Received: 12 April 2023 | Accepted: 3 May 2023

DOI: 10.1111/pai.13961

REVIEW ARTICLE

Environmental influences on childhood asthma: Climate change

Benedetta Biagioni1 | Lorenzo Cecchi2,3 | Gennaro D'Amato4 |

Isabella Annesi-­Maesano5

1
Allergy and Clinical Immunology Unit,
San Giovanni di Dio Hospital, Florence, Abstract
Italy
Climate change is a key environmental factor for allergic respiratory diseases, espe-
2
Centre of Bioclimatology, University of
Florence, Florence, Italy
cially in childhood. This review describes the influences of climate change on childhood
3
SOS Allergy and Clinical Immunology, asthma considering the factors acting directly, indirectly and with their amplifying in-
USL Toscana Centro, Prato, Italy teractions. Recent findings on the direct effects of temperature and weather changes,
4
Division of Respiratory Diseases and
as well as the influences of climate change on air pollution, allergens, biocontaminants
Allergy AORN Cardarelli and University of
Naples, Federico II, Naples, Italy and their interplays, are discussed herein. The review also focusses on the impact
5
Department of Allergic and Respiratory of climate change on biodiversity loss and on migration status as a model to study
Diseases, Montpellier University Hospital,
Institute Desbrest of Epidemiology and environmental effects on childhood asthma onset and progression. Adaptation and
Public Health, University of Montpellier mitigation strategies are urgently needed to prevent further respiratory diseases and
and INSERM, Montpellier, France
human health damage in general, especially in younger and future generations.
Correspondence
Benedetta Biagioni, Allergy and Clinical KEYWORDS
Immunology Unit, San Giovanni di Dio air pollution, allergens, asthma, biocontaminants, children, climate change, environmental
Hospital, Florence, Italy. exposure, migration, mitigation, thunderstorm asthma
Email: biagionibenedetta@gmail.com

Editor: Ömer Kalayci

1 | I NTRO D U C TI O N
Asthma is a major noncommunicable disease (NCD), affecting an esti-
mated 262 million people in 20191 and representing the most common
chronic disease among children. The incidence of asthma has risen in the
last decades, and evidence for climate change perpetration is increas-
ing. Earth's temperature has risen by an average of 0.08° Celsius (0.14°
Fahrenheit) per decade since 1880 and the rate of warming since 1981
is more than twice as fast, 0.18°C (0.32°F) per decade. The 2022 sur-
face temperature was 0.86°C (1.55°F) warmer than the 20th-­century
average and 1.06°C (1.90°F) warmer than the preindustrial period.2
Several epidemiological studies have pointed out that climate
change is leading to an increased incidence of this respiratory dis-
ease, through various effects,3 largely among more vulnerable sub-
jects, such as children.4,5 Climate change impacts respiratory allergic
diseases including asthma by altering the environment to which the
6,7
subject is exposed and therefore acting on his/her exposome
a direct (through heat waves, floods and other extreme weather
events), indirect (modulating allergen levels and location, augment-
ing pollution damages, modifying biocontamination and microbial
exposure) and mixed way (effect of thunderstorm on pollen or
moulds, of climate change on air pollution on pollen or infections) 8
(Figure 1).
Climate change can also be one of the causes forcing people to
migrate, which according to the situation, can be responsible for the
development or the aggravation of asthma.9
Efforts to mitigate climate change effects are urgently needed
to protect the public's health, especially for the more vulnerable
populations, including children. Mitigation and adaptation strategies
targeting both air pollution and climate change simultaneously are
necessary to improve respiratory health and beyond and to secure a
future for younger generations.
We present here evidence of the multifaceted action of climate
in change on childhood asthma.

© 2023 European Academy of Allergy and Clinical Immunology and John Wiley & Sons Ltd.

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https://doi.org/10.1111/pai.13961
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2 of 11 BIAGIONI et al.

