limited from consuming the food products that declare the pres-ence of food allergens. Now they also have to avoid food productslabeled with allergy advisory statements. This severely limits theirchoices of food products and further adds to their parents’ frustra-tion, especially knowing that possibly 90% or more of these foodproducts with allergy advisory statements actually do not containfood allergens. Although further data are needed on the prevalenceof milk, egg, soy, or wheat allergens in food products labeled withallergy advisory statements, it would seem reasonable to placemore responsibility on the food companies to accurately measurethe amount of food allergens in their products and to provideclearer information for parents or patients with food allergy.

Peck Y. Ong, MD

From the Division of Clinical Immunology/Allergy, Children’s Hospital Los Angeles,

and the Department of Pediatrics, University of Southern California Keck School

of Medicine, Los Angeles, Calif. E-mail: pyong@chla.usc.edu.

Disclosure of potential conflict of interest: The author has declared that he has no conflict

of interest.

REFERENCE

1. Hefle SL, Furlong TJ, Niemann L, Lemon-Mule H, Sicherer S, Taylor SL. Consumer

attitudes and risks associated with packaged foods having advisory labeling regard-

ing the presence of peanuts. J Allergy Clin Immunol 2007;120:171-6.

Available online January 3, 2008.doi:10.1016/j.jaci.2007.11.006

Reply

To the Editor:I am quite sure that many of the readers of our article1 share the

perspective of Dr Ong.2 Certainly, patients with peanut allergy arefrustrated by the proliferation of food products bearing advisorylabels for peanuts. Our data showing that 90% of such productscontain no detectable peanut protein surely adds to the frustration.No wonder that increasing numbers of patients with peanutallergy are ignoring advisory labels and consuming such pro-ducts, as shown in Fig 1 of our article. Yet let me emphasizethat these patients are taking a risk when they choose to ingestproducts bearing advisory labels. The potential risk of experienc-ing allergic reactions on 1 of every 10 or even every 100 occasionsis unacceptable. Certainly, I would agree with Dr Ong that thefood industry should analyze such products for residual peanutand only put advisory labels on products where such a quantitativerisk assessment would indicate some level of risk. However, theUS Food and Drug Administration has not established a safethreshold level for peanut residues in foods. Because there is noestablished guidance on safe levels, the food industry choosesto err on the side of consumer safety. It is important to emphasizethat we only analyzed 2 samples of each product, and therefore wecannot categorically state that a particular product never containsdetectable peanut residues. If particulate peanut contamination ispossible because of use of shared processing equipment, then theoccasional spike of peanut residue could occur, leading to somepackages of potentially hazardous product that would justify theadvisory label; we might just have missed selecting such samples.Finally, I would note that my laboratory intends to conduct a sim-ilar survey for detectable residues of peanut in packaged foodsbearing advisory levels to ascertain whether trends are changingover time. Furthermore, my laboratory is currently conductingan analytic survey of products bearing advisory labels for milk.

Steve L. Taylor, PhD

From the Food Allergy Research and Resource Program, Department of Food Science

and Technology, University of Nebraska, Lincoln, Neb. E-mail: staylor2@unl.edu.

Disclosure of potential conflict of interest: S. L. Taylor has received grant support from

Advance Food Company; Agrana Fruit US, Inc; Ajinomoto Corporate Services, LLC;

Amy’s Kitchen, Inc; Archer Daniels Midland Company; Barry Callebaut; Ben &

Jerry’s Homemade, Inc; Blommer Chocolate Company, Inc; Blue Diamond Growers;

Bodendorfer-Johnson, LLC; Bunge Milling, Inc; Cadbury; Campbell Soup Company;

Cargill, Inc; Charm Sciences, Inc; Chr. Hansen, Inc; Coca-Cola Company; ConAgra

Foods, Inc; Continental Mills, Inc; Danone Research; DSM Nutritional Products;

Ecolab, Inc; General Mills, Inc; Gerber Products Company; Givaudan Flavors

Corporation; H. C. Brill Company, Inc; Hershey Foods Corporation; H. J. Heinz

Company; John B. Sanfilippo & Son, Inc; Kellogg Company; Kerry Ingredients;

Keystone Foods, LLC; Kraft Foods Global, Inc; Lallemand, Inc; Malt-O-Meal

Company; Manildra Group USA; MARS Snackfood US, LLC; McCormick & Co,

Inc; Neogen Corporation; Nestec Ltd.–Nestle USA; Newly Weds Foods, Inc; Norland

Products, Inc; Oscar Mayer; PepsiCo, Inc; Proctor and Gamble; Ralston Foods;

R-Biopharm, Inc; Sara Lee Corporation; Schweppes Americas’ Beverages; Sensient

Flavors, Inc; The Solae Company, LLC; Tate & Lyle Unilever; and Wm. Wrigley Jr.

Company.

REFERENCES

1. Hefle SL, Furlong TJ, Niemann L, Lemon-Mule H, Sicherer S, Taylor SL. Consumer

attitudes and risks associated with packaged foods having advisory labeling

regarding the presence of peanuts. J Allergy Clin Immunol 2007;120:171-6.

