Gustavo Falbo Wandalsen

Prevalence of symptoms of asthma, rhinitis, and atopic eczema among Brazilian children and adolescents identified by the International Study of Asthma and Allergies in Childhood (ISAAC): phase 3

OBJECTIVES To determine the prevalence of symptoms of asthma, rhinitis, and atopic eczema among schoolchildren aged 6 to 7 years and adolescents aged 13 to 14 years in 20 Brazilian cities by using the standardized ISAAC written questionnaire, and to assess the association of this prevalence with latitude, altitude and average annual temperature of collaborating centers. METHODS Schoolchildren and adolescents from five Brazilian regions participated in the study, totaling 23,422 ISAAC questionnaires answered by schoolchildrens parents and 58,144 questionnaires answered by adolescents. The values for latitude, altitude and average annual temperature were obtained from the Brazilian Institute of Geography and Statistics. RESULTS The mean prevalence rates among schoolchildren and adolescents were respectively 24.3 and 19.0% for active asthma; 12.6 and 14.6% for rhinoconjunctivitis; and 8.2 and 5.0% for atopic eczema. A significant negative association was observed between latitude and physician-diagnosed asthma among schoolchildren, severe asthma, physician-diagnosed asthma, eczema and atopic eczema among adolescents. No association with altitude was found. CONCLUSIONS The prevalence of asthma, rhinitis and atopic eczema in Brazil varies considerably. Higher prevalence rates, especially of asthma and eczema, were found at centers located closer to the equator.

Prevalência de sintomas de asma, rinite e eczema atópico entre crianças e adolescentes brasileiros identificados pelo International Study of Asthma and Allergies (ISAAC): fase 3

OBJETIVO: Determinar a prevalencia de sintomas relacionados a asma, rinite e eczema atopico em escolares (EC) entre 6 e 7 anos e adolescentes (AD) entre 13 e 14 anos, residentes em 20 cidades brasileiras, empregando o questionario escrito padronizado do ISAAC, e avaliar a sua associacao com a latitude, altitude e temperatura media anual dos centros de residencia. METODOS: Participaram do estudo EC e AD das cinco regioes do Brasil, totalizando 23.422 questionarios ISAAC respondidos pelos pais de EC e 58.144 pelos proprios AD. Os indices de latitude, altitude e temperatura media anual foram obtidos do Instituto Brasileiro de Geografia e Estatistica. RESULTADOS: As prevalencias medias para os EC e AD, respectivamente, foram: asma ativa, 24,3 e 19,0%; rinoconjuntivite, 12,6 e 14,6%; e eczema flexural, 8,2 e 5,0%. Associacao significante e negativa foi observada entre latitude e prevalencia de asma diagnosticada por medico para os EC, asma grave, asma diagnosticada por medico, eczema e eczema flexural para os AD. Nao houve associacao com a altitude dos centros. CONCLUSAO: A prevalencia de asma, rinite e eczema atopico no Brasil foi variavel. Valores mais altos, sobretudo de asma e eczema, foram observados nos centros localizados mais proximos ao Equador.

Is rhinitis alone or associated with atopic eczema a risk factor for severe asthma in children

