A Crystal Clear Picture of Age and Gender Specific Incidence of Severe Persistent Allergic Rhinitis and Triggers of Allergic Rhinitis in Central India

Abstract

The prevalence of allergic rhinitis (AR) is associated with various environmental allergens, and the. Level of exposure occurs through inhalation or ingestion. It is clear from several studies and guidelines that screening and identifying various allergens in a particular region can facilitate in diagnosing, treating, and formulating preventive strategies against AR. To study the incidence of severe persistent allergic rhinitis across different age groups and genders, and to identify the allergens responsible for triggering this condition in Central India. The study included 2097 patients of either sex, aged 5 to 70 years suffering from severe persistent allergic rhinitis from January 2003 to Dec 2023. Selection of study group was as per ARIA classification. Modified Skin Prick Test was performed according to the method of Pepys and Bernstein. Study indicates that in Central India, the common allergens responsible for causing severe persistent allergic rhinitis are pre dominantly aero allergens (86%) and food allergens (14%). The three most common aero allergens are house dust mite (D. farinae) (47.97%), housefly (26.23%), and mosquito (25.99%). Among pollens, the most common are Ricinus communis (10.01%), Prosopis juliflora (8.30%), and Gynandropis gynandra (7.15%). Among food allergens, the most common are baker’s yeast (2.48%), almond (1.67%), and milk (1.62%). The findings of the study were highly beneficial for counseling on avoidance therapy and making decisions about allergen – specific immunotherapy, which is currently the standard treatment protocol to alter the natural progression of allergic rhinitis.

Introduction

Allergic rhinitis (AR) is one of the most common allergic diseases, affecting 35–40% of the population world wide, with one-fifth of those affected living in the Indian subcontinent. A global rising trend of AR has been observed in the past decades. The prevalence varies widely, particularly in developing nations [1–5]. The reported incidence of AR in India ranges between 20 and 30%. The increasing prevalence can be attributed to high concentrations of airborne allergens and pollution, poor indoor ventilation, dietary factors, smoking, and more sedentary lifestyles. In developing countries, this increase could be related to environmental and climate changes and the adoption of an urbanized Western lifestyle [6–10]. Allergic rhinitis can directly impact social life, including mood changes, anxiety, depression, and impairment of cognitive function and quality of life.

Impacts of Allergic Rhinitis

Some common indoor triggers of allergic rhinitis include mites and insects, while common outdoor allergens include pollen and dust and environmental triggers include tobacco smoke and automobile exhaust (ozone, oxides of nitrogen, and sulfur dioxide). Identifying specific allergens for a specific geographical area, particularly in India with a drastic increase in incidence, can be crucial in planning avoidance and treatment regimen. The skin prick test is found to be a safe simple and valuable test for detecting offending allergens in AR patients and is considered to provide one of the best combinations of sensitivity and specificity. Despite the high burden, there is limited information on detailed epidemiological data about AR in India. Therefore, this study was undertaken to investigate the incidence of AR, specifically age-wise and gender-wise, and to estimate allergen sensitivity in patients with severe persistent allergic rhinitis from Central India.

Material and Methods

This observational study was conducted in Indore, Madhya Pradesh, India for 20years (2003 to 2023) at ENT Centre. The study included patients with severe persistent allergic rhinitis, ranging in age from 5 to70 years. The study included patients of either sex, aged 5 to 70 years, presenting with itching of the nose, sneezing, rhinorrhea, nasal congestion, and nasal obstruction. Modified Skin Prick Test was performed according to the method of Pepys and Bernstein. A total of 2,097 patients were included in the study. The patients ages ranged from 5 to 70 years, with 1,101 males and 996 females.

Participants were considered positive for Allergic Rhinitis as per ARIA (Allergic Rhinitis and its Impact on Asthma) guidelines i.e. if they had two or more symptoms out of-watery runny nose, nasal itching, nasal obstruction or sneezing; lasting for at least one hour per day; for 4 days or more per week and more weeks in past 12 months. Food allergies are more prevalent among children and can be life- threatening, differing from food intolerances.

