Hygiene hypothesis: association between hygiene and asthma among preschool children in Lebanon
Main Article Content
Keywords
hygiene, hypothesis, asthma, pre-school, children.
Abstract
Objectives: To validate a scale to assess the hygiene hypothesis and the association between hygiene and asthma among Lebanese preschool children aged 3–5 years.
Methods: This cross-sectional study, conducted between November 2018 and March 2019, enrolled 515 preschool children. Asthma and potential risk factors, including hygiene, were assessed using a standardized questionnaire. A specific hygiene hypothesis scale has been generated and validated for this purpose.
Results: The hygiene hypothesis scale items converged over a solution of nine factors that had an Eigenvalue over 1, explaining a total of 65.86% of the variance. An acceptable Cronbach’s alpha value was recorded for the hygiene hypothesis scale (0.696). Variables correlated with higher odds of asthma were male gender (ORa = 0.41 for females), living near a prairie sprayed with pesticides (ORa = 3.09), having a heating system in the bedroom compared to the sitting room (ORa = 9.97), attending kindergarten (ORa = 2.80), having a mother who smokes waterpipe compared to not smoking (ORa = 3.34), having a mother with a history of asthma (ORa = 5.50), and having respiratory infections (ORa = 14.72). However, the hygiene hypothesis score was not associated with higher odds of asthma (p = 0.881).
Conclusions: The current results suggested that neither home cleaning nor personal cleanliness was correlated with asthma in preschool children. Larger prospective studies that measure the intensity and duration of exposure to each toxicant are suggested to better assess the hygiene hypothesis items and their association with asthma.
References
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13. Metsala J, Lundqvist A, Virta LJ, Kaila M, Gissler M, Virtanen SM. Prenatal and post-natal exposure to antibiotics and risk of asthma in childhood. Clin Exp Allergy. 2015;45(1):137–145. 10.1111/cea.12356
14. Sonnenburg ED, Smits SA, Tikhonov M, Higginbottom SK, Wingreen NS, Sonnenburg JL. Diet-induced extinctions in the gut microbiota compound over generations. Nature. 2016;529(7585):212–215. 10.1038/nature16504
15. Figueiredo CA, Alcantara-Neves NM, Amorim LD, Silva NB, Pontes de Carvalho LC, Cooper P, et al. Evidence for a modulatory effect of IL-10 on both Th1 and Th2 cytokine production: the role of the environment. Clin Immunol. 2011;139(1):57–64. 10.1016/j.clim.2010.12.019
16. Ajdacic-Gross V, Mutsch M, Rodgers S, Tesic A, Muller M, Seifritz E, et al. A step beyond the hygiene hypothesis-immune-mediated classes determined in a population-based study. BMC Med. 2019;17(1):75. 10.1186/s12916-019-1311-z
17. Cooper P. Toxocara canis infection: an important and neglected environmental risk factor for asthma? This editorial discusses the findings of the paper in this issue by E. Pinelli et al. [19], pp. 649–658. Clin Exp Allergy. 2008;38(4):551–553. 10.1111/j.1365-2222.2008.02934.x
18. van Tilburg Bernardes E, Arrieta M-C. Hygiene hypothesis in asthma development: Is hygiene to blame? Arch Med Res. 2017;48(8):717–726. 10.1016/j.arcmed.2017.11.009
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20. Jeong JS, Choi JK, Jeong IS, Paek KR, In HK, Park KD. [A nationwide survey on the hand washing behavior and awareness]. J Prev Med Public Health. 2007;40(3):197–204. 10.3961/jpmph.2007.40.3.197
21. Haas JP, Larson EL. Measurement of compliance with hand hygiene. J Hosp Infect. 2007;66(1):6–14. 10.1016/j.jhin.2006.11.013
22. Stevenson RJ, Case TI, Hodgson D, Porzig-Drummond R, Barouei J, Oaten MJ. A scale for measuring hygiene behavior: development, reliability and validity. Am J Infect Control. 2009;37(7):557–564. 10.1016/j.ajic.2009.01.003
23. Sordillo JE, Hoffman EB, Celedon JC, Litonjua AA, Milton DK, Gold DR. Multiple microbial exposures in the home may protect against asthma or allergy in childhood. Clin Exp Allergy. 2010;40(6):902–910.
