International Journal ofPediatric Otorhinolaryngolo~, 24 (1992) I 1 1- 120 C 1992 Elsevier Science Publishers B.V. All rights reserved OlhS-587h/92/$05.00
PEDOT
Ill
00796
Atopy and environmental factors in upper respiratory infections: an epidemiological survey on 2304 school children E. Porro, P. Calamita, I. Rana, L. Montini and S. Criscione Department
of Experimental
Medicine. Unil ervlty of’ I. :ilquila, Collemaggio, L t4quilu (Ituly)
(Revised
Key words: Upper
respiratory
(Received 14 May 1991) version received 26 November (Accepted 29 November 199 I)
infection;
Atopy:
Epidemiology;
1991)
Rhinitis;
Blocked
nose; Otitis
Abstract
Upper respiratory infections CURI) during the first years of life are mostly viral in origin. However, a number of observations suggest the influence of both predisposing and triggering factors. Atopy in particular seems to play an important role as do environmental factors. Many children with early symptoms such as blocked or runny nose are likely to become skin-positive later in life to antigens such as, e.g., D. pteronissinus. A standardized questionnaire was administered to 2304 schoolchildren in order to ascertain the URI frequency and to correlate it with family and environmental factors and with results of prick tests for main allergens in our climate CD. pteronissinus and Grasses). Results showed a wide overlapping of URI and lower respiratory illnesses (in particular, asthma), which are widely distributed in the families of patients. Passive smoking and the quality of housing are the main triggering environmental factors. In our sample. skin positivity for D. pteronissinus and Grasses largely exceeds the symptomatic portion of the whole population. It is therefore suggested that many asymptomatic children are “at risk” for allergic respiratory illness. The highest incidence of winter rhinitis in skin-negative subjects (71.7%) and the skin positivity for D. pteronissinus in patients with perennial symptoms, suggest the importance of both atopy and viral
Correspondence 67100 L’Aquila.
10: S. Criscione, Italy.
Dept.
Experimental
Medicine.
University
of L‘Aquila.
C’ollemaggio.
112
infections in the occurrence of URI. Nasal troubles are most frequent in asthmatic subjects and may be considered the actual additional symptom in asthma.
Introduction
It is well known [19] that children undergo very frequent episodes of upper respiratory infections CURI) during the first years of life, most of which occur in winter. This frequent morbidity is increased by early nursery attendance. However, infections in most cases diminish or disappear with age [l]. As with lower respiratory diseases various factors should be considered: (a) anatomical features such as narrowing of the upper respiratory airways [211 increased by physiological hypertrophy of the adenoid tissue [2]; (b) functional factors, such as rheologic characteristics of the mucous lining and clearing by the cyliar movement. The latter is maximally compromised in Kartagener Syndrome [22]. This seems now to be the most severe alteration of a whole range of partial and possibly transient failures of the mucociliar clearance which is often underestimated 1731. (c) Amongst immunological factors, the transient deficit of secretory IgA in children [20], lowering the surface defence mechanisms, should be considered (fig. 1). Triggering factors are mostly viral in origin [l], depending also on the slow maturation of the T-dependent immunosystem [12]. On the other hand a number of observations suggest the influence of other factors such as sex: males are
PREDISPOSING
FACTORS
Family Age m,l Anatomical Defence
history
of asthma
SQX or chronic
sacio-economic
bronchitis
, r/itions
5 year\‘::,.
features
= lg A
Muco-ciliary
function
Allergy
(Smoking
- indoor
TRIGGERING Fig. 1.
\nf ec t ions
Environment pollution)
FACTORS
113
affected more than females [21]. However, a role of increasing importance is attributed to family and environmental factors; atopy, hereditary in origin 1151, plays the major role. URI are frequently correlated to atopy as well as to asthma and recurrent bronchitis [6].
