Atopy and environmental factors in upper respiratory infections: an epidemiological survey on 2304 school children

Prevalence, comorbidities, diagnosis, and treatment of nonallergic rhinitis: real-world comparison with allergic rhinitis

Rhinitis is among the most common respiratory diseases in children. Nonallergic rhinitis, which involves nasal symptoms without evidence of systemic allergic inflammation or infection, is a heterogeneous entity with diverse manifestations and intensities. Nonallergic rhinitis accounts for 16%-89% of the chronic rhinitis cases, affecting 1%-50% (median 10%) of the total pediatric population. The clinical course of nonallergic rhinitis is generally rather mild and less likely to be associated with allergic comorbidities than allergic rhinitis. Here, we aimed to estimate the rate of coexisting comorbidities of nonallergic rhinitis. Nonallergic rhinitis is more prevalent during the first 2 years of life; however, its underestimation for children with atopic tendencies is likely due to low positive rates of specific allergic tests during early childhood. Local allergic rhinitis is a recently noted phenotype with rates similar to those in adults (median, 44%; range, 4%-67%), among patients previously diagnosed with nonallergic rhinitis. Idiopathic rhinitis, a subtype of nonallergic rhinitis, has been poorly studied in children, and its rates are known to be lower than those in adults. The prevalence of nonallergic rhinitis with eosinophilia syndrome is even lower. A correlation between nonallergic rhinitis and pollution has been suggested owing to the recent increase in nonallergic rhinitis rates in highly developing regions such as some Asian countries, but many aspects remain unknown. Conventional treatments include antihistamines, intranasal corticosteroids, and recent treatments include combination of intranasal corticosteroids with azelastin or decongestants. Here we review the prevalence, diagnosis, comorbidities, and treatment recommendations for nonallergic rhinitis versus allergic rhinitis in children.

Lifetime prevalence of self-reported atopic diseases in a population-based sample of elderly subjects: results of the ESTHER study

BACKGROUND

Prevalence studies of atopic diseases such as atopic dermatitis (AD), hay fever and allergic asthma have mostly been performed in children. Studies in the adult population are still rare.

OBJECTIVES

We estimated the lifetime prevalence of different atopic diseases in an elderly population in Saarland, Germany. Additionally we investigated the association between atopic diseases and sociodemographic factors including age, gender, duration of school education (as a proxy measure of socioeconomic status), family history, and size of place of residence.

METHODS

This study was conducted between June 2000 and December 2002 in the State of Saarland, Germany. Participants aged 50-75 years (n=9961) were recruited by their general practitioner in the context of a general health screening examination. All filled out a standardized questionnaire and reported whether a physician had ever diagnosed an atopic disease (hay fever, AD or asthma).

RESULTS

Overall, 9949 subjects (mean age 62 years, 45% men) were included in this analysis. The lifetime prevalence of reported AD, hay fever and asthma was 4.3%, 8.3% and 5.5%, respectively. Lifetime prevalence of AD and asthma among women, and lifetime prevalence of hay fever among both genders, strongly decreased with age. Duration of school education (<or= 9 years, 10-11 years, > 11 years) was strongly associated with AD (3.7%, 5.7%, 6.8%; P trend < 0.0001) and hay fever (7.2%, 11.2%, 12.8%; P trend < 0.0001), but only tentatively with asthma.

CONCLUSIONS

The lifetime prevalence of AD is considerably lower in the elderly compared with the prevalence reported among younger adults in recent studies. Adults with a longer duration of school education appeared to have a higher risk for atopic diseases.

Prevalence and risk factors for allergic rhinitis in primary school children

OBJECTIVE

Allergic rhinitis is a common chronic illness of childhood. The aim of the study was to evaluate the prevalence and risk factors of allergic rhinitis in 6-12-year-old schoolchildren in Istanbul.

METHODS

A total of 2500 children aged between 6 and 12 years in randomly selected six primary schools of Istanbul were surveyed by using the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire between April and May 2004.

