Volume 120, Issue 2 , Pages 381-387, August 2007
Seasonal allergic rhinitis is associated with a detrimental effect on examination performance in United Kingdom teenagers: Case-control study
Article Outline
Background
Seasonal allergic rhinitis is common globally, and symptoms have been shown to impair learning ability in children in laboratory conditions. Critical examinations in children are often held in the summer during the peak grass pollen season.
Objective
To investigate whether seasonal allergic rhinitis adversely impacts examination performance in United Kingdom teenagers.
Methods
Case-control analysis of 1834 students (age 15-17 years; 50% girls) sitting for national examinations. Cases were those who dropped 1 or more grades in any of 3 core subjects (mathematics, English, and science) between practice (winter) and final (summer) examinations; controls were those whose grades were either unchanged or improved. Associations between allergic rhinitis symptoms, clinician-diagnosed allergic rhinitis, and allergic rhinitis–related medication use, recorded on examination days immediately before the examination, were assessed using multilevel regression models.
Results
Between 38% and 43% of students reported symptoms of seasonal allergic rhinitis on any 1 of the examination days. There were 662 cases (36% of students) and 1172 controls. After adjustment, cases were significantly more likely than controls to have had allergic rhinitis symptoms during the examination period (odds ratio [OR], 1.4; 95% CI, 1.1-1.8; P = .002), to have taken any allergic rhinitis medication (OR, 1.4; 95% CI, 1.1-1.7; P = .01), or to have taken sedating antihistamines (OR, 1.7; 95% CI, 1.1-2.8; P = .03).
Conclusion
Current symptomatic allergic rhinitis and rhinitis medication use are associated with a significantly increased risk of unexpectedly dropping a grade in summer examinations.
Clinical implications
This is the first time the relationship between symptomatic allergic rhinitis and poor examination performance has been demonstrated, which has significant implications for clinical practice.
Key words: Seasonal allergic rhinitis, examination performance, learning outcomes
Abbreviations used: GCSE, General Certificate of Secondary Education, OR, Odds ratio, UK, United Kingdom
The International Study of Asthma and Allergies in Childhood found that seasonal allergic rhinoconjunctivitis (more commonly referred to as allergic rhinitis) each year affects between 1.4% and 39.7% of the pediatric population,1 with a peak age of onset in adolescence.2, 3 Common symptoms include sneezing, itching, watery rhinorrhea, and nasal blockage, which may lead to sleep disturbance, limitations in activity, and both practical and emotional problems.4 More specifically, a few studies have investigated the effects of allergic rhinitis on learning ability by using computer simulation in a classroom situation. They showed significant learning impairment in children with symptomatic allergic rhinitis compared with asymptomatic control subjects,5 effects that were compounded by sedating antihistamines.6
However, as far as we are aware, there are no studies looking at the effect of seasonal allergic rhinitis on actual examination performance. This is a crucial question in populations such as the United Kingdom (UK), where a quarter of adolescents experience seasonal allergic rhinitis and critical student examinations (General Certificate of Secondary Education [GCSE] examinations) in children 15 to 17 years old, which have a major bearing on future educational and employment trajectories, take place during a 6-week period (mid May to the end of June) when grass pollen counts are at their highest.7
Depending on their academic abilities, GCSE students sit for between 5 and 15 examinations in different subjects during a 5-week period between early May and the end of June. Examinations in 3 subjects—mathematics, English, and science—are taken by all students. Practice examinations in the winter (November through January) are structured similarly to the final examinations and are used to give students a trial run before their finals. Students are encouraged to treat practice examinations seriously and to study as they would for their finals. Both sets of examinations are marked on an 8-point scale. The results of practice examinations, together with other information about the child such as any learning difficulties, home pressures, or school problems, allow teachers to predict what results students might expect in their finals if they study at a similar level. The expectation is that most children will either achieve their predicted grades or, with increased effort, improve on them when sitting for finals. Any drop in grade is therefore unexpected.
