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Frequency of Hymenoptera allergy in an atopic and normal population
Frequency of Hymenoptera allergy in an atopic and normal population Guy A. Settipane, M.D.,. Graham J. Newstead, George K. Boyd, M.D. Providence, R. I.
M.D., and
The frequency of bee sting allergy in 3,964 boy scouts who averaged abozlt 18 years of age was fownd to be 0.8 per cent. The frequency of asthma and/or hay fever difwas at least 11 per cent in this particular age grozlp. There was no significant ference in the frequency of Hymenoptera allergy in the normal and atopic segments of this population, and this appears to support the theory that atop& individzcals may have a defect in their mzlcosa.l membranes. It was also ascertained that the term bee sting or insect allergy is poorly understood by the general population.
In separate studies, past investigations L 2 have reported frequencies of Hymenoptera allergy in populations of normal and atopic individuals. Since these populations differ in age structure, habits, social backgrounds, and methodology of study, the results could not be directly compared. One of the purposes of the present report is to study this problem in the same population. The previous epidemiologic study done with boy scouts relied on replies given by parents to a question listed on the camp health cards which was, “Does he have any allergies?” In the present investigation, the question on these cards was changed to ask, “Is he allergic to bee stings or insect stings?” It was felt that the data based on the former health cards was valid because it was assumed that parents of scouts about to spend at least one week camping outdoors would strongly consider listing any possible stinging-insect allergy. However, the revised cards used in the present report eliminated this assumption and directly asked the question dealing with bee sting or insect sting allergy. Another purpose of this study is related to the theory that atopic individuals may have a defect in their mucosal membranes. Since the antigen in Hymenoptera allergy is introduced through the subcutaneous route and circumvents the mucosal membranes, the results of this investigation may serve as an aid in determining the validity of this theory. MATERIALS
AND
METHODS
In the summer of 1969, 3,000 boy scouts, who ranged in age from about 11 to 16 years, camped out for at least one week during the last 6 weeks of an 8 week camping period at a local scout reservation.’ Their parents had completed the history portion of the official health From the Division of Bio-Medical Sciences, Brown University, cine, Rhode Island and Miriam Hospitals. Supported in part by the Louisa Dexter Fund. Received for publication March 16, 1972. Reprint requests to: Guy A. Settipane, M.D., 184 Waterman *Camp Yawgoog, R. I. Vol.
50, No.
3, pp.
146-150
and the Departments
Street,
Providence,
of Medi-
R. I. 02906.
VOLUME 50 NUMBER 3
Frequency
of Hymenoptera
allergy
147
cards, and their physicians had completed the physical examinations. Both the health cards and physical examinations have been reviewed for this study. All affirmative answers were noted to specific questions on these health cards which inquired if there were a history of bee sting or insect sting allergy as well as a history of asthma or hay fever. Parents of these scouts were sent one or more of 3 separate questionnaires detailing the scouts’ allergy history. The questionnaire dealing with bee sting allergy outlined the type of reaction, time interval between sting and symptoms, duration of symptoms, treatment received, name and address of attending physician, and in addition asked again if there were any history of asthma or hay fever. The physician so named was sent a second questionnaire which asked for corroboration of the reactions, physical findings, and treatment. Separate questionnaires dealing with asthma and hay fever were sent to the appropriate parents who in turn detailed a description of symptoms, seasonal occurrence if any, the year of onset, and duration of symptoms, as related to the boy scout. The following criteria established in our past population studiesI! 3 are significant. A diagnosis of asthma was accepted if there was a history of recurrent episodes of wheezing and dyspnea not caused by any known organic condition. A diagnosis of hay fever was aecepted if there was a history of watery, itchy eyes, rhinorrhea, and sneezing occurring during the same seasonal period for at least 2 consecutive years. Hymenoptera allergy was defined as generalized urticaria, angioedema, wheezing, or shock occurring shortly after the Hymenoptera sting. Local reactions no matter how large were not considered in the Hymenoptera allergy category. After we reviewed the answers on the questionnaires returned by the parents as well as those returned by the attending physician, and after we reviewed the results of the physical examination findings that were completed by the family physician at the time the health cards were filled out, the boy scouts were divided into 2 main categories-those with a history of asthma and/or hay fever and those without a history of these 2 diseases. The frequency of Hymenoptera allergy was then determined in each of these 2 categories. Subjects in this study were not skin tested with any allergens including insect extracts.
