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Prevalence, time trends and treatment practices of asthma in India: the Global Asthma Network study

Sheetu Singh, Sundeep Salvi, Daya Krishan Mangal, Meenu Singh, Shally Awasthi, Padukudru Anand Mahesh, Sushil K. Kabra, Sabir Mohammed, Thevaruparambil U. Sukumaran, Aloke G. Ghoshal, Monica Barne, Sanjeev Sinha, Sanjay K. Kochar, Nishtha Singh, Udaiveer Singh, Kamalesh Kumar Patel, Arvind Kumar Sharma, Bhushan Girase, Anil Chauhan, Niranjan Sit, Jayaraj B. Siddaiah, Virendra Singh
ERJ Open Research 2022 8: 00528-2021; DOI: 10.1183/23120541.00528-2021
Sheetu Singh
1Dept of Pulmonary Medicine, Rajasthan Hospital, Jaipur, India
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Sundeep Salvi
2Pulmocare Research and Education Foundation, Pune, India
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Daya Krishan Mangal
3Dept of Public Health, IIHMR University, Jaipur, India
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Meenu Singh
4Dept of Pediatrics, Postgraduate Institute of Medical Education and Research, Changdigarh, India
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Shally Awasthi
5Dept of Pediatrics, King George's Medical University, Lucknow, India
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Padukudru Anand Mahesh
6Dept of Respiratory Medicine, Jagadguru Sri Shivarathreeshwara Medical College, JSSAHER, Mysuru, India
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  • ORCID record for Padukudru Anand Mahesh
Sushil K. Kabra
7Dept of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
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Sabir Mohammed
8Dept of Pulmonary Medicine, Kothari Medical College and Research Institute, Bikaner, India
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Thevaruparambil U. Sukumaran
9Dept of Pediatrics, Caritas Hospital, Thellakom, Kottayam, India
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Aloke G. Ghoshal
10National Allergy Asthma Bronchitis Institute, Kolkata, India
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Monica Barne
2Pulmocare Research and Education Foundation, Pune, India
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Sanjeev Sinha
11Dept of Medicine, All India Institute of Medical Sciences, New Delhi, India
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Sanjay K. Kochar
8Dept of Pulmonary Medicine, Kothari Medical College and Research Institute, Bikaner, India
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Nishtha Singh
12Dept of Respiratory Medicine, Asthma Bhawan, Jaipur, India
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Udaiveer Singh
13Division of Research, Asthma Bhawan, Jaipur, India
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Kamalesh Kumar Patel
3Dept of Public Health, IIHMR University, Jaipur, India
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Arvind Kumar Sharma
14Dept of Community Medicine, Mahatma Gandhi Medical College and Hospital, Jaipur, India
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Bhushan Girase
15Family Health, PATH, New Delhi, India
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Anil Chauhan
16Dept of Telemedicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Niranjan Sit
10National Allergy Asthma Bronchitis Institute, Kolkata, India
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Jayaraj B. Siddaiah
6Dept of Respiratory Medicine, Jagadguru Sri Shivarathreeshwara Medical College, JSSAHER, Mysuru, India
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Virendra Singh
12Dept of Respiratory Medicine, Asthma Bhawan, Jaipur, India
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  • For correspondence: drvirendrasingh93@gmail.com
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  • FIGURE 1
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    FIGURE 1

    Flow chart depicting recruitment into the Global Asthma Network study.

  • FIGURE 2
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    FIGURE 2

    Time trends in various aspects of asthma including current wheeze, wheeze ever, nocturnal cough, severe asthma and asthma ever through the International Study of Asthma and Allergies in Childhood (ISAAC) Phase I and Phase III, and the Global Asthma Network (GAN) Phase I, in the two age groups of children. #: severe asthma is defined as more than four attacks of wheezing in previous 12 months or wheeze affecting sleep or speech in previous 12 months. *: p<0.05; **: p<0.01; ***: p<0.001 when ISAAC Phase I compared to ISAAC Phase II. ¶¶¶: p<0.001 when ISAAC Phase III compared to GAN Phase I.

