m o n methods of diagnostic antigen tests in patients of respiratory allergy. Indian J. Chest Dis. 4:102, 1962. Shivpuri, D.: Pollinosis in India and modern approach. J. Indian Med. Assoc. 40:555, 1963. Shivpuri, D. N., and Dua, K. L.: Allergy to Carica papaya tree. Ann. Allergy 21:139, 1963. Shivpuri, D. N., and Singh, M. P.: On etiologic diagnosis of offending allergens in 200 patients of bronchial asthma a n d / o r allergic rhinitis. J. Palynol. India 1:90, 1965. Shivpuri, D. N., and Kartar Singh: Studies in local allergens in 324 patients of bronchial asthma and rhinitis in New Delhi and Delhi, India. Proc. all India, 21st Tuberculosis and Chest Disease Workers Conference, Calcutta, 1966. Shivpuri, D. N., and Dharam Prakash: Studies in allergy to Prosopis juliflora. Ann. Allergy 25:643, 1967. Gupta, C. K.; Kartar Singh; Agarwal, M. K.; and Shivpuri, D. N.: On the atopic relationship amongst some species of Chenopodiaceae and Amaranthaceae. Indian J. Med. Res. 58:610, 1970. Kartar Singh, and Shivpuri, D. N.: Studies in yet unknown allergenic pollens of Delhi State metropolitan (botanical aspects). Indian J. Med. Res. 59:1397, Sept. 1971. Shivpuri, D. N., and Kartar Singh: Studies in yet unknown allergenic pollens of Delhi State metropolitan (clinical aspects). Indian J. Med. Res. 59:1411, 1971. Shivpuri, D. N.: Results of hypo-sensitization in pollinosis in Delhi area with local pollen extracts. J. Indian Med. Assoc. 40:539, 1963. Shivpuri, D. N., and Dua, K. L.: Results of hypo-sensitization in 250 patients of bronchial asthma in India against local allergens (a seven year study). Ann. Allergy 22:632, 1964. Dharam Prakash; Garg, O.; and Shivpuri, D. N.: Hyposensitization in children with bronchial asthma. Indian J. Pediat. 37:366, 1970.

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India Sandhu, D. K.; Shivpuri, D. N.; and Sandhu, R. S.: Studies in the air-borne fungal spores in Delhi—Their role in respiratory allergy. A n n . Allergy 22:374, 1964. Agarwal, M. K.; Shivpuri, D. N.; and Mukerji, K. G.: Studies o n the allergenic fungal spores of Delhi, India, metropolitan area (botanical aspects). J. Allergy 44:104, 1969. Shivpuri, D. N., and Agarwal, M. K.: Studies in allergenic fungal spores of Delhi State (clinical aspects). J. Allergy 44:204, 1969. Agarwal, M. K.; Shivpuri, D. N.; Mukerji, K. G.; and Shali, P. L.: Species specific antigens in fungi. Aspects Allergy Appl. Immunol. 2:69, 1968. Agarwal, M. K.; Shali, P. L.; Shivpuri, D. N.; and Asgar, S. S.: Studies on biologically active fractions of Aspergillus tamarii. Aspects Allergy Appl. Immunol. 4. 1970. Shivpuri, D. N.; Shali, P. L.; Agarwal, M. K.; Dharam Prakash; and Bhatnagar, P. L.: Studies in insect allergy in India. A n n . Allergy 29:588, Nov. 1971. Shali, P. L.; Agarwal, M. K.; and Shivpuri, D. N.: Sex specific antigens in insects. Aspects Allergy Appl. Immunol. 3:77-83, 1969. Indian Council of Medical Research, New Delhi: Morbidity survey of contributory health scheme beneficiaries. New Delhi, 1961. Viswanathan, R.; M o d y , R. K.; Prasad, S. S.; and Sinha, S. P.: Bronchial asthma and chronic bronchitis. A pilot survey. J. Indian Med. Assoc. 45:480, 1965. Shivpuri, D. N.: Presidential address delivered at the 5th annual convention of Indian College of Allergy and Applied Immunology, Oct. 28, 1971. Aspects Allergy Appl. Immunol. 5:1, 1971. Shivpuri, D. N.: Studies in allergy and allergens in India and some newer methods of treatment. Aspects Allergy Appl. Immunol. 1:71, 1967. Kasliwal, R. M . ; Sanghvi, L. M . ; and Gupta, K. D.: Respiratory allergens in Rajasthan. J. Assoc. Physicians India 3:184-188, Oct. 1955. Sanghvi, L. M . ; Sethi, J. P.; and Kasliwal, R. M.: Pollen allergy in Rajasthan—A preliminary study of the botanical flora and aerial pollens. J. Indian Med. Assoc. 29:43-47, 1957. Kasliwal, R. M . ; Sethi, J. P.; and Sogani, I. C.: Studies in atmospheric pollen: A daily census of pollens at Jaipur, 1957-58. Indian J. Med. Res. 47:515-521, Sept. 1959. Gupta, K. D.; Kasliwal, R. M . ; Selomon, S. K.; and Sogani, I. C.: Investigation of the causal allergen in 100 cases of bronchial asthma. J. Assoc. Physicians India 7:268-272, May 1959. Bhargava, R. K.; Kasliwal, R. M . ; Sethi, J. P.; and Sogani, I. C.: Prevalence of respiratory allergy to molds in Jaipur. Indian J. Chest Dis. 3:81-91, April 1961. Kasliwal, R. M . ; Gupta, K. D.; Sanghvi, L. M . ; and Sogani, I. C.: Evaluation of the results of specific hyposensitization therapy in cases

