The Journal of Allergy and Clinical Immunology
Volume 124, Issue 6 , Pages 1251-1258.e23, December 2009

Global variations in prevalence of eczema symptoms in children from ISAAC Phase Three

  • Joseph A. Odhiambo, MMed

      Affiliations

    • Centre for Respiratory Diseases Research, Kenya Medical Research Institute, Nairobi, Kenya
    • ,
  • Hywel C. Williams, PhD

      Affiliations

    • Centre for Evidence Based Dermatology, University of Nottingham, Nottingham, United Kingdom
    • ,
  • Tadd O. Clayton, MSc

      Affiliations

    • Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
    • Corresponding Author InformationReprint requests: Tadd O. Clayton, MSc, Department of Paediatrics: Child and Youth Health Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand.
    • ,
  • Colin F. Robertson, MD

      Affiliations

    • Murdoch Children's Research Institute, Melbourne, Australia
    • ,
  • M. Innes Asher, MBChB

      Affiliations

    • Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
    • ,
  • ISAAC Phase Three Study Group

Received 2 July 2009; received in revised form 4 October 2009; accepted 7 October 2009.

Article Outline

Background

In 1999, The International Study of Asthma and Allergies in Childhood (ISAAC) Phase One reported the prevalence of eczema symptoms in 715,033 children from 154 centers in 56 countries by using standardized epidemiologic tools.

Objective

To update the world map of eczema prevalence after 5 to 10 years (ISAAC Phase Three) and include additional data from over 100 new centers.

Methods

Cross-sectional surveys using the ISAAC questionnaire on eczema symptoms were completed by adolescents 13 to 14 years old and by parents of children 6 to 7 years old. Current eczema was defined as an itchy flexural rash in the past 12 months and was considered severe eczema if associated with 1 or more nights per week of sleep disturbance.

Results

For the age group 6 to 7 years, data on 385,853 participants from 143 centers in 60 countries showed that the prevalence of current eczema ranged from 0.9% in India to 22.5% in Ecuador, with new data showing high values in Asia and Latin America. For the age group 13 to 14 years, data on 663,256 participants from 230 centers in 96 countries showed prevalence values ranging from 0.2% in China to 24.6% in Columbia with the highest values in Africa and Latin America. Current eczema was lower for boys than girls (odds ratio, 0.94 and 0.72 at ages 6 to 7 years and 13 to 14 years, respectively).

Conclusion:ISAAC Phase Three provides comprehensive global data on the prevalence of eczema symptoms that is essential for public health planning. New data reveal that eczema is a disease of developing as well as developed countries.

Key words: Eczema, prevalence, global, children, ISAAC, sex

Abbreviations used: OR, Odds ratio, ISAAC, International Study of Asthma and Allergies in Childhood

 

Estimating the prevalence of eczema is important for several reasons including monitoring disease burden, documenting changing trends, and understanding possible causes by contrasting prevalence within and between countries. Atopic eczema (or atopic dermatitis) is the most common form of eczema in childhood. Atopic eczema manifests as a chronic, relapsing itchy rash that usually starts in early life and, in many children, wanes in severity later in childhood.1, 2 Not everyone with atopic eczema is truly atopic in terms of demonstrating a specific IgE response to common allergens, especially in developing countries, where helminth infestations are common.3 Yet the term “atopic eczema” or “atopic dermatitis” is still commonly used to define the phenotype of poorly demarcated skin inflammation with surface changes (such as scaling or lichenification), a predilection for the flexures (such as the insides of the elbows and backs of the knees4), and association with a personal or family history of asthma and/or hay fever. Severe eczema in childhood and persistence into adult life are associated with considerable direct costs.5 Constant itching, which can lead to sleep deprivation, as well as the stigmata associated with visible skin disease can have a major impact on quality of life for such individuals.6, 7, 8, 9, 10 The International Study of Asthma and Allergies in Childhood (ISAAC) was designed to allow comparisons of the prevalence of symptoms of asthma, rhinitis, and eczema between populations in different countries through use of standardized epidemiologic tools.11 The prevalence of symptoms of eczema in ISAAC Phase One (1992-1997) estimated in 154 centers in 56 countries (715,033 children) varied widely throughout the world. The 1-year period prevalence of eczema symptoms estimated by ISAAC Phase One previously published in this journal ranged from 0.6% to 20.5% of the population.12 Trends in eczema symptoms over a 5-year to 10-year period in just under half a million adolescents and children who participated in both ISAAC Phase One and Three indicate that the prevalence of eczema is rising, especially in younger children,13 suggesting that environmental factors could be playing a key role in determining disease expression. This article describes global prevalence data on eczema symptoms in more than a million adolescents and children from ISAAC Phase Three (1999-2004). ISAAC Phase Three provides new data from Phase One centers and includes more than 100 new centers in more than 40 countries not previously studied, thereby providing recent and comprehensive global data that are essential for public health planning.

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Methods 

ISAAC Phase Three used the same protocol, framework for registration of participating centers, and sampling as ISAAC Phase One.12, 14 Briefly, 2 age groups (6-7 and 13-14 years old) were chosen from a random sample of schools from defined geographical areas. A simple questionnaire with questions related to symptoms of wheezing, rhinoconjunctivitis, and eczema was completed by parents of the children and by the adolescents. Only the eczema data are reported and discussed here; the asthma and rhinoconjunctivitis results are reported separately.15, 16 Questionnaires were translated, if necessary, from English into the local language for both age groups. Translated questionnaires were back-translated into English by an independent person according to ISAAC translation guidelines to confirm that other languages used terms as equivalent as possible to the English version.17 The full text of the questions concerning eczema symptoms is included in this article's Fig E1 in the Online Repository at www.jacionline.org. These questions on symptoms of eczema include both sensitive and specific questions that are repeatable and have reasonable content, construct, concurrent, and predictive validity.12, 18, 19 The key outcome reported (current symptoms of eczema) is that of respondents who answered positively to the question, “Has your child/Have you had this itchy rash at any time in the past 12 months?” and answered positively to the question, “Has this itchy rash at any time affected any of the following places: the folds of the elbows, behind the knees, in front of the ankles, under the buttocks, or around the neck, ears or eyes?” Current eczema associated with sleep disturbance 1 or more nights per week (question 6) was used as a surrogate of severe eczema. To explore the effects of disease labeling, we also report the results for lifetime “eczema” (question 7) or the appropriate local term.

Centers were expected to obtain ethics approval and parental consent according to the requirements of the country, and to fund their own study.

Data analysis 

Centers were examined for adherence to protocol, and only centers that met ISAAC standards were included in analyses. The same approach to data analysis in ISAAC Phase One12 was used in Phase Three. All data submitted to the ISAAC International Data Center were checked for coding errors, omissions, and inconsistencies and were corrected with the assistance of collaborators. Symptom prevalence values in each center were calculated by dividing the number of positive responses to each question by the number of completed questionnaires. Odds ratios and associated 95% CIs were calculated by using logistic regression. All analyses were carried out with SAS (version 9; SAS Institute Inc, Cary, NC).

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Results 

For the age group 6 to 7 years, data from 421,543 participants in 165 centers (65 countries), and for the age group 13 to 14 years, data for 814,837 participants in 242 centers (98 countries) were submitted to the ISAAC International Data Centre for analyses. Adherence to the ISAAC Protocol was assessed, and centers that had not included the eczema questionnaire or had serious deviations from protocol were excluded from the analyses (22 centers from 17 countries with 35,690 participants for the age group 6-7 years and 12 centers from 8 countries with 151,581 participants for the age group 13-14 years). For the age group 6 to 7 years, there were 385,853 participants from 143 centers in 60 countries, and for the age group 13 to 14 years, there were 663,256 participants from 230 centers in 96 countries. Generally high response rates were achieved (age group 6-7 years, 41% of centers registered response rates of 90% to 100%, 31% of 80% to 89%, 17% of 70% to 79%, and 11% of 60% to 70%; age group 13-14 years, 65% of centers registered response rates of 90% to 100%, 25% of 80% to 89%, and 10% of 70% to 79%). The response rate varied between regions from 77% (North America) to 94% (Africa) in the age group 6 to 7 years, and from 78% (North America) to 94% (Eastern Mediterranean) in the age group 13 to 14 years. Details of the languages used are reported elsewhere.16

Fig 1, A and B, shows color-coded world maps of the prevalence of current symptoms of eczema for children 6 to 7 and 13 to 14 years old, respectively. This article's Fig E2, A and B, in the Online Repository at www.jacionline.org presents similar maps illustrating the prevalence of symptoms of severe eczema. This article's Tables E1 and E2 in the Online Repository at www.jacionline.org include detailed results at a center level.

