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Rutter CE, van Tongeren M, Fletcher T, Rhodes S, Chen Y, Hall I, Warren N, Pearce N. Risk factors for SARS-CoV-2 infection at a UK electricity-generating company: a test-negative design case-control study. Occup Environ Med 2024; 81:184-190. [PMID: 38508710 DOI: 10.1136/oemed-2023-109184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 02/11/2024] [Indexed: 03/22/2024]
Abstract
OBJECTIVES Identify workplace risk factors for SARS-CoV-2 infection, using data collected by a UK electricity-generating company. METHODS Using a test-negative design case-control study, we estimated the OR of infection by job category, site, test reason, sex, vaccination status, vulnerability, site outage and site COVID-19 weekly risk rating, adjusting for age, test date and test type. RESULTS From an original 80 077 COVID-19 tests, there were 70 646 included in the final analysis. Most exclusions were due to being visitor tests (5030) or tests after an individual first tested positive (2968).Women were less likely to test positive than men (OR=0.71; 95% CI 0.58 to 0.86). Test reason was strongly associated with positivity and although not a cause of infection itself, due to differing test regimes by area, it was a strong confounder for other variables. Compared with routine tests, tests due to symptoms were highest risk (94.99; 78.29 to 115.24), followed by close contact (16.73; 13.80 to 20.29) and broader-defined work contact 2.66 (1.99 to 3.56). After adjustment, we found little difference in risk by job category, but some differences by site with three sites showing substantially lower risks, and one site showing higher risks in the final model. CONCLUSIONS In general, infection risk was not associated with job category. Vulnerable individuals were at slightly lower risk, tests during outages were higher risk, vaccination showed no evidence of an effect on testing positive, and site COVID-19 risk rating did not show an ordered trend in positivity rates.
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Affiliation(s)
- Charlotte E Rutter
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Martie van Tongeren
- Division of Population Health, Health Services Research & Primary Care, School of Health Sciences, The University of Manchester, Manchester, UK
- Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Tony Fletcher
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Sarah Rhodes
- Division of Population Health, Health Services Research & Primary Care, School of Health Sciences, The University of Manchester, Manchester, UK
| | - Yiqun Chen
- Science Division, Health and Safety Executive, Buxton, UK
| | - Ian Hall
- Division of Population Health, Health Services Research & Primary Care, School of Health Sciences, The University of Manchester, Manchester, UK
- Public Health, Advice, Guidance and Expertise, UK Health Security Agency, London, UK
| | | | - Neil Pearce
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
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Rutter CE, Millard LAC, Borges MC, Lawlor DA. Exploring regression dilution bias using repeat measurements of 2858 variables in ≤49 000 UK Biobank participants. Int J Epidemiol 2023; 52:1545-1556. [PMID: 37336529 PMCID: PMC10555784 DOI: 10.1093/ije/dyad082] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 05/30/2023] [Indexed: 06/21/2023] Open
Abstract
BACKGROUND Measurement error in exposures and confounders can bias exposure-outcome associations but is rarely considered. We aimed to assess random measurement error of all continuous variables in UK Biobank and explore approaches to mitigate its impact on exposure-outcome associations. METHODS Random measurement error was assessed using intraclass correlation coefficients (ICCs) for all continuous variables with repeat measures. Regression calibration was used to correct for random error in exposures and confounders, using the associations of red blood cell distribution width (RDW), C-reactive protein (CRP) and 25-hydroxyvitamin D [25(OH)D] with mortality as illustrative examples. RESULTS The 2858 continuous variables with repeat measures varied in sample size from 109 to 49 121. They fell into three groups: (i) baseline visit [529 variables; median (interquartile range) ICC = 0.64 (0.57, 0.83)]; (ii) online diet by 24-h recall [22 variables; 0.35 (0.30, 0.40)] and (iii) imaging measures [2307 variables; 0.85 (0.73, 0.94)]. Highest ICCs were for anthropometric and medical history measures, and lowest for dietary and heart magnetic resonance imaging.The ICCs (95% confidence interval) for RDW, CRP and 25(OH)D were 0.52 (0.51, 0.53), 0.29 (0.27, 0.30) and 0.55 (0.54, 0.56), respectively. Higher RDW and levels of CRP were associated with higher risk of all-cause mortality, and higher concentration of 25(OH)D with lower risk. After correction for random measurement error in the main exposure, the associations all strengthened. Confounder correction did not influence estimates. CONCLUSIONS Random measurement error varies widely and is often non-negligible. For UK Biobank we provide relevant statistics and adaptable code to help other researchers explore and correct for this.
