MedTrain

Allergists, Asthma Specialists: Do We Need These Specialists Really?

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By Dr.Divya Goil

While there are dedicated fellowships for Allergy and Asthma training for doctors in many countries abroad, in India our doctors have been pushing boundaries to ensure advancements in this field are nurtured here as well. 

However, with all the new data on the varying types of allergies and asthma and advanced new treatment methods, isn’t it time to take the burden of becoming allergy experts through self-study off their collective shoulders and give them opportunities to undertake training and become experts in this field? There is certainly no shortage of patients.

  • The Indian Study on Epidemiology of Asthma, Respiratory Symptoms and Chronic Bronchitis (INSEARCH) estimated the prevalence of asthma in India to be 2.05% among those aged >15 years, with an estimated national burden of 18 million asthmatics.[1] And this number is only increasing.
  • The phase 3 International Study of Asthma and Allergy in Children (ISAAC) reported an overall prevalence of wheeze at 7% in Indian children aged 6–7 and 13–14 years, with up to 10–20% in some areas. 50% of this cohort had uncontrolled asthma.
  • An Indian study reported that prevalence of allergic rhinitis was 11·3% in children aged 6–7 years, and 24·4% in children aged 13–14 years.
  • The ISAAC study 4 reported 2·7% overall prevalence of current eczema among Indian children aged 6–7 years, and 3·6% among Indian children aged 13–14 years.
  • It is estimated that 1 out of every 4 OPD visits in India is for allergic disorders.

 

Why is the burden of disease so high in India?

India has one of the highest concentrations of air pollution in the world.
 
•    Nearly 55.5% of the population is reliant on solid fuels, up to 75% in certain states.[2] 
•    Annual weighted mean particulate matter levels (PM2.5) are measured to assess air pollution exposure.[2]

WHO threshold for PM2.5                                                              <10 mcg/m3
National Ambient Air Quality threshold for PM2.5                           <40mcg/m3
 

Air Quality Index
Image 1. Understanding Air Quality Index Levels.


Shockingly, 77% of Indians are exposed to PM2.5 levels > 40mcg/m3.[2]
In New Delhi, Uttar Pradesh, Bihar, and Haryana, these PM2.5 levels are even higher at > 125 mcg/m3 possibly attributed to the crop burning practices in these areas.[2] 

  • Rapid urbanisation with increasing dependence on fossil fuels, along with indoor sources of air pollution such as smoking, burning of incense sticks, and mosquito coils have contributed to the rise in airway diseases such as COPD, asthma, allergic rhinitis, and other allergic disorders. 
  • While preventative measures are extremely important in controlling air pollution, we need to give due importance to managing the damage already caused and continually being caused by it. 
  • Of the total global DALYs (Disability Adjusted Life Years) due to chronic pulmonary illnesses in 2016, 32% were in India. In India, COPD and asthma were responsible for 75·6% and 20% of the chronic respiratory disease DALYs, respectively.[2]

What are the types of asthma? What are the recent advancements in the treatment of bronchial asthma?

The global burden of respiratory diseases has been increasing and the rise of asthma and allergic disorders has led to a deeper understanding of these conditions and the development of breakthrough therapies in the management of even the most severe form of the diseases. 

In the majority of the developed world, the classification of asthma has shifted from triggers to Th2 high (allergic) and non-Th2 (non-allergic) asthma. Phenotyping, and treatment based on it, for severe asthma is not uncommon in these countries.

 Th2 high asthma is typically defined by:

1.    Elevated airway eosinophil counts.
2.    Elevated peripheral blood eosinophil counts. 
3.    Blood periostin level, fractional exhaled nitric oxide, and allergen-specific IgE levels have been used as surrogate markers.[3]

 

 

Pathogenesis of Th2 Asthma
Image 2. Pathogenesis of Th2 high bronchial asthma.[4]

•    The Th2 high asthma shows response to certain monoclonal antibodies such as omalizumab, dupilumab, mepolizumab, reslizumab, and benralizumab that target the mediators that cause eosinophil accumulation and IgE production.[5] They’ve also shown response in atopic dermatitis, nasal polyposis, and urticaria.
•    Although more studies are required to make concrete conclusions in India, so far, the data shows that about 60 percent of cases in India are likely to be Th2 high variants and severe cases of asthma and other allergies could benefit from treatment with biologicals if they were more widely used here.[5]
•    Bronchial thermoplasty is another new therapy for severe, uncontrolled asthma which bronchoscopically delivers thermal heat to the bronchi walls and reduces smooth muscles.

What are the factors affecting the management of asthma and allergic disorders?

In India, multiple factors contribute to the sub-optimal treatment of asthma and allergic disorders despite treatment guidelines, such as:

•    The unaffordability of medications especially inhaled medication.
•    Stigma related to chronic illnesses.
•    Illiteracy
•    Lack of allergy specialists (allergists)
•    Inadequate allergy training in most medical specialties at MBBS and MD levels.
•    Lack of access to allergen-specific immunotherapy for allergic rhinitis and biological treatment for severe asthma. 
•    High-quality allergen extracts for skin tests and adrenaline auto-injectors are also currently not available in India. 
•    Specialist training programs in Allergy, Asthma and Immunology are also not prevalent.[2] 

What can be done?

Given the rising prevalence of allergic disorders, increasing pollutant exposure, the advent of new therapies, and the inadequate importance given to allergic disorders, we at Med-Train have developed a 6-month certified online course for doctors “Allergy Asthma Certificate Course” (AACC) to provide 100 ambitious doctors knowledge from international experts in the field. 

Well-researched information from faculty across the world will help you gain different perspectives and knowledge so that you can become an expert yourself and apply the best evidence-based treatment for this hidden epidemic. 

The course is endorsed by the American Academy of Allergy, Asthma and Immunology (AAAAI) and the Center for Global Health – Colorado School of Public Health. On completion of the course, you will be certified by the International Asthma Services (IAS), Bharati Vidyapeeth and Med Train.

References

1.    Koul PA, Patel D. Indian guidelines for asthma: Adherence is the key. Lung India. 2015;32(Suppl 1): S1-S2. doi:10.4103/0970-2113.154511
2.    Salvi S, Kumar G, Dhaliwal R, Paulson K, Agrawal A, Koul P et al. The burden of chronic respiratory diseases and their heterogeneity across the states of India: the Global Burden of Disease Study 1990–2016. The Lancet Global Health. 2018;6(12):e1363-e1374.
3.    Saco T, Pepper A, Casale T. Uses of biologics in allergic diseases. Annals of Allergy, Asthma & Immunology. 2018;120(4):357-366.
4.    Brahmi M, Cassier P, Dufresne A, Chabaud S, Karanian M, Meurgey A et al. Long term term follow-up of tyrosine kinase inhibitors treatments in inoperable or relapsing diffuse type tenosynovial giant cell tumors (dTGCT). PLOS ONE. 2020;15(5):e0233046.
5.    Vora A, Meshram P, Asawale K, Billa G. The Management of Severe Asthma - An Indian Perspective. Journal of the association of physicians of India. 2021;68(8):82-88.