  • View full-size image.
  • Fig 1. 

    World maps showing prevalence of current symptoms of eczema for the age group 6 to 7 years (A) and 13 to 14 years (B). Each symbol represents a center. Blue squares indicate prevalence of less than 5%, green circles indicate prevalence of 5% to less than 10%, yellow diamonds indicate prevalence of 10% to less than 15%, and red stars indicate prevalence of 15% or more. Europe is shown in greater detail in the inset section.

Range of prevalence of eczema 

The prevalence of current eczema symptoms among the age group 6 to 7 years varied from 0.9% (Jodhpur, India) to 22.5% (Quito, Ecuador) (Fig 2, A). For the age group 13 to 14 years, the prevalence varied from 0.2% (Tibet, China) to 24.6% (Barranquilla, Colombia) (Fig 2, B). For symptoms of severe eczema, the prevalence varied from 0.0% (Hong Kong; Davangere, India; Kharkiv, Ukraine) to 4.9% (La Habana, Cuba) for the age group 6 to 7 years and from 0.0% (Ho Chi Minh City, Vietnam; Borivali, India) to 5.8% (Marrakech, Morocco) for the age group 13 to 14 years (see this article's Fig E3, A and B, and Fig E4, A and B, in the Online Repository at www.jacionline.org). For lifetime reported “eczema,” the prevalence varied from 1.2% (Panevezys, Lithuania; Cuernavaca, Mexico) to 38.6% (Linköping, Sweden) for the age group 6 to 7 years and from 0.8% (Ciudad Victoria, Mexico) to 48.3% (Linköping) for the age group 13 to 14 years (see this article's Fig E5, A and B, in the Online Repository at www.jacionline.org).

Global pattern of eczema, age group 6 to 7 years 

Higher prevalence values for current symptoms of eczema (≥15%) were found in centers from 5 of 9 world regions including Asia-Pacific (centers in Thailand), Latin America (centers in Colombia, Cuba, Ecuador, Honduras, and Nicaragua), Northern and Eastern Europe (1 center in Sweden), Oceania (centers in Australia, New Zealand, and Niue), and Western Europe (1 center in the United Kingdom). Lower prevalence values (<5%) were found in centers in 6 of 9 regions including Asia-Pacific (centers in Hong Kong, Indonesia, and Vietnam), Eastern Mediterranean (centers in Iran, Malta, Pakistan, Sultanate of Oman, and the Syrian Arab Republic), Indian Subcontinent (centers in India), Latin America (centers in Argentina and Mexico), Northern and Eastern Europe (centers in Albania, Bulgaria, Croatia, Georgia, Hungary, Kyrgyzstan, Lithuania, and Ukraine), and Western Europe (centers in Greece and Spain). Overall, higher prevalence centers were generally more common in Oceania, and lower prevalence centers were generally more common in the Indian Subcontinent, the Eastern Mediterranean region, and Northern and Eastern Europe (see this article's Fig E3, A, in the Online Repository at www.jacionline.org).

A broadly similar pattern was found for symptoms of severe eczema with higher prevalence centers more common in Oceania and Latin America, and lower prevalence centers more common in the Indian Subcontinent and Northern and Eastern Europe.

For lifetime reported “eczema,” there was less consistency across the world. Although Oceania and the Indian Subcontinent were again the regions which most commonly included high and low prevalence centers, respectively, there was a greater range of prevalence in those regions and in all other regions. Of those with lifetime reported “eczema,” 31% had current eczema symptoms.

The proportion of boys studied varied among the centers from 38.2% to 66.1%, and the proportion of girls varied from 33.9% to 61.8%. When the data for all centers were combined, there was no clear pattern observed for the main outcome measures. Boys showed a lower prevalence of current symptoms of “eczema” (7.7% for boys and 8.2% for girls; odds ratio [OR], 0.94; 95% CI, 0.92-0.97; P < .001). In contrast, there was little difference in prevalence between boys and girls for symptoms of severe eczema (1.0% male, 1.1% female; OR, 0.97; 95% CI, 0.91-1.03; P = .319) and a slightly higher prevalence for boys for lifetime reported “eczema” (14.4% males, 14.1% females; OR, 1.02; 95% CI, 1.01-1.04; P = .009; see this article's Fig E6, A-C, in the Online Repository at www.jacionline.org).

Global pattern of eczema, age group 13 to 14 years 

Higher prevalence values (≥15%) were found in 4 of 9 regions including Africa (centers in Congo, Cote d'Ivoire, Ethiopia, Kenya, Morocco, and République de Guinée), Latin America (centers in Bolivia, Chile, Colombia, Ecuador, Honduras, Nicaragua, and Paraguay), Northern and Eastern Europe (1 center in Finland), and Oceania (centers in Kingdom of Tonga and Niue).

Lower prevalence values (<5%) were found in 8 of 9 regions including Africa (1 center in Sudan), Asia-Pacific (centers in China, Hong Kong, Indonesia, Taiwan, Thailand, and Vietnam), Eastern Mediterranean (centers in Egypt, Iran, and the Syrian Arab Republic), Indian Subcontinent (centers in India), Latin America (centers in Brazil and Mexico), North America (1 center in the United States), Northern and Eastern Europe (centers in Albania, Bulgaria, Croatia, Former Yugoslav Republic of Macedonia, Georgia, Hungary, Kyrgyzstan, Latvia, Lithuania, Russia, Serbia and Montenegro, and Ukraine), and Western Europe (centers in Italy, Portugal, and Spain).

In general, higher prevalence centers are generally more common in Africa and Oceania, and lower prevalence centers are generally more common in the Indian Subcontinent and Northern and Eastern Europe (see this article's Fig E3, B, in the Online Repository at www.jacionline.org).

A generally similar pattern was found for symptoms of severe eczema, with higher prevalence centers more common in Africa and Oceania, and lower prevalence centers more common in the Indian Subcontinent and Northern and Eastern Europe.

For lifetime reported “eczema,” there was again less consistency across the world. Oceania and Africa are the regions where high prevalence centers were most common. However, there was a difference in ranking of regions for low prevalence because North America was the region where low prevalence centers were most common. This contrasts with the ranking for current symptoms of eczema and severe eczema, for which North America showed an intermediate range of prevalence. There was again a greater range of prevalence for lifetime reported “eczema” within all other regions than for symptoms of current eczema and severe eczema. Of those with lifetime reported “eczema,” 26% had current eczema symptoms.

The proportion of boys studied varied among the centers from 18.7% to 71.4%, and the proportion of girls varied from 28.6% to 81.3%. When the data for all centers were combined, a clear pattern for lower prevalence among boys emerged for age 13 to 14 years. Male adolescents showed a lower prevalence of current symptoms of eczema (6.2% for boys and 8.3% for girls; OR, 0.72; 95% CI, 0.71-0.74; P < .001). Similar differences in prevalence between boys and girls were found for symptoms of severe eczema (0.9% boys, 1.4% girls; OR, 0.63; 95% CI, 0.61-0.66; P < .001) and lifetime reported “eczema” (11.4% boys, 14.1% girls; OR, 0.78; 95% CI, 0.77-0.79; P < .001; see this article's Fig E6, D-F, in the Online Repository at www.jacionline.org).

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Discussion 

Main findings 

This is the largest study to date that estimates the prevalence of eczema symptoms in children and adolescents, and it contains over twice as much data and increased global coverage when compared with ISAAC Phase One. For the age group 6 to 7 years, Phase Three includes a further 87 centers from 27 new countries, and for the age group 13 to 14 years, a further 133 centers from 43 new countries. The increased coverage provides valuable new insights into the global variation of symptoms of eczema. As in Phase One, the results show large variations in prevalence of symptoms in both the 6 to 7–year and 13 to 14–year age groups. Additional centers available in Phase Three provide interesting new information.

