Article: Á. REMÉNYI, A. GRÓSZ, F. HELFFERICH (HUNGARY)
Prevalence of Allergic Rhinitis in Hungary in the Population Applying for Military Service
Scientific surveys have shown an increase in the incidence of allergic rhinitis in recent decades. This condition, infrequent earlier, has now become a more common disease, representing a significant problem for general epidemiology and the economy due to the impairment of health and reduction in work ability caused by its symptoms. The emergence of this disease can be mainly observed in young adults, and this means that the military medical service faces a special challenge. In the case of military personnel, fitness for service and deployability to missions have to be assessed if allergic rhinitis is present. The purpose of this study is to determine the prevalence of the condition in the population applying for military service. The latest similar survey was conducted in Hungary in 2001. The authors present their method of analysis, their results and a comparison with earlier data, providing a summary of their findings.
Definition and forms of rhinitis allergica
Allergic rhinitis (rhinitis allergica, hay fever, AR, RA) is an inflammatory reaction of the mucous membrane and sub-mucous of the nose mediated by IgE. The main symptoms include nasal congestion, convulsive sneezing, nasal discharge, and itching of the nose, which is also frequently associated with conjunctivitis of the eye. Restricted respiration through the nose as a stand-alone symptom is not sufficient for the diagnosis.
A form appearing periodically is seasonal allergic rhinitis. It is defined as a ‘recurrent allergy of the respiratory tract caused by pollen or fungal spores in a specific period of the year’. More recently, it has also been described as intermittent, with the symptoms persisting for 4 or fewer days per week or for 4 or fewer subsequent weeks per year. The form arising over longer periods than described above during the year is regarded as perennial (referred to as persistent more recently). In such cases, the symptoms persist over more than 4 days per week and over 4 subsequent weeks.
With respect to severity, the condition of the patient is considered slight if there is not a single typical activity (sleeping, daily activities: work, study, sports, other leisure activities) that would be hindered by the hay fever (asthma). Medium-severe-severe is the allergic condition if at least one of the daily activities listed above is significantly affected.
The condition has a steadily growing significance – due to its prevalence, the steadily growing incidence year after year, the major negative influence on the quality of life of individuals, with the concomitant reduction in work ability and the high costs of treatment, with a significant impact on the economy. Research conducted into the reduction of morbidity of allergic rhinitis, already an endemic disease in the 21st century, represents a high-priority objective of public health.
Impact of allergic rhinitis on the cognitive functions
It is well known that the disease may also cause daytime drowsiness, impairing the cognitive functions. According to observations, this drowsiness is not primarily the outcome of the quality of sleep being deteriorated by the other symptoms, but it is caused by the systemic effect of the mediators and cytokines liberated. Moreover, the most frequent and most important central side effect of the H1-receptor blocking anti-histamines proposed as active ingredients for therapy can be sedation. This affects alertness, concentration, attention, memory, perception, the accuracy of physico-motorium performance, and even emotional states. It is important to note that sedation may also arise without its subjective detection. The deterioration in cognitive functions detected by appropriate tests may originate from either the very nature of allergic rhinitis or its treatment. The deterioration in cognitive functions may result in the latency of problem-solving capability, which may represent a major problem in critical security situations. However, based upon the most recent research results, today we have anti-histamines. When applied in the proposed therapeutic dose, and simultaneously with the treatment of symptoms representing safety risk, these have been confirmed as having no sedative side-effect profile. Therefore, they offer an optimum treatment solution without creating risks of their own.
Special implications of allergic rhinitis in the case of military personnel
In case of a service that requires complete physical and mental health – such as the military profession - it is very difficult to form an opinion on the health of the future service person and forecast its future evolution, or in a specific case, the mission capability of already trained personnel, when the condition of allergic rhinitis persists. In many cases, allergic rhinitis may disqualify an otherwise suitable candidate or a fully trained soldier from military service because, to a very great extent, the natural progression of the disease, the efficiency of pharmaceutical therapy, and the occurrence and the gravity of the potential side-effects are specific to the individual.
Safety risks are represented by both the basic disease and the drug therapy on their own (in addition to the well-known, disagreeable symptoms of the disease, deterioration in visual functions, impairment of intellectual capacity or, for example, barotrauma while flying). In view of these considerations, the Hungary’s military medical code in effect today specifies unsuitability for service for medium-severe/severe cases of allergic rhinitis. Even in cases rated “slight”, a suitable qualification can be granted through the so-called special assessment if it can be done subject to the other capabilities of the patient examined (possibility of treatment by drugs, the compensation potential of the individual’s organism, the already acquired service experience and the service activities required in the position). This problem is also subject of active research in NATO.
