Discussion
Results of our study showed that the overall compliance rate among
patients receiving AIT was 86,1% and short duration of AIT and
receiving venom or asthma immunotherapy were found to be associated with
non-compliance. In addition, the most common reasons for drop-out were
moving to another city, improvement of symptoms and ineffectiveness.
However, nearly one-third of children dropped out during the COVID-19
pandemic, and fear of being infected with COVID-19 was the most common
reason.
Compliance rates for SCIT range from 44% to 89%, in the present study
compliance found to be better than other
studies3. Similar to our
results, Pajno et all found that AIT compliance of children on SCIT was
89%4. In a population
of 311 allergic adult and child patients receiving dust mite SCIT in
China, 34,5% of caseswere noncompliant and ineffectiveness(28%) was
the leading reason for
drop-out15. The cost of
AIT in our country is under the umbrella of social security system. This
may be a major reason for high compliance rates we achieved.
Additionally our staff reminds the patients if a patient does not come
to a regular visit (except COVID-19 period).
We concluded that drop-out was significiantly higher in patients who
receiving immunotherapy for asthma and venom allergy. As the patients
who received VIT admitted from another city, most of them dropped out
due to the long distance or frequency of injections. However in previous
studies, the association of kind of respiratory allergic diseases and
adherence were inconsistent. In one study, allergic conjunctivitis were
found associated with non-adherence whereas in other study patients with
asthma and rhinitis were found more
adherent16,17.
More et all reported that the kind of respiratory allergic diseases was
not correlated with
adherence18.
In the current literature the data about the AIT compliance were mostly
attained from studies in adults, and there are few data related to SCIT
adherence in children. The studies comparing different age groups with
respect to the AIT compliance give us conflicting
results19,20.
Yang et all found that children had higher adherence than
adults15. Lee et al
concluded that patients aged <20 years and 20-40 years were
more likely to be nonadherent than those aged >40 years.
Rhodes found, nonadherent patients were
younger21.
In the present study, gender did not influence the adherence rate before
pandemic. However during the COVID-19 pandemic period males droped out
more significantly. Musa, Rhodes and Gelincik found no correlation with
gender5,20,21.
Rhodes found, males were more
nonadherent21. However
in Yang’ and Lower’s study males had higher
adherence2,15.
Our results suggested that moving to another city (32,9%) was the main
cause of drop-outs. Due to the lack of allergologists in some cities,
treatment could not be resumed. In addition, all of the patients
receiving AIT were at school age, and increased injection frequency,
transportation to different city and long distances probably caused
school absences and AIT drop-out.
Improvement of symptoms was the second leading reason of drop out
(17,9%). Lourenco reported that the frequency of drop-out because of
clinical improvement was 23% and mostly during the second and third
year of SCIT19. Yang
reported it as 22%15.
We found treatment ineffectiveness (14,3%) as another important reason
of AIT drop-outs. Ineffectiveness was reported in previous studies in 8
to 66% of drop-out
results1,4,15,19,20.
Adverse reactions were also reported in several studies as a reason for
drop-outs in 3,9% to -11% of
drop-outs19,21.
Systemic reactions were also one of the leading reasons for drop-out
(14,3%) in the present study although it was not reported frequently in
our center
previously22,23(24).
In contrast to literature, cost was not a reason for drop-out in the
present study as AIT treatment is covered by social security system of
our country.
During the COVID-19 pandemic period, in allergy department, patient
admissions were stopped except for emergency situations and
immunotherapy vaccination. Even so, among the 108 patients receiving
AIT, 31 (28,7%) dropped out. Fear of being infected with COVID-19 was
the most reason. Although the necessary precautions were taken, the
patients chose not to continue to AIT, as the hospital was a COVID-19
pandemic center. Twenty nine percent of patients dropped out thinking
that the AIT was cancelled because of the news on the press that the
admissions of patients stopped except for emergencies. In COVID-19
pandemic period, intercity transportation was banned and, in most of the
cities including Ankara curfews were declared. This situation resulted
in 22,7% of patients’s drop-out due to transportation problems. Six and
a half percent of patients could not get access to allergen extract. One
patient was unable to continue AIT, as his father, a health worker, was
hospitalized because of COVID-19 pneumonia. One patient’s AIT was
terminated earlier, who was an out of town patient and in the final
months of AIT.
Older age and male gender were correlated with drop-out during the
COVID-19 pandemic. Closure of schools and home-quarantine during
pandemic was reported to cause anxiety in
adolescents24. Older
adolescens may have taken the treatment responsibility themselves and
tended to refuse outpatient admission. Besides, male sex was reported as
a risk factor for COVID-19
severity25. These might
be associated with reduced outpatient admissions.
Longer AIT duration, was found to be associated with drop-out during the
COVID-19 pandemic period. We may speculate that the effectiveness of the
AIT up to this period, might cause noncompliance.
Although our study brings some new data to the field there are some
limitation. Firstly, this is a retrospective study up to the COVID-19
pandemic period, and there are some missing data related laboratory
parameters. Secondly, in the present study, definition of compliance
differs from in many studies and may lead to difficulty in comparing
factors associated with AIT compliance. Thirdly, some of the patient’s
immunotherapy is stilll ongoing. Therefore the compliance rate may be
higher than other studies for this reason. Despite this limitations, the
present study had the benefits of a large study population including
only children and analyzes the effect of COVID-19 pandemic on AIT for
the first time.