Interactive effects of allergens and air pollution on respiratory health: A systematic review

BACKGROUND: Studies have demonstrated an adverse role of outdoor allergens on respiratory symptoms. It is unknown whether this effect is independent or synergistic of outdoor air pollutants. METHODS: We systematically reviewed all epidemiological studies that examined interaction effects between counts of outdoor airborne allergens (pollen, fungal spores) and air pollutants, on any respiratory health outcome in children and adults. We searched the MEDLINE, EMBASE and Scopus databases. Each study was summarized qualitatively and assessed for quality and risk of bias (International Prospective Register for Systematic Reviews, registration number CRD42020162571). RESULTS: Thirty-five studies were identified (15 timeseries, eight case-crossovers, 11 panels and one cohort study), of which 12 reported a significant statistical interaction between an allergen and air pollutant. Eight interactions were related to asthma outcomes, including one on lung function measures and wheeze, three to medical consultations for pollinosis and one to allergic symptoms (nasal, ocular or bronchial). There was no consensus as to which allergen or air pollutant is more likely to interact. No study investigated whether interactions are stronger in atopic individuals. CONCLUSION: Despite strong evidence from small experimental studies in humans, only a third of studies identified significant allergen-pollutant interactions using common epidemiological study designs. Exposure misclassification, failure to examine subgroups at risk, inadequate statistical power or absence of population-level effects are possible explanations.