Prevalence of asthma and wheeze in primary school children in northern Jordan

Prevalence of asthma among children and adolescents in WHO's Eastern Mediterranean Region: a meta-analysis of over 0.5 million participants

OBJECTIVE

This study aims to evaluate the epidemiology of asthma among children and adolescents in the Eastern Mediterranean Region.

METHODS

Exhaustive searches were conducted across databases, including PubMed, Scopus, Web of Knowledge Core Collection, Embase, and Google Scholar. The selection criteria included studies reporting asthma prevalence in individuals aged 0 to 19 years, using validated questionnaires. Data were extracted and synthesized using the DerSimonian and Laird random effects model.

RESULTS

The overall prevalence of asthma in Eastern Mediterranean Regional Office (EMRO) countries, among the 514,468 children and adolescents included in this meta-analysis, was 10.61%, synthesized from 95 studies. Among the countries studied, Qatar exhibited the highest prevalence at 16.69%, followed by Saudi Arabia at 16.57%, Iraq at 16.22%, Oman at 15.20%, and Afghanistan at 14.90%. Adolescents showed a slightly higher prevalence of asthma at 10.10% compared to children at 9.70%. Boys exhibited a higher prevalence at 11.48% compared to girls at 9.75%. Urban areas demonstrated a higher prevalence at 11.27% than rural areas at 8.29%.

CONCLUSION

Efforts to reduce asthma prevalence in Arab countries and address underdiagnosis in African nations within the EMRO are crucial. Targeted interventions should focus on addressing environmental triggers and improving access to healthcare. Enhanced diagnostic capabilities and healthcare infrastructure are necessary in African countries. Collaborative action is essential to alleviate the asthma burden and promote respiratory health across the EMRO region.

Life Course of Asthma

Asthma is a heterogeneous chronic airway disease that can vary over a lifetime. Although broad categories of asthma by severity and type have been constructed, there remains a tremendous opportunity to discover an approach to managing asthma with additional factors in mind. Many in the field have suggested and are pursuing a novel paradigm shift in how asthma might be better managed, considering the life course of exposures, management priorities, and predicted trajectory of lung function growth. This approach will require a more holistic view of prenatal, postnatal, adolescence, hormonal and gender aspects, and the aging process. In addition, the environment, externally and internally, including in one's genetic code and epigenetic changes, are factors that affect how asthma progresses or becomes more stable in individuals. This chapter focuses on the various influences that may, to differing degrees, affect people with asthma, which can develop at any time in their lives. Shifting the paradigm of thought and strategies for care and advocating for public policies and health delivery that focus on this philosophy is paramount to advance asthma care for all.

Direct Medical Cost of Pediatric Asthma in Jordan: A Cost-of-Illness Retrospective Cohort Study

OBJECTIVES

This study aimed to estimate and analyze the direct medical costs of pediatric patients with asthma in Jordan from the provider's perspective.

METHODS

A retrospective analysis of a cohort of pediatric patients with asthma treated during 3 years in a teaching hospital was conducted. The prevalence-based, bottom-up approach has been used to estimate the cost-of-illness of asthma. The total annual direct medical cost was stratified by control status and the severity of asthma.

RESULTS

The total annual cost for whole the sample (N = 613) in the average of 3 years was Jordanian dinar (JD) 110 874 (US$ 156 382). Pediatrics with uncontrolled asthma had significantly higher annual total direct medical costs than partly controlled and controlled asthma (JD 396 [US$ 558], JD 258 [US$ 364], and JD 150 [US$ 211], respectively) (P < .001). The annual total direct medical cost for severe asthma (JD 455 [US$ 641]) was significantly higher than moderate, mild, and intermittent (JD 176 [US$ 248], JD 35 [US$ 49], and JD 7 [US$ 9.8], respectively) (P < .001). Medications were the most expensive healthcare resource used, accounting for 79.8% of the total cost, followed by outpatient clinic visits and hospitalizations.

CONCLUSIONS

Healthcare sources utilization and direct medical costs of asthma were highly related to disease severity and control status of the disease. Health policies targeting the achievement of better and stricter asthma control will play a crucial role in the reduction of the economic burden of asthma for society and the patient.

