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Prevalence of atopic dermatitis, asthma and rhinitis from infancy through adulthood in rural Bangladesh: a population-based, cross-sectional survey

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Objective: Describe the pattern of atopic disease prevalence from infancy to adulthood. Design: Cross-sectional household survey. Setting: Community-based demographic surveillance site, Mirzapur, Bangladesh. Participants: 7275 individuals in randomly selected clusters within 156 villages. Primary and secondary outcome measures: The 12-month prevalence of atopic dermatitis (by UK Working Party Criteria (UK criteria) and International Study of Asthma and Allergies in Childhood (ISAAC)), asthma and rhinitis (by ISAAC); disease severity (by ISAAC); history of ever receiving a medical diagnosis. Results: Children aged 2 years had the highest prevalence of atopic dermatitis-18.8% (95% CI 15.2% to 22.4%) by UK criteria and 14.9% (95% CI 11.6% to 18.1%) by ISAAC- and asthma (20.1%, 95% CI 16.4% to 23.8%). Prevalence of rhinitis was highest among 25-29 year olds (6.0%, (95% CI% 4.5 to 7.4%). History of a medical diagnosis was lowest for atopic dermatitis (4.0%) and highest for rhinitis (27.3%) and was significantly associated with severe disease compared with those without severe disease for all three conditions (atopic dermatitis: 30.0% vs 11.7%, p=0.015; asthma; 85.0% vs 60.4%, p<0.001; rhinitis: 34.2% vs 7.3%, p<0.001) and having a higher asset-based wealth score for asthma (29.7% (highest quintile) vs 7.5% (lowest quintile), p<0.001) and rhinitis (39.8% vs 12.5%, p=0.003). Prevalence of having >1 condition was highest (36.2%) at 2 years and decreased with age. Having atopic dermatitis (ISAAC) was associated with significantly increased odds ratios (OR) for comorbid asthma (OR 5.56 (95% CI 4.26 to 7.26)] and rhinitis (3.68 (95% CI 2.73 to 4.96)). Asthma and rhinitis were also strongly associated with each other (OR 8.39 (95% CI 6.48 to 10.86)). Conclusions: Atopic disease burden was high in this rural Bangladeshi population. Having one atopic condition was significantly associated with the presence of another. Low incidence of ever obtaining a medical diagnosis highlights an important opportunity to increase availability of affordable diagnosis and treatment options for all age groups.
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PedersenCJ, etal. BMJ Open 2020;10:e042380. doi:10.1136/bmjopen-2020-042380
Open access
Prevalence of atopic dermatitis, asthma
and rhinitis from infancy through
adulthood in rural Bangladesh: a
population- based, cross- sectional survey
Courtney J Pedersen,1 Mohammad J Uddin,2 Samir K Saha,2
Gary L Darmstadt 1
To cite: PedersenCJ, UddinMJ,
SahaSK, etal. Prevalence of
atopic dermatitis, asthma and
rhinitis from infancy through
adulthood in rural Bangladesh:
a population- based, cross-
sectional survey. BMJ Open
2020;10:e042380. doi:10.1136/
bmjopen-2020-042380
Prepublication history for
this paper is available online.
To view these les, please visit
the journal online (http:// dx. doi.
org/ 10. 1136/ bmjopen- 2020-
042380).
Received 08 July 2020
Revised 23 September 2020
Accepted 29 September 2020
1Department of Pediatrics,
Stanford University School of
Medicine, Stanford, CA, USA
2Child Health Research
Foundation, Dhaka, Bangladesh
Correspondence to
Dr Gary L Darmstadt;
gdarmsta@ stanford. edu
Original research
© Author(s) (or their
employer(s)) 2020. Re- use
permitted under CC BY- NC. No
commercial re- use. See rights
and permissions. Published by
BMJ.
ABSTRACT
Objective Describe the pattern of atopic disease
prevalence from infancy to adulthood.
Design Cross- sectional household survey.
Setting Community- based demographic surveillance site,
Mirzapur, Bangladesh.
Participants 7275 individuals in randomly selected
clusters within 156 villages.
Primary and secondary outcome measures The
12- month prevalence of atopic dermatitis (by UK Working
Party Criteria (UK criteria) and International Study of
Asthma and Allergies in Childhood (ISAAC)), asthma and
rhinitis (by ISAAC); disease severity (by ISAAC); history of
ever receiving a medical diagnosis.
Results Children aged 2 years had the highest prevalence
of atopic dermatitis—18.8% (95% CI 15.2% to 22.4%) by
UK criteria and 14.9% (95% CI 11.6% to 18.1%) by ISAAC—
and asthma (20.1%, 95% CI 16.4% to 23.8%). Prevalence of
rhinitis was highest among 25–29 year olds (6.0%, (95% CI%
4.5 to 7.4%). History of a medical diagnosis was lowest for
atopic dermatitis (4.0%) and highest for rhinitis (27.3%) and
was signicantly associated with severe disease compared
with those without severe disease for all three conditions
(atopic dermatitis: 30.0% vs 11.7%, p=0.015; asthma; 85.0%
vs 60.4%, p<0.001; rhinitis: 34.2% vs 7.3%, p<0.001) and
having a higher asset- based wealth score for asthma (29.7%
(highest quintile) vs 7.5% (lowest quintile), p<0.001) and
rhinitis (39.8% vs 12.5%, p=0.003). Prevalence of having
>1 condition was highest (36.2%) at 2 years and decreased
with age. Having atopic dermatitis (ISAAC) was associated
with signicantly increased odds ratios (OR) for comorbid
asthma (OR 5.56 (95% CI 4.26 to 7.26)] and rhinitis (3.68
(95% CI 2.73 to 4.96)). Asthma and rhinitis were also strongly
associated with each other (OR 8.39 (95% CI 6.48 to 10.86)).
Conclusions Atopic disease burden was high in this
rural Bangladeshi population. Having one atopic condition
was signicantly associated with the presence of another.
Low incidence of ever obtaining a medical diagnosis
highlights an important opportunity to increase availability
of affordable diagnosis and treatment options for all age
groups.
INTRODUCTION
Atopic diseases are a set of conditions
including atopic dermatitis, asthma and
allergic rhinitis that are estimated to affect
approximately20 of the world’s popula-
tion.1Atopic dermatitis is the leading contrib-
utor to the global burden of skin disease,
affecting an estimated 230 million people,
while asthma is estimated to affect nearly
340 million people and is the most common
chronic disease among children.2 3 The
International Study of Asthma and Allergies
(ISAAC) was a global epidemiological effort
to standardise research on the prevalence
of these conditions. Their data revealed
an increasing prevalence of atopic derma-
titis, asthma and rhinitis globally, however,
with great variations within and between
countries.4–6 The most rapid increases in
prevalence were seen among countries with
previously documented low prevalence of
Strengths and limitations of this study
Despite increasing prevalence of atopic disease in
low- income and middle- income countries, there are
limited data describing the pattern of atopic disease
prevalence across the life course; to our knowledge,
this is the rst description of the cross- sectional
period prevalence of atopic conditions from in-
fancy through adulthood reported from the Indian
subcontinent.
