Welcome, everyone. I'm excited. This is our first Community Day session at the AAPMNR for the South Asian Physiatry Community. I really appreciate you all joining in. Our session is South Asian Physiatry COVID Across the Continents. We'll start off with two lectures. The first one will be by Dr. Henry. It'll be the challenges and scope of the COVID-19 pandemic in India. And then Dr. Balakrishnan will be talking about tackling the two waves of COVID-19 in India. This will be then followed by our panel discussion. So I'm going to briefly introduce the speakers. The first one is Dr. Henry, who is a professor in the Department of PMNR at the Christian Medical College in Vellore, India. He completed a fellowship in spinal cord injury at the Princess Royal Spinal Cord Injury Center in Sheffield, UK and received his medical training at St. John Medical College in Bangalore, followed by residency in PMNR at the Christian Medical College in Vellore. Thank you, Dr. Henry, for signing in from India so early. Good morning, good afternoon, and good evening, everybody. The next one is Dr. Balakrishnan. He is an assistant professor in the Department of Medicine at St. John National Academy of Health Sciences in Bangalore. He received his medical training from Kempegowda Institute of Medical Sciences in Bangalore. He is currently pursuing his MRCP degree in internal medicine in the specialty of hematology and oncology from the Royal College of Physicians in the UK. Thank you, Dr. Balakrishnan, as well, for signing in so early. Thank you. Good evening and good morning, everybody. The next speaker is Dr. Huma Naqvi, who is an assistant professor at the University of Connecticut in Hartford HealthCare. She received her medical training at the Jinnah Postgraduate Medical Center in Karachi, Pakistan, and completed her PMNR residency at the Montefiore Medical Center, Albert Einstein College of Medicine. Dr. Ambrose is a brain injury certified physiatrist at Montefiore Medical Center. She is an associate professor, as well as a director of research in the Department of PMNR at Albert Einstein College of Medicine. Dr. Ambrose obtained brain injury board certification, as well as her master's in clinical research while at the Mount Sinai Medical Center. She is a member of the New York, New Jersey COVID Collaborative and the AA PMNR Collaborative for post-COVID. Her medical training was at St. John Medical School in Bangalore, and she received her postgraduate medical training in PMNR at the Albert Einstein College of Medicine. Our last, but not the least, panelist is Dr. Surendra Varshiker, who is an associate professor and the vice chair of clinical operations for PMNR at UT Southwestern. He is the medical director of the UT Southwestern and Parkland PMNR clinics. Dr. Varshiker is part of the AA PMNR Collaborative for post-COVID, as well. He completed his medical school at the Vaishampai Memorial Medical College, and his PMNR residency at New York Medical College. Welcome, panelists, and thank you so much for spending your time with us today, and looking forward to great discussion and lectures. So I'm going to hand it off to Dr. Henry, who's going to talk about the challenges and scope of the COVID-19 pandemic in India. Take it away, Dr. Henry. Thank you very much. I think there was a little bit of signal drop when Nandita was speaking. I don't know if it was only for me. Can you hear me? Yeah. Okay. So I was not very sure as to what the real focus should be, because the topic was what's happening in India and what the scope of this COVID-19 has been going to be. So we are now into two years since this problem started, and we still have not learned everything about this virus. We have a long way to go as to how it behaves, what it does, and why it does. Interestingly, two years back, before 2019, if you all read Asterix and Obelix, they had published a story called Asterix and the Chariot Race. And interestingly, the main person there is called Coronavirus. He wears a mask, and he is competing with Asterix and Obelix in a race. So it's a race that's happening in Italy. So when I went through this, and there was a lot of Coronavirus cheering in that magazine, so I think probably it was written somewhere just after 2019. But if you look at the publication, it was actually published in 2017. And the mask and the Coronavirus is very obvious throughout the story. So it's really impressive that somebody had thought through this. So Coronavirus has given us a lot of headache. And I will share another screen now to show us where we are. So if you look at India, that's the general trend, cumulative. Can you all see the graphs and the scrolling? Yes. Yeah. So that's where we are as of yesterday. The cumulative cases, active cases, the green one, the recovered ones, the diseased ones, and of course, the vaccination data. And if you go at the daily level, again, we are settling down as of yesterday. The numbers are huge because the country itself is pretty big. And we all know that we had a double problem spike in the second wave, which really hit us hard. So we are a country of more than a billion people. The problems are, though the virus is the same, the problems are different. And how we kind of managed it also was a little different. So I'll just share the other screen now and go back to my presentation. Yeah. So when we talk of this virus, one of the most important things that comes to us is population density sitting, standing close by. And right from the beginning, one of my interest was to follow this little piece of land in Mumbai, which many of you would have heard. And for those who have not heard about this, this is a small patch, which is about less than two square kilometers or probably in mines less than 0.7 miles square as far as the area is concerned. And if you look at the population there, it's like 600,000 almost. So it's like huge. So you can imagine what this place would have gone through. And as soon as the virus broke out, I used to regularly follow this area because this was where science was for me, because we were talking about distancing, we were talking about washing, we are talking about cleanliness and air and, and impossible to achieve any of those things in this two square kilometer radius with 600,000 population. So, it was very interesting to follow this area. And again, this is an area where you don't find only rich people, mostly are middle class and lower middle class who are working class. And if you look at last year's data, you look at the total death, of course, I mean, everybody knows India, it's not easy to get exact numbers. But I think following the trend makes sense. And if you look at 2020 data, they were casualties, but not as we expected in that area. After that, we were a little overconfident, we were arrogant. We did think that we have won the war. And we went on to do all kinds of things. Some were necessary, some were unnecessary. And then the second wave came. So election rallies happened with a lot of crowd, festivals happened with a lot of crowd. And these are pictures from last year's elections, and the festivals. And one of the major challenges we faced, and we realized that well soon after the first wave was lack of infrastructure. The most troubling thing for the common man was lack of beds when he reached any nursing home or any hospital. There were no beds, they were turned around, they had to run from hospital to hospital. And most of them didn't have infrastructure to take them in because they were already full, or they were getting it all wrong. So lots of things were happening outside the hospital, on the road, oxygen, IV fluids, treatment, people dying. So the second wave, there were more of this, it was pretty disturbing. But then it did settle down in a couple of weeks. All of you must have heard, I guess media had published all these issues. We had a major problem with oxygen, especially in North India, where lots of lives were lost because of lack of oxygen. Interestingly, we had the capacity to produce a lot of oxygen because in India, we do have a lot of steel industry and steel industry produces a lot of oxygen which can be converted to medical oxygen. So the production bit was there, the transport bit was missing. We didn't have enough trucks to transfer those oxygens from those factories to the hospital. We had to do it with what we had. We borrowed some trucks. And of course, we managed to distribute them in time and save a few lives. So space is what I thought was one of the major problems for laymen and patients to get into a hospital for care. And second thing which was really disturbing, and there was a mass hysteria and everybody was kind of scrambling around was for oxygen during the second wave. But then yeah, things got sorted out. Then came the vaccination bit. We were one of the biggest producers of the vaccine in this country. But again, didn't match the need. There's a huge population there which are still struggling to get over the idea of should I vaccinate myself or shouldn't I? And that's the distribution of vaccinations which were done up to the 17th September. We did get into trouble a little bit because of this spike here, which people questioned as to how could you do this numbers on one day. But then yeah, so our vaccination drive is still going on. As of yesterday, I think we are about single dose has been given to about 50% and double dose of fully vaccination only 20%. So there's a long way to go with complete vaccination for most of the adults. This is leaving out the children. And now the vaccination drive is going on well in most of the districts and people have to come forward and take it. So we should be covering the double vaccination for most of the people in this country. We