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of respiratory allergies treated in S.M.S. Hospital, Jaipur. Indian J. Chest Dis. 1:17, 1959. Gupta, K. D., and Jagdish Singh: Pollination calendar of allergenic plants of Bikaner (Rajasthan), Part 1 (botanical survey of the area). J. Assoc. Physicians India 13:915, 1965. Gupta, K. D., and Jagdish Singh: Pollination calendar of allergenic plants of Bikaner (Rajasthan), Part 2 (aerial survey of pollens and fungi). J. Assoc. Physicians India, 13:919, 1965. Gupta, K. D.; Agarwal, R. G.; and Sulemani, A. A.: Pollination calendar of allergenic plants of Bikaner (Rajasthan), Part 3 (investigation of the allergenicity of pollens). J. Assoc. Physicians India 17:225, 1969. Gupta, K. D. and Banerji, A.: Allergenic pollens of Rajasthan: Assessment of the role of individual pollen. Indian J. Chest Dis. 8:153, 1966. Lakhanpal, R. N., and Nair, P. K. K.: Survey of the atmospheric pollen at Lucknow. J. Sci. Ind. Res. 17C:80, 1958. Vishnu Mittre: Aerospora of Lucknow. (Personal communication.) Agnihotri, M. S. and Singh, A. B.: Observations on pollinosis in Lucknow with special reference to offending factors. (Personal communication.) Rajan, B. S. V.; Nigam, S. S.; and Shukla, R. K.: A study of atmospheric fungal flora at Kanpur. Proc. Indian Acad. Sci. (B) 35:33, 1952. Lakhanpal, R. N., and Nair, P. K. K.: Atmospheric pollen survey at Almora. J. Sci. Ind. Res. 190:51, 1960. Nair, P. K. K.: An analysis of atmospheric pollen, fungal spores, and other vegetable matter at Vellore, Madras State (India). Indian J. Med. Res. 51:447, 1963. Ramalingam, A.: Airspora of Mysore. Proc. Indian Acad. Sci. (B) 74(5) :227, 1971. Sreeramulu, T.: Aero-biology in India. J. Sci. Ind. Res. 26:474, 1967. Sreeramulu, T.: Concentrations of fungus spores in the air inside a cattle shed. Acta Allergol. 16:337, 1961. Reddi, C. S.: A comparative survey of atmospheric pollen and fungus spores at two places twenty miles apart. Acta Allergol. 25:189, 1970. Baruah, H. K., and Chetia, M.: Aerospora and allergic human diseases: A study of certain fungal spores and pollen grains of Gauhati. Indian J. Exp. Biol. 4:236, 1966. Kalra, S. L. and Dumbrey, D. G.: Aerobiology of army medical campus, Poona (Part 1). Pollens, spores and mites. Armed Force Med. J. (India) 13:3, 1957. Chaubal, P. D., and Deodikar, G. B.: Airborne spores around Poona. J. Univ. Poona, Science and Technology Section, no. 26, p. 123, 1964. Saha, J. C., and Kalyanasundaram, S.: Studies on pollen allergy in Pondicherry, Part 1. Survey of potentially allergenic plants. Indian J. Med. Res. 50:881, 1962. Shivpuri, D. N.; Menon, M. P. S.; and Prakash, D.: A preliminary

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India study on leaves of Tylophora indica in the treatment of 56 patients with bronchial asthma and allergic rhinitis. J. Assoc. Physicians India 16:9, 1968. Shivpuri, D. N.; Menon, M. P. S.; and Prakash, D.: Crossover double-blind study on Tylophora indica in the treatment of 110 patients with asthma and allergic rhinitis. J. Allergy 43:145, 1969. Shivpuri, D. N.; Singhal, S. C.; and Prakash, D.: Treatment of asthma with an alcoholic extract of Tylophora indica, a cross doubleblind study. Ann. Allergy 30:407, 1972.

Iran Majid Kimiayi Mohammad Tawaf Mohammad Beheshti

Geography and Climate Iran lies in southwest Asia between the Caspian Sea and the Persian Gulf. It has a total area of 1,642,000 square kilometers and a population of 31 million. There are two major mountain ranges which form an inverted V—the Zagros range in the west, and the Alborz range in the north. Between these two ranges lies the central plateau with its two great deserts, Dasht-e-Lut and Dasht-e-Kavir, the most arid deserts in the world. Iran lies in the temperate belt but shows a wide variety of climates. The mountains have cold winters, mild summers, and a short rainy season; the air is usually dry. The lowlands, with the exception of the Caspian littoral, have dry weather, with hot summers and large temperature fluctuation. The southern coastal plains have long hot summers and short mild winters, with high humidity but little precipitation. The Caspian littoral in the north has moderate temperatures, high humidity, and heavy rainfall the year around. Winter is the rainy season in Iran, but the southern region receives very little rain even then. Summers are generally dry except in the Caspian littoral. Teheran receives an average rainfall of 218 mm a year.