For the age group 6 to 7 years, there was an increase in the number of participating centers in Phase Three for all regions except North America and Oceania, with large increases in the Eastern Mediterranean region, Latin America, Northern and Eastern Europe, and Western Europe. Many of the new centers have a relatively high prevalence of current symptoms of eczema, and this is reflected in the region summary values for Phase One and Phase Three. All regions except Northern and Eastern Europe and Western Europe have higher summary prevalence values in Phase Three than in Phase One. The global summary prevalence value for Phase Three (7.9%) is also higher than the comparable value for Phase One (6.1%).12

For the age group 13 to 14 years, there was an increase in the number of participating centers in Phase Three for all regions except Western Europe, with large increases in Africa, Asia-Pacific, the Eastern Mediterranean region, the Indian Subcontinent, Latin America, and Northern and Eastern Europe. In contrast with the age group 6 to 7 years, many of the new centers have a relatively low prevalence of current symptoms of eczema, and this is reflected in the region summary values for Phase One and Phase Three. Only Asia-Pacific, the Indian Subcontinent, and Latin America have higher summary prevalence values in Phase Three than in Phase One. The global summary prevalence value for Phase Three (7.3%) is also lower than the comparable value for Phase One (8.8%).12

Sex differences in eczema symptoms were found in ISAAC Phase One in both age groups.12 In Phase Three, our finding of a decreased risk of eczema in boys was strongest in the age group 13 to 14 years and was consistent regardless of how eczema symptoms were defined (current, ever, or severe). Recent studies showing similar findings of lower prevalence among boys have been reported from Singapore,20 Spain,21 Japan,22 Lebanon,23 and Russia.24 Possible explanations could include different genetic-environmental interactions, which become more prominent as children mature, or possibly misclassification of irritant contact dermatitis or allergic contact dermatitis (eg, from nickel earrings), which could be more common in adolescent girls.

Emerging patterns 

For the age group 6 to 7 years, the key feature of the more comprehensive picture of global prevalence provided by ISAAC Phase Three compared with Phase One is the emergence of Latin America as a region of comparatively high prevalence of symptoms. This is particularly evident in Central America and the Northern part of South America, where new centers such as La Habana (Cuba), San Pedro Sula (Honduras), Managua (Nicaragua), Barranquilla (Colombia), and Quito (Ecuador) show prevalence values of more than 15%. A similar, if less pronounced, new area of high prevalence has emerged in Southeast Asia, where new and existing centers in Thailand show high or moderate to high prevalence values. For the age group 13 to 14 years, Latin America again emerges as a region of comparatively high prevalence compared with the corresponding results from Phase One. However, the distribution of new high prevalence centers is somewhat different from the age group 6 to 7 years, with some such as Santa Cruz (Bolivia) and Calama (Chile) occurring further South in the South American continent. A more detailed analysis of time trends in eczema symptoms for those children who participated in both ISAAC Phase One and Phase Three is to be found elsewhere.13

Comparison with other studies 

There are few other comparable studies that use a common methodology to examine prevalence of eczema or atopic dermatitis, either within or between countries. The prevalence patterns described in this article are broadly similar to those described in 25 countries that participated in the European Community Respiratory Health Survey, but that is where the similarity ends because that survey recorded lifetime prevalence of reported symptoms in adults age 27 to 56 years.25 There have been surveys of children within countries that have shown a prevalence of atopic dermatitis of 6% in the United States,26 a prevalence of 9.2% of eczema symptoms in Switzerland,27 prevalence values of eczema symptoms of 7.3% (6-12 years) and 3.9% (12-15 years) in South Korea,28 and prevalence values of examined eczema of 11.8% (6-7 years) and 10.5% (11-12 years) in Japan29 and 6.4% in Italy.30 For the studies occurring in countries that also participated in ISAAC, the prevalence values are broadly similar to those reported here in spite of significant differences in methodology in some cases.

Only 3 examples of studies between countries have been identified. A study primarily focused on lifetime prevalence of atopic dermatitis among children 7 to 8 years old in Greenland (14.0%)31 contrasted the prevalence with that of a similar group in Denmark (22.9%). A study of 7-year-old children in Denmark, Germany, and Sweden in 1992 showed a prevalence of atopic dermatitis of 15.6% with some regional differences.32 Another study reported in 1994 of 4353 children age 12 years living in defined areas in Wales, New Zealand, South Africa, and Sweden showed that a report of “eczema ever” was highest in Sweden (22.0%) and lowest in South Africa (11.1%), with prevalence values of 15.9% for both Wales and New Zealand.33

Strengths and weaknesses of the study 

The major strengths of ISAAC Phase Three are the comprehensive world coverage with participation from all regions of the world and the well established standardized protocol that has been successfully applied by researchers with varying resources and experience. ISAAC Phase One provided the first large-scale internationally comparable data regarding variation in symptoms of eczema throughout the world. Participation in ISAAC Phase Three was open to researchers who were able to obtain sufficient resources and who agreed to adhere to the protocol.34 Centers were therefore not specifically selected to be representative of their country, and any attempt at such a generalization should be interpreted with considerable caution. This is particularly true of large countries with relatively few participating centers. The limited coverage in some regions was more prominent with respect to the age group 6 to 7 years. Many of the urban centers are from coastal areas, so the results may not be applicable to more central or rural areas. Phase Three has provided new information about parts of the world not previously studied in terms of eczema symptoms including new areas within Africa, Asia-Pacific, Latin America, and Oceania. New centers have revealed some interesting new patterns such as comparatively high prevalence in Africa and Latin America for the age group 6 to 7 years.

As in Phase One, the simple, standardized protocol used in Phase Three proved to be practical and feasible for investigators with widely varying resources and experience, resulting in a great deal of enthusiasm from investigators. A further important component of Phase Three was the rigorous data and methodology checks to ensure that the data from participating centers were complete and comparable.

For an international study such as ISAAC, translation of questionnaires is a key issue that may affect the validity of comparisons between centers, particularly when suitable local terminology is not available. To address this concern, all translations have been carried out by using detailed guidelines that include back-translation of the translated questionnaire to English.34 All back-translations have been reviewed by members of the ISAAC Steering Committee, and data from specific questions have been excluded in some cases.17 We acknowledge that some of the prevalence estimates based on translated questionnaires might not have been as precise as they needed to be for local public health planning,35 although such estimates are still likely to be valid for comparisons of patterns between countries.17 In low-income settings in which other itchy skin conditions such as scabies are common, it is possible that resulting confusion may have contributed to higher eczema estimates.

Public health and research implications 

This report shows that eczema is common in most countries and will be competing for meager resources in poorer countries. This scenario has important public health implications related to priority setting, costs, advocacy, and research. It is essential in the next phase that eczema research is focused on establishing better understanding of key environmental risk factors for eczema that could be modified as part of public health intervention in wealthy and poorer countries, especially because eczema may be prevented to some degree.36 ISAAC Phase Three included an optional environmental questionnaire that addressed a range of putative risk and protective factors.37 Publications presenting the results of analyses of these factors are in preparation or have recently been published.38, 39, 40

Clinical implications

Data on eczema symptoms from more than a million children in 97 countries show that eczema (atopic dermatitis) is a major problem in developing as well as developed countries.

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We thank the children and parents who participated in ISAAC Phase Three, the school staff for their assistance and help with coordination, the Phase Three principal investigators and their colleagues, and the many funding bodies throughout the world that supported the individual ISAAC centers and collaborators and their meetings.