2 | D I R EC T E FFEC T S O F C LI M ATE
C H A N G E O N C H I LD H O O D A S TH M A Key message

Climate change is a key environmental factor for the rise

In the last decades, a plethora of studies demonstrated that changes
in some climate variables increase respiratory morbidity and mor-
tality in adult patients with chronic respiratory diseases, such as
asthma and COPD, and other serious less common lung diseases.
Extreme weather events, such as heatwaves and cyclones, as well as
high humidity, can trigger asthma symptoms. Future studies with a
larger cohort are necessary to deeper examine the relationship be-
tween respiratory diseases and weather patterns, in order to predict
the onset of symptoms and diseases in various regions and weather
conditions.
2.1 | Heatwaves and Wildfires
Heatwaves can be defined as a period of at least three–­five con-
secutive days of prolonged heat, in which the daily maximum tem-
perature is higher than the average maximum temperature by 5°C
(9°F) or more. Wildfires, unplanned fires that burn in natural areas,
can be caused by human activity or by natural phenomena and are
and worsening of allergic respiratory diseases, especially
in children. Climate change influences childhood asthma
in direct, indirect and mixed ways and represents a global
issue to urgently address with adaptation and mitigation
strategies.
often more frequent and severe during heatwaves. The detrimental
effects of heatwaves have been extensively described in numerous
epidemiological studies, showing that respiratory diseases increased
among children during such events and that children with respiratory
diseases were more frequently hospitalized during these extreme
weather periods.10 Fine particulate levels can reach extreme con-
centrations during wildfires causing acute asthma exacerbations11
and acute decrements in peak expiratory flow.12 Long-­term effect
of wildfire smoke exposure is also well documented. An increase in
physician-­dispensed short-­acting beta-­agonists for asthmatic chil-
dren was observed in the years following cataclysmic wildfires,13

F I G U R E 1 The multiple roles of Climate Change on childhood asthma. Climate change acts directly with weather events (in brown)
and indirectly –­through its influence on air pollution, allergens, biodiversity, biocontaminants and their interplay (in green) –­on childhood
asthma development, progression and/or exacerbation. These interconnected factors can act directly on asthma in pediatric populations
(continuous arrows) or through genetic/epigenetic modifications (dotted arrows).

