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Next-generation ARIA care pathways for rhinitis and asthma: a model for multimorbid chronic diseases

  • J. Jean BousquetEmail author
  • Holger J. Schünemann
  • Alkis Togias
  • Marina Erhola
  • Peter W. Hellings
  • Torsten Zuberbier
  • Ioana Agache
  • Ignacio J. Ansotegui
  • Josep M. Anto
  • Claus Bachert
  • Sven Becker
  • Martin Bedolla-Barajas
  • Michael Bewick
  • Sinthia Bosnic-Anticevich
  • Isabelle Bosse
  • Louis P. Boulet
  • Jean Marc Bourrez
  • Guy Brusselle
  • Niels Chavannes
  • Elisio Costa
  • Alvaro A. Cruz
  • Wienczyslawa Czarlewski
  • Wytske J. Fokkens
  • Joao A. Fonseca
  • Mina Gaga
  • Tari Haahtela
  • Maddalena Illario
  • Ludger Klimek
  • Piotr Kuna
  • Violeta Kvedariene
  • L. T. T. Le
  • Desiree Larenas-Linnemann
  • Daniel Laune
  • Olga M. Lourenço
  • Enrica Menditto
  • Joaquin Mullol
  • Yashitaka Okamoto
  • Nikos Papadopoulos
  • Nhân Pham-Thi
  • Robert Picard
  • Hilary Pinnock
  • Nicolas Roche
  • Regina E. Roller-Wirnsberger
  • Christine Rolland
  • Boleslaw Samolinski
  • Aziz Sheikh
  • Sanna Toppila-Salmi
  • Ioanna Tsiligianni
  • Arunas Valiulis
  • Erkka Valovirta
  • Tuula Vasankari
  • Maria-Teresa Ventura
  • Samantha Walker
  • Sian Williams
  • Cezmi A. Akdis
  • Isabella Annesi-Maesano
  • Sylvie Arnavielhe
  • Xavier Basagana
  • Eric Bateman
  • Anna Bedbrook
  • K. S. Bennoor
  • Samuel Benveniste
  • Karl C. Bergmann
  • Slawomir Bialek
  • Nils Billo
  • Carsten Bindslev-Jensen
  • Leif Bjermer
  • Hubert Blain
  • Mateo Bonini
  • Philippe Bonniaud
  • Jacques Bouchard
  • Vitalis Briedis
  • Christofer E. Brightling
  • Jan Brozek
  • Roland Buhl
  • Roland Buonaiuto
  • Giorgo W. Canonica
  • Victoria Cardona
  • Ana M. Carriazo
  • Warner Carr
  • Christine Cartier
  • Thomas Casale
  • Lorenzo Cecchi
  • Alfonso M. Cepeda Sarabia
  • Eka Chkhartishvili
  • Derek K. Chu
  • Cemal Cingi
  • Elaine Colgan
  • Jaime Correia de Sousa
  • Anne Lise Courbis
  • Adnan Custovic
  • Biljana Cvetkosvki
  • Gennaro D’Amato
  • Jane da Silva
  • Carina Dantas
  • Dejand Dokic
  • Yves Dauvilliers
  • Antoni Dedeu
  • Giulia De Feo
  • Philippe Devillier
  • Stefania Di Capua
  • Marc Dykewickz
  • Ruta Dubakiene
  • Motohiro Ebisawa
  • Yaya El-Gamal
  • Esben Eller
  • Regina Emuzyte
  • John Farrell
  • Antjie Fink-Wagner
  • Alessandro Fiocchi
  • Jean F. Fontaine
  • Bilun Gemicioğlu
  • Peter Schmid-Grendelmeir
  • Amiran Gamkrelidze
  • Judith Garcia-Aymerich
  • Maximiliano Gomez
  • Sandra González Diaz
  • Maia Gotua
  • Nick A. Guldemond
  • Maria-Antonieta Guzmán
  • Jawad Hajjam
  • John O’B Hourihane
  • Marc Humbert
  • Guido Iaccarino
  • Despo Ierodiakonou
  • Maddalena Illario
  • Juan C. Ivancevich
  • Guy Joos
  • Ki-Suck Jung
  • Marek Jutel
  • Igor Kaidashev
  • Omer Kalayci
  • Przemyslaw Kardas
  • Thomas Keil
  • Mussa Khaitov
  • Nikolai Khaltaev
  • Jorg Kleine-Tebbe
  • Marek L. Kowalski
  • Vicky Kritikos
  • Inger Kull
  • Lisa Leonardini
  • Philip Lieberman
  • Brian Lipworth
  • Karin C. Lodrup Carlsen
  • Claudia C. Loureiro
  • Renaud Louis
  • Alpana Mair
  • Gert Marien
  • Bassam Mahboub
  • Joao Malva
  • Patrick Manning
  • Esteban De Manuel Keenoy
  • Gailen D. Marshall
  • Mohamed R. Masjedi
  • Jorge F. Maspero
  • Eve Mathieu-Dupas
  • Poalo M. Matricardi
  • Eric Melén
  • Elisabete Melo-Gomes
  • Eli O. Meltzer
  • Enrica Menditto
  • Jacques Mercier
  • Neven Miculinic
  • Florin Mihaltan
  • Branislava Milenkovic
  • Giuliana Moda
  • Maria-Dolores Mogica-Martinez
  • Yousser Mohammad
  • Steve Montefort
  • Ricardo Monti
  • Mario Morais-Almeida
  • Ralf Mösges
  • Lars Münter
  • Antonella Muraro
  • Ruth Murray
  • Robert Naclerio
  • Luigi Napoli
  • Leila Namazova-Baranova
  • Hugo Neffen
  • Kristoff Nekam
  • Angelo Neou
  • Enrico Novellino
  • Dieudonné Nyembue
  • Robin O’Hehir
  • Ken Ohta
  • Kimi Okubo
  • Gabrielle Onorato
  • Solange Ouedraogo
  • Isabella Pali-Schöll
  • Susanna Palkonen
  • Peter Panzner
  • Hae-Sim Park
  • Jean-Louis Pépin
  • Ana-Maria Pereira
  • Oliver Pfaar
  • Ema Paulino
  • Jim Phillips
  • Robert Picard
  • Davor Plavec
  • Ted A. Popov
  • Fabienne Portejoie
  • David Price
  • Emmanuel P. Prokopakis
  • Benoit Pugin
  • Filip Raciborski
  • Rojin Rajabian-Söderlund
  • Sietze Reitsma
  • Xavier Rodo
  • Antonino Romano
  • Nelson Rosario
  • Menahenm Rottem
  • Dermot Ryan
  • Johanna Salimäki
  • Mario M. Sanchez-Borges
  • Juan-Carlos Sisul
  • Dirceu Solé
  • David Somekh
  • Talant Sooronbaev
  • Milan Sova
  • Otto Spranger
  • Cristina Stellato
  • Rafael Stelmach
  • Charlotte Suppli Ulrik
  • Michel Thibaudon
  • Teresa To
  • Ana Todo-Bom
  • Peter V. Tomazic
  • Antonio A. Valero
  • Rudolph Valenta
  • Marylin Valentin-Rostan
  • Rianne van der Kleij
  • Olivier Vandenplas
  • Giorgio Vezzani
  • Frédéric Viart
  • Giovanni Viegi
  • Dana Wallace
  • Martin Wagenmann
  • De Y. Wang
  • Susan Waserman
  • Magnus Wickman
  • Dennis M. Williams
  • Gary Wong
  • Piotr Wroczynski
  • Panayiotis K. Yiallouros
  • Arzu Yorgancioglu
  • Osman M. Yusuf
  • Heahter J. Zar
  • Stéphane Zeng
  • Mario Zernotti
  • Luo Zhang
  • Nan S. Zhong
  • Mihaela Zidarn
  • the ARIA Study Group
  • the MASK Study Group
Open Access
Review

Abstract

Background

In all societies, the burden and cost of allergic and chronic respiratory diseases are increasing rapidly. Most economies are struggling to deliver modern health care effectively. There is a need to support the transformation of the health care system into integrated care with organizational health literacy.

Main body

As an example for chronic disease care, MASK (Mobile Airways Sentinel NetworK), a new project of the ARIA (Allergic Rhinitis and its Impact on Asthma) initiative, and POLLAR (Impact of Air POLLution on Asthma and Rhinitis, EIT Health), in collaboration with professional and patient organizations in the field of allergy and airway diseases, are proposing real-life ICPs centred around the patient with rhinitis, and using mHealth to monitor environmental exposure. Three aspects of care pathways are being developed: (i) Patient participation, health literacy and self-care through technology-assisted “patient activation”, (ii) Implementation of care pathways by pharmacists and (iii) Next-generation guidelines assessing the recommendations of GRADE guidelines in rhinitis and asthma using real-world evidence (RWE) obtained through mobile technology. The EU and global political agendas are of great importance in supporting the digital transformation of health and care, and MASK has been recognized by DG Santé as a Good Practice in the field of digitally-enabled, integrated, person-centred care.

Conclusion

In 20 years, ARIA has considerably evolved from the first multimorbidity guideline in respiratory diseases to the digital transformation of health and care with a strong political involvement.