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Appendix E1. ISAAC Phase Three Study Group 

ISAAC Steering Committee 

N. Aït-Khaled∗ (International Union Against Tuberculosis and Lung Diseases, Paris, France); H. R. Anderson (Division of Community Health Sciences, St Georges, University of London, United Kingdom); M. I. Asher (Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health Sciences, University of Auckland, New Zealand); R. Beasley∗ (Medical Research Institute of New Zealand, Wellington); B. Björkstén∗ (Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden); B. Brunekreef (Institute of Risk Assessment Science, Universiteit Utrecht, The Netherlands); J. Crane (Wellington Asthma Research Group, Wellington School of Medicine, New Zealand); P. Ellwood (Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health Sciences, University of Auckland, New Zealand); C. Flohr (Department of Paediatric Allergy & Dermatology, St John's Institute of Dermatology, St Thomas' Hospital, London, United Kingdom); S. Foliaki∗ (Centre for Public Health Research, Massey University, Wellington, New Zealand); F. Forastiere (Department of Epidemiology, Local Health authority Rome, Italy); L. García-Marcos (Respiratory Medicine and Allergy Units, “Virgen de la Arrixaca” University Children's Hospital, University of Murcia, Spain); U. Keil∗ (Institut für Epidemiologie und Sozialmedizin, Universität Münster, Germany); C. K. W. Lai∗ (Department of Medicine and Therapeutics, Chinese University of Hong Kong, SAR China); J. Mallol∗ (Department of Paediatric Respiratory Medicine, University of Santiago de Chile); E. A. Mitchell (Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health Sciences, University of Auckland, New Zealand); S. Montefort∗ (Department of Medicine, University of Malta), J. Odhiambo∗ (Centre for Respiratory Diseases Research, Kenya Medical Research Institute, Nairobi); N. Pearce (Centre for Public Health Research, Massey University, Wellington, New Zealand); C. F. Robertson (Murdoch Children's Research Institute, Melbourne, Australia); A. W. Stewart (Population Health, Faculty of Medical and Health Sciences, University of Auckland, New Zealand); D. Strachan (Division of Community Health Sciences, St Georges, University of London, United Kingdom); E. von Mutius (Dr von Haunerschen Kinderklinik de Universität München, Germany); S. K. Weiland† (Department of Epidemiology, University of Ulm, Germany); G. Weinmayr (Institute of Epidemiology, University of Ulm, Germany); H. Williams (Centre for Evidence Based Dermatology, Queen's Medical Centre, University Hospital, Nottingham, United Kingdom); G. Wong (Department of Paediatrics, Prince of Wales Hospital, Hong Kong, SAR China).

∗Regional coordinators.

†Deceased.

ISAAC International Data Center 

M. I. Asher, T. O. Clayton, P. Ellwood, E. A. Mitchell, Department of Paediatrics: Child and Youth Health, and A. W. Stewart, Population Health, Faculty of Medical and Health Sciences, University of Auckland, New Zealand.

ISAAC Phase Three Principal Investigators 

Albania: A. Priftanji∗ (Tiranë); Algeria: B. Benhabylès (Wilaya of Algiers); Argentina: C. E. Baena-Cagnani∗ (Córdoba), C. D. Crisci (Rosario City), M. Gómez (Salta), G. E. Zabert (Neuquén); Australia: C. F. Robertson∗ (Melbourne); Austria: G. Haidinger∗ (Kärnten, Urfahr-Umgebung); Barbados: M. E. Howitt∗ (Barbados); Belgium: J. Weyler (Antwerp); Bolivia: R. Pinto-Vargas∗ (Santa Cruz); Brazil: C. d. S. D. Bernhardt (Itajaí), W. G. Borges (Brasília), P. A. M. Camargos (Belo Horizonte), M. d. S. Cardoso (Manaus Amazonas), A. J. L. A. Cunha (Nova Iguaçu), G. B. Fischer (Porto Alegre), J. M. Motta (Aracaju), A. P. Neto (Passo Fundo), F. J. Passos (Maceió), A. C. Pastorino (São Paulo West), N. Rosário (Curitiba), A. Silva (Caruaru), D. Solé∗ (Rural Santa Maria, Santa Maria, São Paulo), N. Wandalsen (Santo Andre), M. de Britto (Recife), L. de Freitas Souza (Feira de Santana, Salvador, Vitória da Conquista); Bulgaria: T. Popov∗ (Sofia); Cameroon: C. Kuaban∗ (Yaounde); Canada: A. Ferguson (Vancouver), D. Rennie (Saskatoon); Channel Islands: R. Goulding (Jersey), P. Standring (Guernsey); Chile: P. Aguilar (South Santiago), L. Amarales (Punta Arenas), L. A. V. Benavides (Calama), M. A. Calvo (Valdivia), A. Contreras (Chiloe); China: Y.-Z. Chen∗ (Beijing, Tong Zhou), O. Kunii (Tibet), Q. Li Pan (Wulumuqi), N.-S. Zhong (Guangzhou); Colombia: G. Aristizábal (Bogotá), A. M. Cepeda∗ (Barranquilla), G. A. Ordoñez (Cali); Congo: J. M'Boussa (Brazzaville); Cook Islands: R. Daniel∗ (Rarotonga); Costa Rica: M. E. Soto-Quirós∗ (Costa Rica); Cote d'Ivoire: B. N. Koffi∗ (Urban Cote d'Ivoire); Croatia: K. Lah Tomulic (Rijeka); Cuba: P. Varona Peréz∗ (La Habana); Ecuador: S. Barba∗ (Quito), C. Bustos (Guayaquil); Egypt: M. L. Naguib (Cairo); El Salvador: M. Figueroa Colorado∗ (San Salvador); Estonia: M.-A. Riikjärv∗ (Tallinn); Ethiopia: K. Melaku (Addis Ababa); Fiji: R. Sa'aga-Banuve (Suva); Finland: J. Pekkanen∗ (Kuopio County); Former Yugoslav Republic of Macedonia: E. Vlaski∗ (Skopje); Gabon: I. E. Hypolite∗ (Port-Gentil); Georgia: M. Gotua∗ (Kutaisi); Germany: U. Keil∗ (Münster); Greece: J. Tsanakas (Thessaloniki); Honduras: A. Bueso-Engelhardt∗ (San Pedro Sula); Hong Kong: Y. L. Lau (Hong Kong 6-7 y), G. Wong (Hong Kong 13-14 y); Hungary: Z. Novák (Szeged), G. Zsigmond∗ (Svábhegy); India: S. Awasthi (Lucknow), S. Bhave (Rasta Peth), J. Chhatwal (Ludhiana), N. M. Hanumante (Pune), K. C. Jain (Jodhpur), M. K. Joshi (Mumbai [16]), V. A. Khatav (Borivali), L. Kumar (Chandigarh), S. N. Mantri (Mumbai [29]), A. V. Pherwani (Mumbai [18]), S. Rego (Bangalore), M. Sabir (Bikaner), S. Salvi (Nagpur, Pimpri), G. Setty (Chennai [3]), S. K. Sharma (New Delhi [7]), V. Singh (Jaipur), T. U. Sukumaran (Kottayam), P. S. Suresh Babu (Davangere); Indonesia: C. B. Kartasasmita (Bandung), P. Konthen (Bali), W. Suprihati (Semarang); Iran: M.-R. Masjedi∗ (Birjand, Rasht, Tehran, Zanjan); Isle of Man: A. Steriu (Isle of Man); Italy: L. Armenio (Bari), L. Bisanti (Milano), E. Bonci (Cosenza), E. Chellini (Firenze), G. Ciccone (Torino), V. Dell'Orco (Colleferro-Tivoli), F. Forastiere∗ (Roma), C. Galassi (Emilia-Romagna), G. Giannella (Mantova), S. La Grutta (Palermo), M. G. Petronio (Empoli), S. Piffer (Trento), P. Sestini (Siena); Jordan: F. Abu-Ekteish (Amman); Kenya: F. O. Esamai (Eldoret), L. Ng'ang'a∗ (Nairobi); Kingdom of Tonga: S. Foliaki (Nuku'alofa); Kuwait: J. A. al-Momen (Kuwait); Kyrgyzstan: C. Imanalieva∗ (Balykchi, Bishkek), S. Sulaimanov (Jalalabat); Latvia: V. Svabe (Riga); Lithuania: J. Bojarskas (Panevezys, Siauliai), J. Kudzyte∗ (Kaunas); Malaysia: B. S. Quah (Kota Bharu), K. H. Teh (Alor Setar), J. de Bruyne∗ (Klang Valley); Malta: S. Montefort∗ (Malta); Mexico: M. Baeza-Bacab∗ (Mérida), M. Barragán-Meijueiro (Ciudad de México [3]), B. E. Del-Río-Navarro (Ciudad de México [1]), R. García-Almaraz (Ciudad Victoria), S. N. González-Díaz (Monterrey), F. J. Linares-Zapién (Toluca), J. V. Merida-Palacio (Mexicali Valley), N. Ramírez-Chanona (Ciudad de México [4]), S. Romero-Tapia (Villahermosa), I. Romieu (Cuernavaca); Morocco: Z. Bouayad∗ (Benslimane, Boulmene, Casablanca, Marrakech); The Netherlands: R. Engels (The Netherlands); New Zealand: I. Asher∗ (Auckland), R. MacKay (Nelson), C. Moyes (Bay of Plenty), P. Pattemore (Christchurch), N. Pearce (Wellington); Nicaragua: J. F. Sánchez∗ (Managua); Nigeria: B. O. Onadeko (Ibadan); Niue: M. Magatogia (Niue Island); Nouvelle Caledonie: I. Annesi-Maesano (Nouvelle Caledonie); Pakistan: N. Mahmood∗ (Karachi), M. O. Yusuf (Islamabad); Palestine: N. El Sharif∗ (Ramallah), S. Mortaja (North Gaza); Panama: G. Cukier∗ (David-Panamá); Paraguay: J. A. Guggiari-Chase∗ (Asunción); Peru: P. Chiarella∗ (Lima); Philippines: F. Cua-Lim∗ (Metro Manila); Poland: A. Brêborowicz (Poznan), G. Lis∗ (Kraków); Polynesie Francaise: I. Annesi-Maesano (Polynesie Francaise); Portugal: M. L. Chiera (Coimbra), R. Câmara (Funchal), J. M. Lopes dos Santos (Porto), C. Nunes (Portimao), J. E. Rosado Pinto∗ (Lisbon); Republic of Ireland: L. Clancy (Republic of Ireland); Republique Democratique du Congo: J.-M. Kayembe (Kinshasa); Reunion Island: I. Annesi-Maesano∗ (Reunion Island); Romania: D. Deleanu (Cluj); Russia: E. G. Kondiourina (Novosibirsk); République de Guinée: O. Y. Sow (Conakry); Samoa: P. Fuimaono (Apia); Serbia and Montenegro: O. Adzovic (Podgorica), M. Hadnadjev (Novi Sad), E. Panic (Sombor), S. Zivanovic (Nis), Z. Zivkovic∗ (Belgrade); Singapore: D. Y. T. Goh (Singapore); South Africa: K. Voyi (Polokwane), H. J. Zar∗ (Cape Town); South Korea: H.-B. Lee∗ (Provincial Korea, Seoul); Spain: A. Arnedo-Pena (Castellón), J. Batlles-Garrido (Almeria), A. Blanco Quirós (Valladolid), R. M. Busquets (Barcelona), I. Carvajal-Urueña (Asturias), G. Garcia-Hernández (Madrid), L. García-Marcos∗ (Cartagena), C. González Díaz (Bilbao), F. Guillén-Grima (Pamplona), A. López-Silvarrey Varela (A. Coruña), M. M. Morales Suárez-Varela (Valencia), E. G. Pérez-Yarza (San Sebastián); Sri Lanka: K. D. Gunasekera∗ (Sri Lanka); Sudan: O. A. A. Musa (Khartoum); Sultanate of Oman: O. Al-Rawas∗ (Al-Khod); Sweden: H. Vogt (Linköping); Syrian Arab Republic: S. Mohammad∗ (Tartous), Y. Mohammad (Lattakia), K. Tabbah (Aleppo); Taiwan: J.-L. Huang∗ (Taipei), C.-C. Kao (Taoyuan); Thailand: A. Kongpanichkul (Nakorn Pathom), R. Nettagul (Chiangrai), T. Prasarnphanich (Chantaburi), J. Teeratakulpisarn (Khon Kaen), M. Trakultivakorn (Chiang Mai), P. Vichyanond∗ (Bangkok); Togo: O. Tidjani (Lome); Tokelau: T. Iosefa∗ (Tokelau); Trinidad and Tobago: M. A. Monteil (St Augustine, Tobago); Tunisia: M. Jerray (Sousse), F. Khaldi (Grand Tunis); United States: G. J. Redding (Seattle), H. H. Windom (Sarasota); Ukraine: V. Ognev∗ (Kharkiv, Rural Kharkiv); United Kingdom: H. R. Anderson∗ (North Thames, South Thames), J. B. Austin (Scotland), M. Burr (Wales), M. H. Shamssain (Sunderland), D. Strachan (Surrey/Sussex); Uruguay: D. Holgado∗ (Montevideo), M. C. Lapides (Paysandú); Venezuela: O. Aldrey∗ (Caracas); Vietnam: B. Vaên Cam (Ho Chi Minh City).

