Questions answered by Nidhi Rohatgi, MD, Aruna Subramanian, MD, Angela Rogers, MD, Kari Nadeau, MD, Neera Ahuja, MD, Linda Barman, MD, SV Mahadevan, MD

Stanford Medicine faculty: Dr. Nidhi Rohatgi (twitter: @nrohatgi2) and Dr. Neera Ahuja (twitter: @neera_ahuja) practice General Medicine in the hospital setting, Dr. Aruna Subramanian (twitter: @ArunaSubraman12) is an Infectious Disease Specialist, Dr. Angela Rogers is an ICU physician and lung specialist, Dr. Kari Nadeau is an allergist and immunologist, Dr. Linda Barman practices General Medicine in the outpatient setting, and Dr. SV Mahadevan is an emergency medicine physician.

In this document, a panel of Stanford Medicine faculty who participated in the first Stanford-India COVID-19 Q&A webinar provide answers to additional questions that were sent by the attendees. Thanks again to >8500 people who registered for this event and sent us >1700 questions. We answered several of these questions during the webinar, several of them were answered in the chat by us during the live webinar, and here we provide answers to a few more. These are general considerations for educational purposes and do not replace the recommendations and clinical judgment of the local doctors.

This document has the following sections:

This document has been compiled as part of the Stanford Resources for the India COVID-19 Crisis page. To view the other resources there, click the button below.


Vaccines and antibodies

A 28 minute informational video on COVID-19 vaccines from Stanford Faculty, made for an Indian audience, intended to answer common questions.

We do not check antibodies. We don’t know what the numbers mean yet. There is a study underway currently to try to figure out if certain levels of antibodies imply immunity. We do not have those results yet and don’t know how to interpret antibody results. In addition, there are other important parts of the immune system, such as the T-cells, which help fight infections but aren’t measured in the antibody test. In summary, at this time we do not recommend getting antibodies checked. It may change in 6 months.

It takes about 2-3 weeks for immunity to develop after a dose of vaccine. Given the high prevalence of COVID in India at this time, we think masks, social distancing, hand hygiene, should continue. There is no difference between Covaxin and Covishield in terms of how quickly antibodies will develop after taking a dose

It is not known at this time how long natural immunity lasts after getting COVID-19. It typically does not last for longer than 3-6 months and it is not very strong. Therefore, everyone should get vaccinated, even those who got COVID-19 naturally before.

Depends on the local blood donation center policies. At Stanford, for blood donation, symptoms of COVID should have resolved and patient should have a negative PCR

Currently, there are no data on the safety and efficacy of COVID-19 vaccines in people who received monoclonal antibodies or convalescent plasma as part of COVID-19 treatment. Based on the estimated half-life of such therapies and evidence suggesting that reinfection is uncommon in the 90 days after initial infection, vaccination should be deferred for at least 90 days. This is a precautionary measure until additional information becomes available, to avoid potential interference of the antibody therapy with vaccine-induced immune responses. Source: https://www.cdc.gov/vaccines/covid-19/info-by-product/clinical-considerations.html

Vaccines will reduce the deaths and severe illness from COVID. The Spanish flu is VERY different than COVID and it went too fast to even develop a vaccine. We have evolved and our science is much more advanced than it was in 1918 so we should take the COVID vaccine and benefit from our progress in science. The Spanish flu was a different virus. It is substantially clear that COVID continues to move across the world and vaccines are the ONLY way to prevent the disease. We should not wait until 50 million people die like what happened in the case of the Spanish flu.

Pneumonia vaccine will reduce the chances of getting severe bacterial pneumonia but may not protect against COVID-19. They are completely different vaccines. Each one protects you against the infectious agent it was specified for.

As far as we know now, no additional vaccination may be needed at that time. The duration of immunity after COVID vaccine is yet to be determined

Continue the precautions as before at this time, unless the local government institutes different policies

It is an interesting question and we are looking into this but it is important to know that of the patients requiring hospital treatment, 80% had not been vaccinated and tended to be people with comorbidities.

