Clinical Commentary Review
Epidemic Thunderstorm Asthma: Lessons Learned
from the Storm Down-Under
Dwan Price, PhD
, Kira M. Hughes, BSc
, Francis Thien, MD, FRACP, FCCP
, and Cenk Suphioglu, PhD
Ponds, Burwood, Box Hill, VIC, Australia
Epidemic thunderstorm asthma (ETSA) is a global health
problem that can strike without sufﬁcient warning and can have
catastrophic consequences. Because of climate change, future
events are likely to become more common, more disastrous, and
more unpredictable. To prevent loss of life and avoid surge
events on health care infrastructure, identifying at-risk
individuals and their potential biomarkers is the most
prophylactic approach that can be taken to mitigate the deadly
consequences of ETSA. In this review, we provide an update on
the clinical mechanism, global prevalence, and characteristics of
those patients moderately or severely at risk of ETSA. Identifying
these patient characteristics will aid clinical professionals to
provide suitable and personalized treatment plans and, in turn,
avoid future loss of life. Ó2020 The Authors. Published by
Elsevier Inc. on behalf of the American Academy of Allergy,
Asthma & Immunology. This is an open access article under the
CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/). (J Allergy Clin Immunol Pract 2020;-:---)
Key words: Epidemic thunderstorm asthma; Grass pollen; Al-
lergens; Allergic rhinitis; Sensitization; Allergen-speciﬁc IgE;
Melbourne; Risk factors; Biomarkers; Asthma treatment
Epidemic thunderstorm asthma is characterized by the
emergence of acute asthma presentations after a thunderstorm.
For example, on November 21, 2016, sensitized individuals in
Melbourne were impacted by the most signiﬁcant epidemic
thunderstorm asthma event in recorded history. Thousands were
hospitalized for severe respiratory presentations, a majority of
whom were found to suffer from allergic rhinitis or asthma, and
the death of 10 patients have been associated with the event.
Asthma-related hospital admissions rose by almost 1000% dur-
ing the 12-hour storm, an unprecedented number that the health
infrastructure was not prepared to handle.
epidemics have been observed across developing countries
worldwide, thunderstorm asthma events have occurred most
frequently in Melbourne, Australia, with at least 7 separate
Events have been observed across other
states, but they are far less common and pose less of a risk to
public health compared with those in Melbourne.
The interactions between aeroallergens and meteorological
factors that occur during these epidemic thunderstorm asthma
(ETSA) events contribute to an increased severity of asthmatic
symptoms within sensitized populations.
The arrival of thun-
derstorms has been strongly linked with increased levels of
Thunderstorm outﬂow concentrates
airborne allergens, such as pollen, near ground level,
the risk of exposure for predisposed individuals.
Pollen is well
documented to be present during ETSA events,
pollen identiﬁed as a major factor to trigger asthmatic
Other aeroallergens, such as fungal spores, have also
seen huge atmospheric increases during thunderstorms and may
also have an impact on respiratory health.
Intact pollen grains are too large to normally reach the lower
airways. However, pollen can naturally swell and rupture from
osmotic shock when exposed to high levels of moisture during
releasing hundreds of ﬁne allergenic starch
granules of respirable size (Figure 1) into the atmosphere.
Recently, it has been shown that concentrations of pollen frag-
ments are at their highest, and remain high, during convective
These particulates can be small enough to
travel past the pharynx, reach the lower respiratory tract, and
trigger asthmatic symptoms.
Thunderstorm asthma epidemics usually occur during late
spring where pollen concentrations are highest. All 7 Melbourne
epidemics occurred in November, when ryegrass pollination was
at its peak.