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Affiliation(s)
- Charlotte E Rutter
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine (LSHTM), London, UK
| | - Louise A C Millard
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Maria Carolina Borges
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Deborah A Lawlor
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol NIHR Biomedical Research Centre, University of Bristol, Bristol, UK
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Langan SM, Mulick AR, Rutter CE, Silverwood R, Asher I, García‐Marcos L, Ellwood E, Bissell K, Chiang C, Sony AE, Ellwood P, Marks G, Mortimer K, Martínez‐Torres AE, Morales E, Perez‐Fernandez V, Robertson S, Williams H, Strachan DP, Pearce N, Bissell K, Chiang CY, Marks , Mortimer K, Masekela R, Perez‐Fernández V, Martinez‐Torres AE, Robertson S, Rutter CE, Silverwood RJ, Mallol J, Soto‐Martinez ME, Cabrera Aguilar A, Douros K, Mohammed S, Singh M, Singh V, Sukumaran TU, Awasthi S, Kabra SK, Salvi S, Mérida‐Palacio JV, González‐Díaz SN, Navarrete‐Rodriguez EM, Sánchez JF, Falade AG, Zar HJ, López‐Silvarrey Varela A, González Díaz C, Nour M, Dib G, Mohammad Y, Huang J, Chinratanapisit S, Soto‐Quirós ME, El‐Sony A, Vichyanond P, Aguilar P, Barba S, Kumar L, Sharma SK, Hanumante NM, García‐Almaráz R, Merida‐Palacio JV, Del‐Río‐Navarro BE, Linares‐Zapién FJ, Onadeko BO, Musa OAA, Aguirre V, Baeza‐Bacab M, Mohammad S, Cortéz E, Gratziou CH, Chopra K, Nelson H, Rubio AD, Hsieh K, Shah J. Trends in eczema prevalence in children and adolescents: A Global Asthma Network Phase I Study. Clin Exp Allergy 2023. [DOI: 10.1111/cea.14276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Affiliation(s)
| | - Amy R. Mulick
- London School of Hygiene & Tropical Medicine London UK
| | | | - Richard J. Silverwood
- London School of Hygiene & Tropical Medicine London UK
- Centre for Longitudinal Studies, UCL Social Research Institute University College London London UK
| | - Innes Asher
- Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health Sciences University of Auckland Auckland New Zealand
| | - Luis García‐Marcos
- Paediatric Allergy and Pulmonology Units, Virgen de la Arrixaca University Children's Hospital University of Murcia Murcia Spain
- IMIB Bio‐health Research Institute Murcia Spain
- ARADyAL Allergy Network Murcia Spain
| | - Eamon Ellwood
- Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health Sciences University of Auckland Auckland New Zealand
| | - Karen Bissell
- School of Population Health, Faculty of Medical and Health Sciences University of Auckland Auckland New Zealand
| | - Chen‐Yuan Chiang
- International Union Against Tuberculosis and Lung Disease Paris France
- Division of Pulmonary Medicine, Department of Internal Medicine, Wan Fang Hospital Taipei Medical University Taipei Taiwan
- Division of Pulmonary Medicine, Department of Internal Medicine, School of Medicine, College of Medicine Taipei Medical University Taipei Taiwan
| | - Asma El Sony
- Epidemiological Laboratory (Epi‐Lab) for Public Health, Research and Development Khartoum Sudan
| | - Philippa Ellwood
- Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health Sciences University of Auckland Auckland New Zealand
| | - Guy B. Marks
- Respiratory & Environmental Epidemiology University of New South Wales Sydney New South Wales Australia
| | - Kevin Mortimer
- Department of Medicine University of Cambridge Cambridge UK
- Department of Respiratory Medicine Liverpool University Hospitals NHS Foundation Trust Liverpool UK
- Department of Paediatrics and Child Health, College of Health Sciences, School of Clinical Medicine University of KwaZulu‐Natal Durban South Africa
| | - A. Elena Martínez‐Torres
- Paediatric Allergy and Pulmonology Units and Nurse Research Group Virgen de la Arrixaca University Children's Hospital Murcia Spain
- IMIB Bio‐health Research Institute, Edificio Departamental‐Laib Murcia Spain
| | - Eva Morales
- IMIB Bio‐health Research Institute, Edificio Departamental‐Laib Murcia Spain
- Department of Public Health Sciences University of Murcia Murcia Spain
| | - Virginia Perez‐Fernandez
- IMIB Bio‐health Research Institute, Edificio Departamental‐Laib Murcia Spain
- Department of Biostatistics University of Murcia Murcia Spain
| | - Steven Robertson
- Centre for Longitudinal Studies, UCL Social Research Institute University College London London UK
| | - Hywel C. Williams
- Centre for Evidence‐Based Dermatology University of Nottingham Nottingam UK
| | - David P. Strachan
- Population Health Research Institute St George's, University of London London UK
| | - Neil Pearce
- London School of Hygiene & Tropical Medicine London UK
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García-Marcos L, Chiang CY, Asher MI, Marks GB, El Sony A, Masekela R, Bissell K, Ellwood E, Ellwood P, Pearce N, Strachan DP, Mortimer K, Morales E, Ajeagah GA, Alkhayer G, Alomary SA, Ambriz-Moreno MJ, Arias-Cruz A, Awasthi S, Badellino H, Behniafard N, Bercedo-Sanz A, Brożek G, Bucaliu-Ismajli I, Cabrera-Aguilar A, Chinratanapisit S, Del-Río-Navarro BE, Douros K, El Sadig H, Escalante-Dominguez AJ, Falade AG, Gacaferri-Lumezi B, García-Almaráz R, Garcia-Muñoz R, Ghashi V, Ghoshal AG, González-Díaz C, Hana-Lleshi L, Hernández-Mondragón LO, Huang JL, Jiménez-González CA, Juan-Pineda MÁ, Kochar SK, Kuzmicheva K, Linares-Zapien FJ, Lokaj-Berisha V, López-Silvarrey A, Lozano-Sáenz JS, Mahesh PA, Mallol J, Martinez-Torres AE, Masekela R, Mérida-Palacio JV, Mohammad Y, Moreno-Gardea HL, Navarrete-Rodriguez EM, Ndikum AE, Noor M, Ochoa-Lopez G, Pajaziti L, Pellegrini-Belinchon J, Perez-Fernández V, Priftis K, Ramos-García BC, Ranasinghe JC, Robertson S, Rodriguez-Perez N, Rutter CE, Sacre-Hazouri JA, Salvi S, Sanchez JF, Sánchez JF, Sanchez-Coronel MG, Saucedo-Ramirez OJ, Singh M, Singh N, Singh V, Sinha S, Sit N, Sosa-Ferrari SM, Soto-Martínez ME, Urrutia-Pereira M, Yeh KW, Zar HJ, Zhjeqi V. Asthma management and control in children, adolescents, and adults in 25 countries: a Global Asthma Network Phase I cross-sectional study. Lancet Glob Health 2023; 11:e218-e228. [PMID: 36669806 PMCID: PMC9885426 DOI: 10.1016/s2214-109x(22)00506-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 11/02/2022] [Accepted: 11/09/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND Asthma is one of the most common non-communicable diseases globally. This study aimed to assess asthma medicine use, management plan availability, and disease control in childhood, adolescence, and adulthood across different country settings. METHODS We used data from the Global Asthma Network Phase I cross-sectional epidemiological study (2015-20). A validated, written questionnaire was distributed via schools to three age groups (children, 6-7 years; adolescents, 13-14 years; and adults, ≥19 years). Eligible adults were the parents or guardians of children and adolescents included in the surveys. In individuals with asthma diagnosed by a doctor, we collated responses on past-year asthma medicines use (type of inhaled or oral medicine, and frequency of use). Questions on asthma symptoms and health visits were used to define past-year symptom severity and extent of asthma control. Income categories for countries based on gross national income per capita