Journal Citation
Joneja JMV and Monteiro LN. Review of Ten Years of Dietetic Management of Adverse Reactions to Foods: The Allergy Nutrition Program at Vancouver Hospital and Health Sciences Centre 1991-2001
Review of Ten Years of Dietetic Management of Adverse Reactions to Foods:
Allergy Nutrition Research Program
Vancouver Hospital and Health Sciences Centre
*Janice M. Vickerstaff Joneja, Ph.D., RDN
Lisa N. Monteiro, B.Sc., RDN
Allergy Nutrition Research Program,
Vancouver Hospital and Health Sciences Centre,
B.C. Canada
*Author for correspondence at:
2016 High Canada Place,
Kamloops,
British Columbia V2E 2E3
Canada
Abstract
The Allergy Nutrition Research Program, designed to address the needs of individuals and families at risk as a result of adverse reactions to foods, was inaugurated in the Vancouver Hospital and Health Sciences Centre in 1991. The program comprises an outpatient clinic; education for students, dietitians and other health care professionals in the Clinic as well as university courses, workshops, lectures and seminars at locations throughout Canada and abroad; and clinical research in dietary management of adverse reactions to foods.
In the first ten years, a total 6,063 attendances in the Allergy Nutrition Clinic were recorded – 3,067 for initial consultation, 2,996 for follow-up visits. The number of follow-up consultations indicates the need for continued supervision and management advice.
Symptoms presented fell into ten main categories: Gastrointestinal tract; urticaria/angioedema; rhinitis and asthma; eczema and contact dermatitis; infant atopy prevention; hyperactivity and other behaviour problems; anaphylaxis; migraine headaches; oral allergy syndrome and latex allergy; and a category designated multiple somatic complaints.
Clients are optimally assisted when research, education and counselling are focussed on specific mechanisms of reactions (immunological and biochemical), nutritional needs (age and disease-related), and life-style adjustments, within a clear framework of response (symptoms) in the management of adverse reactions to foods.
Introduction
Articles on food allergy have increased remarkably in the past ten years, both in the scientific and medical literature and in the popular press. As a consequence, people are becoming increasingly concerned about the negative impact of their diets. Although the real incidence of adverse reactions to food and food additives is unknown, since each assessment depends on different criteria for determining food allergy and intolerance [1,2], the number of people believing that “food allergy” is the cause of many of their symptoms is as high as 50 percent of the population. The perception that food is making a person ill inevitably leads to avoidance of the incriminated food, and many people are restricting their diets as a result. Elimination of essential food groups can lead to malnutrition, which can be a significant problem, especially during the times when complete nutrition is so critical, such as infancy, childhood, pregnancy, illness, and aging.
Whenever diets are restricted, it is essential to ensure that the foods that are being avoided are the ones that are actually responsible for the symptoms. Accurate identification of the culprit foods is critical in correct management of food sensitivities. In addition, it is crucial that alternative sources of nutrients that would normally be supplied by the restricted foods are provided from alternative sources, to avoid any risk of nutritional deficiency.
Food Allergy and Food Intolerance
Adverse reactions to foods can be broadly defined as either allergy, which is a response of the immune system, or food intolerance, which is loosely described as a non-immunologically-mediated reaction. In traditional Western medicine, the term allergy, or atopy, is restricted to an immune reaction of immediate onset, mediated by IgE antibodies specific to the causative antigen (allergen), termed Type I hypersensitivity. The most severe allergic response to food is an anaphylactic reaction, which involves many organ systems simultaneously and in extreme cases can result in death.
Food allergy is most prevalent in young children whose immature immune and digestive systems predispose them to mounting an immune response to the foreign proteins in foods [3,4]. After adolescence, food allergy is much less common, and many of the adverse reactions to foods described by adults appear to be due to either a non-IgE-mediated immune response, or non-immunological food intolerance. The medical specialty of allergy focuses on the Type I hypersensitivity reactions.
