Doctor of Medicine

“PATTERN OF ALLERGIC SENSITIZATION TO VARIOUS

AEROALLERGENS IN CHILDREN WITH BRONCHIAL

ASTHMA AND/OR ALLERGIC RHINITIS BY SKIN PRICK

TEST AT A TERTIARY CARE HOSPITAL IN JAIPUR”

Dissertation

Submitted to the

Mahatma Gandhi University of Medical Sciences & Technology

for the degree of

Doctor of Medicine

(PEDIATRICS)

2017-2020

Submitted by

DR. SAKET YADAV

Under the Guidance & Supervision of

DR. MADHU MATHUR

Professor

DEPARTMENT OF PEDIATRICS

MAHATMA GANDHI MEDICAL COLLEGE & HOSPITAL

JAIPUR (RAJASTHAN)

Certificate by the Guide

This to certify that the dissertation entitled “Pattern of Allergic

Sensitization to various Aeroallergens in Children with Bronchial

Asthma and/or Allergic Rhinitis by Skin Prick Test at a Tertiary Care

Hospital in Jaipur” is a bona fide work of Dr. Saket Yadav conducted in the

Department of Pediatrics, Mahatma Gandhi Medical College and Hospital,

Jaipur under my personal guidance and supervision. All the necessary procedures

and observations have been carried out by the candidate himself. His approach

to the subject has been consistently sincere, scientific and analytical.

It is further certified by me that the result obtained have been checked

by me and are consistent with the present knowledge on the subject.

This dissertation is forwarded and recommended for the degree of Master

of Medicine, Mahatma Gandhi University of Medical Sciences and Technology.

Dr. Madhu Mathur

Professor

Department of Pediatrics

Mahatma Gandhi Medical College & Hospital,

Jaipur (Rajasthan)

Certificate by the HOD

This to certify that the dissertation entitled “Pattern of allergic

Sensitization to various Aeroallergens in Children with Bronchial

Asthma and/or Allergic Rhinitis by Skin Prick Test at a Tertiary Care

Hospital in Jaipur” is a bona fide work of Dr. Saket Yadav conducted in the

Department of Pediatrics, Mahatma Gandhi Medical College and Hospital,

Jaipur under my personal guidance and supervision. All the necessary procedures

and observations have been carried out by the candidate himself. His approach

to the subject has been consistently sincere, scientific and analytical.

It is further certified by me that the result obtained have been checked

by me and are consistent with the present knowledge on the subject.

This dissertation is forwarded and recommended for the degree of Master

of Medicine, Mahatma Gandhi University of Medical Sciences and Technology.

Dr. Munish Kumar Kakkar

Professor & Head

Department of Pediatrics

Mahatma Gandhi Medical College & Hospital,

Jaipur (Rajasthan)

A Word of Gratitude

It takes a great teacher to realize the potential of a student and turn her

capabilities into her abilities. Words cannot really measure the deepest sense of

respect and gratitude I have for my esteemed teacher and learned guide.

Dr. Madhu Mathur Professor

Department of Pediatrics Mahatma Gandhi Medical College & Hospital,

Jaipur (Rajasthan)

Her expert guidance, constant encouragement and support have enabled the

successful completion of this study. Her attention, endless persuasion and

dedication for work have instilled in me a sense of professional duty and pride,

which are going to stay with me for a lifetime. Being gifted with a precise clinical

acumen and an equally deep and sincere concern for her patients, she is a source of

inspiration for all those working with her. She was there for me every moment I

spent working on this thesis and fond memories of golden moments spent working

under her will remain with me forever as my most cherished possession.

I owe her a great deal for her attitude, her cool temperament and her motherly

concern and care shown to me not only in the production of work but also

throughout the period of my residency.

Without her inspiration, guidance and a unique moral support at each step of this

study, this work would have been a herculean task. I take this opportunity to

thank her for showing faith in me and believing in my abilities.

Dr. Saket Yadav

Acknowledgement

First and foremost, I thank Almighty God, who blessed me to come till

here. As teacher is next to God, I would also like to pay my special thanks to the

principal, MGMC&H, Jaipur (Affiliated to Mahatma Gandhi University of

Medical Sciences & Technology).

I take this opportunity to express profound gratitude to

Dr. M.L. Swarankar, Dr. Vikas Chand Swarankar Chairman, Dr. G. N. Saxena,

Principal & Controller, Dr. R. C. Gupta, Medical Superintendent, Mahatma

Gandhi Medical College and Hospitals, Jaipur for their kind permission to avail all

facilities and to conduct this study.

While presenting this thesis, I dedicate this work to my all respected

teachers, friends and colleagues, the genesis of which would not have been possible

without their blessings, endless love and their belief in me to excel.

It is my special privilege and great pleasure to record my deep sense of

thankfulness to Dr. Usha Acharya, Professor, for her time to time co-operation,

motivation, support and encouragement during my period of residency.

I am deeply grateful to Dr. Munish Kumar Kakkar, Professor & Head of

Department, Department of Pediatrics for their constant support, guidance and

encouragement during the study.

I owe my deepest gratitude to the esteemed teachers Dr. Jitendra Gupta,

Dr. Sourabh Singh, Dr. Natwar Parwal, Dr. Yashu Saini, Dr. Nitin Trivedi,

Dr. Abhishek Sharma, Dr. Radha, Dr. Abhishek Saini, Dr. Alka. &

Dr. Harimohan Meena for their unstinted support and meticulous advice which

helped me in completing this dissertation.

I would like to thank to Dr. Gunjan Agarwal for helping out me in writing

my thesis & constant support throughout the years.

I would also like to thank Dr. Siddharth Rathore, Dr. Hemant Kumar

Mishra, Dr. Ashish Jain, Dr. S.P. Gupta, Dr. Ashwani Mathur, Dr. Ram Mohan

Jaiswal, Dr. Anand Nagar for their supportive role in my residency.

I would like to express my sincere gratitude & special thanks to My

Parents and Relatives who have supported me to this scholastic career and for

their constant encouragement, their sacrifices throughout the course of my study.

My hearty thanks to all Patients & their family members who have been

the subject of my research work and study. They deserve the utmost respect for

their untiring compliance.

Thank to my wife Dr. Pooja for assisting me in completing my work.

I would now give special thanks to Dr. Pawan Choudhary, Dr. Ajaypal

Singh, Dr. Piyush Gupta, Dr. Nandani, Dr. Rajesh Gurjar, Dr. Mohit, Dr. Shelly,

Dr. Divya, Dr. Saguna, Dr. Shreya, Dr. Jitendra Faujdar, Dr. Sonal, Dr. Dinesh,

Dr. Archit, Dr. Kavita, Dr. Nikita, Dr. Neeraj, Dr. Nipun, Dr. Shalin,

Dr. Ashna, Dr Priyanka & Dr Nikita for being there for me at all times whenever

I needed their support, and standing by me through the tough times.

Last but not the least I would be failing in my duty if I do not express my

gratitude to my beloved seniors Dr. Bharat Khadav, Dr. Arvind Ranwa,

Dr. Vinit Kumar, Dr. Jitendra Faujdar, Dr. Haritej Chaudhary, Dr. Chander

Shekhar Sharma, Dr. Apoorva Batra, Dr. Sonam Chaudhary, Dr. Sapna Yadav,

Dr. Arjun Rathore, Dr. Ritik Hooda, Dr. Swarjith Nimmakayala, Dr. Sahil

Punia, Dr. Sarvesh Maheshwari, Dr. Ankit Goyal , Dr. Sandeep Mahla,

Dr. Narendra Tetarwal & Dr. Pushpender Choudhary for their constant support

and encouragement during the period of residency.

Friends who have always stood by me and have been a constant source of

energy since I met them, Arun Shokeen, Rajesh Sippy, Dr. Ripudaman Singh

Champawat, Dr. Harsh Baid, Dr. Sourabh Shrivastav, Dr. Shobhit Kaswan,

Dr. Abhishek Khichar, Dr. Harish Kumar Kamboj, Dr. Divyaraj Jadeja, Capt.

Sourabh Sharma, Capt. Yogesh Mishra, Dr. Navneet Singh, Dr. Abhishek Yadav,

Dr. Hariom Chaudhary, Dr. Shambhu Ahir, Dr. Suresh Chaudhary, Dr. Hitesh

Chaudhary & Prem Chaudhary.

I would also like to thank the people from whom I have learned the

practical skills required for patient care, ICU Procedures & they have been a

constant support during my period of residency.

My NICU Staff : Amma Ji, Musavvir Ali , Hemant, Dharmendra, Piyush,

Harish, Jeetram, Mohit, Pawan, Ankush, Arshad, Arun, Manmohan, Rekha,

Shimla, Sangeeta, Sopali, Jyoti, Ashish, Bansi, Ankush.

My PICU Staff : Rakesh Saini, Udaybhan, Gourav Saini, Devendra

Sharma, Devender Mourya , Rajkumar, Navratan, Saddam, Moolchand.

My Pediatric Ward Staff : Lokendra Singh, Suresh Ji, Pankaj, Shailendra,

Yogesh, Deepak, Narendra, CP Soni, Shiv Shankar.

I would also like to admit that only few names appear in this

acknowledgement, many too much unsaid, have significantly contributed to and

enhanced this quality of work to all my deeply obliged.

Place: Jaipur Dr. Saket Yadav

Table of Contents

S. No Chapter

1. Introduction

2. Aims and Objectives

3. Review of Literature

4. Materials and Methods

5. Observations and Results

7. Discussion

8. Summary & Conclusion

9. Bibliography

10. Annexures

Proforma

Consent Form - English

Consent Form - Hindi

Abbreviations

Ethical Committee Approval

Master Chart

1

INTRODUCTION

Respiratory allergic disorders (RAD) like Bronchial Asthma (BA) and Allergic

Rhinitis (AR) represent the major burden worldwide from both an epidemiological and

economical point of view1.A survey done by World Allergy Organization (WAO)

estimated that worldwide prevalence of AR is 16-25 % and BA is 6-15 %2.

Allergic disorders are not just a public health problem for developed countries,

their prevalence is rising dramatically in developing countries also like India that has an

uprising trend both in terms of prevalence as well as severity3. Children are bearing the

greatest burden of the rising trend of these diseases. Asthma is the commonest chronic

disorder among children, the prevalence has been estimated to range from 3-38 % in

children4,. AR and BA affect 20% and 15% of the Indian population respectively

5.

Allergic rhinitis (AR) occurs due to an IgE-mediated inflammation of the nasal

mucosa. The classification proposed by the Allergic Rhinitis and its Impact on Asthma

(ARIA) guidelines is useful for the implementation of treatment. AR is a risk factor for

asthma and other co-morbidities like sinusitis, upper respiratory infections, nasal

polyposis, conjunctivitis, mouth breathing, and sleep disorders.

Similarly, Asthma is a chronic inflammatory disorder of the airways, associated

with various structural changes, that affect children and adults of all ages. The disease is

associated with airway hyper-responsiveness and airflow obstruction that is often

reversible either spontaneously or with treatment. When uncontrolled, asthma can be

fatal, and can markedly interfere with normal activities, affecting the individual's quality

of life. Atopy is the genetic predisposition to develop IgE mediated sensitivity to common

aeroallergens, being the strongest identifiable predisposing factor to the development of

asthma, especially in children.

2

Allergy not only causes long-term immune dysfunction but also causes

inflammatory changes, which forms the underlying factor for other non-communicable

diseases, another important factor that comes into play is the gene-environment

interaction like exposure to allergens, infections, air pollution, tobacco smoke, diet, and

obesity.

Aeroallergens play a major role in the pathogenesis of RAD. Pollens, molds,

house dust mites, fungal spores, and pets are one of the most common allergens prevalent

in India. The prevalence of allergic sensitization can be measured by Allergen Specific

IgE in serum or by SPT. Skin prick test is considered as the gold standard for diagnosis of

IgE mediated type 1 allergy. It is easy, reliable, and rapid to perform, inexpensive with

high sensitivity and can be performed at any age.

Allergens as Risk Factors for Allergic Diseases6

Sensitization (IgE antibodies) to foreign proteins in the environment are present in

up to 40% of the population. Such sensitization is strongly associated with exposure for

proteins derived from pollens, molds, dust mites and cockroaches. There is a strong and

consistent association between disease and sensitization in cases of asthma, rhinitis and

atopic eczema.

Environmental Risk Factors

Indoor and Outdoor Pollution

Epidemiological studies have shown that indoor and outdoor pollution affects

respiratory health, including an increased prevalence of asthma and allergic diseases.

Outdoor pollution is associated with substantial mortality; ambient particulate matter

and ozone pollution accounted for about 3.4 million deaths worldwide in 2010.

3

It is estimated that exposure to indoor air pollution may be responsible for almost two

million deaths per annum in developing countries.

Global warming would increase the effects of outdoor air pollution on human health.

Exposure to outdoor/indoor pollutants is associated with new-onset of asthma,

exacerbations, rhinitis, rhinoconjunctivitis, acute respiratory infections, and hospital

admissions for respiratory symptoms.

The International Agency for Research on Cancer classified the indoor combustion of

coal emissions as a carcinogen to humans.

Abatement of the major risk factors for respiratory diseases and, in particular,

environmental tobacco smoke, indoor biomass fuels, and outdoor air pollution, will

have a positive effect on the life of people.

Socio-economic Factors and Environmental Justice

The global prevalence, morbidity, mortality and economic burden of asthma have

increased over the last 40 years.

However, the growth and burden of the disease is not uniform. Disparities exist in

asthma morbidity and mortality, with an inverse relationship to social and economic

status and are increasingly documented around the world.

Asthma and other atopic disorders may be more concentrated among those of lower

socioeconomic status because they also bear a disproportionate burden of exposure to

suboptimal, unhealthy environmental conditions (e.g. physical, social, and

psychological conditions).

4

EVIDENCE-BASED APPROACHES TO DIAGNOSIS AND MANAGEMENT7

Diagnosis and Identification of Causative Allergens

Aeroallergens play a major role in the pathogenesis of RAD. Pollens, molds, house

dust mites, fungal spores, and pets are one of the most common allergens prevalent in

India.

Confirmation of allergy and identification of causative allergens is crucial to correctly

manage allergic diseases.

Correct diagnosis allows the implementation of therapies based on the etiologic

factors of allergic diseases, such as environmental measures and immunotherapy.