24. Schaub B, Lauener R, von Mutius E. The many faces of the hygiene hypothesis. J Allergy Clin Immunol. 2006;117(5):969–977; quiz 978. 10.1016/j.jaci.2006.03.003
25. Weinmayr G, Weiland SK, Bjorksten B, Brunekreef B, Buchele G, Cookson W, et al. Atopic sensitization and the international variation of asthma symptom prevalence in children. Am J Respir Crit Care Med. 2007;176(6):565–574. 10.1164/rccm.200607-994OC
26. van Dijk CE, Garcia-Aymerich J, Carsin A-E, Smit LAM, Borlée F, Heederick DJJ, et al. Risk of exacerbations in COPD and asthma patients living in the neighbourhood of livestock farms: observational study using longitudinal data. Int J Hyg Environ Health. 2016;219(3):278–287. 10.1183/13993003.congress-2015.OA2912
27. Kramer M, Matush L, Bogdanovich N, Dahhou M, Platt R, Mazer B. The low prevalence of allergic disease in Eastern Europe: Are risk factors consistent with the hygiene hypothesis? Clin Exp Allergy. 2009;39(5):708–716. 10.1111/j.1365-2222.2009.03205.x
28. Braun-Fahrlander C, Riedler J, Herz U, Eder W, Waser M, Grize L, et al. Environmental exposure to endotoxin and its relation to asthma in school-age children. N Engl J Med. 2002;347(12):869–877. 10.1056/NEJMoa020057
29. Cooper PJ, Vaca M, Rodriguez A, Chico ME, Santos DN, Rodrigues LC, et al. Hygiene, atopy and wheeze-eczema-rhinitis symptoms in schoolchildren from urban and rural Ecuador. Thorax. 2014;69(3):232–239. 10.1136/thoraxjnl-2013-203818
30. Ardura-Garcia C, Garner P, Cooper PJ. Is childhood wheeze and asthma in Latin America associated with poor hygiene and infection? A systematic review. BMJ Open Respir Res. 2018;5(1):e000249. 10.1136/bmjresp-2017-000249
31. Waked M, Salameh P. Asthma, allergic rhinitis and eczema in 5-12-year-old school children across Lebanon. Public Health. 2008;122(9):965–973. 10.1016/j.puhe.2007.10.006
32. Hallit S, Raherison C, Malaeb D, Hallit R, Kheir N, Salameh P. The AAA risk factors scale: a new model to screen for the risk of asthma, allergic rhinitis and atopic dermatitis in children. Med Princ Pract. 2018;27(5):472–480. 10.1159/000490704
33. Hallit S, Raherison C, Malaeb D, Hallit R, Waked M, Kheir N, et al. Development of an asthma risk factors scale (ARFS) for risk assessment asthma screening in children. Pediatr Neonatol. 2019;60(2):156–165. 10.1016/j.pedneo.2018.05.009
34. Hallit S, Raherison C, Waked M, Hallit R, Layoun N, Salameh P. Validation of the mini pediatric asthma quality of life questionnaire and identification of risk factors affecting quality of life among Lebanese children. J Asthma. 2019;56(2):200–210. 10.1080/02770903.2018.1441417
35. Malaeb D, Hallit S, Sacre H, Hallit R, Salameh P. Factors associated with wheezing among Lebanese children: Results of a cross-sectional study. Allergologia et Immunopathologia, 2021, 10.1016/j.aller.2020.02.003
36. Castro-Rodriguez JA, Forno E, Rodriguez-Martinez CE, Celedon JC. Risk and protective factors for childhood asthma: What is the evidence? J Allergy Clin Immunol Pract. 2016;4(6):1111–1122. 10.1016/j.jaip.2016.05.003
37. Malaeb D, Hallit S, Sacre H, Rahme C, Malaeb B, Hallit R, et al. Preconception exposure to over-the-counter medications and antibiotics and the risk of childhood asthma in Lebanon: A cross-sectional study. Allergologia etimmunopathologia. 2020;48:523-9.
38. Carson CG, Halkjaer LB, Jensen SM, Bisgaard H. Alcohol intake in pregnancy increases the child’s risk of atopic dermatitis: the COPSAC prospective birth cohort study of a high risk population. PLoS One. 2012;7(8):e42710. 10.1371/journal.pone.0042710
39. Hallit S, Raherison C, Waked M, Salameh P. Association between caregiver exposure to toxics during pregnancy and childhood-onset asthma: a case-control study. Iran J Allergy Asthma Immunol. 2017;16(6):488–500.