A variety of skin tests and blood tests which depend on the presence of allergen-specific IgE, such as RAST and CAP-RAST are used in the diagnosis of IgE-mediated food allergy. Unfortunately, none of the tests available carry a high degree of accuracy when relied on exclusively to identify the specific food allergens responsible for a person’s symptoms [5]. Patients often discover that foods that they have eaten with impunity in the past are now considered allergenic, and sometimes foods that they are convinced trigger an adverse reaction, based on experience, are considered “safe” as a result of allergy tests. Any test for the identification of allergenic foods requires confirmation that the symptoms resolve when the food is withdrawn, and elicit symptoms when it is consumed [6,7]. Even more perplexing in the diagnosis of adverse reactions to foods is the fact that there are very few scientifically valid tests for non-IgE-mediated reactions. Consequently, people experiencing symptoms that they suspect result from the ingestion of a food or food additive that cannot be confirmed by skin or blood tests are left in doubt as to the origin, and sometimes validity of their reactions. As a result people suffering from adverse reactions to foods are frequently faced with a number of significant problems in managing their diet, which can not only compromise their nutritional status, but also negatively impact many aspects of their life. Psychosocial problems, family disruption, economic distress, and eating disorders, are but a few of the negative outcomes recorded [1].
The Allergy Nutrition Program
In 1991 a service for providing accurate, scientifically-based information on the management of diet and life-style for individuals and families at nutritional risk as a result of food sensitivities was developed by means of a hospital/community joint initiative program instituted by the B.C. Ministry of Health. The Allergy Nutrition Program was inaugurated in September 1991 at Vancouver Hospital and Health Sciences Centre. Funding was provided initially for one year. On evaluation, after the first year, the Allergy Nutrition Program was approved for continuing support, and thereafter became a permanent outpatient service provided by Vancouver Hospital.
The following provides a summary of the activities and achievements of the Program during the ten years of its existence, which we hope will inspire other dietitians to consider similar projects in their communities for persons unnecessarily suffering the effects of adverse reactions to food.
Purpose and Mandate of the Allergy Nutrition Program
The mandate of the Allergy Nutrition Program is to provide assistance to persons and their families suffering the effects of adverse reactions to foods. This is made available at several levels:
Personnel
From 1991 to 1994 the Allergy Nutrition Program employed one full time dietitian and a part time (.5 FTE (full time equivalent)) receptionist. Because of increasing demand, in 1994 the receptionist position was expanded to full time. In 1996, again as a result of increased demand, a second dietitian joined the Program on a part-time basis (.6 FTE)
The Allergy Nutrition Clinic (ANC)
The process of management of adverse reactions to foods tends to vary according to the requirements of the client. We have found that babies, children and adults have quite different needs as a result of the processes, both immunological and developmental, that underlie the causes of their food sensitivities.
Selection of Clients
The Appointment
Prior to attending the clinic, the client is required to complete three forms, which are mailed to them as soon as the appointment is made:
Initial Interview
Each client new to the clinic is allotted a one hour initial appointment.
At this appointment an appropriate diet is formulated based on:
The Initial Diet
Based on these parameters, a therapeutic diet is formulated, which the client usually follows for an initial period of four weeks.
If multiple factors exist, which does not allow the use of a therapeutic diet, and especially when allergy testing has indicated positive reactions to many different foods, a few foods elimination diet is prescribed [8,12], which is followed for an initial 10-14 days.
Follow-up Visits
After following the prescribed diet for four weeks, clients return for evaluation of the outcome.
If significant improvement in their symptoms has been achieved, clients proceed to the reintroduction phase of the program. Verbal and written instructions are provided for reintroducing each individual component of the restricted foods that are likely to be responsible for an adverse reaction. The method of reintroduction, called sequential incremental dose challenge (SIDC), provides for monitoring of increasing doses of the food over a two-day period. This allows detection of immediate reactions (within 4 hours of ingestion) and delayed reactions (up to 48 hours after consumption). Details of SIDC for most foods can be found in References 8,12 and 13.
