Challenges in allergy practice

Abstract

Allergies are very common in India.[1] There are, however, many misconceptions among both clinicians and patients about allergy management, and the field has changed rapidly over the past 5–10 years from a focus on avoidance to tolerance. The lack of knowledge of allergies amongst physicians is fuelled by inadequate attention to the subject of allergy in the undergraduate and postgraduate syllabuses. Fellowship programs in the USA have a minimum of 60 programs of 3-year duration in allergy and immunology, while in India, there are no National Medical Council-recognized programs in allergy. There is a trend to start short-term diploma and certificate courses in allergy nationwide, but these are much handicapped by a lack of hands-on training programs.[2] There are two reputed organizations in allergy in the USA and 12 indexed allergy journals published each year. In India, there are no indexed journals. In a postgraduate examination of pediatrics, it was found that on a question of allergic rhinitis, 70% of the candidates did not go beyond the standard oral drugs and in another examination, 70% did not exactly know what standard immunotherapies are in the management of allergies. Among the Indian public, many are turning to alternative therapies with no proven scientific basis for the treatment of their allergic diseases. An example is the use of fish medicine by people from all over India for respiratory problems. In a study published in Indian Paediatrics, 30% felt that there is a cure for asthma, with a significant section feeling that it can be cured by alternative medicines. The shocking report was that 10% felt that it can be cured by saints.[3] The latter is a popular concept in India, reinforced by our culture and films. Based on this backdrop, it is not difficult to envisage the problems in practice; a few examples are narrated below: Asthma For some parents, this diagnosis in their child is worse than cancer.[4] No amount of convincing will work for a minority of such patients. They avoid the term asthma and prefer descriptive words such as wheezy chest, hyperactive airways, and chesty cough. The moment it is announced, it is like a death sentence. In a busy practice, doctors fail to take the time or follow a standardized approach to the education of their patients. This leaves the patient even more confused. One of the reasons behind this practice is that inhalers are synonymous with asthma treatment. Educating groups of patients and families is a powerful and time-saving tool. There is a need to educate teachers too about how to use inhalers effectively. We have found that many school teachers are unaware and some even consider inhalers as a taboo. The wrong perceptions in the community and the schools need to be corrected. Atopic Dermatitis Parents of eczema patients are more receptive to the diagnosis of atopic dermatitis or eczema. Eczema can be more distressing and troublesome than asthma with the constant itch. Doctor shopping because of the chronicity and frequent relapses is very common. In counseling, patients need to partner their care and be taught not only how to use creams and ointments but also the science behind it. There is also the need for the formation of eczema support groups for the long-term care of patients. Urticaria Urticaria, especially if long-standing or chronic, leads to a lot of frustration among the patients to the extent of spending innumerable sums of money to find the cause, where there may not be one. Many cheap packaged tests advertised in newspaper dailies, often with false-positive results lead to unnecessary avoidance causing much nutritional deficiency and a psychological impact. Patients in search of a miracle diagnosis are willing to pay for expensive tests, which have no value. Physicians often also encourage these tests. Some patients are even subjected to immunotherapy, which has zero value in urticaria. Many cases of hereditary angioedema where the risk of death from airway obstruction in the undiagnosed/untreated is a third have been falsely labeled as allergies. Allergic Rhinitis The approach to allergic rhinitis is not much different. Physicians need to understand and freely prescribe intranasal drugs, but most importantly, they need to communicate the proper technique. Immunotherapy, especially for dust mites and pollen, can be beneficial if the treatment is taken regularly. However, the care is offset by the lack of availability of standardized and high-quality products in India. Food Allergies We have no data on the exact prevalence of food allergies in India. Prevalence studies based on public surveys report prevalence as high as 50%–60%, but it is likely to be much less.[5] Thanks to our traditional food habits, the incidence of food allergies in the Indian population in India is very low. The food allergy patients seen are more of the Non resident Indian (NRIs). The difficulty is in understanding the concept of food allergy. It is reported to be more common in childhood than in adults. It is estimated to affect around 7%–8% of children in the United States and under 2% in India.[6] Food allergy results in a significant burden in terms of medical facilities’ usage to the health care system and imposes quite a burden on the family. Anaphylaxis As food allergies increase, so does anaphylaxis. At present, there is no ready availability of adrenaline auto-injectors. Patients are being made to purchase directly from abroad or have to make do with an Indian Jugaad system of loaded adrenaline in shaded covers whose validity cannot be ascertained. Many deaths due to anaphylaxis go unreported in the community as well as in institutions. Drug Allergy The practice of drug allergy is hugely limited due to the lack of awareness among professionals about the concept of drug allergy and drug adverse reactions. There is a paucity of testing facilities too. To conclude, allergy training needs to start with undergraduates, and a standardized approach is adopted at least in the urban areas, especially through well-coordinated professional bodies, including the Indian Academy of Paediatrics. Robust data on the prevalence of food allergies and anaphylaxis death need to be created. Then, the Government of India may appreciate the burden of disease and act on it. There is also an urgent need to make the easy availability of standardized and high-quality products in allergy for the care of patients.