Covid 19 and its impacts in Asia

1. Professor AKM Akhtaruzzaman
Department of Anaesthesia, Analgesia and Intensive Care Medicine
Bangabandhu Sheikh Mujib Medical University
President, South Asian Regional Pain Society (SARPS)
email: akm.akhtaruzzaman@bsmmu.edu.bd
Long COVID and Pain: Asian Perspectives

2. Bangabandhu Sheikh Mujib Medical University
 Premier Medical Institution in
Bangladesh, established in 1998
 No of Beds- 1800 beds
 No of Department- 56
 No of teacher- 563
Ref: www.bsmmu.edu.bd

3. Learning
Objectives Spectrum of post COVID
conditions
01
Asian perspectives of long
haulers
02
Understanding of post COVID
pain
03

4. As of 08 September 2021, COVID 19 has infected 222
million people worldwide and number of deaths 46
million (worldometer).
Although the clinical presentation and disease severity
is portrayed differently among demographic and
geographical population, attention and policies are
focused towards the acute care throughout the world.
The medical facilities continued to be overwhelmed by
the COVID-19 pandemic which leads to -
Travelling
restrictions
Completely or
partly closure of
non-urgent
services
including pain
management
facilities
Nationwide
lockdowns
Reallocation
of health
resources

5. Developed Countries
 Prioritize and re-allocate resources
 Increase their capabilities to test and contact
tracing
 Maintain strict isolation and quarantine policy
 Enrich health care facilities
 Provide healthcare services digitally
 Development of drugs and vaccines
 Creating awareness and start vaccination
Effects:
 Reduction of new cases
 Decrease mortality and morbidity
 Reorganization of health care settings
 Provision of non-emergency services
 Develop guidelines to assess and manage long
COVID and its consequences

6. Low and middle resource countries
Cause
• Fail to increase testing capabilities
• Unable to maintain strict isolation and quarantine policy
• Have limited health care resources and poor infrastructures
• Unable to apply modern technologies
• Fail to vaccinate the people at a pace with developed
countries
• Appearance of new variants with high virulence like Delta
variant
Effect
• Rapid increase of new cases
• Increase mortality and morbidity
• Breakdown of health care services
• Focused only to acute outcome
• Unable to provide non-emergency services
• Less attention to long haulers and its consequences

7. Lessons from Previous Epidemics
2012
Middle-East
Respiratory Virus 2013-
Western African Ebola
Virus
2013-19
Avian Influenza Virus,
H7N9
2015-16
Zikah Virus
Reported first at Africa,
prevalent in South East Asia,
2018 in Bangladesh
2013-19
Chikungunya
.
2019
COVID-19 Pandemic

8. Post Viral Syndrome
Lorem ipsum
In libris graecis appetere mea.
At vim odio lorem omnes, pri
id iuvaret partiendo. Vivendo
menandri et sed. Lorem
volumus blandit cu has.Sit cu
alia porro fuisset.
Ea pro natum invidunt
repudiandae, his et facilisis
vituperatoribus. Mei eu ubique
altera senserit, consul eripuit
accusata has ne. Ignota
verterem te nam, eu cibo
causae menandri vim. Sit
rebum erant dolorem et, sed
odio error ad.Vel molestie
corrumpit deterruisset ad,
mollis ceteros ad sea.
Relationship with chronic post covid syndrome

9. • Fatigue
• Diffuse myalgia
• Depression
• Non-restorative sleep
• Fever
• Headache
• Myalgia
• Fatigue
• Loss of appetite
• organ-specific
symptoms.
Acute viral illnesses
Chronic
post-SARS
syndrome
• Pain
• Fatigue
• Memory difficulties
Post-viral
syndrome
• Joint pain
• Arthritis
• Neuropathic pain
• Chronic widespread
pain
Post-chikungunya
Spectrum of Syndromes

10. Post- COVID-19 Syndromes

11. Consensus Definition ??
 An integrative classification is proposed by International Journal of
Environmental Research and Public Health on March, 2021
• Potentially infection related-symptoms (up to 4–5 weeks)
• Acute post-COVID symptoms (from week 5 to week 12)
• Long post-COVID symptoms (from week 12 to week 24)
• Persistent post-COVID symptoms (lasting more than 24 weeks)

12. Managing Post COVID Pain
12

13. Studies in Asia
.
China
About 76% of patients reported
long COVID symptom at
follow-up and a higher
percentage was observed in
women.
India
There are 41.8 percent patients who
complained of persistent symptoms.
After the second wave of COVID-19,
number of cases reported for long
COVID and post-COVID complications
has been four times more than what was
reported last year.
Bangladesh
The incidence of post-COVID-19
syndrome was 46%. In total, 30%
patients showed at least one post-
COVID-19 symptom, while 16%
patients showed multiple symptoms.
Japan
A survey done by a Japanese health
ministry team showed people who
were diagnosed with COVID-19
suffered symptoms six months later.
Malaysia
It was reported that 66% of
patients have experienced
post-COVID symptoms

