SKIMS Pulmonary and Internal Medicine Consultant Dr Syed Mudasir Qadri tells HirraAzmat
KASHMIR LIFE (KL): What are the most common pulmonary diseases and disorders found in Kashmir?
DR Syed MUDASIR QADRI (DSMQ): The respiratory disorders morbidity is quite humongous in Kashmir as smoking and biomass fuel exposure is common to many of these disorders. The common ones are COPD (chronic obstructive pulmonary disease), lung cancers, Bronchial Asthma, tuberculosis, bronchiectasis, bacterial Pneumonia and of course viral infections especially influenza for which the season is setting in. Presently the world is busy in tackling the pandemic and we too are severely affected by it.
KL: As winter is setting in, what are the precautions we can take?
DSMQ: Winters lead to dry weather that’s why we see our skin becoming dry and cracks develop over the exposed areas. The same way our mucosal membranes of the respiratory tract also become dry and inhalation of cold air also diminishes the local immune response in the nasal passages leading to decreased defence against microorganisms especially viruses. That’s the reason why colds are more common during winters. Decreased sun exposure because of staying inside homes and shorter daylight time also adds to the diminishing immunity. Same holds true for Covid-19 and it’s a viral illness too. With great difficulty, we seem to have got a bit of control over Covid-19 as the peak seems to be over and the patient numbers are slowly but surely going down, but this should not make us complacent as winters make the right substrate for the spread of the contagion. Moreover, flu outbreaks also occur during winters in Kashmir. We should not allow this to become a twindemic. So, we need to maintain the three basic principles of – use face mask; maintain physical distancing and hand hygiene. By this, we can take care of both of these illnesses. We should keep ourselves warm, take a balanced healthy diet including fruits, maintain a healthy lifestyle and avoid going out during extremely cold temperatures. Influenza vaccine (Flu shots) for the year 2020-21 NH is available and people especially with comorbid illnesses, at the extremes of age and health care workers should go for it.
KL: Every year, a new strain of influenza emerges and poses a threat to the public. In this scenario, how effective are flu shots? Also, which age group is most susceptible and should get vaccinated first?
DSMQ: Yes, to find out which strain of influenza is going to be responsible for a possible epidemic in the upcoming season is a very difficult task. That’s why every year Flu vaccines are updated to better match the strains of viruses expected to be circulating in the community. For this, a set mechanism is there by which a group of experts try to find out the same based on past experiences and the latest studies from different parts of the world and come up with the strains to be incorporated in the vaccine for that particular season. The effectiveness of an influenza vaccine can range anywhere from 20% to 60% in a particular season.
Adults aged 65 and older and children less than five years are at high risk of flu complications so should receive influenza vaccination on priority. The WHO Strategic Advisory Group of Experts (SAGE) on Immunization for influenza vaccination during the Covid-19 pandemic puts healthcare workers among the top priority groups for receiving flu vaccine as this time around they are being exposed to both influenza as well as Coronavirus infection at the same time. The other groups that should be prioritized to receive influenza vaccine include pregnant females, patients with other health conditions like respiratory disorders like COPD and asthma, heart disease and stroke, diabetes mellitus, chronic kidney disease, cancers, and HIV/AIDS.
KL: What about those who have recently recovered from Covid-19 infection? After how many days should they go for influenza vaccination?
DSMQ: As we are still learning about Covid-19 infection and its effects, till now there is no hard-clinical data regarding the optimal timing of flu vaccination of a patient who recovered from Covid-19. But, till we get the final recommendations on this issue, we can apply a few common principles of internal medicine in deciding the appropriate time for flu vaccination for each patient recovered from Covid-19:
A). Vaccination should be deferred for people with suspected or confirmed Covid-19 infection, regardless of whether they have no symptoms or mild to severe symptoms.
B). For asymptomatic or mildly symptomatic patients flu vaccination is not prohibited but it is better to wait till they complete their isolation period.
C). For hospitalized Covid-19 patients who are sick, we should wait till the resolution of their symptoms.
D). It is also better to wait for a couple of weeks if the patient has received antivirals and/or high-dose steroids during the course of treatment.
KL: Could you please explain the difference between pneumonia caused due to influenza and that caused due to Covid-19?
DSMQ: I would answer this question in two ways, radiological and clinical.
