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:
- Vaccines and antibodies
- Clinical progression of illness
- Blood thinners and D-dimer
- Long COVID
- Masking, isolation, and home care
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
- This blog answers several of the questions: https://nidhirohatgi.medium.com/protecting-india-against-covid-19-through-vaccines-answers-to-frequently-asked-questions-3ffb98d32c6d
- This is another reliable source: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/facts.html
- Take the vaccine that is currently available to you, even if you got COVID-19, because allvaccines are equally effective at preventing severe illness or death, even with the variants in India.
- Antibody testing after getting COVID-19: Should you get it? If yes, when and how to interpret these numbers? Should I decide when I get the COVID-19 vaccine based on these number?
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.
- How long it will take for the antibodies to develop after the first dose and the second dose of the vaccine? Is it advisable that we can stop using masks or other precautionary measures after the antibodies are developed? Is there any difference between the two available vaccine in India, i.e., Covaxin and Covishield in the above-mentioned context?
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
- How long does immunity last for after getting COVID-19?
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.
- How long after COVID-19 can I donate blood? How long after COVID-19 vaccine can I donate blood?
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
- Why should we wait for 3 months to get the vaccine if we received monoclonal antibodies for COVID-19?
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
- The Spanish flu in 1918 ended without vaccinations, why do we need to take vaccines?
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.
- I have been taking pneumonia vaccine every 5 years, will it protect me against COVID-19, or protect me from getting bacterial infection with COVID-19 even if I get COVID?
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.
- I had the two doses of Moderna Vaccine in March in US but am now in India. How long will the immunity from my vaccine last? Will I have to get vaccinated again when I return to US few months later?
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
- I got both doses of Pfizer vaccine in US but am now in India. Will this vaccine protect me, or should I take all the precautions are before (masking, distancing, isolation)?
Continue the precautions as before at this time, unless the local government institutes different policies
- In Seychelles, >60% people are vaccinated, yet the COVID-19 cases are rising. Why?
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.
- If my family member has COVID but I don’t think I have it yet, should I get the vaccine or wait for some time? If wait, for how long?
Even if a family member has COVID, then other members can take the vaccine
- Should I try to get a third dose of vaccine (AstraZeneca) as a booster? Should I get my antibody level checked to make that decision and if yes, when should I get my antibody level checked?
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
- Should patients with immunocompromising, rheumatological conditions, or cancer get the COVID vaccine?
Yes, patients with these conditions should get the COVID-19 vaccine.
- Does herd immunity mean that some % of patients have to first be infected with COVID? What is that ?
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.
- Why are people getting diagnosed with COVID right after they take the vaccine? Is it because the COVID clinic is next to the vaccination clinic in some places?
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
- How long should I wait to get pregnant after getting the 2nd dose of vaccine?
No waiting period is recommended based on current data
- Is there any contraindication for autoimmune thyroiditis patients with anti-TPO antibody level >1500 unit for taking any type of COVID vaccine available in the market?
Based on current data, there should not be a contraindication, please discuss with your local specialist
- I got COVID after my first vaccine dose. I did not get monoclonal antibody. When can I take the second dose of vaccine? Should I wait 90 days or 4-8 weeks from my first dose or get it as soon as my symptoms resolve and I am out of isolation?
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).
- Why do mutations/variants happen?
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.
- The 2 vaccines currently available in India (AstraZeneca-Covishield, and Covaxin-inactivated-virus) are not in use in the USA. What’s known/assumed about the risk of Antibody-Disease Enhancement (ADE) with these coronavirus vaccines, specifically with the inactivated-virus type?
From what we know, these vaccines have been effective and no ADE was noted
- We should not take medicines that don’t have enough proof of effectiveness because there are not enough studies. But for vaccination, even if there is not enough studies, we are recommended to have vaccines. Why?
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.
- If I have to take steroids for another indication 2-3 days after the vaccine, does it reduce the effectiveness of the vaccine?
No, it does not reduce the effectiveness from what we understand
- For how long should I delay IVF treatment after the second dose?
From what we know, no delay is recommended
- Is it ok to give vaccine to my child with asthma and one with G6PD deficiency?
Currently, we don’t have data on Covaxin and Covishield in children
- Will the vaccine be effective if you took it within 4 weeks of COVID?