RESULTS Of the 3,000 health cards reviewed, 479 indicated a history of asthma, hay fever, and/or beesting allergy. Parents of these scouts were sent one or more of 3 separate questionnaires that detailed the scout’s allergy history and symptoms. After repeated attempts to complete these questionnaires by several mailings, and finally by telephone calls, 443 (93 per cent) completed their appropriate questionnaires. We were unable to contact the families of 36 individuals despite our frequent and varied attempts, and this reduced our total population to 2,964 boy scouts, Of those 36 who could not be reached, 10 had reported only bee sting allergy, 5 reported both asthma and hay fever, 13 reported only asthma, and 8 reported only hay fever. From data on the 443 returned questionnaires, findings of the physical examination on the initial health cards, and questionnaires completed by attending physicians, the frequency of asthma, hay fever, and Hymenoptera allergy was determined. These represent minimum figures since those who could not be reached might have increased our frequency of allergy somewhat. In this age group, the frequency of asthma was found to be 4.1 per cent, that of hay fever was 8.0 per cent, and that of bee sting allergy was 0.8 per cent (Table I). The frequency of bee sting allergy in 318 boy scouts with asthma and/or hay fever was 0.9 per cent as compared to 0.8 per cent in 2,639 scouts without asthma or hay fever (Table II). This difference is not statistically significant (p > 0.05).
148
Settipane,
Newstead,
TABLE 1. Frequency
of allergy
and
among
With asthma With hay fever With bee sting allergy *Forty-two
individuals
TABLE II. Frequency
149 253 116
and/or
of Hymenoptera
allergy
No. in population*
No. ascertained to have definite allergy
% Correct diagnosis by parents
% With definite allergy
81.9 94.1 19.8
4.1 8.0 0.8
122” 238* 23
in an atopic
and normal
population
Scouts determined to have Hymenoptera allergy No.
I
%
p Vulue
hay 318
Without fever
boy scouts
had both asthma and hay fever.
Boy scouts
W~e~esthma
2,964
No. that clatmed to have allergy
Boy scouts
J. ALLERGY CLIN. IMMUNOL. SEPTEMBER 1972
Boyd
3
0.9
asthma or hay
20 2,639 *Not including 3 questionable reports of asthma and 4 questionable tN.S. = not significant (p>O.O5).
N.S.1
0.8 reports
of hay fever.
The frequency of atopy (asthma and/or hay fever) in our total population is 318 of 2,964 (11 per cent). The frequency of atopy (asthma and/or hay fever) in the Hymenoptera allergy population is 3 of 23 (13 per cent). Although the latter population is quite small it again tends to demonstrate that our general population and our Hymenoptera allergy population appear to be similar as far as the frequency of atopy is concerned (Table III). DISCUSSION The frequency of Hymenoptera allergy has been found to be the same in an atopic and normal population of boy scouts. One reason why Hymenoptera allergy is not localized in an atopic population may be that the antigen challenge to an individual is by an entirely different route. In pollen allergy it is through the mucosal membranes, while in bee sting allergy it is through the subcutaneous route. Salvaggio, Lowell, and associateP have felt that one of the basic differences between an atopic and normal individual lies in a possible mucosal membrane defect found in the former individuals. This theory was supported by Schwartz and Kahn7 who suggested that atopy is not a prerequisite for the development of other types of anaphylactic hypersensitivity. Other investigationPO have found reagin in secretions surrounding conjunctival and nasal mucosal membranes. Our past investigations in epidemiology of Hymenoptera allergy revealed a frequency of 0.35 per cent in girl scouts11 and 0.40 per cent in boy scouts1 of the same age group, who had similar outdoor habits and lived in the same area. This sex difference was not significant, and identical methods of gathering information were used, Our present figures are much higher, and this is probably due to the revised wording on the health card used in this investigation where the question about beesting or insect allergy was asked much more directly. Chafee2 reviewed 3,705 of his patients with asthma and/or allergic rhinitis
VOLUME 50 NUMBER 3
TABLE III. Frequency
Frequency
of atopy
in a normal
and Hymenoptera
of Hymenoptera
allergy
Those with asthma hay fever No. in population
Total boy scouts Hymenoptera allergy
2,964 23
allergy
149
population
and/or
No.
%
p Value
318 3
11 13
N.S.