had a good fight. I can only talk from my hospital perspective. I work in a major teaching hospital in southern India, which is more than 120 years old now. And we are a large institution under one roof. We have 2700 beds. We have about 11,000 staff, frontline staff in this hospital, in the single hospital. And maybe fortunately, we are not located in a big city. So we were not inundated with patients, but we were running full. In the second wave, there was a point where we had converted our whole system into a single COVID hospital. We had 1300 odd COVID positive patients. We had about 125 ventilators, and about 300 respirators going on. And the nursing staff and medical staff actually pitched in pretty well and fought the war well. It was difficult. It was April, May, June. It's one of the hottest seasons in this place. And my hospital is based in a very hot place. The average temperatures in summer or the maximum temperatures can mostly hovering around 40 to 43 degrees centigrade. So it is hot. Working with overalls with PPE was not easy. Doctors doing work for six hours, it was really, really tiring. Doctors and the nursing staff, patients struggled. I mean, I went a couple of times to see some of my spinal injury patients who are there. And this is a virus, you know, we've been alive around for 4 million years on this earth. And as humans, we have always got together when we are happy, and when we are sad, to share both happiness and sorrow. But this is a virus which kept us apart in both these issues. And once you're in a hospital, and you're all alone, and you're on a respirator or a ventilator or whatever, an IV, and you don't get any of your kitten around you, and you're sinking, and you see a lot of mortality around, like we were discussing, most of us as wards where each hall will have about 30 patients. It was not easy for the patients because they were not getting in, they couldn't recognize anybody, they didn't know who's coming and taking care of them, everybody masked, everybody's wearing PPE. So that personal touch, that human touch was kind of missing from the patient's point of view, though they were being taken care of, and they could not meet their own. However serious they were, at times when they were really bad, the attender would be let in with PPE, and they could meet them. So it was pretty distressing for patients, especially for spinal injury and stroke patients who were in this. But then I think we did well. I work in a spinal injury center here, which follows up about 400 odd patients who live within the 100 kilometer radius. And we have lost only one tetraplegic, as far as my knowledge goes, and I'm sure we would have known if somebody else, they would have come to us, but none of the spinal injury guys got into serious trouble. I was wondering all the tetraplegics will be wiped away in the first wave because of the respiratory issues, but out of 400 odd follow-up patients, we lost only one tetraplegic. So that was quite reassuring. And then we did put out this little piece of research, and like I said, we are 11,000 staff, so it was easy to do this, look at this study where we looked at how many people were vaccinated and how many needed oxygen and hospitalization. This is data from my hospital, my staff, and look at the number of people who actually succumbed. There was only one death out of 11,000 frontline staff who were working full-time, and this was in the second wave. So I think that is pretty impressive for a frontline crowd of 11,000 to lose one. She was a non-medical, she was obese, and she had diabetes, and she was not vaccinated. So that's how we could reach with the limited resources and space, and so I think we did well, we fought this well. We lost a lot, there was a lot of economic losses. I was wondering how will stroke patients, paraplegic patients, cerebral palsy children, all the neurologically and orthopedically disabled will be able to reach us, how will they be able to afford treatment, because unlike the western models here, the patients pay for their treatment, and there was a lot of job losses in the first and the second wave, and we were really worried as to how, even if they come to our doorstep, how are we going to help them. So the middle class, lower middle class had a big hit, they lost a lot, but at the same time, if you look at, people did make a lot of money in this season. So if you look at tech services, digital services, pharmaceuticals, online sellers, they did very well. Of course, many of them did put their profits back into the community or into helping the community and help us take care of them, but they did make a lot of, so TCS is one of the largest, Tata Consultancy Services is one of the largest tech services in the world, which is based in Mumbai, India. So they made their staff work. In fact, people working from home were made to work more, apparently, I believe, rather than coming to the office. And we all know about Zoom, we don't have to talk about that. Apparently, Eric Yuan, who started Zoom in 2011, was apparently refused visa to the US eight times before he actually came to US in 2011, and now see where he is. So yeah, economics is a major part, because we need to look at this closely, because affordability in future for patients who have had or people who have had job losses who are struggling to get back is very important. So a focus on rehab, I work in this rehab center in CMC Velo, we have about 130 beds, we have about 30 acute beds where we keep all our brain injuries, stroke injury and spinal acute injuries admitted. And once they are stable, we bring them to the spinal injury center. We have a facility for 100 beds here. Again, there was a lot of worry as to how will we manage this? We all know rehab is labor intensive, it is hands on, you have to go near the patient to teach him become independent for his activities. Yeah, then a lot of that happened through telecom telemedicine, we could reach out to a lot of people through this. So we've learned a lot in this two years as to how to help people without moving them out of their house. And probably for the neurologically and orthopedically disabled, that was a big advantage where they could seek some advice, sitting from home and decide whether to come all the way or not, and get some basic support. Interestingly, during the second wave, I had two T10 complete paraplegic ladies who were pregnant and we were wondering, my God, how are we going to handle this now with this COVID? But fortunately, both of them came in, they had a cesarean section and both mother and baby in the second wave did not have any problem. What have I learned from the my patients who are now my colleagues, many of them have become pretty resilient. I can give you an example of Justin Yesudas, who is a tetraplegic, C6 tetraplegic. He is on the wheelchair, he was stuck in his house in the lockdown for three months, his wife was away in her hometown, there was no transport. And he managed to stay good for three months doing everything himself, working, cooking, cleaning. And one of the most important things I learned is that he kind of taught himself to catheterize without getting into a problem with what little hand function he has, because he had no other option, he was scared to go to the nearest hospital or nursing home. So he now does catheterization for himself with that little hand function which is unbelievable. He couldn't believe it, I couldn't believe it, but he's able to do that. And that brought in a lot of resilience, a lot of patients are able to, rehabilitated persons are able to realize that they are able to do much more than what they thought and these are the people who actually should come in and teach us how they did it, how the other person can do it. So I bring in Justin quite often to talk to as a peer group support, to talk to people as to how he managed three months all by himself without letting anybody come into his flat with basic groceries just coming in. So that was a big story and a lot of learning for me. What have we lost in rehab and in clinical services? I think medicine is all about reducing anxiety and we always made eye contact, smiled, touched people, felt them, made them comfortable and reduced the anxiety whatever the disease was, whether it was a curable or an uncurable disease. But we have lost a lot of that now, at least during this first and second wave we did lose a lot of connectivity. We were not allowed to touch them or we always have masks and visors on, the patient is not able to relate to us, they don't know who you are, you can't hear them properly with the mask and visor, they can't hear you properly. So that was a very very troubling thing for me when I saw that and this was how rounds used to be and most of the rounds were converted around the computer. So that human connect is missing and I think the PG registrars or the trainees have lost out a lot in these two years because they have not touched many patients, they have not examined many patients as they were supposed to do and of course the hospital was shut down and there were hardly any skills to be picked up because everything was COVID, they were doing only COVID duty. So across the board, I think many specialties would have, within those two years, some of the registrars would have lost a lot of opportunity for hands-on training, whichever specialty they were. And I think seeing somebody smile is one thing which we have all been kind of, we've lost it, everybody wears a mask, you don't know who's thinking what and so I feel a little bad about that. But then I guess slowly we will get over that. Long COVID is what apparently the discussions were supposed to be, I believe. In India right now, I don't think there's a uniform