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International Study of Asthma and Allergies in Childhood (ISAAC): Rationale and Methods

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International Study of Asthma and Allergies in Childhood (ISAAC): Rationale and Methods Eur Respir J, 1995, 8, 483–491 Copyright ERS Journals Ltd 1995 DOI: 10.1183/09031936.95.08030483 European Respiratory Journal Printed in UK - all rights reserved ISSN 0903 - 1936 INTERNATIONAL STUDY PROTOCOL International study of asthma and allergies in childhood (ISAAC): rationale and methods M.I. Asher*, U. Keil**, H.R. Anderson***, R. Beasley+, J. Crane+, F. Martinez++, E.A. Mitchell*, N. Pearce+, B. Sibbald***, A.W. Stewart*, D. Strachan***, S.K. Weiland**, H.C. Williams+++ International study of asthma and allergies in childhood (ISAAC): rationale and methods. *Depts of Paediatrics & Community Health, M.I. Asher, U. Keil, H.R. Anderson, R. Beasley, J. Crane, F. Martinez, E.A. Mitchell, N. School of Medicine, University of Auckland, Pearce, B. Sibbald, A.W. Stewart, D. Strachan, S.K. Weiland, H.C. Williams. ERS Auckland, New Zealand. **Institut für Epi- Journals Ltd 1995. demiologie und Sozialmedizin, Universität ABSTRACT: The aetiology of asthma and allergic disease remains poorly under- Münster, Münster, Germany. ***Depts of Public Health Sciences & Primary Health stood, despite considerable research. The International Study of Asthma and Care, St George's Hospital Medical School, Allergies in Childhood (ISAAC), was founded to maximize the value of epidemiological University of London, London, UK. +Dept research into asthma and allergic disease, by establishing a standardized methodo- of Medicine, School of Medicine, Wellington, logy and facilitating international collaboration. New Zealand. ++Dept of Paediatrics, Health Its specific aims are: 1) to describe the prevalence and severity of asthma, rhinitis Sciences Center, University of Arizona, and eczema in children living in different centres, and to make comparisons within Tucson, Arizona, USA. +++Dept of Der- and between countries; 2) to obtain baseline measures for assessment of future matology, Queens Medical Centre, Univer- trends in the prevalence and severity of these diseases; and 3) to provide a framework sity Hospital, Nottingham, UK. for further aetiological research into genetic, lifestyle, environmental, and medical Correspondence: M.I. Asher, Dept of Pae- care factors affecting these diseases. diatrics, School of Medicine, University of The ISAAC design comprises three phases. Phase 1 uses core questionnaires Auckland, Private Bag 92019, Auckland, designed to assess the prevalence and severity of asthma and allergic disease in New Zealand. defined populations. Phase 2 will investigate possible aetiological factors, particu- Keywords: Allergies, asthma, childhood, larly those suggested by the findings of Phase 1. Phase 3 will be a repetition of eczema, rhinitis. Phase 1 to assess trends in prevalence. Received: May 19 1994 Eur Respir J., 1995, 8, 483–491. Accepted for publication December 29 1994 Background baseline measures for assessment of future trends in the prevalence and severity of these diseases; and 3) to pro- There is considerable concern that the prevalence of vide a framework for further aetiological research into asthma and allergic diseases is increasing in Western lifestyle, environmental, genetic and medical care fac- and developing countries. The International Study of tors affecting these diseases. Asthma and Allergies in Childhood (ISAAC) developed from the merging of two multinational collaborative projects, each investigating variations in childhood Asthma asthma at the population level. These projects were an initiative from Auckland, New Zealand to conduct an Asthma is one of the most important diseases of international comparative study of asthma severity, and childhood, causing substantial morbidity [1–3]. Increases an initiative from Bochum, Germany, in 1990, for an in the rates of hospital admission and primary care con- international study to monitor time trends and determi- tacts for asthma in childhood [4, 5] have led to concern nants of the prevalence of asthma and allergies in children. that the prevalence or severity of wheezing illness may ISAAC has attracted worldwide interest and large scale be increasing in children. Trends in routine data are participation. difficult to interpret because not all wheezy children receive a diagnosis of asthma, and the proportion who do has increased substantially over recent decades [6]. Aims and objectives A number of surveys, first conducted in the 1960s and 1970s, have been repeated in recent years using similar The aims and objectives of the study are: 1) to describe methodology, and these are consistent in showing an the prevalence and severity of asthma, rhinitis and eczema increase in the prevalence of wheezing illness (irrespec- in children living in