BIAGIONI et al.
and the exposure to wildfire smoke was also associated with a sig-
nificant decline in lung function among children without bronchial
hyper-­reactivity.14
2.2 | Coldspells
A cold spell is an extreme atmospheric event characterized by anom-
alous low-­temperatures over consecutive days. Currently, there is
not a single standard definition of a cold spell. This meteorological
event consists of a rapid fall in temperature within a period of 24–­
72 h, with a variable temperature drop rate compared with a mini-
mum temperature that depends on the geographical region and time
of year. It has been observed that exposure to a cold spell increases
the risk of premature morbidity and mortality, especially for patients
with cardiovascular and respiratory diseases.15 Studies conducted
in China showed an association between cold spells and both child-
hood asthma and allergic rhinitis. It was found that the association
between cold spells and asthma is stronger in boys and school-­age
children and that if a cold spell lasts for several days, its impact in
later days tends to be greater than that of the previous ones.16 It
was also demonstrated that cold spells may significantly increase al-
lergic rhinitis in pediatric patients, especially in male children, aged
5–­18 years and nonscattered children.17
3 | I N D I R EC T E FFEC T S O F C LI M ATE
C H A N G E O N C H I LD H O O D A S TH M A
Climate change plays a role on respiratory health including asthma
also in an indirect way, affecting some of the major risk factors for
the development, progression and exacerbation of lung diseases.
Risk factors for childhood asthma that are enhanced by climate
change are air pollution, aeroallergens, greenspaces and biocontami-
nants (like viruses and bacteria). Climate change can act on these
factors alone or through their multiple interplay.
3.1 | Air pollution
It is well known that climate change and air pollution influence and
enhance each other, as many of the air pollutants are greenhouse
gases. It is foreseeable that in the near future global warming will
lead to increasingly prolonged episodes of peak ozone concentra-
tion in urban areas and that atmospheric concentrations of pollut-
ants and levels of atmospheric particulate matter (PM) will increase
in industrialized and more prone to vehicle traffic environments.8
Several reports showed the association of increased ambient levels
of air pollutants with reduced lung function,12,18 worsening asthma
19–­23
symptoms and asthma-­related emergency department visits or
hospitalizations in children, 24–­29 as well as asthma development.30–­34
The relationship between air pollution exposure and children's
lung function was shown with stronger evidence for PM2.5 and
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3 of 11
NO2.12,35 The strongest impact of long-­term exposures on lung func-
tion is demonstrated on FEV1, while FVC seems to be less affected,
suggesting that air pollutants can modulate especially the airflow
obstruction rather than children's overall lung size.12
The effect of high levels of air pollution on asthma exacerbations
in the pediatric population has been reported in the last decades
worldwide, but mainly from developed countries.19–­24 Babin et al. re-
ported in 200725 an association between pediatric asthma ED visits
in Washington, DC, from 2001 to 2004 and outdoor ozone concen-
tration with the strongest evidence regarding children aged 5–­12. In
the same year, Ko et al. 26 assessed the relationship between levels
of outdoor NO2, O3, PM10 and PM2.5 and hospitalization rates for
asthma in Hong Kong, demonstrating that patients from the younger
age group (0–­14 years) had a higher RR for each 10 mg/m3 increase
in air pollutants, compared with older patients, aged 15–­65 years. A
large population-­based study conducted in Atlanta between 1993
and 200427 showed that, even at relatively low ambient concen-
trations, both ozone and primary pollutants from traffic sources
independently contributed to the burden of the daily emergency
department visits for asthma or wheeze among children aged from
5 to 17 years. Subsequently, Silverman et al28 demonstrated a rela-
tionship between severe asthma morbidity and both PM2.5 and O3
levels in the warm season, analysing asthma admission in New York
City hospitals from 1999 to 2006. Stratification in 4 age groups (<6,
6–­18, 18–­50, >50) demonstrated that children aged 6–­18 years had
the highest risk of severe asthma exacerbations with a 26% (95%
CI, 10%–­4 4%), increased rate of ICU admissions and a 19% (95% CI,
12%–­27%), increased rate of general hospitalizations for each 12-­
mg/m3 increase in PM2.5 and a 19% (95% CI, 1%–­4 0%), increased risk
for ICU admissions, and a 20% (95% CI, 11%–­29%) increased risk for
general hospitalizations for each 22-­ppb increase in ozone. Lastly, a
recently published questionnaire-­based retrospective cohort study,
including data from 2011 to 2012 on 39,782 preschool children in
China, explored the effects of temperature–­pollution interactions
during pre-­and postnatal periods on asthma, 29 showing that asthma
prevalence in children aged 3–­6 years was significantly associated
not only with traffic-­related air pollutant (NO2) exposure but also
with exposure to an increased temperature during lifetime, preg-
nancy and postnatal period.
Several studies have shown that exposure to the classic air
pollutants (PM10 and/or SO2) in utero or during the first years of
life was positively related to asthma and allergies. The first evi-
dence of a significant association between childhood asthma and
early-­life exposure to ambient air pollutants was demonstrated in
2010. 30 Subsequent studies showed that not only asthma but also
other childhood allergic diseases, including allergic rhinitis and ec-
zema, were mainly associated with exposure to traffic-­related air
pollutant, namely NO2 and especially in a specific trimester during
pregnancy. In fact, the authors showed that exposure during the
first trimester of pregnancy was related to higher risk of develop-
ing eczema (1.54, 1.14–­2 .09), the second trimester with higher risk
of asthma occurrence (1.72, 1.02–­2 .97), and the third trimester
with the onset of allergic rhinitis (1.77, 1.09–­2 .89). 31 Recently, the
