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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.

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Asthma in Indian children

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  1. 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

  2. Disease Trends Infectious Diseases Allergic (Inflammatory) Diseases

  3. 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

  4. Prevalence

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

  6. ISAAC - India • Groups 6 - 7 Yrs 13-14 Yrs • Wheeze 5.6 % 6.0% (0.8 - 14.6) (1.6 - 17.8) • > 4 attacks 1.5% 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.

  7. ISAAC – IndiaVideo 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 Wheeze2.5% (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.

  8. 12-month prevalence of self-reported asthma symptoms from written questionnaires 12-month prevalence of asthma symptoms from video questionnaires

  9. 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

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

  11. 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 Factors associated with higher incidence

  12. Equivocal factors • Parental smoking • Pets at home • Low SES • Air pollution

  13. Asthma / Pets

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

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

  16. Respiratory allergies / asthma in children related to industrialization

  17. Allergic bronchopulmonary aspergillosis in Indian children with bronchialasthma • 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.

  18. 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

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 Study of asthma patients in a tertiary care center at Mumbai, India bhave et al Unpublished Total = 1050

  20. Religion Bhave et alUnpublished

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 Bhave et al Symptoms Bhave Unpublished Pamesh (Indian J Pediatr 2002; 69(4):309-312)

  22. Smoking in family Bhave et al n =1050Unpublished

  23. Triggers for acute exacerbation Bhave et al unpublished N = 1050

  24. Bhave et al Unpublished Seasonal variation

  25. Associated Upper airway conditionsBhave et al Unpublished

  26. 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 • 75.0% - in asthmatics * H. Paramesh Indian Journal of Pediatrics 2002

  27. 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. • 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

  28. Positive reactions to different allergens Bhave et al

  29. 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. • 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).

  30. Pulmonary Function Test (Average of predicted values in %) Bhave et al * P < 0.001

  31. Exercise induced bronchospasm in mite sensitive children Bhave et al

  32. Bhave et al Treatment protocol 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

  33. 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

  34. 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 al Unpublished Response to treatment

  35. Bhave et al Unpublished 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

  36. 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. 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

  37. Management programs in India • Public health Education • Community awareness • Parental programs • School health programs • Asthma camps • Pamphlets, CD,s Video • TV programs, radio talks

  38. IAP Environment & child health chapter 2000 • Radio talks , TV Interviews • Public awareness rallies on world environment day • School children education programs monthly for awareness • Environmental issues like air pollution , air water soil and sound pollution • Respiratory Infections and allergy disorders • Conferences national & International sponsoring *Indian Academy of Pediatrics

  39. 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

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