Background

Every year, seasonal pollen allergies affect the health of millions of individuals around the world, causing many disruptive symptoms that harm their daily life. The main contributor to seasonal allergic reactions is airborne pollen, produced by different types of trees, grass, and weeds. The most allergenic of these comes from the Ambrosia species, more commonly known as ragweed. Ragweed is particularly allergenic due to its ability to produce large amounts of pollen per plant, the highly allergenic particles that make up its pollen grains, and its ability to thrive in the loose soils of urban environments. In addition, ragweed is an invasive species to most parts of Europe and Australia, making ragweed allergies more common in these places (Montagnani et al., 2017).

1.1 Seasonal Allergies are Serious and Increasing

Seasonal allergies can cause general symptoms such as inflammation, watery eyes, runny nose, sneezing, and coughing, but can also be diagnosed in more severe cases like hay fever and/or asthma. As of 2016, it is estimated that 10–30% of the global population is affected by hay fever and 300 million people are affected by asthma (Pawankar et al., 2011). Asthma is the most serious in Europe, with 14 EU countries in the world’s top 20 for asthma in adults, costing approximately more than €72.2 billion every year (Walker et al., 2016). Allergy symptoms are serious, and trends in data suggest that the prevalence of asthma and hay fever are rising every year. For example, France’s Rhône-Alpes Center of Epidemiology and Health Prevention shows that hay fever prevalence rose from 8% of the local population in 2004 to 12% in 2015 (Schmidt, 2016). This increased occurrence is exacerbated by the quick spread of allergenic plants across the globe.

1.2 Ragweed is a Leading Pollen Allergen

Allergenic pollen comes from many species, with the most common groups being trees, grasses, and weeds. They grow in different seasons, producing pollen from early spring to late fall. Ragweed is a leading invasive weed that produces pollen mainly in the summer into the fall. It prefers to grow in unoccupied or freshly mown ground. Therefore, it favors human-touched lands such as gardens, building sites, cultivated fields, and along roadways. It can produce up to six thousand seeds per plant, which are easily spread by human activities such as farming, gardening, moving soil, and vehicle use (Taramarcaz et al., 2005). In addition, ragweed produces pollen at much higher levels than most plants, at up to a billion grains per plant per season. The allergenic factors of pollen are also much more potent in ragweed than other types of pollen (Montagnani et al., 2017). It only takes 10 grains of ragweed pollen per cubic meter of air to trigger an allergic reaction (Chen et al., 2018). These characteristics contribute to ragweed pollen’s ability to produce a severe immune response. This also makes it one of the greatest species of interest when discussing pollen allergies and bio-pollutants, especially considering its recent spread across continents.

2.1.3 Global Spread of Ragweed

While ragweed is native to North America, it has spread to every continent, invading most of Europe, China, and subtropical regions of Australia (Taramarcaz et al., 2005). Figure 1 below shows the current global ragweed status, with the invaded countries shown in red.

https://drive.google.com/file/d/1aCtooE7OccRr4LczVyrN4wh4cXKqjlgw/view?usp=sharing

Figure 1: Global distribution of Ambrosia artemisiifolia, L. species (ragweed) (Montagnani et al., 2017).

Ragweed spread has mostly affected Europe, where the highly allergenic variety of the plant became widely distributed throughout Europe after World War I through American shipments of food supplies (Hufnagel et al., 2015). Ragweed’s extremely high level of pollen production allows it to spread easily within a region upon its introduction. The large-scale spread of allergenic ragweed is mostly attributed to human factors, such as contamination of feedlots and bird seed. It is also susceptible to quick local spread caused by wind (Montagnani et al., 2017).

In the last 30 years, ragweed has been spreading further, reaching Sweden and the Baltic regions, and covering 90% of the Rhone valley travelling from France to Hungary (Taramarcaz et al., 2005). It continues to spread eastward, now covering nearly every Eastern European country. Many countries in Europe are making efforts to understand and manage the spread of ragweed, as well as informing the public about personal health effects they may experience from this issue.

The global spread of ragweed is increasing rapidly and can be attributed to several factors that affect the pollen levels in an urban environment. It is important to understand the relationships between these factors, ragweed pollen and allergy symptoms, as well as how awareness and treatment of symptoms can impact allergy patients of urban environments.

There are many factors that may affect pollen distribution and allergies. In this project, our main focus is on environmental factors such as city upkeep, climate change, and elements of lifestyle. These factors are key to understanding how a city’s aerobiology will change and how it will impact the population.

2.2.1 The Effects of Urban Maintenance and Land Usage

Cities have been studying the spread of invasive species for decades. The city provides a unique environment for plants to grow that favors some species over others. Neophytes, a category of plants which includes invasive species like ragweed, are some of the best suited plants in the city landscape. Conditions that benefit neophytes are loosely packed soil, warmer air, and lack of competition. Areas where the land has been disturbed and the sun shines are ideal growth spots for these invasive species (Deutschewitz et al., 2003). Another key feature is the interconnected pollen network that one may not anticipate in the urban environment. Using mapping techniques to find proximity to areas that support growth in Hungary, it was found that 65% of the growing space in Debrecen could be traveled by pollen and was therefore biologically connected. While a connection like this helps the many plants native to the environment maintain their diversity, it can also lead to invasive species overrunning the local species and spreading uncontrollably.

https://drive.google.com/file/d/1PHTn8R6TKJjPA7Md3rNIvVKDjQ7gR9TY/view?usp=sharing

Figure 2: Pollen network of Debrecen (Hüse et al., 2016).