Prevalence of allergic rhinitis
In 1819, Bostock, a geologist-physician, was the first to summarise the typical symptoms of seasonal allergic rhinitis under the current terminology. The first nationwide research into allergy is also connected to his name, in the course of which he registered 28 more individuals having comparable symptoms, diagnosed with ‘catarrhus aestivus’, ‘summer catarrh bronchitis’ in England.
From 1831, Elliotson started to use the term hay fever for such complaints.
Among European countries, changes in the prevalence of hay fever were studied most widely in Switzerland. The earliest data were published by Rechsteiner in 1926. He examined 77,000 individuals, and 0.82% of these manifested symptoms typical of hay fever.
From the examination of 8,246 people by Batschelet et al. in Zurich in 1956, the prevalence of the disease was observed to be 4.8%, while Wüthrich detected a prevalence of 9.6% from the observation of 2,524 persons in 1985. A survey by Hagy and Settipane in the period 1924–1969 among college students in the USA found the prevalence of allergic rhinitis to be at 3.3% at the start of the survey and 25% at the end of it. Through a questionnaire survey involving 7,702 residents of London in the age range of 16–65 years, Sibbald and Rink established the prevalence of allergic rhinitis at 24% in 1988. Data published by Japanese authors in 2010 showed a prevalence of 43%, which represented an increase of 10% over 10 years. No substantial survey was conducted into the epidemiology of allergic diseases in Hungary up to the 1970s. Analysis through questionnaire surveys carried out on large population samples with a single centre has since become widespread both in Hungary and abroad. As a result, the prevalence of seasonal allergic rhinitis was established within wide limits from 3% to 42%, while the prevalence of perennial rhinitis ranged from 1% to 13%. Bittera and Gyurkovits measured the prevalence of allergic rhinitis in children of 6–14 years of age in 1987. After the examination of 903 persons, the result was 8.1%. The survey was repeated under identical conditions in 1997 and 2002. By that time, the prevalence of the allergic rhinitis in children had already risen to 14% and 17%, respectively. Using a questionnaire survey and a follow-up analysis, Kadocsa established in 1993 that, in Szeged, the prevalence of rhinitis in the age group of 5–75 years was 11%.
Studies concerning the prevalence of hay fever and other diseases of allergic origin based upon geographic approach and covering an entire continent, being suitable also for international comparison, have been undertaken only in the last 10 years (ISAAC, ECRHS, APRES studies). Since 2003, Hungary has also joined the ISAAC survey with two centres. The questionnaire data of close to 10,000 school children in two age brackets were processed in Komárom-Esztergom and Csongrád counties. From the analysis of responses from school children of 13–14 years of age, summarising the data of the two centres, the prevalence of allergic rhinitis was 9.93% in Hungary. A survey made by Balogh et al. in 2002 in Budapest, covering the entire population, yielded a comparable result . The disease could be identified in the case of 7 children from among one thousand nursery school children in 2003, whereas this applied to 40 pupils among the children in the 11th grade. Harangi et al. carried out comparative surveys in Pécs and Veszprém among school children in accordance with the ISAAC protocol. Responses from close to 2,600 pupils were analysed in three age categories. The assessments reported hay fever symptoms in 34% of the pupils in one year, while the prevalence of allergic rhinitis also diagnosed by the physicians was 14%. The questionnaire survey conducted by Koppány et al. in 2004 in Hungary in the population of 5–70 years of age set the prevalence of the disease at 25%, while the prevalence corrected by allergic tests came to 16%. Using the ISAAC protocol with amendments, Sultész et al. carried out a questionnaire survey primary schools pupils of 6–12 years of age in Budapest in 2007. According to their research, the examination results showed a prevalence of 26.5% in the age group of the children concerned.
The series of tests of the ECRHS (European Community Respiratory Health Survey) surveyed the prevalence of allergic rhinitis, among others, in 30 regions of 15 countries across the European Union. The survey was joined in 1994 also by Switzerland, Estonia, Algeria, India, New Zealand, Australia and the USA. Men and women of 20–44 years of age participated in the questionnaire survey, 1,500 persons from each region. The highest prevalence of allergic rhinitis was documented not in the European centres, but in Australia, the USA and New Zealand (Melbourne 40.9%, Portland 39.4%, Auckland 35.1%); the lowest levels were also registered in non-European centres, e.g., 9.5% in Algeria and 10.1% in Bombay. The prevalence of the disease was strikingly high in Europe in the French and British centres, e.g., 34.4% in Montpellier, 30.3% in Paris, 30.2% in Bordeaux and 29.2% in Cambridge. At the same time, the prevalence was particularly low in the regions of Spain and Italy, 12.1% in Albacete, 12.5% in Pavia and 13.1% in Barcelona.