∗National coordinator.

ISAAC Phase Three National Coordinators not identified above 

Canada: M. Sears; Channel Islands: H. R. Anderson; Chile: V. Aguirre; Croatia: V. Ahel; Greece: C. Gratziou; Hong Kong: C. K. W. Lai; India: J. Shah; Indonesia: K. Baratawidjaja; Isle of Man: H. R. Anderson; Kingdom of Tonga: T. Fakakovi; The Netherlands: R. Otten; Nouvelle Caledonie: S. Barny; Polynesie Francaise: R. Chansin; Republic of Ireland: P. Manning; Republique Democratique du Congo: E. Bahati; Russia: R. M. Khaitov; Samoa: N. Tuuau-Potai; Singapore: B.-W. Lee; Sudan: A. El Sony; Sweden: L. Nilsson.

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Fig E1. 

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Fig E2. 

  • View full-size image.

  • World maps showing prevalence of current symptoms of severe eczema for the age groups 6 to 7 years (A) and 13 to 14 years (B). Each symbol represents a center. Blue squares indicate prevalence of less than 1%, green circles indicate prevalence of 1% to less than 1.5%, yellow diamonds indicate prevalence of 1.5% to less than 2%, and red stars indicate prevalence of 2% or more. Europe is shown in greater detail in the inset section.

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Fig E3. 

  • View full-size image.

  • Ranked prevalence plots of current symptoms of eczema for the age groups 6 to 7 years (A) and 13 to 14 years (B). Each symbol represents a center. Regions are ordered by average prevalence.

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Fig E4. 

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Fig E5. 

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Fig E6. 

  • View full-size image.
  • View full-size image.

  • Scatter plots illustrating prevalence by sex for current symptoms of eczema (A), current symptoms of severe eczema (B), and lifetime reported “eczema” (C) for the age group 6 to 7 years, and current symptoms of eczema (D), current symptoms of severe eczema (E), and lifetime reported “eczema” (F) for the age group 13 to 14 years. Each symbol represents a center. The line of equality is shown on each plot.

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Table E1. 

