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Dr Gerry Lee (Host): Chronic rhinosinusitis with nasal polyps or CRSwNP affects all races and ethnicities, but certain groups have experienced greater social or economic barriers to diagnosis and treatment. The goal of the Moving Toward Equity podcast series is to raise awareness of the challenges, strategies, and resources for moving the needle toward equitable immunology care for all patients and practitioners in all communities.

Welcome to the podcast series from the American College of Allergy, Asthma and Immunology. I'm Gerry Lee. And this is the second of our three-part series entitled Moving Toward Equity: Disparities in Chronic Rhinosinusitis with Nasal Polyps or CRSwNP. In this episode, we will discuss the impact of air pollution and environment on CRSwNP and how this disproportionately affects minority and underserved populations.

To start, let's hear again from Deanna, a young woman with CRS with nasal polyps who describes how the environment affects her health.

Dr Gerry Lee: do you have any concern about the environment where you live or where you work, where you can't be sort of protected from some of the things that make your sinus problems.

Deanna Shaw: Yes. I'm allergic to like grass, dust, cats and dogs and, stuff just like in a normal life. So basically if you going outside the trees, the grass, I can get, irritated really fast or have allergi action outta nowhere. being around any kinda dust or certain kind of perfume.

And it's a lot of things that trigger so. Me going anywhere basically can trigger it.

Dr Gerry Lee: do you have any concerns of your home environment where you live? Some people do have indoor triggers as well.

Deanna Shaw: I stay in the city so it's more, cluttered. So it's more grass and it's a lot of stuff around here. So yeah, it's, it's a lot of trigger where I actually live.

Dr Gerry Lee: But like, how about your place? I don't know if you live in a house or an

apartment and what's the condition of

that?

Deanna Shaw: I have carpet, which that triggers it too, but it's a whole lot with getting the carpet pulled up. I have carpet. I had a dog. I had to get rid of my dog because of my allergies were so out of control. I try to keep it clean where it's not so dusty, so I don't have so many flares.

But again, with the weather changing, I can have my heat on and I have to keep it cool, so I can actually breathe while I don't trigger my asthma and stuff like that.

Dr Gerry Lee: And, you know, there's a lot of, comment and door triggers in the city. Is any of those relevant to you? Those would be like, water damage or mold or pest like cockroach or mouse. Has that ever been a concern for you?

Deanna Shaw: it was like the mice, because we, in the area where, I guess, they say that the reps are outta control. So at first it was that, but, every now and then might be like a spider or a cockroach or something. I don't pretty much think nothing about mold. I don't think we have any mold or that I can't see, but it could be in the walls or anything or under the carpet, which could trigger it.

But that's about it. we do have every now and then a lot of spiders or bugs, apac, roha that comes out every now and then. So, yeah, that's the trigger.

Dr Gerry Lee: Yeah. And a lot of people discuss about inner city environments and, pollution from cars and trucks or that sort of thing. How would you characterize where you live in the city? Is that something that you think the air quality of where you live is a.

Deanna Shaw: for sure. I notice if I go certain places, I, it don't trigger as fast. So in my neighborhood, I don't know if it's just like around here or you go outside, it smells different or the air is just different So yeah, I think around where I stay is a big trigger. Okay. If I was to go out of town or something, I don't have so much flare ups that I do.

That I do at home.

Dr Gerry Lee (Host): Patients like Deanna are concerned that the environment is a trigger for their CRS with nasal polyps. So let's hear again from our expert panel to continue the discussion.

Joining me are Dr. Mahboobeh Mahdavinia and Dr. Anjeni Keswani. Dr. Mahdavinia is a physician scientist and Associate Professor of Medicine Pediatrics at Rush University Medical Center. She is a board-certified allergist immunologist with a background in immunology of allergic diseases and a PhD in molecular epidemiology. She runs an active academic clinical practice in both adult and pediatric allergy, while leading a clinical translational research team on food allergy and chronic rhinosinusitis. In addition to being the research director of the Rush Center for Sinusitis, Asthma and Allergies, Dr. Mahdavinia is involved in several national and international collaborative studies.

Dr. Keswani is an Associate Professor of Medicine and the Division Director for Allergy and Immunology at the George Washington University School of Medicine and Health Sciences. Her clinical research interests are in optimizing care for patients with chronic rhinosinusitis, as well as the effects of climate change on respiratory health. Thank you very much, doctors, for joining us.

Dr Mahboobeh Mahdavinia: Thank you, Gerry.

Dr Anjeni Keswani: Thanks for having us.

Dr Gerry Lee (Host): Okay. Wonderful. Well, we'll start with you again, Dr. Keswani. In the last episode, you mentioned that environmental exposures explained some of the differences in chronic rhinosinusitis with nasal polyps among different groups. To set the stage for this podcast, could you describe these exposures felt to be responsible? What are they and what are some of the sources?

Dr Anjeni Keswani: When considering social determinants of healthcare disparities, the role of the environment, particularly air pollution, can be of particular importance for inflammatory respiratory diseases such as chronic sinusitis with nasal polyps. The sinonasal epithelium can be the first direct contact between the respiratory system and an environmental exposure such as particulate matter, which is labeled by size as PM 10 or course particulate matter, PM 2.5 or fine particulate matter and PM 0.1 or ultrafine particular matter, as well as the gaseous air pollutants, sulfur dioxide, nitrogen dioxide, and ground-level ozone. These air pollutants arise from both natural as well as human-based activities, such as traffic exhaust, industrial sectors and power plants. And air pollutants exist in a mixture of all these substances, which can have a cumulative effect on the airway's response.