Keywords

Health care transformation Care pathways Rhinitis ARIA MASK POLLAR 

Abbreviations

AIRWAYS ICPs

integrated care pathways for airway diseases

AR

allergic rhinitis

ARIA

Allergic Rhinitis and its Impact on Asthma

BTS/SIGN

British Thoracic Society/Scottish Intercollegiate Guidelines Network

CRD

chronic respiratory diseases

EIP on AHA

European Innovation Partnership on Active and Healthy Ageing

EIT-Health

European Institute for Innovation and technology-Health

Euforea

European Forum for Research and Education in Allergy and Airway Diseases

GARD

Global Alliance against Chronic Respiratory Diseases

GDPR

General Data Privacy Regulation

GLASS-ARIA

Global Allergy Simple Solution

GP

general practitioner

GRADE

Grading of Recommendation, Assessment, Development and Evaluation

ICP

integrated care pathways

MASK

Mobile Airways Sentinel Network

MHealth

mobile health

OTC

over-the-counter

PG

pocket guides

POLLAR

Impact of Air POLLution in Asthma and Rhinitis

RWE

Real World Evidence

SDM

shared decision making

WAO 

World Allergy Organization

WHO

World Health Organization

Background

In all societies, the burden and cost of non-communicable diseases (NCDs) are increasing rapidly as advances in sanitation, public health measures and clinical care result in changes in demography [1]. Most, if not all, economies are struggling to deliver modern health care effectively [2]. Budgets will continue to be challenged with the move towards universal health coverage as demand increases and newer, more expensive technologies become available [3, 4, 5]. Traditional programmes, heavily reliant on specialist and supporting services, are becoming unaffordable. Innovative solutions are required to alleviate system wide pressures [6, 7]. There is a need to support authorities in the transformation of the health care system into integrated care with organizational health literacy [8].

Integrated care pathways (ICPs) are structured multi-disciplinary care plans detailing the key steps of patient care [9]. They promote the translation of guideline recommendations into local protocols and their application to clinical practice. They may be of particular interest in patients with multimorbidities since guidelines rarely consider them appropriately [10, 11]. An ICP forms all or part of the clinical record, documents the care given, and facilitates the evaluation of outcomes for continuous quality improvement [12]. ICPs should be carried out by a multidisciplinary team including physicians, pharmacists [13, 14] and allied health care professionals [15]. ICPs should integrate recommendations from clinical practice guidelines, but they usually (i) enhance recommendations by combining interventions, integrating quality assurance and (ii) describe co-ordination of care. Self-care and shared decision making are at the forefront of ICPs with the aim of empowering patients and their (professional and lay) care givers.

Rhinitis and asthma multimorbidity can be used as a model for chronic diseases since there is a broad agreement on the ‘gold standard’ of care [16, 17, 18]. In allergic rhinitis (AR) and asthma, adherence to treatment is a major unresolved problem [19, 20]. The vast majority of physicians prescribe regular treatment but patients (and physicians when they are allergic [21]) do not adhere to the advice. Instead of they self-treat based on personal experience as suggested by real-world data [19, 22]. There is thus a major disconnect between physicians and patients, either because of the clinical approach utilised or due to a lack of patient health literacy, with insufficient shared decision making (SDM). On-demand (prn) approaches are now proposed in both diseases [23, 24, 25] and represent a major change from previous recommendations. This new approach should be integrated in ICPs, but it needs to be applied to self-management and based on solid evidence.

ICPs have been proposed with a focus on new technologies that, through personally-held data on tablet devices and recording of ‘symptom load’, should enhance self-management and adherence to guidelines and ICPs. The science of supporting self-care and ICPs through mobile devices (mHealth) is in its infancy, but preliminary results are encouraging [26, 27, 28]. In the context of asthma, a systematic review showed that mobile apps were generally as effective as traditional models of supported self-management, but that they may be preferred in some clinical and demographic contexts as being convenient as well as efficient for the patient and the professional [29]. Standardisation and the establishment of the Privacy Code of Conduct for mHealth apps [25] will be important in ensuring patients on the safeguard of their data and in helping them choose reliable technological tools, which will be essential for ICP implementation.

As an example for chronic disease care, a new development of the ARIA initiative (ARIA phase 4) [30], along with POLLAR (Impact of Air POLLution on Asthma and Rhinitis), in collaboration with professional and patient organizations in the field of allergy and airway diseases, are proposing real-life ICPs centred around the patient with rhinitis, and using mHealth to monitor environmental exposure.

The current document was finalized and reviewed during a meeting involving ARIA, POLLAR (Impact of Air POLLution on Asthma and Rhinitis (EIT Health)), the European Innovation Partnership on Active and Healthy Ageing and the Global Alliance against Chronic Respiratory Diseases (GARD, WHO Alliance). Major allergy societies and patient’s organizations participated in this meeting (Paris, December 3, 2018). The event was carried out with the support of many organizations (Fig. 1).
Fig. 1

Organizations supporting the meeting

The gaps in allergic rhinitis and asthma

AR is the most common chronic disease worldwide. Treatment guidelines have improved the knowledge on rhinitis and have had a significant impact on AR management. However, many patients still fail to achieve sufficient symptom control [31] and the costs for society are enormous, in particular due to a major impact on school and work productivity [32] and on allergic or non-allergic multimorbidities [33, 34]. Allergic Rhinitis and its Impact on Asthma (ARIA) has promoted the use of its recommendations [16, 35, 36] to be integrated in ICPs using mobile technology in AR and asthma multimorbidity across the life cycle [37].

The clinical problem is that a large number of AR patients do not consult physicians because they think their symptoms are ‘normal’ and/or trivial, even though AR negatively impacts social life, school and work productivity [36]. Many AR patients rely on over-the-counter (OTC) drugs and do not see the need to consult with physicians [38, 39, 40, 41]. The vast majority of patients who visit general practitioners (GPs) or specialists have moderate-to-severe rhinitis [42, 43, 44, 45, 46]. ICPs should take this reality into account and consider a multi-disciplinary approach as proposed by AIRWAYS ICPs (Fig. 2).
Fig. 2

ICPs for rhinitis and asthma multimorbidity

(adapted from [102])

Supported self-management

People with AR and asthma are, by default, making day-to-day decisions about the management of their condition (avoiding triggers, using various treatments and seeking professional advice). Reflecting this broad concept, self-management is defined as “the tasks that individuals must undertake to live well with one or more chronic conditions. These tasks include having the confidence to deal with the medical management, role management and emotional management of their conditions” [47].

The term self-care includes generic “healthy lifestyle behaviours required for human development and functioning” [48]. However, self-care and self-management overlap as, for example, smoking cessation is a generic self-care behaviour and a component of self-management for people with respiratory conditions.

Self-management support is the assistance that professionals (pharmacy, primary care, specialist), patient’s organizations and other sources of information, as well as informal caregivers, give patients in order to make decisions about their condition and to manage disease and health-related tasks [49]. A taxonomy of 14 components of self-management support [50] offers a pick-list of activities that may be considered when planning self-management. These could be practical activities (e.g. teaching inhaler technique, discussing an action plan, helping to quit smoking) and imply SDM [50]. Mobile technology has the potential to contribute to many aspects of the supported self-management of chronic diseases [51].

Supported self-management is a ‘key principle’ for ICPs in long-term conditions [52, 53]. This not only reflects the paradigm shift towards SDM, but also includes pragmatic, economic imperatives, as healthcare systems respond to the increasing NCD burden. The economic impact of effective supported self-management goes beyond healthcare savings. For example, major economic return can be in the workplace where absenteeism and, more importantly, presenteeism are reduced [32] leading to an increased productivity.

Patient activation, defined as the “knowledge, skills and confidence a person has in managing his/her own health and health care” [54], is a goal of many ICP models. “Activation” encompasses the patients’ beliefs about their ability to self-manage (self-efficacy) and the likelihood that they will put these beliefs into action. Levels of activation range from the disengaged patients who let others manage their condition to the fully “activated” patients who embrace SDM and manage their health in partnership with their healthcare advisors, understanding the escalation of treatment options and when to seek pharmacy or medical advice. Higher levels of activation have been associated with better process and health outcomes in adults [55] and there is some evidence that appropriately-targeted self-management support may be more beneficial to disadvantaged groups than to higher literacy/socioeconomic status patients.

Although ARIA appears to meet the patient’s needs, real-life data obtained using the Allergy Diary (MASK-air®) app from around 10,000 people in 23 countries (Argentina, Austria, Australia, Belgium, Brazil, Canada, Czech Republic, Denmark, Finland, France, Germany, Greece, Italy, Lithuania, Mexico, Netherlands, Poland, Portugal, Spain, Sweden, Switzerland, UK. Brazil is a developing country) have shown that very few patients are being treated according to guidelines and that they often self-medicate [19]. Self-medication is the treatment of common health problems with medicines without medical supervision. It is important to ensure that well-written, short and accurate self-management information is available for people to pick up in pharmacies, or for download. In the case of AR, many patients have prescribed medications at home and, when symptoms occur, they use them. Self-care and SDM centred around the patient should be used more often [56]. ARIA has already followed a change management (CM) strategy embedding the AR-asthma multimorbidity in every day practice [30], but a new CM is now being considered to increase the benefits of self-care and SDM in ICPs using currently-available IT tools. In the case of AR and asthma multimorbidity, aeroallergen exposure and pollution impact disease control and medications. However, there is currently no ICP in airway diseases that takes such environmental parameters into account [57]. These initiatives should prepare and support individuals, teams and organizations in making organizational change centred around the patient.

mHealth, such as apps running on consumer smart devices, is becoming increasingly popular and has the potential to profoundly affect health care and health outcomes [58]. Several apps exist for AR and asthma [59, 60, 61, 62, 63]. A review of the Apps in the field of allergic diseases has recently been completed (Matricardi et al. in preparation). One of the reviews—MASK (Mobile Airways Sentinel NetworK), the Phase 3 ARIA initiative [37, 64]—is based on the freely-available MASK app (the Allergy Diary, Android and iOS platforms) for AR and asthma. Importantly, MASK is available in 17 languages and deployed in 23 countries [64]. Data from 26,000 users reporting over 200,000 days of treatment are available. It complies with the recent General Data Protection Regulation (EU) 2016/679 (GDPR) enforced by the EU, May 25, 2018 [65]. The GDPR aims primarily to give control to citizens and residents over their personal data and to simplify the regulatory environment by unifying the regulation within the EU [66, 67]. Importantly, MASK enables the assessment of treatment patterns in real life and provides detailed information on treatment, given that the Allergy Diary is able to distinguish between AR medications [19].