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Official American Thoracic Society Workshop Report stated that
long-­term exposure to air pollution is associated with the onset of
childhood asthma, especially traffic-­related air pollution (NO2 and
black carbon). 32 A subsequent meta-­analysis by Han K. et al. 33 fo-
cussed on the effect of early childhood exposure to traffic-­related
air pollution (TRAP) on asthma development. The causative role
of fine particulate matter (PM2.5), nitrogen dioxide (NO2), benzene
and total volatile organic pollutants (TVOCs) exposures was anal-
ysed in the 27 studies included in this meta-­analysis, demonstrat-
ing that TRAP increases the risk of asthma among children with
the following odd ratios and confidence intervals: meta-­O R = 1.07,
95% CI: 1.00–­1.13 for PM2.5, meta-­O R = 1.11, 95% 23 CI: 1.06–­
1.17 for NO2 , meta-­O R: 1.21, 95% CI: 1.13–­1.29 for Benzene and
meta-­O R: 1.06, 95% CI: 24 1.03–­1.10 for TVOC. The most recent
and extensive review on this topic, performed by Moreira and
coll., 34 focussed on the relationship between childhood asthma
and air pollution—­specifically industrial pollutants, traffic-­related,
due to disinfection products and tobacco smoke—­underlying the
role of environmental inequality at the basis of an unequal dis-
tribution of the risks and benefits of different living settings and
conditions.
All this evidence points to the urgent need to designate accept-
able thresholds for air pollutants, in order to prevent severe or life-­
threatening asthma episodes, especially in more vulnerable subjects,
such as the pediatric population.
3.2 | Allergens
Climate change influences aeroallergens too, increasing their pro-
duction, their atmospheric concentration and their geographical dis-
tribution as well as we will see below their allergenicity.36 Climate
change impacts the quantity and quality of aeroallergens. These
can trigger or enhance the production of pro-­
inflammatory and
immunomodulatory mediators necessary to the occurrence of IgE-­
mediated sensitization, thus accelerating the onset of allergic res-
piratory diseases and causing their exacerbations.3,6,7
3.2.1 | Pollen
Airborne pollen are one of the most common causative agents of
allergic respiratory disease. Climate change influences not only the
quantity but also the quality of pollen allergens; in fact, seasonal var-
iations in pollens due to weather events have occurred worldwide,
along with an increased sensitization rate to pollen both in pediat-
9
ric and adult population. Weather conditions may influence pollen
concentrations altering the biogeographic distribution of plants and
affecting the vegetal life cycle.37 An increased pollen production and
an augmented duration of pollen season with anticipation of the pol-
len season was demonstrated for grass,37 birch, oak and olive tree
pollen.38 Moreover, allergenic plants, such as ragweed, are spread-
ing, finding favourable conditions in a soil more and more damaged
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BIAGIONI et al.
by urbanization and desertification.39,40 Climate conditions leading
to the increase in airborne pollen concentration influence the preva-
lence and severity of ARD. In particular, high temperatures, low
atmospheric humidity and sunny meteorological conditions have
all been associated with increased pollen count and augmented al-
lergic rhinitis prevalence in children.37 Climate factors are probably
able to directly influence pollen potency too: preliminary data from
HIALINE project showed that the content of group five grass aller-
gens is positively associated with outdoor humidity.41 We published
a systematic review and meta-­analysis, showing that in the last dec-
ades a large number of studies reported the evidence of a significant
positive association between total pollen concentrations and asthma
exacerbations in the pediatric population, requiring ED visits or hos-
pital admission.42 Among them, in the last decade an association
between children asthma-­related ED admissions or hospitalizations
and total pollen counts was reported in Australia in a case-­crossover
study43 and in a time-­series analysis,44 the latter reporting a positive
association with a 10 unit increase in total pollen count. As we sum-
marized,42 the strongest evidence of this association was observed
in patients under 18 years of age, especially regarding grass pollen
concentration increase in the 2 days before the asthma exacerbation
reports.43,45–­48 Similar results were described for pollen of various
tree species: several studies showed a positive association between
severe asthma exacerbations in patients younger than 18 years old
and an increase in pollen concentration from different tree species in
the previous 2–­4 days.42,43,46,48 Positive associations were found for
birch pollen concentration increase in patients of this age group.42,49
A positive association between the increase in pollen concentration
and an augmented risk of reduced lung function was also observed
in a recent meta-­analysis by Idrose et al.,50 considering the obtain-
able data on the effect of outdoor pollen exposure on both lung
function parameters and airway inflammation markers.
3.2.2 | Dust mites
Dust mites are a major source of allergens inside homes,
Dermatophagoides pteronyssinus and Dermatophagoides farinae
being the most common species of dust mite reported in Western
Countries.51 Global warming affects dust mite proliferation and sur-
vival because both temperature and relative humidity are important
adjuvating factors for the natural life cycle of these invisible arthro-
podes. Older homes, increased population density, lower income,
presence of cockroaches and mould, presence of carpeting and lack
of air conditioning are all factors involved in the increase of dust
mite exposure.52 House dust mite allergens have a high allergenic
potency, activating both the innate and adaptive immune response
towards a Th2-­polarization and thus causing the onset and aggrava-
tion of allergic respiratory diseases.53 Early exposure to house dust
mite allergens has been associated with asthma development long
ago, and to date the suggested threshold level for sensitization to
Dermatophagoides pteronyssinus major allergen, Der p 1 is >2 μg/g
while a level of 10 μg/g of Der p 1 represents a significant risk