40. Hallit S, Salameh P. Exposure to toxics during pregnancy and childhood and asthma in children: a pilot study. J Epidemiol Glob Health. 2017;7(3):147–154.
41. Thavagnanam S, Fleming J, Bromley A, Shields MD, Cardwell CR. A meta-analysis of the association between Caesarean section and childhood asthma. Clin Exp Allergy. 2008;38(4):629–633. 10.1111/j.1365-2222.2007.02780.x
42. Zock JP, Plana E, Jarvis D, Anto J, Kromhout H, Kennedy S, et al. The use of household cleaning sprays and adult asthma: an international longitudinal study. Am J Respir Crit Care Med. 2007;176(8):735–741. 10.1164/rccm.200612-1793OC
43. Howden-Chapman P, Pierse N, Nicholls S, Gillespie-Bennett J, Viggers H, Cunningham M, et al. Effects of improved home heating on asthma in community dwelling children: randomised controlled trial. BMJ. 2008;337:a1411. 10.1136/bmj.a1411
44. Howden-Chapman P, Matheson A, Crane J, Viggers H, Cunningham M, Blakely T, et al. Effect of insulating existing houses on health inequality: cluster randomised study in the community. BMJ. 2007;334(7591):460. 10.1136/bmj.39070.573032.80
45. Wang Z, May SM, Charoenlap S, Pyle R, Ott NL, Mohammed K, et al. Effects of secondhand smoke exposure on asthma morbidity and health care utilization in children: a systematic review and meta-analysis. Ann Allergy Asthma Immunol. 2015;115(5):396–401, e392. 10.1016/j.anai.2015.08.005
46. Office on Smoking and Health (US). The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Atlanta (GA): Centers for Disease Control and Prevention (US); 2006. Available from: https://www.ncbi.nlm.nih.gov/books/NBK44324/
47. Hallit, S., Haddad, C., Bou Malhab, S. Rabbaa Khabbaz L, Salameh P. Construction and validation of the water pipe harm perception scale (WHPS-6) among the Lebanese population. Environ Sci Pollut Res 27, 3440–3448 (2020). 10.1007/s11356-019-07247-8
48. Guilbert TW, Morgan WJ, Zeiger RS, Bacharier LB, Boehmer SJ, Krawiec M, et al. Atopic characteristics of children with recurrent wheezing at high risk for the development of childhood asthma. J Allergy Clin Immunol. 2004;114(6):1282–1287. 10.1016/j.jaci.2004.09.020
49. Jackson DJ, Gangnon RE, Evans MD, Roberg KA, Anderson EL, Pappas TE, et al. Wheezing rhinovirus illnesses in early life predict asthma development in high-risk children. Am J Respir Crit Care Med. 2008;178(7):667-672. 10.1164/rccm.200802-309OC
50. Hallit S, Leynaert B, Delmas MC, Rocchi S, De Blic J, Marguet C, et al. Wheezing phenotypes and risk factors in early life: The ELFE cohort. PLoS One. 2018 Apr 27;13(4):e0196711. 10.1371/journal.pone.0196711.
2. Pearce N, Ait-Khaled N, Beasley R, Mallol J, Keil U, Mitchel E et al. Worldwide trends in the prevalence of asthma symptoms: phase III of the International Study of Asthma and Allergies in Childhood (ISAAC). Thorax. 2007;62(9):758–766. 10.1136/thx.2006.070169
3. Strachan DP. Hay fever, hygiene, and household size. BMJ. 1989;299(6710):1259–1260. 10.1136/bmj.299.6710.1259
4. Strachan DP. Family, size, infection and atopy: the first decade of the “hygiene hypothesis”. Thorax. 2000;55 Suppl 1:S2–S10. 10.1136/thorax.55.suppl_1.s2
5. U.S. Food and Drug Administration. What do clean houses have in common with childhood infections? Available from: http://www.fda.gov/BiologicsBloodVaccines/ResourcesforYou/Consumers/ucm167471.htm. 2018. Accessed on August 18, 2019.