Clients return to the Clinic for evaluation of the results of their SIDC, typically 6 to 8 weeks after commencing the SIDC. Following completion of the SIDC, a maintenance diet is formulated, which eliminates all the foods causing any adverse response, and supplies complete balanced nutrition from alternative sources. Once the process is completed, the client may return for re-evaluation of their diet, at any time they deem necessary. Ideally every client would attend the ANC for a minimum of three appointments; an initial visit and two follow-up visits.
The stages of management outlined above also apply to the paediatric population. In the ANC the paediatric population includes children from 0-14 years. The paediatric dietitian (LM) deals exclusively with the particular concerns of this age group, as well as pregnant mothers, and mothers with a strong family or personal history of allergy who wish to become pregnant, and to take whatever precautions possible to reduce the risk of allergy in their babies.
In addition to the above activities, the additional services provided by the paediatric dietitian include stage of life concerns such as:
Results
Table 1 records the primary referral sources of clients during the 10-year period.
The number of clients referred directly to the ANC by physicians has increased gradually over time. From an initial 36% physician referrals in 1991-1992 to 92% currently.
The number of clients referred by other health care practitioners, including dietitians, nurses and practitioners of alternative medicine has diminished to about 8% from a high of about 40% in 1993-1994.
The number of clients admitted without referrals is currently less than 1% and this number usually represents close relatives of current clients.
Primary Diagnosis of Clients Referred to ANC 1997-2001
Since the beginning of 1997 clients were categorized according to the diagnosis on initial referral to the ANC. Based on the medical history supplied by the referring physician, clients were assigned to ten categories:
| GI Tract: | Irritable bowel syndrome and other symptoms in the digestive tract |
| Urticaria: | Skin conditions including urticaria, angioedema and pruritus |
| Eczema: | Atopic dermatitis and contact dermatitis |
| Respiratory: | Rhinitis and asthma |
| Infant atopy: | Atopy prevention and introducing solids for the allergic infant |
| Hyperactivity: | Behavioural problems and ADHD |
| Migraine: | Migraine and other headaches |
| OAS: | Oral allergy syndrome (OAS) and latex allergy |
| MSC: | Multiple somatic complaints, in which no single symptom predominates; Diagnoses included fibromyalgia, myalgic encephalomyelitis, weight loss due to food restrictions (distinct from eating disorders). This category encompasses clients in which several symptoms from the other categories are present simultaneously and no single diagnosis predominates. |
Table 2 summarises the main symptom categories for 1477 clients referred to the ANC from 1997 to 2001,
Initial Visits and Follow-up Appointments
Table 3 provides a summary of initial visits and follow-up appointments of clients registered in the Allergy Nutrition Clinic for the ten years under discussion.
Reasons for non-attendance cited by clients contacted:
For the ten year period, the percentage distribution of clients according to age categories was:
Adults in the 20-70 year age group 54.2% (n=1663)
Babies and children in the 0-6 years category 37.4% (n=1146)
Children in the 7-12 year group 5.8% (n=179)
Adolescents in the 13-19 year category 1.7% (n=52)
Adults over 70 years 0.9% (n=27)
Gender Distribution of Clients [Table 4]
In all ten years, males predominate in the 0-6 age group, and females greatly
outnumber males in the 20-70 age group.
Discussion
Selection of Clients
Initially we admitted clients without referrals from physicians, but this practice was gradually phased out for several reasons:
Importance of the Initial Interview
The most important aspect of the initial visit is education. Each client is given extremely detailed information on the reason for each aspect of the recommended diet. He or she is provided with specific lists of foods and food components to avoid (such as naturally occurring chemicals and foods additives), and is supplied with extensive lists of alternate food choices, sources of these foods, and information on how to prepare foods with which they are unfamiliar. Clients are “recruited” as an equal participant in the process, and invited to share their experiences, recipes, and information regarding alternative sources of appropriate foods with the clinic staff at their subsequent appointments.
We have found that the greater the amount of information provided at this stage, and the intimate involvement of the client in the process, the greater the compliance with the diet, and the greater chance that their symptoms will improve or resolve. As a result, the client is more likely to return for their follow-up appointments, which is reflected in the statistics [Table 3]
A written report of each clinic visit is sent to the referring physician or health care provider, thus ensuring that everyone involved in the health of the client is fully aware of the management strategy advised, and the client’s progress.