Figure 2 demonstrates the pollen network of Debrecen, Hungary, where the green space represents areas that plants can grow. The interconnectivity of these spaces is key in understanding how seemingly small changes can proliferate through the environment (Hüse et al., 2016). Empty urban lots provide an abundance of land for these non-native species to grow in. Non-native plants in Canada have been found to thrive in what is known as “medium” urban environments, found by algorithmically analyzing satellite images. These medium environments do not include downtown areas, nor the suburbs, but represent the in-between level of urbanization. The invasive weeds are able to grow in empty lots without competition from larger plants and are given plenty of sun to quickly establish a homogenous culture. Other studies also confirm that the downtown area of the cities generally have lower pollen counts than their surroundings (Blouin et al., 2019). Like empty lots, abandoned urban structures and undeveloped areas also present a ripe opportunity for pollen species to take advantage of the unmaintained land and spread into these areas (Cariñanos & Casares-Porcel, 2011).

The usage of city space has many effects on pollen and the symptoms it produces in allergic individuals. Urban green spaces are a critical part of city planning and design, providing a break from the otherwise uninterrupted landscape of unnatural structures. These amenities are not only considered important to the mental health of citizens, but can also provide some of the answers to reducing the symptoms of allergens if developed properly (Cariñanos & Casares-Porcel, 2011). Parks produce a large amount of their own native pollen but with good maintenance, they will produce lower levels of invasive pollen. The diverse pollen profile of a well built and maintained park reduces severe pollen allergies and helps filter the polluted city air. It can also increase the environment's biodiversity by spreading its seeds beyond the park’s edges. Some sources claim that up to 30% of harmful allergenic pollen could be eliminated by a green space. Great care and commitment must accompany these parks, which are otherwise at risk of being overrun by a single species, similar to other abandoned city features. Those responsible for planting the park must take great care in selecting robust, native, low pollen producing, and diverse plants to ensure that it will have a positive impact on the public. Suggestions can even go as far as to say that the genders of the plants should be selected to have more female plants that do not produce pollen (Cariñanos & Casares-Porcel, 2011). By artificially adding a strong and native plant population back into a city, the biological network that connects the arable land of the city would allow biodiversity to spread back through the city (Hüse et al., 2016). Similarly, urban wastelands can also be maintained with native plants and utilized against invasive species (Montagnani et al., 2017). The continued financial and manpower commitment of a city is vital to employing these solutions, though they offer ways to restore some balance to the pollen levels of a city.

2.2.2 The Effects of the Climate

Ambrosia season begins in late summer to early fall, and ends by the date of the first frost. Milder winters and warmer seasonal temperatures lengthen the frost-free period, leading to an earlier and longer ragweed season duration. Using simple regressions for data collected in 1995-2009, researchers have determined that the increase in duration of the ragweed pollen season correlates with latitude in North America. For latitudes above ~44^oN, the season increases as much as 13-27 days in 2009 compared to 1995. This is consistent with findings from the Intergovernmental Panel on Climate Change (IPCC), stating that global warming is affecting seasonal temperature and duration, thus, impacting aeroallergen seasons (Ziska et al., 2010).

Natural phenomenons such as thunderstorms and heavy rains, possibly increasing due to global warming, also exacerbate the symptoms of pollen allergies. A severe storm in Australia in 2016 caused 10 allergic-asthma deaths and approximately 9000 people were hospitalized. It was proven that during the storm, pollens (grass and mold in this case) were brought to ground level, rainwater penetrated the pollen shell and released fine allergenic granules that could access the lower airways. Even those without asthma can experience bronchoconstriction due to such events (D’Amato et al., 2018).

The combination of climate change and urbanization also worsens the situation and introduces more environmental risk to human health. In urban areas, emissions from the increasing use of vehicles and factories, combined with the “urban heat island” effect, add to the rise in temperature and the greenhouse effect. Air pollutants and dust caused by urbanization enter the human body through the airways and damage the inner membranes of organs. This triggers the immune system, thus making it more sensitive to allergenic pollen. Air pollutants contain nitrogen oxide gases, particulate matters (PM), and ozone, which cause inflammation in the lungs and create allergies or bronchial asthma. PM_2.5, PM₁₀ , and NO₂ are confirmed to have a long term impact on mortality and morbidity due to increased risk in cardiovascular and respiratory diseases (Sanyal et al., 2018). Since people are consuming more energy sources and emitting more gas and fuel from vehicles, air pollution is increasing. As a result, respiratory allergy and asthma is also increasing, more in urban than rural areas. Health problems are especially significant during the time of this project, as the COVID-19 pandemic is causing serious respiratory concerns and the need to address such issues has become much more evident.

In the United States, children living near major roads have increased risk of respiratory disease, as well as deficits in lung function. A study done on 5277 children in Southern California showed that children living within 500m of a major freeway are 10 times more likely to develop pollen related rhinitis if they are already sensitized to at least one pollen group. This study, among others in the US, linked air pollutants to the development and exacerbation of respiratory diseases (Zhou et al., 2018).

In addition, global warming and climate change worsen the situation because they cause changes in the concentration and distribution of gases, as well as lengthening the seasons when allergenic pollens are the most prevalent (D’Amato et al., 2010). A study in Mongolia supported the theory that urbanization does in fact correlate with the rise in respiratory diseases (Nicolaou et al., 2005). Not only that, pollution also increases the allergenic potential of pollen and the growth of some plants, including Ambrosia (Chirilă & Florescu, 1990).

2.2.3 The Effects of Lifestyle

Although climate plays a large role in the rise of pollen and, in turn, pollen allergies, it is not the only factor that contributes to this global problem. As the most dominant species in the world, humans can greatly affect the environment, and our lifestyle remarkably influences the pollen concentration and allergies. Lifestyle umbrellas many categories: behaviors that affect the climate, exposure to pollen and other allergens, and attitudes towards healthcare. These factors collectively contribute to the complexity of pollen-related issues.

