|Year : 2015 | Volume
| Issue : 2 | Page : 62-66
An observational study of bronchial asthma in 6-12 years school going children of Agra District
Mohammad Amir1, Santosh Kumar1, Rajesh Kumar Gupta1, Gajendra Vikram Singh1, Rajesh Kumar2, Sanjeev Anand1, Devesh Pratap Singh1, Dileep Singh Rajauria1
1 Department of Tuberculosis and Chest Diseases, S.N. Medical College, Agra, Uttar Pradesh, India
2 Department of Pediatrics, S.N. Medical College, Agra, Uttar Pradesh, India
|Date of Web Publication||9-Mar-2016|
Department of Tuberculosis and Chest Diseases, S.N. Medical College, Agra, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: The present epidemiological study was planned and conducted to determine the prevalence of bronchial asthma in school going children of Agra, and to assess the precipitating factors in the causation of bronchial asthma mainly on the basis of the questionnaire and spirometry wherever possible. Methods: A total of 2175 school children in the age group 6-12 years from the two schools located in Agra were surveyed. These schools were selected on the basis of the surrounding environment and the socioeconomic status of their students. A detailed history was taken from students using a validated questionnaire. A total 153 cases of bronchial asthma were identified on the basis of the questionnaire. Out of which only 79 cases were subjected to spirometry. Spirometry could not be done in 74 students as their parents did not give consent. Results: The prevalence of bronchial asthma was found to be 7%. There were 61.4% male and 38.6% female patients having the disease. The study revealed that the upper classes had the largest number of students suffering from bronchial asthma. There is a higher prevalence of bronchial asthma in nonvegetarian children. Conclusion: This survey shows that the prevalence rates of bronchial asthma in school population (6-12 years) of Agra are almost similar to those seen in other parts of Northern India.
Keywords: Allergy, atopy, bronchial asthma, childhood asthma, school going children
|How to cite this article:|
Amir M, Kumar S, Gupta RK, Singh GV, Kumar R, Anand S, Singh DP, Rajauria DS. An observational study of bronchial asthma in 6-12 years school going children of Agra District. Indian J Allergy Asthma Immunol 2015;29:62-6
|How to cite this URL:|
Amir M, Kumar S, Gupta RK, Singh GV, Kumar R, Anand S, Singh DP, Rajauria DS. An observational study of bronchial asthma in 6-12 years school going children of Agra District. Indian J Allergy Asthma Immunol [serial online] 2015 [cited 2019 Sep 20];29:62-6. Available from: http://www.ijaai.in/text.asp?2015/29/2/62/178269
| Introduction|| |
Bronchial asthma is the most common chronic respiratory illness encountered during childhood. A wide variation in the prevalence rates has been documented. Studies of both children and adults have revealed low prevalence rates (2-4%) in Asian countries (especially China and India) and high prevalence rates (15-20%) in the United Kingdom, Canada, Australia, New Zealand, and other developed countries. ,,, There is limited data on asthma epidemiology from the developing world, including India.  Although some attempts have been made, studies suffer from several scientific drawbacks including lack of uniformity of the methodology and analysis of data.  Asthma rates are officially low in India, although there is some recent evidence that the true prevalence is higher than previously thought.  To date, the total estimated burden of asthma is an overall prevalence of 3% (30 million patients), and among adults over the age of 15, a median prevalence of 2.4%.  The population prevalence of asthma reported in different field studies is variable and ranges from 2.4% to 6.4%. Among school children, higher prevalence rates have been reported. 
| Methods|| |
Subjects for the survey were selected from two schools located in Agra. These schools were selected on the basis of the surrounding environment and the socioeconomic status of their students which represent all strata of the population. A total of 2175 school children in the age group 6-12 years were surveyed. The preset International Study of Asthma and Allergies in Childhood questionnaire has been used for obtaining a history of asthma. Every child was subjected to this questionnaire in the presence of their parents. On the basis of the questionnaire, those students who were found to be asthmatic were selected for spirometry. Spirometry could be performed only on those students whose parents gave consent and various lung functions (forced expiratory volume [FEV], forced vital capacity [FVC], and peak expiratory flow [PEF]) were measured with it.
Criteria for selection of patients for further assessment
Subjects were excluded from further assessment and from the study if there was an evidence of:
- History of dyspnea with wheeze
- Currently symptomatic
- Age group between 6 and 12 years
- Both males and females were taken for study
- H/O bronchial asthma and allergic diathesis.
