Asthma in Indian

children

Dr. Swati BhaveFormer President ( IAP)Indian Academy of Pediatric(2000)

National Co-coordinator IAP Asthma awareness program

Honorary Fellow ( AAP) American Academy of Pediatrics

Standing Committee member 2001-03 (IPA)

International Pediatric association

Disease Trends

Asthma Prevalence in India

No Representative National Data Vast Country Variable population density Variable Climates Variable Pollution Levels Wide variety in education, life style,

infections, Infectious Diseases are still a priority

Prevalence

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

Vishwanathan, 1966 Chhabra, 98 Chhabra, 99 Chakravorty, 2002

ISSAC Phase-I “ever had asthma” 14 centers, 228 schools, n=100,000

13-14 years ( 95 % responded) 2.6 - 6.5% (Kottayam-12.4%) average 4.5 % 6-7 years ( 92 % responded )

1- 4.2% (Kottayam 14.4%, ) average 3.7%. Prevalence of wheeze (in response to self-completed wheezing questionnaire (video)

data) 13-14 yrs - 0.8 to 7.1% average 2.9%.

Prevalence of Asthma in Indian Children First Populations study, ISAAC Study in 1990s.

ISAAC - India

Groups 6 - 7 Yrs 13-14 Yrs Wheeze 5.6 % 6.0%

(0.8 - 14.6)(1.6 - 17.8)

> 4 attacks1.5% 1.6% (0.1 - 4.7) (0.5 - 3.5)

Night Cough 12.3% 14.1% (3.3 - 27) (3.8 - 32.2)

Ever had Asthma 3.7% 4.5% (1.0 - 14.4) (1.8 - 12.4)

Shah, Amdekar, Mathur, IJMS,6,2000,213-220.

ISAAC – India

Video Data 13-14 Years (n = 30,043)

Wheeze 2.9 % (0.8 - 7.1)

Night Wheeze 2.3% (0.8 -7.5)

Night Cough 3.7% (0.9 - 7.8)

Severe Wheeze 2.5% (0.7 - 6.2)

Wheezing (Ave 12 mths) 6%

Shah, Amdekar, Mathur, IJMS,6,2000,213-220.

Shah, Amdekar, Mathur, IJMS,6,2000,213-220.

12-month prevalence of self-reported asthma

symptoms from written questionnaires

12-month prevalence of asthmasymptoms from video questionnaires

Urban rural

0%10%20%30%40%50%60%70%80%90%

100%

Past BD NocturnalCough

RecentWheeze

DiagnosedAsthma

ExerciseInduced

Urban

Rural

Chakravorty, Chennai. Natl Med J India 2002; 15:260-3Sudhir P Prasad CE, Hyderabad. J Trop Pediatr 2003 Apr; 49(2):104-8

Rural children2001 n=119, Age – 06-15 yrs, Ratio – M:F – 1:2.3

8.40%

2.52%

5.80%

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

9.00%

Total Boys GirlsSource - H. Paramesh, E. Cherian. Ind. Joul of Pediatr 2002

Factors associated with higher incidence

Positive association School in heavy

traffic areas Low SES Male sex No windows Atopy or asthma in

family Grandparents, sibling

NO association Air pollution: Suspended particles Over crowding Type of domestic kitchen

fuel Location of kitchen Over crowding

H/O worm infestation food allergy

Equivocal factors

Parental smoking Pets at home Low SES Air pollution

Asthma / Pets

16.63%

5.12% 5.70% 7.50%

26.12%

6.20%

14.90%

2.40%

15.60%

42.30%

68.50%

1.00%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

School Children(Urban)

School Children(Rural)

Traffic Police Non Traffic Police Rural FarmWorkers

Poultry FarmWorkers

% of asthma % of Pets

0

10

20

30

40

50

60

70

80

1970-1971 1980-1981 1990-1991 2000-2001

Industrial

Transport

Domestic

Contribution of various sectors to ambient air pollution

Ministry of Environment & Forests, 1997

% age

Prevalence of asthma in school children effect of traffic age 6 –15 yrs

No.273 (31.14%)

No.3722 (19.34%)

No. 2565 (11.15%)

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

Schools in low trafficregions

Schools in heavy trafficregions

Schools in heavy trafficwith low socio economic

status

P. Value I, II & III < 0.001. H. Paramesh, Down to earth - 2001

Respiratory allergies / asthma in children related to industrialization

Year Asthma %

Industries Population in million

Automobiles in million

% increase / year

1979 9 4700 2.55 0.140

1984 10.5 7887 3.29 0.236 0.3

1989 18.5 14384 4.6 0.460 1.6

1994 24.5 25758 5.3 0.714 1.2

1999 29.5 40145 6.3 1.223 1.0

Source – H. Paramesh. Down to Earth – July 2001

Allergic bronchopulmonary aspergillosis in Indian children with bronchial asthma

243 children with BA 107 children (44%):perennial asthma.

14 % had 4 or more of the criteria for ABPA.

Chetty A, et al. Ann Allergy.1985 Jan;54(1):46-9.

