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Prevalence, morbidity and treatment seeking behavior for allergic conjunctivitis in children in a North Indian community

      Abstract

      Purpose

      To assess the prevalence, morbidity and treatment seeking behavior amongst children aged 5–15 years, suffering from allergic conjunctivitis.

      Methods

      A cross-sectional survey was done in a semiurban low-income community in Chandigarh, India. Children of age group 5–15 years, having allergic conjunctivitis were identified by systematic random sampling technique. A survey proforma and an interview schedule was used to gather information on socio demographic profile and data pertaining to allergic conjunctivitis and related morbidities among the study subjects. Intensity of symptoms of allergic conjunctivitis was also assessed using proforma and an observation checklist.

      Results

      A total of 217 subjects were enrolled. Prevalence of allergic conjunctivitis was 12.22%. Occurrence was more in males (13.44%) than females (10.71%). Itching and frequent eye rubbing were the commonly reported symptoms. Dust (35%) was the most common precipitating factor and perennial conjunctivitis was more common (54.8%). Reported co-morbidities included allergic rhinitis / hay fever (23.9%), dermatitis (9.7%) and asthma (0.5%). Only 44% subjects had sought treatment from a doctor; and barely 11% completed their treatment.

      Conclusions

      Allergic conjunctivitis has a high prevalence among children but is frequently overlooked. Inspite of its frequency, treatment seeking behavior is low amongst the affected population. Identification of patients and their appropriate treatment is important to improve the ophthalmic health of the community.

      Keywords

      1. Introduction

      Allergy is a medical problem which affects more than 15% of the world population.
      • Nathan R.A.
      • Meltzer E.O.
      • Selner J.C.
      • Storms W.
      Prevalence of allergic rhinitis in the United States.
      Allergic tendency tends to target more than one organ system in the body and hence, the patient may have symptoms related to multiple organ systems.
      • Hesselmar B.
      • Aberg B.
      • Eriksson B.
      • Aberg N.
      Allergic rhinoconjunctivitis, eczema, and sensitization in two areas with differing climates.
      ,
      • Singla J.P.
      • Parashar Y.
      Prevalence of allergic rhinitis, allergic conjunctivitis and atopic dermatitis in children with recurrent wheeze.
      However, ocular component is frequently the most prominent and disabling feature of their allergy as it leads to continuous symptoms like itching and watering of eyes, which leads to significant irritation.
      • Biswas J.
      • Saha I.
      • Das D.
      • Bandyopadhyay S.
      • Ray B.
      • Biswas G.
      Ocular morbidity among children at a tertiary eye care hospital in Kolkata, West Bengal.
      The prevalence of allergic conjunctivitis is surprisingly high and it is supposed to be the most common allergic disorder. Currently it is estimated that at least 20% of the general population suffers from some form of allergic conjunctivitis.
      • Gomes P.J.
      Trends in prevalence and treatment of ocular allergy.
      Numerous reports indicate that the incidence and prevalence of allergic conditions have increased dramatically all over the world during the past 40 years and they continue to rise.
      • Davies R.J.
      • Rusznak C.
      • Devalia J.L.
      Why is allergy increasing?-environmental factors.
      ,
      • Rachelefsky G.S.
      National guidelines needed to manage rhinitis and prevent complications.
      This is because of rapid urbanization, industrialization, increased air pollution and dry-eye syndrome.
      • Nimmagadda S.R.
      • Evans R.
      Allergy: etiology and epidemiology.
      Allergic conjunctivitis is often under-diagnosed and consequently undertreated. Recurrent symptoms for several years may turn patient behavior towards under-reporting of problems and ignoring ocular care. Patients of allergic conjunctivitis, having significant debilitating symptoms like itching, watering of eyes and ropy discharge have interference in their day to day activities, difficulty in concentrating in their work and these adversely affect their quality of life.
      • John L.J.
      • Ahmed S.
      • Anjum F.
      • Kebab M.
      • Mohammed N.
      • Darwich N.
      • et al.
      Prevalence of allergies among university students: a study from Ajman, United Arab Emirates.
      These aspects underscore the importance of estimating the disease burden and its consequent morbidity in the community. Hence the present study was undertaken to assess the prevalence, morbidity features and treatment seeking behavior amongst children of 5–15 years age group.

