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ORIGINAL ARTICLE
Year : 2006  |  Volume : 23  |  Issue : 2  |  Page : 53-58 Table of Contents   

Prevalence and risk factors for bronchial asthma in adults in Jaipur district of Rajasthan (India)


1 Department of Chest & TB, SMS Medical College Jaipur., India
2 OSD, Medical & Health, Govt. of Rajasthan, Jaipur., India

Correspondence Address:
P R Gupta
A-66, Subhash Nagar Shopping Centre, Jaipur-302016.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-2113.44409

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   Abstract 

No information is available on epidemiology of bronchial asthma in Rajasthan. A field study was therefore, undertaken to estimate prevalence of bronchial asthma and to define the risk factors influencing the disease prevalence in Jaipur district of the state using a previously validated questionnaire. Besides demographic data, information on smoking habits, domestic cooking fuel used, atopic symptoms, and family history suggestive of asthma was also collected. Multivariate logistic regression analysis was performed to calculate odds ratio of various potential risk factors. Data from 8863 respondents (5010 men, 3853 women) were analyzed after excluding children below 15 years of age. One or more respiratory symptoms were present in 5.3% of the subjects. Asthma was diagnosed in 1.86%, 1.44%, 0.51 and 0.38% of the rural male, rural female, urban male and urban female respondents respectively, with an overall prevalence of 0.96%. History of atopy in self and/or history of atopy/asthma in the first-degree relative were found to be the most important risk factor. Advancing age, usual residence in rural area and tobacco smoking, especially hookah smoking, were also associated with significantly higher odds of having asthma.

Keywords: Asthma, Epidemiology, Prevalence, Risk factors, Tobacco smoking


How to cite this article:
Gupta P R, Mangal D K. Prevalence and risk factors for bronchial asthma in adults in Jaipur district of Rajasthan (India). Lung India 2006;23:53-8

How to cite this URL:
Gupta P R, Mangal D K. Prevalence and risk factors for bronchial asthma in adults in Jaipur district of Rajasthan (India). Lung India [serial online] 2006 [cited 2019 Nov 20];23:53-8. Available from: http://www.lungindia.com/text.asp?2006/23/2/53/44409


   Introduction Top


Data on prevalence of asthma are now available from several countries including India. Prevalence varies from region to region depending upon the definition used for diagnosis of asthma. [1],[2],[3],[4],[5],[6],[7],[8],[9],[10] Diagnosed asthma (i.e. asthma ever diagnosed by a clinician) in adults is generally reported as 2.7 to 4.0% in most European countries, 12.0% in England and 7.1% in US. [1],[6],[7],[8] In Australia, the prevalence is rather high (9.5 to 17.9%). [2],[4] Tristan da Cunha is an unique example where more than half the population (56%) is reported to suffer from asthma, supporting a strong genetic link. [9] Aggarwal et al [11] has reported a prevalence of 2.38% in Indian population based on a survey conducted in Delhi, Chandigarh, Kanpur and Bangalore. India is a vast country with immense geographical, economical, racial, religious and socio-political diversity. There are obvious differences in prevalence of disease and the above data can not automatically be applied to Rajasthan. Since it is an enormously difficult and costly proposition to collect state-wise statistics, as it requires coordination and cooperation between several centers spread across the State, a field study was undertaken at Jaipur district of the State.


   Material and Method Top


The Material and methods used in the present study were essentially similar to those used in the nationwide study by Aggarwal et al. [11] The essential components of this study design were (a) a single definition of asthma developed prior to initiation of data collection, (b) a standardized and validated Hindi study questionnaire developed at the Central Coordinating Centre i.e. Chandigarh, (c) uniform method of data collection and input of data at Jaipur, and (d) data analysis at the coordinating centre.

Jaipur district in Rajasthan has a population of 5252388 (Census 2001). Of this 49.38% are the urbanites constituted by the capital city of Jaipur and 10 towns. The remaining 50.62% are living in rural areas, constituted by 2267 villages. It was planned to sample 15000 subjects (about 0.03% of the population) for the purpose of this study. Ten wards of Jaipur city, 2 towns and 50 villages of the district were randomly selected to act as clusters of the study. Survey team consisted of 4 field workers and 1 field supervisor. Each field worker formed a sampling unit and it had to fill up 35 to 45 questionnaires each day in the assigned area, namely Jaipur city (164 units ), Kishangarh-Renwal (10 units), Chaksu (11 units) and 50 villages (3-4 units each with a total of 190 units).