We conducted population- based household surveil-
lance in rural Bangladesh using validated instru-
ments for detection of atopic diseases.
We lacked longitudinal data that would allow us
to suggest a driving mechanism for comorbidity
among atopic conditions, such as the atopic march;
a prospective cohort study would more easily enable
conclusions to be drawn about risk factors and the
relationships among the three atopic diseases.
We were able to identify subjects whose atopic
condition was diagnosed by a medical provider,
but lacked data on medical management of atopic
conditions.
2PedersenCJ, etal. BMJ Open 2020;10:e042380. doi:10.1136/bmjopen-2020-042380
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these conditions and were mostly low- income and middle-
income countries (LMICs).5 7
The natural history of atopic conditions classically
begins with atopic dermatitis and progresses in an addi-
tive manner to include asthma and allergic rhinitis—a
pattern known as the ‘atopic march.’8 However, limited
research in LMICs suggests that atopic sensitisation is
not as strongly correlated with the sequential develop-
ment of atopic dermatitis, asthma and rhinitis as it is in
high- income countries (HICs) where the atopic march
was first described.9–11 Additionally, despite associations
between allergic sensitisation and atopic conditions, the
atopic march was not observed among a birth cohort in
Uganda.12 The authors concluded that environmental
exposures in late childhood may dissociate atopic condi-
tions from each other.
The hygiene hypothesis is a widely accepted explana-
tion for both the higher prevalence of atopic diseases in
HICs and the trend of increasing prevalence in LMICs
as they industrialise, arguing that reduced exposure to
microbes early in life increases the risk of developing
immunoregulatory disorders including atopic disease.13
However, research is beginning to show that these condi-
tions are multifactorial and even within risk factors there
can be great variation.14 15 For example, until recently,
helminths have been thought to be universally protective
against the development of atopic conditions but recent
evidence shows that these associations are heterogeneous
and vary drastically even within helminth species.16 17
While much of the global effort to understand atopic
conditions has focused on the paediatric population, it
is essential to understand the prevalence of atopic condi-
tions in children and adults in order to inform policy
and the implementation of interventions that target the
appropriate populations. This is especially true as the
prevalence of these conditions increases in LMICs. Here,
we present the findings of a cross- sectional study of the
period prevalence of atopic conditions from infancy to
adulthood in rural Bangladesh.
METHODS
The methods and reporting of this study followed
Strengthening the Reporting of Observational Studies in
Epidemiology guidelines (https://www. strobe- statement.
org/ fileadmin/ Strobe/ uploads/ checklists/ STROBE_
checklist_ v4_ combined. pdf).
Study population
The study took place within the demographic surveillance
site (DSS) of the Child Health Research Foundation and
the International Centre for Diarrhoeal Disease Research,
Bangladesh in Mirzapur, Bangladesh. Mirzapur is a rural
subdistrict of Bangladesh located approximately 60 km
north of Dhaka, the capital city. Bangladesh is classified
by the World Bank as an LMIC, with a per capita gross
domestic product of Int$4372 in 2018, ranking 137th
among 182 countries. Mirzapur is representative among
Bangladesh subdistricts, falling towards the middle
in terms of educational, health and economic indica-
tors. The economy is mostly dependent on agriculture.
Mirzapur is also broadly representative of the Gangetic
plains region of the Indian subcontinent. There are
three main seasons in Mirzapur: summer (March–June),
monsoon (June–October) and winter (October–March).
The Mirzapur DSS was created in 2007 and has nearly
300 000 individuals enrolled in approximately 70 000
households. The DSS is served by Kumudini Hospital, a
private, non- profit 750- bed referral hospital.
Study design
We conducted a community- based cross- sectional survey
of households enrolled in the Mirzapur DSS from
November 2017 to April 2018. This study was nested
within the weekly household visits that community health
workers (CHW) perform while conducting active surveil-
lance of serious childhood illness within the Mirzapur
DSS. The target sample size of 2149 under-5 children was
calculated assuming a 6.5% prevalence of atopic derma-
titis and a 95% CI of ±1% precision in a population of
27 000. Each of the 156 villages in the DSS was subdi-
vided into 110 clusters and ten clusters among them were
chosen at random to be included in the study, achieving
the desired population- based sample. The CHWs were
bilingual, had an educational attainment of secondary
school or higher, and were well known to the community.
They attended 2 days of classroom instruction on the aims
of the study and on atopic disease identification, ISAAC
protocol, UK Working Party Criteria, and the research
study protocol after which they performed 1 day of field
practice with observation and feedback. One month
after the initial training session, they received a refresher
training. Supervisors, who also attended the training,
monitored the CHWs’ work weekly.
Surveillance for atopic diseases
CHWs visited DSS members in their homes to admin-
ister oral informed consent for enrolment. As this study
was nested within a severe childhood illness surveil-
lance programme, the female head of household typi-
cally responded for herself and for all of the children,
including adolescents. Other adults within the household
responded to questionnaires about their own health.
Questionnaires took between 5 and 20 min per person to
complete; more questions were asked if the participant
screened positive for any one condition. Households
with all adults missing during the first visit were visited a
second time and if missing on the second visit, that house-
hold was excluded from the study.
International Study of Asthma and Allergies in Childhood
The questionnaire was translated from English to Bangla
(by author MJU) and back- translated from Bangla to
English to verify accuracy by Zabed bin Ahmed, Senior
Research Officer at the Child Health Research Founda-
tion. The questionnaire was pilot tested in the community,
3
PedersenCJ, etal. BMJ Open 2020;10:e042380. doi:10.1136/bmjopen-2020-042380
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discussed with CHWs and adjusted following the recom-
mendations of the ISAAC phase 3 Manual.18 Demo-
graphic data were obtained from the Mirzapur DSS data
repository linked to the individual and household identi-
fication numbers of participants in this study.