Since 1990, the number of allergy patients have drastically increased. Many attribute this to the growing lifestyle of staying indoors, leading to the development of different forms of allergies. Being indoor for the majority of their activities leads children to have increased sensitization to the indoor allergens such as dust mites and fungi spores. Additionally, children in the United States spend a lot of time indoors in front of a screen and consume a diet of more processed food. These habits decrease physical activity and encourage obesity, which is linked to asthma (Platts-Mills, 2016).

a. Behaviors that affect the climate

Cities are expanding and there is a growing need to travel further and more frequently. As a result, people are choosing cars as their main means of transportation, especially in big metropolitan cities. Automobiles offer great benefits, especially convenience and efficiency. However, when more vehicles are used, more air pollutants are being emitted to the environment. Gas emission accounts for 23% of the total energy-related carbon dioxide equivalent emissions (IPCC, 2014) and doubled from 4.9% to 8.6% of the total Greenhouse gas emission (World Bank & World Development Indicators, 2018). By adding more pollutants to the environment, we are increasing our risk of having respiratory diseases (Te & Lianghua, 2019).

b. Exposure to pollen and other allergens

Exposure to pollen and other allergens correlates with the likelihood of having a respiratory disease. Exposure can happen through many sources, including environmental exposure, both indoor and outdoor, and diet/hygiene (Gilles et al., 2018). Figure 3 below summarizes how different environmental factors interact to contribute to human health.

https://drive.google.com/file/d/1Jpk10NQSjyNhdNWodOQOdgggb6Uj7r3S/view?usp=sharing

Figure 3: Anthropogenic environmental factors (Gilles et al., 2018)

Environmental Exposure: Both Indoor and Outdoor

A study done in Melbourne, Australia showed that infants have a higher chance of having aeroallergen sensitization, asthma, and hay fever when they are exposed to ambient levels of pollen in the first 6 months after birth. Even though these babies are high-risk subjects, it links high pollen concentration to sensitization and poses a possibility of a solution to lower the risk of contracting these diseases with early intervention (Erbas et al., 2012).

That being said, exposure to the environment should not be completely inhibited. Studies have indicated that rural environments provide exposure to beneficial aerosols. Cowshed dust, for example, produces an immune modulatory that is good for the immune system. People living near a traditional farm are less likely to develop allergic responses (Gilles et al., 2018). Similarly, in Europe, the risk of asthma is lowest in the rural farming community, and living close to well-controlled livestock is also associated with a better immune system (Nicolaou et al., 2005). Therefore, being exposed to natural immunological stimulants during childhood may help build immunity to pollen allergies.

Not only the outdoor environment, but the condition of one’s own inhabiting space can also negatively affect respiratory health. In South Asia, a study shows that children are more susceptible to wheeze (28.7% vs 12.5%) when they live in an old-fashioned and congested city (Gilles et al., 2018). In Bucharest, humidity and ventilation were found to be the main cause of respiratory allergies. Apartments with higher levels of humidity and insufficient ventilation had more pathogenic fungi spores, increasing the likelihood of contracting bronchial asthma (Chirilă & Florescu, 1990). In the US, many attribute the increasing number of allergy patients to the growing habit of staying indoor that leads to the sensitization of different forms of indoor allergens, such as dust mites and fungi spores (Platts-Mills, 2016).

Diet and Physical Health

Not only the exterior environment, but what happens inside our own body can also affect allergy development. A person’s microbiome is dependent on their diet and dictates his or her immune system, which is linked to the resistance to having an allergy. In rural areas, studies are being done suggesting that using unpasteurized milk and increasing endotoxin exposure can cause the body to produce more proteins that benefit the immune system (Nicolaou et al., 2005). In westernized societies, lifestyle can be overly protective, as children have little exposure to farm animals, less food diversity, more processed food, and less contact with siblings or peers because of increased time being indoors. This lifestyle lowers the immune system and can lead to future hypersensitivity to particles such as allergens (Gilles et al., 2018).

Atopic Dermatitis (AD), also known as eczema, is a common allergic disease among the US population. Heat, sweat, body pain, sleep deprivation, fatigue, and depression make exercising challenging and cause a decrease in physical activities in AD patients, making them susceptible to many health risks (Silverberg et al., 2016). Adults with eczema who have decreased physical activity, smoke and consume alcohol are at higher risk of developing cardiovascular and cerebrovascular diseases (Silverberg, 2015). They are also more likely to have a higher body mass index (BMI) and are at a higher risk of obesity, hypertension, diabetes, and high cholesterol, especially those who also experience fatigue or insomnia (Silverberg et al., 2015). Even though the risk of developing a cardiovascular disease is low, children with asthma and hay fever have a higher chance of obesity and vice versa (Silverberg, 2016).

Exposure to the environment and choosing a balanced and hygienic diet is crucial to maintaining a good immune system, therefore decreasing the likelihood of developing an allergy. However, not all air particles and food options are beneficial to human health, thus, a good overall knowledge about these factors is needed to fully understand how to best build up the immune system.

c. Attitudes towards healthcare

When having an allergic disease, perspective towards disease management is an important factor in the extent and severity of the symptoms. A study was done in Australia to determine the perspectives of 47 adult allergic rhinitis patients on disease management. It shows that patients are usually confident in their ability to control the disease themselves. They often seek over-the-counter treatments and delay or avoid seeking help from professional health care providers. They reported feeling fatigued and uncomfortable in their daily lives. However, the financial burden and being mistaken for having an infectious disease discourages them from going to a clinic. The combination of blind self-confidence and financial obstacles makes many patients opt for self-treatment, which can have a negative effect on the disease if done incorrectly. Inappropriate treatment at the onset of allergies can lead to future diagnosis of a more severe form of respiratory disease (Cvetkovski et al, 2018).

