Pasca COVID-19 kronik

Diah Handayani
Covid update
Fakta dan data
 hospital,whosedifficultjourneytorecoveryisbetterunderstood. Theseareoftenphysicallyfit,younger

mj.m3392 on 3 September 2020. D

Twit er@fgodlee Thepeoplewhoreportpersistentexerciseintolerance,breathlessnessandcough, 3 anxiety,palpitations,and
FionaGodlee editorin chiefLiving with covid-19
BMJ

BMJ: first published as 10.1136/bmj.m3392 on 3 Septem

Citethis as: BMJ 2020;370:m3392 TwiCipoorconcentration.PaulGarnerdescribesboomandbust—theillusionofrecoveryonlytofallbackinto
fgodlee@bmj.com Follow Fiona on
tter @fgodlee
Fiona Godlee editor in chief
mentalandphysicalexhaustion.
te this as: BMJ 2020;370:m3392 4 Thesefalsedawnsaddtotheburdenfor“longhaulers,”hesays,which
“Deathi s nottheonlyadverseoutcomeofcovi d -19,”wri t esNi s reenAlwan,anepi
http://dx.doi.org/10.1136/bmj.m3392 “Death is not the only adverse outcome of covid-19,” writes Nisreen Alwan, an epidemiologist who is
http:/ dx.doi.org/10.1136/bmj.m3392 Publforhimincludesintensefatigue,moodswings,muscleandj
ished: 03 September 2020 experiencing a range of prolonged, fluctuating, andodebilitating
intpains,headaches,andbrainfog.
symptoms several months after her initial
mild illness.1 Like a growing number of people around the world, she has what is being called post-acute or
Published:03September2020 experiencingarangeofprolonged,fluctuati
long covid.
n g,anddebi
Oneofthemostdistressingaspectsoflivingwithlongcovid,saysGarner,isthedismissiveattitudeofsome l i t ati n gsymptomssevera
Whilemostpeoplerecoverquicklyandcompletelyfromthevirus,storiesofpersistentandtroublingsymptoms
1
mildillness. Lipeoplekeagrowi
have not fullynrecovered
gnumberofpeoplearoundtheworld,shehaswhati sb
Latar belakang doctors.Thismaychangeasmoredoctorsfindthemselvesaffected.Sohowshoulddoctorsrespondtotheir
have now moved from anecdote to the evidence of crowd sourced cohorts. Reports suggest that one in three
several weeks after initial illness. A smaller but still substantial proportion
patientsstrugglingwiththiscomplexandworryingmultisystemdisorder?TrishGreenhalghandcolleagues
have symptoms and difficulties that persist for months. These are not people who have been seriously ill in
longcovid. people who report persistent exercise intolerance, breathlessness and cough,3 anxiety, palpitations, and
hospital, whose difficult journey to recovery is better understood.2 These are often physically fit, younger
recommendtakingawholeperson,pragmaticapproachwithsymptommanagementthatavoids
overinvestigation.5 Withsomuchuncertaintyaboutthecauseandcourseoflongcovid,adoctor’
poor concentration. Paul Garner describes boom and bust—the illusion of recovery only to fall back into
s keyrole
While mostpeoplfor hime recoverqui cklymoodandcompl
swings, muscleeand
teljointy fromthevi
pains, headaches,rand
us,stori
brain fog. esofpersisten
mental and physical exhaustion.4 These false dawns add to the burden for “long haulers,” he says, which
istobeawitness,theysay,“‘ honouringthestory’ofthepatientwhoseprotractedrecoveryisunexpected,
includes intense fatigue,