package or a protocol. Again we know long COVID comes with 200 odd symptoms and I personally believe that in India people are a little more resilient and they don't talk too much, they don't tell too much of their problems so they take it on. In one way it's good because it doesn't extend but sometimes it can become worse. So to be very frank, in the last two years I have not taken any holiday off, long leave, I have been working and I have seen three or four people coming to me with this problem of fatigue and I have not seen anybody with fogging of the brain and all that but general fatigue, unable to carry on is the complaint. But then I don't know what the answers are. I think there are a lot of protocols saying do this, do that, get over slowly and think like that and all that. So I think the other experts can pitch into that but I personally believe one of the best ways not to get into trouble is to be aerobically fit and even if you get into trouble, if you are aerobically fit, whatever the disease may be, you will be able to get out fast or handle it better even if you are not able to cure it if you are aerobically and physically fit. And we saw that throughout COVID where the comorbidities were very, very important as far as the mortality was concerned. Fatigue came out as one of the most common causes for mortality in South India at least. So there are lessons to be learned here. If you are aerobically fit, probably you won't get into these problems and even if you, you might be able to get over it or handle it in a much better way. So I do a lot of long distance running and I practice what I preach. So yeah, the problem is still not over. As of yesterday, three of the states have a R number going above one and there is some data from North India, from Chandigarh, a big institute where they say that they have done a zero survey of children there. We have not vaccinated our children and the worry was the third wave will bring down pediatrics in a big way but there are some interesting research pieces coming, small ones from different institutions, credible institutions, where they have found that in Chandigarh, PGI Chandigarh has brought out some data saying that 70% of the children are zero positive. So it means they have been exposed, they have developed some kind of immunity. So probably we will not see a third wave with a lot of children suffering, which was a big worry six months, one year back. And we are still understanding what this virus is. Ivermectin, Remdesivir, all that came in a big way and at the end of the second year, most of us proved that none of them made a big difference at the end to mortality except steroids, probably chitinia will be able to dwell on that more. So as far as rehab is concerned, I think we are back on track with both neurologically and orthopedically disabled patients. They have started coming in, our hospital is full. Most of them have got vaccinated, disabled have a priority here now in the area where I live, where they get vaccinated. And we are not seeing major problems with tetraplegics, which is very reassuring. So thank you very much. I'll be happy to take questions and discuss at the end of the session. Thank you. That was excellent, Dr. Henry. And now we'll turn it over to Dr. Balakrishnan. So Chaitanya is going to talk about tackling the two waves of COVID-19 in India. Good evening and good morning to all those who are logging in. Thank you for this opportunity to talk about what we faced in two waves that we faced in India. So I'm an internist from St. John's, Bangalore, so I'll be giving the internist's point of view on COVID-19. So as we all know, January 2020, the 30th was the index case reported in Kerala, a medical student from Wuhan. Since then, we've had two major waves that the country has declared, but a lot of states like Maharashtra, Kerala, and even Delhi have reported up to four waves. Of course, a couple of the waves did tend to overlap, but generally four waves in a few states just left a lot of devastation. This is a rough timeline for everyone to understand what we went through as a country. The first index case was March 2020. That's when we were all a little apprehensive on this. I remember the first COVID patient I saw was a gentleman from Wuhan as well, sometime in March, and there was so much apprehension around and there's also so much, a little bit of hype, a little bit of excitement as well, if you can call it that. And then of course, April and May were relatively okay. We had a few inpatients and I was one of the first physicians to go into the COVID wards. And it was a completely different experience, both for the patient and for us, to stand at a distance, to wear PPE, and to quote Hollywood, the fear of the unknown is sometimes so great. And this is one of the few places where as a physician, you're more worried about your health sometimes, especially when you're facing something that you don't know. The first wave was not kind to us at all. The peak was approximately in the mid of September, and then receded by January 2021, where the self-proclaimed and turned out to be true, the largest vaccination drive in the world started. I remember January 16th was the first time St. John's started to vaccinate the healthcare workers. And we were all part of that, and it was so good to see the turnout for that from the healthcare worker. Of course, when I talk about the vaccination in India, the population turning out for the vaccine, especially the first one was quite poor, unfortunately. Between Jan and March, as Dr. Henry had mentioned, I think we were a little lax, both as a country and as a population as well. And unfortunately, didn't prepare or didn't anticipate a possible second wave or the seriousness of it. And then we had a huge second wave in March, which is a deluge. I mean, we were so overwhelmed in a matter of two to three weeks, we had lines of ambulances outside St. John's. There was one day where there were about 25 to 30 ambulances in our emergency. And that patient in the 30th ambulance got into the emergency 36 hours later. And our emergency physicians were giving steroids for those who are hypoxic inside the ambulance with no guarantee of a bed. And this is how bad the wave was. In the ward, if you wanted an ICU bed for a critically ill patient, the waiting period was anywhere between a day to three. If at all. And we had set up our own triage systems to figure out who got the ICU bed. So playing God inside the COVID wards is extremely distressing for all of us. Delta variant was announced. And when I talk about the clinical manifestations, it was a 360 difference from first wave to second wave on the type of patients, the type of presentation that we saw, and all the various complications of COVID-19. Then by May, the second wave started to recede, leaving behind a very high mortality and morbidity rate and a lot of patients with either severe lung damage or unfortunately a new beast or rather an old beast in a new disguise, mucormycosis, which again, I'll touch upon later. Dr. Samaraswamy and I then announced that it's endemic, Singapore's already announced that it's endemic. And I'm afraid that India is going down the same way. It is going to become like H1N1 and where it's going to be endemic, but we still have to continue to be extremely wary because a third wave will devastate our healthcare system if it hits. This is a nice model from the business today, which showed that the peak, the time between the onset of cases to the peak in the first wave was 110 days, and that's close to three and a half months. Whereas in the second wave, it was half of that. This deluge of cases really hit us badly because we really were not prepared. Numbers as of 3rd October, which is when I submitted the slides, Dr. Henry's already touched upon this. I don't want to repeat it. I just want to show that the percentage of deaths reported, and as Dr. Henry mentioned, getting accurate numbers in India is often difficult, 1.33% is a gross underestimation in my opinion. And saying we've had only four and a half lakh deaths is again an underestimation for sure because when you report COVID deaths in India, we report deaths as definitely due to COVID and attributed to COVID. A lot of people who are attributed to COVID were those who had a sudden cardiac death during their isolation or quarantine due to COVID. So despite this, this is a very, very large number. And especially in rural India, it has left a lot of people faced with large volumes of their family lost due to COVID. But with every dark cloud, there is a silver lining, which is our vaccination. We've already hit nine digits worth of vaccination doses. We've had the highest or the fastest to 10 million doses. Most vaccinations in one day, all the enviable records for COVID vaccination have been achieved. But as numbers show, only 18 to 20% of our population has been double vaccinated. And we're estimating that if you want two third of our population to be double vaccinated, it's going to take at least another six to eight months. So we're looking at somewhere in 2022 to achieve that. So my talk again is about the resources that we use in COVID-19 and the management strategies in India. This is something that I think is extremely, it brings a lot into perspective. These statistics as of 2017 survey, we have 0.5 government hospital beds per 1,000 population. I know that sounds an odd figure, but that's actually 2,000, for every 2,000 people, we have one government hospital bed, right? And unlike in the US and UK, government hospital beds are not completely free, there is a nominal fee to be paid and some basic charges. But still, one bed for 2,000 is a very, very stark comparison to what's required. The elderly