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Review article

Finnish Allergy Programme 2008–2018 – time to act and change

the course

Allergy is frequently a life-long immune dysfunctionaffecting the quality of life and causing a lot of visits tohealth care, hospitalization days, work disability and useof medication. Allergic diseases are the most commonchronic disorders of children and adolescents (1). Simi-larly to many other western countries, prevalences ofallergic diseases in Finland are high (2) (Table 1), andhave, except eczema, steadily increased since the 1960s�(3). Although some countries have reported that theoccurrence of atopy and atopic disease have levelled off,or even decreased (4), such reversing trends have not yetbeen discernible in Finland. In 2007, 9% of the adultsliving in Helsinki reported to have doctor-diagnosedasthma (The Finnish-Estonian-Swedish Study, unpub-

lished data). Sensitization rates to common allergens (oneor more positive skin prick test result) are approaching50%; a population study in 2003 showed that 43% ofschool aged Finnish children were sensitized (5), and in2006, that was true for 47% of the adults (6).

Unravelling the mechanisms in the development oftolerance has given an impetus for revisiting the currentviews and dogmas in allergy. Strategies that have beenused for years have not been able to halt the �allergyepidemic� and reduce the burden because of allergies. InFinland, an exception is the benefits gained with theAsthma Programme discussed below. We have to enter anew era, from mere treatment of symptoms to preventionand preventive management. The novel data challenge

Background: The prevalence of allergic diseases has grown in Finland, similarlyto many other western countries. Although the origin of allergy remains unre-solved, increasing body of evidence indicates that the modern man living inurban built environment is deprived from environmental protective factors(e.g. soil microorganisms) that are fundamental for normal tolerance develop-ment. The current dogma of allergen avoidance has not proved effective inhalting the �epidemic�, and it is the Finnish consensus that restoring andstrengthening tolerance should more be in focus.Aim: The national 10-year programme is aimed to reduce burden of allergies.The main goals are to (i) prevent the development of allergic symptoms; (ii)increase tolerance against allergens; (iii) improve the diagnostics; (iv) decreasework-related allergies; (v) allocate resources to manage and prevent exacerba-tions of severe allergies and (vi) decrease costs caused by allergic diseases.Methods: For each goal, specific tasks, tools and evaluation methods are defined.Nationwide implementation acts through the network of local co-ordinators(primary care physicians, nurses, pharmacists). In addition, three nongovern-mental organizations (NGOs) take care of the programme implementation. The21 central hospital districts carry out a three step educational process: (i)healthcare personnel; (ii) representatives and educators of NGOs and (iii)patients and the general population. For outcome evaluation, repeated surveysare performed and healthcare registers employed at the beginning, at 5 years,and at the end of the programme. The process will be evaluated by an inde-pendent external body.Conclusion: The Finnish initiative is a comprehensive plan to reduce burden ofallergies. The aim is to increase immunological tolerance and change attitudes tosupport health instead of medicalizing common and mild allergy symptoms. It istime to act, when allergic individuals are becoming a majority of western pop-ulations and their numbers are in rapid increase worldwide. The Programme isassociated with the Global Alliance of Chronic Respiratory Diseases (GARD),WHO.

T. Haahtela1, L. von Hertzen1,M. M�kel�1, M. Hannuksela2,the Allergy Programme WorkingGroup*1Skin and Allergy Hospital, Helsinki UniversityCentral Hospital; 2Allergy and Asthma Federationin Finland, Helsinki, Finland

Key words: allergen avoidance; allergy prevention;allergy programme; asthma programme;immunotherapy; tolerance.

Prof. Tari HaahtelaSkin and Allergy HospitalHelsinki University Central HospitalPO Box 16000029 HuchHelsinkiFinland

*Tari Haahtela, Leena von Hertzen, Mika M�kel�,Matti Hannuksela, Marina Erhola, Minna Kaila,Ritva Kauppinen, Lola Killstrçm, Timo Klaukka,Krista Korhonen, Antti Lauerma, Jan Lindgren, SatuL�hteinen, Pertti Paakkinen, Juha Pekkanen, AnnePietinalho, Anneli Pouta, Elina Toskala, Outi Vaarala,Erkka Valovirta, Erkki Vartiainen, Petra Vidgren.

Accepted for publication 19 February 2008

Allergy 2008: 63: 634–645 � 2008 The AuthorsJournal compilation � 2008 Blackwell Munksgaard

DOI: 10.1111/j.1398-9995.2008.01712.x

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many of those action models that have been adopted inthe healthcare system and the society to counteractallergies. The need for a change in Finland was recog-nized already in 1998 in a consensus meeting (AllergicPopulation – a consensus statement 1998).In allergy, there is no straightforward trend of wors-

ening; mild symptoms often improve, even withouttreatment. Mild allergy symptoms are common andresolve often gradually and spontaneously, particularlyin children. The available data show that majority ofchildren with food allergies outgrow their disease (7, 8).For mild allergy, guided self-management and follow-upare generally sufficient. Extensive diagnostic examina-tions should be performed only if the symptoms continue,become more severe and cause disability or markedinconvenience.Because of the high occurrence of allergic diseases in

western countries, even the numbers of patients withsevere symptoms are high; the healthcare system shouldallocate resources to manage these patients. Severesymptoms additionally cause the majority of costs;preventive and good control of the disease can thusconsiderably reduce these costs (Fig. 1).