Age of Onset and Severity of Asthma

84

48

0102030405060708090

Mild Severe

Ag

e (M

on

ths)

Median Age of Onset

Ratageri, Delhi. Indian Pediatr 2000 Oct; 37(10): 1072-82

Age of onset below 5 years

Odds ratio for development of Severe asthma

2.44 (95% CI 1-4.54)

Study of asthma patients in a tertiary care center at Mumbai, India bhave et al Unpublished

050

100150200250300350

1M-1 Y

1-3Y

3-5Y

5-10Y

10-12Y

12-18Y

Male Female

Total = 1050

Religion Bhave et al Unpublished

745

262

3211

Hindu Muslim

Christians Others

Symptoms

0%10%20%30%40%50%60%70%80%90%

Cough

Whe

eze

Chest P

ain

Abdomin

a Pai

n

(Cough

+ W

heeze

)

Bhave, Mumbai

Parmesh, Bangalore

Bhave Unpublished

Pamesh (Indian J Pediatr 2002; 69(4):309-312)

Bhave et al

Smoking in family Bhave et al n =1050

Unpublished

80%

1%

10% 9%

FATHER MOTHER

RELATIVE VISITOR

78%

22%

No Yes

Triggers for acute exacerbation Bhave et al unpublished

37%

9%

8%

8%

7%

11%

14%

5% 1%Viral infection

Colddrinks/icecreams

Food item

Dust exposure

Change of season

Picnics/camps

Physical stress

Emotional stressN = 1050

Seasonal variation

Author

City

Effect seen Monsoon Winter summer

H parmesh Bangalore

35 % 75.8% 82. 3% 2 %

Bhave

Mumbai

40 % 80 .4% 70 .4% 10 .5%

Bhave et alUnpublished

Associated Upper airway conditions Bhave et al Unpublished

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1-12M

1 - 3Y

3 –5 Y

5–10

Y

10–12

Y

12-18 Y

NoAssociatedConditionTonsillitis+Rhinitis

Sinusitis +Tonsillitis

Rhinitis+Sinusitis

Ottitis media

Sinusitis

Tonsillitis

AllergicRhinitis

• ISAAC – 0.8 – 14.95%. 6 – 7 yr old

1.4 – 39.7%. 13 – 14 yr old• Low in Indonesia, Georgia, Greece• High in U.K., Australia and Latin America• Dr Paremesh Study in Bangalore *

22.5% - 1994 6-15yrs 27.0% - 1998 6-15yrs 75.0% - in asthmatics

Epidemiology Allergic Rhinitis

* H. Paramesh Indian Journal of Pediatrics 2002

IgE mediated hypersensitivity to house dust mite in

causation of exercise induced spasm in children.

250 children with h/o asthma SPT and PFT done Serum IgE done in patients with positive

SPT Selected cases above 12 years underwent

exercise test for EIB

Joshi SV, Tripathi DM, Bhave SY, Dhar HL, Indian J Allergy Immunol 2000; 14(1):21-23.

Positive reactions to different allergens

18%

17%

14%12%

12%

8%

19% Mite Sp.

Dusts

Pollens

Fungi

Insects

Epithelia

Foods

Bhave et al

Sensitivity to house dust mite in asthmatic children

and its correlation with pulmonary functions.

1-5 years, 250 asthmatic children, SPT done in all

60% strongly positive for dust, 64% for mite, and 64.8% for food allergens

PFT were significantly (p <0.001) reduced in mite sensitive children

40% of children with positive SPT developed exercise induced bronchospasm (EIB).

Joshi SV, Tripathi DM, Bhave SY, Dhar HL, Indian J Allergy Immunol 1999; 13(1):1-3.

Pulmonary Function Test (Average of predicted values in %)

55.5

86.21

55.5

94.28

33.75

86.33

33.75

86.33

125128

0

20

40

60

80

100

120

140

FVC* FEV1* FEF* PEFR* MVV

Positive to mite Ag

Negative to mite Ag

* P < 0.001

Bhave et al

Exercise induced bronchospasm in mite sensitive children

Lability Index

Average and S.D.

Percentage

12.5+4.2 60

42.25*+20 40

*p <0.001

Bhave et al

Treatment protocol

9 0 % put on inhalation

Prophylaxis with steroids in all moderate grade asthma 1- 3 yrs duration

Choose between

Beclemethasone,

Budesonide

Fluticasone

Combination : long acting B agonist /steroids

Patient education for inhalation therapy

Bhave et al

Treatment protocol ( contd)

If patient refuses steroids Sodium cromoglycate , ketotefen ACUTE ATTACK NEBULISATION ,beta agonist , Ipratropium bromide ORAL rescue steroids 1-5 days Follow protocol of acute severe asthma for

hospitalized patients

Bhave et al

Response to treatment

80 % regular inhaled steroids well controlled

10 % drop outs

10 % irregular follow up

Diagnosis and treatment of associated conditions

GER Tuberculosis Upper respiratory

disease

Bhave et alUnpublished

Barriers to inhalation therapy

Fear about steroids Do not like public labeling as asthmatic Fear of addiction Feel pumps reserved for serious or severe

attacks or will fail ot act Misconception that costly Prefer oral medications Physicians lack of knowledge and time

Bhave et alUnpublished

Study on management practices of medical practitioners in bronchial asthma. Gupta PR, Verma SK, Indian Journal of Allergy Asthma and Immunology. 2002 Jul-Dec; 16(2): 89-92

280 doctors/135 patients.

Lack of awareness recent advances

Non-adherence: guidelines

oral drugs prefereed Both patient and doctor

seemed responsible for unpopularity of inhaled therapy.

Over and erratic use of oral steroids

injudicious use of supportive measures

under use PFT PEFR Inadequate attention to health education .

Need for updating the knowledge of doctors together with imparting health education to the patients.

Management programs in India

Public health Education Community awareness Parental programs School health programs Asthma camps Pamphlets, CD,s Video TV programs, radio talks

IAP Environment & child health chapter 2000

Environmental issues like air pollution , air water soil and sound pollution

Respiratory Infections and allergy disorders

Conferences national & International sponsoring

Radio talks , TV Interviews

Public awareness rallies on world environment day

School children education programs monthly for awareness

*Indian Academy of Pediatrics

IAP *Respiratory Chapter 1987

More than a 1500 members Quarterly bulletin Annual conferences, CME,s etc Patient education camps asthma camps World asthma day

*Indian Academy of Pediatrics