Even if a family member has COVID, then other members can take the vaccine

At this time, a third booster dose has not been recommended and the decision to give or not give vaccine is not made based on the antibody levels

Yes, patients with these conditions should get the COVID-19 vaccine.

Herd immunity can occur through natural infection with COVID or with the vaccine or both. We need about 70% of the world to have immunity to COVID to receive the benefits publicly.

We think it may be coincidental that the timing of diagnosis of COVID is around the time of getting the vaccine. If the COVID clinic and vaccination clinic are in proximity and no masking or social distancing is occurring, then there may be a potential for exposure to the virus

No waiting period is recommended based on current data

Based on current data, there should not be a contraindication, please discuss with your local specialist

If you have not taken the first dose of vaccine and are currently infected with COVID, then you can get the COVID vaccine as soon as your symptoms resolve and isolation ends(https://www.cdc.gov/vaccines/covid-19/info-by-product/clinical-considerations.html).

If you get COVID after the first dose, then Covaxin can be taken 4-6 weeks from the first dose (as long as the symptoms of COVID have resolved and the patient is out of isolation). For Covishield, the second dose is recommended after 4-8 (even up to 12-16) weeks after the first dose (as long as the symptoms of COVID have resolved and the patient is out of isolation).

Because virus gets to grow/replicate in patients. Once a person is vaccinated, the chance of infection goes down drastically, and the chance that the virus will have the opportunity to grow/replicate in our bodies will be minimized.

From what we know, these vaccines have been effective and no ADE was noted

There are enough studies for COVID vaccines. There are as many studies for these COVID vaccines as there have been for other vaccines we use.

No, it does not reduce the effectiveness from what we understand

From what we know, no delay is recommended

Currently, we don’t have data on Covaxin and Covishield in children

We think the vaccine will be effective 

There is no need to stop blood thinners before COVID vaccine unless there is another medical reason to do so. Patients should continue their home medications (e.g., for diabetes, blood pressure, cholesterol) they were taking prior to COVID when they get COVID.

We don’t think so based on what we know at this time

We don’t think so based on what we know at this time. Multiple conditions can affect the menstrual cycle.

Patients with anaphylaxis to a vaccine in the past should not take the COVID vaccine. But if anaphylaxis was to another medication, then it should be ok to take COVID vaccine. Please check with local vaccine manufacturer recommendations.


Medications

Patients who are older or have lung, heart, liver, brain or kidney disease or have a weak immune system are at higher risk of getting severe COVID, along with obese and pregnant. Vaccines are the only way right now to protect us against severe illness, along with masking, instancing and isolation

Combination monoclonal antibodies (e.g., bamlanivimab + etesevimab, casirivimab + imdevimab) if given within 10 days of start of symptoms of COVID-19 in those with mild to moderate illness can be helpful in preventing progression to severe disease. This has only been found to be helpful for people who are at high risk for progression to severe disease due to age, weight, or underlying medical problems. Now with emergency authorization in India, they may be more widely available in the near future. 

There are no special protocols or medications just for the variants. Masking, isolation, hand hygiene, and getting the vaccine are most important. Avoid smoking and exposure to smoke/fumes.

We used dexamethasone 6 mg once daily for 10 days most commonly, but any other steroids that are available are ok (e.g., prednisone 40 mg per day, methylprednisolone 32 mg per day, or hydrocortisone 160 mg per day). We used this same dose for those on nasal cannula or high flow oxygen or noninvasive or invasive mechanical ventilation. The more important thing is to give steroids only if the patient needs at least 2 L/min of external oxygen to maintain an oxygen level of >90-92%.

We did not give steroids based on CRP level or levels of any other inflammatory markers. We only gave steroids to those who needed at least 2 L/min of oxygen to keep their oxygen levels ≥90%

Patients with COVID-19 can have fluctuations in their blood pressure or heart rate. Ensure they are not dehydrated (in which case fluids first), readings are accurate, machine is working properly, they are making urine or not and what color the urine is, is patient lethargic, patient did not take too much of their home blood pressure medications by mistake, they are not bleeding, not septic, they were not on steroids for too long and then abruptly discontinued. Would not give such high dose steroids to start. If blood pressure not improving and patient not looking good, then they need to be in the hospital for additional tests and medications

The most important study on steroids in COVID-19 (https://www.nejm.org/doi/full/10.1056/NEJMoa2021436) showed less deaths with dexamethasone only in those who were on oxygen. It did not show benefit of steroids in those with no oxygen need and may be even a potential for harm. We do not use CT score or inflammatory markers to decide who gets steroids, only with oxygen received steroids.