The Finnish Allergy Programme 2008–2018

Experience from the Asthma Programme 1994–2004 hasbeen used to facilitate also the Allergy Programme. Theburden of a chronic disease can be decisively decreased.Although signs of reversing trends in asthma prevalencehave not emerged in Finland, the programme has been amajor success; hospitalization days because of asthmahave decreased by 70% in relation to the number of

patients, and the absolute number of individuals withdisability pensions caused by asthma has shrunk 76% (9).In spite of increasing prevalence, the overall costs causedby asthma have levelled off and are now decreasing,contrary to what was predicted. Even annual costs perpatient attributable to asthma have been reduced by 50%.The overall costs of asthma in 1993 were c. €285 million(loss of production also taken into account) and €230million in 2005. According to prediction, based on the1993 trends, the 2005 costs would have been around €800million (Nordic Healthcare Group 2008, unpublisheddata).

The Finnish Asthma Programme comprised bothmanagement guidelines and an action plan with a prioridefined tools to achieve the goals. The process andoutcomes were also evaluated. The Asthma Programmehas served as a model for other programmes in Finland(e.g. COPD, tuberculosis, sleep apnoea) aimed at reduc-ing the burden of chronic diseases.

Nonetheless, allergy is a multifaceted and morecomplex entity than asthma. The goals and foci of thenovel Allergy Programme have to target the centralproblems and be pragmatic as well as achievable. Thebackground of the programme stands, not only on themost recent scientific data, but also on long clinicalexperience, which are equally important in pursuing achange for the better.

In the programme, strategies are chosen, goals set andtools and evaluation methods defined (Fig. 2). Childrenand families are brought into focus more than in theAsthma Programme. Allergy Programme also revisitsold dogmas and attitudes. In prevention and manage-ment, �avoidance and fear of all� is not the right strategybut can lead to isolation, actions that deteriorate dailyliving and in the worst case, to serious reactions ifexposure occurs unexpectedly (e.g. food exposure).Avoidance of allergens will always be important, but itmust have justified and precise grounds and betterdefined time limits. Psychosocial factors should be betteraddressed as they play an important role in individuals¢

Table 1. Estimated prevalences of allergic conditions in Finland in the 2000s(modified from ref. 2)

%

Adult asthma 8–10Childhood asthma 5Asthma-like symptoms 5–10Allergic rhinitis (seasonal and perennial) 30Hay fever (pollen allergy) 20Allergic conjunctivitis 15Atopic eczema 10–20Urticaria 7Contact dermatitis 8–10Food allergy (adults) 2–5Food allergy (children) 5–10Drug hypersensitivity 2Insect hypersensitivity 2Light hypersensitivity 15–20Allergy to animals 15At least one positive SPT result (adults) 47Allergy in family 30Use of asthma or allergy medication (past 12 months) 35

SPT, skin prick test.

Severe symptoms 10%

Moderate symptoms 20%

Mild symptoms 70%

Disease severity Costs

Figure 1. The schematic allergy pyramid. Most of the allergysymptoms are mild and intermittent, but due to the high allergyprevalence, severe symptoms are also common and causemajority of the costs.

Finnish Allergy Programme 2008–2018

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perception of symptom severity and create also �imag-ined allergy�.

Implementation and collaboration

The Allergy Programme is an educational action plan,which takes the advantage of the contact personnetwork created during the Asthma Programme (10).In each municipal healthcare centre there are asthmacontact persons (in 2008, 200 physicians and 580 nursesspecifically trained in asthma). Similarly in pharmacies,695 pharmacists have been educated as asthma con-tact persons (94% coverage of the pharmacies inFinland). These networks will be strengthened and anew one will be created in maternity and child healthclinics.National collaborators in the Allergy Programme are

the Ministry of Social Affairs and Health, the NationalPublic Health Institute, the Social Insurance Institution,the Finnish Institute of Occupational Health, theAssociations of Finnish Pharmacies, specialist associa-tions, the Finnish Lung Health Association FILHA andthe patient organizations, the Allergy and AsthmaFederation and the Pulmonary Association HELI.The last three nongovernmental organizations (NGOs)are responsible for the implementation of theprogramme.The Finnish initiative joins the Global Alliance of

Chronic Respiratory Diseases (GARD), WHO, a volun-tary alliance of national and international organizations,

institutions and agencies working towards the commongoal of improving global lung health (1). The AllergyProgramme will also benefit from the co-operation withthe European Allergy Network (GA2LEN), and theessential global guidelines and action plans, such as theGlobal Initiative for Asthma (GINA), and the AllergicRhinitis and its Impact on Asthma (ARIA) (11–13). Theinternational dimension of the Programme may helpothers to create better models, while learning from thesuccesses and failures of the Finnish initiative. Preventingthe increase in allergies and asthma will be a particularlyimportant topic in areas with developing national econ-omy (14).

