Health impact of Ambrosia artemisiifolia reflected by allergists practice in Romania. A questionnaire –based survey

Abstract

Ambrosia artemisiifolia (ragweed) is an invasive weed with pollen representing one of the most potent seasonal aeroallergenes. Romania is considered a ragweed infested country, based on field observations performed in different regions, pollen counts done in the West region and some clinical reports from allergists in the West and South parts. The aim of this paper is to evaluate the situation of allergies induced by Ambrosia artemisiifolia from the perspective of allergists practice in Romania and to draw some conclusions regarding consequences and possible measures to reduce this burden. The study was based on a questionnaire addressed to allergists attending the national annual allergology conference in 2013. The answers showed that part of the allergists are aware of the importance of allergies induced by Ambrosia pollen. We concluded that research projects in this field, application of eradication measures and public information are important for increase awareness of people about health impact of Ambrosia pollen in Romania. KEY WORDS: allergy, Ambrosia artemisiifolia, health impact

Full text

Annals of West University of Timişoara, ser. Biology, 2015, vol XVIII (1), pp. 43-54
43
HEALTH IMPACT OF AMBROSIA ARTEMISIIFOLIA
REFLECTED BY ALLERGISTS PRACTICE IN ROMANIA. A
QUESTIONNAIRE –BASED SURVEY
Polliana Mihaela LERU
1
, Dumitru MATEI
1
, Nicoleta IANOVICI
2
1
Carol Davila University of Medicine and Pharmacy Bucharest, Romania
2
West University of Timisoara, Faculty of Chemistry-Biology-Geography, Department of
Biology and Chemistry, Pestalozzi 16, Timisoara, Romania
Corresponding author e-mail:
polianaleruu@yahoo.com
Received 29 December 2014; accepted 27 May 2015
ABSTRACT
Ambrosia artemisiifolia (ragweed) is an invasive weed with pollen representing one of
the most potent seasonal aeroallergenes. Romania is considered a ragweed infested
country, based on field observations performed in different regions, pollen counts
done in the West region and some clinical reports from allergists in the West and
South parts. The aim of this paper is to evaluate the situation of allergies induced by
Ambrosia artemisiifolia from the perspective of allergists practice in Romania and to
draw some conclusions regarding consequences and possible measures to reduce this
burden. The study was based on a questionnaire addressed to allergists attending the
national annual allergology conference in 2013. The answers showed that part of the
allergists are aware of the importance of allergies induced by Ambrosia pollen. We
concluded that research projects in this field, application of eradication measures and
public information are important for increase awareness of people about health
impact of Ambrosia pollen in Romania.
KEY WORDS: allergy, Ambrosia artemisiifolia, health impact
INTRODUCTION
Respiratory allergic diseases, mainly allergic rhinitis and asthma represent an
important health problem in Europe. It is estimated that about 40% of European
population suffer different forms of pollen-induced allergies. Pollen-induced allergies
have an increasing trend and significant consequences on quality of life of sensitized
population. Climate changes, cultural factors, changes in agricultural practice and
intensification of international traffic are contributing to the expansion of some
allergenic pollens, such as Ambrosia artemisiifolia (ragweed) in many European
countries rise important problems for both national health systems and European
authorities (D'Amato et al, 2007). Biodiversity loss, exposure to ozone and air
pollution has also been shown to influence allergic disease (Oswalt & Marshall, 2008;
Haahtela et al, 2013). Artificial environment with life style in urban areas may
contribute to increasing frequency of respiratory allergy and asthma (D'Amato, 2011).
Ambrosia artemisiifolia is one of the most common causes of respiratory
allergy in North America. Over 20% of people in the United States are sensitized to