Radiologically bacterial pneumonia have different patterns than viral pneumonia (alveolar infiltrates Vs interstitial infiltrates on imaging respectively). Both influenza and Covid-19 are viruses and give rise to interstitial infiltrates that are often referred to as ground-glass opacities (GGOs) that may ultimately lead to severe pneumonia and ARDS (crazy-paving pattern or even consolidation). However, the distribution of these infiltrates in Covid-19 is usually peripheral or sub-pleural more often involving the lower zones whereas influenza didn’t show such selective distribution and was more commonly associated with the findings of mucous impaction and pleural effusion.
Clinically Influenza rarely causes a severe illness in healthy individuals and if severe pneumonia occurs in influenza, it is invariably due to a secondary or superadded bacterial infection that too in the presence of an immune-compromised state or co-morbid illness on most occasions. And we do have specific antivirals to treat influenza infection. In comparison, Covid-19 is much more aggressive and causes severe lung involvement on many occasions even in healthy individuals and we do not have a proven specific antiviral drug against it.
Regarding influenza and Covid-19 as a combination or influenza infecting post-Covid patients, we have to wait and watch how it goes. It is for everyone to see whether influenza will cause a more severe illness in Covid-19 recovered patients or not although there’s a strong theoretical possibility of a severe illness in these patients especially those who have recently recovered or are in convalescence as their immune system is still in recovery mode from the insult of Covid-19.
KL: How early is the recovery in patients with pneumonia caused due to Covid-19?
DSMQ: It depends on the severity of infection/Pneumonia. We grade Covid-19 pneumonia as perCT severity scoring into mild, moderate and severe Covid-19 pneumonia. If it is mild pneumonia then the patient usually recovers in a couple of weeks’ time, moderate pneumonia recovers in 4-6 weeks’ time and severe pneumonia may take a few months for complete recovery.
KL: Have you seen any difference between smokers and non-smokers, whether the symptoms of Covid-19 or influenza are severe in smokers or not?
DSMQ: Tobacco smokers are more vulnerable to contract both Covid-19 or influenza, as the act of smoking, involves contact of fingers (and possibly contaminated cigarettes) with the lips, which increases the possibility of transmission of viruses from hand to mouth. Moreover, smoking in itself is an insult to the lungs leading to defective local/mucosal immunity in smokers, making them vulnerable to respiratory infections and their complications as well. Many studies have proven this adverse relationship between smoking and influenza but hard data on Covid-19 and smoking is yet to come and is expected to be available in a few months from now and hopefully it’ll be from our own centre (SKIMS) as well.
KL: Can air pollutants in winter have any impact on people with respiratory illness?
DSMQ: Of course, air pollution is an important cause of many respiratory illnesses and it can even exacerbate a pre-existing respiratory condition like bronchial asthma, chronic bronchitis etc. As mentioned earlier, people need to avoid exposure to extreme cold and keep themselves and their homes warm. Avoid exposure to smoke and if possible, use non-smoke forming ways to warm themselves and their homes like hot water bottles and electrical appliances respectively. Use warm clothing and take a balanced and healthy diet rich in fruits. Few home remedies during winters to keep infections at bay include use of kehwa, a combination of warm milk and turmeric has also been shown to have antiviral properties. Honey has been used in upper respiratory infections from times immemorial. Frequent steam inhalations also do help in sanitizing the upper respiratory airways.
KL: Has SKIMS initiated or has done any research on the effects of Covid-19?
DSMQ: SKIMS has always been at the forefront in dealing with such situations and has in the past contributed many times towards the better understanding and management of many disorders. We do update our management protocols from time to time as per the new evidence pouring in from different parts of the world, and based on our own experiences as well. And of course, research is a part and parcel of our academics and patient management protocol. In the present scenario, the main focus is on Covid-19 and its management. We are the first institution in J&K to start convalescent plasma therapy, although the international data doesn’t seem to be conclusively in favour of this form of therapy we did find that it helped in some patients who received it at a particular stage of their disease. We are accumulating and analyzing our data and hopefully, we’ll come out with a word or a recommendation on it soon. Similarly, many projects on other parameters like patients with co-morbid illnesses, antibody response, various treatment options and patient outcomes are going on and hopefully in a few weeks to a couple of months’ time we’ll be better educated about the response of our population to Covid-19 and we may come up with our own recommendations on it.