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DE LA SALLE HEALTH SCIENCES INSTITUTE COLLEGE OF MEDICINEDEPARTMENT OF FAMILY AND COMMUNITY MEDICINE

CM2 SY 2011-2012

OUTPUT 2: REVIEW OF RELATED LITERATURE (REVISED)

Group 1A, Dr. Abong

Research Question: Is there a difference in the prevalence of allergic rhinitis in high school students, aged 13-14,of selected schools in Dasmarias, Cavite based on their exposure to air-conditioned rooms?

General Objective: To determine if there is a difference in the prevalence of allergic rhinitis in high schoolstudents, aged 13-14, of selected schools in Dasmarias, Cavite based on their exposure to air-conditioned rooms.

Specific Objectives:

o To identify the prevalence of allergic rhinitis among high school students, aged 13-14, of selected

schools in of Dasmarias, Cavite based on their exposure to air-conditioned rooms.o

To identify the prevalence of allergic rhinitis among high school students, aged 13-14, of selectedschools in Dasmarias, Cavite based on their exposure to non-air-conditioned classrooms.o To determine which studying environment is more suitable in the prevention of allergic rhinitis.

Background Information Regarding the Research Question:

According to a demographic and epidemiologic study by Settipane, allergic rhinitis affects more than 20% of theAmerican population. [1] This percentage is alarming on its own, making allergic rhinitis fairly common among thepopulation. Furthermore, it was observed by the ISAAC (International Study of Allergy and Asthma in Children)that the Philippines was ranked with the highest prevalence rate of common allergies (rhinitis and asthma) -encompassing countries like Thailand, Indonesia, and South Korea. These studies have triggered interest into thedisease and have inspired us to study the disease further as well.

From the same study by the ISAAC, they discovered that among Filipino teenagers, 13-14 year-oldspresented with the highest incidence rate among age groups with 32.5% of them having allergic rhinitis. [2] Hence,our study will be focusing on the specific age group mentioned.

Ventilation and air-conditioning systems can be sources of microbial aerosols either from contaminated airentering the system or directly from microbial growth within the system. Poor ventilation may allow anaccumulation of particulates, pollutants, and allergens inside school buildings and decreased air circulation mayincrease transmission of respiratory infections. Building structural problems, such as heating or air conditioningsystems venting near an air intake may contribute to these exposures. Due to this, the associations between schoolabsenteeism and poor ventilation, vermin, and cumulative exposure to building condition problems are greater foryounger students. Young children are also known to bemore susceptible to airborne pollutants than older children oradults because of their greater activity, smaller airways, and faster ventilation rates.[3] Therefore, it is important to

look into which of the learning environments is more likely to help students achieve their full potential and keepthem healthy.Research Hypothesis: Exposure to air-conditioned rooms alleviates the symptoms and occurrence of allergicrhinitis and poor ventilation leads to its exacerbation.

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Summary of Current Knowledge Regarding Disease and Exposure of Interest

Allergic Rhinitis

Allergic rhinitis represents a global health problem affecting approximately 600 million people in the worldpopulation [4], [5]. Allergic rhinitis occurs when a person breathes in something that he or she is allergic to. When a

person inhales an allergen, such as dust, pollen, or dander, the body releases certain chemicals, like Histamine, as areaction to the allergen. Since the allergens are breathed into the body, the symptoms of allergic rhinitis usuallymanifest in the nose or eyes. [6]

Symptoms that may occur immediately after inhalation of the allergen include itching of the nose, eyes, orthroat, having a runny nose (rhinorrhea), sneezing, tearing of the eye, or even problems with olfaction. Symptomsthat develop during chronic exposure include coughing, clogging of the ear, sore throat, dark circles under the eyes,fatigue, and irritability [6].