population has a slightly better number. It was estimated that in the first wave, 19 lakh hospital beds, 95,000 ICU beds and 48,000 ventilators were available in the first wave. Strangely, this is a combination of both government and private hospitals, government hospital ICU beds and ventilators across the country with only one third of the total contribution. So private hospitals have a huge role to play. But thankfully, by the second wave, the government had stepped up their percentage. So the initial percentage was 16,000 in wave one of ventilator beds, they made it 57,000. Was that enough? Definitely not. I just like to bring your notice to the graph on the right. And that shows something that Dr. Henry already mentioned, and I want to reiterate that, if you look at the study blue curve, which is the number of oxygen beds, there was a steady increase till the peak in September. So with the ICU and the ventilator beds, but if you look at the graph here, which shows the dip, this is where we became lax as an administration and as possibly a medical fraternity and as possibly a population, we allowed this to dip. And there was no preparation for or stepping up of infrastructure for a possible second wave. And this dip cost us dearly, because by the time the second wave hit us, in a matter of two weeks, cases were over a lakh a day in various states, including and so many cases, especially in Bangalore, where I work. We did not have time to step up our resources as we would have liked. Though we did, we would increase the beds by 150-200 inpatient beds every week. And in St. John's, we treated over 1000 inpatients at one point of time. But unfortunately, because of this dip, a lot of our resources were not prepared. And a lot of patients were lost because of this. Purely not because of just getting a bed, but also getting the various resources associated with it. Oxygen consumption, as Dr. Henry mentioned, became a huge issue. The demand tripled by me. We are able to produce enough oxygen, but converting it into medical oxygen was a huge issue and transport became an issue. There was a tender for 160 oxygen plants, especially put up at Tata. But unfortunately, only 60 or 80 have come up. The other thing was a lot of tanks which carry various other gases were sort of refurbished, redeployed for transport of oxygen. A lot of hospitals across India suffered from severe oxygen shortage, leading to loss of life. And I think that is something that's very, very disheartening. You know, you're already having such a bad lung disease and you die because of a lack of oxygen is extremely distressing. The other thing that commonly hit us was oxygen concentrators and cylinders. All of you would have read this in the news. People were hoarding cylinders at home. Not because they had COVID, but if they get COVID, they're not going to get a hospital bed. They're not going to get oxygen. And the fear was so, so rampant. I've had so many people call us and say, you know, could you get us a five litre oxygen concentrator? Could you get us a 10 litre oxygen concentrator? We're six people in the family. We don't want to take any risks. I've had people buying BiPAP machines for home and keeping it home. And this hoarding was something that really hit us because at the peak when we needed to rent concentrators, etc., it became a huge issue. So the state governments, as well as hospitals like St. John, set up an oxygen rationing committee. We had an oxygen manager in the second wave. A team would go through and PP to every ward and ensure that oxygen delivery devices were used optimally. There was no oxygen wastage. And a very important study came out from IMS and of course, a lot of studies from Europe, which showed that HFNC, though being extremely effective in delivering oxygen, was actually quite a wasted model, because of which HFNC usage came down almost by 30% in the second wave in favour for BiPAP. And especially in a hospital like St. John's, having an oxygen manager was very important and we saved a lot of oxygen because of diligent use. Remdesivir became a huge scandal, though we upped our production again by four times. Everyone thought this was the magic elixir, to quote Asterix and Oblitz, the magic potion. And unfortunately, spent 10 times the market value of Remdesivir, procured Remdesivir from the black market, fake Remdesivir. We had so many controversies. Patients believe that this is going to save their lives. And even if they're in their 11th or 12th year of illness, doctor, you haven't given us Remdesivir. Why? And when you try to explain to them the narrow therapeutic range, the benefit versus risk and how steroids is the only proven medication to work in COVID fell on deaf ears. We've had patients trying to force us to give Remdesivir when we knew there was no active indication. And unfortunately, the black market made its killing on this. And of course, our largest vaccination drive, and this is something I think we should stand up, put our hand up and say we deserve credit for. Both Covishield and Covaxin have been given. We have Sputnik as well, which hasn't caught on. But this is the largest vaccination drive in the world. We've broken various records, but the records and all that are secondary. I think to achieve the vaccination status in our country, given its population density and given the resistance to vaccination, I've had doctor friends who've told me that I can't take a risk with one in 10 million risk of a blood clot to take it. I've had doctors who've taken dabigatran and aspirin for one month after taking the vaccine and prescribed it to patients and family alike. There is so much controversy with regards to vaccination, but if you're finding it difficult to get healthcare workers to get vaccinated, you can imagine our challenge to get patients vaccinated. A lot of my hematology patients, convincing them to get vaccinated was again a very, very difficult thing, including my internal medicine patients who said, you know, doctor, have you taken it? We'd like to observe you for three months, and if you're still around the OPD, when we come back for consultation, then we'll consider it. And these are actual things that have been told to me. And thankfully now with the extent of the drive going to the very villages and homes of people in rural India, we've been able to tackle this, but again, a long way to go. How did the patient presentation vary from wave one to wave two, and given the thousands of patients we've seen in the fever clinic and the inpatient in St. John's, I can tell you that they were 360 degrees. They were completely poles apart. Renal and GI symptoms, the pink eye, sudden onset hearing loss were much more common in the second wave. The exact pathophysiology is still up for debate. Variants of concern, especially Delta, were escaping RT-PCR and RET detection. And this is something that we faced, especially in end of April, early May. There are a lot of patients with CT scans showing evidence of COVID behaving like saris, but repeat RT-PCR is negative. And these are patients who were treated in normal wards or non-COVID wards for the first week or two, and unfortunately were spreading the virus. So as a national policy and as a state policy, we set up a separate ward called a COVID-like illness where you were COVID negative, but you were behaving as sari. Again ethical dilemmas, whether to give them remdesivir, whether to give them steroids or just oseltamivir and antibiotics was a huge issue, but we managed to circumvent that with some strict protocols. A lot of large vessel occlusions, we've had, St. John's has got one of the largest registries of stroke in COVID set up by our neurology department, especially in younger patients. We've had patients with demyelinated disease like ADEM and GBS, both due to COVID and post-vaccination as well. Multisystem inflammatory syndrome, I've seen a few in adults, children, of course, we have reported quite a few, but adults I've seen very few, but unfortunately with devastating side effects because by the time they're picked up and by the time you think about it as a differential diagnosis, they're possibly out of the window for IV immunoglobulins. In terms of the respiratory complications, this is a study produced from Ames which showed that every single parameter, be it dyspnea, be it the development of ARDS, be it the need for oxygen of any form or a ventilator were much higher in the second wave. And this is something we saw, not only the duration of stay in the ICU or ICU, but the need for HFNC and BiPAP. I have had a personal patient of mine, longest survivor of COVID, I think he was on HFNC and he was declared COVID negative and then shifted out. He was in a hospital for four and a half months on HFNC. That's how bad his lungs were. Now he's at home on 15 liters of oxygen, but it's a very, very bleak outcome for him. Cardiac complications, including arrhythmia and myocarditis are much higher. We had to deal with cytokine storm, especially in the younger patients. We had patients who had multiple cytokine storms in the same visit. And of course, mortality was increased, all cause mortality in all age groups, except less than 20, possibly because of the reduced numbers. Myocarditis hit us really badly. This is something we didn't expect. And again, none of us were prepared for. As a he-mong team, we usually see two, three mucos a month to seeing six to eight a day was really, really scary, especially disseminated rhinocerpal disease. We've seen pulmonary mucor, we've seen urinary mucor. I've seen gastrointestinal mucor, which I've never heard or read of before that day. And of course, invasive aspergillosis. I have lost a lot of patients post COVID due to invasive aspergillosis