LERU et al: Health impact of Ambrosia artemisiifolia reflected by allergists practice in Romania. A questionnaire –
based survey
44
ragweed pollen and this percentage is rising (Katz & Care, 2014). The efforts to
‘‘eradicate’’ ragweed from several regions in the United States were unsuccessful
(Oswalt & Marshall, 2008).
The expansion of ragweed species into European countries has been well has
been documented. In Europe, the countries with the highest concentrations of ragweed
are Hungary, Romania, Serbia, Croatia, Slovenia, Slovakia, Ukraine, France (Rhône-
Alpes region and Burgundy), Italy (north-western Milan and south Varese) and the
south-western part of the European Russia (Juhasz et al, 2004; Peternel et al, 2006;
Reznik, 2009; Šikoparija et al, 2009; Thibaudon et al, 2010; Skjøth et al, 2010;
Rodinkova et al, 2012; Bonini et al, 2012; Ianovici et al, 2013). Less extended habitat
areas with smaller pollen levels occur in Switzerland (Clot et al, 2002), Germany (Zink
et al, 2012), Czech Republic (Rybníček et al, 2000), Poland (Kasprzyk et al, 2011),
Bulgaria (Yankova et al, 2000), Austria (Jäger, 2000), Lithuania (Šaulienė &
Veriankaitė, 2012), Spain (Fernandez-Llamazares et al, 2012), Sweden (Dahl et al,
1999), United Kingdom, Denmark, Belgium (Bullock et al, 2010). The human health
impacts were estimated to affect around 4 million people with total estimated medical
costs of €2,136 million per year for European countries (Bullock et al, 2010).
Ragweed is an annual, herbaceous and wind-pollinated plant. This dangerous
invasive non-native plant in Europe has a wide ecological tolerance and can colonize a
large range of disturbed habitats (Kazinczi et al, 2008). They can reach average
densities of up to 16 plants per m
2
(Simard & Benoit, 2010). Is a prolific producer of
pollen and long distance transport is possible and can be a significant source of
allergenic pollen at great distances (Makra et al, 2011; Šikoparija et al, 2013). A single
plant can generate an average of 3000 to 6000 seeds (D'Amato et al, 2007). Its
invasion is also facilitated by it’s the lack of natural enemies (MacKay & Kotanen,
2008) and the high genetic variability of invasive populations (Chun et al, 2010).
Ambrosia has less sensitivity to herbicides than other weeds (Patzoldt et al, 2001).
The aim of this paper is to evaluate the situation of allergies induced by
Ambrosia artemisiifolia from the perspective of allergists practice in Romania.
MATERIALS AND METHODS
A questionnaire with 20 questions was addressed to the 150 allergists
attending the annual National Allergology Conference in 2013. We obtained a number
of 50 completed questionnaires, representing a 30% response rate. The gender and age
distribution was 78% women and 22% men. Regarding the place of work, 22% of
allergists worked in hospitals, 44% in ambulatory and 34% in both hospital and
ambulatory. The monthly patient population is equally represented by adults and
children for almost half of the allergists.

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45
RESULTS AND DISCUSSIONS
The most frequent diseases encountered in allergists practice are allergic
rhinitis for all responders, followed by conjunctivitis and urticaria for 98%, athma for
84% and dermatitis for 62% of allergists (Fig.1).
Regarding the importance of respiratory allergies induced by Ambrosia
artemisiifolia pollen, 94% of respondents considered it important or very important
(Fig.2) and 84% considered Ambrosia a health problem in Romania (Fig.3).
Regarding the number of patients with hypersensitivity and/or allergy to
Ambrosia in their current recordings, 64% of responders had more than 20 patients and
36% had less than 10 patients (Fig.4).
The proportion of pollinosis induced by Ambrosia was considered to be 20%
by 52% of responders, more than 30% by 34% and less than 10% by 24% of allergists
(Fig.5).
Referring to the regions of Romania where Ambrosia is mostly spread, 62% of
allergists considered the West, 30% the South, 24 % the North and 10% the East
(Fig.6). The distribution between rural and urban areas was considered equal by 52%
and predominantly rural by 36% of responders (Fig.7).
To the question about factors that have influenced the spread of Ambrosia
artemisiifolia in Romania, 40% of responders considered first the abandoned land and
buildings, followed by pollution by 20% and climate change by 24%, while 16% did
not know (Fig.8).
The diagnosis of allergies induced by Ambrosia pollen is based on skin prick
tests for 72% of allergists, on anamnesis for 8% and on serum specific IgE for 5%
(Fig.9). The recommended treatment is mainly antihistamines for 60% and
immunotherapy for 22% of responders (Fig.13).
The answer to the question regarding prevention of allergies induced by
Ambrosia revealed that 64% of allergists did not know any measure, while 20% agree
some eradication measures and 8% mentioned public information (Fig. 11).
The factors responsible for reducing health impact of Ambrosia in Romania
are equally considered Health Ministry, allergy clinics and doctors by 32% responders
for each (Fig. 12).
Referring to research projects in the field of allergy to Ambrosia, 96% of
allergists considered them useful and important (Fig.13) and 62% expressed their
interest to be involved in such projects (Fig.14).

