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ABC of Allergies

ABC of Allergies

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 ABC of allergies
 The epidemiology of allergic disease
D Jarvis, P Burney
 Atopy is defined as the production of specific IgE in response toexposure to common environmental allergens, such as housedust mite, grass, and cat. Being atopic is strongly associated withallergic disease such as asthma, hay fever, and eczema, but not everyone with atopy develops clinical manifestations of allergyand not everyone with a clinical syndrome compatible withallergic disease can be shown to be atopic when tested for specific IgE to a wide range of environmental allergens. This isparticularly so for asthma. Asthma is arguably the most serious of the allergic diseasesin that it is disabling (causing more than 100 000 hospitaladmissions each year in England and Wales) and occasionallyfatal. In 1995, 137 people aged under 45 died as a result of asthma. Although concern has been expressed that deathcertificates may overestimate or underestimate asthma mortalitydepending on diagnostic fashion, significant misclassification with other forms of chronic obstructive lung disease in this agegroup is unlikely. In the early 1960s asthma mortality increaseddramatically in many countries. The increase was attributed tothe excessive use of non-selective
agonists, which weresubsequently withdrawn from the market. More recent increasesin asthma mortality reported from Britain, France, and theUnited States may be related to increased prevalence or severityof asthma or inadequate health care. Evidence for the latter comes from audits and confidential inquiries that showinadequate treatment of asthma in the months leading up todeath and during the fatal attack and the observation of higher mortality in populations recognised as often receiving poor health care (socioeconomically deprived people in Britain; blackpeople in the United States). In England and Wales asthmamortality rose between the mid-1970s and the mid-1980s but declined steadily during the early 1990s.Hay fever and eczema are important causes of morbidity, being responsible for a substantial proportion of health serviceuse, particularly in primary care, and reduced quality of life.
Prevalence
Time trends
 The prevalence of diseases associated with atopy has increasedin many parts of the world over the past 20 to 30 years. In theUnited Kingdom the prevalence of diagnosed asthma andsymptoms strongly suggestive of asthma in children hasincreased at a rate of about 5% a year. Increases of a similar magnitude have been observed in Sweden, Switzerland, Norway,the United States, Australia, New Zealand, and Taipei. Some of this apparent rise may have occurred in response to greater public awareness of asthma and a greater tendency of parentsto report wheezing illnesses in their children and to attend their doctor for treatment of asthma.Few serial surveys have examined an increase in objectivemarkers for asthma, although the prevalence of exerciseinduced bronchial constriction has increased in Welshschoolchildren over 15 years, suggesting that the increase inreported symptoms reflects a genuine change in health status.Few reported serial surveys have examined the prevalence of asthma in adults, although the proportion of military recruits with asthma has increased in Finland, Sweden, and Israel.
1995
Year 
    M   o   r   t   a    l    i   t   y    /   m    i    l    l    i   o   n   p   o   p   u    l   a   t    i   o   n
199019851980197519701965 15025303520
Age standardised asthma mortality, England and Wales, 1969-94 (both sexes,15-64 years)
Year of survey 
    P   r   e   v   a    l   e   n   c   e    (    %    )
200019901980197019601950 0.10101001
Changes in prevalence of asthma and wheeze, according to surveysconducted 1956-93 worldwide
1990
Year 
    P   r   e   v   a    l   e   n   c   e    (    %    )
198019700101520Wheeze in past 12 monthsAsthma ever>25% drop in peak expiratory flow after exerciseEczema everHay fever ever5
Change in prevalence of wheeze, asthma, exercise induced bronchialconstriction, hay fever, and eczema in children in south Wales between 1973and 1988
607
BMJ
VOLUME 316 21 FEBRUARY 1998
on 6 January 2009bmj.comDownloaded from
 
Most of the surveys that have shown increases in theprevalence of asthma have also shown increases in theprevalence of other allergic diseases, such as hay fever andeczema. In the United Kingdom, results from the three national birth cohorts (samples of people born in 1946, 1958, and 1970)have shown a marked increase (5.1%, 7.3%, and 12.2%respectively) in the prevalence of eczema as reported by themother in children aged under 5. The rising prevalence of allergic disease has resulted inincreased use of health services. For asthma, hospitaladmissions (particularly among children aged under 5 years),consultation with general practitioners, and the use of drug treatment all rose sharply during the 1980s. Consultations withgeneral practitioners for managing hay fever also increased. The increased prevalence of all allergic diseases suggeststhat the prevalence of atopy has increased. Epidemiologicalinformation from Switzerland and Japan shows that theprevalence of atopy is increasing in children. In both thesestudies the increase in the prevalence of atopy was due to anincrease in sensitisation to a variety of allergens and not dominated by an increase in sensitisation to one particular allergen. In Britain no evidence exists that exposure to allergenhas increased
in fact grass pollen levels have steadily decreasedover the past 20 years and pet ownership has probably not changed. At present the extent to which changes in theprevalence of atopy and changes in allergen exposure explainthe time trends in allergic disease is unknown.
Geographical distribution
Until recently the methods used for assessing the prevalence of allergic disease were not standardised and comparisons of disease prevalence between countries were flawed. Two major research initiatives, the European Community respiratoryhealth survey (ECRHS) and the international study of asthmaand allergies in childhood (ISAAC) have developed andexecuted standardised protocols for the assessment of diseaseprevalence in many different countries in adults and children. The European Community respiratory health survey hasshown wide geographical variation in the reported prevalenceof symptoms highly suggestive of asthma, treatment for asthma,and current hay fever or nasal allergies in adults. In general,symptoms are more common in New Zealand, Australia, theBritish Isles, and the United States than in mainland Europe,although there is wide variation even within some countries. The distribution of atopy (for these purposes defined assensitisation to house dust mite, grass, cat, or cladosporiumspecies) shows a similar distribution, with marked variation between countries, although the extent to which variation inatopy explains variation in symptoms is still under investigation.
IndiaAlgeriaUnited StatesAustraliaand NewZealandAlgeriaUnited StatesAustraliaand NewZealandUnited StatesAustraliaand NewZealandIndia
Areas with high (red) and low (blue) prevalence of asthma (top), hay feverand nasal allergies (centre), and sensitisation to any one of house dust mite,cat, timothy grass, or cladosporium species (bottom), according to results of the European Community respiratory health survey (white circles represent areas that participated in the study but which did not have a particularlyhigh or low prevalence)
Year 
    P   r   e   v   a    l   e   n   c   e    (    %    )   o    f   s   e   n   s    i   t    i   s   a   t    i   o   n   t   o   c   o   m   m   o   n   a    l    l   e   r   g   e   n   s
01975 1980 1985 1990 19952030JapanSwitzerland405010
Change in prevalence of sensitisation to common allergens inschoolchildren in Japan and Switzerland
608
BMJ
VOLUME 316 21 FEBRUARY 1998
on 6 January 2009bmj.comDownloaded from

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