Increase in follow-up visits:
The increase in the number of clients returning for follow-up consultations in the Clinic [Table 3] reflect several management strategies, which have been implemented over time:
Distribution of Clients According to Age [Table 4]
Under 6 years of age, IgE-mediated (Type I hypersensitivity) reaction is the major reason for an adverse reaction to food [38]. Between the age of 18 months and 5 years most children outgrow their early food allergies [39]. The allergies to foods that do not resolve usually persist into adulthood and tend to be ones that have the potential to produce anaphylaxis [38]. The foods responsible for allergy in an individual over the age of 7 years are usually very few; more than three is extremely rare [4]. The foods that are the most frequent causes of immediate-onset allergy in adulthood are peanuts, tree nuts, shellfish and fish [40]. Occasionally others, such as egg, cause immediate reactions [39,4].
The small number of clients in the 7-12 years age group reflects two main factors:
The extremely small number of clients in the 13-19 age group reflects two important factors:
The same reasons may explain the very small number of clients in the >70 age group, coupled with the fact than undoubtedly there is a much smaller number of people in this age group in the general population.
The large number of clients in the 20-70 years age group, reflect several factors:
The food components responsible for the reactions designated as intolerances are much more difficult to identify than those causing atopic allergy. The symptoms tend to be more subtle, and are usually delayed in onset compared to the immediate appearance of symptoms in an allergic response. In addition, the response is dose-dependent, often conditional not only on the quantity of the chemical consumed, but also on the level of a mediator such as histamine already in the body as a result of a previous allergic response to an air-borne allergen.
Gender Distribution of Clients [Table 3]
In all ten years, males predominate in the 0-6 age group, and females greatly outnumber males in the 20-70 age group.
There seems to be general consensus that young boys tend to outnumber girls in several aspects of allergy, including asthma, eczema, and reactions to foods [38], and our experience in the ANC reflects this observation.
The predominance of females in the over-20 category is open to speculation. Many suggestions have been made, but unfortunately there is a paucity of scientific evidence to account for the enormous difference in numbers of males compared to females who seek help in managing sensitivity to food. The factors that have been suggested to account for this include:
What have we learned?
The management of food sensitivities is arguably the only field of dietetic practice where food components can be the sole etiological factor in triggering a disease condition, and in extreme cases, death. No other field depends so greatly on the appropriate choice of food – not only to ensure complete balanced nutrition – but to achieve and maintain absence of disease.
The practice of food sensitivity management is complex, and requires a great deal of knowledge about the ways in which the body responds to antigens, haptens, pharmacologically active agents and reactive chemicals in the plant and animal matter, and manufactured materials that humans consume. In addition, it is necessary for the dietitian to understand the ways in which concomitant disease states impact on a person’s sensitivity to food. Diabetes, heart disease, renal disease, gout, asthma and other acute and chronic conditions, especially involving the immune system, may be exacerbated by, or trigger, adverse reactions to food components. The dietitian must be in a position to assess all risk factors when counselling a client about the appropriate choice of food in all these situations.
Although we have come a long way in the past decade in understanding some of these processes, we still have a great deal further to go in the education of students entering the dietetics profession, and making this information available to those already in practice. Each person suffering the sometimes disastrous effects of food sensitivities should have access to a dietitian suitably qualified in the field so that they can achieve the maximum health possible. At the present time, there is a great shortage of appropriately qualified dietitians, not only in Canada, but worldwide. We believe that this is due to the fact that the scope of knowledge required to function effectively in this field of dietetics practice has not been acknowledged previously. Our experience in the Allergy Nutrition Program has clearly defined the education and experience required for supervising and educating clients in the complexities and frustrations of eating a healthy diet while avoiding their “reactive” foods, and yet avoiding the pitfalls of malnutrition, societal dysfunction and disordered eating that may challenge them in the process.