We think the vaccine will be effective
- I got COVID after the first dose, I was put on Apixaban for COVID. Should I stop Apixaban before taking the second dose of vaccine?
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.
- Will taking paracetamol reduce the efficacy of vaccine or how much antibody we make after COVID?
We don’t think so based on what we know at this time
- Do vaccines cause menstrual irregularity?
We don’t think so based on what we know at this time. Multiple conditions can affect the menstrual cycle.
- I had anaphylaxis last year, should I take the vaccine?
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.
- In terms of medications for COVID-19, less is more. If not sure if a medication is truly effective or not, don’t take it because it can be harmful.
- This blog answers several of the questions: https://nidhirohatgi.medium.com/managing-covid-19-in-india-breaking-through-the-myths-and-caring-at-home-7d541792b9c5
- This video provides detailed discussion about COVID-19 management with Stanford Medicine faculty: https://www.youtube.com/watch?v=JGI1RIv2Sec&t=51s
- Are controlled asthmatics or those with sinusitis more at risk? Who else is at risk and what can we do to protect them? Will vaccines work as effectively for me?
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
- Are monoclonal antibodies the best to treat COVID-19? I don’t have them in my city, what can I do?
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.
- Any special protocols or medications for the new variants? Is the replication pattern and pathogenicity different for these variants?
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.
- Which steroids are recommended? Is one steroid better than the other?
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%.
- Should I take steroids starting 5th day of COVID? Or, should I start taking steroids if C-reactive protein (CRP) is high (and at what level)?
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%
- We have discussed a lot about oxygen issues. In addition to lungs, COVID seems to be affecting other organs too. If a patient at home maintains oxygen above 90 but their BP falls (say to ~30 Diastolic, ~65-70 Systolic), and fluctuates between 30-55/65-90), what is a good course of treatment? Does a patient like this need hospitalization? What is this a sign of? Does a patient experiencing these symptoms need a high dose of steroids? What’s your reaction on injecting this patient with 500 mg of IV methylprednisolone?
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
- Will it not be too late if I wait for oxygen level to drop before taking steroids? We are prescribing steroids if CT score is high and inflammatory markers are high.
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.
- What are the side effects of steroids?
Steroids can increase the blood sugar and suppress the body’s ability to fight infections.
- Is there a role of pulse steroids for 3 days for a young patient with severe hypoxia (methylprednisolone 125-250 mg IV)?
We did not give pulse high-dose steroids. Refer to answer 4 above for doses.
- If I am prescribed steroids, should I start taking antibiotics, just in case?
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)
- I was given steroids, but my oxygen level still dropped, does it mean the steroids are not working for me?
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
- Can I take both steroids and Remdesivir?
Yes, if patient is needing oxygen
- Which patients can take inhaled budesonide? If I inhale steroids, are my chances of getting black fungus even higher?
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).
- What are your thoughts on combination of budesonide and formoterol (like Symbicort) for shortness of breath or chest pain during COVID?
It is ok to take any available inhaled steroids (see response 13 above) in combination with any available medications like salbutamol
- Is it ok to take both inhaled steroid and by mouth if my oxygen level is low?
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
- What dose of vitamin D should I take?
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.
- Ivermectin for prophylaxis? What are the side effects?
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).
- Should a COVID positive patient or one who is having symptoms suggestive of a likely infection, start on antibiotics like Azithromycin or Doxycycline?
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
- What was your experience using Remdesivir for pregnant/lactating mothers?
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.
- If the oxygen level is ok and CT score 12.5, should I take Remdesivir?
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
- Did you see bradycardia with Remdesivir?
We did not
- If I can’t find Remdesivir, can I give Tocilizumab instead? There were 3 deaths reported with Tocilizumab
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.
- What is the efficacy of convalescent plasma?
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).
- Is there international consensus on Favipiravir (Fabiflu)?
The general consensus is that there is not enough evidence to support the use of Favipiravir for COVID-19 at this time.
- Are ayurvedic/herbal medications effective for COVID?
This is beyond the scope of our practice as allopathic doctors.
- When do you give Baricitinib?
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
- Are Posaconazole or Liposomal amphotericin good medications for mucormycosis?