Subjects and methods
In order to understand the relative role of different factors, environment and atopy in particular, an epidemiological study was performed on 2304 schoolchildren (age range 6-14 years). A standardized anamnestic questionnaire was administered to ascertain: t 1) Frequency of the following symptoms: Blocked nose Otitis Runny nose Asthma Recurrent bronchitis. These were defined by the following questions: ‘Has the child had a blocked or runny nose for most of the year or in particular periods of the year?‘-If so, from which age? In which period of the year. 9 ‘Has the child ever had otitis?‘-More than once a year?-With ear secretion. 3 “Has the child ever had asthma? (audible respiratory wheezing), in a particular season? If so, in which season? From which age? ‘Has the child’s physician ever told you that the child had bronchitis’? If so, how many times‘? (2) The following socio-economic
conditions:
(a) Father’s job (b) Mother’s job (if not housewife) (cl Educational level of parents. The definition of “low socio-economic conditions” was obtained by a combination of the scores for these items and the following environmental conditions: (d) Total daily cigarette consumption by cohabitants (e) Home humidity (answer yes/no) (f) Room/cohabitant ratio. (3) The following family history conditions: (a) Asthma (b) Chronic bronchitis (C.E.C.A.? (4)
definition of CNSLD)
(a) Frequency of medical consultation (b) Occurrence of tonsillectomy
and absence from school
114
The parameters (2); (3); (4); and the frequency of asthma and recurrent bronchitis (the latter defined by the presence of more than 5 episodes) have been correlated with rhinitis (defined as “runny nose” in the questionnaire) and/or blocked nose and with otitis (defined by positive answers to all the relative questions in the questionnaire) by a x2 standard test calculating the confidence limits of Odd’s ratio. All the subjects, and those giving positive answers to asthma, recurrent bronchitis, otitis, blocked nose and/or rhinitis in particular, underwent a prick test using Pharmacia (Uppsala) extracts.
Results
Results of the correlation between URI (rhinitis and/or blocked nose and otitis) and anamnestic parameters are depicted in Table I. Regression coefficients are presented only for those variables which were significant when entered into the model. The significance of the correlation is expressed in terms of P values by a ‘multiple logistic analysis’ with blocked nose and/or rhinitis and otitis as separate dependent variables, while all the other factors are examined as independent variables. Nose troubles are strongly increased by asthma and recurrent bronchitis
TABLE
I
Significativity of correlations for anamnestic parameters/ ‘Multiple Logistic Analysis’ Independent oariables
Asthma Recurrent Blocked
Rhinitis and/or blocked nose
bronchitis nose
Low socio-economic
conditions
Environmental conditions Total cigarett. smoked daily Home humidity Room/cohabit.
consult.
Tonsillectomy
bronchitis
Otitis P
St. err.
P
Regress. coeff:
St. err.
Regress. coeff. 0.79 0.81 _
0.21 0.22
0.001 0.001 _
* 0.80 0.59
n.s. 0.22 0.18
0.001 0.01
0.31
0.15
0.05
0.34
ns. n.s. 0.16
0.05
0.16 n.s. ns.
0.80 0.83
0.22 0.23
0.001 0.001
n.s. n.s.
> 20
> 0.3
Family history of asthma of chronic Medical
us URI ( * = not significant) calculated by
and school absences
n.s
0.32
n.s. 0.32
0.16
0.05
ns. 0.05
0.32
0.16
0.05
TABLE
II
Frequency of the illness among the sample (2304 xhoolchildren) Rhinitis and/or blocked Otitis Asthma Recurrent bronchitis
TABLE
190
nose
(8.2%) (5.9%) (5.6%) (3.2%)
137 129 71
III
Frequency of skin positirity in the sample (2304 schoolchildren) Skin positilsityof at least I allergen
Skin positiclty to Dennatophagoides
Skin positicity to Grasses
15.1% (n = 307) Positivity to both Dermatophagoides
7.7% (n = 157) (pteronissinus
5.6% (n = 114)
TABLE
and farinae)
= 84.45%
IV
Skin positility frequency (prick tests for Grasse, and D. pteronissinus and farinae) in di@mt Among which, p0sitil.e for Dermatophagoides (n = 167)
n. positi[,e for any allergen (n = 243) Rhinitis and/or blocked nose Otitis Asthma Recurrent bronchitis
TABLE
illnessrs
84 39 9x
44.2 2x.5 76.0
62 26 68
73.x 66.7 66.7
22
29.7