The 12- month prevalence of atopic dermatitis, asthma
and rhinitis were ascertained using the ISAAC Phase
3 core symptom questionnaires. Atopic dermatitis was
defined as an itchy rash at any time coming and going for
at least 6 months that had at any time affected the folds
of the elbows, behind the knees, in front of the ankles,
under the buttocks or around the neck, ears or eyes in
the past 12 months. Severe atopic dermatitis was defined
as being kept awake one or more nights per week on
average by this itchy rash in the past 12 months. While
previous surveys with ISSAC have not included infants, if
the child was under the age of 6 months we considered
any presence of rash as affirmative and determined a
positive screen by an affirmative response to the question
regarding anatomical location of the rash as described
above. Asthma was defined as the presence of whistling or
wheezing in the previous 12 months. Severe asthma was
defined as any of the following in the previous 12 months:
more than three attacks of wheezing, sleep disturbed by
wheezing on average one or more nights per week, or at
least one episode where wheezing limited speech to only
two words or cries at a time between breaths. Rhinitis was
defined as sneezing, rhinorrhoea or nasal obstruction
in the previous 12 months not associated with the cold
or influenza. Severe rhinitis was defined as having this
nose problem interfere with daily activities ‘a lot’ in the
previous 12 months.
UK criteria
We also administered the UK criteria,19–21 a modification
of the Hanifin and Rajka criteria,22 to screen for atopic
dermatitis since the ISAAC questionnaires have been
primarily used in children over the age of 5 years. The
ISAAC and UK criteria have been administered together
in previous studies among non- Caucasian populations
and have yielded heterogeneous results.23–25 However,
the UK criteria have been validated in infants25 26 and
young children.21 The ‘questions- only’ format was used
as recommended for population- based surveys.27–29 Using
this criteria, atopic dermatitis was defined as having a
history of itchy skin within the past 12 months and at
least two of the following: (1) history of flexural derma-
titis (fronts of elbows, behind the knees, fronts of ankles,
around the neck, on the cheeks or around the eyes), (2)
onset <age of 2 years (not applied if a child was <4 years of
age), (3) personal history of asthma or allergic rhinitis or
maternal/paternal history of either if a child was <4 years
of age and (4) affected by dry skin in general.
Data analysis
Study data were collected and managed using Research
Electronic Data Capture tools hosted at the Stanford
University School of Medicine.30
For each of the four conditions (ISAAC atopic derma-
titis, asthma and rhinitis and UK criteria atopic dermatitis),
we calculated the prevalence using the total number of
individuals in each age group as the denominator for that
age group. In one instance where age was missing, that
individual was deleted from analysis. The corresponding
95% CIs were calculated separately for each age group.
In order to have a sufficient sample size for comparison
of atopic conditions between groups while still main-
taining age groups at various developmental stages, we
ran χ2 tests on the following age groups: under 5 years,
6–14 years, 15–24 years and 25 years. We used bivariate
logistic regression analysis to calculate ORs. Asset- based
wealth index quintiles were calculated based on source
of drinking water, toilet facility, household building mate-
rials, livestock, land use and number of rooms in the
home.31 Wealth indices were calculated using the entire
Mirzapur DSS, of which our sample is a subset as previ-
ously described. We used SAS Studio 3.8 (SAS Institute)
to perform all data analysis.
Patient and public involvement
Patients or the public were not involved in the design,
conduct, reporting, or dissemination plans of our
research.
Verbal informed consent was obtained from heads of
households after informing them of the study’s proce-
dures and the purpose of the study.
RESULTS
During the study period, 2068 households were
approached for enrolment; no households that were
approached refused participation. We surveyed 7275 indi-
viduals with a mean age of 18.8 years (SD 14.4 years) of
whom 2242 (30.8%) were under 5 years of age (table 1).
The sample included 3425 (47.1%) men and 3850
(52.9%) women. The majority of households (86.6%)
were Muslim. Approximately half of adult women (50.7%)
and men (48.9%, not shown) had not completed primary
school. The highest wealth index quintile comprised
32.9% of the sample and the lowest comprised 5.6%.
Atopic dermatitis
The UK criteria identified 550 participants as having
atopic dermatitis for an overall 12- month prevalence of
7.6% (95% CI 7.0% to 8.1%). Atopic dermatitis preva-
lence showed a bimodal pattern increasing from 9.3%
in children <1 year (95% CI 6.7% to 12.0%) and peaking
at 18.8% (95% CI 15.2% to 22.4%) at 2 years (figure 1).
Prevalence then decreased to 3.8% (95% CI 2.1% to
5.4%) in children 6–9 years old and increased again
during adolescence to 6.4% (95% CI 3.9% to 9.0%) in
the 15–19 years age group. In adulthood, the prevalence
decreased to a low of 2.8% (95% CI 1.4% to 4.3%) in
the 40 years age group. Females 25 years had a higher
prevalence of atopic dermatitis than males (5.9% vs 3.0%,
4PedersenCJ, etal. BMJ Open 2020;10:e042380. doi:10.1136/bmjopen-2020-042380
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p=0.001); there was no difference in childhood preva-
lence between the sexes.
ISAAC identified 498 participants with atopic derma-
titis for an overall 12- month prevalence of 8.1% (95% CI
4.6% to 11.6%) ranging from a high of 14.9% (95% CI
11.6% to 18.1%) at 2 years to lows of 3.2% (95% CI 1.8%
to 4.7%) and 3.4% (95% CI 1.8% to 5.0%) in the 35–39
years and 40 year age groups, respectively (figure 1).
Similar to the UK criteria, the ISAAC results displayed a
bimodal trend with peak prevalence in early childhood
and in adolescence (9.0% (95% CI 6.0% to 11.9%) in the
15–19 years age group). Prevalence of atopic dermatitis
was also higher in females than males in adulthood (5.3%
vs 3.1%, p=0.003) by this measure. Severe disease was
found among 12.4% of those affected overall. Males also
had more severe disease in early adulthood than females
(33.3% vs 4.4%, p=0.015). There were no differences in
severity among the other age groups.
Asthma
Five hundred and eight participants met the ISAAC
criteria for asthma for an overall 12- month prevalence
of 7.0% (95% CI 6.4% to 7.6%). The highest prevalence
was 20.1% (95% CI 16.4% to 23.8%) in children 2 years
old (figure 2). The prevalence then down- trended and
reached its nadir at 2.2% in the 15–19 (95% CI 0.7%
to 3.8%) and 20–24 (95% CI 1.1% to 3.3%) years age
groups before increasing again slightly to 3.9% (95%
CI 2.7% to 5.1%) and 4.1% (95% CI 2.5% to 5.7%) in
the 25–29 years and 35–39 age groups, respectively.
The prevalence of asthma was higher in males under 5
years of age compared with females (16.2% vs 13.3%,
Figure 2 The 12- month prevalence of asthma and
proportion of severe cases by age group of subjects in
Mirzapur, Bangladesh.
