Transcript Asthma in Indian children

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
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No Representative National Data
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Vast Country
Variable population density
Variable Climates
Variable Pollution Levels
Wide variety in education, life style,
infections,
Infectious Diseases are still a priority
Prevalence
25.00%
20.00%
15.00%
10.00%
5.00%
0.00%
Vishwanathan, 1966
Chhabra, 98
Chhabra, 99
Chakravorty, 2002
Prevalence of Asthma in Indian Children
First Populations study, ISAAC Study in 1990s.
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ISSAC Phase-I “ever had asthma”
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14 centers, 228 schools, n=100,000
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13-14 years ( 95 % responded)
 2.6 - 6.5% (Kottayam-12.4%) average 4.5 %
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6-7 years ( 92 % responded )
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1- 4.2% (Kottayam 14.4%, ) average 3.7%.
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Prevalence of wheeze
(in response to self-completed wheezing questionnaire (video)
data)
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13-14 yrs - 0.8 to 7.1%
average 2.9%.
ISAAC - India
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Groups
Wheeze
6 - 7 Yrs
5.6 %
13-14 Yrs
6.0%
(0.8 - 14.6)
(1.6 - 17.8)
> 4 attacks 1.5%
1.6%
(0.1 - 4.7)
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Night Cough
Ever had Asthma
(0.5 - 3.5)
12.3%
14.1%
(3.3 - 27)
(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)
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Wheeze
2.9 %
2.3%
 Night Cough
3.7%
 Severe Wheeze 2.5%
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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
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Urban
Rural
Past BD
Chakravorty, Chennai. Natl Med
J India 2002; 15:260-3
Sudhir P Prasad CE, Hyderabad.
J Trop Pediatr 2003 Apr; 49(2):104-8
Nocturnal
Cough
Recent
Wheeze
Diagnosed
Asthma
Exercise
Induced
Rural children
2001 n=119, Age – 06-15 yrs, Ratio – M:F – 1:2.3
9.00%
8.00%
7.00%
8.40%
6.00%
5.00%
5.80%
4.00%
3.00%
2.00%
2.52%
1.00%
0.00%
Total
Boys
Source - H. Paramesh, E. Cherian. Ind. Joul of Pediatr 2002
Girls
Factors associated with higher
incidence
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Positive association
School in heavy
traffic areas
Low SES
Male sex
No windows
Atopy or asthma in
family
Grandparents, sibling
NO association
 Air pollution:
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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
70.00%
68.50%
60.00%
50.00%
42.30%
40.00%
26.12%
30.00%
16.63%
14.90%
20.00%
10.00%
5.12%
5.70% 7.50%
15.60%
6.20%
2.40%
1.00%
0.00%
School Children
(Urban)
School Children
(Rural)
Traffic Police
% of asthma
Non Traffic Police
% of Pets
Rural Farm
Workers
Poultry Farm
Workers
Contribution of various sectors to
ambient air pollution
80
70
60
50
Industrial
% age
40
Transport
Domestic
30
20
10
0
1970-1971
1980-1981
1990-1991
2000-2001
Ministry of Environment & Forests, 1997
Prevalence of asthma in school children effect of traffic
age 6 –15 yrs
No.273
(31.14%)
35.00%
30.00%
No.3722
(19.34%)
25.00%
20.00%
15.00%
No. 2565
(11.15%)
10.00%
5.00%
0.00%
Schools in low traffic
regions
Schools in heavy traffic
regions
P. Value I, II & III < 0.001.
H. Paramesh, Down to earth - 2001
Schools in heavy traffic
with low socio economic
status
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
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243 children with BA
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107 children (44%):perennial
asthma.
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14 % had 4 or more of the
criteria for ABPA.
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Chetty A, et al. Ann Allergy.1985 Jan;54(1):46-9.
