Introduction

Obstructive sleep apnea (OSA) is a serious disorder of repetitive pharyngeal collapse during sleep due to decreased pharyngeal airway size because of craniofacial structure or body fat. Patients with OSA report snoring, witnessed apneas, waking up with a choking sensation, excessive daytime sleepiness, fatigue, tiredness, and headache.1 Moderate to severe OSA has been found to affect 50% males and 25% females in the middle-aged population.3

OSA is an emerging public health concern globally. It has been linked to several comorbidities like metabolic syndrome, diabetes mellitus, insulin resistance, hypertension, coronary artery disease, stroke, increased risk of vehicular accidents, and various psychiatric disorders.4 

Causes of OSA

The predisposing factors of OSA can be divided into anatomical and physiological factors (Figure 1).1,3

Figure 1: Etiological factors of OSA (Adapted from Whyte A et al. 2020)3

Risk factors for OSA

The Indian Initiative on Obstructive Sleep Apnea (INOSA) guidelines suggest the following risk factors linked to OSA (Figure 2).4

Figure 2. Factors that may contribute to OSA (Adapted from Sharma et al., 2014)4

Modification of certain risk factors can modulate the incidence of OSA

Hormonal changes: Males are more commonly affected than females, possibly due to hormonal effects on upper airway muscles and collapsibility. Post-menopausal women have a three times higher risk of developing OSA than premenopausal women due to dramatic changes in sex hormone levels.7

Obesity: Increased levels of cholesterols and obesity are major modifiable risk factors for sleep-related disorders, which predispose individuals to OSA due to mass loading in the upper airway.7

Smoking and alcohol: Smoking can cause airway inflammation and smoking-related diseases. Nicotine levels can also affect sleep stability. These effects of smoking could contribute to OSA. Alcohol consumption reduces motor output to the upper airways, causing hypotonia of the oropharyngeal muscles.7

Consequences of OSA on other systems

OSA significantly affects the social, emotional, and physical health of the patients. The consequences of OSA are characterized by overlapping symptoms such as lack of concentration, fatigue, loss of interest, and decreased libido.11 Figure 3 highlights the disease progression of OSA.3,5,6

Figure 3. OSA disease progression (Source: Whyte A et al., 2020; Kim H et al., 2013; Arnaud C et al., 2020)3,5,6

The disease progression of OSA has a deleterious effect on various systems of the body (Figure 3).4

Figure 4. Complications of OSA (Adapted from Whyte A et al., 2020)3

OSA and comorbidities – A cross-linkage

A strong correlation exists between OSA and comorbidities due to common risk factors contributing to the etiology of one another.7

Hypertension: OSA is particularly common in patients with resistant hypertension. Evidence suggests that the chances of developing hypertension increase with a consecutive decline in nocturnal oxygen saturation.7

Cardiovascular diseases: The prevalence of OSA is high in patients with congestive heart failure. Recent studies suggest that the treatment of OSA in patients with congestive heart failure has improved symptoms over time.7

Stroke: OSA is highly prevalent in patients with stroke and transient ischemic attacks, leading to lower functional capacity and longer hospital stay.7

Diabetes Mellitus: Diabetes mellitus and OSA often coexist. Studies have demonstrated that poor metabolic and glycemic control have a significantly higher apnea-hypopnea index. Anti-diabetic medications, physical activity, and diet are reported to alleviate OSA-related effects.7,8

Conclusion

Obstructive sleep apnea significantly affects the quality of life and is associated with several long-term comorbidities. Therefore, spreading awareness about OSA and its proper diagnosis and treatment among the general population and healthcare practitioners is imperative

The COVID-19 pandemic had a “devastating” impact on the fight against HIV, tuberculosis and malaria in 2020, according to a report released by the Global Fund.

“To mark our 20th anniversary, we had hoped to focus this year’s report on the extraordinary stories of courage and resilience that made possible the progress we have achieved against HIV, TB and malaria over the last two decades,” said Peter Sands, the Global Fund’s executive director.

“But the 2020 numbers force a different focus. They confirm what we feared might happen when COVID-19 struck,” he said.

