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Why the increases in upper respiratory problems?


[Much of this information has been published in an article by the same name in Medical Hypotheses, September 2001]

Since the early 1970's we have witnessed a three-fold increase in upper respiratory problems in this country.

  • Technically upper respiratory problems include abnormalities in the nose, ears and sinuses because they are all interconnected.

  •  Infections in these areas begin with bacteria that normally live in the back of the nose. 

    • Schappert's  data from the National Center for Health Statistics shows that the incidence of ear infections went from 9.9 million in 1975 to 24.5 million in 1990.  

    • This rate of increase is about 6.25% per year. 

    • Extending this line to the present shows that we can expect about 35 million ear infections in the year 2000 – more than a three-fold increase since 1975. 

    • The graph  is a representation of this data in a bar chart form with the data for 2000 extrapolated.  

       

     I am old enough to remember, during the Viet Nam war, the nightly statistics of how many of the enemy were killed and how many battles were won. I know that we can kill the enemy, win battles, and still lose the war. I think of this every time I see a child with an ear infection. When I began practicing medicine the dose of Amoxicillin used to treat an ear infection was 10 milligrams for every kilogram the child weighed. There are now more than three times as many infections and the dose is 8 times what it was then. What we are doing is not working.

 

Sinus infections occur when these same bacteria, again living in the back of the nose, climb up into the sinuses.  

  • While there are no comparable national statistics for sinus infections the consensus of smaller studies is that they too are increasing in the range of 5% per year. 

  • The American College of Otorhinolaryngologists present the following information for the United States:

    • Chronic sinusitis afflicts approximately 37 million.

    • Sinusitis is more prevalent than arthritis or hypertension.

    • Chronic sinusitis resulted in approximately 13 million physician office visits in 1994.

    • The health impact of chronic sinusitis on bodily pain and social functioning is worse than that of congestive heart failure, angina, or back pain.  (Information accessed  5/24/01)

 We are not helping the problem and we may be doing something wrong. 

  • People looking at this problem from the viewpoint of pediatric infectious disease look at the increase in day care as being the main  reason for these increases, but there are problems with this: 

    • Sinus infections, where day-care is not an issue, have also increased.

    •  Native Alaskans have the highest incidence of ear infections in this country and perhaps the world.

      • They did not have a problem with these infections before they were "civilized." 

      • The native children in Nome's sister city of Provideniya, in Siberia, do not have this problem today.

      •  Most doctors explain this by saying they are just not diagnosed, but the painful and draining ears seen by the tribal elders making this report do not need a doctor to substantiate them.

Another reason I think there is more to it is because we have also seen, in this same period, comparable increases in allergies and asthma. 

  • The graph below is from the totals of reported cases of asthma from several states compiled by Mannino and his staff at the CDC.  

  • These increases represents  annual increases of about 5.25%. Again the data for 1971 and 2000 are extrapolated.

Even more dramatic are the increases in hospital discharges for asthma in Charleston,SC from 1958 to 1997. 

  • I particularly like this study because it shows a stable baseline up until the early 1970's when all of these increases began.

(Total Medical University of South Carolina asthma discharges in each five-year period from 1958 to 1997 for children age 0-18. By permission from Pediatrics.)

  • If the scale were the same the increases from the CDC study would fall in between the bars on the Charleston study. 

  • The reason they don't look the same is because of the 20 fold increases in asthma in the black population. 

The authors of this study point out that there were no environmental or social changes that occurred in the early seventies that would explain these increases. So what did happen?

  • Like the infectious disease specialists looking at ear infections, those specialists looking at asthma tend to see only asthma. 

  • The reasons they come up with to explain the increases are pollution, increased allergies and increased infections. 

  • One author of the Charleston study wrote to the editors of Pediatrics that they thought the increases were related to obesity. 

There is other information, currently being reported, that confounds this problem.  

  • Recent studies on the incidence of asthma, using a questionnaire standardized for the International Study of Allergy and Asthma in Children (ISAAC), have reported increases in many foreign countries. 

  • It turns out that the increases in asthma are not seen in the eastern bloc countries.   

    • Albania, Kazakhstan, and rural Chinese communities do not show these increases despite having similar levels of, if not more, pollution.

    • The more western the orientation of the country the higher the incidence of asthma.

A problem with these explanations is that they focus on the particular illnesses. 

  • This is a case of not seeing the forest for the trees. 

    • The specialists are looking at their particular trees when what we need to do is back up and look at the forest. 

    • The forest for all these problems is the back of the nose.

      • This is where the bacteria live that cause the infections.