Age (Months)
Age of Onset and Severity of Asthma
90
80
70
60
50
40
30
20
10
0
Age of onset
below 5 years
Odds ratio for
development of
Severe asthma
84
48
Mild
Severe
Median Age of Onset
Ratageri, Delhi. Indian Pediatr 2000 Oct;
37(10): 1072-82
2.44 (95% CI
1-4.54)
Study of asthma patients in a tertiary
care center at Mumbai, India bhave et al
Unpublished
350
300
250
200
150
100
50
0
1
1-3 3-5
MY
Y
1 Y
Male
Total = 1050
5- 10- 1210 12 18
Y
Y
Y
Female
Religion
Bhave et al
Unpublished
32
11
262
745
Hindu
Christians
Muslim
Others
Symptoms
Bhave et al
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
e)
W
+
gh
(C
ou
om
in
a
Pa
he
ez
in
in
Pa
A
bd
C
he
st
he
ez
e
W
C
ou
gh
Bhave, Mumbai
Parmesh, Bangalore
Bhave Unpublished
Pamesh (Indian J
Pediatr 2002;
69(4):309-312)
Smoking in family
Bhave et al n =1050
Unpublished
10%
22%
9%
1%
80%
78%
No
Yes
FATHER
RELATIVE
MOTHER
VISITOR
Triggers for acute exacerbation Bhave et al
unpublished
Viral infection
5%
1%
Cold
drinks/icecreams
14 %
37%
Food item
Dust exposure
11%
Change of season
Picnics/camps
7%
9%
8%
Physical stress
8%
N = 1050
Emotional stress
Seasonal variation
Bhave et al
Unpublished
Author
City
Effect seen
H
35 %
parmes
h
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
No
Associated
Condition
Tonsillitis
+Rhinitis
100%
90%
80%
Sinusitis +
Tonsillitis
70%
60%
Rhinitis
+Sinusitis
50%
Ottitis media
40%
30%
Sinusitis
20%
Tonsillitis
10%
0%
1-12 1 - 3
M
Y
3 –
5 Y
5
–10
Y
10
12–12 18 Y
Y
Allergic
Rhinitis
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 *
 22.5% - 1994
6-15yrs
 27.0% - 1998
6-15yrs
* H. Paramesh Indian Journal of Pediatrics 2002
 75.0% - in asthmatics
IgE 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.
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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
Positive reactions to different allergens
Bhave et al
18%
19%
8%
17%
12%
12%
14%
Mite Sp.
Dusts
Pollens
Fungi
Insects
Epithelia
Foods
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.
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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
140
125128
120
100
80
86.21
60 55.5
94.28
86.33
86.33
Positive to mite Ag
Negative to mite Ag
55.5
40
33.75
33.75
20
* P < 0.001
0
FVC*
FEV1*
FEF*
PEFR*
MVV
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
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If patient refuses steroids
Sodium cromoglycate , ketotefen
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ACUTE ATTACK
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NEBULISATION
,beta agonist , Ipratropium bromide
ORAL rescue steroids 1-5 days
Follow protocol of acute severe asthma for
hospitalized patients
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Response to treatment
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80 % regular
inhaled
steroids well
controlled
10 % drop
outs
10 % irregular
follow up
Bhave et al
Unpublished
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Diagnosis and
treatment of
associated
conditions
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GER
Tuberculosis
Upper respiratory
disease
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Bhave et al
Unpublished
Barriers to inhalation therapy
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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
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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.
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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
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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
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Environmental issues
like air pollution , air
water soil and sound
pollution
Respiratory
Infections and allergy
disorders
Conferences national
& International
sponsoring
*Indian Academy of Pediatrics
Radio
talks , TV
Interviews
Public
awareness
rallies on world
environment day
School
children
education
programs monthly
for awareness
IAP *Respiratory Chapter 1987
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More than a 1500 members
Quarterly bulletin
Annual conferences, CME,s etc
Patient education camps
asthma camps
World asthma day
*Indian Academy of Pediatrics