Table 1 Demographic characteristics of the study sample
(N=7275)
% (n)*
Age in years, mean (SD) 18.8 (14.4)
<1 year 6.2 (450)
1 year 6.5 (473)
2 years 6.3 (458)
3 years 6.1 (446)
4 years 5.7 (415)
5 years 1.5 (106)
6–9 years 6.9 (504)
10–14 years 6.0 (435)
15–19 years 4.9 (357)
20–24 years 9.5 (690)
25–29 years 13.6 (992)
30–34 years 11.9 (866)
35–39 years 8.1 (586)
≥40 years 6.8 (497)
Sex
Male 47.1 (3424)
Female 52.9 (3851)
Religion
Muslim 86.6 (6291)
Hindu 13.3 (963)
Highest female education (N=2053)
No primary 9.9 (205)
Less than primary 40.5 (837)
Primary 25.7 (530)
Some secondary 10.4 (210)
Secondary or higher 13.2 (271)
Wealth quintile
Poor 5.6 (111)
Lower middle 14.6 (288)
Middle 22.0 (432)
Upper middle 24.9 (490)
Wealthy 32.9 (647)
*Percentages may not sum to 100% due to rounding
Figure 1 The 12- month prevalence of atopic dermatitis
and proportion of severe cases by age group of subjects in
Mirzapur, Bangladesh. ISAAC, International Study of Asthma
and Allergies in Childhood.
5
PedersenCJ, etal. BMJ Open 2020;10:e042380. doi:10.1136/bmjopen-2020-042380
Open access
p=0.049). Overall, 65.6% of those identified with asthma
met criteria for severe disease. Those >5 years were more
likely to have severe disease than those 5 years (73.2% vs
61.2%, p=0.010). There was no difference in prevalence
of severe asthma between the sexes (66.7% male vs 64.4%
female, p=0.620).
Rhinitis
For rhinitis, 303 participants met ISAAC criteria for an
overall 12- month prevalence of 4.2% (95% CI 3.7% to
4.6%). Prevalence was highest among participants from
the highest wealth quintile (5.1%, p=0.003). Among
under-5 children, the prevalence was highest in the 2- year
age group (4.8%, 95% CI 2.9% to 6.8%) and 4- year age
groups (4.8%, 95% CI 2.8% to 6.9%) (figure 3). Starting
from a low of 0.9% (95% CI 0.0% to 2.8%) at 5 years, prev-
alence increased until the 25–29 years age group where it
peaked at 6.0% (95% CI 4.5% to 7.4%) and decreased
again to 3.0% (95% CI 1.5% to 4.5%) in the 40 years age
group. Males had a higher prevalence in early childhood
(4.3% vs 2.7%, p=0.017) and lower prevalence in adult-
hood (3.7% vs 6.5%, p<0.001) compared with females in
the same age groups. Overall, 14.5% of those identified
with rhinitis had severe disease and those >5 years had a
higher proportion of severe rhinitis than those 5 years
(17.3% vs 7.2%, p=0.027).
Physician diagnosis
The proportion of participants who had received a
doctor’s diagnosis was 25/549 (4.6%) for the UK criteria,
20/495 (4.0%) for ISAAC atopic dermatitis, 95/507
(18.7%) for asthma and 82/300 (27.3%) for rhinitis.
Those with severe disease were significantly more likely
to have received a doctor’s diagnosis compared with
those without severe disease for atopic dermatitis (30.0%
vs 11.7%, p=0.015), asthma (85.0% vs 60.4%, p<0.001)
and rhinitis (34.2% vs 7.3%, p<0.001). For asthma, the
proportion of participants who had received a physician’s
diagnosis increased from 7.5% for the lowest wealth quin-
tile to 29.7% (p<0.001) for the highest quintile. A similar
trend was found with rhinitis ranging from 12.5% in the
lowest wealth quintile to 39.8% (p=0.003) in the highest
quintile. No association was found between atopic derma-
titis diagnosis and wealth quintile.
Concurrent atopic disease
The prevalence of having any one atopic condition
peaked early in life, affecting over one- third (36.2%)
of children 2 years of age (figure 4). The prevalence of
having two atopic conditions also peaked at 2 years of
age (10%), was lowest (1.4%) in children 6–9 years old
and rose again slightly in adulthood to between 3.3% and
3.4% in the 25–29 and 35–39 age groups, respectively.
The percentage of those with all three conditions ranged
from 0.0% to 1.2%. Participants with atopic dermatitis
as defined by the UK criteria had a higher prevalence
of asthma (24.2% vs 5.6%, p<0.001; OR 5.41 (95% 4.34–
6.75)) and rhinitis (15.6% vs 3.2%, p<0.001; OR 4.49
(95% CI 3.55 to 5.68)) compared with those without
atopic dermatitis. The same pattern was found for those
with atopic dermatitis as defined by the ISAAC criteria
for asthma (21.9% vs 5.9%, p<0.001; OR 5.56 (95% CI
4.26 to 7.26)) and rhinitis (12.1% vs 3.6%, p<0.001; OR
3.68 (95% CI 2.73 to 4.96)). Similarly, those with asthma
had a higher prevalence of rhinitis compared with those
without asthma (20.3% vs 2.9%, p<0.001; OR 8.39 (95%
CI 6.48 to 10.86)).
DISCUSSION
To our knowledge, this is the first description of the
period prevalence of atopic conditions over the life
course from infancy through adulthood reported from
the Indian subcontinent. Atopic dermatitis and asthma
followed a similar pattern, peaking in the second year
of life and decreasing in prevalence with age, although
with an upturn in prevalence of atopic dermatitis during
adolescence. Longitudinal studies from HICs similarly
have documented that children aged 2 years and under
3 years have the highest prevalences of atopic dermatitis
and wheezing, respectively.32–34 In contrast, rhinitis was
Figure 3 The 12- month prevalence of rhinitis and
proportion of severe cases by age group of subjects in
Mirzapur, Bangladesh.
Figure 4 Proportions of comorbid atopic conditions by age
group of subjects in Mirzapur, Bangladesh.
6PedersenCJ, etal. BMJ Open 2020;10:e042380. doi:10.1136/bmjopen-2020-042380
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relatively stable until increasing from adolescence to
adulthood. Global estimates of rhinitis are heterogeneous
and difficult to compare.35
As found in multiple previous studies,12 36–38 having
atopic dermatitis was associated with increased odds of
concurrently having asthma or rhinitis, and asthma was
associated with rhinitis. Thus, comorbid development
of these atopic diseases clearly occurs in this popula-
tion. However, the proportion of those affected with any
one condition decreased with age and those with two or
more conditions did not substantially increase. Research
among a Ugandan birth cohort found that atopic sensi-
tisation increased to the level of HICs with age, but the
prevalence of atopic disease did not increase as expected
based on data from HICs leading the authors to conclude
that the atopic march did not occur in this population.12
While our data support the comorbid nature of these
conditions, we lack the longitudinal data that would allow
us to suggest a driving mechanism, such as the atopic
march.