According to Badash, a risk factor is something that increases the risk of contracting the illness or disease.The most common risk factors for allergic rhinitis include eczema, food allergies, and asthma. However, it is still possible to contract allergic rhinitis whether a person has one of the aforementioned factors or not. Moreimportantly, the primary risk factor for getting would also depend on the persons genetic history. If one parent has

allergic rhinitis, then it is probable their offspring will also have allergic rhinitis. The chances are even greater whenboth parents have histories of allergic rhinitis.A study done by Tamay et. al. stated that the prevalence of childhood allergic rhinitis shows wide variation

throughout the world, ranging from 0.8% to 39.7%. This prevalence of allergic rhinitis and other allergic diseaseshas increased predominantly in developed countries, wherein the researchers have claimed that this indicates thatenvironmental risk factors and lifestyle seem to be major determinants of allergic diseases rather than geneticpredisposition. However, the study concluded that family history of atopy, having a cat at home in the first year oflife, and dampness at home are some of the important independent risk factors for allergic rhinitis.[7]

Allergic rhinitis can appear at any age. If this condition appears in early childhood, it is more likely that itwill not continue throughout adulthood. However, if a patient manifests allergic rhinitis above his or her 20s, then itis more likely that it will persist throughout middle adulthood [8].

A study conducted by Wang, et al. in China focused on the prevalence and related factors of allergicrhinitis in the rural and urban areas of China. The data they were able to collect consisted of five thousand and ten(5,010) cases of which eight hundred twenty-three (823) showed signs and symptoms of Allergic Rhinitis but only146 (9.3%) of them were diagnosed with allergic rhinitis. Moreover, it was noted that the most common allergenswere dog and cat epithelium in the rural areas and dust mites in the city[9].

Another study by Sandini, et al. shows the effect of lifestyle and environmental factors on developingAtopy and Allergic Rhinitis. It was a cohort study in which they followed the growth of 1,223 children born in tofamilies with histories of allergies. The researchers later on found out that allergies in both parents are anindependent predictor of eczema and other allergic disease until the ages of 2 and 5. Exclusive and long breast-feeding was associated with increased eczema at the ages of 2 and 5. Cat or dog exposure was also associated withdecreased IgE sensitization and allergic rhinitis [10].

A similar study on allergic rhinitis was also conducted by Siriarkson, et al. in 2011. It involved allergicrhinitis and immunoglobulin deficiency being suspects for frequent upper respiratory infections (URIs). The

researchers found that the prevalence of allergic rhinitis in preschool children with frequent URIs in their study was42.55%. Moreover, the researchers believe that allergic rhinitis should be considered if a family has a historyof allergic rhinitis. However, the results showed that Immunoglobulin deficiency was not present.[11]

Summary of Related/Similar Studies

Most studies have shown prevalence rates of allergic rhinitis among adults. One of which is a two-step, cross-sectional, population-based study done by Bauchau & Durham, which measured the prevalence of allergic rhinitis

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among adults in several European countries. The study revealed that out of a population of nine thousand sixhundred forty-six people (9,646), only 19% of them were self-aware that they have allergic rhinitis. 70% of thosewho are self-aware, however, were physician-diagnosed. Of the total population, only seven hundred fifty six (756)samples agreed to proceed to the second part of the study which was clinical confirmation of the disease. The studyconcluded that allergic rhinitis affects more than one out of every five adults in western Europe and those patientswho were undiagnosed with the disease showed less severe symptoms, but would benefit from consultation and

treatment by a physician [12].Aside from adult studies, allergic rhinitis was also studied in younger patients. Individuals are affected the

most with allergic rhinitis during their childhood and adolescence. According to Meltzer, approximately one in fivechildren will develop symptoms of allergic rhinitis by two to three years of age. In children who are six years of age,about 40% of them will have symptoms and up to 30% will be affected during their adolescence. [13] Furthermore, astudy by Blaiss pointed out that allergic rhinitis can interfere with a childs daily activities such as learning inschool. It also affects a childs behavior and psychosocial health thus affecting the childs quality of life overall. Dueto this, a consensus panel was formed in 2004 to assess the impact allergic rhinitis has on school children anddetermine how to improve prevention and treatment, so an affected childs quality of life and school performancecould improve. One of the things they considered in this consensus is that poor environmental conditions, such asplaces that have inadequate ventilation or poor indoor quality, can exacerbate allergic rhinitis. It is advised that the

best way to prevent allergic rhinitis from occurring is by providing clean indoor environments that will reduce theamount of allergens present indoors. This includes having an air-conditioning system and proper ventilation.[13], [14]

