The Prevalence, Clinical Picture, and Triggers of Allergic Rhinitis in Saudi Population: A Systematic Review and Meta-Analysis

Figures & data

Figure 1 PRISMA flow diagram.

Table 1 Summary of the Included Studies

Name	Study Design	City/Area	Study Duration	Study Tool	Total Sample	Prevalence of AR %	Age	Gender (Female n,%)	Inclusion Criteria	Main Finding
Alruwaili 2021^Citation22	Cross-sectional study	Arar city	12 months	Self-administered questionnaire (Arabic)	304	7.80%	From 15 years to 18 years	100%	All female secondary schoolsschools’ students, aged between 15–18 years in Arar city	The reported prevalence of allergic rhinitis was 7.8% which was lower than most reported figures. Prevalence of allergic rhinitis can be reduced by effective preventive interventions such as raising awareness of the incidence of allergic disease and its risk factors and treatment options.
Almatroudi 2021^Citation20	Cross-sectional study	Qassim region	4 months	A self-administered questionnaire was developed based on three questionnaires for screening of respiratory allergies, namely the Asthma Control Questionnaire to measure asthma control in adults, the International Study of Asthma and Allergies in Childhood and the European Community Respiratory Health Survey asthma questionnaire	850	13.50%	From 18 years to 45 years and above 45 years	406 (47.8%)	Any adult individual (aged ≥ 18 years), who was literate to respond to an online questionnaire in English or Arabic and was living in the Qassim region	Prevalence The prevalence of respiratory allergies is varies from region to region in the KSA according to different studies. Gender and family history of respiratory allergy were found to have an association with the prevalence of respiratory allergies.
Alanazy 2021^Citation21	Cross-sectional study	Qassim region	12 months	Interview questionnaire	455	100%	From 20 years to 60 years and above 60 years	169 (37.1%)	Outpatients from the ENT clinic of King Saud Hospital in Unaizah city, Qassim region	Family history of AR and living in urban areas increase the risk of AR. Dust consider the most common trigger for AR, and oral histamine an intranasal steroids were the most frequent treatment used by AR patients. In clinical examination, inferior turbinate hypertrophy with pale bluish discoloration was the most common finding, and mild non-specific nasal symptoms are the most common presenting symptoms in AR patients.
Alqahtani 2020^Citation8	Cross-sectional study	Najran University, in southwestern Saudi Arabia	5 months	Interview questionnaire according to the ISASAC questionnaire	222	5%	21.5 ± 1.5 years	106 (47.747%)	Students in the health colleges of Najran University, in southwestern Saudi Arabia, during the period from January to May 2018.	Atopy and allergy disorders are common in Saudi young Saudi people, which is concerning. Comorbid allergic disorders were more common in their atopic disease group. The identification of allergen sensitization patterns in atopic illness patients is critical for developing effective preventative prevention and treatment methods.
Al-Ghamdi 2020^Citation5	Cross-sectional study	Aseer region	NR	Arabic version of the validated ISAAC questionnaire	960	30.20%	Mean= 39.43 ± 14.63 years and a median of 36 years	255 (26.6%)	Adult Adults aged 20 years or older who attended any of the selected primary health care centers for any reason.	In the Aseer area, the prevalence of AR was shown to be higher in this study. During the management of AR, health policymakers, doctors, and healthcare professionals should examine the spread of the disorder and its related factors.
Mahnashi 2019^Citation23	Cross-sectional study	Jazan	3 months	Arabic version of the validated ISAAC questionnaire	1400	27.10%	Mean = 12.8 ± 1.456 years and a median of 13 years.	560 (40%)	Students in both level elementary and intermediate schools all over Jazan Region	Prevalence and severity of AR are significantly affected by living in urban or lowland areas and intermediate school education level.
Almehizia 2019^Citation25	Cross-sectional study	NR	6 months and 21 days	Self-report electronic survey	3458	82.40%	Mean= 29±10 years	1691 (59.4%)	Any adults who had at least one of the four signs of AR, ie, a watery runny nose, sneezing (violent/in bouts), nasal obstruction (inability to breath), itchy nose; watery/red itchy eyes, during the past year and not related to an episode of cold/flu	Dust is considered the most common trigger for AR. Other common triggers included pollen, mold, and fur. In Saudi Arabia, more than half of the AR patients had moderate to severe symptoms and an intermittent pattern of the disease pattern. Male gender, older age group, smoking, and chronic AR were all linked to pollen pollen-inducing AR. Mold-induced AR was linked to persistent forms of the illness, whereas AR produced by fur was linked to smoking. The female gender, younger age, smoking, and mild forms of the illness were all linked to AR caused by dust. Patients with AR are recommended to lose weight since they are more prone to develop the chronic forms of the illness if they are overweight.
Albaloushi 2019^Citation24	Cross-sectional study	Al-Ahssa	1 month	Self-report electronic survey	807	48%	From all age groups (under 15 years to above 55 years)	631 (78.2%)	Males and females from all age groups from Al-Ahssa, Saudi Arabia	Symptoms of AR are associated with living near farms and are usually triggered by dust. To improve the quality of life in AR cases, we need early recognition and diagnosis of the disease.
Alotaibi 2018^Citation26	Cross-sectional study	The University of Hail, Northern Saudi Arabia	NR	Self-report survey	1578	74%	NR (university students)	482 (30.5%)	Students in Hail University, Northern Saudi Arabia	AR is common among Hail University students, with a slightly larger male-to-female ratio. For better future control, more study is needed to identify the most common environmental and occupational allergens.