alarming,anddoesnotmakesense. ” as more doctors find themselves affected. So how should doctors respond to their
havenowmovedfromanecdotetotheevidenceofcrowdsourcedcohorts.Reports
One of the most distressing aspects of living with long covid, says Garner, is the dismissive attitude of some
doctors. This may change
patientsstrugglingwiththiscomplexandworryingmultisystemdisorder?TrishGreenhalghandcolleagues
 –“very bizarre disease” that had
left him feeling “repeatedly
battered the first two months”
Long covid? and then experiencing lesser
episodes in the subsequent four
months with continual fatigue.
“Navigating help is really difficult
(PAUL GARNER)
 –Ketidak mampuan Kembali bekerja
normal
–Kehilangan pekerjaan
Dampak
Long covid –Keterbatasan interaksi dengan
keluarga
–Keterbatasan ekonomi,pangan dan
stigma
 There is no internationally agreed definition
of Long COVID
In early literature a variety of terms are used, includin
“post-COVID syndrome”. The National Institute for H
Long covidExcellence
and Clinical : (NICE), the Scottish Intercolleg
Definisi Guidelines
gejala danNetwork, and the Royal
tanda setelah College
kondisi akutof Gener
Practitioners include two conditions within the umbr
long covid-19 Covid (4-12(Ongoing
Long COVID minggu)symptomatic COVID-19: signs
symptoms
Post Covid of syndrome:
COVID-19 from 4 to 12 weeks; and Pos
COVID-19 syndrome: signs and symptoms that devel
gejala
during ordan tanda
after pada lebih
an infection dari 12
consistent with COVID-1
continue for more than 12 weeks and are not explain
minggu
an alternative diagnosis). The French Haute Autorité
Santé specifies three criteria to identify patients suffe
COVID-19 rapid guideline:
from "symptômes prolongés de la Covid-19": having
managing the long-term
effects of COVID-19

presented with a symptomatic form of Covid-19; pre

NICE guideline
Published: 18 December 2020

by 12 weeks after acute
not had one already and
y symptoms
ovid-19 leads to long term
ificant impact on quality
ce for National Statistics,
DEFINISI
sting positive for covid-19
od LONG COVID
of five weeks or more.1
determining best-practice
o commonly agreed
erm covid-19 exists, nor a
nt pathway. To assist
titute for Health and Care
tish Intercollegiate
established for monitoring and research. Box 1 gives
on 22 January 2021. Downloaded from http
definitions.
Box 1: Covid-19 definitions
• Acute covid-19 infection—Signs and symptoms of
covid-19 for up to four weeks
• Ongoing symptomatic covid-19—Signs and symptoms
of covid-19 present from four weeks and up to 12
weeks
• Post-covid-19 syndrome—Signs and symptoms that
develop during or after an infection consistent with
covid-19, present for more than 12 weeks and are not
attributable to alternative diagnoses
Identifying people with ongoing symptomatic
 In Switzerland, around a third of ambulatory patients had reported persisting fatigue in 40% of hospitalized patients,
persistent symptoms of COVID-19 between 30 and 45 days also 60 days after symptom onset, with breathlessness in
after diagnosis with COVID-19, with cough and loss of taste 30% (Carvalho-Schneider et al., 2020). Similarly,

–Table
NO DATA
2 Summary OF LONG
of selected COVID-19
studies on the prevalence of Long COVID in hospitalized patients postdischarge

NUMBER
COUNTRY STUDY OF CASES RESULTS
INCLUDED

• 51% had persistently reduced quality of life and 50% had shortness of breath at
Canada Wong et al. (2020) 78
12 weeks after symptom onset

Berapa banyak France

Carvalho-Schneider et
al. (2020)
130
• 40% reported persistent fatigue and 30% breathlessness at 60 days after
symptom onset

orang yang Italy

Carfì, Bernabei & Landi
(2020)
143 • 87% had symptoms, 55% had three or more symptoms at 60 days after discharge

mengalami Cruz et al. (2020) 119

• 68% reported persistent fatigue, 57% sleep disturbance and 32% breathlessness
at 60 days after discharge

LONG COVID-19 United Kingdom

Arnold et al. (2020) 110

• 74% had persistent symptoms, typically breathlessness and fatigue and 10% had
persistent anomalies on chest X-ray or respiratory function testing at 12 weeks
after discharge

• 19.9% were readmitted, 9.1% died and 27% were readmitted or died within
USA Donnelly et al. (2020) 2 179
60 days after discharge

• 76% reported persistent symptoms, and 50% had residual anomalies on chest
China Huang et al. (2021) 1 733
imaging 6 months after discharge

Source: Authors
Data di UK?
 –Semakin tua semakin berisiko
Siapa yang –Kerusakan paru luas dan berat
berisiko long saat di rawat
covid-19?
–perempuan
Proses
terjadinya
Long covid-19

Fig. 1. A e ie f he a h h doi:10.20944/preprints202012.0242.v1
Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 10 December 2020
i g , , a d e ia ea e i ed i g-
 REVIEW ARTICLE | FOCUS NATURE MEDICINE