N.8. = not significant.
and found that 14 or 0.38 per cent also had true Hymenoptera allergy. However, no direct comparison could be made between Chafee’s patients and our population because of marked difference in the characteristics of these 2 populations as well as the difference in the methodology used to obtain information. We feel that the best type of population in which to investigate the frequency of Hymenoptera allergy is in a population that spends a great deal of time outdoors and, therefore, has a substantial exposure to stinging insects. The frequency of asthma in our scout age group, 4.1 per cent, was somewhat lower than the 5.3 per cent found in the Brown University student investigation previously reported.3 This small difference can be explained by the fact that our boy scout -population averages about 5 years younger than the college population, and since the frequency of asthma increases with age, this small difference in the 2 populations appears rational. Another reason for a lower frequency in scouts than in college students could be that parents may be reluctant to allow children with frequent asthma episodes to camp outdoors for at least one week. Our frequency of hay fever, 8.0 per cent, is much lower than the 21.1 per cent found in tfhe college population. This marked difference between the frequencies of hay fever is probably due to the rapidly increasing risk factor for acquiring hay fever that exists between early and late teenage life. The average age of onset for hay fever in our boy scout population was found to be 8 years. By use of the age onset graph for hay fever developed in the previous epidemiologic study in college students,12 we can predict the frequency of hay fever in a given population with an age onset for hay fever of 8 years old as 8.4 per cent. This figure is similar to our observed frequency of hay fever in scouts, 8.0 per cent, and tends to demonstrate that the atopic characteristics of our boy scout and college populations are similar. An interesting by-product of this study sheds some information on the degree of understanding of allergy diagnosis by the general population, Those parents who have reported that their child has either hay fever or asthma on the initial health card were found to be correct in understanding these diagnoses 94.1 per cent of the time for hay fever and 81.9 per cent of the time for asthma. However, those who initially reported that their child had bee sting allergy were correct only 19.8 per cent of the time. The data show that the term bee sting or insect allergy is poorly understood by the general population. It is not possible for us to determine how many “false negative” answers were given by the parents of scouts who were classified in the nonallergic group. We wish to express our thanks to Ruth Fish, R.N., Ethel Creed, R.N., and Daphne Phillips for their clerical assistance.
150
Settipone, Newstead,
and Boyd
J. ALLERGY CLIN. IMMUNOL. SEPTEMBER 1972
REFERENCES
5 6 7 8 9 10 11 12
Settipane, G. A., and Boyd, G. K.: Prevalence of bee sting allergy in 4,992 boy scouts, Acta Allergol. (Kbh.) 25: 286, 1970. Chafee, F. H.: The prevalence of bee sting allergy in an allergic population, Acta Allergol. (Kbh.) 25: 292, 1970. asthma, allergic rhinitis, and allergy skin Hagy, G. W., and Settipane, G. A.: Bronchial tests among college students, J. ALLERGY 44: 323, 1969. Salvaggio, J. E., Cavanaugh, J. J. A., Lowell, F. C., and Leskowitz, 8.: A comparison of the immunologic responses of normal and atopie individuals to intranasally administered antigen, J. ALLERGY 36: 62, 1964. Salvaggio, J., Kayman, H., and Leskowitz, S.: Immunologic responses of atopic and normal individuals to aerosolized dextran, J. ALLERGY 38: 31, 1966. Schwartz, H. J., Leskowitz, S., and Lowell, F. C.: Studies on ‘~intrinsic” allergic respiratory disease, with a hypothesis concerning its pathogenesis, J. ALLERGY 42: 169, 1968. Schwartz, H. J., and Kahn, B.: Hymenoptera sensitivity. II. The role of atopy in the development of clinical hypersensitivity, J. ALLERGY 45: 87, 1970. Settipane, G. A., Connell, J. T., and Sherman, W. B.: Reagin in tears, J. ALLERGY 36: 92, 1965. Samter, M., and Becker, E. L.: Ragweed reagins in nasal secretion, Proc. Sot. Exp. Biol. Med. 65: 140, 1947. Remington, J. S., Vosti, K. L., Lietze, .A., and Zimmerman, A. L.: Serum proteins and antibody activity in human nasal secretions, J. Clin. Invest. 43: 1613, 1964. Abrishami, M. A., Boyd, G. K., and Settipane, G. A.: Prevalence of bee sting allergy in 2,010 girl scouts, Acta Allergol. (Kbh.) 26: 117, 1971. Hagy, G. W., and Settipane, G. A.: Prognosis of positive allergy skin tests in an asymptomatic population, J. ALLERGY CLIN. IMMUNOL. 48: 200, 1971.
