Sneezing fit? God bless you, pop a pill.
Got a bad rash? Slather on some cream.
Horrible itch? Look for that ointment that worked last time.
Going to the bogs all night? Take a costive.
It’s just an allergy, right? There is nothing called just an allergy. At best, you get away with a runny nose, watery eyes and restless sleep. Or you get eczema or hives. Things can get serious like allergic asthma, which inflames the lungs so much that you can’t breathe; the inflammation causes the swelling and restricts airflow.
At worst, you could die from anaphylaxis: your blood pressure drops, your pulse becomes weak and you could become unconscious—if not treated immediately. Anaphylaxis, the Darth Vader of allergies occurs when a specific antibody that identifies any threat to the body’s immune system, triggers the production of histamine, leading to dilation of blood vessels, inflammation of tissues, itching of the skin and respiratory symptoms like wheezing, coughing or sneezing.
Whether diagnosed or not, allergies—mild or severe—must be taken seriously since one allergic reaction cannot indicate the severity of another; some mild reactions can become severe later. A paper published in March 2019 in the Journal of Evolution of Medical and Dental Sciences, mentions that 36 per cent of Indians suffer from one form of allergy or the other.
According to the Global Asthma Report 2018, an estimated 300 million people worldwide have asthma, with 37.9 million of them living in India. In another study published in the same year in the journal Clinic Resp J, the prevalence of allergic rhinitis was at 11.3 per cent in Indian children aged six to seven years and 24.4 per cent in children aged 13 to 14 years.
The person who knows the poorly treated, and often ignored, danger too well is Dr Neeraj Gupta. Five years ago, he would see around three or four odd allergy patients in a day. Today, the number has gone up to 10. “Allergies are on the rise and often they are misdiagnosed,” says Dr Gupta.
Simply put, an allergy is the immune system’s response to the invasion of a foreign substance, which could be pollen, bee venom, pet dander or a specific food like shellfish. The phenomenon is a vast medicopedia of irony since something that doesn't cause an allergy in one person could affect someone else and vice versa.
More than 170 food items create allergic reactions of which the biggest culprits are milk, egg, peanut, tree nuts, wheat, soy, fish, crustacean shellfish and sesame. In India, 20-30 per cent of the population reportedly has at least one allergic disease. The most common of these include dal, prawns, aubergine, milk and egg.
By the way, North Indians could think twice about their Sunday rajma chawal; kidney bean allergy affects over 20 per cent of the food-allergic population in Delhi. Dr Gupta, a paediatric allergy specialist, who conducts the ‘Paediatric Allergy & Asthma’ diploma course in Sir Ganga Ram Hospital (SGRH), Delhi, is irked when his peers suggest an allergy drug panel test to patients without bothering to narrow down the problems to key four to six allergens for the test. The national medical curriculum, till date, has not incorporated allergology as a field of study. “There should be specialists to treat allergies in patients, just like with other medical specialities,” he stresses.
Gurugram resident Saisha Verma is one such individual. The 17-year-old student’s mornings start with a bout of sneezing. By the time she is ready to leave for school, she has an itchy nose, watery eyes and a scratchy throat. Chances of her tiffin being left at home are higher than not finding an Allegra in her bag. “Popping Allegra has become a way of life,” says Verma. An otolaryngologist diagnosed her condition as swollen sinuses and gave her a nasal spray and prescribed medicines for a fortnight. “But it was of little help.
Every morning, I still wake up sneezing,” she says. She is lucky. Earlier last month, Nikhitha N, a 20-year-old girl from Thodupuzha in Kerala, died after accidentally eating prawn curry served in her hostel. In 2021, a government panel studying Covid-19 vaccine side-effects had confirmed that the death of a 68-year-old man was from an allergic reaction to the vaccination. According to the Dyson Global Dust Study 2022, 69 per cent of homes surveyed reported one person allergic to dust.
Allergies are everywhere. And they are on the rise. Under the sun, anybody could be allergic to anything, including the sun.
A to Z of Allergy
In India, weather and allergies are like bread and butter. People with allergies may get their worst symptoms during the summer months, when it’s hotter and plants and grasses pollinate. Last year, an allergy study by Mumbai-headquartered Metropolis Healthcare Ltd tested 65,000 individuals; 30 per cent tested positive for one or more allergens. “In the allergic population, the highest allergy was towards dust mites, closely followed by food allergies,” says Dr Alap Christy, Associate Vice President, Lab Operations & Scientific Business Head, Clinical Chemistry, Metropolis Healthcare Ltd.
