Helmy Haja Mydin
Death is not the only bad outcome for those who contract COVID-19. Although there is a tendency to focus on the daily total numbers and the number of deaths, these figures do not paint the entire picture.
There are many other consequences of the pandemic that are not made readily apparent by the daily statistics. One example is the impact of hospitals filled up with COVID-19 cases on the management and outcome of other diseases. Each occupied bed displaces another case, just as each case reviewed by a doctor takes away time from another case. This has implications on the manner and timing in which other conditions are diagnosed and treated.
Although the vast majority of patients infected with the SARS-CoV-2 virus remain thankfully asymptomatic, those who do develop symptoms and survive do not always get away Scot-free.
The level of severity and risk of complications from COVID-19 are higher in the elderly and those with comorbidities such as diabetes, kidney disease, heart failure, cancer and obesity. Symptoms related to COVID-19 manifest in different ways, and the duration differs between individuals. These do not always correlate with the level of severity or presence of complications.
Prolonged symptoms that persist beyond 12 weeks of the start of the disease are part of the so-called Long-COVID-19 Syndrome, which is more common amongst those with complicated or severe illness. They can be classified into a number of subgroups:
Respiratory - breathlessness, coughing and need for supplemental oxygen. Symptoms and impact on the quality of life are higher in those who have significant damage to the lung tissue especially scarring of the lungs (fibrosis).
Mental Health - anxiety, depression, sleep disturbances, post-traumatic stress disorder, headaches and a disturbance or slowing down cognitive function (known as ‘brain fog’)
Cardiac - palpitations, chest pain
Miscellaneous - fatigue, muscle ache, generalised weakness, joint ache, hair loss.
Studies from China, the United States and Europe have shown that the most common symptoms are breathlessness, fatigue and anxiety/depression. A study in Italy found that 87.4% of patients discharged from hospital who recovered from COVID-19 still had symptoms at day 60. More than 50% complained of fatigue, approximately 40% had breathlessness and 44.1% felt that they had a decline in their quality of life.
A study published in the latest edition of the journal The Lancet Psychiatry found that one in three COVID-19 survivors was diagnosed with a neurological or psychiatric ailment within six months of infection with the SARS-CoV-2 virus. The study, which looked at 230 000 patient health records, identified the most common mental health conditions as anxiety disorders, mood disorders (such as depression), substance misuse disorders and insomnia. The neurological conditions included diagnoses such as strokes and dementia.
As symptoms present themselves in a variety of ways, it is only logical that long-term care is ideally handled by a multidisciplinary team that not only assesses and manages the physical aspects of rehabilitation, but the mental health aspects as well. Besides doctors, there is a need to rope in psychiatrists, psychologists, physiotherapists and occupational therapists.
Besides specifically addressing the above, nutritional and rehabilitation needs must be taken into account and appropriate intervention introduced early. All long-term COVID-19 follow-up studies have noted significant declines in quality of life and function. Severe COVID-19 can cause muscle wasting and feeding difficulties, which when combined with malnutrition can worsen both physical and psychological outcomes.
Globally, there are increasing numbers of patient advocacy and support groups. Many of these are on social media platforms such as Facebook. They provide a space for patients to share their struggles, which may prove to be cathartic. For some, it is an avenue to learn from the experiences of others and to be more aware of the stories behind the numbers.
Healthcare workers need to remind themselves that care does not conclude at discharge. From a management perspective, we must proactively identify those at higher risk of long-term complications, and to screen for the conditions listed above, especially mental health. These can be done in person, or with increasingly available telemedicine tools.
As we see the number of active cases go up, it is inevitable that we will have more patients with long COVID-19 syndrome. Policymakers will need to provide the necessary funding as services will need to be rejigged in anticipation of increasing needs.
The public has a more important role - we are at the frontline of the disease, and many of us need to be less nonchalant regarding the ongoing risks of the SARS-CoV-2 virus. The more cases there are, the more complications there will be. It is imperative that we continue to adhere to the SOPs in place, especially the use of masks, physical distancing and avoiding closed, crowded and poorly ventilated areas.
Last but not least, we must take advantage of the blessing that we have in the form of COVID-19 vaccines. Many countries are still without access, and as we increase momentum in Phase 2 of the national vaccination programme, it is worth reminding ourselves that this modern miracle of science has been proven time and again to decrease the incidence of severe COVID-19 disease.
Dr Helmy Haja Mydin is a respiratory physician and the head of the Lung Centre at Pantai Hospital Kuala Lumpur.
This article was originally published in The Star Online.