Prevalence of symptoms of eczema, age group 6 to 7 years
Current symptoms of eczemaCurrent symptoms of severe eczemaEczema ever
CenterYearNo.No.PercentNo.PercentNo.Percent
Africa
Nigeria
Ibadan20022,3961195.0261.11636.8
South Africa
Polokwane20043,48042712.31323.81,20534.6
Region total20035,8765469.31582.71,36823.3
Asia-Pacific
Hong Kong
Hong Kong20014,4482064.600.01,36530.7
Indonesia
Bandung20022,503933.7100.41064.2
Malaysia
Alor Setar20023,78648212.7290.8691.8
Klang Valley20013,04436512.0250.81504.9
Kota Bharu20013,11040212.9351.1551.8
Country total20019,9401,24912.6890.92742.8
Singapore
Singapore20015,3894828.9631.24408.2
South Korea
Provincial Korea20004,25846610.9922.21,21628.6
Seoul20001,76021212.0362.053530.4
Country total20006,01867811.31282.11,75129.1
Taiwan
Taipei20014,8323226.7601.21,26926.3
Taoyuan20023,2932858.7441.379424.1
Country total20028,1256077.51041.32,06325.4
Thailand
Bangkok20014,20971116.9691.61,04024.7
Chantaburi20013,32144513.4732.266920.1
Chiang Mai20013,10650716.3752.480926.0
Chiangrai19951,6771549.2231.433019.7
Khon Kaen19992,65831411.8431.681130.5
Nakorn Pathom19961,8211357.4211.236420.0
Country total199916,7922,26613.53041.84,02324.0
Vietnam
Ho Chi Minh City20013,8791814.7130.31523.9
Region total200057,0945,76210.17111.210,17417.8
Eastern Mediterranean
Iran
Birjand19962,693752.8291.11435.3
Rasht20013,057923.0270.936111.8
Tehran20013,008321.190.337112.3
Zanjan19962,7771655.9612.231011.2
Country total199911,5353643.21261.11,18510.3
Jordan
Amman20012,5981786.9451.72017.7
Malta
Malta20013,7951514.0140.442711.3
Pakistan
Islamabad20023,9662055.2270.71233.1
Karachi20022,113743.590.4954.5
Country total20026,0792794.6360.62183.6
Palestine
North Gaza20003,57540811.41544.32115.9
Ramallah20003,7542606.9661.81724.6
Country total20007,3296689.12203.03835.2
Sultanate of Oman
Al-Khod20014,1301754.2541.33207.7
Syrian Arab Republic
Lattakia20032,373562.430.1502.1
Tartous20012,734732.7130.51344.9
Country total20025,1071292.5160.31843.6
Region total200040,5731,9444.85111.32,9187.2
Indian Subcontinent
India
Bangalore20032,9591163.9110.4682.3
Davangere20023,043321.100.02066.8
Jaipur20012,5451576.2271.154621.5
Jodhpur20032,114200.950.2301.4
Kottayam∗20022,619612.3 26510.1
Lucknow20023,000762.5110.4551.8
Ludhiana20023,225772.4110.3461.4
Mumbai (16)20032,865531.840.1481.7
Mumbai (18)20024,8621182.490.21232.5
Mumbai (29)20021,833311.750.3271.5
Nagpur20024,2941283.090.2631.5
New Delhi (7)20023,7061574.2170.51905.1
Pimpri20023,8381042.7190.51774.6
Pune20012,711532.050.2933.4
Rasta Peth20013,147973.1110.31203.8
Country total200246,7611,2802.71440.32,0574.4
Sri Lanka
Sri Lanka20013,3452417.2571.740512.1
Region total200250,1061,5213.02010.42,4624.9
Latin America
Argentina
Neuquén20021,9301889.7281.524712.8
Rosario City20012,9521234.2140.52729.2
Country total20024,8823116.4420.951910.6
Brazil
Aracaju20032,44324610.1271.12439.9
Itajaí20011,5111056.9120.820413.5
Maceió20021,9901417.1361.819910.0
Manaus Amazonas20023,0112337.7401.345915.2
Nova Iguaçu20023,2492898.9752.350115.4
Salvador20021,069656.1121.115214.2
Santo Andre20002,1671155.3170.81727.9
São Paulo20023,0472076.8270.939813.1
São Paulo West20023,3122457.4401.239812.0
Country total200221,7991,6467.62861.32,72612.5
Chile
Punta Arenas20013,05236812.1391.394130.8
outh Santiago20013,07545614.8632.056018.2
Valdivia20013,18337311.7421.335311.1
Country total20019,3101,19712.91441.51,85419.9
Colombia
Barranquilla20023,20967020.9762.443713.6
Bogotá20023,25646614.3491.52868.8
Cali20023,0052207.3371.239213.0
Country total20029,4701,35614.31621.71,11511.8
Costa Rica
Costa Rica20023,2342878.9521.62798.6
Cuba
La Habana20021,80332918.2894.947626.4
Ecuador
Quito20033,05568822.5812.733410.9
El Salvador
San Salvador20031,365876.480.613810.1
Honduras
San Pedro Sula20021,90730415.9743.926013.6
Mexico
Ciudad Victoria20032,603612.370.3532.0
Ciudad de México (1)20023,2052788.7240.71304.1
Ciudad de México (3)20023,4933078.8361.0852.4
Cuernavaca20022,5791034.090.3301.2
Mexicali Valley20032,5681385.4210.8933.6
Monterrey20013,0301234.1190.6872.9
Mérida20032,8962388.2220.81986.8
Toluca20023,2351755.4100.31093.4
Villahermosa20022,6781636.1271.01455.4
Country total200226,2871,5866.01750.79303.5
Nicaragua
Managua20023,28665820.0952.957217.4
Panama
David-Panamá20012,94242414.4521.81,03435.1
Uruguay
Paysandú20021,5121197.9362.41228.1
Venezuela
Caracas20022,99937112.4842.899633.2
Region total200293,8519,36310.01,3801.511,35512.1
North America
Barbados
Barbados20012,7592559.2421.538514.0
Canada
Saskatoon20031,25515012.0131.041933.4
Region total20024,01440510.1551.480420.0
Northern and Eastern Europe
Albania
Tiranë20002,8961083.7210.7401.4
Bulgaria
Sofia20021,181383.210.1806.8
Croatia
Rijeka20021,633724.4100.617410.7
Estonia
Tallinn20012,38527411.5110.52289.6
Georgia
Kutaisi20032,666632.480.3471.8
Hungary
Svábhegy20032,4511164.7241.024410.0
Kyrgyzstan
Bishkek20023,146531.780.3882.8
Jalalabat∗20031,664352.1
Country total20034,810881.880.3882.8
Lithuania
Kaunas20022,772823.030.1983.5
Panevezys19971,176282.440.3141.2
Siauliai19971,341372.8100.7302.2
Country total19995,2891472.8170.31422.7
Poland
Kraków20012,49725910.4371.572228.9
Poznan20021,99925812.9180.968934.5
Country total20024,49651711.5551.21,41131.4
Russia
Novosibirsk20022,7301816.6160.62499.1
Serbia and Montenegro
Belgrade20011,9321357.0191.033317.2
Nis20011,002646.420.211211.2
Novi Sad20021,044535.120.212111.6
Sombor20021,029555.360.613613.2
Country total20025,0073076.1290.670214.0
Sweden
Linköping20022,08946622.3261.280638.6
Ukraine
Kharkiv20021,9501045.300.0623.2
Rural Kharkiv19983,0001143.870.2943.1
Country total20004,9502184.470.11563.2
Region total200142,5832,5956.12330.64,36710.7
Oceania
Australia
Melbourne20022,96850917.1602.095832.3
New Zealand
Auckland20023,54150814.3892.593426.4
Bay of Plenty20022,15029713.8331.562829.2
Christchurch20033,31561318.5621.91,25537.9
Nelson20031,86721611.6140.760732.5
Country total200310,8731,63415.01981.83,42431.5
Niue
Niue Island2002471123.424.3817.0
Region total200213,8882,15415.52601.94,39031.6
Western Europe
Austria
Kärnten20024,8472835.8150.370114.5
Urfahr-Umgebung20022,0291336.6130.630415.0
Country total20026,8764166.1280.41,00514.6
Belgium
Antwerp20025,64565611.6460.81,24722.1
Germany
Münster19993,8303027.9200.556214.7
Greece
Thessaloniki20001,228413.310.113911.3
Isle of Man
Isle of Man20011,09613812.660.532329.5
Italy
Bari20021,9431769.150.31678.6
Colleferro-Tivoli20021,143958.350.412310.8
Emilia-Romagna20022,26523410.390.439917.6
Empoli20021,152998.640.313211.5
Firenze20021,03610410.020.215314.8
Mantova20021,28814511.310.121216.5
Milano20022,24922410.050.240818.1
Roma20022,22422610.270.335215.8
Torino20022,36125110.660.340817.3
Trento20022,35924410.370.335515.0
Country total200218,0201,79810.0510.32,70915.0
Portugal
Funchal20021,81918210.0351.920911.5
Lisbon20022,47725310.2291.238715.6
Portimao20011,069868.0151.416215.2
Porto20022,4642108.5251.026910.9
Country total20027,8297319.31041.31,02713.1
Spain
A Coruña20033,0162207.3190.61,07435.6
Almeria19963,3492858.5491.562918.8
Asturias20023,1932066.5110.397730.6
Barcelona20023,0021194.090.375025.0
Bilbao20013,1572146.8140.41,00331.8
Cartagena20022,9481344.5170.682327.9
Castellón20023,9152095.390.21,15629.5
Madrid20022,3471416.0130.673231.2
Pamplona20013,1762227.0110.31,00631.7
Valencia20023,3981995.970.21,02130.0
Country total200131,5011,9496.21590.59,17129.1
United Kingdom
Sunderland20011,84329516.0412.266636.1
Region total200277,8686,3268.14560.616,84921.6
Global total2001385,85330,6167.93,9651.054,68714.2

∗Blank cells represent cases in which valid data were not available.

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Table E2. 