Apart from American studies, there are also findings on the distribution and prevalence of allergic rhinitisin foreign countries. In Serbia and Montenegro, ISAAC conducted a study using a questionnaire to determine theprevalence of asthma, allergic rhinitis, and eczema in 2 different age groups: 6-7 years old and 13-14 years old.They did the study over a 12-month period with their phase 3 type questionnaire. As a result, in the thirteenthousand four hundred eighty-five (13,485) children from five study centers, the prevalence for allergicrhinoconjunctivitis ranged from 4.6% to 21%. Also, childhood asthma ranged from 2.5% to 9.8% and it ranged from8.2% to 17.2% for the prevalence of eczema. In conclusion, asthma was found in to be more prevalent in 6-7 yearolds in urban or large cities. Also, their study showed that the prevalence of asthma, allergic rhinitis and eczema inschool children of Serbia and Montenegro seems similar to that of other countries in Central and South-EasternEurope. [15]

Another study that concerns transmission of airborne diseases was conducted in Peru. Rooms that only hadnatural measures for encouraging airflow were compared with mechanically ventilated rooms that were built muchmore recently. A comparison was also done between naturally ventilated rooms in old hospitals and naturallyventilated rooms in newer hospitals. Results showed that natural ventilation had high rates of air exchange, with anaverage of 28 air changes per hour. 50 year old hospitals had the highest ventilation with an average of 40 airchanges per hour due to its structure. This rate is far higher compared to the 17 air changes per hour in naturallyventilated rooms in modern hospitals, which have lower ceilings and smaller windows.[16]

In a study about the impact of school building conditions on student absenteeism in Upstate New York,researchers investigated this by obtaining data from the 2005 Building Condition Survey of Upstate New Yorkschools with 2005 New York State Education department students absenteeism data at the individual school leveland evaluated associations between building conditions and absenteeism at or above the 90th percentile. As a result,

researchers associated absenteeism with visible molds, humidity, poor ventilation, vermin, building conditionproblems, and building system or structural problems related to these conditions. They also saw that schools inlower socioeconomic districts and schools attended by younger students showed the strongest association betweenpoor building conditions and absenteeism. With this study, there were some limitations. Some confounding variableswere the external exposures such as traffic pollution and exposures from a students home could have affected thisstudy. In addition, absenteeism due to illness or other reasons could not be distinguished. The study's ecologicaldesign did not allow collection of information on individual health outcomes or reasons for absenteeism. Inconclusion, they found associations between student absenteeism and adverse school building conditions. As a

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recommendation, further studies should confirm these findings and prioritize strategies for school conditionimprovements. [3]

Conceptual Framework:

Exposure to Air-conditioning System

Improves allergic Rhinitis

Exacerbates Allergic Rhinitis

**independent variable predictor**dependent variable outcome

Bibliography:[1] Settipane, R.A. (2001). Demographics and Epidemiology of Allergic and Nonallergic Rhinitis [Abstract].

Allergy Asthma Proc. 22(4): 185-9. Retrieved July 8, 2011 from:http://www.medscape.com/medline/abstract/11552666.

[2] Philippine Star (2008). Allergic Rhinitis Prevalent among Pinoys. Retrieved July 8, 2011 from:http://library.pchrd.dost.gov.ph/index.php/news-archive/1080.

[3] Simons, E., Hwang, S., Fitsgerald, E., Keilb, C. & Lin, S. (2009). The Impact of School Building Conditions onStudent Absenteeism in Upstate New York. 100 (9). Research and Practice.

