Protocolo Post-Covid Malasia 2021

1st Edition 2021
ANNEX 50
iv POST COVID-19 MANAGEMENT PROTOCOL
Advisors
Tan Sri Dato’ Seri Dr Noor Hisham Abdullah

Director General of Health
Ministry of Health
Dato’ Dr Norhizan Ismail

Deputy Director General of Health (Medical)
Ministry of Health
Datuk Dr Chong Chee Keong

Deputy Director General of Health (Public Health)
Ministry of Health
Datuk Dr Hishamshah Mohd Ibrahim

Deputy Director General of Health (Research and Technical Support)
Ministry of Health
Dr Ahmad Razid Salleh

Director
Medical Development Division
Ministry of Health
Datuk Dr Norhaya" Rusli

Director
Disease Control Division
Ministry of Health
Dr Khebir Verasahib
Director
Family Health Development Division
Ministry of Health
Da"n Seri Dr Asmah Samat

Senior Deputy Director
Ministry of Health
Dr Nazrila Hairizan Nasir

Deputy Director
Family Health Development Division
Ministry of Health
Dr Nor’Aishah Abu Bakar

Deputy Director
Ministry of Health
POST COVID-19 MANAGEMENT PROTOCOL v
List of Contributors
Dato’ Dr Mahiran Mustafa Dr Thahira A Jamal Mohamed

Dato’ Dr Ong Loke Meng Dr Nik Khairulddin Nik Yusoff
Dr G. Letchuman Ramanathan Dr Saari Mohamad Ya"m
Datuk Dr Zanariah Hussein Dr Akmal Hafizah Zamli
Dr Ravichandran Jeganathan Dr Ahmad Rostam Md Zin
Dr Mollyza Mohd Zain Dr Adlin Salleh
Dato’ Dr Suresh Kumar Chidambaram Dr Muniswaran Ganesham @ Ganeshan
Dr Kalaiarasu M. Peariasamy Dr Liza Mohd Isa
Dr Sabeera Begum Kader Ibrahim Dr Noor Aziah Zainal Abidin
Dato’ Dr Noel Thomas Dr Salina Md Taib
Dr Asri Rangga Ramaiah Abdullah Dr Suraya Amir Husin
Dr Ridzuan Dato’ Mohd Isa Dr Fatanah Ismail
Dr Shan" Rudra Deva Dr Rachel Koshy Kallumadiyil Geevarghese Koshy
Prof Dr Goh Bak Leong Dr Suraihan Sulaiman
Dr Wong Hin Seng Dr Mohamad Ariff Fahmi Ahmad Zawawi
Dr Tan Swee Looi Dr Radhiyah Hussin
Dr Rosnawa" Yahya Dr Nor Mashitah Jobli
Dr Haniza Omar Dr Sangeeta Subramaniam
Dr Ros Suzanna Ahmad Bustaman Dr Nor Azilah Abu Bakar
Dr Jeyaseelan Nachiappan Dr Ana Fizalinda Abdullah Sani
Dr Fong Siew Moy Dr Umawathy Sundrajoo
Dr Sharmini Diana Parampalam Dr Si" Zubaidah Ahmad Subki
Dr Ir#an Ali Hyder Ali Dr Shahanizan Mohd Zin
Dr Zaiton Yahaya Dr Puteri Aida Alyani Mohamed Ismail
Dr Ker Hong Bee Dr Nazihah Rejab
Dr Leong Chee Loon Dr Zafferina Zulghaffar
Dr Aishah Ibrahim Dr Sarah Shaikh Abdul Karim
Dr Chow Ting Soo Dr Stefanie Hung Kar Yan
Dr Carol Lim Kar Koong Dr Alan Pok Wen Kin
Dr Tang Min Moon Dr Ahmad Rostam Md Zin
Dr Azah Abdul Samad Dr Syazatul Syakirin Sirol Aflah
Dr See Kwee Ching Dr Hema Yamini Devi Ramarmuty
vi POST COVID-19 MANAGEMENT PROTOCOL
Dr Nor Zaila Zaidan Dr Elizabeth Chong Gar Mit

Dr Lim Lay Ang Dr Syahiskandar Sybil Shah
Dr Nurul Akmanidar Zainuddin Dr Thor Ju An
Dr Nasibah Tuan Yaacob Dr Sara Aley Easaw
Dr Nurmaimun Musni Dr Nik Farah Nik Yusof Fuad
Dr Ng Tiang Koi Dr Muhammad Akmal Mohd Nor
Dr Nor Arisah Misnan Dr Natasha Subhas
Dr Lavitha Vyvegananthan Dr Khairil Erwan Khalid
Dr Hemavathy Ramachandram Dr Rahimah Ibrahim
Dr Albert Iruthiaraj L.Anthony Dr Rizah Mazzuin Razali
Dr Noorul Afidza Muhammad Dr Mohd Hafiz Norzan
Dr Yap Mei Hoon Dr Si" Suhaila Hamzah
Dr Aisya Natasya Musa Dr Rohaya Abdullah
Dr Sarah Jane Chan Jia Chyi Dr Suriana Aishah Zainal
Dr Sathya Rao Jogulu Dr Jafanita Jamaludin
Dr Nicholas M Jagang Dr Muhamad AlAmin Safri
Dr Grace Jikinong Dr Mohd Aizuddin Abdul Rahman
Dr Mohd Adam Mohd Akil Dr Tan Li Peng
Dr Tan Gi Ni Dr Muhamad Aadiyat Abdul Hamid
Dr Yogeeta Gunasagran Dr Noor Amelia Abd Rasid
Dr Maizatul Azma Masri Dr Mohan Dass Pathmanathan
Dr Eddie Wong Dr Wong Xin Ci
Dr Si$ Sulhoon Mohamed Pn Juliana Ibrahim
Dr Pazlida Pauzi Cik Nur Hazrina Iderus
Dr David Ng Chun Ern
POST COVID-19 MANAGEMENT PROTOCOL vii
Secretariat
Dr Salina Md Taib
Public Health Physician
Medical Service Unit Medical Development Division
Dr Suraya Amir Husin

Senior Principal Assistant Director &
Head of Infec"on Control Unit
Dr Shahanizan Mohd Zin

Senior Principal Assistant Director &
Head of Medical Service Unit
Dr Nor Farah Bakh"ar

Senior Principal Assistant Director
Infec"on Control Unit
Dr Sara Sofia Yahya

Principal Assistant Director
Suhaily Othman
Nursing Matron
Norhanida Shariffudin
Nursing Sister
Che Liza Che Abdullah

Nursing Sister
Chung Yun Mui @ Suzanna

Administra"ve Assistant (Clerical/Opera"on)
Medical Service Unit
CONTENT
Foreword iii
Advisors iv
List of contributors v
Secretariats vii
Content: Chapters viii
List of Tables xi
List of Figures xii
List of Abbrevia"ons xiv
CHAPTERS
General Post COVID19 Management 1

1.0 Introduc"on
2.0 Jus"fica"on
3.0 Scope
4.0 Objec"ve
5.0 Opera"onal defini"ons
6.0 Symptoms of Post COVID19 pa"ents
CHAPTER 1 7.0 Assessment
8.0 Iden"fy phases of Post COVID19 cases
9.0 Inves"ga"on
10.0 Management
11.0 Pa"ent’s outcomes and assessment tools
12.0 Conclusion
13.0 Appendix
14.0 References
Post COVID19 Management Protocol In Primary Care 14

1.0 Introduc"on
2.0 Scope
3.0 Symptoms
4.0 Assessment and management
a. Respiratory
b. Cardiovascular
CHAPTER 2 c. Neurology
d. Psychiatry and mental health
e. Rehabilita"on / musculoskeletal
f. Geriatric popula"on (60 years and above)
5.0 Pa"ent’s outcome
6.0 References
Post COVID19 Respiratory Management Protocol 43
1.0 Introduc"on
2.0 Scope and objec"ve
CHAPTER 3 3.0 Symptoms
4.0 Assessment (Clinical assessment and inves"ga"on)
5.0 Management
6.0 Pa"ent’s outcome and assessment tools
7.0 References
Organizing Pneumonia In COVID19 54

1.0 Introduc"on
2.0 Scope
3.0 Sign and symptoms
CHAPTER 4 4.0 Inves"ga"on
5.0 Diagnosis
6.0 Treatment and management
7.0 Follow up
8.0 References
Post COVID19 Management Protocol For 62

Immunocompromised Pa"ent On
Immunosuppresant / Chemotherapy
1.0 Introduc"on
CHAPTER 5 2.0 Autoimmune diseases
3.0 Solid organ transplant
4.0 Haematology
5.0 Oncology
6.0 References
Post COVID19 Management Protocol For 75

Kidney Diseases
1.0 Introduc"on
2.0 Scope
4.0 Assessment (Clinical assessment and inves"ga"on)
5.0 Management
6.0 Pa"ent’s outcome and assessment tools
7.0 References
Post COVID19 Management And Protocol In 91

Obstetrics Pa"ent
1.0 Introduc"on
2.0 Scope
CHAPTER 7 3.0 Objec"ve
4.0 Plan of ac"on
a. Following Acute COVID19 infec"on during antenatal period
b. Following Acute COVID19 infec"on during peripartum period
c. Following Acute COVID19 infec"on during puerperium
6.0 References
Post COVID19 Management And Protocol In Children 99
1.0 Introduc"on
2.0 Scope
4.0 Assessment
5.0 Management
6.0 References
Post COVID19 Follow Up Rehabilita"on 106

Recommenda"ons
1.0 Introduc"on
2.0 Jus"fica"on
3.0 Scope
4.0 Objec"ve
5.0 Follow up loca"on
CHAPTER 9 6.0 Symptoms of Post COVID19 pa"ents
7.0 Assessment
9.0 Inves"ga"on
10.0 Management
11.0 Monitoring and Evalua"on / Surveillance
12.0 Standardized Outcome Measures
13.0 Conclusion
14.0 References
Management Of Psychological Issues In 144

Post COVID19 Infec"on
1.0 Introduc"on
2.0 Trauma related issue
a. Adjustment disorder
b. Posttrauma"c stress disorder (PTSD) & acute stress
disorder (ASD)
CHAPTER 10 c. Posttrauma"c stress disorder (PTSD) & acute stress
disorder (ASD)
3.0 Grief and loss
4.0 Underlying Mental Health Issues
5.0 S"gma and isola"on
6.0 Emergence of Mental Health Disorder
7.0 Psychiatry condi"ons that require Psychiatry Referral
8.0 References
APPENDIX
Appendix 1 Post COVID19 (Category 4 And 5) Management Flow Chart at Hospitals / Ins"tu"ons 154
Appendix 2 Management Flow Chart For WalkIn Post COVID19 Pa"ents 155
Appendix 3 COVID19 Pa"ent’s Discharge Note 156
Appendix 4 Post COVID19 Referral Le&er 157
Appendix 5 Clerking Sheet For Post COVID19 Pa"ents 159
List of Tables
Table 1.1 COVID19 infec"on further classified into clinical categories 2

Table 1.2 COVID19 specific significant sequelae 5
Table 2.1 Whooley Ques"onnaire (Malay Version) 18
Table 2.2 Pa"ent Health Ques"onnaire – PHQ2 (Malay Version) 19
Table 2.3 Modified Barthei Index 32
Table 2.4 Fall Risk Increasing Drugs (FRIDs) 40
Table 3.1 Post COVID19 followup 44
Table 3.2 Modified Medical Research Council (mMRC) Scale for Dyspnoea 45
and Post COVID19 Func"onal Status (PCFS) Scale.
Table 3.3 Post COVID19 respiratory assessment should include the following 45
Inves"ga"ons
Table 3.4 Other assessment 46
Table 3.5 Indica"on to con"nue or to ini"ate LTOT 50
Table 3.6 Modified medical research council scale for dyspnoea 51
Table 5.1 Immunosuppressants in Transplant, Autoimmune and Inflammatory Condi"ons, 63
and Oncology in Post COVID19 Management
Table 5.2 Recommenda"ons for treatment of hematological malignancies during 68
COVID19 pandemic
Table 5.3 Summary of Results 73
Table 6.1 Nephrology Post COVID19 Clerking Sheet 80
Table 6.2 Suggested Followup Schedule for Long COVID with Nephropathy 82
Table 6.3 Follow Up Schedule 83
Table 6.4 Post COVID19 Management Protocol for Kidney Diseases: Work Process 85
Table 7.1 Two Ques"ons on Depression and One Ques"on on HELP (Malay Version) 97
Table 8.1 Symptoms of Post COVID19 in Peadiatrics 100
Table 9.1 Referral process and management principle of rehabilita"on process 110
Table 9.2 Symptom Relieving Posi"ons 116
Table 9.3 Breathing techniques 118
Table 9.4 Warm Up Exercises 120
Table 9.5 Aerobic Exercises 123
Table 9.6 Strengthening Exercises 125
Table 9.7 Cool Down Exercises 128
Table 9.8 Managing Cogni"ve Issues 131
Table 9.9 Managing Stress and Emo"onal Health 132
Table 9.10 Managing Fa"gue 134
Table 9.11 Managing Ac"vi"es of Daily Living and Improving Quality of Life 135
Table 9.12 Suggested Surveillance Checklist Ques"ons 138
Table 9.13 Home Exercise Diary and Monitoring Log 139
Table 9.14 Monitoring Exercise Intensity 140
Table 9.15 COVID19 Rehabilita"on Database Template 141
List of Figures
Figure 1.1 Possible common symptoms a'er acute COVID19 (but are not limited to) 3
Figure 1.2 Timeline of PostAcute COVID19 4
Figure 1.3 Outcome a'er 4 weeks of ini"al onset of acute COVID19 symptoms 5
Figure 1.4 Types and frequency of symptoms experienced by survivors with ongoing
symptoma"c COVID19 5
Figure 1.5 Outcome a'er 12 weeks of ini"al onset of acute COVID19 symptoms 5
Figure 1.6 Types and frequency of symptoms experienced by survivors with Post COVID19
syndrome 5
Figure 2.1 Pa"ent Health Ques"onnaire 9 – PHQ9 19
Figure 2.2 Depression Anxiety Stress Scale 21 (DASS 21) (Malay Version) 20
Figure 2.3 Generalized Anxiety Disorder 7 (GAD7 Anxiety) 23
Figure 2.4 Scoring notes on PHQ9 Depression Severity and Generalized Anxiety Disorder 7 23
(GAD7 Anxiety)
Figure 2.5 Fa"gue Severity Scale (FSS) 25
Figure 2.6 Visual Analogue Fa"gue Scale (VAFS) 26
Figure 2.7 Mini Cogni"ve Instruments (MiniCog) 31
Figure 2.8 Modified Borg Scale 33
Figure 2.9 Guidance on Exercise Rehabilita"on in Postacute COVID19 34
Figure 2.10 Clinical Frailty Scale 35
Figure 2.11 Early Cogni"ve Assessment Ques"onnaire ECAQ 36
Figure 2.12 Mini Mental State Examina"on (Malay Version) 37
Figure 2.13 Geriatric Depression Scale (short form) 38
Figure 2.14 Montreal Cogni"ve Assessment (MoCA) (Malay Version) 39
Figure 3.1 Algorithm Post COVID19 Stage 3 48
Figure 3.2 Algorithm Post COVID19 Pa"ent with Severe Disease (Stage 4&5) 49
(including pa"ent discharged with prednisolone course)
Figure 3.3 Post COVID19 Func"onal Status Scale 52
Figure 4.1 Clinical Course of Pa"ents with COVID19 55
Figure 4.2 HRCT showing patchy areas of subpleural consolida"on showing peri lobula
distribu"ons (arrow) with associated re"cular opaci"es (arrowhead) 57
Figure 4.3 CTPA image showing mixed ground glass (arrow) and consolida"on (arrow "p)
opaci"es with linear margins and peri lobular opaci"es (circle) 58
Figure 4.4 Algorithm on Management of Organizing Pneumonia in COVID19 60
Figure 5.1 Management Flow Chart for Post COVID19 Pa"ents on Immunosuppressant 66
Post Discharge from Hospital/Ins"tu"ons
Figure 5.2 Management of Malignant Haematology Pa"ents with COVID19 72
Receiving Chemotherapy
Figure 6.1 Referral Le&er to Nephrology Clinic 78
Figure 6.2 Discharge checklist 79
Figure 6.3 List of nephrology clinics 79
Figure 6.4 Post COVID19 Management Protocol for Kidney Diseases 89
Figure 7.1 COVID19 Infec"on in Pregnancy Informa"on for Pa"ents 97
Figure 8.1 Flow Chart for FollowUp of Acute COVID19 Infec"ons in Paediatrics 101
(Mild Disease)
Figure 8.2 Flow Chart for FollowUp of Acute COVID19 Infec"ons in Paediatrics 102
(ModerateSevere Disease)
Figure 8.3 Flow Chart for Post COVID19 Syndrome Management for Paediatrics 103
Figure 8.4 Post COVID19 Syndrome Paediatric Clerking Sheet 104
Figure 9.1 Workflow for Rehabilita"on Referral upon Ini"al Acute Discharge 115
Figure 9.2 Workflow Algorithm for Outpa"ent based Post COVID19 Pulmonary 137
Rehabilita"on (PCPR) Program
Figure 10.1 5 Domains of Mental Health Issues Post COVID19 145
xiv POST COVID-19 MANAGEMENT PROTOCOL
List of Abbreviations
ABG Arterial blood gas

ABVD Adriamycin, Bleomycin, Vinblas"ne and Dacarbazine
ACEi Angiotensin conver"ng enzyme inhibitors
ADL Ac"vi"es of daily living
AFSS Analogue Fa"gue Severity Scale
ASD Acute stress disorder
αIFN Alpha interferon
AKD Acute kidney disease
AKI Acute kidney injury
AlloSC Allogeneic Stem Cell Transplant
ALI Acute lung injury
ALL Acute Lymphocy"c Leukemia
An"TNFα An"Tumor necrosis factor α
AML Acute Myeloid Leukemia
APL Acute promyelocy"c leukemia
ARB Angiotensin receptor blockers
ARDS Acute Respiratory Distress Syndrome
ATRA Arsenic trioxide and alltrans re"noic acid
CRIMES Concentra"on, Restlessness, Irritability, Muscle tension, Energy decrease, Sleep disturbance
(Mnemonic for anxiety)
BADL Basic ac"vi"es of daily living
BCRABL Breakpoint cluster region gene. Abelson protooncogene
BCRi Beta Cell Receptors Inhibitors
BMI Body Mass Index
BMSE Brief Mental State Examina"on
BP Blood Pressure
BPH Bilateral Prostate Hyperplasia
CART Chimeric An"gen Receptor TCell Therapy
CBD Con"nuous bladder drainage
CCSAC Canadian Cardiovascular Society Angina Classifica"on
CFS Clinical Frailty Scale
CHC Combined hormonal contracep"on
CKD Chronic Kidney DIsease
CLL Chronic Lymphocy"c Leukemia
CML Chronic Myeloid Leukemia
COAD Chronic obstruc"ve airway disease
CaPO4 Calcium Phosphate
CL Consulta"on liaison
CPG Clinical Prac"se Guideline
CROSS COVID19 Rehabilita"on Outpa"ent Specialized Services
CRS Cytokine release syndrome
POST COVID-19 MANAGEMENT PROTOCOL xv
CR2 Complete Remission 2

CTPA Computed Tomography Pulmonary Angiography
CTScan Computed Tomography Scan
CV Cardiovascular
CXR Chest Xray
DAEPOCHR Doseadjusted Etoposide, Prednisone, Oncovin, Cyclophosphamide, Doxorubicin
Hydrochloride, Rituximab
DASS Depression Anxiety Stress Scale
DaraVD Daratumumab, Velcade and Dexamethasone
DLco Diffusing capacity of the lungs for carbon monoxide
DMARDs Diseasemodifying an"rheuma"c drugs
DOMS Delayed onset muscle soreness
DSM5 Diagnos"c and Sta"s"cal Manual 5
EBM Expressed breast milk
ECAQ Early Cogni"ve Assessment Ques"onnaire
ECHO Echocardiogram
ECOG score Eastern Coopera"ve Oncology Group score
ECG Electrocardiograph
ED Emergency Department
eGFR Es"mated glomerular filtra"on rate
ENT Ear, Nose and Throat
ESA Erythropoiesis S"mula"ng Agents
ESKD End Stage Kidney Disease
FBC Full blood count
FRID Fallrisk increasing drugs
FMS Family Medicine Specialist
FSS Fa"gue Severity Scale
GAD Generalized Anxiety Disorder
GDS Geriatric Depression Scale
GCSF Granulocyte Colony S"mula"ng Factor
GGO Ground glass opacity
HbA1c test Hemoglobin A1c test
HCW Healthcare Worker
HDMTX High Dose Methotrexate
HDT/ASCT High Dose Therapy/Autologous Stem Cell Transplant
HRCT High resolu"on Computed Tomography
HSCT Hematopoie"c stemcell transplanta"on
IADL Instrumental ac"vi"es of daily living
ICU Intensive Care Unit
ID Infec"on Disease
Ida Idarubici
xvi POST COVID-19 MANAGEMENT PROTOCOL
ILD Inters""al lung disease

IL6 Interleukin 6
IPSSR Interna"onal Prognos"c Scoring System
ITMTX Intrathecal Methotrexate
JAK Inhibitors Janus kinase inhibitors
KDIGO Kidney Disease Improving Global Outcomes
LTOT Long term oxygen therapy
LMWH dose Lowmolecularweightheparin
MBI Modified Barthel Index
MCH Maternal and Child Health
Mini Cog MiniCogni"ve test
MEC Medical eligibility criteria for contracep"ve use
MERS Middle East respiratory syndrome
MH Mental Health
mMRCS Modified Medical Research Council Scale
MMSE Mini Mental State Examina"on
MoCA Montreal Cogni"ve Assessment
MOH Ministry of Health Malaysia
MHPSS Mental Health and Psychological Support Services
MRC Medical Research Council
mTOR inhibitors Mechanis"c target of rapamycin inhibitors
MTX Methotrexate
NICE Na"onal Ins"tute for Health and Care Excellence
NHL NonHodgkin Lymphoma
NYHA New York Heart Associa"on
O2 Oxygen
O&G Obstetrics and Gynaecology
OP Organizing Pneumonia
PaO2 Par"al pressure of oxygen
PCFS Post COVID19 Func"onal Status
PCPR Post COVID19 Pulmonary Rehabilita"on
PCR Polymerase chain reac"on
PE Pulmonary embolism
PEP Posi"ve expiratory pressure
PETCT Positron Emission TomographyComputed Tomography
PFAOMC Psychological factors affec"ng other medical condi"ons
Ph’ + ALL Philadelphia chromosome posi"ve Acute Lymphoblas"c Leukemia
Ph’ – ALL Philadelphia chromosome nega"ve Acute Lymphoblas"c Leukemia
PHQ2 Pa"ent Health Ques"onnaire
PHQ9 Pa"ent Health Ques"onnaireDepression
PMBCL Primary Medias"nal Large BCell Lymphoma
POST COVID-19 MANAGEMENT PROTOCOL xvii
PPE Protec"ve Personal Equipment

PR Pulse rate
PSA ProstateSpecific An"gen
PTSD Posttrauma"c stress disorder
QoL Quality of Life
RCHOP Rituximab, Cyclophosphamide, Doxorubicin Hydrochloride, Oncovin, Prednisolone
RCGP Royal College of General Prac""oners
RCVP Rituximab, cyclophosphamide, Vincris"ne and Prednisone
RHR Res"ng heart rate
RNA Ribonucleic acid
ROM Range of mo"on
RR disease Relapsed / refractory disease
RRT Renal replacement therapy
RTD Return to drive
RTK Rapid test kit
RTPCR Reverse transcrip"on Polymerase chain reac"on
RTW Return to work
TFR Treatment Free Remission
TUG TimedUpandGo test
SaO2 Oxygen satura"on
SARS severe acute respiratory syndrome
SARSCoV2 RNA Severe acute respiratory syndrome coronavirus 2 ribonucleic acid
SCr Serum Crea"nine
SIGECAPS Sleep changes, Interest, Guilt, Energy, Cogni"on, Appe"te, Psychomotor, Suicide
(pneumonic for depression)
SPO2 Oxygen Satura"on
TQWHQ Two Ques"ons on Depression and One Ques"on on Help
UFEME Urine Full examina"on microscopy examina"on
UK United Kingdom
UTI Urinary Tract Infec"on
VAFS Visual Analogue Fa"gue Scale
VGPR Very Good Par"al Response
VTd Velcade, Thalidomide and low dose Dexamethasone
VRd Velcade, Revlimid and low dose Dexamethasone
VTE Venous thromboembolism
WHO World Health Organiza"on
WHODAS World Health Organiza"on Disability Assessment Scale
WM Waldenstrom Macroglobulinemia
6MT 6Mercaptopurine
6MWT 6Minute Walking Test
CHAPTER 1
GENERAL POST COVID19 MANAGEMENT
1.0 Introduc"on
1.1 Coronavirus disease 2019 (COVID19) is an infec"ous disease caused by

a newly discovered coronavirus. Most people who fall sick with COVID
19 will experience mild to moderate symptoms and recover without
special treatment. It has been further classified into 5 clinical categories
(Table 1.1).
1.2 COVID19 pandemic has resulted in a growing popula"on of individuals

recovering from acute SARSCoV2 infec"on. Research thus far is
showing that COVID19 has the poten"al to affect mul"ple organs in
the body. It is best known for causing a range of degrees of respiratory
symptoms, including respiratory failure and Acute Respiratory Distress
Syndrome (ARDS). It also has cardiac, cardiovascular, thromboembolic,
and inflammatory complica"ons, and autopsies have shown that the
virus can disseminate systemically: in addi"on to the respiratory tract,
SARSCoV2 RNA has been found in the kidneys, liver, heart, and brain.
1.3 Although the evidence base is limited, accumula"ng observa"onal data

suggest that pa"ents recovering from COVID19 may experience a wide
range of symptoms a'er recovery from acute illness. A holis"c approach
is required for follow up care and wellbeing of all Post COVID19
recovering pa"ents.
2 POST COVID-19 MANAGEMENT PROTOCOL
CLINICAL STAGE
1 Asymptoma"c
2 Symptoma"c, no pneumonia MILD
3 Symptoma"c, pneumonia Table 1.1:
4 Symptoma"c, pneumonia, requiring supplemental COVID19
SEVERE infec"on further
oxygen classified into
clinical
5 Cri"cally ill with mul"organ involvement categories1:
2.0 Jus"fica"on
This guidance is to ensure that pa"ents are followed up in a "mely manner

taking into account factors such as disease severity, likelihood of longterm
sequelae and func"onal disability. This can help to improve pa"ent’s health
related quality of life.
3.0 Scope
3.1 This guide contains informa"on for healthcare workers who are
providing care for pa"ents previously tested posi"ve to COVID19 or
have a history sugges"ve of undiagnosed COVID19 and have or are at
risk of Post COVID19 condi"ons.
3.2 This document will be updated from "me to "me as new evidence
becomes available.
4.0 Objec"ves
4.1 This guideline provides a pla)orm for a comprehensive and coordinated

treatment approach to COVID19 a'ercare by mul"disciplinary teams.
4.2 It makes recommenda"ons about care in all healthcare se$ngs for

adults, children and elderly who have post COVID19 symptoms.
POST COVID-19 MANAGEMENT PROTOCOL 3
5.0 Opera"onal defini"ons
5.1 Case defini"ons
To effec"vely diagnose, treat and manage a condi"on it needs to be

defined and dis"nguished from other condi"ons. A set of defini"ons
has been used to dis"nguish three phases following infec"on consistent
with COVID192:
a. Acute COVID19:
Signs and symptoms of COVID19 for up to 4 weeks.
b. Ongoing symptoma"c COVID19:

Signs and symptoms of COVID19 from 4 to 12 weeks.
c. Post COVID19 syndrome:

Signs and symptoms that develop during or a'er an infec"on
consistent with COVID19, con"nue for more than 12 weeks and
are not explained by an alterna"ve diagnosis.
5.2 Followup loca"ons
a. Hospitals (preferably with specialist)

b. Government health clinics
6.1 Majority of pa"ents seen with Post COVID19 syndrome will have mild
or asymptoma"c COVID19 infec"ons (refer Figure 1.13). Postacute
COVID19 syndrome may s"ll occur a'er mild infec"on. Symptoma"c
Post COVID19 cases are usually present with clusters of symptoms,
o'en overlapping, which may change over "me and can affect any
system within the body1. Symptoms and the "meline of its occurrence
are as illustrated in Figure 1.13 and 1.24. This list of symptoms, signs
and the "meline will be updated as new evidence emerges.
Figure 1.1:
Possible common
symptoms a'er
acute COVID19
(but are not
limited to)3
Figure 1.2:
Timeline of
PostAcute
COVID194.
Acute COVID19 usually last un"l 4 weeks from the onset of symptoms, beyond which replica"on
competent SARSCoV2 has not been isolated. Postacute COVID19 is defined as persistent
symptoms and/or delayed or longterm complica"ons beyond 4 weeks from the onset of symptoms.
The common symptoms observed in postacute COVID19 are summarized
6.2 From the local perspec"ve, preliminary data analyses from Hospital
Sungai Buloh COVID19 Rehabilita"on Outpa"ent Specialized Services
(CROSS) 12 database containing 1,880 referrals for its service, a tele
consulta"on service conducted a'er 4 weeks of the ini"al acute COVID
19 symptoms for 1,004 Category 4 and 5 survivors observed that 662
(65.9%) con"nue to experience ongoing symptoma"c COVID19
symptoms. The five most commonly reported symptoms were fa"gue
543(82%); exer"onal dyspnoea 343(51.8%); insomnia 106(16%); cough
88(11.4%) and anxiety 30(4.5%) (Figure 1.3 and 1.4).
6.3 Meanwhile, of the 745 survivors a&ended physical review a'er 12

weeks of the ini"al onset of acute COVID19 symptoms, 474(63.6%)
experienced Post COVID19 syndrome. The five most commonly
reported symptoms were fa"gue 276 (73.4%); exer"onal dyspnoea
92(19.4%); insomnia 66(13.9%); cough 46(9.7%) and pain 35(7.3%)
(Figure 1.5 and 1.6).
Figure 1.3:
Outcome a'er 4
weeks of ini"al
onset of acute
COVID19
symptoms
(N=1,004)
Figure 1.4:
Types and
frequency of
symptoms
experienced by
survivors with
ongoing
symptoma"c
COVID19.
(N=662)
Figure 1.5:
Outcome a'er 12
weeks of ini"al
onset of acute
COVID19
symptoms
(N=745)
Figure 1.6:
Types and
frequency of
symptoms
experienced by
survivors with
Post COVID19
syndrome.
(N=474)
6.4 When assessing any pa"ent, it is important to have an awareness of

the known significant sequelae as in Table 1.2.
Organs affected Sequelae

Gastrointes"nal Liver dysfunc"on
Malnutri"on due to vomi"ng and diarrhoea/
breathlessness / loss of appe"te
Nephrology Renal impairment
Acute kidney injury
Dermatology Skin rashes
Hair loss

Pulmonary Persis"ng inters""al lung disease
Impaired lung func"on
Pneumonia/lung cavita"on
Complica"ons of intuba"on/ven"la"on
Cardiovascular Myocardial infarc"on
Myocardi"s
Pericardi"s
Arrhythmia
Heart failure
Neurological Stroke
Cogni"ve impairment
Encephalopathy
Epilepsy
Myeli"s
Cri"cal care neuropathy/myopathy
Cogni"ve impairment / school performance
deteriora"on
Sleep disturbances
Haematological Hypercoagulable state
Anaemia
Venous thromboembolism (VTE)
Rheumatological Postviral syndrome similar to chronic fa"gue
syndrome
Endocrine Deteriora"on of diabe"c control
Newonset diabetes
Thyroidi"s and thyroid dysfunc"on
Primary and secondary adrenal insufficiency
Osteoporosis due to prolonged immobiliza"on
Mental health Worsening of cogni"ve decline
Depression
Anxiety
Posttrauma"c stress disorder (PTSD) following
severe illness

Post–intensive care Dyspnoea
syndrome Anxiety
Depression
Prolonged pain
Reduced physical func"on
Reduced quality of life
Nonspecific mul"system Cardiac/respiratory/musculoskeletal
postviral symptoms decondi"oning
Pressure sores
Common symptoms:
i. fa"gue
ii. dyspnoea
iii. joint pain
iv. chest pain
v. cough
vi. change in sense of smell or taste.
Less common symptoms include:

vii. insomnia
viii. lowgrade fevers
ix. headaches
x. neurocogni"ve difficul"es
xi. myalgia and weakness
Table 1.2: xii. gastrointes"nal symptoms
COVID19
specific xiii. rash
significant
xiv. depression.
sequelae6
7.0 Assessment
7.1 Assessment of Post COVID19 pa"ents is as following:
a. All Category 4 and 5 of COVID19 cases will be followedup and

given appointment upon discharge to their own clinicians at
hospital. Provide pa"ent with a discharge note (refer Appendix 3)
and appointment to Post COVID19 Clinic if no exis"ng followed
up (refer flow chart: Appendix 1) using recommended referral

le&er (refer to Appendix 4).
b. Other categories of COVID19 cases can be referred to Primary

Care health facili"es upon discharge if necessary for followup.
Referral Le&er as in Appendix 4 can be used for this purpose. They
can also walk in to any primary care health facili"es for further
assessment and management if symptoms persist (refer flow
chart: Appendix 2). Referral can be made for those who require a
ter"ary care management to the nearest hospital (use Referral
Le&er in Appendix 4).
c. Pa"ents with redflag symptoms should be assessed and

stabilized. Refer to hospital if necessary.
7.2 Use a holis"c, personcentered approach to assess all cases. This

includes a comprehensive clinical history and appropriate examina"on
that involves assessing physical, cogni"ve, psychological and psychiatric
symptoms, as well as func"onal abili"es. Refer to Appendix 5 for
Clerking Sheet for Post COVID19 Pa"ents. Individual facility or
discipline may amend the clerking sheet according to the need of local
se$ng.
7.3 Include this point in the comprehensive clinical history2,4,8,9,10,11:
a. History of suspected or confirmed acute COVID19.
b. The nature and severity of other health condi"ons and current

symptoms.
c. Timing and dura"on of symptoms since the start of acute COVID

19.
7.4 Important points to note2,4,8,9,10,11:

a. While inves"ga"ng the Post COVID19 syndromes, ensure
symptoms are not a&ributable to other diagnoses.
b. Be aware that people can have wideranging and fluctua"ng

symptoms a'er acute COVID19, which can change in nature over
"me.
c. Discuss how the person's life and ac"vi"es, for example their work
or educa"on, mobility and independence, have been affected by
ongoing symptoma"c COVID19 or suspected Post COVID19
syndrome.
d. Discuss the person's experience of their symptoms and ask about

any feelings of worry or distress. Listen to their concerns with
empathy and acknowledge the impact of the illness on their day
today life, for example ac"vi"es of daily living, feelings of social
isola"on, work and educa"on, and wellbeing.
e. For people who may benefit from support during their

assessment, for example to help describe their symptoms, include
a family member or carer in discussions if the person agrees.
f. Do not predict whether a person is likely to develop Post COVID

19 syndrome based on whether they had certain symptoms (or
clusters of symptoms) or were in hospital during acute COVID19.
g. When inves"ga"ng possible causes of a gradual decline,

decondi"oning, worsening frailty or demen"a, or loss of interest
in ea"ng and drinking in older people, bear in mind that these can
be signs of ongoing symptoma"c COVID19 or suspected Post
COVID19 syndrome.
h. If the person reports new cogni"ve symptoms, use a validated

screening tool to measure any impairment and impact (e.g., Mini
Mental State Examina"onMMSE and Early Cogni"ve Assessment
Ques"onnaire ECAQ)
7.5 Appropriate examina"ons must be tailored to history taking findings.
Iden"fy the phases of Post COVID19 pa"ents (refer 5.0) to effec"vely

diagnose, treat and manage the condi"ons.
9.0 Inves"ga"ons
9.1 All Post COVID19 pa"ents must undergo inves"ga"ons based on clinical
indica"ons and availability of tests at your health facili"es.
9.2 Establish red flag symptoms that could indicate the need for emergency
assessment for serious complica"on of COVID19. Red flag symptoms
include severe, new onset, or worsening of4,12:
a. breathlessness or hypoxia,
b. syncope,
c. unexplained chest pain, palpita"ons or arrhythmias,
d. delirium, or focal neurological signs or symptoms.
e. Mul"system inflammatory syndrome (in children).
10.0 Management
10.1 Give advice and informa"on on selfmanagement to people with

ongoing symptoma"c COVID19 or Post COVID19 syndrome, star"ng
from their ini"al assessment. This should include:
a. Ways to selfmanage their symptoms, such as se$ng realis"c
goals.
b. Who to contact if they are worried about their symptoms or they

need support with selfmanagement.
c. Sources of advice and support, including support groups, social

prescribing, online forums and apps.
d. How to get support from other services, including social care,

housing, and employment, and advice about financial support.
e. Informa"on about new or con"nuing symptoms of COVID19 that

the person can share with their family, carers and friends.
10.2 Develop a management plan with the person addressing their main
symptoms, problems, or risk factors, and an ac"on plan. Consider
individual factors and access issues in determining loca"on for further
treatment or rehabilita"on e.g., homebased, telehealth or facetoface
op"ons.
10.3 Management plan is depending on clinical need and local pathways:

a. Support from integrated and coordinated primary care,
community, rehabilita"on and mental health services
b. Referral to an integrated mul"disciplinary assessment service
c. Referral to specialist care for specific complica"ons.
10.4 When discussing with the person the appropriate level of support and
management:
a. Think about the overall impact their symptoms are having on their
life, even if each individual symptom alone may not warrant
referral
b. Look at the overall trajectory of their symptoms, taking into

account that symptoms o'en fluctuate and recur so they might
need different levels of support at different "mes.
10.5 Pa"ent who developed Post COVID19 complica"ons will be referred

to relevant specialty and managed accordingly.
10.6 Diabetes care Post COVID19 should ideally address the following;
a. Preven"on of type 2 diabetes in those at risk with reinforcement
of lifestyle measures
b. Detec"ng new cases of diabetes early and implemen"ng

appropriate pharmacological and nonpharmacological
management.
c. Considera"on for induc"on of diabetes remission in newonset

and early type 2 diabetes by lifestyle changes and behaviour
therapy that promote weight loss.
d. Effec"ve treatment of glycaemia with appropriate use of various

an"diabe"c therapies. Effec"ve treatment of related
comorbidi"es such as blood pressure, lipid and weight
management to prevent diabetesrelated complica"ons
e. Effec"ve screening and monitoring to detect diabetesrelated

complica"ons early and treat appropriately.
f. Safe care in pa"ents during hospital admission
10.7 Management of common symptoms

a. Cough or breathlessness:
i. Op"mize management of pre‑exis"ng respiratory
condi"ons
ii. Posi"oning & breathing technique
iii. Recommend respiratory muscle condi"oning (pulmonary
rehabilita"on)
iv. Recommend gradual return to exercise guided by symptoms
v. Consider die""an assistance if symptoms interfere with
nutri"on
b. Fa"gue:
i. Maximize self‑care, sleep, relaxa"on and nutri"on
ii. Recommend pa"ents pace and apply priori"za"on to daily
ac"vi"es
iii. Recommend cau"on with return to exercise (reduce if there
is any increase in symptoms)
iv. A monitored return to exercise can be supported by
physiotherapy or rehabilita"on referral
v. If fa"gue is causing difficulty with ac"vi"es of daily living
(ADLs) refer to rehab
c. Chest pain:
i. Exclude acute coronary syndrome, myocardi"s, pericardi"s
and arrhythmia
ii. Manage with reassurance and educa"on regarding
symptoms of concern
iii. Pa"ents who have had myocardi"s or pericardi"s as a
component of their acute illness should have 36 months
of rest from physical training and athletes should have
cardiology supervision of return to training
d. Headaches, lowgrade fever and myalgia:

i. Exclude COVID‑19 reinfec"on or recrudescence
ii. Prescribe simple suppor"ve measures and analgesia or
an"pyre"cs as needed
iii. Rule out other infec"ons
e. Neurocogni"ve difficulty:
i. Prescribe suppor"ve management
ii. If severe enough to cause difficulty with ADLs, consider
cogni"ve tes"ng and occupa"onal therapy support
f. Depression/anxiety:
i. Provide informa"on about Post COVID recovery
ii. Address mul"factorial contributors that may require
assistance with pain management, independence with
ADLs, financial and other social supports and loneliness
iii. Consider op"ons for supported access to mental health
services or online support if pa"ent is unwilling to access
facetoface counselling
g. Thrombosis risk and contracep"ve choice:

i. COVID19 causes a hypercoagulable state in some people,
which may worsen the VTE risk associated with combined
hormonal contracep"on (CHC). The incidence of VTE in
biological females of reproduc"ve age with COVID19
infec"on is currently not known.
ii. Pa"ents should be advised of this risk to allow informed
choice of contracep"ve op"on
iii. Pa"ents who have severe illness due to COVID19 should
cease their CHC and VTE prophylaxis should be considered
iv. The dura"on of risk is not yet ascertained, so consider
recommending a progestogen only or nonhormonal
method of contracep"on for those who cease CHC
v. It is reasonable to con"nue CHC in pa"ents who have had
asymptoma"c or mild COVID19 infec"on
11.0 Pa"ents’ outcomes and assessment tools
Pa"ent should be assessed for the improvement of Post COVID19 complica"ons.

Assessment depends on the pa"ent complica"ons.
12.0 Conclusion
12.1 It is s"ll unknown about how COVID19 will affect people over "me, but
research is ongoing hence it is recommended that the health condi"ons
of people who have had COVID19 to be closely monitored.
12.2 Even though, most people who have COVID19 recover quickly, there
are poten"ally longlas"ng problems following COVID19 infec"on
which make the precau"onary measures even more important. These
include wearing masks, physical distancing, avoiding crowds, ge$ng a
vaccine when available and keeping hands clean.
13.0 Appendix:
1. Flow Chart of Post COVID19 Management at Ter"ary Centre (Category

4 and 5)
2. Flow Chart of Post COVID19 Management for Walk in Cases
3. Discharge Note for COVID19 Pa"ents
4. Referral Le&er for Post COVID19 Pa"ents
5. Clerking Sheet for Post COVID19 Pa"ents
References:
1. Clinical Management for confirm COVID19 in Adult and Pediatric: COVID

19 Management Guideline in Malaysia 2020.
2. COVID19 rapid guideline: Managing the longterm effects of COVID19.
NICE Guideline 18/10/2020 (www.nice.org.uk/guidance/ng188)
3. Shah W, Hillman T, Playford E D, Hishmeh L. Managing the longterm effects
of covid19: summary of NICE, SIGN, and RCGP rapid guideline. BMJ 2021;
372: n136 doi:10.1136/bmj. n136.
4. Ani Nalbandian, Kar"k Sehgal, Aakri" Gupta et al. Postacute COVID19
Syndromes. Nature Medicine 2021; Vol 27; 601–615.
5. COVID19 Rehabilita"on Outpa"ent Specialized Services (CROSS)
Pandemic Calamity Response. Malaysian Medical Associa"on Newsle&er
Feb 2021; Volume 51; No 2: 2829.
6. Caring for adult’s pa"ents with Post COVID19 condi"ons Royal Australian
College of General Prac"ce Oct 2020.
7. Care of People Who Experience Symptoms PostAcute COVID19. Na"onal
COVID19 Clinical Evidence Task Force Australia. Version 1.1 25/02/2021.
8. Bin Zeng, Di Chen, Zhuoying Qiu et al. Expert consensus on protocol of
rehabilita"on for COVID19 pa"ents using framework and approaches of
World Health Organiza"on Interna"onal Family Classifica"ons. Aging
Medicine. 2020; 3:82–94.
9. Derick T Wade. Rehabilita"on a'er Covid19: An evidence based approach.
Clinical Medicine 2020; Volume 20; No 4; 35964.
10.Demeco A, Maro&a N, Barle&a M et al. Rehabilita"on of pa"ents Post
COVID19 infec"on: a literature review. Journal of Interna"onal Medical
Research 2020; 48(8) 1–10.
11.COVID19 rapid guideline: Managing the longterm effects of COVID19.
12.Care of People Who Experience Symptoms PostAcute COVID19. Na"onal
CHAPTER 2
POST COVID19 MANAGEMENT PROTOCOL IN
PRIMARY CARE
1.0 Introduc"on
1.1 Post COVID19 pa"ents can present with a variety of symptoms (new
onset / persistent / relapse of symptoms) that developed as a sequela
of the COVID19 infec"on. Pa"ents diagnosed with Category 13 COVID
19 infec"on do not require follow up unless indicated, while pa"ents
diagnosed with Category 45 COVID19 infec"on will be followed up in
ter"ary centers. However, recent literatures have found that pa"ents
who had milder forms of COVID19 infec"on can develop long term
complica"ons as well1. Therefore, primary care doctors should be
prepared to receive Post COVID19 pa"ents who walk in to primary care
clinics, post home quaran"ne, referred from quaran"ne centers or
hospitals for shared care.
1.2 This guideline serves to aid primary care doctors in assessing and
managing Post COVID19 pa"ents in a comprehensive and holis"c
manner, which include op"mizing the pa"ents’ general health
condi"on, underlying comorbidi"es along with their psychosocial well
being.
2.0 Scopes
2.1 Evaluate Post COVID19 pa"ents who present to primary care with long
COVID symptoms.
2.2 Iden"fy presence of red flags and indica"ons to refer to ter"ary centers.
2.3 Followup pa"ents with Post COVID19 infec"on, whom were given
appointment for monitoring comorbidi"es or complica"ons (vital signs
and blood parameters).
3.0 Symptoms
3.1 Post COVID19 pa"ents may be symptoma"c or asymptoma"c of

COVID19 infec"on.
3.2 Symptoma"c Post COVID19 pa"ents may have new, ongoing or

worsening symptoms.
3.3 Symptoms are highly variable and wide ranging, which may be singular,
mul"ple, constant, transient, or fluctua"ng, and can change in nature
over "me.
3.4 It is also important to be aware of the known significant sequelae while

assessing postacute COVID19 pa"ents3 (refer Table 1.2).
4.0 Assessment and management
1. Respiratory
Assessment /
Symptoms Management
assessment tools
Presence of • Respiratory rate 1. Refer FMS / respiratory physician if

respiratory • Pulse oximeter presence of abnormal findings.
symptoms (new • 6minutes 2. Consider further inves"ga"on and imaging
onset / walking test with (if clinically indicated).
recurrence / SPO2* level • Lung func"on test (spirometry &
persistence) – monitoring / diffusion capacity test).
cough / chest exer"onal • HRCT (+/ CTPA).
pain / desatura"on 3. Refer chest physician if satura"on test falls
breathlessness test* (1minute of 3% from the baseline.
sit to stand test) 4. Respiratory rehabilita"on
• Chest Xray* • Breathing exercises and posi"oning.
*perform if
indicated
2. Cardiovascular
Assessment /
Symptoms Management
assessment tools
New onset / 1. BP, PR, ECG. 1. Refer ED / physician / Cardiologist.

recurrent / 2. NYHA 2. Shared care with primary care for
persistent 3. CCSAC* op"miza"on of risk factors upon discharge.
a) Chest pain
b) Palpita"on To op"mise management of hypertension,
c) Failure *Canadian lipid and diabetes management in high
symptoms Cardiovascular CV risk
Society Angina
Cardiovascular Classifica"on
(CV) risk
Framingham
cardiovascular risk
assessment
3. Neurology
Assessment /
Symptoms Management
assessment tools
New onset of Full neurological • Refer Neurologist / Physician /

acute examina"on medical team
neurological • Consider admission
symptoms focal
weakness/
reduced
sensa"on/
seizure/ altered
behaviour /
worsening of
headache
Poor cogni"ve Cogni"ve • Mild to moderate – refer occupa"onal

func"on assessment: therapist
(worsening of Mini Mental State • Severe refer Neurologist / Physician /
cogni"ve Examina"on medical team
func"on) (MMSE) /
Montreal Cogni"ve
Assessment
(MoCA)
4. Psychiatry / mental health

Assessment /
Symptoms Management
assessment tools
Major Depressive Disorder (CPG MDD, 2019)
• Sleep Available Mild to Moderate (supervised by FMS):

disturbance assessment tools: • Psychoeduca"on
• Interest a. Whooley • Psychotherapy
Reduced Ques"ons • Pharmacotherapy
• Guilt and self b. DASS 21
blame c. PHQ2 Moderate to Severe
• Energy loss d. PHQ9 • Refer Psychiatrist
and fa"gue
• Concentra"on Suicidal thoughts / a&empt
problem • Referred to Psychiatrist urgently
• Appe"te
changes
• Psychomotor
changes
• Suicidal
thoughts
*SIGECAPS
Mnemonic for
depression
Generalised Anxiety Disorder (GAD) (DSM5)
• Anxiety GAD7 Mild to Moderate (supervised by FMS):

• Worry • Psychoeduca"on
• Concentra"on • Psychotherapy
difficulty • Pharmacotherapy
• Restlessness
• Irritability Moderate to Severe
• Muscle • Refer Psychiatrist
tension
• Energy
low/fa"gue
• Sleep
disturbance
*A&W CRIMES
Mnemonic for
anxiety
PTSD (DSM5)
• Recurrent Nil Refer Psychiatrist

distressing
memories
• Recurrent
distressing
dream
• Flashbacks
• Intense
psychological
distress
towards the
event
• Marked
psychological
reac"ons
towards the
event
Other psychological symptoms – refer topic psychology
Table 2.1:
Whooley
Ques"onnaire
(Malay Version)
Table 2.2:
Pa"ent Health
Ques"onnaire –
PHQ2 (Malay
Version)
*A cutoff score 3 or more is posi"ve
Figure 2.1:
Pa"ent Health
Ques"onnaire 9
– PHQ9
DEPRESSION ANXIETY STRESS SCALE21 (DASS21)

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!"#1+)"!",25"*+$51")$"/2&(*4"
69" #$%$"+2.$("1-)&-,$*0$+".-*0$*"$/$"B'$"%$*0"&$%$"3$('($*4"
5" 6" 7" 8"
!",25"%&2:+1")$":1*$91"1&)0%5(25)(*"2:$%)"2&>)0(&4"
6;" #$%$")$&$"+2.$("1-02+'"1-)>$)0$"&-1$0$2"&-=)$*0"2*.2F2.'4"
5" 6" 7" 8"
!"#1+)"!",25&?)",$-)0"9%*0"25"2"/1-5$&6"
6@" #$%$")$&$",'.$>"+-)&-*+'>4"
5" 6" 7" 8"
!"#1+)")02)"!",25&?)",$-)0"9%*0"25"2"/1-5$&6"
Figure 2.2:
Depression
Anxiety Stress
Scale 21 (DASS
21) (Malay
Version)
Figure 2.3:
Generalized
Anxiety
Disorder 7
(GAD7
Anxiety)
Figure 2.4:
Scoring notes
on PHQ9
Depression
Severity and
Generalized
Anxiety
Disorder 7
(GADAnxiety)
5. Rehabilita"on / musculoskeletal
Assessment /
Symptoms Management
assessment tools
Common 1. Full history taking and 1. Relevant inves"ga"ons to

musculoskeletal relevant physical rule out other differen"al
symptoms: examina"on diagnosis.
Myalgia, Arthralgia, 2. Assessment of the
Pain, Weakness, baseline outcome 2. Mul"disciplinary team
Fa"gue, Reduce effort measures: involvement*:
tolerance, Limited joint I. Pa"ent educa"on:
Outcome Assessment
movements. lifestyle and general
Measures Tool
health, exercise
Muscle Manual muscle
programme, ADL
strength test
adapta"ons and
Balancing Berg Balance
scale
modifica"ons.
II. Physiotherapy
Endurance 6min walking
test III. Occupa"onal therapy.
IV. Pharmacological
ADL Modified
independence Barthel Index treatment
Pain Numerical
V. Psychosocial support.
ra"ng scale
Fa"guability Fa"gue *to refer hospital if
Severity Scale necessary
and Visual (e.g., inadequate
Analogue equipment)
Fa"gue Scale
Dyspnea Modified Borg
scale
Complex medical As above Refer to Rehabilita"on

impairment with Medicine Specialist
complex or exis"ng
rehabilita"on needs.
Persistent Reassessment of outcome Refer to Rehabilita"on

musculoskeletal measures. Medicine Specialist
symptoms a'er 12
weeks of interven"on
at primary care facility.
Red flags:
1. Nonresolving Full history taking and 1. Relevant inves"ga"ons.
dyspnoea or hypoxia, relevant physical
headache, dizziness, examina"on. 2. Urgent referral to
syncope, delirium, or respec"ve department.
focal neurological
signs or symptoms.
Assessment /
Symptoms Management
assessment tools
2. Unexplained chest
pain, palpita"ons
or arrhythmias.
3. Mul"system
inflammatory
syndrome
(in children).
FATIGUE SEVERITY SCALE (FSS)
Date ________________________ Name________________________________
Please circle the number between 1 and 7 which you feel best fits the following
statements. This refers to your usual way of life within the last week. 1 indicates
“strongly disagree” and 7 indicates “strongly agree.”
Read and circle a number Strongly Disagree → Strongly Agree
1. My mo"va"on is lower when I 1 2 3 4 5 6 7

am fa"gued.
2. Exercise brings on my fa"gue. 1 2 3 4 5 6 7
3. I am easily fa"gued. 1 2 3 4 5 6 7
4. Fa"gue interferes with my
1 2 3 4 5 6 7
physical func"oning.
5. Fa"gue causes frequent
problems for me. 1 2 3 4 5 6 7
6. My fa"gue prevents sustained