Programme goals

The general aim is to reduce the burden because of allergyin 2008–2018, and the Programme has six main goals.Baseline will be 2007–2009, depending on survey.

1 To prevent the development of allergy symptoms:Prevalence of asthma, allergic rhinitis, atopic eczemaand contact dermatitis is decreased by 20%.

2 To increase tolerance against allergens: Numbers ofsubjects on elimination diets caused by food allergyare decreased by 50%.

3 To improve allergy diagnostics: All patients are testedin quality certified allergy testing centres.

4 To reduce work-related allergies: Allergic diseasesdefined as occupational are decreased by 50%.

Figure 2. The strategic planning of the Finnish Allergy Programme 2008–2018.

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5 To allocate resources to manage and prevent exac-erbations of severe allergies: �Allergy Control Cards�are in use in the whole country and emergency visitscaused by asthma are decreased by 40%.

6 To decrease costs due to allergic diseases: Predefinedcosts are reduced by 20%.

For each goal, specific tasks, tools and measures forevaluation have been defined. Tasks are the activities ortargets in pursuing the goal. Tools are the means by whichthe tasks are carried out. Measures are the verificationsources or methods to evaluate the outcome. In thefollowing, each goal is considered separately and specifictasks, tools and measures are presented in some detail.

Goal 1. Development of allergy symptoms is prevented

Allergy health is promoted by various methods

There have been few, if any, methods available forpromotion of allergy health. We introduce here theconcept of �allergy health� to mean physical, psychologicaland social well-being irrespective of allergy. An individualcan be healthy and functional, although allergic. Allergyis recognized as an individual feature rather than illnesswhen the condition is minor and relative. People must beencouraged to adopt such a way of living that promotesgeneral health and immune balance. This is especiallyimportant in children and adolescents, whose develop-ment is endorsed by balanced diet, physical activity and aclose connection with the natural environment, whetherallergic or not. Anti-smoking advice and legislation mustbe improved. Exposure of children to environmentaltobacco smoke is still a problem. Efficacy of asthmamedication is poor in smoking patients, and asthmapatients smoke as frequently as the population as a whole(9).

Tasks Tools Measures

Allergy health is pro-moted.Well-being andawareness ofprotective factors,risk factors, naturalhistory and outcomesof the disease amongindividuals withallergy are improved.

Public information,education, counselling.

Internet-based AllergyLibrary for general public.Duodecim Health Library,allergy articles, http://www.terveyskirjasto.fi.Allergy & Asthma Book,includes self-managementguidelines.

Peer activities organized bythe NGOs.

Knowledge measure-ment of personnel in theNGOs before-after theProgramme.

Surveys of the quality oflife, awareness andattitudes of allergicindividuals before–afterthe Programme.

Poor air quality increases symptoms

Indoor air is in many dwellings and workplaces unac-ceptably poor. In Finland, indoor temperature is gener-

ally too high and air conditioning often defective,functions inadequately or brings pollutants and particlesinside. Quality issues concerning buildings remain largelyunresolved. There are too many dampness-associatedindoor problems, and unacceptable building practicesproduces such problems ever more. The urban, ambientair in Helsinki and some other cities contains too highconcentrations of small particles from increasing trafficand energy production. Small particles gain access deepinto the respiratory tract and body increasing the risk ofillness and worsening of symptoms.


Overall exposure topassive smoking isreduced.

Exposure of childrento passive smokingis reduced.

Education, counselling, possiblylegislation.

In maternity and child healthclinics parents of small childrenare counselled to stop smoking(Current Care Guidelines).

Annual survey of smokeexposure at homes andin adults (NationalInstitute of PublicHealth).

Survey from the journalsof maternity and childhealth clinicsbefore–after theProgramme.

Problems of damp(mouldy) dwellingsare taken seriouslyand activelyreduced.

Information, counselling, largeco-operation with public healthauthorities, building sector andhealthcare specialists.

Annual survey of visiblesigns of dampness andmouldy smell indwellings (NationalPublic Health Institute).

Exposure to ambientair small particles isreduced.

Information, counselling how toreduce diesel exhausts, improvewood burning, reduce springdust in cities, affect traffic andair quality politics.

Local rules and nationallegislation.

Ambient air PM2.5 jaPM10 concentrations inbigger cities aremonitored and reported.