Pollen allergies have become a global issue. Many countries across the globe have begun studying pollen and its relationship to climate change, air pollutants, and lifestyle, in order to take preventative measures and develop better methods for dealing with the increase in the pollen production and allergies. This helps us understand what the implications of similar data in Bucharest may be.

2.3.1 Efforts in Croatia

In the South-East region of Europe, a study in Croatia studied the correlation between pollen levels and ragweed sensitization. The data they gathered is summarized in Table 1 below.

https://drive.google.com/file/d/1bWPcwiNqqQYvO9vXf8tTB9mTPGAUfdCs/view?usp=sharing

Table 1: Ragweed pollen levels and children sensitized

The results of this study showed that high levels of pollen in the atmosphere correlates with ragweed sensitization, associated with allergic response, rhinitis, and asthma, for children 2-13 years old. It suggested that ragweed control is the best approach to reduce this risk (Agnew et al., 2018).

A year later, the same group in Croatia performed a follow-up study to examine the severity of allergies in children. Their parents were asked to record the children’s symptoms and medications each day over 306 days. The time span was enough to account for 3 pollen seasons. Children were the focus of this study because they often carry allergy symptoms into adulthood, and have less complex medical histories. The surveys were completed for 85 children for a total of over 10,000 entries. Survey questions asked the parents for their location, daily weather, observed air pollution, and household conditions. The answers to the survey were matched with daily pollen counts based on their locations. The results from these surveys were used to determine the threshold pollen level that would cause these children to exhibit symptoms. The three main symptoms caused by ragweed pollen were examined separately. Eye symptoms proved to be the most immediate response to pollen, followed by nasal, then bronchial symptoms. More specifically, it took four days for children to exhibit watery, irritated eyes after pollen counts reached symptom-causing amounts. Their results also showed that if the children took preventative medication one day before their symptoms were supposed to start, it highly reduced the effect that those symptoms had on their body (Jones et al., 2019). This important information can help people treat their symptoms earlier if they are able to understand how the current pollen count affects the start of their symptoms. This information is helpful in drawing conclusions about symptoms in Bucharest and aid in developing information about personal symptom management.

2.3.2 Advancements in Western Europe

In another study, a group of researchers from across all of Europe came together to analyze pollen count data from 66 stations over 16 years (1995-2010) to examine a multitude of variables: start, end and duration of the ragweed pollen season, maximum daily pollen count, first frost, last frost, and number of days in the frost-free period. These variables were all compared to their geographical coordinates. This data found three highly infected areas: the Pannonian Plain (encompassing much of Romania), Western Lombardy, and the Rhone-Alps region. The study found that all the variables were longitude dependent because the temperature changes the most over different longitudes. These variables also varied greatly based on altitude because at high altitudes the lack of oxygen stops the growth of plants. There were no significant trends based on latitude because much of Europe’s varying geography with both mountainous and valley regions (Matyasovszky et al., 2018). In this study, there is only one pollen trap located in Romania out of the 66 total pollen traps located near the city of Timișoara in western Romania, about a 7-hour drive from Bucharest. Therefore, the data found in this study gave us no information about how pollen counts vary in Bucharest. However, this data from other areas of Europe was valuable to further focus our studies in Bucharest to analyze the most important information.

A different group of allergists and scientists from The European Commission Cooperation in Science and Technology (COST) came together to try to understand spatial and temporal variations of Ambrosia pollen in Europe in order to develop a strategy to manage invasive species in the future. They compiled 10 years of pollen count data for this study that spanned from 2004 to 2013. Not all 242 pollen traps collected data for the entirety of the 10-year span. Only 143 locations were included because they had 8 or more years of data. Seasons that were missing 7 or more days of pollen trap data during ragweed season were also removed from the data. The study found that the number of days when Ambrosia pollen grains were recorded decreased as distance away from infested areas increased. Figure 4 displays which of the 242 locations in this study showed the highest number of days where ragweed pollen was present (Sikoparija et al., 2016).

https://drive.google.com/file/d/1xV-g9ROdSRLpIJRAd2_lHkMjpSPTiPfi/view?usp=sharing

Figure 4: Map from COST study depicting the number of days Ambrosia pollen was present (Sikoparija et al., 2016)

Similar to the previous study, only one location in Romania was included in this study (although some symbols overlap the country make it appear that there are more). The symbols closest to Romania showed high levels of ragweed pollen, so if the rest of Romania follows this pattern, there may be a serious need for ragweed management. As Sikoparija et al. stated “It is also important to note for several spatially large countries (i.e. Romania, Turkey and Ukraine) pollen-monitoring networks are not dispersed over the entire territory, and so data included in this study are not representative of the entire area of these vast countries” (Sikoparija et al., 2016). So, although this study provided valuable insight about the change in pollen counts over time, we can only use it for comparative purposes in Bucharest.

The availability of pollen information in Western European cities is very high. Pollen levels and forecasts are published daily to a central website produced by the European Aeroallergen Network. The data is gathered so that maps of Western Europe’s pollen levels during particular seasons can be viewed, as well as predictions of how bad symptoms will be, which is affected by other factors as well. The predictions are based on 10-15 years of data from over 300 collectors. The website also hosts an app, allowing a European allergy patients to be conveniently informed at all times during the allergy season (Pollen Info., 2020). All of this information being available to the public allows allergy patients to make decisions that will help mitigate their suffering during the pollen seasons.