6. Ege MJ, Bieli C, Frei R, can Strien RT, Riedler J, Ublagger E, et al. Prenatal farm exposure is related to the expression of receptors of the innate immunity and to atopic sensitization in school-age children. J Allergy Clin Immunol. 2006;117(4):817–823. 10.1016/j.jaci.2005.12.1307
7. Weber J, Illi S, Nowak D, Schierl R, Holst O, von Mutius E, et al. Asthma and the hygiene hypothesis. Does cleanliness matter? Am J Respir Crit Care Med. 2015;191(5):522–529. 10.1164/rccm.201410-1899OC
8. Romano-Keeler J, Weitkamp JH. Maternal influences on fetal microbial colonization and immune development. Pediatr Res. 2015;77(1–2):189–195. 10.1038/pr.2014.163
9. Shanahan F, Quigley EM. Manipulation of the microbiota for treatment of IBS and IBD-challenges and controversies. Gastroenterology. 2014;146(6):1554–1563. 10.1053/j.gastro.2014.01.050
10. Scudellari M. News feature: cleaning up the hygiene hypothesis. Proc Natl Acad Sci USA. 2017;114(7):1433–1436.10.1073/pnas.1700688114
11. Bloomfield SF, Rook GA, Scott EA, Shanahan F, Stanwell-Smith R, Turner P. Time to abandon the hygiene hypothesis: new perspectives on allergic disease, the human microbiome, infectious disease prevention and the role of targeted hygiene. Perspect Public Health. 2016;136(4):213–224. 10.1177/1757913916650225
12. Lapin B, Piorkowski J, Ownby D, Freels S, Chavez N, Hernandez E, et al. Relationship between prenatal antibiotic use and asthma in at-risk children. Ann Allergy Asthma Immunol. 2015;114(3):203–207. 10.1016/j.anai.2014.11.014
13. Metsala J, Lundqvist A, Virta LJ, Kaila M, Gissler M, Virtanen SM. Prenatal and post-natal exposure to antibiotics and risk of asthma in childhood. Clin Exp Allergy. 2015;45(1):137–145. 10.1111/cea.12356
14. Sonnenburg ED, Smits SA, Tikhonov M, Higginbottom SK, Wingreen NS, Sonnenburg JL. Diet-induced extinctions in the gut microbiota compound over generations. Nature. 2016;529(7585):212–215. 10.1038/nature16504
15. Figueiredo CA, Alcantara-Neves NM, Amorim LD, Silva NB, Pontes de Carvalho LC, Cooper P, et al. Evidence for a modulatory effect of IL-10 on both Th1 and Th2 cytokine production: the role of the environment. Clin Immunol. 2011;139(1):57–64. 10.1016/j.clim.2010.12.019
16. Ajdacic-Gross V, Mutsch M, Rodgers S, Tesic A, Muller M, Seifritz E, et al. A step beyond the hygiene hypothesis-immune-mediated classes determined in a population-based study. BMC Med. 2019;17(1):75. 10.1186/s12916-019-1311-z
17. Cooper P. Toxocara canis infection: an important and neglected environmental risk factor for asthma? This editorial discusses the findings of the paper in this issue by E. Pinelli et al. [19], pp. 649–658. Clin Exp Allergy. 2008;38(4):551–553. 10.1111/j.1365-2222.2008.02934.x
18. van Tilburg Bernardes E, Arrieta M-C. Hygiene hypothesis in asthma development: Is hygiene to blame? Arch Med Res. 2017;48(8):717–726. 10.1016/j.arcmed.2017.11.009
19. Benn CS, Melbye M, Wohlfahrt J, Bjorksten B, Aaby P. Cohort study of sibling effect, infectious diseases, and risk of atopic dermatitis during first 18 months of life. BMJ. 2004;328(7450):1223. 10.1136/bmj.38069.512245.FE
20. Jeong JS, Choi JK, Jeong IS, Paek KR, In HK, Park KD. [A nationwide survey on the hand washing behavior and awareness]. J Prev Med Public Health. 2007;40(3):197–204. 10.3961/jpmph.2007.40.3.197
21. Haas JP, Larson EL. Measurement of compliance with hand hygiene. J Hosp Infect. 2007;66(1):6–14. 10.1016/j.jhin.2006.11.013
22. Stevenson RJ, Case TI, Hodgson D, Porzig-Drummond R, Barouei J, Oaten MJ. A scale for measuring hygiene behavior: development, reliability and validity. Am J Infect Control. 2009;37(7):557–564. 10.1016/j.ajic.2009.01.003
23. Sordillo JE, Hoffman EB, Celedon JC, Litonjua AA, Milton DK, Gold DR. Multiple microbial exposures in the home may protect against asthma or allergy in childhood. Clin Exp Allergy. 2010;40(6):902–910.