BIAGIONI et al.
factor for the development of asthma in already dust mite-­sensitized
51
individuals.
3.2.3 | Mould
Global warming affects the quantity, intensity and frequency of pre-
cipitation type as well as the frequency of extreme weather events
such as flood and intensive precipitation, which can result in damp-
ness, leading to mould proliferation, causing asthma exacerbations
in sensitized subjects.54 Recent reviews about indoor mould expo-
sure and respiratory allergic diseases have established the causal re-
lationship between the presence of visible mould and mould odour
55
with the development and exacerbations of asthma in children.
Mould-­sensitized children affected by asthma and living in inner-­city
environments are exposed to airborne fungi in both indoor and out-
door air,56 and it has been demonstrated that the exposure to higher
levels of indoor fungi causes a significant increase in unscheduled
visits for asthma in urban children, even after controlling for outdoor
fungal levels.57 Studies have also focussed on the relevance of mould
in the school environment and its impact on respiratory health in
58
students. Chen et al. demonstrated the association between
Aspergillus/Penicillium and basidiospores presence in classroom
and childhood asthma during school attendance,59 while Holst et al.
showed that high levels of dampness in Danish classroom correlated
60
with increased wheezing and decreased lung function in students.
The importance of fungi exposure and sensitization in children has
been demonstrated also during extreme weather conditions, such as
thunderstorm asthma episodes, discussed below.
4 | CO M B I N ATI O N O F D I R EC T A N D
I N D I R EC T E FFEC T S O F C LI M ATE C H A N G E
O N C H I LD H O O D A S TH M A
The combination of direct and indirect effects of climate change
can result in a synergic action on respiratory health. The interac-
tion between climate change, air pollutants, aeroallergens, epithelial
barrier and biocontaminants has a favourable knock-­on effect on
atopic sensitization as well as respiratory disease exacerbations and
development.7
4.1 | Air pollution and pollen
Throughout the increase in greenhouse gases (GHGs), to date CO2,
NO2 and O3 are the air pollutants that have shown the most relevant
impact on aeroallergen production and potency. A number of stud-
ies have shown the influence of air pollutants level, especially CO2,
not only in augmenting the rise of pollen concentrations but also
leading to a higher expression of allergenic proteins in the pollen
itself. This increased ‘allergenicity’ is responsible for the aggravation
or development of allergic diseases in already sensitized subjects.9
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5 of 11
Furthermore, several experimental studies have demonstrated that
the permeability of the respiratory epithelium and the mucociliary
clearance are subject to modification by atmospheric pollutants,
O3, NO2 and diesel particulate emissions in particular.7 The increase
in permeability and the reduction of mucociliary clearance due to
these pollutants facilitate the permanence of allergens and irritating
products on the epithelium surface and allow its entry at the level
of the submucosa, favouring pathogenic immunological pathways.
4.2 | Thunderstorm asthma
The peculiar interaction between extreme weather events due to
climate change, aeroallergens and respiratory epithelia of sensitized
subjects can lead to acute and dangerous asthma epidemics, such as
in the case of thunderstorm asthma, detailed below.
Thunderstorms are weather events characterized by striking
electrical activity and strong convective updraft in early phases,
followed by a strong downdraft in a column of precipitation in dis-
sipating stages. Thunderstorm asthma (TA) can be defined as the
occurrence of acute asthma attacks immediately following a thun-
derstorm.36 These events are due to the combination of meteoro-
logical and aerobiological factors and can lead to asthma epidemics
affecting predisposed atopic patients. Thunderstorm outflows cause
the concentration of aeroallergens (mainly pollen or mould allergens)
at ground level, releasing respirable allergenic particles after their
rupture by osmotic shock caused by humidity and rainfall. The inhala-
tion of high concentrations of these aeroallergens by sensitized indi-
viduals can induce an early asthmatic response, eventually followed
by a late inflammatory phase.61 In the last decades, these extreme
weather events became a global health concern, because of the im-
portant and seldom fatal clinical consequences in patients affected
by respiratory allergies. Climate change acceleration has the poten-
tial of causing more frequent and unpredictable extreme weather
events such as TA; consequently, the health system has to be pre-
pared to face more severe epidemics worldwide.57 Previous data on
thunderstorm asthma pandemics62–­6 4 suggested that asthma symp-
toms during thunderstorms aggravated predominantly in the adult
population, affecting just 15% or less of children. Nevertheless, in
2020 Y.-­Y. Xu et al. described the effect on pediatric patients of
the thunderstorm asthma that happened on 11 September 2018 in
Yulin, China.65 This study showed that thunderstorm asthma can se-
riously affect children, especially if suffering from allergic rhinitis or
untreated asthma and that mugwort pollen can be a relevant aeroal-
lergen in thunderstorm asthma epidemics. An increase of 2.7 and
16 times, respectively, in the mean number of daily visits to emer-
gency/outpatient department and of daily admission to hospital was
observed, with a gender prominence of males between children.
Among the hospitalized children, 56% of them had never experi-
enced asthma symptoms while 25% had a confirmed diagnosis of
asthma. The vast majority of the hospitalized children (94%) showed
positive IgE against mugwort pollen, 78% of them being monosensi-
tized to this pollen species.
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4.3 | Climate variables and infections
Extreme weather events, such as heat waves, floods, major storms,
drought and wildfires, affect respiratory infections, and there-
fore respiratory health, by affecting vectors and host immune re-
35