      • This where the irritants and pollutants are that trigger allergies. 

      • And allergies, chronic sinus problems and viral upper respiratory infections are the major triggers for asthma. 

      • We don't often think of asthma as an upper airway disease, but the major triggers for asthma are in the nose.

These graphs represent the best available data on the national increases in these problems. 

These are two unrelated illnesses.  

They should raise several questions:   

  • Why are the graphs so similar?  

  • What happened in the early '70's that has led to these increases?  

  • The similarity in the graphs strongly suggests some common cause. 

  • Again the nose is a nidus; the bacteria that live there cause ear, sinus and bronchial infections, and the irritants that enter the nose trigger allergies and asthma. 

  • This is the forest that the specialists are missing as they look at their individual trees.

These graphs, my experience, that of the native American elders looking at their children's ear infections, and the international ISAAC studies on the incidence of asthma, suggest that we may be doing something in this country that is promoting these problems. 

I believe that we are. 

We are interfering with our normal nasal cleaning—a sometimes messy defense that nevertheless gives us a survival value.

 

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References:

 
Adv Data 1992 Sep 8;(214):1-19

Office visits for otitis media: United States, 1975-90.

Schappert SM

Division of Health Care Statistics, National Center for Health Statistics.

Data from the National Ambulatory Medical Care Survey show a steady increase in the number and rate of physician office visits for otitis media over the period from 1975 to 1990. The annual visit rate during this period more than doubled, and for children under age 15, increased 175 percent. Though the increase is greatest for males under age 2, there are substantial increases for males and females under age 15. Reasons for this dramatic increase are not readily apparent. Data from the National Health Interview Survey (NHIS), however, suggest that the increased visit rate may reflect an increase in the incidence of ear infections. According to NHIS data, the incidence of acute ear infections among the U.S. population increased by about 40 percent between 1982 and 1990, from 6.1 to 8.6 conditions per 100 persons per year. This compares with an increase of about 52 percent in the physician office visit rate for otitis media, from 1980 to 1990. (Because of gaps in data collection, it is not possible to compare precisely concurrent time periods.) The under 15 age group, which accounts for about 80 percent of otitis media physician office visits, experienced a 60 percent increase in office visit rate from 1980 to 1990. This parallels data from the NHIS that show a 60 percent increase in the incidence of acute ear infections among the under 17 age group from 1982 to 1990. The reporting of an acute ear infection in the NHIS does not necessarily equate to an incidence of otitis media, but the parallel increases in ear infection incidence and otitis media physician visits are mutually supportive and likely to be related.

PMID: 10126841

Office visits for otitis media: United States, 1975-90.

Schappert SM

Division of Health Care Statistics, National Center for Health Statistics.

Data from the National Ambulatory Medical Care Survey show a steady increase in the number and rate of physician office visits for otitis media over the period from 1975 to 1990. The annual visit rate during this period more than doubled, and for children under age 15, increased 175 percent. Though the increase is greatest for males under age 2, there are substantial increases for males and females under age 15. Reasons for this dramatic increase are not readily apparent. Data from the National Health Interview Survey (NHIS), however, suggest that the increased visit rate may reflect an increase in the incidence of ear infections. According to NHIS data, the incidence of acute ear infections among the U.S. population increased by about 40 percent between 1982 and 1990, from 6.1 to 8.6 conditions per 100 persons per year. This compares with an increase of about 52 percent in the physician office visit rate for otitis media, from 1980 to 1990. (Because of gaps in data collection, it is not possible to compare precisely concurrent time periods.) The under 15 age group, which accounts for about 80 percent of otitis media physician office visits, experienced a 60 percent increase in office visit rate from 1980 to 1990. This parallels data from the NHIS that show a 60 percent increase in the incidence of acute ear infections among the under 17 age group from 1982 to 1990. The reporting of an acute ear infection in the NHIS does not necessarily equate to an incidence of otitis media, but the parallel increases in ear infection incidence and otitis media physician visits are mutually supportive and likely to be related.

PMID: 10126841
 Mor Mortal Wkly Rep CDC Surveill Summ 1998 Apr 24;47(1):1-27

Surveillance for asthma--United States, 1960-1995.

Mannino DM, Homa DM, Pertowski CA, Ashizawa A, Nixon LL, Johnson CA, Ball LB, Jack E, Kang DS

Division of Environmental Hazards and Health Effects.