On-line information

Most patients check on-line to help them decide what the problem is and how to address it. This is a crucial self-management area of support and we need to think about how it can be optimized. Because of the multiplicity of sources and the lack of reliability control, it should be recognized that such a task would require an enormous effort. Consequently, it has been abandoned by many other bodies/disease areas. One approach that may be of value in improving reliability would be to focus on sites that provide useful information and generate an accreditation process with international standing.

Pharmacist care

Pharmacists are trusted health care professionals. Most patients with rhinitis are seen by pharmacists who are the initial point of contact of AR management in most countries. Depending on the country, few or most AR medications are available over-the-counter (OTC) [68, 69, 70, 71] and are used by many patients. Therefore, as trusted health care professionals in the community, pharmacists are well placed to play a critical role identifying the symptoms of AR, recommending appropriate OTC treatment [38, 39, 41] and integrating health care teams through ICPs [13, 14]. The specific role of pharmacists in the management of AR within ICPs can been evidenced from several strategies that have been initiated [72] or completed and from studies confirming the important impact of pharmacist interventions on AR outcomes [40, 70, 73, 74, 75, 76, 77, 78, 79, 80].

ARIA in the pharmacy 2004 [38] is being revised in order to propose ICPs involving a multi-disciplinary approach. This paper has been built on the evidence and provides tools intended to help pharmacists give optimal advice/interventions/strategies to patients with rhinitis. The ARIA-pharmacy ICP includes a diagnostic questionnaire specifically focusing attention on key symptoms and markers of the disease, a systematic Diagnosis Guide (including a differential diagnosis) and a simple flowchart proposing treatment for rhinitis and asthma multimorbidity. Key prompts for referral within the ICP are included. The use of technology is critical for enhancing the management of AR. The ARIA-pharmacy ICP should be adapted to local health care environments/situations as large regional or national differences in pharmacy-based care exist.

Next-generation guidelines

Practice guidelines contain evidence-based statements about treatment, tests, public health actions and policy decisions intended to assist recipients of care and their care providers in making informed decisions.

ARIA was one of the first chronic respiratory disease guidelines to adopt the GRADE (Grading of Recommendation, Assessment, Development and Evaluation) approach, an advanced evidence evaluation and development approach for guidelines [16, 81, 82, 83]. GRADE-based guidelines are available for AR from other organizations and their recommendations are similar [16, 17, 18]. However, a limitation of GRADE is that evidence often lacks applicability because the populations studied do not reflect most of the patients seen in primary care [84]. The GRADE recommendations are often based on RCT in which patients regularly use their treatment, whereas most AR or asthma patients are non-adherent. GRADE rarely includes recommendations based on implementation research.

The more recently completed work by the GRADE working group on its Evidence to Decision Frameworks requires that guideline developers regularly address implementation and monitoring strategies [85, 86, 87, 88, 89]. Searching for and synthesizing evidence of effective implementation strategies enabled the BTS/SIGN asthma guideline to make a recommendation on how supported self-management for asthma could be embedded into routine practice [90]. Strategies include proactively engaging and empowering patients, training and motivating professionals as well as providing an environment that promotes self-management and monitors implementation [91]. In AR, cluster-randomized controlled trials have confirmed the overall value of guidelines [92, 93]. However, there has been only one direct testing of individual guideline recommendations in real–life studies in an effort to achieve optimization [94].

Next-generation ARIA-GRADE guidelines should consider testing the recommendations based on the GRADE approach with real-world evidence (RWE) using data obtained by mHealth tools such as MASK in order to confirm the efficiency or to refine current GRADE-based recommendations. The first results of MASK confirm the feasibility of the project [19]. Adherence to treatment is very low as < 5% of users record symptoms and medications for a period of 2 weeks. This indicates that it is important to further test whether on-demand is equally or even more efficient than regular-continuous treatment and that guidelines should consider both regular and on-demand treatment [19, 95].

Guideline recommendations often address isolated questions or focus on a single disease or problem. They should be considered in the context of the many decisions that are made. ICPs try to address the multiple options and iterative changes in a patient’s status and problems. Guideline recommendations should support these iterative changes.

The key challenge for conventional treatment guidelines is that available evidence, both from randomized trials and non-randomized studies, does not usually address the complex pathways, but only affects isolated decision points within a pathway. For example, when an oral H1-antihistamine is not achieving symptom control, we propose to replace it by an intra-nasal corticosteroid. However, this is often not the way that studies are designed and not how patients use these medications. Assuming that properly developed pathways require evidence, our guidelines must start identifying the best available evidence to support decision points. When the evidence is indirect, which is frequently the case, connecting the relevant decision points and considering all of that evidence together results in low certainty on the overall structure and timing of an ICP.

The next-generation guidelines, if complemented by the intelligent use of tools such as MASK, which records patients’ symptoms and provides advice at given time points to follow ICPs, could exemplify unique new tools to both implement and evaluate recommendations in the context of pathways. Studies should be carried out in which patients are randomized to ICPs or to follow ARIA recommendations that are not presented as pathways. Such studies will provide both information on the use of the recommendations and on the usefulness of the pathways. Through implementation of recommendations, we will be able to increase our certainty in the evidence by evaluating the entire pathway and measuring outcomes in direct population-based studies that record what patients do as opposed to what clinicians prescribe (and patients do not do).

Study proposals of ARIA phase 4 and POLLAR

ARIA Phase 4 is the change management strategy for AR and asthma [96]. POLLAR is an EIT-Health (European Institute for Innovation and technology) project which aims to better understand, prevent and manage the impact of air pollution and allergen exposure on airway diseases [57]. POLLAR will use the MASK App, which is a Good Practice [64]. One of the POLLAR work-packages is the development of ICPs integrating aerobiology and air pollution. This will be developed using a step-wise approach centred around the patient. The four-step project is a WHO Global Alliance against Chronic Respiratory Diseases (GARD) demonstration project.

Step 1: First meeting (December 3, 2018, Paris): Development of next-generation ICPs with a focus on self-management, pharmacy care and next-generation guidelines

The Paris meeting addressed a number of areas as delineated below (Fig. 3).
Fig. 3

Next-generation ICPs for rhinitis and asthma multi-morbidity

Step 2: 2019–2021: Further development and implementation of next-generation ICPs

  1. 1.

    Develop a strategic and practical approach to improving patient autonomy and self-management programmes.

     
  2. 2.

    Deploy to other chronic respiratory diseases (asthma, COPD and rhinosinusitis [97]) and NCDs developing a multimorbidity App based on MASK expertise and experience.

     
  3. 3.

    Develop documents for specific age groups: pre-school and school children, older adults.

     
  4. 4.

    Establish a best practice across several regions in the EU linking the study to policy makers aiming to improve air quality and outcomes in their population.

     

Step 3: Second meeting (December 2019): Embedding environmental data in next-generation ICPs

Using the results obtained by POLLAR for air pollution, a second meeting will be held to integrate aerobiology and air pollution data in mobile technology and to propose ICPs for the prevention of severe exacerbations and asthma during peaks of allergens and/or pollution. This meeting will also consider the deployment to other chronic diseases (Fig. 4) and the impact of biodiversity in chronic diseases [98].
Fig. 4

Embedding aerobiology and air pollution in ICPs

Embedding next-generation care pathways in the EU and global political agendas for allergic and chronic respiratory diseases

The Polish Presidency of the EU Council (2011) targeted CRDs in children to promote their early recognition, prevention and management to ultimately impact active and healthy ageing (AHA) [99]. The developmental determinants of CRDs in ageing were reinforced during the Cyprus Presidency of the EU Council “Healthy ageing across the lifecycle” (2012) [100] and an EU-NIH meeting held in Montpellier (2013) [101].

The objective of AIRWAYS-ICPs [102] was to launch a collaboration to develop multi-sectoral ICPs for CRDs in European countries and regions. AIRWAYS-ICPs was initiated in 2014 by the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA, DG Santé and DG CONNECT) [103] as a GARD (Global Alliance against Chronic Respiratory Diseases) demonstration project [104]. In collaboration with GARD, the Directorate General of Health of Portugal, the EIP on AHA and the Région Occitanie (France), a high-level meeting was organized July 1, 2015 with all major European scientific societies and patient’s organizations in Lisbon to review the implementation results of AIRWAYS ICPs [105].

Euforea (European Forum for Research and Education in Allergy and Airway Diseases) [56] proposed an annual stepwise strategy at the EU or ministerial levels. A European Symposium on Precision Medicine in Allergy and Airways Diseases was held at the EU Parliament October 14, 2015 [106]. Another EU Parliament meeting was held in Brussels March 29, 2017 on the Prevention and Self-Management of CRDs using novel mobile health tools [37, 56, 97].

POLLAR (Impact of air POLLution on Asthma and Rhinitis, EIT Health) is focusing on the impact of allergens and air pollution on airway diseases and aims to propose novel ICPs integrating pollution, sleep and patients’ literacy and to assess the societal implications of the interaction [57].

Euforea organized an EU Summit in Vilnius, Lithuania (March 2018) in collaboration with the Ministers of Health of Lithuania, Moldova, Georgia and Ukraine. The aim was to discuss and start the implementation of the POLLAR concepts, and to deploy it to EU neighboring countries. The Vilnius Declaration on Chronic Respiratory Diseases proposed multisectoral ICPs embedding guided self-management, mHealth and air pollution in CRDs [107].

The joint meeting discussed in this report (December 3, 2018) proposed next-generation care pathways based on the Vilnius Declaration.

