BY Dr. Charuni Kohombange  As the pandemic continues, the World Health Organisation (WHO) reports over 211 million of confirmed Covid-19 cases and 4.4 million deaths across the globe, at the time of writing. According to the officially released reports of the Epidemiology Unit, more than 412,000 cases have been reported and the death count has surpassed the 8000 tragic landmark in Sri Lanka. With the rapidly spreading Delta variant, home-based management of mildly symptomatic patients was initiated as the health system is overwhelming. In general, patients are observed and managed for two weeks from the identification of the infection and discharged unless severe symptoms persist. However, the recovery from the Covid-19 infection may take time which may vary from person to person. This article aims to explain the sequel of recovery from the disease.  Post Covid-19 effects  Most of the people who contracted Covid-19, recover completely within a few weeks from the infection. However, some people even after having mild disease continue to experience certain symptoms after the initial recovery.  These symptoms may include: 

• Muscle weakness and joint stiffness 
• Extreme tiredness and lack of energy
• Persistent cough and breathlessness 
• Loss of appetite, weight loss, difficulty in swallowing
• Difficulty in sleeping, nightmares/flashbacks, particularly if the patient had been severely ill and hospitalised  
• Problems related to memory (For example, not being able to remember some events, think clearly and being forgetful) 
• Mood changes like anxiety and depression 

Managing the breathlessness Some patients may find continuing breathlessness after the initial recovery from the disease. If a person experiences this, it is important to seek medical advice to exclude any underlying pathology. If pathologies are excluded, breathlessness can be managed by adopting to certain modifications to one’s lifestyle;  Exercising to help managing breathing

• Breathing exercises: It can help to manage breathlessness and reduce its impact on the day-today activities. Take a slow breath through the nose and allow the air to fill up the chest and breathe out gently through lips 
• Breathing control while walking: By synchronising your breathing in and out with the stepping will reduce breathlessness while walking. It will help to walk in a flat and also to climb stairs and slopes 

Keep the environment well-ventilated  Make sure that you have good air circulation in the room by opening a window or door. Use a wet flannel to cool the area around your nose and mouth. This can help reduce the sensation of breathlessness. Managing the persistent cough Most patients complain of a dry cough, while some patients may present with a productive (chesty) cough.  The persistent dry cough can be relieved by staying well hydrated, sipping a warm drink and continuing of steam inhalation two times a day. If there is a persistent productive cough, trying to move around and positioning to drain out of the phlegm will help in addition to the hydration and steam inhalation.   Changes to the voice  If the patient has had excessive coughing for prolonged periods, their vocal cords may get swollen and inflamed.  As a result they may experience some changes to the sound of the voice, and may feel uncomfortable when talking as it may take an effort to produce the voice. These changes are similar to changes you would expect to experience with a cold or ‘flu’ but sometimes expected to be more intense and longer lasting taking six to eight weeks to gradually resolve.  Managing the voice changes 

• • Keep well hydrated and continue steam inhalation 
  • Avoid persistent, deliberate throat clearing as much as possible 
  • Chewing sugar-free gum or taking sugar-free sweets/lozenges will promote the saliva flow to lubricate the throat and reduce throat clearing 
  • Avoid smoking 
  • Talk for short periods at a time. Stop and take a break if your voice feels tired 
  • Always use your normal voice. Don’t worry if all that comes out is a whisper, just avoid straining to force the voice to sound louder 

 

• Avoid attempting to talk over background noises such as loud music and started engines, as this will force you to try raising the volume, which can be damaging 