Alqahtani 2016^Citation27	Cross-sectional study	Najran Region, Southwestern Saudi Arabia	4 months	Modified ISAAC Phase III questionnaire	1700	6.30%	Mean= 12.2 ± 3.3	849 (49.9%)	Saudi school children in Najran Region, Southwestern Saudi Arabia	Asthma and other allergy illnesses are very common, which is concerning. The outcomes of this study highlight the need for multidisciplinary teams (pediatricians, immunologisimmunologistst, health educators, psychologists, social workers, rhinologistrhinologists, and dermatologists) to collaborate to regulate and reduce the burden of allergic disorders. To decrease morbidity and mortality due to under- or over-diagnosis, this program should involve the creation of school-based asthma clinics with facilities for proper diagnosis ofly diagnosing asthma in children. To raise knowledge of children allergy disorders, developing a comprehensive school-based asthma education program for allergic students, their parents, and school personnel should be explored. Developing a comprehensive school-based asthma education program for allergic students, parents, and school personnel should be explored to raise knowledge of children’s allergy disorders. Meanwhile, determining allergen sensitization patterns in allergic patients will aid pediatricians in educating patients about environmental modification, as well as healthcare policy and decision-makers in selecting appropriate treatment strategies for asthma and other allergies, including allergen-specific immunotherapy when appropriate.
Al-Ghobain 2012^Citation28	Cross-sectional study	Riyadh, Saudi Arabia	NR	ISAAC questionnaire	3073	21.30%	From 16 years to 18 years	1569 (51.1%)	Secondary school students (16 to 18 years old) in Riyadh, Saudi Arabia	The most common age group associated with rhinitis in Saudi Arabia is 16 to 18 years old, and more common in females. A high frequency of asthma symptoms is linked to rhinitis symptoms.
Nahhas 2012^Citation29	Cross-sectional study	Madinah	1 month	Arabic version of the validated ISAAC questionnaire	5188	4.20%	From 6 years to 9 years	1603 (30.9%)	Primary school students aged 6–8 years in Madinah	Over 40% of children in primary school-aged children in Madinah, Saudi Arabia, show symptoms suggestive of allergic disease prevalence within the first eight years of life, ranking among the highest in the world. More investigation is necessary to estimate the incidence of allergy issues in various locations of Saudi Arabia, among other age groups, and to track illness changes. Given these alarming figures, the Saudi government must carefully consider developing health and educational policies that ensure efficient treatment of these children while limiting the effects of these conditions on educational performance; there is also a need to better understand what is driving this epidemic in Saudi children and prioritise prioritize the search for effective primary prevention strategies.
Abdul Rahman 2017^Citation30	Cross-sectional study	Egypt, Iran, Lebanon, Saudi Arabia, and the United Arab Emirates	3 months	Self-report survey	501 (Saudi =100)	3.00%	From 7 years to 88 years (18–88 years of age; mean, 35.0 ± 11.6 years) (4–17 years of age; mean, 10.7 4.0 years).	277 (55.3%)	Adults, children, and adolescents ≥4 years old with a physician diagnosis of AR who were currently experiencing or being treated for AR	The prevalence of AR in Saudi Arabia was 3%, which was lower than in Egypt, Iran, Lebanon, and the United Arab of Emirates.
Sabry 2011^Citation19	Cross-sectional study	Taif City	11 months	Sabry’s Arabic Questionnaire for Allergy Diagnosis-143 (SAQAD-143)	854	52.81%	From 3 years to 65 years	543 (63.58%)	Saudi students, employees, and staff members in at Taif University	The questionnaire proved its capability in aiding the diagnosis of various allergic morbidities. It evidenced a high prevalence of allergic diseases in Taif city. This is an important health issue which that requires the strategic application of primary health care facilities to achieve adequate control.
Harfi 2010^Citation16	Cross-sectional study	Riyadh, Saudi Arabia	1 month	ISAAC Phase I questionnaire	1100	12.70%	From 6 years to 14 years	285 (25.9%)	School-age children aged 6–14 years in Riyadh, Saudi Arabia	Allergy rhinitis is the most frequent allergic condition in children, followed by bronchial asthma and eczema, showing a significant decline in prevalence rates when compared to previous studies in this region. Food and medication allergies were the least prevalent and non-significant in children. Periodic investigations in different parts of the country would be useful in obtaining a more accurate picture of the prevalence of allergy diseases in Saudi children.
Sobki 2004^Citation15	Cross-sectional study	From the four main provinces of the kingdom of Saudi Arabia (Central, East, Southern, and West)	NR	(WHO / PDHI) World Health Organization (1992) questionnaire for HI surveys and ISAAC Phase I questionnaire	9540	26.51%	From 4 years to 15 years	5351 (56%)	Children in the Kingdom of Saudi Arabia, the who were association associated with hearing impairment (HI) and bronchial asthma.	The frequency of allergic rhinitis in children is rising in Saudi Arabia, as it is in other parts of the world. Saudi Arabia is divided into several geographic regions, and the prevalence of allergic rhinitis varies by province; living in urban and the use of areas, and using carpets, air conditioning, and domestic pets are new variables in this country. The frequency of allergic rhinitis was shown to be greater in the offspring of consanguineous parents and those with a positive family history of allergy. This might point to inherited genetic risk factors. Within the rhinitis population, there is a significant frequency of HI.