with massive hemoptysis or respiratory failure. And this is something due to the indiscriminate use of steroids, inappropriate use of steroids, and possibly, of course, a COVID trigger as well. We can't call it lung fibrosis. The American Thoracic Society has said, call it post COVID ILD because they've seen that in nine to 12 months, there is a chance of recovery. We've had a significant amount of patients with residual lung damage requiring home oxygen. It's estimated 30,000 as of the last week of September are due for a double lung transplant to ensure that they survive the next three to six months post COVID. And this is reported cases. You can imagine the impact it's had in terms of respiratory function. Long haul COVID or post acute sequelae, this is something that we are really, really underreporting and not really looking out for. I had a presentation on this with one of my post graduates a few months ago, about two, months ago, where we talked about it. There are only two or three studies across India, St. John's is doing one currently, which show that 23 to 40% of patients with COVID will have it. Not only those who are severe, but also those who are mild and at home as well. And as you know, there are almost 200 different types of presentation. Brain fog is something I commonly see, fatigue, anxiety, and the uncovering of a lot of our non-communicable diseases, including hypertension, diabetes, and dyslipidemia. I think we've setting up long haul COVID or post COVID clinics is the way forward for us. Coming to the last part of today, which is how we manage COVID in India. This is specific to the management protocols. I'm not going to go into the details, obviously, but I just like to touch upon that this was set up by the AIMS ICMR taskforce and as updated as early as May. The unfortunate part of this particular guideline is it hasn't been updated post that. And it still sticks to some of the older protocols as for the first wave, which we did not follow. A lot of these protocols we have changed and modified based on institute to institute. As you know, there's a mild, moderate, and severe disease. The definitions and cutoff remain the same. But what they still included, which I had objection to St. John's as a department, as a hospital, we took a policy to avoid was ivermectin and HCQS. We stopped using it after the first wave. What we did take was the use of inhalation which I found more than reduced the viral load as claimed, reduces the respiratory symptoms, especially that troubling cough. The jury is out on methylprednisolone versus dexamethasone, though we in St. John's follow only dexamethasone unless they're extremely severe or not responding to it. The doses of anticoagulants, I've seen all types of indiscriminate use, but classically 0.5 milligram per kg once a day, especially in moderate patients. One thing I'd like to bring about, and this particular box is for moderate COVID patients, is HRCT test. I think as a country, as a medical fraternity, I've had patients who had four CT scans in a 10 week, in a 10 to 15 day stay in the hospital or for diagnosis and treatment of COVID. HRCT, there are very specific indications for HRCT in COVID, but I've had patients who got HRCTs done even for mild COVID, send me their COVID score and say, Chaitanya, what do you think is going to happen? And my standard response would be, I'm not sure. The indiscriminate use of inflammatory markers on a daily basis led to a lot of problems and patients getting much more anxious than they should. Severe cases, of course, in the ICU with a double dose of anticoagulation was the way to go. Again, here, methylprednisolone and dexamethasone, but double the dose. So 0.1 mg of dexamethasone versus 1 to 2 mg per kg of methylprednisolone was the dose. HFNC was very commonly used in the first wave, but secondly, we started going back to BiPAP purely because of the oxygen conservation strategy. But on a personal opinion, I find that HFNC in patients who are not extremely tachypneic, but severely hypoxic is very beneficial. Of course, if used judicially, especially maintaining the pressures and the oxygen concentration. Thankfully, AIIMS and the ICMR put remdesivir under the EUA or the off-label use. But despite this, because this came out in May, unfortunately, the damage is already done. The media had taken remdesivir to be our magic potion. But as you know, there's a very, very narrow therapeutic range. We disagree with the 10 days of onset. We believe if it's only used in the first five days, it's useful, if at all, very specific indications for the same. The use of Tocilizumab, I think we would have used for about maybe 15, 20 patients in the second wave for cytokine storm. 50-50 usage. I think choosing the patient and the clinical scenario and where to use it is key. Last part of today would be to talk about the use of JAK inhibitors. I know this is, again, a huge thing abroad. I've used Tofacitinib to a reasonable amount of success. We're waiting for data to be published from St. John's on this. Again, there are very specific indications in patients who have not received Tocilizumab or not responding in 12, 24 hours of dexamethasone or progressively getting worse. The monoclonal antibody cocktail, Donald Trump is most famous for taking this, I think. Again, very few patients in Connecticut and Bangalore where I work, but across India, I think they've had less than a hundred patients who've taken the cocktail. Again, very specific indications, early disease patients who've had transplants or patients who have on CKD on dialysis. Again, the jury is out on this as well. I'd like to conclude saying, are we going to get a third wave? I'd just like to point out the IIT Kharagpur model, which said that if you put our situation back to normal and without any restrictions or curfews, we'll have a third wave by October. If there is delta plus, epsilon, et cetera, et cetera, mu, then we'll have the third wave in September. Thankfully, we've overcome that or we haven't faced that. With strict interventions, you're going to get a third wave, of course, less than the second wave, but possibly in late October. Fingers crossed. We really hope that the medical fraternity doesn't have to face the third wave. Award on children, the Lancet COVID-19 taskforce, as well as AIMS has said that a future wave affecting only children is unfounded. The PGI study, which Dr. Henry mentioned, said that 70% of children are C-eligible positive, which shows that you are not going to get a third wave in children causing devastation. I've seen so many WhatsApp messages, keep your children safe. And I think everyone should stay safe. These are the four things that I think, irrespective of variant, race, country, or where you're from, you should follow social distancing, wearing a mask, hand hygiene, and of course, get vaccinated. And I think this is the only way forward in prevention of COVID-19. And I think as everyone says, prevention is better than cure. Thank you so much again for this opportunity. And I'd be happy to take questions at the end of the session. Thank you so much, Chaitanya. That was a great presentation and really helped us understand in both your presentation and Dr. Henry's as to what the situation has been like in India. I'm going to move on now to the questions for the panel. I'm going to start off my first question to Dr. Henry. You did mention that post-COVID, and both of you mentioned that even though that's something that you guys might do in the future, there aren't any post-COVID or long-haul patients there aren't any post-COVID or long-haul patients currently being tracked or managed. So, as I saw in the presentation, now the number of patients with an infection is sort of receding. So, do you think in your institutions, there's any talk or plans for multidisciplinary post-COVID clinics for this? So, as far as CMC Valor is concerned, I did have some discussions just yesterday to get recent data from the Department of Medicine where a lot of follow-up is happening where people who have had COVID got discharged are okay now are coming back for some follow-up. Again, it's very difficult to tell whether it is because of the virus, because of the inflammation. Most of the inflammatory markers are not high in most of the patients. Probably what is happening is that a lot of people have lost jobs during the last two years. They've lost their own seniors, mother, father, whatever. And it's to do a lot of with the mental health, which keeps bugging them. I'm sure there might be a little bit of myalgia, a little bit of whatever, very difficult to objectively kind of quantify it. But subjectively, people who are having these symptoms are people who had some losses, both personal and economic or struggling to get back or are depressed because of something. So, one of the common examples which I can give is when you look at an order sheet, I worked with a spinal injury center in the West. And when you look at the order sheet, you see at least six or eight pain medications in the standard spinal cord injury patients in the ward. Whereas here, you hardly see two. And of course, for pain physicians, they will not really like this idea of keeping them on minimum pain medications. But like I showed you in one slide, resilience is very important. And I believe that our crowd is a little more resilient to both depression and pain. Even if they're not resilient, they don't talk about it. So, it doesn't get amplified very much. Probably the pressures, economic pressures and other logistic pressures after losing a job or struggling to run a family is causing some symptoms. And these are the guys who are coming back. I saw one medical staff. She's an anesthesiologist who works in the