M.D., and
The frequency of bee sting allergy in 3,964 boy scouts who averaged abozlt 18 years of age was fownd to be 0.8 per cent. The frequency of asthma and/or hay fever difwas at least 11 per cent in this particular age grozlp. There was no significant ference in the frequency of Hymenoptera allergy in the normal and atopic segments of this population, and this appears to support the theory that atop& individzcals may have a defect in their mzlcosa.l membranes. It was also ascertained that the term bee sting or insect allergy is poorly understood by the general population.
In separate studies, past investigations L 2 have reported frequencies of Hymenoptera allergy in populations of normal and atopic individuals. Since these populations differ in age structure, habits, social backgrounds, and methodology of study, the results could not be directly compared. One of the purposes of the present report is to study this problem in the same population. The previous epidemiologic study done with boy scouts relied on replies given by parents to a question listed on the camp health cards which was, “Does he have any allergies?” In the present investigation, the question on these cards was changed to ask, “Is he allergic to bee stings or insect stings?” It was felt that the data based on the former health cards was valid because it was assumed that parents of scouts about to spend at least one week camping outdoors would strongly consider listing any possible stinging-insect allergy. However, the revised cards used in the present report eliminated this assumption and directly asked the question dealing with bee sting or insect sting allergy. Another purpose of this study is related to the theory that atopic individuals may have a defect in their mucosal membranes. Since the antigen in Hymenoptera allergy is introduced through the subcutaneous route and circumvents the mucosal membranes, the results of this investigation may serve as an aid in determining the validity of this theory. MATERIALS
AND
METHODS
In the summer of 1969, 3,000 boy scouts, who ranged in age from about 11 to 16 years, camped out for at least one week during the last 6 weeks of an 8 week camping period at a local scout reservation.’ Their parents had completed the history portion of the official health From the Division of Bio-Medical Sciences, Brown University, cine, Rhode Island and Miriam Hospitals. Supported in part by the Louisa Dexter Fund. Received for publication March 16, 1972. Reprint requests to: Guy A. Settipane, M.D., 184 Waterman *Camp Yawgoog, R. I. Vol.
50, No.
3, pp.
146-150
and the Departments
Street,
Providence,
of Medi-
R. I. 02906.
VOLUME 50 NUMBER 3
Frequency
of Hymenoptera
allergy
147
cards, and their physicians had completed the physical examinations. Both the health cards and physical examinations have been reviewed for this study. All affirmative answers were noted to specific questions on these health cards which inquired if there were a history of bee sting or insect sting allergy as well as a history of asthma or hay fever. Parents of these scouts were sent one or more of 3 separate questionnaires detailing the scouts’ allergy history. The questionnaire dealing with bee sting allergy outlined the type of reaction, time interval between sting and symptoms, duration of symptoms, treatment received, name and address of attending physician, and in addition asked again if there were any history of asthma or hay fever. The physician so named was sent a second questionnaire which asked for corroboration of the reactions, physical findings, and treatment. Separate questionnaires dealing with asthma and hay fever were sent to the appropriate parents who in turn detailed a description of symptoms, seasonal occurrence if any, the year of onset, and duration of symptoms, as related to the boy scout. The following criteria established in our past population studiesI! 3 are significant. A diagnosis of asthma was accepted if there was a history of recurrent episodes of wheezing and dyspnea not caused by any known organic condition. A diagnosis of hay fever was aecepted if there was a history of watery, itchy eyes, rhinorrhea, and sneezing occurring during the same seasonal period for at least 2 consecutive years. Hymenoptera allergy was defined as generalized urticaria, angioedema, wheezing, or shock occurring shortly after the Hymenoptera sting. Local reactions no matter how large were not considered in the Hymenoptera allergy category. After we reviewed the answers on the questionnaires returned by the parents as well as those returned by the attending physician, and after we reviewed the results of the physical examination findings that were completed by the family physician at the time the health cards were filled out, the boy scouts were divided into 2 main categories-those with a history of asthma and/or hay fever and those without a history of these 2 diseases. The frequency of Hymenoptera allergy was then determined in each of these 2 categories. Subjects in this study were not skin tested with any allergens including insect extracts.