The objective of this study was to evaluate the role of rhinitis (R) and atopic eczema (E) on asthma severity among asthmatic (A) schoolchildren identified by the International Study of Asthma and Allergies in Childhood written questionnaire (WQ). WQ was applied to parents of 6–7‐yr‐old schoolchildren (SC, n = 3033), and to adolescents (AD, 13–14 yr old, n = 3487), living in São Paulo, Brazil. An affirmative response to ‘has your child/have you had wheezing/whistling in the last year’ identified those with A, and an affirmative response to ‘the last 12 months has your child/have you had sneezing/runny/blocked nose when he/she you did not have a cold/flu?’ identified those with R. Subjects with an affirmative response to ‘has your child/have you had this itchy rash at any time in the past 12 months?’ were identified as having E. Subjects who had R associated with A were identified as AR and those with A associated with R and E as ARE. A who had at least two affirmative responses to questions for asthma severity: speech disturbance, more than four acute attacks, sleep disturbance, and wheezing with exercise were defined as having severe asthma. 22.1% AD and 24.3% SC were identified as A; 47.1% of those AD and 42.0% SC had AR and 10.0% of those AD and 12.8% of SC had ARE. Considering ARE, AR and A groups, speech disturbance during an acute episode of asthma was significantly higher among ARE AD (20.0% vs. 11.5% vs. 8.7%, p < 0.05), and ARE SC (22.1% vs. 13.9% vs. 10.5%, p < 0.05) in comparison with A. Likewise, more than four acute attacks in the last year was significantly higher among ARE AD (24.0% vs. 14.0% vs. 10.5%, p < 0.05) and ARE SC (32.6% vs. 19.4% vs. 12.8%, p < 0.05) as the frequency of sleep disturbance due to wheezing, for AD (61.3% vs. 42.0% vs. 38.4%, p < 0.05) and SC (77.9% vs. 67.3% vs. 58.4%, p < 0.001) and for ‘wheezing associated with exercise’ for AD (72.0% vs. 47.5% vs. 39.9%, p < 0.001) and SC (36.8% vs. 31.4% vs. 14.1%, p < 0.001). Prevalence of severe asthma was higher among ARE AD (57.3% vs. 31.9% vs. 27.0%, p < 0.05) and ARE SC (52.6% vs. 36.9% vs. 22.5%). In patients with A, the presence of R or E are risk factors for severe asthma, and both together (R and E) are a higher risk.

Avaliação de critérios para o diagnóstico de asma através de um questionário epidemiológico

OBJECTIVE To evaluate criteria for the diagnosis of asthma in an epidemiological survey. METHODS Adolescents (13-14 years of age) and legal guardians of schoolchildren (6-7 years of age) in the city of Santo André, Brazil, completed the International Study of Asthma and Allergies in Childhood (ISAAC) standard written questionnaire. Affirmative responses regarding wheezing within the last 12 months, asthma ever, bronchitis ever (question added at the end of the questionnaire), as well as the overall ISAAC score above the predefined cutoff points, were considered indicative of asthma. RESULTS The legal guardians of 2,180 schoolchildren and 3,231 adolescents completed the questionnaires properly. Depending on the criterion adopted, the prevalence of asthma ranged from 4.9% to 26.8% for the schoolchildren and from 8.9% to 27.9% for the adolescents. The criteria with the lowest and highest prevalences were, respectively, physician-diagnosed asthma and physician-diagnosed bronchitis. When compared with other criteria, physician-diagnosed bronchitis showed concordance levels between 71.9% and 79.4%, positive predictive values between 0.16 and 0.63 and poor concordance (kappa: 0.21-0.46). Strong concordance levels were found only between wheezing within the last 12 months and the overall ISAAC score (kappa: 0.82 and 0.98). CONCLUSIONS The prevalence of asthma varied significantly, depending on the criterion adopted, and there was poor concordance among the criteria. Wheezing within the last 12 months and the overall ISAAC score are the best criteria for the diagnosis of asthma, whereas the question regarding bronchitis ever did not improve the questionnaire. Modifications in this instrument can make it difficult to draw comparisons and should therefore be carefully evaluated.

Is the prevalence of asthma and related symptoms among Brazilian children related to socioeconomic status

Objective. To evaluate the relationship between socioeconomic status (SES) and the prevalence of asthma and related symptoms among Brazilian children. Methods. The International Study of Asthma and Allergies in Childhood (ISAAC) written questionnaire was applied to 23,457 six- to seven- year-old schoolchildren (SC) and 58,144 thirteen- to fourteen-year-old adolescents (AD) from 20 Brazilian cities. SES was evaluated by infant mortality index, poverty index, and average nominal income for people older than 10 years of age. Results. Current asthma ranged from 16.5% to 31.2% among SC and from 11.8% to 30.5% among AD and severe asthma from 2.9% to 8.5% (SC) and 2.6% to 9.1% (AD). Higher values were observed in Brazilian-Northern, -Northeastern and -Southeastern centers. No significant association between SES and prevalence of asthma and related symptoms was observed. Conclusions. In Brazil, the prevalence of asthma and related symptoms is quite variable and independent of SES.