Steroids can increase the blood sugar and suppress the body’s ability to fight infections. 

We did not give pulse high-dose steroids. Refer to answer 4 above for doses.

Antibiotics (e.g., doxycycline, azithromycin) should be taken only if there is suspicion of bacterial infection (fevers, new phlegm in significant quantity, shortness of breath). High-dose steroids, especially in those with pre-existing immunocompromising conditions may increase the chance of getting bacterial infection, and antibiotics may be prescribed in these patients based on local practice. 

Antibiotics may have side effects (e.g., azithromycin can sometimes affect the heart, there is a chance of nausea, vomiting, diarrhea with antibiotics and may make things worse for the patient)

Steroids may not prevent oxygen levels from dropping immediately. We give steroids for 10 days (see response 4), but some patients were still on oxygen after that. We did not keep giving more steroids beyond these 10 days to most. Very rarely, we repeated steroids at the same dose one more time if there is extensive lung fibrosis with high oxygen requirement

Yes, if patient is needing oxygen

Inhaled budesonide may be helpful in moderate illness (or, even mild illness) and keep patients out of the hospital and shorten the time to recovery. 

Rinse your mouth after using inhaled steroids carefully to avoid thrush (examine your mouth for any white growth that is hard to peel off). Inhaled steroid may increase the chance of thrush (caused by a fungus called Candida albicans), especially if mouth is not rinsed after use. We are not aware of cases of mucormycosis with inhaled budesonide. 

In one study, patients with symptoms of COVID-19 (new onset cough and fever or anosmia, or both) within 7 days of start of symptoms showed benefit with inhaled budesonide (https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(21)00160-0/fulltext). These patients did not receive additional steroids by tablet or injection. 

In another study, inhaled budesonide showed benefit in non-hospitalized patients aged ≥65 years, or age ≥50 years with comorbidities, and unwell for ≤14 days with suspected COVID-19 (https://www.medrxiv.org/content/10.1101/2021.04.10.21254672v1.full.pdf).

It is ok to take any available inhaled steroids (see response 13 above) in combination with any available medications like salbutamol

If the oxygen level is low, then favor taking steroids by mouth over inhaled steroids. No need to take both inhaled steroids and by mouth

No definite data at this time for benefit with vitamins (C or D) or zinc in COVID-19. We did not prescribe it to our patients. If you have an open space, without smoke or too much pollution, then you can sit outside in the sun.

We did not use ivermectin for treatment or prevention of COVID-19 because of insufficient proof of benefit at this time (https://jamanetwork.com/journals/jama/fullarticle/2777389).

Antibiotics (e.g., doxycycline, azithromycin) should be taken only if there is suspicion of bacterial infection (fevers, new phlegm in significant quantity, shortness of breath). See response 10 above

Remdesivir was given to a few pregnant/lactating mothers at our institution and they tolerated it well. We only used it in pregnant patients when they were needing oxygen support, and carefully monitored patients for liver function abnormalities. 

Remdesivir was given only to those with oxygen levels ≤94% on room air. Usually, patients were needing ≥2 L/min of external oxygen to keep oxygen levels ≥90-92%. We did not give Remdesivir to those who only had abnormal chest x-ray or CT scan but no oxygen need. Remdesivir was not given in the outpatient setting and we were only admitting patients to the hospital who needed oxygen and/or breathing too fast or too dehydrated, etc

We did not

Tocilizumab is approved only for very sick patients within 24 hours of their being started on high flow oxygen (e.g., 30-40 L/min of oxygen) or mechanical ventilation and may reduce the chance of death in these patients (https://www.nejm.org/doi/full/10.1056/NEJMoa2100433). Since tocilizumab is given to severely ill patients, it is hard to say if the death was due to COVID or this medication.

