Divergent trends in the prevalence of asthma-like symptoms and asthma in a developing country: three repeated surveys between 2002 and 2016
Main Article Content
Keywords
Adolescence, Asthma, Prevalence, Temporal trends, Risk factors, Wheeze
Abstract
Introduction and objectives: There have been differences in temporal trends of asthma prevalence by geographic region and economic prosperity. The aim of this study was to assess temporal trends in asthma prevalence among young adolescents in Skopje, Republic of North Macedonia as a developing country with a low asthma prevalence.
Subjects and methods: Data were obtained from three cross-sectional surveys (2002, 2006, and 2016) of adolescents (12-15 years) from randomly selected schools in Skopje. Trends in the prevalence of asthma and asthma-like symptoms were investigated descriptively and using multiple logistic regression to adjust for potential confounding factors.
Results: The prevalence of asthma increased, although the changes were not statistically significant (2002: 1.7%; 2006: 2.0%; 2016: 2.8%; p = 0.075). Statistically significant (p < 0.05) reductions in wheeze prevalence over time (2002, 2006, 2016) were observed for current wheeze (8.8%, 7.2%, 5.5%), exercise-induced wheeze (14.2%, 7.9%, 1.9%), and night dry cough (16.5%, 13.5%, 9.6%). After adjustment for potential confounding factors, there was an increase in asthma likelihood by year compared to 2002 (2006: OR = 1.22, 95% CI = 0.67-2.22; 2016: OR = 2.45, 95% CI = 1.24-4.84). In the adjusted analyses, associations between year and the asthma-like symptoms confirmed the descriptive results, except for current wheeze, where statistical significance disappeared.
Conclusions: Divergent trends in prevalence with a decrease in asthma-like symptoms and an increase in physician-diagnosed asthma in Skopje during a period of 14 years were established. Improved asthma labelling and effective preventative treatment of symptoms may explain some of these changes, although changes in environment and lifestyle could not be ruled out.
References
[1]. Lai CKW, Beasley R, Crane J, Foliaki S, Shah J, Weiland S, the ISAAC Phase Three Study Group. Global variation in the prevalence and severity of asthma symptoms: phase three of the International Study of Asthma and Allergies in Childhood (ISAAC). Thorax. 2009;64:476-83, http://dx.doi.org/10.1136/thx.2008.106609.
[2]. Masoli M, Fabian D, Holt S, Beasley R. Global Initiative for Asthma (GINA) Program. The global burden of asthma: executive summary of the GINA Dissemination Committee Report. Allergy. 2004;59:469-78, http://dx.doi.org/10.1111/j.1398-9995.2004.00526x.
[3]. Eder W, Ege MJ, von Mutius E. The asthma epidemic. N. Engl. J. Med. 2006;355:2226-35, http://dx.doi.org/10.1056/NEJMra054308.
[4]. Bråbäck L, Hjern A, Rasmussen F. Trends in asthma, allergic rhinitis and dermatitis among Swedish conscripts from farming and non-farming environments. A nationwide study over three decades. Clin. Exp. Allergy. 2004;34:38-43.
[5]. Ninan TK, Russell G. Respiratory symptoms and atopy in Aberdeen schoolchildren: evidence from two surveys 25 years apart. BMJ. 1992;304:873-5, http://dx.doi.org/10.1136/bmj.304.6831.873.
[6]. Asher MI, Montefort S, Björkstén B, Lai CKW, Strachan DP, Weiland SK, et al., ISAAC Phase Three Study Group. Worldwide time trends in the prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and eczema in childhood: ISAAC Phases One and Three repeat multicountry cross-sectional surveys. Lancet. 2006;368:733-43, http://dx.doi.org/10.1016/S0140-6736(06)69283-0.
[7]. The global asthma report 2011. Paris, France: The International Union Against Tuberculosis and Lung Diseases; 2011. ISBN: 978-2-914365-83-3.
[8]. García-Marcos L, Quirós AB, Hernández GG, Guillén-Grima F, Diaz CG, Urena˜ IC, et al. Stabilization of asthma prevalence among adolescents and increase among schoolchildren (ISAAC phases I and III) in Spain. Allergy. 2004;59:1301-7, http://dx.doi.org/10.1111/j.1398-9995.2004.00562.x.