PROBLEM/CONDITION: Asthma is one of the most common chronic diseases in the United States, and it has increased in importance during the preceding 20 years. Despite its importance, no comprehensive surveillance system has been established that measures asthma trends at the state or local level. REPORTING PERIOD: This report summarizes and reviews national data for specific end-points: self-reported asthma prevalence (1980-1994), asthma office visits (1975-1995), asthma emergency room visits (1992-1995), asthma hospitalizations (1979-1994), and asthma deaths (1960-1995). DESCRIPTION OF SYSTEM: The National Center for Health Statistics (NCHS) annually conducts the National Health Interview Survey, which asks about self-reported asthma in a subset of the sample. NCHS collects physician office visit data with the National Ambulatory Medical Care Survey, emergency room visit data with the National Hospital Ambulatory Medical Care Survey, and hospitalization data with the National Hospital Discharge Survey. NCHS also collects mortality data annually from each state and produces computerized files from these data. We used these datasets to determine self-reported asthma prevalence, asthma office visits, asthma emergency room visits, asthma hospitalizations, and asthma deaths nationwide and in four geographic regions of the United States (i.e., Northeast, Midwest, South, and West). RESULTS: We found an increase in self-reported asthma prevalence rates and asthma death rates in recent years both nationally and regionally. Asthma hospitalization rates have increased in some regions and decreased in others. At the state level, only death data are available for asthma; death rates varied substantially among states within the same region. INTERPRETATION: Both asthma prevalence rates and asthma death rates are increasing nationally. Available surveillance information are inadequate for fully assessing asthma trends at the state or local level. Implementation of better state and local surveillance can increase understanding of this disease and contribute to more effective treatment and prevention strategies.

PMID: 9580746
 
Br J Gen Pract 1999 Jun;49(443):436-40

Influence of prescription patterns in general practice on anti-microbial resistance in Norway.

Lindbaek M, Berild D, Straand J, Hjortdahl P

Division of General Practice, University of Oslo, Norway.

BACKGROUND: The global pandemic of antibiotic resistance is causing considerable concern, and a major reason for the growing world-wide resistance problem is the overuse of anti-infective drugs, especially the use of broad spectrum antibiotics. This is still a relatively minor problem in most of the Nordic countries where the consumption of antibiotics is less than half of that reported from southern Europe and the United States of America (USA). AIM: To describe the resistance pattern among common respiratory tract pathogens in Norwegian general practice, the national consumption of antibiotics, and GPs' prescription patterns for respiratory tract infections. To offer some suggestions as to why Norway has maintained a favourable situation regarding resistant microbes during the past 10 years. METHODS: An analysis of the prescription patterns in Norwegian general practice. RESULTS: There is a low total prescription volume of antibiotics compared with other countries. Penicillin V is the most commonly used antibiotic for the most common airway diseases in general practice in Norway. CONCLUSION: Although there is a low prevalence of antibiotic resistance in Norway, there is still a great potential for reducing the unnecessary antibiotic prescribing for the most common respiratory illnesses.

Comment in:
  • Br J Gen Pract. 1999 Oct;49(447):838-9
 
Eur Respir J 1998 Aug;12(2):432-7

Prevalence of childhood asthma, rhinitis and eczema in Scandinavia and Eastern Europe.

Bjorksten B, Dumitrascu D, Foucard T, Khetsuriani N, Khaitov R, Leja M, Lis G, Pekkanen J, Priftanji A, Riikjarv MA

Dept of Health and Environment, Linkoping University, Sweden.

There is evidence that the prevalence of allergies and asthma differs between populations in western and eastern Europe. This study investigated the prevalence of wheezing, rhinitis and eczema among schoolchildren in urban and rural areas of Scandinavia and the formerly socialist countries of Eastern Europe. A total of 79,000 children from two age groups (13-14 yrs and 6-7 yrs) in 18 study centres responded to a questionnaire within the International Study of Asthma and Allergy in Children (ISAAC). The 12 month period prevalence of symptoms of asthma, allergic rhinoconjunctivitis and atopic eczema was calculated. The prevalence of wheezing among the 13-14 yr old children was 11.2-19.7% in Finland and Sweden, 7.6-8.5% in Estonia, Latvia and Poland and 2.6-5.9% in Albania, Romania, Russia, Georgia and Uzbekistan (except Samarkand). The prevalence of itching eyes and flexural dermatitis varied in a similar manner between the three regions. The regional differences were less pronounced among the 6-7 yr old children in the seven participating centres. The highest prevalence of rhinitis was recorded in April-July in Scandinavia and during the winter months in the other countries. The prevalence of atopy-related disorders was higher in Scandinavia than in Estonia, Latvia and Poland, which in turn had a higher prevalence than five other countries of eastern Europe with a culture less similar to western Europe. This supports the hypothesis that "Western life style" is associated with a high prevalence of childhood allergy.