II
SO.0
V
Seasonal symptoms in asthma and rhinitu
Asthma skin-positive skin-negative
Rhinitis and/or skin-positive skin-negative
blocked
nose n % ,I C:;
Perennial
Winter
Autumn
Other
50
21 21.43 x 25.80
21 21.43 6 19.36
6
51.02 14 45.16
6.12 3 9.68
28 33.33 18 16.98
36 42.86 76 71.70
I4 16.67 x 7.55
6 7.14 4 3.77
116 TABLE
VI
Age of onset of rhinitis and/or
blocked nose
Age (years) 5
Skin-positive n %
12 14.28
14 16.67
15 17.86
11 13.09
9 10.72
7 8.33
16 19.05
Skin-negative n %
36 33.96
30 28.30
16 15.10
7 6.60
7 6.60
5 4.72
5 4.72
and by family history of asthma or chronic bronchitis in the family, each one playing an independent role from the other. Among predisposing factors, low socioeconomic conditions and low quality housing (rooms/cohabitants ratio > 0.3) seem to be the most important. Tonsillectomy is also a relevant consequence. The same factors, less evidently, concern otitis. It is important to note that smoking affects otitis but is not significant in nose troubles. The frequency of the various illness conditions confirms the clinical relevance of respiratory problems in pediatric practice. (Table II) The high frequency of otitis in particular seems to be important considering its underestimation during the early ages [13]. The sample was screened for frequency of skin positivity (Table III). Since skin positivity for major allergens is high in the sample, it may be argued that skin positivity is frequent in the asymptomatic population: 243 symptomatic subjects (for any considered illness) resulting positive for any tested allergen (see Table IV), as opposed to 307 in the general population. Sixty-four cases (3.1% of the whole population) are therefore skin-positive and symptomless. The estabilished cross-reactivity to Dermatophagoides allergens [5] is confirmed in our study by the high percentage of subjects positive to both acari (Table III). Skin-positivity of subjects affected by various illnesses was also considered in Table IV and it is particularly high in asthmatic subjects, but its incidence is also relevant in nose troubles. Otitis and recurrent bronchitis show a skin-positivity
TABLE
VII
Frequency of symptoms related to upper respiratory airways in 129 asthmatic subjects
Rhinitis a Sinusitis Otitis Blocked nose a a Many subjects
reported
both symptoms.
n
%
63 11 16 58
48.84 8.53 12.40 44.96
117
ASTHMA Fig. 2.
higher than that of the general population (otitis: P < 0.0005; confidence limits (95%) = 0.29 and 0.67-‘ODD’S RATIO’ = 0.44. Relapsing bronchitis: P < 0.001; confidence limits (95%) = 0.24 and 0.72-‘ODD’S RATIO’ = 0.42). Seasonal symptoms in asthmatic and rhinitic skin-positive and -negative subjects were also examined (Table VI. Differences between asthma and rhinitis (skin-positive vs skin-negative) for perennial symptoms: P < 0.07 (n.s.)-confidence limits (95%) = 0.91 and 5.78‘ODD’S RATIO’ = 2.29); for winter symptoms: P < O.OOOl-confidence limits (95%) = 2.07 and 15.2-‘ODD’S RATIO’ = 5.54; for autumn and other seasons: P = ns. Rhinitis and/or blocked nose are prevalent in winter. Age of onset of rhinitis and/or blocked nose in skin-positive and -negative subjects (Table VI) shows an earlier onset for skin-negative subjects: age trend in skin-positive vs -negative subjects: P < 0.00005. The frequency of symptoms related to upper respiratory airways in asthmatic subjects is shown in Table VII; these subjects underwent a more detailed investiga-
TABLE
VIII
Asthma
and rhinitis association
in skin-positive
%
subjects without rhinitis
Asthma (n = 641
Asthma •t Rhinitis (n = 65)
n
and -negatic’e subjects L‘Sasthmatic
Skin -
Skin +
Skin -
Skin +
11 16.92
54 83.08
20 31.25
44 68.75
118
tion, including pulmonary function tests and were asked if they had ever had sinusitis assessed by an X-ray examination. An association with nose troubles is more frequent in asthmatic subjects (more or less 50% of the cases are affected). Cases of overlapping of URI and asthma are reported in Fig. 2. Differences of skin-positivity between asthmatics with or without rhinitis (Table VIII) show that the occurrence of rhinitis does not add any skin-positivity to asthmatics: P < 0.09 (n.s.)-confidence limits (95%): 0.18 and Lll-‘ODD’S RATIO’ = 0.45.