2.3.3 Personalized pollen forecast

Allergic rhinitis is also a prevalent disease in Germany and Austria. In order to tackle this problem, especially when the symptoms of each person vary and are dependent on the concentration and level of exposure, people are in the process of creating a personalized pollen-related data service. Using data similar to that shown in Figure 5 below, the service categorizes sensitivity, identifies different types of pollen, and forecasts the symptoms, designed to fit the profile of each individual.

https://drive.google.com/file/d/17sFrwoB9CPuIJ7ZIdgyhKwwRJQ3pM_Za/view?usp=sharing

Figure 5: Symptoms profile showing symptoms are most prevalent in late spring and summer (Berger et al., 2013)

The data are collected from Patient’s Hay-fever Diary (PHD), pollen concentration data around Europe from the European Aeroallergen Network (EAN) database (ean.polleninfo.eu), data on air quality and pollen forecasting from SILAM modeling (System for Integrated modeling of Atmospheric composition), and analyzed. It also combines all information using computational intelligence methods (CIMs). The pollen concentration data is updated hourly or bihourly through all stations of the EAN. The amount of information is extremely large, therefore, this project still undergoes development (Berger et al., 2013). This technology would be very helpful to use in our project, however, it requires an extremely large dataset. Bucharest has only been tracking pollen for less than 10 years and the amount of data collected is not enough to draw significant conclusions. In the future, when more data is collected, this technology can be revisited and potentially implemented.

2.3.4 Attempted Elimination of Ragweed in Hungary

The chapter, Why is biocontrol of common ragweed, the most allergenic weed in Eastern Europe, still only a hope?, by Levente Kiss, presents a story of the failure of a biologist attempting to find a solution to the ragweed issue that plagues Eastern Europe. Funguses that are known to target the plant in North America are found in Europe, but Kiss was unsuccessful in getting the European strain to infect ragweed. Based on the data of others, the biologist knew that introducing the North American leaf beetle also had limited success in the practice. Searching for other predators of the plant led to the discovery of a different beetle, Ophraella communa, that seemed to be more successful in diminishing ragweed than the original leaf beetle. The collateral environmental impacts of the beetle were minimal. It shows a heavy preference of ragweed over any other plant, but was reported to cause some damage to sunflower plants when no other food source was given. Just as the Australian government had done in the past, the Hungarian government was strictly opposed to allowing the beetles to be imported. The blocking of the import stunted further investigation into the beetle’s effectiveness, and the European Union, out of fear of introducing a destructive invasive insect, would not fund any research into the matter (Levente, 2007).

A lesson to learn from this failure to reduce the ragweed population in Eastern Europe is a political lesson. While the ragweed is an incredibly irritating plant and causes many people to suffer from its highly allergenic pollen, the European Union, always wary of thoroughly tested innovations, does not believe that importing the beetle is worth the accompanying risks. Whether or not more research could be done to prove the beetle could not survive without ragweed, the message that the European Union sends is clear. The insight of what the European union believed 13 years ago helped steer our suggestions away from introducing any form of biological control agent, especially since the European public is widely opposed to any genetic or biological changes in agriculture that might in the future hurt human or traditional natural processes.

2.3.5 Pollen Allergies in North America

Respiratory allergies have been a major chronic disease in North America since the 1990s (Ziska et al., 2010). Since ragweed originated from this area, it would be helpful to further examine its current research and policy concerning pollen allergies in order to compare this information to what can be seen in Romania today.

In the United States, pollen allergies affect the health of a third of the population and cost the country’s economy approximately $11.2 billion in 2005 (Ziska et al., 2010). Allergy symptoms are usually allergic rhinitis, conjunctivitis and asthma, with allergic rhinitis being the most common. The National Allergy Bureau (NAB) is a section of the American Academy of Allergy Asthma and Immunology Aeroallergen Network (AAAAI) and has been collecting pollen information from 51 pollen stations in the United States and Canada (50 in the US and 1 in Canada) since 2003. Some of the station locations are shown in Figure 6 below:

https://drive.google.com/file/d/1V6VKzkWs736drVufmJl3zi3YpNufnq8x/view?usp=sharing

Figure 6: Locations of the NAB stations in the US (Lo et al., 2019)

These stations use Burkard volumetric air samples for pollen data collection, similar to what Dr. Leru has used in Bucharest. Even though tree pollen such as Quercus (oak) and Cupressac (cedar) are the most abundant, Ambrosia (ragweed) remains in the top five most abundant pollen species present. Ambrosia season in North America begins as early as July and extends to November (Lo et al., 2019). The calendar for Ambrosia pollen measurements at each station are shown in Figure 7 below.

https://drive.google.com/file/d/1iYC-WogJt9yxu7QSVKTkuNWTpH7o4RT3/view?usp=sharing

Figure 7: Ambrosia pollen concentration calendar (Lo et al., 2019)

Pollen allergy and related respiratory diseases have been an issue for North America for a long time. With many people affected, the U.S. has been eagerly searching for mitigation strategies.

2.3.6 Efforts to Protect People in North America

The United States has made attempts to protect the people from seasonal allergic diseases. There have been efforts to control the environment to reduce the symptoms. Doctors need to obtain the patient’s environmental and medical history, and determine which allergens or pollutants they are most affected by. The guidelines for these tests can be found in the reports from the American Academy of Pediatrics. Additionally, for the school environment, the Environmental Protection Agency (EPA) and the Centers for Disease Control and Prevention (CDC) provide online resources on their websites to help families and educators to better control children’s exposure to allergens (Matsui, 2016).