Ideally, courses in adverse reactions to foods would be as important in the study of nutrition and dietetics as those on the nutritional aspects of food. Because the biological mechanisms responsible for adverse reactions to foods are so multifaceted, and management of their effects so complex, the field of “food allergy” practice should stand alone as a specialty. We suggest that training in the field would be most effectively achieved in a post-graduate, post-internship, “residency” program, comprising both workshops, and hands-on clinical practice.
Conclusion
The structure of the Allergy Nutrition Program, with facilities for research, education and direct client counselling, has allowed the development of dietetic strategies, based on the most current scientific and clinical research data, that are uniquely designed for this at-risk population. The success of this approach is attested to by the number of physicians who repeatedly refer their food-sensitive patients to the Clinic for management of their conditions, and the large percentage of clients who are relieved of the need for repeated visits to their physicians and hospital for treatment of their symptoms.
Our experience in the ANP should serve as a prototype of specialised dietetic practice within a very circumscribed field. Our observations and results serve to demonstrate what can be achieved when research, education and counselling are focussed on specific mechanisms of reactions (immunological and biochemical), nutritional needs, and life-style adjustments, within a clear framework of response (symptoms). Ideally, we would like to see each of these factors addressed by the team approach, wherein the dietitian would be supported by the nurse, physician, social worker, psychologist, and other health care professional best equipped to provide the services required by each food-sensitive individual. Undoubtedly this integrated approach would provide the most effective means of aiding persons within this population, and ultimately save the health-care system a great deal of money by reducing repeated physician and hospital costs in acute intervention in adverse reactions to foods throughout a life-time.
Relevance to Practice
The Allergy Nutrition Program represents a new concept in the delivery of health care involving dietetics and nutrition. It is the first program entirely devoted to the management of adverse reactions to foods. Other health care facilities manage allergic reactions to foods within the broad scope of “general” allergy, which is largely based on respiratory allergy mechanisms and management. There is a vast difference between the mechanisms, and therefore diagnosis and management of allergic reactions to foods when compared to allergy to environmental factors, such as inhalants and contact allergens. As a result of the emphasis on accurate identification of the foods responsible, and the provision of a nutritionally sound diet at all stages of the process, the results achieved in patient compliance and positive outcome are extremely gratifying. We are in the process of assessing outcome, as well as cost-effectiveness of our approach by means of chart audits [33].
One of the principal reasons that the dietitians in the Clinic are able to offer both diagnostic and management services is that, unlike other areas of medical practice, the accurate identification of the food component(s) responsible for eliciting symptoms is not achievable by laboratory tests alone [5,6,7]. Any “allergy tests” performed need to be confirmed by elimination and challenge of the suspect foods. However, this method of determining the culprit food is never carried out in the Clinic when the food has been shown, or suspected, to be the cause of an anaphylactic reaction.
An important consideration regarding the need for the type of services provided by the ANC is not only improving the quality of life of sufferers of food sensitivity by alleviating their symptoms, but by preventing nutritional deficiency, especially in the paediatric population, that indiscriminate avoidance of foods often causes.
In addition to nutritional deficiency diseases, avoidance of food can result in eating disorders that result from the fear that foods will cause illness and irreparable damage to a person’s health. Sadly, such suggestions seem to be frequently implanted by “allergy practitioners” when an individual has undergone many “allergy tests”, some of which may be of questionable scientific merit.
The Allergy Nutrition Program stands as an example of a specialised area of dietetics existing separately, and distinct from, the field of general dietetic practice. The needs of a select population of clients at risk for nutritional deficiencies as a result of a specific set of circumstances (adverse reactions to food) are addressed effectively by the application of research, education, and direct counselling best suited to their condition.
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Table 1.