LERU et al: Health impact of Ambrosia artemisiifolia reflected by allergists practice in Romania. A questionnaire –
based survey
46
62%
84%
98%
98%
100%
0% 20% 40% 60% 80% 100%
dermatitis
asthma
hives
conjunctivitis
rhinitis
FIG. 1 Recorded answers to the question “How many patients with allergic diseases do you see monthly ?”
2%
4%
34%
60%
0% 20% 40% 60% 80% 100%
do not know
less important
highly important
important
FIG.2 Recorded answers to the question „How do you consider the importance of allergies induced by Ambrosia
artemisiifolia pollen in Romania?”
do not know; 14%
yes; 84%
no; 2%
do not know
yes
no
FIG. 3 Recorded answers to the question “Do you believe that Ambrosia artemisiifolia represents a real danger for
human health in Romania?”

Annals of West University of Timişoara, ser. Biology, 2015, vol XVIII (1), pp. 43-54
47
0%
4%
6%
14%
36%
40%
0% 20% 40% 60% 80% 100%
do not know
>100%
30-50%
>50%
<10%
20-30%
FIG. 4 Recorded answers to the question “How many patients with hypersensitivity or clinical allergy to Ambrosia do
you have in medical recordings?”
24%
52%
8%
10%
6%
0%
0% 20% 40% 60% 80% 100%
<10%
20%
30%
>30%
50%
Do not know
percentage
FIG. 5 Recorded answers to the question “What percentage of the patients with pollinosis do you attribute to Ambrosia
pollen in Romania?”
2%
8%
10%
24%
30%
62%
0% 20% 40% 60% 80% 100%
do not know
center
east
north
south
west
FIG. 6 Recorded answers to the question “In what regions of Romania do you think that Ambrosia pollen is more
prevalent?”

LERU et al: Health impact of Ambrosia artemisiifolia reflected by allergists practice in Romania. A questionnaire –
based survey
48
0%
12%
36%
52%
0% 20% 40% 60% 80% 100%
exclusively rural areas
do not know
mostly rural areas
equal rural-urban
areas
FIG. 7 Recorded answers to the question “How do you appreciate the spread of Ambrosia in rural versus urban
environment in Romania?”
12%
12%
16%
20%
40%
0% 20% 40% 60% 80% 100%
climate
enviromental warming
do not know
pollution
unsuded land,
abandoned buildings
FIG. 8 Recorded answers to the question “What factors do you consider that may influence the spread Ambrosia in
Romania?”
5%
8%
72%
0% 20% 40% 60% 80% 100%
IgE specific
anamnesis
Prick test
FIG. 9 Recorded answers to the question “What diagnostic tools do you currently use to confirm hypersensitivity /
allergy induced by Ambrosia in your practice?”

Annals of West University of Timişoara, ser. Biology, 2015, vol XVIII (1), pp. 43-54
49
18%
22%
60%
0% 20% 40% 60% 80% 100%
others treatments
immunotherapy
antihistamines
FIG. 10 Recorded answers to the question “How you treat patients with allergies induced by Ambrosia in your current
clinical practice?”
others measures;
8%
public information;
8%
plan eradication;
20%
do not know; 64%
others measures
public information
plan eradication
do not know
FIG.11 Recorded answers to the question “What measures should be taken to prevent allergies caused by Ambrosia?”
do not know
4%
allergy clinics
32%
doctors
32%
Ministry of Health
32%
FIG. 12 Recorded answers to the question “What are the main responsible factors for reducing the Ambrosia impact on
human health (listed in descending order of responsibility)?”

