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

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.

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).

Organizations supporting the meeting

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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).

(adapted from [102])

ICPs for rhinitis and asthma multimorbidity

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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].

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.

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.

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).

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).

Next-generation ICPs for rhinitis and asthma multi-morbidity

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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].

Embedding aerobiology and air pollution in ICPs

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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.

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.

Not applicable.

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

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.

Funding

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

Affiliations

1. MACVIA-France, Fondation Partenariale FMC VIA-LR, CHU, 34295, Montpellier Cedex 5, France

   • J. Jean Bousquet
   • , Anna Bedbrook
   • , Gabrielle Onorato
   •  & Fabienne Portejoie

2. INSERM U 1168, VIMA: Ageing and Chronic Diseases Epidemiological and Public Health Approaches, Villejuif Université Versailles St-Quentin-en-Yvelines, UMR-S 1168, Montigny Le Bretonneux, France

   • J. Jean Bousquet

3. European Forum for Research and Education in Allergy and Airway Diseases (EUFOREA), Brussels, Belgium

   • J. Jean Bousquet
   • , Peter W. Hellings
   • , Wytske J. Fokkens
   • , Derek K. Chu
   • , Gert Marien
   • , Benoit Pugin
   •  & Sietze Reitsma

4. Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Uniersität zu Berlin, Berlin, Germany

   • J. Jean Bousquet
   • , Torsten Zuberbier
   •  & Karl C. Bergmann

5. Department of Dermatology and Allergy Member of GA2LEN, Comprehensive Allergy-Centre, Berlin Institute of Health, Berlin, Germany

   • Torsten Zuberbier
   •  & Karl C. Bergmann

6. Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada

   • Holger J. Schünemann
   •  & Jan Brozek

7. Division of Allergy, Immunology, and Transplantation (DAIT), National Institute of Allergy and Infectious Diseases, NIH, Bethesda, USA

   • Alkis Togias

8. National Institute for Health and Welfare, Helsinki, Finland

   • Marina Erhola

9. Dept of Otorhinolaryngology, Univ Hospitals Leuven, Louvain, Belgium

   • Peter W. Hellings

10. Academic Medical Center, Univ of Amsterdam, Amsterdam, The Netherlands

    • Peter W. Hellings

11. Faculty of Medicine, Transylvania University, Brasov, Romania

    • Ioana Agache

12. Department of Allergy and Immunology, Hospital Quirónsalud Bizkaia, Erandio, Spain

    • Ignacio J. Ansotegui

13. ISGlobAL, Centre for Research in Environmental Epidemiology (CREAL), Barcelona, Spain

    • Josep M. Anto
    • , Xavier Basagana
    • , Judith Garcia-Aymerich
    •  & Xavier Rodo

14. IMIM (Hospital del Mar Research Institute), Barcelona, Spain

    • Josep M. Anto
    •  & Xavier Basagana

15. CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain

    • Josep M. Anto
    •  & Xavier Basagana

16. Universitat Pompeu Fabra (UPF), Barcelona, Spain

    • Josep M. Anto
    •  & Xavier Basagana

17. Upper Airways Research Laboratory, ENT Dept, Ghent University Hospital, Ghent, Belgium

    • Claus Bachert

18. Dept of Otolaryngology, Head and Neck Surgery, University of Mainz, Mainz, Germany

    • Sven Becker

19. Hospital Civil de Guadalajara Dr Juan I Menchaca, Guadalarara, Mexico

    • Martin Bedolla-Barajas

20. iQ4U Consultants Ltd, London, UK

    • Michael Bewick

21. Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia

    • Sinthia Bosnic-Anticevich
    • , Biljana Cvetkosvki
    •  & Vicky Kritikos

22. Woolcock Emphysema Centre, Sydney, Australia

    • Sinthia Bosnic-Anticevich
    • , Biljana Cvetkosvki
    •  & Vicky Kritikos

23. Sydney Local Health District, Glebe, NSW, Australia

    • Sinthia Bosnic-Anticevich
    • , Biljana Cvetkosvki
    •  & Vicky Kritikos

24. La Rochelle, France

    • Isabelle Bosse

25. Quebec Heart and Lung Institute, Laval University, Quebec City, QC, Canada

    • Louis P. Boulet
    •  & Guy Joos

26. EIT Health France, Paris, France

    • Jean Marc Bourrez

27. Dept of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium

    • Guy Brusselle

28. Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands

    • Niels Chavannes

29. UCIBIO, REQUINTE, Faculty of Pharmacy and Competence Center on Active and Healthy Ageing of University of Porto (Porto4Ageing), Porto, Portugal

