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

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

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

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.

 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%.

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.

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%


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

Urban rural

100%
90%
80%
70%
60%
50% Urban
40% Rural
30%
20%
10%
0%
Past BD Nocturnal Recent Diagnosed Exercise
Cough Wheeze Asthma Induced

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

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

Factors associated with higher
incidence
 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

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%

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

Contribution of various sectors to
ambient air pollution

80

70

60

50
Industrial
40 age
% 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

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

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

 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.

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 Onset

Ratageri, Delhi. Indian Pediatr 2000 Oct;
37(10): 1072-82

Study of asthma patients in a tertiary care
center 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 Female

Total = 1050

Religion
11
32
262

745

Hindu Muslim
Christians Others

Symptoms

90%
80%
70%
60%
50% Bhave, Mumbai
40% Parmesh, Bangalore
30%
20%
10%
0%
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Bhave Unpublished
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Pamesh (Indian J
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Pediatr 2002;
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69(4):309-312)
(C

Smoking in family

10% 9%
22%
1%

80%

78%
FATHER MOTHER
RELATIVE VISITOR
No Yes

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

Seasonal variation

Author Effect seen Monsoon Winter summer
City

H 35 % 75.8% 82. 3% 2%
parmes
h
Bangalo
re
Bhave 40 % 80 .4% 70 .4% 10 .5%
Mumbai

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

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

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

Positive reactions to different allergens

19% 18% Mite Sp.
Dusts
8% Pollens
Fungi
17% Insects
12% Epithelia
12% 14% Foods

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).

Pulmonary Function Test
(Average of predicted values in %)
140
128
125
120
100 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

Exercise induced bronchospasm in
mite sensitive children

Lability Index Percentage
Average and S.D.

12.5+4.2 60

42.25*+20 40

*p <0.001

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

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

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

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

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.  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.

Management programs in India
 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

 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

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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