1 2 3 4 5 6 7
physical func"oning.
7. Fa"gue interferes with carrying
out certain du"es and 1 2 3 4 5 6 7
responsibili"es.
8. Fa"gue is among my most
1 2 3 4 5 6 7
Figure 2.5: disabling symptoms.
Fa"gue
Severity Scale 9. Fa"gue interferes with my work,
family, or social life. 1 2 3 4 5 6 7
(FSS)
VISUAL ANALOGUE FATIGUE SCALE (VAFS)
Please mark an “X” on the number line which describes your global fa"gue
with 0 being worst and 10 being normal.
Figure 2.6:
Visual
0 1 2 3 4 5 6 7 8 9 10 Analogue
Fa"gue Scale
(VAFS)
6. Geriatric popula"on (60 years and above)
• Assess pa"ent’s condi"on Post COVID19 infec"on by comparing with

premorbid state (to look for new changes or previously missed /
undetected premorbid / chronic condi"ons)
• Suggested condi"ons to assess include:
o Decline in mobility
o Falls
o Decline in ac"vi"es of daily living (ADL)
o Decline in cogni"on or presence of confusion
o Mood or behaviors changes
o Incon"nence (urine / bowel)
o Oral intake and nutri"on
o Sleep
o Increased care or support requirements at home
1 line screening
Assessment /
ques"ons (to
Assessment Management
pa"ent or to
tools
caregiver)
a) Cogni"on: Available 1. New deteriora"on in cogni"on or new

assessment tools: onset of confusion during recent COVID
Is there any • ECAQ 19 infec"on may be due to delirium
problem with • MiniCogni"ve (which may persist for days to weeks a'er
memory? or test (using resolu"on of illness)
Is the pa!ent MiniCog • If improving trend & clinically well –
confused? Instrument) observe
• MMSE • If persistent or worsening – assess for
• Montreal causes of unresolving delirium (consider
Cogni"ve referring for inpa"ent workup & care)
Assessment 2. If cogni"ve impairment or confusion is
(MoCA) chronic consider referring to psychiatrist
Cogni"ve tests / geriatric psychiatrist / geriatrician /
may be affected neurologist to rule out demen"a
by:
• Delirium
• Demen"a
1 line screening
Assessment /
ques"ons (to
pa"ent or to
tools
caregiver)
• Depression
• Other issues
(e.g., vision,
hearing, language,
educa"on, etc)
**Always assess
clinically (history
taking, physical
examina"on, &
relevant
inves"ga"ons); not
solely depend on
assessment tools
b) Mood: Geriatric 1. Refer to FMS / counselor / psychologist

Depression Scale for interven"on if score ≥ 5.
Are you (GDS) 2. If score persistently ≥ 5 a'er interven"on,
depressed / refer to psychiatrist / geriatric psychiatrist.
having low Refer to geriatrician if pa"ent also has
mood? other geriatric issues
c) BP, blood sugar Op"mize BP and glucose to age group

Polypharmacy: and target organ targets
damage
What 1. Target SBP
medica!ons are • <150 mmHg for > 80 years old
you taking? • <140 mmHg for 6580 years old
→ do pill check • <130 mmHg in fit 6580 years old
with caregivers #apply less strict targets for the frail,
and ensure func"onally and/ or cogni"vely impaired,
adherence those with mul" morbidi"es and those with
adverse reac"ons from therapy. Consider de
prescribing in this group of pa"ents
2. HbA1c target
• <7.5% in healthy (few coexis"ng chronic
illness, intact cogni"ve, and func"onal
status)
• <8.0% in complex (mul"ple co exis"ng
chronic illness or mildmoderate cogni"ve
impairment & func"onal impairment)
• <8.5% in very complex / poor health (long
term care / end stage chronic illness or
moderatesevere cogni"ve impairment &
func"onal impairment)
1 line screening
Assessment /
ques"ons (to
pa"ent or to
tools
caregiver)
d) Falls: • Postural BP • Refer to physiotherapist for:

• ECG • Upper and lower limb muscle
Have you had • Eye and hearing strengthening exercises (with breathing
any falls? assessment control)
• Medica"on • Gait and balance training
review • Endurance training
• TimedUpand • Walking aid / wheelchair training
Go test (TUG) • Refer to occupa"onal therapist for home,
normal ≤ 13.5 ADL and footwear assessment
seconds for • Manage postural hypotension (medica"on
community adjustment, fluid management, etc.)
dwelling older • Iden"fy and deprescribe poten"al fallrisk
adults increasing drugs (FRIDS)
• Vision / hearing impairment – consider
referring to ophthalmologist / ENT
e) Incon"nence: UFEME, PSA (if • Further assessment to evaluate type of

indicated) urinary incon"nence (urge / stress /
Do u have mixed) and underlying causes / risk
trouble factors (UTI, BPH, cons"pa"on, etc)
controlling your • Consider nonpharmacological measures
urine or bowel? to improve con"nence (Kegel’s exercises,
bladder training, improving mobility,
"med voiding / scheduled toile"ng, fluid
management, etc.)
f) Frailty: Clinical Frailty 1. CFS 9 – refer pallia"ve care

Scale (CFS)* 2. CFS 48
a) Refer die""an to improve nutri"on
*use CFS b) Refer physiotherapist for strengthening
applica"on exercises
(downloadable
from Google Play
or Apple iStore)
g) Caregiver: DASS 21 1. Manage according to DASS findings.

2. Caregiver educa"on in caring for older
Are yo adults.
stressed? 3. Teaching caregiver Ryle’s tube or catheter
(CBD) change and dressing.
4. Arrange home visit / visit to nursing home
(domiciliary team).
5. Referral for financial aid (social aid,
Baitulmal, Pusat Zakat) if needed.
1 line screening
Assessment /
ques"ons (to
pa"ent or to
tools
caregiver)
h) Is the pa"ent Nil 1. Pressure injury preven"on (regular

bedbound? turning, skin care, pressure relief surfaces,
Always assess nutri"on op"miza"on, etc.)
clinically for 2. Wound management (if present)
underlying cause 3. Newly bedbound postillness intervene if
of immobility reversible cause (e.g. decondi"oning)
4. Premorbidly bedbound – consider
op"mizing mobility if possible (e.g., bed to
wheelchair transfer)
*For other specific systems which are not covered by chapters, refer to respec"ve
departments for further assessment if indicated.
MINI COGNITIVE INSTRUMENTS (MINICOG)

Figure 2.7:
Mini Cogni"ve
Instruments
(MiniCog)
MODIFIED BARTHEL INDEX
NAME :……………………………………………………… I/D NO:……………..............................
DIAGNOSIS:…………………………………………………………………………………....................…
Ac"vity Criteria Date Date Date Date Date
Personal Hygiene Unable to perform task (0)

Substan"al help required (1)
Moderate help required (3)
Bathing Minimal help required (4)
Fully independent (5)
Toilet
Unable to perform task (0)
Stair climbing
Feeding Moderate help required (5)
Dressing Minimal help required (8)
Bowel control Fully independent (10)
Bladder control
Chair/Bed transfers Unable to perform task (0)

Ambula"on Moderate help required (8)
Minimal help required (12)
Fully independent (15)
Or Wheelchair
Unable to perform task (0)
(Score only if
pa"ent is unable to
Moderate help required (3)
ambulate and is
trained in Minimal help required (4)
wheelchair) Fully independent (5)
TOTAL SCORE (100

Table 2.3:
DEPENDENCY LEVEL Modified
Barthei Index
(MBI)
*If score ≥ 50 (Moderate/ Severe/ Total),
to refer pa"ent to Occupa"onal
Therapist.
MBI TOTAL SCORE DEPENDENCY LEVEL

0 – 24 Total
25 – 49 Severe
50 – 74 Moderate
75 – 90 Mild
91 99 Minimal
Assessed by: FMS/MO/OCCUPATIONAL THERAPIST SIGN/OFFICIAL STAMP:……………………….

MODIFIED BORG SCALE
Intensity Scale Descrip"on Descrip"on
0 Nothing at all
0.5 Very, very slight
Low
1 Very slight
2 Slightly
3 Moderate
Moderate
4 Somewhat severe
5 Severe
7 Very severe
High
8
9 Very, very severe

Figure 2.8:
Modified
Borg Scale
10 Maximal
GUIDANCE ON EXERCISE REHABILITATION IN POSTACUTE COVID19
Guidance on Exercise Rehabilita"on

in Postacute COVID19
1. A#er recovery from mild illness:

1 week of low level stretching and strengthening before
targeted cardiovascular sessions.
2. Very mild symptoms:

limit ac"vity to slow walk or equivalent. Increase rest
periods if symptoms worsen.
3. Persistent symptoms:
limit ac"vity to 60% maximum heart rate un"l 23 weeks
a'er symptoms resolve.
4. Ini"al 6 weeks a#er discharge or illness:

it is recommended to keep dyspnoea and fa"gue below
4/10 on the Borg Scale. Avoid over vigorous exercise as it
can set back recovery.
5. Any lymphopenia or required oxygen:

Need respiratory assessment before resuming exercise.
6. Any cardiac involvement:

Need cardiac assessment before resuming.
7. Pa"ents with myalgia:

avoid strengthening exercises un"l myalgia resolves.
8. Exercise termina"on criteria:

Exacerba"on of respiratory symptoms and fa"gue that
are not alleviated a'er rest or presence of new
Figure 2.9:
symptoms such as chest "ghtness, chest pain, dyspnoea, Guidance on
severe cough, dizziness, headache, blurring of vision, Exercise
Rehabilita"on
palpita"ons, profuse swea"ng and unstable gait. in Postacute
COVID19
CLINICAL FRAILTY SCALE (CFS)
Figure 2.10:
Clinical
Frailty Scale
(CFS)
EARLY COGNITIVE ASSESSMENT QUESTIONAIRE ECAQ
Figure 2.11:
Early
Cogni"ve
Assessment
Ques"onnaire
– ECA
MINI MENTAL STATE EXAMINATION (MALAY VERSION)
Figure 2.12:
Mini Mental
State
Examina"on
(Malay
Version)
GERIATRIC DEPRESSION SCALE (GDS) (SHORT FORM)
Instruc"ons:
Circle the answer that best describes how you felt over the past week.
Score 1 point for each bolded answer. A score of 5 or more suggests depression.
1. Are you basically sa"sfied with your life? yes no
2. Have you dropped many of your ac"vi"es and yes no

interests?
3. Do you feel that your life is empty? yes no
4. Do you o'en get bored? yes no
5. Are you in good spirits most of the "me? yes no
6. Are you afraid that something bad is going to yes no

happen to you?
7. Do you feel happy most of the "me? yes no
8. Do you o'en feel helpless? yes no
9. Do you prefer to stay at home, rather than going yes no

out and doing things?
10. Do you feel that you have more problems with yes no
memory than most?
11. Do you think it is wonderful to be alive now? yes no
12. Do you feel worthless the way you are now? yes no
13. Do you feel full of energy? yes no
14. Do you feel that your situa"on is hopeless? yes no
15. Do you think that most people are be&er off than yes no
you are?
Total Score: ...............

Figure 2.13:
Geriatric
Ref. Yes average: The use of Ra!ng Depression Series in the Elderly, Depression
in Poon (ed.): Clinical Memory Assessment of Older Adults, Scale (GDS)
American Psychological Associa!on, 1986 (short form)
MONTREAL COGNITIVE ASSESSMENT (MOCA) (MALAY VERSION)
Figure 2.14:
Montreal
Cogni"ve
Assessment
(MoCA) (Malay
Version
Abnormal < 22/30
FALL RISK INCREASING DRUGS &FRIDs'
PSYCHOTROPIC DRUGS
Type Examples
Benzodiazepine Alprazolam, lorazepam, diazepam,

clonazepam
Z drug Zolpidem, zopiclone
Tricyclic an"depressant (TCA) Amitriptyline, imipramine
Selec"ve serotonin reuptake inhibitor Sertraline, fluvoxamine, fluoxe"ne,
(SSRI) escitalopram
Serotoninnorepinephrine reuptake Venlafaxine, duloxe"ne
inhibitor (SNRI)
Other an"depressant Mirtazapine
An"psycho"c (typical and atypical) Haloperidol, chlorpromazine, risperidone,
que"apine, olanzepine, clozapine
CARDIOVASCULAR DRUGS
Type Examples
Alphablocker Prazosin, terazosin

Centralac"ng agent Methyldopa
Thiazide diure"c Hydrochlorothiazide, chlorthalidone
Loop diure"c Frusemide, bumetanide
ACE inhibitor Captopril, ramipril, enalapril, perindopril
Angiotensinreceptor blocker Losartan, valsartan, telmisartan,
irbesartan
Betablocker Atenolol, metoprolol, propranolol,
carvedilol, bisoprolol
Calcium channel blocker Nifedipine, amlodipine, felodipine,
dil"azem, verapamil
Nitrate Isosorbide mononitrate/dinitrate, glyceryl
trinitrate
An"arrhythmic Digoxin, amiodarone, flecainide
OTHER DRUGS
Type Examples
Opioid Morphine, oxycodone, dihydrocodeine,

tramadol
An"epilep"c Phenytoin, carbamazepine, sodium
valproate, phenobarbitone, gabapen"n,
pregabalin, lamotrigine, leve"racetam,
topiramate
An"parkinson Levodopa
An"parkinson: dopamine agonist Ropinirole, pramipexole
An"parkinson: MAOIB antagonist Selegiline
An"parkinson: an"cholinergic Benzhexol
Muscle relaxant Baclofen
An"histamine (especially first genera"on) Chlorpheniramine, diphenhydramine,
Table 2.4: hydroxyzine
Fall Risk
Drugs for BPH: alpha blocker Terazosin, doxazosin, tamsulosin, alfuzosin
Increasing
Drugs Drugs for overac"ve bladder: Oxybu"nin, trospium, tolterodine,
(FRIDs) an"cholinergic solifenacin
References:
1. Logue JK, Franko NM, McCulloch DJ, McDonald D, Magedson A, Wolf CR,
et al. Sequelae in Adults at 6 Months A'er COVID19 Infec"on. JAMA
Network Open. 2021;4(2):e210830e.
2. Royal Australian College of General Prac"ce. Caring for adult pa"ents with
Post COVID19 condi"ons. October 2020.
3. Wee Kooi Cheah, Hoon Lang Teh, Diana Xiao Han Huang, Alan Swee Hock
Ch’ng, Mun Pung Choy, Ewe Eow Teh, Irene Looi, Valida"on of Malay
Version of Montreal Cogni"ve Assessment in Pa"ents with Cogni"ve
Impairment, Clinical Medicine Research. Vol. 3, No. 3, 2014, pp. 5660. doi:
10.11648/j.cmr.20140303.11.
4. Greve JMDA, Brech GC, Quintana M, Soares ALdS, Alonso AC. Impacts of
COVID19 on the immune, neuromuscular, and musculoskeletal systems
and rehabilita"on. Revista Brasileira de Medicina do Esporte. 2020;26:285
8.
5. BarkerDavies RM, O'Sullivan O, Senaratne KPP, Baker P, Cranley M, Dharm
Da&a S, et al. The Stanford Hall consensus statement for Post COVID19
rehabilita"on. Bri"sh Journal of Sports Medicine. 2020;54(16):94959.
6. Disser NP, De Micheli AJ, Schonk MM, Konnaris MA, Piacen"ni AN, Edon
DL, et al. Musculoskeletal Consequences of COVID19. JBJS.
2020;102(14):1197204.
7. Shanthanna H, Strand NH, Provenzano DA, Lobo CA, Eldabe S, Bha"a A, et
al. Caring for pa"ents with pain during the COVID19 pandemic: consensus
recommenda"ons from an interna"onal expert panel. Anaesthesia.
2020;75(7):93544.
8. Van Aerde N, Van den Berghe G, Wilmer A, Gosselink R, Hermans G.
Intensive care unit acquired muscle weakness in COVID19 pa"ents.
Intensive care medicine. 2020;46(11):20835.
9. Car. A, Bernabei R, Landi F, Group 'GACPACS. Persistent Symptoms in
Pa"ents A'er Acute COVID19. JAMA. 2020;324(6):6035.
10.WHO Clinical management of COVID19 : Rehabilita"on for pa"ents with
physical decondi"oning and muscle weakness a'er COVID19 illness.:
World Health Organiza"on (WHO); 2020.
11.Greenhalgh T, Knight M, A’Court C, Buxton M, Husain L. Management of
postacute covid19 in primary care. BMJ. 2020;370:m3026.
12.Zhao HM, Xie YX, Wang C, Medicine CAoR, Medicine RRCoCAoR,
Cardiopulmonar. Recommenda"ons for respiratory rehabilita"on in adults
with coronavirus disease 2019. Chinese Medical Journal.
2020;133(13):1595602.
CHAPTER 3
POST COVID19 RESPIRATORY MANAGEMENT
PROTOCOL
1.0 Introduc"on
1.1 COVID19 has spread rapidly over several months, affec"ng pa"ents
across all age groups and geographic areas. The disease has a diverse
course; pa"ents may range from asymptoma"c to those with
respiratory failure, complicated by acute respiratory distress syndrome
(ARDS). The alarming severe outcome in these groups of pa"ents is
partly caused by a “cytokine storm”, which calls for means to mi"gate
the inflamma"on. One possible complica"on of pulmonary involvement
in COVID19 is pulmonary fibrosis, which leads to chronic breathing
difficul"es, longterm disability and affects pa"ents' quality of life.
There are no specific mechanisms that lead to this phenomenon in
COVID19 1,2,3, but some informa"on arises from previous severe
acute respiratory syndrome (SARS) or Middle East respiratory syndrome
(MERS) epidemics 4,5.
1.2 In retrospect from the pulmonary fibrosis learnings observed in SARS

and MERS epidemics, pa"ents first develop atypical pneumonia,
followed by acute lung injury (ALI) and acute respiratory distress
syndrome (ARDS), which evolves into fibrosis. Fibrosis occurs more
o'en amongst the older popula"on and pa"ents with a severe course
of the disease6. Fibrosis is correlated with disease dura"on; however,
it may resolve spontaneously7. This observa"on however is not
robustly studied for COVID19 and it remains unclear why certain
individuals are able to recover from such an insult, whereas others
develop accumula"on of fibroblasts and myofibroblasts and excessive
deposi"on of collagen resul"ng in progressive pulmonary fibrosis8. With

the pa&ern of thoracic imaging abnormali"es and growing clinical
experience in COVID19 studies, it is envisaged that inters""al lung
disease, organizing pneumonia and pulmonary vascular disease are
likely to be the most important respiratory complica"ons.
2.0 Scope & Objec"ve
The scope of respiratory assessment is to look for the following condi"ons:

a. Persistent lung fibrosis or Post COVID19 organising pneumonia
b. Pulmonary embolism
c. Undiagnosed respiratory illness
d. Post viral hyper reac"ve airway / cough
e. Decondi"oning / dysfunc"onal breathing
f. Follow up for underlying preexis"ng respiratory condi"on that
may be obscured by COVID19 infec"on
g. Post intuba"on complica"on
3.0 Symptoms
The COVID19 infec"on is a heterogeneous disease with majority

experiencing asymptoma"c, mild illness with spontaneous recoveries but
there are groups who require hospitaliza"on for pneumonia and medical
support.
4.0 Assessment (Clinical assessment & Inves"ga"on)
Follow up pa"ent post discharge should be done at the nearest healthcare

facili"es/clinic and easy access based on pa"ents’ locali"es (Table 3.1). For
pa"ents with prior regular followup, they may be followed up by their regular
primary physician clinic postdischarge.
Selfreport to nearest clinic/healthcare facili"es if

Category 13
symptoma"c
Post COVID19 Clinic by mul"disciplinary team:

● General Physician Table 3.1:
Category 4&5 ● Respiratory Physician Post
● Rehabilita"on physician COVID19
followup
● Physiotherapist
A full clinical assessment includes exploring for both respiratory and nonrespiratory
symptoms as in Table 3.2, 3.3 and 3.4.
Ques"ons Yes/No
Do you s"ll have symptoms?

● Symptoms
● Full recovery
Are you more breathless than before?

● More than you expected
● Back to before COVID illness
Any fa"gue feeling?

● More than you expected
Any cough?
How is your physical strength?
● Weak
Do you have myalgia?

Do you have anosmia?
Have you lost your sense of taste?
Table 3.2:
Is your sleep disturbed?
Modified
Medical Any nightmares or flashbacks?
Research
Council (mMRC) Do you feel low mood/lack of mo"va"on?
Scale for
Dyspnoea and Do you feel more anxious than before?
Post COVID19
Have you lost weight since COVID illness?
Func"onal
Status (PCFS) Any other symptoms – please list
Scale.
Ques"ons Yes/No
Diagnos"c tests
Pulse oximeter (Category 35)
CXR (Category 35)
CT scan (Category 45)
Blood test (Category 45)
● ABG (discharged with oxygen concentrator)

● DDimer (if suspected new onset PE)
Ques"ons Yes/No
● RF and ANA (for persistent lung fibrosis on radiology series)

Lung func"on test (Category 45)
● Spirometry (with single use filter)
● Sta"c lung volume if persistent fibrosis
● Diffusion capacity if indicated
Walking test
● 6minute walking test and oxygen level monitoring or the
Table 3.3:
1minute sittostand test Post COVID
respiratory
Consider addi"onal test: assessment
Sputum culture if suspect infec"on should include
ECG and ECHO the following
Inves"ga"ons
Assessment of con"nua"on oxygen support Refer management
Requirement for pulmonary rehabilita"on
Con"nua"on treatment for provoked VTE during

COVID19 illness
Pallia"ve care management where required

Refer accordingly
Psychosocial assessment
Considera"on of specific postintensive care unit Table 3.4:

complica"ons such as sarcopaenia, cogni"ve impairment Other
and posttrauma"c stress disorder. assessment
CXR = Chest XRay

CT = Computed Tomography
HRCT = High resolu"on Computed Tomography
CTPA = Computed Tomography Pulmonary Angiography
ABG = Arterial blood gas
PE = Pulmonary embolism
VTE = venous thromboembolic
Human resources need for pa"ents’ followup and care
Type Examples
Primary care clinic / Private general clinic Medical officer

Primary care physician
Medical Assistant/Staff Nurse (clinic,
spirometry)
Hospital Medical Officer

Internal Medicine Specialist
Respiratory Physician
Rehabilita"on physician
Physiotherapist
Occupa"onal therapist
Medical Assistant/Staff Nurse (clinic,
spirometry)
5.0 Management
5.1 Algorithm management Post COVID19 respiratory follow up discharge

requirement from hospital:
5.2 Referral le&er (details of ward admission to include category of COVID

19 infec"on, oxygen requirement, treatment received, result of blood
test and status of pa"ent upon discharge). Hard/so' copy radiology
images (chest radiograph and computed tomography scan)
5.3 For pa"ents with prior regular followup, they may be followed up by
their regular primary physician clinic postdischarge.
5.4 Physician to decide to adjust the tapering dose of steroid according to

the latest symptom and radiological. For pa"ent with COVID category
3 who upon discharge has persistent symptoms or persistent CXR
changes, they are to be given clinic appointment according to algorithm
as in Figure 3.1.
5.5 For pa"ent with COVID category 4 or 5 to be followed up at the clinic

according to algorithm as in Figure 3.2.
ALGORITHM POST COVID19 STAGE 3
Follow-up after discharge within 12 weeks after discharge

1. A full clinical assessment
2. Repeat CXR (to compared with previous CXRs if available)
Persistent or progressive Yes

symptoms such as To follow algorithm for
breathlessness, chest pain or stage 4/5
cough
If CXR worsening or
no resolution
No
No
Any CXR
Repeat the CXR in 12 weeks’
resolution? time
Yes
CXR shows resolution (or if there are

only minor insignificant changes such
as small areas of atelectasis) AND
the patient is asymptomatic having
made a full recovery
Figure 3.1:
Algorithm Post
COVID19
Discharge
Stage 3
ALGORITHM POST COVID19 PATIENT WITH SEVERE DISEASE (STAGE 4&5)

(INCLUDING PATIENT DISCHARGED WITH PREDNISOLONE COURSE)
.*--*/#01#2#weeks#'"34+#56789'+:4#
;<#=#"0--#8-6)68'-#'77477,4)3##
><#&414'3#$%&#?6"#1*776(-4@'A'6-'(-4#3*#8*,1'+4#/639#1+4A6*07#$%&7B#
C<#D*#')#4E4+36*)'-#3473#?;#,6)#763F3*F73')5#3473#*+#G#,6)#/'-H6):#3473B#
Abnormal CXR and physiological Abnormal CXR but no physiological

impairment impairment
Repeat CXR in 3 months’