    • Elisio Costa

30. ProAR–Nucleo de Excelencia em Asma, Federal University of Bahia, Bahia, Brazil

    • Alvaro A. Cruz

31. WHO GARD Planning Group, Salvador, Brazil

    • Alvaro A. Cruz

32. Medical Consulting Czarlewski, Levallois, France

    • Wienczyslawa Czarlewski

33. Department of Otorhinolaryngology, Amsterdam University Medical Centres, AMC, Amsterdam, The Netherlands

    • Wytske J. Fokkens
    •  & Sietze Reitsma

34. CINTESIS, Center for Research in Health Technology and Information Systems, Faculdade de Medicina da Universidade do Porto, Porto, Portugal

    • Joao A. Fonseca

35. Medida, Lda Porto, Portugal

    • Joao A. Fonseca
    •  & Maddalena Illario

36. ERS President 2017-2018, Athens Chest Hospital, 7th Resp Med Dept and Asthma Center, Athens, Greece

    • Mina Gaga

37. Skin and Allergy Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland

    • Tari Haahtela
    •  & Sanna Toppila-Salmi

38. Division for Health Innovation, Campania Region and Federico II University Hospital Naples (R &D and DISMET), Naples, Italy

    • Maddalena Illario

39. Center for Rhinology and Allergology, Wiesbaden, Germany

    • Ludger Klimek

40. Division of Internal Medicine, Asthma and Allergy, Barlicki University Hospital, Medical University of Lodz, Łódź, Poland

    • Piotr Kuna

41. Faculty of Medicine, Vilnius University, Vilnius, Lithuania

    • Violeta Kvedariene

42. University of Medicine and Pharmacy, Hochiminh City, Vietnam

    • L. T. T. Le

43. Center of Excellence in Asthma and Allergy, Médica Sur Clinical Foundation and Hospital, México City, Mexico

    • Desiree Larenas-Linnemann

44. KYomed INNOV, Montpellier, France

    • Daniel Laune
    • , Sylvie Arnavielhe
    •  & Eve Mathieu-Dupas

45. Faculty of Health Sciences and CICS–UBI, Health Sciences Research Centre, University of Beira Interior, Covilhã, Portugal

    • Olga M. Lourenço

46. CIRFF, Federico II University, Naples, Italy

    • Enrica Menditto
    •  & Enrica Menditto

47. Rhinology Unit & Smell Clinic, ENT Department, Hospital Clínic, Barcelona, Spain

    • Joaquin Mullol

48. Clinical & Experimental Respiratory Immunoallergy, IDIBAPS, CIBERES, University of Barcelona, Barcelona, Spain

    • Joaquin Mullol

49. Dept of Otorhinolaryngology, Chiba University Hospital, Chiba, Japan

    • Yashitaka Okamoto

50. Division of Infection, Immunity & Respiratory Medicine, Royal Manchester Children’s Hospital, University of Manchester, Manchester, UK

    • Nikos Papadopoulos

51. Allergy Department, 2nd Pediatric Clinic, Athens General Children’s Hospital “P&A Kyriakou”, University of Athens, Athens, Greece

    • Nikos Papadopoulos

52. Allergy Department, Pasteur Institute, Paris, France

    • Nhân Pham-Thi

53. Conseil Général de l’Economie Ministère de l’Economie, de l’Industrie et du Numérique, Paris, France

    • Robert Picard
    •  & Robert Picard

54. The Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, UK

    • Hilary Pinnock
    •  & Aziz Sheikh

55. Pneumologie et Soins Intensifs Respiratoires, Hôpitaux Universitaires Paris, Centre Hôpital Cochin, Paris, France

    • Nicolas Roche

56. Department of Internal Medicine, Medical University of Graz, Graz, Austria

    • Regina E. Roller-Wirnsberger

57. Association Asthme et Allergie, Paris, France

    • Christine Rolland

58. Department of Prevention of Environmental Hazards and Allergology, Medical University of Warsaw, Warsaw, Poland

    • Boleslaw Samolinski
    •  & Filip Raciborski

59. Health Planning Unit, Department of Social Medicine, Faculty of Medicine, University of Crete, Crete, Greece

    • Ioanna Tsiligianni
    •  & Despo Ierodiakonou

60. International Primary Care Respiratory Group IPCRG, Aberdeen, Scotland, UK

    • Ioanna Tsiligianni

61. Institute of Clinical Medicine & Institute of Health Sciences, Vilnius University Faculty of Medicine, Vilnius, Lithuania