A recent editorial highlighted the potential effect of allergic rhinitis on examination results and called for further investigation.8 This study addresses the important and topical question of whether allergic rhinitis adversely affects summer examination performance in adolescents by examining the association between symptomatic allergic rhinitis and unexpectedly poor performance in GCSE examinations.
Methods
We performed a case-control study of students age 15 to 17 years who were sitting for GCSE examinations in 3 core subjects: mathematics, English, and science.
Inclusion and exclusion criteria
State schools in the West Midlands area of the UK were identified from Local Education Authority records. Schools were invited to participate if they had a large (>100 pupils) relevant-aged English-speaking student population and held practice GCSE examinations in the winter (November through January) and finals in the summer (May through June). All students age 15 to 17 years in the last year of study for their GCSE examinations were invited to participate via a letter sent by the school to the child and their parents; students were excluded or withdrawn from the study if at any point they expressed reluctance to participate or in the event of parental or school objections.
Definition of cases and controls
Case status was defined by comparison of the performance of each student in winter practice and final summer examinations. If students dropped at least 1 grade in any of the 3 core subjects, they were considered cases. Controls were students whose grades in their final examinations were at least as good as those in their practice examinations in all 3 subjects.
Reporting of allergic rhinitis, medication use, and other confounders
Two questionnaires were administered, 1 before the grass pollen season and 1 on the day of each relevant examination. The first, in April 2004, ascertained whether students had ever received a diagnosis of seasonal allergic rhinitis from a physician; we also used it to collect information on potential confounders or effect modifiers:
Our main exposure of interest was the presence of symptomatic allergic rhinitis on the day of the examinations. In an attempt to avoid recall bias, this information was collected using a short questionnaire administered immediately before the examination on each of the final examination days in May and June 2004. The questionnaire also asked about the severity of these allergic rhinitis symptoms—using a Likert scale from 0 to 10—and medication use. The questionnaire was designed so that only students who reported symptoms were asked to complete the question on medication. We assumed that students who did not report symptoms—and those who failed to complete the question on medication—were not using treatment on that day. Students who reported oral medication use on an examination day and who had reported taking chlorpheniramine for their allergic rhinitis in the April questionnaire were considered to have taken sedative medication. All other antihistamines were considered to be nonsedating on the basis of current evidence.11
Practice and final GCSE examination results were obtained from schools. These data were entered into a database by a researcher who was unaware of whether students had allergic rhinitis.
Formal National Health Service ethical/institutional review was deemed unnecessary because of the setting of the study in schools rather than within the healthcare system (Multi-Center Ethics Committee, Personal communication, October 2003). In keeping with Good Clinical Practice guidelines,12 the protocol was subjected to rigorous peer review, approvals were obtained from the relevant Local Educational Authorities and schools, informed consent was obtained, and we complied with the Data Protection Act13 to ensure confidentiality throughout.
Outcomes
Our primary comparison was of the proportions of cases and controls with symptomatic allergic rhinitis on the day of any examination. We further looked for evidence of a dose-response relationship between average symptom scores and the odds of dropping a grade.
Not all students with current symptomatic allergic rhinitis will have received a physician-diagnosis of allergic rhinitis, and those who have may represent the more severe end of the disease spectrum. Thus, we repeated the analyses after restricting children to those who had reported physician-diagnosed allergic rhinitis.
To test the specificity of the association between symptoms and (sedative) medication use on dropping a grade, the reverse scenario was also considered—that is, the effect of symptoms and medication use on the risk of increasing at least 1 grade in any subject.
Pollen counts
Pollen counts were measured by the Pollen Research Unit, Worcester, UK. Briefly, tree and grass pollen counts were recorded daily at 3 sites in the West Midlands area during the entire examination period by using a Burkard spore trap at an elevation of 18 m.14 Pollen counts are reported as daily averages.
Statistical methods
Sample sizeOn the basis of the conservative assumption that 15% of adolescents have allergic rhinitis, and on pilot data that 20% of students fail to achieve predicted GCSE grade in at least 1 subject, to have 80% power at the 5% level (2-tailed test), sample size estimates suggested that 1560 students (ratio of cases: controls of 1:5) were required to detect an odds ratio of at least 1.6 for dropping a grade in at least 1 examination.