Referral Sources of Clients
| Year | Physician | Other health Care | None |
| 1991-1992 | 124 (35.98%) | 114 (32.98%) | 108 (31.28%) |
| 1992-1993 | 129 (45.6%) | 110 (38.9%) | 44 (14.5%) |
| 1993-1994 | 173 (55.1%) | 124 (39.5%) | 17 (5.4%) |
| 1994-1995 | 160 (61.3%) | 72 (27.5%) | 29 (11.2%) |
| 1995-1996 | 211 (80.2%) | 30 (11,4%) | 22 (8.4%) |
| 1996-1997 | 230 (87.8%) | 23 (8.8%) | 09 (3.4%) |
| 1997-1998 | 309 (89.5%) | 32 (9.3%) | 05 (1.2%) |
| 1998-1999 | 334 (88.1%) | 43 (11.3%) | 02 (0.6%) |
| 1999-2000 | 286 (92%) | 23 (7.4%) | 02 (0.6%) |
| 2000-2001 | 276 (91.7%) | 23 (7.6%) | 02 (0.7%) |
_
_
Table 2.
Primary Symptom Categories of Clients Referred to the ANC 1997-2001 (n=1477)
| Symptom | Total number of Clients | Percentage of Total |
| Gastrointestinal tract; IBS | 546 | 37.0% |
| Urticaria/angioedema | 179 | 12.1% |
| Rhinitis and asthma | 27 | 1.8% |
| Eczema and contact dermatitis | 204 | 13.8% |
| Infant atopy prevention and introduction of solids | 105 | 7.1% |
| Hyperactivity and other behaviour problems | 26 | 1.8% |
| Anaphylaxis | 63 | 4.3% |
| Migraine | 13 | 0.9% |
| Oral allergy syndrome Latex allergy |
6 | 0.4% |
| Multiple somatic complaints (MSC) | 308 | 20.8% |
_
_
_
Table 3
Initial Referrals and Follow-Up Visits 1991-2001
| Year | NP visits | F/U visits | Total | % FU visit |
| 1991-1992 | 346 | 97 | 443 | 28% |
| 1992-1993 | 283 | 215 | 498 | 76% |
| 1993-1994 | 314 | 218 | 532 | 69.4% |
| 1994-1995 | 261 | 199 | 460 | 76.2% |
| 1995-1996 | 263 | 245 | 528 | 93.2% |
| 1996-1997 | 262 | 296 | 558 | 113.% |
| 1997-1998 | 346 | 391 | 737 | 113.% |
| 1998-1999 | 379 | 430 | 809 | 113 % |
| 1999-2000 | 311 | 445 | 756 | 143 % |
| 2000-2001 | 301 | 460 | 761 | 152.8% |
Table 4. Distribution of Clients by Age and Gender
| Year | Total in Year | Age | Male | Percent | Female | Percent | Total in Age | Percent |
| 1991-1992 | 346 | 0-6 years | 47 | (13.6%) | 39 | (11.3%) | 86 | (24.9%) |
| 7-13 years | 21 | 9 | (6.1%) | (2.6%) | 30 | (8.7%) | ||
| 13-19 years | 3 | (0.9%) | 3 | (0.9%) | 6 | (1.7%) | ||
| 20-70 years | 30 | (8.7%) | 194 | (56.1%) | 224 | (64.7%) | ||
| >70 years | 0 | (0.0%) | 0 | (0.0%) | 0 | (0.0%) | ||
| 1992-1993 | 283 | 0-6 years | 79 | (27.9%) | 31 | (11.0%) | 110 | (38.9%) |
| 7-13 years | 7 | (2.5%) | 6 | (2.1%) | 13 | (4.6%) | ||
| 13-19 years | 4 | (1.4%) | 3 | (1.1%) | 7 | (2.5%) | ||
| 20-70 years | 30 | (10.6%) | 123 | (43.5%) | 153 | (54.1%) | ||
| >70 years | 0 | (0.0%) | 0 | (0.0%) | 0 | (0.0%) | ||