The subjects suspected of having bronchial asthma and/or associated respiratory allergies were requested to come to the Outpatient Department of Tuberculosis and Chest Department, S.N. Medical College, Agra for further evaluation. Those who cooperated and reported to the Tuberculosis and Chest Department, S.N. Medical College, Agra were subjected to a detailed clinical history followed by a thorough clinical examination along with the following investigations:
- Tuberculosis - past or present
- Age group: <6 years or >12 years
- Any other associated respiratory or systemic disease.
A chest skiagram P/A view was done.
- Pulmonary function tests
Spirometry was performed on the children using spirometer.
The spirometry parameters evaluated were:
FEV1/FVC ratio <70% of predicted values for a given height and weight were taken as abnormal. Although it was kept in mind that a case suspected of suffering from bronchial asthma might have a normal PEFR and spirometry at the time of investigation, if the spasm is totally reversed with or without treatment.
- FEV in 1 s (FEV1)
- Ratio between FEV1/FVC
- PEF rate (PEFR).
The children who showed airway obstruction on the basis of spirometry were subjected to salbutamol inhalation (100 mcg, 2 puffs) through a metered dose inhaler. The spirometry was repeated after 20 min to assess the reversibility of the airway obstruction. In this study, intradermal tests, airway reactivity, and bronchoprovocation test were not performed due to inability to persuade the parents of children for giving consent for the tests.
The data collected from the questionnaire and spirometry were subjected to statistical analysis for computing the result. It was an observational study. Various parameters such as age, sex, socioeconomic factors, living conditions, family history, dietary factors, as well as exposure to environmental pollution, were analyzed to find out any relevance in the causation of disease pattern. Statistical methods used for evaluation included Chi-square test. The IBM SPSS Statistics for Windows, Version 20.0. (Armonk, NY: IBM corp.) has been used for the data analysis.
| Results|| |
In this study, 2175 children from two schools located in Agra were surveyed to find out the prevalence of bronchial asthma. After analyzing the data, the prevalence of bronchial asthma in school going children of Agra was found to be 7.0% (153 students) on the basis of the questionnaire.
[Table 1] shows the effect of various factors on bronchial asthma. In this study, the ratio of prevalence of bronchial asthma between boys and girls was found to be 1.4:1 (61.4% boys and 38.6% girls). The prevalence of bronchial asthma showed an increasing trend with an increase in age being 1.3%, 4.7%, 6.2%, 6.6%, and 12.8% in age group of 6, 7, 8, 9, and 10 years, respectively, while in the age group of 11 and 12 years prevalence was 7.6% and 9.1%, respectively. In this study, there is a significant association between the type of house and prevalence of bronchial asthma. The prevalence of bronchial asthma is the highest in upper class (8.2%) and lowest in upper-lower class (5.6%). The number of vegetarian and nonvegetarian children among the school population under study were 1369 and 653, respectively, and numbers of children with bronchial asthma in these groups were 71 and 82, respectively, i.e., there are 2 times higher prevalence of bronchial asthma in nonvegetarian group and this association is highly significant. Out of 2175 children studied, 811 children were subjected to passive smoking and asthma was found in 50 children (prevalence 5.8%), whereas children in which passive smoking was absent asthma was found in 103 children (prevalence 7.8%), but these data were not statistically significant.
|Table 1: Factors affecting the prevalence-of bronchial asthma and its significance |
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[Table 2] presents the effect of various factors on the prevalence of asthma. The prevalence of bronchial asthma is higher in a good environment around the house. The prevalence of bronchial asthma was found to be highest (8.6%) in children who commuted to the school by bus. The majority of households were using liquid petroleum gas (1896 out of 2175) and gobar gas was not used by any households, and no significant association could be drawn between the prevalence of bronchial asthma and type of fuel used. It was observed that out of the total 2175 subjects; 188 households had pets in their house, bronchial asthma was found in 21 children (prevalence 10%). Of the remaining 1836 households without pets in their house, bronchial asthma was found only in 132 children (prevalence 7.1%). Out of 116 children with family history of asthma and/or other allergy, bronchial asthma was present in 78 children (prevalence 42.4%); while in the group without a family history (1908 children), bronchial asthma was found in 75 children (prevalence 3.8%). In this study, out of the total 153 asthmatic children; allergic rhinitis, eye allergy, and skin allergy were found to be in 47 (59.5%), 24 (45.3%), and 9 (69%) children, respectively; while the nonasthmatic group (P < 0.0001) had 32 (5.1%), 29 (5.0%), and 4 (6.7%) cases of allergic rhinitis, eye allergy, and skin allergy, respectively.