      2. Material and methods

      The study was conducted in a low income community of North Chandigarh, India having 3003 numbered houses with a population of 18,000 approximately as per the official records. The residents of the colony are migrants from different states of India like Punjab, Haryana, Bihar, Rajasthan, Uttar Pradesh and neighbouring countries like Nepal. Majority of people residing here belong to a low socio economic group and are unaware of the diseases so they tend to ignore many health problems until their condition becomes severe. All the houses of the colony were divided into six strata of 500 houses each. Randomization of these strata was done to experimental and control by lottery method in which three groups of 500 houses each were in experimental group and three in control group. Sampling technique employed was systematic random sampling. Every 2nd house was surveyed (even numbered house, selected by lottery method) to identify the subjects of 5–15 years having allergic conjunctivitis. The tool was developed by relevant literature search on allergic conjunctivitis through books, national & international journals and internet search and validated by experts in the field of nursing and department of ophthalmology. The tools developed in the study included a survey proforma to identify the children suffering from allergic conjunctivitis; an interview schedule to gather information on socio demographic profile and data pertaining to allergic conjunctivitis in the study subjects. Assessment proforma and observation checklist were used to collect data on the intensity of the symptoms of in allergic conjunctivitis. A house to house survey was conducted to identify the study subjects. The children of age group 5–15 years and their care givers were interviewed as per survey proforma and children with the symptoms of allergic conjunctivitis were enrolled in the study. Any child, male or female in the age group of 5–15 years; presenting with any three of the following symptoms – itching, ropy discharge, frequent eye rubbing, redness or watering of eyes for minimum of one week was diagnosed as having Allergic Conjunctivitis.
      The sample size was calculated by using “Statcalc Software” (Epi Info) taking prevalence of 15%, error interval of 5% at the confidence interval of 95% and 5% level of significance which came out to be 187 and by adding 10% of dropouts (187 × 10/100 = 18.7–19), so the sample required is 187 + 19 = 206–210. Total 1775 children were contacted out of which 217 were identified with the symptoms of allergic conjunctivitis. Subjects older than 10 years were interviewed as per interview schedule and the data was supplemented by their mothers, while in case of younger children of age less than 10 years, their mothers were interviewed.
      Score for each symptom was categorized on a scale of (0–10). They were categorised as - no symptom – (0 score), mild– (0.1–3 score), moderate– (3.1–7 score) and severe– (7.1–10). The individual scores of all the symptoms were added and divided by 5 to obtain the average scores (0–10); i.e. overall intensity of symptoms of allergic conjunctivitis. This overall intensity of symptoms was further categorized as mild– (0.1–3 score), moderate– (3.1–7 score), severe– (7.1–10 score). The data was analysed using standard SPSS-16 software.

      3. Results

      Table 1 depicts the Socio demographic profile of the respondents. Mean age of the subjects was 9.59 ± 3.07 years with a range of 5–15 years. Male respondents were more than female. As per the educational level 38.2% of the subjects had upto primary level of education. Majority (94%) of the subjects were Hindus and 53.9% of the subjects were living in nuclear family. As per family size, 51.6% of the subjects had 5-8 members in their family and the range for the number of family members living together was 3–16.
      Table 1Socio-demographic profile of the respondents N = 217.
      Socio-demographic charactern (%)
      Age (yrs)
      Mean ± S. D (Range) in yrs: 9.59 ± 3.07 (1–11).
       5–883 (38.2)
       9–1169 (31.8)
       12–1565 (30.0)
      Sex
       Male132 (60.8)
       Female85 (39.2)
      Education of the child
      Range:1–11 class.
       upto Primary school (upto 5th std)83 (38.2)
       upto Middle school (5th – 8th)69 (31.8)
       upto High school (9th – 10th)65 (30.0)
      Religion
       Hindu204 (94.0)
       Muslim2 (0.9)
       Sikh8 (3.7)
       Christian3 (1.4)
      Type of family
       Nuclear family117 (53.9)
       Joint family100 (46.1)
      Family size (Total living house members)
      Range: 3–16.
       <469 (31.8)
       5–8112 (51.6)
       9–1230 (13.8)
       13–166 (2.8)
      Type of fuel used
       LPG206 (94.9)
       Kerosene oil/cow dung/coal/wood11 (5.1)
      Separate Kitchen in the house179 (82.4)
      Pet kept in the house22 (10.1)
      a Mean ± S. D (Range) in yrs: 9.59 ± 3.07 (1–11).
      b Range:1–11 class.
      c Range: 3–16.
      Considering environmental factors, liquefied petroleum gas was the type of fuel used by majority (95%) of the families and most of the houses (82.4%) had separate kitchen in their house. Very few (10.1%) had kept a pet in their house.