[9]. Maio S, Baldacci S, Carrozzi L, Pistelli F, Angino A, Simoni M, et al. Respiratory symptoms/diseases prevalence is still increasing: a 25-yr population study. Respir. Med. 2016;110:58-65, http://dx.doi.org/10.1016/j.rmed.2015.11.006.
[10]. Kälvesten L, Bråbäck L. Time trend for the prevalence of asthma among school children in a Swedish district in 1985-2005. Acta Pediatr. 2008;97:454-8, http://dx.doi.org/10.1111/j.1651-2227.2008.00698.x.
[11]. Anderson HR, Ruggles R, Strachan DP, Austin JB, Burr M, Jeffs D, et al. Trends in prevalence of symptoms of asthma, hay fever, and eczema in 12- 14-year-olds in the British Isles, 1995-2002: questionnaire survey. BMJ. 2004;328:1052-3, http://dx.doi.org/10.1136/bmj.38057.583727.47.
[12]. Akinbami LJ, Simon AE, Rossen LM. Changing trends in asthma prevalence among children. Pediatrics. 2016;137:1-7, http://dx.doi.org/10.1542/peds.2015-2354.
[13]. Sears MR. Trends in the prevalence of asthma. Chest. 2014;145:219-25, http://dx.doi.org/10.1378/chest.13-2059.
[14]. Ellwood P, Asher MI, Beasley R, Clayton TO, Stewart AW, on behalf of the ISAAC Steering Committee and the ISAAC Phase Three Study Group. ISAAC Phase Three Manual. Auckland; July 2000. ISBN: 0-473-06910-5.
[15]. Ellwood P, Asher MI, Beasley R, Clayton TO, Stewart AW, the ISAAC Steering Committee. The International Study of Asthma and Allergies in Childhood (ISAAC): Phase Three rationale and methods. Int. J. Tuberc. Lung Dis. 2005;9:10-6.
[16]. Lawson JA, Brozek G, Shpakou A, Fedortstiv O, Vlaski E, Beridze V, et al. An international comparison of asthma, wheeze and breathing medication use among children. Respir. Med. 2017;133:22-8, http://dx.doi.org/10.1016/j.rmed.2017.11.001.
[17]. Ferris B Jr. Epidemiology standardization project. Am. Rev. Respir. Dis. 1978;118:36-47.
[18]. Rennie DC, Lawson JA, Cockcroft DW, Senthilselvan A, McDuffie HH. Differences in respiratory symptoms and pulmonary function in children in 2 Saskatchewan communities. Ann. Allergy. Asthma. Immunol. 2004;92:52---9, http://dx.doi.org/10.1016/S1081-1206(10)61710-3.
[19]. Rennie DC, Lawson JA, Kirychuk SP, Paterson C, Willson PJ, Senthilselvan A, et al. Assessment of endotoxin levels in the home and current asthma and wheeze in school-age children. Indoor Air. 2008;18:447-53, http://dx.doi.org/10.1111/j.1600-0668.2008.00543.x.
[20]. Lawson JA, Dosman JA, Rennie DC, Beach JR, Newman SC, Crowe T, et al. Endotoxin as a determinant of asthma and wheeze among rural-dwelling children and adolescents: a case control study. BMC Pulm Med. 2012;12:56, http://dx.doi.org/10.1186/1471-2466-12-56.
[21]. Vlaski E, Lawson JA. Urban-rural differences in asthma prevalence among young adolescents: the role of behavioural and environmental factors. Allergol. Immunopathol. (Madr.). 2015;43:131-41, http://dx.doi.org/10.1016/j.aller.2013.09.01.
[22]. Cole JT, Bellizzi CM, Flegal MK, Dietz HW. Establishing a standard definition for child overweight and obesity worldwide: international survey. BMJ. 2000;320:1-6, http://dx.doi.org/10.1136/bmj.320.7244.1240.
[23]. Stewart A. Analysis of ISAAC phase three study survey data from one centre. Auckland, New Zealand: ISAAC Phase Three Newsletter; December 2001, 9. Available from: http://isaac.auckland.ac.nz/news/media.html# [accessed5.8.19].
[24]. Thabane L, Mbuagbaw L, Zhang S, Samaan Z, Marcucci M, Ye C, et al. A tutorial on sensitivity analyses in clinical trials: the what, why, when and how. BMC Med Res Methodol. 2013;13:92, http://dx.doi.org/10.1186/1471-2288-13-92.