We gave convalescent plasma rarely, early in disease, to those with immunocompromising condition. Convalescent plasma should not be given only in the hospital – infusion reactions, febrile hemolytic reactions, fluid buildup, and several side effects can occur. Plasma did not decrease the chance of death in COVID (https://www.nejm.org/doi/full/10.1056/nejmoa2031304 and https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)00897-7/fulltext).

The general consensus is that there is not enough evidence to support the use of Favipiravir for COVID-19 at this time. 

This is beyond the scope of our practice as allopathic doctors.

Baricitinib shortened the time to recovery, especially in patients on high-flow oxygen or noninvasive ventilation (18 days versus 10 days) (https://www.nejm.org/doi/full/10.1056/NEJMoa2031994). Baricitinib was given in combination with Remdesivir in this study

Yes, these are good medications for the treatment of mucormycosis, but the mainstay of treatment usually involves surgical debridement to remove the infected tissues and the antifungals are given in addition to surgery. 

There are insufficient data to recommend either for or against the use of fluvoxamine for the treatment of COVID-19 (https://www.covid19treatmentguidelines.nih.gov/immunomodulators/fluvoxamine/)

Bevacizumab needs to be studied in larger numbers of patients with COVID before it can be recommended. There was a very small study early in the pandemic which showed some promise. 

There is insufficient data at this time to recommend for or against colchicine in non-hospitalized patients with COVID-19 and it is recommended not to give colchicine in hospitalized patients with COVID-19 (https://www.covid19treatmentguidelines.nih.gov/immunomodulators/colchicine/)

We did not give hydroxychloroquine to our patients specifically for COVID. No data to show benefit (https://www.nejm.org/doi/full/10.1056/nejmoa2016638,https://www.acpjournals.org/doi/full/10.7326/M20-4207). More common side effects include nausea, vomiting, diarrhea, abdominal discomfort, which may make a patient feel even worse. 

Itolizumab was given emergency authorization for use in India based on a small study showing benefit to reduce the severe inflammatory response in COVID-19. We do not use it in the US, and believe it should only be used in the hospital in a monitored setting with caution. 

We did not give it to our patients due to limited studies at this time


Testing

RT-PCR can sometimes be negative in patients with active infection, more so in the early stages of illness. Symptoms are more important, especially since the rate of exposure to COVID-19 is currently very high in India. We could miss patients who don’t have symptoms but have COVID

Based on symptoms. We rarely repeat RT-PCR to assess for recovery. 

If the patient’s symptoms resolve, we do not repeat RT-PCR. If a patient developed new symptoms within 90 days from the start of initial symptoms, RT-PCR may be repeated if no alternate cause can be found (https://www.cdc.gov/coronavirus/2019-ncov/hcp/duration-isolation.html).

RT-PCR is more sensitive than rapid antigen testing. Exact numbers may depend on local laboratory and technology.

You can get RT-PCR on the first day of symptoms, if negative, still continue isolation and masking, and get repeat RT-PCR between days 2-12, if testing resources are available

SARS-CoV-2 could linger on for up to 12 weeks from start of symptoms but the chance of virus continuing to grow in our body decreases after 10-15 days from start of symptoms.

It may take as long as 14 days from exposure to start of symptoms, median time of 4-5 days.

Ct (cycle threshold) values on RT-PCR are not standardized and multiple factors may affect their accuracy and use. Ct number does not tell if a person is infectious or not (https://jcm.asm.org/content/58/11/e01695-20.long#sec-3)

Treat based on symptoms, signs, oxygen levels instead of blood tests

Oxygen level, risk factors, trajectory of illness (getting better or worse) and severity of symptoms are better than any laboratory marker

It is important to keep people’s blood sugar under good control and to avoid overuse of steroids and antibiotics to avoid the development of mucormycosis. If you develop black discharge from the nose, or cough with black or bloody sputum it is important to have an evaluation for this fungus. Testing involves obtaining specimens for cultures and pathology exams. 