The distribution of grass pollens is dependent on
the weather, and Melbourne’s high susceptibility to ETSA may
be inﬂuenced by local weather patterns interacting with the
environment. Hot northern winds tend to push aeroallergens
from large grasslands down south toward a sensitized urban
Thunderstorms aid in the dispersion of intact and
ruptured pollen grains, leading to sensitized individuals inhaling
NeuroAllergy Research Laboratory (NARL), School of Life and Environment al
Sciences, Faculty of Science, Engineering and Built Environment, Deakin Uni-
versity, Waurn Ponds, VIC, Australia
NeuroAllergy Research Laboratory (NARL), School of Life and Environmental
Sciences, Faculty of Science, Engineering and Built Environment, Deakin Uni-
versity, Burwood, VIC, Australia
Deakin AIRwatch Pollen and Spore Counting and Forecasting Facility, Deakin
University, Burwood and Waurn Ponds, VIC, Australia
Respiratory Medicine, Eastern Health, Box Hill Hospital and Monash University,
Box Hill, VIC, Australia
No funding was received for this work.
Conﬂicts of interest: The authors declare that they have no relevant conﬂicts of
Received for publication July 31, 2020; revised October 6, 2020; accepted for
publication October 18, 2020.
Available online --
Corresponding author: Cenk Suphioglu, PhD, School of Life and Environmental
Sciences, Faculty of Science, Engineering and Built Environment, Deakin Uni-
versity, 75 Pigdons Road, Waurn Ponds, VIC 3216, Australia. E-mail: cenk.
Ó2020 The Authors. Published by Elsevier Inc. on behalf of the American Academy
of Allergy, Asthma & Immunology. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
ETSA- Epidemic thunderstorm asthma
FeNO- Fractional exhaled nitric oxide
ICS- Inhaled corticosteroids
INCS- Intranasal corticosteroids
RAST- Radioallergosorbent test
SLIT- Sublingual immunotherapy
high atmospheric levels of allergens within a short period of
The climate in Australia experiences many spatial and
temporal variations that inﬂuence weather parameters such as
temperature and rainfall. These changes can occur seasonally,
annually, or over long periods of time.
patterns have become more common due to climate change,
which may be responsible for the increased frequency and
severity of extreme weather health events
such as epidemic
thunderstorm asthma. The global impact of climate change has
been well studied in the Northern Hemisphere, with limited
long-term data on its projected ecological impact in the Southern
A POTENTIAL GLOBAL PROBLEM
ETSA events are not unique to Australia (see Figure 2).
Although infrequent, they are a global phenomenon, with 26
known events reported worldwide, and unlike ETSA events in
Australia, are rarely responsible for a large number of asthma
exacerbations. Exceptions include the 1994 London epidemic,
the 2013 Iran epidemic, and the 2016 Saudi Arabia epidemic.
Past ETSA events include those listed in Table I. The prevalence
of atopic conditions in populations from industrialized countries
has been associated with increased air pollutants.
storms occur more frequently in temperate climates, like Europe
or the Middle East, or subtropical environments, like
All documented thunderstorm asthma events, as
shown in Table I and Figure 2, also coincided with their
respective country’s spring and summer pollen seasons.
combination of a susceptible population, extreme weather
patterns, and high aeroallergen concentration results in these
unique asthma epidemics. Thunderstorm-associated asthma
presentations have been observed in Mexico,
but no speciﬁc events have yet to be conﬁrmed and
The allergenic triggers vary from country to country. ETSA
events are largely triggered by major community allergens. For
example, grass pollen is the dominant ETSA trigger in
Conocarpus erectus is the suspected trigger
during ETSA events in Iran,
and Olea europaea and Parietaria
sp. in Italy.
WHO IS MOST AT RISK OF ETSA?
It is estimated that between 20% and 70% of individuals with
asthma are undiagnosed and are not receiving treatment.
is cause for concern, especially when attempting to identify the
subset of individuals who are at risk of ETSA. This is particularly
true for patients with ETSA, because these individuals may not
have previously suffered from asthma.
However, almost all
patients hospitalized suffered from allergic rhinitis or pollen
sensitization, and some patients presented signs of having
Generally, all individuals who attended
emergency departments during the 2016 ETSA event in
Melbourne displayed the following characteristics.