MASK has been selected by the European Commission’s Directorate-General for Health and Food Safety (DG SANTE) and the newly-established Commission Expert Group “Steering Group on Health Promotion, Disease Prevention and Management of Non-Communicable Diseases” as a Good Practice (GP) in the field of digitally-enabled, integrated, person-centred care.

On May 3, 2019, a Euforea-led meeting took place in the Parliament of Malta to review the results of the December 3 meeting and to propose practical strategies at the EU and global levels with GARD.

This new next-generation care pathway is completely aligned with the recommendations issued by the Thematic Network SHAFE—Smart Healthy Age-Friendly Environments (approved by the European Commission—DG SANTE and DG CONNECT)—on its Joint Statement delivered 12th November 2018. The Statement underlined the need to patient empowerment and active involvement in its healthcare process and also urged the use of lifestyle medicine that provides effective impact on the patient’s wellbeing.

Conclusions

There is a need to support the digital transformation of health and care with integrated care. An innovative patient-centered approach is proposed by the ARIA expert group for rhinitis and asthma multimorbidity to be scaled up to chronic diseases.

Notes

Acknowledgements

Dr. Togias’ co-authorship of this publication does not constitute endorsement by the US National Institute of Allergy and Infectious Diseases or by any other United States government agency.

MASK Study group

See Additional file 1.

Authors’ contributions

All authors are MASK members and have contributed to the design of the project. Many authors also included users and disseminated the project in their own country. Moreover, JB, HJ, AT, ME, TZ, IA, IJA, JMA, CB, SBA, IB, GB, EC, AAC, WC, WJF, JF, MI, LK, VK, LTT, DLL, DL, OML, EM, JM, YO, NP, NPT, HP, CR, BS, STS, IT, AV, AAM, MTV, SW, SW, XB, AB, SB, NB, GWC, VC, AMC, LC, AMCS, DC, EC, ME, GM, JM, EM, LM, GO, JLP, FP, DS, RvdK, AZ participated in the meeting held in Paris, December 3, 2018. All authors read and approved the final manuscript.

Funding

Partly funded by POLLAR (Impact of Air POLLution on Asthma and Rhinitis, EIT Health), and ARIA.

Ethics approval and consent to participate

Not applicable.

Consent for publication

All authors gave their agreement for the publication of the paper.

Competing interests

Dr. Ansotegui reports personal fees from Mundipharma, Roxall, Sanofi, MSD, Faes Farma, Hikma, UCB, Astra Zeneca, outside the submitted work. Dr. Bosnic-Anticevich reports grants from TEVA, personal fees from TEVA, Boehringer Ingelheim, AstraZeneca, Sanofi, Mylan, outside the submitted work. Dr. Bousquet reports personal fees and others from Chiesi, Cipla, Hikma, Menarini, Mundipharma, Mylan, Novartis, Sanofi-Aventis, Takeda, Teva, Uriach, others from Kyomed, outside the submitted work. Dr. Boulet reports and Disclosure of potential conflicts of interest—last 3 years. Research grants for participation to multicentre studies, AstraZeneca, Boston Scientific, GlaxoSmithKline, Hoffman La Roche, Novartis, Ono Pharma, Sanofi, Takeda. Support for research projects introduced by the investigator AstraZeneca, Boehringer-Ingelheim, GlaxoSmithKline, Merck, Takeda. Consulting and advisory boards Astra Zeneca, Novartis, Methapharm. Royalties Co-author of “Up-To-Date” (occupational asthma). Nonprofit grants for production of educational materials AstraZeneca, Boehringer-Ingelheim, GlaxoSmithKline, Merck Frosst, Novartis. Conference fees AstraZeneca, GlaxoSmithKline, Merck, Novartis. Support for participation in conferences and meetings Novartis, Takeda. Other participations Past president and Member of the Canadian Thoracic Society Respiratory Guidelines Committee; Chair of the Board of Directors of the Global Initiative for Asthma (GINA). Chair of Global Initiative for Asthma (GINA) Guidelines Dissemination and Implementation Committee; Laval University Chair on Knowledge Transfer, Prevention and Education in Respiratory and Cardiovascular Health; Member of scientific committees for the American College of Chest Physicians, American Thoracic Society, European Respiratory Society and the World Allergy Organization; 1st Vice-President of the Global Asthma Organization “InterAsma”. Dr. Casale reports grants and non-financial support from Stallergenes, outside the submitted work. Dr. Cruz reports grants and personal fees from GlaxoSmithKline, personal fees from Boehrinher Ingelheim, AstraZeneca, Novartis, Merk, Sharp & Dohme, MEDA Pharma, EUROFARMA, Sanofi Aventis, outside the submitted work. Dr. Ebisawa reports personal fees from DBV Technologies, Mylan EPD maruho, Shionogi & CO., Ltd., Kyorin Pharmaceutical Co., Ltd., Thermofisher Diagnostics, Pfizer, Beyer, Nippon Chemifar, Takeda Pharmaceutical Co., Ltd., MSD, outside the submitted work. Dr. Ivancevich reports personal fees from Euro Farma Argentina, Faes Farma, non-financial support from Laboratorios Casasco, outside the submitted work. Dr. Haahtela reports personal fees from Mundipharma, Novartis, and Orion Pharma, outside the submitted work. Dr. Klimek reports grants and personal fees from ALK Abelló, Denmark, Novartis, Switzerland, Allergopharma, Germany, Bionorica, Germany, GSK, Great Britain, Lofarma, Italy, personal fees from MEDA, Sweden, Boehringer Ingelheim, Germany, grants from Biomay, Austria, HAL, Netherlands, LETI, Spain, Roxall, Germany, Bencard, Great Britain, outside the submitted work. V.KV has received payment for consultancy from GSK and for lectures from StallergensGreer, Berlin-CHemie and sponsorship from MYLAN for in the following professional training: ARIA masterclass in allergic rhinitis participation. Dr. Larenas Linnemann reports personal fees from GSK, Astrazeneca, MEDA, Boehringer Ingelheim, Novartis, Grunenthal, UCB, Amstrong, Siegfried, DBV Technologies, MSD, Pfizer., grants from Sanofi, Astrazeneca, Novartis, UCB, GSK, TEVA, Chiesi, Boehringer Ingelheim, outside the submitted work. Dr. Mösges reports personal fees from ALK, grants from ASIT biotech, Leti, BitopAG, Hulka, Ursapharm, Optima; personal fees from allergopharma, Nuvo, Meda, Friulchem, Hexal, Servier, Bayer, Johnson & Johnson, Klosterfrau, GSK, MSD, FAES, Stada, UCB, Allergy Therapeutics; grants and personal fees from Bencard, Stallergenes; grants, personal fees and non-financial support from Lofarma; non-financial support from Roxall, Atmos, Bionorica, Otonomy, Ferrero; personal fees and non-financial support from Novartis; Dr. Okamoto reports personal fees from Eizai Co., Ltd., Shionogi Co., Ltd., Torii Co., Ltd., GSK, MSD, Kyowa Co., Ltd., grants and personal fees from Kyorin Co., Ltd., Tiho Co., Ltd., grants from Yakuruto Co., Ltd., Yamada Bee Farm, outside the submitted work. Dr. Papadopoulos reports grants from Gerolymatos, personal fees from Hal Allergy B.V., Novartis Pharma AG, Menarini, Hal Allergy B.V., outside the submitted work. Dr. Pépin reports grants from AIR LIQUIDE FOUNDATION, AGIR à dom, ASTRA ZENECA, FISHER & PAYKEL, MUTUALIA, PHILIPS, RESMED, VITALAIRE, other from AGIR à dom, ASTRA ZENECA, BOEHRINGER INGELHEIM, JAZZ PHARMACEUTICAL, NIGHT BALANCE, PHILIPS, RESMED, SEFAM, outside the submitted work. Dr. Pfaar reports grants and personal fees from ALK-Abelló, Allergopharma Stallergenes Greer, HAL Allergy Holding B.V./HAL Allergie GmbH, Bencard Allergie GmbH/Allergy Therapeutics, Lofarma, grants from Biomay, ASIT Biotech Tools S.A, Laboratorios LETI/LETI Pharma, Anergis S.A., grants from Nuvo, Circassia, Glaxo Smith Kline, personal fees from Novartis Pharma, MEDA Pharma, Mobile Chamber Experts (a GA2LEN Partner), Pohl-Boskamp, Indoor Biotechnologies, grants from, outside the submitted work. Dr. Todo-Bom reports grants and personal fees from Novartis, Mundipharma, GSK Teva Pharma, personal fees from AstraZeneca, grants from Leti, outside the submitted work. Dr. Tsiligianni reports advisory boards from Boehringer Ingelheim and Novartis and a grant from GSK, outside the submitted work. Dr. Wallace reports and Indicates that she is the co-chair of the Joint Task Force on Practice Parameters, a task force composed of 12 members of the American Academy of Allergy, Asthma, and Immunology and the American College of Allergy, Asthma, and Immunology. Dr. Waserman reports other from CSL Behring, Shire, AstraZeneca,Teva, Meda, Merck, outside the submitted work. Dr. Zuberbier reports and Organizational affiliations: Commitee member: WHO-Initiative “Allergic Rhinitis and Its Impact on Asthma” (ARIA). Member of the Board: German Society for Allergy and Clinical Immunology (DGAKI). Head: European Centre for Allergy Research Foundation (ECARF). Secretary General: Global Allergy and Asthma European Network (GA2LEN). Member: Committee on Allergy Diagnosis and Molecular Allergology, World Allergy Organization (WAO).