For adults, occupational asthma is a great concern, especially for those who work on job sites, accounting for up to 15% of the disabling asthma cases in the US (Cartier, 1994). There are over 200 organic and inorganic allergens for field workers, such as dust, plants, animals, gases and other chemicals (Chan-Yeung et al., 1994). In order to reduce occupational asthma, the Occupational Safety and Health Administration (OSHA) established some permissible exposure limits for some allergenic materials, such as cobalt, nickel, platinum salts, and isocyanates. However, the majority of the materials that cause asthma are still unregulated (Abramson, 2016).

Using the information gathered from the rest of the world and North America up to this point, knowledge can be extended and compared to Romania. The biological mechanisms and invasion of ragweed is known. The impacts of the factors of climate, pollutants, city upkeep, and other diseases are being studied. The efforts of other countries can be used as examples to learn from and can potentially be applied in Romania.

The pollen network in Romania is complex, consisting of many types of pollen, including tree, grass, and weed pollen. The abundance and allergenicity of each species differ from each other. However, with many pollen species in the air, allergic sufferers, especially those with polysensitization, are heavily affected.

2.4.1 Pollen Network in Romania

In Bucharest, trees produce the first pollen recorded in early spring. Species such as poplar (Salicaceae), cypress (Cupressaceae), elm (Ulmaceae), alder and birch (Betulaceae), and fraxinus (Oleaceae) in March. In April, mulberry (Moraceae), plantanus (Platanaceae), Quercus (Fagaceae), and Pinus (Pinaceae) start to grow. In the summer, grass (Gramineae) starts flowering during May and June. Weed season is more dominant in late summer and fall, abundant species are ragweed (Ambrosia artemisiifolia) and mugwort (Artemisia vulgaris). Among all the species, Ambrosia leads in pollen count and allergenicity. (Leru et al., 2019)

The first recorded observation of ragweed in Romania came from the southern region of Orsova, a Danube river port, in 1908, although the allergenic version native to the US had not yet further distributed. Over a time span of many years, the weed spread to the northwest, west, south and southeast areas of the country. There is now evidence that it has spread to all regions of the country and is especially prevalent in the Southern and Central regions (Florincescu-Gheorghe et al., 2019).

2.4.2 North-West and Central Romania

In northwest and central Romania, allergic rhinitis was more prevalent in the northwest. Severe cases of rhinitis were mostly reported in the Central region and monosensitized patients in the northwest. They also concluded that co-sensitization, meaning sensitization to multiple unrelated pollen groups, likely leads to asthma (Boscan et al., 2019). Once data from a similar study is analyzed in Bucharest, it will provide an interesting comparison to this previous study. It will also contribute to the overall knowledge of pollen allergies in Romania to better inform doctors and patients of the risk factors involved.

2.4.3 Southern Romania

A study of 447 allergic rhinitis patients from the Central Romanian Plain looked at sensitization for Asteraceae weed pollen, common ragweed, and mugwort. The results were that 17.89% of the test subjects were sensitive to at least one weed pollen, ragweed being the main source. As shown in Table 2 below, the allergies were reported to be mostly moderate to severe, and when caused by ragweed, they are usually more severe and involve a persistent nasal allergy. The demographic of the participants additionally suggested that most patients are from urban locations (80%) (Cvetkovski et al., 2018).

https://drive.google.com/file/d/1K_v5314z8G-2TU-0xFnEXwygjbCrx99N/view?usp=sharing

Table 2: Characteristics of the sensitization to ragweed pollen (Cvetkovski et al., 2018).

2.4.4 Bucharest

In Romania, the Allergy Center in Bucharest sees the symptoms of ragweed pollen allergies are serious and increasing. Cases of monosensization have become more prevalent in the past three years, as seen by the orange bars in Figure 8 below. Significantly more patients also reported or were diagnosed with having moderate to severe symptoms, which poses a serious issue to the public health (Leru & Anton, 2019).

https://drive.google.com/file/d/1AWiaf4-xPEdH8h1Bo62Dx59EDbQNg3HJ/view?usp=sharing

Figure 8: Number of new cases per year and allergic sensitization (Leru & Anton, 2019)

However, this preliminary study is the first of its kind in Bucharest. Much more data needs to be analyzed to fully understand the scope and factors involved in pollen allergies in Bucharest, which will help inform allergy patients of the risk factors and how to better manage their symptoms.

2.4.5 Efforts in Bucharest

Recognizing allergic disease as a pressing issue, the Romanian government started taking actions. In March of 2018, the Parliament of Romania passed a law in an effort to stop the spread of ragweed in Romania. It states that owners and maintenance personnel of public lands such as railways, lakes, and ponds must make an effort to combat the spread of ragweed and destroy such weeds where possible (Florincescu-Gheorghe et al., 2019). However, until the spread of ragweed in Romania is controlled, it is important to deal with the current allergy issue at hand. The first step in dealing with this is understanding the issue in Bucharest and learning about any factors that may be involved through research in related areas.

Because Bucharest has been left out of many studies to date, Dr. Leru from Colentina Clinical Hospital in Bucharest began new efforts to learn about ragweed pollen and allergies in Bucharest. The first pollen trap in Bucharest was set up in 2013, long after many other pollen collection programs across Europe. In May 2019, Dr. Leru published information about the first 5 years of data for this pollen trap, which spans from 2013 to 2018. Their findings indicated higher atmospheric levels of ragweed pollen and a longer pollen season than anticipated (Leru et al., 2018).