RESULTS

Of them 2387 (1185 M/1202 F) questionnaires were appropriately completed by the parents with an overall response of 95.4%. The prevalence of physician-diagnosed allergic rhinitis was 7.9% (n=189). A family history of atopy (aOR=1.30, 95% CI=1.00-1.68), frequent respiratory tract infection (aOR=1.36, 95% CI=1.08-1.70) and sinusitis (aOR=2.29, 95% CI=1.64-3.19), antibiotic use in the first year of life (aOR=1.26, 95% CI=1.01-1.57), cat at home in the first year of life (aOR=2.21, 95% CI=1.36-3.61), dampness at home (aOR=1.31, 95% CI=1.04-1.65) and perianal redness (aOR=1.26, 95% CI=1.01-1.57) were significant for increased risk for allergic rhinitis. Frequent consumption of fruits and vegetables were inversely, and frequent consumption of lollipops and candies were positively associated with allergic rhinitis symptoms.

CONCLUSION

Our study reconfirmed that family history of atopy, frequent respiratory tract infections, antibiotics given in the first year of life, cat at home in the first year of life, dampness at home, perianal redness and dietary habits are important independent risk factors for AR. Researchers worldwide should be focused to these factors and try to develop policies for early intervention, primary and secondary preventions for allergic diseases.

Respiratory illnesses in early life and asthma and atopy in childhood

BACKGROUND

The relation between respiratory illnesses in early life and the development of asthma and atopy in childhood is incompletely understood.

OBJECTIVE

We sought to examine the relationship between respiratory illnesses in early life and atopic diseases at school age.

METHODS

We performed a prospective birth cohort study of the relationship between respiratory illnesses in the first year of life and asthma, atopy (sensitization to >or=1 allergen), and allergic rhinitis at school age in 440 children with a parental history of atopy. Logistic regression was used to examine the relationship between respiratory illnesses and asthma, atopy, and allergic rhinitis. The relationship between respiratory illnesses in early life and repeated measures of wheezing between the ages of 1 and 7 years was investigated by using a proportional hazards models.

RESULTS

Physician-diagnosed croup (adjusted odds ratio [OR], 0.30; 95% CI, 0.12-0.72) and having 2 or more physician-diagnosed ear infections (adjusted OR, 0.58; 95% CI, 0.35-0.98) in the first year of life were inversely associated with atopy at school age. Physician-diagnosed bronchiolitis before age 1 year was significantly associated with asthma at age 7 years (adjusted OR, 2.77; 95% CI, 1.23-6.22). Recurrent nasal catarrh (>or=3 episodes of a runny nose) in the first year of life was associated with allergic rhinitis at age 7 years (adjusted OR, 2.99; 95% CI, 1.03-8.67).

CONCLUSION

The relationship between early-life respiratory illnesses and asthma and atopy is complex and likely dependent on the type of infection and immune response it initiates.

CLINICAL IMPLICATIONS

Certain respiratory illnesses in early life modify the risk of atopy and asthma at school age.

[Infectious and non infectious factors in otitis media and in sinusitis]

Les infections de la sphère ORL sont fréquentes et les otites chez l’enfant, les sinusites de l’adulte sont généralement perçues comme étant d’origine bactérienne ou virale. Cependant de nombreux facteurs non infectieux jouent un rôle non négligeable, mais restent souvent méconnus et d’interprétation difficile : ils conduisent encore trop souvent à des thérapeutiques antibiotiques inutiles. Ainsi dans l’otite, ont été reconnus divers facteurs de risque non infectieux tels que : atteinte mécanique de la trompe d’Eustache, immaturité immunitaire, tabagisme passif, carence martiale etc… susceptibles de favoriser l’infection de l’oreille moyenne, souvent virale dans un 1^er temps, secondairement surinfectée par les espèces bactériennes du rhinopharynx ((pneumocoques, Haemophilus influenzae, Moraxella catarrhalis). Les sinusites sont d’étiologie multifactorielle et, si les mécanismes et les agents des sinusites infectieuses (virus et bactéries) sont bien connus, en revanche de multiples facteurs non infectieux peuvent être identifiés : l’allergie est un facteur fréquent qui favorise les sinusites à répétition ; moins souvent reconnus sont le diabète, le reflux gastro-oesophagien, des facteurs anatomiques, des anomalies de la fonction muco-ciliaire ou l’immunodépression dans le cadre VIH. Des recherches doivent être poursuivies pour approfondir ces mécanismes complexes.