Iran

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Sources of Airborne Allergens Trees. About 10 percent of the country is covered by forests, especially in the Caspian littoral. Alder, beech, maple, birch, box elder, cedar, poplar, oak, walnut, ash, sycamore, and elm grow here. In the west, northwest, and northeast regions one can also find pine, tree of heaven, locust, and willow. Mesquite, acacia, and date palms grow mainly in southern Iran. Grasses. Grasses are found in most areas and pollinate from March to July. Weeds. The goosefoot and pigweed families are widespread, as are plantain, sagebrush, cocklebur, Russian thistle, and burning bush. In the central dry lands and southern areas grow Russian thistle, hellenia, salt cedar, tamarix, dandelion, and saltbush. Molds. The following molds have been identified: Alternaría, Aspergillus, Candida albicans, Cladosporium, Fusarium, Geotrichum, Helminthosporium, Mucor, Paecilomyces, Penicillium, Rhizopus, Rhodotorula, Saccharomyces, and Trichosporum.

Clinical Observations Dust is a major factor in respiratory allergy. Air pollution is increasing as a predisposing factor in respiratory disease. The humid weather of the Caspian coast favors the growth of mold spores, and mold allergy is quite common there. In the other parts of the country, molds are found mostly in residential areas and as contaminants of certain foods. The incidence of major allergies in Iran is almost the same as the universal figure of 10 percent. Allergic rhinitis, bronchial asthma, and urticaria are most common. Seasonal hay fever is more prevalent than perennial allergic rhinitis and bronchial asthma. There are only a few practicing allergists in Iran, all of them located in Teheran.

87

Iran Pollen Calendar TEHERAN z

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REFERENCES Iran Ministry of Information Publication: Iran. Teheran, 1971. Kimiayi, M.: Pollinosis in Iran. Ann. Allergy 28:28, 1970. Sabeti, H.: Trees and Shrubs of Iran. Teheran: University of Teheran Publication, 1966. Shafiee, A.: Studies of atmospheric pollen in Teheran, Iran, 1974-75. Ann. Allergy 37:133, 1976.

Ireland Nora McNally

Geography and Climate Ireland is the most westerly of Europe's larger islands. It has an area of 84,000 square kilometers and a population of 3 million. It is bounded on three sides by the Atlantic Ocean and on the fourth, by the Irish Sea, which separates it from Britain. The mountains of Ireland are not high and are situated for the most part around the coast of the island, leaving a flat central plain, so that the country is saucer-shaped. Ireland has a mild, maritime climate which benefits from the nearness of the Gulf Stream. As no part of the island is more than 100 kilometers from the sea the climate is cooler in summer and warmer in winter than many other countries in the same latitude. The average rainfall for the whole country is 1,100 mm and is not confined to any particular season. Pastures and crops rarely suffer from drought, receiving sufficient moisture all the year round. Sources of Airborne Allergens Ireland is known affectionately as the Green Isle because of the rich lush grass that grows over most of the country all the year round. The whole central plain and the east coast are one fertile valley of rich pasture land. It is therefore not

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surprising that grass pollen is the most important inhalant allergen. Trees. Trees present little problem as a source of pollen allergens, since there are no forests. Horse chestnut, ash, birch, elm, oak, and sycamore can be f o u n d here and there, but f e w people have symptoms f r o m them. The same can be said of shrubs, the commonest being the heather and gorse which g r o w profusely on the hillsides. Others are hawthorn, lilac, cherry, and hydrangea. Grasses. The most c o m m o n grass is t i m o t h y ; approximately 80 percent of hay fever victims are allergic to its pollen. Its pollination time is f r o m mid-May to the end of July. Next most c o m m o n are orchard grass and m e a d o w grass. Weeds. The sunflower family is not clinically important. Molds. The most c o m m o n mold is Aspergillus, to w h i c h many patients have positive reactions. House dust. Allergy to house dust is not too c o m m o n , though skin tests to house dust and house dust mites are often positive.

Clinical Observations The number of hospitals in Ireland is barely adequate for the population, and their financial support comes f r o m voluntary contributions and the Hospital Sweepstakes. Most of the physicians are in general practice, and it is difficult for a doctor to survive financially specializing purely in allergy. There are no allergy hospitals, but there are a f e w allergy clinics. Exact figures on the prevalence of allergies are not available. A s t h m a is the most c o m m o n of the allergic diseases, followed by eczema and hay fever. Infection is believed to be of prime importance in asthma, especially during the periods October to November and January to February (N. McNally, unpublished data). T h o u g h hay fever is c o m m o n , its importance is diminished by frequent rains w h i c h suppress pollen dispersion. Grass pollen is the most important aeroallergen. Because of the abundance of dairy products, allergy to milk is the most c o m m o n food allergen, particularly in children, but accurate statistics are not available. There is very little heavy industry in Ireland, and air pollution is not an important factor in respiratory disease.

Israel Israel

Glazer

Geography and Climate Israel lies on the southeast coast of the Mediterranean Sea. It has an area of 20,700 square kilometers and a population of 3,400,000. There are four geographic and climatic regions: the Mediterranean coastal plain w i t h w a r m humid summers and mild winters; a range of mountains and hills w i t h hot dry days and cool nights in the summer and relatively cold, snowless winters; the Jordan valley w i t h subtropical climate; and the Negev desert w i t h dry hot weather and marked diurnal temperature differences. Khamsin, a hot dry w i n d from the desert, blows usually in the spring and fall and can have a pronounced effect on allergic reactions.

Sources of Airborne Allergens Trees. There are no natural forests in Israel, and pollinosis from tree pollen is rare. Tree of heaven, acacia, eucalyptus, cypress, junipers, and citrus have been incriminated on rare occasions. However, olive trees can cause both hay fever and asthma. Grasses. Grasses account for most cases of pollinosis. The pollination peak occurs in March and April, but Bermuda grass may flower all year.