Discussion
The present epidemiological investigation assessed the role of atopy in URI. In our previous studies [16,17] the use of ‘self administered’ questionnaires in the screenings and the definition of the illness under study was validated. Our data confirm the relevance of predisposing and triggering factors depicted in Fig. 1 (see also Table I) and agree with the literature: (1) URI overlap in several cases [6] lower respiratory illness and, in particular, asthma. The theoretical separation of the respiratory tree (which should be considered as a whole) in different parts does not seem to represent a reliable clinical tool. In fact, respiratory mucosae tend to react as a whole to the various infective, allergic, and environmental noxae. (2) Amongst the predisposing factors in URI, family history of asthma and chronic bronchitis appear to be relevant: the definition of these anamnestic parameters in our study (occurrence of one or more affected relatives) does not permit the evaluation of the relative role of ‘genetic’ and ‘environmental’ factors (the latter referring to common negative family environment). In any case, it should be noted that the clinical manifestations of lower respiratory diseases in relatives may predispose, also genetically, the child to URI as well to asthma and/or recurrent bronchitis [16,17]. (3) Complete data on hygienic conditions were unavailable, but as the room/cohabitant ratio represents the most significant factor in our analysis, it may then be argued that home environment (i.e. the presence of microorganisms, indoor pollution, etc.) must be carefully considered. (4) Passive smoking is often cited as a contributory factor in respiratory troubles [9,11,18] but according to the present investigation it does not appear to exert a major influence in nose troubles, emerging only in the case of ear troubles. In our opinion the role of passive smoking should not be underestimated as a triggering factor of URI. A correlation between nasal and ear infection is well known and both are affected by the same factors. It is therefore probable that only the most severe and relapsing cases of nasal infection lead to recurrent otitis (231, while passive smoking may be a prominent factor in the severity of these cases. Frequency of the different illnesses in the sample (Table II) agree with previous literature [1,4]. From an allergologic point of view, it is interesting to note (Table III) that skin positivity for Dermatophagoides and Grasses (the main allergens of our climate) largely exceed the symptomatic portion of the whole population.
II’)
This means that the latter includes many subjects at risk [3] of allergic respiratory illness (tested allergens are ‘inhalant’), who are not yet clinically ill perhaps due to the absence of predisposing or triggering factors. It may be suggested on this basis that screenings for allergy on large populations are needed to identify subjects at risk who should be regularly checked in order to provide preventive programs. Dermatophagoides (Table IV) is the main allergen of our climate and this may explain (Table V) the high frequency of perennial symptoms in asthmatic skin-positive subjects. The same observation should apply to rhinitic patients. On the other hand rhinitis is mostly present during winter in skin-negative subjects (71.7%). Many nasal problems are obviously infectious in origin, and these infections arise especially in winter when morbidity is at its highest. Perennial or seasonal rhinitis and/or blocked nose are probably more frequently allergic in origin and should be investigated accordingly [14]. During the early years of life, URI and particularly nose illness are mainly infectious, i.e., of viral origin [l]. In fact (Table VI) while the onset of symptoms is distributed throughout the different ages in allergic subjects, these illnesses arc most frequent in the first three years in skin-negative subjects. Nasal illness is very common in asthmatic subjects (Table VII) and it may be considered the actual additional symptom in asthma [14]. It should be noted (Table VIII>, on the other hand, that rhinitis does not add any allergic positivity to the tests in asthmatic subjects.
References 1 Anderson, H.R., Respiratory disease in childhood, Br. Med. Bull., 42 (1986) 167-174. 2 Battistini, A. and Grzincich, G.L., L’ipertrofia adeno-tonsillare, Riv. It. Ped.. 5 (1979) 561-568. 3 Bjorksten, F., Suoniemi, I. and Koski, V., Neonatal birk-pollen contact and subsequent allergy to birk pollen. Clin. Allergol., 10 (1980) 585-589. 4 Bloor. M.J., Venters, B.A. and Samphier, M.L., Geographical variation in the incidence of operations on tonsils and adenoids. An epidemiological and sociological investigation, J. Laryngol. Otol., 92 (1978) 791-798. 5 Blythe, M.E., Some aspects of the ecological study of the house dust mites. Br. J. Dis. Chest. 70 (1976) 3-7. 6 Braback, L., Kalvesten, L. and Sundstrom, G., Prevalence of bronchial asthma among schoolchildren in a Swedish district. Acta Paediatr. Stand., 77 (1988) 821-825. 7 Burgersdijk, F.J.A., Degroot, J.C.M.J., Graamans, K. and Rademakers, L.H.P.M., Testing ciliary activity in patients with chronic and recurrent infections of the upper airways: experience in 6X cases, Laringoscope, 96 (1986) 1029-1033. 8 Carson, J.L., Collier, A.M. and Hu, S.S., Acquired ciliary defects in nasal epithelium of children with acute viral upper respiratory infections, N. Engl. J. Med., 312 (1985) 463-467. 9 Colley, J.. Holland, W.W. and Corkill, R.T., Influence of passive smoking and parental phlegm on pneumonia and bronchitis in early childhood, Lancet, 2 (1974) 1031-1034. 10 Corbo, G.M., Foresi, A. and Bonfitto, P., Measurement of nasal mucociliary clearance, Arch. Dis. Child, 64 (1989) 546-550. 11 Fergusson, D.M., Horwood, L.J. and Shannon, F.T., Parental smoking and respiratory illness in infancy, Arch. Dis. Child, 55 (1980) 358-361.