Dr Gerry Lee (Host): So, air pollutants seem to be a major factor in chronic rhinosinusitis with nasal polyps. But Dr. Mahdavinia, why are certain populations disproportionately affected by pollutants?

Dr Mahboobeh Mahdavinia: Well, this is definitely multi-dimensional. If you think of the populations living in inner city areas exposed to more car exhaust, those living in neighborhoods close to factories that pollute the air, or neighborhoods that are in areas inside valleys that air doesn't get to move, or areas that people are more prone to pollution.

In general, there's an index called Area Deprivation Index, which is a very validated marker of deprived neighborhoods and lower socioeconomic conditions. And ADI is strongly linked to air pollution. As you can see, unfortunately, most of this is all linked to poverty. So again, the most vulnerable people being affected by poor social economy conditions are living in polluted areas.

Dr Gerry Lee (Host): So, Dr. Keswani, if these groups are more exposed to pollution, what is the exact mechanism where pollutant exposure actually increases the severity or burden of chronic rhinosinusitis with nasal polyps?

Dr Anjeni Keswani: Air pollution, specifically PM 2.5 or fine particulate matter, has been demonstrated to drive a type 2 inflammatory response, which may be responsible for some cases of nasal polyps. PM 2.5, ozone and nitrogen dioxide can all augment type 2 and type 17 immune responses and alter T regulatory cell expression. And pivotal studies have demonstrated that these air pollutants connect as adjuvants to promote allergic sensitization as well as eosinophilic airway inflammation as they drive an increase in allergen-specific IgE, as well as increase Th2 cytokines, IL-4, IL-5 and IL-13. And when we translate these basic science concepts to clinical studies, there have been studies that evaluate the relationship between air pollution exposure and the effects of CRS with nasal polyps. And they found that air pollution exposure exacerbated nasal polyps severity as determined by worse symptom scores and greater radiographic burden of disease.

Researchers have also found that particulate matter could be a risk for the eosinophilic endotype in patients with CRS with nasal polyps, and that increased ozone exposure has been associated with the presence of eosinophilic aggregates in CRS with nasal polyps. So, we see a higher clinical severity of CRS with nasal polyps that we think is stemming from the shift to a type 2 inflammation from air pollution exposure.

Dr Gerry Lee (Host): Okay. So, there does seem to be a lot of research showing the relationship between pollution and the severity of nasal polyposis. But in terms of underserved populations, have they shown those associations? Do we know much about the burden of patients who live in highly polluted areas and clinical outcomes? What sort of studies have examined this, Dr. Mahdavinia?

Dr Mahboobeh Mahdavinia: Unfortunately, there are very few studies that actually have tried to answer this question. But there are a couple. So, our group, in collaboration with another large center, showed that the increased exposure to common air pollutant and specifically looking at PM 2.5 was linked to poor outcome in CRS. And again, there was a strong effect on race because those neighborhoods were mainly populated by African American and partially Latino patients. And these studies have shown that air pollution affects the allergic inflammation as Dr. Keswani explained very well. And it causes increased eosinophilia in the nasal polyp of these patients who were living in a more polluted neighborhood.

And we were able to show that the pollution impact also the microbiome of the nose by decreasing the good bacteria such as corynebacterium in the nose. And therefore, it sort of took away that helpful effect of the microbes and caused more problems. And these are a couple of examples of the studies that show that, when you look at patients living in those neighborhoods, there is a direct exposure to higher level of air pollutant that causes more CRS and poor outcomes.

Dr Gerry Lee (Host): Okay. Well, it's pretty clear then that environmental exposure plays a large role in the disease and therefore it's probably our duty or responsibility in the care of the nasal polyp patient to address these exposures. So, what can individual clinicians do to address some of these exposures and help clinical outcomes? Dr. Kaswani, we could start with you.

Dr Anjeni Keswani: I think about addressing air pollution at three societal levels, and I think clinicians can have an impact at all three, so at the national, the community and the individual level. So, national and state government policies to reduce the amount of fuel burned for electricity generation, industrial production and transportation, as well as policies that set limits on air pollutants and greenhouse gas emissions are really essential to reduce air pollution. Community scale measures such as protecting green space and expanding access for safe walking and bicycling can also encourage changes needed to reduce emissions and to help individuals avoid exposure.

Individual behavioral change can be helpful in avoiding exposure to poor air quality. For example, staying indoors, wearing high quality masks and investing in effective home air filtration systems can reduce exposures. So, clinicians have an important role in both advocating for these health protective government and community actions, as well as counseling individual patients on strategies to reduce their exposure.

Dr Gerry Lee (Host): There seems to be so many challenges, especially that's going to require governmental or community-based measures. But Dr. Mahdavinia, as physicians, as members of medical societies, what do you think our role is Individually or in terms of medical society membership that we also do to advocate for our patients?

Dr Mahboobeh Mahdavinia: So certainly, medical societies can try as they have been to increase awareness. However, we need to partner better with regulatory agencies to hopefully prevent poor outcome in the most vulnerable population.

Dr Gerry Lee (Host): All right. Well, thank you both for your thoughts on this. And that's all the time that we have. But this concludes part two of our three-part series on Moving Toward Equity: Disparities in Chronic Rhinosinusitis with Nasal Polyps from the ACAAI. Please be sure to join us for the last episode where we really talk about access to care for nasal polyposis.

We're going to summarize some of the resources we discuss at our website. That's education dot aca a education.acaai.org/disparities. And we do have two other episodes on atopic dermatitis and immune deficiency disparities. That's on our main channel at college.acaai.org/allergytalk. My name is Gerry Lee. I'm speaking for the American College of Allergy, Asthma and Immunology. And I hope you enjoy the rest of your day. Thanks for listening.