Tables

  • Figures
  • TABLE 1

    Prevalence of symptoms of asthma, severe asthma, asthma ever and doctor-diagnosed asthma in children and adults across both genders

    Symptoms6–7-year age group (n=20 084)13–14-year age group (n=25 887)Adults (n=81 296)#
    Male (n=10 441)Female (n=9643)p-value¶Total n (%)Male (n=12 671)Female (n=13 216)p-value¶Total n (%)Male (n=40 468)Female (n=40 815)p-value¶Total n (%)
    n (%)n (%)n (%)n (%)n (%)n (%)
    Current wheeze380 (3.64)254 (2.63)<0.0001634 (3.16)565 (4.46)375 (2.84)<0.0001940 (3.63)1344 (3.32)1335 (3.27)0.6892680 (3.30)
    Wheeze ever+757 (7.25)498 (5.16)<0.00011255 (6.25)1139 (8.99)778 (5.89)<0.00011917 (7.41)
    Nocturnal cough in past 12 months+1870 (17.91)1370 (14.21)<0.0013240 (16.13)3864 (30.49)3520 (26.63)<0.00017384 (28.52)
    Asthma severe§192 (1.84)128 (1.33)0.004320 (1.59)258 (2.04)157 (1.19)<0.0001415 (1.60)465 (1.15)476 (1.17)0.790942 (1.16)
    Asthma ever174 (1.67)109 (1.13)0.0012283 (1.41)630 (4.97)426 (3.22)<0.00011056 (4.08)714 (1.76)942 (2.31)<0.00011656 (2.04)
    Doctor-diagnosed asthma138 (1.32)88 (0.91)0.0059226 (1.13)354 (2.79)246 (1.86)<0.0001600 (2.32)517 (1.28)659 (1.61)0.0001176 (1.45)

    #: sex not defined for 13 adults. ¶: Chi-squared test. +: questions not included in adult questionnaire. §: severe asthma is defined as more than four attacks of wheezing in previous 12 months or wheeze affecting sleep or speech in previous 12 months.

    • TABLE 2

      Time trends in known environmental trigger factors through the International Study of Asthma and Allergies in Childhood (ISAAC) Phase III and Global Asthma Network (GAN) in the two age groups of children