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Weeds. Weeds are not very important clinically. The goosefoot and pigweed families are represented (spiny amaranth, lamb's quarters), as are Russian thistle, and sagebrush. Molds. Molds have been studied extensively and occur in the following order of frequency: Cladosporium, Alternaria, Pénicillium, Aspergillus, Stemphylium, Actinomycetes, and yeasts. Mold counts are high in the coastal area (TelHashomer) as compared to the desert (Eilat). The coastal cities have a mold peak in the spring and fall. House dust. House dust is an important allergen, as it is in other countries. Clinical Observations Pollen allergy is relatively uncommon and caused most frequently by the pollen of olive trees and grass. During the dry season, beginning in May, the entire country is relatively pollen-free. Weed pollen may cause fall symptoms. The city of Eilat in the Negev desert is a true haven for pollinosis patients; the mold count there is low also. The honeybee is responsible for most insect sting reactions. Of interest are hivelike eruptions from sandfly bites and contact with caterpillars (Taumatopeapenifora wilkinsoni). Dermatitis from contact with fig trees or mango occurs frequently, but poison ivy and poison oak do not grow here. Medical service is good and specialists in allergology are represented in most major cities. A home for asthmatic children is maintained in Arad. Pollen Calendar ISRAEL PLANT

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Spain

REFERENCES Alemany, R.: Polinosis. Ponencia al III. Congreso Nac. de Alergia. Madrid: Edit. Paz Montalvo, 1954. Barrios Gutierrez, J.: Estudio polínico primaveral del Campo de Sanlucar de Barrameda. Rev. Clin. Esp. 6:29, 1942. Canto Borreguero, G.: Aportación botanica al tapiz vegetal de la duna de Castilla la vieja. III. Congreso Español de Alergia, 1954. Charpin, J., and Surinyach, R.: Atlas of European Allergenic Pollens. Madrid: Edit. Sandoz, 1974. Diaz-Rubio, M.: Polinosis en Cadiz. Rev. Clin. Esp. 4:344, 1942. Font, R.: El polen atmosferico de Barcelona en 1955. Pubi. Inst. Biol. Aplicada. Gavilanes, C. R., and Montserrat, P.: La Polinosis en Canarias. Las Palmas: Edit. Museo Canario, 1953. Montserrat, P.: Analisis polínico del aire de Barcelona. Pubi. Inst. Biol. Aplicada 8:209, 1951. Montserrat, P.: Analisis polínico del aire de Barcelona. II. Pubi. Inst. Biol. Aplicada 13:115, 1953. Montserrat, P.: El polen atmosferico del aire de Barcelona. Pubi. Inst. Biol. Aplicada 13:121, 1953. Muñoz Medina, A.: Una introducción al estudio de los alergenos polínicos de Granada. R. Acad. Med. Granada, 1949. Pia Dalmau, J. M.: Aeropolinologia Gerundense. Anales Inst, de Est. Gerundenses, 1958. Posse, J. M.: Contribución al estudio de la alergia respiratoria en Vizcaya. Arch. Hosp. Civil Basurto 2:25. Sanchez Cuenca, B.: Polinosis. Madrid: Edit. Cient. Med., 1932. Surinyach, R.: Observaciones sobre el contenido del polen en el aire de Cardo. In Florula de Cardo, edited by P. Font, 1950. Surinyach, R.: Epidemiologia de la polinosis en Barcelona. Anales Med. 42:36, 1956. Surinyach, R.: Observations on some pollen aerobiological standards in North-East Spain. Acta Allergol. (Kbh) 15:151, 1960. Vieitez, E.: Estudios botánicos sobre la flora alergogena de Santiago de Compostela. Anales Inst. Edafologia Ecol. Fis. Vegetai 5, 1946. Vieitez, E.: Analisis polínico atmosferico de Pontevedra. Anales R. Acad. Farmacia 3, 1947.

Sweden S. Ni/sson S. Wilholm

Geography and Climate Sweden, situated in the Scandinavian peninsula, has an area of 45,OCX) square kilometers and a population of 8 million. There are five topographic regions: the high mountains and plateau of northern Sweden, the northern coastal belt, the lowlands of central Sweden, the uplands of south central Sweden, and the southern lowlands. The climate is transitional between maritime and continental, and benefits from the proximity of the Gulf Stream. The temperature in Stockholm ranges from - 3 ° C in the winter to 28° C in the summer. The yearly mean precipitation is 600 mm. The northern parts of Sweden are snow-covered for eight months of the year. The summers are generally warm with low humidity. Sources of Airborne Allergens Trees. More than 50 percent of Sweden is covered by forests. Pine and spruce grow in the north; pine, spruce, oak, hazel, and elm in the center; and birch, beech, and pine in the south. The following trees are important clinically: hazel, alder, poplar, willow, elm, ash, beech, and oak. Grasses. Grasses flower mostly during the summer months. The most important species are sweet vernal, fescue, bluegrass, conch, orchard, velvet, foxtail, redtop, rye, timothy, and wheat.