With this new data, they also began to look at the number of diagnosed allergies. Their preliminary data showed that the amount of seasonal allergy cases increased 2.5-3 times each year over the course of their data collection. This translates to 2-5 new cases daily during the ragweed season. Most of these new patients are young people who have been living in Bucharest for 2-3 years with relatively high education, implying that sufferers with less knowledge may not realize that they have a treatable disease. Dr. Leru also declares the necessity of further research and further collaboration between Romania and other parts of Europe to share information. This will increase the knowledge of allergies, thereby decreasing the burden of pollen allergies and increasing awareness of the health impacts of ragweed (Leru et al., 2018). Dr. Leru is working towards putting Romania on the map of countries who are serious about researching the health impacts of pollen.

2.4.4 Romanian Familiarity with Allergy Symptoms and Treatment

To inform patients about how to manage ragweed allergies, it is important to know about the symptoms. Common allergy symptoms include inflammation, watery eyes, runny nose, sneezing, and coughing. The most commonly suggested way to reduce allergy symptoms is avoidance, which requires a reduction to exposure to the outdoors and limiting ways for pollen to enter the indoor environment. To help people reduce exposure, there are several internet sources and weather apps that report pollen count data for each day. It is also recommended that people with allergies avoid spending time outside on rainy days and exercise indoors. However, there are other treatment options for people who are unable to limit their exposure or suffer more severe allergic reactions to pollen (Taramarcaz et al., 2005).

The most common of these treatments is over-the-counter allergy medications, such as corticosteroids and antihistamines, which are meant to temporarily alleviate symptoms. However, these may not always improve severe symptoms and require routine taking at specific times of the day in order to be most effective. Ragweed-specific immunotherapy is the only disease-modifying treatment available. Allergen-specific immunotherapy (AIT) involves injecting the patient with ragweed allergen extract through a three year series of treatments. This extract contains the factor Amb 1, which is the most allergenic factor in ragweed pollen, causing 90% of all reactions. AIT allows the patient’s immune system to become exposed to the allergen and build up a tolerance to it for the following pollen season. The effects are long-lasting after the tree-year treatment period, however, they are costly, therefore, not always recommended as the best treatment (Chen et al., 2018). We took into account this knowledge of the symptoms and treatments to devise a method to enhance awareness of pollen allergy in Bucharest.

2.4.5 Romanian Perspective on Health

Even though there are medically recommended treatments for allergies, it is people’s perspective on seasonal allergies and their overall health that determine the actions they are willing to take. Both healthcare specialists and allergy patients’ attitude towards this matter play an important role.

a. From a medical perspective

A German pharmaceutical company from Reinbek, Allergopharma GmbH & Co. KG, hosted The Future of the Allergists and Specific Immunotherapy (FASIT). At this conference, local professionals, including those from Romania, in academia, clinics, regulatory authorities and industry gathered and discussed the shortcomings of the existing immunotherapy service. They reported that even though the number of patients with allergic rhinitis increases and the effectiveness of immunotherapy is also improving, the amount of people that seek this treatment surprisingly decreases. The main concerns are determining the biomarkers to be able to diagnose and treat patients individually and provide early treatment to patients that have a positive response to immunotherapy, and making sure that the results of the effectiveness are not just because of the placebo effect. It appears that the medical professionals are actively putting effort into improving the treatment for allergic diseases (Pfaar et al., 2019).

b. From a Patient Perspective

The patients also play an important role in their own medical treatment, specifically for allergic diseases. A survey done in northeast Romania showed that most people from the urban area define self-medication as treating an illness by themselves without consulting a doctor. About one-third of the respondents said they took over-the-counter medicines after searching the internet, more than one-third said they chose self-medication because of financial reasons. They did think of the risk, however, under less severe circumstances, they would be more inclined to perform self-medication. They also found that women with higher education are more likely to provide self-medication to their children (Manole et al., 2017). At the Allergy Center in Bucharest, only 20% of the patients seek assistance from a healthcare provider within the first month of having allergic symptoms. The remaining 80% of the survey takers reported seeking medical advice only after 7 months to 10 years (Popescu & Tudose, 2011).

2.4.6 Areas for Improvement

The city of Bucharest has made some positive steps in addressing the pollen issue, but there remains room to improve. The public seems to be unaware about the increasing pollen levels. There is little pollen information available for ordinary citizens, and the depth of data is lacking when compared to the distribution of public information in other European countries.

To begin, the public may lack understanding about pollen allergies. The seasonal, irritating but non-lethal symptoms of allergies may not be enough to drive one directly to a hospital. The profile of someone who gets diagnosed with pollen allergies is typically someone who has been living in the city for 2-3 years (Leru et al., 2018). Therefore they may not be able to properly recognize allergy symptoms as they occur.

Unfortunately for those with allergies, the pollen information in Romania is not readily available. The one pollen trap in the country has its past readings available on polleninfo.org, but the data set has not been updated since 2016. As a result, the live readings are not available on a day-by- day basis. (Berger et al., 2016). The live pollen data can be a very useful tool for helping the public mitigate their symptoms, for example, limiting outdoor time and medicating to reduce exposure to high pollen levels on a given day (Fritz, 1986).

Studies performed on pollen data in Romania thus far are not as in-depth as the rest of the European Union’s. Reasons for this include the novelty of the collector device in Bucharest and the lack of multiple collectors. Compared to other European Union studies, which can correlate latitude, longitude, and elevation to pollen at different times of the allergy season, or can linearize years worth of trends, the single data point showing the pollen readings of Romania show that there is more that could be done. (Pollen Info., 2020).