“The impact of COVID-19 on the fight against HIV, TB and malaria and the communities we support has been devastating. For the first time in the history of the global fund, key programmatic results have gone backwards.”

There were “significant” declines in HIV testing and prevention services, the fund said.

Compared with 2019, the number of people reached with HIV prevention and treatment dropped by 11% last year, while HIV testing dropped by 22%, holding back new treatment in most countries.

Nevertheless, the number of people who received life-saving antiretroviral therapy for HIV in 2020, rose by 8.8% to 21.9 million “despite COVID-19”.

The impact of the coronavirus pandemic on the fight against TB worldwide had similarly been “catastrophic”, the report said.

The number of people treated for drug-resistant TB in the countries where the Global Fund invests dropped by “a staggering” 19 percent, with those on treatment for extensively drug-resistant TB registering an even bigger drop of 37 percent, it said.

The fund calculated that around 4.7 million people were treated for TB in 2020, around one million fewer than in 2019.

Interventions to combat malaria “appear to have been less badly affected by COVID-19 than the other two diseases,” the report found.

“Thanks to adaptation measures and the diligence and innovation of community health workers, prevention activities remained stable or increased compared to 2019.”

The number of mosquito nets distributed increased by 17 percent to 188 million and structures covered by indoor residual spraying increased by three percent.

Nevertheless, the Global Fund — which brings together governments, multi-lateral agencies, bilateral partners, civil society groups, people affected by the diseases and the private sector -- said that its “rapid and determined response to Covid-19 prevented an even worse outcome”.

In 2020, the fund disbursed $4.2 billion to continue the fight against HIV, TB and malaria and approved an additional $980 million in funding to respond to COVID-19.

The Global Fund said that since it was set up in 2002, it has saved 44 million lives and the number of deaths caused by AIDS, TB and malaria decreased by 46 percent in countries where it invests

As some experts are saying that children might be more susceptible in the third wave of coronavirus, few health professionals suggest giving influenza shots to children to guard them against it and also said that doctors can begin COVID-19 treatment at an early stage in infected children.

Few of the common symptoms of COVID-19 are fever, cough, sore throat, fatigue, headache, cold, and are similar to the flu. Recently, a journal was published that was titled ‘The flu vaccination might have a protective effect on the course of Covid-19 in the paediatric population: When does SARS-Cov-2 meet influenza’. It stated that COVID-19 positive children, receiving the influenza vaccine in the flu season, have lesser odds of experiencing symptoms, respiratory complications or severe disease.

Dr Srikanta J T, Consultant in Paediatric Pulmonology and Sleep Medicine, Aster CMI Hospital, said that flu vaccine shots are against seasonal flu that are caused by the influenza viruses. The mortality rate of influenza is 1 per cent whereas in COVID-19, it is said to be 0.1 per cent. Therefore, it is important for children who are aged between 6 months to 6 years to get the flu shots. It is more important during this Covid pandemic and an approaching third wave, as COVID-19 and influenza infections are more or less similar with fever, coryzal symptoms in children as few kids develop severe infection that requires hospitalization and other supportive care too. As both the infections are similar, it is relevant to protect children with vaccines which are tried and tested.

The price of the influenza flu vaccines is between Rs 1,500-1,690, which might not be affordable to all. Therefore, doctors have suggested that the government should make it available for free of cost in their healthcare facilities. Children with COVID-19 are largely asymptomatic or mildly symptomatic, while the seasonal flu is more severe in this presentation, though self-limiting and without any later effects. There can be a situation where kids can be a silent asymptomatic carrier of COVID-19, and spread it further after having a co-infection along with the seasonal flu virus.

These vaccines are routinely recommended for children and are very important during this pandemic. At present, the flu vaccines are available in private clinics and hospitals only and it should be made available free of cost at all government facilities as part of the National Immunization schedule, said Dr Kiran Raghu, Consultant, Paediatrics at Prakriya hospitals.

Dr Bhaskar Shenoy, HoD and Consultant, Paediatrics, Manipal Hospital highlighted that the symptoms of flu and COVID-19 are similar and it is important to safeguard children against the flu. People who get the flu and COVID-19 at the same time can have a more serious infection. Vaccination is the most effective way for preventing influenza and possibly severe complications of the disease