The Wisconsin Upper Respiratory Symptom Survey (WURSS) is an evaluative illness-specific quality of life instrument, designed to assess the negative impact of acute upper respiratory infection, presumed viral (the common cold). Long (WURSS-44) and short (WURSS-21) versions have been validated. An even shorter (WURSS-11) version is now available. Influenza-like illness symptoms of headache, body aches and fever are included on the WURSS-24. The newest in our line of self-report instruments is the WURSS for Kids, or WURSS-K, which is currently being assessed for psychometric properties.
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 500 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:
- B. Barrett, K. Locken, R. Maberry, J. Schwamman, J. Bobula, R. Brown, and E. Stauffacher. The Wisconsin Upper Respiratory Symptom Survey: Development of an instrument to measure the common cold. Journal of Family Practice 51(3):265-www.jfponline.com, 2002
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..
Validation of the WURSS-44 and derivation of the WURSS-21 are described in:
- B. Barrett, R. L. Brown, M. P. Mundt, N. Safdar, L. Dye, R. Maberry, and J. Alt. The Wisconsin Upper Respiratory Symptom Survey is responsive, reliable, and valid. Journal of Clinical Epidemiology. 58 (6):609-617, 2005.
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.
- B. Barrett, R. Brown, R. Voland, R. Maberry, and R. Turner. Relations among questionnaire and laboratory measures of rhinovirus infection. European Respiratory Journal 28 (2):358-363, 2006.
A fourth manuscript detailing anchor-based and distribution-based methods of assessing important difference and responsiveness was next made available:
- B. Barrett, R. Brown, and M. Mundt. Comparison of anchor-based and distributional approaches in estimating important difference in common cold.Qual.Life Res. 17 (1):75-85, 2008.
A few years ago, we completed a prospective independent evaluation of the WURSS-21 compared to the WURSS-44 and several other measures. This study included 230 participants who were monitored for 2,457 person-days. See:
- B. Barrett, R. E. Brown, M. P. Mundt, G. R. Thomas, S. K. Barlow, A. D. Highstrom, and M. Bahrainian. Validation of a short form Wisconsin Upper Respiratory Symptom Survey (WURSS-21). Health and Quality of Life Outcomes 7 (76), 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, which we have used with success.
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.
- C. N. Obasi, R. L. Brown, and B. P. Barrett. Item reduction of the Wisconsin Upper Respiratory Symptom Survey (WURSS-21) leads to the WURSS-11. Qual.Life Res., 2013.
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:
- E. Longmier, B. Barrett, and R. Brown. Can patients or clinicians predict the severity or duration of an acute upper respiratory infection? Family Practice 30 (4):379-385, 2013.
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:
- K.M. Henriquez, M. S. Hayney, Y. Xie, Z. Zhang, and B. Barrett. Association of interleukin-8 and neutrophils with nasal symptom severity during acute respiratory infection. J.Med.Virol. 87 (2):330-337, 2015.
Most recently, 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):
- R.L. Brown, C. N. Obasi, and B. Barrett. Rasch analysis of the WURSS-21: Dimensional validation and assessment of invariance. J Lung Pulm Respir Res 3 (2), 2016.
We have used the WURSS-21 as the primary outcome measure in two NIH-funded clinical trials, and are using it in a third.
- B. Barrett, R. Brown, D. Rakel, M. Mundt, K. Bone, S. Barlow, and T. Ewers. Echinacea for treating the common cold: a randomized trial.Ann.Intern.Med.153 (12):769-777, 2010.
- B. Barrett, R. L. Brown, D. P. Rakel, D. Rabago, L. Marchand, J. Scheder, M. Mundt, G. Thomas, and S. Barlow. Placebo effects in common cold: A randomized controlled trial.Annals of Family Medicine 9 (4):312-322, 2011.
- B. Barrett, M. S. Hayney, D. Muller, D. Rakel, A. Ward, C. N. Obasi, R. Brown, Z. Zhang, A. Zgierska, J. Gern, R. West, T. Ewers, S. Barlow, M. Gassman, and C. L. Coe. Meditation or exercise for preventing acute respiratory infection: a randomized controlled trial. Ann.Fam.Med 10 (4):337-346, 2012.