Individuals with moderate risk
Asthmatic history. Compared with common asthma exac-
erbations, individuals who have been impacted by the 2016
Melbourne epidemic have experienced ongoing symptoms.
Approximately 80% of patients with ETSA were observed to
suffer from persistent asthmatic symptoms, 28% on a weekly
basis, with an inability to adequately self-manage.
observed even among patients with a history of well-controlled
asthma, as individuals who were normally able to treat their
chronic condition were unable to ease their breathlessness. Also
of interest, 63% of patients with no prior history of asthma
reported developing symptoms during the months after exposure
to an epidemic thunderstorm event.
Ethnicity. Few studies had accounted for ethnicity when
investigating ETSA events. Independent from other risk factors,
Asian ethnicity has been found to considerably increase the risk
of susceptibility to thunderstorm asthma.
Atopic conditions are
FIGURE 1. Clinical mechanism of epidemic thunderstorm asthma
(ETSA). ETSA events largely coincide with peak pollen season.
High concentrations of aeroallergens (both pollen and fungal) are
swept via high winds toward a population of at-risk individuals.
Larger and intact pollen grains are trapped by the mucosal linings
of the upper airways (1). However, during an ETSA event, high
humidity levels cause the pollen to expand and rupture as a result
of osmotic shock. This releases an abundance of respirable
allergenic particles that are small enough to reach the lower
airways (2), triggering an asthmatic response.
J ALLERGY CLIN IMMUNOL PRACT
2PRICE ET AL
more prevalent among Australians with Asian descent, with
allergic rhinitis twice as common compared with non-Asians.
Asthma severity was also shown to increase among Asian im-
migrants as their length of stay increased.
the 2016 ETSA event in Melbourne, although patients of Asian
descent were less likely to be admitted to hospital compared with
their non-Asian counterparts, this trend reversed if those with
Asian heritage were born in Australia.
Critically, 25% of the
Melbourne population is of Asian descent; 6 of the 10 patients
who died after the 2016 Melbourne epidemic were of Asian
Seasonal allergy. Patients most at risk of ETSA include
those with existing sensitivity to ryegrass,
a history of allergic
rhinitis, and are unlikely to be using inhaled asthma medica-
Sensitivity to ryegrass pollen was the leading contributor
to an individual’s susceptibility to ETSA. Speciﬁcally, a high
radioallergosorbent test (RAST) for grass pollen is a strong
indicator of heightened risk of ETSA in individuals with seasonal
Of importance, some studies report ryegrass pollen
sensitization of all individuals presenting to emergency during
ETSA, further indicating the importance of ryegrass sensitization
as the leading contributor of susceptibility to ETSA.
allergy to ryegrass appears to dominate among patients with
ETSA, many patients also had sensitivities to other seasonal grass
species including elevated IgE for Bermuda grass (94%), and
positive skin prick tests for Bahia grass (94%) and Timothy grass
Medication use. During the 1997 Wagga Wagga epidemic,
the usage of inhaled corticosteroids (ICS) among patients with
asthma was low, but patients who had used ICS before the 1997
Wagga Wagga epidemic experienced less severe symptoms, high-
lighting the importance of prior asthma management to minimize
susceptibility during ETSA.
More recently, risk factors
associated with medication use included individuals taking beta-
blockers, but not those taking nonsteroidal anti-inﬂammatory
drugs, which have been identiﬁed in patients with ETSA.
Individuals severely at risk
Of those individuals who attended emergency departments
during the 2016 ETSA event in Melbourne, a substantial
proportion reacted severely and required hospital admission.
These severely at-risk individuals displayed the following
Asthma. Not all individuals who suffered during ETSA had a
history of asthma. However, during an ETSA event, individuals
more likely to suffer severely and require hospital admission were
those who had a doctor-diagnosed history of their asthma,
aware of their asthma,
displayed asthmatic symptoms prior
and importantly, if they were admitted to hospital in the
previous 12 months.