Goal 2. Tolerance against allergens in population isincreased

Tolerance is actively strengthened and avoidance reduced

Accumulating evidence supports the view that allergenavoidance alone does not prevent the development ofallergic disease (15, 16), although in single cases it is ofimportance. Complete avoidance is virtually impossibleand cannot provide long-lasting clinical benefits, except incertain specific cases (e.g. anaphylaxis). Even a govern-mental campaign of food allergen avoidance targeted toatopic pregnant and breast-feeding mothers and theirinfants has been unable to reduce allergy (17). Instead ofallergen avoidance, tolerance to allergens in populationmust be improved by various means. Allergen avoidanceis often necessary in acute occasions of severe symptoms,but as soon as the situation has resolved, other meansthat strengthen tolerance should be used.


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Tolerance to foodand inhaled aller-gens is promoted.

New methods forimproving toleranceare sought for.

Specific preventive dietsare not used.

Breastfeeding at least4–6 months, solid foodsfrom 4 months, alongwith breastfeeding.

Instructions forpreventive allergenavoidance areabandoned.

Surveys of the numbers ofallergy diets in day carecentres and schools before–after the Programme and at5 years.

Surveys of the use ofallergen avoidance methodsby allergic personsbefore–after theProgramme.

Allergy symptomsand their severityare decreased.

The immune system isstrengthenednonspecifically (e.g. withprobiotic products), andspecifically with aller-gen immunotherapy (SITand SLIT).

Numbers of SITs and SLITsbefore–after the Programme(statistics of pharmaceuticalindustry).

Diagnostics of mildallergy symptoms isdecreased.

The healthcare profes-sionals evaluate theseverity of symptoms byusing an AllergyBarometer.

Use of Allergy Barometer inprimary health care and inspecialist services before–after the Programme.

Severity evaluation survey atpharmacies.

Food allergy problems are reduced

The entity �food allergy� comprises much imaginedallergy and unnecessary avoidance of foods. Propor-tions of children on specific diets are too high,unnecessary avoidance of foods can even be deleteriousas it may endanger the child�s intake of importantnutrients and distort the child�s imagine of food andhealthy eating.


Symptom diary is sys-tematically used in foodchallenge tests.

Symptom diary freelyavailable at internet.�Food Allergy ControlCard�.

Surveys of the numbers ofallergy diets in day carecentres and schools before–after the Programme.

At most 2% of allchildren with cow�s milkallergy uses aminoacid-based formulas.

Education and self-management guidelinesfor the patient.

Registers of specialreimbursements for cow�smilk allergy.

Sales statistics.

Diets of children startingschool are evaluated.

Numbers of specificdiets are reduced by50%.

Health Library atinternet.

Education andguidelines for nursesin child health clinics.

General informationof parents.

Inquiries of diets to parents.Inquiries to personsresponsible for cateringservices in workplaces andschools before–after theProgramme and at 5 years.

Goal 3. Diagnostics of allergy is improved

Diagnostic practices vary greatly between differenttesting centres in the country. Allergy testing withallergens (skin prick tests, patch tests, challenge tests)will be centralized in large hospitals and in those privateunits which fulfil the quality requirements and in whichan allergist is responsible for testing. In Fig. 3, examplesof reading keys of skin prick testing are depicted. Skinand Allergy Hospital, Helsinki University Central Hos-pital, together with the Finnish Dermatological Associ-ation, is in the key position in improving the quality ofallergy testing.

GA2LEN audit for the Allergy Centre of Excellencewas performed 1.2.2008 in Skin and Allergy Hospital andhas promoted the quality of work.


Quality of skin test-ing (skin prick tests,patch tests) andinterpretation of theresults areimproved.

Standardized testing system.�Standard operatingprocedures� of uniformpractices.Reading keys for the 30most important inhalant andfood allergens used in skinprick tests.

Certification system intesting centres.

Education of personnel inthe key testing centres.

Auditing of testingcentres in centralhospitals and in privateunits.

Challenge testing isperformed accordingto previouslydefined guidelinesand is alwaysguided by anallergist.

Guidelines available to alltesting centres. Education.

Quantity and quality ofallergen challenge testsbefore–after theProgramme.

Goal 4. Occurrence of work-related allergies is decreased

Exposure to allergens and chemicals that cause rhinitis,asthma and contact dermatitis is still common inworkplaces. Exposure, however, can be reduced in manyways. Dampness problems in workplaces cause morbid-ity and worsening of the work atmosphere. Buildingshave been closed and even wrecked because of seriousmicrobial problems (day care centres, schools, offices,etc.). �Mouldy house diagnostics� does not work at theindividual level. Occupational diseases need to beredefined medicolegally. Sensitization to chemicals caus-ing contact dermatitis still occurs and exposure must bereduced. Patch tests are interpreted nonuniformly,depending on the tester�s and interpreter�s expertiseand education.

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Exposure toallergens causingasthma, rhinitis andcontact dermatitis isreduced.