RESULTS Of the 3,000 health cards reviewed, 479 indicated a history of asthma, hay fever, and/or beesting allergy. Parents of these scouts were sent one or more of 3 separate questionnaires that detailed the scout’s allergy history and symptoms. After repeated attempts to complete these questionnaires by several mailings, and finally by telephone calls, 443 (93 per cent) completed their appropriate questionnaires. We were unable to contact the families of 36 individuals despite our frequent and varied attempts, and this reduced our total population to 2,964 boy scouts, Of those 36 who could not be reached, 10 had reported only bee sting allergy, 5 reported both asthma and hay fever, 13 reported only asthma, and 8 reported only hay fever. From data on the 443 returned questionnaires, findings of the physical examination on the initial health cards, and questionnaires completed by attending physicians, the frequency of asthma, hay fever, and Hymenoptera allergy was determined. These represent minimum figures since those who could not be reached might have increased our frequency of allergy somewhat. In this age group, the frequency of asthma was found to be 4.1 per cent, that of hay fever was 8.0 per cent, and that of bee sting allergy was 0.8 per cent (Table I). The frequency of bee sting allergy in 318 boy scouts with asthma and/or hay fever was 0.9 per cent as compared to 0.8 per cent in 2,639 scouts without asthma or hay fever (Table II). This difference is not statistically significant (p > 0.05).
148
Settipane,
Newstead,
TABLE 1. Frequency
of allergy
and
among
With asthma With hay fever With bee sting allergy *Forty-two
individuals
TABLE II. Frequency
149 253 116
and/or
of Hymenoptera
allergy
No. in population*
No. ascertained to have definite allergy
% Correct diagnosis by parents
% With definite allergy
81.9 94.1 19.8
4.1 8.0 0.8
122” 238* 23
in an atopic
and normal
population
Scouts determined to have Hymenoptera allergy No.
I
%
p Vulue
hay 318
Without fever
boy scouts
had both asthma and hay fever.
Boy scouts
W~e~esthma
2,964
No. that clatmed to have allergy
Boy scouts
J. ALLERGY CLIN. IMMUNOL. SEPTEMBER 1972
Boyd
3
0.9
asthma or hay
20 2,639 *Not including 3 questionable reports of asthma and 4 questionable tN.S. = not significant (p>O.O5).
N.S.1
0.8 reports
of hay fever.
The frequency of atopy (asthma and/or hay fever) in our total population is 318 of 2,964 (11 per cent). The frequency of atopy (asthma and/or hay fever) in the Hymenoptera allergy population is 3 of 23 (13 per cent). Although the latter population is quite small it again tends to demonstrate that our general population and our Hymenoptera allergy population appear to be similar as far as the frequency of atopy is concerned (Table III). DISCUSSION The frequency of Hymenoptera allergy has been found to be the same in an atopic and normal population of boy scouts. One reason why Hymenoptera allergy is not localized in an atopic population may be that the antigen challenge to an individual is by an entirely different route. In pollen allergy it is through the mucosal membranes, while in bee sting allergy it is through the subcutaneous route. Salvaggio, Lowell, and associateP have felt that one of the basic differences between an atopic and normal individual lies in a possible mucosal membrane defect found in the former individuals. This theory was supported by Schwartz and Kahn7 who suggested that atopy is not a prerequisite for the development of other types of anaphylactic hypersensitivity. Other investigationPO have found reagin in secretions surrounding conjunctival and nasal mucosal membranes. Our past investigations in epidemiology of Hymenoptera allergy revealed a frequency of 0.35 per cent in girl scouts11 and 0.40 per cent in boy scouts1 of the same age group, who had similar outdoor habits and lived in the same area. This sex difference was not significant, and identical methods of gathering information were used, Our present figures are much higher, and this is probably due to the revised wording on the health card used in this investigation where the question about beesting or insect allergy was asked much more directly. Chafee2 reviewed 3,705 of his patients with asthma and/or allergic rhinitis
VOLUME 50 NUMBER 3
TABLE III. Frequency
Frequency
of atopy
in a normal
and Hymenoptera
of Hymenoptera
allergy
Those with asthma hay fever No. in population
Total boy scouts Hymenoptera allergy
2,964 23
allergy
149
population
and/or
No.
%
p Value
318 3
11 13
N.S.