Paediatric asthma exacerbation admissions and stringency of non-pharmaceutical interventions: Results from a developing country

BACKGROUND

Non-pharmaceutical interventions (NPI) mitigation measures implemented to mitigate COVID-19 has brought unprecedented global impact. Changes in daily living routines, reduction in physical activities, and changes in environmental indicators were suggested to positively impact paediatric asthma indicators in western cultures. Little is known about such impact in developing countries. This study investigated the potential impact of COVID-19 NPI measures on paediatric asthma exacerbation admissions in Northern Jordan.

METHODS

Aggregate data from a paediatric hospital, Princess Rahma Pediatric Teaching Hospital, and King Abdulla University Teaching Hospital were utilised from 2018 to 2020. The number of paediatric asthma exacerbation admissions was calculated by week and compared by year, lockdown status, and weeks for lockdown (weeks 13-19). The stringency index was correlated with the number of weekly paediatric asthma exacerbation admissions for 2020.

RESULTS

A total of 1,207 paediatric asthma exacerbation admissions were reported; 40.3%, 35.2%, and 24.5% in 2018, 2019 and 2020, respectively. The number of weekly admissions ranged from 1 to 13 paediatric asthma cases (mean (SD) = 7.6 (2.7)). In 2018 and 2019, respectively, mean weekly admissions were 9.2 (1.9) and 8.0 (2.0) paediatric asthma cases, while in 2020 the mean was 5.6 (2.7) cases. Significant differences in mean weekly paediatric asthma exacerbation admissions were detected by year, with mean weekly admissions for 2020 being significantly lower than that for 2018 and 2019. During the lockdown (22 March to 1 May 2020), mean weekly admissions (2.6 (1.4)) was significantly lower than that before the lockdown (8.6 (2.0)) and after the lockdown (5.2 (2.0)). For the lockdown weeks only, the mean admissions for the year 2020 was significantly lower than that for years 2019 and 2018. The stringency index negatively correlated with the number of weekly admissions.

CONCLUSION

NPI measures in Jordan seem to have positively impacted paediatric asthma exacerbation admissions. Further studies are needed to draw public health policies and fine-tune environmental and community policies.

Operational definitions of paediatric asthma used in epidemiological studies: A systematic review

Background

Researchers use different definitions to identify children with asthma in epidemiological surveys. We conducted a systematic review to describe the definitions used in epidemiologic studies for wheeze and asthma in the paediatric population, aimed to inform the development of a uniform definition of paediatric asthma for future epidemiological research.

Methods

We systematically searched terms to identify asthma and/or wheeze among children aged <13 years and published between 1995-2020 across seven databases (MEDLINE, EMBASE, PsycINFO, Global Health, AMED, LILACS and CINAHL). PRISMA guidelines were followed for this review.

Results

We extracted a total of 11 886 records, where 190 met our eligibility criteria and included in the analysis. Among the included studies, 62.1% (n = 118/190) used the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaires, predominantly in developing countries (80%, n = 64/80). ‘Wheeze’ was reported in five categories, subdivided by 14 different definitions. “Current wheeze”, defined as caregivers report of wheezing sounds from the chest of the child in the past 12 months and “Wheeze ever”, defined as caregivers’ report of wheezing or whistling in the chest of the child at any previous time, were the most common wheeze category reported in 129 and 95 studies, respectively. Asthma was reported in nine categories using 53 definitions. The most common asthma category was “Asthma ever”, which was reported in 89 studies, based on caregiver statement that the child had asthma in the past.

Conclusion

Definitions of wheeze and asthma for children used in surveys are primarily based on parent-reported clinical features. Studies from developing countries more frequently used the ISAAC definitions to report childhood asthma and wheeze compared to the studies from developed counties. The use of a uniform asthma definition will aid the interpretation of research findings globally.

Applicability of GLI 2012 spirometry equation among preschool aged Jordanian

OBJECTIVES

The Validation of Global Lung Initiative (GLI 2012) equations is required prior to their application in clinical practice in different regions. This study validated the GLI 2012 equations in Middle Eastern preschool aged children, which was not previously conducted.

STUDY DESIGN

Spirometry measures were collected from 765 (54% males) healthy 3 to 5-year-old Jordanian children. z scores, percent predicted values, and frequency of measures below lower limit than normal (LLN) were calculated using GLI 2012 equations for Caucasians and Other or Mixed.