Bucharest’s cityscape has changed rapidly over the years since 1990. A case study of Băneasa’s neighbourhood revealed the extent to which the city has been affected by the expanding economy. Băneasa was chosen for its close relations with the capital Bucharest, meaning the changes made to one closely reflect the other. The overall effects on Băneasa are that around 8% of its green space was lost over 11 years (Scăunas et al., 2019). The significance of this finding relates to the idea that urbanization creates conditions that allow invasive species to quickly dominate the under-maintained areas and lower biodiversity, making pollen allergies more severe for the locals. With these changes being representative of the development of Bucharest, it gives an explanation to the rise in allergy symptoms.

Romanian allergists have agreed that more research and more air data is required to form better opinions on the pollen situation in Romania, though they confirmed that an increased number of patients have come to them with ragweed allergies in recent years (Leru et al., 2018).

With the increasing number of seasonal allergy patients in Romania, and the lack of available information regarding their symptoms, it is important that the gap in the public knowledge is addressed. It seems that the public may also appreciate having access to local pollen information for prevention and avoidance, as well as preparation and planning. (Medek, et al., 2019).

2.5.1 Different Strategies to Raise Awareness

A public awareness campaign can help raise awareness, educate, and increase interest in the respiratory allergy research. Research on different awareness campaigns show that there are three main approaches that prove to be effective: using still images, multimedia, and utilizing the involvement of the government and community.

a. Still images

Still images such as photographs and posters can replace lengthy words and sentences to convey a message effectively. They should always be included as part of a public outreach program, as is suggested by a study on the performance of the two European Years campaign to raise awareness about common European issues (Cmeciu et al., 2014). Print media, such as posters and billboards, are widely used for their accessibility and informative quality. Still images can also be seen on social media and websites. As technology evolves and the number of internet users increases, social media and websites are major platforms for many campaigns to utilize and provide more in-depth knowledge (Iannacone & Green, 2014).

b. Multimedia

Multimedia, such as video and audio, is another approach. The Australian campaign to educate the public about skin cancer had commercial videos on television, radio, and websites (Iannacone & Green, 2014). The public outreach program by the Office of Public Health Preparedness and Response in the Centers for Disease Control and Prevention (United States) sent its subscribers videos providing advice on how to prepare for natural or manmade winter hazards in 2011. They also reported that more than half of the videos (54%) were watched on cell phones, 32% on computers, and the rest by people searching the internet. 21% of the participants, who did not have internet connection in their phone, still received and were able to watch the videos. This suggests that at this time cell phones are the most effective platform to deliver a multimedia message, although anti-spam laws might create some complications (Bandera, 2016).

c. Government and community

During the awareness campaign on skin cancer in Australia mentioned above, the government and community also participated. The government funded most of the campaigns and passed legislation, from sunscreen testing and UV protection ratings on clothing to restricting tanning devices. They also provided educational sessions at schools, and encouraged local clinics and hospitals to inform their patients about skin cancer (Iannacone & Green, 2014).

2.5.2 Choosing the best strategy

In order to choose the best strategy for our campaign, we need to fully evaluate the message we will convey, the Romanian people’s current understanding of the message, and different ways the people might perceive this message because of the nature of Romanian culture.

a. The Message to Convey

The key aspects that determine the success of an awareness campaign are the message (54%), visual identity (24%), social cause (16%), and concept (6%), according to a study done on 50 Communication and Public Relations students in Romania. Social campaigns usually aim to influence the emotions of the people, which is the first step to reach their belief and change their behavior. The report of this study suggested that by targeting emotions, these campaigns can catch people’s attention positively and effectively (Petrovicia & Dobrescub, 2013). In Romania, it is important to understand the social and cultural aspects of its history. Before the emergence of Communism, Romania was a peasant society whose characteristics included a higher collectivism index than individualism, meaning most people valued the community and helping others more than “every man for himself”. Under Communism, ideal collectivism was reinforced, however, due to the highly diverse society, the process was unsuccessful. The totalitarian government put the Romanian people under repression, making them obey but also creating a distrust against the authorities. Therefore, even though Romania used to be a peasant society, true collectivism and national identity were not quite established. (Gallagher, 2005). Since the history of Romania is complex, with a long heritage of authoritarianism, we believe that appealing to the traditional sense of communal responsibility and reminiscing about the past, awareness campaigns can reach Romanians in a more emotional way, which can help convey the message. The question was, how could we present the message to effectively influence people?

b. The Challenges

The advertising industry in Romania is still relatively new and was negatively perceived when it was first introduced. In a study on how people perceive advertising and its socio-economic effects, Romanians seem to have a more positive attitude nowadays. They find advertisement informative, entertaining and fulfilling a social role. However, they are still reserved and skeptical about its social benefit (Iannacone & Green, 2014). In the difficult transition from communism to capitalism, the removal of governmental regulations that occured with the collapse of the command economy meant that it was hard to prevent corruption in businesses and government practices. At the expense of the people, medical establishments were also subject to criticism and advertisement could be considered a form of propaganda. On the other side of the matter, the advertising industry, especially nowadays, has boomed. Competition is intense and companies are trying hard to be creative, sometimes in controversial ways. Female sexuality, materialistic and simple-minded exploitation are some of the popular approaches in the United States that are controversial and heavily criticized. Therefore, having a good understanding of the message we wanted to convey with our awareness campaign, along with the cultural and socio-economic background of citizens of Romania was beneficial in deriving an appropriate strategy.

In conclusion, the rise in pollen allergies has been causing health problems in many countries around the world. However, research on this field in Romania is relatively new and dispersed. It is important to centralize all the information so that data collection and analysis can be done effectively and integrated to the European Aeroallergen Network. Additionally, by conducting an in-depth comparative study between Romania and other countries affected, we can better understand the local pollen allergies problem in a worldwide context. Lastly, through an appropriate awareness strategy, it is necessary that the public is informed and knowledgeable about pollen allergies for better prevention and treatment methods.