Food allergies are on the upward trend. Some of them, such as milk and egg allergy, are more likely to be outgrown in late childhood compared to others such as peanuts and tree nuts. According to research conducted by the National Institute of Nutrition in Hyderabad, published in The Journal of Allergy and Clinical Immunology in May, 91.6 per cent of eczema patients believed that at least one common food item was linked to their condition; 77 food items perceived to trigger and/or exacerbate it were identified. The most notable allergens were cumin, chickpeas, walnut, cabbage and betel leaf. “Understanding the different types of allergies is crucial for proper diagnosis,” explains Dr Gupta. He believes that awareness must begin in hospitals where instead of a one-size-fits-all approach, allergy cases are treated after detailed investigation. “Awareness is crucial for patients, too,” he adds.
Samira Ferns, a 44-year-old event planner from Chennai is a case in point. Over the last two decades, she has been dealing with multiple allergies. She has self-diagnosed the trigger points and taken precautions accordingly because “it doesn’t matter as much anymore”. Initially, she used to pop an antihistamine but realised it was leaving her in a daze. She has switched to paracetamol though “it doesn’t really help”, but provides her “psychological” satisfaction. “I have a pollen allergy, dust allergy and detergent allergy. Even perfumes trigger a sneeze fest. I have noticed extreme stress also flares up my allergy,” she reveals.
An allergy apocalypse is slowly brewing in India. And it is not going anywhere, anytime soon.
An Allergy Avalanche
Allergies, like any severe physical response can indeed stress you out because you are dependent on medication: you never know when and where it will strike. Until recently, Akash Mohla was allergic to onions. The only way he dealt with it was to strictly avoid them. When he was four years old, he had a severe outbreak of painful rashes all over his body and scalp. Someone recommended he take a dip in a hot sulphur spring as a cure, but ended up landing in Emergency care. Today, Mohla is a veteran at dealing with irritated immune systems. After he became an adult, his allergies have become sporadic. “Still, I can’t afford to leave home without an antihistamine,” says the 32-year-old stock trader from Noida.
Everything comes with a price, including economic growth. The construction and infrastructure boom that marked the first two decades have also caused an allergy boom. So has uncontrolled urban migration and industrial expansion. One of the highest concentration rates in the world in air pollution from fossil fuels, and vehicles is in India. Mosquito coils, incense and dhoop sticks are responsible for indoor pollution, according to a reputed health lab in Bengaluru.
Crowded urban living conditions lead to poor sanitation, which encourages the growth of insects and dust mites. Cockroaches are blamed for many things, but news is that they may trigger atopic asthma. India’s tropical and humid climate allows allergy-causing moulds and fungi to flourish. Then, there is climate change: as heat waves push the thermometer to even cross 50 oC in some places; this has altered the pollination cycle of weeds, which had led to a higher discharge of pollen in the air. Dr Neha Rastogi Panda, consultant-infectious diseases at Fortis Memorial Research Institute, Gurugram, is concerned that seasonal allergies are no longer seasonal. For many individuals, symptoms are beginning earlier, and extending beyond, the traditional pollen period. She is seeing more patients with allergic symptoms post-Covid.
“There is a 15 to 25 per cent increase in their numbers. Pollen allergy or dust, contact dermatitis or food-related, almost all allergies are on the rise,” says Dr Panda. A new report from the Association of American Medical Colleges, released last year, places blame on climate change since warmer temperatures result in longer allergy seasons and more intense conditions. “We have seen many changes in the immune systems of people who had Covid. They have become hypersensitive to eternal stimuli.
Sedentary lifestyles have changed the allergy paradigm. What we used to consider as only food allergies previously, could be from pollen,” explains Dr Panda. Oral Allergy Syndrome, also known as Pollen Food Allergy Syndrome, often affects adults with a history of seasonal allergies and can develop during adolescence or adulthood due to cross-reactivity between proteins in certain fruits, vegetables and pollen. It appears, of late, our immune systems are throwing a wild rave.
Trigger and Treatment
As Dr Gupta mentioned earlier, the problem is how we look at allergies, which are often dismissed as minor ailments. A search for an allergy specialist is likely to throw up doctors of ENT, gastrologist and dermatologist or even homoeopathy.
“Research on allergies is still in its infancy except for in the UK, the US and Italy, where considerable work in the field has been done,” says Dr Shubnum Singh, a consultant allergist from Delhi, who has spent over three decades in the profession. Her interest in allergies began a few decades ago when her daughter, who got urticaria every time she went out, never got a proper diagnosis. “It was only when I was visiting the US and she got a violent allergic reaction, that she was diagnosed with a nickel allergy from her wrist watch. I realised how poorly allergies were understood back home, which deepened my interest in the subject,” says Dr Singh, then a pathologist.