      3.1 Prevalence of allergic conjunctivitis

      From the total 1775 children surveyed, allergic conjunctivitis was found to be prevalent in 217 (12.22%) subjects. Prevalence was higher amongst males (13.44%) than in females (10.71%).

      3.2 Episodes of allergic conjunctivitis during the last three months

      Children had single to multiple episodes of the symptoms of allergic conjunctivitis during the last three months of the period of enquiry and very frequent recurrence was reported. During the previous three months, 40.5% of the subjects had reported 3 episodes of allergic conjunctivitis, 35.9% had 2 episodes and 15.2% had 4 episodes. A few subjects (4.6%) had as many as 5 episodes while 3.7% had only a single episode of allergic conjunctivitis.

      3.3 Precipitating factors and seasonal variation in allergic conjunctivitis

      Dust, smoke, sunlight pollen/grass/weed, dandruff, dry eyes and cream (cosmetic) were the reported precipitating factors for allergic conjunctivitis (Fig. 1). One third (35%) of the subjects had reported dust as the most common precipitating factor followed by smoke (19.3%) and sunlight (14.8%). Other allergens included pollen, grass and ragweed (11.9%), dandruff (3.2%), dry eye syndrome (1.8%) and cosmetics (1.9%).
      Fig. 1
      Fig. 1Prevalence of precipitating factors* of Allergic Conjunctivitis among study subjects. N-217*More
      than one precipitating factor was reported by the subject.
      More than half (54.8%) of the subjects reported having symptoms of allergic conjunctivitis throughout the year i.e. perennial allergic conjunctivitis while others reported seasonal variation in the appearance of symptoms. Nearly 22.6% of the subjects reported having symptoms of allergic conjunctivitis mostly during rainy season whereas 18.8% reported severe symptoms during the summer season and 4.6% in winter.

      3.4 Family history of allergic conjunctivitis and co morbidities reported by study subjects

      Most of the subjects (81.1%) had no family history of allergic conjunctivitis. In the rest, 14.7% of the parents/grandparents and 4.1% of the siblings had history of allergic conjunctivitis.
      It was further observed (Fig. 2) that 23.9% of the subjects had allergic rhinitis/hay fever and few (9.7%) had associated dermatitis present along with allergic conjunctivitis; while asthma was present in only one subject (0.5%). Almost 2/3rd of the subjects (65.8%) had no associated co morbidity along with allergic conjunctivitis while.
      Fig. 2
      Fig. 2Co morbidities reported by study subjects N- 217.

      3.5 Symptoms of allergic conjunctivitis present in the study subjects

      It was observed that 70.5% of the subjects had reported 3 symptoms, 23% had reported 4 symptoms while only 6.5% of the subjects had reported all the five symptoms in allergic conjunctivitis i.e. itching, frequent eye rubbing, watering of eyes, redness and ropy discharge.
      Itching and frequent eye rubbing were observed in all the subjects; followed by watering of eyes (96.3%); while redness was observed in 29.5% and ropy discharge in 10.1% of the subject (Fig. 3).
      Fig. 3
      Fig. 3Symptoms of Allergic Conjunctivitis present in the study subjects N-217.