A comprehensive history was taken, which included details about an itchy nose, sneezing, runny nose, nasal congestion, seasonal variations in symptoms and a history of similar episodes. All patients were

required to undergo an ENT examination. A Modified Skin Prick Test (MSPT) was also performed for 127 common allergens in a single visit. Allergens included mites, pollens, fungi, insects, dusts, dander’s, fabrics and food [11]. Patients were off anti-histaminic medication, homeopathic and ayurvedic medicines for a minimum of seven days. In case of any uncertainty, use the histamine and saline in the MSPT, and if the histamine wheal is greater than 3 mm, I proceed with the MSPT.

Procedure

Skin-prick testing involves using a 1 mm blood lancet to puncture a drop of allergen extract or a control solution placed on the patient's forearm. The skin is then gently raised at a 45-degree angle (known as Tenting) to create a small break in the epidermis, allowing the allergen solution to enter. The optimal reactivity for skin-prick tests occurs between 15 to 20 minutes, during which the size of the resulting wheal is measured in millimeters and compared to both a positive (histamine solution) and a negative (saline solution) control. The average distance between the two skin prick tests was1.2 to1.5cm and the diameter of the wheal caused by the allergens was recorded. The reactions with a wheal diameter of 3 mm or greater than the reading in the negative control were considered ‘marked positive reactions’[12]. The negative control glycerinated buffered saline and the positive control Glycerinated Histamine acid phosphate were used. Food and aero allergens extract (50% glycerinated) were procured from a standard company.

Observation & Results

A total of 2,097 patients were included in the study, with ages ranging from 5 to 70 years. Of these patients,1,101 (52.5%) were male and 996 (47.5%) were female with a male female ratio of 1.1: 1 Severe Persistent Allergic Rhinitis in Different Age Group affects predominantly 21–40 years group (54.13%) followed by 5–20 years group (23.27.%) and 41–70 years group (22.6%).

The ratio of allergen wheal to histamine wheal was used to evaluate the results. Reactions with a wheal diameter of 3 mm or greater than the reading in the negative control were considered positive reactions. The most common age group was 21 to 40 years (54.13%; 1,135 out of 2,097 patients), followed by 5 to 20 years (23.27%; 488 out of 2,097 patients), and 41 to 70 years (22.6%; 474 out of 2,097 patients).

According to the data, Aero allergens were frequently associated with severe persistent allergic rhinitis as compared to food allergens (86% vs.14%) (Table 1).

Table 1.

Showing most common allergens

Most common allergens (%Wise) responsible for causing SPAR is as follows
Aero allergens		Food allergens
House dust mite (D. Farinae)	47.97%	Baker’s yeast	2.48%
House fly	26.23%	Almonds	1.67%
Mosquitoes	25.99%	Milk	1.62%
Cockroach female	22.56%	Egg white	1.38%
Cockroach male	18.74%	Soyabean flour	1.24%
D. pteronyssinus	14.26%	Bengal gram	1.14%
Ricinus communis	10.01%	Citrus	1.10%
Prosopis juliflora	8.30%	Dhania leaves	1.05%

Results of the study indicate that in Central India, the most common aero allergens are house dust mite (D. farinae) (47.97%), house fly (26.23%), and mosquito (25.99%). Among pollens, the most common are Ricinus communis (10.01%), Prosopis juliflora (8.30%), and Gynandropis gynandra (7.15%).

Among food allergens, the most common are baker’syeast (2.48%),almond(1.67%),and milk(1.62%) (Table 1).