The most recent estimate of atopic dermatitis in Bangla-
desh was reported in 2005 among 6–7 and 13–14 years
age groups to be 6.0% and 7.1%, respectively, and 6.5%
overall.39 This falls within both the UK criteria and ISAAC
measures for our 10–14 years age group but is higher than
our estimates for the 6–9 years age group. The overall
estimate is also within our sample’s estimated prevalence
when the two groups are combined. More recently asthma
prevalence has been reported as high as 20.2% and 6.8%
in 4.5 and 10 years old, respectively.40 These are higher
than the estimates reported here; however, an asthma
prevalence of 8.7% in 5 years from the same surveillance
site was also reported, similar to the prevalence we report
here.41 These differences in prevalence could be due to
environmental variation between the research sites within
the country. Wide variations were seen between Indian
centres from the ISAAC Phase 3 study which reported
prevalence ranging from 4.6% to 45.7% for rhinitis and
0.9% to 9.2% for eczema among 13–14 years.42 While
we followed the ISAAC Phase 3 Manual instructions for
translation closely, there is also the possibility that differ-
ences in translation resulted in different understandings
of the questions for our study sample compared with
other samples within the country or region.
The prevalence provided by the UK criteria was higher
than the ISAAC prevalence for 1–5 years. The ISAAC
questionnaires are typically deployed in populations 6–7
and 13–14 years old but they have been used in children
as young as 2 years in modified versions.12 Here, we used a
modified ISAAC questionnaire for atopic dermatitis and
it showed good agreement with the UK criteria in chil-
dren <1 year. The deviation in the 1–4 years age groups,
with higher prevalence measured by the UK criteria than
ISAAC, was likely due to the use of the ‘questions only’
format of the UK criteria, which uses one major criterion
plus two or more minor criteria and eliminates the photo-
graphical protocol. This format showed increased sensi-
tivity and decreased specificity in a paediatric population
under 11 years of age.28 The original authors of the UK
critieria also suggested that in communities with lower
prevalence of atopic dermatitis, this modified version may
exhibit a reduced specificity due to increased prevalence
of pruritus of other aetiologies.28
Of concern, there was a paucity of official medical diag-
noses among participants who were positive by the study’s
various criteria. There are several potential reasons for
this, including limited care- seeking, and limitations in
reaching a medical diagnosis. Rhinitis was most likely to
be diagnosed, possibly due to it being a condition expe-
rienced later in life and frequently for more years than
asthma and atopic dermatitis. Asthma was more commonly
medically diagnosed than atopic dermatitis, likely due in
part to a higher proportion of severe disease. Rasul et al
found that within Bangladesh, higher educational attain-
ment and socioeconomic status, shorter distance from
the household to the health centre, and fewer household
members with a chronic disease were associated with
seeking care for a chronic non- communicable disease,
such as asthma, from a qualified provider.43 They also
found a high burden of out- of- pocket medical expendi-
tures, mostly related to pharmaceutical treatments. This
supports our findings that those from the highest wealth
quintiles were more likely to have received a diagnosis
of their condition. We also speculate that there may be
limitations in the capabilities of medical practitioner to
identify atopic diseases and distinguish them from other
common conditions, for example, differentiating scabies
from atopic dermatitis. Taken together, it is clear that
there is an important opportunity to increase affordable
medical interventions, both in identification and diag-
nosis of cases as well as in prevention and treatment.
Limitations
Cross- sectional studies have well- known limitations
inherent to their design. Recording the disease preva-
lence across age groups is not as informative as recording
the natural history of a disease especially in such a rapidly
LMIC such as Bangladesh where the living conditions
and health systems experienced by age groups through
their respective lifetimes are substantially different. While
cross- sectional data do provide insight into the burden
of disease of various age groups, a prospective cohort
study would more easily allow us to draw conclusions
about risk factors and the relationships among the three
atopic diseases. There is a lack, however, of longitudinal
data from LMICs on prevalence of atopic diseases. Addi-
tionally, while households were chosen at random from
a subset of zones within the DSS, there was an imbalance
of wealth quintiles among all participants, suggesting
that there was some imbalance in the study subset. We
are missing asset data from 50 households—33 migrated
out of the DSS area and 17 were not home during the
DSS assessment. Poorer households may have been more
likely to migrate out of the area for work or more likely
to have all adults engaged in the workforce such that they
would not be available during DSS activities.
7
PedersenCJ, etal. BMJ Open 2020;10:e042380. doi:10.1136/bmjopen-2020-042380
Open access
CONCLUSION
Research is beginning to suggest differences in the pattern
and etiologies of atopic diseases between HICs and LMICs.
As LMICs experience increasing prevalence of these
conditions, research should continue to re- evaluate the
associations among atopic diseases previously established
by data from HICs in both paediatric and adult popula-
tions. Additionally, given the high disease burden in early
childhood and substantial proportion that persists into
adulthood, there is great opportunity to increase educa-
tional outreach to both healthcare providers and patients
and their families about the medical importance of these
conditions and options for management. Lastly, it is
imperative that policies are formulated to allow increased
access to affordable medical interventions for diagnosis,
treatment and prevention for all age groups.
Twitter Gary L Darmstadt @gdarmsta
Contributors CP and GLD conceptualised and designed the study, interpreted
the data, drafted the initial manuscript and reviewed and revised the manuscript.
CP also designed the data collection instruments, participated in oversight of data
collection and conducted the analysis of the data. MJU and SKS participated in
designing the study and the data collection instruments, supervised data collection
and reviewed and revised the manuscript. All authors approved the nal manuscript
as submitted and agreed to be accountable for all aspects of the work.
Funding CP received a Medical Scholars award from the Stanford University
School of Medicine, and a Benjamin H Kean Travel Fellowship from the American
Society of Tropical Medicine and Hygiene. REDCap platform services are made
possible by the Stanford University School of Medicine Research Ofce. The
REDCap platform services at Stanford are subsidised by the National Center for
Research Resources and the National Center for Advancing Translational Sciences,
National Institutes of Health (NIH).
Disclaimer The data content is solely the responsibility of the authors and does
not necessarily represent the ofcial views of the NIH.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in
the design, or conduct, or reporting, or dissemination plans of this research.
Patient consent for publication Not required.
Ethics approval Ethical approval was obtained from the Institutional Review
Boards at both the Stanford University School of Medicine (protocol #41405) and
the Bangladesh Institute of Child Health in Dhaka.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data are available on reasonable request to the
senior author through a data sharing agreement.
Open access This is an open access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY- NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non- commercially,
and license their derivative works on different terms, provided the original work is
properly cited, appropriate credit is given, any changes made indicated, and the use
is non- commercial. See:http:// creativecommons. org/ licenses/ by- nc/ 4. 0/.