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.
- Can SSRIs such as Fluvoxamine help with mast cell stabilization?
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/)
- Please comment on bevacizumab in COVID.
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.
- Does colchicine have a role in cytokine storm?
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/)
- Can we use hydroxychloroquine?
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.
- Can you comment on Itolizumab?
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.
- Can we give methylene blue?
We did not give it to our patients due to limited studies at this time
- In general, we avoid blood tests unless the patient is severely ill or has other chronic medical conditions that may be affected. The role of inflammatory markers such as interleukin-6, lactate dehydrogenase, C-reactive protein, or ferritin is very limited. How the patient looks and what the oxygen levels are is much more important and helpful than a blood test. We do not repeat blood tests or RT-PCR after symptoms have improved. We discuss when to do CT scan in the webinar.
- Can a person infected with COVID-19 with fever and cough still have RT PCR negative?
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
- Since RT-PCR may not be the most accurate test for this strain, how does one ascertain the infection has subsided? Do I need a negative RT-PCR to show recovery?
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).
- What is the sensitivity of RT-PCR and Rapid antigen testing?
RT-PCR is more sensitive than rapid antigen testing. Exact numbers may depend on local laboratory and technology.
- When should I get RT-PCR – on the first day I have symptoms, or wait for 2-3 days?
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
- How long will it take for RT-PCR to become negative?
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.
- How many days after getting exposed to someone with COVID, could I get symptoms?
It may take as long as 14 days from exposure to start of symptoms, median time of 4-5 days.
- Does the Ct number on RT-PCR tell about transmission potential? Should I use Ct on RT-PCR to determine when to stop isolating?
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)
- If CRP rises suddenly to 18 after 11 days of COVID diagnosis, what all should I do?
Treat based on symptoms, signs, oxygen levels instead of blood tests
- Which is the better prognostic marker – CRP or D-dimer?
Oxygen level, risk factors, trajectory of illness (getting better or worse) and severity of symptoms are better than any laboratory marker
- Is there a test for early detection of black fungus? What symptoms to watch out for?
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.
- Can you comment on the timing and utility of CT scans? If HRCT shows CT severity score of 23 out of 25 and oxygen level is reading is around 60%, what is recommended immediately? Do you use CT score? Is there a similar score for chest x-ray?
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
- Proposed treatment plans for COVID-19 in India are posted here: https://globalhealth.stanford.edu/wp-content/uploads/2021/05/India-Covid-Treatment-Plan_14May2021.pdf
- Stanford treatment algorithm: https://globalhealth.stanford.edu/wp-content/uploads/2021/05/Stanford_covid-19guidanceMar52196-1.pdf
- Stanford proning protocol and ICU care: https://sites.google.com/view/stanfordcovid
- What is normal oxygen level on pulse oximeter?
Oxygen levels of ≥90-92% are ok
- Can we predict early on which patients will progress to severe acute respiratory distress syndrome (ARDS)?
There are a number of risk scores that have been developed for COVID progression, but by far the most important things to watch are:
- 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?
- 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.
- Role of inhaled nitric oxide?
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.
- My family member is in his 50s and diagnosed with COVID 6-7 weeks ago, got steroids, Remdesivir, antifungals, ventilator support, now on ECMO. Tracheal secretions were growing Aspergillus and Acinetobacter but that has cleared up. Has single organ failure, vitals are stable now, alert, doing physiotherapy. Last CT scan of chest still showing significant bilateral ground glass opacities and consolidations. What is recommended?
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
- My family member has been on the concentrator for 2 days now and cannot keep oxygen levels in the 90s without the oxygen concentrator. Oxygen drops to the low 80s without external oxygen. We decided not to go to the hospital, what can we do if the situation deteriorates (gasping for air) to ease the pain?
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.
- My family member was vaccinated with the second dose of Covishield but 7 days after this 2nd dose, he got high fever (no other symptoms). Five days after that, he got very short of breath suddenly and passed away. He had pink foam coming from his mouth before he passed. How did this happen? Why did this happen?
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.
- What does fever (with normal blood tests and normal oxygen) mean?
Fever is a sign of infection
- I don’t have fever and my vitals (temperature, blood pressure, heart rate, breathing rate) are ok. But my chest feels heavy and heart shivers. I am in my 20s. Should I get my heart checked?