120 12 Harada, R.N. and Rapine, J.E., Pulmonary host defense mechanisms, Chest, 87 (1985) 247-252. 13 Hayden, G.F. and Schwartz, R.H., Characteristics of earache among children with acute otitis media, Am. J. Dis. Child, 139 (1985) 721-723. 14 Kemp, A. and Bryan, L., Perennial rhinitis. A common childhood complaint, Aust. Med. J. 141 (1984) 640-643. 15 Levine, B., Genetics of atopic allergy and reagin production, Clinical Immunology Allergy in Paediatric Medicine, Blackwell, Oxford, 1974. 16 Ronchetti, R., Martinez, F., Criscione, S., Macri’, F., Tramutoli, G.M., Antognoni, Cl., Ciofetta, G. and Imperato, C., Influence of familial and environmental factors on the prevalence of asthmatic and bronchitic syndromes of children (epidemiological survey on 2500 roman pupils), Riv. It. Ped., 8 (1982) 755-756 (English Summary). 17 Ronchetti, R., Criscione, S., Macri’, F., Tramutoli, G.M., Martinez, F., Tripodi, S., Barretta, A. and Pennacchia, M., Respitatory function and environmental factors in children, Bull. Eur. Physiopath. Resp., 16 (1980) 3-4. 18 Schimettz, I., Hoffman, D. and Hynder, E.L., The influence of tobacco smoke in indoor atmospheres, Prev. Med., 4 (1975) 66-71. 19 Stephan, U. and Wiesemann, H.G., The common cold in children: a pediatric viewpoint, Therapiewoche, 35 (19851 429-434 (English summary). 20 Taylor, B., Norman, A.P., Orgel, H.A., Stokes, C.R., Turner, M.W. and Soothill, J.F., Transient IgA deficiency and pathogenesis of infantile atopy, Lancet, 3 (1973) 2-6. 21 Tos, M. and Stangerup, SE., Secretory otitis and pneumatization of the mastoid process: sexual differences in the size of mastoid cell system, Am J. Otolaringol., 6 (1985) 199-205. 22 Umeki, S., Primary mucociliary transport failure, Respiration, 54 (1988) 220-225. 23 Van Lauwenberge, P.B., Relationship between nasal and middle ear pathology in children, Rhinology, 9 (SuppI.) (1989) 81-86.
PEDOT
Ill
00796
Atopy and environmental factors in upper respiratory infections: an epidemiological survey on 2304 school children E. Porro, P. Calamita, I. Rana, L. Montini and S. Criscione Department
of Experimental
Medicine. Unil ervlty of’ I. :ilquila, Collemaggio, L t4quilu (Ituly)
(Revised
Key words: Upper
respiratory
(Received 14 May 1991) version received 26 November (Accepted 29 November 199 I)
infection;
Atopy:
Epidemiology;
1991)
Rhinitis;
Blocked
nose; Otitis
Abstract
Upper respiratory infections CURI) during the first years of life are mostly viral in origin. However, a number of observations suggest the influence of both predisposing and triggering factors. Atopy in particular seems to play an important role as do environmental factors. Many children with early symptoms such as blocked or runny nose are likely to become skin-positive later in life to antigens such as, e.g., D. pteronissinus. A standardized questionnaire was administered to 2304 schoolchildren in order to ascertain the URI frequency and to correlate it with family and environmental factors and with results of prick tests for main allergens in our climate CD. pteronissinus and Grasses). Results showed a wide overlapping of URI and lower respiratory illnesses (in particular, asthma), which are widely distributed in the families of patients. Passive smoking and the quality of housing are the main triggering environmental factors. In our sample. skin positivity for D. pteronissinus and Grasses largely exceeds the symptomatic portion of the whole population. It is therefore suggested that many asymptomatic children are “at risk” for allergic respiratory illness. The highest incidence of winter rhinitis in skin-negative subjects (71.7%) and the skin positivity for D. pteronissinus in patients with perennial symptoms, suggest the importance of both atopy and viral
Correspondence 67100 L’Aquila.
10: S. Criscione, Italy.
Dept.
Experimental
Medicine.
University
of L‘Aquila.
C’ollemaggio.
112
infections in the occurrence of URI. Nasal troubles are most frequent in asthmatic subjects and may be considered the actual additional symptom in asthma.