  Prolonged tiredness/ fatigue after Covid-19  Since Covid-19 is a new virus, scientists and clinicians are on a steep learning curve about how it behaves and guidance is constantly evolving. One of the things that clinicians are becoming aware of is that a small proportion of people experience a range of ongoing symptoms following Covid-19 infection, including overwhelming fatigue or tiredness.  It is normal to have some degree of fatigue or weakness after any viral infection, which is known as ‘post viral fatigue’. Often it is short-lived and people return to normal within a few weeks. However, for some individuals a full return to health can take months rather than weeks which is referred to as ‘long Covid’.  From the existing knowledge of post viral fatigue and other previous similar viral infections such as SARS, there are some general principles around managing fatigue that can help in supporting the natural recovery process from Covid-19 infection.  The initial phase  For most infections, initial fatigue will be mild to moderate with recovery occurring over a week or two. During this initial phase it is important to;  Have adequate sleep: You may find that you need to sleep much more than you ever needed before and it is normal during an infection. Hence, sleep as much as you feel you need  Have adequate rest: This allows your body to focus on dealing with the infection. In this situation, rest means the periods of time during the day doing very little, physically or mentally. Even low-level activity such as TV or reading may need to be paced or minimised, depending on your level of illness.  Eat and hydrate: Have nutritious meals and drink fluids often as you can, increase your fluid intake if your appetite is low  Move: If you feel well enough, move at regular intervals throughout the day to keep your body and circulation moving. This could be simple stretches either in your bed or chair if you are unable to walk around  Pause your work/education: Allow yourself to fully recover from the initial infection before returning to your previous activity levels  The recovery phase  When people start to feel better after the initial infection, they are often enthusiastic to return to previous levels of work, leisure and social activities. However, if fatigue and other symptoms are continuing it is important to return to the routines more gradually and gently. Trying to do too much, too soon, can often be counter-productive. If you tend to overdo the activities as you will feel good, it can end up in an increase of symptoms, requiring you to rest. Therefore, the most important aspect of managing post infection fatigue is giving the body some time for recovering. This requires a combination of rest, relaxation and gentle activity.  Gradual adapting to the routines  Activity management: Activities should be balanced with periods of low-level gentle activity with periods of rest. You could start with some light activity followed by longer periods of rest. Mixing up the physical and mental activities throughout the day is also important  Setting the limits: The balance of activity management depends on each individual physical and psychological capacities and the stage of the recovery. Once you have sorted out the levels and extent of activities, do not exceed that limit  Rest: Body needs rest to help the healing and recovery process. Listen to your body and take as much rest as you need. Try to resume a pattern of sleep, mealtimes and activity. Avoid doing too much on a good day, since that might exacerbate the fatigue and other symptoms  Relaxation/meditation: Approaches such as mindfulness or relaxation/breathing techniques can help to aid restorative rest and help to release anxiety and stress  Diet: Maintaining a healthy diet with regular fluid intake will help to improve energy levels. It’s important to avoid caffeine and alcohol  Exercise: Depending on the stage of your recovery, some exercises such as gentle stretches, yoga or a short walk might be helpful. The athletes and people who usually do strenuous exercise, it is important to only do a small fraction of what you would normally do and at a gentle pace. Resume slowly and gradually increase over time as your illness improves  In most instances people do eventually recover from post-viral fatigue after a period of convalescence, but sometimes it can take many months. However, if your health condition is not improving, or if you continue to experience persistent symptoms after a few months that interfere with your capacity to carry out normal everyday activities, it is advisable to speak with your doctor and exclude any underlying illnesses.  Emotional impact  The experience of infection with Covid-19 can cause a massive psychological impact with all the stressful news and personal experiences. Whether you have had mild or severe symptoms, these are some common difficulties that you may be having: 

• Feeling anxious when breathless 
• Worries about health or about family or friends getting ill 
• Feeling low in mood 
• Poor sleep 
• If you were treated in a hospital or a treatment centre, you may also experience nightmares and feelings of panic with any reminders of the hospital  

It is important to know that these symptoms are quite normal following the infection and deal with them positively. Always speak to a family member or a friend and talk about your fears and experiences you had during the hospitalisation to release your worries. Avoiding watching too much news or social media will help to relieve anxiety. If these symptoms persist it is advisable to consult a psychiatrist.  Post Covid-19 diet  Often patients may find their taste and the appetite is lost during the infection and sometimes this can last over weeks. However it is important to eat and remain well hydrated to support the body for its recovery. If we do not eat and drink enough our body will use its natural stores of energy, protein, minerals and vitamins. In this instance, you may notice some weight loss or your muscles getting smaller and weaker. 

• Take a diet rich in proteins and energy: Protein foods include beans, pulses, fish, eggs, meat and other proteins. Eat more beans and pulses and reduce the intake of red and processed meat 
• Drinking more fluids: Set yourself a target to drink two liters of water each day. Try drinking at the end of the meal - drinking before or during a meal may cause you to feel too full 
• Try eating little and often: For example, choose smaller meals and snacks rather than three larger meals 
• Get enough vitamins and minerals: Different coloured fruits and vegetables contain their own combination of vitamins, minerals and fibre,  try to eat one portion from each colour group. Aim to take five fruits and vegetables per day 

More often, people tend to believe in food supplements for immunity boosting and recovery. However, there are no proven benefits in taking these food supplements and it is not necessary to take these if you take a balanced diet and keep well hydrated.  Smoking and Covid-19  Smoking increases the risk of developing a severe disease due to the damage caused to the immune system and lungs. Hence, smoking is linked with poor outcome from the disease. However, it is not too late to stop this habit and you can see the benefits of quitting within 24 hours.  Helpline for medical information on post Covid-19 management You can dial 247 from any mobile connection or 1247 from any land-line to contact a doctor and clarify any doubts. This is a toll-free service launched by the Sri Lanka Medical Association in collaboration with SLT Mobitel and Suwa Seriya.  The length of time that it takes to recover from Covid-19 varies from person to person, depending on their age and the severity of the symptoms they experienced. For some individuals it will be days and others it will last over weeks or months.  In the situation of ‘long Covid’ these symptoms may last even for more than three to six months. The symptoms that persists mostly are the shortness of breath, fatigue and cognitive dysfunction (brain fog). However, if you are still experiencing symptoms following six to eight weeks it is advisable to seek medical advice.  (The writer is a Medical Officer at the Directorate of Healthcare Quality and Safety at the Ministry of Health)