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
- We are seeing fever in the initial stages in almost 80% of the patients but actual suffering starts on day 8-9 with strong cough and brown sputum. Should I take antibiotics?
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
- Should a pregnant woman continue her pregnancy if she gets COVID?
Most of our pregnant patients with COVID did well and delivered healthy babies
- My family member took azithromycin and doxycycline on day 1 after diagnosis, had a normal chest x-ray on Day 7, got steroids on Day 8 because of high fever, CRP was 144 on Day 10, oxygen level was >90% till Day 11 but then had to be taken to the hospital on Day 11 because of shortness of breath. CT chest showed severe pneumonia (CT score 21 out of 25). Why did my family member get so severe disease despite all these medications?
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.
- My child has nephrotic syndrome and is on low-dose steroids. We both are COVID positive, but our child is COVID negative. How can I reduce the chance of black fungus in my child?
The chance of black fungus is not higher than before
- I am older, history of high blood pressure and diabetes. I have had fever for 5 days, but oxygen level is >95% on room air. I already took doxycycline, ivermectin, vitamin C. What other medications should I take now?
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.
- Can I relapse and get COVID again? After how many weeks of getting COVID should I start feeling safe?
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
- Why is there so much black fungus?
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
- Is mucormycosis iatrogenic, opportunistic, or nosocomial?
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)
- I have bad smell in my nose, does this mean I have black fungus?
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 are seeing mucormycosis as the ferritin levels are coming down in those who had extremely high level of ferritin to start off. Is there a correlation?
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.
- I don’t have COVID, can I still get black fungus?
Patients with immunocompromising conditions are at higher risk of black fungus
- How do you decide who to admit to the hospital? We filled our hospitals with asymptomatic or mild illness patients when this started because patients are worried they may succumb to the disease in a few days, even if they don’t feel too sick right now and the beds may be taken away by the time they come back.
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
- Do patients with “happy hypoxia” (look good but oxygen level low) have worse outcomes?
Patients with lower oxygen are sicker
- Which group of patients got heart attacks or stroke 10-14 days after diagnosis of COVID? Is there a chance of cardiac arrest after recovery from COVID?
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.
- If I want to use CPAP in the interim while waiting for a bed, what level should I set it to?
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.
- Patients are crashing after 10 days – is that the cytokine storm?
This is the overall inflammatory phase of the illness in which elevated cytokine levels are seen.
- How can we distinguish normal flu from COVID?
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)
- Is the COVID virus in my blood? Why does it randomly affect not just lungs, but also heart, kidney, liver?
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
- For severe breathlessness and agitation, can we give morphine and haloperidol respectively?
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
- Should we give aspirin for prevention of blood clots to all patients with COVID-19?
This has not yet been proven, and is not at all our practice at Stanford, even for sick patients needing oxygen.
- What is the dose of anticoagulants for patients with COVID-19 – in outpatient and hospital setting?
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)
- If the D-dimer is as high as 8000 pg/mL post-COVID, what would be the appropriate blood thinner?
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.
- Should I keep getting D-dimer frequently even after I recover from COVID, I am afraid of dying from a blood clot?
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.
- Why are there blood clots with COVID?
The science behind these blood clots is not yet clear, but we are seeing clotting at higher rates than normal.
- I am in a big dilemma. Despite thromboprophylaxis, the rates of venous and arterial thrombosis are 16-34%. Is it prudent to give therapeutic anticoagulation in moderate to severe COVID? What about extended anticoagulation till 6 weeks with dabigatran or apixaban after COVID?
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:
- Symptoms, especially fatigue, can persist for ≥4 weeks after symptoms of COVID-19, even in those with mild illness. COVID-19 can affect many parts of the body.
- Video on Long COVID by Stanford Medicine researchers is posted here: https://www.youtube.com/watch?v=U08JHVAs3g4&t=2s
- Another excellent resource: https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-care/post-covid-conditions.html
- What tests should we do to track after acute severe COVID-19 symptoms have subsided?
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
- Can we get occasional chest pain after recovering from COVID-19? What does it mean?
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
- I got skin rash 3 weeks after COVID, but I am otherwise ok. Should I take steroids?
