Features of sensitization and quality of life of patients with allergic rhinitis: A study in North Viet Nam

Use your smartphone to scan this QR code and download this article ABSTRACT Introduction: Allergic rhinitis (AR) is a critical disease related to otorhinolaryngology, allergology, and pediatrics worldwide due to its high prevalence and treatment costs. This article considers its prevalence based on regional characteristics of sensitization and the quality of patientswith allergic rhinitis in North Vietnam. Methods: The study was conducted from June to September 2018 by the Department of Otorhinolaryngology, Thai Nguyen Central General Hospital, Vietnam. A total of 158 patients with symptoms of chronic rhinitis, aged 5–70 years, were examined. All patients with allergic rhinitis were subjected to standard, specific allergological tests, such as skin scarification tests, the determination of specific IgE in the blood, and statistics according to the NOSE scale. All the patients were also examined by otolaryngologists. Results: Among the 158 patients identified with chronic year-round rhinitis, 64 patients were diagnosed with allergic rhinitis. The sensitization to house dust mites and fungi was high. A reduction in quality of life was observed in 70 patients (31%). Conclusion: Allergic rhinitis can adversely affect every aspect of a patient's life, including sleep quality, mood, and daily activities. Sensitization of patients with allergic rhinitis in Northern Vietnam is similar to those in Asia, with allergy to house dust mites being common.


INTRODUCTION
In recent decades, the prevalence of allergic rhinitis (AR) has increased significantly, making the disease a major contributor to the healthcare burden and morbidity in several countries. Treatment of the established disease is mainly aimed at symptom control and allergen avoidance 1 . Currently, in the general population, the percentage of residents with seasonal or year-round AR is between 10 to 25%, and in some countries, up to 50% have signs characteristic of this disease 2,3 . In the United States, the number of patients with AR is 25-30 million. In England, the prevalence of AR is 16%, in Denmark-19%, and in Germany-13-17%. In different regions of the Russian Federation, the prevalence of AR ranges from 12.7-24% 4 ; the prevalence is 23-30% in Europe, 12-30% in the USA, 5.5-45.1% in Latin America, 7.2-54.1% in Africa, and 9.1-35.7% in Japan/Korea 5 . Differences in geography, climate, and urbanization affect the global distribution of aeroallergens and, correspondingly, their sensitization patterns in humans. Different patterns of aeroallergen sensitization have been seen in various parts of the world; the Asian allergome and allergic disease phenotypes are distinct from those in Europe and the United States 1 .
Atopic patients in Europe and the United States are more highly sensitized to animal dander (cat and dog) and pollen than Asians. House dust mites (HDM) are by far the most common aeroallergen implicated in allergic people in Asian countries. The highest rates of HDM sensitization have been reported in Singapore (70 to >90%) and South India (89.7%); the lowest sensitization rates have been described in North India (7.8%), Vietnam (9-23%), and the Philippines (33-47%) 1 . Even though the manifestations of AR are not regarded as a serious illness, they have negative effects on the physical, psychological and social aspects of human life 6 . AR contributes to missed or unproductive time at work and school, problems with sleep, and in affected children, reduced involvement in outdoor activities.
Many studies of quality of life have emphasized that adult patients are disturbed by sleep disturbances and by annoying practical problems, such as the need to blow one's nose and carry handkerchiefs, as well as restrictions on their daily activities. Studies have shown that although younger children show less concern about emotional dysfunction and disturbances in everyday life, they are more concerned about the need to take medicine and wear handkerchiefs 7 . Moreover, their parents seem more worried than the children Cite this article : Kryukov A I, Bondareva G P, Nguyen T P T. Features of sensitization and quality of life of patients with allergic rhinitis: A study in North Viet Nam. Biomed. Res. Ther.; 6(11): 3485 -3491.
themselves. In addition to poor sleep quality, daytime tiredness and drowsiness are often observed in children 7 .
The assessment of quality of life has become a major area of interest for clinical research. Quality of life (QOL) questionnaires have been developed to assess the effects of clinical management and of reducing the symptoms of chronic diseases on the patient's daily life, and to evaluate the effects of particular methods of treatment on controlling the disease. The nasal obstruction symptom evaluation (NOSE) scale and QOL questionnaires are brief, valid, reliable, and responsive surveys to measure disturbances in the quality of life specific to nasal obstruction. The NOSE Scale was conducted as part of a parallel prospective multicenter observational clinical study. This multicenter study was commissioned and funded by the American Academy of Otolaryngology-Head and Neck Surgery Foundation, and coordinated under the auspices of its National Center for the Promotion of Research in Otolaryngology 8 . Many recent studies have used the NOSE scale as a primary outcome measure for surgical treatment of nasal obstruction 9 . A study conducted in India (2015) provided further evidence that the quality of life of allergic rhinitis patients was worse than that of non-rhinitis subjects. Indeed, allergic rhinitis impairs the quality of life of persons in different domains 7 . Our study was conducted to assess the sensitization and quality of life of patients with symptoms of nasal obstruction and characteristics of allergic rhinitis in Northern Vietnam.