ICU, who has had COVID, who's about 26 years old now. She came with all these tiredness, basically very tired, I'm not able to walk back after work. She does her six-hour, eight-hour duty, but she's unable to walk even 500 meters and reach back to her accommodation. And being a staff, being a doctor here, she's had the gamut of investigations, blood and imaging and what could be wrong and everything is normal. And symptoms are still there of general fatigue. How do you prove it? How do you get over it? I don't know whether you need to really chase it and prove it unless and until there's a focal neurological or some focal deficit objectively, which you can pick up. I think the only advice is to get aerobically fit. How you want to do it is your choice. You play a game, you go for a walk, you swim, you dance. So, I don't know. So, to each his own on that. So, I believe we will not, as of now, we will not have a COVID follow-up clinic, very unlikely, because number one, we don't have space for any new clinics as of now. And each department will be seeing some. And if it's very severe, they do refer finally to PMR when they have started their gabapentin, pregabalin, nematriplein, serotonin, whatever, and things are not moving. They said, okay, go to PMR. They look after you. When they come here, there's nothing much to start because everything has been started and stopped. So, then you need to talk them into lifestyle change and thought process change and get, I'm sure most of them will get over it. It's how you handle it, how you talk to them, how they handle it and how they get over it. Yeah. Well, thank you. That was definitely interesting. And we're going to have Dr. Barsikar talk a little bit more about that here, about the fatigue, especially. My next question is to Dr. Nakti. So, we heard a lot about, you know, Dr. Henry and Dr. Balakrishnan about what's going on in India. And I know you've not been practicing there, but you've been in touch with a lot of your colleagues in Pakistan. And so, we were hoping you could shed some light on the situation with regards to COVID management in Pakistan. And has it been focused primarily on COVID management or has there been a lot of rehabilitation management as well? Thank you very much. And thank you for all the great presentations, very interesting and informative. So, talking about Pakistan, I would say in a way, Pakistan has been fortunate enough to not being hit hard as the neighboring countries. So, there it might be multifactorial, but number one thing which I noticed and which probably the reason that they were kind of very well prepared. They did a lot of preventive measures like everybody's talking. Although everybody did it, but since they learned and it kind of came later part of the air in Pakistan. Although the neighboring China was the first one, but I remember that the first thing they did is to close their borders and restrict the travelers. And the big thing they did is the lockdown. Every time we used to get connected with them, this is the first thing we were listening that they are trying to keep the isolation, lockdowns are there. It reached to an extent that people, especially the day-to-day workers and the daily wagers, they were getting very frustrated and it was a very difficult situation, but actually that works. And the other thing which I think was very helpful, the cultural practice, because most of the people pray like five times a day and they do a practice called vizu where they clean their nose and mouth and face very often. So, I mean, if I think back and look it up that their hygiene was very good relatively. So, I think that helps also. So, many things contributed, but in spite of that, we had a big wave when it was a crisis situation. So, I've been volunteering with an organization called the Philanthropic Doctors Association, which helps globally. So, we have been doing online webinars during that time. So, we did a lot of e-clinics and we keep on updating the doctors there. They were like a group of doctors in different hospitals and we did several webinars. And because, of course, it's not a rich country, it's poor. So, major problem was initially was PPEs, like everywhere else, but in Pakistan it was worse. So, we designed something to teach them to make their own PPEs, like there are ladies who stay home and because as I told you, the daily wagers were affected so poorly. So, we trained them how to start stitching the mask, how to start stitching the dresses for the PPEs and gowns and this type of thing, which they start doing at home and they were able to make some money and their livelihood was much better. So, these type of little things were very helpful through the telemedicine and the e-clinics. And we did on different, different topics, like including medicine and they were very receptive. The government was very receptive. So, we did this global educational program, which was very effective. And in addition to, I know everybody talked about the medication part of it and antiviral and steroids. So, I don't want to go into that one, but a simple thing I want to mention about, there was a group of dentists who were educating the people, like very common, starting from the kids to the adult and seniors, how to take care of your oral hygiene. Because we knew in the beginning that it was spreading from the nose and the mouth. So, first thing they said, okay, if you have a problem, don't come to the dentist. We will arrange a team which can come to you and do, and if you can delay the treatment, dental treatment, just do it, don't come to the clinic. And they did a couple of things to keep the, how to keep the mouth moist and what to do and how to prevent it. So, that was also very effective. And so, these little, little things, I think together made a big difference. And I just want to take an opportunity to talk a little bit about the post-COVID syndrome. So, we are running a very intense post-COVID recovery clinic in Hartford Hospital in Connecticut. And in the last three months, I have seen 400 people, patients. So, it's extremely prevalent. And I cannot tell you that what are the cases we are seeing. It's starting from fatigue to mental fog to emotional issues to depression to loss of jobs and loss of function. And the way it's growing, because we are seeing people who had COVID last year in like March or April of 2020. They are still not able to go back to work or function. And they are extremely fatigued and lots and lots of issues are coming up, especially the most difficult one to treat is called the POTS syndrome, which is the Postural Osteostatic Tachycardic Syndrome. And in my clinical experience, we are seeing a lot of young females and they are the working class, highly active. Most of them are nurses and therapists and things like that. So, they are the ones who are suffering this one. And what is the treatment? This clinic we are doing with a multidisciplinary approach. So, as everybody mentioned that therapies, especially the physical activity is playing a role because body is releasing endorphins and keflins that's helping. And then we are doing speech therapy for the brain fog, which is relatively helpful. And then we are providing sometimes small dose of anti-inflammatory medication for a short period of time. And a very interesting thing I'm doing it, which is showing some good promising result and hopefully we'll try to publish it, is we are doing auricular acupuncture, which is the acupuncture in the air, because most of the post COVID syndromes are autonomic dysfunction. So, there are autonomic points in the air we are stimulating with the acupuncture needles and those people are improving significantly. The only thing is that we have to see how long these things last. Right now, our protocol is we are doing every week in addition to the physical therapy, but we'll see how long it goes. But this is something which is coming up as quite promising. So, just I don't want to mention about things that this post COVID thing is a real thing and it's existing. The only success which we don't get it so far is in the loss of taste and smell. That is seems like it's not coming back with any type of treatment. We tried speech therapy, we tried auricular acupuncture, but so far no significant success. Thank you. Yeah. Well, thank you, Dr. Nakbe. That was very illuminating. Moving on to Ann. So, Dr. Ambrose, have you found any difference? Because I know you've done a lot of research and I mean, I've listened to your presentations at AAP and AAPMNR. So, have you found any difference in COVID long-haul symptoms between the unvaccinated and vaccinated patients with breakthrough infections? Oh, I think you're muted. Sorry about that. Yes, I was muted. So, this is really an area that's just beginning to have, the research is beginning to emerge. If you think about it, most people in the U.S. and around the world started getting vaccinated really in the spring of this year. So, spring and summer. So, for post-COVID to show up in the vaccinated population, that happened more or less towards the end of summer, early fall, and that the first researchers are beginning to being published in this population. So, we really don't have that much information to go by. What we do know is, you know, post-COVID has got a significant amount of research. Sort of the first papers that came out last year, I think, was that paper by Carfi, the 179 patients in Italy, where he showed, you know, that at three months, still 55% had, sorry, at two months, 55% of patients still had some symptoms. Not all of it was serious, but they had them. There was a nice paper in the Annals of Internal Medicine, Chopra, who looked at all the, it was Blue Cross, they looked at all the Blue Cross