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
- Is there a medication for post-COVID lung fibrosis? I am currently prescribed oxygen for 20 hours a day, BiPAP, nebulization, and steroids
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
- Why are some patients feeling worthless and helpless even after they recovered from COVID?
Anxiety, depression, memory difficulties, sleep disturbances have been reported weeks after recovery from acute illness with COVID. This is still an area under study
- Why am I always feeling sleepy since recovering from COVID?
Patients with COVID may experience fatigue for weeks-months after COVID, even if they had mild illness
- Can I have too much sweating at night after recovering from COVID?
Up to 15-20% of the patients may experience excessive sweating weeks after recovery from acute illness with COVID.
- How common is brain fog or headache after COVID? What can we do?
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.
- What should we eat after COVID? Should we become vegetarian?
Drink plenty of fluids, have fresh fruits and vegetables. Changing to vegetarian diet is a personal choice, unrelated to COVID
- Are there heart problems in people after 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.
- Are there changes in menstrual cycle or vaginal irritation 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
- This blog answers several of the questions for home care: https://nidhirohatgi.medium.com/managing-covid-19-in-india-breaking-through-the-myths-and-caring-at-home-7d541792b9c5
- IndiaSOS has excellent resources for home care: https://www.indiacovidsos.org/home-care
- Few excellent resources for oxygen use at home: https://www.indiacovidsos.org/oxygen1 and https://globalhealth.stanford.edu/wp-content/uploads/2021/05/Home-Oxygen-for-COVID-19-patients76-1.pdf
- What type of masks are effective? Cloth, 3-layers of cloth, surgical mask, N-95?
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
- I don’t have a face shield, can I wear regular eyeglasses?
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
- Can 1 COVID patient infect >5000 people?
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
- What precautions can I take at home after I get COVID?
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.
- How does COVID spread? What does airborne mean?
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.
- For people exhibiting mild symptoms post-vaccination (both doses), what is the recommended isolation period? For how many days should I quarantine after getting COVID-19? I have COVID but no symptoms, HRCT was negative, can I stop isolating and go to work? Can I go to the gym?
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
- What is the treatment for fever (>100 F) without any other symptoms except some mucus after 1-12 days of getting COVID?
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).
- Are 5-liter oxygen concentrators good enough?
Depends on your oxygen need
- Should oxygen concentrators not be used in an air-conditioned room?
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.
- Does external oxygen cause harm after a few days?
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
- Should I check oxygen at home after 6-minute walking test? What numbers should worry me?
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.
- How can I manage anxiety?
Few techniques: https://www.youtube.com/watch?v=BmvNCdpHUYM&t=7s
Helpline for healthcare workers: https://www.indiacovidsos.org/mentalhealth
- Isn’t elevation of head much more effective than proning or laying on the side? Is there any other body posture or physiotherapy that may improve oxygen? Can chest therapy help? Can I massage the front and back of chest with cupped hands?
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.
- Can we use nebulizers at home?
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
- What can I do for high blood sugars with steroids?
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.
- What is the correct way to use a pulse oximeter?
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).
- What is the rationale for Piroxicam in COVID?
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
- Will steam inhalation help?
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
- How should I disinfect my home after I get COVID? How can family member protect themselves from getting COVID while caring for their family with COVID? What are the COVID-19 care precautions for elderly at home?
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
- Any precautions for dentists?
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
- Can I drink alcohol if I have COVID?
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.
Disclaimer: The information is provided for educational purposes and does not replace a treating physician’s judgment. The information and content in this article is produced using best evidence and Stanford Medicine protocols and policies. Our best effort has been put forth to provide quality information. Any errors, typographical errors, omissions, etc., are possible. Stanford Medicine does not claim to provide completely accurate information. You acknowledge and agree that the information contained herein is provided “as is” and without any warranty, condition, or representation of any kind.
The information and content on this website are produced using best evidence and Stanford Medicine protocols and policies. Our best effort has been put forth to provide quality information. Any errors, typographical errors, omissions, etc, are possible. Stanford Medicine does not claim to provide completely accurate information. You understand that by using our site and services, you acknowledge and agree that the information contained herein is provided “as is” and without any warranty, condition, or representation of any kind.
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