|Table 2: Factors affecting the prevalence-of bronchial asthma and its significance |
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| Discussion|| |
This study in school going children of Agra showed the prevalence of bronchial asthma 7.0% which is almost similar to those seen in other parts of Northern India. The findings of our study are supported by a study conducted by Prasad et al. (year 2007, Lucknow) in their questionnaire-based study, which recorded the prevalence as 7.7%. 
According to Behl et al., prevalence is 2.3% in Shimla.  Singh et al. 2004 reported 12.8% prevalence rate based on pretested, modified, already validated asthma questionnaire.  However, Chhabra et al. in 1999 reported 15.7% prevalence of bronchial asthma (questionnaire-based).  The high prevalence rate was also reported by Parmesh, who showed a prevalence of 29.5%.  According to Gaur et al., the prevalence of asthma and rhinitis in children as 8% and 7.3%.  The low prevalence of bronchial asthma in Agra as compared to other major cities of India could be explained by the lack of industrialization because of Taj Mahal. In this study, males have a higher prevalence of bronchial asthma with 61.4% males and 38.6% females. According to Anuradha et al. in 2011, males (71.66%) outnumbered females (28.33%).  Chhabra et al. 1999 also reported a higher prevalence of asthma among male children of Delhi.  According to Kumar et al., the prevalence of bronchial asthma in school girls in Delhi was found to be 8.78%.  Dawson et al. (1969) found that among children of Aberdeen, the prevalence rate of asthma was 4.8%. The incidence in boys compared to girls was found to be 2:1. Shaw et al. found that the overall prevalence of wheeze in Kawarau children was 21.3%; prevalence was much higher in boys as compared to girls (1:7.1).  Male sex is a risk factor for asthma in children. Before the age of 14, the prevalence of asthma is nearly twice as great in boys as in girls.  As a child gets older, the difference between the sexes narrows and by adulthood the prevalence of asthma is greater in women than in men. It may be explained by lung size; lung size is smaller in male than female at the time of birth and in childhood but larger in adulthood.  In our study, the prevalence of asthma increases from 6 years to 10 years of age and then falls in 11 th and 12 th year. According to Aggarwal et al., the total estimated burden of asthma is an overall prevalence of 3% (30 million patients), and among adults over the age of 15, a median prevalence of 2.4%.  Researchers in the field opined that a higher prevalence of asthma in the younger age group was consistent with the widely believed concept of "children growing out of allergic diseases." 
The study revealed upper class had the largest number of patients suffering from bronchial asthma. Our finding is supported by the studies of Jain et al. and Prasad et al. and unlike the finding of Anuradha et al. which shows positive association between asthma and lower socioeconomic status people. ,, Goh et al. 1996 also reported the prevalence of parent-reported asthma to be greater among subjects of higher socioeconomic status in Singapore.  The prevalence of bronchial asthma is significantly higher (2 times) in nonvegetarian children. A vegetarian diet exerts an effect in decreasing the prevalence of asthma. Some other studies also suggest that increased consumption of green leafy vegetables and fruits are associated with a decreased risk of atopic diseases. ,,, The prevalence of bronchial asthma is higher in a good environment around the house. This finding is in the favor of the hygiene hypothesis of bronchial asthma that suggest that exposure to infection in early life influence the development of a child's immune system along a "nonallergic" pathway, leading to a reduced risk of asthma and other allergic diseases.
About 77% of total cases of bronchial asthma were detected in the children who commuted to the school by bus, foot, or rickshaw. The highest prevalence in these groups is explained by more exposure to diesel exhaust particle and other traffic pollutants. In this study, the prevalence of bronchial asthma was found to be higher in association with allergic rhinitis, eye allergies, and skin allergies.