We did CT scan of the chest only if oxygen was not improving after several days despite proning, rest, steroids, and any other medications we felt were needed for that particular patient. CT scan of chest was done to check for blood clots in lungs or extent of fibrosis most commonly. We did not use CT scores to determine clinical severity or disease progression. We did chest x-ray in those needing oxygen and rarely did CT scan of chest.


Clinical progression of illness

Oxygen levels of ≥90-92% are ok

There are a number of risk scores that have been developed for COVID progression, but by far the most important things to watch are: 

  1. How does the person look?  How short of breath are they (high respiratory rate, high work of breathing), and how much oxygen are they needing?  
  2. How high risk are they (especially age)?   A big reason to go to the hospital, if beds are available, is to carefully watch a person who is looking really short of breath for signs of tiring/needing more oxygen or even intubation.

Inhaled nitric oxide can help with Ventilation/Perfusion matching and can help patients with extremely low oxygen levels avoid the next step of care (if on high flow oxygen, to avoid intubation; if intubated, to avoid ECMO).  But it is usually very expensive, would only be used in the hospital setting, and has not been proven in non-COVID ARDS to improve outcomes.

Some patients are able to very slowly improve over time—even this long into illness, and if a patient doesn’t have scarring, the patient may still recover and get off ECMO.  Some patients develop scarring and are unlikely to ever come off ECMO;  then consideration of evaluation for lung transplant if available as an option has been occasionally considered in very selected patients

If the goal is to not pursue aggressive treatment and make the patient comfortable, then medications such as morphine and lorazepam can reduce unnecessary suffering at the end of life. 

These medications may allow for a more peaceful passing and death.

For some patients, fans at the face to decrease shortness of breath, playing familiar music or spiritual songs (if the patient prefers) may also help ease the suffering. If the patient/family believe in any religious rituals that can be safely implemented while social distancing and staying at home, then they can comfort the patient/family as well. 

We are very sorry for your loss.  COVID infection can present with fever and shortness of breath/ lung fluid especially if patients are very very sick. A blood clot in the lungs can present with sudden difficulty in breathing, drop in oxygen levels, especially in patients who have not been moving around much, or have other medical conditions that could make them more likely to develop blood clots. It takes at least a couple weeks to develop immunity in most after vaccination.  

Fever is a sign of infection

Occasionally chest pains, heart racing can happen with COVID, could be due to dehydration, worry, heartburn. If the chest pain is not going away or if you have any known heart problems, contact your local doctor

Antibiotics can be taken if significant sputum with fever/chills, shortness of breath, especially if any immunocompromising conditions are present. 

Cough suppressants can be taken as needed but caution against decongestant / benadryl containing medications in older patients as they can cause confusion, dizziness, sleepiness, dry mouth. Plain guaifenesin syrup, if available, may be the safer one to use

Most of our pregnant patients with COVID did well and delivered healthy babies

Even with all the available treatments, people may still progress and develop severe COVID-19.  The inflammatory response can be very severe even with steroids and other medicines to try to reduce the severity. 

The chance of black fungus is not higher than before 

Patients with COVID who have high blood pressure and diabetes should continue their medications. If there is cough/fever, then fever reducing medications or cough drops/syrups can be taken. 

The chance of reinfection with COVID has been reported to be very low. If 90 days have passed since the initial infection and patient is vaccinated, then the chance of reinfection is extremely low

Limit steroid use to only those who need ≥2L/min of external oxygen to maintain levels >90-92%. If you are using an oxygen concentrator but don’t have distilled water or cannot boil water, then don’t use the humidifier; take plenty of fluids by mouth to avoid dry mouth. Control blood sugars

High dose steroids may make the patient more likely to have fungal infection, especially if they have additional immunocompromising conditions, uncontrolled blood sugars. If using oxygen concentrators, patients should clean the humidifier bottle and oxygen tubing/masks as directed by the manufacturer and use distilled/boiled water (or, not use the humidifier bottle if clean water is not available)

This does not necessarily indicate a fungal infection. Please talk to your doctor about whether you need any further work up for a sinus infection. 