Introduction
It is well known [19] that children undergo very frequent episodes of upper respiratory infections CURI) during the first years of life, most of which occur in winter. This frequent morbidity is increased by early nursery attendance. However, infections in most cases diminish or disappear with age [l]. As with lower respiratory diseases various factors should be considered: (a) anatomical features such as narrowing of the upper respiratory airways [211 increased by physiological hypertrophy of the adenoid tissue [2]; (b) functional factors, such as rheologic characteristics of the mucous lining and clearing by the cyliar movement. The latter is maximally compromised in Kartagener Syndrome [22]. This seems now to be the most severe alteration of a whole range of partial and possibly transient failures of the mucociliar clearance which is often underestimated 1731. (c) Amongst immunological factors, the transient deficit of secretory IgA in children [20], lowering the surface defence mechanisms, should be considered (fig. 1). Triggering factors are mostly viral in origin [l], depending also on the slow maturation of the T-dependent immunosystem [12]. On the other hand a number of observations suggest the influence of other factors such as sex: males are
PREDISPOSING
FACTORS
Family Age m,l Anatomical Defence
history
of asthma
SQX or chronic
sacio-economic
bronchitis
, r/itions
5 year\‘::,.
features
= lg A
Muco-ciliary
function
Allergy
(Smoking
- indoor
TRIGGERING Fig. 1.
\nf ec t ions
Environment pollution)
FACTORS
113
affected more than females [21]. However, a role of increasing importance is attributed to family and environmental factors; atopy, hereditary in origin 1151, plays the major role. URI are frequently correlated to atopy as well as to asthma and recurrent bronchitis [6].
Subjects and methods
In order to understand the relative role of different factors, environment and atopy in particular, an epidemiological study was performed on 2304 schoolchildren (age range 6-14 years). A standardized anamnestic questionnaire was administered to ascertain: t 1) Frequency of the following symptoms: Blocked nose Otitis Runny nose Asthma Recurrent bronchitis. These were defined by the following questions: ‘Has the child had a blocked or runny nose for most of the year or in particular periods of the year?‘-If so, from which age? In which period of the year. 9 ‘Has the child ever had otitis?‘-More than once a year?-With ear secretion. 3 “Has the child ever had asthma? (audible respiratory wheezing), in a particular season? If so, in which season? From which age? ‘Has the child’s physician ever told you that the child had bronchitis’? If so, how many times‘? (2) The following socio-economic
conditions:
(a) Father’s job (b) Mother’s job (if not housewife) (cl Educational level of parents. The definition of “low socio-economic conditions” was obtained by a combination of the scores for these items and the following environmental conditions: (d) Total daily cigarette consumption by cohabitants (e) Home humidity (answer yes/no) (f) Room/cohabitant ratio. (3) The following family history conditions: (a) Asthma (b) Chronic bronchitis (C.E.C.A.? (4)
definition of CNSLD)
(a) Frequency of medical consultation (b) Occurrence of tonsillectomy
and absence from school
114
The parameters (2); (3); (4); and the frequency of asthma and recurrent bronchitis (the latter defined by the presence of more than 5 episodes) have been correlated with rhinitis (defined as “runny nose” in the questionnaire) and/or blocked nose and with otitis (defined by positive answers to all the relative questions in the questionnaire) by a x2 standard test calculating the confidence limits of Odd’s ratio. All the subjects, and those giving positive answers to asthma, recurrent bronchitis, otitis, blocked nose and/or rhinitis in particular, underwent a prick test using Pharmacia (Uppsala) extracts.
Results
Results of the correlation between URI (rhinitis and/or blocked nose and otitis) and anamnestic parameters are depicted in Table I. Regression coefficients are presented only for those variables which were significant when entered into the model. The significance of the correlation is expressed in terms of P values by a ‘multiple logistic analysis’ with blocked nose and/or rhinitis and otitis as separate dependent variables, while all the other factors are examined as independent variables. Nose troubles are strongly increased by asthma and recurrent bronchitis
TABLE
I
Significativity of correlations for anamnestic parameters/ ‘Multiple Logistic Analysis’ Independent oariables
Asthma Recurrent Blocked
Rhinitis and/or blocked nose
bronchitis nose
Low socio-economic
conditions
Environmental conditions Total cigarett. smoked daily Home humidity Room/cohabit.
consult.
Tonsillectomy
bronchitis
Otitis P
St. err.
P
Regress. coeff:
St. err.
Regress. coeff. 0.79 0.81 _
0.21 0.22
0.001 0.001 _
* 0.80 0.59
n.s. 0.22 0.18
0.001 0.01
0.31
0.15
0.05
0.34
ns. n.s. 0.16
0.05
0.16 n.s. ns.
0.80 0.83
0.22 0.23
0.001 0.001
n.s. n.s.
