Allergic reactions or allergies are on the rise in both developing and developed nations with common allergies affecting 10-30% of the world population at any given point of time in their lives (Ring 2012). Asthma and allergic rhinitis are among the common air-borne allergic reactions affecting nearly 300-500 million people around the world (Pawankar et al. 2014). Furthermore, food (nearly 400 million), and drug-induced allergic reactions (1/10th of the world population) are prevalent in different parts of the world (Pawankar et al. 2014). Since the prevalence has increased to such an extent, allergies should be regarded as major health concerns. The research on allergies initiated with the identification of the situation in India in terms of understanding the mechanism and identification of common allergies, diagnostic procedures and treatment protocols. It surfaced that unfortunately in India, there is a lack of specialized services which is mainly due to the fact that the prevalence of different allergies is still at a nascent stage. Thus, this extended to drawing a comparison among 6 different countries so that the situation can be compared in terms of prevalence, diagnostic procedures and treatment protocols among industrialized countries like USA, UK, Japan, Australia and emerging economies like India and Africa.
Different types of allergic reactions
Different allergies explored in the study have different prevalence and thus the burden also varies. Table 1 below summarizes the common causes of different allergic reactions.
|1||Allergic Rhinitis||IgE-Mediated Inflammation of Nasal Mucosa|
|2||Allergic Conjunctivitis||IgE sensitization to aeroallergens|
|3||Asthma||Airway hyper-responsiveness and airflow obstruction|
|4||Food Allergy||IgE-Mediated Inflammation|
|6||Drug Allergy||IgE/T-Cell mediated Hypersensitivity|
|7||Insect Allergy||Ig-E Mediated Inflammation|
|5||Urticaria||Mast Cells and Basophils release Histamines, bradykinin, leukotriene, Prostaglandin and other vasoactive substances|
|8||Occupational Allergy||Exposure to allergens “on the job”|
Table 1: Common causes of different allergic reactions
Among the allergies which have been studied, occupational allergy is an umbrella of allergic reaction which can be caused by exposure to allergens at the workplace. Occupational allergies can be categorized into respiratory and skin-related allergic reactions and are problematic because they remain undetected by the patient for a long time. The different incidence of different occupational diseases has been reported to affect 10% of the total population. 9-20% of UK and Japanese population is reported to be affected by some kind of occupational allergy. Incidence in the UK, US and Australia however, has been found to decline by 5-10% in the last decade with the adoption of strict safety guidelines. In terms of developing countries like India and Africa higher incidence is reported in Africa (nearly 50%) with an upward trend due to unhygienic conditions and use of obsolete technologies (Greiner, Hellings, Rotiroti, & Scadding, 2011; Kurt et al., 2009; Dobashi, 2012).
In terms of respiratory allergic reactions, the common cause for allergic rhinitis (AR) is inflammation of nasal mucosa when exposed to dust, mite or pollen (Seidman et al., 2015) and affects 10-15% of the global population (Ozdoganoglu & Songu, 2012). In Japan, the prevalence was found to be highest affecting 60-80% of the population followed by US and UK where 30-40% of the population was found to be affected (Bousquet et al., 2007; Masanari, Jun, Hiroyuki, & Saeko, 2016). In comparison, the prevalence in Australia was least among all affecting only 15% of the population. In terms of emerging economies, research indicates that 20-30% in both Africa and India are affected by AR. Allergic conjunctivitis, on the other hand, is caused due to the sensitization of aeroallergens and affects nearly 40% of the world population (Azari & Barney, 2013). Prevalence in case countries was found similar in the US, UK and Australia affecting 15-20% of the population when compared to Japan the affected population percentage was found to be 40% with an upward trend. On the other hand, the prevalence in Africa (32%) and India (25%) was considerably higher than the western counterparts. High prevalence in Japan, India and Africa can be attributed to high pollution levels in these countries. Asthma which is caused due to airway hyperresponsiveness and obstruction of airflow is a chronic disease which affects the lungs (Asthma and Allergy Foundation of America, 2015) affecting 8-15% of the world population (Global Asthma Network 2014). Figure 1 below reflects the prevalence of disease across different countries with an average prevalence of 10-20% across different population groups. As can be seen the maximum prevalence in India is found among children affecting nearly 38% of the population (Cavkaytar & Sekerel 2014; Jindal et al. 2012).
Furthermore, food allergy is mediated due to inflammation caused by the intake of specific food products and found to affect children more than adults due to their immature digestive system. Globally, nearly 8% of children and 2% of adults (Pawankar, 2013) are affected by food allergies. Among all the case countries, the lowest incidence was reported in India (1-2%) followed by Africa (3.5%), while in terms of developed economies the prevalence percentage was between 5-8% with peanut, egg and dairy products cause most allergic reactions. Further, drug-related hypersensitivity, which is caused due to the immune response mediated due to the drug reaction and affects 15-25% of the patients globally. The US is among the most affected where nearly 90% of the population aged 65 years and above are on the drug of which nearly 25% are affected with hypersensitive reaction. Similar trends are observed in adult and children population as well. Furthermore, the Australian population is the second most affected impacting nearly 1/3rd of the total population. Prevalence in UK, Japan and Africa was found to be between 15-20% (Naisbitt et al, 2014; Beisl Noblat et al., 2011; Gomes & Demoly, 2005) and on the other hand, in India the incidence reported was found to be least reported by only 3-6% of the total population which does not give the actual incidence percentage. Among all the drugs, allergy to antibiotics, penicillin and acetaminophen like paracetamol was mostly reported.