There was no significant correlation detected between the prevalence rates of bronchial asthma and pets in the house. The reason for this finding may be that allergens are ubiquitous and can be found in any environment outside the home which affect the subjects. ,, In the case of dogs and cats, some epidemiologic studies have found that early exposure to these animals may protect a child against allergic sensitization or the development of asthma, ,, but others suggest that such exposure may increase the risk of allergic sensitization. ,,, Likewise, cooking fuel used also was not found to be associated with bronchial asthma. The number of liquefied petroleum gas users was too high than the other fuel users so that no statistically significant conclusion could be drawn.
In this study, no significant association has been found between passive smoking and asthma. Exposure to tobacco smoking both prenatally and after birth is associated with measurable harmful effects including greater risk of developing asthma-like symptoms in early childhood. However, evidence of the increased risk of allergic diseases is uncertain. ,
| Conclusion|| |
It is, therefore, suggested that the explanation for the low prevalence of bronchial asthma in Agra District are due to paucity of industries as Taj Mahal is situated here. There is strict government control on activities and establishments that increases pollution in Agra to protect Taj Mahal from the hazardous effects of pollution. These findings suggest that environment is a very important determinant of bronchial asthma.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Worldwide variations in the prevalence of asthma symptoms: The International Study of Asthma and Allergies in Childhood (ISAAC). Eur Respir J 1998;12:315-35.
Janson C, Anto J, Burney P, Chinn S, de Marco R, Heinrich J, et al.
The European Community Respiratory Health Survey: What are the main results so far? European Community Respiratory Health Survey II. Eur Respir J 2001;18:598-611.
Asher MI, Montefort S, Björkstén B, Lai CK, Strachan DP, Weiland SK, et al.
Worldwide time trends in the prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and eczema in childhood: ISAAC Phases One and Three repeat multicountry cross-sectional surveys. Lancet 2006;368:733-43.
Zock JP, Heinrich J, Jarvis D, Verlato G, Norbäck D, Plana E, et al.
Distribution and determinants of house dust mite allergens in Europe: The European Community Respiratory Health Survey II. J Allergy Clin Immunol 2006;118:682-90.
Subbarao P, Mandhane PJ, Sears MR. Asthma: Epidemiology, etiology and risk factors. CMAJ 2009;181:E181-90.
Aggarwal AN, Chaudhry K, Chhabra SK, D'Souza GA, Gupta D, Jindal SK, et al.
Prevalence and risk factors for bronchial asthma in Indian adults: A multicentre study. Indian J Chest Dis Allied Sci 2006;48:13-22.
Pal R, Dahal S, Pal S. Prevalence of bronchial asthma in Indian children. Indian J Community Med 2009;34:310-6.
Prasad R, Verma SK, Ojha S, Srivastava VK. A quistionnaire based study of bronchial asthma in rural children of Lucknow. Indian J Allergy Asthma Immunol 2007;21:15-8.
Behl RK, Kashyap S, Sarkar M. Prevalence of bronchial asthma in school children of 6-13 years of age in Shimla city. Indian J Chest Dis Allied Sci 2010;52:145-8.
Singh M, Singh SP, Singh K, Bhatia AS, Kajal NC, Aggarwal D, et al
. Prevalance of bronchial asthma among school children in urban and rural areas. Chest 2004;126:762S.
Chhabra SK, Gupta CK, Chhabra P, Rajpal S. Risk factors for development of bronchial asthma in children in Delhi. Ann Allergy Asthma Immunol 1999;83:385-90.
Paramesh H. Epidemiology of asthma in India. Indian J Pediatr 2002;69:309-12.
Gaur SN, Rajpal S, Rohatgi A. Prevalence of bronchial asthma and allergic rhinitis among school children in Delhi. Intern Med J Thail 2004;20:8-13.
Anuradha A, Kalpana VL, Narsingarao S. Epidemiological study on bronchial asthma. Indian J Allergy Asthma Immunol 2011;25:85-9.
Kumar R, Singhal P, Jain A, Raj N. Prevalence of bronchial asthma and allergic rhinitis in school girls in Delhi. Indian J Allergy Asthma Immunol 2008;22:99-104.
Shaw R, Woodman K, Crane J, Moyes C, Kennedy J, Pearce N. Risk factors for asthma symptoms in Kawerau children. N Z Med J 1994;107:387-91.
Horwood LJ, Fergusson DM, Shannon FT. Social and familial factors in the development of early childhood asthma. Pediatrics 1985;75:859-68.