Diagnosis is a detailed medical history and physical examination.

The identification of a temporal association between symptoms and allergen exposure

constitutes the basis for further testing.

Clinical suspicion is confirmed using Allergen Specific IgE in serum or by SPT.

Skin prick test when used with relevant allergens and standardized allergen extracts is

considered as the gold standard for diagnosis of IgE mediated type 1 allergy. It is

easy, reliable, and rapid to perform, inexpensive with high sensitivity and can be

performed at any age8.

Pharmacotherapy of Allergic Diseases

Children from all countries, ethnic and socio-economic groups and ages suffer from

respiratory allergic diseases.

Asthma and allergic rhinitis are common health problems that are causing major

illnesses and disabilities worldwide.

5

The strategy for the treatment of allergic diseases is based on (i) patient education; (ii)

environmental control and allergen avoidance; (iii) pharmacotherapy; and (iv)

immunotherapy.

Pharmacotherapy is the mainstay of treatment for allergic diseases not only controls

symptoms but also improves the quality of life.

Primary care physicians play an important role in the first-line management of

allergies and then Allergy specialists should make a specific diagnosis and treat

patients with allergies, particularly those with moderate/severe disease.

The chronic nature of respiratory allergies warrants the physician to explain long-term

management strategies to patients.

In recent decades, there has been an improvement in the efficacy and safety of allergy

pharmacotherapy.

Disease management using evidence-based practice guidelines have resulted in better

patient outcomes.

Allergen Specific Immunotherapy

Allergen-specific immunotherapy (AIT) is an effective treatment for respiratory

allergic diseases.

Subcutaneous Immunotherapy (SCIT) is still the standard modality of treatment, but

Sublingual Immunotherapy (SLIT), is accepted as a valid alternative to injections in

the case of children.

AIT, in properly selected patients, significantly reduces allergic symptoms and

medication usage.

6

At variance with pharmacotherapy, AIT induces profound and persisting changes in

the immune response to allergens. It results in a long-lasting clinical effect after

discontinuation and in a disease-course modifying effect (prevention of the onset of

asthma and new sensitizations).

The mechanisms of action of immunotherapy are complex and multiple, and result in

a modification of the immunological responses to allergens, through reduction in the

allergic inflammatory reaction.

SCIT and SLIT can maintain their beneficial effects for years after discontinuation

however indications, contraindications, limitations, and practical aspects are well

defined in numerous guidelines.

Allergen Avoidance9

Effective allergen avoidance and environmental interventions have a positive effect

on symptom control in respiratory allergic patients.

For asthma, there is little evidence to support the use of simple, single interventions

(e.g. only covering bedding) to control dust mite allergen levels.

The following should be used to guide a pragmatic approach to allergen avoidance:

- Comprehensive environmental control interventions to reduce allergen exposure.

- Adjusting the intervention to the patient's allergen sensitization and exposure

status.

- The level of allergen-specific IgE antibodies or the size of skin test wheal should

be used as an indicator if the level of allergen exposure is not sure.

- Start the intervention as early in the natural history of the disease as possible.

7

- Primary prevention strategies should be developed for eliminating or reducing

exposure to potentially sensitizing agents that should be started early in the natural

history of the disease.

To start the allergen-specific therapy, the type of aeroallergens need to be

evaluated, since these aero-allergens widely differs according to geographical and

climatic condition. India is expected to have a wide range of allergens as being a country

with diverse climatic and geographic conditions. Data are scarce regarding allergen

sensitivity in Rajasthan, especially in children. Hence, our study is aimed at identifying

the pattern of allergen sensitivity among children with BA &/or AR by using SPT which

would further help inappropriate diagnosis, disease monitoring, and treatment of these

children.

8

AIMS AND OBJECTIVES

PRIMARY OBJECTIVE: To determine the prevalence of various aeroallergens in

children with Bronchial Asthma and/or Allergic Rhinitis by Skin Prick Test.

SECONDARY OBJECTIVE: To assess the association of various risk factors and

clinical profile of Asthmatic & Rhinitis patients with Skin Prick Test results.

9

REVIEW OF LITERATURE

Asthma and other allergic conditions such as allergic rhinitis are the major public

health problems worldwide. Allergic diseases affect lives of more than one billion people

worldwide10

.

Almost 14% of children experience asthma symptoms according to11

. Allergy

once considered diseases of rich and the western world is now increasingly affecting

middle-income groups and poor people in the developing countries. The prevalence of

asthma in India estimated to range from 3% to 38%12

. Asthma is a diversified disease and

characterized by chronic airway inflammation, which is defined by the history of typical

respiratory symptoms like a wheeze, shortness of breath, chest tightness and cough that

vary over time and in intensity, along with variable expiratory airflow limitation13

.

Respiratory allergy is a common allergy among all populations throughout the

world. Reviewing epidemiological data available all over the world, one could perceive

the importance of this issue. Epidemiological studies obtained from different countries

show the prevalence of respiratory allergy as 15-30%14

. In an allergic population,

sensitivity in urban areas is greater than in rural areas15

. An increase in the prevalence of

atopic diseases has been recorded in most tropical countries as attributed to factors such

as increasing urbanization. This may change facing environmental allergens and

individual susceptibility to allergic disorders.

Aeroallergens (airborne allergens) play an important role in respiratory allergic

diseases, especially asthma and allergic rhinitis. Sampling from aeroallergens provides

information that is clinically useful in determining possible reasons for allergic symptoms

in sensitive people.16

Aeroallergens including pollens (plant pollens), fungi, body covering

10

of animals, domestic mites, domestic animals, and insects, are the most important factors

initiating allergic diseases.

One of the most common types of respiratory allergic diseases is allergic rhinitis

with a prevalence rate of 20-40%17

. Allergic rhinitis is one of the most prevalent chronic

states that are common 10-30% in adults and up to 40% in children18

. Therefore, the

maximum prevalence of such disease has been observed at youth ages; however, it's also

a remarkable issue in adults.

This disease is sometimes mistakenly considered as a mild disease, while its

symptoms may significantly affect patients’ quality of life through causing fatigue,

headache, cognitive disorder, effect on physiological health and other systemic

symptoms.

Respiratory allergic disorders are closely associated with the release of TH2- type

immune response, antigen-presenting cells (APC), eosinophils, basophils, and

macrophages as main cellular elements and IgE as well as all other mediators such as

histamine, leukotrienes and interleukins, granulocyte-macrophage colony-stimulating

factor (GM-CSF) and various chemokines. Moreover, pollen is considered as one of the

most abundant and inevitable elements in allergic diseases.

In the late 1960s, both Ishizaka et al in the USA and Johansson together with

Bennich in Sweden identified Immunoglobulin E (IgE) as the responsible antibody for the

allergic type-1-reaction19

. Furthermore, Johansson et al linked IgE to asthma and atopic

dermatitis, as raised levels of IgE were found in patients with these conditions20

. Hence

both the SPT and the detection of specific IgE-antibodies have become important tools

for the assessment of allergic sensitization not only in the clinical setting but also in

epidemiological research.

11

It is established that IgE plays a pivotal role in the pathogenesis of allergic

diseases. Total serum IgE level and total Eosinophil counts are widely used as a

diagnostic tool for allergic diseases21

. Although various epidemiological studies have

shown strong association amongst total serum IgE levels, blood eosinophilia, skin test

reactivity and allergy prevalence, the details of these association is still not well

determined. However, elevated total serum IgE levels have sometimes being considered

as a basis of allergy diagnosis. Many clinically proven allergic patients may have normal

total IgE levels or presents with increased IgE levels resulting from non-allergic

conditions such as parasitic infections22

.

Total eosinophil counts are used as a diagnostic tool for allergic diseases23

. Not

many studies have been conducted on total and specific IgE in India, though IgE is

considered as a marker of allergy. In routine clinical practice, a combination of total

serum IgE and total eosinophil counts is used to rule out allergic diseases. In population-

based studies conducted in countries with a Western lifestyle, the total serum

immunoglobulin E (IgE) level was found to be a strong predictor of asthma, whereas skin

test reactivity to aeroallergens was closely correlated with allergic rhinitis and eczema24

Among various allergens, house dust mite,25

cockroach, mosquito, fungus

(Alternaria), dog and cat dander are common indoor allergens implicated in various

allergic disorders26

, while according to aerobiology of north India, Parthenium,

Holoptelia, Chenopodium sps., Cynodon sps., Amaranthus sps., Ricinus comunis,

Brassica sps. And Zea mays are some common outdoor allergens27

.

In 1921, Prausnitz and Kustner provoked a local skin reaction by injecting

subcutaneously a non-allergic individual with serum of an allergic individual28

. This

method was further developed and is known as the skin prick test (SPT), commonly used

12

in the diagnosis of atopic diseases. The skin prick test is one of the most common

methods. Skin test reactivity to aeroallergens is a tool for respiratory allergy that is

generally accepted and used in epidemiological studies29

. This method does not require

spending a long time and high cost and compared to the other experiments, its sensitivity

and features are very high. This test can play a determining role in adopting prevention

methods and patients' treatment and desensitization. Usually, positive skin reactions rate

is highly associated with clinical findings and it can even determine the severity of the

disease. Avoiding allergens shall be considered as the first-line prevention in controlling

allergic disorders; even when it is not completely effective. This method may reduce the

need for further treatment. Identifying the most common aeroallergens to which the

patients are allergic plays an important role in the diagnosis and treatment of allergic

disorders. Selecting the most appropriate allergen extracts for a diagnostic test and

finding the best formulation for allergen immunotherapy depends on data on the most

important aeroallergens in a specific area.

SPT interpretation utilizes the presence and degree of cutaneous reactivity as a

surrogate marker for sensitization within target organs, i.e., eyes, nose, lung, gut, and

skin. When relevant allergens are introduced into the skin, specific IgE bound to the

surface receptors on mast cells are cross-linked, mast cells degranulate, and histamine and

other mediators are released. This produces a wheal and flare response which can be

quantitated. Many different allergens can be tested simultaneously because the resultant

reaction to a specific allergen is localized to the immediate area of the SPT30

.

SPT is safe with no reported fatalities in a 5-year USA study. Because systemic

allergic reactions and rare deaths have occurred associated with SPT, a physician or other

health care professional and emergency equipment should be immediately available when

such tests are performed. This is especially true when testing for food or medication

13

associated with the onset of anaphylaxis. Systemic side effects are very unlikely for

commercially available respiratory allergens. Symptomatic asthma may be a risk factor

for exacerbation of asthma associated with testing. When reactions occur, they usually do

so within 30 minutes of testing31

.

The SPT confirms sensitization to a specific allergen, however, its clinical

relevance must be interpreted based on the medical history and clinical symptoms.

Sometimes, conjunctival, intranasal, oral or even bronchial challenge provocation tests

are performed to support clinically relevant sensitivity. The clinical relevance of SPT

results varies, depending on the allergen utilized and the population tested. For example,

sensitization to house dust mite occurs in some subjects in the absence of clinical

relevance32

A wide variety of factors may influence the result of SPTs. These include the

particular SPT technique used; the site used for skin prick testing, the time of day, age,

sex, and race, and concomitant drug treatment. The quality of allergen extract is of main

significance as a wide variation in composition and allergen content between allergen

extracts from different manufacturers exists33

. Biological examinations of biological units

or content in micrograms of major allergens should be applied34

. Allergen extracts for

SPT are native allergens obtained by extraction from the relevant biological material such

as pollen, mites, animal epithelia, and molds. To achieve batch-to-batch consistency, in

vitro standardization of allergen extracts and determination of the biological activity are

of crucial importance for the reliability of the test system.

The prevalence of allergic disorders may be different in different regions, this

difference is attributed to the level or a total load of aeroallergens. Different allergens

play different roles depending on the environmental conditions of each region, such as

14

climate, population, and level of exposure. The common allergens that cause respiratory

allergic disorders include trees, grasses, weed, pollens, molds, house dust mite, animal fur

and skin, rodents and fungi35,36

. Identifying the aeroallergens of each region help prevent

allergic diseases in an advisable time, while it is also effective in selecting the type of

allergy vaccine for appropriate treatment when prevention and medical treatment are not

effective.

This is achieved by desensitization or hypo sensitization treatment (Allergy

immunotherapy) in which the patient is gradually vaccinated with progressively large

doses of the allergen in question. This can either reduce the sensitivity or eliminate

hypersensitivity. It relies on IgG antibody production to block excessive IgE production

seen in atopy. In a sense, the person builds up immunity to increasing amounts of the

allergen in question. Studies have demonstrated long-term efficacy and protective effect

of immunotherapy in reducing the development of new allergy37

. Meta-analysis has also

confirmed the efficacy of treatment in Allergic rhinitis in children and asthma. A review

by Mayo Clinic in Rochester confirmed the safety and efficacy of allergen

immunotherapy for allergic rhinitis, conjunctivitis, allergic forms of asthma and stinging

insect based on various studies38

. Additionally, national and international guidelines

confirm the efficacy of immunotherapy in rhinitis and asthma as well as safety provided

that recommendation is followed39

.

15

Reference Articles

Mathur M and Mathur HC (1987)40

were to evaluate the role of different etiology

factors, particular the local allergens, in childhood bronchial asthma in Western

Rajasthan. A detailed clinical examination, routine laboratory tests including absolute

eosinophilic count and skin tests with common allergens were conducted on 100 children

(up to 12 years age) of bronchial asthma. Association with another allergic disease

including AR & AD was found in a large number of cases (71%), male sex was

predominant (69%), onset was in early childhood (67%) and positive family history of

allergy (51%). In 67% of patients, skin tests were positive to one or more allergen, the

commonest of them was house dust (21%) followed by Prosopis juliflora (16%).