different centres, and to make com- tive of diagnosis) in Britain, Australasia, Scandinavia, parisons within and between countries; 2) to obtain Israel and Taiwan, although the magnitude of the increase 484 M.I. ASHER ET AL. varies considerably between studies [7–17]. Few studies gested that eczema is more common amongst recent have been able to investigate trends in the severity of generations of children [45]. Studies of children whose wheezing [18, 19], or changes in the pattern of health parents have migrated from developing to developed service utilization [15]. Only a few studies [10, 20] have countries suggest that eczema is associated with urbani- included an objective assessment of bronchial reactivity zation, and with development within those industralized in the same location at two points in time. countries [46, 47]. Geographical variations in the prevalence of wheez- In theory, eczema is more readily confirmed by objec- ing illness have been found in Britain [21], Australia tive tests than either asthma or rhinitis. However, there [22], and Germany [23, 24]. These are small by com- are currently no internationally accepted criteria for parison with urban-rural differences described in southern defining atopic eczema in epidemiological surveys. A Africa [25, 26]. Whilst genetic factors predispose to list of major and minor criteria proposed by HANIFIN and asthma, studies of children whose parents have migra- RAJKA [48] in the 1970s have been further evaluated [49] ted from developing to developed countries suggest that and widely applied in clinical studies, but have not been there is an increased risk of asthma associated with the defined and standardized in a manner suitable for epi- environment or lifestyle of an industralized society [27, demiological studies. A team of British dermatologists 28]. A further possibility is that some forms of asthma and paediatricians has recently developed and validated treatment might themselves be increasing asthma mor- definitions of atopic dermatitis based on questionnaire bidity. There have been few international comparisons data with and without clinical signs [50–52]. These of prevalence using standardized methodology [29, 30], recommendations, which correspond closely to the major and none of these have included developing countries. criteria proposed by HANIFIN and RAJKA [48], have been The recent development of a standardized written and incorporated into the present study. video questionnaire for self-completion by teenage child- ren [31] offers scope for large scale studies of the pre- valence and severity of wheezing illness in both developed Rationale of the ISAAC initiative and developing countries. Much research has been conducted into the reasons why some individuals rather than others develop asthma Rhinitis and other atopic diseases, such as rhinitis and eczema. A major risk factor is a family history of atopic disease, There are no widely agreed criteria for the diagnosis but various environmental factors are also considered or classification of rhinitis, and surprisingly little is known important in the expression of disease. Such studies about its prevalence or distribution among children [32, within populations have shed little light on the reasons 33]. The estimated prevalence of hay fever among school why the occurrence of atopic disease varies from popula- children in different countries has been reported to vary tion to population. Factors affecting the prevalence of between 0.5 and 28% [34], but much of this variation is disease at a population level may be different to those likely to be due to the diagnostic criteria and age group that determine which individuals within a population are chosen. A few studies using a standardized case defi- at greatest risk [53, 54]. In addition, between populations nition have suggested variations in prevalence within the relationship between the three atopic conditions may countries, by region or degree of urbanization [21, 24, be different. Ecological analyses between populations 35, 36]. may reveal further important risk factors. One obstacle Seasonal allergic rhinitis appears to have been exceed- to the investigation of population differences (and of ingly rare in Britain [37] and Switzerland [38] before the trends) has been the lack of a suitable and generally industrial revolution, and the prevalence of reported hay- accepted method of measuring the prevalence and seve- fever has increased in the United States [39], Sweden rity of asthma and other atopic diseases in children. [9], and Britain [40] in recent decades. These trends Another obstacle has been the absence of a coordinated may reflect changes in the perception and labelling of research programme to obtain and analyse comparative symptoms, or in presentation for medical diagnosis and data. ISAAC has been developed to address these issues. treatment.
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