Materials
The study was conducted from June to September 2018 by the Department of Otorhinolaryngology, Thai Nguyen Central General Hospital, Vietnam. The field of study included urban and rural areas. An urban area was defined as having a population density (in 2018) from 400 to 3000 people per km 2 , and a rural area was defined as having a developing modern agricultural production and industrial plants 6 . A total of 556 patients (aged 5 to 70 years) with pathology of ear-nose-throat (ENT) organs were examined, of which 158 patients were identified and diagnosed as having chronic rhinitis (CR).

Methods
All patients with CR were assessed for complaints of nasal congestion, olfactory disturbance, sneezing, itching (in the nasal cavity and eyes), rhinorrhea, and drainage of mucus along the back wall of the pharynx. In this study, the exclusion criteria were as follows: pregnancy or lactation, acute infectious pathologies, autoimmune diseases, oncopathology, psychosomatic disorders, AIDS, treatment with antihistamines, use of glucocorticosteroids, and use of mast cell stabilizers. All patients with CR underwent a standard specific and thorough allergological study, which included allergological history, NOSE scale ( Table 2), skin scarification tests, and the determination of specific IgE in the blood in response to house dust, pollen, and epidermal allergens (manufactured by NPO Microgen, Russia). The study was approved by the Medical Ethics Research Committee of Thai Nguyen Central General Hospital, Vietnam. Informed consent was obtained from the patients before any tests or evaluations were conducted.

Allergological history
The interview questionnaire used was the recently developed questionnaire from the Russian Association of Allergologists and Clinical Immunologists 10 . Additional questions were taken from the Global Allergy and Asthma European Network (GA2LEN) questionnaire 11 . The questionnaire of our study herein included questions mainly about respiratory and allergic symptoms, diagnoses, and smoking habits, such as the below: • a. Allergic rhinitis (AR): "Do you have nasal allergy, including hay fever?" • b. AR symptoms lasting 12 months: "Have you been troubled by nasal allergies in the last 12 months?" • c. "When/what was the frequency of duration of nasal congestion (year, month or season)?" • d. "What is the reason for AR? (describe exact conditions)" • e. Definitions of possible risk factors including smoking habits have been described in detail previously. "Are you a smoker?" • f. "What concomitant diseases (bronchial asthma, nasal polyp, etc.) do you have?" • g. Patients carry out an anamnesis collection questionnaire with scores ( Table 1 ). Patients are evaluated for nasal congestion, rhinorrhea, and olfactory disturbance. The severity of symptoms is noted as points. The presence of 7-9 points indicates a severe course of the disease,

NOSE scale
The NOSE scale is composed of five questions about the severity of nasal obstruction. Each item is evaluated using a Likert scale-from 0 (not a problem) to 4 (severe problem). The data is summarized and then multiplied by 5 for a total final NOSE score ranging between 0 to 100. A higher NOSE score reflects greater severity of self-reported nasal obstruction. The total NOSE scores were categorized into previously described severity ranges including: mild (range of 5-25), moderate (range of 30-50), severe (range of 55-75), or extreme (range of 80-100) 12 .

Skin scarification tests (SST)
The skin scarification tests (SST) were performed according to the standards developed by the Russian University of Allergology and Clinical Immunology 10 , using a special disposable lancet with allergens fixed on it. Ten allergen extracts were used and provided by NPO "Microgen" (Russia): house dust, cat, dog, Dermatophagoides pteronyssinus, Dermatophagoides farinae, Alternaria alternata, mixed grass, mixed tree, pollen from Atriplex, and pollen from Artemisia. At the same time, tests with histamine (10 mg/ml) and physiological saline were carried out in a similar way (they were used as positive and negative controls). A positive reaction was recorded if the mean diameter of the wheal was ≥5 mm. The wheal was recorded after 15-20 minutes, and the mean wheal diameter was measured by adding the largest diameter and its perpendicular diameter. No subjects had a reaction to the negative control agent, but all subjects had a positive reaction to histamine. The exclusion criteria for participation in the SST was age 15-70 years, with also the above exclusion criteria.