Legislation concerning thesafety of workplacesnationally andinternationally (EU).

Improved working methodsand safety to preventoccupational allergy.

Recorded and reportedchanges in legislation.Statistics of CentralHospitals and theFinnish Institute ofOccupational Health.

Statistics ofoccupational allergicdiseases.

Diagnostics ofoccupationalasthma, rhinitis andcontact dermatitis isimproved.

Standardized testingmethods.

Evidence-based diagnosticpractices.

Annual monitoring oftest results andevaluation of allergensneeded in testing.

Grounds for occu-pational diseasesare clarified.

Co-operation between theFinnish Institute ofOccupational Health,specialist services andinsurance companies.

Surveys of occupationalallergies before–afterthe Programme.

Goal 5. Resources are allocated to severe allergiesand prevention of exacerbations

Treatment control of asthma and rhinitis is strengthened

The good results from the Finnish Asthma Programme1994–2004 are further improved. Early detection, anti-inflammatory intervention and disease control areemphasized. Treatment problems associated with severeasthma need specific attention. Exacerbations of asthmaare still a major problem and their prevention is the keyfor reducing both suffering and costs. Majority of asthmapatients suffers from concomitant rhinitis, which must berecognized and treated at an early stage. This improvesalso the control of asthma. Pollen allergy is increasing inyoung population and new modes of specific immuno-therapy (SIT) and sublingual immunotherapy (SLIT) areemployed to improve access and adherence to treatment.Diagnosis of asthma in young children needs precision,and both under- and over-diagnostics are watched. Theformer causes unnecessary suffering and the latter overuseof drugs.

Adult asthma and rhinitis


Proportion of pa-tients with chronicasthma (thoseentitled specialreimbursement forasthma medication)is decreased by 5%.

Early intervention in asthmasymptoms, rhinitis, smokingand indoor air problems.

Early detection and effectivetreatment of inflammation.

Asthma visits in centralhospitals (registers).

Use of asthma medication(registers).


70% of adult asth-ma remains mild.

�Asthma Control Card�.

Guided self-management-medication-physical activity-avoidance of those aller-gens only that clearly wor-sen the symptoms.

Asthma Barometer inpharmacies.

Exacerbations of asthma(emergency visits,registers) before–after theProgramme.

Hospitalization days (reg-isters).

Disability pensions(registers).

Zero tolerance toasthma deaths.

Good acute treatment inemergency units.

Surveys of the skills of thepersonnel before–afterthe Programme.

Asthma deaths (statistics).

Rhinitis in asthmapatients is treated.

Asking rhinitis symptoms inevery asthma patient.

Lung function measurementsin rhinitis patients at earlystages.

Surveys of the manage-ment of rhinitis in patientswith asthma before–afterthe Programme.

Allergic rhinitis istreated better.

�Rhinitis Control Card�.Education of healthcarepersonnel.

Guided self-management.

Surveys of the number ofuntreated rhinitis patients,and impact of rhinitis onquality of life.

Childhood asthma and rhinitis


The number of asthmadiagnoses in infants andyoung children does notincrease, regional varia-tion is reduced.Asthma in infants andyoung children is treatedmore accurately accord-ing to real need.

Previously defined guide-lines.

The Finnish Current CareGuidelines are used inasthma diagnosis.

�Asthma Control Card forYoung Children�.

Use of medication,special reimburse-ments (registers).

When asthma diagnosisis made, rhinitis isdiagnosed and treatedappropriately.

Inquiry of symptoms.Treatment of rhinitis in everypatient with asthma.

Patient recordsurveys.

A specific questionto the AsthmaBarometer.

Exposure of children totobacco smoke is re-duced.

Anti-smoking advice toyoung children�s parents atmaternity clinics accordingto the Finnish Current CareGuidelines.

Surveys of thematernity clinic re-cords before–afterthe Programme.

Treatment control of atopic eczema is strengthened

Marked symptoms should be treated like asthma andrhinitis; take the eczema into early control, find out in the


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long run what treatment is needed for maintenance, andprevent exacerbations.Patient and his/her family, even healthcare profes-

sionals, do not recognize what is just dry skin andwhat eczema that should be treated with medi-cation. The patients and their families have only avague idea of the severity of eczema. Many familieshave incorrect perception of the causes of atopiceczema. Elimination allergy diets, that have beenjustified in infancy, are continued without medicalneed. Foods that do not cause symptoms are avoidedunnecessarily. Topical corticosteroids are not usedproperly; too mild corticosteroids are used, and thecourses are too short and stopped abruptly. Manypeople are afraid of using topical corticosteroids insummer.


Severity andexacerbations ofatopic eczema arereduced.

The Finnish Current CareGuidelines.

�Atopic Eczema ControlCard�.

Use of medication, particularlyfor children prescribed topicalcorticosteroids, topicalcalcineurin inhibitors andemollients (registers).