followed the 2020 World Bank classification. Proportions (and 95% CI clustered by centre) were used to describe results. Generalised structural equation multilevel models were used to assess factors associated with receiving medicines and having poorly controlled asthma in each age group. FINDINGS Overall, 453 473 individuals from 63 centres in 25 countries were included, comprising 101 777 children (6445 [6·3%] with asthma diagnosed by a doctor), 157 784 adolescents (12 532 [7·9%]), and 193 912 adults (6677 [3·4%]). Use of asthma medicines varied by symptom severity and country income category. The most used medicines in the previous year were inhaled short-acting β2 agonists (SABA; range across age groups, 29·3-85·3% participants) and inhaled corticosteroids (12·6-51·9%). The proportion of individuals with severe asthma symptoms not taking inhaled corticosteroids (inhaled corticosteroids alone or with long-acting β2 agonists) was high in all age groups (934 [44·8%] of 2085 children, 2011 [60·1%] of 3345 adolescents, and 1142 [55·5%] of 2058 adults), and was significantly higher in middle-to-low-income countries. Oral SABA and theophylline were used across age groups and country income categories, contrary to current guidelines. Asthma management plans were used by 4049 (62·8%) children, 6694 (53·4%) adolescents, and 3168 (47·4%) adults; and 2840 (44·1%) children, 6942 (55·4%) adolescents, and 4081 (61·1%) adults had well controlled asthma. Independently of country income and asthma severity, having an asthma management plan was significantly associated with the use of any type of inhaled medicine (adjusted odds ratio [OR] 2·75 [95% CI 2·40-3·15] for children; 2·45 [2·25-2·67] for adolescents; and 2·75 [2·38-3·16] for adults) or any type of oral medicine (1·86 [1·63-2·12] for children; 1·53 [1·40-1·68] for adolescents; and 1·78 [1·55-2·04] for adults). Poor asthma control was associated with low country income (lower-middle-income and low-income countries vs high-income countries, adjusted OR 2·33 [95% CI 1·32-4·14] for children; 3·46 [1·83-6·54] for adolescents; and 4·86 [2·55-9·26] for adults). INTERPRETATION Asthma management and control is frequently inadequate, particularly in low-resource settings. Strategies should be implemented to improve adherence to asthma treatment guidelines worldwide, with emphasis on access to affordable and quality-assured essential asthma medicines especially in low-income and middle-income countries. FUNDING International Union Against Tuberculosis and Lung Disease, Boehringer Ingelheim New Zealand, AstraZeneca, UK National Institute for Health Research, UK Medical Research Council, European Research Council, the Spanish Instituto de Salud Carlos III. TRANSLATION For the Spanish translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Luis García-Marcos
- Paediatric Allergy and Pulmonology Units, Virgen de la Arrixaca University Children‘s Hospital, University of Murcia and IMIB Bio-medical Research Institute, Murcia, Spain,ARADyAL Allergy Network, Murcia, Spain,Correspondence to: Prof Luis García-Marcos, Paediatric Allergy and Pulmonology Units, Virgen de la Arrixaca University Children‘s Hospital, University of Murcia and IMIB Bio-medical Research Institute, 30120 Murcia, Spain
| | - Chen-Yuan Chiang
- International Union Against Tuberculosis and Lung Disease, Paris, France,Division of Pulmonary Medicine, Department of Internal Medicine, Wan Fang Hospital, and Division of Pulmonary Medicine, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - M Innes Asher
- Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Guy B Marks
- Respiratory and Environmental Epidemiology, University of New South Wales, Sydney, NSW, Australia
| | - Asma El Sony
- Epidemiological Laboratory for Public Health, Research and Development, Khartoum, Sudan
| | - Refiloe Masekela
- Inkosi Albert Luthuli Central Hospital, College of Health Sciences, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa,Department of Paediatrics and Child Health, College of Health Sciences, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Karen Bissell
- School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Eamon Ellwood
- Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Philippa Ellwood
- Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Neil Pearce
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - David P Strachan
- Population Health Research Institute, St George's, University of London, London, UK
| | - Kevin Mortimer
- Department of Paediatrics and Child Health, College of Health Sciences, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa,Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK,Respiratory Medicine, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK,Department of Medicine, University of Cambridge, Cambridge, UK
| | - Eva Morales
- Department of Public Health Sciences, University of Murcia and IMIB Bio-medical Research Institute, Murcia, Spain
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5
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Pembrey L, Brooks C, Mpairwe H, Figueiredo CA, Oviedo AY, Chico M, Ali H, Nambuya I, Tumwesige P, Robertson S, Rutter CE, van Veldhoven K, Ring S, Barreto ML, Cooper PJ, Henderson J, Cruz AA, Douwes J, Pearce N. Asthma inflammatory phenotypes on four continents: most asthma is non-eosinophilic. Int J Epidemiol 2022; 52:611-623. [PMID: 36040171 PMCID: PMC10114118 DOI: 10.1093/ije/dyac173] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 08/14/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Most studies assessing pathophysiological heterogeneity in asthma have been conducted in high-income countries (HICs), with little known about the prevalence and characteristics of different asthma inflammatory phenotypes in low-and middle-income countries (LMICs). This study assessed sputum inflammatory phenotypes in five centres, in Brazil, Ecuador, Uganda, New Zealand (NZ) and the United Kingdom (UK). METHODS We conducted a cross-sectional study of 998 asthmatics and 356 non-asthmatics in 2016-20. All centres studied children and adolescents (age range 8-20 years), except the UK centre which involved 26-27 year-olds. Information was collected using questionnaires, clinical characterization, blood and induced sputum. RESULTS Of 623 asthmatics with sputum results, 39% (243) were classified as eosinophilic or mixed granulocytic, i.e. eosinophilic asthma (EA). Adjusted for age and sex, with NZ as baseline, the UK showed similar odds of EA (odds ratio 1.04, 95% confidence interval 0.37-2.94) with lower odds in the LMICs: Brazil (0.73, 0.42-1.27), Ecuador (0.40, 0.24-0.66) and Uganda (0.62, 0.37-1.04). Despite the low prevalence of neutrophilic asthma in most centres, sputum neutrophilia was increased in asthmatics and non-asthmatics in Uganda. CONCLUSIONS This is the first time that sputum induction has been used to compare asthma inflammatory phenotypes in HICs and LMICs. Most cases were non-eosinophilic, including in settings where corticosteroid use was low. A lower prevalence of EA was observed in the LMICs than in the HICs. This has major implications for asthma prevention and management, and suggests that novel prevention strategies and therapies specifically targeting non-eosinophilic asthma are required globally.