[25].Rothman K, Greenland S. Modern epidemiology. Philadelphia, USA: Lippincott-Raven Publishers; 1998.
[26]. Johannessen A, Verlato G, Benediktsdottir B, Forsberg B, Franklin K, Gislason T, et al. Longterm follow-up in European respiratory health studies - patterns and implications. BMC Pulm Med. 2014;14:63, http://dx.doi.org/10.1186/1471-2466-14-63.
[27]. Leonardi GS, Houthuijs D, Nikiforov B, Volf J, Rudnai P, Zejda J, et al. Respiratory symptoms, bronchitis and asthma in children of Central and Eastern Europe. Eur. Respir. J. 2002;20:890-8, http://dx.doi.org/10.1183/09031936.02.00260802.
[28]. Sarac¸lar Y, Kuyucu S, Tuncer A, S¸ekerel B, Sac¸kesen C, Kocabas¸ C. Prevalence of asthmatic phenotypes and bronchial hyperresponsiveness in Turkish schoolchildren: An International Study of Asthma and Allergies in Childhood (ISAAC) phase 2 study. Ann. Allergy. Asthma. Immunol. 2003;91:477-84, http://dx.doi.org/10.1016/S1081-1206(10)61517-7.
[29]. Brozek G, Shpakou A, Lawson J, Zejda J. Rural dwelling and temporal trends in relation to childhood asthma and related conditions in Belarus: a repeated cross-sectional survey. J Agromed. 2015;20:332-40, http://dx.doi.org/10.1080/1059924X.2015.1042616.
[30].Solé D, Rosário Filho NA, Sarinho ES, Camelo-Nunes IC, Barreto BA, Medeiros ML, et al. Prevalence of asthma and allergic diseases in adolescents: nine-year follow-up study (2003-2012). J. Pediatr. (Rio. J). 2015;91:30-5, http://dx.doi.org/10.1016/j.jped.2014.05.002.
[31]. Brozek G, Lawson J, Szumilas D, Zejda J. Increasing prevalence of asthma, respiratory symptoms, and allergic diseases: four repeated surveys from 1993-2014. Respir. Med. 2015;109:982-90, http://dx.doi.org/10.1016/j.rmed.2015.05.010.
[32]. Meng Q, Nagarajan S, Son Y, Koutsoupias P, Bielory L. Asthma, oculonasal symptoms, and skin test sensitivity across National Health and Nutrition Examination Surveys. Ann. Allergy. Asthma. Immunol. 2016;116, http://dx.doi.org/10.1016/j.anai.2015.11.006, 118-25.e5.
[33]. Ma YC, Lin CC, Li CI, Chiang JH, Li TC, Lin JG. Time-trend analysis of prevalence, incidence and traditional Chinese medicine use among children with asthma: a population-based study. J Public Health (Oxf). 2016;38:e263-71, http://dx.doi.org/10.1093/pubmed/fdv144.
[34]. Huang C, Liu W, Hu Y, Zou Z, Zhao Z, Shen L, et al. Updated prevalences of asthma, allergy, and airway symptoms, and a systematic review of trends over time for childhood asthma in Shanghai, China. PLoS ONE. 2015;10:e0121577, http://dx.doi.org/10.1371/journal.pone.0121577.
[35]. Weber A, Herr C, Hendrowarsito L, Meyer N, NennstielRatzel U, von Mutius E, et al., GME Study Group. No further increase in the parent-reported prevalence of allergies in Bavarian preschool children: results from three cross-sectional studies. Int. J. Hyg. Environ. Health. 2016;219:343-8, http://dx.doi.org/10.1016/j.ijheh.2016.02.001.
[36]. de Korte-de Boer D, Mommers M, Gielkens-Sijstermans CM, Creemers HM, Mujakovic S, Feron FJ, et al. Stabilizing prevalence trends of eczema, asthma and rhinoconjunctivitis in Dutch schoolchildren (2001-2010). Allergy. 2015;70:1669-73, http://dx.doi.org/10.1111/all.12728.
