Validation of the International Study of Asthma and Allergies in Children (ISAAC) and U.K. criteria for atopic eczema in Ethiopian children

Background: Reliable diagnostic criteria for atopic eczema (AE) are essential in order to make international comparisons and to identify possible disease risk factors. Little is known about the prevalence of atopic eczema and validity of diagnostic criteria for AE in developing countries where English is not the first language. Objectives: We sought to determine the prevalence of AE in an area of urban and rural Ethiopia, and to compare the predictive values of different questionnaire and examination methods for diagnosing AE in this population. Methods: We conducted a cross-sectional survey of 7915 children aged 1-5 years living in and around the town of Jimma in southwest Ethiopia. AE prevalence was assessed in two ways: (i) by using the International Study for Asthma and Allergies in Childhood (ISAAC) questionnaire, and (ii) using the U.K. refinement of Hanifin and Rajka's diagnostic criteria. All possible cases identified by screening questions and random samples of controls were then examined by an experienced local paediatrician, who acted as a reference standard to determine the predictive value of the criteria used to diagnose AE. Results: The overall 1-year period prevalence of AE according to ISAAC and U.K. criteria was 4.4% [95% confidence interval (CI) 3.95-4.85] and 1.8% (95% CI 1.5-2.1), respectively. Corresponding point prevalence estimates (symptoms in the last week) were 1.8% for ISAAC and 1.3% for the U.K. criteria. The positive predictive values of the ISAAC and U.K. criteria questions for AE symptoms still reported to be present (in the last week) at the doctor's examination were 48.8% and 55.5%, respectively. Corresponding negative predictive values were 90.5% and 90.1%, respectively. The sign of visible flexural dermatitis (a component of the U.K. criteria) when used alone had positive and negative predictive values of 57% and 91%, respectively. Conclusions: Neither the ISAAC nor U.K. criteria performed especially well in predicting cases of AE in this survey. Possible reasons include problems with questionnaire translation, cultural conceptions of terminology, asking parents rather than the child about symptoms, the transient nature of AE signs, and differences in what a doctor perceives to constitute a typical case of AE. The results do not preclude the use of standardized diagnostic criteria alongside a doctor's examination in future surveys of Ethiopian children, and knowledge of the criteria's limited predictive value should help to interpret study findings that have employed such criteria. Consideration should be given to adopting the sign of visible flexural dermatitis as a standard for estimating the point prevalence of AE throughout the world because it is less susceptible to problems with translation and interpretation.