Consult physician time
Refer to hospital to arrange for repeat HRCT/+-
CTPA
Consider Echo and pulmonary function test
Note: !"#$%&#'()*+,'-##
-If suspected Pulmonary embolism/angiopathy
to do CTPA
Yes Interstitial No
Figure 3.2: lung disease
Algorithm Post Patient’s physiological or functional
Refer to Respiratory (ILD)and/ impairment as well as other diagnoses
COVID19 physician PE should be considered and managed
Pa"ent with (if not yet refer) & manage OR
accordingly If well considered discharge
Severe Disease
(Stage 4&5)
(including Discuss the serial HRCTs in
pa"ent multidisciplinary meeting-ILD Dysfunctional breathing and breathing
discharged with ILD investigation pattern disorder – refer physio for
prednisolone To decide the final diagnosis and pulmonary rehabilitation
treatment
course)
5.6 Respiratory test follows up
Spirometry Baseline (if available) for comparison

+/ DLco During first appointment
(if test available) 6th month post COVID
12th month post COVID
6minute walk test or Baseline (if available) for comparison

1 minute sittostand test During first appointment
5.7 Long term oxygen therapy (LTOT)
LTOT may improve outcome measures other than mortality, including

quality of life, cardiovascular morbidity, depression, cogni"ve func"on,
exercise capacity, and frequency of hospitaliza"on.812 The LTOT should
be prescribed only when there is evidence of persistent hypoxemia in
a clinically stable pa"ent who is receiving otherwise op"mal medical
management (Table 3.5)
General Indica"on
PaO2 ≤55 mmHg (7.32 kPa) or SaO2 ≤88 percent
In the presence of corpulmonale
PaO2 ≤59 mmHg (7.85 kPa) or SaO2 ≤89 percent

ECG evidence of P pulmonale
Haematocrit >55 percent
Clinical evidence of right heart failure
Specific situa"on
PaO2 ≥60 mmHg (7.98 kPa) or SaO2 ≥90 percent with lung disease and other clinical
needs such as sleep apnoea with nocturnal desatura"on not corrected by CPAP.
If the pa"ent meets criteria at rest, O2 should also be prescribed during sleep and
exercise, and appropriately "trated.
If the pa"ent is normoxemic at rest but desaturates during exercise (PaO2 ≤55 mmHg Table 3.5:
[7.32 kPa]), O2 is generally prescribed for use during exercise. Indica"on to
con"nue or to
ini"ate LTOT
For pa"ents who desaturate (PaO2 ≤55 mmHg [7.32 kPa]) during sleep, further
evalua"on with polysomnography may be indicated to assess for sleepdisordered
breathing.
5.6 Medical treatment
a. Inhaled medica"on:
i. For hyper reac"ve airway triggered by COVID19
ii. Newly diagnosed COPD
iii. Newly diagnosed bronchial asthma
b. Oral medica"on:
i. Refer Post COVID19 organising pneumonia
recommenda"on
ii. Adjustment on prednisolone tapering dose
iii. An"fibro"c medica"on for progressive fibrosing lung
disease
5.7 Pulmonary rehabilita"on
For indicated pa"ent (refer rehabilita"on recommenda"on)
6.0 Pa"ent outcome & assessment tool
6.1 Pa"ent outcome:

a. Recover to baseline
b. Persistent lung fibrosis
c. Requiring long term oxygen therapy
d. Requiring an" fibro"c treatment for progressive fibrosing lung
fibrosis (long term follow up)
e. Death
6.2 Assessment tool:
Pa"ent selfreport method for the Post COVID19 func"onal status

scale14
a. Flow chart
b. Pa"ent ques"onnaire
Grade of
Symptoms
dyspnoea
0 Not troubled by breathlessness except on strenuous exercise
1 Short of breath when hurrying or walking up a slight hill
2 Walks slower than contemporaries on the level because of

breathlessness or has to stop for breath when walking at own
pace
Table 3.6:
3 Stops for breath a'er walking 100m or a'er a few minutes on
Modified
medical the level
research
council scale 4 Too breathless to leave the house or breathless when dressing
for dyspnoea or undressing
POST COVID19 FUNCTIONAL STATUS SCALE
Figure 3.3:
Post COVID19
Func"onal
Status Scale
References:
1. Wu Z., McGoogan J.M. Characteris"cs of and Important Lessons from the

Coronavirus Disease 2019 (COVID19) Outbreak in China: Summary of a
Report of 72314 Cases from the Chinese Centre for Disease Control and
Preven"on. JAMA. 2020 doi: 10.1001/jama.2020.2648.
2. Chen N., Zhou M., Dong X., Qu J., Gong F., Han Y., Qiu Y., Wang J., Liu Y.,
Wei Y., et al. Epidemiological and clinical characteris"cs of 99 cases of 2019
novel coronavirus pneumonia in Wuhan, China: A descrip"ve study. Lancet.
2020;395:507–513. doi: 10.1016/S01406736(20)302117.
3. Huang C., Wang Y., Li X., Ren L., Zhao J., Hu Y., Zhang L., Fan G., Xu J., Gu X.,
et al. Clinical features of pa"ents infected with 2019 novel coronavirus in
Wuhan, China. Lancet. 2020;395:497–506. doi: 10.1016/S0140
6736(20)301835.
4. Hui D.S.C., Zumla A. Severe Acute Respiratory Syndrome: Historical,
Epidemiologic, and Clinical Features. Infect. Dis. Clin. North Am.
2019;33:869–889. doi: 10.1016/j.idc.2019.07.001.
5. Nassar M.S., Bakhrebah M.A., Meo S.A., Alsuabeyl M.S., Zaher W.A. Middle
East Respiratory Syndrome Coronavirus (MERSCoV) infec"on:
Epidemiology, pathogenesis and clinical characteris"cs. Eur. Rev. Med.
Pharm. Sci. 2018;22:4956–4961. doi: 10.26355/eurrev_201808_15635.
6. Pulmonary fibrosis and COVID19: the poten"al role for an"fibro"c therapy.
George PM, Wells AU, Jenkins RG. Lancet Respir Med. 2020 Aug; 8(8):807
815.
7. The Na"onal Ins"tute for Health and Care Excellence (NICE), the Sco$sh
Intercollegiate Guidelines Network (SIGN) and the Royal College of General
Prac""oners (RCGP)
8. Eaton T, Lewis C, Young P, et al. Longterm oxygen therapy improves health
related quality of life. Respir Med 2004; 98:285.
9. Weitzenblum E, Oswald M, Apprill M, et al. Evolu"on of physiological
variables in pa"ents with chronic obstruc"ve pulmonary disease before
and during longterm oxygen therapy. Respira"on 1991; 58:126.
10.Borak J, Sliwiński P, Tobiasz M, et al. Psychological status of COPD pa"ents
before and a'er one year of longterm oxygen therapy. Monaldi Arch Chest
Dis 1996; 51:7.
11.Ringbaek TJ, Viskum K, Lange P. Does longterm oxygen therapy reduce
hospitalisa"on in hypoxaemic chronic obstruc"ve pulmonary disease? Eur
Respir J 2002; 20:38.
12.Haidl P, Clement C, Wiese C, et al. Longterm oxygen therapy stops the
natural decline of endurance in COPD pa"ents with reversible hypercapnia.
Respira"on 2004; 71:342.
13.Rehabilita"on of pa"ents Post COVID19 infec"on: a literature review.
A.Demeco, N.Maro&a, M. Barle&a. Journal of Interna"onal Medical
Research 48(8) 1–10.
14.Klok FA, Boon GJAM, Barco S, et al. The Post COVID19 Func"onal Status
(PCFS) Scale: a tool to measure func"onal status over "me a'er COVID19.
European Respiratory Journal 2020 56: 2001494.
CHAPTER 4
ORGANIZING PNEUMONIA IN COVID19
1.0 Introduc"on
1.1 Organizing Pneumonia (OP) is increasingly described as a poten"al

consequence or evolu"on of COVID19 pneumonia in moderate to
severe COVID19 pa"ents. Organizing pneumonia is a cor"costeroid
responsive inflammatory lung disease1 and has been reported to
appear as the viral load of Coronavirus19 decreases.2
1.2 Organizing pneumonia in COVID19 is regarded as secondary OP which

may occur from direct lung injury from the COVID19 virus itself or due
to the hyperinflammatory state as postulated by the cytokine release
syndrome (CRS) hypothesis. The figure below shows the evolu"on of
COVID19 pneumonia with OP as a poten"al sequalae.3 (See Figure 4.1)
1.3 Organizing pneumonia histological findings such as intraluminal loose

connec"ve "ssue within the alveolar ducts and bronchioles associated
with the fibrinous acute injury have also been reported in postmortem
biopsy of late COVID19 death (around 20 days a'er symptoms).4
1.4 Although the gold standard in OP diagnosis requires histological

confirma"on, typical radiological findings is sufficient to make a
confident diagnosis of OP in COVID19 as lung biopsy is invasive and
should be avoided. 5 A good interobserver concordance has also been
described between imaging and histopathological findings for OP in
COVID19 pa"ents.6
Figure 4.1:
Clinical course
of COVID19
Source: Parra Gordo ML, Weiland GB, García MG et al. Radiologic aspects of COVID19 pneumonia:
outcomes and thoracic complica!ons. Radiologia; 2021
1.5 Common radiological features on chest computer topography (CT) are

arched consolida"on bands (arcadelike) with shaded margins
distributed around the structures of surrounding secondary pulmonary
lobules followed by ground glass opaci"es (GGOs) with irregular lines
changes predominantly in bilateral and mul"focal distribu"ons.5 In a
case series of 106 pa"ents, 74.5% of OP cases were nonsevere and
97.1% cases had good prognosis with recovery.7
2.0 Scope
2.1 The scope of the guideline is:
a. Pa"ents who are s"ll admi&ed in hospital with confirmed COVID

19 reverse transcrip"on polymerase chain reac"on (RTPCR) and
b. suspected or confirmed organizing pneumonia diagnosis.
2.2 The general COVID19 and Post COVID19 respiratory guideline should
be followed in the management of pa"ents who are not admi&ed and
have mild COVID19 symptoms or pa"ents who are discharged Post
COVID19.
3.0 Signs and Symptoms
3.1 Symptoms of OP may vary from mild cough and dyspnoea to severe
acute respiratory distress. A high index of suspicion is needed in mild
symptoms. For pa"ents who are not responding to COVID19

treatment, OP should be suspected a'er ruling out other differen"al
diagnosis.
3.2 A Bri"sh cohort of 837 pa"ents followed up found that 39% of pa"ents
were symptoma"c at four weeks and 4.8% of these pa"ents had
organizing pneumonia assessed by CT scan.8
3.3 Clinical assessment of suspected COVID19 OP pa"ents should be

specialist driven. Physical findings are nonspecific and may not be
dis"nguished from other acute respiratory illness. In severe cases,
pa"ents may have respiratory distress with varying degrees of hypoxia.
Pa"ent with COVID19 OP typically manifests a subacute disease
behaviour without apparent lung fibrosis.2
3.4 COVID19 OP should be suspected in pa"ents with:

a. Persistent or new onset of symptoms
i. Dyspnea (including exer"onal dyspnea)
ii. Cough
iii. Pleuri"c chest pain
b. Persistent hypoxia or increasing requirement of supplemental

oxygen
c. Worsening or persistent chest radiographic abnormality
3.5 Differen"al diagnosis:

a. Secondary bacterial or fungal pneumonia
b. Pulmonary embolism
c. Pulmonary oedema / cardiomyopathy / myocardi"s
d. Pneumothorax
e. Acute coronary syndrome
4.0 Inves"ga"on
4.1 Laboratory
There are no specific laboratory inves"ga"ons to diagnose OP in COVID

19. Inves"ga"ons such as electrocardiogram, Creac"ve protein, blood
cultures, echocardiogram and CT pulmonary angiogram (CTPA) should
be done to rule out the differen"al diagnosis.
4.2 Imaging
Chest radiograph should not be used to diagnose COVID19 OP. High

resolu"on chest CT (HRCT) thorax is recommended as the imaging
modality of choice in pa"ents suspected with COVID19 OP. (See Figure
4.2 and 4.3)
High resolu"on chest CT should be requested in pa"ents who remains

symptoma"c and show signs of deteriora"on despite ini"al therapy (see
Algorithm) as overlapping radiological features between covid
pneumonia and OP have been reported. This is also in accordance to
WHO guideline.9
The most common and dominant findings of OP is the presence of

GGOs with or without consolida"on in a subpleural distribu"on.7
Other HRCT findings can include:3
a. Groundglass opaci"es and mixed groundglass and consolida"on

opaci"es
b. Peri lobular distribu"on pa&ern
c. Linear subpleural opaci"es
d. Re"cular pa&ern
e. Inverted halo or atoll sign
Due to the variability of OP findings in imaging, the diagnosis should be

made by an experienced radiologist.
5.0 Diagnosis
The diagnosis of OP should follow a mul"disciplinary discussion involving the

trea"ng physician, the radiologist and the respiratory physician.
Figure 4.2:
HRCT showing
patchy areas of
subpleural
consolida"on
showing peri
lobular
distribu"ons
(arrow) with
Source: Parra Gordo ML, Weiland
associated
GB, García MG et al. Radiologic
re"cular
aspects of COVID19 pneumonia:
opaci"es
outcomes and thoracic
(arrowhead)
complica!ons. Radiologia; 2021
Figure 4.3:
CTPA image
showing mixed
ground glass
(arrow) and
consolida"on
(arrow "p)
Source: Parra Gordo ML, Weiland
opaci"es with
GB, García MG et al. Radiologic
linear margins
aspects of COVID19 pneumonia:
and peri lobular
outcomes and thoracic
opaci"es (circle)
complica!ons. Radiologia. 2021
6.0 Treatment & Management
6.1 Aim of treatment
Organizing Pneumonia cases of COVID19, fortunately have a favourable

prognosis. The main aim of treatment is to prevent func"onal
disabili"es and irreversible lung fibrosis.
a. Cor"costeroids
i. Cor"costeroids are currently the mainstay of treatment for

most pa"ents. A significant minority of pa"ents may have
mild disease and may not show progression. This group of
pa"ents may not benefit from cor"costeroid therapy and
surveillance should suffice to study disease behaviour. In
these pa"ents, the imaging findings may represent ongoing
recovery.
ii. Evidence regarding the treatment of OP in COVID19 is
mainly from case reports and expert opinions.10,11,12,13,14,15 The
decision on the dosage and dura"on of cor"costeroids
should preferably follow a mul"disciplinary consensus
including input from a respiratory physician.
iii. Prior to ini"a"on of high dose cor"costeroids, pa"ents
should be assessed for any significant infec"on including
tuberculosis. While on treatment with cor"costeroids,
pa"ents should be assessed and monitored for complica"ons
such as secondary bacterial and fungal infec"ons,
hyperglycemia and gastrointes"nal bleed.
iv. In noncri"cally ill pa"ents, prednisolone (0.51mg/kg/day,
maximum 60mg per day) should be ini"ated.
v. Lower doses of prednisolone may be considered in pa"ents

with:
• high risk of complica"ons (e.g., elderly,
immunosuppressed group, poorly controlled diabe"cs,
mul"ple comorbidi"es)
• less extensive CT changes
• extensive CT changes but with high risk of complica"ons
vi. Dura"on of treatment varies between one to three months.
Prednisolone may be "trated down by 5 mg every five days
un"l first clinic followup visit.
vii. Dosage of intravenous Methylprednisolone and oral
prednisolone in cri"cally ill pa"ents should be individualised.
6.2 Other treatment strategies
Pulmonary rehabilita"on is part of nonpharmacological, inpa"ent

management of COVID19 OP. This should be con"nued upon hospital
discharge.
7.0 Follow up
7.1 Pa"ents are recommended to be followed up at a specialist clinic in 4–

6 weeks a'er discharge. The follow up review should include:
a. assessment of side effects of cor"costeroid uses and

b. chest radiograph
7.2 Subsequent follow up should be at 12 weeks a'er discharge.

Assessment should include:
a. chest radiograph
b. pulmonary func"on test and 6Minute Walking Test (6MWT) may
be considered
7.3 Pa"ents who develop side effects of cor"costeroid therapy and those
with persistent or worsening symptoms should be followed up earlier.
A HRCT with or without CTPA and an echocardiogram is warranted in
pa"ents with persistent chest radiograph changes, abnormal pulmonary
func"on tests or 6MWT desatura"on. A respiratory physician should
then be consulted regarding further management.
POST COVID19 FUNCTIONAL STATUS SCALE
*Prednisolone
• decision to start steroids should be done following a mul"disciplinary consensus Figure 4.4:
• dose 0.51mg/kg/day (maximum 60mg per day) Algorithm on
• "trate by 5mg every 5days un"l first follow up review Management
• steroids should be commenced a'er ruling out significant infec"on including of Organizing
tuberculosis Pneumonia in
COVID19
References:
1. Arabi YM, Chrousos GP, Meduri GU. The ten reasons why cor"costeroid
therapy reduces mortality in severe COVID19. Intensive Care Med. 2020
Nov;46(11):20672070
2. Okamori S, Lee H, Kondo Y, et al. Coronavirus disease 2019associated
rapidly progressive organizing pneumonia with fibro"c feature: Two case
reports. Medicine (Bal"more). 2020 Aug 28;99(35):e21804
3. Parra Gordo ML, Weiland GB, García MG et al. Radiologic aspects of COVID
19 pneumonia: outcomes and thoracic complica"ons. Radiologia. 2021 Jan
Feb;63(1):7488
4. Copin MC, Parmen"er E, Duburcq T, et al. Time to consider histologic
pa&ern of lung injury to treat cri"cally ill pa"ents with COVID19 infec"on.
Intensive Care Med. 2020 Jun;46(6):11241126
5. Ng FH, Li SK, Lee YC, et al. Temporal changes in computed tomography of
COVID19 pneumonia with perilobular fibrosis. Hong Kong Med J. 2020
Jun;26(3):250.e1251.e2
6. Pogatchnik BP, Swenson KE, Sharifi H, et al. Radiologypathology Correla"on
in Recovered COVID19, Demonstra"ng Organizing Pneumonia. Am J Respir
Crit Care Med. 2020 Jul 1;202(4):598–9
7. Wang Y, Jin C, Wu CC, et al. Organizing pneumonia of COVID19: Time
dependent evolu"on and outcome in CT findings. PLoS One. 2020 Nov
11;15(11):e0240347
8. Myall KJ, Mukherjee B, Castanheira AM, et al. Persistent Post COVID19
Inflammatory Inters""al Lung Disease: An Observa"onal Study of
Cor"costeroid Treatment. Ann Am Thorac Soc. 2021 Jan 12
9. WHO. Use of chest imaging in COVID19 updated: 11 June 2020 at
h&ps://www.who.int/publica"ons/i/item/useofchestimagingincovid
19 assessed on 6 April 2021
10.Kim T, Son E, Jeon D, et al. Effec"veness of Steroid Treatment for SARSCoV
2 Pneumonia with Cryptogenic Organizing PneumoniaLike Reac"on: A
Case Report. Disaster Med Public Health Prep. 2020 Oct 26:14
11.de Oliveira Filho CM, Vieceli T, de Fraga Basso&o C, et al. Organizing
pneumonia: A late phase complica"on of COVID19 responding
drama"cally to cor"costeroids. Braz J Infect Dis. 2021 JanFeb;25(1):101541
12.Simões JP, Alves Ferreira AR, Almeida PM, et al. Organizing pneumonia and
COVID19: A report of two cases. Respir Med Case Rep. 2021;32:101359
13.Kanaoka K, Minami S, Ihara S, et al. Secondary organizing pneumonia a'er
coronavirus disease 2019: Two cases. Respir Med Case Rep. 2021 Feb
1;32:101356
14.Takumida H, Izumi S, Sakamoto K, et al. Sustained coronavirus disease
2019related organizing pneumonia successfully treated with
cor"costeroid. Respir Inves"g. 2021 Jan 21:S22125345(21)000022
15.Horii H, Kamada K, Nakakubo S, et al. Rapidly progressive organizing
pneumonia associated with COVID19. Respir Med Case Rep.
2020;31:101295
CHAPTER 5
POST COVID19 MANAGEMENT PROTOCOL FOR
IMMUNOCOMPROMISED PATIENT ON
IMMUNOSUPPRESANT / CHEMOTHERAPY
1.0 Introduc"on
1.1 This is a general recommenda"on for management of pa"ents on

immunosuppressants during and a'er COVID19 infec"on. Highquality
evidence regarding the effects of stopping or maintaining medica"ons
for systemic rheuma"c diseases in the se$ng of COVID19 exposure is
lacking. In the absence of established treatment of COVID19 infec"on
most professional society have issued recommenda"on to reduce or
withheld immunosuppressant to a level that are considered safe and
aim at balancing the risk of infec"on against disease control.
1.2 Cellular immunity is key in determining the course and outcome of

COVID19 infec"on. However, cellular immunity is compromised in
pa"ent taking immunosuppressants. Generally, there are four groups
of pa"ents who are taking longterm immunosuppressant:
a. Pa"ents with autoimmune diseases, moderate to severe chronic
dermatological condi"ons (psoriasis, eczema, autoimmune
blistering diseases, chronic spontaneous ur"carial etc.)
b. Solid organ transplant recipients
c. Hematopoie"c stem cell transplant recipients
d. Solid organ tumours and haematological malignancy pa"ents

receiving chemotherapy.
1.3 Lymphopenia has been shown to be nega"vely associated with COVID

19 severity. Pa"ent who are cri"cally ill COVID19 pa"ents has been
shown to have high level of cytokines especially IL6 and this suggest
that hyper inflamma"on may contribute to morbidity and mortality.
1.4 Immunosuppressive agent used in the management of the above

pa"ents typically causes lymphopenia and impairs lymphocyte
func"ons.
2.0 Autoimmune Diseases
In pa"ents with autoimmune diseases, there are 3 clinical situa"ons:

a. Pa"ents who newly diagnosed or relapsing disease.
In this group of pa"ents, Ini"a"on of immunosuppressants should be
considered is there is life threatening disease (e.g., rapidly progressive
glomerulonephri"s, life threatening lupus flare, ac"ve autoimmune
blistering diseases).
b. Pa"ents on the maintenance phase of immunosuppressant diseases.

In this group of pa"ents, an individualized riskbenefit evalua"on is
necessary to assess the risk of immunosuppressants versus risk of
disease relapse.
c. Pa"ents in remission on tapering dose of immunosuppressant.

In this group of pa"ents, con"nued tapering of immunosuppressants
may be considered. However, treatment decision should be made on a
caseto case basis. Discussion with primary care team is important
CATEGORY DRUGS COMMENTS
1. Cor"costeroids
Uncomplicated COVID19 pa"ents on long

term steroids for the underlying disease
should be con"nued on the steroid
maintenance dose prior to admission.
Pa"ents requiring high dose steroids due to
COVID19 related complica"ons or underlying
disease flare should be tapered accordingly by
respec"ve physician.
2. Solid organ transplant
Calcineurin Cyclosporine Please consult with transplant physician

inhibitors Tacrolimus regarding immunosuppressant during and
a'er COVID19 infec"on.
Please be noted on the drugdrug interac"on

with transplant medica"on prior to star"ng
new medica"ons to avoid transplant rejec"on.
An" Cyclosporine Please consult with transplant physician

prolifera"ve Tacrolimus regarding immunosuppressant during and
a'er COVID19 infec"on.
Mammalian Everolimus Please consult with transplant physician

target of Sirolimus regarding immunosuppressant during and
Rapamicin a'er COVID9 infec"on.
inhibitors
(mTORi) Please be noted on the drugdrug interac"on
with transplant medica"on prior to star"ng
new medica"ons to avoid transplant rejec"on.
3. Haematopoe"c stem cell transplant
Most immunosuppressants in transplanted

pa"ents should be con"nued. Please consult
with transplant physician regarding
immunosuppressants during and a'er COVID
19 infec"on.
4. Autoimmune and Inflammatory Rheuma"c and Dermatological Diseases
Immunosup Cyclophosphamide Regardless of COVID19 severity all the

pressants Mycophenolate immunosuppressants, biologics, DMARDS and
Mofe"l JAK Inhibitors should be stopped during ac"ve
Azathioprine COVID19 infec"on. However, HCQ and SSZ
Tacrolimus maybe con"nued in stable pa"ents. IL6 may
Cyclosporin be con"nued in selected cases of COVID19
associated with heightened immune response.
Biologics e.g., An"TNFα, IL
6, IL17 inhibitors, Reini"a"ng treatment:
IL12/23 inhibitor, 1. Posi"ve PCR but asymptoma"c
IL23 inhibitor, • Can be started 1017 days a'er PCR test
Rituximab, was reported.
Omalizumab 2. Uncomplicated COVID19 (mild or no
pneumonia and treated in Ambulatory
JAK Inhibitors Tofaci"nib, Care or selfquaran"ne):
Barici"nib • Restart within 714 days of symptom
resolu"on
DMARDS Hydroxychloroquine 3. Severe COVID19:
Sulphasalazine • Reini"a"ng’s treatment should be made by
Leflunomide the trea"ng physician.
Methotrexate Reference: ACR guidelines, NICE guidelines,

Up To Date
An" Dapsone
inflammatory
Vitamin A Isotre"noin,
deriva"ves acitre"n
5. Oncology
Haematological Chemotherapy Acute haematological malignancy

malignancy chemotherapy should be withheld. However,
in life threatening situa"on, less intensive
chemotherapy can be given.
In general, chronic haematological
malignancy pa"ents may con"nue with the
chemotherapy.
Solid organ Chemotherapy All chemotherapy is withheld during acute

tumours phase of infec"on.
Table 5.1: Reini"ate therapy at least 24 hours a'er
Immunosuppre fever resolu"on without an"pyre"c, and
ssants in there is improvement of symptoms (cough,
Transplant, dyspnoea).
Autoimmune
and
Inflammatory
For asymptoma"c pa"ents who are not
Condi"ons, and immunocompromised, chemotherapy
Oncology in can be considered at least 10 days a'er
Post COVID19 ini"al posi"ve test, and 20 days if
Management immunocompromised.
MANAGEMENT FLOW CHART FOR POST COVID19 PATIENTS ON

IMMUNOSUPPRESSANT POST DISCHARGE FROM HOSPITAL/INSTITUTIONS
Figure 5.1:
Management
Flow Chart for
* Prednisolone Post COVID19
• decision to start steroids should be done following a mul"disciplinary consensus Pa"ents on
• dose 0.51mg/kg/day (maximum 60mg per day) Immunosuppre
• "trate by 5mg every 5days un"l first follow up review ssant Post
• steroids should be commenced a'er ruling out significant infec"on including Discharge from
tuberculosis Hospital/
Ins"tu"ons
3.0 Solid Organ Transplant
Solid organ transplant recipient requires lifelong maintenance immunosuppressant.