RESULTS

The mean of z-scores produced by GLI 2012 equation for Caucasians in FEV_0.75, FEV₁, FVC, FEV₁/FVC% and FEF25-75 in boys were 0.03, 0.02, -0.13, 0.26 and -0.08 respectively, while in girls it was -0.03, 0.01, 0.02, -0.01 and -0.04 respectively, and the mean of z-scores produced by GLI-2012 Other or Mixed equations in FEV₁, FVC, FEV₁/FVC% and FEF25-75 in boys were 0.56, 0.51, 0.09 and 0.12 respectively, and in girls it was 0.56, 0.67, -0.22 and 0.18 respectively. The frequency of measures below LLN as produced by Caucasians equation were not significantly different from the expected 5% in any of the spirometry parameters.

CONCLUSION

The GLI 2012 for Caucasians is a reasonable fit for Jordanian preschool aged children.

Quality of Life Questionnaires for Children With Bronchial Asthma at Jordan University Hospital: An Observational Study

Background:

Asthma is a common chronic illness worldwide. Identifying and treating impaired health-related quality of life, is now recognized as an important component of asthma management. A high prevalence of behavioral and emotional difficulties was noticed among children with asthma.

Methods:

This is a cross-sectional study that was conducted over 8 weeks involving 45 asthmatic children, between the ages of 7-17 years old, presented to Jordan University Hospital in Amman, Jordan. General demographic characteristics were collected, and two questionnaires were used: asthma control test (ACT), and the pediatric asthma quality of life questionnaire (PAQLQ). We also used the feeling thermometer scale, and a pulmonary function test was done for patients. SAS Software version 9.4 USA and Pearsons coefficient were used to find associations.

Results:

Among 45 patients, 53% of the sample had poor asthma control. The mean FEV1 on lung function testing was 80% (± 16.18) of predicted. The mean for clinical asthma scores (ACT) was 18.8 ± 4.53 (out of 25). FEV1 was significantly higher in children with good control compared to those with a low ACT score (P-value <0.05). The mean total PAQLQ score was 5.3 ± 1.06 and it correlated significantly with ACT score (P-value <0.001).

Conclusion:

This study highlights the association of poorly controlled asthma with a poor quality of life. It is recommended that the quality of life of children should be assessed and observed during clinic visits, for a better comprehensive approach and effective improvement of outcome.

Role of the pharmacist in improving inhaler technique and asthma management in rural areas in Jordan

Introduction

Pharmacists can have a valuable role in educating patients on correct inhaler technique leading to improved asthma management. Rural areas can benefit from the role of the pharmacist considering the barriers found in attending primary health-care facilities.

Objectives

This study aimed to assess the impact of inhaler technique education delivered by pharmacists on patients’ inhaler technique, Asthma Control Test (ACT) score, forced expiratory volume in the first 1 second (FEV₁%), and reliever use (puffs/day).

Methods

A pre–post interventional study was conducted over 6 months from February 2017 to July 2017 in rural areas in Jordan. Asthma patients visiting respiratory clinics and using metered dose inhaler (MDI) or turbuhaler (TH) controlled medication were randomly recruited. Inhaler technique was assessed via published checklists. The ACT, FEV₁%, and reliever use (puffs/day) were assessed. Patients were educated on inhaler technique via demonstration with return demonstration education. All assessments were repeated 3 months post education.

Results

A total of 103 (TH, n=44; MDI, n=59) patients were recruited (mean age=46.5±13.5), 74% females. Patients reported an overuse of their reliever (5.1±4.2 puffs/day). Only 2 patients (1.9%) had well-controlled asthma, while the rest had either moderately (19.4%) or poorly (78.6%) controlled asthma. Patients using the MDI achieved 3.03±4.30 ACT score improvement (p<0.001), which is a clinically significant improvement in control. Patients using the TH achieved a statistically significant improvement of 2.07±4.72 (p=0.031). FEV₁% improved significantly for MDI users (p=0.005) but not for TH users (p=0.097). Reliever use decreased significantly for MDI and TH users.

Conclusion

Asthmatic patients living in rural areas in Jordan reported poor inhaler technique, ACT scores, and FEV₁% scores and high use of reliever medications. Pharmacist-led educational intervention resulted in improved inhaler technique scores, ACT scores, and FEV₁% scores and lowered reliever use over time.