Figure 2 Overall prevalence of AR; shows the forest plot of the random effect estimated prevalence of AR.

Figure 3 Sensitivity analysis of overall prevalence of AR; shows the sensitivity analysis of overall prevalence of AR.

Figure 4 Funnel plot; shows the funnel plot of the overall prevalence of AR.

Figure 5 Prevalence of AR in females vs males; shows the forest plot of random-effect estimated odds ratio of the difference between males and females in terms of the prevalence of AR.

Table 2 Subgroup Analysis Based on the Demographic and Study Characteristics

Prevalence of AR		Prevalence % (95% CI)	I^2; P-value	Number of Studies
Gender	Male	31.7 (24.1–40.4)	99.17%; <0.001	13
	Female	27.1 (18.8–37.3)	99.37%; <0.001
Age group	Child	12.7 (7.50–20.7)	99.75%; <0.001	7
	Adults	31.1 (11.6–60.9)	99.47%; <0.001	5
	Both	36.5 (24.8–50.1)	95.79%; <0.001	3
Area	Central	29.2 (6.20–72.0)	99.89%; <0.001	4
	Western	18.1 (0.90–84.2)	99.91%; <0.001	2
	Northern	23.0 (2.50–77.6)	99.23%; <0.001	2
	Southern	13.7 (6.20–27.7)	98.98%; <0.001	4
	Eastern	48.0 (44.5–51.4)	-	1
Residency	Rural	13.0 (9.20–17.9)	90.77%; <0.001	3
	Urban	38.4 (7.20–83.4)	99.65%; <0.001
Smoking	Yes	7.00 (4.70–10.2)	92.20%; <0.001	5
	No	41.4 (18.7–68.5)	99.59%; <0.001
Family history of allergy in all of the family members	Yes	40 (20.2–63.7)	98.84%; <0.001	3
Allergy relation to a certain period of the year	Summer	17.3 (10.2–27.8)	96.97%; <0.001	4
	Spring	6.00 (1.60–20.6)	98.27%; <0.001
	Winter	17.6 (9.10–31.1)	98.09%; <0.001
	Autumn	5.20 (1.50–16.5)	98.01%; <0.001
QA	Good	20.7 (8.30–43.1)	99.83%; <0.001	9
	Fair	22.3 (13.3–34.8)	99.28%; <0.001	6
Sample size	≤500	7.20 (5.20–9.80)	15.06%; 0.308	3
	501–1500	28.3 (17.5–42.5)	99.10%;<0.001	6
	1501–2500	20.9 (1.80–79.4)	99.83%;<0.001	2
	>2500	27.3 (7.80–62.5)	99.92%;<0.001	4
Assessment tool	Validated	16.2% (10.5–24.2%)	99.44%; p<0.001	10
	Self-developed	35.1% (16.5–59.7%)	99.57%; p<0.001	5