The greatest prevalence of allergic rhinitis was established by APRES (Allergy Prevalence Survey) starting in 2005 from the questionnaire survey of 5,482 people in Ukraine (40%) and the United Kingdom (32%), while the lowest figure was recorded in Azerbaijan (3%).
Several studies, in addition to confirming the continuous increase in the prevalence of the disease, also determined that this disease was influenced by several additional factors. The confirmed influencing factors contributing to the emergence of the disease include, for example, the climate of the geographic location of the domicile, the type of settlement, the rate of environmental pollution, the so-called socio-economic status, the age and life style of the individual as well as the incidence of the disease within the family. Despite major research efforts, the exact aetiology is not fully clear even today. However, according to a WHO forecast, every second person may have the allergy by 2050.
Limited data about the prevalence of the disease for the purposes of military health care are available in the Hungarian and international literature. In connection with the Gulf War, an increase in the incidence of AR was detected in the US armed forces. Among the soldiers deployed to that mission 9.9% suffered from the disease, contrasting with 5.1 % recorded in the home-based troops. In Hungary, allergic rhinitis occurred in 1.7% of the 18-year-old men enlisted for conscript service in 1973, while this figure was 4.6% in 2001. Through an epidemiological survey in 1999, Medveczki and Kollár confirmed the growing prevalence of allergic rhinitis among the conscript population (8.4%).
Establishment of prevalence of allergic rhinitis among people applying for military service
Exact data about the prevalence of the disease – i.e., the frequency of cases in the population surveyed at a specific moment in time – are difficult to obtain even though several earlier surveys are available. The statistics of patients and the morbidity data do not exactly reflect reality, as the disease is influenced also by several other factors and its reporting is not obligatory. A point to be considered in the assessment of military medical surveys conducted so far is that the surveys were conducted in an era of compulsory military service. Even under the code in effect at that time, allergic rhinitis disqualified conscripts, barring them from military service for medical reasons. Thus, a possibility for disqualification was provided with easy documentation not only for the persons suffering from this disease but also for “draft dodgers” trying to evade conscription. It should also be noted here that allergic sensitisation is not confirmed or precluded with full certainty either by skin tests or the specific and total IgE tests applied in the course of diagnostics. Thus, the patient may be free of complaints even with a positive test result and may produce typical symptoms with negative test results. The latest survey for military-medical purposes was conducted back in 2001. No precise data are available at this time concerning this important issue, with a continuous increase in prevalence manifest from the reference data and with the elimination of the data distortion caused by the ending of conscription in 2004.
The purpose of our study is to establish the current prevalence of allergic rhinitis in the Hungarian Defence Forces. As the earlier survey targeted the people enlisted for military service, therefore, the current survey includes only new applicants in order to ensure comparability.
Materials and methods
After preliminary permission was obtained, 510 questionnaires concerning the symptoms related to a potential allergy of the respiratory tract were distributed among applicants for military service, without selection and on a voluntary basis at the Aeromedical and Health Screening Institute of the Hungarian Defence Forces Medical Center in Kecskemét between 28 January and 29 June 2015. The data collection was anonymous, because the fear of being declared unsuitable due to the strict regulations could have led to distortion of data in case admitting to the disease.
A series of questions permitting ‘structured interviews’ proposed by the Hungarian and international directives was used in the survey, in order to promote establishment of the diagnosis as much as possible, as well as its differentiation from other diseases of the respiratory tract. First, the questionnaire addressed the sex and age of the respondents. The respondents were asked about previous diagnosis of allergic rhinitis and, where so, who had made the diagnosis (family GP, specialist). We have considered these respondents as ‘known to have AR’.
‘Presumed to have AR’ were the persons who responded yes to at least two questions – of which one concerned the nasal congestion, ‘Have you had the following symptoms: watery runny nose; sneezing, especially violent and in bouts; nasal obstruction; nasal itching; conjunctivitis?’. Differential diagnosis from rhinitis leading to similar nasal complaints but having no allergic background to other rhinological symptoms (e.g., nasal polyposis, acute or chronic rhinitis/rhinosinusitis or even tumours of the nasal chamber) was assisted by the following series of questions. ‘Do you have the following symptoms: one-sided nasal complaints; thick, green or yellow nasal discharge; postnasal drip; facial pain; recurrent nose bleeds; loss of smell?’ In the majority of the ‘yes’ responses to these questions, the patient was considered as non-allergic.