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Affiliation(s)
- Lucy Pembrey
- Corresponding author. Department of Medical Statistics, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, UK. E-mail:
| | - Collin Brooks
- Centre for Public Health Research, Massey University, Wellington, New Zealand
| | | | - Camila A Figueiredo
- Institute of Collective Health, Federal University of Bahia, Salvador, Brazil
| | - Aida Y Oviedo
- Fundacion Ecuatoriana Para Investigacion en Salud, Quito, Ecuador
| | - Martha Chico
- Fundacion Ecuatoriana Para Investigacion en Salud, Quito, Ecuador
| | - Hajar Ali
- Centre for Public Health Research, Massey University, Wellington, New Zealand
| | - Irene Nambuya
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Pius Tumwesige
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Steven Robertson
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Charlotte E Rutter
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Karin van Veldhoven
- Department of Non-communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Susan Ring
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- MRC Integrative Epidemiology Unit at University of Bristol, Bristol, UK
| | - Mauricio L Barreto
- Institute of Collective Health, Federal University of Bahia, Salvador, Brazil
- Center for Data and Knowledge Integration for Health (CIDACS), Fiocruz, Bahia, Brazil
| | - Philip J Cooper
- Fundacion Ecuatoriana Para Investigacion en Salud, Quito, Ecuador
- School of Medicine, Universidad Internacional del Ecuador, Quito, Ecuador
- Institute of Infection and Immunity, St George’s University of London, London, UK
| | | | - Alvaro A Cruz
- ProAR, Federal University of Bahia, Salvador, Brazil
- Institute for Health Sciences, Federal University of Bahia, Salvador, Brazil
| | - Jeroen Douwes
- Centre for Public Health Research, Massey University, Wellington, New Zealand
| | - Neil Pearce
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
- Centre for Public Health Research, Massey University, Wellington, New Zealand
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Mortimer K, Lesosky M, García-Marcos L, Innes Asher M, Pearce N, Ellwood E, Bissell K, El Sony A, Ellwood P, Marks GB, Martínez-Torres A, Morales E, Perez-Fernandez V, Robertson S, Rutter CE, Silverwood RJ, Strachan DP, Chiang CY. The burden of asthma, hay fever and eczema in adults in 17 countries: GAN Phase I study. Eur Respir J 2022; 60:13993003.02865-2021. [PMID: 35210319 PMCID: PMC9474894 DOI: 10.1183/13993003.02865-2021] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 02/03/2022] [Indexed: 11/05/2022]
Abstract
Asthma, hay fever and eczema are three common chronic conditions. There are no recent multi-country data on the burden of these three conditions in adults; the aims of this study are to fill this evidence gap.The Global Asthma Network (GAN) Phase I is a multi-country cross-sectional population-based study using the same core methodology as the International Study of Asthma and Allergies in Childhood (ISAAC) Phase III. It provides data on the burden of asthma, hay fever, and eczema not only in children and adolescents but also for the first time in their parents/guardians.Data were available from 193 912 adults (104 061 female; mean age 38 (sd 7.5)) in 43 centres in 17 countries. The overall prevalences (range) of symptoms of current wheeze, asthma ever, hay fever ever and eczema ever were 6.6% (0.9%-32.7%), 4.4%(0.9%-29.0%), 14.4%(2.8%-45.7%), and 9.9%(1.6%-29.5%), respectively. Centre prevalence varied considerably both between countries and within countries. There was a moderate correlation between hay fever ever and asthma ever, and between eczema ever and hay fever ever at the centre level. There were moderate to strong correlations between indicators of the burden of disease reported in adults and the two younger age groups.We found evidence for a substantial burden of asthma, hay fever ever and eczema ever in countries examined highlighting the major public health importance of these diseases. Prevention strategies and equitable access to effective and affordable treatments for these three conditions would help mitigate the avoidable morbidity they cause.