      6–7-year age group13–14-year age group
      GAN (n=20 084)ISAAC Phase III (n=47 166)p-value#GAN (n=25 887)ISAAC Phase III (n=52 289)p-value#
      Paracetamol use in last 12 months
       Never6639 (33.1)8945 (19.0)0.0009838 (38.0)14 689 (28.1)0.000
       At least once a year9496 (47.3)21 499 (45.6)10 283 (39.7)18 749 (35.9)
       At least once per month2104 (10.5)5940 (12.6)4441 (17.2)9530 (18.2)
       No response1845 (9.2)10 782 (22.8)1325 (5.1)9321 (17.8)
      Farm animals during pregnancy¶
       Yes1307 (6.5)3357 (7.1)0.000
       No18 051 (89.9)34 474 (73.1)
       No response726 (3.6)9335 (19.8)
      Farm animals during first year of life¶
       Yes1059 (5.3)4267 (9.0)0.000
       No18 297 (91.1)33 585 (71.2)
       No response728 (3.6)9314 (19.8)
      Trucks pass through the street
       Never9999 (49.8)9451 (20.0)0.37411 063 (42.7)10 978 (21.0)0.000
       Seldom (not often)8631 (43.0)13 793 (29.2)9573 (37.0)15 354 (29.4)
       Frequently through the day1028 (5.1)8276 (17.6)2902 (11.2)9550 (18.3)
       Almost the whole day426 (2.1)5808 (12.3)1268 (4.9)2718 (5.2)
       No response09838 (20.9)1081 (4.2)13 689 (26.2)
      Child ever breastfed¶
       Yes16 569 (82.5)35 215 (74.7)0.000
       No2728 (13.6)2549 (5.4)
       No response787 (3.9)9402 (19.9)
      Cat in the home during first year of life¶
       Yes991 (4.9)3756 (8.0)0.000
       No18 360 (91.4)34 107 (72.3)
       No response733 (3.7)9303 (19.7)
      Cat in the home in last 12 months
       Yes985 (4.9)3632 (7.7)0.0003221 (12.4)8491 (16.2)0.000
       No17 875 (89.0)34 277 (72.7)22 041 (85.1)35 480 (67.9)
       No response1224 (6.09)9257 (19.63)625 (2.5)8318 (15.9)
      Dog in the home during first year of life¶
       Yes1102 (5.5)4102 (8.7)0.000
       No18 280 (91.0)33 836 (71.7)
       No response702 (3.5)9228 (19.6)
      Dog in the home in last 12 months
       Yes1200 (6.0)3779 (8.0)0.0003930 (15.2)7934 (15.2)0.000
       No18 150 (90.4)34 183 (72.5)21 394 (82.6)36 000 (68.8)
       No response734 (3.6)9204 (19.5)563 (2.2)8355 (16.0)
      Fast food
       Never or only occasionally13 286 (66.2)10 754 (22.8)0.00016 535 (63.9)12 553 (24.0)0.000
       Once or twice per week3445 (17.2)7383 (15.7)5200 (20.1)12 018 (23.0)
       Most or all days462 (2.3)9865 (20.9)1690 (6.5)10 236 (19.6)
       No response2891 (13.3)19 164 (40.3)2462 (9.5)17 482 (33.4)
      Antibiotic in first year of life¶
       Yes3350 (16.7)17 706 (37.5)0.373
       No16 734 (83.3)17 711 (37.6)
       No response011 749 (24.9)
      Fresh fruit
       Never or only occasionally4590 (22.9)11 179 (23.7)0.0007698 (29.7)12 031 (23.0)0.000
       Once or twice per week6841 (34.1)12 503 (26.5)6106 (23.6)14 409 (27.6)
       Most or all days6341 (31.6)11 511 (24.4)9255 (35.8)15 061 (28.8)
       No response2312 (11.4)11 973 (25.4)2828 (10.9)10 788 (20.6)
      Vegetables
       Never or only occasionally5565 (27.7)12 291 (26.1)0.00013 150 (50.8)12 721 (24.3)0.000
       Once or twice per week5792 (28.8)9395 (19.9)4666 (18.0)11 230 (21.5)
       Most or all days5842 (29.1)13 726 (29.1)5193 (20.1)17 681 (33.8)
       No response2885 (14.4)11 754 (24.9)2878 (11.1)10 657 (20.4)
      Mother smoking during first year of life
       Yes209 (1.0)385 (0.8)0.000
       No19 194 (95.6)37 637 (79.8)
       No response681 (3.4)9144 (19.4)

      Data are presented as n (%), unless otherwise stated. #: Chi-squared test. ¶: questions included in the 6–7-year age group questionnaire only.

      • TABLE 3

        School absenteeism, exercise-induced wheeze and medical assistance required among children and adults with current wheeze with or without doctor-diagnosed asthma, and healthy subjects

        In past 12 months6–7-year age group 13–14-year age groupAdults
        Current wheezers with doctor-diagnosed asthma (n=115)Current wheezers without doctor-diagnosed asthma (n=519)Subjects without current wheeze (n=19 450)p-value#Current wheezers with doctor-diagnosed asthma (n=239)Current wheezers without doctor-diagnosed asthma (n=701)Subjects without current wheeze (n=24 947)p-value#Current wheezers with doctor-diagnosed asthma (n=603)Current wheezers without doctor-diagnosed asthma (n=2077)Subjects without current wheeze (n=78 616)p-value#
        Missed school due to breathing problem ≥1 day76 (66.09)13 (2.50)53 (0.27)0.000126 (52.72)168 (23.96)1499 (6.01)0.000
        Wheezy chest with exercise39 (33.91)117 (22.54)399 (2.05)0.000103 (43.10)237 (33.81)1943 (7.79)0.000
        Urgent visit to doctor due to breathing problem (≥1 time)81 (70.43)16 (3.08)54 (0.28)0.000119 (49.79)208 (29.67)1606 (6.44)0.000391 (64.84)74 (3.56)244 (0.31)0.000
        Urgent visit to emergency department due to breathing problem (≥1 time)42 (36.52)5 (0.96)18 (0.09)0.00053 (22.17)73 (10.41)598 (2.40)0.000180 (29.85)32 (1.54)106 (0.13)0.000
        Admitted to hospital due to breathing problem (≥1 time)51 (44.35)6 (1.16)22 (0.11)0.00061 (25.52)61 (8.70)679 (2.72)0.000165 (27.36)32 (1.54)101 (0.13)0.000
        Limited usual activity (at work or in the home) due to breathing problem216 (35.82)366 (17.62)932 (1.19)0.000

