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A letter to the editor is presented in response to an article related to whole-cell pertussis-containing vaccines and acellular pertussis-containing vaccines by M.A. Witt et al. in the 2013 issue.

Summary: Background: Eczema is a chronic inflammatory skin disease. Domestic water with high mineral content (hard water) is a risk factor for eczema in children, but this association has not been assessed in adults. Objectives: To examine the association between domestic hard water supply and eczema prevalence and incidence in adults aged 40–69 years and the contextual effect in eczema outcomes by postcode in adults in the UK. Methods: We used data from the UK Biobank study collected in 2006–10 (baseline) and 2013–14 (follow‐up). Eczema prevalence at baseline (2006–10) and at follow‐up (2013–14) and incidence (new onset between baseline and follow‐up) were determined from the touchscreen questionnaires and nurse‐led interviews. Domestic hard water information was obtained in 2005 and 2013 from the local water supply companies in England, Wales and Scotland as CaCO3 concentrations. We fitted multilevel logistic regression models with random intercepts for postcode areas to examine the effect of domestic hard water on eczema outcomes, and we measured components of variance. Results: In total, 306 531 participants with a mean age of 57 years nested across 7642 postcodes were included in the baseline analysis, and 31 036 participants nested across 3695 postcodes were included in the follow‐up analysis. We observed an increase in the odds of eczema at baseline [odds ratio (OR) 1·02, 95% confidence interval (CI) 1·01–1·04] per 50 mg L−1 of CaCO3 increase. Furthermore, exposure to domestic hard water (> 200 mg L−1 of CaCO3) was associated with increased odds of prevalent eczema at baseline (OR 1·12, 95% CI 1·04–1·22). Moreover, there was a significant linear trend (P < 0·001) in which increasing levels of hard water increased eczema prevalence risk. No association was observed with incident eczema or eczema at follow‐up. The intraclass correlation coefficient for postcode was 1·6% (95% CI 0·7–3·4), which remained unexplained by area‐level socioeconomic measures. Conclusions: Increasing levels of domestic hard water, as measured by CaCO3 concentrations, were associated with an increased prevalence of eczema in adults but not increased incidence. Ongoing efforts to reduce hard water exposure may have a beneficial effect in reducing the burden of eczema in adults. Further research is needed to explore area‐level factors that may lead to eczema. What is already known about this topic?Hard water is formed when minerals are dissolved in water from filtration through sedimentary rocks.Several studies have reported a higher prevalence of eczema in areas with hard water.However, all studies on this topic have assessed this in infants and school‐aged children, while this association has not been explored in adults. What does this study add?Our findings suggest that exposure to higher concentrations of domestic hard water is associated with an increase in eczema prevalence in adults aged 40–69 years.Ongoing efforts to reduce hard water exposure may have a beneficial effect in reducing eczema prevalence in adults. [ABSTRACT FROM AUTHOR]

HealthNuts is a single-centre, multi-wave, population-based longitudinal study designed to assess prevalence, determinants, natural history and burden of allergy (particularly food allergy) in the early years of life. It is novel in the use of serial food challenge measures within its population frame to confirm food allergy. The cohort comprises 5276 children initially recruited at age 12 months from council-run immunization sessions across Melbourne, Australia. As well as parent-completed questionnaires and researcher-observed eczema status, all infants underwent skin-prick testing to egg, peanut, sesame and either cow's milk or shellfish, and those with detectable wheals underwent food challenges to determine clinical allergy. In wave 2, conducted at age 4 years, validated questionnaires collected data on asthma, allergic rhinitis (hay fever), eczema and food allergies. Food challenges were repeated in children previously identified as food allergic to determine resolution. In wave 3, all children (irrespective of food allergy status) were invited for clinical assessment at age 6 years, including lung function, physical measurements, skin-prick testing to foods and aeroallergens and food challenges if food sensitized. Biological specimens (blood, cheek swabs) were collected at each wave for ancillary immunological, genetic and epigenetic studies. Applications to access data and/or samples can be submitted to [katrina.allen@mcri.edu.au]. [ABSTRACT FROM AUTHOR]