A separate questionnaire form was completed for each respondent in a households. Interview started in the selected household. The field workers carried out interviews of all the members in each household, moving to the next selected house once the previous one was exhausted, and continued till the requisite sample had been covered. Interviews were conducted face to face in privacy and in homes of the respondents. Help was taken from one of the parents in case the subject was aged less then 15 years of age. In case a selected household was locked or a respondent was not available, the field worker noted it as such, and returned at a subsequent date at a time convenient to the respondent to fill the questionnaire. If such attempt at meeting residents of a household was unsuccessful, the household was dropped from the list.

A field supervisor at each participating centre collected the list of all households visited by the field workers, and later made a visit to five percent randomly selected households to verify if the interview was actually conducted. He also administered the questionnaire again to randomly selected respondents to check for any mistakes made by the interviewer. Data input was carried out at Jaipur on a computer programme, specifically written for this project, using the software Epilnfo (version 6). All data were later transferred to SPSS (version 10.0) software (SPSS Inc., Chicago, IL) for further analysis. Data related to respondents below the age of less then 15 years of age were excluded from the further analysis. Asthma was diagnosed if the respondent answered affirmatively both to (a) wheezing or whistling sound from chest, or chest tightness or breathlessness in morning, and (b) having suffered from asthma, or having an attack of asthma in past 12 months, or using inhaled or oral bronchodilators. Prevalence of asthma was calculated as the number of subjects categorized as having asthma (based on the definition described above) divided by the total number of subjects in that particular group. Multivariate logistic regression modeling was also performed to assess odds ratio for each potential risk factor after adjusting for others.


   Results Top


The survey started in August' 2002 and was completed in February'2003. Out of the expected 15000, a total of 12805 responses were collected from the study population (85.4%). The response was better in urban areas as compared to rural areas. After exclusion of 3942 subjects below 15 years of age (questionnaire has not been yet validated for this group) , data collected from the 8863 adult respondents was analysed. There were 5010 (56.5%) men and 3853 (43.5%) women. 4860 of the subjects (54.7%) were urbanites, the remaining 4003 (46.3%) belonged to rural areas. More then half of the subjects (54.7%) were aged between 15 and 34 years and only 4.0 percent individuals were aged 65 years or more. [Table 1]. The distribution of the subjects based on occupation, education and socio-economic status are shown in [Table 2],[Table 3] and [Table 4] respectively.

[Table 5] shows the smoking status of the subjects. Less women smoked (52 out of 3835) as compared to men (1332 out of 4986), this difference being more marked in urban areas. Cigarette and bidi were the commonest forms of tobacco smoked by the study subjects. Only a small minority of smokers had quit smoking, majority of them doing so in the recent past. Environmental tobacco smoking (ETS) was very common in the study subjects, more so in females on account of smoking by their spouses [Table 5]. About one third of the study subjects studied (35%) were regularly cooking food at home. Vast majorities of these subjects were women. While liquefied petroleum gas (LPG) was the commonest cooking fuel used in urban areas, solid fuels (e.g. coal and dung) were more common in use in rural areas [Table 6].

One or more respiratory symptoms were present in 5.3% of the study subjects [Table 7]. Cough, breathlessness, phlegm, wheezing and tightness in chest were the common symptoms, being present in 3.3%, 2.8%, 2.4%, 2.0% and 1.6% of the subjects respectively. Atopy (skin rash, rhinorrhoea or itchiness in eyes) was present in about 3.8% of the individuals. Family history of atopy or asthma was found in about 0.3% of the subjects [Table 8]. All the respiratory symptoms were more in rural areas (6.8%) as compared to urban areas (3.6%).

Based on the criteria used in the survey, asthma was diagnosed in 0.96% of the respondents in Jaipur district of Rajasthan. History of atopy in self or a family member was the most important risk factor (p<0.001). Rural domicile, history of hookah smoking and advancing age were also identified as significant risk factors for occurrence of asthma [Table 9]. On univariant analysis male sex, low socioeconomic status, other forms of smoking and cooking with kerosene or dung also figured as risk factors to asthma but on multiple logistic regression analysis, it was found to be insignificant.


