The Finnish Allergy Program 2008-2018: Society-wide proactive program for change of management to mitigate allergy burden

Abstract

A 10-year national program to improve prevention and management of allergic diseases and asthma was implemented in Finland (population 5.5. million) in 2008-2018. The main aim was to reduce the long-term burden of these conditions. The strategy was changed from traditional avoidance to tolerance and resilience of the population. Health was endorsed instead of medicalization of mild symptoms. Disease severity was reevaluated, and disabling clinical manifestations were given high priority. For health care, 5 quantitative goals and 1 qualitative goal were set. For each of the goals, specific tasks, tools, and outcome evaluation were stipulated. During the program, 376 educational sessions gathered 24,000 health care participants. An information campaign targeted the lay public, and social media was used to contact people. In the 10 years of the program, the prevalence of allergic diseases and asthma leveled off. Asthma caused fewer symptoms and less disability, and 50% fewer hospital days. Food allergy diets in day care and schools decreased by half. Occupational allergies were reduced by 45%. In 2018, the direct and indirect costs of allergic diseases and asthma ranged from €1.5 billion to €1.8 billion, with the 2018 figures being 30% less than in the respective figures in 2007. The Finnish proactive and real-world intervention markedly reduced the public health burden of allergic disorders. The allergy paradigm was revisited to improve management with systematic education. A 10-year national program to improve prevention and management of allergic diseases and asthma was implemented in Finland (population 5.5. million) in 2008-2018. The main aim was to reduce the long-term burden of these conditions. The strategy was changed from traditional avoidance to tolerance and resilience of the population. Health was endorsed instead of medicalization of mild symptoms. Disease severity was reevaluated, and disabling clinical manifestations were given high priority. For health care, 5 quantitative goals and 1 qualitative goal were set. For each of the goals, specific tasks, tools, and outcome evaluation were stipulated. During the program, 376 educational sessions gathered 24,000 health care participants. An information campaign targeted the lay public, and social media was used to contact people. In the 10 years of the program, the prevalence of allergic diseases and asthma leveled off. Asthma caused fewer symptoms and less disability, and 50% fewer hospital days. Food allergy diets in day care and schools decreased by half. Occupational allergies were reduced by 45%. In 2018, the direct and indirect costs of allergic diseases and asthma ranged from €1.5 billion to €1.8 billion, with the 2018 figures being 30% less than in the respective figures in 2007. The Finnish proactive and real-world intervention markedly reduced the public health burden of allergic disorders. The allergy paradigm was revisited to improve management with systematic education. Allergy is a systemic, immunologic, and heterogenous disorder, with variable organ manifestations that change during the life span. They cause a fair amount of disability and costs both for individuals and for society. There are no reports of coordinated action plans to combat allergic conditions in a defined population. In Finland (population 5.5 million), several successful national public health programs to control respiratory diseases have been completed.1Erhola M. Vasankari T. Jormanainen V. Toppila-Salmi S. Herrala J. Haahtela T. 25 years of respiratory health in Finland.Lancet Respir Med. 2019; 7: e16Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar The Finnish Asthma Program 1994-2004 was successful and deployed in many countries.2Selroos O. Kupczyk M. Kuna P. Łacwik P. Bousquet J. Brennan D. et al.National and regional asthma programmes in Europe.Eur Respir Rev. 2015; 137: 474-483Crossref Scopus (64) Google Scholar The latest action plan, the Finnish Allergy Program 2008-2018, was initiated to further reduce the burden on individuals and society by emphasizing prevention. The Finnish Allergy Program was based on an extensive review3von Hertzen L.C. Savolainen J. Hannuksela M. Klaukka T. Lauerma A. Mäkelä M.J. et al.Scientific rationale for the Finnish Allergy Programme 2008-2018: emphasis on prevention and endorsing tolerance.Allergy. 2009; 64: 678-701Crossref PubMed Scopus (54) Google Scholar of the new knowledge regarding immune regulation and the importance of nature relatedness.4Ege M.J. Mayer M. Normand A.C. Genuneit J. Cookson W.O. Braun-Fahrländer C. et al.GABRIELA Transregio 22 Study Group. Exposure to environmental microorganisms and childhood asthma.N Engl J Med. 2011; 364: 701-709Crossref PubMed Scopus (1044) Google Scholar, 5Hanski I. von Hertzen L. Fyhrquist N. Koskinen K. Torppa K. Laatikainen T. et al.Environmental biodiversity, human microbiota, and allergy are interrelated.Proc Natl Acad Sci U S A. 2012; 109: 8334-8339Crossref PubMed Scopus (628) Google Scholar, 6Lynch S.V. Wood R.A. Boushey H. Bacharier L.B. Bloomberg G.R. Kattan M. et al.Effects of early-life exposure to allergens and bacteria on recurrent wheeze and atopy in urban children.J Allergy Clin Immunol. 2014; 134: 593-601Abstract Full Text Full Text PDF PubMed Scopus (259) Google Scholar, 7Haahtela T. Laatikainen T. Alenius H. Auvinen P. Fyhrquist N. Hanski I. et al.Hunt for the origin of allergy - comparing the Finnish and Russian Karelia.Clin Exp Allergy. 