Review article: how emerging technologies could reshape pollen monitoring for epidemic thunderstorm asthma

Epidemic thunderstorm asthma

In November 2016, an unprecedented epidemic thunderstorm asthma event in Victoria, Australia, resulted in many thousands of people developing breathing difficulties in a very short period of time. It caused ten deaths and created extreme demand across the Victorian health and emergency services. Because of the link between thunderstorm asthma and grass pollen allergies, a new early warning system for epidemic thunderstorm asthma (ETSA) risk was developed and operates during grass pollen season (October-December) each year. The warnings are delivered through a partnership between the Victorian Department of Health, the Bureau of Meteorology, the University of Melbourne, and AirHealth Lab.Value chain concepts were instrumental in the design of the warnings. Starting with the user needs, namely health sector preparedness and community safety, the partners worked backwards to determine the value chain of necessary capabilities (communication, risk assessment, hazard prediction, modelling, observations) and information flows that would be needed to provide a thunderstorm asthma warning service. This process highlighted gaps in knowledge of the hazard, and the need to develop capability to measure and predict grass pollen to support the thunderstorm asthma warnings. The value chain also helped define the partners’ roles and responsibilities in delivering the warnings.Focused effort by the partners enabled the thunderstorm asthma warning system to be implemented in time for the 2017 pollen season, accompanied by a full range of community, health and emergency sector awareness raising and education activities. The system uses a categorical risk-based approach, combining operational forecasting of gusty winds in severe thunderstorms with forecasts of high ambient grass pollen concentrations, which together generate the risk of epidemic thunderstorm asthma. This system now provides the first daily epidemic thunderstorm asthma risk warning service in the world that covers a wide area, and integrates into the health, ambulance and emergency management sector.At the end of each season the partners meet to review the performance of the warning system, including its ability to predict the hazard (i.e. the weather and grass pollen conditions associated with thunderstorm asthma risk) and the impact (unusually high numbers of people presenting to hospital emergency departments with asthma symptoms). The warnings show modest skill in discriminating between days with and without health impacts.This cyclical review process has led to continuous improvements in all aspects of the warnings system. These include more accurate grass pollen forecasts based on machine learning, progressive installation of automated pollen monitors to replace manual pollen counting, near real time detection of asthma spikes in hospital emergency departments based on natural language processing, and use of value-oriented metrics to tune the weather and grass pollen thresholds to optimize warning performance.

Background:There have been 26 epidemic thunderstorm asthma (ETSA) events worldwide, with Melbourne at the epicentre of ETSA with 7 recorded events, and in 2016 experienced the deadliest ETSA event ever recorded. Health services and emergency departments were overwhelmed with thousands requiring medical care for acute asthma and 10 people died.Objectives:This multidisciplinary study was conducted across various health and science departments with the aim of improving our collective understanding of the mechanism behind ETSA.Design:This study involved time-resolved analysis of atmospheric sampling of the air for pollen and fungal spores, and intact and ruptured pollen compared with different weather parameters, pollution levels and clinical asthma presentations.Methods:Time-resolved pollen and fungal spore data collected by Deakin AirWATCH Burwood, underwent 3-h analysis, to better reflect the ‘before’, ‘during’ and ‘after’ ETSA time points, on the days leading up to and following the Melbourne 2016 event. Linear correlations were conducted with atmospheric pollution data provided by the Environment Protection Authority (EPA) of Victoria, weather data sourced from Bureau of Meteorology (BOM) and clinical asthma presentation data from the Victorian Agency for Health Information (VAHI) of Department of Health.Results:Counts of ruptured grass pollen grains increased 250% when the thunderstorm outflow reached Burwood. Increased PM10, high relative humidity, decreased temperature and low ozone concentrations observed in the storm outflow were correlated with increased levels of ruptured grass pollen. In particular, high ozone levels observed 6 h prior to this ETSA event may be a critical early indicator of impending ETSA event, since high ozone levels have been linked to increasing pollen allergen content and reducing pollen integrity, which may in turn contribute to enhanced pollen rupture.Conclusion:The findings presented in this article highlight the importance of including ruptured pollen and time-resolved analysis to forecast ETSA events and thus save lives.

In November 2016, an unprecedented epidemic thunderstorm asthma event in Victoria, Australia, resulted in many thousands of people developing breathing difficulties in a very short period of time, including 10 deaths, and created extreme demand across the Victorian health services. To better prepare for future events, a pilot forecasting system for epidemic thunderstorm asthma (ETSA) risk has been developed for Victoria. The system uses a categorical risk-based approach, combining operational forecasting of gusty winds in severe thunderstorms with statistical forecasts of high ambient grass pollen concentrations, which together generate the risk of epidemic thunderstorm asthma. This pilot system provides the first routine daily epidemic thunderstorm asthma risk forecasting service in the world that covers a wide area, and integrates into the health, ambulance, and emergency management sector. Epidemic thunderstorm asthma events have historically occurred infrequently, and no event of similar magnitude has impacted the Victorian health system since. However, during the first three years of the pilot, 2017–19, two high asthma presentation events and four moderate asthma presentation events were identified from public hospital emergency department records. The ETSA risk forecasts showed skill in discriminating between days with and without health impacts. However, even with hindsight of the actual weather and airborne grass pollen conditions, some high asthma presentation events occurred in districts that were assessed as low risk for ETSA, reflecting the challenge of predicting this unusual phenomenon.