Context It has been hypothesized that a mother's diet during pregnancy may modulate her offspring's immune system development and lead to development of allergic diseases among offspring. However, the evidence for this is unclear and inconclusive. Objective This systematic review was undertaken to examine the weight of evidence for causality from cohort studies on the association between maternal free sugar intake during pregnancy and development of allergies in offspring. Data Sources Using a systematic search strategy, PubMed, SCOPUS, and Web of Science databases were searched from inception to May 2020. Data Extraction For the reporting of this systematic review, the PRISMA guideline was followed. Studies examining maternal sugar consumption during pregnancy (using self-reported data) and the development of allergic diseases among offspring (infancy to 5 years) were included. Data Analysis The Newcastle–Ottawa Scale quality assessment tool was used to assess the study quality. Meta-analysis was conducted using a random-effects model to synthesize the findings. Of 159 publications identified from the search, 5 articles with 4 unique cohort studies were included in this systematic review. The limited meta-analysis showed that a mother's increased free sugar intake during pregnancy was associated with an increased risk of developing asthma in offspring (odds ratio 1.07 [95% CI, 1.00 to 1.14; I2 = 0%]). High free sugar intake by the mother during pregnancy was also associated with increased odds of offspring (to age 7.7 years) developing other common allergies, including allergic rhinitis, atopy and eczema, wheeze, and food allergies. Conclusion From the limited evidence, this review suggests that high free sugar consumption during pregnancy may be associated with the development of allergies in offspring. Clinical guidelines and public health policy recommendations for maternal diet in pregnancy should include advice about reducing free sugar intake due to a possible association with allergies in offspring. However, recommendations should be made with caution considering other maternal and fetal risk factors. [ABSTRACT FROM AUTHOR]

Background: Beneficial effects of greenness on birth outcomes have been reported, but few studies have investigated the associations in both urban and non-urban settings. We aimed to evaluate and compare linear and nonlinear associations between greenness and birth outcomes in urban and non-urban settings.Methods: From October 2015 to December 2018, participants were recruited into the Maoming Birth Cohort Study. A total of 11 258 live birth records were obtained. Greenness exposure was assessed using the normalized difference vegetation index (NDVI) and enhanced vegetation index (EVI). Linear regression and nonlinear restricted cubic spline models were implemented to investigate the associations between greenness and birthweight, birth length, gestational age, preterm birth, low birthweight, small for gestational age and the potential for effect variation under urban or non-urban settings, after adjusting for covariates.Results: A 0.1-unit increase in NDVI-500m was significantly associated with an increase of 35.4 g in birthweight [95% confidence interval (CI): 13.2, 57.7], 0.15 cm in birth length (95% CI: 0.03, 0.26), 0.88 days in gestational age (95% CI: 0.05, 1.71) and lower odds of low birthweight [odds ratio (OR) = 0.69, 95% CI: 0.56, 0.85] and preterm birth (OR = 0.70, 95% CI: 0.58, 0.85). No association with head circumference was observed. For all outcomes, no significant linear associations were observed among non-urban dwellers. Inversed 'U-shaped' associations between greenness exposure and birth outcomes were observed in the total study population.Conclusions: Greenness exposure was associated with increased gestational age, birthweight and birth length in urban dwellers. Nonlinear associations assessed by restricted cubic splines suggested that health benefits could be larger when increasing greenness levels from low to medium compared with increasing greenness from medium to high levels. Further studies adopting nonlinear methods are warranted to verify our findings. [ABSTRACT FROM AUTHOR]