N.8. = not significant.
and found that 14 or 0.38 per cent also had true Hymenoptera allergy. However, no direct comparison could be made between Chafee’s patients and our population because of marked difference in the characteristics of these 2 populations as well as the difference in the methodology used to obtain information. We feel that the best type of population in which to investigate the frequency of Hymenoptera allergy is in a population that spends a great deal of time outdoors and, therefore, has a substantial exposure to stinging insects. The frequency of asthma in our scout age group, 4.1 per cent, was somewhat lower than the 5.3 per cent found in the Brown University student investigation previously reported.3 This small difference can be explained by the fact that our boy scout -population averages about 5 years younger than the college population, and since the frequency of asthma increases with age, this small difference in the 2 populations appears rational. Another reason for a lower frequency in scouts than in college students could be that parents may be reluctant to allow children with frequent asthma episodes to camp outdoors for at least one week. Our frequency of hay fever, 8.0 per cent, is much lower than the 21.1 per cent found in tfhe college population. This marked difference between the frequencies of hay fever is probably due to the rapidly increasing risk factor for acquiring hay fever that exists between early and late teenage life. The average age of onset for hay fever in our boy scout population was found to be 8 years. By use of the age onset graph for hay fever developed in the previous epidemiologic study in college students,12 we can predict the frequency of hay fever in a given population with an age onset for hay fever of 8 years old as 8.4 per cent. This figure is similar to our observed frequency of hay fever in scouts, 8.0 per cent, and tends to demonstrate that the atopic characteristics of our boy scout and college populations are similar. An interesting by-product of this study sheds some information on the degree of understanding of allergy diagnosis by the general population, Those parents who have reported that their child has either hay fever or asthma on the initial health card were found to be correct in understanding these diagnoses 94.1 per cent of the time for hay fever and 81.9 per cent of the time for asthma. However, those who initially reported that their child had bee sting allergy were correct only 19.8 per cent of the time. The data show that the term bee sting or insect allergy is poorly understood by the general population. It is not possible for us to determine how many “false negative” answers were given by the parents of scouts who were classified in the nonallergic group. We wish to express our thanks to Ruth Fish, R.N., Ethel Creed, R.N., and Daphne Phillips for their clerical assistance.
150
Settipone, Newstead,
and Boyd
J. ALLERGY CLIN. IMMUNOL. SEPTEMBER 1972
REFERENCES
5 6 7 8 9 10 11 12
Settipane, G. A., and Boyd, G. K.: Prevalence of bee sting allergy in 4,992 boy scouts, Acta Allergol. (Kbh.) 25: 286, 1970. Chafee, F. H.: The prevalence of bee sting allergy in an allergic population, Acta Allergol. (Kbh.) 25: 292, 1970. asthma, allergic rhinitis, and allergy skin Hagy, G. W., and Settipane, G. A.: Bronchial tests among college students, J. ALLERGY 44: 323, 1969. Salvaggio, J. E., Cavanaugh, J. J. A., Lowell, F. C., and Leskowitz, 8.: A comparison of the immunologic responses of normal and atopie individuals to intranasally administered antigen, J. ALLERGY 36: 62, 1964. Salvaggio, J., Kayman, H., and Leskowitz, S.: Immunologic responses of atopic and normal individuals to aerosolized dextran, J. ALLERGY 38: 31, 1966. Schwartz, H. J., Leskowitz, S., and Lowell, F. C.: Studies on ‘~intrinsic” allergic respiratory disease, with a hypothesis concerning its pathogenesis, J. ALLERGY 42: 169, 1968. Schwartz, H. J., and Kahn, B.: Hymenoptera sensitivity. II. The role of atopy in the development of clinical hypersensitivity, J. ALLERGY 45: 87, 1970. Settipane, G. A., Connell, J. T., and Sherman, W. B.: Reagin in tears, J. ALLERGY 36: 92, 1965. Samter, M., and Becker, E. L.: Ragweed reagins in nasal secretion, Proc. Sot. Exp. Biol. Med. 65: 140, 1947. Remington, J. S., Vosti, K. L., Lietze, .A., and Zimmerman, A. L.: Serum proteins and antibody activity in human nasal secretions, J. Clin. Invest. 43: 1613, 1964. Abrishami, M. A., Boyd, G. K., and Settipane, G. A.: Prevalence of bee sting allergy in 2,010 girl scouts, Acta Allergol. (Kbh.) 26: 117, 1971. Hagy, G. W., and Settipane, G. A.: Prognosis of positive allergy skin tests in an asymptomatic population, J. ALLERGY CLIN. IMMUNOL. 48: 200, 1971.