Prevalence, associated factors, and control level of asthma symptoms among adolescents in Northern Jordan

Objective To investigate the prevalence, associated factors, and control level of asthma in Jordanian high school students. Methods A descriptive, comparative, cross sectional design was used and a cluster sample of 2691 students (mean age = 14.5 years, 51.0% girls), drawn from eight randomly selected public high schools in Northern Jordan, participated in the study. Each student had the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire completed in the classroom between February and May, 2015. Results The prevalence of recent wheezing in the last 12 months was 11.7% whereas the prevalence of diagnosed asthma was 6.2%. About 49% of students experienced cough all the time, and 33.5% experienced waking up at night due to wheezing some of the time. About 30.9% of students reported moderate to big exercise-induced asthma. The mean total Asthma Control Test (ACT) score was 5.85 (SD = 3.56) with all of students reporting uncontrolled asthma during the last month. Higher rates of asthma symptoms were reported by females, 10th graders, and students with negative family history. Importantly, students with diagnosed asthma or recent wheezing reported higher rates of ever smoking tobacco vs. non-asthmatics (p < 0.000); dual (18.6% vs. 9.8%), cigarettes only (11.2% vs. 7.3%), and waterpipe only (18.0% vs. 14.7%). Conclusion Overall, students with asthma or wheezing had increased rates of tobacco smoking. Policies need to be set and enforced to provide a better environment for these youth, especially making all schools smoke-free zones. A multifaceted, comprehensive awareness and management program is required in schools to control and manage asthma symptoms.

The prevalence of asthma and related symptoms in Middle East countries

OBJECTIVES

Asthma is a chronic inflammatory airway disease characterized by reversible airway constriction and airway hyperresponsiveness. Asthma is a worldwide problem and its prevalence varies among different parts of the world. There are insufficient data about the prevalence and risk factors of this disease in Middle East countries.

DATA SOURCE

The objective of this review article was to determine the prevalence of asthma in Middle East countries by searching EMBASE, Medline, Web of Science and Google Scholar for articles about asthma prevalence in children and adults in this region.

STUDY SELECTION

The prevalence of asthma in different countries and different cities of each country in the Middle East was reviewed in children and adults of both sexes. The possible risk factors for asthma in different areas were also reviewed from 1985 to 2012.

RESULTS

The highest asthma prevalence in children and adults was 35.4% in Tehran, Iran by ISAAC phase I and 15% in Kuwait by self-designed questionnaire and the lowest prevalence was 1% in Kermanshah, Iran by ISAAC and 2% in Tehran, Iran by ECRHS questionnaire, respectively. Most studies showed that the prevalence of this common disease declines with increasing age.

CONCLUSION

The data showed that the prevalence of asthma varies among different countries and even among different cities of the same country. The common risk factors for this disease were genetic predisposition, cigarette smoking, family history of asthma and allergic diseases.

Effect of novel inhaler technique reminder labels on the retention of inhaler technique skills in asthma: a single-blind randomized controlled trial

Inhaler technique can be corrected with training, but skills drop off quickly without repeated training. The aim of our study was to explore the effect of novel inhaler technique labels on the retention of correct inhaler technique. In this single-blind randomized parallel-group active-controlled study, clinical pharmacists enrolled asthma patients using controller medication by Accuhaler [Diskus] or Turbuhaler. Inhaler technique was assessed using published checklists (score 0-9). Symptom control was assessed by asthma control test. Patients were randomized into active (ACCa; THa) and control (ACCc; THc) groups. All patients received a "Show-and-Tell" inhaler technique counseling service. Active patients also received inhaler labels highlighting their initial errors. Baseline data were available for 95 patients, 68% females, mean age 44.9 (SD 15.2) years. Mean inhaler scores were ACCa:5.3 ± 1.0; THa:4.7 ± 0.9, ACCc:5.5 ± 1.1; THc:4.2 ± 1.0. Asthma was poorly controlled (mean ACT scores ACCa:13.9 ± 4.3; THa:12.1 ± 3.9; ACCc:12.7 ± 3.3; THc:14.3 ± 3.7). After training, all patients had correct technique (score 9/9). After 3 months, there was significantly less decline in inhaler technique scores for active than control groups (mean difference: Accuhaler -1.04 (95% confidence interval -1.92, -0.16, P = 0.022); Turbuhaler -1.61 (-2.63, -0.59, P = 0.003). Symptom control improved significantly, with no significant difference between active and control patients, but active patients used less reliever medication (active 2.19 (SD 1.78) vs. control 3.42 (1.83) puffs/day, P = 0.002). After inhaler training, novel inhaler technique labels improve retention of correct inhaler technique skills with dry powder inhalers. Inhaler technique labels represent a simple, scalable intervention that has the potential to extend the benefit of inhaler training on asthma outcomes.