Statistical analysisUnivariate comparisons between case status, sex, smoking, and other variables were made by using χ2 tests, Fisher exact tests, or Mann-Whitney tests. Mean symptom scores were calculated from all symptom scores reported on examination days. Associations with case status were quantified using multilevel regression models, with the school defined as a nested cluster. Evidence of effect modification was investigated by performing stratified analyses, and by including interaction terms in the multilevel models. All statistical analyses were undertaken by using SAS (SAS Institute, Inc, Cary, NC) and Stata (StataCorp LP, College Station, Tex).
Results
Study population
Of the 18 schools approached, 14 (78%) agreed to participate, with an eligible population of 3295 students. Ninety-seven students (3%) declined to take part. One school (167 students) was subsequently excluded because they forgot to administer questionnaires on some examination days. Students were included in the analysis if they completed the April questionnaire.
A total of 1834 students (57% of the available population and 80% of participating individuals) from 13 schools contributed complete information; 923 (50%) were girls (Table I).
Table I. Characteristics of cases and controls
| Cases (n = 662) | Controls (n = 1172) | P value | |
|---|---|---|---|
| Sex, n (%) male | 359 (54.2%) | 552 (47.1%) | .003 |
| School | |||
 1 | 56 (8.5%) | 91 (7.8%) | <.001 |
| 2 | 32 (4.8%) | 126 (10.8%) | |
| 3 | 73 (11.0%) | 58 (5.0%) | |
| 4 | 55 (8.3%) | 160 (13.7%) | |
| 5 | 19 (2.9%) | 92 (7.9%) | |
| 6 | 68 (10.3%) | 40 (3.4%) | |
| 7 | 20 (3.0%) | 65 (5.6%) | |
| 8 | 46 (7.0%) | 92 (7.9%) | |
| 9 | 108 (16.3%) | 79 (6.7%) | |
| 10 | 26 (3.9%) | 129 (11.0%) | |
| 11 | 74 (11.2%) | 94 (8.0%) | |
| 12 | 37 (5.6%) | 101 (8.6%) | |
| 13 | 48 (7.3%) | 45 (3.8%) | |
| Deprivation score, n (%) high | 50 (7.6%) | 83 (7.1%) | .71 |
| Smokers, n (%) | 163 (24.8%) | 205 (17.6%) | <.001 |
| Ethnic group | |||
| White | 572 (87.1%) | 999 (85.8%) | .53 |
| Black | 21 (3.2%) | 33 (2.8%) | |
| Mixed | 18 (2.7%) | 27 (2.3%) | |
| South Asian | 43 (6.5%) | 91 (7.8%) | |
| Chinese | 1 (0.2%) | 7 (0.6%) | |
| Other | 2 (0.3%) | 7 (0.6%) | |
| Recent personal events, n (%) | 189 (29.7%) | 325 (28.6%) | .64 |
| Season of birth | |||
| Spring | 160 (24.2%) | 303 (25.9%) | .48 |
| Summer | 179 (27.0%) | 288 (24.6%) | |
| Autumn | 153 (23.1%) | 295 (25.2%) | |
| Winter | 170 (25.7%) | 286 (24.4%) |
Case status
One hundred thirty (7%) students dropped at least 1 grade in mathematics, 281 (15%) in English, and 363 (20%) in science. This resulted in 662 (36%) cases and 1172 controls. Cases were more likely to be boys, to be smokers, and to be at certain schools (Table I). Univariate analyses failed to demonstrate any association between deprivation score, ethnic group, recent personal events, or season of birth and case status.
Allergic rhinitis symptoms and medication use
Allergic rhinitis symptoms on different examination days were reported by between 38% and 43% of students; between 19% and 23% reported medication use (Table II). Almost 2/3 (n = 1001; 63%) of students reported allergic rhinitis symptoms, and 542 (37%) reported medication use at least once during the examination period. A total of 84 of 1425 (6%) students took sedative medication at some point during the examination period. Daily pollen counts varied according to the examination day (Table II).