We do see mucormycosis in people who have iron overload and high ferritin so there may be some correlation. However, the high ferritin may be more of a marker of severe inflammation in these cases. High blood sugars are especially correlated with higher risk of fungal infections. 

Patients with immunocompromising conditions are at higher risk of black fungus

We admit patients who currently need external oxygen to keep levels 90-92% or are breathing too fast, not looking well, too dehydrated, lethargic. For those that don’t need the hospital, we ask them to keep an eye on their symptoms, temperature and oxygen levels and we call them frequently for the next few days to check in on them

Patients with lower oxygen are sicker

COVID is a very hard disease that can present in so many ways, all the way from many patients having no symptoms at all (but able to spread the virus) to being very sick on the ventilator, to having heart attacks and strokes. It is not specific to one group, very young, healthy people can have these devastating complications, as can older patients. Even after recovery from COVID, we have seen patients still develop blood clots.  And many people have long-term side effects.

CPAP mask has to be fitted to you to be sure it fits —a badly fitting mask would not work well.  CPAP can help give some extra oxygen, and some machines even have BIPAP settings (for extra help) but when a patient is very short of breath/needing more support, by far the safest place is in the hospital if one is available.

This is the overall inflammatory phase of the illness in which elevated cytokine levels are seen. 

Symptoms of flu and COVID can be very similar. Given the high number of COVID cases in India at this time, patient should be tested for COVID (can test for both flu and COVID)

COVID can affect multiple systems in the body, either the virus causing direct damage or triggering inflammation in the body that can affect many parts of the body

We did not give morphine for breathlessness unless the goal was to keep the patient comfortable near the end of their life. If a patient was getting agitated, we use haloperidol and any other antipsychotics very sparingly. We would first try to find the cause for agitation (e.g., electrolytes are abnormal, dehydration, constipation), engage their family on phone/facetime if possible, ensure they are able to sleep at night, mobilize (gentle walks or exercise in the bed or stand at the side of the bed or march in one place), reorient them frequently, keep lights on in the daytime


Blood thinners and D-dimer

This has not yet been proven, and is not at all our practice at Stanford, even for sick patients needing oxygen.

Because anticoagulants can cause bleeding and the studies to answer this question are still ongoing, we did not give blood thinners to our patients in the outpatient setting. We encouraged patients to keep walking as tolerated instead of always resting in bed while recovering from COVID.

These below are only applicable to patients who were not already on blood thinners for any other non-COVID medical conditions:

We give prevention dose of blood thinners to patients in the hospital.

Since there is a shortage of beds in India at this time and some patients with severe illness are being managed at home, we think prevention dose of blood thinner could be considered in these patients if their blood counts (CBC) and kidney tests are ok (e.g., enoxaparin 40 mg once daily or 30 mg twice a daily in obese patients). 

If enoxaparin is not available or too expensive or patient is excessively afraid of needles, and if blood counts (CBC) are ok, then NOACs may be considered (e.g., apixaban or Eliquis 2.5 mg twice a day, rivaroxaban or Xarelto 10 mg once daily)

More recent clinical trials being published suggest that blood thinner can be dangerous EVEN IN THE HOSPITAL for very sick/critically ill patients, regardless of the initial D-dimer. Taking blood thinners at home where there will be a major delay for dealing with bleeding complications is probably doing more harm than good.   

There is no evidence that this is helpful.  We do not follow D-dimer even in patients in the hospital, and certainly not at home.

The science behind these blood clots is not yet clear, but we are seeing clotting at higher rates than normal.