ASTHMA

REMINDER LABELS IMPROVE INHALER TECHNIQUE: Personalized labels on asthma inhalers remind patients of correct technique and help improve symptoms over time. Iman Basheti at the Applied Science Private University in Jordan and co-workers trialed the approach of placing patient-specific reminder labels on dry-powder asthma inhalers to improve long-term technique. Poor asthma control is often exacerbated by patients making mistakes when using their inhalers. During the trial, 95 patients received inhaler training before being split into two groups: the control group received no further help, while the other group received individualized labels on their inhalers reminding them of their initial errors. After three months, 67% of patients with reminder labels retained correct technique compared to only 12% of controls. They also required less reliever medication and reported improved symptoms. This represents a simple, cheap way of tackling inhaler technique errors.

Prevalence, patterns and correlates of cigarette smoking in male adolescents in northern Jordan, and the influence of waterpipe use and asthma diagnosis: a descriptive cross-sectional study

Our study investigates the prevalence, patterns and predictors of tobacco smoking among early adolescent males in Northern Jordan and whether asthma diagnosis affects smoking patterns. A descriptive cross sectional design was used. Males in grades 7 and 8 from four randomly selected high schools in the city of Irbid were enrolled. Data on waterpipe (WP) use and cigarette smoking patterns were obtained (n = 815) using a survey in Arabic language. The overall prevalence of ever having smoked a cigarette was 35.6%, with 86.2% of this group smoking currently. Almost half of the sample reported WP use. The most common age in which adolescents started to experiment with cigarettes was 11–12 years old (49.1%), although 10 years was also common (25.3%). Significant predictors of male cigarette smoking were WP use (OR = 4.15, 95% CI = 2.99–5.76), asthma diagnosis (OR = 2.35, 95% CI = 1.46–3.78), grade 8 (OR = 1.52, 95% CI = 1.10–2.11), and having a sibling who smokes (OR = 2.23, 95% CI = 1.53–3.24). However, this cross-sectional study cannot establish causality, thus longitudinal studies are needed. Public health programs and school-based anti-tobacco smoking interventions that target children in early years at high schools are warranted to prevent the uptake of tobacco use among this vulnerable age group. High school students with asthma should be specifically targeted.

Breastfeeding and childhood asthma: systematic review and meta-analysis

Asthma and wheezing disorders are common chronic health problems in childhood. Breastfeeding provides health benefits, but it is not known whether or how breastfeeding decreases the risk of developing asthma. We performed a systematic review and meta-analysis of studies published between 1983 and 2012 on breastfeeding and asthma in children from the general population. We searched the PubMed and Embase databases for cohort, cross-sectional, and case-control studies. We grouped the outcomes into asthma ever, recent asthma, or recent wheezing illness (recent asthma or recent wheeze). Using random-effects meta-analyses, we estimated pooled odds ratios of the association of breastfeeding with the risk for each of these outcomes. We performed meta-regression and stratified meta-analyses. We included 117 of 1,464 titles identified by our search. The pooled odds ratios were 0.78 (95% confidence interval: 0.74, 0.84) for 75 studies analyzing "asthma ever," 0.76 (95% confidence interval: 0.67, 0.86) for 46 studies analyzing "recent asthma," and 0.81 (95% confidence interval: 0.76, 0.87) for 94 studies analyzing recent wheezing illness. After stratification by age, the strong protective association found at ages 0-2 years diminished over time. We found no evidence for differences by study design or study quality or between studies in Western and non-Western countries. A positive association of breastfeeding with reduced asthma/wheezing is supported by the combined evidence of existing studies.

The effect of asthma education program on knowledge of school teachers: a randomized controlled trial

The purpose of this study was to examine the effect of an asthma education program on schoolteachers' knowledge. Pre-test-post-test experimental randomized controlled design was used. A multistage-cluster sampling technique was used to randomly select governorate, primary schools, and schoolteachers. Schoolteachers were randomly assigned either to the experimental group (n = 36) and attended three educational sessions or to the control group (n = 38) who did not receive any intervention. Knowledge about asthma was measured using the Asthma General Knowledge Questionnaire for Adults (AGKQA). The results indicated that teachers in the experimental group showed significantly (p < .001) higher knowledge of asthma in the first post-test and the second post-test compared with those in the control group. Implementing asthma education enhanced schoolteachers' knowledge of asthma. The asthma education program should target schoolteachers to improve knowledge about asthma.

