In Focus

Waking Up to Sleep Therapy

With 93 per cent of Indians not sleeping enough and 34 per cent are at risk of Obstructive Sleep Apnea (OSA), hospitals are investing in treating sleep disorders, says Sonal Shukla

With more than one billion population turning sleepless with each passing day, India is finally waking up to fact that various types of sleep disorders do exist and need treatment. The market forces, growing incidence of the various disorders and increased awareness among doctors as well as patients has made sleep therapy a rising segment in India. The increasing number of sleep labs, mostly coming up in major cities in India, is a witness to this phenomenon.

Need Indeed

Philips Sleep Survey, conducted in November 2009, revealed some startling facts about how sleep deprived Indians are. The survey revealed that 93 per cent of Indians are not sleeping enough and 34 per cent are at risk of Obstructive Sleep Apnea (OSA), which can lead to weight gain and even serious situations such as worsening of the heart. Dr David White, well-known sleep disorders specialist from Harvard Medical School says "Snoring in combination with conditions such as obesity, small jaw lines, narrow nasal passages and enlarged tonsils is indicative of OSA. In children, OSA can result from excessive weight gain. It's also been observed that children with this condition may experience learning and memory deficits, and have low IQ scores." This in itself is an eye opener and highlights the need for sleep therapy initiatives in the country, considering a huge percentage of our population is already suffering from it. The occurrence of OSA is relatively high in certain parts of the population across Asia, partly fuelled by a sedentary lifestyle.

"The situation in India is no different from that in USA. Although there are not many large epidemiological studies available, but from whatever data is available, the incidence in the urban population ranges from 2.5 to 20 per cent of the general population. It is more common in males than females," shares Dr Vivek Nangia, Director-Pulmonology, Fortis Ft Lt Rajan Dhall Hospital, Delhi. It is estimated that in India, for example, close to four per cent of the adult population suffers from moderate to severe OSA, with only a fraction being diagnosed.

A study suggests that 93 per cent of urban Indians are deprived of sleep and 62 per cent display high risk of OSA. Lack of sleep not only impacts the overall quality of life and productivity of a person's life but also leads to serious health issues such as increased risk of diabetes, weight gain, high blood pressure and irregular heart beat. According to industry estimates, the number of sleep apnea patients in the country could be somewhere between 40 million to 70 million.

Winds of Change

Penetration of home care ventilators in India for treating sleep and related respiratory disorders, is still in its infancy due to lack of awareness and low insurance coverage among other reasons. However, the mindset of urban Indian patients is changing from treating illness to managing wellness, point out experts. "The market is expected to gradually pick up for the next one to two years and is estimated to grow at an average growth rate of 12-15 per cent in the next five years down the line," states Swarna Sundar, Industry Analyst-South Asia and Middle East, Healthcare, Frost & Sullivan.

Increasing awareness amongst the specialist for the OSA-due to efforts taken by companies and hospitals, increase in insurance coverage (both private and Government)-even though only 10 per cent of the Indian population today has health insurance coverage, has given impetus to this market segment. Health insurance coverage among urban, middle and upper class Indians, however, is significantly higher and stands at approximately 50 per cent. Several private players have entered into the market, and trade pundits are expecting good growth prospects of this segment over the next five to 10 years as a result of it.

Eyeing the Opportunity

"Sleep lab is important for diagnostic purposes, as it is crucial to diagnose whether there are any sleep abnormalities in the patient" - Dr Sushil T Jain Department of Pulmonary Medicine Kokilaben Dhirubhai Ambani Hospital

"Patients find it difficult to accept that they have a serious medical problem if they are snoring loudly" - Dr Vivek Nangia Director-Pulmonology Fortis Ft Lt Rajan Dhall Hospital

Currently, the country has around 100 sleep labs. Moreover, with increasing awareness about sleep disorders, more and more hospitals are now looking at setting up sleep labs. Philips Respironics and Resmed are the major players in this market. GE is also coming up with its Breas Vivo product lines. Other companies include Datex, Euromedical, Nidek and Viasys. Philips plans to set up another 100 sleep labs by the end of the calendar year 2010. The company has assisted in establishing 30 sleep labs till the end of 2009. It has partnered with Gurgaon-based Medicity, branches of Fortis, R&R and Mumbai-based Hinduja and Seven Hills, among others. "Philips India is assisting leading hospitals and clinics in establishing sleep labs by providing sleep lab equipment such as the ALICE 5 and ALICE PDX for clinical training to physicians and specialists. The equipment will also be used for training on software diagnosis and reporting to general practitioners and technicians," shares Anjan Bose, Vice President and Business Head, Philips Healthcare, India, Bangladesh, Sri Lanka and Nepal. The diagnosis and treatment will be done using Philips devices such as Cflex AutoCPAP with Aflex, BIPAP with Biflex and BIPAP autoSV. The major hurdles in sleep medicine practice is the limitation of diagnostic devices, proper training of the software on analysis and reporting for sleep physicians and technicians; and awareness. Philips has also provided training on sleep diagnosis for technicians and physicians of some of these hospitals.