Another cause of concern is insect allergy, prevalent in almost all countries except USA and UK with a global prevalence of 1-7% (Heddle & Golden, 2015). Among remaining countries, incidence in Japan was found to affect 61.5% of the total population followed by India (30%), Africa (28%) and Australia (25%) (Heddle & Brown, 2004; Tang, Osborne, & Allen, 2009; Burns, 2016). These are attributed to dense forest in the region wherein insects such as yellow jackets, honeybees, paper wasps, hornets and fire ants reside. The incidence of skin related allergic reactions is also found to affect the global population. One such allergic response is Urticaria which is characterized by the development of wheels is found to affect 8.8% of the globally and found to affect mostly female adults. Among Australia, the US, and UK incidence of 15-20% (Sánchez-Borges et al., 2012) has been reported with a common allergic agent being house dust mite. On the other hand, incidence in India and Africa was found between 30-35% which is greater when compared to industrialized countries. Common causes reported for the same in these two countries include bacterial infection, food and insect bite. Figure 2 below summarizes incidences of different allergies in case countries.
Common diagnosis and treatment measures to allergic reactions
Optimization of patient care is dependent on patient history, analysis of possible environmental factors and the performance of in-vivo and in-vitro tests. In the absence of proper diagnosis and mistreatment of symptoms, multiple complications can arise. The skin test is a common in-vivo test to diagnose several allergic reactions. In-vitro tests, on the other hand, are allergen-specific test wherein allergen-specific IgE antibody is detected based on serological markers. The table below is a summary of common diagnostic procedures for the case countries:
|Common Diagnostic Procedures|
|Utricaria||Autologous Skin Serum Test||Patch Testing||Skin biopsy|
|Insect Allergy||Skin test||Mast Cell Tryptase measurement||Sting challenge|
|Drug Allergy||Allergic Drug Reactions|
|Occupational Allergy||Epicutaneous skin prick test (in-vivo)||RAST or ELISA (In-vitro)|
|Allergic Rhinitis||Nasal provocation test||Nasal cytology||Nasolaryngoscopy||Inter-dermal skin test|
|Asthma||Pulmonary test or spirometry test||Methacholine Challenge tests|
|Food Allergy||Oral food challenge|
|Allergic Conjunctivitis||Scraping of the conjunctiva tissue||Visual Acuity Measurement|
Table 2: Common diagnostic procedures used across case countries for different allergic responses
There are several drugs which are available to treat the symptoms of allergic reactions. The most common are anti-histamines, corticosteroids, or decongestants which can be used individually or in combination. For example allergic rhinitis, allergic conjunctivitis and asthma are three allergies which are commonly manifested together, however, affect different parts of the body and thus each of them needs different treatment procedures. Like India, most of the countries face competition in the formulation and manufacturing market and with the introduction of DNA vaccines and advanced immunotherapies the burden on the drug market will further increase. Currently, the government of India is undertaking several initiatives in terms of training programs for doctors, the establishment of allergy clinics and education and awareness initiatives (Prasad 2013).
The economic and social burden
Allergies can generate a specific immune response in the body when exposed to allergens. Prevalence of different allergies in both developed and developing countries was explored which reflected on different trends with respect to different allergies. It can be concluded that while the incidence of occupational allergies especially urticaria and asthma is higher in developing countries due to lack of hygienic conditions, other allergies like food-related, drug-related and respiratory allergic reactions were found to have a higher incidence in developed nations like the US, UK and Australia. Among all the countries, the Japanese population was found to have been highly affected by many allergic reactions affecting nearly 30-40% of the population with at least one kind of allergy. In terms of diagnostic procedures, both in-vivo and in-vitro techniques have been adopted across all countries with skin prick test being the most commonly applied diagnostic tool. Finally, in terms of treatment, antihistamines, decongestants, or corticosteroids are the three most commonly used treatment procedures used to control of symptoms of allergic reaction. However, the most effective treatment is to prevent the exposure to an allergen.
It is important to note that allergic reactions not only have health implications on patients but also carry large social and economic burden. The social burden includes a lower quality of life, and loss of valuable time dealing with reaction. Furthermore, the economic burden of allergic reactions includes both direct and indirect costs. Direct costs include expenditure on medications and healthcare provision, indirect cost includes a cost to society due to loss of work, loss of taxable income, lower productivity of patient, and modifications undertaken at public places at home (Tripathi and Patterson 2001; Zuberbier et al 2009; Khan et al, 2013). In India, the social burden of diseases, such as urticaria, impact and impair patient’s quality of life and overall job performance. Social isolation is also observed leading to frustration and depression. Further, respiratory allergies and their co-morbidities such as rhinitis, asthma, conjunctivitis, sinusitis etc have similar implications on a patient’s social life. Latest studies show respiratory allergies cost USD 637 per patient per annum; of which indirect costs account for 62.1% of the total cost (Ghosal et al 2016).
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