2015; 45: 891-901Crossref PubMed Scopus (92) Google Scholar The main aim was to transform the strategy from avoidance to tolerance and resilience. It focused on allergy health (ie, having a good life despite allergies). Reducing unnecessary treatments and measures was important, especially in children and families. Severe allergy and asthma were given attention. Goals for health care, such as standardizing diagnostics,8Heinzerling L. Frew A.J. Bindslev-Jensen C. Bonini S. Bousquet J. Bresciani M. et al.Standard skin prick testing and sensitization to inhalant allergens across Europe-a survey from the GALEN network.Allergy. 2005; 60: 1287-1300Crossref PubMed Scopus (202) Google Scholar halving the prevalence of food allergy diets, and reducing the total costs of allergic diseases and asthma by 20%, were set. The program has now been completed, and it represents a successful change management initiative at the country level. In this review, we present the program's main outcomes and discuss the possibilities of scaling up the experience for other countries and extending it into the future. In Finland and globally, the incidence of asthma and allergic diseases has been increasing for decades.9Haahtela T. Lindholm H. Björksten F. Koskensuo K. Laitinen L.A. Prevalence of asthma in Finnish young men.BMJ. 1990; 301: 266-268Crossref PubMed Scopus (227) Google Scholar,10Bach J.F. The effect of infections on susceptibility to autoimmune and allergic diseases.N Engl J Med. 2002; 347: 911-920Crossref PubMed Scopus (1978) Google Scholar Currently, 30%-40% of Finnish schoolchildren and young adults appear to be sensitized to 1 or more common allergens.11Ruokolainen L. Paalanen L. Karkman A. Laatikainen T. von Hertzen L. Vlasoff T. et al.Significant disparities in allergy prevalence and microbiota between the young people in Finnish and Russian Karelia.Clin Exp Allergy. 2017; 47: 665-674Crossref PubMed Scopus (65) Google Scholar The problem was already discernible in the 1980s, when the first allergy management guideline in Finland was published,12Ministry of Social Affairs and Health, Helsinki, Finland, A statement of an allergy commission. 1983;28;1-105 [in Finnish and Swedish].Google Scholar and also in 1998, when a consensus report was prepared.13The Finnish Medical Association Duodecim and the Academy of Finland 1998. Allergic population – allergy as a publich health problem. Consensus Meeting in Hanasaari 11.11.1998, pp 1-189 [in Finnish].Google Scholar The numbers of patients with allergy and asthma grew in the 1990s, and neither children nor adults received satisfactory allergy care. The 10-year Finnish Asthma Program was based on new information on asthma, primarily as an inflammatory disease.14Haahtela T. Järvinen M. Kava T. Kiviranta K. Koskinen S. Lehtonen K. et al.Comparison of a beta 2-agonist, terbutaline, with an inhaled corticosteroid, budesonide, in newly detected asthma.N Engl J Med. 1991; 325: 388-392Crossref PubMed Scopus (672) Google Scholar In a relatively short period, management was improved and costs were reduced by better early diagnostics and by turning from β2-agonists to inhaled corticosteroids as the first-line medications.15Haahtela T. Tuomisto L.E. Pietinalho A. Klaukka T. Erhola M. Kaila M. et al.A 10 year asthma programme in Finland: major change for the better.Thorax. 2006; 61: 663-670Crossref PubMed Scopus (302) Google Scholar,16Haahtela T. Herse F. Karjalainen J. Klaukka T. Linna M. Leskelä R.L. et al.The Finnish experience to save asthma costs by improving care in 1987-2013.J Allergy Clin Immunol. 2017; 139: 408-414Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar But the main problem of how to prevent asthma and allergic diseases in the first place remained. At the population level, avoidance and fear of all exposure leads to (1) an increased need for treatment, (2) social consequences such as isolation and impairment of daily living, and (3) even serious allergic reactions if exposure (eg, to foods) occurs unexpectedly. Avoidance of allergens is always important for individual patients, especially in cases of severe food allergy, but it requires justified grounds and better-defined time limits. Concern and medicalization became visible as new allergy day care centers, allergy schools, and allergen-free working environments were demanded. At the same time, large trials indicated that the avoidance of allergens to prevent clinical symptoms may not be feasible in the long term.3von Hertzen L.C. Savolainen J. Hannuksela M. Klaukka T. Lauerma A. Mäkelä M.J. et al.Scientific rationale for the Finnish Allergy Programme 2008-2018: emphasis on prevention and endorsing tolerance.Allergy. 2009; 64: 678-701Crossref PubMed Scopus (54) Google Scholar Psychosocial factors should also be addressed, as they play an important role in patient decisions and adherence to treatment. Tolerance and resilience are immunologic, psychological, and societal.17Haahtela T. Anto J.M. Bousquet J. Fast and slow health crises of Homo urbanicus: loss of resilience in communicable diseases, like COVID-19, and non-communicable diseases.Porto Biomed J. 2020; 5: e073Crossref PubMed Google Scholar The allergy paradigm was revisited, and loss of immune balance was regarded as more important than any possible new risk factor. At the population level, endorsing tolerance, especially in children, adolescents, and families, was regarded as central.18Pelkonen A.S. Kuitunen M. Dunder T. Reijonen T. Valovirta E. Mäkelä M.J. et al.Allergy in children: practical recommendations of the Finnish Allergy Programme 2008-2018 for prevention, diagnosis, and treatment.Pediatr Allergy Immunol. 