Over the counter products are also being offered by Pharma firms. Modi Omega Pharma, recently entered the sleep market by launching an anti-snoring spray. Modi Omega Pharma is a 50:50 venture company of Modi Mundi Pharma and a European Pharma company called Omega Pharma.

Now and Then

If Indians are this sleep deprived, what has kept this segment relatively unexplored hitherto? Experts blame it on the lack of awareness among general population as well as doctors. "In the last few years, many new sleep laboratories have been established in India in various cities. However, the awareness among the general public and general practitioners about sleep disorders and available treatments is poor," states Dr Padma Sundaram, Consultant Pulmonologist, Respiratory Medicine Department, Manipal Hospital, Bangaluru.

The cost of treatments has also played a role in creating this inertia. Experts believe that the cost of getting sleep study done and the even more expensive sleep therapy is out of reach for average Indians. Many insurance companies do not reimburse the same. Lack of seriousness about sleep disorders among patients is another reason that kept them away from approaching doctors. "Patients find it difficult to accept that they have a serious medical problem if they are snoring loudly," opines Dr Nangia. Sleep disorder was also given the short shift by the medical community. According to Dr Zarir Udwadia, Consultant- Pulmonology Department, Hinduja Hospital, Mumbai, OSA is one of the most under recognised diseases and it is estimated that 80 per cent of patients with it have not yet been given the right label. The less number of sleep labs, restricted mainly to only tier I cities and availability of few specialists trained in sleep medicine are the other prominent reasons. Says Dr Avdhesh Bansal, Senior Consultant, Respiratory and Sleep Medicine, Indraprastha Apollo Hospitals, New Delhi, "Inability to suspect and diagnose the problem, inability to read sleep study, lack of training of sleep studies in medical colleges and non-availability of trained of sleep technicians are the major reasons which have kept hospitals away from entering this segment."

Future Course

With all the signs of sleep disorders and therapy segment getting increasingly approachable, it is believed that awareness will further widen its growth trajectory. Says Swarna Sundar, "If companies effectively communicate the benefits i.e. possibility of regular monitoring, greater prevention, higher convenience, cost-effectiveness, lesser chances of getting hospital-acquired infections, etc, they will be able to create value in the minds of the customers." With efforts taken by OEMs and hospitals in rising awareness of sleep disorders, more people are expected to undergo tests to understand the basics of their sleep disorder condition. The sleep therapy market in India is still at a nascent stage; however, the promise of a sound sleep is creating a huge market for the medical industry in India.

Treatment and Cost

According to International Classification of Sleep Disorders (ICSD), there are over 90 plus sleep disorders that exist. The gold standard therapy for a sleep related breathing disorder is the use of CPAP devices which come in two types-mechanical and automatic. They deliver air under pressure to keep the airways splinted. The newer devices available deliver different pressures during different phases of respiration which makes them even more comfortable for the patients and improves patient compliance. Recently, newer generation of CPAP machines called 'Smart CPAP' and drugs to combat daytime sleepiness like Modafenil have been introduced in the market. One of the biggest challenges is the acceptance of use of external device like CPAP with mask/interface. Though this is a gold standard form of treatment, but faces a major patient drop out in the initial phases. Besides the use of CPAP, depending upon the individual assessment, surgical correction of the upper airways and use of oral appliances can be considered. "A particular medication is used as an adjunctive therapy in patients with OSA who complain of persistent daytime sleepiness, despite CPAP use and in whom good compliance with optimal levels of CPAP has been checked objectively," shares Dr Vivek Nangia, Director-Pulmonology, Fortis Ft Lt Rajan Dhall Hospital, Delhi. The sleep labs offer OSA patients and others with sleeping disorders, the means to evaluate their sleeping patterns and to diagnose their sleep disorders. "Sleep lab is important for diagnostic purposes, as it is very important to diagnose whether there are any sleep abnormalities in the patient. Without that we can't go further with the management," opines Dr Sushil T Jain, Department of Pulmonary Medicine, Kokilaben Dhirubhai Ambani Hospital, Mumbai. A simple study known as polysomnogram or PSG is conducted on a patient in a lab setting and is painless. A sleep lab generally contains a complete diagnostic system. Shares Dr Manvir Bhatia, Honorary Senior Consultant, Department of Sleep Medicine, Sir Ganga Ram Hospital, New Delhi, "What we should ideally have is comprehensive sleep centers, because it is not any one type of a sleep disorder, you should be able to recognise the disorder and give appropriate treatment." Timely treatment of sleep disorders prevents several complications like sudden death, heart attacks, congestive heart failure and brain strokes to name a few. Cost of treatment at a sleep lab ranges from Rs 4,000 to Rs 15,000, depending up on the type of diagnostic study. CPAP machine cost ranges from 30,000 to a lakh, depending upon the type of machine- i.e. automatic, bi-level, and single level.

sonal.shukla@expressindia.com