Supplementary material

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Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors and Affiliations

  • J. Jean Bousquet
    • 1
    • 2
    • 3
    • 4
    Email author
  • Holger J. Schünemann
    • 6
  • Alkis Togias
    • 7
  • Marina Erhola
    • 8
  • Peter W. Hellings
    • 3
    • 9
    • 10
  • Torsten Zuberbier
    • 4
    • 5
  • Ioana Agache
    • 11
  • Ignacio J. Ansotegui
    • 12
  • Josep M. Anto
    • 13
    • 14
    • 15
    • 16
  • Claus Bachert
    • 17
  • Sven Becker
    • 18
  • Martin Bedolla-Barajas
    • 19
  • Michael Bewick
    • 20
  • Sinthia Bosnic-Anticevich
    • 21
    • 22
    • 23
  • Isabelle Bosse
    • 24
  • Louis P. Boulet
    • 25
  • Jean Marc Bourrez
    • 26
  • Guy Brusselle
    • 27
  • Niels Chavannes
    • 28
  • Elisio Costa
    • 29
  • Alvaro A. Cruz
    • 30
    • 31
  • Wienczyslawa Czarlewski
    • 32
  • Wytske J. Fokkens
    • 3
    • 33
  • Joao A. Fonseca
    • 34
    • 35
  • Mina Gaga
    • 36
  • Tari Haahtela
    • 37
  • Maddalena Illario
    • 38
  • Ludger Klimek
    • 39
  • Piotr Kuna
    • 40
  • Violeta Kvedariene
    • 41
  • L. T. T. Le
    • 42
  • Desiree Larenas-Linnemann
    • 43
  • Daniel Laune
    • 44
  • Olga M. Lourenço
    • 45
  • Enrica Menditto
    • 46
  • Joaquin Mullol
    • 47
    • 48
  • Yashitaka Okamoto
    • 49
  • Nikos Papadopoulos
    • 50
    • 51
  • Nhân Pham-Thi
    • 52
  • Robert Picard
    • 53
  • Hilary Pinnock
    • 54
  • Nicolas Roche
    • 55
  • Regina E. Roller-Wirnsberger
    • 56
  • Christine Rolland
    • 57
  • Boleslaw Samolinski
    • 58
  • Aziz Sheikh
    • 54
  • Sanna Toppila-Salmi
    • 37
  • Ioanna Tsiligianni
    • 59
    • 60
  • Arunas Valiulis
    • 61
  • Erkka Valovirta
    • 62
  • Tuula Vasankari
    • 63
  • Maria-Teresa Ventura
    • 64
  • Samantha Walker
    • 65
  • Sian Williams
    • 62
  • Cezmi A. Akdis
    • 66
  • Isabella Annesi-Maesano
    • 67
  • Sylvie Arnavielhe
    • 44
  • Xavier Basagana
    • 13
    • 14
    • 15
    • 16
  • Eric Bateman
    • 68
  • Anna Bedbrook
    • 1
  • K. S. Bennoor
    • 69
  • Samuel Benveniste
    • 70
  • Karl C. Bergmann
    • 4
    • 5
  • Slawomir Bialek
    • 71
  • Nils Billo
    • 72
  • Carsten Bindslev-Jensen
    • 73
    • 74
  • Leif Bjermer
    • 75
  • Hubert Blain
    • 76
    • 77
  • Mateo Bonini
    • 78
    • 79
  • Philippe Bonniaud
    • 80
  • Jacques Bouchard
    • 81
    • 82
  • Vitalis Briedis
    • 83
  • Christofer E. Brightling
    • 84
    • 85
  • Jan Brozek
    • 6
  • Roland Buhl
    • 86
  • Roland Buonaiuto
    • 87
  • Giorgo W. Canonica
    • 88
  • Victoria Cardona
    • 89
  • Ana M. Carriazo
    • 90
  • Warner Carr
    • 91
  • Christine Cartier
    • 92
  • Thomas Casale
    • 93
  • Lorenzo Cecchi
    • 94
  • Alfonso M. Cepeda Sarabia
    • 95
    • 96
  • Eka Chkhartishvili
    • 97
  • Derek K. Chu
    • 3
  • Cemal Cingi
    • 98
  • Elaine Colgan
    • 99
  • Jaime Correia de Sousa
    • 100
    • 101
  • Anne Lise Courbis
    • 102
  • Adnan Custovic
    • 103
  • Biljana Cvetkosvki
    • 21
    • 22
    • 23
  • Gennaro D’Amato
    • 104
  • Jane da Silva
    • 105
  • Carina Dantas
    • 106
    • 107
  • Dejand Dokic
    • 108
  • Yves Dauvilliers
    • 109
  • Antoni Dedeu
    • 110
    • 111
  • Giulia De Feo
    • 112
  • Philippe Devillier
    • 113
  • Stefania Di Capua
    • 114
  • Marc Dykewickz
    • 115
  • Ruta Dubakiene
    • 116
  • Motohiro Ebisawa
    • 117
  • Yaya El-Gamal
    • 118
  • Esben Eller
    • 73
    • 74
  • Regina Emuzyte
    • 119
  • John Farrell
    • 101
  • Antjie Fink-Wagner
    • 120
  • Alessandro Fiocchi
    • 121
  • Jean F. Fontaine
    • 122
  • Bilun Gemicioğlu
    • 123
  • Peter Schmid-Grendelmeir
    • 124
  • Amiran Gamkrelidze
    • 125
  • Judith Garcia-Aymerich
    • 13
  • Maximiliano Gomez
    • 126
  • Sandra González Diaz
    • 127
  • Maia Gotua
    • 128
  • Nick A. Guldemond
    • 129
  • Maria-Antonieta Guzmán
    • 130
  • Jawad Hajjam
    • 131
  • John O’B Hourihane
    • 132
  • Marc Humbert
    • 133
  • Guido Iaccarino
    • 134
  • Despo Ierodiakonou
    • 59
    • 62
  • Maddalena Illario
    • 35
  • Juan C. Ivancevich
    • 135
  • Guy Joos
    • 25
  • Ki-Suck Jung
    • 136
  • Marek Jutel
    • 137
  • Igor Kaidashev
    • 138
  • Omer Kalayci
    • 139
  • Przemyslaw Kardas
    • 140
  • Thomas Keil
    • 141
    • 142
  • Mussa Khaitov
    • 143
  • Nikolai Khaltaev
    • 144
  • Jorg Kleine-Tebbe
    • 145
  • Marek L. Kowalski
    • 146
  • Vicky Kritikos
    • 21
    • 22
    • 23
  • Inger Kull
    • 147
    • 148
  • Lisa Leonardini
    • 149
  • Philip Lieberman
    • 150
  • Brian Lipworth
    • 151
  • Karin C. Lodrup Carlsen
    • 152
    • 153
  • Claudia C. Loureiro
    • 154
  • Renaud Louis
    • 155
  • Alpana Mair
    • 156
  • Gert Marien
    • 3
  • Bassam Mahboub
    • 157
  • Joao Malva
    • 107
    • 158
  • Patrick Manning
    • 159
  • Esteban De Manuel Keenoy
    • 160
  • Gailen D. Marshall
    • 161
  • Mohamed R. Masjedi
    • 162
  • Jorge F. Maspero
    • 163
  • Eve Mathieu-Dupas
    • 44
  • Poalo M. Matricardi
    • 164
  • Eric Melén
    • 148
    • 165
  • Elisabete Melo-Gomes
    • 166
  • Eli O. Meltzer
    • 167
  • Enrica Menditto
    • 46
  • Jacques Mercier
    • 168
  • Neven Miculinic
    • 169
  • Florin Mihaltan
    • 170
  • Branislava Milenkovic
    • 171
  • Giuliana Moda
    • 172
  • Maria-Dolores Mogica-Martinez
    • 173
  • Yousser Mohammad
    • 174
    • 175
  • Steve Montefort
    • 176
  • Ricardo Monti
    • 177
  • Mario Morais-Almeida
    • 178
  • Ralf Mösges
    • 179
    • 180
  • Lars Münter
    • 181
  • Antonella Muraro
    • 182
  • Ruth Murray
    • 183
    • 184
  • Robert Naclerio
    • 185
  • Luigi Napoli
    • 186
  • Leila Namazova-Baranova
    • 187
  • Hugo Neffen
    • 188
    • 189
  • Kristoff Nekam
    • 190
  • Angelo Neou
    • 191
  • Enrico Novellino
    • 192
  • Dieudonné Nyembue
    • 193
  • Robin O’Hehir
    • 194
  • Ken Ohta
    • 261
  • Kimi Okubo
    • 195
  • Gabrielle Onorato
    • 1
  • Solange Ouedraogo
    • 196
  • Isabella Pali-Schöll
    • 197
  • Susanna Palkonen
    • 198
  • Peter Panzner
    • 199
  • Hae-Sim Park
    • 200
  • Jean-Louis Pépin
    • 201
    • 202
  • Ana-Maria Pereira
    • 203
    • 204
  • Oliver Pfaar
    • 206
  • Ema Paulino
    • 207
  • Jim Phillips
    • 208
  • Robert Picard
    • 53
  • Davor Plavec
    • 209
    • 210
  • Ted A. Popov
    • 211
  • Fabienne Portejoie
    • 1
  • David Price
    • 212
    • 213
  • Emmanuel P. Prokopakis
    • 214
  • Benoit Pugin
    • 3
  • Filip Raciborski
    • 58
  • Rojin Rajabian-Söderlund
    • 215
  • Sietze Reitsma
    • 3
    • 33
  • Xavier Rodo
    • 13
  • Antonino Romano
    • 216
    • 217
  • Nelson Rosario
    • 218
  • Menahenm Rottem
    • 219
  • Dermot Ryan
    • 220
  • Johanna Salimäki
    • 221
  • Mario M. Sanchez-Borges
    • 222
  • Juan-Carlos Sisul
    • 223
  • Dirceu Solé
    • 224
  • David Somekh
    • 225
  • Talant Sooronbaev
    • 226
  • Milan Sova
    • 227
  • Otto Spranger
    • 120
  • Cristina Stellato
    • 112
  • Rafael Stelmach
    • 228
  • Charlotte Suppli Ulrik
    • 229
  • Michel Thibaudon
    • 230
  • Teresa To
    • 231
  • Ana Todo-Bom
    • 154
  • Peter V. Tomazic
    • 232
  • Antonio A. Valero
    • 233
  • Rudolph Valenta
    • 234
    • 235
    • 236
  • Marylin Valentin-Rostan
    • 237
  • Rianne van der Kleij
    • 238
    • 239
  • Olivier Vandenplas
    • 240
  • Giorgio Vezzani
    • 241
  • Frédéric Viart
    • 92
  • Giovanni Viegi
    • 242
    • 243
  • Dana Wallace
    • 244
  • Martin Wagenmann
    • 245
  • De Y. Wang
    • 246
  • Susan Waserman
    • 247
  • Magnus Wickman
    • 248
  • Dennis M. Williams
    • 249
  • Gary Wong
    • 205
  • Piotr Wroczynski
    • 71
  • Panayiotis K. Yiallouros
    • 250
    • 251
  • Arzu Yorgancioglu
    • 252
  • Osman M. Yusuf
    • 253
  • Heahter J. Zar
    • 254
    • 255
  • Stéphane Zeng
    • 256