    • Arunas Valiulis

62. Department of Lung Diseases and Clinical Immunology, University of Turku and Terveystalo Allergy Clinic, Turku, Finland

    • Erkka Valovirta
    • , Sian Williams
    •  & Despo Ierodiakonou

63. FILHA, Finnish Lung Association, Helsinki, Finland

    • Tuula Vasankari

64. Unit of Geriatric Immunoallergology, University of Bari Medical School, Bari, Italy

    • Maria-Teresa Ventura

65. Asthma UK, Mansell Street, London, UK

    • Samantha Walker

66. Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, Davos, Switzerland

    • Cezmi A. Akdis

67. Epidemiology of Allergic and Respiratory Diseases, Department Institute Pierre Louis of Epidemiology and Public Health, INSERM and Sorbonne Université, Medical School Saint Antoine, Paris, France

    • Isabella Annesi-Maesano

68. Department of Medicine, University of Cape Town, Cape Town, South Africa

    • Eric Bateman

69. Dept of Respiratory Medicine, National Institute of Diseases of the Chest and Hospital, Dhaka, Bangladesh

    • K. S. Bennoor

70. National Center of Expertise in Cognitive Stimulation (CEN STIMCO), Broca Hospital, Paris, France

    • Samuel Benveniste

71. Department of Biochemistry and Clinical Chemistry, Faculty of Pharmacy with the Division of Laboratory Medicine, Warsaw Medical University, Warsaw, Poland

    • Slawomir Bialek
    •  & Piotr Wroczynski

72. Global Alliance against Chronic Respiratory Diseases (WHO GARD), Joensuu, Finland

    • Nils Billo

73. Department of Dermatology and Allergy Centre, Odense University Hospital, Odense Research Center for Anaphylaxis (ORCA), Odense, Denmark

    • Carsten Bindslev-Jensen
    •  & Esben Eller

74. Termofischer Scientific, Uppsala, Sweden

    • Carsten Bindslev-Jensen
    •  & Esben Eller

75. Department of Respiratory Medicine and Allergology, University Hospital, Lund, Sweden

    • Leif Bjermer

76. Department of Geriatrics, Montpellier University hospital, Montpellier, France

    • Hubert Blain

77. EA 2991 Euromov, University Montpellier, Montpellier, France

    • Hubert Blain

78. UOC Pneumologia, Istituto di Medicina Interna, F Policlinico Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy

    • Mateo Bonini

79. National Heart and Lung Institute, Royal Brompton Hospital & Imperial College, London, UK

    • Mateo Bonini

80. CHU, Dijon, France

    • Philippe Bonniaud

81. Clinical Medicine, Laval’s University, Quebec City, Canada

    • Jacques Bouchard

82. Medicine Department, Hôpital de la Malbaie, Quebec city, QC, Canada

    • Jacques Bouchard

83. Department of Clinical Pharmacy of Lithuanian, University of Health, Kaunas, Lithuania

    • Vitalis Briedis

84. Institute of Lung Health, Respiratory Biomedical Unit, University Hospitals of Leicester NHS Trust, Leicestershire, UK

    • Christofer E. Brightling

85. Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, UK

    • Christofer E. Brightling

86. Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz, Germany

    • Roland Buhl

87. Municipality Pharmacy, Sarno, Italy

    • Roland Buonaiuto

88. Personalized Medicine Clinic Asthma & Allergy, Humanitas University, Humanitas Research Hospital, Rozzano, Milan, Italy

    • Giorgo W. Canonica

89. Allergy Section, Department of Internal Medicine, Hospital Vall d’Hebron & ARADyAL Research Network, Barcelona, Spain