[Viral infections and asthma]

Les infections respiratoires à rhinovirus, parainfluenza, influenza, adénovirus et virus syncytial respiratoire sont des causes fréquentes d'exacerbations asthmatiques surtout chez l'enfant. Tous ces virus peuvent induire une inflammation des bronches qui, en se superposant à l'inflammation allergique propre à l'asthme, peut aggraver l'obstruction et l'hyperréactivité bronchiques des asthmatiques. En outre, les infections virales respiratoires peuvent amplifier la réaction allergique bronchique induite par inhalation d'un allergène et favoriser l'éclosion d'un asthme ou d'un état d'atopie. Certains virus peuvent induire la synthèse d'IgE spécifiques et une réponse immunologique privilégiant le phénotype lymphocytaire TH2 promoteur de l'allergie. L'asthme et l'atopie prédisposent aux infections virales de l'organe de choc, peut-être à la faveur de l'inflammation allergique locale (expression d'ICAM-1, desquamation de la muqueuse, mucostase, etc.) et/ou des effets anti-inflammatoires de l'histamine.

[Atopy and infections]

Il existe de toute évidence des relations réciproques et importantes entre atopie et infection. L'atopie prédispose aux infections de l'organe de choc c'est-à-dire le siège de la réaction allergique. Puisque c'est l'inflammation allergique qui fait le lit de ces infections, il importera avant tout de lutter contre celle-ci en éliminant de l'environnement des sujets atopiques les allergènes et les irritants. Dans certains cas, il faudra recourir aux médicaments anti-inflammatoires topiques tels que le cromoglycate ou les corticostéroïdes en spray ou en pommade. Réciproquement, les infections de l'organe de choc aggravent les maladies atopiques en superposant les phénomènes inflammatoires qui leur sont propres à ceux de la réaction allergique, en amplifiant celle-ci et en créant une hyperréactivité de l'organe cible. Le rôle possible des infections à Chlamydia pneumoniae dans la genèse de certains asthmes chroniques sévères pourrait voir attribuer aux macrolides une place dans le traitement voire la prophylaxie de l'asthme.

The miseries of passive smoking

Passive smoking is defined as an involuntary exposure to a combined but diluted cigarette sidestream smoke (SS, gas and particle phases that are evolved from the smoldering end of a cigarette while the smoker is not puffing) and the exhaled smoke from smokers. SS contains numerous cytotoxic substances such as polycyclic aromatic hydrocarbons (PAHs), aromatic amines, nitrosamines, heavy metals, poisonous gases, pesticide residues, and radioactive elements in quantities much higher than those found from the cigarette mainstream smoke (MS) which is puffed by smokers. Passive smoking is found to be the cause of death from cancers and cardiac disease. Furthermore, it damagingly involves reproductive organs, the nervous system, genetic materials, and is particularly hazardous to mother and child during pregnancy and to those with a history of asthma, chronic infections, induced or earned immune deficiency, or predisposed susceptibility.

Correlation between respiratory alterations and respiratory diseases due to urban pollution

BACKGROUND

Air pollution is strongly correlated with allergic and infectious diseases. Chronicity of the stimulation and immaturity of the defense system make children prone to respiratory diseases. The aim of this study was to assess the adverse effects of urban levels of air pollution, correlating children's respiratory diseases and ultrastructural studies in rats, compared to controls in a clean area.

METHODS

An epidemiological survey was conducted with 2000 school children (age range 7-14 years old), divided into two groups of 1000 children each: the Red group from São Paulo city (17,000,000 inhabitants) and the Green group from a rural area around the city of Tupã with no air pollution at all. A questionnaire was given to the children's parents in order to estimate history of respiratory diseases and predisposing factors. A total of 69 rats were housed for 6 months in the center of São Paulo, and ultrastructural studies of the epithelium of the airways were done and compared to 56 control animals in the rural area.

RESULTS

The Red group of children had a statistically significant (P < 0.005) high prevalence of respiratory diseases such as rhinitis, sinusitis, and upper respiratory infections (URI). Rats exposed to air pollution developed ultrastructural ciliary alterations.

CONCLUSION

The results obtained in the present investigation suggest that chronic exposure to urban levels of air pollution may cause respiratory diseases in children and ultrastructural ciliary alterations in the epithelium of the airways in rats, when compared to controls in a pollution-free rural area.

Health effects of passive smoking. 4. Parental smoking, middle ear disease and adenotonsillectomy in children

BACKGROUND

A systematic quantitative review was conducted of evidence relating parental smoking to acute otitis media, recurrent otitis media, middle ear effusion, and adenoidectomy and/or tonsillectomy.

