Acute respiratory infection (ARI), including the common cold and influenza, is the most prevalent of human illnesses. Surveys report that over 70% of people experience at least one cold in a given year, with adults averaging 2 or 3 colds and young children averaging as many as 4 to 6 colds per year. More than 45 million days of work and 22 million days of school are lost as a result. In the U.S. alone, more than $2 billion is spent out of pocket annually on cold remedies, with more than $7 billion in sick pay losses attributable to non-influenza ARI. One study estimated annual direct costs at $17 billion and indirect costs at $22.5 billion, for a total economic impact of close to $40 billion. ARI is the most important cause of asthma exacerbation, and often leads to otitis media, sinusitis, bronchitis or pneumonia. For those at increased risk, such as the very old, those with multiple illnesses, or the immune compromised, ARI may be fatal.
Despite the fact that more than a thousand randomized controlled trials have spent many millions of dollars testing dozens of cold remedies, prior to WURSS there was no well-developed, standardized and validated measure for assessing the symptomatic and functional impact of ARI.
In order to develop and validate such an instrument, we chose to combine qualitative and quantitative methodologies, including cognitive interview and focus group. A published description of the development process is available:
We then went on to prospectively validate the WURSS-44, aiming for assessment of reliability, responsiveness, importance-to-patients, and convergent validity. Over 18 months some 149 people with colds filled out the WURSS-44, the Jackson scale and the SF-8 (24-hour recall version) each day from the beginning of their colds until their symptoms had resolved, generating a data set of 1,681 person-days. Using importance-to-patient and responsiveness as guides, a subset of items was selected for the WURSS-21..
A third paper comparing WURSS with laboratory-based measures was published next. Using data from an NIH-funded randomized controlled trial in an induced cold experimental rhinovirus infection model, this paper compares WURSS scores with quantitative viral culture, nasal mucus weight, neutrophil count, interleukin-8 and glutathione, and with the self-report questionnaire scores from the Jackson cold scale and the SF-8 general health-related quality-of-life instrument.
A fourth manuscript detailing anchor-based and distribution-based methods of assessing important difference and responsiveness was next made available:
Our next project was to complete a prospective independent evaluation of the WURSS-21, as compared to the WURSS-44, along with several other comparator measures. Those results were published in 2009:
Aiming for a version to assess influenza-like illness, we added items on fever, headache and body ache from the WURSS-44 to the WURSS-21, making the WURSS-24. We recommend this version for studies of influenza, influenza-like-illness, and COVID-19.
Next, we developed the short-form WURSS-11 using factor analysis, and by excluding items with redundancy and floor effects. This shortest version of WURSS will be quicker and easier to use, and may increase response rates among research participants.
We took a look at whether doctors or patients could predict the course of new-onset colds, and found that while they couldn’t, the WURSS did, to a limited extent:
Using a data set from 811 people, we analyzed the association of symptoms assessed by WURSS with inflammatory biomarkers, and found that nasal symptoms correlated more closely with interleukin-8 and nasal neutrophil count than did other symptoms and functions:
In another project, we used item response theory and Rasch modelling to evaluate WURSS data, and found strong support for the recommended scoring method of simply summing all WURSS items (excluding the first and last items, which assess global illness and change-over-time):
We have used the WURSS-21 as the primary outcome measure in three NIH-funded randomized clinical trials:
There are no perfect definitions of “common cold,” “upper respiratory tract infection,” “acute respiratory infection,” “influenza-like illness” or similar terms. Researchers, however, need definitions in order to implement protocols. We have found the following to be useful:
The beginning of each common cold acute respiratory infection (ARI) illness episode is defined by: 1) answering “Yes” to either: “Do you think you have a cold?” or “Do you think you are coming down with a cold?” AND 2) reporting at least 1 of 4 cold symptoms (or synonyms): nasal discharge (runny nose); nasal obstruction (plugged or congested); sneezing; or sore (scratchy) throat, AND 3) scoring at least 2 points on the Jackson scale. The Jackson score is calculated by summing 8 symptom scores (sneezing, headache, malaise, chilliness, nasal discharge, nasal obstruction, sore throat and cough), rated as 0=absent, 1=mild, 2=moderate, and 3=severe. In order for these symptoms to be classified as an ARI illness episode (and analyzed as such), at least 2 days in a row must meet these criteria. From the first day of ARI illness and forward each participant fills out a daily WURSS until they answer “No” to the question “Do you think that you are still sick with this respiratory infection?” for 2 days in a row. The last day the participant answers “Yes” and fills out a WURSS instrument will be the last day classified as ARI illness.
Daily WURSS summary scores are calculated by summing scores of individual item scores, excluding the first and last items, which have categorically different reference domains, and are analyzed separately. Summary scores of ARI illness episodes are calculated by summing daily scores, or by trapezoidal approximation, or by other methods as advised by the study statistician. Imputation of missing data may be useful. Data from individual items or groups of items can be analyzed separately, depending on research questions. Each study has its own aims and methods. Adjusting the Jackson criteria threshold for ARI illness definition may be advisable. Excluding allergy and other illnesses with cold-like symptoms is usually recommended. An experienced multidisciplinary team and rigorous peer review is almost always a good idea.
We’re not the only ones to use WURSS. Numerous investigators from around the world have selected WURSS for their research and/or education work. The list of registered WURSS users represents more than 400 institutions in more than 50 countries.
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Please let us know of the results of your WURSS-related work, and please alert us to any relevant publications. Contact: firstname.lastname@example.org