Table II. Allergic rhinitis symptoms, medication use, and pollen counts over the examination period
| Date | Examination | Allergic rhinitis symptoms | Medication use | Pollen count (grains/m3) |
|---|---|---|---|---|
| 07/06/2004 | Science 1 (n = 1769) | 724 (40.9%) | 335 (19.0%) | 205 |
| 08/06/2004 | Maths 1 (n = 1737) | 742 (42.7%) | 357 (20.6%) | 306 |
| 10/06/2004 | English 1 (n = 1569) | 594 (37.9%) | 307 (19.6%) | 83 |
| 14/06/2004 | Science 2 (n = 1667) | 712 (42.7%) | 357 (21.5%) | 357 |
| 14/06/2004 | English 2 (n = 1632) | 705 (43.2%) | 370 (22.7%) | 357 |
| 15/06/2004 | Maths 2 (n = 1649) | 700 (42.4%) | 374 (22.8%) | 66 |
| 22/06/2004 | Science 3 (n = 1118) | 464 (41.5%) | 221 (19.9%) | 100 |
| Any (n = 1583) | 1001 (63.2%) | 542 (36.9%) |
Students who were smokers and those who reported recent personal events that might have affected their examination performance were more likely to report allergic rhinitis symptoms, use of allergic rhinitis medication, and use of sedative medication during the examination period (Table III). Season of birth was related to reporting of (sedative) medication use but not symptoms. There were no associations between deprivation and reported allergic rhinitis symptoms or medication use.
Table III. Associations between demographic and allergic factors with reported symptoms or medication use during the examination period
| Allergic rhinitis during examinations | Medication use during examinations | Sedating antihistamine use during examinations | ||||
|---|---|---|---|---|---|---|
| Demographic factors | N (%) | P value | N (%) | P value | N (%) | P value |
| Sex | .13 | .47 | .89 | |||
| Female | 528 (65.0%) | 285 (37.8%) | 44 (6.0%) | |||
| Male | 473 (61.4%) | 257 (35.9%) | 40 (5.8%) | |||
| Deprivation score | ||||||
| Low | 926 (63.2%) | .94 | 501 (36.9%) | .99 | 80 (6.1%) | .30 |
| High | 75 (63.6%) | 41 (36.9%) | 4 (3.7%) | |||
| Smoking | ||||||
| No | 768 (61.2%) | .001 | 417 (35.7%) | .07 | 66 (5.5%) | .23 |
| Yes | 229 (71.6%) | 121 (41.4%) | 21 (7.4%) | |||
| Ethnic group | ||||||
| White | 848 (62.7%) | .12 | 455 (36.2%) | .64 | 71 (5.8%) | .87 |
| Black | 38 (77.6%) | 21 (47.7%) | 3 (7.3%) | |||
| Mixed | 29 (72.5%) | 13 (36.1%) | 3 (8.3%) | |||
| South Asian | 71 (61.2%) | 42 (39.3%) | 7 (6.8%) | |||
| Chinese | 5 (71.4%) | 3 (42.9%) | 0 | |||
| Other | 3 (37.5%) | 2 (25.0%) | 0 | |||
| Recent personal events | <.001 | .004 | .02 | |||
| Absent | 637 (59.4%) | 343 (34.4%) | 48 (5.0%) | |||
| Present | 328 (71.6%) | 180 (42.5%) | 34 (8.2%) | |||
| Season of birth | ||||||
| Spring | 261 (65.7%) | .33 | 149 (40.0%) | .01 | 23 (6.4%) | .05 |
| Summer | 261 (64.4%) | 157 (41.6%) | 26 (7.1%) | |||
| Autumn | 245 (63.0%) | 127 (35.4%) | 25 (7.1%) | |||
| Winter | 234 (60.0%) | 109 (30.2%) | 10 (2.9%) | |||
| Allergic history | ||||||
| Diagnosed allergic rhinitis | ||||||
| Absent | 628 (53.0%) | <.001 | 229 (21.0%) | <.001 | 22 (2.1%) | <.001 |
| Present | 366 (94.1%) | 308 (82.8%) | 62 (17.7%) | |||
| Diagnosed asthma | ||||||
| Absent | 685 (58.5%) | <.001 | 354 (32.8%) | <.001 | 45 (4.3%) | <.001 |
| Present | 308 (77.0%) | 182 (48.2%) | 37 (10.2%) | |||
| Previous allergic rhinitis | ||||||
| Absent | 241 (34.6%) | <.001 | 71 (10.9%) | <.001 | 1 (0.2%) | <.001 |
| Present | 750 (86.0%) | 466 (58.0%) | 81 (10.5%) | |||
