asthma in indian children dr. swati bhave former president ( iap)indian academy of pediatric(2000)...
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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
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Disease Trends
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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
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Prevalence
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
Vishwanathan, 1966 Chhabra, 98 Chhabra, 99 Chakravorty, 2002
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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.
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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.
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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.
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12-month prevalence of self-reported asthma
symptoms from written questionnaires
12-month prevalence of asthmasymptoms from video questionnaires
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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
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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
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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
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Equivocal factors
Parental smoking Pets at home Low SES Air pollution
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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
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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
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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
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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
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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.
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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)
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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
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Religion Bhave et al Unpublished
745
262
3211
Hindu Muslim
Christians Others
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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
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Smoking in family Bhave et al n =1050
Unpublished
80%
1%
10% 9%
FATHER MOTHER
RELATIVE VISITOR
78%
22%
No Yes
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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
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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
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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
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• 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
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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.
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Positive reactions to different allergens
18%
17%
14%12%
12%
8%
19% Mite Sp.
Dusts
Pollens
Fungi
Insects
Epithelia
Foods
Bhave et al
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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.
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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
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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
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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
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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
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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
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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
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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.
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Management programs in India
Public health Education Community awareness Parental programs School health programs Asthma camps Pamphlets, CD,s Video TV programs, radio talks
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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
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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