| 1993-1994 | 314 | 0-6 years | 80 | (25.5%) | 50 | (15.9%) | 130 | (41.4%) |
| 7-13 years | 25 | (8.0%) | 11 | (3.5%) | 36 | (11.5%) | ||
| 13-19 years | 4 | (1.3%) | 4 | (1.3%) | 8 | (2.5%) | ||
| 20-70 years | 31 | (9.9%) | 109 | (34.7%) | 140 | (44.6%) | ||
| >70 years | 0 | (0.0%) | 0 | (0.0%) | 0 | (0.0%) | ||
| 1994-1995 | 261 | 0-6 years | 54 | (20.7%) | 36 | (13.8%) | 90 | (34.5%) |
| 7-13 years | 4 | (1.5%) | 6 | (2.3%) | 10 | (3.8%) | ||
| 13-19 years | 0 | (0.0%) | 3 | (1.1%) | 3 | (1.1%) | ||
| 20-70 years | 22 | (8.4%) | 136 | (52.1%) | 158 | (60.5%) | ||
| >70 years | 0 | (0.0%) | 0 | (0.0%) | 0 | (0.0%) | ||
| 1995-1996 | 264 | 0-6 years | 56 | (21.2%) | 33 | (12.5%) | 89 | (33.7%) |
| 7-13 years | 7 | (2.7%) | 14 | (5.3%) | 21 | (8.0%) | ||
| 13-19 years | 1 | (0.4%) | 5 | (1.9%) | 6 | (2.3%) | ||
| 20-70 years | 19 | (7.2%) | 124 | (47.0%) | 143 | (54.2%) | ||
| >70 years | 3 | 1.1%) | 2 | (0.8%) | 5 | (1.9%) | ||
| 1996-1997 | 262 | 0-6 years | 48 | (18.3%) | 29 | (11.1%) | 77 | (29.4%) |
| 7-13 years | 3 | (1.1%) | 7 | (2.7%) | 10 | (3.8%) | ||
| 13-19 years | 3 | (1.1%) | 2 | (0.8%) | 5 | (1.9%) | ||
| 20-70 years | 38 | (14.5%) | 129 | (49.2%) | 167 | (63.7%) | ||
| >70 years | 1 | (0.4%) | 2 | (0.8%) | 3 | (1.1%) | ||
| 1997-1998 | 346 | 0-6 years | 78 | (22.5%) | 49 | (14.2%) | 127 | (36.7%) |
| 7-13 years | 8 | (2.3%) | 16 | (4.6%) | 24 | (6.9%) | ||
| 13-19 years | 2 | (0.6%) | 4 | (1.2%) | 6 | (1.7%) | ||
| 20-70 years | 22 | (6.4%) | 162 | (46.8%) | 184 | (53.2%) | ||
| >70 years | 2 | (0.6%) | 3 | (0.9%) | 5 | (1.4%) | ||
| 1998-1999 | 379 | 0-6 years | 91 | (24.0%) | 81 | (21.4%) | 172 | (45.4%) |
| 7-13 years | 6 | (1.6%) | 12 | (3.2%) | 18 | (4.7%) | ||
| 13-19 years | 2 | (0.5%) | 4 | (1.1%) | 6 | (1.6%) | ||
| 20-70 years | 20 | (5.3%) | 158 | (41.7%) | 178 | (47.0%) | ||
| >70 years | 2 | (0.5%) | 3 | (0.8%) | 5 | (1.3%) | ||
| 1999-2000 | 311 | 0-6 years | 80 | (25.7%) | 72 | (23.2%) | 152 | (48.9%) |
| 7-13 years | 8 | (2.6%) | 0 | (0.0%) | 8 | (2.6%) | ||
| 13-19 years | 0 | (0.0%) | 3 | (1.0%) | 3 | (1.0%) | ||
| 20-70 years | 15 | (4.8%) | 129 | (41.5%) | 144 | (46.3%) | ||
| >70 years | 0 | (0.0%) | 4 | (1.3%) | 4 | (1.3%) | ||
| 2000-2001 | 301 | 0-6 years | 54 | (17.9%) | 59 | (19.6%) | 113 | (37.5%) |
| 7-13 years | 2 | (0.7%) | 7 | (2.3%) | 9 | (3.0%) | ||
| 13-19 years | 0 | (0.0%) | 2 | (0.7%) | 2 | (0.7%) | ||
| 20-70 years | 40 | (13.3%) | 132 | (43.9%) | 172 | (57.1%) | ||
| >70 years | 2 | (0.7%) | 3 | (1.0%) | 5 | (1.7%) | ||
| Total | 3067 | 1054 | 2013 | |||||
| 1991-2001 |