        Data are presented as n (%), unless otherwise stated. #: Chi-squared test.

        • TABLE 4

          Treatment undertaken for current wheeze and severe asthma in children and adults

          Medications usedCurrent wheezeSevere asthma#
          6–7-year age group (n=634)13–14-year age group (n=940)Adults (n=2680)6–7-year age group (n=320)13–14-year age group (n=562)Adults (n=1499)
          n%n%n%n%n%n%
          Inhaler medicines9715.3027028.7248718.177222.5020837.0138925.95
          Nebuliser11518.1411512.2330911.538526.568915.8423115.41
          Oral medications7611.9923825.3239214.636119.0618332.5632421.61
          Inhaled β-agonists
           Only when needed518.0414014.892398.923611.2512021.3518812.54
           In short courses233.63272.87371.38165.00264.63342.27
           Every day50.7990.96331.2330.9491.60291.93
          ICS
           Only when needed243.79434.57672.50144.38346.05563.74
           In short courses132.05525.53240.90113.44478.36221.47
           Every day50.7980.85130.4930.9450.89110.73
          Combined (ICS+LABA)
           Only when needed182.84818.621124.18103.137112.63815.40
           In short courses91.42101.06220.8241.2581.42181.20
           Every day101.5870.74371.3882.5071.25322.13

          ICS: inhaled corticosteroid; LABA: long-acting β-agonist. #: severe asthma is defined as current wheeze with more than four attacks per year or wheeze affecting speech or activity.

          • TABLE 5

            Use of various types of medicines in subjects with current wheeze and severe asthma with or without doctor-diagnosed asthma