Acute COVID-19 Post-acute COVID-19

Subacute/ongoing COVID-19 Chronic/post-COVID-19

Detection unlikely PCR positive PCR negative

Fatigue
Decline in quality of life
Muscular weakness
Joint pain

Dyspnea
Nasopharyngeal Cough
Persistent oxygen requirement

Proses Viral isolation from

respiratory tract
Anxiety/depression
Sleep disturbances
PTSD

terjadinya Viral load

Cognitive disturbances (brain fog)
Headaches

Long covid-19 Palpitations

Chest pain

SARS-CoV-2 Thromboembolism
exposure

Chronic kidney disease

Hair loss

Week –2 Week –1 Week 1 Week 2 Week 3 Week 4 Week 12 6 months

Before symptom onset After symptom onset

Fig. 1 | Timeline of post-acute COVID-19. Acute COVID-19 usually lasts until 4!weeks from the onset of symptoms, beyond which replication-competent
SARS-CoV-2 has not been isolated. Post-acute COVID-19 is defined as persistent symptoms and/or delayed or long-term complications beyond 4!weeks
Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 10 December 2020
from the onset of symptoms. The common symptoms observed indoi:10.20944/preprints202012.0242.v1
post-acute COVID-19 are summarized.
Spektrum long covid
• Miokardiopati, Gangguan ventrikel, emboli
kardiovaksular
Respirasi/paru • Penurunan fungsi paru, fibrosis, ILD

ginjal • Gagal ginjal akut

dermatologi • Rash, alopecia

• Disfungsi penciuman , pengecapan, gangguan tidur,

neurologi Penurunan kognitif. Gangguan memori

gangguan psikis • Depresi, Ansietas, Gangguan mood

https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-care/late-sequelae.html
Multimorbiditi
pasca COVID
Proses pasca SteardoJr. et al. Translational Psychiatry (2020)10:261 Page 3 of 12

covid-19 pada
otak

Fig. 1 Neuropsychiatric sequelae of COVID-19. The SARS-COV-2 enters the body through various routes and causes systemic and tissue
inflammation. Systemic inflammation compromises the blood-brain barrier (BBB) and floods the brain with pro-inflammatory factors. The virus may
also cross the BBB at the level of the circumventricular organs or through retrograde axonal transport via olfactory bulb and infect the brain, thus
instigating reactive gliosis, which leads to an increased production and secretion of cytokines and other pro-inflammatory factors. The combination
of systemic inflammation, hypoxia resulting from respiratory failure and neuroinflammation may trigger or exacerbate psychiatric diseases.

doses, only the CNS was disseminated5, strengthening the respiratory failure associated with COVID-19 identified
concept of an intrinsic neurotropism of coronaviruses. In SARS-COV-2 viral particles in the olfactory nerve, in the
 Fig. 1 The long-term effects of COVID-19

FATIGUE

HEADACHE LOSS OF SMELL

TINNITUS PERSISTENT COUGH

Gejala
CHEST PAIN
HEART INFLAMMATION
SHORTNESS OF BREATH
PALPITATIONS
5–20%
OF PATIENTS WILL
HAVE SYMPTOMS
MUSCLE PAIN DIARRHOEA LASTING OVER
PINS AND NEEDLES ABDOMINAL PAIN FOUR WEEKS

FORGETFULNESS RASH
DEPRESSION RECURRENT FEVER
Long covid-19
in primary care
Long covid-19
in primary care
 Belum
Pengobatan
ada
obatnya
 ha ace ica d g , bi ic a d ebi ic ha e bee ed
19, i g i fa ab e afe fi e i h be efi f e ic i
a i eg a i (O ai a e a . 2020).

Tab e 2. The e ia d g ha a be e ed f g-ha C

D g Mecha i f ac i P
i e
COV
Ri a i d D b e- a ded RNA ec e ac i g a I
TLR3 ag i e he d c i ME
f -i f a a c i e ia he g
M D88-i de e de c ic TRIF f d
a h a (Mi che 2016). a d
(S

I
e
O a adi e Ma ce abi i e a d hi a i e H1 I
ece a ag i i hibi hi a i e MC
e ea e (Ka i e e a . 2010). g
Ke ife Ma ce abi i e , e i hi i hibi , f fa

Pengobatan C a i h ci
a d hi
1990).
A ibi
i hibi
a

ic,
i e H1 a

f e
a ce
ag i (G a

abi i e , a d
hi a d e i hi
e a .
i
Ka
a

e i a b (B c e a . 2005; I
Ka a a e a . 2016). e
H d c i e C i ha i hibi GR-de e de -
i f a a a h a (O e e a .
2016).
De a e ha e L g- a i g g c c ic id ha i hibi
GR-de e de -i f a a
a h a (C c e a . 2005).
Ni eda ib S a ec e a ag i f FGFR, I
PDGFR, a d VEGFR i hibi he
ife a i f fib b a (W i e a . a . 2
2015).
Pi fe id e S a ec e i hibi f TGF- 1- I
de e de i a i f - e
i f a a c i e a d fib b a
ife a i (R a a e a . 2020).
 Ch eca cife Vi a i D3 ha eg a e he i e I
e a d RAS e e e ce i e C V
i fa a i a d b ad i i he
acc a i , e ec i e (A a 2011;
Ga i e a . 2020). I
c ea
e
202

