Expert panel opinion on adult pneumococcal vaccination in the post-COVID era (NAP- EXPO Recommendations-2024).

INTRODUCTION: Pneumococcal diseases pose a significant public health concern in India, with substantial morbidity and mortality, with the elderly and those with coexisting medical conditions being most at risk. Pneumococcus was also seen to be one of the main reasons for co-infection, pneumonia and complications in COVID. Current guidelines recommend vaccination for specific adult populations, but there is a lack of uniformity and guidance on risk stratification, prioritisation and optimal timing. METHODS: Nation Against Pneumococcal Infections - Expert Panel Opinion (NAP-EXPO) is a panel convened to review and update recommendations for adult pneumococcal vaccination in India. The panel of 23 experts from various medical specialties engaged in discussions and evidence-based reviews, discussed appropriate age for vaccination, risk stratification for COPD and asthma patients, vaccination strategies for post-COVID patients, smokers and diabetics, as well as methods to improve vaccine awareness and uptake. OUTCOME: The NAP-EXPO recommends the following for adults: All healthy individuals 60 years of age and above should receive the pneumococcal vaccine; all COPD patients, regardless of severity, high-risk asthma patients, post-COVID cases with lung fibrosis or significant lung damage, should be vaccinated with the pneumococcal vaccine; all current smokers and passive smokers should be educated and offered the pneumococcal vaccine, regardless of their age or health condition; all diabetic individuals should receive the pneumococcal vaccine, irrespective of their diabetes control. Strategies to improve vaccine awareness and uptake should involve general practitioners (GPs), primary health physicians (PHPs) and physicians treating patients at high risk of pneumococcal disease. Advocacy campaigns should involve media, including social media platforms. CONCLUSION: These recommendations aim to enhance pneumococcal vaccination coverage among high-risk populations in India in order to ensure a reduction in the burden of pneumococcal diseases, in the post-COVID era. There is a need to create more evidence and data to support the recommendations that the vaccine will be useful to a wider range of populations, as suggested in our consensus.

Pleural effusion guidelines from ICS and NCCP Section 1: Basic principles, laboratory tests and pleural procedures.

Pleural effusion is a common problem in our country, and most of these patients need invasive tests as they can't be evaluated by blood tests alone. The simplest of them is diagnostic pleural aspiration, and diagnostic techniques such as medical thoracoscopy are being performed more frequently than ever before. However, most physicians in India treat pleural effusion empirically, leading to delays in diagnosis, misdiagnosis and complications from wrong treatments. This situation must change, and the adoption of evidence-based protocols is urgently needed. Furthermore, the spectrum of pleural disease in India is different from that in the West, and yet Western guidelines and algorithms are used by Indian physicians. Therefore, India-specific consensus guidelines are needed. To fulfil this need, the Indian Chest Society and the National College of Chest Physicians; the premier societies for pulmonary physicians came together to create this National guideline. This document aims to provide evidence based recommendations on basic principles, initial assessment, diagnostic modalities and management of pleural effusions.

Expert Opinion on the Management of Acute and Chronic Cough: An Indian Perspective in Primary Care Setting.

Cough is the body's reflex when the throat or airway is irritated by a foreign body, such as irritants, microbes, and fluids. Cough caused due to a disorder or infection can last for a few days to a couple of weeks and is usually self-limiting and self-resolving. However, in certain cases, cough can persist for months, disrupting everyday activities, affecting the patient's mental health, and causing pain and fatigue. There are a number of different therapeutic strategies to manage acute and chronic cough, depending on the cause. Dry cough can be treated using opioids, nonopioids, antitussives, and antihistamines. Expectorants and mucolytics are widely used in the management of productive cough. The underlying cause of cough should be appropriately managed with specific therapy. The choice of treatment regimen is dependent on the patient's medical history, symptoms, and preexisting conditions. Based on the literature review and clinical practice, a comprehensive approach to the management of cough as a symptom has been proposed.

Scoring System for the Use of Nebulizers in the Primary Care Settings: An Expert Consensus Statement.

BACKGROUND: The use of nebulizers is an important and useful method for delivering drugs to the lungs in patients with various airway and lung parenchymal disorders. They are primarily used in patients with acute symptoms and in a selected group of patients for maintenance treatment. Its use has increased, especially during the coronavirus disease 2019 (COVID-19) pandemic. To ensure the appropriate use of nebulizers by primary care physicians and to guide them, we aimed to develop a simple nebulizer use score. METHODS: An expert working group (EWG) of pulmonologists were formed who using a semi- Delphi method, developed a list of variables and a cut-off score to decide when to use nebulizers. We started with a total of 55 variables that were developed through an exhaustive review of the literature. These were further reduced to smaller numbers that had the maximum score as well as concordance with the EWG. The scores ranged from 1 to 10 (completely disagree to completely agree), and only those above 7.5 were selected. RESULTS: A total of 8 variables with the highest scores were selected (Table 1), which had a total maximum score of 40. A score of <15 was suggested to indicate no use of nebulizer and >20 to suggest definite use of nebulizer. A score between 15 and 20 was suggested for physician judgment. A separate table of 12 conditions was made where the use of nebulizers was mandatory. CONCLUSION: This first-of-its-kind nebulizer score can be used by primary care physicians to decide which patients should be put on nebulizer treatment.

