Research and Reviews ENT Physicians’ Efforts to Treat Allergic Diseases at Schools JMAJ 52(3): 178–183, 2009 Kazuya SHIMADA*1 Abstract Recently Sinusitis is declining in severity, while allergic rhinitis is increasing in prevalence. Although improved nutrition and the spread of hygiene information have caused a decline of sinusitis, air pollution has caused an increase in rhinitis. Behind these changes, the first factor to consider is air pollution. While areas with no air pollution have more schoolchildren with infectious rhinitis, sinusitis and allergic rhinitis are both notably more prevalent among schoolchildren in air-polluted areas. In a nationwide survey, the prevalence of cedar and cypress pollen allergies was the highest at 26.9% in Yamanashi Prefecture, followed by Nagano, Kochi, and Shizuoka Prefectures. Although it is said that pollen allergies have come to affect children at younger ages, teenagers and younger children are also more likely to have perennial allergic rhinitis. Analysis of the association between allergic rhinitis and sports showed that the prevalence rate was higher among children playing indoor sports and lower among children playing outdoor sports or no sports. The prevalence rate was lower among children who received treatment, health management guidance, and hygiene management guidance. With respect to the association between allergic rhinitis and learning, healthy children had better academic performance records, while placebo-treated children performed worse, and those who received medication showed varying results, with some children performing well depending on what drugs were administered. Key words Allergic rhinitis, School health, Health management, ENT physicians 50% of students had sinusitis around 1950, and A Shift from Sinusitis to Allergic Rhinitis this rate dropped to 10% after 30 years. In a survey of outpatients at a hospital in Before discussing allergic rhinitis, let us take a Tokyo where I worked, sinusitis decreased from historical look at the changes in nose and sinus 59.9% in 1963 to 34.5% in 1979, while allergic inflammations. Shortly after World War II, many rhinitis increased from 14.5% to 24% during children had purulent nasal discharge as a sign the same period. This trend is believed to have of so-called empyema. Nowadays, they present expanded further in later years. Considering with watery nasal discharge and sneezing. Behind changes such as this transition, the management this change are factors reflecting the changing of allergic rhinitis and patient support at schools times, such as improved nutrition, the spread of is discussed below. hygiene information, air pollution, and lifestyle changes, and the progress of this gradual change Epidemiology—Nose and sinus can be traced through the records of school inflammations in school health health screening. Sinusitis, which was relatively screening uncommon before World War II, increased in the postwar period, particularly in rural areas. A With respect to nutrition, there has been a decline survey of one village showed that approximately in the severity of sinusitis associated with the *1 Vice-President, Yamanashi Medical Association, Kofu, Japan ([email protected]). This article is a revised English version of a paper originally published in the Journal of the Japan Medical Association (Separate Vol.137, No.4, 2008, pages 53–56). The article is based on a presentation made at the school physician symposium “Allergic Diseases at Schools: Support and Management” held at the JMA hall on February 23, 2008. 178 JMAJ, May/June 2009 — Vol. 52, No. 3 ENT PHYSICIANS’ EFFORTS TO TREAT ALLERGIC DISEASES AT SCHOOLS (%) Areas with no air pollution Areas with air pollution 40 Rhinitis Sinusitis Allergic rhinitis 30 20 Prevalence rate Prevalence 10 A e.s. B e.s. C j.h. D e.s. E e.s. F e.s. G e.s. H j.h. I j.h. J e.s. K e.s. L e.s. M e.s. N n.s. (Kaneko Y, et al. Oto-rhino-laryngology Tokyo. 1979;22(supple. 3):247–295, supplemented with recent observation results.) Fig. 1 Prevalence rates of various nasal disorders by area and school e.s.: elementary school, j.h.: junior high school, n.s.: nursery school change from the postwar period when people to house dust in their childhood, a great majority combated hunger with carbohydrates to nowa- of patients have perennial allergic rhinitis. Non- days when plenty of protein (animal protein, in allergic diseases that need to be distinguished particular) and fat are consumed. A nutritional from allergic rhinitis include vasomotor rhinitis survey conducted by a university has shown that and eosinophilic rhinitis, which are subtypes of the areas in which people pay less for food have non-infectious hyperesthetic rhinitis, as well as more sinusitis than the areas in which people pay infectious rhinitis and irritative rhinitis. more for food. In essence, these differences seem to have arisen because well-balanced, adequate Allergic Rhinitis nutrition enhances