Treatment I

candidate Pe
202
P bi ic a d P bi ic a e i e ic ga i ha I
ebi ic ide hea h be efi he c ed a g
ade a e a , i g hei 202
d a effec he g
ic bi e. P ebi ic efe b ae I
ha he g h fc e a g f
bac e ia (O ai a e a . 2020).
(O
Abb e ia i : FGFR; fib b a g h fac ece ; GR, g c
 690 Figure 1: Natural history of long COVID, the COVERSCAN study in low-risk individuals (n=201) and policy recommendations.
1 Multi-organ impairment in low-risk individuals with long COVID
medRxiv preprint doi: https://doi.org/10.1101/2020.10.14.20212555; this version posted October 16, 2020. The copyright holder for this preprint
(which was not certified by peer review) is the author/funder, who has granted 1
2 Andrea Dennis PhD , Head of Biomarker Science, Perspectum medRxiv a license to display the preprint in perpetuity.
It is made available under a CC-BY-NC-ND 4.0 International license .

3 andrea.dennis@perspectum.com
694 2, 3
Figure 2: Proportion of low-risk individuals with long-COVID by hospitalisation (n=201) for (a)
4
695 Malgorzata Wamil PhD
symptoms; and (b) evidence of organ impairment. , Consultant Cardiologist gosia.wamil@googlemail
5
696
697 (a)
Sandeep Kapur MBBS4, Associate Medical Director kapur.sandeep@mayo.
6 Johann Alberts MBBCh5, Medical Director jalberts@alliance.co.uk
7 Andrew D. Badley MD6, Professor of Medicine & Chair, Mayo Clinic COVID
8 Taskforce badley.andrew@mayo.edu
9 Gustav Anton Decker MBBCh6, President, Mayo Clinic International
MULTI ORGAN 10 decker.anton@mayo.edu
Stacey A Rizza6, Professor of Medicine Rizza.stacey@mayo.edu
IMPAIRMENT IN 11
12 Rajarshi Banerjee DPhil* 1,3
medRxiv preprint doi: https://doi.org/10.1101/2020.10.14.20212555; this version posted October 16, 2020. The copyright holder for this pr
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuit
, Chief Executive and Honorary Consultant Phys It is made available under a CC-BY-NC-ND 4.0 International license .

LONG COVID 13 rajarshi.banerjee@perspectum.com

694 Figure 2: Proportion of low-risk individuals with long-COVID by hospitalisation (n=201) for (a)
695 symptoms; and (b) evidence of organ impairment.
7,8,9
14
698 Amitava Banerjee DPhil* , Associate
696 Professor of Clinical Data Science a
699 (b) 697 (a)

15 Consultant Cardiologist ami.banerjee@ucl.ac.uk

16 691On behalf of the COVERSCAN study investigators (listed at the end of manu
692
17
6931
18 Perspectum, 5520 John Smith Drive, Oxford, OX4 2LL, UK
2
19 Great Western Hospitals NHS Foundation Trust
3
20 Oxford University Hospitals NHS Foundation Trust
4
21 Mayo Clinic Healthcare, 15 Portland Pl, Marylebone, London W1B 1PT
5
22 Alliance Medical Limited, Iceni Centre, Warwick Technology Park, Warwick
6
23 Mayo Clinic | 200 First Street SW, Rochester, MN 55905
7
24
700 Institute of Health Informatics, University
698
medRxiv
College London, 222 Euston Road
preprint doi: https://doi.org/10.1101/2020.10.14.20212555; this version posted October 16, 2020
8 699 (b)
25
701 University College London Hospitals NHS Trust,
(which was not certified 235
by peer review) is theEuston
author/funder, whoRoad, London
has granted medRxiv a license to
Manajemen
terpadu
 – Long covid-19 muncul di berbagai organ
– Long covid-19 membutuhkan penanganan
seksama
kesimpulan – Long covid-19 memberi dampak psikis,
ekonomi dan social
– Butuh dukungan keluarga setelah perawatan
COVID