ORCID iD
Gary LDarmstadt http:// orcid. org/ 0000- 0002- 7522- 5824
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... (13,14) In the 1993 Pelotas (Brazil) Birth Cohort Study, participants with persistent symptoms of asthma, such as wheezing, had significantly higher odds of being diagnosed with an allergy (OR 6.18; 95% CI: 3.59 -10.61) compared to those with never/infrequent wheezing. (15) However, despite the increasing prevalence of these conditions among adolescents and young adults in lower-and upper-middle-income countries, (1,16,17) few populationbased studies have described the co-occurrence of all three conditions. Pedersen et al. (2020) reported that the prevalence of having two atopic conditions peaked at 10.0% at 2 years of age and was approximately 3.4% among adults in a rural area of India. ...
... (15) However, despite the increasing prevalence of these conditions among adolescents and young adults in lower-and upper-middle-income countries, (1,16,17) few populationbased studies have described the co-occurrence of all three conditions. Pedersen et al. (2020) reported that the prevalence of having two atopic conditions peaked at 10.0% at 2 years of age and was approximately 3.4% among adults in a rural area of India. (16) In Brazil, the prevalence of these health conditions has also mostly been studied separately, (18)(19)(20) especially among adolescents and young adults. ...
... Pedersen et al. (2020) reported that the prevalence of having two atopic conditions peaked at 10.0% at 2 years of age and was approximately 3.4% among adults in a rural area of India. (16) In Brazil, the prevalence of these health conditions has also mostly been studied separately, (18)(19)(20) especially among adolescents and young adults. (15,21,22) The co-occurrence of asthma, AD, and AR reduces quality of life, rest, and academic performance among adolescents. ...
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Objectives To estimate the prevalence of allergic rhinitis (AR), atopic dermatitis (AD), and wheezing, and to describe their patterns of co-occurrence according to different characteristics in adolescence and early adulthood. Methods Cross-sectional analyses from the 15-year and 22-year follow-ups of the 1993 Pelotas (Brazil) Birth Cohort. The outcomes were assessed based on self-reported data, and the patterns of co-occurrence were determined using cluster analysis. The sample was described using absolute and relative frequencies according to the independent variables. Venn diagrams were generated to visualize the co-occurrence of AR, AD, and wheezing. Results Data on AR, AD, and wheezing were available for 4,286 participants at 15 years and 3,789 at 22 years. At 15 years, AR was reported by 20.9% of participants, AD by 25.2%, and wheezing by 33.4%. Meanwhile, at 22 years, AR was reported by 24.6%, AD by 14.2%, and wheezing by 30.7%. Notably, the overlap between AR and wheezing was greater than that of the other conditions (6.9% at 15 years and 8.3% at 22 years). Participants with lower maternal education and lower income were more likely to report having “no health condition”. At 15 years, White individuals most frequently reported “three conditions” (4.1%; p<0.001), whereas at 22 years, they primarily reported “two conditions” (15.6%; p<0.001). The co-occurrence of all three health conditions was found to be greater than expected, with an observed rate 2.1 times higher (95% CI 1.4 - 3.0) at 22 years. Conclusions This study highlights the social gradient in the diagnosis and reporting of co-occurrence of AR, AD, and wheezing.
... Saat ini, peningkatan prevalensi mulai berkembang pesat terlihat pada sebagian besar negara yang sebelumnya memiliki prevalensi DA yang rendah dan termasuk negara sedang berkembang. (Pedersen et al., 2020) Di Indonesia, angka prevalensi kasus DA yaitu sebesar 3,7% pada usia 6-7 tahun dan 3,1% pada usia 13-14 tahun (Tsai et al., 2019). (Hidajat et al., 2015) METODE Metode penelitian yang digunakan adalah deskriptif retrospektif yaitu dengan cara mengambil data sekunder dari rekam medis pada pasien terdiagnosis DA selama 5 tahun yaitu dari Januari 2017 -Desember 2021 yang datang berobat ke Poliklinik Rawat Jalan Kulit dan Kelamin RSUDP NTB. ...
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... Esto se debería a que la DA no tuvo un desencadenamiento por aspectos genéticos, sino ambientales, debido a que los pacientes de la muestra acudieron en la temporada de verano, cuando es más común encontrar este tipo de enfermedad, aunque también existe la probabilidad de que se hayan exacerbado síntomas previos. A su vez, se observaron características de atopia, como asma y rinitis, en porcentajes no mayores al 20 %, similar a lo encontrado por los estudios de Pedersen et al. 25 y Lule et al. 26 Dentro de las limitaciones de este estudio retrospectivo, no se recolectaron los datos completos de todos los pacientes atendidos en el Servicio de Dermatología, lo que no permitiría la representatividad de la muestra. Además, los resultados de este estudio no necesariamente son extrapolables. ...
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Background: Allergic transfusion reactions (ATRs) are common adverse events during blood transfusions, ranging from mild urticaria to severe anaphylactic shock. Elevated serum immunoglobulin E (IgE) levels are known to mediate these reactions. This study aimed to assess the relationship between serum IgE levels and the Presence of ATRs in patients receiving fresh frozen plasma (FFP) transfusions. Methods: A cross-sectional observational study was conducted at the Department of Transfusion Medicine, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh, from March 2019 to August 2021. The study included 55 patients aged 5-60 years who received FFP transfusions. Demographic data, clinical symptoms, and IgE levels were recorded. Data were analyzed using SPSS version 26, with statistical significance set at p<0.05. Result: The majority of participants were males (94.55%) and aged 11-20 years (45.45%). Most patients (85.45%) received multiple units of FFP. Clinical symptoms included itching (56.36%), urticarial rash (29.09%), vomiting (7.27%), and hypotension (7.27%). Raised IgE levels were found in 52.73% of participants, and a significant association was observed between elevated IgE levels and the presence of allergic reactions (p<0.01). Patients with allergic reactions had significantly higher mean IgE levels (521.4±434.6 IU/mL) compared to those without allergic reactions (67.8±33.2 IU/mL). Conclusion: Elevated serum IgE levels are significantly associated with the Presence of ATRs in patients receiving FFP transfusions. Monitoring IgE levels can help predict and manage allergic reactions, thereby improving transfusion safety and patient outcomes.