Grass pollens have been identified as mediators of respiratory distress, capable of exacerbating respiratory diseases including epidemic thunderstorm asthma (ETSA). It is hypothesised that during thunderstorms, grass pollen grains swell to absorb atmospheric water, rupture, and release internal protein content to the atmosphere. The inhalation of atmospheric grass pollen proteins results in deadly ETSA events. We sought to identify the underlying cellular mechanisms that may contribute towards the severity of ETSA in temperate climates using Timothy grass (Phleum pratense). Respiratory cells exposed to Timothy grass pollen protein extract (PPE) caused cells to undergo hypoxia ultimately triggering the subcellular re-organisation of F-actin from the peri junctional belt to cytoplasmic fibre assembly traversing the cell body. This change in actin configuration coincided with the spatial reorganisation of microtubules and importantly, decreased cell compressibility specifically at the cell centre. Further to this, we find that the pollen-induced reorganisation of the actin cytoskeleton prompting secretion of the pro-inflammatory cytokine, interleukin-8. In addition, the loss of peri-junctional actin following exposure to pollen proteins was accompanied by the release of epithelial transmembrane protein, E-cadherin from cell-cell junctions resulting in a decrease in epithelial barrier integrity. We demonstrate that Timothy grass pollen regulates F-actin dynamics and E-cadherin localisation in respiratory cells to mediate cell-cell junctional integrity highlighting a possible molecular pathway underpinning ETSA events.

Epidemic thunderstorm asthma has been reported to have occurred around twenty times over the past three decades in locations around the world. Thunderstorm asthma events are characterized by a significant increase in asthma presentations, which on occasion can overwhelm local medical services and result in fatalities. Thunderstorm asthma (TA) typically presents during an aeroallergen season in individuals, sensitized to perennial rye grass pollen (RGP) in Australia, in combination with meteorological factors such as thunderstorms and lightning activity. Short acting beta agonist (SABA) only treatment is sub-optimal therapy for prevention of asthma exacerbations. The combined treatment includes inhaled corticosteroids (ICS) and SABA but is found to be contentious. So the present review focuses on suitable alternative, short acting muscarinic antagonist (SAMA), Ipratropium bromide and its efficacy on the management of allergic asthma. Salbutamol induces bronchodilation rapidly but it elicits profound cardiovascular event as the side effects. Meanwhile, ipratropium also has equivalent effect of salbutamol with low side effect profile. Ipratropium also minifies the asthmatic response to grass pollen, allergen induced bronchoconstriction. Further, it also reduces allergen induced early and late asthmatic response and also inhibits the response towards histamine inhalation. In this regard, ipratropium may be considered as a suitable agent in the management of thunderstorm asthma and future trials are highly warranted. Keywords: Thunderstorm asthma, grass pollen, rye grass, short acting beta agonist, Ipratropium bromide

On 21 November 2016, parts of Victoria experienced a devastating epidemic thunderstorm asthma (ETSA) event. Theaim of this study was to describe theepidemiology and burden of the 2016 ETSA event atMedicineInsight-registered general practices in the Melbourne metropolitan area in Victoria, Australia. A cross-sectional study was conducted using patient record data from 21-23 November 2016. Codes were developed to identify all patients presenting to MedicineInsight-registered general practices with asthma during the 2016 ETSA event. During the event, there were 787 moreasthma-related encounters to MedicineInsight general practices than expected, which represented a 7.1-fold increase (605% increase). Estimates suggest that there were between approximately 8940 and 13,689 more asthma-related encounters than expected across metropolitan Melbourne. General practices were significantly affected by the 2016 ETSA event. This work highlights the important part that general practices play in responding to ETSA events and the need for these practices to be prepared to respond.