Numbers of patients that havebeen allowed financial supportfor treatment (registers).

70% of the patientsand 90% ofhealthcare person-nel adopt the newtreatmentguidelines.

Education. Surveys in pharmacies,specialist clinics, and childhealth clinics, how the newguidelines have been adopted.

Surveys to members of thepatient organizations.

n = 619n = 631

3 4 5 6 7 8 9 10 3 4 5 6 7 8 9 10

Birch (mm)Age 7–71 years

Dog (mm)Age 6–74 years

Soya bean (mm)Age 28–53 years

Peanut (mm)Age 10–57 years

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Figure 3. Examples of the reading keys of skin prick tests. The wheal diameter is illustrated on the X-axis, and the percentage ofsubjects suffering from actual symptoms on the Y-axis. Allergen preparations; birch, ALK-Abello SQ 10 HEP (ALK-Abello A/S,Hørsholm, Denmark); dog, ALK-Abello SQ 10 HEP; peanut, in-house extract; soya bean, in-house extract. A positive skin prick testresult does not equal to clinically significant allergy, it is a sign of exposure and IgE-associated sensitization, but must be related tosymptoms history. The test does not make the patient allergic, e.g. foods should not be eliminated from the diet on the basis of the testresult only.

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Treatment of anaphylaxis is improved

Anaphylaxis, a serious general allergic reaction, is noteither recognized or treated properly.


Recognition and treat-ment of anaphylaxis isimproved.

Guided self-manage-ment of patients withanaphylaxis risk is im-proved.

Information to allhealthcare units. Abooklet and a video.

�Anaphylaxis ControlCard�

Hospitalization days(registers).

Deaths from anaphylaxis(statistics).

Numbers of i.m.adrenalin auto-injectorprescriptions (industry).

Reporting is improved. Internet-basednotification form.

Co-operation with theNational Agency ofMedicines (register ofdrug adverse reactions).

Quality and quantity ofnotifications to theNational AnaphylaxisRegister in Skin andAllergy Hospital/HUCH,Helsinki.

Goal 6. Costs as a result of allergy are reduced

Allergies cause relatively little hospital days and long-termwork disability, but load strongly maternity and childhealth clinics, day care centres, schools, garrisons, primaryhealth care and occupational health care. Allergies cause alot of short absences from work, school and day care.Asthma and allergy drugs are major sectors of medicalindustry and pharmacies. Allergies affect markedly foodindustry, hotel and restaurant business, travelling andmany authority activities, such as surveillance of medi-cines (hypersensitivity to drugs) and other products.Allergies are associated with building sector (indoorproblems), surveillance of ambient air in communities(traffic exhausts, public sanitation) and with tobaccopolicy. Costs because of allergies have ramificationswidely in the society and are not easily calculated. It mustalso be borne in mind that allergies benefit considerablydifferent sectors of business (e.g. drugs, cosmetics, build-ing and interior materials, household appliances).Allergies are a problematic issue from another point of

view of cost evaluation; allergies can manifest in the skin,nose, eyes, respiratory tract or gastrointestinal tract, andthe symptoms are not always easily differentiated fromsymptoms caused by other diseases. Because of this,allergies and their treatment are often inaccuratelyreported. Direct costs due to asthma and allergies werenonetheless recently estimated (Tolerance and itsimprovement in allergy; National Public Health InstitutePublications B 5/2007, in Finnish, English summary).Direct costs in 2005 were €348 million per year (c. 3% ofthe overall costs of health care). According to the goal 6,direct costs will be reduced by 20% by the end of the year2018.


Indicators that identifychanges in predefinedallergy-associated costsare created.

Registers and statisticsof different institutions.

Population surveys.

Use and sales ofantihistamines and otherdrugs closely associatedwith allergies (registers).

Numbers and costs ofprimary healthcare visits andhospitalization days due toasthma and allergies(specific survey, registers).

Economic value of workdisabilities due to asthmaand allergies.

Key messages of the Allergy Programme

1 Endorse health, not allergy.2 Strengthen tolerance.3 Adopt a new attitude to allergy. Avoid allergens onlyif mandatory.

4 Recognize and treat severe allergies early. Preventexacerbations.

5 Improve indoor air quality. Stop smoking.

Implementation of the Programme

The messages and principles of the Allergy Programmeare targeted to the whole population, to patients withallergy and asthma and their families, to public healthand patient organizations, to experts, authorities andlegislators.

The primary target groups of education and publicityare

1 Healthcare professionals, authorities and personsresponsible in day care centres, schools and othereducational institutions.

2 Key persons and peer workers in patient organiza-tions and

3 Media.

The Finnish Lung Health Association FILHA, togetherwith the Allergy and Asthma Federation and the Pulmo-nary Association HELI, is responsible for co-ordinatingthe implementation. Because of the co-operation betweenthese three NGOs with a common project organization,the programme targets the whole population in a shorttime and can be implemented cost-effectively in all partsof the country.