METHODS

Forty five relevant publications were identified after consideration of 692 articles selected by electronic search of the Embase and Medline databases using keywords relevant to passive smoking in children. The search was completed in April 1997 and identified 13 studies of acute otitis media, nine of recurrent otitis media, five of middle ear effusion, nine of glue ear surgery, and four of adenotonsillectomy. A quantitative meta-analysis was possible for all outcomes except acute otitis media, using random effects modelling where appropriate to pool odds ratios from each study.

RESULTS

Evidence for middle ear disease is remarkably consistent, with pooled odds ratios if either parent smoked of 1.48 (95% CI 1.08 to 2.04) for recurrent otitis media, 1.38 (1.23 to 1.55) for middle ear effusion, and 1.21 (0.95 to 1.53) for outpatient or inpatient referral for glue ear. Odds ratios for acute otitis media are in the range 1.0 to 1.6. No single study simultaneously addresses selection bias, information bias and confounding, but where these have been investigated or excluded in the design or analysis, the associations with parental smoking persist virtually unchanged. Large French and British studies are inconsistent with regard to the association of parental smoking and tonsillectomy.

CONCLUSIONS

There is likely to be a causal relationship between parental smoking and both acute and chronic middle ear disease in children.

Health effects of passive smoking. 3. Parental smoking and prevalence of respiratory symptoms and asthma in school age children

BACKGROUND

A systematic quantitative review of the evidence relating parental smoking to the prevalence of asthma and respiratory symptoms was conducted amongst school age children.

METHODS

Sixty relevant studies were identified after consideration of 1593 articles selected by electronic search of the Embase and Medline databases using keywords relevant to passive smoking in children. The search was completed in April 1997 and identified 25 studies of asthma, 41 of wheeze, 34 of chronic cough, seven of chronic phlegm and six of breathlessness which were included in a quantitative overview.

RESULTS

The pooled odds ratios for either parent smoking were 1.21 (95% CI 1.10 to 1.34) for asthma, 1.24 (95% CI 1.17 to 1.31) for wheeze, 1.40 (95% CI 1.27 to 1.53) for cough, 1.35 (95% CI 1.13 to 1.62) for phlegm, and 1.31 (95% CI 1.08 to 1.59) for breathlessness. Adjustment for confounding had little effect. Evidence of heterogeneity between studies appeared largely explicable by publication bias with a superfluity of small studies with large odds ratios. However, excluding these had little effect on the pooled odds ratios. The prevalence of all symptoms increased with the number of parents who smoked. While maternal smoking had a greater effect than paternal smoking, the effect of father only was clearly significant.

CONCLUSIONS

The relationship between parental smoking and respiratory symptoms seems very likely to be causal given statistical significance, robustness to adjustment for confounding factors, consistency of the findings in different countries, and evidence of dose response. The raised risk in households where the father, but not the mother, smoked argues for a postnatal effect.

Susceptibility of asthmatic children to respiratory infection

OBJECTIVE

A case-control study of patients with pneumonia was conducted to investigate whether wheezing diseases could be a risk factor.

METHODS

A random sample was taken from a general university hospital in S. Paulo City between March and August 1994 comprising 51 cases of pneumonia paired by age and sex to 51 non-respiratory controls and 51 healthy controls. Data collection was carried out by two senior paediatricians. Diagnoses of pneumonia and presence of wheezing disease were independently established by each paediatrician for both cases and controls. Pneumonia was radiologically confirmed and repeatability of information on wheezing diseases was measured. Logistic regression analysis was used to identify risk factors.

RESULTS

Wheezing diseases, interpreted as proxies of asthma, were found to be an important risk factor for pneumonia with an odds ratio of 7.07 (95% CI = 2.34-21.36), when the effects of bedroom crowding (odds ratio = 1.49 per person, 95% CI = 0.95-2.32) and of low family income (odds ratio = 5.59 against high family income, 95% CI = 1.38-22.63) were controlled. The risk of pneumonia attributable to wheezing diseases is tentatively calculated at 51.42%.

CONCLUSION

It is concluded that at practice level asthmatics should deserve proper surveillance for infection and that at public health level pneumonia incidence could be reduced if current World Health Organisation's guidelines were reviewed as to include comprehensive care for this illness.