2. Ong PY. Are allergy advisory statements helpful to patients with food allergy?

J Allergy Clin Immunol 2008;121:536-7.

Available online January 21, 2008.doi:10.1016/j.jaci.2007.11.007

J ALLERGY CLIN IMMUNOL

VOLUME 121, NUMBER 2

CORRESPONDENCE 537

Thunderstorm-related asthma: Not only grasspollen and spores

To the Editor:In the September 2007 issue of the Journal, Pulimood et al1

suggest sensitization to Alternaria species to play a key role inthunderstorm-related asthma. In the editorial of the same issue,Marks and Bush2 provide a review of environmental factors in-volved in asthma epidemics, listing 4 necessary conditions tomake them possible.2 In the list they cited fungal spores and grasspollen as the unique airborne allergens (points 1, 2, and 3) that areimplicated in the pathogenesis of thunderstorm-related asthma.This is not completely true. During the episode registered inNaples on June 4, 2004 (between 1:30 and 2:00 AM), 6 adults (3women and 3 men between 38 and 60 years old) and a girl of11 years had attacks of severe bronchial asthma, and the attackwas nearly fatal in one case.3,4 This is the first report of thunder-storm-related asthma in the Mediterranean area. All patientsreceived treatment in emergency departments, and one was ad-mitted to an intensive care unit for very severe bronchial obstruc-tion and acute respiratory insufficiency. All subjects wereoutdoors when the thunderstorm struck. None of the 7 subjectsregularly took antiallergy drugs, antiasthma drugs, or both, con-firming the findings of Pulimood et al.1 Four had a history ofasthma, whereas 2 had a history of only rhinitis. We found thatall 7 patients were sensitized, with allergic respiratory symptomson exposure, to Parietaria species pollen but were not sensitizedto grasses or other aeroallergens, such as other pollen grains andmolds.3,4 Parietaria species is an urticacea weed that is wide-spread in the Naples and Mediterranean area, with a spring andsummer pollen season in part contemporaneous with that ofgrasses.5,6 During the thunderstorm, the concentration of airborneParietaria species pollen grains was particularly high, with a peakof 144 grains/m3 being recorded on June 3, whereas airborne con-centrations of grasses and Alternaria species were very low. Airpollution levels for both gaseous and particulate componentsbased on the hourly concentrations of nitric dioxide, ozone, andrespirable particulate matter were not particularly high in Napleson June 3 and 4. There is clear evidence that Parietaria species

Intranasal corticosteroids reduce ocular symp-toms of allergic rhinitis as a class effect

To the Editor:In their study of fluticasone furoate nasal spray, Kaiser et al1

make an important but possibly underappreciated contributionto the growing amount of evidence demonstrating that intranasalcorticosteroids (INSs), as a class, reduce the ocular symptomsassociated with allergic rhinitis (AR). Unfortunately, the authorsconcluded that ‘‘older INSs failed to show consistent efficacy forocular symptoms in adult subjects with SAR’’ (seasonal allergicrhinitis), and characterized fluticasone propionate (FP) and mo-metasone furoate (MF) nasal sprays as ‘‘older’’ INSs. However,the literature supports the positive effect on ocular allergy symp-toms of older INS agents as a class effect. One possible reason thatolder studies may not have consistently shown a positive effect forocular symptoms is that those studies did not focus on the oculardomain of allergy symptoms, but combined all symptoms into asingle component of the total nonnasal symptom score. However,studies published over the past 5 years with FP, MF, budesonide,triamcinolone acetonide, and beclomethasone dipropionate havecollected and reported ocular allergy signs and symptomsseparately.

In the article by Bernstein et al2 cited by Kaiser et al,1 a 28-daystudy comparing FP, oral loratadine, and placebo found that sub-jects treated with FP had statistically significant decreases com-pared with placebo in the total ocular symptom score, whichwas the sum of scores for the symptoms of itching (pruritus), tear-ing (epiphora), and redness (erythema). The data also suggestedthat FP had reduced ocular symptoms more than or comparableto oral loratadine.

The positive effect of MF on ocular allergy symptoms was seenin an analysis of pooled data from 4 randomized blind studies.Subjects who received MF had significantly greater reductions in

J ALLERGY CLIN IMMUNOL

FEBRUARY 2008

538 CORRESPONDENCE

pollen was a risk factor for an asthma epidemic during the thun-derstorm in Naples, with a close temporal association between thearrival of the thunderstorm, a major increase in the concentrationof Parietaria species pollen grains, and the onset of the epidemic.

We completely agree with Marks and Bush2 about the ‘‘4 nec-essary conditions’’ for asthma epidemics, but more than fungalspores and grass pollen have to be taken into consideration. Thesame mechanisms might involve other pollen grains in differentgeographic areas, depending on the seasonality of thunderstormsand allergenic pollen.