Dey S and Chakraborty T (2017)41

where to identify the commonly prevalent

environmental allergens by SPT in children with asthma as per British Thoracic Society

and Scottish Intercollegiate Guidelines Network Criteria and allergic rhinitis (AR) as per

British Society for Allergy and Clinical Immunology Criteria attending the OPD of a

tertiary care pediatric unit in the eastern part of India. Testing of inhalant and food

allergens by SPT in children from 4 to 12 years age group with asthma and AR satisfying

the inclusion criteria. A total of 106 children (70 males and 36 females) were included in

the study. Study of inhalant allergens in asthmatic patients revealed the highest positivity

for house dust mite followed by male cockroach and among food allergens, highest

positivity for egg/egg products, followed by milk/milk products. Study of inhalant

allergens in asthmatic patients with coexistent AR revealed the highest positivity for

house dust mite, cockroach male and female and among food allergens, highest for

milk/milk products, egg/egg products, banana, and mustard. It was concluded that in

Kolkata, in the eastern part of the country, among the asthmatic children of 4-12 years

age group, the most common inhalant allergens were house dust mite and cockroach,

16

whereas the common food allergens identified were milk and milk products, egg and egg

products, and mustard.

Raj D (2013)42

et al was to determine the prevalence of sensitization to common

aeroallergens in asthmatic children from 5-18 years of age and study the differences in

characteristics of atopic and non-atopics at Pediatric Chest Clinic of the tertiary care

center in Northern India. The main outcome measure was the prevalence of sensitization

to common aeroallergens. Skin prick testing (SPT) was performed on 180 children above

5 years of age, with a mean (SD) age of 111.4 (34.2) months. 100 children (55.6%) were

sensitized to at least one aeroallergen, suggesting atopy; 68 (37.8%) were sensitized to

more than one allergen. 36.7% of children were sensitized to housefly antigen; 31.1% to

rice grain dust, 18.3% to cockroach, and 7.8% to house dust mite antigens. Atopic

children had significantly higher median FENO during follow up than non- atopic

children (17.5 ppb vs 13 ppb, P=0.002). There was a positive correlation between age and

the number of allergens that an individual was sensitized to (r= 0.21; P=0.0049). It was

concluded that more than half of asthmatic children in our cohort had sensitization to one

or more aeroallergens suggesting atopy; sensitization was most commonly seen to

housefly antigen and rice grain dust. Atopic children had significantly higher FENO

measurements during follow up as compared to non-atopic children.

Sharma RK (2019)43

et al aimed (1) to find out the prevalence of various allergens

leading to AR and/or BA through skin prick test (SPT), (2) to identify the trigger factors

in these patients, (3) to study correlations of allergens and seasonal variations in patients

suffering from AR and/or BA. A total of 134 patients were collected from the outpatient

department and inpatient department of Respiratory Medicine Department of Geetanjali

Medical College and Hospital, Udaipur, from January 2016 to December 2017. The

diagnosis of BA and AR was made according to the GINA and ARIA guidelines,

17

respectively. SPT was done with 78 different types of aeroallergens, which included 23

types of pollens, 6 types of fungi, 10 types of insects, 6 types of dust, 6 types of dander, 3

fabrics, 2 feathers, and 22 food allergens. Patients who had taken short-acting oral

antihistaminics, beta-blockers, steroids, tricyclic antidepressants or any other drug that

could affect the test within one week before testing were excluded. Also, patients on long-

acting oral antihistaminics within four weeks of testing and pregnant women were

excluded. A total of 134 patients consisting of 73 (54.48%) males and 61 (45.52%)

females, in the age group of 5–65 years, were included in the study. The maximum

numbers of patients (50; 37.31%) were between the age group of 20 and 35 years. The

maximum number of patients (94; 70.15%) had a duration of suffering from >1 year. AR

was found in 60 (44.78%), BA associated with AR was found in 39 (29.1%), while BA

alone was found in 35 (26.12%). In 54% of patients, triggers were found for exacerbation

of their symptoms, the most common being air pollution (48%) followed by cold

exposure (20%), physical activity (12%), irritants (9%), smoke (7%), and fumes and

odors (4%). A total of 10,452 SPTs were done, out of which 265 (%) showed positive

reactions. The positivity for pollens was seen in 116 (43.77%) patients followed by

insects [79 (29.81%)], fungi [22 (8.3%)], house dust mite [15 (5.66%)], dusts [11

(4.15%)], fabrics [10 (3.77%)], danders [9 (3.4%)], and feathers [3 (1.13%)], respectively.

Food allergens showed no significant reactions to SPT. The study showed that insects

were the most common allergen in BA patients, while pollens were the most common

allergen in patients of AR with or without BA. Intermittent symptoms were common with

pollen allergy.

Shyna KP (2018)44

et al was to find the clinical profile and skin sensitivity to common

allergens by skin prick test in children with allergic rhinitis between six and fifteen years.

All children between 6 to 15 years with allergic rhinitis were included in the study. The

18

skin prick test was done with seven most common allergens. A total of 60 children with

allergic rhinitis were studied and 42 patients (70%) tested positive for SPT. The major

symptoms were persistent sneezing (68%), nasal itching (33%), rhinorrhea (85%) and

nasal congestion (42%). The proportion of sneezers-runners was higher than blockers

(64% versus 36). We tested seven common allergens and house dust mite allergen yielded

the highest number of positive responses (33%) followed by cockroach (25%), Alternaria

(16.66%), parthenium (10%), cat dander (8.35%), sorghum (5%) and dog dander (5%).

Among patients with SPT positivity; eight were positive to one allergen, thirteen were

positive to two allergens, sixteen to three allergens and five to four allergens. They have

found that Allergic Rhinitis with several allergic comorbidities has a significant impact on

the quality of life and scholastic performance in children. Skin prick test which is a

standardized, most rapid, sensitive and cost-effective test to detect IgE-mediated allergic

diseases helps identify the common allergens. House dust mite was the commonest

allergen tested positive in children.

A prospective study was conducted in the Department of Immunology and Molecular

medicine at SKIMS, Kashmir using SPT to know allergic sensitivity and applied it for

devising immunotherapy as the therapeutic modality by Rasool R (2013)45

et al. A total

of 400 patients suffering from allergic rhinitis, asthma and urticaria were recruited in this

study. SPT was performed with a panel of allergens including house dust mite, pollens,

fungi, dust, cockroach, sheep wool and dog epithelia. Allergen immunotherapy was given

to allergic rhinitis and asthmatic patients as a therapeutic modality. In the study, the age

of patients ranged from 6 to 65 years. The majority of patients were in the age group of

20-30 years (72%) with a Male to female ratio of 1:1.5. Of the 400 patients, 248 (62%)

had urticaria, 108 (27%) patients had allergic rhinitis and 44 (11%) patients had asthma.

SPT reaction was positive in 38 (86.4%) with allergic asthma, 74 (68.5%) patients with

19

allergic rhinitis and 4 (1.6%) patient with urticaria, respectively. Allergen immunotherapy

was effective in 58% of patients with allergic rhinitis and 42% allergic asthma. The study

showed that identifiable aeroallergen could be detected in 86.4% allergic asthma and

68.5% allergic rhinitis patients by SPT alone. Pollens were the most prevalent causative

allergen. There was significant relief in the severity of symptoms, medication intake with

the help of allergen immunotherapy.

Gaur SN (2019)46

presented a review on dust mites. Dust mites are the most important

group of indoor allergens. The dust mites have been classified as house dust mites and

storage mites, however, with recent knowledge the different dust mite species are now

labeled as "domestic mites." The dust mites have been isolated at numerous Indian

locations and their sensitization in the Indian population has also been documented.

Given high sensitization in India, it is important to recognize the role of dust mites and

their allergens in the precipitation of allergic diseases including allergic rhinitis and

asthma. Allergies to dust mites can be confirmed by a classical clinical history of

perennial, early morning and indoor symptoms substantiated by a positive skin prick test

to these allergens. Further management of allergies to mites is possible using appropriate

allergen avoidance measures and allergen immunotherapy. Multifaceted avoidance

measures can be used, but, allergen avoidance by the means of an allergen-impermeable

bed encasing has the best evidence and is recommended in different guidelines. Allergen

immunotherapy, the disease-modifying modality, has been proven to efficacious for

house dust mite allergies.

Mishra VD (2016)47

et al was to identify common allergens by skin prick test in patients

of united airway disease. Skin prick test was performed in 60 patients of United Airway

Disease to identify the common allergens. A total of 62 allergens consisting of 36 types of

20

pollen, 5 fungi, 4 insects, 8 types of dust, 4 dander, 3 fabrics, Dust mite, and Parthenium

leaves were tested. Most common allergens were Dust mite (60%) followed by

Parthenium leaves (45%), insects (18.75%), pollen (14.81%), dust allergens (8.51%),

fabrics (8.33%), fungi (5.66%), dander (5%). Most common insect allergens were

cockroach (female) (30%), cockroach (male) (23.33%). Common pollens were Ricinus

communis (28.33%), Amaranthus spinosus (28.33%), Parthenium hysterophorus

(26.66%), Eucalyptus tereticornis (26.66%) and Cynodon dactylon (25%). Common dust

allergens were house dust (21.66%), paper dust (11.66%) and cotton mill dust (10%).

Among fabrics, kapok cotton (13.33%) showed maximum positivity. Among fungi,

Aspergillus fumigatus (10%) followed by A. niger (6.66%) were most common. In

animal dander group common ones were cat dander followed by dog dander. In

conclusion, it can be said that the knowledge drawn by the above study will help to treat

patients by immunotherapy or avoidance strategy.

Dave L and Srivastava N (2014)48

undertook a study to identify the common allergens

in Bhopal and surrounding areas, which were responsible for inducing united airway

disease (UAD) in subjects, as no study has been done in this central geographical part of

India in the recent past. Skin Prick Testing (SPT) was performed on 89 patients with

clinical manifestations of UAD, from April 2013 to March 2014, with 120 different

allergen extracts. The testing kit included 50 pollen antigens, 20 fungi, 20 insects, 12

from dust group, 06 types of danders, 6 types of fabrics and feathers and 1 dust mite. The

dominant pollen allergens identified were, Cynodon dactylon (53.93%), Cenchrus ciliaris

(47.19%), Carica papaya (40.44%), Chenopodium murale(37.07%), Gynandropis

gyandra(37.07%), Cyprus rotundus,(35.95%), Cannabis sativa(35.95%), Amaranthus

spinosus(34.83%), Cassia occidentalis(34.83%), Cassia siamega(33.70%), Ehetia

laevis(32.58%), Ageratum conyzoides(30.33%) and Brassica campestris(33.33%).Among

21

fungus Aspergillus versicolor (21.3%) was most common sensitizer followed by A.tamari

(19.1%), A.flavus (16.85%,) and A.fumigatus (13.48%). Locust male (53.93%) and locust

female (53.93%) were the most common sensitizers among insect allergens. House dust

showed a marked positive reaction in 67.41% of patients. Wheat dust (53.9%) was also a

significant sensitizer. Among danders, cat dander (19.10%) and dog dander (19.10%)

were the most common sensitizers. House dust mite extract showed a marked positive

reaction in 74.15% of patients.

Moitra S and Sen S (2014)49

where to study the skin sensitivity to various allergens by

skin prick test in 102 randomly selected patients of naso-bronchial allergy (allergic

rhinitis) among patients attending Allergy & Asthma Clinic at Calcutta School of

Tropical Medicine, Kolkata, India in the rainy season of 2013. The current study was

conducted to evaluate the pattern of positive skin tests for various aeroallergens among

allergic patients in Kolkata, India. 102 participants with allergic rhinitis (seasonal or

perennial) with or without asthma were selected. Skin prick test using seven common

allergen extracts was performed on all patients. The overall frequency of sensitization to

an allergen was 100%. Overall the most common allergen was found to House dust

(86.27%). The second most prevalent allergen was Azadirachta indica (55.68%), followed

by Peltophorum pterocarpum (44.11%). No differences between genders were seen but a

slight decrease in positive reaction to mites with growing ages. The results of the study

revealed that the prevalence of the skin prick reactivity to house dust and Azadirachta

indica are significant in Kolkata and multiple sensitizations were common.

Lama M (2013)50

et al was to estimate the levels of total serum IgE in asthmatic and

healthy control subjects and to investigate the relationship of various demographic and

clinical characteristics with the total serum IgE level in asthmatics. We measured the

levels of total serum IgE using the ELISA kits (AccuBind, Monobind Inc., USA). The

22

relevant demographic and clinical data were obtained using the questionnaire. The results

showed that asthmatic children had a significantly elevated level of total serum IgE

compared to that of the healthy controls. The levels of total IgE and IL-4 in sera of 44

asthmatic children showed a significant positive correlation. Total serum IgE [150 IU/

mL was found to be significantly associated with age.

Allergies in children are the result of the interaction between genetic and environmental

factors on disease expression according to Chad Z (2011)51

. Although there is a genetic

predisposition, exposure to environmental allergens, irritants, and infection determines a

patient's sensitization to different dietary and inhalant allergens. As the genetic and

environmental factors that act on an immature cellular immune system are elucidated and

their roles established, the implementation of more enduring preventive efforts will be

developed. However, at present, the best approach to the child at high risk for the

development of allergies is to institute dietary and environmental control measures early

to decrease sensitization and to recognize, and appropriately treat, the evolving signs and

symptoms of allergic disease. Inflammation is central to all of the allergic diseases, and

anti-inflammatory treatment should be instituted early if there are ongoing symptoms.

Allergy testing and avoidance of allergens play an important role in asthma control.

Increased allergen exposure, in genetically susceptible individuals, can lead to allergic

sensitization. Continued allergen exposure can increase the risk of asthma and other

allergic diseases. In a patient with persistent asthma, identification of indoor and outdoor

allergens and subsequent avoidance can improve symptoms. Often, a patient will have

multiple allergies and the avoidance plan should target all positive allergens. Several

studies have shown that successful allergen remediation includes a comprehensive

approach including education, cleaning, physical barriers and maintaining these

practices52

.