Publication Types:
  • Multicenter study

PMID: 9727797
 
Antimicrob Agents Chemother 1989 Jan;33(1):92-8

Inhibitory activity of cranberry juice on adherence of type 1 and type P fimbriated Escherichia coli to eucaryotic cells.

Zafriri D, Ofek I, Adar R, Pocino M, Sharon N.

Department of Human Microbiology, Sackler Faculty of Medicine, Tel Aviv University, Israel.

Inhibition of bacterial adherence to bladder cells has been assumed to account for the beneficial action ascribed to cranberry juice and cranberry juice cocktail in the prevention of urinary tract infections (A. E. Sobota, J. Urol. 131:1013-1016, 1984). We have examined the effect of the cocktail and juice on the adherence of Escherichia coli expressing surface lectins of defined sugar specificity to yeasts, tissue culture cells, erythrocytes, and mouse peritoneal macrophages. Cranberry juice cocktail inhibited the adherence of urinary isolates expressing type 1 fimbriae (mannose specific) and P fimbriae [specific for alpha-D-Gal(1----4)-beta-D-Gal] but had no effect on a diarrheal isolate expressing a CFA/I adhesin. The cocktail also inhibited yeast agglutination by purified type 1 fimbriae. The inhibitory activity for type 1 fimbriated E. coli was dialyzable and could be ascribed to the fructose present in the cocktail; this sugar was about 1/10 as active as methyl alpha-D-mannoside in inhibiting the adherence of type 1 fimbriated bacteria. The inhibitory activity for the P fimbriated bacteria was nondialyzable and was detected only after preincubation of the bacteria with the cocktail. Cranberry juice, orange juice, and pineapple juice also inhibited adherence of type 1 fimbriated E. coli, most likely because of their fructose content. However, the two latter juices did not inhibit the P fimbriated bacteria. We conclude that cranberry juice contains at least two inhibitors of lectin-mediated adherence of uropathogens to eucaryotic cells. Further studies are required to establish whether these inhibitors play a role in vivo.

 
Pediatrics 2001 Dec;108(6):E97


Asthma hospitalization trends in Charleston, South Carolina, 1956 to 1997: twenty-fold increase among black children during a 30-year period.

Crater DD, Heise S, Perzanowski M, Herbert R, Morse CG, Hulsey TC, Platts-Mills T.

Department of Pediatrics, Children's Hospital, Medical University of South Carolina, Charleston, South Carolina, USA.

OBJECTIVE: The increase in asthma prevalence has been documented worldwide, affecting many races living in many different climates. Multiple studies have demonstrated that the most striking prevalence and morbidity of asthma in the United States has been in black children, but little research has determined the scale of the increase, or specifically when the disease became severe in this group. This study sought to determine exactly when the rise in asthma hospitalizations among black patients began and what the pattern of asthma hospitalizations has been in different races and age groups over a 40-year period in 1 urban area. METHODS: A retrospective chart review of discharges from the Medical University of South Carolina was conducted from 1956 to 1997. Charts with the primary discharge diagnosis of asthma were examined for discharge date, race, and age group (0- to 4-year-olds, 5- to 18-year-olds, 19- to 50-year-olds, > or =51-year-olds). The diagnostic codes used were based on the International Classification of Diseases (ICD)-6, 1956-1957; ICD-7, 1958-1967; ICD-8, 1968-1978; and ICD-9, 1979-1997. Over the period studied, this hospital was the primary inpatient provider for children in this area, and the only provider for uninsured children. Between 1960 and 1990, the racial makeup of the area remained stable, as did the percentage of blacks living at the poverty level. The raw number of asthma discharges, rate per 10 000 discharges of the same race, and rate per 100 000 population in Charleston County were tabulated for each age group and racial category. RESULTS: Over the time period examined, there has been a progressive increase in asthma hospitalizations in black individuals of all age groups and in whites under 18 years. The most striking increase has been in black children 0 to 18 years old (figure). The increase either as raw values or as a rate per 100 000 began around 1970, and was linear. This increase in black children discharged with asthma as a rate per 100 000 population was 20-fold: the rate increased from 18 in 1970 to 370 in 1997. Asthma discharges as a rate per 10 000 black children discharged increased by 24-fold from 1960 to 1997. Total discharges from the hospital increased from 49 000 to 128 000 per year over this period. Blacks made up only 28% of discharges in 1957, but that proportion increased to 56% in 1960 and remained relatively stable over the following 35 years. The increase seen in white children 0 to 18 years of age as a rate per 100 000 population was 5-fold and began around 1980. Both increases seem to be consistent over the time period studied, and continued to 1997. [figure: see text]. CONCLUSIONS: Among a predominantly poor black population living in a southern US city, there has been a steady increase in childhood asthma hospitalizations over the past 30 years. A significant although less dramatic rise has occurred in white children. Over this time period, although there have been many changes in lifestyle that could have contributed to this rise, there have been no major changes in housing conditions for poor patients. In addition, Medicaid coverage for children in South Carolina did not change significantly until 1999. The time course of these increases parallels increases reported in other Western populations, suggesting that there must be 1 or more common factors contributing to the rise. Many explanations have been offered for the changes in incidence and severity of asthma. The scale of the change, time course, and linearity of the increase in this study represent a challenge to many of the hypotheses proposed to explain this epidemic.