patients that they had. So they had a significant number of patients who they had good records on, and about 500 patients they actually contacted at about two months again, and about 12% of those patients had some brand new symptoms, something they did not have before. So it was not a worsening of prior fibromyalgia type things. This was brand new. So, you know, I know there's some skepticism of whether or how much of this is really post-COVID, how much is this economic depression, anxiety. I think they all play a part, but I do think this is a real condition. There was a paper in Lancet looking at six months post-COVID syndrome in the Chinese. And again, you know, the numbers were quite remarkable and significant. So looking at patients who are vaccinated, there's been two studies. One came out of Israel. Both of them are published last month. One was published in the New England Journal last month, looking at a hundred, 1,500 patients, people who are healthcare workers who got both vaccinations and looking to see what happened to them. Did they get post-COVID? So about 2% of those patients who, they were not patients, healthcare workers who got a double vaccination, developed breakthrough infection. Out of that lot, so it's not a very big number, 19% had post-COVID symptoms at six weeks. So by definition it's four weeks. If you have symptoms after four weeks, then that is considered post-COVID. So these people have crossed that point. It's at six weeks, but most of them are very mild. These patients who had the post-COVID symptoms, it was asymptomatic. So most of them were asymptomatic. Those who had symptoms, it was very mild fatigue. So there seems to be a difference between the vaccinated and the unvaccinated if they get COVID. The other study that was published in Lancet, also last month, was in England, they have an app that they've given all the COVID patients. They record their symptoms on an almost daily basis, and they've been following that. So they had about 2 million people who had at least one dose, of which I think about 1.2 million had two doses. And they were watching to see who gets breakthrough infection, if they have post-COVID symptoms as well. So this patient report. So out of that 1.2 million who got the two doses, 0.2% had breakthrough infection. But this is a little more accurate in the sense you're not using patient recall. This is a daily entry. So it's a little more accurate, a little bit more reliable. So out of this lot, they had about 500 or 600 patients who had good records on, because the NHS, which is a national health system, is one system for the whole hospital. So their documentation is accessible. So for the 600 patients who had the vaccine, had a breakthrough infection, they did have records, and they saw that 5% of them had post-COVID. Now this is in comparison to people who never got vaccinated, who got post-COVID. So that rate was about 11%. So it seems like both the intensity and the frequency of post-COVID symptoms seems to be much lower in people who get vaccinated. It's not that they don't get it, but it's very much have on post-COVID symptoms in vaccinated patients. On the question of post-COVID clinics, since it's a hot topic here, we have a post-COVID clinic. I'm part of it. I run this with pulmonary medicine, and we're taking a variety of measures to try to address it. POTS is definitely the hardest symptom to try to manage. I actually have tried various methods of exercise. I put some patients on like a cardiac rehab style intense program, and it did not work. They got worse. I'm using like a lot of respiratory exercises, a very slow graduation, almost like the neuromuscular application. You only take them to the doctor. Most of my patients, and the goal is to get them all back to work and to school and normal life. We're getting there. Most of them have made a recovery within a couple of months, but it's patients. It's also treating their depression, their isolation, getting them connected to this post-COVID support groups that we have. It's all been helpful. Yeah. I mean, it's interesting you say that. I had attended a talk by a lead researcher, a neurologist on post-COVID, and I'd mentioned how some of my patients with MS and some other autoimmune diseases have had exacerbation. I was like, how much of this is because of post-COVID versus an activation or worsening of their primary disease? I think they're finding some of those things as well in patients post-COVID, like autoimmune or diseases that may have autoimmune that are being exacerbated. In patients who had bad, severe COVID, how much of it's like a typical post-ICU, post-prolonged hospitalization? They have these kinds of symptoms too. But the surprising thing is the mild patients, the ones who never had severe... And some of them, I know them personally. They are my friends who got mild COVID, never came to the hospital, just had a clinic test for their PCR. And two months later, one and a half years later, they all returned to work, but they're really struggling. Right. Yeah. They're not trying. They're not people who are malingering and trying to get sympathy. They are actually working and trying to do all the activities and taking care of their family and their jobs. But I see that. I know these people from before. This is not them. Yes. I also saw, of course, everybody probably saw the CBS 60 Minutes that they talked about these people who are marathoners and people are very, very active and post-COVID are unable to do anything. So it's, I mean, they're managing and getting on with their lives, but it's pretty hard. Right. Yeah. So that really leads us to the next question, which is for Dr. Barshaker. So has there been any difference observed for post-viral versus post-COVID fatigue in the long haulers? Yeah. Thank you for the question. So I guess with the talks from prior speakers, it's a perfect transition to talk a little bit more about fatigue and post-viral syndrome in general. As Dr. Ambrose mentioned, fatigue is really very, very commonly seen. We all know that initial acute COVID as well as long COVID affects multiple systems. But if you see most research that has been published so far and different symptoms, fatigue is number one. So there's these two large self-report questionnaire databases that were published, one done by the patient-led research collaborative, and they had over 3,000 responses. And then the other was from the survivor corps. Both, they were like self-report and both had fatigue as number one symptom. 77% of the patients and 79% of the patients with long COVID did report fatigue as their number one symptom, followed by some component of exertional malaise, followed by cognitive complaints. So what exactly is post-viral syndrome? So basically, if a syndrome, it's a syndrome of persisting symptoms that can occur after a viral infection. It's not really new. We have seen this before. After any large pandemic or a large infection in any geographic area, there's always been cases that have been reported with post-viral syndrome. Traditionally, the prior research says that anywhere between 10 to 12% of patients that develop a viral syndrome may end up with a post-viral syndrome type of picture. And these numbers came from prior studies when one from the SARS population and then the other from the MERS, that is the Middle Eastern respiratory syndrome population. So that's the model. So if a large chunk of population gets affected, 10 to 12% of patients may end up with some residual symptoms. And what is post-viral fatigue syndrome? It's a post-viral syndrome that is mainly characterized by fatigue, or fatigue is the larger symptom in this viral syndrome. And then came the concept of myalgic encephalitis or chronic fatigue syndrome. So myalgic encephalitis has been described for many, many, many years, but I guess now it's becoming more popular. And not only popular is healthcare workers, as well as patients are knowing about this more because either advocacy or now with COVID with the slew of population complaining of fatigue and finally getting into this post-viral syndrome phase, they are now looking up and then this shows up. And now we all know, okay, suddenly people are showing these symptoms. So what is myalgic encephalitis or chronic fatigue syndrome is basically a chronic inflammatory physically and neurologically mediated immune response of the body. So, I mean, it's, I know there's multiple words to this, but basically it's chronic, it's inflammatory and it's immune mediated. So the main, main, main culprit here is thought to be cytokine storm. So it's either a cytokine storm or some persistent levels of chronic inflammation that eventually lead this to this post-viral syndrome phase. And the timeframe that was always used for post-exertional malaise or chronic, sorry, CFS and myalgic encephalitis was a six month. So these symptoms have to be there for a six month duration. And the Institute of Medicine defines that these symptoms are chronic for six months and they are severe as so severe that the person is not able to achieve his or her prior occupational, educational, social, or personal activities. And fatigue is a profound, is profound and the predominant symptom. And they also have post-exertional malaise and they have unrefreshed sleep, and they may have one of the other that is cognitive impairment or orthostatic intolerance. Now, if you see that like the long COVID patients and all the surveys and questionnaires, these are the top three or four symptoms that have been, that have been described by every, every study. So Dr. Fauci did mention in one of his talks, when he was talking at the international AIDS conference, that this is something we really need to look at seriously because it very