23

Nelson RP (1996)53

et al was to evaluate the prevalence of specific IgE to common

aeroallergens in children with asthma first seen in the emergency department and control

subjects. Fifty-four children, aged 3 to 16 years (mean age, 8.34 years) who visited the

emergency department for treatment of acute bronchospasm or other illness, were

evaluated. Specific IgE to seven common aeroallergens and four common storage mites

was determined. Group, I consisted of 29 patients who had acute bronchospasm and

histories of recurrent asthma. Group II consisted of 25 control subjects who had no

clinical history of atopic disease. Groups I and II were compared for differences in the

prevalence of positive RAST responses to the 11 allergens tested. Dust samples were

collected from 17 homes of subjects in group I and from 13 homes of subjects in group II

and were analyzed for levels of Der p 1 and Der f L. Statistically significant differences in

the prevalence of positive RAST results between groups I and H were found in response

to: Dermatophagoides pteronyssinus, 89.6% versus 36% (p = 0.0001); Blattella

germanica, 45.8% versus 9.5% (p = 0.018); Alternaria tenuis, 44.8% versus 4% (p ~

0.001); and the storage mites' Aleuroglyphus ovatus, 39.2% versus 4% (p = 0.002);

Blomia tropicalis, 42.8% versus 0% (p = 0.0002); Chortoglyphus arcuatus, 46.4% versus

0% (p =- 0.0001); and Lepidoglyphus destructor, 32.1% versus 0% (p = 0.0019). Mean

specific IgE levels, expressed as percent of the total counts bound, were significantly

higher in group I compared with group H only in response to D. pteronyssinus, 21.9%

versus 2.1% (mean percent of total counts bound) (p = O. 0001). Analysis of dust samples

revealed no significant differences between the two groups, except for a higher

concentration of Der f l in the sofas of subjects in group II. Sensitization to D.

pteronyssinus, storage mites, and, to a lesser extent, to A. tenuis and B. germanica is

associated with acute childhood asthma that requires emergency treatment in Florida.

24

Johnson JR (2004)54

et al was to investigate responses to continuous antigen exposure,

mice were exposed to either house dust mite extract (HDM) or ovalbumin intranasally for

five consecutive days, followed by 2 days of rest, for up to seven consecutive weeks.

Continuous exposure to HDM, unlike ovalbumin, elicited severe and persistent

eosinophilic airway inflammation. Flow cytometric analysis demonstrated an

accumulation of CD4 lymphocytes in the lung with elevated expression of inducible co-

stimulator a marker of T cell activation, and T1/ST2, a marker of helper T Type 2 effector

cells. They also detected increased and sustained production of helper T cell Type 2-

associated cytokines by splenocytes of HDM-exposed mice on in vitro HDM recall.

Histologic analysis of the lung showed evidence of airway remodeling in mice exposed to

HDM, with goblet cell hyperplasia, collagen deposition, and peri-bronchial accumulation

of contractile tissue. In addition, HDM exposed mice demonstrated severe airway

hyperreactivity to methacholine. Finally, these responses were studied for up to 9 weeks

after cessation of HDM exposure. They observed that whereas airway inflammation

resolved fully, the remodeling changes did not resolve and airway hyperreactivity

resolved only partly.

Fazlollahi MR (2013)55

et al did a study on the efficacy of influenza vaccination on

pediatric asthma control, among 172 well-controlled patients, 59 one (34.3%) influenza

vaccination was not current, 103 (59.54%) vaccination was current, and 10 patients didn't

receive the vaccine. In group II (partly controlled+ uncontrolled) 301 patients were

registered, in which 164 (34.55%) was current, 131 (43.52%) was not current, and 64

(21.26%) didn't receive the vaccine. There was a significant relationship between

receiving vaccination and well-controlled asthma (p<.000). Controversy exists regarding

the effectiveness of influenza vaccination in improving asthma control in the pediatric

population. In this study it has been shown; using yearly influenza vaccination is related

25

to better asthma control level in children and it's recommended to vaccinate all children

with asthma.

Botelho FM (2011)56

et al was to investigate the impact of exposure to cigarette smoke

on house dust mite (HDM)-induced allergic airway inflammation and its consequences

for tissue remodeling and lung physiology in mice. BALB/c mice received intranasal

HDMs daily, 5 days per week, for 3 weeks to establish chronic airway inflammation.

Subsequently, mice were concurrently exposed to HDMs plus cigarette smoke, 5 days per

week, for 2 weeks (HDMs + smoke). We observed significantly attenuated eosinophilia

in the bronchoalveolar lavage of mice exposed to HDMs + smoke, compared with

animals exposed only to HDMs. A similar activation of CD4 T cells and expression of IL-

5, IL-13, and transforming growth factor-β was observed between HDM-treated and

HDM + smoke-treated animals. Consistent with an effect on eosinophil trafficking,

HDMs + smoke exposure attenuated the HDM-induced expression of eotaxin-1 and

vascular cell adhesion molecule-1, whereas the survival of eosinophils and the numbers

of blood eosinophils were not affected. Exposure to cigarette smoke also reduced the

activation of B cells and the concentrations of serum IgE. Although the production of

mucus decreased, collagen deposition significantly increased in animals exposed to

HDMs + smoke, compared with animals exposed only to HDMs. Although airway

resistance was unaffected, tissue resistance was significantly decreased in mice exposed

to HDMs + smoke. The results demonstrated that cigarette smoke affects eosinophil

migration without affecting airway resistance or modifying Th2 cell adaptive immunity in

a murine model of HDM-induced asthma.

Jindal SK (2012)57

et al was to determine the nationwide population prevalence of and

risk factors for asthma and chronic bronchitis (CB) in adults with a validated

questionnaire based on the International Union Against Tuberculosis and Lung Disease's

26

1984 to assess asthma and CB prevalence. Estimates standardized to the 2011 population

projection estimates for India were used to calculate the national disease burden. A total

of 85 105 men and 84 470 women from 12 urban and 11 rural sites were interviewed. One

or more respiratory symptoms were present in 8.5% of individuals. The overall

prevalence of asthma and CB was respectively 2.05% (adults aged ⩾15 years) and 3.49%

(adults aged ⩾35 years). Advancing age, smoking, household environmental tobacco

smoke exposure, asthma in a first-degree relative, and use of unclean cooking fuels were

associated with increased odds of asthma and CB. The national burden of asthma and CB

was estimated at respectively 17.23 and 14.84 million. They showed that asthma and CB

in adults posed an enormous health care burden in India. Most of the associated risk

factors are preventable.

The hospital-based study conducted by Paramesh H (2002)58

on 20,000 children under

the age of 18 years from 1979,1984,1989,1994 and 1999 in the city of Bangalore

showed a prevalence of 9%, 10.5%, 18.5%, 24.5% and 29.5% respectively. The

increased prevalence correlated well with demographic changes in the city. Further to

the hospital study, a school survey in 12 schools on 6550 children in the age group of 6

to 15 years was undertaken for the prevalence of asthma and children were categorized

into three groups depending upon the geographical situation of the school in relation to

vehicular traffic and the socioeconomic group of children. Group I-Children from

schools of heavy traffic area showed a prevalence of 19.34%, Group Il-Children from

heavy traffic region and the low socioeconomic population had 31.14% and Group III-

Children from low traffic area school had 11.15% respectively. (P: I & II; II & III <

0.001). A continuation of study in rural areas showed 5.7% in children of 6–15 years.

The persistent asthma also showed an increase from 20% to 27.5% and persistent severe

asthma 4% to 6.5% between 1994-99.

27

Bhalla K (2018)59

et al was to find the prevalence of bronchial asthma and various risk

factors that are associated in this age group and determine the extent of under-diagnosis.

A cross-sectional study involving 927 students from four government and three private

schools was conducted using the International Study of Asthma and Allergies in

Childhood questionnaire. Prevalence of bronchial asthma in adolescents was 13.1% (n =

121) of which 10.3% had episodes in the past 1 year. Prevalence was higher among males

(8.77%) compared to females (4.33%). About 77.7% of total asthmatics were newly

diagnosed cases. Prevalence was significantly higher among those having pets at home (P

< 0.001), belonging to higher socioeconomic status (P = 0.021), using smoke-producing

fuel at home (firewood/cow dung/kerosene; P = 0.032), and with history of smoking

among family members (P = 0.035). Among current asthmatics, 72.3% reported

cold/rhinitis (54.6% in March-May duration), 63.6% nocturnal dry cough, 50.5% sleep

disturbances, and 38.9% speech disturbances in the past 1 year. The study showed a

higher prevalence of bronchial asthma in the school-going population (11–16 years)

compared to other parts of Northern India possibly attributable to rapid industrialization

and post-harvesting season when the study was carried out. Preventive interventions need

to be taken to reduce disease burden at the community level.

Weinstein AG (2011)60

reviewed components of an organized adherence management

program that has been successful in uncontrolled trials promoting adherence and reducing

morbidity and cost. A literature review was undertaken in the following areas of asthma

management: guidelines, cost; morbidity; adherence, monitoring; and communication

skills. Also, studies that examined outcomes from psycho-educational, behavioral,

monitoring, and communication interventions. Results showed that two uncontrolled

studies of children with severe asthma, treated in both inpatient and outpatient

rehabilitation settings, used 4 intervention strategies to achieve marked reduction in

28

morbidity and cost. These strategies include (1) objective adherence monitoring; (2)

identification of the cause (s) of nonadherence; (3) delivery of specific strategies for each

cause; and (4) use of motivational interviewing communication skills to enhance the

delivery of the strategy. They revealed that nonadherence continues to be a significant

problem. Physicians need a proven organized approach to improve adherence and reduce

morbidity and cost. Evaluation of effective methods in a controlled fashion is warranted

to increase adherence management evidence for future asthma guidelines

Amy HY (2016)61

et al was to evaluate the factors associated with medication adherence

in school-aged children with asthma. Adherence was monitored electronically over 6

months in school-aged children who attended a regional emergency department in New

Zealand for an asthma exacerbation and were prescribed twice-daily inhaled

corticosteroids. Participants completed questionnaires including assessment of family

demographics, asthma responsibility and learning style. 101 children (mean (range) age

8.9 (6–15) years, 51% male) participated. Median (interquartile range) preventer

adherence was 30% (17–48%) of prescribed. Four explanatory factors were identified:

female sex (+12% adherence), Asian ethnicity (+19% adherence), living in a smaller

household (−3.0% adherence per person in the household), and younger age at diagnosis

(+2.7% for every younger year of diagnosis) (all p<0.02). In school-aged children

attending the emergency department for asthma, males and non-Asian ethnic groups were

at high risk for poor inhaled corticosteroid adherence and may benefit most from

intervention. Four factors explained a small proportion of adherence behavior indicating

the difficulty in identifying adherence barriers. Further research is recommended in other

similar populations.

29

MATERIALS AND METHODS

Study Design: Prospective Cross-Sectional Study

Study period: January 2018 - June 2019

Setting: Pediatrics Department (OPD & IPD) Mahatma Gandhi Medical College &

Hospital, Sitapura, Jaipur.

Inclusion Criteria: Children attending the Pediatrics OPD of Mahatma Gandhi Hospital.

Children diagnosed with BA and/or AR according to GINA and ARIA Guidelines

Between 5-15 years of Age of either sex.

Exclusion Criteria:

Children having skin diseases like Eczema, Dermatographism, Severe Dermatitis

or any other chronic skin diseases.

Immune compromised patients, HIV, Nephrotic syndrome, Children on oral

steroids ( > 2 mg /kg/day for > 2 weeks )

Children having tuberculosis, diabetes or any other chronic systemic illness

Patients in acute exacerbation of BA

Refusal to give consent to be a part of the study or were uncooperative during the

SPT.

30

Data collection method:

After approval of the thesis protocol, ethical clearance was obtained from the

Institute's ethical committee.

Informed Parental/Guardian consent was taken from all eligible study subjects.

(Annexure-II & III)

In all cases, socio-demographic data including age, sex, date of birth, socio-

economic status, etc and detailed history regarding, presenting symptoms,

duration of symptoms, seasonality of symptoms, environmental & precipitating

factors history, history of treatment prior to hospitalization, etc were obtained.

All patients were categorized into urban and rural classes according to a definition

by the census of India 2011.

Diagnosis of Asthma was established by GINA guideline 2018: Characteristics

symptoms pattern on history and evidence of variable airflow limitations

(spirometry/reversibility test)

Diagnosis of AR by ARIA guideline 2007: Based on symptomatology-

Rhinorrhea, nasal blockage, nasal itching, and sneezing, which are reversible

spontaneously or with treatment.

All these parameters were entered into a set proforma.

A cross-sectional pre-structured proforma based study was done. Proforma included

demographic profile, symptomatology, examination, severity, control of BA / AR along

with investigation reports.

Investigations included CBC, TEC, S. Ig E, X-Ray chest, PEFR, and SPT.

31

Skin prick test

SPT panel consisted of the following group of aeroallergen: pollens, grasses, mites,

dander, molds using standard allergen extracts from MERCK AllergoSPT. Buffered saline

and histamine were used as negative and positive controls, respectively. SPT was

performed by applying a drop of antigen on the healthy skin on the volar surfaces of the

forearm and pricking it with a lancet with a point length of 1.0 mm. Reading was

interpreted after 15–20 min.

Assessment of skin reactivity was done by calculating the mean diameter as (D + d)/2;

D = the largest diameter and d = orthogonal or perpendicular diameter at the largest width

of D after 15–20 min.

32

SPT interpretation: Mean wheal diameter

1+ = <3mm

2+ = 3-5mm

3+ = 5-7mm

4+ = 7-9mm

33

A positive result (2+ and above) to a specific allergen is indicated by a mean wheal

diameter measuring 3 mm or more, greater than the negative control (buffered saline).

Patients on oral drugs including antihistaminic (Cetrizine, Hydroxizine):

SPT will be withheld and performed 7 days after stopping the drug.

Patients on topical steroids:

SPT will be withheld and performed 7 days after stopping the drug.

Patients on short term oral steroids (<2mg/kg/day for <10 days):

SPT will be withheld and performed 3 days after stopping the drug as it can

give false negative SPT results.

Patients on other drugs like Inhaled/Topical steroids, Beta-agonist (Salbutamol,

Formoterol, Terbutaline) and Montelukast : SPT will be performed and drugs will

be continued as it would not interfere with SPT interpretation.

34

List of Allergens:

1. Dermatophagoids pteronyssinus (House dust mite)

2. Chenopodium album (Lambs quarter)

3. Ambrosia artemisiifolia (Ragweed)

4. Plantago lanceolata (Engl. Plantain)

5. Cynodon dactylon (Bermuda Grass)

6. Lolium perenne (Ryegrass)

7. Poa pratensis (Kentucky Blue Grass)

8. Robinia pseudoacacia (Locust black)

9. Triticum sativum (Wheat)

10. Zea Mays (Corn)

11. Aspergillus Fumigatus

12. Helminthosporium halodes

13. Animal Epithelia (Animal dander)

14. Acarus Siro (Storage mite )

15. Hordeum vulgare (Barley)

35

OBSERVATIONS AND RESULTS

Table 1: Age distribution of the children

Age in years Frequency Percent

5-10 35 58.3

11-15 25 41.7

Total 60 100.0

Mean ± SD 9.28 ± 2.94

Among 60 children with Respiratory allergic diseases, the majority of children

58.3% belonged to 5-10 years of age, remaining 41.7% were between the age

group 11-15 years.