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Affiliation(s)
- Kevin Mortimer
- Department of Medicine, University of Cambridge, Cambridge, UK.,Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.,Full professor
| | - Maia Lesosky
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.,School of Public Health and Family Medicine, University of Cape Town, South Africa.,Full professor
| | - Luis García-Marcos
- Paediatric Allergy and Pulmonology Units, Virgen de la Arrixaca University Children's Hospital, University of Murcia and IMIB Bio-health Research Institute, Murcia.,ARADyAL Allergy Network, Edificio Departamental-Laib, Murcia, Spain.,Full professor
| | - M Innes Asher
- Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health Sciences, University of Auckland, , Auckland, New Zealand.,Full professor
| | - Neil Pearce
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK.,Full professor
| | - Eamon Ellwood
- Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health Sciences, University of Auckland, , Auckland, New Zealand
| | - Karen Bissell
- School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Asma El Sony
- Epidemiological Laboratory (Epi-Lab) for Public Health, Research and Development, Khartoum, Sudan.,Full professor
| | - Philippa Ellwood
- Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health Sciences, University of Auckland, , Auckland, New Zealand
| | - Guy B Marks
- Respiratory & Environmental Epidemiology, University of New South Wales, , Sydney , Australia.,Full professor
| | - Antonela Martínez-Torres
- Paediatric Allergy and Pulmonology Units and Nurse Research Group, Virgen de la Arrixaca University Children's Hospital.,IMIB Bio-health Research Institute, Murcia, Edificio Departamental-Laib, Murcia, Spain
| | - Eva Morales
- Department of Public Health Sciences, University of Murcia, and IMIB Bio-health Research Institute, Edificio Departamental-Laib, Murcia, Spain
| | - Virginia Perez-Fernandez
- Department of Biostatistics, University of Murcia, and IMIB Bio-health Research Institute, Edificio Departamental-Laib, Murcia, Spain.,Full professor
| | - Steven Robertson
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Charlotte E Rutter
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Richard J Silverwood
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK.,Centre for Longitudinal Studies, UCL Social Research Institute, University College London, , London WC1H 0AL, UK
| | - David P Strachan
- Population Health Research Institute, St George's, University of London, London, UK.,Full professor
| | - Chen-Yuan Chiang
- International Union Against Tuberculosis and Lung Disease, Paris, France .,Division of Pulmonary Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University.,Division of Pulmonary Medicine, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, , Taipei , Taiwan.,Full professor.,Global Asthma Network Phase I Study Group listed at the end of the report
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García-Marcos L, Innes Asher M, Pearce N, Ellwood E, Bissell K, Chiang CY, El Sony A, Ellwood P, Marks GB, Mortimer K, Elena Martínez-Torres A, Morales E, Perez-Fernandez V, Robertson S, Rutter CE, Silverwood RJ, Strachan DP. The burden of asthma, hay fever and eczema in children in 25 countries: GAN Phase I study. Eur Respir J 2022; 60:13993003.02866-2021. [PMID: 35144987 PMCID: PMC9474895 DOI: 10.1183/13993003.02866-2021] [Citation(s) in RCA: 55] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 01/19/2022] [Indexed: 11/16/2022]
Abstract
Aims There have been no worldwide standardised surveys of prevalence and severity of asthma, rhinoconjunctivitis and eczema in school children for 15 years. The present study aims to provide this information. Methods Following the exact International Study of Asthma and Allergies in Childhood (ISAAC) methodology (cross-sectional questionnaire-based survey), Global Asthma Network (GAN) Phase I was carried out between 2015 and 2020 in many centres worldwide. Results The study included 157 784 adolescents (13–14 years of age) in 63 centres in 25 countries and 101 777 children (6–7 years of age) in 44 centres in 16 countries. The current prevalence of symptoms, respectively, was 11.0% and 9.1% for asthma, 13.3% and 7.7% for rhinoconjunctivitis and 6.4% and 5.9% for eczema. The prevalence of asthma ever was 10.5% and 7.6%, hay fever ever was 15.2% and 11.1% and eczema ever was 10.6% and 13.4%, respectively. Centres in low or lower middle gross national income countries (LICs or LMICs) had significantly lower prevalence of the three disease symptoms and diagnoses (except for hay fever). In children, the prevalence of asthma and rhinoconjunctivitis symptoms was higher in boys, while the reverse occurred among adolescents. For eczema, while the prevalence among female adolescents was double that of males, there was no sex difference among children. Centre accounted for non-negligible variability in all disease symptoms (10–20%). Conclusion The burdens of asthma, rhinoconjunctivitis and eczema vary widely among the limited number of countries studied. Although symptom prevalence is lower in LICs and LMICs, it represents a considerable burden everywhere studied. There is a substantial global burden of asthma, hay fever and eczema in adolescents and children, representing a major global public health problem. Accessible, affordable, equitable and effective strategies are needed to reduce this burden.https://bit.ly/3nXKkzd
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Affiliation(s)
- Luis García-Marcos
- Paediatric Allergy and Pulmonology Units, Virgen de la Arrixaca University Children's Hospital, University of Murcia and IMIB Bio-health Research Institute, Murcia
| | | | - Neil Pearce
- Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | | | - Karen Bissell
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Chen-Yuan Chiang
- International Union Against Tuberculosis and Lung Disease, Paris, France.,Division of Pulmonary Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University.,Division of Pulmonary Medicine, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Asma El Sony
- Epidemiological Laboratory (Epi-Lab) for Public Health, Research and Development, Khartoum, Sudan
| | | | - Guy B Marks
- Respiratory & Environmental Epidemiology, University of New South Wales, Sydney, Australia
| | - Kevin Mortimer
- Department of Medicine, University of Cambridge, Cambridge, UK.,Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - A Elena Martínez-Torres
- Paediatric Allergy and Pulmonology Units and Nurse Research Group, Virgen de la Arrixaca University Children's Hospital.,IMIB Bio-health Research Institute, Murcia, Spain
| | - Eva Morales
- Department of Public Health Sciences, University of Murcia, and IMIB Bio-health Research Institute, Murcia, Spain
| | - Virginia Perez-Fernandez
- Department of Biostatistics, University of Murcia, and IMIB Bio-health Research Institute, Murcia, Spain
| | - Steven Robertson
- Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Charlotte E Rutter
- Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Richard J Silverwood
- Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.,Centre for Longitudinal Studies, UCL Social Research Institute, University College London, London, UK
| | - David P Strachan
- Population Health Research Institute, St George's, University of London, London, UK
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8
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Strachan DP, Rutter CE, Asher MI, Bissell K, Chiang CY, El Sony A, Ellwood E, Ellwood P, García-Marcos L, Marks GB, Morales E, Mortimer K, Pearce N, Pérez-Fernández V, Robertson S, Silverwood RJ. Worldwide time trends in prevalence of symptoms of rhinoconjunctivitis in children: Global Asthma Network Phase I. Pediatr Allergy Immunol 2022; 33:e13656. [PMID: 34453861 PMCID: PMC9012331 DOI: 10.1111/pai.13656] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 07/28/2021] [Accepted: 08/19/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The Global Asthma Network (GAN), by using the International Study of Asthma and Allergies in Childhood (ISAAC) methodology, has updated trends in prevalence of symptoms of childhood allergic diseases, including non-infective rhinitis and conjunctivitis ('rhinoconjunctivitis'), which is reported here. METHODS Prevalence and severity of rhinoconjunctivitis were assessed by questionnaire among schoolchildren in GAN Phase I and ISAAC Phase I and III surveys 15-23 years apart. Absolute rates of change in prevalence were estimated for each centre and modelled by multi-level linear regression to compare trends by age group, time period and per capita national income. RESULTS Twenty-seven GAN centres in 14 countries surveyed 74,361 13- to 14-year-olds ('adolescents') and 45,434 6- to 7-year-olds ('children'), with average response proportions of 90% and 79%, respectively. Many centres showed highly significant (p < .001) changes in prevalence of rhinoconjunctivitis in the past year ('current rhinoconjunctivitis') compared with ISAAC. The direction and magnitude of centre-level trends varied significantly (p < .001) both within and between countries. Overall, current rhinoconjunctivitis prevalence decreased slightly from ISAAC Phase III to GAN: -1.32% per 10 years, 95% CI [-2.93%, +0.30%] among adolescents; and -0.44% [-1.29%, +0.42%] among children. Together, these differed significantly (p < .001) from the upward trend within ISAAC. Among adolescents, centre-level trends in current rhinoconjunctivitis were highly correlated with those for eczema symptoms (rho = 0.72, p < .0001) but not with centre-level trends in asthma symptoms (rho = 0.15, p = .48). Among children, these correlations were positive but not significant. CONCLUSION Symptoms of non-infective rhinoconjunctivitis among schoolchildren may no longer be on the increase globally, although trends vary substantially within and between countries.
