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Tb guidelines during covid 2 and a short note on long covid

  1. Tuberculosis guidelines during Covid -19 Epidemic in the time of Pandemic Dr Ajay Shankar, JR, Respiratory medicine, MMIMSR
  2. Progress till lockdown • Millenium development goals to Sustainable Development Goal • End TB by 2025- 5yrs ahead of SDG • Programme renamed as NTEP • Active screening • Public private partership • Rapid increase in TB Notifications • “Missing million TB cases” 24 lakh cases of 27lakh TB cases notified in 2019
  3. Covid-19 will set fight against TB back by at least 5 years • Imminent disaster of Pandemic VS Long running Palgue
  4. Challenges and stratergies to manage TB during Covid-19 • Diagnosis of new active cases- 78% drop during lockdown • OP setting challenges • Community TB challenges • Contact tracing applications • Monitoring and supply of ATT • Covid 19 testing and TB
  5. Challenges contd.. • Covid -19 and TB disease • Lockdown effects during covid-19 Pandemic • PPE concerns • Personal safety of HCW’s • Effect on TB immunization program • Economic consequence of Covid-19 Pandemic
  6. COVID-19. Tuberculosis
  7. Tuberculosis in the era of COVID-19 in India Vijay Kumar Jain a, *, Karthikeyan P. Iyengar b, David Ananth Samy b, Raju Vaishya c
  8. Covid -19 And TB disease • Early evidence suggest pateints with latent TB and established disease have an increased risk of SARS-CoV 2 infection and predisposition to develop severe Covid-19 pneumonia • Prevelance of Tb among Covid found to be 0.37 -4.47% in different studies
  9. Concurrent infection of SARS CoV and TB • Worser Prognosis • 2.1 fold increased risk of severe COVID-19 Disease • Prexisting lung damage • If clinical picture Atypical test for both • Special care to High risk patients- HIV, DM, Malnutrition
  10. Guidance Note on Bi-Directional TB-COVID Screening of TB among ILI/SARI cases • A- Bi-Directional TB-COVID Screening • B- TB Screening for ILI cases • C- TB Screening for SARI cases
  11. Bi- Directinal TB-Covid Screening • For Diagnosed TB Patients • All newly diagnosed and on treatment should be tested
  12. • TB Screening for Covid Positive Patients • 4-Symptom Complex • Cough > 2 weeks • Fever greater than two weeks • Significant unexplained Weight loss • Night Sweats • History of contact with TB Patient • History of Tb and Symptomatic
  13. Intensive management of TB-COVID co-morbid patients • Link TB service faciities with COVID Isolation facilities • Covid Screening updated in NIkshay Portal
  14. TB Screening For ILI cases • ILI with 4 symptom complex • History of contact with TB • History of TB • ILI symptoms > 10 days
  15. Diagnostic Algorithm
  16. TB screening for SARI case • SARI with 4 symptom complex • History of Contact with TB case • History of SARI symptoms > 10 days
  17. Diagnostic Algorithm for SARI case
  18. Rapid response Plan sept 2020 • Bidirectional TB-COVID screening • Restore diagnostic facility diverted for covid • Introduce lung health concept • Replace smear microscopy by NAAT testing • Home sample collection in Red zones • Infection control, cough etiquette, mask use
  19. Contd.. • Contact tracing and area mapping • Migrant Stratergy • Private sector involvement- IMA, IAP, ICS, FOGSI- professional medical bodies informed about mandatory notification , free drugs and diagnosis. • Modified DOT- TB SAMPARK, tele consultation • Monthly supply of TB drugs with option of home delivery
  20. Contd.. • Use Isolation facilty for DSTB DRTB • Airborne infection control in OPD’s and IPDs • Triaging at entry points • TB ID cards for better mobility • Single window system
  21. *Covid-19 *Tuberculosis
  22. Conclusion • Global health is not a Zero-sum Game, we need to urgently tackle the coronavirus pandemic and simultaneously deal with other existing health priorities, we don’t need to pick one. • Now that we have witnessed how easily one infectious killer can affect millions, we should realize that TB is and will always be a major problem for us all. • The very same urgency and actions we are taking against covid -19 are needed against TB.
  23. Long Covid • The Battle ahead
  24. Long Covid • Currently no delineated consensus definition for the condition • Long covid • Post-covid syndrome • Post acute COVID-19 syndrome • Long haulers
  25. NICE Definition • Presence of signs and symptoms that develop during od following an Infection consistent with Covid -19 which continues for 12 weeks or more and are not explained by an alternate diagnosis. • This includes both ongoing symptomatic covid-19 (4-12wks) and post Covid syndrome (12 weeks or more)
  26. hashtag disease The Tweet that started it
  27. Key literatures • Huang, Jan 2021, cohoty study. 6month consequence • Chopra, Nov 2020, Observational cohort, 60 days outcome • Carvalho Schneider, Oct 2020, non critical COVID 19 follow up after 2months • Carfi, July 2020, persistent symptoms in acute covid • Halpin, July 2020, cross sectional study, post discharge symptoms and rehabilitation needs • Tenforde, July 2020, telephone interview study, delayed return to usual health
  28. 6-month consequences of COVID-19 in patients discharged from hospital: a cohort study (Huang, January 2021). Overall, in this large cohort study of 1,733 patients with COVID-19 assessed 6 months after discharge, most patients exhibited at least one symptom, particularly fatigue or muscle weakness, sleep difficulties, and anxiety or depression. More severely ill patients had increased risk of pulmonary diffusion abnormality, fatigue or muscle weakness, and anxiety or depression. The seropositivity and titers of the neutralizing antibodies were significantly lower than at acute phase.