> 20
> 0.3
Family history of asthma of chronic Medical
us URI ( * = not significant) calculated by
and school absences
n.s
0.32
n.s. 0.32
0.16
0.05
ns. 0.05
0.32
0.16
0.05
TABLE
II
Frequency of the illness among the sample (2304 xhoolchildren) Rhinitis and/or blocked Otitis Asthma Recurrent bronchitis
TABLE
190
nose
(8.2%) (5.9%) (5.6%) (3.2%)
137 129 71
III
Frequency of skin positirity in the sample (2304 schoolchildren) Skin positilsityof at least I allergen
Skin positiclty to Dennatophagoides
Skin positicity to Grasses
15.1% (n = 307) Positivity to both Dermatophagoides
7.7% (n = 157) (pteronissinus
5.6% (n = 114)
TABLE
and farinae)
= 84.45%
IV
Skin positility frequency (prick tests for Grasse, and D. pteronissinus and farinae) in di@mt Among which, p0sitil.e for Dermatophagoides (n = 167)
n. positi[,e for any allergen (n = 243) Rhinitis and/or blocked nose Otitis Asthma Recurrent bronchitis
TABLE
illnessrs
84 39 9x
44.2 2x.5 76.0
62 26 68
73.x 66.7 66.7
22
29.7
II
SO.0
V
Seasonal symptoms in asthma and rhinitu
Asthma skin-positive skin-negative
Rhinitis and/or skin-positive skin-negative
blocked
nose n % ,I C:;
Perennial
Winter
Autumn
Other
50
21 21.43 x 25.80
21 21.43 6 19.36
6
51.02 14 45.16
6.12 3 9.68
28 33.33 18 16.98
36 42.86 76 71.70
I4 16.67 x 7.55
6 7.14 4 3.77
116 TABLE
VI
Age of onset of rhinitis and/or
blocked nose
Age (years) 5
Skin-positive n %
12 14.28
14 16.67
15 17.86
11 13.09
9 10.72
7 8.33
16 19.05
Skin-negative n %
36 33.96
30 28.30
16 15.10
7 6.60
7 6.60
5 4.72
5 4.72
and by family history of asthma or chronic bronchitis in the family, each one playing an independent role from the other. Among predisposing factors, low socioeconomic conditions and low quality housing (rooms/cohabitants ratio > 0.3) seem to be the most important. Tonsillectomy is also a relevant consequence. The same factors, less evidently, concern otitis. It is important to note that smoking affects otitis but is not significant in nose troubles. The frequency of the various illness conditions confirms the clinical relevance of respiratory problems in pediatric practice. (Table II) The high frequency of otitis in particular seems to be important considering its underestimation during the early ages [13]. The sample was screened for frequency of skin positivity (Table III). Since skin positivity for major allergens is high in the sample, it may be argued that skin positivity is frequent in the asymptomatic population: 243 symptomatic subjects (for any considered illness) resulting positive for any tested allergen (see Table IV), as opposed to 307 in the general population. Sixty-four cases (3.1% of the whole population) are therefore skin-positive and symptomless. The estabilished cross-reactivity to Dermatophagoides allergens [5] is confirmed in our study by the high percentage of subjects positive to both acari (Table III). Skin-positivity of subjects affected by various illnesses was also considered in Table IV and it is particularly high in asthmatic subjects, but its incidence is also relevant in nose troubles. Otitis and recurrent bronchitis show a skin-positivity
TABLE
VII
Frequency of symptoms related to upper respiratory airways in 129 asthmatic subjects
Rhinitis a Sinusitis Otitis Blocked nose a a Many subjects
reported
both symptoms.
n
%
63 11 16 58
48.84 8.53 12.40 44.96
117
ASTHMA Fig. 2.