Pulmonary complications in patients with antibody deficiency

OBJECTIVE The aim of this study was to evaluate pulmonary complications in patients with primary antibody deficiency (X-linked agammaglobulinaemia [XLA] and common variable immunodeficiency [CVID]). METHODS Thirty patients over six years of age regularly followed in a reference out-patient clinic on primary immunodeficiency were studied. All of them have been treated with intravenous immunoglobulin (IVIG) replacement therapy. Pulmonary complications were evaluated analysing clinical data (medical records review), lung function test (spirometry) and pulmonary imaging (chest computed tomography [CCT]). RESULTS Patients with normal CCT (N = 14) and those with abnormal CCT (N = 16) have shown no differences regarding the age at onset of symptoms, age of diagnosis, and duration of IVIG treatment. The mean number of pneumonia episodes before IVIG replacement was significantly higher among patients with abnormal CCT (4 vs 7 episodes, p = 0.008). CCT abnormalities observed in 16 patients were: bronchiectasis (12/16); peribronchial thickening (3/16); air trapping (5/16); lung volume reduction (4/16); atelectasis (2/16), follicular bronchiolitis and ground-glass abnormality (2/16) and parenchyma nodule (1/16). Lung function tests showed ventilatory disturbance in 18/30: obstructive pattern in 38.8%, restrictive pattern in 44.4%, and mix pattern in 16.7%. There were no significant differences in lung function between those with and without CCT abnormalities. Negative significant correlations were observed between lung function and number of episodes of pneumonia. Chronic persistent cough was associated with a reduction in lung function. CONCLUSIONS Pulmonary complications are not rare in patients with antibody deficiencies and they must be monitored.

Prevalência e gravidade da sibilância no primeiro ano de vida

Objetivo: Avaliar a prevalencia e a gravidade da sibilância, bem como sua relacao com o diagnostico medico de asma, em lactentes no primeiro ano de vida, utilizando o protocolo padronizado do “Estudio Internacional de Sibilancias en Lactantes” (EISL, Estudo Internacional de Sibilâncias em Lactentes). Metodos: Entre marco de 2005 e agosto de 2006, os pais ou responsaveis de lactentes que procuraram unidades basicas de saude na regiao centro-sul de Sao Paulo (SP) para procedimentos de rotina e imunizacao responderam ao questionario escrito do EISL. Resultados: A amostra foi constituida por 1.014 lactentes (media de idade = 5,0 ± 3,0 meses), 467 (46,0%) dos quais apresentaram sibilância no primeiro ano de vida, sendo que 270 (26,6%) tiveram tres ou mais episodios. Entre esses ultimos, o uso de β 2 -agonista inalatorio, corticosteroide inalatorio e antileucotrieno, assim como a presenca de sintomas noturnos, dificuldade para respirar, pneumonia, idas ao pronto socorro e internacao por sibilância grave, foram significantemente mais frequentes (p < 0,05). Os pais de 35 (7,5%) dos 467 lactentes relataram o diagnostico medico de asma, o qual foi associado ao uso de corticosteroide inalatorio, percepcao de falta de ar durante as crises e seis ou mais episodios de sibilância no primeiro ano de vida. Entretanto, menos de 40% desses lactentes recebiam corticosteroide inalatorio ou antileucotrieno como tratamento. Conclusoes: A prevalencia da sibilância no primeiro ano de vida de lactentes no estudo foi alta e teve inicio precoce. A proporcao de lactentes diagnosticados e tratados como asmaticos foi baixa. Descritores: Asma/diagnostico; Asma/epidemiologia; Sons respiratorios.

