It has been 2 years since the discovery of the SARS CoV2 virus.. As of mid December 2021, the ensuing pandemic has already infected more than 270 million persons globally and more than 5.3 million persons have perished. Rapid scientific progress has resulted in effective vaccines for prevention and numerous treatment modalities. Effective implementation of these interventions have reduced the health and socioeconomic impact of COVID19 infection. Just as we thought that the delta variant has been take care of, the new Omicron variant first isolated in South Africa, has emerged in November 2021 and caused many authorities to pause and re-consider opening their borders to international travel. Clearly, we will be dealing with SARS CoV2 for some time to come.
In Singapore, most vaccinated (up to aged 79 years) and some unvaccinated (up to 59 years) COVID-19 patients are eligible for home recovery and expected to have a good outcome. There may be mild symptoms but that would not usually require hospitalization. In the face of continuous deterioration, the patients or their relatives must access the MOH Hotline as inpatient care may be required. Timely hospitalization will also allow the use of effective monoclonal antibody treatment and anti-viral therapy to prevent further deterioration of COVID-19 infected patients. Detailed information is available at covid.gov.sg. In the region, similar protocols are present or in development in the respective national healthcare systems to aid the acute recovery process.
It has also become apparent since early 2020 that some of the survivors of COVID19 continue to have ongoing or develop new symptoms beyond their initial illness. “Long COVID” is the umbrella term for the symptoms that extend beyond the first 28 days of illness. Many publications including self reported surveys have used varying case definitions and used different sampling frames that have resulted in wide variation in the prevalence of Long COVID. There has also been greater recognition that “Long COVID” is not just slow recovery from organ damage sustained during the acute illness but also other pathological processes.
In a scoping review of “Long COVID”; persistent symptoms numbered more than 100. Long COVID is a multi-system disease that affects multiple organs in varying degrees and varying severity and in different patient populations. In a local study by Ong et al, 10% of recovered patients had ongoing symptoms 6 months after the initial infection. In these patients, immune cytokine signatures indicate ongoing chronic inflammation and angiogenesis. In another study, patients who were admitted for COVID19 infection in 2020, were 3.5 times more likely to be re-admitted for other medical conditions and they were 7.7 times more likely to die within 5 months of diagnosis. Following hospital discharge from COVID19 infection, survivors were more likely be prescribed analgesics, anti-depressants, anti-hypertensive agents and diabetic medications. Almost 1/3 had ongoing neurological or psychiatric diagnoses. The non-linear progression of Long COVID suggests that a variety of mechanisms are involved and these include:
- Ongoing chronic inflammation
- Specific organ damage from COVID19 infection
- Non-specific effects of hospitalization/ICU syndromes
- Effects of social isolation
Our COVID19 Recovery Services encompasses a whole patient perspective that is comprehensive and tailored to the needs of the individual patient. Early in the disease, we offer insights into the trajectory of care for each individual patient and advise for home or hospital recovery. Even when these patients are admitted, we remain available to provide a second opinion in certain difficult situations. After recovery, patients with residual symptoms or long COVID may continue their recovery with us. While we have a multi-disciplinary approach, we do not intend to have each patient to be seen by multiple medical specialists to cater to every organ system that may be affected. Based on numerous published studies, the impact of long COVID may be broadly divided into the following areas:
- Pulmonary sequelae including chronic cough and breathlessness
- Neurologic disorders including neurocognitive impairment
- Mental health issues including general anxiety, sleep disorders, depression
- Functional mobility including mobility decline
- General/ constitutional including flu like symptoms, fatigue, generalised pain and weakness
Without a unified multi-disciplinary COVID19 Recovery pathway such as ours, affected patients may access a number of specialists and come away without a definitive diagnosis.
We are able to utilise both teleconsultation and on-site clinic consultations for evaluation and treatment of Long COVID. For pulmonary and other forms of physical rehabilitation, we can arrange both home and on-site physiotherapy.
There are still numerous gaps in our knowledge on long COVID and it is an evolving field. In Singapore, we have around 270,000 cases by mid December 2021. We need to look into the long term health consequences and intervene early to reduce morbidity and mortality for our COVID19 survivors.