Martinez FD, Wright AL, Taussig LM, Holberg CJ, Halonen M, Morgan WJ. Asthma and wheezing in the first six years of life. The Group Health Medical Associates. N Engl J Med 1995;332:133-8.
Hsieh KH, Shen JJ. Prevalence of childhood asthma in Taipei, Taiwan, and other Asian Pacific countries. J Asthma 1988;25:73-82.
Jain A, Vinod Bhat H, Acharya D. Prevalence of bronchial asthma in rural Indian children: A cross sectional study from South India. Indian J Pediatr 2010;77:31-5.
Goh DY, Chew FT, Quek SC, Lee BW. Prevalence and severity of asthma, rhinitis, and eczema in Singapore schoolchildren. Arch Dis Child 1996;74:131-5.
Strachan DP, Cox BD, Erzinclioglu SW, Walters DE, Whichelow MJ. Ventilatory function and winter fresh fruit consumption in a random sample of British adults. Thorax 1991;46:624-9.
Carey IM, Strachan DP, Cook DG. Effects of changes in fresh fruit consumption on ventilatory function in healthy British adults. Am J Respir Crit Care Med 1998;158:728-33.
Forastiere F, Pistelli R, Sestini P, Fortes C, Renzoni E, Rusconi F, et al.
Consumption of fresh fruit rich in vitamin C and wheezing symptoms in children. SIDRIA Collaborative Group, Italy (Italian Studies on Respiratory Disorders in Children and the Environment). Thorax 2000;55:283-8.
Gilliland FD, Berhane KT, Li YF, Gauderman WJ, McConnell R, Peters J. Children's lung function and antioxidant vitamin, fruit, juice, and vegetable intake. Am J Epidemiol 2003;158:576-84.
Huss K, Adkinson NF Jr, Eggleston PA, Dawson C, Van Natta ML, Hamilton RG. House dust mite and cockroach exposure are strong risk factors for positive allergy skin test responses in the Childhood Asthma Management Program. J Allergy Clin Immunol 2001;107:48-54.
Sears MR, Greene JM, Willan AR, Wiecek EM, Taylor DR, Flannery EM, et al.
A longitudinal, population-based, cohort study of childhood asthma followed to adulthood. N Engl J Med 2003;349:1414-22.
Sporik R, Ingram JM, Price W, Sussman JH, Honsinger RW, Platts-Mills TA. Association of asthma with serum IgE and skin test reactivity to allergens among children living at high altitude. Tickling the dragon's breath. Am J Respir Crit Care Med 1995;151:1388-92.
Platts-Mills T, Vaughan J, Squillace S, Woodfolk J, Sporik R. Sensitisation, asthma, and a modified Th2 response in children exposed to cat allergen: A population-based cross-sectional study. Lancet 2001;357:752-6.
Ownby DR, Johnson CC, Peterson EL. Exposure to dogs and cats in the first year of life and risk of allergic sensitization at 6 to 7 years of age. JAMA 2002;288:963-72.
Gern JE, Reardon CL, Hoffjan S, Nicolae D, Li Z, Roberg KA, et al.
Effects of dog ownership and genotype on immune development and atopy in infancy. J Allergy Clin Immunol 2004;113:307-14.
Celedón JC, Litonjua AA, Ryan L, Platts-Mills T, Weiss ST, Gold DR. Exposure to cat allergen, maternal history of asthma, and wheezing in first 5 years of life. Lancet 2002;360:781-2.
Melén E, Wickman M, Nordvall SL, van Hage-Hamsten M, Lindfors A. Influence of early and current environmental exposure factors on sensitization and outcome of asthma in pre-school children. Allergy 2001;56:646-52.
Almqvist C, Egmar AC, van Hage-Hamsten M, Berglind N, Pershagen G, Nordvall SL, et al.
Heredity, pet ownership, and confounding control in a population-based birth cohort. J Allergy Clin Immunol 2003;111:800-6.
Strachan DP, Cook DG. Health effects of passive smoking .5. Parental smoking and allergic sensitisation in children. Thorax 1998;53:117-23.
Kulig M, Luck W, Lau S, Niggemann B, Bergmann R, Klettke U, et al.
Effect of pre- and post-natal tobacco smoke exposure on specific sensitization to food and inhalant allergens during the first 3 years of life. Multicenter Allergy Study Group, Germany. Allergy 1999;54:220-8.
[Table 1], [Table 2]