- Hayney M, Coe C, Muller D, Obasi C, Ewers T, Barrett B. Age and psychological influences on immune responses to trivalent inactivated influenza vaccine in the Meditation or Exercise for Preventing Acute Respiratory Infection (MEPARI) Trial. Human Vaccines & Immunotherapeutics, 10(1). 2013
- Rakel D, Mundt M, Ewers T, Fortney L, Zgierska A, Gassman M, Barrett B. Value associated with mindfulness meditation and moderate exercise intervention in acute respiratory infection: The MEPARI Study. Family Practice 2013, In Press.
- Obasi C, Barrett B, Brown R, Vrtis R, Barlow S, Muller D, and Gern J. (2014) Detection of viral and bacterial pathogens in acute respiratory infections. Journal of Infection, 68:125-130
- Obasi C, Brown R, Ewers T, Barlow S, Gassman M, Zgierska A, Coe C, Barrett B. Advantage of meditation over exercise in reducing cold and flu illness is explained by improved function and quality of life. Influenza and Other Respiratory Viruses, 2013 In Press.
- Zgierska A, Obasi, C, Brown R, Ewers T, Muller D, Gassman M, Barlow S, Barrett B. Randomized controlled trial of mindfulness meditation and exercise for the prevention of acute respiratory infection: Possible mechanisms of action. Evidence-Based Complementary and Alternative Medicine 2013
For investigators who want to assess influenza, influenza-like illness, or COVID-19, we recommend the WURSS-24, which is identical to the WURSS-21, except for the addition of items assessing headache, body aches, and fever.
Who Uses WURSS?
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.
Here are cites to a few published articles describing research using WURSS:
L. Spence, W. J. Brown, D. B. Pyne, M. D. Nissen, T. P. Sloots, J. G. McCormack, A. S. Locke, and P. A. Fricker. Incidence, etiology, and symptomatology of upper respiratory illness in elite athletes.Med.Sci.Sports Exerc. 39 (4):577-586, 2007.
M. J. Walter, M. Castro, S. J. Kunselman, et al.. Predicting worsening asthma control following the common cold.Eur.Respir.J. 32 (6):1548-1554, 2008.
S. A. Heinz, D. A. Henson, M. D. Austin, F. Jin, and D. C. Nieman. Quercetin supplementation and upper respiratory tract infection: A randomized community clinical trial.Pharmacol.Res. 62 (3):237-242, 2010.
D. C. Nieman, D. A. Henson, M. D. Austin, and W. Sha. Upper respiratory tract infection is reduced in physically fit and active adults.Br.J.Sports Med., 2010.
J. S. Byun, S. Y. Yang, I. C. Jeong, K. E. Hong, W. Kang, Y. Yeo, and Y. C. Park. Effects of So-cheong-ryong-tang and Yeon-gyo-pae-dok-san on the common cold: randomized, double blind, placebo controlled trial.J.Ethnopharmacol. 133 (2):642-646, 2011.
S. Y. Yang, W. Kang, Y. Yeo, and Y. C. Park. Reliability and validity of Wisconsin Upper Respiratory Symptom Survey, Korean version.J.Epidemiol. 21 (5):313-318, 2011.
E. Tiralongo, R. A. Lea, S. S. Wee, M. M. Hanna, and L. R. Griffiths. Randomised, double blind, placebo-controlled trial of echinacea supplementation in air travellers. Evidence Based Complement Alternat Med. 2012:417267, 2012.
D. R. Murdoch, S. Slow, S. T. Chambers, L. C. Jennings, A. W. Stewart, P. C. Priest, C. M. Florkowski, J. H. Livesey, C. A. Camargo, and R. Scragg. Effect of vitamin D3 supplementation on upper respiratory tract infections in healthy adults: the VIDARIS randomized controlled trial. JAMA 308 (13):1333-1339, 2012.
J. Guay, P. Champagne, P. Guibord, and J. Gruenwald. The efficacy and safety of a patent pending combination of ginger and goldenrod extracts on the management of cold symptoms: A randomized, double-blind controlled trial. Food and Nutrition Sciences 3:1651-1657, 2012.