Prevalence of symptoms of eczema, age group 13 to 14 years
Current symptoms of eczemaCurrent symptoms of severe eczemaEczema ever
CenterYearNo.No.PercentNo.PercentNo.Percent
Africa
Algeria
Wilaya of Algiers20024,2032756.5681.62686.4
Cameroon
Yaounde20032,9832157.2622.12066.9
Congo
Brazzaville20021,01216416.2393.929028.7
Cote d'Ivoire
Urban Cote d'Ivoire20013,34260718.2521.656416.9
Ethiopia
Addis Ababa20033,19560619.0802.52106.6
Gabon
Port-Gentil20033,16645414.31123.550516.0
Kenya
Eldoret20013,28950915.51334.093628.5
Nairobi20013,02344914.91304.361520.3
Country total20016,31295815.22634.21,55124.6
Morocco
Benslimane19991,00812212.1373.719819.6
Boulmene20021,2541008.0201.614211.3
Casablanca20011,77740823.01025.735019.7
Marrakech20021,68934620.5985.834620.5
Country total20015,72897617.02574.51,03618.1
Nigeria
Ibadan20013,1422427.7411.360819.4
Republique Democratique du Congo
Kinshasa20032,93032010.9561.967323.0
Reunion Island
Reunion Island20002,36232413.7572.442618.0
République de Guinée
Conakry19973,11558718.81314.276624.6
South Africa
Cape Town20025,03767013.31923.883916.7
Polokwane20044,66052011.2982.189019.1
Country total20039,6971,19012.32903.01,72917.8
Sudan
Khartoum∗20032,8961374.7 1234.2
Togo
Lome20013,09033210.7260.837512.1
Tunisia
Grand Tunis20016,11979313.01873.14667.6
Sousse20013,0422869.4632.12929.6
Country total20019,1611,07911.82502.77588.3
Region total200266,3348,46612.81,7842.810,08815.2
Asia-Pacific
China
Beijing20013,530421.270.243612.4
Guangzhou20013,514561.670.262017.6
Tibet20012,87850.220.1411.4
Tong Zhou20013,542160.530.12406.8
Wulumuqi20013,884300.850.12305.9
Country total200117,3481490.9240.11,5679.0
Hong Kong
Hong Kong20023,3211083.390.344413.4
Indonesia
Bali20012,569953.730.126910.5
Bandung20022,826632.260.22137.5
Semarang20022,435823.440.227711.4
Country total20027,8302403.1130.27599.7
Malaysia
Alor Setar20022,94135912.2230.876926.1
Klang Valley20013,0252799.2280.91214.0
Kota Bharu20012,9892538.5311.02127.1
Country total20018,9558919.9820.91,10212.3
Philippines
Metro Manila20013,6582847.8561.53068.4
Singapore
Singapore20014,2173879.2801.92325.5
South Korea
Provincial Korea20007,3754245.7901.289812.2
Seoul20002,8881665.7441.537913.1
Country total200010,2635905.71341.31,27712.4
Taiwan
Taipei20016,3782624.1310.51,08317.0
Taoyuan20023,1901434.570.243813.7
Country total20029,5684054.2380.41,52115.9
Thailand
Bangkok20014,66948510.4591.31,46131.3
Chantaburi20012,90130810.6250.961721.3
Chiang Mai20013,5383048.6411.287524.7
Chiangrai19951,809915.0160.936220.0
Khon Kaen19993,4101604.7320.983124.4
Nakorn Pathom19966,9753304.7500.71,66023.8
Country total199923,3021,6787.22231.05,80624.9
Vietnam
Ho Chi Minh City20014,2401363.220.02896.8
Region total200192,7024,8685.36610.713,30314.4
Eastern Mediterranean
Egypt
Cairo20023,0471354.4270.92066.8
Iran
Birjand19962,8291174.1541.931911.3
Rasht20023,0041364.5401.352617.5
Tehran20013,1191344.3501.670622.6
Zanjan19962,8051063.8311.142315.1
Country total199911,7574934.21751.51,97416.8
Jordan
Amman20012,4472178.9451.81415.8
Kuwait
Kuwait∗20012,8821756.1 31410.9
Malta
Malta20024,1362245.4290.747411.5
Pakistan
Islamabad20024,06946311.4842.12446.0
Karachi20012,99939613.2541.841613.9
Country total20027,06885912.21382.06609.3
Palestine
North Gaza20003,6272145.9822.33198.8
Ramallah20003,9293097.9691.82957.5
Country total20007,5565236.91512.06148.1
Sultanate of Oman
Al-Khod20013,7472657.1852.354114.4
Syrian Arab Republic
Aleppo20013,0631254.1290.91986.5
Lattakia20013,0101013.4200.72528.4
Tartous20012,9951254.2260.92127.1
Country total20019,0683513.9750.86627.3
Region total200151,7083,2426.37251.55,58610.8
Indian Subcontinent
India
Bangalore20023,4401925.6160.5802.3
Bikaner20013,0592618.5321.094330.8
Borivali20031,00490.900.0424.2
Chandigarh20013,1221133.630.11233.9
Chennai (3)20022,181271.220.11396.4
Davangere∗20022,945401.4 1786.0
Jaipur20013,6071594.4220.670719.6
Jodhpur20032,341632.770.329112.4
Kottayam∗20023,6853419.3 41311.2
Lucknow20013,000993.3110.42438.1
Ludhiana20023,1081244.0190.62076.7
Mumbai (18)20022,982411.490.32438.1
Mumbai (29)20021,829201.130.2563.1
Nagpur20024,1501172.880.21293.1
New Delhi (7)20013,4691223.5160.51614.6
Pimpri20023,128280.930.12086.6
Pune20011,983422.140.21889.5
asta Peth20013,065521.760.22889.4
Country total200252,0981,8503.61610.44,6398.9
Sri Lanka
Sri Lanka20013,7172867.7320.961916.7
Region total200255,8152,1363.81930.45,2589.4
Latin America
Argentina
Córdoba20023,4452166.3310.93299.6
Neuquén20023,1722668.4471.51484.7
Rosario City20013,0991986.4381.23059.8
Salta20023,0002408.0351.238212.7
Country total200212,7169207.21511.21,1649.2
Bolivia
Santa Cruz20023,25768721.11364.243313.3
Brazil
Aracaju20023,0431725.7391.339913.1
Belo Horizonte20023,0881163.8130.437112.0
Brasília20023,0091284.3260.940913.6
Caruaru20023,0261474.9301.042814.1
Curitiba20013,6281333.7130.41484.1
Feira de Santana20021,732653.8201.2442.5
Itajaí20012,737903.370.32469.0
Maceió20022,7451083.9230.81756.4
Manaus Amazonas20023,0091715.7351.242614.2
Nova Iguaçu20023,1851294.1190.62989.4
Passo Fundo20022,9491475.0240.839513.4
Porto Alegre20033,0071224.1200.735211.7
Recife20022,8651384.8301.035012.2
Rural Santa Maria20033,0571224.0200.736311.9
Salvador20023,0201555.1311.0672.2
Santa Maria20033,065983.2210.73029.9
Santo Andre20003,2321113.4120.439312.2
São Paulo20023,1611123.570.240012.7
São Paulo West20023,1811524.8260.82758.6
Vitória da Conquista20021,679784.6161.0422.5
Country total200258,4182,4944.34320.75,88310.1
Chile
Calama20021,61831919.7422.634221.1
Chiloe20023,0002939.8321.146415.5
Punta Arenas20013,04440313.2401.32478.1
South Santiago20013,02666722.0923.096431.9
Valdivia20013,10540613.1521.739212.6
Country total200113,7932,08815.12581.92,40917.5
Colombia
Barranquilla20023,20478924.61253.951516.1
Bogotá20023,83046412.1591.51403.7
Cali20023,1002146.9431.4702.3
Country total200210,1341,46714.52272.27257.2
Costa Rica
Costa Rica20022,4361546.3321.31847.6
Cuba
La Habana20023,02630610.1682.241913.8
Ecuador
Guayaquil20023,08240913.3732.453917.5
Quito20033,01459919.9672.235411.7
Country total20036,0961,00816.51402.389314.6
El Salvador
San Salvador20033,2601745.3200.62146.6
Honduras
San Pedro Sula20022,67541615.6953.62077.7
Mexico
Ciudad Victoria20033,1221605.1341.1260.8
Ciudad de México (1)20023,8913308.5360.9912.3
Ciudad de México (3)20023,4742567.4220.6411.2
Ciudad de México (4)20022,6621796.7170.6391.5
Cuernavaca20021,431402.840.31369.5
Mexicali Valley20022,988852.830.1381.3
Monterrey20013,0061194.0230.8461.5
Mérida20023,0191043.4100.3351.2
Toluca20023,021943.1150.51244.1