Discussion

The main objective of this study was to evaluate the incidence of severe persistent allergic rhinitis based on age, gender and also types of allergy triggers. Based on the current study results, severe persistent allergic rhinitis incidence is maximum in the age group of 21–40 years 54.13% and decreases in the subsequent years. This compares with another study carried out in a community based assessment among adults in Delhi; an incidence of 48% in the age group of 30–39 years was noted and the incidence decreased in the elderly population [13]. In US adults, an occurrence of 33.4% in the 20–38 age group and the incidence rate was similar in the elderly population [14]. In a cross-sectional study conducted among the general population in Italy, allergic rhinitis (AR) was found to be more prevalent in the 20–44 age groups (26.6%) and less prevalent in the 65–85 age groups (11.1%). These trends have been noted in several previous studies. The age - related decrease in the AR prevalence maybe due to the allergen - specific IgE level decrease that occurs with ageing [15]. In comparison to the current results, the incidence was lower in the urban and rural populations of China, which have shown a prevalence of 21.8 – 24.9% among the age group of 28–47 years and was lowest in 58–65years old subjects

[16].However, to the contrary, the incidence of AR was as low as 9.8% in the age group of 31– 40 years and was high (10.7%) in the elderly population of Central Africa [17]. According to various trials, severe persistent allergic rhinitis is significantly associated with gender [18].

In the current study, male patients were more affected than female patients, with a ratio of 52.5% males to 47.5% with a Male: Female Ratio of 1.1:1. Khan etal., noted male to female ratio for AR of 2:1, with 141 men (65%) and 76 women (35%). According to Huureeet al., the incidence rate for allergic rhinitis in males was 13.4 per 1000 person-years, slightly greater than in females, 11.4 per 1000 [19]. The current findings are in contrast with other study results carried out world -wide, in which there has been pre dominance of female sex; in Delhi (12.9% vs.9.3%),11 in other Asian country (61.0%vs.39.0%), 16 in US population (55.1%vs.44.9%),12 in Central Africa (10.7%vs.10%) 15 and in Chinese population (55.3% vs. 44.7%). The prevalence of female sex may be attributed to a greater cough reflex sensitivity of the female airway, the impact of hormones on the airway, and physiological differences between men and women in air way reactivity to allergens [20].However, the predominance of female participants in the current study may be due to more outdoor activities by males. While allergens vary across different geographical areas in India, identifying the most common allergens related to severe persistent allergic rhinitis (SPAR) in each region is crucial for effectively administering the condition. As noted in several studies, aero allergens are the prominent cause of allergic symptoms in SPAR patients [21]. Similarly in the current study, aeroallergens (86%) were frequently associated with severe persistent allergic rhinitis. Under current results, a study at

V.P. Chest Institute, Delhi strongly related aero allergens to allergic rhinitis (p<0.01) [22].

According to a recent study by Kumar R. and the team, aeroallergens were the prominent cause of allergic symptoms in patients with AR. Further, insects (43.90%) were most common off- ending aero allergens [23]. Akerman Metal, hypothesized that asthma severity would increase for adults and children with increased cockroach and dust mite allergen sensitivity [24]. Gowdaetal. carried out allergen sensitivity in patients with AR in Bangalore. It is noted that dust mite was the most common allergen, with positive results in 44.65% of cases. Though India represents a seventh of the world's population with diverse dietary habits, there is limited data on the prevalence of food allergy in this subcontinent. It is known that allergy to foods might further aggravate the symptoms of AR. One of the studies demonstrated that food allergy was estimated to be 4.5% in adolescents and adults with AR. Rice, citrus fruits, black gram and bananas are identified as major allergens for inducing allergic symptoms. In the current study, based on a Modified Skin Prick Test 14% of AR patients were positive to tested food allergens [20]. The information from the current study on age and gender-specific incidence of AR and pre- dominance of aero allergens in patients with SPAR from central India can be useful to healthcare professionals in planning safety considerations and treatment regimens for their patients with severe persistent allergic rhinitis, particularly in Central India.

Conclusion

In central India, the incidence of severe persistent allergic rhinitis is high in adults, particularly in the age group of 21–30 years. The incidence of severe persistent allergic rhinitis is pre-dominant in males than females. Aero allergens are the key causative factors for severe persistent allergic rhinitis in Central India. Further research is required as the type of allergen in atmosphere may be different in different geographical areas.

Declarations

I here by declare that there is no conflict of interest. Written consent was taken before performing Allergy test from every patient.