    • Victoria Cardona

90. Regional Ministry of Health of Andalusia, Seville, Spain

    • Ana M. Carriazo

91. Allergy and Asthma Associates of Southern California, Mission Viejo, CA, USA

    • Warner Carr

92. ASA-Advanced Solutions Accelerator, Clapiers, France

    • Christine Cartier
    •  & Frédéric Viart

93. Division of Allergy/Immunology, University of South Florida, Tampa, FL, USA

    • Thomas Casale

94. SOS Allergology and Clinical Immunology, USL Toscana Centro, Prato, Italy

    • Lorenzo Cecchi

95. Allergy and Immunology Laboratory, Metropolitan University, Simon Bolivar University, Barranquilla, Colombia

    • Alfonso M. Cepeda Sarabia

96. SLaai, Sociedad Latinoamericana de Allergia, Asma e Immunologia, Barranquilla, Colombia

    • Alfonso M. Cepeda Sarabia

97. Chachava Clinic, David Tvildiani Medical University-AIETI Medical School, Grigol Robakidze University, Tbilisi, Georgia

    • Eka Chkhartishvili

98. Medical Faculty, ENT Department, Eskisehir Osmangazi University, Eskisehir, Turkey

    • Cemal Cingi

99. Department of Health, Social Services and Public Safety, Belfast, Northern Ireland, UK

    • Elaine Colgan

100. Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal

     • Jaime Correia de Sousa

101. PT Government Associate Laboratory, ICVS/3B’s, Braga/Guimarães, Portugal

     • Jaime Correia de Sousa
     •  & John Farrell

102. Ecole des Mines, Alès, France

     • Anne Lise Courbis

103. Centre for Respiratory Medicine and Allergy, Institute of Inflammation and Repair, University of Manchester and University Hospital of South Manchester, Manchester, UK

     • Adnan Custovic

104. Division of Respiratory and Allergic Diseases, Department of Respiratory Diseases, High Specialty Hospital A.Cardarelli, Naples, Italy

     • Gennaro D’Amato

105. Allergy Service, University Hospital of Federal University of Santa Catarina (HU-UFSC), Florianópolis, Brazil

     • Jane da Silva

106. Cáritas Diocesana de Coimbra, Coimbra, Portugal

     • Carina Dantas

107. Ageing@Coimbra EIP-AHA Reference Site, Coimbra, Portugal

     • Carina Dantas
     •  & Joao Malva

108. Medical Faculty Skopje, University Clinic of Pulmonology and Allergy, Skopje, Republic of Macedonia

     • Dejand Dokic

109. Sleep Unit, Department of Neurology, Hôpital Gui-de-Chauliac Montpellier, Inserm U1061, Montpellier, France

     • Yves Dauvilliers

110. AQuAS, Barcelna, Spain

     • Antoni Dedeu

111. EUREGHA, European Regional and Local Health Association, Brussels, Belgium

     • Antoni Dedeu

112. Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Salerno, Italy

     • Giulia De Feo
     •  & Cristina Stellato

113. UPRES EA220, Pôle des Maladies des Voies Respiratoires, Hôpital Foch, Université Paris-Saclay, Suresnes, France

     • Philippe Devillier

114. Farmacie Dei Golfi Group, Massa Lubrense, Italy

     • Stefania Di Capua

115. Section of Allergy and Immunology, Saint Louis University School of Medicine, Saint Louis, MO, USA

     • Marc Dykewickz

116. Clinic of Infectious, Chest Diseases, Dermatology and Allergology, Vilnius University, Vilnius, Lithuania

     • Ruta Dubakiene

117. Clinical Reserch Center for Allergy and Rheumatology, Sagamihara National Hospital, Sagamihara, Japan

     • Motohiro Ebisawa

118. Pediatric Allergy and Immunology Unit, Children’s hospital, Ain Shams University, Cairo, Egypt

     • Yaya El-Gamal

119. Clinic of Children’s Diseases, Faculty of Medicine, Vilnius University, Vilnius, Lithuania

     • Regina Emuzyte

120. Global Allergy and Asthma Platform GAAPP, Vienna, Austria

     • Antjie Fink-Wagner
     •  & Otto Spranger

121. Division of Allergy, Department of Pediatric Medicine, The Bambino Gesù Children’s Research Hospital Holy See, Rome, Italy