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Weeds. The majority of weeds flower in late summer and autumn. The following are considered important: dock, sagebrush, goosefoot family, and pellitory. Molds. Mold allergy is caused mainly by the following fungi or groups of fungi: A/ternaria, Cladosporium, Stemphylium, and Epicoccum are present mostly in the summer. Botrytis, Pullularia, and Sphaeropsidales have two peaks, in the spring and in the autumn. Aspergillus, Aleurisma, Fusarium, Penicillium, Mucorales, and Actinomycetes have no particular seasonal variation. House dust. House dust is an important allergen, particularly when the mite concentration is high. Clinical Observations

Regional studies indicate that about 10 percent of the population have some type of allergic disease. Allergies to milk, egg, fish, shellfish, and other foods have been reported. Symptoms are often increased during the pollen season. The influence of air pollution on respiratory allergy is difficult to evaluate. Many industrial by-products have toxic effects on the respiratory mucous membrane, and reactions to many new synthetic chemicals occur frequently. Occupational allergy is not unusual. Contact allergy is most often caused by epoxy resins, perfumes, metals, vulcanizing material in rubber, turpentine (the Swedish product seems to be more allergenic than the American), tars, formaldehyde, and flowers. Knowledge about allergic diseases is growing, and allergology departments exist in all six Swedish university cities. However, allergology has not yet been recognized as a separate medical specialty. The Swedish Society for Allergology has about 200 members, including internists, pediatricians, dermatologists, microbiologists, and basic scientists. There is also a patient association with about 9,000 members.

Pollen Calendar SWEDEN >-

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Trees Hazel Alder Poplar Willow Elm Beech Ash Grasses Weeds Dock Sagebrush Goosefoot Pellitory

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REFERENCES Anas, P.: Luftens innehall av bjfirk- och sSlgpollen f6rsommaren 1970 [The contents of Betula- and Sa//x-pollen in the air, in early summer 1970]. FOA 1 Rapport, C. 1385-34, June 1970. Anas, P.: Luftens innehall av pollen, sporer, och frOn i Ursvik, sommaren 1970 [The contents of pollen, spores and seeds in the air at Ursvik, in the summer 1970]. FOA 1 Rapport, C.1385-34, Nov. 1970. Juhlin-Dannfelt, C.: Nagot om Overkanslighet f6r olika pollensorter [On hypersensitivity of various kinds of pollen]. Nord. Med. 20:2441, 1943. Juhlin-Dannfelt, C.: Nagot om Sverkanslighet f6r prastkragar, maskrosor och andra vaxter tillhorande familjen Compositae [On hypersensitivity of Chrysanthemum leucanthemum, Taraxacum vulgare and other plants of Compositae]. Nord. Med. 24:1836, 1944. Nilsby, J.: Allergi framkallad av mOgelsporer [Allergy caused by molds]. Svenska LSkartidn. 17:1-9, 1947. Nilsby, J.: Investigation of airborne mould spores at Orebro. Acta Allergol. 1:111-113, 1948. Nilsby, J.: Allergy to moulds in Sweden. Acta Allergol. 2:57-90, 1949. Ripe, E.: Mould allergy. I. An investigation of the airborne fungal spores in Stockholm, Sweden. Acta Allergol. 17:130-159, 1963. Ripe, E.: Mould allergy. IV. A study of mould allergy in the respiratory tract. Acta Allergol. 21:370-413, 1966. Ripe, E., and Palmstierna, H.: On the purification of allergens. Allergens from airborne moulds. Sci. Tools 9:25, 1962. Ripe, E., and Palmstierna, H.: Extract preparation of moulds. III. Acta Allergol. 18:413-435, 1963.

Switzerland

(Summary Notes) The major airborne allergens are house dust, grass pollens, cedar pollen, and molds. Source: FUST, B.: Zur aetiologie des asthma bronchiale in der Schweiz. Vortrag im V Internationaler Kongress für Allergologie. Madrid, 1964.

Thailand Thada

Piamphongsant

Geography and Climate Thailand, in southeast Asia, lies between Burma on the west and Laos and Cambodia on the east. Its area is 514,000 square kilometers, and the population is 35 million. Thailand is a tropical country with generally warm and moist climate. The hot season lasts from February to May, and the rainy season from June through October.

Sources of Airborne Allergens Trees. Half the country is covered by forests, mainly hard woods such as teak. Coco palm, mango, acacia, bottle brush, and casuarina are also common. Grasses. Grasses are widespread. The most abundant are Bermuda grass, cogon grass, Manila grass, para grass, Guinea grass, rice, and love grass. Weeds. Although some species of the goosefoot and pigweed families and nut grass are found, they are not thought to be clinically significant. There is no ragweed here. Molds. Mold counts are higher in Bangkok than in the United States. Most common are Alternaria, Cladosporium, and Helminthosporium. Rust is also found frequently. Others identified are Curvu/aria, Fusarium, Spondylocladium, ascospores, and basidiospores.

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Clinical Observations Grass pollen, house dust, and molds are the most important inhalant allergens. Many previously unidentified pollens are now being classified, but their clinical importance is uncertain. Counts of weed and tree pollens are low.

Pollen and M o l d Calendar THAILAND PLANT

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Trees Mango Acacia Peltophorum Coconut Grasses Grass* Rice Weeds Nut grass Pigweed and goosefoot families Molds Alternaria Cladosporium Helminthosporium Stemphylium Fusarium Basidios pores Rusts Smut "Peak pollination occurs in November and December.

REFERENCES Tuchinda, M., and Theptaranon, Y.: Aeroallergens in Bangkok, Thailand. Ann. Allergy 37:47, 1976. Wongsathuaythong, S.: Atmospheric pollens survey in Bangkok. J. Med. Assoc. Thailand 54:897, 1971.