J. Scherr, D. C. Nieman, T. Schuster, J. Habermann, M. Rank, S. Braun, A. Pressler, B. Wolfarth, and M. Halle. Nonalcoholic beer reduces inflammation and incidence of respiratory tract illness. Med Sci Sports Exerc. 44 (1):18-26, 2012.
B. K. McFarlin, K. C. Carpenter, T. Davidson, and M. A. McFarlin. Baker’s yeast www glucan supplementation increases salivary IgA and decreases cold/flu symptomatic days after intense exercise.J.Diet.Suppl 10 (3):171-183, 2013.
D. C. Nieman, B. Luo, D. Dreau, D. A. Henson, R. A. Shanely, D. Dew, and M. P. Meaney. Immune and inflammation responses to a 3-day period of intensified running versus cycling.Brain Behav.Immun., 2013.
Y. Hirose, Y. Yamamoto, Y. Yoshikai, and S. Murosaki. Oral intake of heat-killed Lactobacillus plantarum L-137 decreases the incidence of upper respiratory tract infection in healthy subjects with high levels of psychological stress. J.Nutr.Sci. 2:e39, 2013.
H. G. Ferrari, C. A. Gobatto, and F. B. Manchado-Gobatto. Training load, immune system, upper respiratory symptoms and performance in well-trained cyclists throughout a competitive season. Biol.Sport 30 (4):289-294, 2013.
S. D. Youngstedt, G. Jean-Louis, R. R. Bootzin, D. F. Kripke, J. Cooper, L. R. Dean, F. Catao, S. James, C. Vining, N. J. Williams, and M. R. Irwin. Chronic moderate sleep restriction in older long sleepers and older average duration sleepers: a randomized controlled trial. Contemp.Clin.Trials 36 (1):175-186, 2013.
C. G. Freitas, M. S. Aoki, C. A. Franciscon, A. F. Arruda, C. Carling, and A. Moreira. Psychophysiological responses to overloading and tapering phases in elite young soccer players. Pediatr.Exerc.Sci. 26 (2):195-202, 2014.
Goodall EC, Granados AC, Luinstra K, Pullenayegum E, Coleman BL, Loeb M, Smieja M. Vitamin D3 and gargling for the prevention of upper respiratory tract infections: a randomized controlled trial. BMC Infect Dis. 2014;14:273.
V. F. Milanez, S. P. Ramos, N. M. Okuno, D. A. Boullosa, and F. Y. Nakamura. Evidence of a Non-Linear Dose-Response Relationship between Training Load and Stress Markers in Elite Female Futsal Players.J.Sports Sci.Med. 13 (1):22-29, 2014.
V. Grabs, D. C. Nieman, B. Haller, M. Halle, and J. Scherr. The effects of oral hydrolytic enzymes and flavonoids on inflammatory markers and coagulation after marathon running: study protocol for a randomized, double-blind, placebo-controlled trial.BMC.Sports Sci.Med.Rehabil. 6 (1):8, 2014.
G. Duijker, A. Bertsias, E. K. Symvoulakis, J. Moschandreas, N. Malliaraki, S. P. Derdas, G. K. Tsikalas, H. E. Katerinopoulos, S. A. Pirintsos, G. Sourvinos, E. Castanas, and C. Lionis. Reporting effectiveness of an extract of three traditional Cretan herbs on upper respiratory tract infection: results from a double-blind randomized controlled trial. J.Ethnopharmacol. 163:157-166, 2015.
L. C. Denlinger, T. S. King, J. C. Cardet, etal. Vitamin D Supplementation and the Risk of Colds in Patients with Asthma. Am.J Respir Crit Care Med. 193 (6):634-641, 2016.
E. Tiralongo, S. S. Wee, and R. A. Lea. Elderberry Supplementation Reduces Cold Duration and Symptoms in Air-Travellers: A Randomized, Double-Blind Placebo-Controlled Clinical Trial. Nutrients. 8 (4), 2016.
Advice For Users
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 Want to Hear From You
Please let us know of the results of your WURSS-related work, and please alert us to any relevant publications. Contact: email@example.com
Thanks for your interest in WURSS!
Educational and non-profit use is free, but must be registered. License fees for commercial use of WURSS for testing any intervention with potential for-profit application must be negotiated with the Wisconsin Alumni Research Foundation.