Therapeu"c drug monitoring is the standard of care to balance preven"on of
allogra' rejec"on and increased risk of infec"on. However, there is no data on the
degree of immunosuppressant reduc"on that is effec"ve to contain COVID19
infec"on. Special precau"ons have to be considered in drug interac"ons especially
with calcineurin inhibitors and mTOR inhibitors in posttransplant recipients.
4.0 Haematology
4.1 Pa"ents with haematological malignancies do not have higher incidence

of COVID19 than noncancer pa"ents. However, pa"ents with
haematological malignancies tend to have more significant COVID19
complica"ons than noncancer pa"ents or pa"ents with solid tumours.
Mortalityrate reached 62% that is 23fold higher than general non
haematology pa"ents and 2 "mes higher than solid organ tumour.
4.2 Haematological malignancy pa"ents have prolonged persistence of viral

RNA up to a median of 32.7 days.
4.3 Worse outcomes have been reported in acute leukaemias and lymphoid
malignancies like lymphoma, mul"ple myeloma and chronic
lymphocy"c leukaemia.
4.4 Risk factors for severe COVID19 in haematological malignancies

pa"ents are similar to normal healthy adults e.g., Hypertension,
Diabetes Mellitus, Obesity and old age. In addi"on, haematological
malignancies pa"ents with acute leukaemias, lymphoid malignancies
(lymphoma, mul"ple myeloma and chronic lymphocy"c leukaemia),
lymphopenia (<0.5 x 109/l), uncontrolled haematological malignancy,
ECOG score of 3/4 and neutropenia (< 0.5 x 109/l) have higher risk to
developed severe COVID19.
4.5 All haematological malignant with confirm COVID19 must repeat RT
PCR for COVID19 x 2, 24 hours apart, < 72 hours prior to star"ng
chemotherapy.
4.6 The decision for star"ng chemotherapy in these pa"ents will be based
on the risk level of disease progression, RTPCR COVID19 results and
clinical judgement of individual pa"ent.
Type of
Recommenda"ons
Malignancy
Aggressive Non Front line therapy

Hodgkin Lymphoma • Rituximab, Cyclophosphamide, Doxorubicin
(NHL) Hydrochloride, Oncovin, Prednisolone (RCHOP) as
standard of care. SC Rituximab is recommended to reduce
"me in hospital
• Rmini CHOP with Granulocyte Colony S"mula"ng Factor
(GCSF) support for the elderly
• Doseadjusted Etoposide, Prednisone, Oncovin,
Cyclophosphamide, Doxorubicin Hydrochloride, Rituximab
(DAEPOCHR) for Primary Medias"nal Large BCell
Lymphoma (PMBCL) and triple/double hit lymphoma (R
CHOP + radiotherapy in some PMBCL cases)
• Intrathecal Methotrexate (ITMTX) instead of High Dose
Methotrexate (HDMTX) for Central Nervous System (CNS)
prophylaxis
Relapsed / refractory (R/R) disease

• High Dose Therapy/Autologous Stem Cell Transplant
(HDT/ASCT) in eligible pa"ents, Chimeric An"gen Receptor
TCell Therapy (CART) cells if available
• Consider Bendamus"ne (Treanda) and Rituximab
(Rituxan) (BR) or lenalidomide based regime
Indolent NHL and • In pa"ents with borderline indica"ons, treatment deferral

Mantle cell should be considered
Lymphoma • Rituximab, cyclophosphamide, Vincris"ne and Prednisone
(RCVP) or RCHOP are preferred over bendamus"ne due
to immunosuppressive proper"es
• In view of adverse impact of hypogammaglobulinaemia,
treatment with single agent Rituximab is discouraged as
with maintenance rituximab
• Venetoclax is discouraged due to frequent hospital visits
on ini"a"on of treatment
• In MCL, consolida"on with HDT/ASCT is controversial
• Ibru"nib is a preferred op"on in Waldenstrom
Macroglobulinemia (WM) and relapsed MCL
Chronic Lymphocy"c • Defer therapy if possible during outbreak

Leukemia (CLL) • Oral therapy preferred over intravenous therapy
• Avoid therapy with monoclonal an"bodies
• In COVID19 pa"ents with mild symptoms, Beta Cell
Receptors Inhibitors (BCRi) may be con"nued but
monoclonal an"bodies and/or venetoclax should be
withheld
Hodgkin’s lymphoma Front line therapy

• Early stage: Adriamycin, Bleomycin, Vinblas"ne and
Dacarbazine (ABVD) with radiotherapy, omi$ng
bleomycin a'er nega"ve interim Positron Emission
TomographyComputed Tomography (PET CT)
• Advance stage: ABVD with interim PET CT preferred
Type of
Recommenda"ons
Malignancy
R/R disease
• Gemcitabinebased or Bendamus"nebased regimens
preferred
• HDT/ASCT is recommended with maintenance
brentuximab vedo"n posttreatment
• Rou"ne use of GCSF recommended
Mul"ple Myeloma Front line therapy

(MM) Transplanteligible pa!ents
• Preferred induc"on protocol: Velcade, Revlimid and low
dose Dexamethasone (VRd), Velcade, Thalidomide and
low dose Dexamethasone (VTd) or Daratumumab, Velcade
and Dexamethasone (DaraVD)
• Administered for extended period for up to 68 or even 12
cycles
• Consider delay ASCT or preserving a'er first relapse
• VRD for 612 cycles followed by Lenalidomide is an
op"on. In high risk pa"ents, Bortezomib can be added
every 2 weeks
• Stopping maintenance therapy is not recommended
Transplantineligible pa!ents
• Lenalidomide (Revlimid) and Dexamethasone (Rd) is
recommended in unfit pa"ents, addi"on of bortezomib or
daratumumab considered in highrisk pa"ents
• Whenever possible, weekly or oral regimen preferred
• Weekly bortezomib and carfilzomib might be considered
instead of biweekly; monthly daratumumab by omi$ng
bimonthly phase
• Daratumumab may be safely administered in 90 min
under close supervision
Smouldering MM
• Monitor without ac"ve interven"on
• Virtual consulta"on
R/R disease
• Delay treatment for biochemical relapse
• Daratumumab every 4 weeks a'er Very Good Par"al
Response (VGPR)
Pa"ents with MM and symptoma"c COVID19 should
interrupt an"myeloma treatment un"l recovery.
Asymptoma"c pa"ents should undergo 14 days quaran"ne.
Pa"ents receiving bisphosphonates should be changed to
every 3 months.
Acute Lymphocy"c Front line therapy

Leukemia (ALL) Philadelphia chromosome nega!ve Acute Lymphoblas!c
Leukemia (Ph’ – ALL)
• Proceed with standard cura"ve induc"on; reduc"on of
Type of
Recommenda"ons
Malignancy
daunorubicin (50%) and pegasparginase (1000IU/m2)

should be considered in pa"ents with high risk for
complica"ons.
Philadelphia chromosome posi!ve Acute Lymphoblas!c

Leukemia (Ph’+ALL)
• Tyrosine Kinase Inhibitors (TKI) with minimal steroid
exposure is preferred over aggressive mul"agent therapy
for ini"al treatment. Dasa"nib to be used with cau"on as
it causes pleural effusion.
• Individualized decision for transplant in high risk pa"ents
• Maintenance therapy: 50% reduc"on of steroids and omit
Vincris"ne; con"nue 6Mercaptopurine (6MP) and
Methotrexate (MTX)
COVID19 infec"on, maintenance should be withheld "ll

symptoms resolved for 14 days.
R/R disease
• Allogeneic Stem Cell Transplant (AlloSCT) despite
pandemic in pa"ents achieving Complete Remission 2
(CR2) is recommended
Acute Myeloid Front line therapy

Leukemia (AML) • Intensive induc"on therapy should be offered to all
eligible pa"ents
• Consolida"on/postremission therapy is recommended
for pa"ents in Complete Remission (CR). Decreasing the
number of cycles from 4 to 3 and/or lowering cytarabine
dose from 3gm/m2 to 1.5gm/m2 should be considered
• Individualized decision for AlloSCT; in highrisk pa"ents’
procedure should not be delayed
R/R disease
• Standard salvage regimes are recommended
• Targeted therapy recommended if available
Acute promyelocy"c leukemia (APL)

• Arsenic trioxide and alltrans re"noic acid (ATRA) and ATO
cause prolonged neutropenia, ATRA and Idarubicin (Ida)
preferred
Chronic Myeloid • TKI therapy should not be modified.

Leukemia (CML) • Dasa"nib may cause pleural effusion and during COVID
infec"on, interrup"on of treatment may be considered
• Less frequent Polymerase chain reac"on (PCR) monitoring
may be considered individually.
• Treatment Free Remission (TFR) should be postponed
un"l regular monitoring is possible. Pa"ents started on
TFR < 1 year, without access to regular Breakpoint cluster
Type of
Recommenda"ons
Malignancy
region gene. Abelson protooncogene (BCRABL)

monitoring should consider restar"ng TKI
• TKI should be con"nued in pa"ents with mild symptoms
of COVID19. Decision on TKI in pa"ents with severe COVID

19 should be taken individually, considering drug interac"on
with an"viral.
Myeloprolifera"ve • Cytoreduc"on with Hydroxyurea, Alpha interferon (αIFN)

neoplasm and anagrelide should con"nue
• Janus kinase inhibitors (JAK 2) inhibitors should con"nue
for responding pa"ents and who infected by COVID19.
Not recommended to commence new treatment for new
pa"ents.
• Op"mal aspirin or intermediate dose Lowmolecular
weightheparin (LMWH) to be considered for pa"ents
with COVID19 for Venous thromboembolism (VTE)
prophylaxis
Myelodysplas"c High risk (Revised Interna!onal Prognos!c Scoring System

syndrome (MDS) (IPSSR) score ≥3.5)
• Therapy should be started without delay or dose
adjustment
Low risk (IPSSR score≤3.5)
• Erythropoiesis S"mula"ng Agents (ESA) and Luspatercept
are strongly recommended
Hematopoie"c stem • Cellular therapy can be safely administered during

cell transplanta"on pandemic
(HSCT) • Delay HSCT for candidate with posi"ve COVID19 for at
least 14 days or longer depends on
o Severity of COVID19
o Underlying disease
Table 5.2:
Recommenda" o Status of malignancy
ons for o Risk of cancer relapse and progression
treatment of o Pa"ents’ age and comorbids
hematological o Type and intensity of treatment
malignancies o Adverse effects of treatment regimen
during COVID o Goals of therapy
19 pandemic • Consider reduced intensity condi"oning regimen
MANAGEMENT OF MALIGNANT HAEMATOLOGY PATIENTS WITH COVID19

RECEIVING CHEMOTHERAPY
Malignant hematology pa"ents with

COVID19
Asymptoma"c Symptoma"c
Isolate pa"ent for 10 days a'er Severel

sample collec"on immunocompromisedd?
No Yes
Isolate pa"ent "ll

Isolate pa"ent "ll
48 hours a'er
48 hours a'er
symptoms resolve
symptoms resolve
or un"l 20 days
or 10 days a'er
a'er symptom
symptom onset.
onset.
Discon"nue isola"on and visit Hematology Cancer

center
Individualized management with consulta"on between

Hematologist, ID Physician and
Intensivist
Prior to chemotherapy:
1. Assess the risk level of disease progression
2. Repeat RTPCR for COVID19 x2, 24 hours apart
within 72 hours
Low risk Intermediate risk High risk

Delay> 3 months Delay 13 months No delay
Consider (depends on risk):

• Change in intensity of chemotherapy Figure 5.2:
• Oral chemo regime Management of
• S/C chemo instead of IV infusion to reduce "me spent in hospital Malignant
• Regime with less visits to hospital Haematology
• Omi$ng severely immunosuppressive chemotherapy or reduce dosage Pa"ents with
• GCSF prophylaxis in protocols with FN COVID19
• Virtual clinic Receiving
Chemotherapy.
5.0 Oncology
There are a few studies showed increased risk of complica"ons and mortality for
cancer pa"ents if they are diagnosed with COVID19 compared to the general
popula"ons. In general, pa"ents on cancer treatment, regardless chemotherapy or
radiotherapy, will be withheld from the treatment during the acute phase. The
pa"ents will be transferred to medical ward or ICU care, if required. Once they have
been treated, they will be referred back to oncology ward for further management.
Table 5.3:
Summary of
Results
References:
1. COVID19: implica"ons for immunosuppression in kidney disease and

transplanta"on. Nature Review, Nephrology, Volume 16, July 2020.
2. Immunosuppression in kidney transplant recipients with COVID19
infec"on – where do we stand and where are we heading? RENAL FAILURE
2021, VOL. 43, NO. 1, 273–280
3. Systema"c review of immunosuppressant guidelines in the COVID19
pandemic. Therapeu"c Advances in Drug Safety. 2021, Vol. 12
4. Immunosuppressive drugs and COVID19 Review. Fron"er in Pharmacology.
Published: 28 August 2020.
5. COVID19 and immunosuppression: a review of current clinical experiences
and implica"ons for ophthalmology pa"ents taking immunosuppressive
drugs. Published Online First 12 June 2020.
6. COVID19: implica"ons for immunosuppression in kidney disease and
transplanta"on. Nature Review. Supplementary Informa"on.
7. Ted R. Mikuls , Sindhu R. Johnson , Liana Fraenkel et al..American College
of Rheumatology Guidance for the Management of Rheuma"c Disease in
Adult Pa"ents During the COVID19 Pandemic: Version 3. Arthri"s &
Rheumatology Vol. 73, No. 2, February 2021, pp e1–e1205
8. Talarico R, Aguilera S, Alexander T, Amoura Z, Antunes AM, Arnaud L, Avcin
T, Bere&a L, Bombardieri S, Burmester GR, Cannizzo S, Cavagna L, Chaigne
B, Cornet A, CostedoatChalumeau N, Doria A, Ferraris A, FischerBetz R,
Fonseca JE, Frank C, Gaglio" A, Gale$ I, Grunert J, Guimarães V, Hachulla
E, Houssiau F, Iaccarino L, Krieg T, Limper M, Malfait F, Marie&e X, Marinello
D, Mar"n T, Ma&hews L, MatucciCerinic M, Meyer A, Montecucco C,
Mouthon L, MüllerLadner U, Rednic S, Romão VC, Schneider M, Smith V,
Sulli A, Tamirou F, Taruscio D, Taulaigo AV, Terol E, Tincani A, Ticcia" S,
Turche$ G, van Hagen PM, van Laar JM, Vieira A, de VriesBouwstra JK,
Cutolo M, Mosca M. The impact of COVID19 on rare and complex
connec"ve "ssue diseases: the experience of ERN ReCONNET. Nat Rev
Rheumatol. 2021 Mar;17(3):177184.
9. Zahedi Niaki O, Anadkat MJ, Chen ST, Fox LP, Harp J, Michele$ RG,
Nambudiri VE, Pasieka HB, Shinohara MM, Rosenbach M, Merola JF.
Naviga"ng immunosuppression in a pandemic: A guide for the
dermatologist from the COVID Task Force of the Medical Dermatology
Society and Society of Dermatology Hospitalists. J Am Acad Dermatol. 2020
Oct;83(4):11501159.
CHAPTER 6
POST COVID19 MANAGEMENT PROTOCOL FOR
KIDNEY DISEASES
1.0 Introduc"on
Kidney disease has been recognized to be associated with severe COVID19. Severe
acute kidney injury (AKI) requiring renal replacement therapy (RRT) occurs
especially in cri"cally ill pa"ents with acute COVID19, par"cularly those with severe
infec"ons requiring mechanical ven"la"on. Followup for pa"ents a'er recovered
from acute COVID19 infec"on as well as those with Post COVID19 syndrome is
required.
2.0 Scope
providing care for pa"ents previously tested posi"ve to COVID19 with
underlying kidney disease and renal complica"on.
2.2 This is a living document and it will be updated from "me to "me as
new evidence becomes available.
3.0 Symptoms
3.1 Nephrology diagnosis in pa"ent with history of acute COVID19
a. Pa"ents with underlying end stage kidney disease (on kidney

transplanta"on, haemodialysis or peritoneal dialysis).
b. Pa"ents with chronic kidney disease:

i. With evidence of acute kidney injury base on Kidney Disease
Improving Global Outcomes (KDIGO) defini"on of acute
kidney injury
• Dialysis dependent
• Not dialysis dependent
ii. With no evidence of acute kidney injury base on KDIGO
defini"on of acute kidney injury
c. Pa"ents with normal kidney func"on who developed acute kidney

injury base on KDIGO defini"on of acute kidney injury
i. Dialysis dependent
ii. Not dialysis dependent
d. Pa"ents with normal kidney func"on or chronic kidney disease

who become dialysis dependent a'er acute COVID19
e. Pa"ents with proteinuria and/or hematuria
3.2 Symptoms:
a. Nonrenal related symptoms that sugges"ve of ongoing
symptoma"c COVID19 or Post COVID19 syndrome: refer to
Chapter 1, Figure 1.1: Possible common symptoms a'er acute
COVID19 (but are not limited to).
b. Mental health, refer to Chapter 1, Figure 1.1: Possible common

symptoms a'er acute COVID19 (but are not limited to).
c. Renal related:
i. Raised serum crea"nine
ii. Asymptoma"c hematuria/proteinuria
iii. Uremic symptoms
iv. Symptoms of nephrosis
v. Hypertension
4.0 Assessment (clinical assessments & inves"ga"on)
4.1 All COVID19 pa"ents with renal disease or renal complica"ons will be
given appointment to nephrology clinic upon discharge. See Figure 6.1,
6.2 and 6.3 for referral and Discharge Check list.
4.2 Post COVID19 pa"ents with no known renal complica"ons during acute
COVID19 should have baseline renal profile and urinalysis done if they
present to primary care or other specialty for COVID19 or nonCOVID
19 related illnesses.
4.3 Pa"ents who have no renal disease/renal complica"ons from acute

COVID19 and subsequently noted abnormal kidney func"on or urinary
abnormali"es by primary care or other teams to be referred to
nephrology team for early appointment.

symptoms, as well as func"onal abili"es.
4.5 Include these points in the comprehensive clinical history: (Table 6.1)
a. History of suspected or confirmed acute COVID19 including date
of onset and severity.
b. The nature and severity of previous history of other health
condi"ons and current symptoms.
19.
d. History of other health condi"ons.
e. Establish history of other causes that could contribute to renal
injury:
i. medica"on history including prescribed medica"ons, over
the counter medica"ons, supplements, tradi"onal
medica"ons
ii. other renal causes of renal injury including other form of
glomerulonephri"s, exposure to contrast media
iii. other prerenal causes of renal injury including dehydra"on
Post COVID19, other superimpose infec"on, other events
that contribute to hemodynamic instability
iv. other postrenal causes of renal injury
4.6 Appropriate examina"ons must be tailored to history taking findings.

a. Blood pressure
b. Pulse rate
c. Body weight
d. Fluid status
e. Other specific examina"ons
4.7 Relevant Inves"ga"ons

a. Full blood count
b. Renal profile
c. Urinalysis
d. Quan"fica"on of proteinuria with UPCI or 24 hours urine protein
(if indicated)
e. Imaging (if indicated)
f. Renal biopsy (if indicated)
REFERRAL LETTER TO NEPHROLOGY CLINIC
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Nephrologist,
Nephrology Clinic Hospital______________ Date: ____________
Re: Nephrology Follow up Post COVID-19 Infection

Name: ___________________________________
IC/ MRN: ___________________________________
Thank you for seeing the above named patient who had confirmed COVID - 19 Infection.
He was admitted to: ___________________________________________
Date Positive COVID-19 PCR:

CT value:
COVID-19 category:
Highest oxygen requirement:
RRT Mode during Hospitalization (if any):
Renal profile Upon Discharge (Date: )

Urea: Sodium: Potassium: Creatinine:
Urinalysis (Date: ) Protein Blood
Medications:
Antiviral (Yes/ No): Please state: ______________________________________
Steroids (Yes/ No): Please state: ______________________________________
Biologics (Yes/ No): Please state: ______________________________________
Antibiotics (Yes/ No): Please state: ______________________________________
Discharge Medications:
1.________________________________ 5. ______________________________
2. _______________________________ 6. ______________________________
3. _______________________________ 7. ______________________________
4. _______________________________ 8. ______________________________
Indication for referral: _________________________________
Thank you
Yours sincerely
______________________________
( )
Figure 6.1:
• Please kindly attach a copy of COVID-19 result and serial renal profile (if available). Referral Le&er
to Nephrology
Clinic
DISCHARGE CHECKLIST
Patient’s name:
MRN/IC:
Referral letters
( ) 1. ________________________ Appointment date: ___________________
( )Discharge summary / note
( )Review patient medications

*Restart patient’s own medications if not contraindicated
Figure 6.2:
Discharge ( )Supply adequate medications
checklist *Postal service if needed
LIST OF NEPHROLOGY CLINICS
1. Nephrology clinic, Hospital Tuanku Fauziah Kangar, Perlis

2. Nephrology clinic, Hospital Abdul Halim Sungai Petani, Kedah
3. Nephrology clinic, Hospital Sultanah Bahiyah Alor Setar, Kedah
4. Nephrology clinic, Hospital Kulim, Kedah
5. Nephrology clinic, Hospital Pulau Pinang
6. Nephrology clinic, Hospital Seberang Jaya, Pulau Pinang
7. Nephrology clinic, Hospital Bukit Mertajam, Pulau Pinang
8. Nephrology clinic, Hospital Taiping, Perak
9. Nephrology clinic, Hospital Raja Permaisuri Bainun Ipoh, Perak
10. Nephrology clinic, Hospital Selayang, Selangor
11. Nephrology clinic, Hospital Tengku Ampuan Rahimah Klang, Selangor
12. Nephrology clinic, Hospital Serdang, Selangor
13. Nephrology clinic, Hospital Ampang, Selangor
14. Nephrology clinic, Hospital Kajang, Selangor
15. Nephrology clinic, Hospital Kuala Lumpur, Wilayah Persekutuan
16. Nephrology clinic, Hospital Putrajaya, Wilayah Persekutuan
17. Nephrology clinic, Hospital Melaka
18. Nephrology clinic, Hospital Tuanku Jaafar Seremban
19. Nephrology clinic, Hospital Sultanah Aminah Johor Bahru, Johor
20. Nephrology clinic, Hospital Sultanah Fatimah Muar, Johor
21. Nephrology clinic, Hospital Tengku Ampuan Afzan Kuantan, Pahang
22. Nephrology clinic, Hospital Sultan Haji Ahmad ShahTemerloh, Pahang
23. Nephrology clinic, Hospital Raja Perempuan Zainab II Kota Bharu, Kelantan
24. Nephrology clinic, Hospital Sultanah Nur Zahirah Kuala Terengganu,Terengganu
Figure 6.3: 25. Nephrology clinic, Hospital Queen Elizabeth Kota Kinabalu, Sabah
List of
26. Nephrology clinic, Hospital Umum Kuching, Sarawak
nephrology
clinics 27. Nephrology clinic, Hospital Miri, Sarawak
NEPHROLOGY POST COVID19 CLERKING SHEET
Name Age
MRN/IC Gender
Referred from Date
COVID19 history
Date posi"ve COVID19 PCR Medica"ons
CT value An"viral
COVID19 category Steroid
Highest oxygen requirement Biologics
RRT mode (if any) An"bio"cs
Comorbidi"es: Medica"on (prescribed/OTC/tradi"onal/supplements
Risk factors for CKD Diabetes mellitus

Diabetes mellitus Blood pressure
Hypertension Pulse rate
Obesity Respiratory rate
Family history of kidney disease Temperature
Age SPO2
Smoking Pain score
Systemic
Symptoms examina"on
Cough
shortness of breath
Inves"ga"ons
Palpita"ons
FBC
Chest pain
Tiredness Renal profile
Reduce appe"te UFEME
Diarrhea
Diagnosis
Vomi"ng
Muscle weakness 1
Joint pain 2
Anxiety 3
Depression
Sleep disturbances Plan
Brain fog 1
Leg swelling unilateral/bilateral
2
Frothy urine Table 6.1:
3
Hair loss Nephrology
4 Post COVID19
Rashes
5 Clerking Sheet
Others______________________
5.0 Managements
5.1 All pa"ents who are at risk of chronic kidney disease need to be
screened for kidney func"on with baseline renal profile and urinalysis.
5.2 Risk factors for kidney disease:

a. Hypertension
b. Diabetes mellitus
c. Nephrotoxic drugs
d. Smoking
e. Obesity
f. Family history of kidney disease
g. History of AKI
h. Proteinuria / haematuria
5.3 All pa"ents with kidney disease or kidney complica"ons require long
term follow up with nephrologists following acute COVID19.
5.4 Suggested follow up schedule (Table 6.2 and 6.3)
For long term COVID19 follow, schedule should be at least at month 3,

6 and 12. First follow up will be depending on the underlying condi"on.
Subsequent follow up can be more frequent depending on the clinical
condi"on.
Diagnosis Suggested follow up schedule
End stage kidney 68 weeks a'er discharge from acute COVID19 infec"on
disease 36 monthly a'erwards
CKD with no AKI 68 weeks a'er discharge from acute COVID19 infec"on
36 monthly a'erwards
CKD with AKI, no 46 weeks a'er discharge from acute COVID19 infec"on
dialysis required Frequent followup 46 weekly if renal func"on not stabilized
36 monthly once renal func"on stabilized
CKD with AKI, acute 24 weeks a'er discharge from acute COVID19 infec"on
dialysis required Frequent followup 46 weekly if renal func"on not stabilized
AKI, no dialysis 46 weeks a'er discharge from acute COVID19 infec"on
required Frequent followup 46 weekly if renal func"on not stabilized
AKI, acute dialysis 24 weeks a'er discharge from acute COVID19 infec"on
required Frequent followup 46 weekly if renal func"on not stabilized
AKI or CKD who Con"nuous assessment by nephrology team to assess

became dialysis progression from acute kidney disease (AKD) to chronic
Table 6.2:
dependent kidney disease Suggested
Followup
Schedule for
Proteinuria and/or 24 weeks if nephro"c range proteinuria Long COVID19
hematuria 68 weeks if asymptoma"c hematuria/proteinuria with
Nephropathy
Diagnosis W2 W4 W6 W8 W12 W18 W24 W30 W36 W52
End Stage Kidney