The lines between the impacts of allergies in different regions are blurring. Dr Singh points out that while developed nations have some of the highest allergy rates, the growing urban lifestyles of people living in developing countries, away from nature, are causing a rise in allergies. For long, the “hygiene hypothesis” was the most common reason attributed to allergies; it suggests that exposure to a diversity of microbes in early life protects people against allergies by strengthening their immune systems.
Physicians also believe that the rise in C-sections could be a possible contributing factor since the procedure is more sterile and infants miss out on the beneficial bacterial flora passed on during vaginal birth. Traditionally, food allergies are lower in India compared to the West, thanks partly to Indian genes (we rarely have peanut allergies—the most dreaded allergy in the West). But that is changing. Dairy-free, wheat-free and soy-free versions are appearing in menus and food companies have increased research funding to develop newer varieties.
Researchers are exploring genetic manipulation methods to create wheat varieties with reduced gluten content. Led by Sachin Rustgi, associate professor of Molecular Breeding at Clemson University in South Carolina, a grant-funded study is employing conventional and genome-editing techniques to develop new wheat varieties.
“Research conducted at AIIMS, Delhi, also confirmed an equal prevalence of celiac disease (allergic reaction after consuming gluten) in India, previously misdiagnosed as ‘summer diarrhoea’. These findings, coupled with the realisation that no therapies, other than a gluten-free diet, are available for celiac patients motivated me to embark on research to discover widely acceptable therapies to treat gluten sensitivity,” he explains.
A combination of Westernised diets rich in gluten, and lower exposure to outdoor allergens has over time impacted the health of Indians. “Our exposure to indoor allergens have increased, which is leading to lower immunity. However, improvements in diagnostics and more public awareness have made recording the surge in people with gluten sensitivity more effective,” he adds.
Sensitivity towards people with allergies is low. Rachna Gupta, a 61-year-old fashion entrepreneur in Delhi says, “Most restaurants do not understand that even a dash of dairy can land me in an emergency. They would casually say there’s just very little ghee or curd added to a dish, and that it won’t make a difference,” says Rachna, who had near-death experiences twice despite avoiding dairy in any form.
It’s only when she is travelling abroad that she is confident about the ingredients in food. California-based medical anthropologist Theresa MacPhail, author of Allergic: How Our Immune System Reacts to a Changing World, released last year, says, “I think there is still quite a bit of confusion among the general public—and even some doctors—about what an allergy is and isn’t.” MacPhail’s father died of anaphylaxis after a bee sting in 1996, which provoked her interest in the subject.
Cost to Care
Allergy treatments currently available include over-the-counter antihistamines, decongestants, nasal sprays and eye drops for managing mild symptoms. For moderate to severe allergies, prescription medications like corticosteroids, leukotriene modifiers, and immunotherapy (allergy shots or sublingual tablets) may be recommended. Allergy tests often fail to give accurate results due to false positives and negatives, individual variations in sensitivity and cross-reactivity between allergens. Even though skin prick and blood tests can detect sensitisation, Dr Singh explains, “A skin-prick test done in a controlled environment with the pure form of allergen is a must. Unless the doctor undertakes a detailed investigation to match both, and then interpret the result correctly, the desired result won’t happen. It’s not a black and white situation.”
According to Dr Panda, non-invasive methods such as clinical history assessment, are often precise in identifying allergic manifestations. There are blood tests to determine basic allergy, organ-specific reactions and severity. The multiple technologies for allergy testing are in themselves a debate. “Top allergists are deliberating over which technology is most reliable. Even when an allergy is identified, there are only a few common allergens that can be treated with definite immunotherapy. The rest are still treated symptomatically,” says Dr Christy of Metropolis.
Could acupuncture be the answer? Delhi-based acupuncturist Dr Raman Kapur, whose section in the book, Comprehensive Textbook of Allergy: Striking the Right Balance, speaks of the intervention of acupuncture in treating allergies, says, “Whenever there is an allergic phenomenon, the immune system gets compromised. The lymphocytes start plummeting. As a result, the fighting ability of the body against the allergens drops.
There are no medications available in Western medicine that can boost the lymphocytes. Hence, doctors prescribe anti-allergics which provide temporary relief, but do not address the root cause.’’ In acupuncture, one works on the immune system to build up the lymphocytes. There are specific acupuncture points, which when needled, stimulate production. ‘‘This is scientifically proven. As the immune system gets stronger, the body is able to resist the allergens and the symptoms disappear,” he adds.