  • Mario Zernotti
    • 257
  • Luo Zhang
    • 258
  • Nan S. Zhong
    • 259
  • Mihaela Zidarn
    • 260
  • the ARIA Study Group
  • the MASK Study Group
  1. 1.MACVIA-France, Fondation Partenariale FMC VIA-LR, CHUMontpellier Cedex 5France
  2. 2.INSERM U 1168, VIMA: Ageing and Chronic Diseases Epidemiological and Public Health Approaches, Villejuif Université Versailles St-Quentin-en-Yvelines, UMR-S 1168Montigny Le BretonneuxFrance
  3. 3.European Forum for Research and Education in Allergy and Airway Diseases (EUFOREA)BrusselsBelgium
  4. 4.Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Uniersität zu BerlinBerlinGermany
  5. 5.Department of Dermatology and Allergy Member of GA2LEN, Comprehensive Allergy-CentreBerlin Institute of HealthBerlinGermany
  6. 6.Department of Clinical Epidemiology and BiostatisticsMcMaster UniversityHamiltonCanada
  7. 7.Division of Allergy, Immunology, and Transplantation (DAIT)National Institute of Allergy and Infectious Diseases, NIHBethesdaUSA
  8. 8.National Institute for Health and WelfareHelsinkiFinland
  9. 9.Dept of OtorhinolaryngologyUniv Hospitals LeuvenLouvainBelgium
  10. 10.Academic Medical CenterUniv of AmsterdamAmsterdamThe Netherlands
  11. 11.Faculty of MedicineTransylvania UniversityBrasovRomania
  12. 12.Department of Allergy and ImmunologyHospital Quirónsalud BizkaiaErandioSpain
  13. 13.ISGlobAL, Centre for Research in Environmental Epidemiology (CREAL)BarcelonaSpain
  14. 14.IMIM (Hospital del Mar Research Institute)BarcelonaSpain
  15. 15.CIBER Epidemiología y Salud Pública (CIBERESP)BarcelonaSpain
  16. 16.Universitat Pompeu Fabra (UPF)BarcelonaSpain
  17. 17.Upper Airways Research Laboratory, ENT DeptGhent University HospitalGhentBelgium
  18. 18.Dept of Otolaryngology, Head and Neck SurgeryUniversity of MainzMainzGermany
  19. 19.Hospital Civil de Guadalajara Dr Juan I MenchacaGuadalararaMexico
  20. 20.iQ4U Consultants LtdLondonUK
  21. 21.Woolcock Institute of Medical ResearchUniversity of SydneySydneyAustralia
  22. 22.Woolcock Emphysema CentreSydneyAustralia
  23. 23.Sydney Local Health DistrictGlebeAustralia
  24. 24.La RochelleFrance
  25. 25.Quebec Heart and Lung InstituteLaval UniversityQuebec CityCanada
  26. 26.EIT Health FranceParisFrance
  27. 27.Dept of Respiratory MedicineGhent University HospitalGhentBelgium
  28. 28.Department of Public Health and Primary CareLeiden University Medical CenterLeidenThe Netherlands
  29. 29.UCIBIO, REQUINTEFaculty of Pharmacy and Competence Center on Active and Healthy Ageing of University of Porto (Porto4Ageing)PortoPortugal
  30. 30.ProAR–Nucleo de Excelencia em AsmaFederal University of BahiaBahiaBrazil
  31. 31.WHO GARD Planning GroupSalvadorBrazil
  32. 32.Medical Consulting CzarlewskiLevalloisFrance
  33. 33.Department of OtorhinolaryngologyAmsterdam University Medical Centres, AMCAmsterdamThe Netherlands
  34. 34.CINTESIS, Center for Research in Health Technology and Information SystemsFaculdade de Medicina da Universidade do PortoPortoPortugal
  35. 35.MedidaLda PortoPortugal
  36. 36.ERS President 2017-2018, Athens Chest Hospital7th Resp Med Dept and Asthma CenterAthensGreece
  37. 37.Skin and Allergy HospitalHelsinki University Hospital and University of HelsinkiHelsinkiFinland
  38. 38.Division for Health InnovationCampania Region and Federico II University Hospital Naples (R &D and DISMET)NaplesItaly
  39. 39.Center for Rhinology and AllergologyWiesbadenGermany
  40. 40.Division of Internal Medicine, Asthma and Allergy, Barlicki University HospitalMedical University of LodzŁódźPoland
  41. 41.Faculty of MedicineVilnius UniversityVilniusLithuania
  42. 42.University of Medicine and PharmacyHochiminh CityVietnam
  43. 43.Center of Excellence in Asthma and AllergyMédica Sur Clinical Foundation and HospitalMéxico CityMexico
  44. 44.KYomed INNOVMontpellierFrance
  45. 45.Faculty of Health Sciences and CICS–UBI, Health Sciences Research CentreUniversity of Beira InteriorCovilhãPortugal
  46. 46.CIRFFFederico II UniversityNaplesItaly
  47. 47.Rhinology Unit & Smell Clinic, ENT DepartmentHospital ClínicBarcelonaSpain
  48. 48.Clinical & Experimental Respiratory Immunoallergy, IDIBAPS, CIBERESUniversity of BarcelonaBarcelonaSpain
  49. 49.Dept of OtorhinolaryngologyChiba University HospitalChibaJapan
  50. 50.Division of Infection, Immunity & Respiratory Medicine, Royal Manchester Children’s HospitalUniversity of ManchesterManchesterUK
  51. 51.Allergy Department, 2nd Pediatric Clinic, Athens General Children’s Hospital “P&A Kyriakou”University of AthensAthensGreece
  52. 52.Allergy DepartmentPasteur InstituteParisFrance
  53. 53.Conseil Général de l’Economie Ministère de l’Economie, de l’Industrie et du NumériqueParisFrance
  54. 54.The Usher Institute of Population Health Sciences and InformaticsThe University of EdinburghEdinburghUK
  55. 55.Pneumologie et Soins Intensifs RespiratoiresHôpitaux Universitaires Paris, Centre Hôpital CochinParisFrance
  56. 56.Department of Internal MedicineMedical University of GrazGrazAustria
  57. 57.Association Asthme et AllergieParisFrance
  58. 58.Department of Prevention of Environmental Hazards and AllergologyMedical University of WarsawWarsawPoland
  59. 59.Health Planning Unit, Department of Social Medicine, Faculty of MedicineUniversity of CreteCreteGreece
  60. 60.International Primary Care Respiratory Group IPCRGAberdeenUK
  61. 61.Institute of Clinical Medicine & Institute of Health SciencesVilnius University Faculty of MedicineVilniusLithuania
  62. 62.Department of Lung Diseases and Clinical ImmunologyUniversity of Turku and Terveystalo Allergy ClinicTurkuFinland
  63. 63.FILHA, Finnish Lung AssociationHelsinkiFinland
  64. 64.Unit of Geriatric ImmunoallergologyUniversity of Bari Medical SchoolBariItaly
  65. 65.Asthma UKLondonUK
  66. 66.Swiss Institute of Allergy and Asthma Research (SIAF)University of ZurichDavosSwitzerland
  67. 67.Epidemiology of Allergic and Respiratory Diseases, Department Institute Pierre Louis of Epidemiology and Public HealthINSERM and Sorbonne Université, Medical School Saint AntoineParisFrance
  68. 68.Department of MedicineUniversity of Cape TownCape TownSouth Africa
  69. 69.Dept of Respiratory MedicineNational Institute of Diseases of the Chest and HospitalDhakaBangladesh
  70. 70.National Center of Expertise in Cognitive Stimulation (CEN STIMCO)Broca HospitalParisFrance
  71. 71.Department of Biochemistry and Clinical Chemistry, Faculty of Pharmacy with the Division of Laboratory MedicineWarsaw Medical UniversityWarsawPoland
  72. 72.Global Alliance against Chronic Respiratory Diseases (WHO GARD)JoensuuFinland
  73. 73.Department of Dermatology and Allergy Centre, Odense University HospitalOdense Research Center for Anaphylaxis (ORCA)OdenseDenmark
  74. 74.Termofischer ScientificUppsalaSweden
  75. 75.Department of Respiratory Medicine and AllergologyUniversity HospitalLundSweden
  76. 76.Department of GeriatricsMontpellier University hospitalMontpellierFrance
  77. 77.EA 2991 EuromovUniversity MontpellierMontpellierFrance
  78. 78.UOC Pneumologia, Istituto di Medicina Interna, F Policlinico Gemelli IRCCSUniversità Cattolica del Sacro CuoreRomeItaly
  79. 79.National Heart and Lung InstituteRoyal Brompton Hospital & Imperial CollegeLondonUK
  80. 80.CHUDijonFrance
  81. 81.Clinical MedicineLaval’s UniversityQuebec CityCanada
  82. 82.Medicine DepartmentHôpital de la MalbaieQuebec cityCanada
  83. 83.Department of Clinical Pharmacy of LithuanianUniversity of HealthKaunasLithuania
  84. 84.Institute of Lung Health, Respiratory Biomedical UnitUniversity Hospitals of Leicester NHS TrustLeicestershireUK
  85. 85.Department of Infection, Immunity and InflammationUniversity of LeicesterLeicesterUK
  86. 86.Universitätsmedizin der Johannes Gutenberg-Universität MainzMainzGermany
  87. 87.Municipality PharmacySarnoItaly
  88. 88.Personalized Medicine Clinic Asthma & AllergyHumanitas University, Humanitas Research HospitalMilanItaly
  89. 89.Allergy Section, Department of Internal MedicineHospital Vall d’Hebron & ARADyAL Research NetworkBarcelonaSpain