| Previous allergic rhinitis medication use | ||||||
| Absent | 603 (52.3%) | <.001 | 206 (19.5%) | <.001 | 5 (0.5%) | <.001 |
| Present | 380 (96.5%) | 329 (85.9%) | 79 (22.2%) | |||
Reported allergic rhinitis during examinations was higher for those who reported taking allergic rhinitis medication in the April questionnaire (Table III); average symptom scores were also higher (data not shown). Allergic rhinitis symptoms during the examination were also more likely to be reported by students with diagnosed allergic rhinitis (94% vs 53%; P < .001) and with diagnosed asthma (77% vs 59%; P < .001). Average symptom scores were significantly higher for those who had a diagnosis of allergic rhinitis (median, 4.83; range, 0-10; vs median, 0; range, 0-9.83; P < .001) or asthma (median, 1.83; range, 0-10; vs median, 0.17; range, 0-9.83; P < .001).
Relationship among allergic rhinitis, medication use, and case/control status
Results from the adjusted multilevel models revealed that cases were more likely than controls to have had allergic rhinitis symptoms (odds ratio [OR], 1.43; 95% CI, 1.13-1.81; P = .002), to have taken any allergic rhinitis medication (OR, 1.36; 95% CI, 1.08-1.73; P = .01), or to have taken sedating antihistamines on any examination day (OR, 1.71; 95% CI, 1.06-2.75; P = .03; Table IV). Cases were also significantly more likely to have a diagnosis of asthma (Table IV).
Table IV. Relationship between self-reported allergic rhinitis, allergic rhinitis medication, and asthma and case/control status
| Case (n = 662) | Controls (n = 1172) | Crude odds ratio (95% CI) | P value | Adjusted odds ratio∗ (95% CI) | P value | |
|---|---|---|---|---|---|---|
| Allergic rhinitis symptoms during examinations, n (%) | 385 (67.3%) | 616 (60.9%) | 1.32 (1.06-1.64) | .01 | 1.43 (1.13-1.81) | .002 |
| Allergic rhinitis medication use during examinations, n (%) | 221 (41.1%) | 321 (34.4%) | 1.33 (1.07-1.65) | .01 | 1.36 (1.08-1.73) | .01 |
| Sedating antihistamine medication use during examinations, n (%) | 40 (7.7%) | 44 (4.9%) | 1.64 (1.05-2.55) | .03 | 1.71 (1.06-2.75) | .03 |
| Mean symptom score, n (%) | ||||||
| 0 | 271 (41.4%) | 549 (47.2%) | 1.00 | .04 | 1.00 | .02 |
| >0-2 | 121 (18.5%) | 221 (19.0%) | 1.11 (0.85-1.45) | 1.27 (0.96-1.68) | ||
| >2-5 | 148 (22.6%) | 228 (19.6%) | 1.32 (1.02-1.69) | 1.39 (1.06-1.82) | ||
| >5 | 115 (17.6%) | 165 (14.2%) | 1.41 (1.07-1.87) | 1.48 (1.09-1.99) | ||
| Diagnosed allergic rhinitis, n (%) | 147 (22.3%) | 252 (21.6%) | 1.04 (0.83-1.31) | .73 | 1.09 (0.86-1.40) | .47 |
| Diagnosed asthma, n (%) | 185 (28.1%) | 265 (22.8%) | 1.32 (1.06-1.65) | .01 | 1.31 (1.04-1.66) | .02 |
| Allergic rhinitis symptoms (ever), n (%) | 326 (49.8%) | 606 (52.2%) | 0.91 (0.75-1.10) | .31 | 0.96 (0.78-1.17) | .67 |
| Medication use (ever), n (%) | 150 (23.3%) | 251 (21.9%) | 1.08 (0.86-1.36) | .50 | 1.14 (0.89-1.45) | .30 |
∗Odds ratios adjusted by sex and smoking history, with school as a nested cluster. |
Repetition of the adjusted analyses among those students who had reported physician-diagnosed allergic rhinitis in the spring questionnaire (n = 1010) generated similar results; for any allergic rhinitis symptoms, OR, 1.86 (95% CI, 1.18-2.95; P = .01); any allergic rhinitis medication, OR, 1.42 (95% CI, 1.03-1.96; P = .03); and any sedating medication, OR, 1.91 (95% CI, 1.15-3.18; P = .01).