These rates are much, much higher than what has been reported in the medical literature.   The two biggest studies of anticoagulation in COVID are available below (and under review).  In patients with moderate disease, there is some benefit for anticoagulation BUT ONLY IN THE HOSPITAL. Many people are considering this at home, which has a very different chance of risk over  benefit:

https://www.medrxiv.org/content/10.1101/2021.03.10.21252749v1

https://www.medrxiv.org/content/10.1101/2021.05.13.21256846v1


Long COVID

Depends on the symptoms – up to 80% of the patients may have at least 1 residual symptom after recovery from acute illness with COVID-19. If ongoing lung sequelae: 6-minute walk test, lung function tests/spirometry, CT scan of the chest to assess severity of lung fibrosis. Watch out for any cardiac problems (rarer), problems with nausea, abdominal pain. Neurocognitive tests, and assess sleep, depression, anxiety, memory difficulties

10-15% of the patients may continue to have chest pain weeks/months after recovery from acute illness with COVID-19. Some of it may be related to anxiety or heart rate fluctuations after COVID

Skin changes/rash have been reported in 10-15% of the patients with COVID or after recovery from COVID. The rash would need to be assessed by the local doctor to determine if steroids may or may not be helpful after examining the rash

No medications have been shown yet to help with post-COVID lung fibrosis at this time.  Most lung fibrosis does not respond well to steroids, instead there may be a lot of infections instead with steroids and cause more harm

Anxiety, depression, memory difficulties, sleep disturbances have been reported weeks after recovery from acute illness with COVID. This is still an area under study

Patients with COVID may experience fatigue for weeks-months after COVID, even if they had mild illness

Up to 15-20% of the patients may experience excessive sweating weeks after recovery from acute illness with COVID.

Headache and fatigue are 2 of the most common symptoms noted weeks/months after recovery from acute illness with COVID-19. Up to 40-60% of the patients may experience these symptoms. Around 10% of the patients are noted to have brain fog or difficulty in memory and attention weeks/months after recovery from acute illness with COVID-19.  

Drink plenty of fluids, have fresh fruits and vegetables. Changing to vegetarian diet is a personal choice, unrelated to COVID

Patients with COVID can have new heart problems such as change in rhythm of the heart, inflammation/stress of the muscles of the heart, fluctuations in blood pressure or heart rate, blockage/clots in arteries or veins. However these are not as common and many of these heart problems may not be as long lasting once the patient recovers from COVID. This is still being studied.

Patients with a history of heart disease prior to COVID should continue their heart medications during and after COVID. 

Menstrual cycle can be changed by any illness or stress, including COVID. However it is still possible to get pregnant while having COVID. If your period does not come on time, check a pregnancy test


Masking, isolation, and home care

Any mask is better than no mask. A surgical mask can fit better if the loops are twisted around the ear or an additional cloth mask put on top of the surgical mask. N-95 is effective if getting exposed to patient with COVID 

If getting exposed to patient with COVID, face shield or regular glasses are ok but need to be wiped with a sanitizer with at least 60% alcohol after use

Infection can spread fast in a crowd, even with masking. Masks should cover the nose and fit around the sides of the face. Masking with social distancing is needed to prevent spread along with vaccination

Continue masking, distancing, isolation. If multiple family members have COVID, people with COVID should stay away from those who don’t have COVID. People who don’t have COVID in the family can wear eyeglasses or face shield in the home, if these are available. If there is enough space in the house, family members who started having symptoms of COVID earlier should stay separately from those who started having symptoms later. Avoid eating meals together. Family members with COVID should not cook for those without COVID. Avoid exposure to smoke while cooking if have COVID. Continue disinfecting surfaces in your home. Wash clothes in warm water and detergent. Wash your hands with soap and water multiple time a day, wash for at least 30-45 seconds each time. Avoid touching the outside part of masks and eyeglasses. Use disposable plates if possible. Change your toothbrush and tongue cleaner after you recover from COVID.

This is a good resource: https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/how-covid-spreads.html. COVID-19 spreads when an infected person breathes out droplets and very small particles that contain the virus. These droplets and particles can be breathed in by other people or land on their eyes, noses, or mouth. In some circumstances, they may contaminate surfaces they touch. People who are closer than 6 feet from the infected person are most likely to get infected.

COVID-19 is spread in three main ways: (a) Breathing in air when close to an infected person who is exhaling small droplets and particles that contain the virus, (b) Having these small droplets and particles that contain virus land on the eyes, nose, or mouth, especially through splashes and sprays like a cough or sneeze, and (c) Touching eyes, nose, or mouth with hands that have the virus on them.

