A S T H M A I N I N D I A N C H I L D R E N

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LOT OF THANKS TO SWATI BHAVE MADAM FOR GIVING US SUCH A NICE PRESENTATION FOR MEDICOTESTING. THANKS A LOT MAAM

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A S T H M A I N I N D I A N C H I L D R E N

  1. 1. 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
  2. 2. Disease Trends
  3. 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. 4. Prevalence25.00%20.00%15.00%10.00% 5.00% 0.00% Vishwanathan, 1966 Chhabra, 98 Chhabra, 99 Chakravorty, 2002
  5. 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. 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. 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 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.
  8. 8. 12-month prevalence of self-reported 12-month prevalence of asthma asthma symptoms from video questionnairessymptoms from written questionnaires
  9. 9. Urban rural 100% 90% 80% 70% 60% 50% Urban 40% Rural 30% 20% 10% 0% Past BD Nocturnal Recent Diagnosed Exercise Cough Wheeze Asthma InducedChakravorty, Chennai. Natl MedJ India 2002; 15:260-3Sudhir P Prasad CE, Hyderabad.J Trop Pediatr 2003 Apr; 49(2):104-8
  10. 10. Rural children2001 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 Girls Source - H. Paramesh, E. Cherian. Ind. Joul of Pediatr 2002
  11. 11. Factors associated with higherincidence Positive association NO association School in heavy traffic  Air pollution: areas  Suspended particles Low SES  Over crowding Male sex  Type of domestic kitchen No windows fuel  Location of kitchen Atopy or asthma in family  Over crowding Grandparents, sibling  H/O worm infestation  food allergy
  12. 12. Equivocal factorsParental smokingPets at homeLow SESAir pollution
  13. 13. Asthma / Pets70.00% 68.50%60.00%50.00% 42.30%40.00%30.00% 26.12% 16.63%20.00% 14.90% 15.60% 5.12% 5.70% 7.50% 6.20%10.00% 2.40% 1.00%0.00% School Children School Children Traffic Police Non Traffic Police Rural Farm Poultry Farm (Urban) (Rural) Workers Workers % of asthma % of Pets
  14. 14. Contribution of various sectors to ambient air pollution80706050 Industrial40 age% Transport Domestic302010 0 1970-1971 1980-1981 1990-1991 2000-2001 Ministry of Environment & Forests, 1997
  15. 15. Prevalence of asthma in school children effect of trafficage 6 –15 yrs 35.00% No.273 (31.14%) 30.00% 25.00% No.3722 (19.34%) 20.00% No. 2565 15.00% (11.15%) 10.00% 5.00% 0.00% Schools in low traffic Schools in heavy traffic Schools in heavy traffic regions regions with low socio economic status P. Value I, II & III < 0.001. H. Paramesh, Down to earth - 2001
  16. 16. Respiratory allergies / asthma in childrenrelated to industrializationYear Asthma Industries Populat Automobiles % increase % ion in in million / year million1979 9 4700 2.55 0.1401984 10.5 7887 3.29 0.236 0.31989 18.5 14384 4.6 0.460 1.61994 24.5 25758 5.3 0.714 1.21999 29.5 40145 6.3 1.223 1.0 Source – H. Paramesh. Down to Earth – July 2001
  17. 17. Allergic bronchopulmonary aspergillosisin 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.
  18. 18. Age of Onset and Severity of Asthma 90 Age of onset 80 below 5 years 70 60 Odds ratio for Age (Months) 50 development of 40 84 Severe asthma 30 48 2.44 (95% CI 20 10 1-4.54) 0 Mild Severe Median Age of OnsetRatageri, Delhi. Indian Pediatr 2000 Oct;37(10): 1072-82
  19. 19. Study of asthma patients in a tertiary carecenter at Mumbai, India 350 300 250 200 150 100 50 0 1 1-3 3-5 5- 10- 12- M- Y Y 10 12 18 1 Y Y Y Y Male FemaleTotal = 1050
  20. 20. Religion 11 32262 745 Hindu Muslim Christians Others
  21. 21. Symptoms90%80%70%60%50% Bhave, Mumbai40% Parmesh, Bangalore30%20%10% 0% e in e) gh in ez ez Pa Pa ou he he Bhave Unpublished st a C W in W he om Pamesh (Indian J + C gh bd Pediatr 2002; ou A 69(4):309-312) (C
  22. 22. Smoking in family 10% 9% 22% 1% 80% 78% FATHER MOTHER RELATIVE VISITOR No Yes
  23. 23. Triggers for acute exacerbation 1% Viral infection 5% Cold 14 % drinks/icecreams 3 7 % Food item Dust exposure 11% Change of season 7% Picnics/camps 8% 9% Physical stress 8% Emotional stress N = 1050
  24. 24. Seasonal variationAuthor Effect seen Monsoon Winter summerCityH 35 % 75.8% 82. 3% 2%parmeshBangaloreBhave 40 % 80 .4% 70 .4% 10 .5%Mumbai
  25. 25. Associated Upper airway conditions No 100% Associated Condition 90% Tonsillitis +Rhinitis 80% Sinusitis + 70% Tonsillitis 60% Rhinitis +Sinusitis 50% Ottitis media 40% 30% Sinusitis 20% 10% Tonsillitis 0% 1-12 1 - 3 3 – 5 10 12- Allergic M Y 5 Y –10 –12 18 Y Rhinitis Y Y
  26. 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. 27. IgE mediated hypersensitivity to house dust mite in causation ofexercise 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
  28. 28. Positive reactions to different allergens 19% 18% Mite Sp. Dusts 8% Pollens Fungi 17% Insects 12% Epithelia 12% 14% Foods
  29. 29. Sensitivity to house dust mite in asthmatic children and itscorrelation 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).
  30. 30. Pulmonary Function Test(Average of predicted values in %)140 128 125120100 94.28 86.21 86.33 86.33 80 Positive to mite Ag 60 55.5 55.5 Negative to mite Ag 40 33.75 33.75 20 0 * P < 0.001 FVC* FEV1* FEF* PEFR* MVV
  31. 31. Exercise induced bronchospasm inmite sensitive childrenLability Index PercentageAverage and S.D.12.5+4.2 6042.25*+20 40*p <0.001
  32. 32. 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. 33. 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. 34. Response to treatment 80 % regular  Diagnosis and inhaled treatment of steroids well controlled associated 10 % drop outs conditions 10 % irregular  GER follow up  Tuberculosis  Upper respiratory disease
  35. 35. 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. 36. Study on management practices of medical practitioners inbronchial asthma.Gupta PR, Verma SK, Indian Journal of Allergy Asthma and Immunology. 2002 Jul-Dec; 16(2): 89-92  280 doctors/135 patients.  Over and erratic use of  Lack of awareness oral steroids recent advances  injudicious use of  Non-adherence: supportive measures guidelines  under use PFT PEFR  oral drugs prefereed Inadequate attention to  Both patient and doctor health education . seemed responsible for  Need for updating the unpopularity of inhaled knowledge of doctors therapy. together with imparting health education to the patients.
  37. 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. 38. IAPEnvironment & child health chapter 2000  Environmental issues Radio talks , TV like air pollution , air Interviews water soil and sound pollution Public awareness  Respiratory Infections rallies on world and allergy disorders environment day  Conferences national School children & International education sponsoring programs monthly for awareness *Indian Academy of Pediatrics

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