     • Alessandro Fiocchi

122. Reims, France

     • Jean F. Fontaine

123. Department of Pulmonary Diseases, Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Istambul, Turkey

     • Bilun Gemicioğlu

124. Allergy Unit, Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland

     • Peter Schmid-Grendelmeir

125. National Center for Disease Control and Public Health of Georgia, Tbilisi, Georgia

     • Amiran Gamkrelidze

126. Allergy & Asthma Unit, Hospital San Bernardo Salta, Salta, Argentina

     • Maximiliano Gomez

127. Universidad Autónoma de Nuevo León, San Nicolás de los Garza, Mexico

     • Sandra González Diaz

128. Center of Allergy and Immunology, Georgian Association of Allergology and Clinical Immunology, Tbilisi, Georgia

     • Maia Gotua

129. Institute of Health Policy and Management iBMG, Erasmus University, Rotterdam, The Netherlands

     • Nick A. Guldemond

130. Immunology and Allergy Division, Clinical Hospital, University of Chile, Santiago, Chile

     • Maria-Antonieta Guzmán

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 Santé, Nantes, France

     • Jawad Hajjam

132. Department of Paediatrics and Child Health, University College Cork, Cork, Ireland

     • John O’B Hourihane

133. Université Paris-Sud; Service de Pneumologie, Hôpital Bicêtre, Inserm UMR_S999, Le Kremlin Bicêtre, France

     • Marc Humbert

134. Department of Medicine and Surgery, University of Salerno, Baronissi, Italy

     • Guido Iaccarino

135. Servicio de Alergia e Immunologia, Clinica Santa Isabel, Buenos Aires, Argentina

     • Juan C. Ivancevich

136. Hallym University College of Medicine, Hallym University Sacred Heart Hospital, Anyang, Gyeonggi-do, South Korea

     • Ki-Suck Jung

137. Department of Clinical Immunology, Wrocław Medical University, Wrocław, Poland

     • Marek Jutel

138. Ukrainian Medical Stomatological Academy, Poltava, Ukraine

     • Igor Kaidashev

139. Pediatric Allergy and Asthma Unit, Hacettepe University School of Medicine, Ankara, Turkey

     • Omer Kalayci

140. First Department of Family Medicine, Medical University of Lodz, Łódź, Poland

     • Przemyslaw Kardas

141. Institute of Social Medicine, Epidemiology and Health Economics, Charité-Universitätsmedizin Berlin, Berlin, Germany

     • Thomas Keil

142. Institute for Clinical Epidemiology and Biometry, University of Wuerzburg, Würzburg, Germany

     • Thomas Keil

143. National Research Center, Institute of Immunology, Federal Medicobiological Agency, Laboratory of Molecular Immunology, Moscow, Russian Federation

     • Mussa Khaitov

144. GARD Chairman, Geneva, Switzerland

     • Nikolai Khaltaev

145. Allergy & Asthma Center Westend, Berlin, Germany

     • Jorg Kleine-Tebbe

146. Department of Immunology and Allergy, Healthy Ageing Research Center, Medical University of Lodz, Łódź, Poland

     • Marek L. Kowalski

147. Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden

     • Inger Kull

148. Sach’s Children and Youth Hospital, Södersjukhuset, Stockholm, Sweden

     • Inger Kull
     •  & Eric Melén

149. Mattone Internazionale Program, Veneto Region, Italy

     • Lisa Leonardini

150. Departments of Internal Medicine and Pediatrics (Divisions of Allergy and Immunology), University of Tennessee College of Medicine, Germantown, TN, USA

     • Philip Lieberman

151. Scottish Centre for Respiratory Research, Cardiovascular & Diabetes Medicine, Medical Research Institute, Ninewells Hospital, University of Dundee, Dundee, UK

     • Brian Lipworth

152. Department of Paediatrics, Oslo University Hospital, Oslo, Norway

     • Karin C. Lodrup Carlsen

153. Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway

     • Karin C. Lodrup Carlsen

154. Imunoalergologia, Centro Hospitalar Universitário de Coimbra and Faculty of Medicine, University of Coimbra, Coimbra, Portugal