            Current wheezers with doctor-diagnosed asthmaCurrent wheezers without doctor-diagnosed asthmap-value#Severe asthma with doctor-diagnosed asthma¶Severe asthma without doctor-diagnosed asthma¶p-value#
            6–7-year age groupn=115n=519n=95n=225
             Inhaled β-agonists
              Only when needed41 (35.65)10 (1.93)0.00033 (34.74)3 (1.33)0.000
              In short courses18 (15.65)5 (0.96)15 (15.79)1 (0.44)
              Every day5 (4.35)0 (0.0)3 (3.16)0 (0.0)
              Not using any medicine51 (44.35)504 (97.11)44 (46.31)221 (98.23)
             ICS
              Only when needed16 (13.91)8 (1.54)0.00011 (11.58)3 (1.33)0.000
              In short courses12 (10.43)1 (0.19)11 (11.58)0 (0.0)
              Every day4 (3.48)1 (0.19)3 (3.16)0 (0.0)
              Not using any medicine83 (72.18)509 (98.08)70 (73.68)222 (98.67)
             Combined (ICS+LABA)
              Only when needed14 (12.17)4 (0.77)0.0009 (9.47)1 (0.44)0.000
              In short courses6 (5.22)3 (0.58)4 (4.21)0 (0.0)
              Every day9 (7.83)1 (0.19)8 (8.42)0 (0.0)
              Not using any medicine86 (74.78)511 (98.47)74 (77.90)224 (99.56)
            13–14-year age groupn=239n=701n=182n=380
             Inhaled β-agonists
              Only when needed107 (44.77)41 (5.85)0.00097 (53.30)26 (6.84)0.000
              In short courses18 (7.53)22 (3.14)17 (9.34)7 (1.84)
              Every day8 (3.35)1 (0.14)7 (3.85)1 (0.26)
              Not using any medicine106 (44.35)637 (90.87)61 (33.52)346 (91.06)
             ICS
              Only when needed30 (12.55)13 (1.85)0.00023 (12.64)11 (2.89)0.000
              In short courses46 (19.25)6 (0.86)42 (23.07)5 (1.32)
              Every day8 (3.35)0 (0.0)5 (2.75)0 (0.0)
              Not using any medicine155 (64.85)682 (97.29)112 (61.54)364 (95.79)
             Combined (ICS+LABA)
              Only when needed65 (27.20)16 (2.28)0.00058 (31.86)13 (3.42)0.000
              In short courses6 (2.51)4 (0.57)0.0124 (2.20)4 (1.05)
              Every day5 (2.09)2 (0.29)0.0055 (2.75)2 (0.53)
              Not using any medicine163 (68.20)679 (96.86)115 (63.19)361 (95.0)
            Adultsn=603n=2077n=467n=1032
             Inhaled β-agonists
              Only when needed218 (36.15)24 (1.16)0.000171 (36.62)16 (1.55)0.000
              In short courses33 (5.47)4 (0.19)31 (6.64)3 (0.29)
              Every day30 (4.98)3 (0.14)26 (5.57)3 (0.29)
              Not using any medicine322 (53.40)2046 (98.51)239 (51.17)1010 (97.87)
             ICS
              Only when needed58 (9.62)9 (0.43)0.00049 (10.49)7 (0.68)0.000
              In short courses21 (3.48)3 (0.14)19 (4.07)3 (0.29)
              Every day13 (2.16)0 (0.0)11 (2.36)0 (0.0)
              Not using any medicine511 (84.74)2065 (99.43)388 (83.08)1022 (99.03)
             Combined (ICS+LABA)
              Only when needed101 (16.75)11 (0.53)0.00073 (15.63)8 (0.78)0.000
              In short courses18 (2.99)4 (0.19)14 (3.00)4 (0.39)
              Every day37 (6.14)0 (0.0)32 (6.85)0 (0.0)
              Not using any medicine447 (74.12)2062 (99.28)348 (74.52)1020 (98.83)

            Data are presented as n (%), unless otherwise stated. ICS: inhaled corticosteroid; LABA: long-acting β-agonist. #: the Chi-squared test is used when all expected cell frequencies are ≥5. If expected cell frequency was <5 the Fisher exact probability test was used. ¶: severe asthma is defined as current wheeze with more than four attacks per year or wheeze affecting speech or activity.

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            Prevalence, time trends and treatment practices of asthma in India: the Global Asthma Network study
            Sheetu Singh, Sundeep Salvi, Daya Krishan Mangal, Meenu Singh, Shally Awasthi, Padukudru Anand Mahesh, Sushil K. Kabra, Sabir Mohammed, Thevaruparambil U. Sukumaran, Aloke G. Ghoshal, Monica Barne, Sanjeev Sinha, Sanjay K. Kochar, Nishtha Singh, Udaiveer Singh, Kamalesh Kumar Patel, Arvind Kumar Sharma, Bhushan Girase, Anil Chauhan, Niranjan Sit, Jayaraj B. Siddaiah, Virendra Singh
            ERJ Open Research Apr 2022, 8 (2) 00528-2021; DOI: 10.1183/23120541.00528-2021

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            Prevalence, time trends and treatment practices of asthma in India: the Global Asthma Network study
            Sheetu Singh, Sundeep Salvi, Daya Krishan Mangal, Meenu Singh, Shally Awasthi, Padukudru Anand Mahesh, Sushil K. Kabra, Sabir Mohammed, Thevaruparambil U. Sukumaran, Aloke G. Ghoshal, Monica Barne, Sanjeev Sinha, Sanjay K. Kochar, Nishtha Singh, Udaiveer Singh, Kamalesh Kumar Patel, Arvind Kumar Sharma, Bhushan Girase, Anil Chauhan, Niranjan Sit, Jayaraj B. Siddaiah, Virendra Singh
            ERJ Open Research Apr 2022, 8 (2) 00528-2021; DOI: 10.1183/23120541.00528-2021
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