Statistical analysis
All statistical analyses were performed by a professional statistician using Microsoft Excel version 12.0.4518.1014 and SPSS Statistics 20. Descriptive statistics methods were used to evaluate the results. To find the correlative relationship between the traits, the Friedman and Wilcoxon rank correlation methods were used; a p-value <0.05 was considered statistically significant. Demographic and exposure data were used as independent variables; these included sex, age, area, and smoking habits. The results were expressed as odds ratios (OR) with 95% confidence intervals (CI).

RESULTS
According to the results of our study, among 158 patients with a diagnosis of chronic rhinitis (CR), a total of 64 patients were diagnosed as allergic rhinitis (AR), with an average duration of morbidity of 5.4 ± 1.6 years.  symptoms and the effects of the degree of nasal congestion on the quality of life of the patient. According to the results of skin scarification tests, an isolated sensitization to an allergen from house dust was found in only 3 (4.69%) patients, while sensitization to house dust was combined with mite allergy in 33 (51.56%) patients. Twenty (31.25%) patients showed positive reaction to both D. pteronyssinus and D. farinae, while 18 (28.13%) showed only response to only 1 type of mites (D. pteronyssinus or D. farinae). Sensitization to an allergen from cereal herb mix with an allergy to house dust was found in 3 (4.69%) patients. In the study group of patients, positive scarification tests for pollen and epidermal allergens were rarely detected. Therefore, according to the results of the skin tests, sensitization to epidermal allergens were found in 9 (14.1%) patients; of them, 5 (7.81%) were allergic to cats, and 4 (6.25%) to dogs. In 5 (7.81%) patients, sensitization to a mixture of trees was revealed, in 3 (4.69%) to a mixture of herbs, in 1 (1.56%) to pollen of Atriplex, and in 1 (1.56%) to pollen of Artemisia.

DISCUSSION
At the ENT department of Thai Nguyen Central General Hospital, Vietnam, we discovered a high prevalence of AR in patient referrals, reaching up to 40.5% for chronic rhinitis and 11.5% for ENT pathologies. Our results also demonstrate that the prevalence of AR among men is the same as for women. While men may have more contact with bad habits (smoking, alcohol consumption, etc.), housework is a risk factor for women. An increased risk of allergic diseases among people exposed to tobacco smoke has been reported 19 . Our study results also confirm that smoking is a risk factor associated with AR. Smoking can increase sensitivity to both perennial indoor allergens and some outdoor allergens 20  Allergies to all three allergens were significantly more common among citizens than among rural residents, and were found among patients of the middle age group of 20-45 years old (p<0.001). Before treatment, the chronic symptoms of AR of this study were strongly expressed in chronic nasal congestion (90.6%) and chronic runny nose (70,31%), and were distributed in both urban and rural areas. For comparison, there are no published data on the prevalence of chronic AR symptoms in Southeast Asia; these symptoms have also rarely been studied in other countries. In a recent European study, prevalence of runny nose was reported as 20% in the United Kingdom; in Western Sweden the prevalence of nasal congestion was reported as 15% and chronic runny nose as 13% 17 .
The results obtained from the present study show a significant relationship between quality of life and severity of disease. Indeed, patients with severe permanent or intermittent disease had a poorer quality of life. These observations are consistent with those from other studies, such as one conducted by Ramona Ungureanu and Dorin Sarafoleanu in 2012, which showed that patients with a more severe type of AR have a poorer quality of life 26 .

CONCLUSION
The results show that among patients with chronic year-round rhinitis in the North Vietnam region, 40% of them had AR, with predominant sensitization to house dust mites and molds. Sensitization was three times more common in urban residents than rural residents. Given the significant effects of these symptoms of AR on the patients' quality of life, making an early diagnosis of the disease is the first step to overcoming or managing the disease. The findings of our study can help shape the next steps of treatment for AR, such as reducing environmental allergens and taking measures to prevent the incidence of concomitant diseases, such as asthma and sinusitis, with higher efficiency.