     • Claudia C. Loureiro
     •  & Ana Todo-Bom

155. Department of Pulmonary Medicine, CHU Sart-Tilman, and GIGA I3 Research Group, Liege, Belgium

     • Renaud Louis

156. DG for Health and Social Care, Scottish Government, Edinburgh, UK

     • Alpana Mair

157. Department of Pulmonary Medicine, Rashid Hospital, Dubai, UAE

     • Bassam Mahboub

158. Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra, Coimbra, Portugal

     • Joao Malva

159. Department of Medicine (RCSI), Bon Secours Hospital, Glasnevin, Dublin, Ireland

     • Patrick Manning

160. Kronikgune, International Centre of Excellence in Chronicity Research Barakaldo, Barakaldo, Bizkaia, Spain

     • Esteban De Manuel Keenoy

161. Division of Clinical Immunology and Allergy, Laboratory of Behavioral Immunology Research, The University of Mississippi Medical Center, Jackson, MS, USA

     • Gailen D. Marshall

162. Tobacco Control Research Centre, Iranian Anti Tobacco Association, Tehran, Iran

     • Mohamed R. Masjedi

163. Argentine Association of Allergy and Clinical Immunology, Buenos Aires, Argentina

     • Jorge F. Maspero

164. Department of Pediatric Pneumology and Immunology, AG Molecular Allergology and Immunomodulation, Charité Medical University, Berlin, Germany

     • Poalo M. Matricardi

165. Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden

     • Eric Melén

166. PNDR, Portuguese National Programme for Respiratory Diseases, Faculdade de Medicina de Lisboa, Lisbon, Portugal

     • Elisabete Melo-Gomes

167. Allergy and Asthma Medical Group and Research Center, San Diego, CA, USA

     • Eli O. Meltzer

168. Department of Physiology, CHRU, University Montpellier, Vice President for Research, PhyMedExp, INSERM U1046, CNRS, UMR 9214, Montpellier, France

     • Jacques Mercier

169. Croatian Pulmonary Society, Zagreb, Croatia

     • Neven Miculinic

170. National Institute of Pneumology M Nasta, Bucharest, Romania

     • Florin Mihaltan

171. Clinic for Pulmonary Diseases, Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Serbian Association for Asthma and COPD, Belgrade, Serbia

     • Branislava Milenkovic

172. Regione Piemonte, Turin, Italy

     • Giuliana Moda

173. Mexico City, Mexico

     • Maria-Dolores Mogica-Martinez

174. National Center for Research in Chronic Respiratory Diseases, Tishreen University School of Medicine, Latakia, Syria

     • Yousser Mohammad

175. Syrian Private University, Damascus, Syria

     • Yousser Mohammad

176. Faculty of Medicine and Surgery, University of Medicine, La Valette, Malta

     • Steve Montefort

177. Department of Medical Sciences, Allergy and Clinical Immunology Unit, University of Torino & Mauriziano Hospital, Turin, Italy

     • Ricardo Monti

178. Allergy Center, CUF Descobertas Hospital, Lisbon, Portugal

     • Mario Morais-Almeida

179. Institute of Medical Statistics, and Computational Biology, Medical Faculty, University of Cologne, Cologne, Germany

     • Ralf Mösges

180. CRI-Clinical Research International-Ltd, Hamburg, Germany

     • Ralf Mösges

181. Danish Commitee for Health Education, Copenhagen East, Denmark

     • Lars Münter

182. Food Allergy Referral Centre Veneto Region, Department of Women and Child Health, Padua General University Hospital, Padua, Italy

     • Antonella Muraro

183. MedScript Ltd, Paraparomu, New Zealand

     • Ruth Murray

184. OPC, Cambridge, UK

     • Ruth Murray

185. Johns Hopkins School of Medicine, Baltimore, MD, USA

     • Robert Naclerio

186. Consortium of Pharmacies and Services COSAFER, Salerno, Italy

     • Luigi Napoli

187. Scientific Centre of Children’s Health under the Russian Academy of Medical Sciences, Moscow, Russia

     • Leila Namazova-Baranova

188. Center of Allergy, Immunology and Respiratory Diseases, Santa Fe, Argentina

     • Hugo Neffen

189. Center for Allergy and Immunology, Santa Fe, Argentina

     • Hugo Neffen

190. Hospital of the Hospitaller Brothers in Buda, Budapest, Hungary

     • Kristoff Nekam

191. Die Hautambulanz and Rothhaar Study Center, Berlin, Germany

     • Angelo Neou

192. Department of Pharmacy, University of Naples Federico II, Naples, Italy

     • Enrico Novellino

193. ENT Department, University Hospital of Kinshasa, Kinshasa, Congo

     • Dieudonné Nyembue

194. Department of Allergy, Immunology and Respiratory Medicine, Alfred Hospital and Central Clinical School, Monash University, Melbourne, VIC, Australia