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Affiliation(s)
- David P Strachan
- Population Health Research Institute, St George's, University of London, London, UK
| | - Charlotte E Rutter
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Monica Innes Asher
- Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health Sciences, University of Auckland, Private Bag, Auckland, New Zealand
| | - Karen Bissell
- School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Private Bag, Auckland, New Zealand
| | - Chen-Yuan Chiang
- International Union Against Tuberculosis and Lung Disease, Paris, France.,Division of Pulmonary Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,Division of Pulmonary Medicine, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Asma El Sony
- Epidemiological Laboratory (Epi-Lab) for Public Health, Research and Development, Khartoum, Sudan
| | - Eamon Ellwood
- Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health Sciences, University of Auckland, Private Bag, Auckland, New Zealand
| | - Philippa Ellwood
- Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health Sciences, University of Auckland, Private Bag, Auckland, New Zealand
| | - Luis García-Marcos
- Paediatric Allergy and Pulmonology Units, Virgen de la Arrixaca University Children's Hospital, University of Murcia and IMIB Bio-health Research Institute, Murcia, Spain.,ARADyAL Allergy Network, Edificio Departamental-Laib, Murcia, Spain
| | - Guy B Marks
- Respiratory & Environmental Epidemiology, University of New South Wales, Sydney, New South Wales, Australia
| | - Eva Morales
- Department of Public Health Sciences, University of Murcia, Murcia, Spain.,IMIB Bio-health Research Institute, Edificio Departamental-Laib, Murcia, Spain
| | | | - Neil Pearce
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Virginia Pérez-Fernández
- IMIB Bio-health Research Institute, Edificio Departamental-Laib, Murcia, Spain.,Department of Paediatrics, University of Murcia, Murcia, Spain
| | - Steven Robertson
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Richard J Silverwood
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK.,Centre for Longitudinal Studies, UCL Social Research Institute, University College London, London, UK
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Asher MI, Rutter CE, Bissell K, Chiang CY, El Sony A, Ellwood E, Ellwood P, García-Marcos L, Marks GB, Morales E, Mortimer K, Pérez-Fernández V, Robertson S, Silverwood RJ, Strachan DP, Pearce N. Worldwide trends in the burden of asthma symptoms in school-aged children: Global Asthma Network Phase I cross-sectional study. Lancet 2021; 398:1569-1580. [PMID: 34755626 PMCID: PMC8573635 DOI: 10.1016/s0140-6736(21)01450-1] [Citation(s) in RCA: 143] [Impact Index Per Article: 47.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 06/16/2021] [Accepted: 06/23/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Asthma is the most common chronic disease in children globally. The Global Asthma Network (GAN) Phase I study aimed to determine if the worldwide burden of asthma symptoms is changing. METHODS This updated cross-sectional study used the same methods as the International study of Asthma and Allergies in Childhood (ISAAC) Phase III. Asthma symptoms were assessed from centres that completed GAN Phase I and ISAAC Phase I (1993-95), ISAAC Phase III (2001-03), or both. We included individuals from two age groups (children aged 6-7 years and adolescents aged 13-14 years) who self-completed written questionnaires at school. We estimated the 10-year rate of change in prevalence of current wheeze, severe asthma symptoms, ever having asthma, exercise wheeze, and night cough (defined by core questions in the questionnaire) for each centre, and we estimated trends across world regions and income levels using mixed-effects linear regression models with region and country income level as confounders. FINDINGS Overall, 119 795 participants from 27 centres in 14 countries were included: 74 361 adolescents (response rate 90%) and 45 434 children (response rate 79%). About one in ten individuals of both age groups had wheeze in the preceding year, of whom almost half had severe symptoms. Most centres showed a change in prevalence of 2 SE or more between ISAAC Phase III to GAN Phase I. Over the 27-year period (1993-2020), adolescents showed a significant decrease in percentage point prevalence per decade in severe asthma symptoms (-0·37, 95% CI -0·69 to -0·04) and an increase in ever having asthma (1·25, 0·67 to 1·83) and night cough (4·25, 3·06 to 5·44), which was also found in children (3·21, 1·80 to 4·62). The prevalence of current wheeze decreased in low-income countries (-1·37, -2·47 to -0·27], in children and -1·67, -2·70 to -0·64, in adolescents) and increased in lower-middle-income countries (1·99, 0·33 to 3·66, in children and 1·69, 0·13 to 3·25, in adolescents), but it was stable in upper-middle-income and high-income countries. INTERPRETATION Trends in prevalence and severity of asthma symptoms over the past three decades varied by age group, country income, region, and centre. The high worldwide burden of severe asthma symptoms would be mitigated by enabling access to effective therapies for asthma. FUNDING International Union Against Tuberculosis and Lung Disease, Boehringer Ingelheim New Zealand, AstraZeneca Educational Grant, National Institute for Health Research, UK Medical Research Council, European Research Council, and Instituto de Salud Carlos III.
