Prevalence of Celiac Disease Among School Children in Punjab, North India

Ajit Sood; Vandana Midha; Neena Sood; Gurcharan Avasthi; Alok Sehgal

Disclosures

J Gastroenterol Hepatol. 2006;21(10):1622-1625. 

In This Article

Abstract and Introduction

Abstract

Background: Celiac disease, as of today, is said to exist in almost all parts of the world, although it is rare among people of purely African-Caribbean, Japanese and Chinese background. The disease has also been considered uncommon in India until recently. Hospital records have revealed an increasing trend of the disease in predominantly wheat-eating areas of North India. The aim of the present study was to determine the prevalence of celiac disease among school children in Punjab, North India.
Methods: The study was carried out in the Ludhiana district of Punjab, Northern India. A total of 4347 children aged 3-17 years attending different schools were enrolled. A structured questionnaire was used to collect sociodemographic data and symptoms and signs related to celiac disease and various sociodemographic factors. The screening for celiac disease for the suspected celiacs was done by testing for antitissue transglutaminase (anti-tTG) by indirect solid-phase immunometric assay (ELISA). All children with high anti-tTG whose parents consented underwent upper gastrointestinal endoscopy for small bowel biopsy from the second part of the duodenum. Histopathology was expressed according to the Marsh classification of 1992. Follow up was carried out among children who were put on a gluten-restricted diet, at monthly intervals for 3 months and every 3 months thereafter. The diagnosis of celiac disease was established on the basis of the revised European Society of Paediatric Gastroenterologists and Nutritionists (ESPGAN) criteria (confirmed cases).
Results: A total of 4347 school children (1967 girls, 2380 boys, age range 3-17 years) were screened for celiac disease. Out of these, 198 suspected children were identified for further evaluation. Twenty-one children tested positive for anti-tTG assay (10.6%, 95% confidence interval: 16.91-34.79). Seventeen of these 21 children agreed to undergo biopsy; of these, 14 had histological changes consistent with celiac disease and all these 14 children had clinical response to gluten restriction. Three children with high anti-tTG had normal mucosa on duodenal biopsy and were not labelled as being in the celiac disease group. In the final analysis the disease prevalence was one in 310 children.
Conclusions: This is the first study on celiac disease prevalence among school children from India. Although this disease frequency of one in 310 is thought to be an under-assessment, it clearly shows that celiac disease is not rare in wheat-eating areas of North India.

Introduction

The debate on the true prevalence of celiac disease has been revived by increasing recognition of varied disease presentations, reliability of easily available serologic testing and efforts to screen large numbers of asymptomatic and at-risk population. Until approximately a decade ago, celiac disease was considered uncommon even in the Western world, with a prevalence of 1 in 1000 or lower. These estimates were based solely on case acquisition studies alone and were, hence, a gross underestimation of the true disease.[1,2] Recent studies from Europe and America screening healthy populations have reported the disease to be more common than previously realized, with prevalence reported between 1 in 82 and 1 in 300 persons.3 These studies also lend support to the iceberg analogy linked with celiac disease in that a sizeable proportion of the affected individuals have unrecognized disease. Celiac disease, as of today, is said to exist in almost all parts of the world, although it is rare among people of purely African-Caribbean, Japanese and Chinese background.[1,4,5,6] The disease has also been considered uncommon in India until recently.[7,8] Hospital records, however, have revealed an increasing trend of the disease in predominantly wheat-eating areas of North India.

There are no population screening studies on the epidemiology of celiac disease from India. Although there are no guidelines as to the best age for screening, we decided to study this condition in school children because early diagnosis and treatment are likely to have a greater effect.

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