2012; 23: 103-116Crossref PubMed Scopus (33) Google Scholar A major change of attitude was needed among health professionals, patients, and the lay public. To be effective at a public health level, a program needs to change management and have a societal impact. In this review, the program is presented according to the classical change management model of Kotter,19Kotter J. Leading change. Harvard Business School Press, Boston, Mass1996Google Scholar as an example for many other noncommunicable diseases. Allergic diseases are a model of a life course approach, as they often start at birth and usually persist throughout life. A 10-year program was planned, implemented, and monitored to change the management strategy at the national level to care pathways centered around the patient. Health professionals needed help to adapt new ideas and improve the provision of care, patients needed to be involved for shared decision making, and the lay public needed to be informed. This was achieved in close collaboration with policymakers (the Finnish Institute for Health and Welfare) to provide a new national strategy and create grounds for future initiatives. Allergy management is split into several specialities in the medical discipline. The position of allergology as a main speciality, subspeciality, or additional training courses varies from one country to another. In most countries, a coordinated public health approach to management of allergies is lacking. Are specialists providing support for general practitioners and for those working at the grassroots level? Do private sector and public health professionals have the same goal? Overall, allergy services seem widely inadequate.20Diwakar L. Cummins C. Lilford L. Roberts T. Systematic review of pathways for the delivery of allergy services.BMJ Open. 2017; 7e012647Crossref PubMed Scopus (21) Google Scholar Finland was no exception, with cooperation being problematic both between primary and secondary care and between different specialities. However, Finland's small population with a relatively high level of education and well-organized public health care established a population management model and took steps from treatment to prevention. After a consensus meeting involving clinicians with different specialities, epidemiologists, nutritionists, immunologists, patients, citizens, and health officials, a group of experts prepared the 10-year program, which was launched in April 2008 (see Fig E1 in this article's Online Repository at www.jacionline.org).21Haahtela T. von Hertzen L. Mäkelä M. Hannuksela M. Allergy Programme Working GroupFinnish Allergy Programme 2008-2018 - time to act and change the course.Allergy. 2008; 63: 634-645Crossref PubMed Scopus (124) Google Scholar,22Bousquet J. Bieber T. Fokkens W. Kowalski M. Humbert M. Niggemann B. et al.In Allergy, ‘new day has begun’.Allergy. 2008; 63: 631-633Crossref PubMed Scopus (15) Google Scholar The coalition continued as a program steering group. The organization was kept simple and without hierarchies. Strategies were chosen, and goals were set. The key messages targeted all citizens (Table I). For health professionals, 6 goals (5 of which were quantitative) and indicators were tailored (Table II). Each goal had its specific tasks, tools, and evaluation methods. The tasks were the activities or the targets in pursuing the goal (what to do), and the tools were those used to perform the tasks (how to do it). The outcomes were evaluated and verified. The program linked allergy not only with clinical disease but also with allergy health. Mild symptoms, especially in childhood, were regarded as a immune and not as a for or A.S. Kuitunen M. Dunder T. Reijonen T. Valovirta E. Mäkelä M.J. et al.Allergy in children: practical recommendations of the Finnish Allergy Programme 2008-2018 for prevention, diagnosis, and treatment.Pediatr Allergy Immunol. 2012; 23: 103-116Crossref PubMed Scopus (33) Google messages of the Finnish Allergy Program not a new attitude to allergy, and allergens only if and severe allergies and prevent and in a new goals and key of the Finnish Allergy Program Allergy Program on asthma, and prevalence reduced by of allergic and asthma leveled and symptoms in and are primary of allergic diseases, asthma, and other They are by nature and which have large prevalence of food allergy diets reduced by by increasing contact with environments and by diets (eg, the traditional or only of of food allergy diets in day care decreased by Finland, new recommendations regarding diets for and children were launched in with nature has been improved (eg, in day care by the of of health should be in and food and food for human and from of allergy allergy testing in testing major allergy have been and control patient care, societal and the on health incidence of allergies reduced by of allergies was reduced by control of working conditions of and It also has a major on on severe of disease and reduced by the program, decreased by in and in the decreased by and by in the and save societal and reduce of health care, with allergy and asthma Allergy costs reduced by care and disability costs decreased by 30% million) in 2018 with in for from prevention and better care of individuals with program's measures are in Health to the of systematic in health care. in a new The program's measures are in Health to the of systematic in health care. 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