The ‘conditionally AR’ persons were also examined according to the severity of their complaints. In order to improve objectivity, the ‘visual analogue scale (VAS)’ was used. Accordingly, AR is slight if the disease does not disturb the individual in his/her daily activities, work/study, sleeping at night. AR is of medium severity/severe if the activities above are clearly hindered. This was expressed in numbers on a visual analogue scale in accordance with the protocols noted (0–10), with slight (0–4) and medium severe/severe (5–10).
The data collected have been analysed by percentage calculation. Of the 510 questionnaires, 18 were not filled in completely and were therefore discarded. The 492 questionnaires suitable for evaluation were collected. In keeping with the traditions of the military profession, a significant male dominance was still manifest: 439 men (89.2%); 53 women (10.8%). The average age was 26.61 years (min.: 18, max.: 45).
Among the respondents, we have obtained results typical of rhinitis but not of allergic background or other rhinological diseases leading to similar nasal complaints. As the assessment was carried out at a later date and the respondents did not use the medical help offered in the questionnaire, we have no additional data about them.
Based upon our questionnaire survey, the prevalence of all forms of allergic rhinitis among people applying for military service was 14.03% (‘known’: 4.27% and ‘presumed’: 9.76%). The earlier military medical surveys were conducted using a different methodology and in a regulatory framework that has since changed. As a result, only with reservations can the prevalence values be compared with our result. Nonetheless, it is noted that the earlier surveys were conducted in an environment where the distortion of the values upwards was expected. Therefore, in our present survey, the increase in prevalence is considered even more pronounced. On the basis of our survey, it can be stated that, among applicants for military service, the proportion of persons with allergic rhinitis has clearly increased.
Given that the examination methods for confirming allergic rhinitis (structured interview, skin test, testing allergen-specific IgE levels from blood) make the diagnosis only probable, we will never have exact prevalence data. In earlier research, the objective was to accurately define the patients with AR through properly structured questionnaire surveys. This value was 68.4%. If this is taken into account with respect to our own value of 14.03%, in theory 9.60% is obtained, which is a value higher than the results of the earlier surveys even after such a correction.
It is interesting to note that in the course of our survey, 12 (57.17%) of the 21 (4.27%) patients were classified as ‘known to have AR’, yet more than one half of these patients complained of medium-severe/severe symptoms under VAS. Therefore, although their disease had been diagnosed earlier on, they had not benefited from this because they either failed to use the specified treatment or received no optimal therapy. Subsequent research into this situation may yield valuable conclusions.
We had no possibility to analyse additional parameters without hindering the suitability check-up. The filling-in of a questionnaire also concerning other parameters (e.g., socio-economic status, associated diseases) would have taken much longer and so was omitted out of a desire not to take undue advantage of the voluntary participation of respondents.
Our survey has established that the proportion of patients with allergic rhinitis has increased among applicants for military service (14.03%). This also proves – in line with earlier Hungarian and international observations – that this disease is not only a significant issue of public health but also a military medical problem.
In recent years, anti-histamines have become applicable that are safe both for therapy and in terms of side effects. Utilising the newly acquired knowledge, the regulations in some countries (e.g., the USA, the United Kingdom, Japan) are already different from those in Hungary, and exactly regulate the suitability of service persons and flight personnel suffering from allergic rhinitis, as well as the medications to be administered for treatment, through which their medical suitability can be maintained.
Under the altered conditions presented in this study, and being aware of the recent prevalence data of allergic rhinitis with an increasing weight in current military medicine contrasted with earlier data and using the latest experience in therapy, the introduction of more relaxed rules to ease the rigour of the current medical suitability regulations would also be justified.
Capt. Ákos Reményi M.D. M.C.:
Born 21.03.1974. Joined the Hungarian Defence Force on 2010.
1998. Degree in medicine, Semmelweis Medical University, Budapest.
2003. Specialization in oto-Rhino-laryngology
Working Place: Hungarian Defence Forces Medical Center,
Department of Otorhinolaryngology – Head and Neck Surgery
Status: ENT specialist, assistant professor
Brig. Gen. (ret.) Prof. Andor Grósz M.D. M.C., Ph.D.
Full professor of University of Szeged, Faculty of General Medicine,
Department of Aviation and Space Medicine.
Col. Frigyes Helfferich M.D. M.C., Ph.D.
Head of department of Otorhinolaryngology – Head and Neck Surgery
Hungarian Defence Forces Medical Center, Bupapest.
Address for the authors:
Ákos Reményi Md.
Budapest, Fráter György tér 8/A.
First and corresponding author
Source: Medical Corps International Forum (4/2015)
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