[37]. Engelkes M, Janssens HM, de Ridder MA, de Jongste JC, Sturkenboom MC, Verhamme KM. Time trends in the incidence, prevalence and age at diagnosis of asthma in children. Pediatr. Allergy Immunol. 2015;26:367-74, http://dx.doi.org/10.1111/pai.12376.
[38]. Bloom CI, Saglani S, Feary J, Jarvis D, Quint JK. Changing prevalence of current asthma and inhaled corticosteroid treatment in the UK: population-based cohort 2006-2016. Eur. Respir. J. 2019;53:1802130, http://dx.doi.org/10.1183/13993003.02130-2018.
[39].Hedman L, Lindgren B, Perzanowski M, Ronmark E. Agreement between parental and self-completed questionnaires about asthma in teenagers. Pediatr. Allergy Immunol. 2005;16:176-81, http://dx.doi.org/10.1111/j.1399-3038.2005.00231.x.
[2]. Masoli M, Fabian D, Holt S, Beasley R. Global Initiative for Asthma (GINA) Program. The global burden of asthma: executive summary of the GINA Dissemination Committee Report. Allergy. 2004;59:469-78, http://dx.doi.org/10.1111/j.1398-9995.2004.00526x.
[3]. Eder W, Ege MJ, von Mutius E. The asthma epidemic. N. Engl. J. Med. 2006;355:2226-35, http://dx.doi.org/10.1056/NEJMra054308.
[4]. Bråbäck L, Hjern A, Rasmussen F. Trends in asthma, allergic rhinitis and dermatitis among Swedish conscripts from farming and non-farming environments. A nationwide study over three decades. Clin. Exp. Allergy. 2004;34:38-43.
[5]. Ninan TK, Russell G. Respiratory symptoms and atopy in Aberdeen schoolchildren: evidence from two surveys 25 years apart. BMJ. 1992;304:873-5, http://dx.doi.org/10.1136/bmj.304.6831.873.
[6]. Asher MI, Montefort S, Björkstén B, Lai CKW, Strachan DP, Weiland SK, et al., ISAAC Phase Three Study Group. Worldwide time trends in the prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and eczema in childhood: ISAAC Phases One and Three repeat multicountry cross-sectional surveys. Lancet. 2006;368:733-43, http://dx.doi.org/10.1016/S0140-6736(06)69283-0.
[7]. The global asthma report 2011. Paris, France: The International Union Against Tuberculosis and Lung Diseases; 2011. ISBN: 978-2-914365-83-3.
[8]. García-Marcos L, Quirós AB, Hernández GG, Guillén-Grima F, Diaz CG, Urena˜ IC, et al. Stabilization of asthma prevalence among adolescents and increase among schoolchildren (ISAAC phases I and III) in Spain. Allergy. 2004;59:1301-7, http://dx.doi.org/10.1111/j.1398-9995.2004.00562.x.
[9]. Maio S, Baldacci S, Carrozzi L, Pistelli F, Angino A, Simoni M, et al. Respiratory symptoms/diseases prevalence is still increasing: a 25-yr population study. Respir. Med. 2016;110:58-65, http://dx.doi.org/10.1016/j.rmed.2015.11.006.
[10]. Kälvesten L, Bråbäck L. Time trend for the prevalence of asthma among school children in a Swedish district in 1985-2005. Acta Pediatr. 2008;97:454-8, http://dx.doi.org/10.1111/j.1651-2227.2008.00698.x.
[11]. Anderson HR, Ruggles R, Strachan DP, Austin JB, Burr M, Jeffs D, et al. Trends in prevalence of symptoms of asthma, hay fever, and eczema in 12- 14-year-olds in the British Isles, 1995-2002: questionnaire survey. BMJ. 2004;328:1052-3, http://dx.doi.org/10.1136/bmj.38057.583727.47.
[12]. Akinbami LJ, Simon AE, Rossen LM. Changing trends in asthma prevalence among children. Pediatrics. 2016;137:1-7, http://dx.doi.org/10.1542/peds.2015-2354.
[13]. Sears MR. Trends in the prevalence of asthma. Chest. 2014;145:219-25, http://dx.doi.org/10.1378/chest.13-2059.
[14]. Ellwood P, Asher MI, Beasley R, Clayton TO, Stewart AW, on behalf of the ISAAC Steering Committee and the ISAAC Phase Three Study Group. ISAAC Phase Three Manual. Auckland; July 2000. ISBN: 0-473-06910-5.