resistance to inflammation. The next question is why allergic rhinitis has Prevalence rate by prefecture increased. In considering this problem, we should The most widely quoted data are those from the first look at air pollution. A comparison between survey of ENT physicians and their families con- the prevalence rates of allergic rhinitis at schools ducted by Baba,2 and the following is based on in areas with and without air pollution (Fig. 1) these data. The survey found that among the types shows that the areas with no air pollution have of seasonal allergic rhinitis, the prevalence of more schoolchildren with infectious rhinitis, while cedar and cypress pollen allergies was the highest sinusitis and allergic rhinitis are both remarkably at 26.9% in Yamanashi Prefecture, followed by more prevalent among schoolchildren in air- Nagano, Kochi, Shizuoka, and Mie Prefectures; it polluted areas.1 was the lowest in Okinawa, Kagoshima, and Hokkaido Prefectures. Including allergy to other Classification pollen species, pollen allergies as a whole, includ- ing those other than cedar and cypress pollen There are several types of rhinitis. Although allergies, were the most prevalent in Nagano and allergic rhinitis is generally equated with pollen Yamanashi Prefectures. In contrast, perennial allergies, it is divided into perennial allergic rhi- allergic rhinitis was most common in Fukui and nitis and seasonal allergic rhinitis, and pollen Gifu Prefectures. It was also relatively common allergies are the typical form of seasonal allergic in Hokkaido, Aomori, Yamagata, Miyazaki, and rhinitis. Because many people were sensitized Kagoshima Prefectures, where cedar and cypress JMAJ, May/June 2009 — Vol. 52, No. 3 179 Shimada K Woodlands in Yamanashi Prefecture Yatsugatake Coniferous forest zones (Subarctic zones) Deciduous broad-leaved forest zones Chichibu cordillera (Temperate zones) Evergreen broad-leaved forest zones (Warm-temperate zones) Nirasaki Kofu Enzan Kitadake Otsuki Misakasankai Akaishi cordillera Hokkaido Fujiyoshida 2.2 Minobu Mr. Fuji (3,776) Cedar plants grow well in evergreen broad-leaved forest zones. Aomori 12.5 (Kazuya Shimada: Hospital-Clinic and Clinic-Clinic Collaboration for Allergic Diseases in Cross-Disciplinary Areas. Allergy Frontier, April 2004; Vol.4, No.2. Medical Revies Co., Ltd.) Akita Iwate 14.0 12.1 Yamagata Miyagi Yamanashi Prefecture : 44.5% 25.0 32.5 National average : 26.5% Ishikawa 20.5 Toyama Niigata Fukushima 17.4 15.0 26.4 Gunma Tochigi Ibaraki Nagasaki Saga Fukuoka 31.9 39.6 Shimane Tottori Fukui 21.6 25.6 15.2 26.3 18.2 13.1 24.4 Gifu Nagano Ya maguchi Hyogo Kyoto Shiga 36.5 25.0 Saitama 39.6 27.3 20.5 32.8 26.4 Oita Hiroshima Okayama 22.7 27.8 19.1 Yamanashi Tokyo Kumamoto Osaka 44.5 32.1 Chiba 13.6 25.2 Nara 32.4 Miyazaki Mie Kagawa 21.5 35.0 Kanagawa 8.2 Ehime 33.2 Aichi Shizuoka 33.1 28.3 Tokushima 28.8 28.0 39.3 Kagoshima 20.3 12.1 Kochi 41.2 Wakayama Okinawa 6.0 (Kotaro Baba, et al.: The 2008 National Survey of Nassl Allergy (comparison with 1998)—Epidemiological data from ENT doctors and their families. Progress in Medicine, August 2008; Vol.28, No.8. Life Science Co., Ltd.) Fig. 2 Prevalence of cedar pollen allergy pollen allergies were rare. This may reflect the tion, followed in decreasing order by ragweed, fact that the Hokkaido and Tohoku regions have candida, mugwort, orchard grass and Humulus more house dust and mites, while the Chugoku scandens, and Japanese red pine. and Kyushu regions have more varieties of pollen allergens. The national survey reported in 2007 Allergic rhinitis and age by the Ministry of Education, Culture, Sports, It is said that pollen allergies in general, including Science and Technology 3 presented somewhat cedar and cypress pollen allergies, have started to lower prevalence rates. affect children at lower ages. However, the preva- The survey conducted at my clinic also showed lence of pollen allergies has become substantially a predominance of cedar and cypress pollen and high only in adults aged 30 years or over. It is house dust irrespective of the time of examina- uncommon among elementary school students in 180 JMAJ, May/June 2009 — Vol. 52, No. 3 ENT PHYSICIANS’ EFFORTS TO TREAT ALLERGIC DISEASES AT SCHOOLS 6,000 1998 5,000 1999 4,000 2000 3,000 2001 2002 2,000 2003 1,000 The amount of airborne pollen per year 2004 0 Nirasaki Kofu Tamaho Kasugai Kajikazawa Nakatomi Fujiyoshida Uenohara (Source: Survey by the Yamanashi Environmental Allergy Study Group) Fig. 3 Variations in the amount of cedar pollen in the air in various areas of Yamanashi Prefecture lower grades. Teenagers are more likely to have prevalence rate for allergic rhinitis was lower perennial allergic rhinitis. among children who received treatment, health management guidance, and hygiene management Allergic rhinitis and swimming guidance based on the results of health screening Because allergic rhinitis develops through com- than among those who did not.