Gennaro D’Amato, MDa

Lorenzo Cecchi, MDb

Gennaro Liccardi, MDa

From athe Division of Respiratory and Allergic Diseases, Department of Respiratory

Diseases, High Specialty Hospital A. Cardarelli, Naples, Italy, and bthe Interdepart-

mental Centre of Bioclimatology, University of Florence, Florence, Italy.

Disclosure of potential conflict of interest: The authors have declared that they have no

conflict of interest.

REFERENCES

1. Pulimood TB, Corden JM, Bryden C, Sharples L, Nasser SM. Epidemic asthma and

the role of the fungal mold Alternaria alternata. J Allergy Clin Immunol 2007;120:

610-7.

2. Marks GB, Bush RK. It’s blowing in the wind: new insights into thunderstorm-

related asthma. J Allergy Clin Immunol 2007;120:530-2.

3. D’Amato G, Liccardi G, Viegi G, Baldacci S. Thunderstorm-associated asthma in pol-

linosis patients. Available at: http://bmj.bmjjournals.com/cgi/eletters/309/6947/131/c.

Accessed December 7, 2007.

4. D’Amato G, Liccardi G, Frenguelli G. Thunderstorm-associated asthma in pollino-

sis patients. Allergy 2007;62:11-6.

5. D’Amato G, Ruffilli A, Ortolani C. Allergenic significance of Parietaria (pellitory-

of-the-wall) pollen. In: D’Amato G, Spieksma F, Bonini S, editors. Allergenic pollen

and pollinosis in Europe. Oxford: Blackwell Scientific Publications; 1991. p. 113-8.

6. D’Amato G, Cecchi L, Bonini S, Nunes C, Annesi-Maesano I, Behrendt H, et al.

Allergenic pollen and pollen allergy in Europe. Allergy 2007;62:976-90.

Available online January 3, 2008.doi:10.1016/j.jaci.2007.10.046

Reply

To the Editor:We thank D’Amato et al1 for drawing our attention to a thun-

derstorm-related asthma outbreak that was associated withanother pollen, in this case the weed pollen Parietaria species.We agree that the 4 conditions we outlined in our editorial2

need not only apply to grass pollens, although most previousreports do appear to have been linked to this form of pollen. How-ever, any pollen grains, grass, weed, or tree, that are abundant andcan rupture and release respirable allergenic starch granuleswould be expected to behave in a similar way in the presence ofa thunderstorm outflow.

Guy B. Marks, MBBS, PhDa

Robert K. Bush, MDb

From athe Woolcock Institute of Medical Research, Sydney, New South Wales, Australia,

and bthe William S. Middleton VA Hospital, Madison, Wis. E-mail: G.Marks@unsw.

edu.au.

Disclosure of potential conflict of interest: R. K. Bush has consulting arrangements with

Greer Laboratories and has received grant support from the National Institutes of

Health. G. B. Marks has declared that he has no conflict of interest.

REFERENCES

1. D’Amato G, Cecchi L, Liccardi G. Thunderstorm-related asthma: not only grass

pollen and spores. J Allergy Clin Immunol 2008;121:537-8.

2. Marks GB, Bush RK. It’s blowing in the wind: new insights into thunderstorm-

related asthma. J Allergy Clin Immunol 2007;120:530-2.

Available online January 21, 2008.doi:10.1016/j.jaci.2007.10.047

total ocular symptom score and the component symptoms ofitching, tearing, and redness than those who received placebo overthe entire 2-week course of the study, which was similar to thestudy by Kaiser et al.3,4 Mometasone furoate had an onset ofeffect starting at 24 hours of initiation of treatment.4

Ocular symptom scores also decreased significantly inpediatric patients with perennial AR after 1 year of treatmentwith budesonide,5 adolescents and adults with seasonal allergicrhinitis who received triamcinolone acetonide,6 and patientswith chronic rhinosinusitis with and without allergy given beclo-methasone dipropionate, which significantly improved oculartearing, itching, and redness as well as blepharedema.7

In conclusion, these clinical studies have demonstrated that manyof the INSs have a positive effect on the ocular symptoms of AR.The positive effect appears to be a class effect of INSs, and not, asKaiser et al1 imply, solely an attribute of fluticasone furoate. Theresults of the studies conducted with the other older INSs and theresults of the study by Kaiser et al1 indicate that all of these agentsmay have a similar positive effect on the ocular symptoms of AR.

Leonard Bielory, MD

From the Departments of Medicine, Pediatrics, Ophthalmology, and Visual Sciences,

Division of Allergy, Immunology and Rheumatology, New Jersey Medical School,

Newark, NJ. E-mail: bielory@umdnj.edu.

Disclosure of potential conflict of interest: L. Bielory has consulting arrangements with

Schering-Plough, GlaxoSmithKline, Merck, Novartis, Sanofi-Aventis, Genentech,

UCB Pharma, MedPointe, Inspire, and Vistakon and has received grant support from

Pfizer, Forest, Schering-Plough, GlaxoSmithKline, Merck, Novartis, Sanofi-Aventis,