higher than that of the general population (otitis: P < 0.0005; confidence limits (95%) = 0.29 and 0.67-‘ODD’S RATIO’ = 0.44. Relapsing bronchitis: P < 0.001; confidence limits (95%) = 0.24 and 0.72-‘ODD’S RATIO’ = 0.42). Seasonal symptoms in asthmatic and rhinitic skin-positive and -negative subjects were also examined (Table VI. Differences between asthma and rhinitis (skin-positive vs skin-negative) for perennial symptoms: P < 0.07 (n.s.)-confidence limits (95%) = 0.91 and 5.78‘ODD’S RATIO’ = 2.29); for winter symptoms: P < O.OOOl-confidence limits (95%) = 2.07 and 15.2-‘ODD’S RATIO’ = 5.54; for autumn and other seasons: P = ns. Rhinitis and/or blocked nose are prevalent in winter. Age of onset of rhinitis and/or blocked nose in skin-positive and -negative subjects (Table VI) shows an earlier onset for skin-negative subjects: age trend in skin-positive vs -negative subjects: P < 0.00005. The frequency of symptoms related to upper respiratory airways in asthmatic subjects is shown in Table VII; these subjects underwent a more detailed investiga-
TABLE
VIII
Asthma
and rhinitis association
in skin-positive
%
subjects without rhinitis
Asthma (n = 641
Asthma •t Rhinitis (n = 65)
n
and -negatic’e subjects L‘Sasthmatic
Skin -
Skin +
Skin -
Skin +
11 16.92
54 83.08
20 31.25
44 68.75
118
tion, including pulmonary function tests and were asked if they had ever had sinusitis assessed by an X-ray examination. An association with nose troubles is more frequent in asthmatic subjects (more or less 50% of the cases are affected). Cases of overlapping of URI and asthma are reported in Fig. 2. Differences of skin-positivity between asthmatics with or without rhinitis (Table VIII) show that the occurrence of rhinitis does not add any skin-positivity to asthmatics: P < 0.09 (n.s.)-confidence limits (95%): 0.18 and Lll-‘ODD’S RATIO’ = 0.45.
Discussion
The present epidemiological investigation assessed the role of atopy in URI. In our previous studies [16,17] the use of ‘self administered’ questionnaires in the screenings and the definition of the illness under study was validated. Our data confirm the relevance of predisposing and triggering factors depicted in Fig. 1 (see also Table I) and agree with the literature: (1) URI overlap in several cases [6] lower respiratory illness and, in particular, asthma. The theoretical separation of the respiratory tree (which should be considered as a whole) in different parts does not seem to represent a reliable clinical tool. In fact, respiratory mucosae tend to react as a whole to the various infective, allergic, and environmental noxae. (2) Amongst the predisposing factors in URI, family history of asthma and chronic bronchitis appear to be relevant: the definition of these anamnestic parameters in our study (occurrence of one or more affected relatives) does not permit the evaluation of the relative role of ‘genetic’ and ‘environmental’ factors (the latter referring to common negative family environment). In any case, it should be noted that the clinical manifestations of lower respiratory diseases in relatives may predispose, also genetically, the child to URI as well to asthma and/or recurrent bronchitis [16,17]. (3) Complete data on hygienic conditions were unavailable, but as the room/cohabitant ratio represents the most significant factor in our analysis, it may then be argued that home environment (i.e. the presence of microorganisms, indoor pollution, etc.) must be carefully considered. (4) Passive smoking is often cited as a contributory factor in respiratory troubles [9,11,18] but according to the present investigation it does not appear to exert a major influence in nose troubles, emerging only in the case of ear troubles. In our opinion the role of passive smoking should not be underestimated as a triggering factor of URI. A correlation between nasal and ear infection is well known and both are affected by the same factors. It is therefore probable that only the most severe and relapsing cases of nasal infection lead to recurrent otitis (231, while passive smoking may be a prominent factor in the severity of these cases. Frequency of the different illnesses in the sample (Table II) agree with previous literature [1,4]. From an allergologic point of view, it is interesting to note (Table III) that skin positivity for Dermatophagoides and Grasses (the main allergens of our climate) largely exceed the symptomatic portion of the whole population.
II’)
This means that the latter includes many subjects at risk [3] of allergic respiratory illness (tested allergens are ‘inhalant’), who are not yet clinically ill perhaps due to the absence of predisposing or triggering factors. It may be suggested on this basis that screenings for allergy on large populations are needed to identify subjects at risk who should be regularly checked in order to provide preventive programs. Dermatophagoides (Table IV) is the main allergen of our climate and this may explain (Table V) the high frequency of perennial symptoms in asthmatic skin-positive subjects. The same observation should apply to rhinitic patients. On the other hand rhinitis is mostly present during winter in skin-negative subjects (71.7%). Many nasal problems are obviously infectious in origin, and these infections arise especially in winter when morbidity is at its highest. Perennial or seasonal rhinitis and/or blocked nose are probably more frequently allergic in origin and should be investigated accordingly [14]. During the early years of life, URI and particularly nose illness are mainly infectious, i.e., of viral origin [l]. In fact (Table VI) while the onset of symptoms is distributed throughout the different ages in allergic subjects, these illnesses arc most frequent in the first three years in skin-negative subjects. Nasal illness is very common in asthmatic subjects (Table VII) and it may be considered the actual additional symptom in asthma [14]. It should be noted (Table VIII>, on the other hand, that rhinitis does not add any allergic positivity to the tests in asthmatic subjects.
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