Peer-led education for adolescents with asthma in Jordan: a cluster-randomized controlled trial

OBJECTIVES

To determine the impact of a peer-led education program, developed in Australia, on health-related outcomes in high school students with asthma in Jordan.

METHODS

In this cluster-randomized controlled trial, 4 high schools in Irbid, Jordan, were randomly assigned to receive the Adolescent Asthma Action program or standard practice. Bilingual health workers trained 24 peer leaders from Year 11 to deliver asthma education to younger peers from Year 10 (n = 92), who in turn presented brief asthma skits to students in Years 8 and 9 (n = 148) and to other members of the school community in the intervention schools. Students with asthma (N = 261) in Years 8, 9, and 10 completed baseline surveys in December 2006 and 3 months after the intervention.

RESULTS

Students from the intervention group reported clinically significant improvements in health-related quality of life (mean difference: 1.35 [95% confidence interval: 1.04-1.76]), self-efficacy to resist smoking (mean difference: 4.63 [95% confidence interval: 2.93-6.35]), and knowledge of asthma self- management (mean difference: 1.62 [95% confidence interval: 1.15-2.19]) compared with the control group.

CONCLUSIONS

This trial demonstrated that the Adolescent Asthma Action program can be readily adapted to suit different cultures and contexts. Adolescents in Jordan were successful in teaching their peers about asthma self-management and motivating them to avoid smoking. The findings revealed that peer education can be a useful strategy for health promotion programs in Jordanian schools when students are given the opportunity and training.

Chronic respiratory illnesses in Jordan: pulmonary physicians' experiences in risk reduction

Chronic respiratory diseases are on the rise in Jordan. However, there is limited research on the symptoms reported by patients, the triggers associated with their illnesses, and the health education efforts of pulmonary physicians. Thus, the purpose of this qualitative study was to understand these issues from physicians' perspectives. Fourteen face-to-face interviews were done with pulmonary physicians in their clinics in Amman, Jordan. Physicians indicated that cultural barriers existed such as the social acceptance of smoking, prevalence of olive trees, and cultural practices such as kissing as a form of greeting. In addition, health education materials were scarce and of poor quality. Implications for health education are discussed.

Having a child with asthma--quality of life for Jordanian parents

This study was conducted to assess the quality of life (QoL) of Jordanian parents of children with asthma and its associated factors. Three hundred and twenty-six parents of 200 children participated in the study. The Pediatric Asthma Caregivers' Quality of Life Questionnaire (PACQLQ) was used to measure how parents of children with asthma disease impaired their daily life during the previous week on two domains 'activity limitations' and 'emotional function'. In this study, parents of children with asthma scored their QoL during the past week moderately to the positive end of the scale but they scored more limitations in the domain of activities than in emotions. Parents in the same family scored activity domain fairly similar and there was a significant difference in their scoring of total emotional function. Parents with older children, living in the rural areas, mothers of children with mild asthma were associated with higher QoL. Children received needed daily asthma medication during the preceding week. Asthma medication might mean to the parents that the child was getting the best possible treatment. Further studies to identify the factors that influence QoL of parents of children with asthma in Jordan are needed.

Quality of life in Jordanian children with asthma

The purpose of this study was to describe how Jordanian children with asthma experience their quality of life (QoL). Two hundred children with asthma (34% girls and 66% boys) participated in the study. The Paediatric Asthma Quality of Life Questionnaire was used to measure how children with asthma disease impaired their daily life during the previous week on three domains: 'activity limitations', 'symptoms' and 'emotional function'. The main finding of this study was that children with asthma scored their QoL towards the negative end of the scale, but they scored more limitations in the domain of activities than in emotions and symptoms. Children reported that the most restricted activity was their ability to run. Younger children, being a girl and living in the rural areas, were associated with lower QoL. The children in the present study might not comply with their health regimen, and this might gave a darker view of the daily life of children with asthma. Further studies of Jordanian children and their QoL were suggested to identify and support the factors which influence QoL of children with asthma and other chronic diseases in Jordan.

Comparison of local risk factors for children's atopic symptoms in Hanoi, Vietnam

BACKGROUND

A 1999 study in Hanoi, Vietnam using the International Study on Asthma and Allergies in Childhood (ISAAC) questionnaire showed a high prevalence of atopic symptoms. Identifying risk factors for symptoms in these children may help in understanding the causes for these high estimates.