Continue isolation till at least 10 days from start of symptoms and no fever (without fever reducing medicines) for 24 hours and other symptoms are improving. Occasionally, longer isolation to up to 20 days may be recommended if severe COVID or the patient has immunocompromising conditions. https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/isolation.html

Fever reducing medications such as paracetamol (maximum 4 grams in 24 hours) or brufen can be taken (if the patient does not have any medical conditions prohibiting their use – e.g., avoid paracetamol if significant liver disease (or take less than 2 grams in 24 hours), avoid brufen if kidney disease, bleeding or recent surgery). 

Depends on your oxygen need

Oxygen source should not be used near open flame, cigarette smoke. The concentrator should not be kept in the attic or basement where the temperatures may be high. As far as we know, air-conditioned rooms are ok unless there are certain specific instruction from the manufacturer. The concentrator should also be kept at least a feet away from furniture, so it can suck in air easily.

We use oxygen as needed to keep levels ≥90% for as many days as it takes. A strategy for home oxygen weaning is presented here: https://globalhealth.stanford.edu/wp-content/uploads/2021/05/Home-Oxygen-for-COVID-19-patients76-1.pdf

During acute illness, it can be difficult to do a 6-minute walk test. A 1-minute walk test may be sufficient if walking briskly. If oxygen drops below 95% or if you feel dizzy or have chest pain, call your doctor.

Few techniques: https://www.youtube.com/watch?v=BmvNCdpHUYM&t=7s

Helpline for healthcare workers: https://www.indiacovidsos.org/mentalhealth

We see that oxygen improved a lot with proning for our patients, and it is a part of our routine care.  Chest physiotherapy (percussing the chest with cupped hands) can really only help if a patient is having a lot of thick secretions that are difficult to clear.  It will not help with just low oxygen levels.  

Nebulizers can be used at home. Careful with aerosolization and increased spread of virus with nebulizers and CPAP/BiPAP – if possible, use nebulizer in an open verandah. Inhalers (and if easily available, with spacer) will have less aerosolization

Reduce the amount of carbohydrates in your meals. You may need to take higher dose of your diabetes medication if you are on any medications – discuss this with your local doctor. Good blood sugar control is very important. 

Ensure the battery in the pulse oximeter is working, fingers are warm, try different fingers, try a different pulse oximeter (if you have another one). 

Piroxicam or brufen (non-steroidals) can be used to reduce fever/pain in COVID as long as there are no known kidney problems, risk of bleeding, pregnancy, or other conditions where this class of medications should be avoided. Paracetamol can be used to reduce fever/pain in COVID unless there is a known liver problem or other conditions where this medication should be avoided. It is ok to take fever-reducing medications in COVID instead of getting dehydrated and tired with high fevers

Steam inhalation may give you some comfort in your throat but avoid excessive heat that may burn your mouth/throat. Steam inhalation will not kill the virus

Everyone should be wearing masks, isolate people at different stages of illness if possible in different areas of the home, wash hands with soap and water often, avoid eating meals together, clean surfaces with approved disinfectants (with focus on door knobs, light switches, phones, counters, that are frequently touched). Wiping surfaces with 60% alcohol sanitizer, using disposable plates if possible or washing dishes with warm water while wearing a mask, avoiding exposure to smoke (e.g., while cooking), washing clothes in warm-hot water if possible. If the toilet has a lid, then close the lid while flushing. A few other instructions are here: https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/disinfecting-your-home.html and https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/care-for-someone.htm

From American Dentistry Association: https://success.ada.org/~/media/CPS/Files/COVID/COVID-19_Int_Guidance_Summary.pdf?utm_source=adaorg&utm_medium=covid-resources-lp&utm_content=cv-pm-summary-guidance&utm_campaign=covid-19

Avoid alcohol as it can affect your liver (and COVID can affect your liver), in addition to abnormal blood counts, sleepiness/confusion, nutritional abnormalities, dehydration, and poor immune system


This document has been compiled as part of the Stanford Resources for the India COVID-19 Crisis page. To view the other resources there, click the button below.


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