      3.6 Intensity of symptoms of allergic conjunctivitis

      As seen in Table 2, majority of the subjects (81%) had moderate intensity of itching, frequent eye rubbing and watering of eyes while 18.4% had severe itching and frequent eye rubbing and 11% had severe watering of eyes. Moderate intensity redness was present in some subjects (19%) and ropy discharge in 7.8% subjects. Severe intensity of redness and ropy discharge was observed in 4.6% and 1.3% of the subjects respectively.
      Table 2Intensity of symptoms of Allergic conjunctivitis N-217.
      SymptomIntensity of symptom
      Symptom not presentMildModerateSevere
      Itching0 (0)2 (0.9)175 (80.6)40 (18.4)
      Frequent eye rubbing0 (0)2 (0.9)175 (80.6)40 (18.4)
      Watering of eyes8 (3.6)10 (4.6)175 (80.6)24 (11.1)
      Redness153 (70.5)13 (5.9)41 (18.9)10 (4.6)
      Ropy discharge195 (89.8)2 (0.9)17 (7.8)3 (1.3)
      Overall intensity of all the symptoms
      Average scores of all the symptoms.
      -66 (30.4)147 (67.7)4 (1.8)
      a Average scores of all the symptoms.
      Moreover if we see the overall intensity of symptoms of allergic conjunctivitis, most (68%) of the subjects had moderate intensity of symptoms while 30.4% had mild symptoms and only few (1.8%) had severe symptoms (Table 2).

      3.7 Treatment seeking behavior of the subjects

      Treatment seeking behavior revealed that about 57% of the subjects had not consulted any physician for their problem of allergic conjunctivitis. Out of those who consulted a physician, very few (4.6%) completed their treatment.
      It was also observed that 69.7% of the subjects with mild intensity of symptoms had not taken any treatment for their symptoms. But as the severity of symptoms increased there was increase in treatment seeking behavior though the treatment was still irregular. It was also observed that 42% of the subjects with moderate intensity of symptoms had taken irregular treatment while 75% of the subjects with severe intensity of symptoms had taken treatment; that was again, irregular.
      Further, only 27% of the subjects adopted some home based remedial measure for getting relief from symptoms of allergic conjunctivitis - 17.9% of the subjects washed their eyes with running water and a few (7.3%) washed their eyes with cold water. One subject had also put gulab jal (rose water extract) in his eyes to get relief from the symptoms of allergic conjunctivitis.

      4. Discussion

      Allergies affect 10 to 20% of the population.
      • Hesselmar B.
      • Aberg B.
      • Eriksson B.
      • Aberg N.
      Allergic rhinoconjunctivitis, eczema, and sensitization in two areas with differing climates.
      ,
      • Nathan R.A.
      • Meltzer E.O.
      • Selner J.C.
      • Storms W.
      Prevalence of allergic rhinitis in the United States.
      They often run in families. People who have allergies are more likely to develop allergic conjunctivitis as conjunctiva is easily accessible for the allergens to cause allergic reaction and produce symptoms. When the eyes are exposed to allergens like pollen or mold spores, dust, animal dander, perfumes, cosmetics etc. they may become itchy, red and produce watery discharge. The problem of allergic conjunctivitis is associated more with its frequency (episodes) than its severity; as, a single episode may not be very severe but repeated episodes might be debilitating for patients. Although the burden of allergic conjunctivitis is high, ranging from 15 to 20%
      • Baig R.
      • Ali A.W.
      • Ali T.
      • Ali A.
      • Shah M.N.
      • Sarfaraz A.
      • et al.
      Prevalence of allergic conjunctivitis in school children of Karachi.
      ,
      • Biswas J.
      • Saha I.
      • Das D.
      • Bandyopadhyay S.
      • Ray B.
      • Biswas G.
      Ocular morbidity among children at a tertiary eye care hospital in Kolkata, West Bengal.
      ,
      • Nathan R.A.
      • Meltzer E.O.
      • Selner J.C.
      • Storms W.
      Prevalence of allergic rhinitis in the United States.
      ,
      • Singla J.P.
      • Parashar Y.
      Prevalence of allergic rhinitis, allergic conjunctivitis and atopic dermatitis in children with recurrent wheeze.
      ; it is frequently overlooked by patients and this condition remains under diagnosed in a majority of the population.
      • Gomes P.J.
      Trends in prevalence and treatment of ocular allergy.
      The prevalence of allergic conjunctivitis is reasonably high. In our study, amongst children of age group 5–15 years, prevalence was found to be 12.22%.
      In the present study it was observed that most of the general population does not know the actual cause of the allergies; thus, it becomes difficult for them to avoid the allergen. Supporting this observation, in the present study, the precipitating cause for allergic conjunctivitis was not known to more than half of the subjects; though rest of the subjects had reported known inciting factors like dust, smoke, sunlight, pollen/grass/ragweed, dandruff, dry eyes and cosmetics. A few subjects reported more than one precipitating factor. Dust and smoke were the common allergens, while pollen, grass or ragweed was reported only in few subjects.
      Itching is the most important symptom of this condition, so much so that if itching is absent, the diagnosis of allergic conjunctivitis ought to be questioned.
      • Bielory L.
      • Meltzer E.O.
      • Nicholls K.K.
      • Melton R.
      • Thomas R.K.
      • Bartlett J.D.
      An algorithm for the management of allergic conjunctivitis.
      In the present study, itching and frequent eye rubbing was reported by all the subjects and these symptoms were the basis for the selection of the study subjects.
      Ocular allergy in majority of the cases is overlooked and in spite of its interference in day to day activities, people don't seek medical attention. A cross sectional study supported this finding in which only 19.4% of the subjects had consulted an ophthalmologist and 56.1% had started with self-treatment.
      • Kim H.Y.
      • Kwon E.B.
      • Baek J.H.
      • Shin Y.H.
      • Yum HY,Jee H.M.
      • et al.
      Prevalence and comorbidity of allergic diseases in preschool children.
      This was an interesting pointer towards tendency to access medical attention; in the present study it was found that about 57% of the subjects did not seek any medical treatment from a doctor, however it was noted that with increasing severity of symptoms subjects increasingly sought medical attention.
      Health professionals working in community can play a very important role in creating awareness amongst the general public regarding signs and symptoms of allergic conjunctivitis; and they can also identify patients having this affliction. Patients should be made aware of the consequences of neglecting their ocular health; they can also be taught simple cost effective measures like cold compress for getting relief from their symptoms.