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Affiliation(s)
- M Innes Asher
- Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.
| | - Charlotte E Rutter
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Karen Bissell
- School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Chen-Yuan Chiang
- International Union Against Tuberculosis and Lung Disease, Paris, France; Division of Pulmonary Medicine, Department of Internal Medicine, Wan Fang Hospital, and Division of Pulmonary Medicine, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Asma El Sony
- Epidemiological Laboratory for Public Health, Research and Development, Khartoum, Sudan
| | - Eamon Ellwood
- Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Philippa Ellwood
- Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Luis García-Marcos
- Paediatric Allergy and Pulmonology Units, Virgen de la Arrixaca University Children's Hospital, University of Murcia and IMIB Bio-health Research Institute, Murcia, Spain; ARADyAL Allergy Network, Murcia, Spain
| | - Guy B Marks
- Respiratory & Environmental Epidemiology, University of New South Wales, Sydney, NSW, Australia
| | - Eva Morales
- Department of Public Health Sciences, University of Murcia, and IMIB Bio-health Research Institute, Murcia, Spain
| | - Kevin Mortimer
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Virginia Pérez-Fernández
- Department of Paediatrics, University of Murcia, and IMIB Bio-health Research Institute, Murcia, Spain
| | - Steven Robertson
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Richard J Silverwood
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK; Centre for Longitudinal Studies, UCL Social Research Institute, University College London, London, UK
| | - David P Strachan
- Population Health Research Institute, St George's, University of London, London, UK
| | - Neil Pearce
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
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Rutter CE, Silverwood RJ, Asher MI, Ellwood P, Pearce N, Garcia-Marcos L, Strachan DP. Comparison of individual-level and population-level risk factors for rhinoconjunctivitis, asthma, and eczema in the International Study of Asthma and Allergies in Childhood (ISAAC) Phase Three. World Allergy Organ J 2020; 13:100123. [PMID: 32642022 PMCID: PMC7334817 DOI: 10.1016/j.waojou.2020.100123] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 04/08/2020] [Accepted: 04/24/2020] [Indexed: 12/22/2022] Open
Abstract
Background Symptoms of asthma, allergic rhinoconjunctivitis, and atopic eczema in children cluster at both the individual and population levels. Objectives To assess individual-level and school-level risk factors for symptoms of rhinoconjunctivitis and compare them to corresponding associations with symptoms of asthma and eczema in Phase Three of the International Study of Asthma and Allergies in Childhood. Methods We studied 116,863 children aged 6–7 years from 2163 schools in 59 centres and 22 countries and 224,436 adolescents aged 13–14 years from 2037 schools in 97 centres in 41 countries. Multilevel logistic regression models were fitted with random intercepts for school, centre, and country, adjusting for sex and maternal education at the child level. Associations between symptoms and a range of lifestyle and environmental risk factors were assessed for both the child's exposure and mean exposure at the school. Models were fitted for rhinoconjunctivitis, asthma, and eczema singly (unimorbidity) and for combinations of these conditions (multimorbidity). Results Generally, associations between symptoms and exposures at the school level were similar in direction and magnitude to those at the child level. Associations with multimorbidity were stronger than for unimorbidity, particularly in individuals with symptoms of all three diseases, but risk factor associations found in conventional single disease analyses persisted among children with only one condition, after excluding multimorbid groups. Comparisons of individuals with only one disease showed that many risk factor associations were consistent across the three conditions. More strongly associated with asthma were low birthweight, cat exposure in infancy, and current maternal smoking. Current paracetamol use was more strongly associated with asthma and rhinoconjunctivitis than eczema. Breastfeeding was more strongly associated with eczema than asthma or rhinoconjunctivitis. The direction and magnitude of most risk factor associations were similar in affluent and non-affluent countries, although notable exceptions include farm animal contact in infancy and larger sibships, which were associated with increased risk of rhinoconjunctivitis in non-affluent countries but reduced risk in affluent countries. In both age groups, current paracetamol use increased risk of each disease to a greater extent in affluent countries than in non-affluent countries. Effects of paracetamol and antibiotics in infancy were more consistent between richer and poorer settings. Conclusions Most of the environmental and lifestyle correlates of rhinoconjunctivitis, asthma and eczema in childhood display similarity across the three conditions, even in less affluent settings where allergic sensitisation is less likely to explain the concordant epidemiological patterns. Trial registration Not applicable.