  90. 90.Regional Ministry of Health of AndalusiaSevilleSpain
  91. 91.Allergy and Asthma Associates of Southern CaliforniaMission ViejoUSA
  92. 92.ASA-Advanced Solutions AcceleratorClapiersFrance
  93. 93.Division of Allergy/ImmunologyUniversity of South FloridaTampaUSA
  94. 94.SOS Allergology and Clinical ImmunologyUSL Toscana CentroPratoItaly
  95. 95.Allergy and Immunology LaboratoryMetropolitan University, Simon Bolivar UniversityBarranquillaColombia
  96. 96.SLaai, Sociedad Latinoamericana de Allergia, Asma e ImmunologiaBarranquillaColombia
  97. 97.Chachava ClinicDavid Tvildiani Medical University-AIETI Medical School, Grigol Robakidze UniversityTbilisiGeorgia
  98. 98.Medical Faculty, ENT DepartmentEskisehir Osmangazi UniversityEskisehirTurkey
  99. 99.Department of HealthSocial Services and Public SafetyBelfastUK
  100. 100.Life and Health Sciences Research Institute (ICVS), School of MedicineUniversity of MinhoBragaPortugal
  101. 101.PT Government Associate Laboratory, ICVS/3B’sBraga/GuimarãesPortugal
  102. 102.Ecole des MinesAlèsFrance
  103. 103.Centre for Respiratory Medicine and Allergy, Institute of Inflammation and RepairUniversity of Manchester and University Hospital of South ManchesterManchesterUK
  104. 104.Division of Respiratory and Allergic Diseases, Department of Respiratory DiseasesHigh Specialty Hospital A.CardarelliNaplesItaly
  105. 105.Allergy ServiceUniversity Hospital of Federal University of Santa Catarina (HU-UFSC)FlorianópolisBrazil
  106. 106.Cáritas Diocesana de CoimbraCoimbraPortugal
  107. 107.Ageing@Coimbra EIP-AHA Reference SiteCoimbraPortugal
  108. 108.Medical Faculty SkopjeUniversity Clinic of Pulmonology and AllergySkopjeRepublic of Macedonia
  109. 109.Sleep Unit, Department of NeurologyHôpital Gui-de-Chauliac Montpellier, Inserm U1061MontpellierFrance
  110. 110.AQuASBarcelnaSpain
  111. 111.EUREGHA, European Regional and Local Health AssociationBrusselsBelgium
  112. 112.Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”University of SalernoSalernoItaly
  113. 113.UPRES EA220, Pôle des Maladies des Voies Respiratoires, Hôpital FochUniversité Paris-SaclaySuresnesFrance
  114. 114.Farmacie Dei Golfi GroupMassa LubrenseItaly
  115. 115.Section of Allergy and ImmunologySaint Louis University School of MedicineSaint LouisUSA
  116. 116.Clinic of Infectious, Chest Diseases, Dermatology and AllergologyVilnius UniversityVilniusLithuania
  117. 117.Clinical Reserch Center for Allergy and RheumatologySagamihara National HospitalSagamiharaJapan
  118. 118.Pediatric Allergy and Immunology Unit, Children’s hospitalAin Shams UniversityCairoEgypt
  119. 119.Clinic of Children’s Diseases, Faculty of MedicineVilnius UniversityVilniusLithuania
  120. 120.Global Allergy and Asthma Platform GAAPPViennaAustria
  121. 121.Division of Allergy, Department of Pediatric MedicineThe Bambino Gesù Children’s Research Hospital Holy SeeRomeItaly
  122. 122.ReimsFrance
  123. 123.Department of Pulmonary DiseasesIstanbul University-Cerrahpasa, Cerrahpasa Faculty of MedicineIstambulTurkey
  124. 124.Allergy Unit, Department of DermatologyUniversity Hospital of ZurichZurichSwitzerland
  125. 125.National Center for Disease Control and Public Health of GeorgiaTbilisiGeorgia
  126. 126.Allergy & Asthma UnitHospital San Bernardo SaltaSaltaArgentina
  127. 127.Universidad Autónoma de Nuevo LeónSan Nicolás de los GarzaMexico
  128. 128.Center of Allergy and ImmunologyGeorgian Association of Allergology and Clinical ImmunologyTbilisiGeorgia
  129. 129.Institute of Health Policy and Management iBMGErasmus UniversityRotterdamThe Netherlands
  130. 130.Immunology and Allergy Division, Clinical HospitalUniversity of ChileSantiagoChile
  131. 131.Centich: Centre d’Expertise National des Technologies de l’Information et de la Communication pour l’Autonomie, Gérontopôle Autonomie Longévité des Pays de la Loire, Conseil Régional des Pays de la Loire, Centre d’Expertise Partenariat Européen d’Innovation pour un Vieillissement Actif et en Bonne SantéNantesFrance
  132. 132.Department of Paediatrics and Child HealthUniversity College CorkCorkIreland
  133. 133.Université Paris-Sud; Service de PneumologieHôpital Bicêtre, Inserm UMR_S999Le Kremlin BicêtreFrance
  134. 134.Department of Medicine and SurgeryUniversity of SalernoBaronissiItaly
  135. 135.Servicio de Alergia e ImmunologiaClinica Santa IsabelBuenos AiresArgentina
  136. 136.Hallym University College of MedicineHallym University Sacred Heart HospitalAnyangSouth Korea
  137. 137.Department of Clinical ImmunologyWrocław Medical UniversityWrocławPoland
  138. 138.Ukrainian Medical Stomatological AcademyPoltavaUkraine
  139. 139.Pediatric Allergy and Asthma UnitHacettepe University School of MedicineAnkaraTurkey
  140. 140.First Department of Family MedicineMedical University of LodzŁódźPoland
  141. 141.Institute of Social Medicine, Epidemiology and Health EconomicsCharité-Universitätsmedizin BerlinBerlinGermany
  142. 142.Institute for Clinical Epidemiology and BiometryUniversity of WuerzburgWürzburgGermany
  143. 143.National Research Center, Institute of ImmunologyFederal Medicobiological Agency, Laboratory of Molecular ImmunologyMoscowRussian Federation
  144. 144.GARD ChairmanGenevaSwitzerland
  145. 145.Allergy & Asthma Center WestendBerlinGermany
  146. 146.Department of Immunology and Allergy, Healthy Ageing Research CenterMedical University of LodzŁódźPoland
  147. 147.Department of Clinical Science and EducationSödersjukhuset, Karolinska InstitutetStockholmSweden
  148. 148.Sach’s Children and Youth Hospital, SödersjukhusetStockholmSweden
  149. 149.Mattone Internazionale ProgramVeneto RegionItaly
  150. 150.Departments of Internal Medicine and Pediatrics (Divisions of Allergy and Immunology)University of Tennessee College of MedicineGermantownUSA
  151. 151.Scottish Centre for Respiratory Research, Cardiovascular & Diabetes Medicine, Medical Research Institute, Ninewells Hospital, University of DundeeDundeeUK
  152. 152.Department of PaediatricsOslo University HospitalOsloNorway
  153. 153.Faculty of Medicine, Institute of Clinical MedicineUniversity of OsloOsloNorway
  154. 154.Imunoalergologia, Centro Hospitalar Universitário de Coimbra and Faculty of MedicineUniversity of CoimbraCoimbraPortugal
  155. 155.Department of Pulmonary MedicineCHU Sart-Tilman, and GIGA I3 Research GroupLiegeBelgium
  156. 156.DG for Health and Social Care, Scottish GovernmentEdinburghUK
  157. 157.Department of Pulmonary MedicineRashid HospitalDubaiUAE
  158. 158.Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of MedicineUniversity of CoimbraCoimbraPortugal
  159. 159.Department of Medicine (RCSI)Bon Secours HospitalGlasnevin, DublinIreland
  160. 160.Kronikgune, International Centre of Excellence in Chronicity Research BarakaldoBarakaldoSpain
  161. 161.Division of Clinical Immunology and Allergy, Laboratory of Behavioral Immunology ResearchThe University of Mississippi Medical CenterJacksonUSA
  162. 162.Tobacco Control Research Centre, Iranian Anti Tobacco AssociationTehranIran
  163. 163.Argentine Association of Allergy and Clinical ImmunologyBuenos AiresArgentina
  164. 164.Department of Pediatric Pneumology and Immunology, AG Molecular Allergology and ImmunomodulationCharité Medical UniversityBerlinGermany
  165. 165.Institute of Environmental MedicineKarolinska InstitutetStockholmSweden
  166. 166.PNDR, Portuguese National Programme for Respiratory DiseasesFaculdade de Medicina de LisboaLisbonPortugal
  167. 167.Allergy and Asthma Medical Group and Research CenterSan DiegoUSA
  168. 168.Department of PhysiologyCHRU, University Montpellier, Vice President for Research, PhyMedExp, INSERM U1046, CNRS, UMR 9214MontpellierFrance
  169. 169.Croatian Pulmonary SocietyZagrebCroatia
  170. 170.National Institute of Pneumology M NastaBucharestRomania
  171. 171.Clinic for Pulmonary Diseases, Clinical Center of Serbia, Faculty of MedicineUniversity of Belgrade, Serbian Association for Asthma and COPDBelgradeSerbia
  172. 172.Regione PiemonteTurinItaly
  173. 173.Mexico CityMexico
