29^th May, 2021, Saturday, 9.30 am-10.30 am

Participants: Member NMAs: Dr Yeh Woei Chong, Singapore Medical Association, Chair CMAAO, Dr Ravi Naidu, Malaysian Medical Association, Immediate Past President CMAAO, Dr Alvin Yee-Shing Chan, Hong Kong Medical Association, Treasurer, CMAAO, Dr Marthanda Pillai, India, Member World Medical Council, Dr Angelique Coetzee, President South African Medical Association, Dr Subramanian Muniandy, President Malaysian Medical Association, Dr Md Jamaluddin Chowdhury, Bangladesh Medical Association; Dr Qaiser Sajjad, Secretary General, Pakistan Medical Associatio; Dr Akhtar Husain, South African Medical Association

Invitees: Dr Russell D’Souza, Australia UNESCO Chair in Bioethics, Dr Shikha Gupta, USA, Dr Monica Vasudev, USA, Dr Rohit Aggarwal, USA, Dr Nidhi Aggarwal, USA, Dr S Sharma, Editor IJCP Group, Dr Meenakshi Soni Barnwal, HCFI

Moderator: Mr Saurabh Aggarwal

Key points from the discussion

#1. Post acute sequelae of SARS-COV2 (PASC)

Dr Shikha Gupta, Division of Pulmonary and Critical Care, Excela Health, PA

• Post-acute COVID 19 is persistence of symptoms or development of sequelae beyond 4 weeks of symptom onset of COVID-19, not attributable to alternate diagnoses. 
• Subacute Covid-19 is when patients have symptoms within 4-12 weeks of disease onset, while chronic Covid-19 is defined as symptoms beyond 12 weeks of disease onset.
• Several studies have looked into the epidemiology of Covid-19.
• An overall trend globally is that the numbers are declining.
• A study from Wuhan showed that even 6 months later, patients had at least one symptom.
• Risk factors: Laboratory (Elevated BUN, inflammatory markers [CRP, IL-6, D-dimer levels], lymphopenia (chest tightness), elevated troponin-I (fatigue).
• Patient characteristics: Females, history of anxiety or depression, obesity, age > 70 years and race (African-Americans, Asians and other minorities)
• Presence of ≥5 early symptoms is a risk factor; some studies have reported increased incidence if patient was in the ICU and had received non invasive or invasive mechanical ventilation.
• Seven major categories of symptoms have been identified: Major fatigue or exhaustion, neurological symptoms (neurocognitive, headaches, sensory, autonomic), cardiothoracic, muscular symptoms, ENT, GI and skin / vascular.
• About 10-20% patients require rehospitalization within 30-60 days post-discharge from hospital. Risk factors include age > 65 years, discharge to skilled nursing facilities (SNF), obesity and comorbidities (COPD, CHF, diabetes, CKD).
• In young healthy with mild disease and no hospitalization, no routine follow-up is needed unless symptoms persist.
• Older patients with comorbidities and mild disease and no hospitalization should be evaluated 3-4 weeks after onset of disease.
• Patients with severe disease, who needed hospitalization, should ideally be evaluated within 1 week, but no later than 2-3 weeks after discharge.
• If the symptoms persist beyond 12 weeks, the patient should be referred to COVID-19 recovery clinic.
• Evaluation of the patient includes detailed history and examination (current symptoms, comorbidities and medication history), examination of hospital records; superimposed infection should be ruled out.
• Basic lab investigations include: CBC, renal functions, liver functions, coagulation profile, BNP Tn, D-dimer, and thyroid profile.
• Other investigations include PFTs, HRCT chest, CT angio, EKG, Echo, neuroimaging (CT/MRI) and neuropsychological testing
• A multidisciplinary collaboration is essential for the care of these patients.
• Rehabilitation, both physical (gradually increase the exercise difficulty levels over 4-6 weeks) and behavioral modification and psychological support, has been shown to improve outcomes.
• Differential diagnosis of dyspnea >4 weeks after disease onset includes resolving pneumonia, organizing pneumonia, parenchymal lung abnormalities, lung fibrosis, myocarditis, CHF, neuromuscular weakness (in ICU patients). Evaluation modalities include PFTs, 6MWT, Chest x-ray, HRCT chest, CT chest angio, cardiac examination.
• Cough can be managed with supportive therapy/OTC cough syrups. Some patients can have post-viral asthmatic bronchitis, which can be managed with ICS/bronchodilators.
• Some patients have developed lung fibrosis. Traction bronchiolectasis may be a marker of early pulmonary fibrosis.
• Patients with documented venous thromboembolism need 3 months of anticoagulation. Post-discharge thromboprophylaxis is not routinely recommended. Thromboprophylaxis is not recommended for outpatients.
• Consider prophylaxis for patients with major risk factors such as history of VTE, recent major surgery or trauma.
• Chest pain could be due to bronchospasm; rule out myocarditis or pulmonary embolism.
• Autonomic dysfunction may manifest as unexplained tachycardia, dizziness, orthostatic hypotension; similar to postural tachycardia syndrome (POTS).
• There is the risk for superimposed infections due to prolonged use of steroids as well as immunomodulatory agents. Bacterial infections in catheterized patients or are on ventilator (ventilator associated pneumonia); other infections that may occur are mucormycosis and invasive pulmonary aspergillosis.
• There is a very high incidence of psychiatric problems such as anxiety, depression, PTSD as part of post-Covid-19.
• Some people have reported improvement in long Covid symptoms after vaccination.
• There are more questions than answers.

#2. Country Update

• Pakistan: The number of cases in the third wave is declining; reinfections are becoming common in vaccinated persons often leading to death. Vaccines in use are Sinopharm, Sinovac and AstraZeneca (for > 40 years age group).
• Bangladesh: The country is in lockdown, but it is not very strict. Border districts have a high positivity rate. Vaccination is ongoing with Sinopharm; Sputnik V will also be available soon. Almost 1.3 million people have not yet received their second dose of AstraZeneca-Oxford vaccine, which is of concern.
• India: The second wave is receding; from over 4 lakh cases per day, it has come down to 1.5 lakh cases per day. Variants have contributed to the rapid spread of the infection. Entire families are becoming infected. Infection duration is shorter, but infectivity is higher. Recovery is fast, but the mortality seems is very high. Pneumonia and thromboembolism are very sudden and there are instances where deaths have occurred in such cases. The chances of reinfection are only 0.6% after vaccination. Mucormycosis cases are occurring as a late complication and causes are multifactorial.
• South Africa: The numbers are increasing; there were 4576 cases in the last 24 hours. Deaths are around 100 per day. Vaccination is slow. Breakthrough infections are being reported.
• Hong Kong: Zero cases for the past week; people are still hesitant to take the vaccine. Only 15% of population has been vaccinated. There are various vaccine incentives to encourage people to take the vaccine.
• Australia: No cases in Melbourne for 83 days but, in the last 10 days, the variant from India has been found here. 35 cases have been detected. A week long lockdown has been instituted. Rest of Australia has no cases.
• Singapore: Four generations of spread from the Changi Airport cluster have been seen in just 9 days. The country is the second week of the mini lockdown; cases have come down to 2-3 per day. About 70,000 tests are done every day; the target is to get everyone vaccinated by August.