Asthma in Indian children Dr Swati Bhave Former

Asthma in Indian children Dr. Swati Bhave Former 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 n No Representative National Data n n n Vast Country Variable population density Variable Climates Variable Pollution Levels Wide variety in education, life style, infections, Infectious Diseases are still a priority

Prevalence

Prevalence of Asthma in Indian Children First Populations study, ISAAC Study in 1990 s. n ISSAC Phase-I “ever had asthma” n 14 centers, 228 schools, n=100, 000 n 13 -14 years ( 95 % responded) n 2. 6 - 6. 5% (Kottayam-12. 4%) average 4. 5 % n 6 -7 years ( 92 % responded ) n 1 - 4. 2% (Kottayam 14. 4%, ) average 3. 7%. n n Prevalence of wheeze (in response to self-completed wheezing questionnaire (video) data) n n 13 -14 yrs - 0. 8 to 7. 1% average 2. 9%.

ISAAC - India n n n Groups Wheeze 6 - 7 Yrs 5. 6 % (0. 8 - 14. 6) > 4 attacks 1. 5% (0. 1 - 4. 7) n Night Cough 13 -14 Yrs 6. 0% (1. 6 - 17. 8) 1. 6% (0. 5 - 3. 5) 12. 3% 14. 1% (3. 3 - 27) n Ever had Asthma (3. 8 - 32. 2) 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) n Wheeze 2. 9 % 2. 3% n Night Cough 3. 7% n Severe Wheeze 2. 5% n n n Night Wheeze Wheezing (Ave 12 mths) (0. 8 - 7. 1) (0. 8 -7. 5) (0. 9 - 7. 8) (0. 7 - 6. 2) 6% Shah, Amdekar, Mathur, IJMS, 6, 2000, 213 -220.

12 -month prevalence of self-reported asthma symptoms from written questionnaires 12 -month prevalence of asthma symptoms from video questionnaires

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

Rural children 2001 n=119, Age – 06 -15 yrs, Ratio – M: F – 1: 2. 3

Factors associated with higher incidence n n n n Positive association School in heavy traffic areas Low SES Male sex No windows Atopy or asthma in family Grandparents, sibling NO association n Air pollution: n n n Suspended particles Over crowding Type of domestic kitchen fuel Location of kitchen Over crowding n H/O worm infestation n food allergy

Equivocal factors n Parental smoking n Pets at home n Low SES n Air pollution

Asthma / Pets

Contribution of various sectors to ambient air pollution % age Ministry of Environment & Forests, 1997

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

Respiratory allergies / asthma in children related to industrialization Year Asthma % Industries Populat Automobiles % increase ion in in million / year million 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 n 243 children with BA n 107 children (44%): perennial asthma. n 14 % had 4 or more of the criteria for ABPA. n Chetty A, et al. Ann Allergy. 1985 Jan; 54(1): 46 -9.

Age of Onset and Severity of Asthma Age of onset below 5 years Odds ratio for development of Severe asthma 2. 44 (95% CI 1 -4. 54) Ratageri, Delhi. Indian Pediatr 2000 Oct; 37(10): 1072 -82

Study of asthma patients in a tertiary care center at Mumbai, India bhave et al Unpublished Total = 1050

Religion Bhave et al Unpublished

Symptoms Bhave et al Bhave Unpublished Pamesh (Indian J Pediatr 2002; 69(4): 309 -312)

Smoking in family Bhave et al n =1050 Unpublished

Triggers for acute exacerbation Bhave et al N = 1050 unpublished

Seasonal variation Bhave et al Unpublished Author City Effect seen H 35 % parmesh Bangalo re Bhave 40 % Mumbai Monsoon Winter summer 75. 8% 82. 3% 2% 80. 4% 70. 4% 10. 5%

Associated Upper airway conditions Bhave et al Unpublished

Epidemiology Allergic Rhinitis • 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 * Ø 22. 5% - 1994 6 -15 yrs Ø 27. 0% - 1998 6 -15 yrs * H. Paramesh Indian Journal of Pediatrics 2002 Ø 75. 0% - in asthmatics

Ig. E mediated hypersensitivity to house dust mite in causation of exercise induced spasm in children. Joshi SV, Tripathi DM, Bhave SY, Dhar HL, Indian J Allergy Immunol 2000; 14(1): 21 -23. n n 250 children with h/o asthma SPT and PFT done Serum Ig. E done in patients with positive SPT Selected cases above 12 years underwent exercise test for EIB

Positive reactions to different allergens Bhave et al

Sensitivity to house dust mite in asthmatic children and its correlation with pulmonary functions. Joshi SV, Tripathi DM, Bhave SY, Dhar HL, Indian J Allergy Immunol 1999; 13(1): 1 -3. n n 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).

Pulmonary Function Test (Average of predicted values in %) Bhave et al * P < 0. 001

Exercise induced bronchospasm in mite sensitive children Bhave et al Lability Index Average and S. D. Percentage 12. 5+4. 2 60 42. 25*+20 40 *p <0. 001

Treatment protocol Bhave et al Patient education for inhalation therapy 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

Treatment protocol ( contd) Bhave et al n n If patient refuses steroids Sodium cromoglycate , ketotefen n n ACUTE ATTACK n NEBULISATION , beta agonist , Ipratropium bromide ORAL rescue steroids 1 -5 days Follow protocol of acute severe asthma for hospitalized patients n n n

Response to treatment n n n 80 % regular inhaled steroids well controlled 10 % drop outs 10 % irregular follow up Bhave et al Unpublished n Diagnosis and treatment of associated conditions n GER Tuberculosis Upper respiratory disease n n

Bhave et al Unpublished Barriers to inhalation therapy n n n n 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

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 n n n 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. n n 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 n n n n 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 n n n Environmental issues like air pollution , air water soil and sound pollution Respiratory Infections and allergy disorders Conferences national & International sponsoring *Indian Academy of Pediatrics n. Radio talks , TV Interviews n. Public awareness rallies on world environment day n. School children education programs monthly for awareness

IAP *Respiratory Chapter 1987 n n n More than a 1500 members Quarterly bulletin Annual conferences, CME, s etc Patient education camps asthma camps World asthma day *Indian Academy of Pediatrics