  174. 174.National Center for Research in Chronic Respiratory Diseases, Tishreen University School of MedicineLatakiaSyria
  175. 175.Syrian Private UniversityDamascusSyria
  176. 176.Faculty of Medicine and SurgeryUniversity of MedicineLa ValetteMalta
  177. 177.Department of Medical Sciences, Allergy and Clinical Immunology UnitUniversity of Torino & Mauriziano HospitalTurinItaly
  178. 178.Allergy CenterCUF Descobertas HospitalLisbonPortugal
  179. 179.Institute of Medical Statistics, and Computational Biology, Medical FacultyUniversity of CologneCologneGermany
  180. 180.CRI-Clinical Research International-LtdHamburgGermany
  181. 181.Danish Commitee for Health EducationCopenhagen EastDenmark
  182. 182.Food Allergy Referral Centre Veneto Region, Department of Women and Child HealthPadua General University HospitalPaduaItaly
  183. 183.MedScript LtdParaparomuNew Zealand
  184. 184.OPCCambridgeUK
  185. 185.Johns Hopkins School of MedicineBaltimoreUSA
  186. 186.Consortium of Pharmacies and Services COSAFERSalernoItaly
  187. 187.Scientific Centre of Children’s Health under the Russian Academy of Medical SciencesMoscowRussia
  188. 188.Center of Allergy, Immunology and Respiratory DiseasesSanta FeArgentina
  189. 189.Center for Allergy and ImmunologySanta FeArgentina
  190. 190.Hospital of the Hospitaller Brothers in BudaBudapestHungary
  191. 191.Die Hautambulanz and Rothhaar Study CenterBerlinGermany
  192. 192.Department of PharmacyUniversity of Naples Federico IINaplesItaly
  193. 193.ENT DepartmentUniversity Hospital of KinshasaKinshasaCongo
  194. 194.Department of Allergy, Immunology and Respiratory Medicine, Alfred Hospital and Central Clinical SchoolMonash UniversityMelbourneAustralia
  195. 195.Dept of OtolaryngologyNippon Medical SchoolTokyoJapan
  196. 196.Centre Hospitalier Universitaire Pédiatrique Charles de GaulleOuagadougouBurkina Faso
  197. 197.Dept of Comparative MedicineMesserli Research Institute of the University of Veterinary Medicine and Medical UniversityViennaAustria
  198. 198.EFA European Federation of Allergy and Airways Diseases Patients’ AssociationsBrusselsBelgium
  199. 199.Department of Immunology and Allergology, Faculty of Medicine and Faculty Hospital in PilsenCharles University in PraguePilsenCzech Republic
  200. 200.Department of Allergy and Clinical ImmunologyAjou University School of MedicineSuwonSouth Korea
  201. 201.Laboratoire HP2Université Grenoble AlpesGrenobleFrance
  202. 202.INSERM, U1042 and CHU de GrenobleGrenobleFrance
  203. 203.Allergy UnitCUF-Porto Hospital and InstitutePortoPortugal
  204. 204.Center for Research in Health Technologies and Information Systems, CINTESISUniversidade do PortoPortoPortugal
  205. 205.Maladies Infectieuses et immunitairesCHULQuebec CityCanada
  206. 206.Department of Otorhinolaryngology, Head and Neck Surgery, Section of Rhinology and Allergy, University Hospital MarburgPhilipps-Universität MarburgMarburgGermany
  207. 207.Farmacias HolonLisbonPortugal
  208. 208.Centre for Empowering Patients and CommunitiesSomersetUK
  209. 209.Children’s Hospital SrebrnjakZagrebCroatia
  210. 210.School of MedicineUniversity J.J. StrossmayerOsijekCroatia
  211. 211.University Hospital ‘Sv Ivan Rilski’SofiaBulgaria
  212. 212.Academic Centre of Primary CareUniversity of AberdeenAberdeenUK
  213. 213.Research in Real-LifeCambridgeUK
  214. 214.Department of OtorhinolaryngologyUniversity of Crete School of MedicineHeraklionGreece
  215. 215.Department of Nephrology and EndocrinologyKarolinska University HospitalStockholmSweden
  216. 216.Allergy UnitPresidio Columbus, Catholic University of Sacred HeartRomeItaly
  217. 217.IRCCS Oasi Maria SSTroinaItaly
  218. 218.Hospital de ClinicasUniversity of ParanaParanáBrazil
  219. 219.Division of Allergy Asthma and Clinical ImmunologyEmek Medical CenterAfulaIsrael
  220. 220.Allergy and Respiratory Research GroupThe University of EdinburghEdinburghUK
  221. 221.Association of Finnish PharmacistsHelsinkiFinland
  222. 222.Allergy and Clinical Immunology Department, Centro Médico-Docente laTrinidad and Clínica El AvilaCaracasVenezuela
  223. 223.Sociedad Paraguaya de Alergia Asma e InmunologiaAsunciónParaguay
  224. 224.Division of Allergy, Clinical Immunology and Rheumatology, Department of PediatricsFederal University of São PauloSão PauloBrazil
  225. 225.European Health Futures Forum (EHFF)DromahairUK
  226. 226.Kyrgyzstan National Centre of Cardiology and Internal Medicine, Euro-Asian Respiratory SocietyBishkekKyrgyzstan
  227. 227.Department of Respiratory MedicineUniversity Hospital OlomoucOlomoucCzech Republic
  228. 228.Pulmonary Division, Heart Institute (InCor)Hospital da Clinicas da Faculdade de Medicina da Universidade de Sao PauloSao PauloBrazil
  229. 229.Department of Respiratory MedicineHvidovre Hospital & University of CopenhagenCopenhagenDenmark
  230. 230.RNSA (Réseau National de Surveillance Aérobiologique)BrussieuFrance
  231. 231.Sidkkids Hospitala and Institute of Health Policy, Management and EvaluationTorontoCanada
  232. 232.Department of ENTMedical University of GrazGrazAustria
  233. 233.Pneumology and Allergy Department CIBERES and Clinical & Experimental Respiratory Immunoallergy, IDIBAPSUniversity of BarcelonaBarcelonaSpain
  234. 234.Division of Immunopathology, Department of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and ImmunologyMedical University of ViennaViennaAustria
  235. 235.NRC Institute of Immunology FMBA of RussiaMoscowRussia
  236. 236.Laboratory of Immunopathology, Department of Clinical Immunology and AllergySechenov First Moscow State Medical UniversityMoscowRussia
  237. 237.MontevideoUruguay
  238. 238.Department of Public Health & Primary CareLeiden University Medical Center (LUMC)LeidenThe Netherlands
  239. 239.Department of Obstetrics and GynaecologyErasmus MC, University Medical CenterRotterdamThe Netherlands
  240. 240.Department of Chest Medicine, Centre Hospitalier Universitaire UCL NamurUniversité Catholique de LouvainYvoirBelgium
  241. 241.Pulmonary Unit, Department of Medical SpecialtiesArcispedale SMaria Nuova/IRCCS, AUSL di Reggio EmiliaReggio EmiliaItaly
  242. 242.Pulmonary Environmental Epidemiology UnitCNR Institute of Clinical PhysiologyPisaItaly
  243. 243.CNR Institute of Biomedicine and Molecular Immunology “A Monroy”PalermoItaly
  244. 244.Nova Southeastern UniversityFort LauderdaleUSA
  245. 245.Dept of Otorhinolaryngology, HNO-Klinik, Universitätsklinikum DüsseldorfDüsseldorfGermany
  246. 246.Department of Otolaryngology, Yong Loo Lin School of MedicineNational University of SingaporeSingaporeSingapore
  247. 247.Department of Medicine, Clinical Immunology and AllergyMcMaster UniversityHamiltonCanada
  248. 248.Centre for Clinical Research SörmlandUppsala UniversityEskilstunaSweden
  249. 249.Eshelman School of PharmacyUniversity of North CarolinaChapel HillUSA
  250. 250.Cyprus International Institute for Environmental & Public Health in Association with Harvard School of Public HealthCyprus University of TechnologyLimassolCyprus
  251. 251.Department of PediatricsHospital “Archbishop Makarios III”NicosiaCyprus
  252. 252.Department of Pulmonary DiseasesCelal Bayar University, Faculty of MedicineManisaTurkey
  253. 253.The Allergy and Asthma InstituteIslamabadPakistan
  254. 254.Department of Paediatrics and Child HealthRed Cross Children’s HospitalCape TownSouth Africa
  255. 255.MRC Unit on Child & Adolescent HealthUniversity of Cape TownCape TownSouth Africa
  256. 256.Bull DSASEchirollesFrance
  257. 257.Universidad Católica de CórdobaCórdobaArgentina
  258. 258.Department of Otolaryngology Head and Neck SurgeryBeijing TongRen Hospital and Beijing Institute of OtolaryngologyBeijingChina
  259. 259.State Key Laboratory of Respiratory Diseases, Guangzhou Institute of Respiratory DiseaseThe First Affiliated Hospital of Guangzhou Medical UniversityGuangzhouChina
  260. 260.University Clinic of Respiratory and Allergic DiseasesGolnikSlovenia
  261. 261.National Hospital Organization, Tokyo National HospitalTokyoJapan

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