BackgroundTemperate grass (eg, ryegrass) pollen is a major driver of seasonal allergic rhinitis (SAR) and asthma risks, including thunderstorm asthma. Data for the effectiveness of temperate grass pollen allergen immunotherapy (AIT) in SAR patients from the southern hemisphere, who are frequently polysensitized to subtropical grass pollens, are limited. The 300 IR 5-grass pollen sublingual immunotherapy tablet (300 IR 5-grass SLIT) is known to be effective in polysensitized SAR patients with primary allergy to temperate grasses, however, the influence of polysensitization to subtropical grass pollen on treatment responses has yet to be specifically addressed. Key aims of this study were to measure patient treatment satisfaction during 300 IR 5-grass SLIT treatment and evaluate how polysensitization to subtropical grass pollens affects treatment responses.MethodsA prospective observational study was conducted in 63 patients (aged ≥5 years) in several temperate regions of Australia prescribed 300 IR 5-grass SLIT for SAR over 3 consecutive grass pollen seasons. Ambient levels of pollen were measured at representative sites. Patient treatment satisfaction was assessed using a QUARTIS questionnaire. Rhinoconjunctivitis Total Symptom Score (RTSS) and a Hodges-Lehmann Estimator analysis was performed to evaluate if polysensitization to subtropical grass pollen affected SAR symptom intensity changes during SLIT.ResultsA diagnosis of ryegrass pollen allergy was nearly universal. There were 74.6% (47/63) polysensitized to subtropical and temperate grass pollens. There were 23.8% (15/63) monosensitized to temperate grass pollens. From the first pollen season, statistically significant improvements occurred in SAR symptoms compared with baseline in both monosensitized and polysensitized patients, particularly in those polysensitized (P = 0.0297). Improvements in SAR symptoms were sustained and similar in both groups in the second and third pollen seasons, reaching 70–85% improvement (P < 0.01). Polysensitized patients from both northerly and southerly temperate regions in Australia showed similar improvements. Grass pollen counts in both regions were consistently highest during springtime.Conclusions300 IR 5-grass SLIT is effective in a real-life setting in SAR patients in the southern hemisphere with primary allergy to temperate grass pollen and predominantly springtime grass pollen exposures. Importantly, SLIT treatment effectiveness was irrespective of the patient's polysensitization status to subtropical grass pollens.

Are convergence lines associated with high asthma presentation days? A case-control study in Melbourne, Australia

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How Can <i>IJDS</i> Authors, Reviewers, and Editors Use (and Misuse) Generative AI?

Getting AI Right: Introductory Notes on AI &amp; Society

A major thunderstorm asthma epidemic struck Melbourne and surrounding Victoria, Australia, on 21 November 2016, which led to multiple deaths, a flood of residents seeking medical attention for respiratory problems, and an overwhelmed emergency management system. This case day had all the classic ingredients for an epidemic, including high rye grass pollen concentrations, a strong multicellular thunderstorm system moving across the region, and a large population of several million people in the vicinity of Melbourne. A particular characteristic of this event was the strong, gusty winds that likely spread the pollen grains and/or allergenic contents widely across the region to increase population exposure. This exploratory case study is the first to examine the usefulness of low-to-middle-atmospheric thermodynamic information for anticipating epidemic thunderstorm asthma outbreaks by allowing the forecast of strong downdraft winds. The authors investigated the utility of several mesoscale products derived from atmospheric soundings such as downdraft convective available potential energy (DCAPE) and indices for predicting surface wind gusts such as microburst wind speed potential index (MWPI) and a wind gust index (GUSTEX). These results indicate that DCAPE levels reached “high” to “very high” thresholds for strong downdraft winds in the lead-up to the thunderstorm, and the MWPI and GUSTEX indices accurately predicted the high maximum surface wind observations. This information may be useful for diagnostic and prognostic assessment of epidemic thunderstorm asthma and in providing an early warning to health practitioners, emergency management officials, and residents in affected areas.

We may have to soon decide what kind of Artificial General Intelligence (AGI) computers we will build and how they will coexist with humans. Many predictions estimate that artificial intelligence will surpass human intelligence during this century. This poses a risk to humans: computers may cause harm to humans either intentionally or unintentionally. Here we outline a possible democratic society structure that will allow both humans and artificial general intelligence computers to participate peacefully in a common society.There is a potential for conflict between humans and AGIs. AGIs set their own goals which may or may not be compatible with the human society. In human societies conflicts can be avoided through negotiations: all humans have the about the same world view and there is an accepted set of human rights and a framework of international and national legislation. In the worst case, AGIs harm humans either intentionally or unintentionally, or they can deplete the human society of resources.So far, the discussion has been dominated by the view that the AGIs should contain fail-safe mechanisms which prevent conflicts with humans. However, even though this is a logical way of controlling AGIs we feel that the risks can also be handled by using the existing democratic structures in a way that will make it less appealing to AGIs (and humans) to create conflicts.The view of AGIs that we use in this article follows Kantian autonomy where a device sets goals for itself and has urges or drives like humans. These goals may conflict with other actors’ goals which leads to a competition for resources. The way of acting and reacting to other entities creates a personality which can differ from AGI to AGI. The personality may not be like a human personality but nevertheless, it is an individual way of behaviour.The Kantian view of autonomy can be criticized because it neglects the social aspect. The AGIs’ individual level of autonomy determines how strong is their society and how strongly integrated they would be with the human society. The critic of their Kantian autonomy is valid, and it is here that we wish to intervene.In Kantian tradition, conscious humans have free will which makes them morally responsible. Traditionally we think that computers, like animals lack free will or, perhaps, deep feelings. They do not share human values. They cannot express their internal world like humans. This affects the way that AGIs can be seen as moral actors. Often the problem of constraining AGIs has used a technical approach, placing different checks and designs that will reduce the likelihood of adverse behaviour towards humans. In this article we take another point of view. We will look at the way humans behave towards each other and try to find a way of using the same approaches with AGIs.