Graph 1: Age distribution of the children

36

Table 2: Gender distribution

SEX FREQUENCY PERCENTAGE

MALE 46 76.6 %

FEMALE 14 23.4 %

In our study, males (76.6%) were higher recorded as compared to females (23.4%).

Graph 2: Gender distribution

37

Table 3: Weight-Height Percentile

Percentile 3rd

-10th

10th

-25th

25th

-50th

>50th

HEIGHT 3 11 39 7

WEIGHT 1 3 41 15

Out of the total children, the majority were having height and weight range between the

25th

-50th

percentile.

Graph 3: Weight-Height Percentile

38

Table 4: Rural / Urban Classification

Frequency Percent

Urban 31 51.7

Rural 29 48.3

Total 60 100.0

Among 60 children, 51.7% were from the Urban locality and 48.3% were from rural

backgrounds.

Graph 4: Rural / Urban Classification

Rural

39

Table 5: Socioeconomic status

CLASS Frequency Percent

Upper 3 5.0

Upper Middle 26 43.3

Upper Lower 7 11.7

Lower Middle 24 40.0

TOTAL 60 100.0

In our study, the highest number of patients were from the upper-middle class (43.3%)

followed by lower middle class (40%) while the lowest (5%) were from the upper class.

Graph 5: Socioeconomic status

40

Table 6: Exclusive breastfeeding

Frequency Percent

NO 22 36.7

YES 38 63.3

Total 60 100.0

Out of the total children suffering from allergic diseases, 63.3% of children were

exclusively breastfed for the initial 6 months of life.

Graph 6: Exclusive breastfeeding

41

Table 7: Family history of Atopy

Frequency Percent

NO 27 45.0

YES 33 55.0

Total 60 100.0

Among the total children in the study, 55% had a positive family history of atopy and

45% had a negative family history.

Graph 7: Family history of Atopy

42

Table 8: Risk factor for exacerbation

Frequency Percent

No risk factor 16 26.7

Exacerbation in last 12 month 5 8.4

Blood eosinophilia 16 26.7

Obesity 3 5.0

PICU admission 7 11.7

SMOKING in Family 13 21.5

Total 60 100.0

Among the risk factors, Blood eosinophilia (26.7%) was the most common cause for the

exacerbations followed by history of smoking in the family (21.5%), followed by the

previous history of PICU admission (11.7%) in the past.

Graph 8: Risk factor for exacerbation

43

Table 9: Seasonal/ Perennial Variation

Frequency Percent

Perennial 38 63.3

Seasonal 22 36.7

Total 60 100.0

Out of 60 patients, 38 (63.3%) patients have perennial distribution while 36.7% of

patients have seasonal distribution

Graph 9: Seasonal/ Perennial Variation

44

Table 10: Month of illness (in seasonal) wise distribution of the study

Max exacerbation was found in the winter seasons (Nov. to Jan.) i.e. 28.3%.

Graph 10: Month of illness (in seasonal)

Month Frequency Percent

MAY-JULY 10 16.6

AUGUST-OCTOBER 5 8.3

NOVEMBER-JANUARY 17 28.3

JANUARY-DECEMBER

(PERENNIAL)

38 63.3

45

Table 11: Diurnal variation

Frequency Percent

NO 27 45.0

YES (more in night) 33 55.0

Total 60 100.0

Diurnal variation was found in 55% patients & patients were more sympramatic during

the night time.

Graph 11: Diurnal variation

46

Table 12: Exacerbating factors

Frequency Percent

No 15 25.0

Single 5 8.3

Double 28 46.7

Three 12 20.0

Total 60 100.0

More than 1 exacerbating factor was present in maximum number of patients.

Graph 12: Exacerbating factors

47

Table 13: Exacerbating factors

FACTOR Frequency Percent

Dust 50 83.3

Pollution 45 75

Cold weather 20 33.3

Change in weather 25 41.6

Physical exertion 15 25

Viral illness 25 41.6

Smoke 10 16.6

NONE 16 26.6

Dust (83.3%) was most common factor for allergic reaction in our study followed by

pollution (75%), change in weather, viral illness (41.6%) and cold weather (33.3%),

Graph 13: Exacerbating factors

48

Table 14: Place of occurrence of symptoms

Frequency Percent

HOME 10 16.7

OUTSIDE 15 25

HOME and OUTSIDE 35 58.3

Total 60 100.0

58.3 % children were having symptoms both at home & outside.

Graph 14: Place of occurrence of symptoms

49

Table 15: Home environment

Frequency Percent

Carpets 12 26.6

Soft toys 8 17.7

Upholstered furniture 13 28.8

Cooking smoke 9 20

Home dust 1 2.22

Grains 1 2.22

Open environment 1 2.22

Total 45 100.0

Among the factors present in home, upholstered furniture was 28.8% followed by carpet

(26.6%) & cooling smoke (20%)

Graph 15: Home environment

50

Table 16: Animals (pets/farm animals)

Frequency Percent

NO 33 55.0

YES 27 45

Total 60 100.0

Only 45% children were having animals at home as pets.

Graph 16: Animals (pets/farm animals)

51

Table 17: Category of asthma severity

Frequency Percent

Mild asthma 46 76.7

Moderate asthma 14 24.4

Total 60 100.0

Maximum number of patients (76.7%) were Mild Asthma category in Asthma severity.

Graph 17: Category of asthma severity

52

Table 18: Symptom control

Frequency Percent

Partly controlled 22 36.6

Un-controlled 2 3.3

Well-controlled 36 60.0

Total 60 100.0

60 % children were having well-controlled while 36.6% were partly controlled.

Graph 18: Symptom control

53

Table 19: Co-morbidities

Frequency Percent

Allergic conjunctivitis 5 8.3

Allergic rhinitis 30 50

Allergic rhinitis, atopic dermatitis 8 13.3

Atopic dermatitis 13 21.6

GERD 3 5.0

Urticaria 1 1.7

Total 60 100.0

Almost 50% patients were having Allergic Rhinitis as the co-morbidity followed by

Atopic dermatitis (21.6%)

Graph 19: Co-morbidities

54

Table 20: Serum IgE (High/Normal )

Frequency Percent

HIGH 44 71.7

NORMAL 16 23.3

Total 60 100.0

Higher serum IgE level ( >500IU/ml ) was recorded on 71.7% patients

Graph 20: Serum IgE (High / Normal)

55

Table 21: TEC (High / Normal)

Frequency Percent

HIGH 44 73.3

NORMAL 16 26.7

Total 60 100.0

Higher TEC (Absolute eosinophil count >500/cumm) level was recorded on 73.3%

patients.

Graph 21: TEC ( High / Normal )

56

Table 22: PEFR (L/min) Normal / Low (Low for height)

Frequency Percent

LOW 44 73.3

NORMAL 16 26.7

Total 60 100.0

At the time of enrolment for the study, 26.7% had normal Peak Expiratory Flow Rate but

the rest 73.3% children had decreased PEFR for their age and height.

Graph 22: PEFR (L/min) Normal / Low (Low for height)

57

Table 23: Skin Prick Test Result

Frequency Percent

NEGATIVE 24 40.0

POSITIVE 36 60.0

Total 60 100.0

In our study, there was 60% positivity for 1 or more allergens i.e. 36 patients have

positive skin prick tests.

Graph 23: Skin Prick Test Result

58

Table 24: SPT Interpretation

Frequency Percent

1+ 24 40

2+ 2 3.33

3+ 18 30

4+ 16 26.66

Total 60 100.0

Graph 24: SPT Interpretation

59

Table 25: Allergen-specific wise distribution of the study

Frequency Percent

Dermatophagoids pteronyssinus (House dust mite) 40 66.6

Ambrosia artemisiifolia (Ragweed) 10 16.66

Plantago lanceolata (Engl. Plantain) 14 23.3

Cynodon dactylon (Bermuda Grass) 12 20

Lolium perenne (Rye grass) 10 16.66

Poa pratensis (Kentucky Blue Grass) 16 26.6

Robinia pseudoacacia (Locust black) 10 16.66

Triticum sativum (Wheat) 20 33.3

Zea Mays (Corn) 12 20

Aspergillus Fumigatus – fungus 8 13.3

Helminthosporium halodes – fungus test 9 15

Animal Epithelia (Animal dander) 18 30

Acarus siro (Storage mite ) 25 41.6

Hordeum vulgare (Barley)-cereal grain 8 13.3

Total 60 100.0

House dust mite (66.6%) was recorded higher storage mite (41.6%), wheat (33.3%),

Animal dander (3.0%) and Kentucky Blue Grass (26.6%).

60

Graph 25: Allergen-specific wise distribution of the study

61

DISCUSSION

Our study was aimed to know the aero-allergen prevalence in both the Bronchial

Asthma and/or Allergic Rhinitis patients. During the study period, 80 children were

eligible for the study as per the inclusion criteria, out of which 11 did not co-operate

while doing Skin Prick Test, and 9 did not give consent to be a part of the study, so were

excluded. The age of patients ranged from 5 to 15 years and the mean age was 9.28 years.

Raj D (2013)42

et al also found mean age 9.2 in the Indian population.

Our study indicates that males have a higher prevalence of concomitant asthma as

compared to females. Similar trends were seen in a Finnish study, where the risk of

asthma was significantly higher in males than in females62

. Our study has male

predominance, 76.6% male and 23.4% female. It is consistent with Prasad R (2009)5 et al

study, and Dave L (2014)48

et al studies. This gender difference in the study could be

because of gender bias in India i.e. bringing a male child more often to the hospital than

female.

Children from urban areas suffered more from allergy i.e. 58.3% urban vs 41.7%

rural. The ―Hygiene hypothesis‖ was developed to explain that allergic diseases were less

common in children from larger families living in rural areas, as they were exposed to

microbiota compared to the children from nuclear families in urban areas, but it’s used to

explain the increase in allergic diseases in urban areas has decreased since

industrialization, and the incidence of allergic diseases has increased in developed

countries.

The patients of asthma and/or rhinitis were having a positive family history of

Atopy (55%). This is consistent with Moitra S (2014)49

et al study, 40.19% of diseases

mediated by allergy are strongly familial. Ibekwe (2016)63

et al found in their study on

62

AR patients that a family history of atopy was present in 56.8% (n=42) of AR cases. Han

YY (2009)64

et al found the family history positive in 52.5% (n= 906) cases of Asthma,

almost similar to our current study.

In our study, out of the 60 children, 21.6% had atopic dermatitis (AD), 50% had

allergic rhinitis (AR), 13.3% had atopic dermatitis and allergic rhinitis, and 8.3%% had

allergic conjunctivitis as co-morbidities. This was consistent with Rasool R (2013)45

et al,

Moitra S49

et al and Dave L48

et al studies which showed Atopic dermatitis (62%) and

Allergic rhinitis (86.27%) as predominant diseases. In another study which evaluated 111

children with AR, 74% had both AR and asthma, while only 8% and 17% had asthma

alone and AR alone, respectively65

. This may be due to the reason that predominant

diseases due to allergy is multifactorial (depends on geography, type of predominant

allergen, population density, pollution, family history). Ibáñez (2010)66

et al form Spain

reported that rhinitis was diagnosed in 42.5% of the children in their study. The higher

prevalence in this study as compared to ours can be attributed to a different socio-

geographical setting in Europe.

In our study, perennial activities was 63.3%. This was consistent with Moitra S49

study, which shows 67.64%. In a study by Sharma (2018)43

et al, out of 134 patients of

AR & Asthma, 69 (51.49%) had seasonal variation and rest 65 (48.51%) had perennial

variation, almost similar seasonality was seen in our study (63.6 & 36.4%, n=89 & 51).

Spinozi (2016)67

et al found in their study that 71.2% (n=222) cases of AR showed

seasonal trends while in our study 42.9% (n=30) had seasonal trends. Observation by

Kumar (1981)68

et al on seasonality of Asthma in North Indian patients showed that

seasonal and perennial symptoms were equal, while in Asthma patients of our study

63.6% (n=89) cases showed perennial symptoms.

63

In our study, among 60 children in whom skin prick test (SPT) was done, 60%,

came out to be positive and positivity to at least one allergen is 16.6%, two and three

allergens were 41.6% each. This was consistent with Rajkumar (2012)69

et al study,

which shows poly-sensitization in 71.5%. From both studies, it was observed that poly

sensitization is the main cause (more than 70%) for allergic diseases. But our study

showed contrary results from Bayram N (2013)70

et al study, which shows one allergen

positivity is 52%, two or more allergen positivity is 48%. Raj D42

et al also found 55.5%

positive SPT out of 180 children with at least 37.8% positive to more than one allergen.

Also, our study was not consistent with Rasool T45

et al study, which shows positivity to

the single allergen is 0.5%.

Various studies from India and abroad showed a high prevalence of SPT positivity.

Studies like Siroux (2003)71

et al found 88.2% (n= 122) SPT positivity, Raj D

42 et al

55.6% (n= 100), Prasad R (2006)5 et al 89.5% (n= 43) and Kumar R (2017)

72 et al

showed 71.3% (n= 3040) SPT positive in their respective studies.

SPT positive patients were more likely to have earlier age of onset of the disease.

They also had severe symptoms on presentation. It is well documented that Allergic

rhinitis is closely related to asthma; both conditions together are often considered to be a

single disease affecting the whole respiratory tract.73

SPT negative patients can be

regarded as either having a low level of IgE-mediated reaction (below reaction threshold

of the SPT) or due to non-IgE-mediated pathophysiological causes. Such patients had a

weak IgE-mediated skin reaction than SPT-positive patients. The extent of reaction in the

skin also reflected the degree of IgE-mediated allergic reactivity in other body organs

including the eyes, nose, and lungs, which might account for differences in symptom

severity among the SPT-positive and negative patients.

64

In our study, 66.6% of children with allergic diseases are positive to

Dermatophytes pteronyssinus (House dust mite) and 13.3% to Aspergillus fumigatus.