METHODS

An ISAAC questionnaire with supplemental questions on environmental variables was distributed to 5495 school children in Hanoi and a suburban district, Dong Anh. The response rate was 65.7%.

RESULTS

In Dong Anh, the following were among the significant age and gender adjusted associations: pig ownership [odds ratio (OR) (95% confidence interval), OR = 1.79 (1.18-2.70) for doctor-diagnosed asthma (DDA), OR = 1.72 (1.08-2.78) for doctor diagnosed hay fever (DDHF)] and farming [OR = 1.67 (1.27-2.19) for ever asthma, OR = 1.51 (1.09-2.09) for DDHF]. In multivariate models, tuberculosis (TB) was a significant predictor of atopic symptoms [Hanoi: OR = 3.09 (1.10-8.70) for DDA, Dong Anh: OR = 3.71 (1.40-9.84) for DDA, OR = 4.66 (1.88-11.57) for DDHF].

CONCLUSIONS

These findings are contrary to the "hygiene hypothesis". Recent immunologic and epidemiologic studies refute the inverse association between allergy and TB and may be one explanation for the positive association in this study. The positive association with pig ownership and farming may be because of exposures on farms in a developing country that may be different from exposures in farms of developed countries.

Family history as a predictor of asthma risk

Asthma, one of the most important chronic diseases of children, disproportionately affects minority and low-income children. Many environmental risk factors for asthma have been identified, including animal, mite, and other allergens; cigarette smoke; and air pollutants. Genetics also play an important causative role, as indicated by familial aggregation and the identification of candidate genes and chromosomal regions linked to asthma risk. Using a positive family history of asthma to identify children at increased risk could provide a basis for targeted prevention efforts, aimed at reducing exposure to environmental risk factors. To assess the predictive value of family history as an indicator of risk for childhood asthma, we reviewed population-based studies that evaluated family history of asthma and atopic disease in children with asthma. Our search identified 33 studies from all geographic regions of the world for review. The studies varied in definitions of positive family history and asthma phenotype and used study populations with asthma prevalence ranging from 2% to 26%. Nevertheless, family history of asthma in one or more first-degree relatives was consistently identified as a risk factor for asthma. In ten studies, sensitivity and predictive value of a positive family history of asthma could be calculated: sensitivity ranged from 4% to 43%, positive predictive value from 11% to 37%, and negative predictive value from 86% to 97%. Although a positive family history predicts an increased risk of asthma, it identifies a minority of children at risk. Positive family history may have utility in targeting some individual prevention efforts, but the low positive predictive value limits its value as a means to direct environmental remediation efforts.

Geographical variations of asthma and asthma symptoms among schoolchildren aged 5 to 8 years and 12 to 15 years in Palestine: the International Study of Asthma and Allergies in Childhood (ISAAC)

BACKGROUND

Many studies demonstrated the existence of geographic differences, within and between countries, in the prevalence of asthma, rhinitis, and eczema. However, in Palestine, there are no comprehensive Palestinian data to compare with those from other regional and international centers.

OBJECTIVE

To describe the prevalence of asthma and asthma symptoms in schoolchildren in two districts (Ramallah and North Gaza) in Palestine.

METHODS

After a two-stage stratified systematic sampling, approximately 14,500 schoolchildren, from the first and second grades of elementary school (ages 5 to 8 years) and eighth and ninth school grades (ages 12 to 15 years), were invited to participate in a survey using International Study of Asthma and Allergies in Childhood phase III questionnaires and protocols.

RESULTS

In general, younger children were reported to have a higher 12-month wheezing prevalence rate than older children (9.6 and 7.2%, respectively), and more physician-diagnosed asthma (8.4 and 5.9%, respectively). However, nocturnal cough and exercise-related wheezing were higher in the older age group compared with younger children. Younger children living in North Gaza district showed slightly higher prevalence rates for asthma and asthma symptoms, but older children had higher rates in Ramallah district. After adjustment using logistic regression analysis, male sex, living in inland areas, and younger age were shown to predict 12-month wheezing and physician-diagnosed asthma.

CONCLUSIONS

Palestinian children have asthma symptoms rates that are similar to several countries in the Mediterranean region such as Spain and Turkey, but still lower than other Middle East countries such as Saudi Arabia and Israel.