     • Robin O’Hehir

195. Dept of Otolaryngology, Nippon Medical School, Tokyo, Japan

     • Kimi Okubo

196. Centre Hospitalier Universitaire Pédiatrique Charles de Gaulle, Ouagadougou, Burkina Faso

     • Solange Ouedraogo

197. Dept of Comparative Medicine, Messerli Research Institute of the University of Veterinary Medicine and Medical University, Vienna, Austria

     • Isabella Pali-Schöll

198. EFA European Federation of Allergy and Airways Diseases Patients’ Associations, Brussels, Belgium

     • Susanna Palkonen

199. Department of Immunology and Allergology, Faculty of Medicine and Faculty Hospital in Pilsen, Charles University in Prague, Pilsen, Czech Republic

     • Peter Panzner

200. Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, South Korea

     • Hae-Sim Park

201. Laboratoire HP2, Université Grenoble Alpes, Grenoble, France

     • Jean-Louis Pépin

202. INSERM, U1042 and CHU de Grenoble, Grenoble, France

     • Jean-Louis Pépin

203. Allergy Unit, CUF-Porto Hospital and Institute, Porto, Portugal

     • Ana-Maria Pereira

204. Center for Research in Health Technologies and Information Systems, CINTESIS, Universidade do Porto, Porto, Portugal

     • Ana-Maria Pereira

205. Maladies Infectieuses et immunitaires, CHUL, Quebec City, QC, Canada

     • Gary Wong

206. Department of Otorhinolaryngology, Head and Neck Surgery, Section of Rhinology and Allergy, University Hospital Marburg, Philipps-Universität Marburg, Marburg, Germany

     • Oliver Pfaar

207. Farmacias Holon, Lisbon, Portugal

     • Ema Paulino

208. Centre for Empowering Patients and Communities, Faulkland, Somerset, UK

     • Jim Phillips

209. Children’s Hospital Srebrnjak, Zagreb, Croatia

     • Davor Plavec

210. School of Medicine, University J.J. Strossmayer, Osijek, Croatia

     • Davor Plavec

211. University Hospital ‘Sv Ivan Rilski’, Sofia, Bulgaria

     • Ted A. Popov

212. Academic Centre of Primary Care, University of Aberdeen, Aberdeen, Scotland, UK

     • David Price

213. Research in Real-Life, Cambridge, UK

     • David Price

214. Department of Otorhinolaryngology, University of Crete School of Medicine, Heraklion, Greece

     • Emmanuel P. Prokopakis

215. Department of Nephrology and Endocrinology, Karolinska University Hospital, Stockholm, Sweden

     • Rojin Rajabian-Söderlund

216. Allergy Unit, Presidio Columbus, Catholic University of Sacred Heart, Rome, Italy

     • Antonino Romano

217. IRCCS Oasi Maria SS, Troina, Italy

     • Antonino Romano

218. Hospital de Clinicas, University of Parana, Paraná, Brazil

     • Nelson Rosario

219. Division of Allergy Asthma and Clinical Immunology, Emek Medical Center, Afula, Israel

     • Menahenm Rottem

220. Allergy and Respiratory Research Group, The University of Edinburgh, Edinburgh, UK

     • Dermot Ryan

221. Association of Finnish Pharmacists, Helsinki, Finland

     • Johanna Salimäki

222. Allergy and Clinical Immunology Department, Centro Médico-Docente la, Trinidad and Clínica El Avila, Caracas, Venezuela

     • Mario M. Sanchez-Borges

223. Sociedad Paraguaya de Alergia Asma e Inmunologia, Asunción, Paraguay

     • Juan-Carlos Sisul

224. Division of Allergy, Clinical Immunology and Rheumatology, Department of Pediatrics, Federal University of São Paulo, São Paulo, Brazil