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Affiliation(s)
- Charlotte E Rutter
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Richard J Silverwood
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom.,Centre for Longitudinal Studies, Department of Social Science, University College London, London, United Kingdom
| | - M Innes Asher
- Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health Sciences, University of Auckland, New Zealand
| | - Philippa Ellwood
- Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health Sciences, University of Auckland, New Zealand
| | - Neil Pearce
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom.,Centre for Global NCDs, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Luis Garcia-Marcos
- Pediatric Allergy and Pulmonology Units, 'Virgen de La Arrixaca' University Children's Hospital, University of Murcia, ARADyAL Network and IMIB Bioresearch Institute, Murcia, Spain
| | - David P Strachan
- Population Health Research Institute, St George's University of London, London, United Kingdom
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Rutter CE, Silverwood RJ, Williams HC, Ellwood P, Asher I, Garcia-Marcos L, Strachan DP, Pearce N, Langan SM. Are Environmental Factors for Atopic Eczema in ISAAC Phase Three due to Reverse Causation? J Invest Dermatol 2019; 139:1023-1036. [PMID: 30521836 PMCID: PMC6478380 DOI: 10.1016/j.jid.2018.08.035] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 08/29/2018] [Accepted: 08/30/2018] [Indexed: 11/26/2022]
Abstract
Some previously described environmental associations for atopic eczema may be due to reverse causation. We explored the role of reverse causation by comparing individual- and school-level results for multiple atopic eczema risk factors. The International Study of Asthma and Allergies in Childhood (i.e, ISAAC) Phase Three surveyed children in schools (the sampling unit) regarding atopic eczema symptoms and potential risk factors. We assessed the effect of these risk factors on atopic eczema symptoms using mixed-effect logistic regression models, first with individual-level exposure data and second with school-level exposure prevalence. Overall, 546,348 children from 53 countries were included. At ages 6-7 years, the strongest individual-level associations were with current paracetamol use (odds ratio [OR] = 1.45, 95% confidence interval [CI] = 1.37-1.54), which persisted at school-level (OR = 1.55, 95% CI = 1.10-2.21), early-life antibiotics (OR = 1.41, 95% CI = 1.34-1.48), and early-life paracetamol use (OR = 1.28, 95% CI = 1.21-1.36), with the former persisting at the school level, whereas the latter was no longer observed (OR = 1.35, 95% CI = 1.00-1.82 and OR = 0.94, 95% CI = 0.69-1.28, respectively). At ages 13-14 years, the strongest associations at the individual level were with current paracetamol use (OR = 1.57, 95% CI = 1.51-1.63) and open-fire cooking (OR = 1.46, 95% CI = 1.33-1.62); both were stronger at the school level (OR = 2.57, 95% CI = 1.84-3.59 and OR = 2.38, 95% CI = 1.52-3.73, respectively). Association with exposure to heavy traffic (OR = 1.31, 95% CI = 1.27-1.36) also persisted at the school level (OR = 1.40, 95% CI = 1.07-1.82). Most individual- and school-level effects were consistent, tending to exclude reverse causation.
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Affiliation(s)
- Charlotte E Rutter
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Richard J Silverwood
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Hywel C Williams
- Centre of Evidence-Based Dermatology, University of Nottingham, Nottingham, UK
| | - Philippa Ellwood
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Innes Asher
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Luis Garcia-Marcos
- Pediatric Allergy and Pulmonology Units, Virgen de la Arrixaca University Children's Hospital, University of Murcia and IMIB Bioresearch Institute, Murcia, Spain
| | - David P Strachan
- Population Health Research Institute, St George's University of London, London, UK
| | - Neil Pearce
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK; Red de Asma, Reacciones Adversas y Alérgicas, Madrid, Spain; Centre for Public Health Research, Massey University, Wellington, New Zealand
| | - Sinéad M Langan
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK.
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12
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Silverwood RJ, Rutter CE, Mitchell EA, Asher MI, Garcia‐Marcos L, Strachan DP, Pearce N. Are environmental risk factors for current wheeze in the International Study of Asthma and Allergies in Childhood (ISAAC) phase three due to reverse causation? Clin Exp Allergy 2019; 49:430-441. [PMID: 30508327 PMCID: PMC6487816 DOI: 10.1111/cea.13325] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 10/19/2018] [Accepted: 11/04/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Phase Three of the International Study of Asthma and Allergies in Childhood (ISAAC) measured the global prevalence of symptoms of asthma in children. We undertook comprehensive analyses addressing risk factors for asthma symptoms in combination, at both the individual and the school level, to explore the potential role of reverse causation due to selective avoidance or confounding by indication. OBJECTIVE To explore the role of reverse causation in risk factors of asthma symptoms. METHODS We compared two sets of multilevel logistic regression analyses, using (a) individual level exposure data and (b) school level average exposure (ie prevalence), in two different age groups. In individual level analyses, reverse causation is a possible concern if individual level exposure statuses were changed as a result of asthma symptoms or diagnosis. School level analyses may suffer from ecologic confounding, but reverse causation is less of a concern because individual changes in exposure status as a result of asthma symptoms would only have a small effect on overall school exposure levels. RESULTS There were 131 924 children aged 6-7 years (2428 schools, 25 countries) with complete exposure, outcome and confounder data. The strongest associations in individual level analyses (fully adjusted) were for current paracetamol use (odds ratio = 2.06; 95% confidence interval 1.97-2.16), early life antibiotic use (1.65; 1.58-1.73) and open fire cooking (1.44; 1.26-1.65). In school level analyses, these risk factors again showed increased risks. There were 238 586 adolescents aged 13-14 years (2072 schools, 42 countries) with complete exposure, outcome and confounder data. The strongest associations in individual level analyses (fully adjusted) were for current paracetamol use (1.80; 1.75-1.86), cooking on an open fire (1.32; 1.22-1.43) and maternal tobacco use (1.23; 1.18-1.27). In school level analyses, these risk factors again showed increased risks. CONCLUSIONS & CLINICAL RELEVANCE These analyses strengthen the potentially causal interpretation of previously reported individual level findings, by providing evidence against reverse causation.
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Affiliation(s)
- Richard J. Silverwood
- Department of Medical StatisticsLondon School of Hygiene and Tropical MedicineLondonUK
| | - Charlotte E. Rutter
- Department of Medical StatisticsLondon School of Hygiene and Tropical MedicineLondonUK
| | - Edwin A. Mitchell
- Department of Paediatrics: Child and Youth HealthFaculty of Medical and Health SciencesUniversity of AucklandAucklandNew Zealand
| | - M. Innes Asher
- Department of Paediatrics: Child and Youth HealthFaculty of Medical and Health SciencesUniversity of AucklandAucklandNew Zealand
| | - Luis Garcia‐Marcos
- Pediatric Allergy and Pulmonology Units‘Virgen de la Arrixaca’ University Children's HospitalUniversity of Murcia and IMIB Bioresearch InstituteMurciaSpain
| | - David P. Strachan
- Population Health Research InstituteSt George's University of LondonLondonUK
| | - Neil Pearce
- Department of Medical StatisticsLondon School of Hygiene and Tropical MedicineLondonUK
- Centre for Global NCDsLondon School of Hygiene and Tropical MedicineLondonUK
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