The scary fact is that no definite cure for food allergies is available. Antihistamines and epinephrine provide relief from the symptoms rather than the allergy itself. Research is now focusing on the latter. Oral immunotherapy uses antibodies—made by the same immune cells that react to the allergen—to bind the immune cells and prevent them from reacting adversely.
Last year saw a fourth-generation allergy testing technology that uses AI to assist clinicians. The technology tests for 296-plus allergen components in a single go with its nanotechnology-based array (CRD). For instance, if a person tests positive for shrimp, there is the likelihood that they may also test positive for tropical mites. Every nation depends on the next generation to take it forward.
The Phase 3 International Study of Asthma and Allergy in Children (ISAAC) reported 50 per cent or more of 7 per cent of children surveyed, in the six-seven years and 13-14 years age bracket, had severe uncontrolled asthma caused by allergens and 3·6 per cent among Indian children aged 13-14 years had allergy-caused eczema. Nearly 19 per cent of children (480 million) in the world live in India: which is more than one-third of the country’s population. Without discussion, funding, research and medical recognition, allergies have placed Indian youth at severe risk. AI or no AI, the basic test remains the same: an allergy towards discussing and diagnosing allergies correctly.
In a nutshell
What is an allergic reaction?
It is defined as a hypersensitive immune reaction to a substance that normally is harmless. It is caused by allergens that come into contact with the skin, nose, eyes, respiratory tract and gastrointestinal tract. They can be inhaled, swallowed or injected. It may cause harmful symptoms such as itching or inflammation or tissue injury. In some severe cases, allergies can be fatal
For airborne allergens, additional treatment options include
· Throat lozenges with soothing ingredients, such as menthol, honey or ginger
· Shower and wash all clothing after being exposed to an allergen
· Exercise for a few minutes to help reduce nasal congestion
Treating skin allergies
· Use topical corticosteroid creams or tablets that reduce inflammation and itching
· Moisturising creams and emollient creams with soothing ingredients are a good option
· Applying an ice pack for 10 to 15 minutes intervals can reduce inflammation
Dos and Don’ts
· Use antihistamines or decongestants when in contact with allergens
· A low-fat diet high in complex carbohydrates such as beans, whole grains and vegetables may reduce allergy reactions
· Plant-based chemicals found in citrus fruits and blackcurrants may act as natural antihistamines
· Supplements such as flaxseed oil, zinc, and vitamins A, C and E improve allergy symptoms
· Acupuncture treatments may help some people to find relief
Treatment
· Minor allergy symptoms can be treated with antihistamines
· Saline nasal rinses for congestion-related allergy symptoms
· Corticosteroid creams can treat skin rashes related to allergies
· Immunotherapy is a long-term treatment for chronic allergy symptoms
Antihistamines
These are most effective in treating minor allergies. They reduce the body’s production of histamine, which reduces all symptoms. They can also be taken to prevent allergies. Antihistamines come in several forms:
· oral pills
· dissolvable tablets
· nasal sprays
· liquids
· eye drops
Nasal decongestants
These, in the form of pills, liquids, and sprays can also help reduce stuffy, swollen sinuses and related symptoms
Anti-inflammatory medication
Non-steroidal anti-inflammatory medications (NSAIDs) may also be used to help temporarily reduce pain, swelling and cramping caused by allergies
Types of Common Allergens
Airborne
Airborne allergens can trigger hay fever (allergic rhinitis) symptoms, and can also be responsible for eczema and asthma. These allergies can’t be cured, but one can help reduce the severity. Eg: Pollen, dust mites, pet dander, mold & mildew
Food
Food allergy affects an estimated 8% of children under age 5 and up to 4% of adults. Even a tiny amount of the allergy-causing food can trigger symptoms such as digestive problems, hives or swollen airways. Eg: Tree nuts and peanuts, milk, eggs, soybeans, fish, shellfish and wheat
SKIN
This is the most common form of allergies. Skin allergies can have causes that aren’t due to underlying disease. They are largely an inflammation of the skin triggered when the immune system releases histamine. Eg: nickel, latex, fragrances, cleaners, cosmetics and plants
Medication
It's when your body's immune system overreacts to medications. Your body develops sensitivity to one of the substances in the medication and may produce an antibody against that drug. Eg: chemotherapy medicines, sulfa drugs, penicillin, NSAIDs and anti-convulsants