     • Dirceu Solé

225. European Health Futures Forum (EHFF), Dromahair, UK

     • David Somekh

226. Kyrgyzstan National Centre of Cardiology and Internal Medicine, Euro-Asian Respiratory Society, Bishkek, Kyrgyzstan

     • Talant Sooronbaev

227. Department of Respiratory Medicine, University Hospital Olomouc, Olomouc, Czech Republic

     • Milan Sova

228. Pulmonary Division, Heart Institute (InCor), Hospital da Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil

     • Rafael Stelmach

229. Department of Respiratory Medicine, Hvidovre Hospital & University of Copenhagen, Copenhagen, Denmark

     • Charlotte Suppli Ulrik

230. RNSA (Réseau National de Surveillance Aérobiologique), Brussieu, France

     • Michel Thibaudon

231. Sidkkids Hospitala and Institute of Health Policy, Management and Evaluation, Toronto, Canada

     • Teresa To

232. Department of ENT, Medical University of Graz, Graz, Austria

     • Peter V. Tomazic

233. Pneumology and Allergy Department CIBERES and Clinical & Experimental Respiratory Immunoallergy, IDIBAPS, University of Barcelona, Barcelona, Spain

     • Antonio A. Valero

234. Division of Immunopathology, Department of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria

     • Rudolph Valenta

235. NRC Institute of Immunology FMBA of Russia, Moscow, Russia

     • Rudolph Valenta

236. Laboratory of Immunopathology, Department of Clinical Immunology and Allergy, Sechenov First Moscow State Medical University, Moscow, Russia

     • Rudolph Valenta

237. Montevideo, Uruguay

     • Marylin Valentin-Rostan

238. Department of Public Health & Primary Care, Leiden University Medical Center (LUMC), Leiden, The Netherlands

     • Rianne van der Kleij

239. Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands

     • Rianne van der Kleij

240. Department of Chest Medicine, Centre Hospitalier Universitaire UCL Namur, Université Catholique de Louvain, Yvoir, Belgium

     • Olivier Vandenplas

241. Pulmonary Unit, Department of Medical Specialties, Arcispedale SMaria Nuova/IRCCS, AUSL di Reggio Emilia, Reggio Emilia, Italy

     • Giorgio Vezzani

242. Pulmonary Environmental Epidemiology Unit, CNR Institute of Clinical Physiology, Pisa, Italy

     • Giovanni Viegi

243. CNR Institute of Biomedicine and Molecular Immunology “A Monroy”, Palermo, Italy

     • Giovanni Viegi

244. Nova Southeastern University, Fort Lauderdale, FL, USA

     • Dana Wallace

245. Dept of Otorhinolaryngology, HNO-Klinik, Universitätsklinikum Düsseldorf, Düsseldorf, Germany

     • Martin Wagenmann

246. Department of Otolaryngology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore

     • De Y. Wang

247. Department of Medicine, Clinical Immunology and Allergy, McMaster University, Hamilton, ON, Canada

     • Susan Waserman

248. Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden

     • Magnus Wickman

249. Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA

     • Dennis M. Williams

250. Cyprus International Institute for Environmental & Public Health in Association with Harvard School of Public Health, Cyprus University of Technology, Limassol, Cyprus

     • Panayiotis K. Yiallouros

251. Department of Pediatrics, Hospital “Archbishop Makarios III”, Nicosia, Cyprus

     • Panayiotis K. Yiallouros

252. Department of Pulmonary Diseases, Celal Bayar University, Faculty of Medicine, Manisa, Turkey

     • Arzu Yorgancioglu

253. The Allergy and Asthma Institute, Islamabad, Pakistan

     • Osman M. Yusuf

254. Department of Paediatrics and Child Health, Red Cross Children’s Hospital, Cape Town, South Africa

     • Heahter J. Zar

255. MRC Unit on Child & Adolescent Health, University of Cape Town, Cape Town, South Africa

     • Heahter J. Zar

256. Bull DSAS, Echirolles, France

     • Stéphane Zeng

257. Universidad Católica de Córdoba, Córdoba, Argentina

     • Mario Zernotti

258. Department of Otolaryngology Head and Neck Surgery, Beijing TongRen Hospital and Beijing Institute of Otolaryngology, Beijing, China

     • Luo Zhang

259. State Key Laboratory of Respiratory Diseases, Guangzhou Institute of Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China

     • Nan S. Zhong

260. University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia

     • Mihaela Zidarn

261. National Hospital Organization, Tokyo National Hospital, Tokyo, Japan

     • Ken Ohta

Consortia

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.

Corresponding author

Correspondence to J. Jean Bousquet.

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