Dose-response relationship
Within the whole group, there was a dose-response relationship with cases reporting higher average symptom scores (median, 0.67; range, 0-9.83; vs median, 0.33; range, 0-10; P = .01; Table IV). This exposure-response association was stronger when restricted to the 1010 students who had reported allergic rhinitis in the spring questionnaire (OR, 1.64; 95% CI, 1.01-2.68; OR, 2.07; 95% CI, 1.33-3.24; OR, 2.07; 95% CI, 1.31-3.26; P = .004).
Specificity of the association
There was, using multilevel modeling, no relationship between improvement in grades and any exposure index: any allergic rhinitis symptoms, adjusted OR, 0.96; 95% CI, 0.72-1.28; P = .78; any allergic rhinitis medication use, OR, 0.89; 95% CI, 0.66-1.19; P = .43; any sedative medication use, OR, 0.86; 95% CI, 0.46-1.59; P = .62.
Discussion
In this study, young people with reported allergic rhinitis symptoms on an examination day were, in comparison with their fellow students without symptoms, 40% more likely to drop a grade between their practice and final GCSE examinations, and 70% more likely to drop a grade if they reported taking sedating antihistamines at the time of their examinations. The relationship between symptoms and poor examination performance was specific and exhibited a dose-response relationship. Students who reported a history of allergic rhinitis in previous years and who had symptoms on any examination day of > 2 (on a 10-point Likert scale) were more than twice as likely to drop a grade. These associations are clinically and statistically significant, biologically plausible, and remained largely unaffected by adjustment for a range of important confounding exposures.
The number of children taking sedating antihistamines in this study was high (28% of those who reported taking any allergic rhinitis medication). The only antihistamine we defined as being sedating was chlorpheniramine. This was based on a number of studies investigating the sedative properties of antihistamines that showed significant sedative effects of first-generation but limited sedating effects of second-generation antihistamines.11, 15, 16, 17 The number of children taking sedating antihistamines in this study was high in spite of current guidelines18 that recommend treatment with nonsedating preparations.19 The significant effect of sedating medications on examination performance observed in this study should encourage prescribers to recommend the use of nonsedating alternatives in routine practice.
Although sedation is an important issue when considering the choice of antihistamine treatment, first-generation antihistamines have also been associated with significant effects on learning capacity. Treatment with diphenhydramine (a first-generation antihistamine with similar sedative properties to chlorpheniramine17) resulted in substantial adverse effects on attention span, working memory, vigilance, and speed, as well as higher levels of fatigue, lower levels of motivation, and lower levels of activity compared with placebo.20 The effects of antihistamines are compounded by the fact that allergic rhinitis itself has been shown to interrupt sleep21 and decrease learning capacity in children,22, 23 causing weakness, malaise, irritability, fatigue, headache, and anorexia.24 The systemic effects of allergic rhinitis may result in diminished functional capacity, which may be responsible for the 2 million school days that are lost each year to allergic rhinitis24 and for the increasing direct and indirect costs ($2.3 billion in 1996) of managing symptoms.25
The study was adequately powered, and we achieved a high response rate. We made attempts to minimize the risk of information (recall) bias by measuring symptomatic allergic rhinitis immediately before each examination. Case status was established without knowledge of whether a student had allergic rhinitis.