Of particular concern, 58% of asthmatic
patients with ETSA either lacked an asthma action plan or had
poorly controlled symptoms (55%), and in 68% of cases,
preventative corticosteroids were either underused or not
Many individuals experienced progressively
declining asthma control and persistent symptoms after an ETSA
Allergen specific IgE. Of importance, individuals hospital-
ized during ETSA had elevated titers of IgE. Of particular
interest, 100% of hospitalized individuals had high levels of
ryegrass allergen speciﬁc IgE. These same individuals were also
allergic to Bermuda grass (96%), with some individuals
demonstrating some sensitivity toward common fungal allergens
from the genera Alternaria and Cladosporium.
ically, in addition to overall elevated ryegrass pollen speciﬁc IgE,
patients with ETSA are also more likely to demonstrate serum
speciﬁc IgE to the major ryegrass allergen Lol p 5.
This is a
signiﬁcant observation as Lol p 5 is located within starch granules
inside pollen grains.
These granules are released into the air
on rupturing during certain atmospheric conditions, such as
Thus, detection of allergen speciﬁc IgE toward Lol
p 5 may add to the repertoire of biomarkers to assess an
individual’s risk and vulnerability to future ETSA events.
FIGURE 2. Global prevalence of epidemic thunderstorm asthma (ETSA). Number of documented ETSA events, per country, since 1983.
An ETSA event is described as acute exacerbation of asthmatic symptoms in patients, often leading to an influx of presentations to the
emergency department, during or after a thunderstorm.
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IDENTIFYING AND MANAGING THE PATIENT IN
A comprehensive approach toward management and preven-
tion of ETSA includes: (i) environmental and public health
strategies, with forecasting and early warning to reduce exposure;
and (ii) reduction in individual susceptibility through primary
and secondary prevention.
In regions with thunderstorm asthma history and risk, thun-
derstorm forecasts together with pollen counts can be combined
in a risk matrix to issue public health warnings.
include taking proper precautions to remain indoors, take pre-
ventive inhaled steroids, and have ready access to bronchodilator
inhalers. This forecasting also enables health and emergency
service systems to be on alert and suitably prepared.
Thunderstorm asthma is characterized by airway inﬂamma-
tion with IL-5-mediated sputum eosinophilia and eosinophil
ICS are ﬁrst-line medications for patients with
asthma that have been demonstrated to improve airway
responsiveness and inﬂammation.
As already mentioned above,
a case control study after the Wagga Wagga episode in 1997
found a lower rate of ICS use in thunderstorm cases.
reports of ETSA found that those affected were not on
and this was a factor in ambulance calls,
emergency department presentations,
to respiratory wards.
A number of factors may contribute to
this, including the following: (i) most ETSA-affected individuals
had predominantly allergic rhinitis with no prior diagnosis of
asthma or were not aware of asthma symptoms; (ii) they had less
severe or intermittent asthma for which regular ICS may not
have been indicated, or (iii) they were nonadherent to regular
ICS use despite having persistent asthma. Hence, the evidence
supports regular ICS use for those with diagnosed asthma, or a
history of thunderstorm asthma, throughout the susceptible grass
pollen season of spring and early summer months. The recent
change in Global Initiative in Asthma guidelines for a
combination of low-dose ICS with fast onset long-acting bron-
chodilator (formoterol) on an “as needed”basis in step 1 of
therapy would be a suitable option for these patients with
intermittent or infrequent asthma symptoms.
As ETSA airway inﬂammation is an archetypal type 2
the measurement of the type 2 biomarker
fractional exhaled nitric oxide (FeNO) to guide therapy and dose
of inhaled steroids would be appropriate in these patients if
available. There are no prospective studies in ETSA to conﬁrm
this, but elevated FeNO measurements in those who have
support this approach.