Villahermosa20023,1091655.3341.11193.8
Country total200229,7231,5325.21980.76952.3
Nicaragua
Managua20023,26366720.4993.050315.4
Panama
David-Panamá20013,18346014.5551.71,12935.5
Paraguay
Asunción20023,00053017.7782.669723.2
Peru
Lima20013,02231710.5291.062620.7
Uruguay
Montevideo20023,1771665.2381.22999.4
Paysandú20021,738935.4291.7432.5
Country total20024,9152595.3671.43427.0
Venezuela
Caracas20023,0002157.2501.778626.2
Region total2002165,917136948.32,1351.317,30910.4
North America
Barbados
Barbados20012,4981747.0331.32218.8
Canada
Vancouver20032,8532558.9321.137713.2
Trinidad and Tobago
St Augustine20023,5122797.9671.91083.1
Tobago20021,46415210.4382.6584.0
Country total20024,9764318.71052.11663.3
United States
Sarasota20031,245554.470.6544.3
Seattle20032,4222028.3351.425610.6
Country total20033,6672577.0421.13108.5
Region total200213,9941,1178.02121.51,0747.7
Northern and Eastern Europe
Albania
Tiranë20012,983592.050.2872.9
Bulgaria
Sofia20021,926583.090.524412.7
Croatia
Rijeka20022,194642.950.21878.5
Estonia
Tallinn20013,6033138.7110.32797.7
Finland
Kuopio County20013,05147715.6280.974424.4
Former Yugoslav Republic of Macedonia (FYROM)
Skopje20023,026822.7100.31123.7
Georgia
Kutaisi20032,650481.880.3421.6
Hungary
Svábhegy20034,2192405.7370.93929.3
Szeged20032,8891274.4180.645515.7
Country total20037,1083675.2550.884711.9
Kyrgyzstan
Balykchi20021,382382.720.1574.1
Bishkek20025,0481452.9110.22294.5
Jalalabat20032,404903.7160.7271.1
Country total20028,8342733.1290.33133.5
Latvia
Riga20041,283433.440.3947.3
Lithuania
Kaunas20012,723491.860.2612.2
Panevezys19971,187292.470.6171.4
Siauliai19973,516972.8150.41153.3
Country total19987,4261752.4280.41932.6
Poland
Kraków20022,5452268.9170.739615.6
Poznan20021,8751518.1130.739020.8
Country total20024,4203778.5300.778617.8
Romania
Cluj20013,0191635.4331.1923.0
Russia
Novosibirsk20023,7691433.8130.31644.4
Serbia and Montenegro
Belgrade20013,2282578.0230.757717.9
Nis20011,207786.5161.319616.2
Novi Sad20021,171332.860.5968.2
Podgorica20031,014333.350.510510.4
Sombor20021,105343.150.51039.3
Country total20027,7254355.6550.71,07713.9
Sweden
Linköping20022,67934512.9190.71,29548.3
Ukraine
Kharkiv20022,4281395.740.21656.8
Rural Kharkiv19983,9681042.630.11704.3
Country total20006,3962433.870.13355.2
Region total200272,0923,6655.13490.56,8919.6
Oceania
Australia
Melbourne20022,19223410.7261.249322.5
Cook Islands
Rarotonga2003445245.440.96314.2
Fiji
Suva20023,09340113.01163.82227.2
Kingdom of Tonga
Nuku'alofa†20022,67140015.01053.9
New Zealand
Auckland20012,8702558.9551.959020.6
Bay of Plenty20021,9761618.1191.041621.1
Christchurch20033,1162197.0391.386727.8
Nelson20032,3051727.5160.761726.8
Wellington20013,05037012.1471.598332.2
Country total200213,3171,1778.81761.33,47326.1
Niue
Niue Island2002791215.222.51316.5
Nouvelle Caledonie
Nouvelle Caledonie19987,2475247.2751.090412.5
Polynesie Francaise
Polynesie Francaise20004,2893638.5691.654412.7
Samoa
Apia20032,98641113.81334.51,22941.2
Tokelau
Tokelau200366913.634.5710.6
Region total200236,3853,5559.87091.96,94820.6
Western Europe
Austria
Urfahr-Umgebung20031,4391087.5100.716911.7
Belgium
Antwerp20023,2502337.2280.977323.8
Channel Islands
Guernsey20011,24814011.2332.628823.1
Jersey20027738310.791.218423.8
Country total20022,02122311.0422.147223.4
Germany
Münster19994,1323207.7390.956313.6
Isle of Man
Isle of Man20011,71619011.1291.737922.1
Italy
Bari20021,2871199.270.51007.8
Colleferro-Tivoli20021,361503.730.2695.1
Cosenza2002925333.630.3262.8
Emilia-Romagna20021,3471188.840.31148.5
Empoli20021,229645.250.4574.6
Firenze20021,3831118.060.4836.0
Mantova20021,114797.140.4776.9
Milano20021,4101188.470.519313.7
Palermo20021,221846.9100.8857.0
Roma20021,3251047.870.5644.8
Siena20021,08210810.070.617816.5
Torino20021,18012110.350.411810.0
Trento20021,311886.710.113110.0
Country total200216,1751,1977.4690.41,2958.0
The Netherlands
The Netherlands20036,8965598.1671.02,41835.1
Portugal
Coimbra20021,177716.0151.319716.7
Funchal20023,1611414.5341.143013.6
Lisbon20023,0241695.6331.139112.9
Portimao20021,109544.9100.912211.0
Porto20023,3361775.3371.136510.9
Country total200211,8076125.21291.11,50512.7
Republic of Ireland
Republic of Ireland20033,0892678.6401.344314.3
Spain
A Coruña20032,9791474.990.344414.9
Almeria19964,0512275.6330.83979.8
Asturias20024,1841413.4130.346111.0
Barcelona20023,066792.6100.337612.3
Bilbao20013,4011374.0120.436710.8
Cartagena20023,9981604.0250.654113.5
Castellón20024,0241634.190.248312.0
Madrid20022,6521395.2230.932612.3
Pamplona20012,9321184.090.32649.0
San Sebastián20021,195665.580.716814.1
Valencia20023,1321294.1150.550216.0
Valladolid20022,9441334.5150.540913.9
Country total200138,5581,6394.31810.54,73812.3
United Kingdom
North Thames20022,35626311.2311.362226.4
Scotland20024,66254811.8851.81,16224.9
South Thames20022,43225410.4291.261425.2
Sunderland20012,19322610.3160.763428.9
Surrey/Sussex20025,0824849.5631.21,38827.3
Wales20022,50126510.6642.659523.8
Country total200219,2262,04010.62881.55,01526.1
Region total2002108,3097,3886.89220.917,77016.4
Global total2002663,25648,1317.37,6901.284,22712.8

∗Blank cells represent cases in which valid data were not available.

†Blank cells represent cases where the specific translation was not considered equivalent to the English language question.

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 Currently the main source of funding for the ISAAC International Data Centre (IIDC) is the BUPA Foundation. Many New Zealand funding bodies have contributed support for the IIDC during the periods of fieldwork and data compilation (the Health Research Council of New Zealand, the Asthma and Respiratory Foundation of New Zealand, the Child Health Research Foundation, the Hawke's Bay Medical Research Foundation, the Waikato Medical Research Foundation, Glaxo Wellcome New Zealand, the NZ Lottery Board, and Astra Zeneca New Zealand). Glaxo Wellcome International Medical Affairs supported the regional coordination for Phase Three and the IIDC.

 Disclosure of potential conflict of interest: T. O. Clayton and M. I. Asher have received research support from the BUPA Foundation (UK). C. F. Robertson has received research support from the National Health Medical Research Council. J. A. Odhiambo and H. C. Williams have declared that they have no conflict of interest.

PII: S0091-6749(09)01535-8

doi:10.1016/j.jaci.2009.10.009

The Journal of Allergy and Clinical Immunology
Volume 124, Issue 6 , Pages 1251-1258.e23, December 2009

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