24. Schaub B, Lauener R, von Mutius E. The many faces of the hygiene hypothesis. J Allergy Clin Immunol. 2006;117(5):969–977; quiz 978. 10.1016/j.jaci.2006.03.003
25. Weinmayr G, Weiland SK, Bjorksten B, Brunekreef B, Buchele G, Cookson W, et al. Atopic sensitization and the international variation of asthma symptom prevalence in children. Am J Respir Crit Care Med. 2007;176(6):565–574. 10.1164/rccm.200607-994OC
26. van Dijk CE, Garcia-Aymerich J, Carsin A-E, Smit LAM, Borlée F, Heederick DJJ, et al. Risk of exacerbations in COPD and asthma patients living in the neighbourhood of livestock farms: observational study using longitudinal data. Int J Hyg Environ Health. 2016;219(3):278–287. 10.1183/13993003.congress-2015.OA2912
27. Kramer M, Matush L, Bogdanovich N, Dahhou M, Platt R, Mazer B. The low prevalence of allergic disease in Eastern Europe: Are risk factors consistent with the hygiene hypothesis? Clin Exp Allergy. 2009;39(5):708–716. 10.1111/j.1365-2222.2009.03205.x
28. Braun-Fahrlander C, Riedler J, Herz U, Eder W, Waser M, Grize L, et al. Environmental exposure to endotoxin and its relation to asthma in school-age children. N Engl J Med. 2002;347(12):869–877. 10.1056/NEJMoa020057
29. Cooper PJ, Vaca M, Rodriguez A, Chico ME, Santos DN, Rodrigues LC, et al. Hygiene, atopy and wheeze-eczema-rhinitis symptoms in schoolchildren from urban and rural Ecuador. Thorax. 2014;69(3):232–239. 10.1136/thoraxjnl-2013-203818
30. Ardura-Garcia C, Garner P, Cooper PJ. Is childhood wheeze and asthma in Latin America associated with poor hygiene and infection? A systematic review. BMJ Open Respir Res. 2018;5(1):e000249. 10.1136/bmjresp-2017-000249
31. Waked M, Salameh P. Asthma, allergic rhinitis and eczema in 5-12-year-old school children across Lebanon. Public Health. 2008;122(9):965–973. 10.1016/j.puhe.2007.10.006
32. Hallit S, Raherison C, Malaeb D, Hallit R, Kheir N, Salameh P. The AAA risk factors scale: a new model to screen for the risk of asthma, allergic rhinitis and atopic dermatitis in children. Med Princ Pract. 2018;27(5):472–480. 10.1159/000490704
33. Hallit S, Raherison C, Malaeb D, Hallit R, Waked M, Kheir N, et al. Development of an asthma risk factors scale (ARFS) for risk assessment asthma screening in children. Pediatr Neonatol. 2019;60(2):156–165. 10.1016/j.pedneo.2018.05.009
34. Hallit S, Raherison C, Waked M, Hallit R, Layoun N, Salameh P. Validation of the mini pediatric asthma quality of life questionnaire and identification of risk factors affecting quality of life among Lebanese children. J Asthma. 2019;56(2):200–210. 10.1080/02770903.2018.1441417
35. Malaeb D, Hallit S, Sacre H, Hallit R, Salameh P. Factors associated with wheezing among Lebanese children: Results of a cross-sectional study. Allergologia et Immunopathologia, 2021, 10.1016/j.aller.2020.02.003
36. Castro-Rodriguez JA, Forno E, Rodriguez-Martinez CE, Celedon JC. Risk and protective factors for childhood asthma: What is the evidence? J Allergy Clin Immunol Pract. 2016;4(6):1111–1122. 10.1016/j.jaip.2016.05.003
37. Malaeb D, Hallit S, Sacre H, Rahme C, Malaeb B, Hallit R, et al. Preconception exposure to over-the-counter medications and antibiotics and the risk of childhood asthma in Lebanon: A cross-sectional study. Allergologia etimmunopathologia. 2020;48:523-9.