  29. Sixty-Day Outcomes Among Patients Hospitalized With COVID-19 (Chopra, November 2020). • Overall, in this observational cohort of patients hospitalized with COVID-19 in Michigan, nearly 1 in 3 patients died during hospitalization or within 60 days of discharge. For most patients who survived, ongoing morbidity, including the inability to return to normal activities, physical and emotional symptoms, and financial loss, was common, confirming that the toll of COVID-19 extends well beyond hospitalization.
  30. Follow-up of adults with non-critical COVID-19 two months after symptoms' onset (Carvalho- Schneider, October 2020). • Overall, in this descriptive clinical follow-up study of 150 non-critical patients with COVID-19, two-thirds of adults experienced persistent symptoms up to 2 months after symptom onset, primarily anosmia/ageusia, dyspnea or asthenia.
  31. Post-discharge persistent symptoms and health-related quality of life after hospitalization for COVID-19 (Garrigues, August 2020). • Overall, in this study of patients with COVID-19 discharged from the hospital and interviewed over 3 months post diagnosis, the majority of patients experienced continued symptoms, most commonly including fatigue and dyspnea.
  32. Persistent symptoms in patients after acute COVID-19 (Carfi, July 2020). Patient population: • Overall, in this study of patients with COVID-19 discharged from the hospital with SARS-CoV-2 RNA clearance by RT-PCR and interviewed approximately 2 months after diagnosis, the majority of patients experienced continued symptoms, with the most common symptoms being fatigue and dyspnea.
  33. Post-discharge symptoms and rehabilitation needs in survivors of COVID-19 infection: A cross-sectional evaluation (Halpin, July 2020). • Overall, in this study of patients with COVID-19 discharged from the hospital at least 4 weeks prior to study enrollment, the majority of patients experienced continued symptoms, with the most common symptoms being fatigue and dyspnea.
  34. Symptom duration and risk factors for delayed return to usual health among outpatients with COVID-19 in a multi-state health care systems network — United States, March–June 2020 (Tenforde, July 2020). • Overall, in this study of patients who were diagnosed with COVID-19 in the outpatient setting, primarily had mild disease and were interviewed a median of 16 days post diagnosis, the majority had continued symptoms. The most common symptoms included cough and fatigue.
  35. National Institute for Health Research (NIHR) suggests that Long Covid may be made up of 4 phenotypes •Post-intensive care •Post-viral fatigue •Permanent organ damage •Long-term COVID
  36. Long COVID Symptoms Long COVID can include a range of different signs and symptoms across body systems including, but not limited to: pulmonary, cardiovascular, gastrointestinal, reproductive, genitourinary, endocrine, renal, dermatologic, musculoskeletal, neurological, neuropsychiatric, immunological, ophthalmic, and audiological.
  37. Respiratory and Cardiovascular symptoms • Breathlessness • Cough • Chest tightness • Chest pain • Palpitations
  38. Generalised symptoms • Fatigue • Fever • Pain
  39. Neurological symptoms • Cognitive impairment ('brain fog', loss of concentration or memory issues) • Headache • Sleep disturbance • Peripheral neuropathy symptoms (pins and needles and numbness) • Dizziness • Delirium (in older populations)
  40. Gastrointestinal symptoms • Abdominal pain • Nausea • Diarrhoea • Anorexia and reduced appetite (in older populations) Dermatological • Skin rashes
  41. Musculoskeletal symptoms • Joint pain • Muscle pain Psychological/psychiatric symptoms • Symptoms of depression • Symptoms of anxiety
  42. Ear, nose and throat symptoms • Tinnitus • Earache • Sore throat • Dizziness • Loss of taste and/or smell
  43. Pathological Process • Viral persistence • Continued hyperactive immune response • Cellular metabolic dysfunction • Auto antibodies • Neurological dysfunction • Neuroimmunology • Organ Impairment- Cardiac Impairment.
  44. Mast Cell Activation Syndrome • The prevalence of MCAS is similar to that of severe cases within the Covid-19-infected population. Much of Covid-19's hyperinflammation is concordant with manners of inflammation which MC activation can drive. Drugs with activity against MCs or their mediators have preliminarily been observed to be helpful in Covid-19 patients. • Hyperinflammatory cytokine storms in many severely symptomatic Covid-19 patients may be rooted in an atypical response to SARS-CoV-2 by the dysfunctional MCs of MCAS rather than a normal response by normal MCs. If proven, this theory has significant therapeutic and prognostic implications.
  45. Management of Long Covid • Management of covid-19 after the first three weeks is currently based on limited evidence • Approximately 10% of people experience prolonged illness after covid-19 • Many such patients recover spontaneously (if slowly) with holistic support, rest, symptomatic treatment, and gradual increase in activity • Home pulse oximetry can be helpful in monitoring breathlessness • Indications for specialist assessment include clinical concern along with respiratory, cardiac, or neurological symptoms that are new, persistent, or progressive
  46. 4 point management of MCAS ➢Diet ➢Supplements ➢Anti Histamines ➢Mast Cell Stabilizers
  47. Diet • Low Histamine Diet • Preserved meats such as smoked or cured meat, aged cheeses, fermented foods, and alcohol. Cocoa, certain nuts, avocado, banana, shellfish, tomatoes, citrus fruits, legumes, and strawberries are other foods high in naturally-occurring histamines. • In general, avoid packaged or canned products and turn to fresh foods. Histamine levels in foods can increase as they age, so it’s always ideal to cook fresh food daily when you’re battling histamine.
  48. Supplements • Vitamin C • Vitamin D • Zinc • Niacin • Selenium • Manganese
  49. Anti histamines
  50. Mast Cell Stabilizers
  51. The ABCDEF of covid long care
  52. Thank You