[15]. Ellwood P, Asher MI, Beasley R, Clayton TO, Stewart AW, the ISAAC Steering Committee. The International Study of Asthma and Allergies in Childhood (ISAAC): Phase Three rationale and methods. Int. J. Tuberc. Lung Dis. 2005;9:10-6.
[16]. Lawson JA, Brozek G, Shpakou A, Fedortstiv O, Vlaski E, Beridze V, et al. An international comparison of asthma, wheeze and breathing medication use among children. Respir. Med. 2017;133:22-8, http://dx.doi.org/10.1016/j.rmed.2017.11.001.
[17]. Ferris B Jr. Epidemiology standardization project. Am. Rev. Respir. Dis. 1978;118:36-47.
[18]. Rennie DC, Lawson JA, Cockcroft DW, Senthilselvan A, McDuffie HH. Differences in respiratory symptoms and pulmonary function in children in 2 Saskatchewan communities. Ann. Allergy. Asthma. Immunol. 2004;92:52---9, http://dx.doi.org/10.1016/S1081-1206(10)61710-3.
[19]. Rennie DC, Lawson JA, Kirychuk SP, Paterson C, Willson PJ, Senthilselvan A, et al. Assessment of endotoxin levels in the home and current asthma and wheeze in school-age children. Indoor Air. 2008;18:447-53, http://dx.doi.org/10.1111/j.1600-0668.2008.00543.x.
[20]. Lawson JA, Dosman JA, Rennie DC, Beach JR, Newman SC, Crowe T, et al. Endotoxin as a determinant of asthma and wheeze among rural-dwelling children and adolescents: a case control study. BMC Pulm Med. 2012;12:56, http://dx.doi.org/10.1186/1471-2466-12-56.
[21]. Vlaski E, Lawson JA. Urban-rural differences in asthma prevalence among young adolescents: the role of behavioural and environmental factors. Allergol. Immunopathol. (Madr.). 2015;43:131-41, http://dx.doi.org/10.1016/j.aller.2013.09.01.
[22]. Cole JT, Bellizzi CM, Flegal MK, Dietz HW. Establishing a standard definition for child overweight and obesity worldwide: international survey. BMJ. 2000;320:1-6, http://dx.doi.org/10.1136/bmj.320.7244.1240.
[23]. Stewart A. Analysis of ISAAC phase three study survey data from one centre. Auckland, New Zealand: ISAAC Phase Three Newsletter; December 2001, 9. Available from: http://isaac.auckland.ac.nz/news/media.html# [accessed5.8.19].
[24]. Thabane L, Mbuagbaw L, Zhang S, Samaan Z, Marcucci M, Ye C, et al. A tutorial on sensitivity analyses in clinical trials: the what, why, when and how. BMC Med Res Methodol. 2013;13:92, http://dx.doi.org/10.1186/1471-2288-13-92.
[25].Rothman K, Greenland S. Modern epidemiology. Philadelphia, USA: Lippincott-Raven Publishers; 1998.
[26]. Johannessen A, Verlato G, Benediktsdottir B, Forsberg B, Franklin K, Gislason T, et al. Longterm follow-up in European respiratory health studies - patterns and implications. BMC Pulm Med. 2014;14:63, http://dx.doi.org/10.1186/1471-2466-14-63.
[27]. Leonardi GS, Houthuijs D, Nikiforov B, Volf J, Rudnai P, Zejda J, et al. Respiratory symptoms, bronchitis and asthma in children of Central and Eastern Europe. Eur. Respir. J. 2002;20:890-8, http://dx.doi.org/10.1183/09031936.02.00260802.
[28]. Sarac¸lar Y, Kuyucu S, Tuncer A, S¸ekerel B, Sac¸kesen C, Kocabas¸ C. Prevalence of asthmatic phenotypes and bronchial hyperresponsiveness in Turkish schoolchildren: An International Study of Asthma and Allergies in Childhood (ISAAC) phase 2 study. Ann. Allergy. Asthma. Immunol. 2003;91:477-84, http://dx.doi.org/10.1016/S1081-1206(10)61517-7.