American Academy of Asthma, Allergy and Immunology. The Allergy Report. Vol. 1, page 6. [Even while reporting these facts this academy continues to consider histamine a bad guy.]

Am J Rhinol 1998 Jan-Feb;12(1):37-43

Nasal mucosal endorgan hyperresponsiveness.

Svensson C, Andersson M, Greiff L, Persson CG

Department of Otorhinolaryngology, Head & Neck Surgery, University Hospital, Lund, Sweden.

Nonspecific hyperresponsiveness of the upper and lower airways is a well-known characteristic of different inflammatory airway diseases but the underlying mechanisms have not yet been satisfactorily explained. In attempts to elucidate the relation of hyperresponsiveness to disease pathophysiology we have particularly examined the possibility that different airway endorgans may alter their function in allergic airway disease. The nose, in contrast to the bronchi, is an accessible part of the airways where in vivo studies of airway mucosal processes can be carried out in humans under controlled conditions. Different endorgans can be defined in the airway mucosa: subepithelial microvessels, epithelium, glands, and sensory nerves. Techniques may be applied further in the nose to determine selectively the responses/function of these endorgans. Topical challenge with methacholine will induce a glandular secretory response, and topical capsaicin activates sensory c-fibers and induces nasal smart. Topical histamine induces extravasation of plasma from the subepithelial microvessels. The plasma exudate first floods the lamina propria and then moves up between epithelial cells into the airway lumen. This occurs without any changes in the ultrastructure or barrier function of the epithelium. We have therefore forwarded the view of mucosal exudation of bulk plasma as a physiological airway tissue response with primarily a defense function. Since the exudation is specific to inflammation, we have also suggested mucosal exudation as a major inflammatory response among airway endorgan functions. Using a "nasal pool" device for concomitant provocation with histamine and lavage of the nasal mucosa we have assessed exudative responses by analyzing the levels of plasma proteins (e.g., albumin alpha 2-macroglobulin) in the returned lavage fluids. A secretory hyperresponsiveness occurs in both experimental and seasonal allergic rhinitis. This type of nasal hyperreactivity may develop already 30 minutes after allergen challenge. It is attenuated by topical steroids and oral antihistamines. We have demonstrated that exudative hyperresponsiveness develops in both seasonal allergic rhinitis and common cold, indicating significant changes of this important microvascular response in these diseases. An attractive hypothesis to explain airway hyperresponsiveness has been increased mucosal absorption permeability due to epithelial damage, possibly secondary to the release of eosinophil products. However, neither nonspecific nor specific endorgan hyperresponsiveness in allergic airways may be explained by epithelial fragility or damage since nasal absorption permeability (measured with 51CR-EDTA and dDAVP) was decreased or unchanged in our studies of allergic and virus-induced rhinitis, respectively. Thus, the absorption barrier of the airway mucosa may become functionally tighter in chronic eosinophilic inflammation.

 

The spray described in these pages is not a drug. This means that the people manufacturing this spray cannot advertise what the spray does to prevent disease and illness. The spray only helps to clean your nose. The benefits come from a clean nose. The only way people will learn about this practical and sensible way to help the immune system wash pollutants from the back of the nose is by interested people, like you, sharing this information.

If you have family or friends with any of these problems, they may benefit greatly from your sharing this information with them.

Links in the other sections, referring to a person or study, will take you to a Medline summary, from the National Library of Medicine, of the article in question.

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A. H. 'Lon' Jones D.O.
812 West 8th St. Suite 2A
Plainview, Texas 79072
Phone (806) 291-0700
Fax (806) 293-8229