sponses. Climate change can also play a role in the new onset,
spreading and/or modification of infectious respiratory disease,
some of them representing known risk factors for respiratory dis-
ease onset and/or exacerbation, especially in children, as discussed
further. At the same time, cold weather increases the occurrence
of respiratory infections in individuals with underlying respiratory
3
disease.
It is well known that respiratory virus infections, particularly
respiratory syncytial virus (RSV) and rhinovirus, are important risk
factors for the onset of wheezing in infants and children.66 The
pathogenic role of respiratory viruses as triggers for exacerbations in
asthmatic patients is also established, even if not fully characterized.
However, respiratory infections are common causes of asthma exac-
erbation in children. Climate change can play a role in the new onset,
spreading and/or modification of infectious respiratory disease too.
An extensive body of literature shows climate change's impact on
incidence and severity of infectious respiratory diseases through
the modifications of host immune response, exposure to fungal
and mycobacterial species, vectors' vitality and the spread of novel
viruses.67 Climate change influences respiratory viral transmission
such as influenza epidemics by modifying its ecology and geograph-
ical distribution. In fact, changes in temperature, precipitation and
relative humidity influence viral activity and transmission contrib-
uting to the size and severity of epidemics.68 Recently, studies on
climate change have also considered its influence on the outbreak
of pandemics of novel pathogenic species such as COVID-­19 caused
by the emergence of the new coronavirus SARS-­CoV-­2. Dramatic
temperature shifts can lead to an increased exposure to environ-
ments where vector-­borne pathogens thrive. Rise in temperatures
is able to increase vectors' vitality and therefore the risk of disease
spread.68 This has been shown, for example, in rodents that are res-
ervoirs for Hantaviruses, a virus known for regional outbreaks man-
69
ifesting as pneumonia and diffuse systemic disease. Furthermore,
desertification, expansion of drylands and dust storms have con-
tributed to the release and diffusion of fungal dust-­borne spores
commonly found on soil that can cause respiratory infections, as
70–­73
observed in Southwestern USA with Coccidiomycosis. Another
example is the geographic spread of Cryptococcus gattii, causal agent
of Cryptococcosis, a disease that most commonly affects immuno-
compromised human hosts. This respiratory disease, originally only
present in subtropical areas, is expanding in Mediterranean regions
of Europe and in Pacific Northwest regions of the USA, and it has
been hypothesized that trees and livestock trading, flocks of mi-
gratory birds, anomalous atmospheric events (e.g. tsunamis) and
human interactions have substantially contributed to the diffusion
of this pathogen.74–­76 A similar case is Histoplasma capsulatum, an
endemic fungus transmitted through inhalation in areas with bird
or bat droppings in northern parts of the USA and known to cause
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BIAGIONI et al.
severe pneumonia in immunocompromised hosts. Changes in animal
behaviour and geographic distribution due to global warming likely
have had an impact on the diffusion of this disease.77 Not only fungal
respiratory infections but also the spread of mycobacteriosis is in-
tertwined with climate change. It has been demonstrated that hurri-
canes, which have lately increased due to climate change, contribute
to an increase in nontuberculous mycobacteria (NTM) disease.78,79
Differently from TB, NTM lung diseases are typically conveyed
through environmental sources, such as municipal water and soil,
and environment cross-­contamination by NTM is greatly favoured
by hurricanes.80,81 It is evident to all how public health and safety are
threatened and damaged by emerging viral diseases such as Ebola,
severe acute respiratory syndrome (SARS), the avian flu and novel vi-
ruses in the coronavirus family. Climate change must be considered
an important cofactor in their outbreak and spreading. Notably, both
biodiversity decrease and air pollution increase, caused by climate
change, probably favoured the onset and diffusion of the COVID-­19
pandemic.
5 | B I O D I V E R S IT Y LOS S
Climate change and urbanization are both involved in the reduction
of green spaces, depletion of biodiversity and impoverishment of
microbiota, with relevant consequences on respiratory diseases and
more.82 Although biodiversity is a difficult parameter to measure on
a global scale, in recent years there has been a unanimous scientific
consensus that the planet's biodiversity is declining, and one of the
most important causes of this decline is climate change. The vari-
ety and quality of the ‘internal’ microbiota, present in human skin,
respiratory and intestinal tract is deeply influenced by the ‘external’
microbiota biodiversity, being continuously colonized by the micro-
biome present in water, soil, plants and animals. The ‘Biodiversity
Hypothesis’ connected the reduction in biodiversity to chronic in-
flammatory and allergic diseases, stipulating that the contact with
nature promotes the proper functioning of the immune system and
enables immunological tolerance by enriching the human microbi-
ome.82 According to this largely accepted theory, the reduction of
external biodiversity results in a progressive depletion of the micro-
bial variety with which the human body comes into contact, deter-
mining an insufficient activation of the immunoregulatory pathways
and a consequent state of immunodysregulation. This hypothesis is
now supported by consistent data of subsequent studies; in fact,
many cohorts have shown that alterations in the gut microbiota
during infancy and early childhood are associated with respiratory
diseases.83
6 | M I G R ATI O N S T U D I E S
Finally, climate change is directly or indirectly responsible for migra-
tion, causing an augmented risk in migrant people, and migrant chil-
dren in particular, for the development and severity of presentation
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BIAGIONI et al. 7 of 11