[29]. Brozek G, Shpakou A, Lawson J, Zejda J. Rural dwelling and temporal trends in relation to childhood asthma and related conditions in Belarus: a repeated cross-sectional survey. J Agromed. 2015;20:332-40, http://dx.doi.org/10.1080/1059924X.2015.1042616.
[30].Solé D, Rosário Filho NA, Sarinho ES, Camelo-Nunes IC, Barreto BA, Medeiros ML, et al. Prevalence of asthma and allergic diseases in adolescents: nine-year follow-up study (2003-2012). J. Pediatr. (Rio. J). 2015;91:30-5, http://dx.doi.org/10.1016/j.jped.2014.05.002.
[31]. Brozek G, Lawson J, Szumilas D, Zejda J. Increasing prevalence of asthma, respiratory symptoms, and allergic diseases: four repeated surveys from 1993-2014. Respir. Med. 2015;109:982-90, http://dx.doi.org/10.1016/j.rmed.2015.05.010.
[32]. Meng Q, Nagarajan S, Son Y, Koutsoupias P, Bielory L. Asthma, oculonasal symptoms, and skin test sensitivity across National Health and Nutrition Examination Surveys. Ann. Allergy. Asthma. Immunol. 2016;116, http://dx.doi.org/10.1016/j.anai.2015.11.006, 118-25.e5.
[33]. Ma YC, Lin CC, Li CI, Chiang JH, Li TC, Lin JG. Time-trend analysis of prevalence, incidence and traditional Chinese medicine use among children with asthma: a population-based study. J Public Health (Oxf). 2016;38:e263-71, http://dx.doi.org/10.1093/pubmed/fdv144.
[34]. Huang C, Liu W, Hu Y, Zou Z, Zhao Z, Shen L, et al. Updated prevalences of asthma, allergy, and airway symptoms, and a systematic review of trends over time for childhood asthma in Shanghai, China. PLoS ONE. 2015;10:e0121577, http://dx.doi.org/10.1371/journal.pone.0121577.
[35]. Weber A, Herr C, Hendrowarsito L, Meyer N, NennstielRatzel U, von Mutius E, et al., GME Study Group. No further increase in the parent-reported prevalence of allergies in Bavarian preschool children: results from three cross-sectional studies. Int. J. Hyg. Environ. Health. 2016;219:343-8, http://dx.doi.org/10.1016/j.ijheh.2016.02.001.
[36]. de Korte-de Boer D, Mommers M, Gielkens-Sijstermans CM, Creemers HM, Mujakovic S, Feron FJ, et al. Stabilizing prevalence trends of eczema, asthma and rhinoconjunctivitis in Dutch schoolchildren (2001-2010). Allergy. 2015;70:1669-73, http://dx.doi.org/10.1111/all.12728.
[37]. Engelkes M, Janssens HM, de Ridder MA, de Jongste JC, Sturkenboom MC, Verhamme KM. Time trends in the incidence, prevalence and age at diagnosis of asthma in children. Pediatr. Allergy Immunol. 2015;26:367-74, http://dx.doi.org/10.1111/pai.12376.
[38]. Bloom CI, Saglani S, Feary J, Jarvis D, Quint JK. Changing prevalence of current asthma and inhaled corticosteroid treatment in the UK: population-based cohort 2006-2016. Eur. Respir. J. 2019;53:1802130, http://dx.doi.org/10.1183/13993003.02130-2018.
[39].Hedman L, Lindgren B, Perzanowski M, Ronmark E. Agreement between parental and self-completed questionnaires about asthma in teenagers. Pediatr. Allergy Immunol. 2005;16:176-81, http://dx.doi.org/10.1111/j.1399-3038.2005.00231.x.
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Vlaski, E., Stavrikj, K., Kimovska, M., Cholakovska, V., & Lawson, J. (2020). Divergent trends in the prevalence of asthma-like symptoms and asthma in a developing country: three repeated surveys between 2002 and 2016. Allergologia Et Immunopathologia, 48(5), 475-483. https://all-imm.com/index.php/aei/article/view/151
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How to Cite
Vlaski, E., Stavrikj, K., Kimovska, M., Cholakovska, V., & Lawson, J. (2020). Divergent trends in the prevalence of asthma-like symptoms and asthma in a developing country: three repeated surveys between 2002 and 2016. Allergologia Et Immunopathologia, 48(5), 475-483. https://all-imm.com/index.php/aei/article/view/151