Disease
CKD with no AKI
CKD with AKI, no

dialysis required
CKD with AKI, acute

dialysis required
AKI, no dialysis
required
AKI, acute dialysis

required
AKI or CKD who

became dialysis
dependent
Proteinuria and/or
hematuria
(nephrosis)
Proteinuria and/or
hematuria
(asymptomatic)
!
!! First appointment
!! Compulsory visits
!! If clinically indicated
!
Table 6.3:
Follow Up
Schedule
5.5 Pa"ents who were previously on angiotensin conver"ng enzyme

inhibitors (ACEi) or angiotensin receptor blockers (ARB) should be
con"nued if no contraindica"on.
5.6 Immunosuppressants for transplant pa"ent generally should be

reduced (an"metabolite) or maintained.
5.7 Pa"ents are preferred to be managed by mul"disciplinary team

comprising of pulmonologist, rehabilita"on physician, cardiologist,
die"cian, physiotherapist, psychiatrist, psychologist, primary care
physician, neurologist, nephrologist, endocrinologist and
rheumatologist.
5.8 Give advice and informa"on on selfmanagement to people with

ongoing symptoma"c COVID19 or Post COVID19 syndrome, star"ng
from their ini"al assessment. This should include:
a. Ways to selfmanage their symptoms, such as se$ng realis"c
goals
b. Who to contact if they are worried about their symptoms or they

need support with selfmanagement
c. Sources of advice and support, including support groups, social

prescribing, online forums and apps
d. How to get support from other services, including social care,

housing, and employment, and advice about financial support
e. Informa"on about new or con"nuing symptoms of COVID19 that

the person can share with their family, carers and friends
5.9 Develop a management plan with the person addressing their main
symptoms, problems, or risk factors, and an ac"on plan. Consider
individual factors and access issues in determining loca"on for further
treatment plans.
5.10 Management plan is depending on clinical need and local pathways:

a. Support from integrated and coordinated primary care,
community, rehabilita"on and mental health services
b. Referral to an integrated mul"disciplinary assessment service
c. Referral to specialist care for specific complica"ons.
d. Think about the overall impact their symptoms are having on their
life, even if each individual symptom alone may not warrant
referral
e. Look at the overall trajectory of their symptoms, taking into

account that symptoms o'en fluctuate and recur so they might
need different levels of support at different "mes.
5.11 When discussing with the person the appropriate level of support and
management:
5.12 Encourage pa"ents to gather COVID19 informa"on via official channel

eg: KKM website/Facebook
6.0 Pa"ents’ outcome and assessment tools

a. Recover to baseline
b. Progression to chronic kidney disease
c. Dialysis dependent
d. Death
Process Item Work Process Standard Requirement
1.0 Hospitalized Ins"tu"ons Annex 3 MOH

COVID19 involved: Guidelines of
pa"ents COVID19 COVID19: Senarai
hospital Designated
COVID19 hybrid Hospital Bagi
hospital Pengendalian Kes
Quaran"ne COVID19
center
2.0 Hospitalized
COVID19
pa"ents who
were referred
to
nephrologist
3.0 COVID19
pa"ents with
Acute kidney Defini"on: KDIGO criteria of

injury (AKI) a. Increase in SCr AKI 2012
by ≥26.5 μmol/l
within 48 hours;
or increase in
SCr to ≥1.5
"mes baseline,
which is known
or presumed to
have occurred
within the prior
7 days; or
urine volume
< 0.5ml/kg/h
for 6 hours
b. ICD10:
Diagnosis
captured in
casemix
Chronic kidney Defini"on CPG Management

disease (CKD) a. eGFR of Chronic Kidney
<60ml/min/ Disease MOH 2018
1.73m2 that is
present > 3
months with or
without
evidence of
kidney damage;
or evidence of
kidney damage
that is present >
3 months with
or without eGFR
<60ml/min/
1.73m2
b. Diagnosis
captured in
casemix
Kidney Defini"on
replacement Haemodialysis
therapy (KRT) Peritoneal
dialysis
Kidney
transplanta"on
Proteinuria/ Defini"on CPG Management

hematuria Proteinuria of Chronic Kidney
Hematuria Disease MOH 2018
4.0 Refer to Discharge Figure 6.3:

nephrology summary/ List of nephrology
clinic upon referral le&er to clinic
discharge nephrology
clinic Figure 6.1:
Discharge Referral le&er to
checklist nephrology clinic
Figure 6.3:
Discharge checklist
5.0 Assessment in 5.1 Clinical Chapter 1: Table Post COVID19

nephrology 1.2 (COVID19 Management
clinic a. COVID19 specific significant Protocol for
specific sequelae) Kidney Diseases
significant
sequelae (RCGP)
b. Mental health Chapter 1: Table Post COVID19

1.2 (COVID19 Management
c. Risk of kidney Protocol for
disease specific significant Kidney Diseases
Hypertension sequelae)
Diabetes
mellitus
Nephrotoxic
drugs
Smoking
Obesity
Family history of
kidney disease
History of AKI
Proteinuria/
hematuria
5.2 Laboratory
Renal profile
eGFR
Urinalysis for
proteinuria/
hematuria
Imaging (if
indicated)
6.0 Nephrology Resolved AKI

diagnosis/ AKI progressed
outcome to CKD
Stable CKD
Worsened CKD
ESKD
Proteinuria/
haematuria
Kidney
transplanta"on
6.1 Presence of Refer to respec"ve

nonrenal team
related
symptoms
Refer to
6.2 Presence of psychiatric team
symptoms of
mental health
problem
7.0 Pa"ents not If seen in other

referred to Post COVID19
nephrologist follow up clinic
as inpa"ent Laboratory
assessment
Renal profile
eGFR
Urinalysis for
proteinuria/
hematuria
8.0 Follow up Any abnormality, Table 6.3:

plans and refer to 4.0 Follow up
report to schedule Table 6.4:
Na"onal Renal Post COVID19
Registry Table 6.1: Management
Nephrology Post Protocol for
COVID19 Clerking Kidney
Diseases: Work
Sheet
Process
POST COVID19 MANAGEMENT PROTOCOL FOR KIDNEY DISEASES
1.0 Hospitalized COVID19 pa"ents
No 7.0 Post COVID19 follow up clinic

2.0 Referred to (Other discipline) Renal profile,
nephrologist? eGFR, Urinalysis for
proteinuria/hematuria
Yes
3.0 COVID19 pa"ents with AKI, CKD,

KDT and Proteinuria/Hematuria should Abnormality
be managed according to CPG detected
management of CKD MOH 2018
Yes
4.0 Refer to nephrology clinic upon
discharge
5.1a Clinical assessment of symptoms 6.1 Presence

Refer to Post COVID19 Management of nonrenal
related symptoms Yes
Protocol for Kidney Diseases (Table 1)
Refer to
respec"ve
team
6.2 Presence of
5.1b Assessment of mental health symptoms of mental health
problem symptoms Yes
Refer to
psychiatric
5.1c Clinical assessment for risk of kidney team
disease
• Hypertension, Diabetes mellitus,
Nephrotoxic drugs, Smoking, Obesity,
Family history of kidney disease,
History of AKI Proteinuria/hematuria
5.2 Laboratory Assessment

Renal profile, eGFR, Urinalysis for
proteinuria/hematuria Imaging
(if indicated)
6.0 Nephrology diagnosis

Resolved AKI, AKI progressed to CKD,
Stable CKD, Worsened CKD, ESKD,
Proteinuria/hematuria,
Figure 6.4: Kidney transplanta"on
Post COVID19
Management
Protocol for
8.0 Follow up plans and report to
Kidney Diseases
Na"onal Renal Registry
References:

2. Management of postacute COVID19 in primary care BMJ 11/08/2020 doi:
h&ps://doi.org/10.1136/bmj.m3026
3. Ani N, Kar"k S, Elaine YW et al. Postacute COVID19 syndrome. Nature
Medicine. 22 March 2021
4. ERAEDTA Council and the ERACODA Working Group. Chronic kidney
disease is a key risk factor for severe COVID19: a call to ac"on by the ERA
EDTA. Nephrol Dial Transplant (2021) 36: 87–94 doi: 10.1093/ndt/gfaa31
5. Anne&e Bruchfeld the COVID19 pandemic: consequences for nephrology
Nature Review Nephrology 17, pages81–82(2021)
CHAPTER 7
POST COVID19 MANAGEMENT AND PROTOCOL
IN OBSTETRICS PATIENT
1.0 Introduc"on
Pregnancy is a dynamic condi"on where each stages of pregnancy carries a

mul"tude of issues and challenges. COVID19 infec"on during and a'er pregnancy
requires specific and targeted ac"on plans to suit each phase.
2.0 Scope
2.1 A source of informa"on and guidance to healthcare workers who are

caring for pregnant women, who have been tested posi"ve to COVID
19 and are at risk of having Post COVID19 sequelae.
2.2 This guide covers plan of ac"ons and recommenda"ons for:

a. Acute COVID19 infec"on during antenatal period
b. Acute COVID19 infec"on during peripartum period
c. Acute COVID19 infec"on during puerperium
d. Prepregnancy care for Post COVID19 pa"ents
2.3 This document will be updated accordingly as new evidence becomes

available.
3.0 Objec"ve
This guideline provides a pla)orm for a comprehensive and coordinated treatment

approach to COVID19 a'ercare throughout pregnancy.
4.0 Plan of ac"on
4.1 Following Acute COVID19 infec"on during antenatal period
No Phase Plan of Ac"on
1 Diagnosis of • All women with suspected, probable or confirmed COVID

COVID19 and 19 infec"on diagnosed during pregnancy should be
Admission managed as per MOH guidelines and admi&ed to
appropriate healthcare facility according to MOH
guidelines(1, 2).
• Management by a mul"disciplinary team involving (ID
physician, Intensivist, Anaesthe"st and Obstetrician)
• Start VTE prophylaxis in all pregnant women with ac"ve
COVID19(2).
• Pregnant woman who fulfils criteria for home quaran"ne
are of lowrisk group. VTE risk assessment must be carried
out rou"nely as for any pregnant woman at every
encounter with HCW.
• If the home quaran"ned woman requires
thromboprophylaxis, she should then be admi&ed to
health facility (as her risk is now increased).
• All home quaran"ned women should be advised to do
ambulate and to stay hydrated to reduce the risk of VTE.
They should also be educated on the signs and symptoms
of VTE.
Postdischarge • Upon discharge, a defini"ve followup plan should be

antenatal clearly stated by the O&G team.
followup • Stage 12 – Respec"ve MCH Clinic
• Stage 35 – Respec"ve O&G Clinic (and other discipline
follow up)
• Review a'er discharge in the respec"ve clinic should be
no later than 2 weeks.
• All COVID19 pa"ents should be discharged to their
respec"ve MCH Clinic with a highrisk discharge
no"fica"on.
• Postdischarge / offtag, all pregnant women should
con"nue their rou"ne antenatal care as per their
pregnancy colour coding followup, unless specified
otherwise by the discharging facility.
• VTE prophylaxis should be given for at least 10 days post
discharge / offtag and may con"nue up to 3 weeks
depending on pa"ent’s morbidity.
Post discharge • Assessment during clinic visit should be according to

COVID19 respec"ve Post COVID19 Guidelines according to
followup and discipline.
assessment • Rou"ne antenatal care should be performed according to
pa"ent’s colour coding. No addi"onal monitoring or
interven"on other than rou"ne obstetric care is needed.
• If pa"ent presents with recurrence of symptoms within 90
days, where no alterna"ve ae"ology can be readily
iden"fied, then a consulta"on with an ID physician is
recommended and retes"ng for COVID19 can be
considered(3).
2 Delivery • Delivery is best delayed beyond 14 days of a posi"ve

diagnosis of COVID19 unless there is an obstetric
indica"on.
• Generally may allow postdate, unless there is obstetric
indica"on to deliver earlier(2).
• Delivery as per obstetric indica"on
3 Postpartum • COVID19 is a transient risk factor.

a. VTE • VTE scoring should be done according to Malaysian
prophylaxis Obstetrics Guidelines(4).
b. Mental • Two Ques"ons On Depression and One Ques"on on Help

health (TQWHQ) should be used to assess pa"ents’ mental
assessment. health prior to discharge and an onward referral to the
psychiatrist needs to be made when necessary.
4.2 Following Acute COVID19 infec"on during peripartum period
1 Antenatal ● All women with suspected, probable or confirmed COVID

19 infec"on diagnosed during pregnancy should be
managed as per MOH guidelines and admi&ed to
appropriate healthcare facility according to MOH
guidelines (1).
● Management by a mul"disciplinary team involving (ID
physician, Intensivist, Anaesthe"st and Obstetrician)
● There is no need for addi"onal obstetric monitoring or
interven"ons such as frequent ultrasound monitoring
apart from those done for the usual obstetric indica"ons.
● An"viral medica"ons are not contraindicated in pregnant
pa"ents. Ini"a"ng therapy should be done in consulta"on
with the ID physician.
● Cor"costeroid is recommended for trea"ng COVID19

pa"ents who require supplementary oxygen.
● All mothers (with no evidence of imminent delivery)
admi&ed should be started on thromboprophylaxis
provided there are no contraindica"ons. If they progress
into labour, an"coagulants should be withheld.
2 Delivery ● Delivery is best delayed beyond 14 days of a posi"ve

diagnosis of COVID19 unless there is an obstetric
indica"on, any respiratory issues that warrants a
resuscita"ve hysterotomy or any medical condi"ons that
warrant an earlier delivery.
● If pa"ent spontaneously progresses into labour, vaginal
delivery is not contraindicated if she is in imminent
delivery. Delivery in nega"ve pressure room (if available)
or designated isola"on room.
● Intrapartum fetal monitoring as per high risk cases.
● Women in labour should wear a surgical mask.
● All staff a&ending women in labour should wear adequate
PPE and prac"ce hand hygiene at all "mes(5).
o Refer paediatric team in advance: infant should be
managed according to the current MOH guidelines on
Management of COVID19 in Neonates.
3 Postpartum ● VTE prophylaxis should be restarted for all women if there

a. VTE are no contraindica"ons.
prophylaxis ● VTE prophylaxis should be given for at least 10 days post
discharge / offtag and may con"nue up to 3 weeks
depending on pa"ent’s morbidity.
b.
Breas)eeding ● Breas)eeding is not contraindicated, the risk of
transmission from an asymptoma"c mother is extremely
rare. If the baby is isolated from the mother, expressed
breast milk feeding is encouraged if possible. Refer to
MOH Annex 39 for further guidance if a mother opts to
breas)eed or roomin with her baby(6).
c.
Contracep"on ● All women should be given adequate postnatal
contracep"on advice based on the MEC guidelines a'er a
thorough risk assessment
● During ac"ve infec"on combined hormonal contracep"on
should be avoided (79).
d. ● Two Ques"ons On Depression and One Ques"on on Help

Mental health (TQWHQ) (Table 7.1) should be used to assess pa"ents’
assessment mental health prior to discharge and an onward referral to
the psychiatrist needs to be made when necessary (10, 11).
4 Postdischarge • Upon discharge, a defini"ve followup plan should be

followup clearly stated by the O&G team.
• Stage 12 – Respec"ve MCH Clinic
followup)
respec"ve MCH Clinic with a high risk discharge
no"fica"on.
• Postnatal care should be con"nued as per Perinatal Care
Manual(11).
4.3 Following Acute COVID19 infec"on during puerperium
1 Mother with • Acute COVID19 infec"on in puerperium (within 6 weeks

baby of delivery) should be admi&ed for inpa"ent
management.
• Pa"ent will be managed according to severity as per MOH
guideline.
• Baby has to be tested for COVID19 infec"on.
• Breas)eeding is not contraindicated. If baby is isolated
from the mother, expressed breast milk (EBM) feeding is
encouraged if possible(6).
• All postpartum women should undergo a documented
assessment of risk factors for VTE upon diagnosis of
COVID19.
• VTE prophylaxis should be started for all women if there
are no contraindica"ons and should be con"nued for 10
days post discharge / offtag and may con"nue up to 3
weeks depending on pa"ent’s morbidity(1214).
• Vaccina"on for preven"on of COVID19 is recommended.
Breas)eeding is not contraindicated for vaccina"on.
2 Mother • Acute COVID19 infec"on in puerperium (within 6 weeks

without baby of delivery) should be admi&ed for inpa"ent
management.
• Pa"ent will be managed according to severity as per MOH
guideline.
• EBM feeding is encouraged if baby is separated from
mother.
• All postpartum women should undergo a documented
assessment of risk factors for VTE upon diagnosis of
COVID19.
• VTE prophylaxis should be started for all women if there

are no contraindica"ons and should be con"nued for 10
days post discharge / offtag and may con"nue up to 3
weeks depending on pa"ent’s morbidity(1214).
• Vaccina"on for preven"on of COVID19 is recommended.
3 Contracep"on • All women should be given contracep"on according to

MEC guideline a'er a thorough risk assessment.
• During infec"ve period, combined hormonal
contracep"on should be avoided.
4 Post discharge • Upon discharge, a defini"ve followup plan should be

followup clearly stated by the O&G team.
• Stage 12 – Respec"ve MCH Clinic
followup)
respec"ve MCH Clinic with a high risk discharge
no"fica"on.
• Postnatal care should be con"nued as per Perinatal Care
Manual(11).
Table 7.1:
Two Ques"ons
on Depression
and One
Ques"on on
HELP (Malay
Version)
Figure 7.1:
Covid19
Infec"on in
Pregnancy
Informa"on for
Pa"ents
References:
1. Kementerian Kesihatan Malaysia. Kemaskini Kes Definisi Dan Garis Panduan

Pengurusan Kes COVID19 di Malaysia. h&p://COVID19mohgovmy/garis
panduan/garispanduankkm. 2020.
2. Dr. Ravichandran Jeganathan DMG, Datuk Dr. Soon Ruey, Dr. Yogeeta
Gunasagran, Dr. Tan Gi Ni. Guidelines On the Management Of COVID19 In
Obstetrics and Gynaecology. COVID19 Guideline MOH. 2021;Annex 23.
3. Centre of Diease Control. Interim Guidance on Dura"on of Isola"on and
Precau"ons for Adults with COVID19. h&ps://wwwcdcgov
/coronavirus/2019ncov/hcp/dura"onisola"onhtml. 2021.
4. Bahagian Pembangunan Kesihatan Keluarga. A Training Manual of
Preven"on & Treatment of Thromboembolism in Pregnancy & Puerperium
2nd Edi"on, 2018. 2018;MOH/K/ASA/87.17(HB)(2nd edi"on).
5. Kementerian Kesihatan Malaysia. Infec"on, Preven"on and Control (IPC)
Measures in managing person under surveillance (PUS), Suspected,
probable or confirmed Coronavirus Disease (COVID19). COVID19
Guideline Malaysia. 2020;Annex 8.
6. Kementerian Kesihatan Malaysia. Guidelines to baby friendly hospital
ini"a"ve (BFHI) implementa"on and breas)eeding prac"ces during COVID
19 pandemic. COVID19 guideline Malaysia. 2020;Annex 39.
7. The Faculty of Sexual and Reproduc"ve Healthcare. Provision of
contracep"on during the COVID19 pandemic: FSRH update and overview
statement. wwwfsrhorg/COVID19. 2020.
8. NHMRC Centre of Research Excellence in Sexual and Reproduc"ve Health
for Women in Primary Care. Contracep"ve method considera"ons for
individuals with ac"ve COVID19 infec"on: a consensus statement.
Women’s Sexual and Reproduc"ve Health COVID19 Coali"on.
2020(Version 1).
9. World Health Organiza"on. Medical eligibility criteria for contracep"ve use
Execu"ve summary. 2015;5th edi"on.
10.Family Medicine Specialists Associa"on of Malaysia. Consensus Guide to
Adult Health Screening for General Popula"on A&ending Primary Care
Clinics. ISBN 9789671138922. 2015.
11.Bahagian Pembangunan Kesihatan Keluarga. Perinatal care manual
2013;3rd edi"on.
12.Joshua P. Vogel BT, Michelle Giles, Clare Whitehead. Clinical care of
pregnant and postpartum women with COVID19: Living recommenda"ons
from the Na"onal COVID19 Clinical Evidence Taskforce. Aust N Z J Obstet
Gynaecol 2020; 60: 840–851. 2020(DOI: 10.1111/ajo.13270).
13.Vincenzo Berghella, Brenna Hughes. COVID19: Pregnancy issues and
antenatal care. UpToDate. 2021:Topic 127535 Version 131.0.
14.Royal College of Obstetricians and Gynaecologists. Coronavirus (COVID19)
Infec"on in Pregnancy. 2021;Version 13.
15.Dr Suraihan Sulaiman, Dr Mohamad ‘Ariff Fahmi Ahmad Zawawi. Post
COVID19 Follow Up Recommenda"ons for Primary Care Jabatan Kesihatan
Negeri Sabah. 2020(First Edi"on).
99
CHAPTER 8
POST COVID19 MANAGEMENT AND PROTOCOL
IN CHILDREN
1.0 Introduc"on
1.1 As the COVID19 pandemic evolves, persistent symptoms are being

reported amongst COVID19 survivors, including individuals who
experienced mild illness. The UK office for Na"onal Sta"s"cs’ latest
report es"mates that 12.9% of UK children aged 2 to 11, s"ll have
symptoms five weeks a'er their first infec"on12. Data elsewhere is
scarce.
1.2 The Post COVID19 Syndrome are signs and symptoms that develop
following an infec"on consistent with COVID19 which con"nue a'er
12 weeks and are not explained by an alterna"ve diagnosis (refer to 5.1
Chapter 1).
2.0 Scope
The present protocol aims to:

a. Assist in iden"fica"on and management of Post COVID19 syndrome in
children
b. Provide a followup plan for children who have had severe acute
(moderate to severe disease), postacute COVID19 and chronic COVID
19 infec"on.3
3.0 Symptoms
In recognizing symptoms in the paediatric age group, the clinician should be aware
that their pa"ents range from neonate (age less than 1 month) to adolescent age
group hence both preverbal to verbal clues need to take into considera"on.
System Symptom
General Fa"gue
Fever
Pain
Respiratory Cough
Rhinorrhea, nasal conges"on
Sore throat
Tachypnea / dyspnea
Cardiovascular Chest pain

Palpita"on
Reduced effort tolerance
Neurological Headache
Tinnitus
Ageusia / Anosmia
Sleep disturbances
Cogni"ve impairment / school performance deteriora"on
Gastrointes"nal Abdominal pain

Nausea / Vomi"ng / Diarrhea
Loss of appe"te
Poor weight gain
Musculoskeletal Myalgia
Joint pain
Dermatological Rashes
Anxiety Table 8.1:
Symptoms of
Post COVID19
Psychological Depression in Peadiatrics
4.0 Assessment
4.1 Any child with persistent symptoms, previously diagnosed with or

suspected with COVID19 (any stage), should be referred to hospitals
with paediatricians for assessment.
4.2 The pediatrician or referring clinician may find the Paediatric Clerking
Sheet for Post COVID19 syndrome (See Figure 8.4) useful in iden"fying
areas of concern.
4.3 The inves"ga"ons should be tailored according to clinical presenta"on

and exclude relevant differen"al diagnoses e.g., FBC (looking for
anemia), renal profile (for hypokalemia), CaPO4, thyroid func"on test
among others.
5.0 Management
5.1 Likewise, the management of a child presen"ng with Post COVID19

syndrome depends on their clinical presenta"on. Referrals should be
made to specific subspecial"es as indicated (Figure 8.3).
5.2 An important dis"nc"on should be made between symptoms due

hospital related complica"ons of prolonged stay (including nosocomial
infec"on), sequelae of organ damage (post infec"on hyperac"ve airway,
acquisi"on of other viral infec"ons) and nonspecific social isola"on
since children are some"mes separated from their primary care givers
during this pandemic (nutri"onal anaemia, muscle was"ng, vitamin D
deficiency, hypothyroid etc.)
5.3 This document will be updated from "me to "me as new evidence
become available.
FLOW CHART FOR FOLLOWUP OF ACUTE COVID19 INFECTIONS IN

PAEDIATRICS (MILD DISEASE)
Children diagnosed with acute COVID19 infec"on:

Category 3 & below (mild disease)
Yes
Previous comorbidi"es? Refer back to Primary Paediatric
Team for followup
No
Discharge Give appointment 2 6 weeks to

Figure 8.1: SubSpecialist Clinic for further
Flow Chart for management of the primary
FollowUp of disease.
Acute COVID19
Infec"ons in Referral le&er to primary team
Paediatrics with relevant history, inves"ga"on
(Mild Disease) and drug treatment is impera"ve.
FLOW CHART FOR FOLLOWUP OF ACUTE COVID19 INFECTIONS IN PAEDIATRICS

(MODERATESEVERE DISEASE)
!
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- "*/(+,';!<!*)&!*=,>(!!
?@,&('*/(!/,!-(>('(!&$-(*-(A!
!!
H(-!
B'(>$,1-!0,@,'=$&$/$(-C! D(9('!=*0E!/,!B'$@*';!
B*(&$*/'$0-!F(*@!9,'!
9,%%,.61G!
I,!
H(-!
! D(9('!/,!'(%(>*)/!-1=6
I(.%;!&$*+),-(&!-G(0$*%/;!-G(0$9$0! -G(0$*%/;!9,'!91'/#('!
'(%*/(&!0,@G%$0*/$,)C! @*)*+(@()/!
I,!
J$>(!*GG,$)/@()/!K6<!.((E-!/,!B*(&$*/'$0!
LG(0$*%$-/!"%$)$0!
",)/$)1(!9,%%,.61G!/,!
@,)$/,'!9,'!B,-/!
"2345678!L;)&',@(!*/!
H(-! '& /# /#
M N!O !*)&!7K !@,)/#-!
L/*=%(!*/!9,%%,.61GC! G,-/6$)9(0/$,)!
49!),!B,-/!"2345678!
L;)&',@(!=;!7K!
I,! @,)/#-N!&$-0#*'+(!
9,%%,.61G!
!
",)-$&('!-1=-G(0$*%/;!'(9(''*%!*00,'&$)+!/,!
-;@G/,@-!*)&!9,%%,.!1G!/$%%!'(-,%1/$,)! Figure 8.2:
Flow Chart for
FollowUp of
Acute COVID19
Infec"ons in
Paediatrics
(Moderate
Severe Disease)
Children who present with symptoms of Post COVID19 syndromes regardless of

their clinical stage at presenta"on should be referred to a pediatrician for further
evalua"on.
FLOW CHART FOR POST COVID19 SYNDROME MANAGEMENT FOR

PAEDIATRICS
Walkin pa"ents
Fulfilling defini"on of Post COVID19 syndrome to
Primary Care or ED
Referral to paediatrician inhouse or

nearest hospital
Assessment by Paediatrician
Yes * Admit &

* Look for Pa"ent requires admission?* proceed with
presence of RED hospital care
FLAGS
1. Breathlessness No
or hypoxia
2. Syncope Give appointment to Paediatric Specialist
3. Unexplained Clinic within 24 weeks
chest pain,
palpita"ons or
arrhythmias
4. Delirium, or
focal Inves"gate & manage according to clinical
neurological presenta"on
signs or
symptoms
5. Persistent
fever /
gastrointes"nal Yes
symptoms. Resolu"on of
Post COVID19 Discharge
symptom
No
Figure 8.3:
Flow Chart for
Post COVID19 Consider subspecialty referral according to
Syndrome symptoms and follow up "ll resolu"on
Management
for Paediatrics
POST COVID19 SYNDROME PAEDIATRIC CLERKING SHEET

Name: IC No. / Passport no.:
Age: Na"onality:
Weight: Contact no.:
Height:
Address:
Date of admission: Date of discharge:

Type of COVID test: RTK PCR Date of test:
COVID Category: 1 2 3 4 5 Ini"al symptoms:
Past Medical / Surgical History:
Any medica"ons?
Any allergies? ⬜ Yes ⬜ No Details:
Vaccina"on up to age? ⬜ Yes ⬜ No Details:
Current complaint:
⬜ Fa"gue ⬜ Abdominal pain

⬜ Fever ⬜ Nausea
⬜ Pain ⬜ Vomi"ng
⬜ Diarrhea
⬜ Cough ⬜ Loss of appe"te
⬜ Rhinorrhea/Nasal conges"on ⬜ Poor weight gain
⬜ Sore throat
⬜ Dyspnea/tachypnea ⬜ Myalgia
⬜ Joint pain
⬜ Chest pain
⬜ Palpita"ons ⬜ Rashes
⬜ Reduced effort tolerance
⬜ Anxiety
⬜ Headache ⬜ Depression
⬜ Tinnitus ⬜ Others: specify
⬜ Ageusia/Anosmia
⬜ Sleep disturbances
⬜ Cogni"ve impairment /
school performance deteriora"on
Examina"on findings: Figure 8.4:

Post COVID19
Syndrome
Paediatric
Management Plan: Clerking Sheet
A)ending doctor: ___________________________ Date:___________________

References:
1. Coronavirus (COVID19) Infec"on Survey, UK. Office for Na"onal Sta"s"cs.