Is pulmonary tuberculosis a true risk-factor for chronic obstructive pulmonary disease?

This viewpoint discusses the possible relationship of tuberculosis with chronic obstructive pulmonary disease. Pulmonary tuberculosis as a risk factor and/or complication of COPD is reported in several reports from African and Asian countries. History of TB seems to have an important role in the natural history of COPD. It is difficult to conclude whether this is a true causal relationship or merely an incidental observation due to the concurrent presence of the two commonly prevalent diseases and their risk factors. Many of these disease and treatment-related factors can promote and/or aggravate disease condition.

Management of interstitial lung diseases: A consensus statement of the Indian Chest Society (ICS) and National College of Chest Physicians (NCCP).

BACKGROUND: Interstitial lung disease (ILD) is a complex and heterogeneous group of acute and chronic lung diseases of several known and unknown causes. While clinical practice guidelines (CPG) for idiopathic pulmonary fibrosis (IPF) have been recently updated, CPG for ILD other than IPF are needed. METHODS: A working group of multidisciplinary clinicians familiar with clinical management of ILD (pulmonologists, radiologist, pathologist, and rheumatologist) and three epidemiologists selected by the leaderships of Indian Chest Society and National College of Chest Physicians, India, posed questions to address the clinically relevant situation. A systematic search was performed on PubMed, Embase, and Cochrane databases. A modified GRADE approach was used to grade the evidence. The working group discussed the evidence and reached a consensus of opinions for each question following face-to-face discussions. RESULTS: Statements have been made for each specific question and the grade of evidence has been provided after performing a systematic review of literature. For most of the questions addressed, the available evidence was insufficient and of low to very low quality. The consensus of the opinions of the working group has been presented as statements for the questions and not as an evidence-based CPG for the management of ILD. CONCLUSION: This document provides the guidelines made by consensus of opinions among experts following discussion of systematic review of evidence pertaining to the specific questions for management of ILD other than IPF. It is hoped that this document will help the clinician understand the accumulated evidence and help better management of idiopathic and nonidiopathic interstitial pneumonias.

Management of interstitial lung diseases: A consensus statement of the Indian Chest Society (ICS) and National College of Chest Physicians (NCCP)

Interstitial lung disease (ILD) is a complex and heterogeneous group of acute and chronic lung diseases of several known and unknown causes. While clinical practice guidelines (CPG) for idiopathic pulmonary fibrosis (IPF) have been recently updated, CPG for ILD other than IPF are needed. Methods: A working group of multidisciplinary clinicians familiar with clinical management of ILD (pulmonologists, radiologist, pathologist, and rheumatologist) and three epidemiologists selected by the leaderships of Indian Chest Society and National College of Chest Physicians, India, posed questions to address the clinically relevant situation. A systematic search was performed on PubMed, Embase, and Cochrane databases. A modified GRADE approach was used to grade the evidence. The working group discussed the evidence and reached a consensus of opinions for each question following face-to-face discussions. Results: Statements have been made for each specific question and the grade of evidence has been provided after performing a systematic review of literature. For most of the questions addressed, the available evidence was insufficient and of low to very low quality. The consensus of the opinions of the working group has been presented as statements for the questions and not as an evidence-based CPG for the management of ILD. Conclusion: This document provides the guidelines made by consensus of opinions among experts following discussion of systematic review of evidence pertaining to the specific questions for management of ILD other than IPF. It is hoped that this document will help the clinician understand the accumulated evidence and help better management of idiopathic and nonidiopathic interstitial pneumonias.

Household air pollution in India and respiratory diseases: current status and future directions.

PURPOSE OF REVIEW: Combustion of solid cooking fuels employed by more than 3 billion people globally, contributes to approximately one third of ambient air pollution. In the recent past, the issue has drawn global attention because of its threat to the health of rural communities, particularly women and children. This review is focused on the evidence from India on effects of household air pollution (HAP) on respiratory health and interventions to replace the solid fuels. RECENT FINDINGS: HAP exposure is a major risk factor for increased respiratory symptoms, respiratory infections, and chronic obstructive pulmonary disease. In most studies, the odds ratio for the risk of development of respiratory disorders is more than one in HAP exposed individuals. HAP is also associated with increased risk of tuberculosis, asthma, mortality from cardio-respiratory illnesses, and nonrespiratory problems such as adverse pregnancy outcomes, prematurity, and low birth weight. SUMMARY: Household air pollution is a common but preventable risk factor for respiratory diseases. Replacement of solid cooking fuels with clean fuels such as LPG gas as exemplified by the 'Ujjwala' program of India is likely to be most effective intervention to reduce the HAP related disease burden.