of asthma and other allergic respiratory diseases,9 as discussed

below. Studies in migrant populations provide a unique opportunity
to investigate the role of environmental factors in the pathogen-
esis of asthma and other respiratory noncommunicable diseases.
Overall, these studies highlight the predominant role of environment
in driving the allergic sensitization and respiratory disease initiation
and development in migrant populations. Migrant people may ex-
perience an abrupt exposure to different environmental factors in
the host country, dealing all at once with different climate condi-
tions and new allergens, due to their relocation to areas with differ-
ent weather, flora and fauna, as well as the sudden and prolonged
exposure to high level of new air pollutants. Migrants, and children
in particular may adopt a different lifestyle after moving, including
changes in diet, physical activity and stress levels, all of those im-
pacting their immune system and increasing their risk of developing
atopic diseases. Finally, migrants may experience social and eco-
nomic disadvantages in the host country, including lower income,
limited access to healthcare and discrimination. These factors can
increase their risk of developing noncommunicable disease such as
allergic respiratory diseases and also the risk of poorer disease out-
comes.9,84 Current knowledge suggests that immigrants coming from
less affluent countries with low allergic diseases prevalence tend to
have a lower prevalence of asthma and allergic diseases compared
with native-­born population of the affluent host country, in line with
the so-­called ‘healthy immigrant effect’ observed for other noncom-
municable diseases. Nonetheless, the protective role of migrant sta-
tus towards allergic disease declines with the increasing duration of
residence in the host country and migrant people, especially in more
fragile conditions, can experience higher prevalence and severity of
respiratory diseases.
The main factors influencing the risk of developing atopic dis-
ease in migrant populations compared with autochthonous popula-
tion can be resumed as follows (9; Figure 2):