      5. Strengths of the study

      • It's a close survey (door to door study) thus enabling picking up of many patients who will otherwise not go to hospital.
      • Responding to the questions of this survey proforma enabled patients and their families to increase health awareness about this condition.

      6. Weaknesses of the study

      • As the study relies mainly on subjective responses so 100% sensitivity and specificity is not ensured.
      • Personnel and time limitation did not enable every house to be surveyed.

      7. Conclusion

      The magnitude of allergic conjunctivitis was found 12.22% which is reasonably high and majority of the subjects had not taken any treatment for getting relief from their symptoms.

      Ethical clearance

      Ethical clearance was taken from the Institute ethical committee (PGIMER, Chandigarh). Written informed consent was taken from the study subject. Subjects were empowered with the full autonomy to participate in the research and withdraw at any time. The trial is also registered with Clinical Trials Registry- India (CTRI) with registration number CTRI/2016/02/006586.

      Conflict of interest

      The authors declare that none of the authors have any proprietary interests or conflicts of interest related to this submission.

      Source of funding

      The authors declare that no financial grant was taken for the study project, the study was self sponsored by the primary author.

      Annexure I

      A. Survey Proforma to Identify the Subjects of Allergic Conjunctivitis

      Tabled 1
      Identi-ficationNoS. noH.no.Name of the Child D/o or S/oAge (yrs)(M/F)Symptoms of Allergic conjunctivitis presentmark ( ), if present and mark (X) if not presentIf yes, for how longCases of Allergic conjunctivitis
      Itch-ngFreque-nt eye rubbingRopy discha-rgeRedd-nessWater-ing of eyes<1 wks≥1 wksYes ( )No (X)
      Image 1

      Interview Schedule of Subjects With allergic Conjunctivitis

      C. Assessment of intensity of the symptoms related to allergic conjunctivitis

      Tabled 1
      What is the intensity of the following symptomsDay1 10 paise2 20 paise3 30 paise4 40 paise5 50 paise6 60 paise7 70 paise8 80 paise9 90 paise10 100 paise
      1.ItchingI
      II
      III
      IV
      V
      VI
      2.Ropy dischargeI
      II
      III
      IV
      V
      VI
      3.Frequent eye rubbingI
      II
      III
      IV
      V
      VI
      4.ReddnessI
      II
      III
      IV
      V
      VI
      5.Watering of eyesI
      II
      III
      IV
      V
      VI

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