Turkey Kemaf

OzkaragOz

Geography and Climate Turkey, situated at the eastern end of the Mediterranean Sea, has an area of 780,576 square kilometers and a population of 37 million. Five percent of its land is in Europe, the rest in Asia. Turkey's landscape is dominated by rugged mountains, and the mean altitude is over 1,000 meters. There are seven geographic regions: Marmara (the most urbanized), Aegean area, Mediterranean area, Central Anatolia (with the capital, Ankara), the Black Sea coast (the most densely populated), East Anatolia (the least populous), and Southeastern Anatolia. Climatic conditions vary with the geographic location of the region. The coastal areas have a Mediterranean climate, while the interior has cold winters. Allergy studies in Turkey have been carried on most intensively in Central Anatolia because Hacettepe Medical School is located in Ankara. This region will be presented in detail. Central Anatolia is a plateau, with an altitude of about 1,000 meters, surrounded by mountains. The climate is continental, with four seasons: a short spring, a long summer, fall, and a short winter. Sources of Airborne Allergens (1-3) About 1,000 species of plants are found in the Ankara area, of which 55 are of allergenic importance. The major part of

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the land is covered by steppe vegetation. Wheat is extensively grown here. Trees. The forests that existed in ancient times have disappeared. The most common trees now are the white willow, black poplar, sycamore, black pine, Scotch fir, oak, elm, and sumac. Grasses. Many species are found here; the most common are bluegrass, perennial rye, orchard, Bermuda, feather, fescue, goat, foxtail, timothy, and beard grass. Weeds. Most important are English and common plantain; sheep sorrel, yellow dock, and water dock of the knotweed family; the goosefoot and pigweed families (lamb's quarters, Jerusalem oak, rough pigweed, saltbush), and the cattail family. There is no ragweed. Molds. In order of frequency of isolation, the molds found are Pénicillium, Rhizopus, Mucor, Monilia, Aspergillus, Pullularia, Alternaria, Cladosporium, Helminthosporium, Mycelia, Curvularia, Spicaria, Macrosporium, and Hormiscium. Clinical Observations

Allergic disease is a serious problem in Turkey, as it is in other parts of the world. Two independent studies have shown the incidence of allergy among children to be between 10 and 20 percent (4, 5). Most frequently observed are asthmatic bronchitis, perennial allergic rhinitis, and frequent upper respiratory disease. The most important inhalant allergen is house dust (6). Among pollens, that of grass is most important, followed by weeds and trees. Mold allergy is of secondary importance. Purely seasonal allergy (pollinosis) is rare, less than 0.5 percent, probably because of the absence of ragweed. Food allergy is not common (7), but urticaria from food coloring occurs frequently (8). Sensitization to animal danders is common since many families keep pets, especially cats. The incidence of drug allergy is also increasing. Most drugs can be obtained without prescription. Turkey is becoming increasingly industrialized, and air pollution is increasing. In Ankara and other cities chimney smoke is an irritant, especially in the winter (9).

Turkey

153 Pollen Calendar TURKEY

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REFERENCES 1 2 3 4 5 6

Karamanoglu, K., and Özkaragöz, K.: A preliminary report on the allergenic plants of Ankara. Ann. Allergy 25:23, 1967. Özkaragöz, K.: A study of air borne fungi in Ankara area in 196.6. Acta Allergol. 24:147, 1969. Özkaragöz, K.: Pollen and mold spore count of Ankara; statistical report of the pollen and mold. Edited by Melvin Karan. Committee of the American Academy of Allergy, 1965-1971. Özkaragöz, K.; Pirnar, A.; and Karadeli, F.: The incidence of allergic diseases in a pediatric practice in Turkey. Turkish J. Pediat. 5:155, 1963. Özkaragöz, K., and Cakin, F.: Atopic children in Turkey. Ann. Allergy 27:13, 1969. Özkaragöz, K.: Pollens, mold spores and other inhalants as etiologic agents of respiratory allergy in the central part of Turkey. J. Allergy 40:21, 1967.

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Gögus, S.; Saraglar, Y.; and Özkaragöz, K.: Food as an allergen in the etiology of bronchial asthma of children in Turkey. Turkish J. Pediat. 11:181. 1969. 8 Özkaragöz, K.: Les problèmes alimentaires des enfants allergiques et l'état actuel de l'allergie alimentaire. Rapports du seminaire sur le Nutrition de l'Enfant. Istanbul, 21 Oct. 1968. 9 Özkaragöz, K.: Management of the allergie child in Turkey. Turkish J. Pediat. 7:90, 1965. 10 Özkaragöz, K., and Saraclar, Y.: Studies in antihistamines with Schultz-Dale apparatus. Hacettepe Bull. Med./Surg. 4:25, 1971.

United States of America Walter W. Y. Chang Alexander Roth

Geography and Climate (1) The United States is a federal republic composed of 50 states. The continental part of the United States stretches between the Atlantic and Pacific oceans, and is bounded on the north by Canada, and on the south by Mexico and the Gulf of Mexico. This block of 48 states forms a broad belt across the North American continent. Alaska, the 49th state, occupies the northwestern end of the North American continent, and is separated by 800 kilometers from the rest of the nation. Hawaii, the 50th state, lies 3,800 kilometers southwest of San Francisco. The total area of the country is 9,363,123 square kilometers, and the population is 210 million. Crossing the country from east to west, there is first a coastal plain, then the eastern highland (Appalachian Highlands) which is roughly parallel to the Atlantic coast, the interior plain, and a vast, rugged western highland with high mountains, covering a third of the country. There is wide diversity of climate in the United States. Five climatic areas can be roughly defined: the humid eastern region, the humid Pacific Northwest, the dry western region, the western mountain region, and a transitional subhumid, semiarid region between the humid East and the Rocky Mountains.

