Topic: Role of Radiology in COVID-19 management. The challenges faced, the solutions offered & what we learnt !!

Speaker: Dr Abhishek Bansal, Consultant, Dept. of Radiology & Interventional Oncology, Rajiv Gandhi Cancer Institute & Research Centre, New Delhi

June 4, 2022, Saturday; 9.30-11           

• On 31^st December 2019, Covid-19 was reported to WHO China office. On 30^th January, 2020, a public health emergency was declared and on the same day, India reported its first case of Covid-19 in Kerala. On 11^th March, 2020, WHO declared the outbreak as a pandemic.
• ACE2 is a functional reservoir for SARS-CoV-2. ACE2 is highly expressed in pulmonary epithelial cells.
• The global outbreak disrupted the steady world of healthcare and a vast proportion of healthcare resources were dedicated to the pandemic.
• The main challenge was the diversity of the virus. We didn’t know how to manage these patients. 
• The guidelines kept on changing. Many existing drugs were tried including plasma therapy. There is conflicting data about plasma therapy. It was realized that collaboration of multi-specialty clinical teams improves patient outcomes.
• Compared to the previous viral pandemics, for the first time, radiology was taking an active interest in diagnosing and also in managing these patients.
• There was a tsunami of Covid-19 publications even in radiology journals.
• There was a huge demand for chest CT scans as aid to diagnosis of Covid-19 as there was a long waiting time for RT PCR.
• A human challenge vaccine trial was going on to look for a reliable vaccine. Then came the news about Covid dogs – medical sniffer dogs who could detect the infection. The UK government sanctioned 500,000 pounds on this.
• There was a sudden huge workload on radiology services as the number of chest CT scans in a day rose sharply.
• Lot of awareness had to be created to reduce the panic. There was a simultaneous impact on the economy.
• There was limited manpower and resources in the radiology departments. The scanners had to be sanitized after each scan.
• At RGCI, there was overall a 61.7% decline in workload between April 20`9 and April 2020. A drastic drop was seen in mammography (89% drop) and interventional radiology (27% drop).
• It was then scary not just for the patients, but for the families of healthcare staff as well. Even now the pandemic is not over. Cases keep on coming and going but cases now do not have a serious presentation as seen previously.
• The total number of cases is around 4.32 crore and total deaths are 5.25 lakhs.
• Vaccination changed the course of the pandemic. 64.5% of population in India is fully vaccinated. Globally, 60.7% is fully vaccinated.
• Chest x-ray was the first imaging modality and was useful in serial monitoring of the patients. In acute infection, unilateral/bilateral basal consolidation with hazy opacification was seen on chest x-ray.
• CT scan has been the workhorse. Covid has highlighted the importance of CT amongst radiologists and also among the general physicians and the public. It changed how Covid was managed by informing the early features as well as the worse prognostic features so that these patients could be managed early.
• The typical CT findings in Covid-19 are peripherally distributed multifocal ground glass opacities (GGOs) with lower lobe predilection. Increasing numbers, extent and density of GGOs on CT indicate disease progression. Thin-slice chest CT plays a vital role.
• USG was useful for bedside evaluation of pleural effusion. MRI was less useful and more time-consuming.
• It was difficult to manage cancer patients especially the hematological malignancy patients. Timely diagnosis and timely intervention are crucial to managing such patients.
• The Fleischner Society guideline says that look for pre-test probability. If there is moderate to high pre-test probability and there are risk factors for progression, then imaging is indicated. If there is worsening of respiratory symptoms, then again imaging is indicated. But CT scan is not a substitute for RT PCR. 
• In long Covid cases, the patches are seen to persist on CT scan. Fibrotic strands, some interstitial thickening and some nodules are also seen.
• Omicron cases usually did not undergo a CT scan, but those patients who had severe symptoms had a CT Scan done and GGOs were still present.
• CT findings have always positively correlated with clinical findings.
• If d-dimers are very high and there is a high risk of PE, then not just HRCT but a contrast CT is advised to look for PE.