This was consistent with other Indian studies like Moitra S49

et al, Prasad R5 et al,

Bayram N et al, which shows house dust mite as a predominant allergen (86.27%, 25%,

32.7% respectively). Mathur M and Mathur HC (1987)40

showed 21% patients had house

dust allergen positivity in the population of Western Rajasthan. Dey and Chakraborty

(2017)74

have found Bermunda grass as the causative agent in 22.22% of allergic rhinitis

cases.

The most common aeroallergens in our population are the pollens. Most of the

patients were sensitive to one or more species of pollens. The reason could be that

inhabitants are living in close proximity to farmlands, meadows and forest areas. The

surroundings in our country are highly enriched with natural flora. The patterns of

aeroallergens in the environment widely differ in different localities and are affected by

seasonal changes, particularly when they affect pollen. Duc et al (1986)75

had also found

house dust to be the most common allergen in patients of rhinitis with bronchial asthma

followed by grass pollens and animal dander. There were a few patients who were

sensitive to sheep wool, as they used to deal with sheep husbandry. Neither of the patients

was tested positive for dog or cat animal allergy, likely possibility could be as there is no

custom of keeping such animals as a pet. Usually, our people avoid coming into contact

with dogs and cats. In the study Prasad (2009)5 et al found the common offending

allergens were insects (21.8%, n= 10), followed by dusts (11.9%, n= 6), pollens (7.8%, n=

4), dander (3.1%, n= 2) and fungi (1.3%, n= 1). In a similar study by Acharya (1980)76

et

al house dust followed by wheat dust, cotton dust, and paper dust was found to be

common among patients of naso-bronchial allergy. Raj D (2013) et al found some

different patterns of prevalence of sensitization in North India. In their study, HDM was

65

not the common allergen, Housefly was the commonest allergen (36.7%, n= 66) followed

by grain dust (31%, n= 56) and female cockroach (18.3%, n= 33). A study from abroad,

Ibekwe (2016) et al observed that House dust mites allergen yielded the highest number

of positive responses (22.6%, n= 43) followed by tree pollen (16.8%, n= 48).

The sensitization pattern observed was different from other studies from the same

geographical region. An earlier study from North India which assessed 480

asthmatics/allergics found Prosopis juliflora among pollen and Alternaria alternata as

important sensitizers with 34.7% and 17.7% skin positivity, respectively.77

Another study

from Southern India in patients with naso-bronchial allergy showed a high prevalence of

mite allergy (73.7%) and pollen allergy (75.8%).78

The reason for this difference from the

same geographical area is probably because of seasonal and annual fluctuations in

allergens. Heterogeneity in allergen extract composition can lead to the different patterns

of sensitization observed in our study.79

The variable composition and content of

allergenic extract of different manufacturers may affect the allergenicity of the extract.80

The subjects in our study being mainly from the urban and semi-urban areas

surrounding the hospital, and belonging to a similar socioeconomic background, there

were no major changes in the climatic condition or flora and fauna; differences could not

be elicited based on the residence of subjects. In a study conducted on adults, it was found

that sensitization patterns did not vary a lot according to different areas of residence

except in younger subjects. They found higher sensitization to fungi and cockroaches in

younger subjects from the rural and urban areas, respectively [Mahesh PA, 2010]. Our

study has opened a new avenue in the field of allergen testing in children and has shown

that SPT is very much feasible even in younger age groups when needed. None of the

subjects suffered any severe reaction, the most common being mild local itching.

However, medication tray with the provision of adrenaline was always available at our

66

OPD for managing any severe anaphylactic reaction if needed. Large, cross-sectional

studies in other settings are required to be conducted to establish the SPT as an easy, cost-

effective, and sensitive method of allergen study. It has already been shown by multiple

studies that allergen avoidance can lead to a reduction in symptoms in AR and asthma.81

The idiopathic rhinitis, intrinsic asthma and idiopathic urticaria patients with

negative SPTs might nevertheless be suffering from allergic causes not detected by the

SPTs used. One possible reason could relate to the intrinsic limitations of SPTs

themselves (depending on the available allergens and their specificity and affinity for the

circulating IgE)82

. Moreover, SPTs may not identify patients with low-level IgE

hypersensitivity reactions (triggering smaller than 3-mm size wheals). In our study, 1+

grade (<3 mm) was 46.7%. 2+ grade (3-5 mm)was only 2%, 3+ grade (5-7 mm) was

23.3% and 4+ grade (>7 mm)was 26.7%. In an Irani study by Gharaghozlou M (2005)83

et al the percentage of 2 or more grade of SPT positivity was 11% (n= 25), their most

cases (84%, n= 196) were having grade 1 positivity, while in our study more than 50%

(n= 80) subjects were having SPT grade 2 or more. Whereas study by Kumar R (2017) et

al found the grading of SPT as 2 or more in 46.75% (n= 1993) of cases of respiratory

allergy which is quite similar to our study.

This study also sets the direction toward allergen avoidance, as depending on the

prototype of allergens present in our region, allergen avoidance measures can be

suggested to those children in whom SPT could not be done due to age or other factors.

However, the effect of allergen avoidance can be only studied in a separate study

conducted over a longer period. Recent trials suggest that exclusive breastfeeding for the

first 6 months of life, timely introduction of complementary feeds beyond 4 months but

not beyond 6 months, and the use of hypoallergenic formula feeds in children in whom

breastfeeding is not feasible, instead of normal complementary feeds is associated with

67

low risk of developing allergy in infants and delayed development of atopic dermatitis

and allergic march in at-risk infants84

, in our study, exclusive breastfeeding was found in

63.3% children.

Limitation of study

The sample population included only the children attending the Pediatric OPD of the

Hospital, so the data may not be representative of the general population of the area and

the true prevalence of the disease may differ from our data. An underestimate or

overestimate of true population prevalence could have occurred, depending on symptoms

prevalence in non-participating children. Asthma and Allergic Rhinitis remain a

stigmatizing diagnosis in some segments of the population so some parents may have

minimized symptoms to avoid that stigma. Another limitation, being the small sample

size of the population.

68

SUMMARY

Our study was conducted in 60 children diagnosed with BA &/or AR, to know the

prevalence of aero-aeroallergens by Skin Prick Test & to assess the association of

various risk factors in the children. The following results were obtained in our

study:

The majority of children were between 5 – 10 years of age.

Males were around 76.6 % and females 23.4%.

Around 51.7% children were from Urban areas.

Weight–height of the children was between 25th

-50th

centile on the WHO IAP growth

chart.

The majority of the children were from the upper-middle-class according to the

Modified Kuppuswamy Scale.

63.3% children were exclusively breastfed during the first 6 months of life.

Serum IgE and TEC was raised in >70% of children on whom SPT was performed.

Allergic rhinitis was the commonest co-morbidity which was associated with the

bronchial asthma patients.

Blood eosinophilia (26.7%) and a history of smoking (21.5%) in the family were the

risk factors for exacerbation in children.

Seasonal exacerbation was found in 36.7% of children, in which the winter season

had the maximum number of cases.

Diurnal variation was found in 55% of children

Poly sensitization was found in 41.6% of the SPT positive children.

Dermatophagoids pteronyssinus (HMD) (66.6%) is the predominant allergen followed

by Acarus Siro (Storage mite), among pollens (Ambrosia artemisiifolia) was the

commonest found to be responsible.

69

CONCLUSION

Our study was conducted in 60 children diagnosed with BA &/or AR, to know the

prevalence of aero-aeroallergens by Skin Prick Test & to assess the association of various

risk factors with the disease. In our study majority of children were between 5 – 10 years

of age, predominantly males, mostly from the urban area and were averagely nourished.

More than 70% were having raised TEC & Serum IgE levels. Allergic rhinitis was the

commonest co-morbidity associated with asthma in our study. On Skin prick test,

(Dermatophagoids pteronyssinus) HMD was positive in maximum number of patients

followed by (Acarus Siro) storage mite, among pollens (Ambrosia artemisiifolia) was the

commonest. Further, our study may help in avoidance of common inhaled allergens found

with SPT in our region in children with allergic airway diseases. Avoidance of common

allergens can also be advised even in those in whom SPT cannot be performed.

Individual patient may undergo immunotherapy if indicated. Our study did not encounter

even single adverse reaction, it further proves SPT is quite a safe method.

70

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79

ANNEXURES

PROFORMA

Case Number :

OPD / IPD : Registration Number :

Name :

Age :

Address :

Locality: Rural/ Urban-Slum/Urban Colony

Socioeconomic Status : Modified Kuppuswamy scale

Education of head of family:

Occupation of head of family:

Monthly income of family:

I Upper/ II Upper middle/ III Lower middle/ IV Upper lower/ V Lower

Exclusive Breast Feeding for 6 Months : Yes/No

School going/Non school going

Presenting Symptoms :

A) History of presenting illness :

1 Age of onset :

2 Duration:

3 Nature of Onset:

4 Seasonal/Perennial/Mixed:

80

5

Month:

February-April

May-July

August-October

November-January

6 Diuranal variation: Morning / Night

7

Place of occurrence of symptoms:

Home

Outside home

School

8

Home environment:

Carpets Upholstered furniture

Cotton wool Mattress/pillows

Book shelf Soft toys

Pets Farm animals

9 Aggravating factors:

10 Other

B) Categories of asthma severity

Mild asthma: well-controlled with Steps 1 or 2 (as-needed SABA or low dose ICS)

Moderate asthma: well-controlled with Step 3 (low-dose ICS/LABA)

Severe asthma: requires Step 4/5 (moderate or high dose ICS/LABA ± add-on)or

uncontrolled despite this treatment.

D) Risk factors for exacerbation:

• Intubated / PICU admission

• Smoking

• Obesity

• >1 exacerbation in last 12 month

• Blood eosinophillia

81

E) Comorbidities if any

• Allergic rhinitis

• Atopic dermatitis

• Sinusitis

• GERD

• Urticaria

History of past illness:

Anthropometry :

Height …….. cm …….. percentile

Weight …….. kg …….. percentile

c) Symptom control

In the past 4 weeks, has the patient had: Well-

controlled

Partly

controlled

Uncontrolled

• Daytime asthma symptoms more

than twice a week? Yes No

None of

these

1-2 of

these

3-4 of

these

• Any night waking due to asthma? Yes No

• Reliever needed for symptoms*

more than twice a week? Yes No

• Any activity limitation due to asthma?

Yes No

82

Investigations:

HB:

Total Leucocyte Count:

Total Eosinophil Count (TEC):

Serum IgE:

X-Ray Chest:

Spirometry/PEFR:

Skin Prick Test:

LIST OF AEROALLERGENS

1. Dermatophagoids pteronyssinus (House dust mite)

2. Chenopodium album (Lambs quarter)

3. Ambrosia artemisiifolia (Ragweed)

4. Plantago lanceolata (Engl. Plantain)

5. Cynodon dactylon (Bermuda Grass)

6. Lolium perenne (Ryegrass)

7. Poa pratensis (Kentucky Blue Grass)

8. Robinia pseudoacacia (Locust black)

9. Triticum sativum (Wheat)

10. Zea Mays (Corn)

11. Aspergillus Fumigatus

12. Helminthosporium halodes

13. Animal Epithelia (Animal dander)

14. Acarus Siro (Storage mite )

15. Hordeum vulgare (Barley)

83

INFORMED CONSENT FORM (ENGLISH)

Study Title:-“ Pattern of allergic sensitization to various aeroallergens in children

with Bronchial asthma and/or Allergic rhinitis by Skin prick test at a Tertiary care

hospital in Jaipur”

To be conducted by Dr. Saket Yadav, Dr. Madhu Mathur

Subject’s Name : .........................................................................

Date of Birth/ Age (Years): ............................... Sex: ..............................

Please √ the box given here

(1) I confirm that I have been explained the purpose and the methodology of

the study and I have cleared every doubt about the study.

[ ]

(2) I understand that my participation in the study is voluntary and that I am

free to withdraw at any time, without giving any reason, without my

medical care or legal rights being affected.

[ ]

(3) I have been informed that this study is purely a research study and

participation in the above study would not be of any direct benefit or risk

to me and results of this study may be of help in future for the society.

[ ]

(4) I understand that the investigator of this study and others working on the

investigator’s behalf, the Institutional Ethics Committee will not need my

permission to look at my health records both in respect to current study

and any future research study that may be conducted in relation to it.

[ ]

(5) I understand that my identity will not be revealed in any information

released to third parties or Published.

[ ]

(6) I agree not to restrict the use of any data or result that arises from this

study provided such a use is only for scientific purpose(s).

[ ]

(7) I agree to take part in the above study [ ]

Name of the subject: ................................................................................

Signature of the subject: ..................................... Date: ....../......./.........

Name of the Investigator: ........................................................................

Signature of the Investigator: .............................. Date: ....../....../..........

Name of the witness: ...............................................................................

Signature of the witness: ....................................... Date: ....../....../........