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Objective Allergen immunotherapy (AIT) is the therapeutic exposure to an allergen or allergens selected by clinical assessment and allergy testing to decrease allergic symptoms and induce immunologic tolerance. Inhalant AIT is administered to millions of patients for allergic rhinitis (AR) and allergic asthma (AA) and is most commonly delivered as subcutaneous immunotherapy (SCIT) or sublingual immunotherapy (SLIT). Despite its widespread use, there is variability in the initiation and delivery of safe and effective immunotherapy, and there are opportunities for evidence‐based recommendations for improved patient care. Purpose The purpose of this clinical practice guideline (CPG) is to identify quality improvement opportunities and provide clinicians trustworthy, evidence‐based recommendations regarding the management of inhaled allergies with immunotherapy. Specific goals of the guideline are to optimize patient care, promote safe and effective therapy, reduce unjustified variations in care, and reduce the risk of harm. The target patients for the guideline are any individuals aged 5 years and older with AR, with or without AA, who are either candidates for immunotherapy or treated with immunotherapy for their inhalant allergies. The target audience is all clinicians involved in the administration of immunotherapy. This guideline is intended to focus on evidence‐based quality improvement opportunities judged most important by the guideline development group (GDG). It is not intended to be a comprehensive, general guide regarding the management of inhaled allergies with immunotherapy. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experience and assessment of individual patients. Action Statements The GDG made a strong recommendation that (Key Action Statement [KAS] 10) the clinician performing allergy skin testing or administering AIT must be able to diagnose and manage anaphylaxis. The GDG made recommendations for the following KASs: (KAS 1) Clinicians should offer or refer to a clinician who can offer immunotherapy for patients with AR with or without AA if their patients' symptoms are inadequately controlled with medical therapy, allergen avoidance, or both, or have a preference for immunomodulation. (KAS 2A) Clinicians should not initiate AIT for patients who are pregnant, have uncontrolled asthma, or are unable to tolerate injectable epinephrine. (KAS 3) Clinicians should evaluate the patient or refer the patient to a clinician who can evaluate for signs and symptoms of asthma before initiating AIT and for signs and symptoms of uncontrolled asthma before administering subsequent AIT. (KAS 4) Clinicians should educate patients who are immunotherapy candidates regarding the differences between SCIT and SLIT (aqueous and tablet) including risks, benefits, convenience, and costs. (KAS 5) Clinicians should educate patients about the potential benefits of AIT in (1) preventing new allergen sensitizations, (2) reducing the risk of developing AA, and (3) altering the natural history of the disease with continued benefit after discontinuation of therapy. (KAS 6) Clinicians who administer SLIT to patients with seasonal AR should offer pre‐ and co‐seasonal immunotherapy. (KAS 7) Clinicians prescribing AIT should limit treatment to only those clinically relevant allergens that correlate with the patient's history and are confirmed by testing. (KAS 9) Clinicians administering AIT should continue escalation or maintenance dosing when patients have local reactions (LRs) to AIT. (KAS 11) Clinicians should avoid repeat allergy testing as an assessment of the efficacy of ongoing AIT unless there is a change in environmental exposures or a loss of control of symptoms. (KAS 12) For patients who are experiencing symptomatic control from AIT, clinicians should treat for a minimum duration of 3 years, with ongoing treatment duration based on patient response to treatment. The GDG offered the following KASs as options : (KAS 2B) Clinicians may choose not to initiate AIT for patients who use concomitant beta‐blockers, have a history of anaphylaxis, have systemic immunosuppression, or have eosinophilic esophagitis (SLIT only). (KAS 8) Clinicians may treat polysensitized patients with a limited number of allergens.
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Background: In spite of high prevalence rates, little is known about health seeking and related expenditure for chronic non-communicable diseases in low-income countries. We assessed relevant patterns of health seeking and related out-of-pocket expenditure in Bangladesh. Methods: We used data from a household survey of 2500 households conducted in 2013 in Rangpur district. We employed multinomial logistic regression to assess factors associated with health seeking choices (no care or self-care, semi-qualified professional care, and qualified professional care). We used descriptive statistics (5% trimmed mean and range, median) to assess related patterns of out-of-pocket expenditure (including only direct costs). Results: Eight hundred sixty-six (12.5%) out of 6958 individuals reported at least one chronic non-communicable disease. Of these 866 individuals, 139 (16%) sought no care or self-care, 364 (42%) sought semi-qualified care, and 363 (42%) sought qualified care. Multivariate analysis confirmed that the following factors increased the likelihood of seeking qualified care: a higher education, a major chronic non-communicable disease, a higher socio-economic status, a lower proportion of chronic household patients, and a shorter distance between a household and a sub-district public referral health facility. Seven hundred fifty-four (87 %) individuals reported out-of-pocket expenditure, with drugs absorbing the largest portion (85%) of total expenditure. On average, qualified care seekers encountered the highest out-of-pocket expenditure, followed by those who sought semi-qualified care and no care, or self-care. Conclusion: Our study reveals insufficiencies in health provision for chronic conditions, with more than half of all affected people still not seeking qualified care, and the majority still encountering considerable out-of-pocket expenditure. This calls for urgent measures to secure better access to care and financial protection.
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Numerous studies have investigated the risk of developing asthma due to early-life experiences and environmental exposures. However, the influence of intrauterine growth restriction and postnatal undernutrition on childhood wheezing/asthma remains unclear. Thus, we examined the effects of both small for gestational age (SGA) and postnatal stunted growth on ever asthma among children in the rural areas in Bangladesh. Multiple follow-up studies were conducted in a cohort of randomized clinical trial of nutrition interventions during pregnancy (the MINIMat trial). Overall, 1208 and 1697 children were followed-up for asthma at 4.5 and 10 years, respectively. Anthropometric measurements were obtained at various intervals from birth to 10 years of age. Ever asthma was identified using the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire. Results showed that SGA was significantly associated with increased risk of ever asthma at 4.5 and 10 years after adjusting for sex, body mass index, socioeconomic status, family history of asthma, gestational age at birth, mother’s parity, mother’s age at birth and intervention trial arm [odds ratio (OR)=1.97 (95% confidence interval (CI): 1.34–2.90) and 1.86 (95% CI: 1.18–2.72)]. For the postnatal effect of undernutrition, stunting at 1 and 2 years was significantly associated with ever asthma at 4.5 and 10 years [1 year: OR=1.77 (95% CI: 1.22–2.57) and OR=1.72 (95% CI: 1.16–2.56), 2 years: OR=1.49 (95% CI: 1.06–2.10) and OR=1.41 (95% CI: 1.02–1.96)]. In conclusion, SGA and undernutrition during infancy has an influence on childhood asthma among children in Bangladesh, indicating the need for nutritional interventions early in life.