38. Carson CG, Halkjaer LB, Jensen SM, Bisgaard H. Alcohol intake in pregnancy increases the child’s risk of atopic dermatitis: the COPSAC prospective birth cohort study of a high risk population. PLoS One. 2012;7(8):e42710. 10.1371/journal.pone.0042710
39. Hallit S, Raherison C, Waked M, Salameh P. Association between caregiver exposure to toxics during pregnancy and childhood-onset asthma: a case-control study. Iran J Allergy Asthma Immunol. 2017;16(6):488–500.
40. Hallit S, Salameh P. Exposure to toxics during pregnancy and childhood and asthma in children: a pilot study. J Epidemiol Glob Health. 2017;7(3):147–154.
41. Thavagnanam S, Fleming J, Bromley A, Shields MD, Cardwell CR. A meta-analysis of the association between Caesarean section and childhood asthma. Clin Exp Allergy. 2008;38(4):629–633. 10.1111/j.1365-2222.2007.02780.x
42. Zock JP, Plana E, Jarvis D, Anto J, Kromhout H, Kennedy S, et al. The use of household cleaning sprays and adult asthma: an international longitudinal study. Am J Respir Crit Care Med. 2007;176(8):735–741. 10.1164/rccm.200612-1793OC
43. Howden-Chapman P, Pierse N, Nicholls S, Gillespie-Bennett J, Viggers H, Cunningham M, et al. Effects of improved home heating on asthma in community dwelling children: randomised controlled trial. BMJ. 2008;337:a1411. 10.1136/bmj.a1411
44. Howden-Chapman P, Matheson A, Crane J, Viggers H, Cunningham M, Blakely T, et al. Effect of insulating existing houses on health inequality: cluster randomised study in the community. BMJ. 2007;334(7591):460. 10.1136/bmj.39070.573032.80
45. Wang Z, May SM, Charoenlap S, Pyle R, Ott NL, Mohammed K, et al. Effects of secondhand smoke exposure on asthma morbidity and health care utilization in children: a systematic review and meta-analysis. Ann Allergy Asthma Immunol. 2015;115(5):396–401, e392. 10.1016/j.anai.2015.08.005
46. Office on Smoking and Health (US). The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Atlanta (GA): Centers for Disease Control and Prevention (US); 2006. Available from: https://www.ncbi.nlm.nih.gov/books/NBK44324/
47. Hallit, S., Haddad, C., Bou Malhab, S. Rabbaa Khabbaz L, Salameh P. Construction and validation of the water pipe harm perception scale (WHPS-6) among the Lebanese population. Environ Sci Pollut Res 27, 3440–3448 (2020). 10.1007/s11356-019-07247-8
48. Guilbert TW, Morgan WJ, Zeiger RS, Bacharier LB, Boehmer SJ, Krawiec M, et al. Atopic characteristics of children with recurrent wheezing at high risk for the development of childhood asthma. J Allergy Clin Immunol. 2004;114(6):1282–1287. 10.1016/j.jaci.2004.09.020
49. Jackson DJ, Gangnon RE, Evans MD, Roberg KA, Anderson EL, Pappas TE, et al. Wheezing rhinovirus illnesses in early life predict asthma development in high-risk children. Am J Respir Crit Care Med. 2008;178(7):667-672. 10.1164/rccm.200802-309OC
50. Hallit S, Leynaert B, Delmas MC, Rocchi S, De Blic J, Marguet C, et al. Wheezing phenotypes and risk factors in early life: The ELFE cohort. PLoS One. 2018 Apr 27;13(4):e0196711. 10.1371/journal.pone.0196711.
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Hallit, S., Sacre, H., Kheir, N., Hobeika, E., Hallit, R., Waked, M., & Salameh, P. (2021). Hygiene hypothesis: association between hygiene and asthma among preschool children in Lebanon. Allergologia Et Immunopathologia, 49(1), 135-145. https://doi.org/10.15586/aei.v49i1.41
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How to Cite
Hallit, S., Sacre, H., Kheir, N., Hobeika, E., Hallit, R., Waked, M., & Salameh, P. (2021). Hygiene hypothesis: association between hygiene and asthma among preschool children in Lebanon. Allergologia Et Immunopathologia, 49(1), 135-145. https://doi.org/10.15586/aei.v49i1.41