DE LA SALLE HEALTH SCIENCES INSTITUTE COLLEGE OF MEDICINE DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE CM2 SY 2011-2012 OUTPUT 2: REVIEW

W 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 school students, 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 selected schools 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 the American population. [1] This percentage is alarming on its own, making allergic rhinitis fairly common among the population. 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 the disease 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-olds presented 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 air entering the system or directly from microbial growth within the system. Poor ventilation may allow an accumulation of particulates, pollutants, and allergens inside school buildings and decreased air circulation may increase transmission of respiratory infections. Building structural problems, such as heating or air conditioning systems venting near an air intake may contribute to these exposures. Due to this, the associations between school absenteeism and poor ventilation, vermin, and cumulative exposure to building condition problems are greater for younger students. Young children are also known to be more susceptible to airborne pollutants than older children or adults 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 keep them healthy. Research Hypothesis: Exposure to air-conditioned rooms alleviates the symptoms and occurrence of allergic rhinitis and poor ventilation leads to its exacerbation.

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 world population [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 a reaction to the allergen. Since the allergens are breathed into the body, the symptoms of allergic rhinitis usually manifest in the nose or eyes. [6] Symptoms that may occur immediately after inhalation of the allergen include itching of the nose, eyes, or throat, having a runny nose (rhinorrhea), sneezing, tearing of the eye, or even problems with olfaction. Symptoms that 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. More importantly, 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 when both 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 diseases has increased predominantly in developed countries, wherein the researchers have claimed that this indicates that environmental risk factors and lifestyle seem to be major determinants of allergic diseases rather than genetic predisposition. However, the study concluded that family history of atopy, having a cat at home in the first year of life, 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 it will not continue throughout adulthood. However, if a patient manifests allergic rhinitis above his or her 20s, then it is 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 allergic rhinitis 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 only 146 (9.3%) of them were diagnosed with allergic rhinitis. Moreover, it was noted that the most common allergens were 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 developing Atopy and Allergic Rhinitis. It was a cohort study in which they followed the growth of 1,223 children born in to families with histories of allergies. The researchers later on found out that allergies in both parents are an independent predictor of eczema and other allergic disease until the ages of 2 and 5. Exclusive and long breastfeeding was associated with increased eczema at the ages of 2 and 5. Cat or dog exposure was also associated with decreased IgE sensitization and allergic rhinitis [10]. A similar study on allergic rhinitis was also conducted by Siriarkson, et al. in 2011. It involved allergic rhinitis 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 was 42.55%. Moreover, the researchers believe that allergic rhinitis should be considered if a family has a history of 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, crosssectional, population-based study done by Bauchau & Durham, which measured the prevalence of allergic rhinitis

among adults in several European countries. The study revealed that out of a population of nine thousand six hundred forty-six people (9,646), only 19% of them were self-aware that they have allergic rhinitis. 70% of those who 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 study concluded that allergic rhinitis affects more than one out of every five adults in western Europe and those patients who 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 five children 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, a study by Blaiss pointed out that allergic rhinitis can interfere with a childs daily activities such as learning in school. It also affects a childs behavior and psychosocial health thus affecting the childs quality of life overall. Due to this, a consensus panel was formed in 2004 to assess the impact allergic rhinitis has on school children and determine how to improve prevention and treatment, so an affected childs quality of life and school performance could improve. One of the things they considered in this consensus is that poor environmental conditions, such as places 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 the amount 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 rhinitis in foreign countries. In Serbia and Montenegro, ISAAC conducted a study using a questionnaire to determine the prevalence 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 thirteen thousand four hundred eighty-five (13,485) children from five study centers, the prevalence for allergic rhinoconjunctivitis ranged from 4.6% to 21%. Also, childhood asthma ranged from 2.5% to 9.8% and it ranged from 8.2% to 17.2% for the prevalence of eczema. In conclusion, asthma was found in to be more prevalent in 6-7 year olds in urban or large cities. Also, their study showed that the prevalence of asthma, allergic rhinitis and eczema in school children of Serbia and Montenegro seems similar to that of other countries in Central and South-Eastern Europe. [15] Another study that concerns transmission of airborne diseases was conducted in Peru. Rooms that only had natural measures for encouraging airflow were compared with mechanically ventilated rooms that were built much more recently. A comparison was also done between naturally ventilated rooms in old hospitals and naturally ventilated rooms in newer hospitals. Results showed that natural ventilation had high rates of air exchange, with an average of 28 air changes per hour. 50 year old hospitals had the highest ventilation with an average of 40 air changes per hour due to its structure. This rate is far higher compared to the 17 air changes per hour in naturally ventilated 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 York schools with 2005 New York State Education department students absenteeism data at the individual school level and evaluated associations between building conditions and absenteeism at or above the 90 th percentile. As a result, researchers associated absenteeism with visible molds, humidity, poor ventilation, vermin, building condition problems, and building system or structural problems related to these conditions. They also saw that schools in lower socioeconomic districts and schools attended by younger students showed the strongest association between poor building conditions and absenteeism. With this study, there were some limitations. Some confounding variables were the external exposures such as traffic pollution and exposures from a students home could have affected this study. In addition, absenteeism due to illness or other reasons could not be distinguished. The study's ecological design did not allow collection of information on individual health outcomes or reasons for absenteeism. In conclusion, they found associations between student absenteeism and adverse school building conditions. As a

recommendation, further studies should confirm these findings and prioritize strategies for school condition improvements. [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 on Student 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 on asthma (ARIA) 2008 update (in collaboration with the World Health Organization, GA(2)LEN and AllerGen). Allergy 63: 8+. Retrieved July 8, 2011 from http://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 from http://www.mbmc.org/healthgate/GetHGContent.aspx?token=9c315661-83b7-472d-a7abbc8582171f86&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 from http://www.ncbi.nlm.nih.gov/pubmed/21720181 [11]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 from http://www.ncbi.nlm.nih.gov/pubmed/21560491 [12] Bauchau, V. & Durham S.R. (2004). Prevalence and rate of diagnosis of allergic rhinitis in Europe. European Respiratory Journal, 24: 758-764.

[13] Blaiss, MS. Allergic rhinitis and impairment issues in schoolchildren: a consensus report. Current Medical Research 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 from http://www.ncbi.nlm.nih.gov/pubmed/21560491.