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Background: The prevalence of pollen allergy has increased due to urbanization, climate change and air pollution.
The effects of green space and air pollution on respiratory health of pollen allergy patients are complex and best
studied in spatio-temporal detail.

Methods: We tracked 144 adults sensitized to Betulaceae pollen during the tree pollen season (January–May) of
2017 and 2018 and assessed their spatio-temporal exposure to green space, allergenic trees, air pollutants and birch pollen. 

Participants reported daily symptom severity scores. We extracted 404 case days with high symptom severity scores and matched these to 404 control days. 

The data were analyzed using conditional logistic regression with a 1:1 case-crossover design.

Results: Case days were associated with exposure to birch pollen concentration (100 grains/m3) [adjusted odds
ratio 1.045 and 95% confidence interval (1.014–1.078)], O3 concentration (10 μg/m3) [1.504 (1.281–1.766)]
and PM10 concentration (10 μg/m3) [1.255 (1.007–1.565)] on the day of the severe allergy event and with the cu-
mulative exposure of one and two days before. Exposure to grass cover (10% area fraction) [0.655 (0.446–0.960)],
forest cover (10% area fraction) [0.543 (0.303–0.973)] and density of Alnus (10%) [0.622 (0.411–0.942)] were
protective for severe allergy, but only on the day of the severe allergy event. Increased densities of Betula trees
(10%) were a risk factor [unadjusted OR: 2.014 (1.162–3.490)].

Conclusion: Exposure to green space may mitigate tree pollen allergy symptom severity but only when the den-
sity of allergenic trees is low. Air pollutants contribute to more severe allergy symptoms. Spatio-temporal track-
ing allows for a more realistic exposure assessment