1. the burden of allergic diseases is lower in immigrants compared

with autochthonous population when the migration occurred
from a less affluent country to a high-­
income host country
(healthy immigrant effect).
2. the prevalence of allergic disorders in immigrants reaches the
prevalence of the local population in a time-­dependent process
(assimilation effect).
3. the age at migration influences the risk of ARD development.
F I G U R E 2 Main factors influencing ARDs risk in immigrant
4. there is a risk gradient between first-­and second-­generation im- people. Adapted from figure 4 Biagioni B, et al. The rising of allergic
migrants and within the second generation. respiratory diseases in a changing world: from climate change to
migration. Expert Rev Respir Med. 2020;14(10):973–­986. Ref.9
Many studies have demonstrated the role of environmental
exposures, such as air pollution and allergen levels, in augmenting
the risk of asthma and allergic respiratory disease in migrant chil- prevalence of asthma than local residents and recently Cacciani
dren. For example, Leung et al.85 found that migrant status was as- et al.87 investigated potentially avoidable hospitalizations for asthma
sociated with an increased risk of hospitalizations for asthma and in children and adolescents by migrant status in Italy and found
other wheezing disorders in Hong Kong children, afterwards Li that children with migrant backgrounds had a higher risk of hospi-
et al.86 investigating the prevalence of asthma and allergic symp- talization. Similar observations have been reported in 2021 by the
toms in Suzhou, China, found that domestic migrants had a higher group of Gallo Marin,88 with a scoping review of noncommunicable
 |
8 of 11
diseases and maternal and child health needs of Venezuelan mi-
grants in South America, and the study observed that environmental
factors, such as poor housing conditions and exposure to air pollu-
tion, may contribute to the development of asthma and allergies in
this population. The role of farm environment was analysed by Timm
89
et al. in a three-­generation cohort study in Denmark founding that
selective migration from farming environments was associated with
an increased risk of asthma, suggesting that changes in environmen-
tal exposures, such as decreased exposure to endotoxins and farm
animals, may contribute to this increased risk. Finally, the impor-
tance of life condition of migrant children has been observed; for
example, Richter et al.90 investigated the burden of atopy in immi-
grant families living in substandard apartments in Sweden and found
a high prevalence of atopy in this population, suggesting that poor
housing conditions, such as dampness and mould, may contribute to
this increased risk.
Overall, these studies confirm that environmental exposures,
such as climate conditions, air pollution, allergen levels and poor
housing conditions, play a massive role in the development of asthma
and allergies. Improving environmental setting may be an important
strategy for preventing and managing these conditions in more frag-
ile populations such as children and migrant children in particular.
7 | M ITI G ATI O N S TR ATEG I E S
As discussed above, climate change has a huge impact on respira-
tory health and beyond, acting directly and through the complex
interplay between patient genetic factors, airborne allergens and
pollutants. Anthropogenic climate change is a severe and press-
ing global issue we must address now and tackling both air pollu-
tion and climate change simultaneously is of striking importance to
achieve a mitigation of climate-­related health events in general and
respiratory diseases in children in particular. Suffice to say that it
has been estimated that meeting the minimum air pollution levels
for NO2 (1.5 μg·m−3), PM2.5 (0.4 μg·m−3) and BC (0.4 × 10−5 m−1) can
prevent 135,257 (23%), 191,883 (33%) and 89,191 (15%) cases of
asthma in children, respectively.91 It is also known that exposure
to high temperatures and pollution, as direct effects of climate
change, can affect the host immune system. Therefore, the fight
against fossil fuel emissions and air pollution can prevent the out-
break of new viral diseases and therefore new epidemics but also
limit the damage on societies and health systems caused by these
diseases. According to the Centre for Research on the Epidemiology
of Disasters (CRED), in the first half of 2022 the EM-­DAT disaster
database recorded 187 disasters from natural hazards worldwide,
their impact amounting to at least 6347 deaths and 50 million peo-
ple affected. The vast majority of these events were climate-­related,
namely floods and storms.92 In 2015, the Paris Agreement set the
goal of limiting global temperature increase to 2°C by 2100 through
strategies for climate change abatement. To date, three main climate
change mitigation approaches to pursue this aim are identified. The
first one is conventional mitigation, represented by well-­established
13993038, 2023, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/pai.13961 by Universidad Nacional Autonoma De Mexico, Wiley Online Library on [12/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
BIAGIONI et al.
and known decarbonization technologies and techniques that re-
duce fossil-­based CO2 emissions, including renewable energy, nu-
clear power, carbon capture and storage (CCS) as well as utilization
(CCU), fuel switching and efficiency gains. The second one is nega-
tive emissions, represented by new technologies and methods that
have been recently proposed, aiming to capture and sequester at-
mospheric carbon to reduce carbon dioxide levels. The third and
last one is radiative forcing geo-­engineering, and these techniques
aim to alter the earth's radiative energy budget to stabilize or re-
duce global temperatures.93 Urbanization, industrialization, trans-
portation, deforestation, livestock and fossil fuel burning are the
main drivers of anthropogenic climate change, which has irrevers-
ible impacts on human health with present and future generations
of children bearing unacceptably high disease burden caused by cli-
mate change. Conserving and implementing biodiversity is critical
to address climate change94; therefore, protecting natural elements,
revegetating urban areas, reforestation and improvement of public
transport, walking and bicycling also represent important strategies
to both climate change mitigation and adaptation. UNHCR promotes
protection and assistance to people displaced by the effects of cli-
mate change as well as helps to increase their resilience to future dis-
asters. Mitigation of climate change can only be reached with global
and public health policy action. Media, political and public support
is therefore necessary and urgent for the development of efficient
climate change mitigation and adaptation strategies.
AU T H O R C O N T R I B U T I O N S
Benedetta Biagioni contributed to writing—­
original draft and
writing—­review and editing; Isabella Annesi-­Maesano and Lorenzo
Cecchi contributed to writing—­review and editing and conceptual-
ization; Gennaro D'Amato contributed to review and editing.
PEER REVIEW
The peer review history for this article is available at https://
www.webof​s cien​ce.com/api/gatew​ay/wos/peer-­revie​w/10.1111/
pai.13961.
ORCID
Isabella Annesi-­Maesano https://orcid.
org/0000-0002-6340-9300
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