[4] Bousquet J, Khaltaev N, Cruz AA, Denburg J, Fokkens WJ, et al. (2008) Allergic rhinitis and its impact onasthma (ARIA) 2008 update (in collaboration with the World Health Organization, GA(2)LEN andAllerGen). Allergy 63: 8+. Retrieved July 8, 2011 fromhttp://www.nlm.nih.gov/medlineplus/ency/article/000813.htm

[5] Nathan RA (2007). The burden of allergic rhinitis. Allergy and Asthma Proceedings 28: 39.[6] Wallace DV, Dykewicz MS, Bernstein DI, Blessing-Moore J, Cox L, Khan DA, et al. The diagnosis and

management of rhinitis: an updated practice parameter.J Allergy Clin Immunol. 2008 Aug:122(2).[7] Tamay, Z., Akcay, A. Ones, U., Gular, N., Kilic, G. & Zencir, M. (2006). Prevalence and risk factors for allergic

rhinitis in primary school children. Retrieved from:http://www.sciencedirect.com/science/article/pii/S016558760600485X

[8] Badash, M. (2010). Risk factors for allergic rhinitis. Baptist Health Systems. Retrieved July 8, 2011 fromhttp://www.mbmc.org/healthgate/GetHGContent.aspx?token=9c315661-83b7-472d-a7ab-bc8582171f86&chunkiid=19053

[9] Wang, et al. (2011). Research on prevalence and related factors in allergic rhinitis. PubMed. 46(3):225-31.Retrieved July 8, 2011 from http://www.ncbi.nlm.nih.gov/pubmed/21575415

[10] Sandini, et al. (2011). Protective and risk factors for allergic diseases in high-risk children at the ages of two

and five years. PubMed: 156(3):339-348. Retrieved July 8, 2011 fromhttp://www.ncbi.nlm.nih.gov/pubmed/21720181

[11]Siriaksorn, S. (2011). Allergic rhinitis and immunoglobulin deficiency in preschool children with frequent upperrespiratory illness. PubMed. 29(1):73-7. Retrieved July 8, 2011 fromhttp://www.ncbi.nlm.nih.gov/pubmed/21560491

[12] Bauchau, V. & Durham S.R. (2004). Prevalence and rate of diagnosis of allergic rhinitis in Europe.EuropeanRespiratory Journal, 24: 758-764.

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[13] Blaiss, MS. Allergic rhinitis and impairment issues in schoolchildren: a consensus report.Current MedicalResearch and Opinion. 2004 Dec; 20(12):1937-52. From:http://www.redorbit.com/news/health/131029/allergic_rhinitis_and_impairment_issues_in_schoolchildren_a_consensus_report/index.html

[14]Meltzer, E.O. (1998). Treatment Options for the Child with Allergic Rhinitis. Clinical Pediatrics. Jan 1998; 37,1; ProQuest Research Library. Accessed July 7, 2011.

[15] ivkovi, Z., Vukainovi Z., Cerovi, S., Radulovi, S., ivanovi, S., Pani, E., Hadnadjev, M. & Adovi,O. (2010). Prevalence of childhood asthma and allergies in Serbia and Montenegro.World Journal of

Pediatrics, 6(4). Retrieved from: www.wjpch.com[16]Siriaksorn, S. (2011). Allergic rhinitis and immunoglobulin deficiency in preschool children with frequent upper

respiratory illness. PubMed. 29(1):73-7. Retrieved July 8, 2011 fromhttp://www.ncbi.nlm.nih.gov/pubmed/21560491.

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Blaiss%20MS%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/15704310http://www.ncbi.nlm.nih.gov/pubmed/15704310http://www.ncbi.nlm.nih.gov/pubmed?term=%22Blaiss%20MS%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/15704310http://www.ncbi.nlm.nih.gov/pubmed/15704310