Table 3 Associated Conditions, Including Asthma, Atopic Dermatitis, and Eczema

Associated Conditions	Prevalence (95% CI)	I^2; P-value	Number of Studies
Prevalence of associated- asthma	16.8 (11.8–23.4)	99.15%; <0.001	13
● Studies less than 500	21.6 (12.5–34.7)	94.12%; <0.001	4
● Studies of more than 500	15.1 (9.90–22.5)	99.36%; <0.001	9
● Children and adolescents	11.5 (6.90–18.4)	99.27%; <0.001	6
● Adults	17.4 (9.50–29.8)	98.11%; <0.001	4
● Both (adults and children)	32.2 (21.6–45.0)	95.59%; <0.001	3
Prevalence of associated- AD	13.6 (4.40–34.8)	99.20%; <0.001	4
● Studies less than 500	6.50 (1.40–24.8)	93.93%; <0.001	2
● Studies of more than 500	25.7 (5.80–66.0)	99.67%; <0.001	2
● Children and adolescents	6.40 (1.50–23.7)	94.98%; <0.001	2
● Adults	13.1 (9.20–18.2)	–	1
● Both (adults and children)	45.4 (42.1–48.8)	–	1
Prevalence of associated- eczema	8.50 (4.10–16.8)	99.32%; <0.001	6
● Studies less than 500	10.3 (7.80–13.5)	–	1
● Studies of more than 500	8.20 (3.60–17.6)	99.46%; <0.001	5
● Children and adolescents	6.40 (2.10–18.1)	99.61%; <0.001	3
● Adults	10.3 (7.80–13.5)	–	1
● Both (adults and children)	11.5 (2.10–44.1)	99.06%; <0.001	2

Table 4 Signs and Symptoms of AR

Signs and Symptoms of AR	Prevalence (95% CI)	I^2; P-value	Number of Studies
Sneezing	24.6 (14.5–38.6)	99.18%; <0.001	7
Runny nose	22.2 (4.40–63.8)	99.36%; <0.001	4
Nasal obstruction or congestion	22.0 (3.20–70.7)	99.54%; <0.001	4
Itchy nose	24.2 (5.40–64.3)	98.55%; <0.001	3
Loss of smell	21.9 (6.80–52.0)	94.53%; <0.001	2
Headache	33.9 (14.2–61.4)	94.97%; <0.001	2
Itchy, reddnes redness or watery eyes	8.60 (5.50–13.1)	71.89%; 0.029	3
Watery discharge	28.6 (5.70–72.7)	97.39%; <0.001	2
Cough	13.8 (6.10–28.5)	96.32%; <0.001	3
Wheeze	17.2 (9.20–29.8)	95.75%; <0.001	3

Table 5 Allergy Triggers

Allergy Triggers	Prevalence % (95% CI)	I^2; P-value	Number of Studies
Air pollution	14.5 (9.10–22.4)	95.51%; <0.001	4
Specific food	4.70 (2.40–9.00)	94.23%; <0.001	6
Dust	27.3 (11.7–51.5)	99.40%; <0.001	7
Animals like dogs and cats	8.50 (3.40–19.9)	99.29%; <0.001	9
Insects	10.2 (4.40–22.2)	94.71%; <0.001	3
Weather or temperature changes	17.8 (6.80–39.3)	93.18%; <0.001	3
Tobacco	10.8 (1.60–48.0)	98.85%; <0.001	3
Respiratory infections	6.80 (3.40–13.2)	58.34%; 0.121	2
Atopy	10.3 (0.30–79.2)	99.35%; <0.001	2
Perfume	36.8 (14.8–66.1)	98.84%; <0.001	3
Air conditioning	23.4 (10.0–45.7)	91.75%; <0.001	2
Grass or plant	9.20 (0.30–74.7)	99.55%; <0.001	2
Pollen	4.80 (0.50–34.1)	98.46%; <0.001	2
Drugs or chemicals	13.8 (7.30–24.4)	89.51%; <0.001	3

Table 6 Effect of AR on Life

Effect of AR on Life	Prevalence % (95% CI)	I^2; P-value	Number of Studies
Stuffy nose (overall)	7.00 (5.90–8.40)	0.00%; 0.694	2
Stuffy noses affect daily activities	7.70 (6.50–9.10)	0.00%; 0.745	2
Difficulty The difficulty of breath due to a stuffy nose	8.80 (4.30–17.1)	89.18%; 0.002	2
Stuffy A stuffy nose caused causes sleep problems	5.80 (3.70–9.10)	73.62%; 0.052	2
Nasal obstructions led to the emergency department	7.90 (1.20–37.8)	97.02%; <0.001	2
Hospital admission due to AR	1.50 (0.10–16.90)	85.75%; 0.008	2
Allergic rhinitis caused causes school absenteeism	6.50 (5.40–7.80)	0.00%; 0.837	2
Allergic rhinitis affects the daily activities (overall)	10.6 (3.10–30.6)	96.42%; <0.001	2

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