LERU et al: Health impact of Ambrosia artemisiifolia reflected by allergists practice in Romania. A questionnaire –
based survey
50
do not know; 4%
no; 0%
yes; 96%
do not know
no
yes
FIG. 13 Recorded answers to the question “Do you consider relevant for your practice to develop national and/or
international research projects refering to Ambrosia impact and management?”
no; 2%
do not know; 36%
yes; 62%
no
do not know
yes
FIG. 14 Recorded answers to the question „Are you interested to be involved in any research project about the impact
assessment of Ambrosia pollen on human health?”
The answers highlight some gaps in knowledge about this aeroallergen, in the
evaluation of the role of the allergens in sensibilisation, in the orientation of specific
prophylaxis measures, in the directing of immediate and long term therapeutic plans,
including specific immunotherapy with allergens vaccine.
Romania is considered a ragweed infested country, based on field observations
performed in different regions and some clinical reports from allergists in the West,
North-West and South parts (Ianovici et al, 2009; Bocsan et al, 2010; Popescu &
Tudose, 2011; Bocsan et al, 2012; Ianovici et al, 2013; Panaitescu et al, 2014;
Florincescu-Gheorghe et al, 2014). Till now it has indicated from all Romanian
provinces. The spreading of the Ambrosia artemisiifolia has been studied by a high
number of romanian biologists and many articles have been written on this topic
(Sîrbu, 2008; Ianovici, 2009; Ianovici, 2011; Andrei & Ianovici, 2011). Ragweed is
common along roadsides, railway embankments, cultivated fields, vacant lots,
construction sites and pastures. The infestations on waste land or roadsides are rarely
controlled. The pollination season in Romania begins in July and ends in October, with

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51
maximum in August and September. Increasing concentrations of pollen in the
atmosphere has been reported since 2000 (Faur et al, 2001; Faur & Ianovici, 2001;
Juhasz et al, 2001; Ianovici & Faur, 2001). The annual pollen counts show an
increasing tendency, indicating an increased local population (Ianovici & Sirbu, 2007;
Ianovici, 2014).
Ambrosia artemisiifolia is an invasive weed with pollen representing one of
the most potent seasonal aeroallergenes. There are 22 known allergens, with 6
considered major (Laaidi et al, 2003; Gadermaier et al, 2008). Ambrosia and Artemisia
plants are flowering nearly at the same time of the year. Ambrosia pollen cross react
with almost all other Asteraceae, especially with Artemisia pollen (Faur et al, 2001;
Asero et al, 2014). Throughout the pollen season, winds can carry pollen for many
miles and produce high concentrations in urban areas, far from their rural and suburban
sources. In another train of thoughts, the literature contains data that there are racial
inequities in the allergenic impact of this taxa (Wegienka et al, 2012). Research is
needed to determine which is the real prevalence of this allergy in the population of
our country. It is also necessary to determine which are the protein fractions
responsible for producing pollen allergy symptoms (Kanter et al, 2013). It requires the
intensified public information through media channels. It is necessary to create a
system to monitor pollen concentrations in the atmosphere since the only station
belonging West University of Timisoara is not enough. The use of temporary stations
has indicated high allergenic load for other areas of the country (Ianovici et al, 2013b).
Ambrosia pollen is the aetiological agent in about half of cases of pollinosis in
late summer-autumn. The sensitization rate for ragweed in Timisoara was 34% in 2009
(Ianovici et al, 2013a). The number of sensitized individuals might significantly
increase in the near future. Prevention of ragweed allergy depends on informing and
educating the public through reports and updates. Anthropogenic influence in the last
25 years has allowed excessive spread of this species in our country. But it is possible
that the influence of topography (latitude) and the climatic factors to be equally
important. Ambrosia plants are very widespread in Romania where having encountered
ideal conditions for their expansion (Ianovici, 2011; Ianovici & Sîrbu, 2013; Ianovici,
2015).
At present, Ambrosia pollen constitutes a serious allergological threat in
Romania. Limiting the expansion is made possible by plucking and repeated
mechanical cutting on public and private lands. Realizing the danger, must be the
urgent need for legislative action and to introduce anti-Ambrosia campaigns under the
control of the national and local authorities.
CONCLUSIONS
Our study showed that most of the allergists are aware of the importance of
allergies induced by Ambrosia pollen and of the danger represented by this invasive

LERU et al: Health impact of Ambrosia artemisiifolia reflected by allergists practice in Romania. A questionnaire –
based survey
52
weed. The real prevalence of sensitization and allergy to Ambrosia in Romania is not
known, the number of specialists and allergy centers is significantly lower than in
other European countries and there are no coherent measures to reduce its health
impact. Research projects in this field are considered useful and important and increase
awareness at national level looks imperative.
Acknowledgments
This study was supported by COST Action FA1203 “Sustainable management of Ambrosia artemisiifolia in
Europe” (SMARTER). The two authors (Polliana Leru and Nicoleta Ianovici) of the article are members of
Management Committee for Romania.
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