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Sources of Airborne Allergens (2-6) Trees. The most important trees allergenically, are members of the birch family (birch, alder, hazel), the beech family (beech, oak), the elm family (elm, hackberry), the mulberries, the walnut-hickory family, the willow-poplar family, the maple family, and the olive family (ash). Grasses. Of 1,100 species of grasses, only a handful are responsible for the majority of hay fever symptoms. The most important are bluegrass, timothy, Bermuda, orchard, redtop, sweet vernal, and velvet grass. Weeds. The most important allergenic plants in the United States are weeds, most particularly the ragweeds (short, giant, western, southern, slender, and false ragweeds). Other weeds that cause allergic reactions are burweed marsh elder, rough marsh elder, and cocklebur of the marsh elder family; wormwoods and sages (tansy family); and spiny pigweed, Russian thistle, firebush, and sugar beet (goosefoot and pigweed families). Molds. Clinically, the most important fungi are Mucor and Rhizopus in the class Zygomycetes, Chaetomium in the class Ascomycetes, and the Fungi Imperfecti Aspergillus, Monilia, Pénicillium, Alternaria, Cladosporium, Helminthosporium, Stemphylium, and Fusarium. Basidiomycetes have recently been shown to cause allergic symptoms (4). Alternaria and Cladosporium are especially prevalent in the East and the Midwest; 58 percent of the molds isolated over a 4-year period in New York were of these two genera (5). More recently, colony counts in such widely separated areas as Miami, Tacoma, Pittsburgh, and San Antonio showed Cladosporium to be the most frequently cultured fungus, followed by Pullularia, nonsporulating white fungi, Pénicillium, Alternaria, and yeast (7). Clinical Observations The incidence of hay fever in the United States appears to be higher than in other countries from which statistics are available (8) and it is believed that the wide distribution of ragweed is responsible. Pollen and mold levels are monitored in many different parts of the country, and the results are published annually by the Pollen and Mold Committee of the

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American Academy of Allergy (6). Because of the importance of ragweed, many newspapers publish daily ragweed pollen counts in the fall. There are several hundred practicing allergists in the United States, and most of them belong to one of the four national, or the many regional or local allergy societies. A conjoint board in allergy and immunology came into being in 1974, and the study of allergy is actively supported by the Allergy Foundation of America. Urbanization, industrialization, and fuel consumption combine to make atmospheric pollution a major problem in the United States. With only 6 percent of the world's population, 48 percent of all automobiles are operated here, and 55 percent of the world's gasoline is used in the United States. Motor vehicles account for 60 percent of the total air pollutants, industrial plants for 16 percent, and power plants for 14 percent. Increase in the sulfur dioxide content of the air has been linked with higher mortality rates from respiratory illness in Donora (Pennsylvania), and New York. In the United States, New York City, Chicago, and Philadelphia have the highest yearly average of sulfur dioxide pollution, and New York City, Los Angeles, and Philadelphia have the highest concentration of nitrogen dioxide in the atmosphere.

Pollen Calendar NORTHEASTERN UNITED STATES* PLANT

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Goosefoot and pigweed familiest Marsh eldert Plantain

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Ragweed Russian thistlet

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"States included in this region are California, Oregon, and Washington. tMost important, particularly in Washington, are Russian thistle and firebush.

REFERENCES 1 2 3 4 5 6 7 8

Encyclopedia Britannica, 15th ed., s.v. "United States." Samter, M., and Durham, 0 . C.: Regional allergy of the United States, Canada, Mexico, and Cuba. Springfield, III.: Thomas, 1955. Sheldon, J. M.; Lovell, R.G.; and Mathews, K. P.: A Manual of Clinical Allergy. 2nd ed. Philadelphia: Saunders, 1967. Herxheimer, H.; Hyde, H. A.; and Williams, D. A.; Allergic asthma caused by basidiospores. Lancet 2:131, 1969. Four-year mold survey, plate exposure 1969-1972. Center Laboratories, Port Washington, N.Y. Statistical report of the pollen and mold committee of the American Academy of Allergy, 1974. Sorenson; W. G.; Bulmer, G. S.; and Criep, L. H.: Airborne fungi from five sites in the continental United States and Puerto Rico. Ann. Allergy 33:131, 1974. Smith, J. M.: Incidence of atopic disease. Med. Clin. N. A. 58:3, Jan. 1974.

Venezuela Ramon

Rangel

Geography and Climate Venezuela lies in the extreme north of Latin America. It has an area of 912,050 square kilometers and a population of 11 million. There are four regions: the Maracaibo lowlands, the northern highlands, the Orinoco plains, and the Guiana highlands. The climate varies according to the altitude. With the exception of Maracaibo, most cities have springlike weather all year. There are two well-defined seasons: a hot, rainy season from March to September, and a cool, dry season from September to March. Sources of Airborne Allergens Trees. Fifty percent of the country is covered by forests, most of them tropical. In the hot areas grow most of the large trees, for example ceiba, gum tree, mora de Guayana, and monkeypod, but also mango, mesquite, acacia, and most of the palms. Grasses. Wild grasses cover wide areas of the country. Important species are Bermuda, orchard, velvet, love grass, paspalum, perennial rye, timothy, molasses grass, and bent grass. Weeds. As in other tropical countries, weed pollen is not an important factor. The goosefoot and pigweed families are represented, also plantain and sagebrush.