mild, it very well might be a post-viral syndrome associated with it. So he talks about it. And if we, if you follow prior models, when 10 to 12% of the patients after a viral syndrome may end in this kind of a chronic viral syndrome phase, then the numbers for COVID are going to be insane. Basically they are going to overwhelm our healthcare system, right? Because we know how bad the numbers are. I mean, all over the world, but especially in U.S. And as one of, I mean, Dr. Henry did mention that we don't really know how much resiliency plays a role in it, but I absolutely understand where he comes from. And I see the difference myself with, with especially the cultural difference of how we report symptoms, how we talk about it. And for example, he said the pain medication in different countries is absolutely different. And I agree to that. So especially for U.S. when we have a different mindset and different culture, if it really follows that 10 to 12%, then we are going to see a huge, huge population of, of post COVID postpartum. Now, whether there's a difference between any post-viral syndrome or post-COVID, we are going to have a full talk about that at the AAPMNR. But, but one, one point I would definitely like to suggest is post-COVID is, it's not just post-viral syndrome. That is the crump, the one that was known before, because as we all know, with post-COVID, we have seen myocarditis, persistent lung damage, interstitial lung damage, or, I mean, like Dr. Chaitanya mentioned, not lung fibrosis, but interstitial lung disease, post-COVID interstitial lung disease. We have seen a lot of autonomic dysfunction. We have seen something like POTS. So yes, it's a post-viral syndrome, but it's with plus many, many, many, many other things. So I would say that is the big difference, at least at this time. At this time, we don't know if it's going to evolve into just a regular post-viral syndrome, which was always known and end up in this chronic fatigue syndrome, myalgic encephalitis bucket. We really know, we really don't know at this time, so time will tell. Talking about fatigue, the AAPMNR collaborative for the post-acute sequelae of COVID collaborative that AAPMNR has led recently published the guidelines or recommendations for physicians and providers on how to assess and manage fatigue. So I'm quickly, I know we are almost towards the end of time. I'm quickly going to summarize like a minute or two about what exactly is a main recommendation. I think it's a very useful paper for anyone, especially primary care providers, where our providers that do not usually manage these type of patients, they should read this because it gives a good guideline of what to do, what to expect, and how, when the reference should be made. So basically in assessing fatigue, it's recommended that you need to assess the full day-to-day pattern of the patient, not only when the patient comes to your clinic visit. So basically you need to check for their activity guide, their day-to-day functions. When you get fatigue, what makes it worse? Is it during a certain time of the day? Also look at the energy windows, which many patients describe, look at how it is associated with any work that they do. Assessment should include some kind of standardized measures, activity measures, and you could do as simple as 30 seconds sit to stand. It could be a two-minute walk test. It could be a, sorry, two-minute step challenge. It could be a 10-minute walk test. So some kind of a standardized fatigue assessment should be done. There are certain scales that are commonly used with fatigue, which are like simple numerical scale from one to two or fatigue quality, which can be also used, but as long as there's an objective, some kind of a standard assessment of fatigue. And that's only because if you have something in place, you can actually follow it, trend it. What's making it worse? What's making it better? Associated symptoms. This is the main thing. Associated symptoms has to be really understood. So you need to look at patient sleep, patient's psychosocial issues, patient's mood, anxiety, depression, stress. What is the patient going on? What's going on in the patient's life at this time? Any other cardiopulmonary comorbidities, including autonomic dysfunction, heart rate variability, autoimmune issues, and endocrine issues have to be explored. So when the patient gets into a chronic phase, when your basic conservative management, including good sleep hygiene, comorbid issues are addressed. And if the patient is still not improving, sometimes a blood work may be needed. Obviously we do not want to overutilize any kind of laboratory testing because we do expect majority of times those to be normal. But still, if it's, if my conservative means your fatigue is not getting better. And if the recent, in the recent past two, three months, no investigation has been done. It's always good to check a basic CVC, a CMP, including liver function, immune, some kind of immune markers, CRP or ESR, just to make sure there's no information ongoing, because some patients are ending up in some kind of a chronic inflammatory phase or syndrome. And also looking at your hormonal levels, at least the thyroid to start with is a good practice. And then based on your fatigue severity is what they base the recommendations on. So again, once you do all this, some kind of aerobic exercise program, which is very, very individualized, is as tolerated by the patient. And it's not just a generic exercise prescription that people end up getting is what is recommended. So fatigue is always, has been divided with mild, moderate, severe, depending on how, what you can do, what you cannot do. Basically mild ones are doing most of the things, but they cannot do exertional activities. Moderate ones are able to do ADLs, but they have issues with IDLs and community ambulation. While severe fatigue is people that are barely getting their ADLs done and they have limited ambulation even indoors. If you divide fatigue that way, for mild fatigue, continue doing what you're doing and start with some kind of aerobic program. Again, it's patient tailored and easy rule to follow is a rule of 10. And that's been mentioned in this guidance statement. So basically you start with a very comfortable level of exercise and based on the rate of perceived exertion, you increase with a 10% every 10 days. So it could be a self-tailored exercise program. Patients can slowly go up on their activity as tolerated. And for moderate, the recommendation is to start at a very low exertion or a sub-maximal threshold, starting with rate, a lower rate of exertion between nine to 10, which is very light to light. So light activity, and then slowly going up to moderate level of activity as tolerated. And for severe fatigue, it's recommended to start with a very simple upper extremity, lower extremity stretching, followed by slight strengthening exercises. And then once the patient is comfortable at that level, starting at sub-maximal exercise thresholds at a rate of perceived exertion, seven to nine, and gradually increasing to mild activity is tolerated. Again, here, noting for post-exertional malaise, things that make the symptoms worse, things that make the symptoms better is definitely recommended. And finally, there's a very good framework that we can tell these patients is the four Ps, and this has always been used for, for patients with chronic fatigue syndrome, myalgic encephalitis. The four Ps are pacing, prioritizing, positioning, and planning. I would say this is, this is like the key. If you're seeing a patient with this chronic fatigue, if you, you definitely need to educate your patients on this. So pace yourself during your day, um, prioritize your activities, do important things, what you really need to do on that day, position yourself to make things easier, um, position your work, position your how, like things at work, things at work so that you are more efficient, ergonomic, uh, and then planning. Planning is going ahead, not just for the day, plan your future, plan your activities, what you have. If you know your energy window, do something that is important during that time. And so that you don't crash and get things done. So I would say, um, for this is most important, pharmaceutical management, very little evidence. I wouldn't recommend starting that right away. Uh, other supplements. Sure. Why not try it, but no benefit at this time. Um, obviously healthy diet is the number one key hydration is number two. Sleep is number three. Aerobic activity is, is number four. Right. Thank you. Yeah, I think, uh, that was great. Uh, thank you so much for the summary. And, um, I think we're done for, um, our session. I think our time we've gone a little bit over, uh, thank you everybody for your time. And I know some of you are probably going to watch the session after, um, we, uh, yeah, you can always contact me or anybody in the session for any further questions that you may have, and I can open it up for a few minutes if anybody else has any questions. So thank you Nandita. I want to take this opportunity to say you've done a wonderful job moderating the session and bringing us, bringing all the speakers together and organizing the questions. Thank you very much. Thank you. Thank you guys. And, uh, have a good rest of your evening and have a great rest of your day, Dr. Henry and Dr. Chaitanya. Thank you. Thank you. And, uh, look forward to further collaborations with you. Thank you very much. Bye-bye. Bye-bye everybody. Bye-bye. Thank you. Bye. Good night.

COVID-19 pandemic

India

challenges

oxygen shortage

vaccine distribution

aerobically fit

second wave

resources

management strategies

post-COVID syndrome

physical health

mental health