Background Paediatric asthma-related readmissions significantly challenge public health systems. As evidence suggests readmissions are possibly associated with ambient grass pollen levels, we sought to determine the relationship between grass pollen exposure and the risk of readmission for asthma among children in Victoria, Australia. Methods The Victorian Admitted Episodes Dataset 1st July 1997–30th June 2009 was used to identify primary admissions with a principal diagnosis of asthma for children aged 2-18 years. Total sample size was 48,068 admissions. Readmissions were defined as a subsequent admission within 28 days of index discharge. Multiple semi-parametric Poisson Generalized Additive Models were used to assess associations between the grass pollen season and daily grass pollen counts (lagged and cumulative) with repeat admissions, while controlling for meteorological factors and air pollutants. Results Readmissions totalled to 2,152 (4.47% of all admissions). Mean daily readmissions were 1.44 times higher during the grass pollen season (95%CI 1.03-2.02). Pollen season was associated with readmission only for the youngest age group (2-5), incident rate ratio 1.99 (95%CI 1.26-3.14). Daily readmission was non-linearly associated with same day pollen counts only for the 13-18-year age group. Lag 2 pollen counts were non-linearly associated with all daily readmissions for boys in gender-stratified and younger age groups (2-5, 6-12) in age-stratified analysis. Conclusions Grass pollen exposure was associated with higher readmission rates for paediatric asthma. Key messages Younger children and boys with severe or poorly controlled asthma need to be assessed for preventive therapies before the grass pollen season to reduce the repeat admissions. [ABSTRACT FROM AUTHOR]

Background: Mothers' smoking during pregnancy increases asthma risk in their offspring. There is some evidence that grandmothers' smoking may have a similar effect, and biological plausibility that fathers' smoking during adolescence may influence offspring's health through transmittable epigenetic changes in sperm precursor cells. We evaluated the three-generation associations of tobacco smoking with asthma.Methods: Between 2010 and 2013, at the European Community Respiratory Health Survey III clinical interview, 2233 mothers and 1964 fathers from 26 centres reported whether their offspring (aged ≤51 years) had ever had asthma and whether it had coexisted with nasal allergies or not. Mothers and fathers also provided information on their parents' (grandparents) and their own asthma, education and smoking history. Multilevel mediation models within a multicentre three-generation framework were fitted separately within the maternal (4666 offspring) and paternal (4192 offspring) lines.Results: Fathers' smoking before they were 15 [relative risk ratio (RRR) = 1.43, 95% confidence interval (CI): 1.01-2.01] and mothers' smoking during pregnancy (RRR = 1.27, 95% CI: 1.01-1.59) were associated with asthma without nasal allergies in their offspring. Grandmothers' smoking during pregnancy was associated with asthma in their daughters [odds ratio (OR) = 1.55, 95% CI: 1.17-2.06] and with asthma with nasal allergies in their grandchildren within the maternal line (RRR = 1.25, 95% CI: 1.02-1.55).Conclusions: Fathers' smoking during early adolescence and grandmothers' and mothers' smoking during pregnancy may independently increase asthma risk in offspring. Thus, risk factors for asthma should be sought in both parents and before conception.Funding: European Union (Horizon 2020, GA-633212). [ABSTRACT FROM AUTHOR]

Background. Previous research has mainly targeted older people with high risk of falling. The effectiveness of exercise interventions in older people with mild levels of balance dysfunction remains unexplored. Objective. This study evaluated the effectiveness of a home balance and strength exercise intervention in older people systematically screened as having mild balance dysfunction. Design. This was a community-based, randomized controlled trial with assessors blinded to group allocation. Participants. Study participants were older people who reported concerns about their balance but remained community ambulant (n=225). After a comprehensive balance assessment, those classified as having mild balance dysfunction (n=165) were randomized into the trial. Intervention. Participants in the intervention group (n=83) received a 6-month physical therapist-prescribed balance and strength home exercise program, based on the Otago Exercise Program and the Visual Health Information Balance and Vestibular Exercise Kit. Participants in the control group (n=82) continued with their usual activities. Outcome Measures. Laboratory and clinical measures of balance, mobility, and strength were assessed at baseline and at a 6-month reassessment. Results. After 6 months, the intervention group (n=59) significantly improved relative to the control group (n=62) for: the Functional Reach Test (mean difference=2.95 cm, 95% confidence interval [CI]=1.75 to 4.15), the Step Test (2.10 steps/15 seconds, 95% CI=1.17 to 3.02), hip abductor strength (0.02, 95% CI=0.01 to 0.03), and gait step width (2.17 cm, 95% CI=1.23 to 3.11). There were nonsignificant trends for improvement on most other measures. Fourteen participants in the intervention group (23.7%) achieved balance performance within the normative range following the exercise program, compared with 3 participants (4.8%) in the control group. Limitations. Loss to follow-up (26.6%) was slightly higher than in some similar studies but was unlikely to have biased the results. Conclusions. A physical therapist-prescribed home exercise program targeting balance and strength was effective in improving a number of balance and related outcomes in older people with mild balance impairment. [ABSTRACT FROM AUTHOR]