Potential limitations include the lack of formal validation—when used in this context—of the method we used to measure the presence and severity of allergic rhinitis symptoms, reporting bias, and the generalizability of findings. Summer allergic rhinitis symptoms may not always be the result of pollen exposure, and although the question, “Do you have any of the following allergic rhinitis symptoms of sneezing, itchy eyes, a runny or blocked nose today?” has been validated elsewhere,1 we used it in isolation of other supporting questions because of time and space limitations of the questionnaires administered on examination days. Thus, students' responses may not have been specific. For this reason, we repeated the analysis in those who reported a previous diagnosis of allergic rhinitis. True allergic rhinitis is likely to affect learning ability during the whole examination period (with persistent symptoms occurring over an extended period) rather than just a single day; this may explain the greater impact of allergic rhinitis on examination performance in those who report previous allergic rhinitis. Because of this seasonal effect of allergic rhinitis, efforts to control symptoms prophylactically and throughout the entire grass pollen season are likely to be more effective than attempting to manage symptoms on a daily basis.
For the purposes of the analysis, we assumed that students who did not complete the medication question on the questionnaire were not using treatment on that day, even if they reported having symptoms. There was, however, a possibility that students had in fact taken medication, but not answered that particular question. To investigate this possibility, we undertook a sensitivity analysis and found that repeating the analysis after removing those symptomatic students who did not complete the medication questions (n = 101) had negligible effects on the estimates (OR for any seasonal allergic rhinitis symptoms for the whole sample, 1.43; 95% CI, 1.13-1.81; OR for any seasonal allergic rhinitis symptoms confining analysis to those completing the medication question, 1.44; 95% CI, 1.14-1.82). We also assumed, again because of time and space limitations, that those who did not report symptoms were not using medication and that those previously reporting using sedating medication were still doing so.
Seasonal allergic rhinitis is a common condition across the economically developed and developing world,1 and it is important to consider the generalizability of our findings. We studied a predominantly middle class population of children from large urban and rural schools in the UK, which may not be representative of other populations globally. However, we see no obvious reason why our findings could not be expected in any country in which students of this age take examinations during a period of high allergen exposure. Certainly they are consistent with studies of the effects of allergic rhinitis and allergic rhinitis treatments on simulated examinations,5, 6 although this is the first time that the effect has been measured on actual examination performance.
We anticipated there would be other factors influencing poor performance in the final examinations: sex, concomitant asthma, smoking status, ethnic group, other long-term illness, and disruptive life events. Of these, only male sex, smoking, and school were associated with case status. Male sex is known to affect educational performance at certain ages26; we suspect that the effect of smoking is indirect and explained by its association with other behaviors or demographic variables.27
The effect of school on examination performance is understandable given the inherent variability of teachers and teaching methods between schools. We did not replicate previous research that has shown an effect of ethnic group on educational performance,26 nor did we find an effect of social deprivation, although there was little variability in this measure in our population.
This work has substantially progressed understanding of the social effect of seasonal allergic rhinitis in this population. Important questions that remain unanswered include whether intensive case management of symptomatic children leading up to the examination season or shifting of examinations to a time that does not coincide with the peak pollen season can remove the bias operating against those with allergic rhinitis.
We thank the staff and students of the schools for their time and effort in participating in the study, and Mrs Beryl Lockwood at Warwick Local Education Authority for her help in implementing it. We also thank the staff at Education for Health, Warwick, for their encouragement and support, and particularly Kim Esslemont for her help with the study administration and data collection. We thank the anonymous reviewers for their helpful comments and suggestions.
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Supported by a restricted grant from Schering-Plough UK.Disclosure of potential conflict of interest: S. Walker has consulting arrangements with and has received grant support from Schering-Plough. M. Fletcher has received grant support from GlaxoSmithKline, AstraZeneca, and Novartis. The rest of the authors have declared that they have no conflict of interest.
PII: S0091-6749(07)00632-X
doi:10.1016/j.jaci.2007.03.034
© 2007 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.
Volume 120, Issue 2 , Pages 381-387, August 2007