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Background Universal health coverage (UHC) is a key area in post-2015 global agenda which has been incorporated as target for achieving health-related Sustainable Development Goals (SDGs). A global framework has been developed to monitor SDG indicators disaggregated by socioeconomic and demographic markers. This review identifies the indices used to measure socio-economic status (SES) in South Asian urban health studies. Methods Two reviewers searched six databases including Cochran Library, Medline, LILACS, Web of Science, Science Direct, and Lancet journals independently. All South Asian health studies covering urban population, with any research-designs, written in English language, and published between January 2000 and June 2016 were included. Two reviewers independently screened and assessed for selection of eligible articles for inclusion. Any conflict between the reviewers was resolved by a third reviewer. Results We retrieved 3529 studies through initial search. Through screening and applying inclusion and exclusion criteria, this review finally included 256 articles for full-text review. A total of 25 different SES indices were identified. SES indices were further categorized into 5 major groups, e.g., (1) asset-based wealth index, (2) wealth index combining education, (3) indices based on income and expenditure, (4) indices based on education and occupation, and (5) “indices without description.” The largest proportion of studies, irrespective of country of origin, thematic area, and study design, used asset-based wealth index (n = 142, 54%) as inequality markers followed by the index based on income and expenditure (n = 80, 30%). Sri Lankan studies used income- and expenditure-based indices more than asset-based wealth index. Majority of the reviewed studies were on “maternal, neonatal, and child health” (n = 98, 38%) or on “non-communicable diseases” (n = 84, 33%). Reviewed studies were mostly from India (n = 145, 57%), Bangladesh (n = 42, 16%), and Pakistan (n = 27, 11%). Among the reviewed articles, 55% (n = 140) used primary data while the rest 45% studies used secondary data. Conclusion This scoping review identifies asset-based wealth index as the most frequently used indices for measuring socioeconomic status in South Asian urban health studies. This review also provides a clear idea about the use of other indices for the measurement SES in the region. Electronic supplementary material The online version of this article (10.1186/s13643-018-0867-6) contains supplementary material, which is available to authorized users.
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Background: In high-income countries, allergy related-diseases (ARDs) follow a typical sequence, the "Atopic March". Little is known about the life-course of ARDs in the markedly different, low-income, tropical environment. We describe ARDs in a tropical, African birth cohort. Methods: Ugandan children were followed from birth to nine years. ISAAC questionnaires were completed at intervals; doctor-diagnosed ARDs were recorded throughout follow-up. Skin prick tests (SPTs) were done at three and nine years. Atopy was defined as ≥1 positive SPT. Results: Of 2345 live-born children, 1214 (52%) were seen at nine years. Wheeze and eczema were common in infancy but by nine years only 4% reported recent wheeze, 5% eczema and 5% rhinitis. Between three and nine years, atopy prevalence increased from 19% to 25%. Atopy at three or nine years was associated with reported ARD events at nine years, for example OR=5.2 (95% CI 2.9-10.7) for atopy and recent wheeze at nine years. Reported or doctor-diagnosed ARD events in early childhood were associated with the same events in later childhood, for example OR=4.4 (2.3-8.4) for the association between reported wheeze before three years with reported recent wheeze at nine years, but progression from early eczema to later rhinitis or asthma was not observed. Conclusion: Allergen sensitisation started early in childhood and increased with age. Eczema and wheeze were common in infancy and declined with age. Atopy was strongly associated with ARD among the few affected children. The typical Atopic March did not occur. Environmental exposures during childhood may dissociate atopy and ARD. This article is protected by copyright. All rights reserved.
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We read with great interest the paper by Ahumada et al. [1] on the association between asthma symptoms and IgE responses to Ascaris and mites in a population living in the tropics. They report for the first time in a nation-wide case control study performed in Columbia that IgE sensitization to housedust mite or Ascaris tropomyosin has clinical relevance. They also report that specific IgE to tropomyosins from Ascaris and mites strongly correlate, and speculate that co-exposure to both mite and Ascaris generates conditions to increase the allergic symptoms. This article is protected by copyright. All rights reserved.
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Asthma and allergic diseases have become more prevalent, although the reasons for this increase in disease burden are not known. Understanding why these diseases have become more common requires knowledge of the disease pathogenesis. Multiple studies have identified respiratory viral infections and atypical bacteria as potential etiologic agents underlying the development of asthma (and possibly allergies). This review discusses the epidemiology and potential mechanistic studies that provide links between these infectious agents and the development (and exacerbation)of asthma. These studies provide insight into the increase in disease prevalence and have identified potential targets for future therapeutic intervention.
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Objective: We aim to describe the data collected from India during phase 3 of the International study of asthma and allergy in childhood (ISAAC) study. Prevalence, severity and population characteristics associated with rhinitis, rhinoconjunctivitis and eczema were assessed. Methods: Children from two age groups (6-7 and 13-14 yr) were included in the study as per the ISAAC protocol. The symptoms of allergy and associated features were assessed using a questionnaire. Results: The prevalence of allergic rhinitis among the 6-7 yr age group was 11.3%, while it was 24.4% in the 13-14 yr age group. The prevalence of allergic rhinoconjunctivitis was 3.9% in the 6-7yr age group and 10.9% in the 13-14 yr age group. The prevalence of eczema was 2.8% in the 6-7yrage group and 3.7% in the 13-14yrage group. The passage of trucks near home, parental smoking, use of paracetamol, use of antibiotics, cooking with firewood and television watching were associated with allergic rhinitis, rhinoconjunctivitis and eczema. Maternal smoking was the strongest of all the associated features for allergic rhinitis, rhinoconjunctivitis and eczema, especially in the 6-7 yr age group (odds ratio: 1.9, 95% CI: 1.5-2.4;odds ratio: 2.9, 95% CI, 2.2-3.9; and odds ratio: 3.5,95% CI: 2.6-4.8, respectively). Conclusion: Allergic conditions like allergic rhinitis, rhinoconjunctivitis and eczema are prevalent among Indian children and are associated with environmental tobacco smoke, paracetamol use, antibiotic use, television watching, and outdoor and indoor air pollution. This article is protected by copyright. All rights reserved.
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Asthma is one of the most common diseases in the world, resulting in a substantial burden of disease. Although rates of deaths due to asthma worldwide have reduced greatly over the past 25 years, no available therapeutic regimens can cure asthma, and the burden of asthma will continue to be driven by increasing prevalence. The reasons for the increase in asthma prevalence have not been defined, which limits the opportunities to develop targeted primary prevention measures. Although associations are reported between a wide range of risk factors and childhood asthma, substantiation of causality is inherently difficult from observational studies, and few risk factors have been assessed in primary prevention studies. Furthermore, none of the primary prevention intervention strategies that have undergone scrutiny in randomised controlled trials has provided sufficient evidence to lead to widespread implementation in clinical practice. A better understanding of the factors that cause asthma is urgently needed, and this knowledge could be used to develop public health and pharmacological primary prevention measures that are effective in reducing the prevalence of asthma worldwide. To achieve this it will be necessary to think outside the box, not only in terms of risk factors for the causation of asthma, but also the types of novel primary prevention strategies that are developed, and the research methods used to provide the evidence base for their implementation. In the interim, public health efforts should remain focused on measures with the potential to improve lung and general health, such as: reducing tobacco smoking and environmental tobacco smoke exposure; reducing indoor and outdoor air pollution and occupational exposures; reducing childhood obesity and encouraging a diet high in vegetables and fruit; improving feto-maternal health; encouraging breastfeeding; promoting childhood vaccinations; and reducing social inequalities.