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Molds. The following molds have been identified in Caracas: Pénicillium, Mycelia sterila, Aspergillus, Monilia sitophila, Cladosporium, Pullularia, and Streptomyces. In Maracaibo the following predominate: Aspergillus, Monilia sitophila, Pénicillium, Micelia sterila, Cladosporium, Helminsthosporium, Curvularia, and Paecilomyces. Clinical Observations The most common allergic illnesses of the population are bronchial asthma, allergic rhinitis, conjunctivitis, urticaria, and contact dermatitis. The main allergens, in order of their importance, are house dust, molds, grass pollen, and tree pollen. Pollinosis is rare. Air pollution is not a serious problem. REFERENCES Casas Rincón, G.: Contribución al estudio de AspergiHus y aspergilosis. Kasmera 4:107, 1972. Ewel, John J., and Madriz, Arnaldo.: Zonas de vida de Venezuela. Ministerio de Agricultura y Cría, República de Venezuela, 1968. Hurtado, I., and Medina, E.: Alergenos aereos en la aerea metropolitana de Caracas. Arch. Venezolano Pueric. Pediat. 25 (86-87):124, 1962. Mendez, Romero H, and Casas Rincón, G.: Estudios de los hongos atmosféricos de la ciudad de Maracaibo, Venezuela. Kasmera 3:89, 1968. Montemayor, L., and de Meza Caglianone, D.: Observaciones de micologia alergógena. Estudio Sistemático de la flora micològica alergógena de Caracas. Datos estadísticos. Acta Médica Venezolana 10 (5-6): 103, 1962. Pittier, H.: Manual de las Plantas usuales de Venezuela 1926. Fondación Eugenio Mendoza, 2nd printing, 1971. Caracas, Venezuela: Talleres Gráficos Ariel., S.A. Serrano, Helman: Aeroalergenos y alergia respiratoria. Doctoral thesis, Universidad Nacional del Zulia, Maracaibo, Venezuela, 1972.

Yugoslavia Iva

Vo/aric-Mrs/6

Geography and Climate The Socialist Federal Republic of Yugoslavia is situated on the Adriatic Sea. It has an area of 255,800 square kilometers and a population of 21 million. There are three main regions: the coastal plain, the mountains, and the inland river valley formed by the Danube and its tributaries. The Adriatic coast has a mild and sunny climate, w i t h rain falling mainly in the spring and fall. The mountains have a continental climate, while the Danube valley is humid throughout the year.

Sources of Airborne Allergens Trees. Pines are widespread, especially the black pine. There are several species of willows, and poplars. Of the birch family, birch, hornbeam, ironwood, and hazel are present. The oaks are represented by the sessile, the pedunculated, and the sylvatic oaks. The sycamore or plane tree is used for ornamental plantings in the towns. Members of the walnut-hickory family and maples are abundant in parks, and linden, elm, wild cherry, ash, and elderberry are also seen. Grasses. The following grasses are c o m m o n : orchard, blue, fescue, rye, velvet, redtop, foxtail, t i m o t h y , sweet vernal, Bermuda, and Johnson grass. Weeds. A wide variety of weeds are found. The most im-

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portant are hemp, pellitory, dock, members of the goosefoot and pigweed families, ragweed, plantain, and the castor bean. Burning bush, saltbush, and cocklebur are of lesser importance. Molds. Molds are most prevalent during the summer months. Counts carried out in Hvara show the total mold count exceeding the total pollen count during July, August, September, and October. Clinical Observations A study of 100 patients with allergy showed that 93 had rhinitis, 63 conjunctivitis, and 37 asthma. The most important allergens were grasses. In patients sensitive to tree pollens, the most frequent reactions were to elderberry, linden, hazel, and birch, while 38 patients were sensitive to ragweed. It appeared that many cases of asthma were not caused by inhalant allergens. The importance of molds in Yugoslavia remains to be investigated.

REFERENCES Horvati6, S.: TipoloSko raSCIanjenje primorske vegetacije gariga i borovih Suma. [Typological analysis of the littoral vegetation in pine forests and burned-over areas.] Acta Botanic Croatica 17:7, 1958. Mimica, M., Babi6, D., and Volari6-Mr5i6, I.: Polenoza. [Pollenosis.] Lijec. Vjesn. 85:497, 1963. Volari6-Mr§i6, I.: The study of pollen in the air of Zagreb. Acta Allergol. (Kbh) 15:43, 1960. Volari6-Mr§i6, I., Mimica, M., and Maljevac, I.: AerobioloSka ispitivanja u Zagrebu i na otoku Rabu. [Aerobiological investigations in Zagreb and on the island of Rab.] Rad. Med. Fak. Zagrebu 10:39, 1962. Volari6-Mr5i6, I., and Dujmovi6, Z.: Prva istraiivanja peludi i spora u aeroplanktonu Hvara. [First studies of pollens and spores in the aeroplankton of Hvar.] Jugoslovenska Akademija Znanosti i Umjetnosti, 95 pp. 1968.

Pollen Calendar YUGOSLAVIA Z f l n 5 i r f Z _ i Ç J T

Trees Birch Alder Hazel Elm Beech Maple Elderberry Linden Grasses Weeds Hemp Pellitory Dock Goosefoot Saltbush Burning bush Sage Cocklebur Castor bean Plantain

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