   Discussion Top


A significant proportion of the general population may suffer from respiratory symptoms due to varied etiologies including asthma. In the present study at Jaipur district, as many as 469 out of the 8863 (5.3%) subjects suffered from respiratory symptoms. This compares well with the national prevalence of 4.3­-6.9%, reported by Aggarwal et al. [11] To correctly identify asthmatics from the symptomatics a questionnaire which has been validated against physician-diagnosed asthma under both hospital and field conditions [12] was used. Based on this questionnaire Aggarwal et al [11] have estimated that about 2.38% of Indian population suffers from asthma. This estimate was found to be close to an earlier estimate of 2.78%, reported three decades ago in a middle-aged urban population. [13] Using the same methodology [11] , the prevalence of asthma in our study population was found to be 0.96%. Our estimates of prevalence of asthma in Jaipur district of Rajasthan are low as compared to the National figures. We have tried to analyze the possible reasons of this. We have followed the same methodology, data analysis and definition of asthma as was used by Aggarwal et al. [11] Essential part of the definition of asthma is the knowledge and/ or admission on the part of the respondent of having suffered from asthma or using inhaled or oral bronchodilators. Some patients might not have disclosed the "asthma diagnosis" to the interviewer at time of questionnaire administration due to stigma attached to this disease. Few others might not be knowing of their asthma due to ignorance or lack of knowledge. Further, physicians might not be using inhalers or disclosing the diagnosis of asthma to the patient. These factors might have contributed to the lower then actual prevalence of asthma in this part of the country, where the population in general is less educated and less knowledgeable as compared to the Metros. The prevalence of asthma may be genuinely low in this part of the country. Aggarwal et al [11] have also found regional differences i.e. prevalence of asthma was much lower in Delhi (1.69%) as compared to Banglore (3.4%).

In the present study about 3.8% of the population was suffering from atopy and about 0.3% population had family history of atopy/asthma. About half of the asthma patients were attributable to atopy in the present study (Odd's Ratio=12.09). This compares well with about one third to one half of asthma cases in population-based studies attributable to atopy. [11],[14] Variations in factors related to the expression of asthma and the prevalence of sensitization, particularly to house dust mite [15] possibly contribute to these differences. A positive relationship between asthma in family members and development of airway hyper­responsiveness and/or asthma in an individual is well recognized. [16],[17] Odd's ratios for a first-degree relative with asthma have ranged from 1.5 to 10 in several studies on childhood asthma. [18] In our study in adult population, the Odd's ratio for a first-degree relative with asthma was 61.5. Though, a pure genetic basis of asthma appears unlikely, several chromosomal regions and loci showing linkage to, and association with, airway inflammation, asthma and asthma-linked phenotypes have recently been identified. [19],[20]

Data on the importance of tobacco smoking in relationship to prevalence of asthma are conflicting. Another problem to interpreting and comparing these data is difficult in differentiating asthma and chronic obstructive pulmonary disease based on symptoms alone. The later problem was overcome by including questions with high specificity for asthma into disease definition. Tobacco smoking by hookah emerged a highly significant risk factor in our study population even after adjusting for other confounding factors like age, gender and socioeconomic factors. Smoking cigarette or bidi also increased chances of asthma but the effect was not significant. It is, therefore, possible that tobacco smoking through hookah is an independent risk factor for bronchial asthma. The higher prevalence of asthma in rural areas of the study population is also possibly related to hookah smoking. Active smoking was observed to have an association with bronchial asthma by some [11],[21],[22] but not by others [23],[24] Cooking food with kerosene also appeared to be associated with a higher risk of asthma in our study population.

This is the first epidemiological study on this subject in Rajasthan. Although, this study was limited to Jaipur district only yet this epidemiological investigation provides useful inputs into the epidemiology and other relevant factors influencing asthma in this part of the country.


   Acknowledgements Top


The authors thank the Government of Rajasthan for permitting to conduct this asthma prevalence study in Jaipur District of Rajasthan. The study was supported by a financial grant from MIS Sun Pharma­ Radiant Division. Authors also express their gratitude to the Department of Pulmonary Medicine, PGIMER, Chandigarh for their help and valuable suggestions.

 
   References Top

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]


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