Contact person network

There are five university hospital districts and 21 hospitaldistricts in Finland. Primary healthcare services areprovided by c. 250 primary care centres or units of


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municipal federations, including at least a threefoldnumber of maternity and child health clinics and c.1000 units of occupational health. One-third of the last-mentioned units are private. The private sector is ingeneral responsible for a growing part of all healthcareservices.In 2008, in hospital based specialist clinics (paediatrics,

pulmonary medicine), primary health care, part of theoccupational sector and pharmacies there were c. 1500appointed asthma contact persons (doctors, nurses,pharmacists). For the Asthma Programme this networkof skilled contact persons was the key to effectiveimplementation. These contact persons will continuetheir invaluable work further in the Allergy Programme,and the network is additionally completed by nurses inmaternity and child health clinics.

Education of healthcare professionals

Healthcare professionals are regionally educated by thehospital district, with the involvement of provincialgovernments. The NGO FILHA will co-ordinate thiseducation, which is performed in 2008–2010 coveringthe whole country. Educators are mainly the specialistsin each hospital district (allergists, dermatologists,pulmonologists, rhinolaryngologists, paediatricians andspecialists in primary health care as well as nursesspecifically trained in the area). Education will takeplace in own locales of the health care during thenormal office hours as part of the regular educationalprogrammes. External experts are used according toneed.

Other education

Patient organizations arrange regional education to theirkey persons and peer workers. This education will betemporally linked to the education of healthcare person-nel.The Allergy and Asthma Federation and the Pulmo-

nary Association HELI will organize annually c. 10public events in different parts of the country, andeducate personnel in regional offices during the first3 years of the programme. The patient organizationsproduce the material needed

1 Publicity material for authorities, media and popu-lation.

2 Education material to regional offices.3 Education material to population (general informa-tion) and to patients (self-management material).

After this first stage, education continues to graduallytarget key persons in pharmacies, in day care centres andschools (phase II). During the last tertile of theProgramme (phase III), the messages and principles arereinforced, and finally, the process and outcome of theProgramme evaluated.

Evaluation

A plan to evaluate both the process and outcome of theProgramme has been produced.

Outcome (effectiveness) evaluation

The general and social outcome of the Programme will beevaluated. Understanding and adoption of the messagesand principles of the Programme are clarified in healthcare as well as in organizations. In addition, changes inattitudes of the patients and the general population willbe assessed. The focus, however, will be on the goals; howwell the goals have been achieved? Have the chosen toolsand measures been relevant in this respect?

The main methods to evaluate the outcomes are

1 Surveys before-after (and possibly in the mid of) theProgramme targeting different groups, physicians,nurses in maternity clinics and schools, customers inpharmacies, parents of allergic children, etc. Thesurveys need resources, and not all of the mentionedsurveys will be taken, and some others will come inaddition or instead. Nevertheless, the list of surveyshelps to target actions, which would be helpful whileevaluating the progress and results of the Pro-gramme.

2 Inquiries of the effectiveness of education and func-tioning of guidelines targeting the groups in question.

3 Hospitalization days and emergency department vis-its because of allergy and asthma in 2007–2009 and in2018 (registers).

4 Costs due to allergy and asthma medication, dailyallowances paid by sickness insurance for allergiesand asthma, disability pensions and rehabilitationbecause of allergy and asthma in 2007–2009 and 2018(registers).

5 Monitoring of treatment costs before-after the pro-gramme in randomly chosen units representing dif-ferent types and sizes of healthcare units.

Process evaluation

Evaluation of the process will be performed by anindependent external body (Helsinki University).

Overall evaluation

In the overall evaluation, the results from both processand outcome evaluation are considered. At the beginningof the Programme in 2008–2009, a baseline clarificationby interviewing the key persons in the Programme isperformed to get a view of their expectations andthoughts concerning the Programme. In 2018, thisinterview is repeated. Effectiveness of publicity andeducation targeted to patients and the whole populationwill be additionally assessed using questionnaires.

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Scientific background of the Programme

Tolerance

In allergy, the key issue is the impaired tolerance againstallergens and irritants because of defective immuneregulatory mechanisms. At the population level, the roleof and guidance for allergen avoidance has been debated,and inducing or restoring tolerance to allergens in oneway or another has become a hot topic.To develop normally, the mucosal immune system

needs challenges which the modern sedentary lifestyle inurban built environment does not provide. Especiallyexposure to saprophytic microorganisms/commensals viathe skin, respiratory tract and, particularly the gutappears to be decisive for maintaining epithelial homeo-stasis and tolerance (18). Continuous exposure to sapro-phytes that have co-existed with man since ancient timesdoes not elicit proinflammatory defence mechanisms, butinstead, seems to induce the regulatory network associ-ated with tolerance (19). Impaired function of thisregulatory network may then lead to immune-mediateddiseases including asthma, allergies, type 1 diabetes andinflammatory bowel disease. The regulatory networkcomprises most importantly regulatory T (T reg) cellsand dendritic cells and the cytokines secreted by them(20–23). Data are accumulating that the balance betweenT reg cells and T effector cells has tottered in patients withallergies (24–26), or the function of T reg cells may bedefective (25), implicating that the T reg cell functionand/or T reg/T effector cell balance in these individualsmust be restored by using novel innovative methods.In addition to impaired physiological tolerance, even

the psychological tolerance in population has beenweakened. Fear of allergy or pseudoallergy, that arecommon today, must be dispelled.