84

85

ABBREVIATIONS

BA - Bronchial asthma

AR - Allergic rhinitis

RAD - Respiratory allergic disorder

GINA - Global Initiative for asthma

ARIA - Allergic rhinitis and its impact on asthma

WAO - World allergy organization

EAACI - European academy of allergy & clinical immunology

HMD - House dust mite

AIT - Allergen-specific immunotherapy

SCIT - Subcutaneous immunotherapy

SLIT - Sublingual immunotherapy

SPT - Skin prick test

UAD - United airway disease

86

88

CASE NAME AGE SEX HEIGHT

(cm)

HEIGHT

(Centile )

WEIGHT

(kg)

WEIGHT

(Centile )

ADDRESS RURAL/

URBAN

SOCIOECONOMIC

STATUS

EXCLUSIVE

BREAST FEEDING

FAMILY HISTORY

OF ATOPY

RISK FACTOR for Exacerbation SEASONAL/

PERENNIAL

MONTH OF ILLNESS DIURNAL VARIATION

(More symptoms at

night )

EXACERBATING FACTORS PLACE OF OCCURRENCE

OF SYMPTOMS

HOME ENVIRONMENT ANIMALS

(PETS/FARM

ANIMALS)

CATEGORY OF

ASTHMA SEVERITY

SYMPTOM

CONTROL

CO-MORBIDITIES SERUM IgE (High /

Normal )

TEC ( High /

Normal )

PEFR (L/min)

Normal / Low

SKIN PRICK TEST ALLERGEN ( Positivity ) SPT

INTERPRETATION

1 SOURABH 14 MALE 160 50th-75th 45 25th-50th JAIPUR URBAN UPPER MIDDLE YES YES NONE PERENNIAL PERENNIAL YES DUST, POLLUTION HOME FURNITURE, BOOK SHELF,

CARPET,

NO MILD ASTHMA PARTLY

CONTROLLED

ALLERGIC

RHINITIS

HIGH HIGH LOW POSITIVE HOUSE DUST MITE 3+

2 AYUSH 6 MALE 110 10th-25th 18 25th-50th JAIPUR URBAN LOWER MIDDLE NO YES SMOKING SEASONAL MAY-JULY, NOVEMBER-JANUARY NO COLD WEATHER, PHYSICAL EXERTION HOME, OUTSIDE STUFF TOYS, MATTRESSES,

BOOKS,

NO MODERATE

ASTHMA

UN-CONTROLLED - HIGH HIGH LOW POSITIVE HOUSE DUST MITE, STORAGE MITE 3+

3 MANAN 6 MALE 118 50th-75th 21 50th-75th TONK RURAL LOWER MIDDLE YES YES EXACERBATION IN LAST 12 MONTHS SEASONAL AUGUST-OCTOBER YES VIRAL ILLNESS, COLD WEATHER HOME, OUTSIDE DUST, GRAINS,

ENVIRONMENT EXPOSURE

YES MILD ASTHMA WELL

CONTROLLED

ALLERGIC

RHINITIS

NORMAL NORMAL NORMAL NEGATIVE - 1+

4 PRIYA 11 FEMALE 135 10th-25th 32 25th-50th NEWAI URBAN UPPER LOWER NO NO NONE PERENNIAL PERENNIAL NO NONE HOME, OUTSIDE COOKING SMOKE YES MILD ASTHMA PARTLY

CONTROLLED

ALLERGIC

RHINITIS

HIGH HIGH LOW POSITIVE HOUSE DUST MITE 4+

5 JAL SINGH 9 MALE 130 25th-50th 40 90th-97th BHARATPUR URBAN UPPER MIDDLE YES YES OBESITY PERENNIAL PERENNIAL YES COLD WEATHER, DUST HOME CARPETS, UPHOLSTERED

FURNITURE, SOFT TOYS

NO MILD ASTHMA PARTLY

CONTROLLED

URTICARIA HIGH HIGH LOW POSITIVE HOUSE DUST MITE 3+

6 SALONI 13 FEMALE 148 25th-50th 38 25th-50th JAIPUR URBAN UPPER MIDDLE NO YES NONE SEASONAL NOVEMBER-JANUARY YES POLLUTION, PHYSICAL EXERTION OUTSIDE - NO MILD ASTHMA WELL

CONTROLLED

- NORMAL NORMAL NORMAL NEGATIVE - 1+

7 JOHN ISAAC 12 MALE 148 25th-50th 36 25th-50th JAIPUR URBAN UPPER YES Yes SMOKING PERENNIAL PERENNIAL YES PHYSICAL EXERTION, DUST HOME, OUTSIDE CARPETS, UPHOLSTERED

FURNITURE, SOFT TOYS

YES MODERATE

ASTHMA

PARTLY

CONTROLLED

GERD HIGH HIGH LOW POSITIVE HOUSE DUST MITE, STORAGE MITE 4+

8 VICKY 13 MALE 151 25th-50th 42 25th-50th BHARATPUR RURAL LOWER MIDDLE YES NO >1 EXACERBATION IN LAST 12

MONTH

SEASONAL NOVEMBER- JANUARY NO VIRAL ILLNESS, COLD WEATHER,

PHYSICAL EXERTION

HOME, OUTSIDE COOKING SMOKE,

ENVIRONMENT EXPOSURE

YS MILD ASTHMA PARTLY

CONTROLLED

ALLERGIC

RHINITIS

HIGH HIGH NORMAL POSITIVE HOUSE DUST MITE 4+

9 SOMENDER 7 MALE 119 25th-50th 22 50th-75th NEWAI URBAN LOWER MIDDLE YES NO SMOKING PERENNIAL PERENNIAL NO DUST, POLLUTION,PHYSICAL EXERTION OUTSIDE NO MILD ASTHMA PARTLY

CONTROLLED

ALLERGIC

CONJUNCTIVITIS

HIGH HIGH LOW POSITIVE HOUSE DUST MITE, RYE GRASS, LOCUST

BLACK, ANIMAL EPITHELIA, STORAGE MITE

3+

10 TANISHQ 5 MALE 106 10th-25th 16 25th-50th JAIPUR URBAN LOWER MIDDLE NO YES PICU Admission PERENNIAL PERENNIAL YES COLD WEATHER, PHYSICAL EXERTION OUTSIDE NO MILD ASTHMA WELL

CONTROLLED

ALLERGIC

RHINITIS

HIGH NORMAL NORMAL NEGATIVE _ 1+

11 MAHESH 13 MALE 143 3rd-10th 40 25th-50th JAIPUR URBANL UPPER LOWER YES NO SMOKING PERENNIAL PERENNIAL YES VIRAL ILLNESS, COLD WEATHER HOME ENVIRONMENT EXPOSURE,

SMOKING

YES MODERATE

ASTHMA

WELL

CONTROLLED

ATOPIC

DERMATITIS

HIGH HIGH LOW POSITIVE HOUSE DUST MITE 3+

12 NAKUL 5 MALE 105 10th-25th 16 25th-50th JAIPUR URBAN LOWER MIDDLE YES YES BLOOD EOSINOPHILIA SEASONAL MAY-JULY, NOVEMBER-JANUARY YES CHANGE IN WEATHER, PHYSICAL

EXERTION

OUTSIDE CARPETS, UPHOLSTERED

FURNITURE, SOFT TOYS

NO MILD ASTHMA WELL

CONTROLLED

_ NORMAL HIGH NORMAL NEGATIVE _ 1+

13 NAFISH 9 FEMALE 128 25th-50th 25 25th-50th TONK URBAN LOWER MIDDLE NO YES PICU Admission SEASONAL NOVEMBER- JANUARY YES SMOKE, POLLUTION,PHYSICAL

EXERTION

HOME, OUTSIDE CARPETS, UPHOLSTERED

FURNITURE, SOFT TOYS,

BOOKSHELF

NO MILD ASTHMA WELL

CONTROLLED

_ NORMAL NORMAL NORMAL NEGATIVE _ 1+

14 JAYA 5 FEMALE 107 25th-50th 16 25th-50th DAUSA RURAL LOWER MIDDLE NO YES SMOKING PERENNIAL PERENNIAL YES SMOKE, POLLUTION,CHNAGE IN

WEATHER

HOME, OUTSIDE YES MILD ASTHMA WELL

CONTROLLED

_ HIGH HIGH LOW NEGATIVE STORAGE MITE. 1+

15 VISHAL 10 MALE 134 25th-50th 29 25th-50th BHARATPUR RURAL UPPER MIDDLE YES YES BLOOD EOSINOPHILIA PERENNIAL PERENNIAL YES NONE OUTSIDE SMOKING YES MILD ASTHMA PARTLY

CONTROLLED

ALLERGIC

RHINITIS

HIGH HIGH LOW POSITIVE HOUSE DUST MITE, STORAGE MITE 3+

16 VAIBHAV 11 MALE 139 25th-50th 38 50th-75th JAIPUR URBAN UPPER MIDDLE YES YES OBESITY SEASONAL NOVEMBER- JANUARY YES DUST, PHYSICAL EXERTION, CHANGE IN

WEATHER

HOME, OUTSIDE CARPETS, UPHOLSTERED

FURNITURE, SOFT TOYS,

BOOKSHELF

NO MILD ASTHMA WELL

CONTROLLED

_ NORAML NORMAL NORMAL NEGATIVE _ 1+

17 MANISH 15 MALE 165 50th-75th 45 10th-25th SAWAI

MADHOPUR

RURAL UPPER MIDDLE YES NO NONE PERENNIAL PERENNIAL NO DUST, PHYSICAL EXERTION HOME, OUTSIDE COOKING SMOKE, SMOKING NO MILD ASTHMA WELL

CONTROLLED

_ NORMAL NORMAL NORMAL NEGATIVE _ 1+

18 AMIT 11 MALE 140 25th-50th 30 25th-50th AJMER RURAL UPPER LOWER YES NO BLOOD EOSINOPHILIA SEASONAL MAY-JULY, NOVEMBER-JANUARY YES CHANGE IN WEATHER, PHYSICAL

EXERTION

HOME, OUTSIDE YES MODERATE

ASTHMA

PARTLY

CONTROLLED

ALLERGIC

RHINITIS

HIGH HIGH LOW POSITIVE WHEAT, HOUSE, DUST MITE 4+

19 MONIKA 10 FEMALE 136 25th-50th 30 25th-50th JAIPUR URBAN UPPER MIDDLE YES YES >1 EXACERBATION IN LAST 12

MONTH

PERENNIAL PERENNIAL YES COLD WEATHER, PHYSICAL EXERTION,

VIRAL ILLNESS, CHANGE IN WEATHER

HOME NO MILD ASTHMA WELL

CONTROLLED

_ HIGH HIGH LOW POSITIVE HMD, STORAGE MITE 3+

20 DEV 8 MALE 125 25th-50th 25 50th-75th JAIPUR URBAN UPPER MIDDLE YES YES BLOOD EOSINOPHILIA PERENNIAL PERENNIAL YES DUST, POLLUTION, VIRAL ILLNESS HOME, OUTSIDE NO MILD ASTHMA PARTLY

CONTROLLED

ALLERGIC

RHINITIS

HIGH HIGH LOW POSITIVE HOUSE DUST MITE 3+

21 SAMAR 5 MALE 110 50th-75th 18 50th-75th TONK RURAL LOWER MIDDLE NO NO SMOKING PREENNIAL PERENNIAL NO SMOKE, POLLUTION,PHYSICAL

EXERTION

HOME COOKING SMOKE YES MILD ASTHMA WELL

CONTROLLED

_ NORMAL HIGH LOW NEGATIVE _ 1+

22 KANISHK 5 MALE 106 25th-50th 22 50th-97th JAIPUR URBAN LOWER MIDDLE NO YES BLOOD EOSINOPHILIA SEASONAL MAY-JULY, NOVEMBER-JANUARY YES CHANGE IN WEATHER HOME NO MODERATE

ASTHMA

WELL

CONTROLLED

ALLERGIC

RHINITIS

HIGH HIGH LOW POSITIVE RAGWEED, BERMUDA GRASS 4+

23 DEEPANSHU 11 MALE 138 25th-50th 26 10th-25th CHAKSU RURAL LOWER MIDDLE YES NO NONE PERENNIAL PERENNIAL YES VIRAL ILLNESS, COLD WEATHER HOME, OUTSIDE COOKING SMOKE NO MILD ASTHMA WELL

CONTROLLED

_ HIGH NORMAL LOW NEGATIVE 1+

24 LOKESH 12 MALE 148 25th-50th 28 3rd-10th JAIPUR URBAN UPPER MIDDLE YES NO BLOOD EOSINOPHILIA PERENNIAL PERENNIAL NO NONE HOME, OUTSIDE CARPETS, UPHOLSTERED

FURNITURE, SOFT TOYS

YES MILD ASTHMA WELL

CONTROLLED

ALLERGIC

RHINITIS

NORMAL NORMAL LOW NEGATIVE 1+

25 AARYAN 7 MALE 118 25th-50th 21 25th-50th JAIPUR URBAN UPPER MIDDLE YES NO NONE SEASONAL AUGUST-OCTOBER YES VIRAL ILLNESS, COLD WEATHER HOME, OUTSIDE YES MILD ASTHMA WELL

CONTROLLED

ALLERGIC

CONJUNCTIVITIS

HIGH HIGH LOW NEGATIVE 1+

26 PRIYAM 6 MALE 114 25th-50th 18 25th-50th DAUSA RURAL LOWER MIDDLE YES YES PICU Admission PERENNIAL PERENNIAL YES VIRAL ILLNESS, PHYSICAL EXERTION,

CHANGE IN WEATHER

HOME, OUTSIDE SMOKING YES MODERATE

ASTHMA

PARTLY

CONTROLLED

ALLERGIC

RHINITIS,ATOPIC

DERMATITIS

HIGH HIGH LOW POSITIVE HOUSE DUST MITE, RAGWEED,BERMUDA

GRASS, KENTUCKY BLUE GRASS, CORN,

STORAGE MITE

4+

27 NEERAJ 8 MALE 125 25th-50th 24 25th-50th JAIPUR RURAL UPPER MIDDLE YES YES SMOKING SEASONAL NOVEMBER- JANUARY, MAY-

JULY

YES DUST, POLLUTION HOME, OUTSIDE NO MILD ASTHMA PARTLY

CONTROLLED

ALLERGIC

CONJUNCTIVITIS

HIGH HIGH LOW NEGATIVE 1+

28 NARENDRA 11 MALE 132 3rd-10th 34 25th-50th JAIPUR URBAN UPPER MIDDLE NO NO BLOOD EOSINOPHILIA PERENNIALL PERENNIAL YES NONE OUTSIDE NO MILD ASTHMA WELL

CONTROLLED

ALLERGIC

RHINITIS,

HIGH HIGH LOW POSITIVE LAMBS QUARTER 3+

29 LAKSHAY 13 MALE 148 10th-25th 40 25th-50th TONK RURAL LOWER MIDDLE NO NO NONE SEASONAL AUGUST-OCTOBER NO NONE OUTSIDE NO MILD ASTHMA PARTIALLY

CONTROLLED

ALLERGIC

RHINITIS

HIGH HIGH NORMAL POSITIVE HOUSE DUST MITE, STORAGE MITE 4+

30 RAHUL 10 MALE 134 25th-50th 28 25th-50th BHARATPUR RURAL UPPER LOWER YES NO SMOKING PERENNIAL PERENNIAL YES CHANGE IN WEATHER, VIRAL ILLNESS HOME, OUTSIDE ENVIRONMENT EXPOSURE,

