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The Hygiene Hypothesis: How Valid Is It?
What Are Allergies?
Allergies are an overreaction of the immune system to substances that under normal circumstances would cause no reaction in most people. The results of this immunologic overreaction are symptoms such as rashes, sneezing, watery eyes, and itching.
What Is Asthma?
Asthma is a disease in which the airways become narrowed or even blocked due to inflammation, causing wheezing, coughing, shortness of breath, breathing trouble, and other serious symptoms. In the case of a severe asthma attack, a person may need emergency treatment to restore normal breathing.
What Is the Hygiene Hypotheses?
In 1989, David Strachan proposed the hygiene hypothesis. He suggested that the rising incidence of allergic disease, such as asthma or allergies, was actually linked to reduced exposure to germs through declining family sizes, more limited exposure to animals, and higher general standards of cleanliness. Strachan reasoned that repeated exposure to microbes at an early age, for example as a result of having siblings, owning a pet, living on a farm, or attending day care, actually helped our immune systems to properly adapt so they would not overreact to routine environmental stimuli, such as potential allergens.
According to this hypothesis, in the absence of this repeated exposure, our under-stimulated, developing immune system would then be over stimulated by harmless substances like pollen, resulting in the development of allergies.
What Does the Evidence Say?
One example of the hygiene hypothesis comes from comparing the prevalence of allergies in the East and West German populations before and after unification. Before unification, East Germany had more children growing up on farms and in larger families than West Germany; the population also had much lower rates of allergies and asthma than West Germany.
After unification however, when East Germany developed a more western culture, its rates of allergies and asthma increased to the degree that they now resemble those of West Germany. East Germany also had a quite highly developed healthcare system, so it is less likely that the observed differences in asthma diagnosis were due to different patterns of medical diagnosis rather than true differences in disease prevalence.
Other evidence came from a cohort study done in Denmark that was published in the BMJ. In the study of 13,070 children, researchers found that factors associated early and repeated microbial exposure were associated with a decreased risk of developing allergies later in life. Factors included increasing number of siblings, day care, pet ownership, and farm residence. Repeated infectious diseases before age 6 months was associated with an increased risk. The risk of atopic dermatitis increased with each infectious disease. These findings are consistent with the hygiene hypothesis as it applies to microbial exposure, but did not take into account that exposure to allergens may have been the reason. The increase risk associated infectious diseases seems to indicate that it may not be exposure to microbes, but some other factor related to increasing number of siblings, day care, pet ownership, and farm residence.
Other studies have also found an association between pet early exposure and decreased risk of atopic dermatitis. However these studies focused on allergens and not microbes.
What Can a Concerned Parent Do?
The original hypothesis has evolved over several years, giving scientists insight to dig a bit deeper into how these factors work together. Today, there may be no clear answers as to why more people have more allergies or asthma, but the focus has shifted toward allergens. Early-age exposure to environments with higher allergen concentrations, such as a farm, playing in a dusty room or a having a pet cat, may be more of a driving force behind developing a tolerance than exposure to bacteria or viruses.
American Academy of Allergy, Asthma, & Immunology
Asthma and Allergy Foundation of America
Allergy Asthma Information Association
Calgary Allergy Network
Asthma overview. Asthma and Allergy Foundation of America website. Available at: http://www.aafa.org/page/asthma.aspxamp;sub=14&. Accessed October 2015. Accessed July 14, 2016.
Atopic dermatitis. EBSCO DynaMed website. Available at: http://www.ebscohost.com/dynamed. Updated June 1, 2015. Accessed July 14, 2016.
Benn CS, Melbye M, Wohlfahrt J, Björkstén B, Aaby P. Cohort study of sibling effect, infectious diseases, and risk of atopic dermatitis during the first 18 months of life. BMJ. 2004;328(7450):1223.
Bremner SA, Carey IM, DeWilde S, et al. Infections presenting for clinical care in early life and later risk of hay fever in two UK birth cohorts. Allergy. 2008;63(3):274-283.
Daley D. The evolution of the hygiene hypothesis: the role of early-life exposures to viruses and microbes and their relationship to asthma and allergic diseases. Curr Opin Allergy Clin Immunol. 2014;14(5):390-396.
Doews J, Pearce N. Commentary: The end of the hygiene hypothesis? Int J Epidemiol. 2008;37(3):570-572.
Langan SM, Flohr C, Williams HC. The role of furry pets in eczema: a systematic review. Arch Dermatol. 2007;143(12):1570-1577.
Liu AH, Leung DY. Renaissance of the hygiene hypothesis. J Allergy Clin Immunol. 2006;147(5):1063-1066.
Lynch SJ, Sears MR, Hancox RJ. Thumb-sucking, nail-biting, and atopic senitization, asthma, and hay fever. Pediatrics. 2016 Jul 11 [Epub ahead of print].
Schaub B, Lauener R, von Mutius E. The many faces of the hygiene hypothesis. J Allergy Clin Immunol. 2006;117(5):969-977.
- Reviewer: Michael Woods, MD
- Review Date: 07/2016
- Update Date: 07/14/2016