15. Persistent fatigue
Shortness of breath
Sleep disturbance

16. Post-COVID Pain

17. Post-COVID Pain
SARS
CoV-2
involving
central
nervous
system
,
Peripheral
nervous
system
and
skeletal
muscle
damage
Pre-COVID Chronic pain continuation
Worsening of chronic pain after COVID
Newly acquired acute pain turned into chronic pain

19. A Cycle of Sufferings
High Risk of Acute Pain
Painful symptoms of COVID-19
Procedural pain
Inadequate symptom management.
Neurological Insult
Neuroimmune response to COVID 19
Painful Sequele-stroke, Meningitis,
Gullaine-Barre Syndrom
Psychological and Social Health
Factor
Risk of PTSD
Increased Stress due to pandemic
Social Isolation
ICU Specific Risk
Prolonged Ventilation
Prolonged Immobility
Repeated Proning
Repeated Procedural Pain
Risk of Sepsis
Rehabilitation Challenge
Oversaturated health and
rehabilitation service
Lack of co-ordinated rehab
pathways
Lack of COVID specific rehab
evidence
Population at
risk of
developing
chronic pain is
also at risk of
COVID -19

20. Journey of a Long
Hauler
Name: Md. Asaduzzaman
Age: 31 years
Occupation: Service
holder
Comorbidity: None
RT PCR Positive: 5th April 2021
Symptoms: Mild
Treatment: Home
RT PCR negative: 21st April 2021
Complication: None
 Persistent fatigue
 Shortness of breath
 Memory difficulties
 Inability to concentrate
 Sleep disturbance
BPI score:
1. Pain intensity score:
Worst – 7/10
Least – 3/10
Average – 5/10
2. Pain interference score: 5/10
PCFS score: 1/4
Sufferings after recovery
Post COVID pain and disability
Ref: Eur Respir J 2020, 56

21.  RT PCR Positive: 6th June 2020
 Symptoms: Mild
 Treatment: Home
 RT PCR negative: 25th June 2020
 Complications: None
 Generalized body ache
 Persistent fatigue
 Increased intensity of low back pain
 Memory difficulties
 Unable to perform her daily activity
During COVID 19
Sufferings after recovery
BPI score:
1. Pain intensity score:
• Worst – 7/10
• Least – 4/10
• Average – 5/10
2. Pain interference score: 5.2/10
PCFS score: 3/4
Post COVID pain and disability
 Name: Mrs. Morzina Khatun
 Age: 58 years
 Occupation: Housewife
 Comorbidity: Hypertension
 First visit at Pain Management Centre: 13th January
2020
 Presenting feature: Mechanical low back pain with out
radiation. Pain intensity by VAS was 4/10.
 Management: Conservative with physiotherapy.
 Follow up: She kept going well and managed her daily
activities without significant interruption.

22. Studies related to post-COVID pain

23. Currently we are conducting an academic
research titled “Assessment of pain and
disabilities in post-COVID-19 patients in a
tertiary care teaching hospital in Bangladesh”.
Characteristics Value
Pre-COVID status
Pain
Disability
3 (20%)
-
Post-COVID status
Pain
Disability
15 (100%)
7 (46.66%)
Brief Pain Inventory
Pain intensity score
Worst (0-10)
Average (0-10) Least (0-10)
Now (0-10)
Pain interference score (0-10)
Pain severity
Mild (1-3)
Moderate (4-6)
Severe (7-10)
5.86 ± 1.76
4.2 ± 1.80
2.86 ± 1.65
4.06 ± 1.90
3.53 ± 1.68
10 (66.66%)
3 (20%)
2 (13.33%)
PCFS score (1-4) 1.66 ± 0.89
Studies in Bangladesh

24. Upsurge of cases
increase burden of
pain management
services

25. Chronic Pain: Will it be different in pre COVID and post
COVID era?
Pre-COVID era:
 1 in 5 patients come to seek medical
care because of pain.
 1 in 10 patients are newly diagnosed
with chronic pain every year.
 In developing countries 18% patients
are suffering from chronic pain.
But what will be the estimation of Post
COVID burden of pain ?????

26. Looking Towards Future
Another epidemic
is coming and WE
MUST BE
PREPARED.
 Identification of risk factors.
 Characterization of Post-COVID pain-Intensity,
Onset, Duration
 Medications and Intervention.
 Rehabilitation-psychological evaluation.
 Prepare health infrastructure with proper training
and necessary preparation
 Research, evidence and policy making