Objective Improvement in Nasal Congestion and Nasal Hyperreactivity with Use of Nasal Steroids in Persistent Allergic Rhinitis

Objective Our objective was to evaluate the action of topical nasal steroid in nasal congestion and nasal hyper-reactivity in children and adolescents with persistent allergic rhinitis. Methods Twenty atopic children and adolescents (6 to 18 years) with moderate-to-severe persistent allergic rhinitis (PAR) were treated with mometasone furoate (100 μg once a day) for 21 days. At the beginning and end of treatment, the following were recorded: a) nasal symptoms score; b) several parameters of nasal congestion measured by acoustic rhinometry (SRE 2000 Rhinometrics); c) degree of nasal hyper-reactivity to histamine (concentration of histamine necessary to induce at least 100% increase in total nasal resistance during nasal provocation test). Data were compared with those from 20 controls. Results Compared to controls, PAR patients had significantly higher score of symptoms, as well as higher degree of nasal hyper-reactivity and lower nasal volumes. After treatment, there was a significant decrease in the mean nasal symptoms score (8.0 versus 3.8; p < 0.001) and in the nasal hyper-reactivity (histamine concentration: 0.72 mg/ml versus 2.60 mg/ml; p < 0.001). Congestion improvement was observed by the increase in all acoustic rhinometry parameters. Among all studied volumes, the volume in the segment between 2 and 5 cm showed the highest mean increase (19.8%). Conclusions Treatment with topical nasal steroid objectively reduced nasal congestion and nasal histamine hyper-reactivity in children and adolescents with PAR.

Prevalence of rhinitis-related symptoms in Latin American children - results of the International Study of Asthma and Allergies in Childhood (ISAAC) phase three.

Solé D, Mallol J, Camelo‐Nunes IC, Wandalsen GF, Latin American ISAAC Study Group. Prevalence of rhinitis‐related symptoms in Latin American children – Results of the International Study of Asthma and Allergies in Childhood (ISAAC) phase three.
Pediatr Allergy Immunol 2010: 21: e127–e136.
© 2009 John Wiley & Sons A/S

Ecological correlation among prevalence of asthma symptoms, rhinoconjunctivitis and atopic eczema with notifications of tuberculosis and measles in the Brazilian population

This study aims to assess the relationship among incidence of tuberculosis and measles, in the general population, within the year of birth and the prevalence of asthma, rhinoconjunctivitis and atopic eczema in teenagers from different Brazilian cities enrolled in the International Study of Asthma and Allergies in Childhood (ISAAC) phases I and III. Positive answers to the questions: ‘Have you had wheezing or whistling in the chest in the past 12 months?’, ‘In the past 12 months, has this nose problem been accompanied by itchy‐watery eyes?’ and ‘Has this itchy rash at any time affected any of the following places: the folds of the elbows, behind the knees, in front of the ankles, under the buttocks, or around the neck, ears or eyes?’ identified the teenagers with asthma, rhinoconjunctivitis, and atopic eczema, respectively. The incidence of tuberculosis and measles, in the general population, observed in the year of birth of the enrolled teenagers (1981/82 and 1988/89) were obtained from governmental agencies: National Foundation of Health (FUNASA) and Brazilian Institute of Geography and Statistics (IBGE). They were compared with the prevalence of asthma, rhinoconjunctivitis and atopic eczema reported in both ISAAC phases I and III. Although we observed reduction of the incidence of tuberculosis and measles in the general population in all cities, the prevalence of asthma, rhinoconjunctivitis and atopic eczema remained stable in most of the centers. In Pernambuco and Paraná, there has been a significant increase in the prevalence of rhinoconjunctivitis. These data do not corroborate the findings of an inverse relationship between the prevalence of atopic diseases and the decreasing incidence of tuberculosis and measles.