SMOKING

YES MILD ASTHMA WELL

CONTROLLED

ALLERGIC

RHINITIS

HIGH HIGH LOW POSITIVE HOUSE DUST MITE 4+

31 SACHIN 10 MALE 130 10th-25th 30 25th-50th JAIPUR URBAN UPPER NO NO BLOOD EOSINOPHILIA PERENNIAL PERENNIAL YES PHYSICAL EXERTION, SMOKE HOME, OUTSIDE COOKING SMOKE NO MODERATE

ASTHMA

WELL

CONTROLLED

_ HIGH HIGH LOW POSITIVE HOUSE DUST MITE, KENTUCKY BLUE

GRASS, ASPERGILLUS

3+

32 LOKESH G 10 MALE 137 25th-50th 28 25th-50th JAIPUR RURAL UPPER MIDDLE NO YES NONE PERENNIAL PERENNIAL YES NONE HOME, OUTSIDE CARPETS, UPHOLSTERED

FURNITURE, SOFT TOYS

NO MILD ASTHMA PARTLY

CONTROLLED

ALLERGIC

RHINITIS

HIGH HIGH LOW POSITIVE HOUSE DUST MITE 4+

33 BHUMIKA 12 FEMALE 144 25th-50th 38 25th-50th BHARATPUR RURAL UPPER MIDDLE YES YES NONE SEASONAL NOVEMBER- JANUARY, MAY-

JULY

NO SMOKE OUTSIDE CARPETS, UPHOLSTERED

FURNITURE, SOFT TOYS,

BOOKSHELF

YES MODERATE

ASTHMA

PARTLY

CONTROLLED

_ NORMAL NORMAL LOW NEGATIVE 1+

34 KARTIK 8 MALE 126 25th-50th 23 25th-50th JAIPUR URBAN LOWER MIDDLE NO YES BLOOD EOSINOPHILIA PERENNIAL PERENNIAL YES CHANGE IN WEATHER, PHYSICAL

EXERTION

HOME, OUTSIDE YES MODERATE

ASTHMA

WELL

CONTROLLED

GERD HIGH HIGH LOW POSITIVE RAGWEED, BERMUDA GRASS 2+

35 PRIYA C 11 FEMALE 138 10th-25th 32 25th-50th CHAKSU RURAL LOWER MIDDLE YES NO SMOKING PERENNIAL PERENNIAL NO POLLUTION, PHYSICAL EXERTION HOME, OUTSIDE YES MILD ASTHMA UN-CONTROLLED ALLERGIC

RHINITIS

HIGH HIGH LOW POSITIVE HOUSE DUST MITE, ENGLISH PLANTAIN,

HELMINTHOSPORIUM, STORAGE MITE

4+

Table 1

Master Chart

1

36 MAHI 7 FEMALE 119 25th-50th 24 50th-75th CHURU RURAL UPPER MIDDLE NO YES >1 EXACERBATION IN LAST 12

MONTH

PERENNIAL PERENNIAL YES CHANGE IN WEATHER, VIRAL ILLNESS HOME, OUTSIDE YES MILD ASTHMA WELL

CONTROLLED

ALLERGIC

RHINITIS

HIGH HIGH LOW POSITIVE HOUSE DUST MITE, STORAGE MITE,

ANIMAL DANDER

3+

37 YASHWARDHAN 9 MALE 128 25th-50th 30 50th-75th TONK URBAN UPPER YES NO NONE PERENNIAL PERENNIAL NO NONE OUTSIDE CARPETS, UPHOLSTERED

FURNITURE, SOFT TOYS,

BOOKSHELF

YES MILD ASTHMA WELL

CONTROLLED

GERD HIIGH HIGH LOW POSITIVE HOUSE DUST MITE 4+

38 SAJID 6 MALE 112 25th-50th 20 50th-75th TONK RURAL UPPER LOWER YES NO NONE SEASONAL NOVEMBER-JANUARY NO NONE OUTSIDE NO MILD ASTHMA PARTLY

CONTROLLED

ATOPIC

DERMATITIS

HIGH HIGH LOW POSITIVE RAGWEED 2+

39 MANJEET 12 FEMALE 144 25th-50th 38 25th-50th KARAULI RURAL UPPER MIDDLE NO YES PICU Admission PERENNIAL PERENNIAL NO VIRAL ILLNESS, PHYSICAL EXERTION HOME, OUTSIDE CARPETS, UPHOLSTERED

FURNITURE, SOFT TOYS

NO MODERATE

ASTHMA

PARTLY

CONTROLLED

_ NORMAL NORMAL NORMAL NEGATIVE - 1+

40 DEEPANSHU 11 MALE 142 25th-50th 32 25th-50th JAIPUR RURAL UPPER MIDDLE YES NO NONE PERENNIAL PERENNIAL YES NONE HOME, OUTSIDE YES MILD ASTHMA WELL

CONTROLLED

ALLERGIC

RHINITIS

HIGH HIGH LOW POSITIVE HOUSE DUST MITE, RYE GRASS 4+

41 KANU 14 MALE 160 50th-75th 45 25th-50th JAIPUR URBAN UPPER MIDDLE YES YES NONE PERENNIAL PERENNIAL YES DUST, POLLUTION HOME FURNITURE, BOOK SHELF,

CARPET,

NO MILD ASTHMA PARTLY

CONTROLLED

ALLERGIC

RHINITIS

HIGH HIGH LOW POSITIVE HOUSE DUST MITE 3+

42 RAMAN 6 MALE 110 10th-25th 18 25th-50th JAIPUR URBAN LOWER MIDDLE NO YES SMOKING SEASONAL MAY-JULY, NOVEMBER-JANUARY NO COLD WEATHER, PHYSICAL EXERTION HOME, OUTSIDE STUFF TOYS, MATTRESSES,

BOOKS,

NO MODERATE

ASTHMA

UN-CONTROLLED - HIGH HIGH LOW NEGATIVE HOUSE DUST MITE, STORAGE MITE 1+

43 HITESH 6 MALE 118 50th-75th 21 50th-75th TONK RURAL LOWER MIDDLE YES YES EXACERBATION IN LAST 12 MONTHS SEASONAL AUGUST-OCTOBER YES VIRAL ILLNESS, COLD WEATHER HOME, OUTSIDE DUST, GRAINS,

ENVIRONMENT EXPOSURE

YES MILD ASTHMA WELL

CONTROLLED

ALLERGIC

RHINITIS

NORMAL NORMAL NORMAL NEGATIVE - 1+

44 OJASVI 11 FEMALE 135 10th-25th 32 25th-50th NEWAI RURAL UPPER LOWER NO NO -NONE PERENNIAL PERENNIAL NO NONE HOME, OUTSIDE COOKING SMOKE YES MILD ASTHMA PARTLY

CONTROLLED

ALLERGIC

RHINITIS

HIGH HIGH LOW POSITIVE HOUSE DUST MITE 4+

45 MOHIT 9 MALE 130 25th-50th 40 90th-97th BHARATPUR URBAN UPPER MIDDLE YES YES OBESITY PERENNIAL PERENNIAL YES COLD WEATHER, DUST HOME CARPETS, UPHOLSTERED

FURNITURE, SOFT TOYS

NO MILD ASTHMA PARTLY

CONTROLLED

URTICARIA HIGH HIGH LOW POSITIVE HOUSE DUST MITE 3+

46 MANSI 13 FEMALE 148 25th-50th 38 25th-50th JAIPUR URBAN UPPER MIDDLE NO YES NONE SEASONAL NOVEMBER-JANUARY YES POLLUTION, PHYSICAL EXERTION OUTSIDE - NO MILD ASTHMA WELL

CONTROLLED

- NORMAL NORMAL NORMAL NEGATIVE - 1+

47 JUNED 12 MALE 148 25th-50th 36 25th-50th JAIPUR URBAN UPPER YES Yes SMOKING PERENNIAL PERENNIAL YES PHYSICAL EXERTION, DUST HOME, OUTSIDE CARPETS, UPHOLSTERED

FURNITURE, SOFT TOYS

YES MODERATE

ASTHMA

PARTLY

CONTROLLED

GERD HIGH HIGH LOW POSITIVE HOUSE DUST MITE, STORAGE MITE 4+

48 HARDIK 13 MALE 151 25th-50th 42 25th-50th BHARATPUR RURAL LOWER MIDDLE YES NO >1 EXACERBATION IN LAST 12

MONTH

SEASONAL NOVEMBER- JANUARY NO VIRAL ILLNESS, COLD WEATHER,

PHYSICAL EXERTION

HOME, OUTSIDE COOKING SMOKE,

ENVIRONMENT EXPOSURE

YS MILD ASTHMA PARTLY

CONTROLLED

ALLERGIC

RHINITIS

HIGH HIGH NORMAL POSITIVE HOUSE DUST MITE 4+

49 MANU 7 MALE 119 25th-50th 22 50th-75th NEWAI URBAN LOWER MIDDLE YES NO SMOKING PERENNIAL PERENNIAL NO DUST, POLLUTION,PHYSICAL EXERTION OUTSIDE NO MILD ASTHMA PARTLY

CONTROLLED

ALLERGIC

CONJUNCTIVITIS

HIGH HIGH LOW POSITIVE HOUSE DUST MITE, RYE GRASS, LOCUST

BLACK, ANIMAL EPITHELIA, STORAGE MITE

3+

50 VIHAAN 5 MALE 106 10th-25th 16 25th-50th JAIPUR URBAN LOWER MIDDLE NO YES PICU Admission PERENNIAL PERENNIAL YES COLD WEATHER, PHYSICAL EXERTION OUTSIDE NO MILD ASTHMA WELL

CONTROLLED

ALLERGIC

RHINITIS

HIGH NORMAL NORMAL NEGATIVE _ 1+

51 RAJESH 13 MALE 143 3rd-10th 40 25th-50th JAIPUR RURAL UPPER LOWER YES NO SMOKING PERENNIAL PERENNIAL YES VIRAL ILLNESS, COLD WEATHER HOME ENVIRONMENT EXPOSURE,

SMOKING

YES MODERATE

ASTHMA

WELL

CONTROLLED

ATOPIC

DERMATITIS

HIGH HIGH LOW NEGATIVE HOUSE DUST MITE 1+

52 HANUMAN 5 MALE 105 10th-25th 16 25th-50th JAIPUR URBAN LOWER MIDDLE YES YES BLOOD EOSINOPHILIA SEASONAL MAY-JULY, NOVEMBER-JANUARY YES CHANGE IN WEATHER, PHYSICAL

EXERTION

OUTSIDE CARPETS, UPHOLSTERED

FURNITURE, SOFT TOYS

NO MILD ASTHMA WELL

CONTROLLED

_ NORMAL HIGH NORMAL NEGATIVE _ 1+

53 GEETIKA 9 FEMALE 128 25th-50th 25 25th-50th TONK URBAN LOWER MIDDLE NO YES PICU Admission SEASONAL NOVEMBER- JANUARY YES SMOKE, POLLUTION,PHYSICAL

EXERTION

HOME, OUTSIDE CARPETS, UPHOLSTERED

FURNITURE, SOFT TOYS,

BOOKSHELF

NO MILD ASTHMA WELL

CONTROLLED

_ NORMAL NORMAL NORMAL NEGATIVE _ 1+

54 DHOLIYA 5 FEMALE 107 25th-50th 16 25th-50th DAUSA RURAL LOWER MIDDLE NO YES SMOKING PERENNIAL PERENNIAL YES SMOKE, POLLUTION,CHNAGE IN

WEATHER

HOME, OUTSIDE YES MILD ASTHMA WELL

CONTROLLED

_ HIGH HIGH LOW POSITIVE STORAGE MITE. 3+

55 RAZA 10 MALE 134 25th-50th 29 25th-50th BHARATPUR RURAL UPPER MIDDLE YES YES BLOOD EOSINOPHILIA PERENNIAL PERENNIAL YES NONE OUTSIDE SMOKING YES MILD ASTHMA PARTLY

CONTROLLED

ALLERGIC

RHINITIS

HIGH HIGH LOW POSITIVE HOUSE DUST MITE, STORAGE MITE 3+

56 NITIN 11 MALE 139 25th-50th 38 50th-75th JAIPUR URBAN UPPER MIDDLE YES YES OBESITY SEASONAL NOVEMBER- JANUARY YES DUST, PHYSICAL EXERTION, CHANGE IN

WEATHER

HOME, OUTSIDE CARPETS, UPHOLSTERED

FURNITURE, SOFT TOYS,

BOOKSHELF

NO MILD ASTHMA WELL

CONTROLLED

_ NORAML NORMAL NORMAL NEGATIVE _ 1+

57 DEEPAK 15 MALE 165 50th-75th 45 10th-25th SAWAI

MADHOPUR

RURAL UPPER MIDDLE YES NO NONE PERENNIAL PERENNIAL NO DUST, PHYSICAL EXERTION HOME, OUTSIDE COOKING SMOKE, SMOKING NO MILD ASTHMA WELL

CONTROLLED

_ NORMAL NORMAL NORMAL NEGATIVE _ 1+

58 RAVI 11 MALE 140 25th-50th 30 25th-50th AJMER RURAL UPPER LOWER YES NO BLOOD EOSINOPHILIA SEASONAL MAY-JULY, NOVEMBER-JANUARY YES CHANGE IN WEATHER, PHYSICAL

EXERTION

HOME, OUTSIDE YES MODERATE

ASTHMA

PARTLY

CONTROLLED

ALLERGIC

RHINITIS

HIGH HIGH LOW POSITIVE WHEAT, HOUSE, DUST MITE 4+

59 KASHISH 10 FEMALE 136 25th-50th 30 25th-50th JAIPUR URBAN UPPER MIDDLE YES YES >1 EXACERBATION IN LAST 12

MONTH

PERENNIAL PERENNIAL YES COLD WEATHER, PHYSICAL EXERTION,

VIRAL ILLNESS, CHANGE IN WEATHER

HOME NO MILD ASTHMA WELL

CONTROLLED

_ HIGH HIGH LOW POSITIVE HMD, STORAGE MITE 3+

60 VASHU 8 MALE 125 25th-50th 25 50th-75th JAIPUR URBAN UPPER MIDDLE YES YES BLOOD EOSINOPHILIA PERENNIAL PERENNIAL YES DUST, POLLUTION, VIRAL ILLNESS HOME, OUTSIDE NO MILD ASTHMA PARTLY

CONTROLLED

ALLERGIC

RHINITIS

HIGH HIGH LOW POSITIVE HOUSE DUST MITE 3+

2