TABLE I. Global occurrences of thunderstorm asthma events: location, date, and number of individuals affected during the documented
Location Date No. of individuals affected Reference
Saudi Arabia November 2, 2002 No data
Ahvaz, Iran November 2, 2013 2000
Israel October 25, 2015 No data
Ahvaz, Iran October 28, 2015 33
Kuwait, Saudi Arabia December 1, 2016 844
Yulin, China September 11, 2018 391
Birmingham, England July 6, 1983 106
Nottingham, England June 20, 1984 19
UK July 22, 1989 32
London, England June 24, 1994 640þ
Cambridge, England July 29, 2002 57
Naples, Italy June 4, 2004 7
Puglia, Italy May 27, 2010 20
London July 23, 2013 40
Melbourne November 11, 1984 85
Melbourne November 8, 1987 154
Melbourne November 29, 1989 277
Tamworth November 1, 1990 110
Wagga Wagga October 30, 1997 215
Newcastle October 27, 1998 6
Melbourne November 19, 2003 70
Melbourne November 25, 2010 36
Melbourne November 8, 2011 30
Canberra October 27, 2014 15
Melbourne November 21, 2016 w10,000
Canada July 31, 2000 157
ETSA, Epidemic thunderstorm asthma.
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As previously mentioned, almost all patients hospitalized with
ETSA suffered from allergic rhinitis and pollen allergy even if
there was no history of diagnosed asthma. Adequate control of
allergic rhinitis is recommended for control of asthma.
and systematic review
of the role of intranasal
corticosteroids (INCS) in asthma demonstrated improved
asthma outcomes with the use of INCS compared with placebo,
despite a lack of further improvement with INCS as an addition
to ICS. Hence, identiﬁcation of undiagnosed asthma symptoms
in those with allergic rhinitis and adequate treatment of allergic
rhinitis in those without a history of asthma are both important
factors in reducing the risk of ETSA.
Apart from the pharmacological approaches above, desensiti-
zation with speciﬁc allergen immunotherapy
immune tolerance to the responsible allergen. Sublingual
immunotherapy (SLIT) for grass pollen allergy has shown to ease
asthmatic symptoms for susceptible individuals who were
exposed to an ETSA event compared with individuals taking ICS
alone. Of those treated with SLIT (Oralair; manufactured by
Stallergenes, London, UK) before the 2016 ETSA event in
Melbourne, allergic individuals either had no asthma symptoms
(71%) or exacerbation of their asthma (0%), compared with
24% and 41%, respectively, of individuals who did not receive
preventative SLIT before the ETSA event.
SLIT before the pollen season have fewer allergic symptoms, and
even fewer again if repeat treatments are given over 2 consecutive
Patients with allergic rhinitis receiving SLIT
over 3 years demonstrate a decrease in airway inﬂammation,
-cell proliferation, increased serum allergen
speciﬁc IgG, and lasting levels of IgG
memory B cells, indi-
cating a persistent and lasting protective immune response
attributed to repeat SLIT of ryegrass pollen allergen.
suggests a primary and secondary role for allergen immuno-
therapy in reducing the risk of ETSA.
ETSA is a global health issue that will most likely become
more frequent and severe over the coming years due to climate
change. Australia, being the country hit hardest and most often
by these events, should prepare for future epidemics to avoid
burdening our current health infrastructure. It is crucial for
health professionals to identify potential biomarkers and risk
factors in affected individuals. These may include existing
sensitivity to seasonal allergenic grasses, prior history of allergic
rhinitis, overall elevated titers of IgE, elevated grass pollen
speciﬁc IgE, serum speciﬁc IgE to major grass allergens, such as
Lol p 5 from ryegrass and its cross-reactive analogues in other
grasses, and high RAST or positive skin prick tests to seasonal
allergens. Determining these factors will help patients receive
appropriate and effective treatment methods and reduce the
aftermath of the 2016 Melbourne epidemic from happening
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