Prevalence of bronchial asthma and allergic rhinitis in Istanbul school children

The aim of this study was to determine the prevalence of asthma, allergic rhinitis and their related symptoms in Istanbul and to investigate the effect of socioeconomic status on the prevalence of asthma and allergic rhinitis and whether there are differences between the prevalence of childhood asthma in the same and different regions as found in previous studies and our own. The study period was the 1996-1997 school year in three primary schools in Istanbul. For proportional representation of high, middle, and low socioeconomic levels, the schools were selected from three different regions of Istanbul. A translated version of the International Study of Asthma and Allergies in Childhood (ISAAC) was used. The questionnaire was distributed to the parents of 2600 students aged 6-15 years. All of the 2276 children whose parents responded were included in the survey. The overall cumulative and current prevalences of wheezing were 13.7 and 7.2% respectively and the overall cumulative prevalence of allergic rhinitis was 17.6%. There was no statistically significant difference between asthmatics and non-asthmatics by sex, socioeconomic status and passive smoking. Family history of atopy was found to be significantly higher in asthmatics. Although there are differences in the results of studies concerning the prevalence of asthma and allergic rhinitis not only between different countries but also between different regions of the same city, by using a standardized international method, the actual values may be obtained.

Systematic review: Exposure to pets and risk of asthma and asthma-like symptoms

BACKGROUND

Studies of exposure to pets and risk of asthma have yielded conflicting results.

OBJECTIVES

We performed a systematic review to synthesize the evidence of the effect of exposure to pets in the home on the risk of asthma and asthma-related symptoms. We also assessed differences between the studies as sources of heterogeneity of the results.

METHODS

We conducted a MEDLINE search (until the end of 1999) using the following boolean search command: (asthma[all] OR wheez*[all]) AND (domestic animal*[all] OR pets[all]). The outcome was limited to either diagnosis of asthma or the symptom of wheezing. The exposure of interest was domestic animals in the home. Appropriate temporal relationship was defined as present in studies with either pet keeping within the first 2 years of life, in the past, or exposure to pets preceding the outcome.

RESULTS

Thirty-two of the 217 retrieved articles fulfilled the eligibility criteria. Inappropriate time sequence of the exposure and outcome information was an important source of heterogeneity and an indication of potential selection bias. Therefore we analyzed studies focusing on early exposure or ensuring appropriate temporal sequence. The pooled risk estimates for both asthma (fixed-effects odds ratio, 1.11; 95% CI, 0.98-1.25; heterogeneity, P =.04; random-effects odds ratio, 1.09; 95% CI, 0.89-1.34) and wheezing (fixed-effects odds ratio, 1.19; 95% CI, 1.05-1.35; heterogeneity, P =.03; random-effects odds ratio, 1.17; 95% CI, 0.95-1.44) indicated a small effect, which was limited to studies with a median study population age of over 6 years (fixed-effects odds ratio, 1.19; 95% CI, 1.02-1.40; heterogeneity, P =.04; random-effects odds ratio, 1.15; 95% CI, 0.86-1.56; fixed-effects odds ratio, 1.29; 95% CI, 1.12-1.48; heterogeneity, P =.31). In younger children the harmful effect disappeared for wheezing (odds ratio, 0.80; 95% CI, 0.59-1.08; P =.38).

CONCLUSION

Exposure to pets appears to increase the risk of asthma and wheezing in older children. The observed lower risk among exposed than among unexposed young children is consistent with a protective effect in this age group but could also be explained by selection bias.

Urbanization and the risk of asthma among schoolchildren in the Palestinian Authority

The aim of the present survey was to compare the prevalence of symptoms suggestive of asthma in boys and girls aged 6-7 and 13-14 years in a rural and an urban area in the West Bank. For this purpose, the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire was issued to 970 schoolchildren in the two regions. The response rate was 92.2%. The prevalences of ever wheezing in the urban and rural areas were 16.4% and 12.0%, respectively (p < 0.05); the 12-month prevalences of wheezing were 10.5% and 5.5%, respectively (p < 0.05); the prevalences of more severe wheeze were 4.5% and 1.7%, respectively (p < 0.05); and prevalences of diagnosed asthma were 4.2% and 2.8%, respectively (p = NS). When controlling for age by stratification, the significant association between prevalence rates and place of residence persisted in the 13-14-year age group. These results also show that the prevalence of asthma among Palestinian children is moderately high in comparison with that reported from developing countries, but lower than those reported from Western countries. This survey, the first epidemiological survey on asthma in the West Bank, demonstrates a marked difference between urban and rural areas. The findings emphasize the need for further study of the environmental determinants of the disease among Palestinian children.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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