• In a patient with moderate to severe symptoms, a CT scan would tell about the severity of the disease and serve to guide the treatment.
• Covid changed how the radiology department functioned. Covid screening clinics were outside the hospital; Covid test was necessary before interventional radiology; the entire CT room was sanitized after each CT scan. All precautions were taken such as staff wearing PPE kits. The timings were staggered, there were two teams on alternate days, minimal handling of the patient, working from home. Now there is lot of gap between reporting stations. 
• Physical academic meetings were a complete ‘no’. Social distancing introduced us to the world of webinars. This was something new to us, but is here to stay. It brought people across the globe much closer to each other than before.
• India had a mobile app (Arogya Setu) for Bluetooth and GPS tracking.
• The pandemic has taught us that we have to be ready for the next variant/peak/pandemic. Covid-19 cannot be taken lightly yet.
• Along with lab upgradation, radiology infrastructure also needs to be upgraded. Most hospitals now have their own CT scanners and have integrated radiology as part of their routine clinical work. The existing upgraded radiological infrastructure has to be maintained.
• Radiological services play an important role in the multidisciplinary management of Covid-19 or other pandemics that may strike the human race. There have to be adequate training opportunities and telemedicine is going to stay at least for follow-ups.
• The way forward is to continue with the vaccination drive to cover the whole world and invest in healthcare suitably. Adequately sized hospitals should have full fledged radiology departments. Covid appropriate behavior should stay with us.
• Chest imaging should be used cautiously. It is not indicated in suspected Covid-19 and mild clinical features unless patients are at risk for disease progression. Imaging is indicated in Covid-19 and worsening symptoms.
• In resource-constrained environment, imaging is indicated for medical triage of patients with suspected Covid-19 who present with moderate-severe clinical features.
• Rural areas have poor penetration of healthcare facilities as well as diagnostic radiological facilities. Without radiology it becomes difficult to diagnose and prognosticate these patients.
• Radiologists were also treating these patients, not directly, but indirectly by managing conditions that arose because of it such as pleural fluid aspiration, pericardiocentesis, management of pulmonary embolism, catheter thrombolysis, embolization, IVC filter placements, etc. Percutaneous jejunostomy under LA was another procedure done during the peak when surgeons/anesthetists were not available and oxygen was in short supply. 
• The biggest problem during the delta peak was a dedicated oxygen supply. All elective surgeries were postponed. Radiology was playing a supportive role in the management of these patients.
• Modern day CT scanners are so optimally built that the radiation is very trivial. 
• In a chest CT scan, the radiation dose varies from 2-3 milliSievert (mSv); in contrast CT scan, it is 10mSv. In HRCT, the dose is 3mSv. This is the average amount of radiation that a person receives from the cosmic world in a single year, though this varies in a range depending on geographical location. With this dose, side effects are not anticipated but the impact will be known only in few years. Follow up is important.
• The risk has to be weighed against the benefits. But there should be no unnecessary CT scans.
• Radiologists work on the principle of ALARA i.e., as low as reasonably achievable.
• In a shift from the earlier “no threshold theory” where any amount of radiation was harmful, a new developing “threshold theory” is being debated, which suggests that small radiation doses (≤50mSv) are not harmful.

Participants

Member National Medical Associations

Dr Yeh Woei Chong, Singapore, Chair CMAAO

Dr Alvin Yee-Shing Chan, Hong Kong, Treasurer, CMAAO

Dr Marthanda Pillai, India Member World Medical Council, Advisor CMAAO

Dr Ravi Naidu, Malaysia

Dr Akhtar Hussain, South Africa

Dr Qaiser Sajjad, Pakistan 

Dr Mvuyisi Mzukwa, South Africa

Dr Md Jamaluddin Chowdhury, Bangladesh 

Invitees

Dr Russell D’Souza, Australia UNESCO Chair in Bioethics

Dr Monica Vasudev, USA

Dr Abhishek Bansal

Dr Arvind Chaturvedi

Dr Anil Bansal

Dr Varun Sehrawat

Dr PK Tiwari

Dr PC Pahwa

Dr Yeo Khoon Hui

Dr Carol Lim

Dr EC Ng

Dr Rajiv Gupta

Dr Brij Bajaj

Dr Rajesh G Parthsarthi

Moderator

Mr Saurabh Aggarwal