Objective. To improve health outcomes of children and adolescents with asthma using a multifaceted intervention for GPs. [ABSTRACT FROM PUBLISHER]

Background: the aim of this study was to develop a brief screening tool for use in the emergency department (ED), to identify people who require further assessment and management. Methods: this prospective study included 344 community-dwelling older people presenting to an ED after a fall. After direct discharge participants had a home-based assessment performed that included the Falls Risk for Older People in the Community (PROP-Com), a comprehensive, yet simple, multifactorial falls risk assessment tool. They were then monitored for falls for 12 months. The items from the PROP-Com assessment tool predictive of falls in a multifactorial logistic regression were used to develop the FROP-Com screen. Results: the items significantly predictive of falls and combined to form the PROP-Com screen were: falls in the previous 12 months, observation of the person's balance and the need for assistance to perform domestic activities of daily living. At the cut-off with the highest Youden index sensitivity was 67.1% (95% CI 59.9-74.3) and specificity was 66.7% (95% CI 59.8-73.6). Conclusion: the FROP-Com screen has a relatively good capacity to predict falls. It can be used in time-limited situations to classify those at high risk of falls who require more detailed assessment and management. [ABSTRACT FROM AUTHOR]

Background: the Falls Risk for Older People in the Community assessment (FROP-Com) tool was designed for use in targeted multi-factorial falls prevention programmes. It fills the gap between the short screening tools and the longer assessment tools, e.g. the physiological profile assessment (PPA). The aim of this study was to determine the reliability and predictive accuracy of the FROP-Com. Methods: the intra-rater and inter-rater reliability studies were performed with 20 participants each. The prospective study was performed with 344 community-dwelling older people presenting to an emergency department after a fall and being discharged directly home. Following a home-based assessment, including the FROP-Com, Timed Up and Go (TUG) and functional Reach (FR), participants were monitored for falls for 12 months. Results: the intra-class correlation coefficient (ICC) for intra-rater reliability and inter-rater reliability for the FROP-Com was 0.93 (95% CI 0.84-0.97) and 0.81 (95% CI 0.59-0.92) respectively. The AUC for the FROP-Com was 0.68 (95% CI 0.63-0.74). At the cut-off 18/19, sensitivity was 71.3% (95% CI 64.4-78.3) and specificity was 56.1% (95% CI 48.9-63.4). The AUC for the TUG was 0.63 (95% CI 0.57-0.69) and for the FR was 0.60 (95% CI 0.54-0.66). Conclusion: the FROP-Com demonstrated good reliability and a moderate capacity to predict falls. [ABSTRACT FROM AUTHOR]

Background. There is currently no standard approach to falls risk assessment and management lot older fallers presenting to the emergency department (ED) who are discharged directly home. Hence, this study was conducted to describe the prevalence of falls risk factors associated with older fallers presenting to the ED and to identify the factors associated with postdischarge decline in function in this group. Methods. This cross-sectional study was performed with 300 community-dwelling individuals, aged 60 years or older admitted to the ED following a fall, and discharged directly home. A home-based assessment after ED discharge was performed, which included the prevalence of falls risk factors, identification of functional decline, and objective measurements of balance, gait, depression, and falls efficacy. Results. Fall-related injuries were sustained by 91% (95% confidence interval [CI], 87.2%-94.0%) of participants presenting to the ED. The most common falls risk factors identified in the home assessment were polypharmacy (79.0%, 95% CI, 73.9%-83.5%), home hazards (76.0%, 95% CI, 70.8%-80.7%), decreased balance (61.3%, 95% CI, 55.6%-66.9%), and arthritis (61.3%, 95% CI, 55.6%-66.9%). A decline in function was reported by 35% of participants (95% CI, 29.6%-40.7%). Sustaining a fracture, functional independence before the fall, being female, depression, and slower Timed Up and Go (TUG) scores were associated with a decline in function (p < .05). Conclusion. Older fallers discharged directly from the ED have a high prevalence of falls risk factors and are at risk of functional decline. [ABSTRACT FROM AUTHOR]