Strengthening or restoring of tolerance

Tolerance can be strengthened, even restored, as shownby treating allergic individuals with SIT or, morerecently, by SLIT, which target the regulatory networkand restore the balance between T reg and T effectorcells (27, 28).Crucial factors in the development of tolerance and in

the responses produced via TLR activation in general arethe dose and frequency of allergen exposure, the nature ofallergen, and factors specific to host cells (29). As to thedose of allergen, a large body of data now show that inmany cases, the dose–response relationship follows a bell-shaped curve (Fig. 4); increasing exposure at relative lowdoses is associated with increasing frequency of symp-toms/disease, whereas after a plateau, increasing exposureinduces tolerance. Such a nonlinear relationship has beenfound e.g. for bee venom allergen (30), cat, mite, rat,mouse allergens (16, 31–33) and for endotoxin (34),suggesting that this bell-curve is a rather universalphenomenon for different allergens/bioparticles.

Continuous exposure to antigens is necessary

The fundamental role of continuous exposure to com-mensals and saprophytes in the development and main-tenance of tolerance has become increasingly clear.Rakoff-Nahoum et al. (18) were among the first to showthat recognition of commensal flora by TLRs is necessaryfor the development and maintenance of mucosal homeo-stasis and tolerance, a finding that has been corroboratedthereafter by others (35, 36). Most recently, Hedl et al.(37) showed an important role for the breakdown productof peptidoglycan, muramyl dipeptide and its receptorNOD2, in inducing nonspecific tolerance in humanintestinal macrophages. Much of the novel experimentaldata of mucosal homeostasis/tolerance and antigenexposure has indeed been obtained from studies exploringintestinal cells. The findings are evidently relevant also forinhalant allergens, as it has been shown that the majorityof allergens after aerosol administration are found in thegut (38).

Other lines of evidence of the importance of continuousantigen stimulation in the development of tolerance comefrom epidemiology. Numerous studies of farm childrenconsistently show that living in a microbe-rich environ-ment confers protection against allergic disease (39). Ananalysis of house dusts in Finland and Russia usingadvanced methods showed that dust samples obtainedfrom Russian Karelia, a microbe-rich area with lowoccurrence of atopic diseases, contained mostly Gram-positive bacteria, whereas in Finland, majority of the dustbacteria were of the Gram-negative lineage (J. Pakarinen,unpublished data). This is in line with the concept that insoil and natural environment, Gram-positive bacteriapredominate (39, 40).

Much attention has during the last few years beendevoted to farm milk (41, 42), as it has shown aparticularly strong protective effect against allergies.The microbiota in fresh farm milk is similarly predom-inated by Gram-positive bacteria (43). Moreover, innormal flora of the healthy skin and respiratory mucosa

Exposure

Prevalence of atopy/atopic disease

Figure 4. The bell-shaped curve for the dose–response rela-tionship between occurrence of atopic diseases/symptoms andthe dose of exposure to an allergen or bioparticle.


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(44, 45), even in the gut using advanced methods (46),Gram-positive bacteria seem to predominate. Indeed,TLR2 and NOD2, the receptors of cell wall componentsrich in Gram-positive bacteria (teichoic and lipoteichoicacids, peptidoglycan and its degradation fragments) havebeen particularly associated with the development oftolerance (37, 47, 48), in addition to TLR9, which alsoappears to be important in this respect (36, 49). Thequestion of a distinctive role of Gram-positive bacteria inconferring protection against allergic diseases has beenraised already in 2001 in a study of faecal flora of allergicand nonallergic children (50).In sum, sustained adequate exposure to microbial

antigens in terms of quantity, composition and diversity

seems to be necessary for the normal development andmaintenance of mucosal tolerance. This tolerance isapparently nonspecific via the by-stander effect andactions of regulatory cytokines (22, 51).

Acknowledgments

The NGO, Allergy and Asthma Federation in Finland has funded ahalf-day secretary for the programme 2007–2008. The Finnishprogramme is indebted to Professor Gunnar Johansson, whoinitiated the World Allergy Organization project �Prevention ofAllergy and Allergic Asthma� (Int Arch Allergy Immunol 2004;135:83–92.)

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