2. Bhopal BS. BMJ 2021; 372: n157
3. COVID19 Rapid Guideline: Managing the longterm effects of COVID19.
The Na"onal Ins"tute for Health and Care Excellence (NICE) Guidelines, 18
December 2020.
4. *Red flag symptoms* are based on Australian guideline (references from
Organising pneumonia protocol) & adapted to this guideline’s use.
5. Annex 2e : Clinical Management Of Confirmed COVID19 Case In Adult &
paeditrics (updated 3 November 2020) .
CHAPTER 9
POST COVID19 FOLLOW UP REHABILITATION
RECOMMENDATIONS
1.0 Introduc"on
1.1 COVID19 has led to an increasing burden of disease and disability

throughout the globe and it is expected to con"nue to do so in the next
few years. It has brought many challenges and has caused major
impacts to exis"ng ministra"on including the rehabilita"on services.1,2
Comparable to the a'ermath of any other major illness or injury, many
COVID19 survivors require rehabilita"on services to facilitate them
back to normal func"on or in some cases to adapt to living with residual
disability.3 Due to its novelty, the full spectrum of postdischarge
impacts in COVID19 survivors remains unknown.13
1.2 Experience with previous outbreaks of coronaviruses have been

associated with persistent pulmonary func"on impairment, muscle
weakness, pain, fa"gue, depression, anxiety, voca"onal problems, and
reduced quality of life to various degrees.4,5 Severe COVID19 survivors
who have required prolonged intensive care are expected to experience
greater degree of impairments and shall require wider physical,
cogni"ve, func"onal and psychological health support needs following
discharge from the acute se$ngs.15
2.0 Jus"fica"on
2.1 World Health Organiza"on (WHO) defined rehabilita"on as a set of

measures that assist individuals who experience, or are likely to
experience disability to achieve and maintain op"mal func"oning in

interac"on with their environment. Its main goals are to prevent loss
of func"on; slow the rate of loss of func"on; improve and restore
func"on; compensate for the loss of func"on and maintenance of
current func"on.6
2.2 Considering the mul"systems impairment o'en associated with severe

COVID19,15 complex rehabilita"on needs are an"cipated, hence access
to its services are required. This aims to facilitate the COVID19
survivors towards recovery and op"mal func"oning or in severe cases
to adapt to living with disability; with the ul"mate aim for full re
integra"on into society.15
2.3 These goals are best achieved through a pa"ent centred mul"
disciplinary approach involving Infec"ous Disease Physician, Respiratory
Physician, Geriatric Physician, Psychiatrist, Rehabilita"on Physician,
Physiotherapist, Occupa"onal Therapist and others allied healthcare
personnel as the need arises.13,5 With this approach; the diagnosis,
management and prognos"ca"on of complex medical impairments and
disabili"es are comprehensively made. Hence, a realis"c rehabilita"on
program shall be formulated based on the individual pa"ents needs
with the balances of input from the other mul"disciplinary team
members.13,5
3.0 Scope
providing COVID19 a'ercare and rehabilita"on services.
3.2 This is a living document and it will be updated from "me to "me as
new evidence becomes available.
4.0 Objec"ves
4.1 This guideline provides a basis for a comprehensive, coordinated and

structured rehabilita"on management approach to COVID19 a'ercare
by mul"disciplinary teams.
4.2 It makes recommenda"ons for COVID19 survivors with persistent

symptoms and/or delayed or longterm complica"ons beyond the ini"al
acute hospital discharge requiring rehabilita"on interven"on.
5.0 Followup loca"ons
Followup centers include:

a. Government Healthcare facili"es/centers preferably with Family Medicine
Specialist
b. Private General Prac"ce
c. Hospitals preferably with Rehabilita"on Physician (government and private)
Recent literature reported commonly observed Post COVID19 symptoms, "meline

of its occurrence and specific sequelae are as illustrated in Chapter 1 (Figure 1.1
1.6 and Table 1.2).
7.0 Assessment

symptoms, as well as func"onal abili"es. 2,3,5,7,8
7.2 Include in the comprehensive clinical history: 2,3,5,7,8

a. History of suspected or confirmed acute COVID19.
b. The nature and severity of previous and current symptoms.
19.
d. History of other health condi"ons.
e. Course of acute admission, complica"ons and its management
including treatment rendered.
f. Mul"systems impairments iden"fica"on and its func"onal
impacts especially pertaining to respiratory func"on.
g. Home and community environment.
h. Psychosocial support evalua"on.
Iden"fy the phases of Post COVID19 pa"ents as described in Chapter 1 for

effec"vely diagnose, treat and manage the condi"ons.
9.0 Inves"ga"on
9.1 All Post COVID19 pa"ents must undergo inves"ga"ons based on

clinical indica"ons and availability of tests at the healthcare facili"es.
9.2 Establish red flag symptoms that could indicate the need for emergency
assessment for serious complica"on of COVID19. Red flag symptoms
include severe, new onset, or worsening of:9
a. Breathlessness or hypoxia,
b. Syncope,
c. Unexplained chest pain, palpita"ons or arrhythmias,
d. Delirium, or focal neurological signs or symptoms.
e. Mul"system inflammatory syndrome (in children).
10.0 Management
10.1 Develop a management and an ac"on plan with pa"ents; addressing

their main symptoms, problems and risk factors. Consider individual
factors and access to healthcare facili"es issues in determining loca"on
for further treatment or rehabilita"on e.g., homebased, telehealth or
facetoface op"ons. Refer to the ter"ary center if needed. 13,5,710,12
10.2 Mul"systems impairments shall be iden"fied and intervened

accordingly to op"mize the COVID19 survivors’ return to their best
func"onal level or in severe cases to adapt to living with residual
disabili"es. 13,5,710 Comparable to the other specialised rehabilita"on
medicine services, the ul"mate aim of rehabilita"on medicine response
in COVID19 is for full reintegra"on of the survivors back into society.
2,3,5,10,12,16
10.3 The principal goal of rehabilita"on is to op"mize func"oning and reduce

disability. Rehabilita"on should be targeted to the specific goals of
pa"ent, however in general, rehabilita"on for mul"system
impairmentaims to:13,5,710,11
a. Empower the pa"ent and their family to understand the
impairment and how to manage it in their daily lives
b. Improve func"on; and
c. Compensate for deficits in func"oning.
10.4 The following areas should be targeted in a rehabilita"on programme

that addresses difficul"es in lung func"oning which are the primary
impairment in COVID19. Many of these apply known pulmonary
rehabilita"on concepts and principles.11
a. Increasing ven"la"on
b. Airway clearance
c. Educa"on for breathlessness
d. Returning to everyday ac"vi"es
e. Physical exercise and fitness
10.5 The process of referral and its management principle at different

spectrum of rehabilita"on process as described in Table 9.1. and
Figure 9.1.
Spectrum Process Personnel
Predischarge Referral shall be made to the Referral by primary

respec"ve rehabilita"on services such team Specialist /
as Physiotherapy and/or Occupa"onal Medical Officer
Therapy for iden"fied elementary
impairment and rehabilita"on need.
Referral shall be made for
Rehabilita"on Medicine services for
mul"system medical impairment with
complex rehabilita"on needs requiring
for comprehensive mul"system
evalua"on; iden"fica"on of
impairments and complex
rehabilita"on needs; implement ini"al
rehabilita"on program; provision and
facilita"on of early supported
discharge.
At discharge Schedule date for outpa"ent physical Referral le&er to be

review at 1 month provided by primary
• All COVID19 survivors Category 4 team Medical Officer.
and 5 Ward nurse to obtain
• All other COVID19 categories with the appointment date
iden"fied rehabilita"on needs
• All pa"ent with exis"ng
rehabilita"on needs whom acquire
COVID19 infec"on.
2 weeks post Teleconsulta"on surveillance checklist Rehabilita"on Medical

discharge: Tele ques"ons for general mul"system Officer
consulta"on medical impairment and func"onal
limita"on screening (Table 9.2).
1month post (1) Clinical evalua"on Rehabilita"on Physician

discharge: • Surveillance checklist ques"ons for and Medical Officer
Comprehensive general mul"system medical
physical review impairment and func"onal limita"on
(Table 9.2).
• Focused physical examina"on
• Imaging, laboratory, treatment, lung
func"on and all others related
review as available.
• Consulta"on with other relevant
special"es if indicated.
(2) Comprehensive mul"system Rehabilita"on Physician

medical impairment and func"onal and Medical Officer;
evalua"on using standardized Physiotherapist;
outcome measure: 2,3,5,10,12,13,16 Occupa"onal Therapist
• Cogni"ve: Brief Mental State and Rehabilita"on Nurse

Examina"on (BMSE); Mini Mental
State Examina"on (MMSE) if
impaired BMSE.
• Psychological: Depression Anxiety
Stress Scale (DASS21).
• Nutri"on: Body Mass Index (BMI)
• Respiratory: Oxygen Satura"on
(SPO2); Respiratory Rate (RR); Lung
Ausculta"on; Modified Medical
Research Council Dyspnoea Scale
(mMRC); 6Minute Walking Test
(6MWT); Peak Expiratory Flow
Rate/Peak Cough Flow
• Cardiovascular: Blood Pressure (BP)
and Heart Rate (HR); 6Minute
Walking Test (6MWT) with SPO2 and
HR monitoring.
• Musculoskeletal: Medical Research
Council (MRC) muscle strength
grading; Joint range of mo"on
(ROM); Analogue Fa"gue Severity
Scale (AFSS);
• Aerobic exercise capacity: 6minute
Walking Test (6MWT) with SPO2
and HR monitoring; 1minute Chair
Rising Test
(3) Assessment of ac"vi"es of daily Occupa"onal Therapist

living (ADL)
• Generic: Modified Barthel Index
(MBI)13,5,1014,16
• Disease Specific: Post COVID19
Func"onal Scale (PCFS)4,12
• Addi"onal: Return to Drive (RTD);
Return to Work (RTW); Return to
school/educa"on as applicable.
(4) Assessment of Quality of Life Occupa"onal Therapist

(QOL)1,2
• World Health Organiza"on
Disability Assessment Scale
(WHODAS) 2.0
1month post (1) Pa"ent educa"on / empowerment Rehabilita"on Physician

discharge: strategies and Medical Officer;
Comprehensive • Individual or group educa"on / Physiotherapist;
rehabilita"on demonstra"on and training of skills Occupa"onal Therapist
interven"on and involving pa"ents and caregivers as and Rehabilita"on Nurse
prescrip"on available. These are adapted using
the World Health Organiza"on
(WHO) Support for Rehabilita"on
Self Management for COVID19
related illness.14 Homebased
rehabilita"on can be a useful and
equivalently effec"ve alterna"ve to
an outpa"ent hospital based
rehabilita"on program.15
• Enhanced with brochures/ pamplet/
video/ websiteinternet resources or
any other educa"onal material to
enhance understanding of
rehabilita"on importance and its
specific strategies; healthy lifestyle
educa"on; encourage pa"ents to
par"cipate in family and social
ac"vi"es. 3,1015
(2) Prescrip"on of rehabilita"on Rehabilita"on Physician

program customized to the and Medical Officer;
comprehensive assessment findings. Physiotherapist.
2,3,5,1214
• Symptom Relieving Posi"ons11,14: * Whenever required for

(Table 9.2) more intensive
Post COVID19 symptoms such as ins"tu"onal based
dyspnoea may be relieved by program, the individuals
adop"ng various posi"ons. The are referred to their
pa"ent should be encouraged to try most logis"cally
each of these suggested posi"ons to convenience facili"es
iden"fy which may be beneficial to with available resources.
them. Pa"ent also should be
encouraged to combine dyspnoea **Access for tele
relieving posi"oning with pursed lip consulta"on are
breathing technique for more provided for those on
effec"veness. complete homebased
• Breathing training: (Table 9.3) program.
Guided by pa"ent symptoms such as
dyspnoea, cough, difficulty with ***Exercise / ac"vity
sputum expectora"on. Breathing diary are advised for
techniques training included deep compliance checks of
breathing exercises; thoracic therapy.
mobility exercise, diaphragma"c
breathing, purse lips breathing,
spirometer, inspiratory muscle ****Selfmonitoring and

trainer.2,5,1114 documenta"on of heart
• Cough and sputum expectora"on
techniques: Breathing techniques as rate response and
above; reducing energy consump"on oxygen satura"on
during sputum clearance such as during physical exer"on
huff cough methods; use of cough are advised for
assist devices such as posi"ve addi"onal safety during
expiratory pressure (PEP)/oscillatory home exercise.
PEP. 2,5,1114
• Muscle strength training: (Table 9.4)
Progressive and graded resistance
training is recommended for
strength training with a frequency of
2 to 3 "mes per week, with a
training period of 6 weeks and a
weekly increase of 5% to 10%.2,5
• Balance training: Including hands
free training and balance training
using a device if applicable under the
guidance of a physiotherapist. 2,5
• Aerobic exercise: Advised pa"ents
for safe gradual progression of
walking, brisk walking, jogging,
cycling, stairs climbing, threadmill
based on the comprehensive
evalua"on findings. This shall begin
from low intensity, gradually
increasing the intensity and
dura"on: 3 to 5 "mes per week for
20 to 30 minutes each "me.
Intermi&ent exercise and pacing of
ac"vi"es are advocated in those
affected by fa"gue. 2,5,1114
• Specific exercise prescrip"on: To
include frequency ("mes per day;
"mes per week); intensity (Borg
Ra"ng of Perceived Exer"on scale
and/ or heart rate response); "me
(dura"on per exercise) and type
(specific anaerobic; aerobic
exercise). Intensity is an important
parameter as it relates to safe
exercise performance.11,12,14
(3) Ac"vi"es of Daily Living (ADL) Occupa"onal Therapist

training are provided tailored to the
comprehensive evalua"on findings: * Whenever required for
13,5,1014
(Table 9.8) more intensive
ins"tu"onal based
• Basic ac"vi"es of daily living (BADL) program, the individuals

such as transfer, grooming, toile"ng, are referred to their
bathing, feeding. most logis"cally
• Instrumental ac"vi"es of daily living convenience facili"es
(IADL) such as cooking, laundry with available resources.
management, safety aspects;
finance.
• Return to driving as indicated.
• Return to work program as
indicated.
• Iden"fy obstacles in life task
par"cipa"on, and conduct targeted
interven"on such as energy
conserva"on techniques, pacing,
relaxa"on techniques.
• Iden"fy needs for home aids and
environmental adapta"ons such as
safety bar, reacher, sock aids.
3 months post Assessment for ongoing rehabilita"on Rehabilita"on Physician

discharge needs. Customized interven"on and / and Medical Officer;
or mul"disciplinary specialty referral if Physiotherapist;
indicated. Occupa"onal Therapist
and Rehabilita"on Nurse
6 months post Assessment for ongoing rehabilita"on
discharge needs. Customized interven"on and/
or mul"disciplinary specialty referral if
indicated.
12 months post Assessment for ongoing rehabilita"on

discharge needs. Customized interven"on and/
or mul"disciplinary specialty referral if
indicated. Table 9.1:
Referral
process and
management
*Access to other mul"discipline special"es such as infec"ous disease, respiratory, principle of
psychiatry, emergency services are available whenever indicated at any spectrum of rehabilita"on
rehabilita"on services process
WORKFLOW FOR REHABILITATION REFERRAL UPON INITIA

ACUTE DISCHARGE
Survivors of severe
COVID19 (Stage 4 Referral Rehabilita"on clinic
& 5) at discharge date at 4/52
Yes Tele No
Clinic review at consulta"on at 2/52 Clinic review at
earliest date for need of early 4/52
review
Mul"discipline referral
Yes Residual
if indicated &
medical
prescrip"on of impairments & physical
customized disabili"es
rehabilita"on
program
No
Discharge
Figure 9.1:
Outcome evalua"on at
Workflow for
3,6 & 12 months
Rehabilita"on
Referral upon
Ini"al Acute
Discharge
SYMPTOM RELIEVING POSITIONS
Posi"on Instruc"ons
High side lying • The pa"ent lies on his side with knees
slightly flexed.
• The head and neck are propped up by
pillows.
Forward lean si*ng • The pa"ent sits at a table, leaning

forwards from the waist with the head
and neck res"ng on a pillow.
• The arms may remain res"ng on the
table.
Forward lean si*ng, • The pa"ent sits on a chair, leaning

without table forwards with the arms res"ng on his
thighs or on the armrests of the chair.
Forward lean standing • While standing, the pa"ent leans

forwards onto a windowsill, chairback or
any other stable surface.
Posi"on Instruc"ons
Standing with back support • The pa"ent leans with his back against a
wall and hands at his sides.
• His feet should be about one foot away
from the wall and placed slightly apart.
Table 9.2:
Symptom
Relieving
Posi"ons
Breathing techniques may also be taught to pa"ents as a method to improve lung

capacity, respiratory muscle efficiency, to facilitate airway clearance and to reduce
symptoms such as dyspnoea.
BREATHING TECHNIQUES
Technique Instruc"ons
Diaphragma"c Breathing • The pa"ent sits in a comfortable, relaxed

and supported posi"on
• One hand is placed on the chest while
the other is on the abdomen
• The pa"ent is asked to breathe in slowly
through the nose and then to breathe
out through the nose
• With each breath, the pa"ent should
appreciate the hand over the abdomen
rising more than the hand over the chest.
• The pa"ent is advised to use as li&le
effort as possible and to ensure breaths
are slow, relaxed, and smooth.
• Perform __repe""ons per set and do __
sets per day
Thoracic Mobility Exercise (TME) • The pa"ent sits in a comfortable, relaxed

• The pa"ent slowly takes a deep breath
while raising his arms towards the ceiling.
• The pa"ent is then instructed to hold his
breath for 3 seconds.
• The arms are slowly brought down to the
lap while breathing out through the
mouth with a pursed lip.
• Perform__ repe""ons per set and do __
sets per day.
Pursed Lips Breathing • The pa"ent sits in a comfortable, relaxed

• Ensure that the neck and shoulder
muscles are relaxed.
• The pa"ent breathes in through the nose
slowly for 2 counts, while keeping the
mouth closed.
• The lips are pursed as if about to whistle
or gently flicker the flame of a candle.
• The pa"ent is then asked to breathe out
slowly through pursed lips while coun"ng
to 4.
Technique Instruc"ons
• These steps are repeated un"l breathing

normalizes.
• This technique may be used in
combina"on with the symptom relieving
postures to ease dyspnoea.
• Perform__ repe""ons per set and do __
sets per day
Huffing Technique • Huffing technique is a cycle of deep

breathing, thoracic expansion and huff
with the purpose of airway clearance.
• Huffing occurs through forced expira"on
with an open mouth.
• A huff is an ac"ve breath out with an
open throat, like a sigh, as if trying to fog
up a mirror.
• The pa"ent is asked to perform a
sequence of 23 deep breaths then 12
huffs, followed by a cough to clear any
Table 9.3: sputum.
Breathing • Perform__ repe""ons per set and do __
techniques sets per day
1 Exercise Precau"ons
a. Exercising safely is important, even if the pa"ent was premorbidly

independent with his mobility. Addi"onal precau"on should be taken
with pa"ents who are at a higher risk of complica"ons, such as the
following:
i. Impaired mobility premorbidly
ii. History of falls before or during hospital admission
iii. Comorbidi"es that may put them at risk during exercise (heart
disease, musculoskeletal injury)
iv. Discharged from hospital with home oxygen therapy
b. Pa"ents who fall in the above listed categories will require close
supervision during their exercise sessions. The following advice should
be given to these pa"ents to ensure safety during exercise.
i. Stretching and warm up sessions should be performed before
exercising, whereas cool down sessions are to be done a'er
exercising
ii. Clothing used for exercise should be loose and comfortable, while
shoes should be stable and suppor"ve
iii. Exercises should be performed at least one hour a'er a meal

iv. Pa"ents should drink adequate amounts of water
v. Outdoor exercises should be avoided during hot weather
c. Exercise should be terminated if the pa"ent develops the following

symptoms:
i. Nausea
ii. Dizziness or light headedness
iii. Severe shortness of breath
iv. Clamminess or swea"ng
v. Chest "ghtness
vi. Increased pain
In the event of the above symptoms, the pa"ent is advised to contact their
healthcare professional.
2. Warm Up Exercises
a. Warming up prepares the body for exercise and helps to prevent injury.
Warm up exercises should last for approximately 5 minutes, and it
should result in the pa"ent feeling slightly breathless. These exercises
may be done in si$ng or standing posi"ons. If the warm up exercises
are done in the standing posi"on, the pa"ent should hold on to a stable
surface for support as needed.
b. Each movement is repeated 2 to 4 "mes.
Examples of warm up exercises are given below.11,14
Exercise Instruc"ons
Shoulder Shrugs • The shoulders are li'ed slowly towards

the ears and then down again
Shoulder Circles • As the pa"ent’s arms are kept relaxed by

the side or res"ng on the lap, the
shoulders are slowly moved around in
forward circle.
• This is then repeated in a backward
circle.
Side Bends • The pa"ent’s body is kept straight with

the arms hanging down on either side.
• One arm is slid down towards the floor
while bending the body laterally and
then returned to the start posi"on.
• This is repeated for the other arm.
Knee Li#s • The pa"ent’s knees are li'ed up and

down slowly one at a "me, without
exceeding hip height.
Ankle Taps • While seated on a chair, the pa"ent taps

his toes followed by his heel on the
ground in front of him.
• This is done in an alterna"ng, repe""ve
sequence with the other foot.
Ankle Circles • While seated, the pa"ent uses his toes to

draw circles in the air
• This is repeated with the other foot.
Table 9.4:
Warm Up
Exercise
3. Types of Exercises
a. Aerobic exercises (Fitness Training)

These exercises aim to improve overall endurance and fitness. Any
physical ac"vity that leaves the pa"ent slightly breathless may be
considered aerobic training.
Aerobic exercises should be "med and gradually increased over "me

according to the pa"ent’s tolerance. Increases may be done in periods
of 30 to 60 seconds at a "me.
These exercises should be done for 2030 minutes per day, 5 days per
week.
Examples of aerobic exercises are given below:

Marching on the Spot • The pa"ent is in standing posi"on,

holding on to a stable surface or chair for
support if necessary. A chair for res"ng
should be placed nearby.
• The knees are li'ed one at a "me
• For exercise progression, the knees may
be li'ed higher, aiming to reach hip
height if possible
• This exercise may be indicated if the
pa"ent is unable to walk for long
distances without rest or if the pa"ent if
unable to go outside for walking
exercises.
Stepups • The pa"ent stands at the bo&om step of

a flight of stairs. A chair for res"ng should
be placed nearby.
• The handrail may be held for support if
necessary.
• The pa"ent begins by stepping up and
down, changing the leg he started with
every 10 steps.
• For exercise progression, the height of
the step or the speed of stepping may be
increased. Once the pa"ent has achieved
good balance, this exercise may be done
without holding on to handrails.
Eventually it may also be done while
carrying weights.
pa"ent is unable to walk for long
distances without rest or if the pa"ent if
unable to go outside for walking
exercises.
Walking • Assis"ve aids such as walking frame,

crutches or walking s"ck may be used if
necessary.
• Selected routes for walking should be
rela"vely flat.
• For exercise progression, the speed or
distance of walking may be increased. If
possible, uphill routes may also be
included.
pa"ent is able to go outdoors for
exercise.
Distance of walking: ____in 20 minutes
Jogging or cycling • Jogging or cycling should only be

prescribed if it is medically safe for the
pa"ent.
pa"ent was already able to cycle or jog
premorbidly and if walking is not
adequately exer"ve. Table 9.5:
Aerobic
Exercises
b. Strengthening Exercises
These exercises are also known as resistance training exercises and aim
to improve muscle strength. Muscles may atrophy and become weaker
due to decondi"oning following Post COVID19 infec"on. Hence these
exercises should be incorporated into the pa"ent’s program.
Strengthening exercises should be performed repe""vely with regular

pauses in between. However, they are not recommended to be done
on consecu"ve days due to the risk of muscle soreness and fa"gue.
These exercises may be done three "mes in a week, on non

consecu"ve days.
Examples of strengthening exercises are given below:

Bicep Curl • The pa"ent stands with arms to the side,

while holding a weight in each hand.
• Forearms are supinated so that the
palms face forward.
• The shoulder and proximal arm are kept
sta"onary while the pa"ent gently li's
the weights by flexing bilateral elbows.
The weights should be brought up to the
chest level.
• This exercise may be done in si$ng or
standing posi"on.
Wall Push Off • The pa"ent stands facing a wall with his

hands placed flat against it at shoulder
height.
• Fingers should be poin"ng upwards and
the feet should be placed one foot away
from the wall.
• With the pa"ent’s body always kept
straight, the elbows are flexed slowly to
lower the body towards the wall.
• The pa"ent should then gently push
away from the wall again un"l bilateral
elbows are extended again.
• This exercise is repeated ___ "mes, over
____ cycles.
Arm Raises to The Side • The pa"ent stands with arms to the side,
holding a weight in each hand and with
the palms facing inwards.
• Both arms are abducted to shoulder level
(not beyond this) and slowly lowered
back down.
• This exercise may be done in si$ng or
standing.
____ cycles.
Sit to Stand • The pa"ent sits on a chair with the feet

placed hipwidth apart.
• With the arms kept at the side or crossed
over the chest, the pa"ent slowly stands
up, holding the end posi"on for 3
seconds.
• The pa"ent then slowly lowers himself
back into si$ng posi"on on the chair.
• The pa"ent’s feet should be kept on the
floor throughout this exercise.
• If the pa"ent is unable to rise from the
chair without using his arms, a higher
chair may be used. If he is s"ll unable to
rise, then he may push up with his arms.
____ cycles.
• For exercise progression, the movement
should be done as slowly as possible.
Alterna"vely, a lower chair may be used
or the pa"ent may hold a weight close to
chest while performing this exercise.
Knee Straightening • The pa"ent sits in a chair with feet

together.
• One knee is extended and the leg is held
straight for a moment before it is slowly
lowered.
• This is repeated with the other leg.
____ cycles.
• For exercise progression, the "me with
the leg held in extension may be
increased. Alterna"vely, the exercise may
be performed with an ankle weight.
Squats • The pa"ent stands with his back against

a wall or any other stable surface, feet
placed slightly apart.
• The feet are moved about a foot away
from the wall.
• Alterna"vely, the pa"ent may rest his
hands on the back of a stable chair.
• While keeping the back against the wall
or holding on the chair, the knees are
slowly and slightly flexed, allowing the
back to slide down the wall. Hips should
be maintained at a higher height than
the knees.
• The end posi"on is maintained for a
moment before knees are extended.
____ cycles.
• For exercise progression, the amount of
knee flexion or the dura"on of
maintaining the end posi"on may be
increased.
Heel Raises • In standing posi"on, the pa"ent’s hands

rest on a stable surface for balancing
support. Leaning on the hands is not
allowed.
• The pa"ent then slowly raises himself to
stand on "ptoes before lowering himself
down again.
____ cycles.
• For exercise progression, the "me spent
on "ptoes may be increased or the
Table 9.6: pa"ent may stand on one leg at a "me.
Strengthening
Exercises
4. Cool Down Exercises
Cool down exercises are indicated at the end of an exercise session. These
allow the body to return to a more physiological state in a gradual manner
before termina"ng an exercise session.
Cool down exercises should be performed for approximately 5 minutes.
Examples of cool down exercises are given below:
Slow Walk/ Gentle March • The pa"ent may walk at a slower pace or
gently march on the spot, for
approximately 2 to 5 minutes.
Repe""on of Warm • The recommended exercises for the

Up Exercises warm up session may be repeated as
cool down exercises, with the aim of
mobilizing the joints.
• These may be done in si$ng or standing.
Muscle stretches • Stretching of the muscles may help to

reduce any soreness the pa"ent may feel
over the next few following exercise
(DOMS delayed onset muscle soreness).
• Each stretch should be performed gently,
and should be held for 1520 seconds
each.
• Examples of muscle stretches are given
below.
Shoulder:
• The pa"ent’s arm is placed in front and

then brought across the body to the
opposite shoulder.
• The other hand is now used to press the
arm against the chest.
• The pa"ent should feel a stretch around
the posterolateral shoulder joint.
• The pa"ent now returns to star"ng
posi"on and the same exercise is
repeated on the opposite side.
Back of Thigh (Hamstring):
• The pa"ent sits at the edge of a chair

with the back straight and the feet flat on
the ground.
• One leg is placed in front with the heel
res"ng on the ground.
• The hands may be placed on the other
thigh for support.
• While si$ng as tall as possible, the
pa"ent bends slightly forwards at the
hips un"l a slight stretch may be felt
along the posterior aspect of the
stretchedout leg.
Lower Leg (Calf):
• The pa"ent sits at the edge of a chair

with the back straight and the feet flat on
the ground.
• One leg is placed in front with the heel
res"ng on the ground.
• The hands may be placed on the other
thigh for support.
• While si$ng as tall as possible, the
pa"ent bends slightly forwards at the
hips un"l a slight stretch may be felt
along the posterior aspect of the
stretchedout leg.
Front of Thigh (Quads):
• The pa"ent stands with the feet apart

and leans forward onto a wall or
something sturdy for support.
• One knee is flexed behind the pa"ent
and if he is able to reach it, the pa"ent
uses the hand on the same side to grip
the ankle or the back of the leg.
• The foot is then brought up to the level
of gluteal muscles.
• The pa"ent should feel a stretch along
the anterior aspect of the thigh.
• The knees should be kept close together
and back maintained in a straight
posi"on.
posi"on and the same exercise is Table 9.7:
Cool Down
Exercises
Descrip"on Cogni"ve func"on is a broad term that refers to mental

processes involved in the acquisi"on of knowledge,
manipula"on of informa"on, and reasoning. Cogni"ve
func"ons include the domains of percep"on, memory,
learning, a&en"on, decision making, and language abili"es.
People undergoing crises may experience temporary or
permanent loss of cogni"ve func"on. Early interven"ons
offered for this impairment will facilitate recovery of op"mal
cogni"ve func"on.
Assessment Mental State Examina"on (MSE) is a simple assessment tool

that is used to screen cogni"ve func"on and helps to
determine suitable interven"ons that may assist pa"ents in
regaining cogni"ve recovery.
Interven"on 1. Pa"ent educa"on

Both the pa"ent and the family members should be
educated on the possibility of cogni"ve impairment
following COVID19 as well as prolonged hospital stays.
Awareness, tolerance and pa"ence are important in
crea"ng an ideal environment for the ongoing
rehabilita"on process. Family members should
accommodate the pa"ent’s impairment by allowing the
pa"ent to have more "me for response and processing
"me.
2. Examples of strategies:
(i) Using orienta"on boards to train pa"ents with
impaired orienta"on
(ii)Using external aids like notebooks, smartphones or

calendars to do lis"ng, se$ng alarms or wri"ng notes
for pa"ents with impaired memory
3. Using internal memory strategies like mnemonic
Table 9.8: strategies, visualizing concepts or organizing informa"on
Managing to enhance memory
Cogni"ve 4. Breaking down ac"vi"es into individual steps to help
Issues pa"ents with impaired execu"ve func"on
Descrip"on The COVID19 pandemic has been a source of stress and

anxiety for many pa"ents. These impairments may largely
impact a pa"ent’s func"on and quality of life.
Assessment DASS is a standard general assessment which is easily

available and accessible for everyone. DASS evaluates the
stress, anxiety and depression levels of a pa"ent and helps
to decide on further management when necessary.

It is important to provide the right informa"on for
pa"ents who have recovered from COVID19 infec"on to
alleviate the stress and anxiety to promote recovery.
Suitable coping techniques can be adopted by pa"ents at
home and support from family and friends will be helpful.
2. Relaxa"on techniques
(i) Progressive muscle relaxa"on
By slowly contrac"ng and relaxing each muscle
group in order, pa"ents will be aware of the various
physical and sensory feedback.
The pa"ent is made to contract the muscle for 5
seconds and relax it for 30 seconds and this is then
repeated for other muscle groups.
The pa"ent may either start from the distal to
proximal muscles (toes to neck) or proximal to distal
muscles (neck to toes).
(ii) Relaxa"on breathing
The pa"ent can prac"ce relaxa"on breathing
technique by si$ng comfortably on a chair or lying
on a bed. By slowly contrac"ng and relaxing each
muscle group in order, the pa"ent will become
more aware of the physical feedback.
Relaxa"on:
Si$ng
posi"on
Relaxa"on:
Lying
posi"on
3. The pa"ent is advised to be physically ac"ve by gradually

increasing their physical ac"vi"es in a safe manner
(i) Ini"ate rou"ne ac"vi"es

Start by performing dressing, simple cooking, slow
walking.
Outdoor
walking
(ii) Explore new ac"vi"es

Planning a new leisure ac"vity will help in managing
stress and improving mood.
Playing the
words
scramble
board game
Table 9.9:
Managing Composing Gardening
Stress and flowers/ simple
Emo"onal home decora"on
Health
Descrip"on Fa"gue or "redness is used to describe an overall feeling of

lack of energy. Following COVID19 infec"on, pa"ents
experience physical fa"gue as well as emo"onal fa"gue. This
subsequently results in a 60% reduc"on in the ability to
perform basic ADL compared to their premorbid status.
Assessment Analogue Fa"gue Score Scale (AFSS) is a simplified tool which

is used to evaluate fa"gue severity. It is a selfreport scale
which reflects global fa"gue on a scale of 110.

Educa"on on awareness of fa"gue offers a be&er
understanding for pa"ent to selfmanage their symptoms
at home and boost the pa"ent’s confidence when
performing daily ac"vi"es.
2. Energy conserva"on technique
(i) Planning
Organize daily ac"vi"es at the start of the day
U"lize modified aids and equipment where possible
(ii) Priori"ze
Iden"fy important tasks and complete that first
Eliminate nonessen"al tasks
(iii) Pacing
Avoid rushing through tasks
Break down larger tasks into smaller por"ons and
distribute them throughout the day
Stop for breaks before becoming "red
3. Introducing physical exercise Table 9.10:
Gradually introducing physical exercise including aerobic Managing
Fa"gue
exercise into daily rou"ne will help to cope with fa"gue.
Descrip"on Returning to independent func"on is closely interlinked with

the pa"ent’s quality of life. Maintaining independence in
performing selfcare and social ac"vi"es is par"cularly
important in preserving dignity. This leads to selfsa"sfac"on
and op"mized quality of life. Post COVID19, these pa"ents
may need assistance due to physical and mental
deteriora"on.
Assessment 1. Modified Barthel Index (MBI) is a suitable assessment

used to assess the pa"ent’s independence in performing
ADL. It is also easily accessible and performed by
therapists, being used as an indicator of baseline func"on
as well as to monitor progress.
2. WHODAS is a general assessment consis"ng of 36 items
including cogni"ve func"on, mobility, selfcare and social
interac"on.2

It will be beneficial to advice pa"ents to become ac"ve
again during the recovery period. Simple tasks may
require more effort than before and pa"ents will become
"red more easily. Advise pa"ents to set small goals and
progress gradually to meet their expecta"ons while also
allowing others to help them when the tasks become too
strenuous for them.
2. Modifica"ons in performing ac"vi"es of daily living
(i) Perform tasks while si$ng down whenever possible to
save energy
Si$ng on high
chair during
grooming
(ii) Choose lighter equipment during ac"vi"es
Using lighter
cooking pan
during meal
prepara"on
(iii) Use adap"ve devices to facilitate ac"vi"es and

prevent excessive body movements.
3. When the pa"ent is ready to return to work, work

simplifica"on techniques will be useful in the workplace
for the pa"ent to gradually resume their work at full
capacity. Table 9.11:
(i) Prepare and plan the ac"vity Managing
(ii) Minimize hand and body mo"ons during ac"vity Ac"vi"es of
(iii)Organize the workplace and required tools Daily Living and
(iv)Change to more appropriate tools Improving
Quality of Life
(v) Change the method of tool u"liza"on
10.6 Pa"ents shall be considered for enrollment in a hospitalbased

outpa"ent pulmonary rehabilita"on program if they are able to ac"vely
par"cipate in therapy and able to a&end the weekly Physiotherapy and
Occupa"onal Therapy sessions of 1 hour respec"vely for total dura"on
of 8 weeks.13 Refer Figure 9.2 (Workflow Algorithm for Outpa"ent
based Post COVID19 Pulmonary Rehabilita"on (PCPR) Program).
WORKFLOW ALGORITHM FOR OUTPATIENT BASED POST COVID19

PULMONARY REHABILITATION (PCPR) PROGRAM13
Figure 9.2:
Workflow
Algorithm for
Outpa"ent
based Post
COVID19
Pulmonary
Rehabilita"on
(PCPR) Program
11.0 Monitoring and Evalua"on / Surveillance
General surveillance checklist ques"ons adapted from literature review

framework2,3 for mul"system medical impairment and iden"fica"on of
rehabilita"on needs shall be used. Suggested surveillance checklist ques"ons for
mul"system medical impairment and iden"fica"on of rehabilita"on needs for
COVID19 survivors applicable during teleconsulta"on as in Table 9.9 (Suggested
Surveillance Checklist Ques"ons). This framework may also be applied throughout
the spectrum of rehabilita"on process physical review.
Domain Questions Remark

Opening Introduction - name, designation, Initial open
question hospital; reason for enquiry for post- ended question
discharge progress, issues and planning
for intervention if required.
Do you experience any new symptoms or

problems that concerns you compared to
before you had COVID-19?
Bodily structure Do you still experience persisting or new Based on some

& function. problems commonly associated with post of the common
COVID-19 symptoms such as: symptoms
Post COVID-19 reported in
common ! Abnormality of smell? literature2-4,7-10
symptoms ! Abnormality of taste? and identified in
enquiry ! Overly tired? the CROSS12
! Breathing difficulties? database.
! Cough?
! Muscle weakness?
! Difficulty sleeping?
! Slow thinking process?
! Forgetful?
! Pain?
! Abnormal sensations?
! Mood disturbance?
! Dysfunctional bladder and bowel?
! Skin problems?
Any other problems concerning you?
Activity & Are you able to perform, if you wishto and Based on the
Participation at your level of expectation: common activity
& participation
challenges
reported in
literature2-4,7-10
and identified in
the CROSS12
database.
Activity & Are you able to perform, if you wishto and Based on the
Participation at your level of expectation: common activity
& participation
! Self care? challenges
! Household and domestic reported in
activities? literature2-4,7-10
! Swallowing, eating, drinking? and identified in
! Communicating? the CROSS12
! Walking within the house including database.
the stairs?
! Walking outside the house?
! Transportation / driving?
! Activities related to your leisure?
! Activites related to your job?
! Do you use any adaptive/ assistive
devices?
Ending Is there any other challenges in your daily End with

questions life that concerns you? general advice
and positive
Thank you for the information given. You encouragement
may contact our healthcare facilities shall for recovery.
you have any new concerns. Otherwise
we shall review you at the scheduled
Table 9.12: appointment date.
Suggested
Surveillance Note: To be applied whenever applicable as per judgement of attending
Checklist clinician
Ques"ons
Name: Registration number:

Date begins: Date end:
Week:
Day Breathing Strengthening Duration Aerobic Duration Intensity HR/SPO2 HR/SPO2 HR/SPO2
exercise exercise activity before during after
!"# # # # # # # # # #
$"# # # # # # # # # #
Table 9.13: %"# # # # # # # # # #
Home &"# # # # # # # # # #
Exercise '"# # # # # # # # # #
Diary and ("# # # # # # # # # #
Monitoring )"# # # # # # # # # #
Log Note: Upon completion of the 8 weeks program, please bring this diary along at your next appointment
with the doctor.
#
Methods Scale
Borg Scale11,14
Monitoring of exercise intensity is done
Intensity Scale Description
using the Borg scale and may assist
0 Nothing at all
patients to exercise at their optimal levels.
0.5 Very, very
• Reassure the patient that feeling
slight
breathless whilst exercising is
1 Very slight
normal and is not harmful or
Low 2 Slightly
dangerous.
3 Moderate
• The Borg scale can help patients
Moderate 4 Somewhat
rate how much effort is required to
severe
complete the prescribed exercise,
5 Severe
hence help them to monitor the
progress of their fitness level. High 6
7 Very severe
• Start at lower intensities (scale 2-3)
especially during the initial 6 weeks 8
following COVID-19, and gradually 9 Very, very
progress to moderate intensities severe
(scale 4-5) and high intensities 10 Maximal
(scale 6-7) as tolerance.
17
Heart rate prescription Increment over resting heart rate
Exercise intensity may be prescribed by (RHR + intensity)
allowing a specific increment of the heart Low intensity: 10-25 bpm above RHR
rate over the resting heart rate (RHR). Moderate intensity: 20-35 bpm above
• For patients at higher risk, a limited RHR
increment is allowed during exercise High intensity: 30-55 bpm above RHR
sessions.
• Patients may be taught this method
to monitor their home program as it Table 9.14:
is simple assessment that does not Monitoring
Exercise
require tools.
Intensity
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! "H7Z! "H7Z! "H7Z! "H7Z! "H7Z!
! "F#23*0%! "F#23*0%! "F#23*0%! "F#23*0%! "F#23*0%!
"E#3,! "E#3,! "E#3,! "E#3,! "E#3,!
"J051C%! "J051C%! "J051C%! "J051C%! "J051C%!
[%#I,%55! [%#I,%55! [%#I,%55! [%#I,%55! [%#I,%55!
"72M%.5&! "72M%.5&! "72M%.5&! "72M%.5&! "72M%.5&!
$J6(!:58,4%#! ! ! ! ! !
9)H!\E#3,]! ! ! ! ! !
)FHH! ! ! ! ! !
ZJ'! ! ! ! ! !
E/F6!U!E(F! ! ! ! ! !
^JXL!! ! ! ! ! !
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L%52! !
Z.3%K!JH/! ! ! ! ! !
JZ'! ! ! ! ! !
:)HH! ! ! ! ! !
E(FH! ! ! ! ! !
Table 9.15: 6L:!\T%5!U!"4]! ! ! ! ! !
6LX!\T%5!U!"4]! ! ! ! ! !
COVID19
XW7:)H!@S_! ! ! ! ! !
Rehabilita"on
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(40*M!FC4[`!6L:;!6%20.,!24!:.3P%`!6LX;!6%20.,!L4!X4.I`!XW7:)H;!X4.C-!W%#C2M!7.*#,3D#234,!:35#G3C32>!)55%55$%,2!H1#C%S!
!
12.0 Standardized Outcome Measures
12.1 The standardized outcome measures and assessment tools in

Table 9.12, Table 9.13 and Table 9.14 shall be used. These include (but
not limited to) 6 Minute Walk Test, 1 Minute Chair Rise; Depression
Anxiety Stress Scale; Analogue Fa"gue Scale Score; Modified Medical
Research Council Dyspnoea Scale; Modified Barthel Index; Brief Mental
State Examina"on; Mini Mental State Examina"on; Post Covid19
Func"onal Status Scale; Peak Expiratory Flow Rate/ Peak Cough Flow;
Return To Work; Return to Drive; Visual Analogue Scale; World Health
Organiza"on Disability Assessment Scale 2.0). 15,12
12.2 These standardised outcome measures for the specific mul"system

domains shall be used for monitoring of quality rehabilita"on
interven"on;to standardize the repor"ng of rehabilita"on outcomes;
to facilitate data analysis especially pertaining to func"onal based
research, and to improve the comparability of evidencebased data. 15
13.0 Conclusion
13.1 Rehabilita"on needs of individuals with COVID19 exist during the

acute, subacute and throughout the longterm phases of care. It is
o'en amplified pa"ents with underlying medical comorbidi"es,
decrements in health associated with ageing process and indirectly by
pandemic containing measures.
13.2 Rehabilita"on services play an important integral role alongside other

healthcare professionals in providing comprehensive care of COVID19
survivors towards op"mal medical and func"onal recovery, hence
successful reintegra"on back into community.
13.3 In the community, emphasis shall be made specifically for pa"ent and
their caregivers empowerment, increase their confidence level in self
management, improve their overall func"on hence their quality of life.
References:
1. Rehabilita"on considera"ons during the COVID19 outbreak. World Health

Organiza"on Regional Office publica"on for America/PAHO 2020.
2. Bin Zeng, Di Chen, Zhuoying Qiu et al. Expert consensus on protocol of
rehabilita"on for COVID19 pa"ents using framework and approaches of
World Health Organiza"on Interna"onal Family Classifica"ons. Aging
Medicine. 2020; 3:82–94.
3. Derick T Wade. Rehabilita"on a'er Covid19: An evidence based approach.
Clinical Medicine 2020; Volume 20; No 4; 35964.
4. Frederikus A K, Gudula J A M, Boon et al. The Post COVID19 Func"onal
Scale Status: A tool to measure func"onal status over "me a'er COVID
19.The European Respiratory Journal 2020 Jul;56(1):2001494.
5. Demeco A, Maro&a N, Barle&a M et al. Rehabilita"on of pa"ents post

COVID19 infec"on: a literature review. Journal of Interna"onal Medical
Research 2020; 48(8) 1–10.
6. World Health Organiza"on Guidelines on HealthRelated Rehabilita"on
Concept Paper (h&ps://www.who.int/disabili"es/care/rehabilita"on
_guidelines_concept)
8. Ani Nalbandian, Kar"k Sehgal , Aakri" Gupta et al. Postacute COVID19
Syndromes. Nature Medicine 2021; Vol 27; 601–615.
9. Care of People Who Experience Symptoms PostAcute COVID19. Na"onal
10.Margaret Phillips, Lynne Turner Stokes, Derick Wade et al. Rehabilita"on
in the wake of Covid19 A phoenix from the ashes. Bri"sh Society of
Rehabilita"on Medicine. Issue 1. 2020. (h&ps://www.bsrm.org.uk/).
11.World Health Organiza"on. Clinical management of COVID19.
Management of Pa"ents with Lung Impairment A'er COVID19 Illness.
12.COVID19 Rehabilita"on Outpa"ent Specialized Services (CROSS)
Pandemic Calamity Response. Malaysian Medical Associa"on Newsle&er
Feb 2021; Volume 51; No 2: 2829.
13.Post COVID19 Pulmonary Rehabilita"on Protocol, Rehabilita"on Medicine
Department, Hospital Queen Elizabeth Sabah.
14.World Health Organiza"on. Support for Rehabilita"on SelfManagement
a'er COVID19 Related Illness.
15.Maltais F, Bourbeau J, Stan Shapiro S et al.Effects of HomeBased
Pulmonary Rehabilita"on in Pa"ents with Chronic Obstruc"ve Pulmonary
Disease A Randomized Trial.Annals of Internal Medicine. Jan 2009;
149(12):86978.
16.Aytür YK, Köseoğlu BF, Taşkıran OO. Consensus Report. Pulmonary
Rehabilita"on Principles in SARSCOV2 Infec"on (COVID19): A Guideline
for the Acute and Subacute Rehabilita"on. Turkey Journal Physical
Medicine Rehabilita"on 2020;66(2):104120.
17.Alan J G, Marian U C. Best Prac"ce Guidelines For Cardiac Rehabilita"on
and Secondary Preven"on. Heart Research Centre. Department of Human
Services Victoria. April 1999.
18.MonterrosaCastro A, RedondoMendoza V, MercadoLara M. Psychosocial
Factors Associated with Symptoms of Generalized Anxiety Disorder in
General Prac""oners during the COVID19 pandemic. Journal of
Inves"ga"veMedicine 2020. 68(7), 12281234.
19.Ricci É.C, Dimov T, da Silva Cassais T, Dellbrügger A.P. Occupa"onal Therapy
in Brazil during the COVID19 Pandemic: Peer Support Groups as Mental
Health Interven"on Strategy. World Federa"on of Occupa"onalTherapists
Bulle"n 2020; 13.
CHAPTER 10
MANAGEMENT OF PSYCHOLOGICAL ISSUES IN
POST COVID19 INFECTION
1.0 Introduc"on
1.1 Pandemic COVID19 has been living a huge impact on the psychology
of the mass popula"on. It is not only in Malaysia but all over the world.
Till date, we are s"ll accumula"ng more data pertaining to the impact
to psychological wellbeing of the popula"on and at the same "me the
direct psychological impact to everyone affected by the illness itself. By
middle of March 2021, there were more than 300,000 were affected
by the illness and more than 1,200 have succumbed to it.
1.2 With these large number of survivors of the illness, we will start to see
the emergence of psychological effects of it directly or indirectly. During
the ini"al part of the pandemic, experts were discussing the impact
based on the knowledge of the psychological impacts during and post
disaster. However, we are more interested to know what will be the
direct sequelae of the illness to the survivor and how we can offer our
services to them.
1.3 There are 5 iden"fied mental health related issues that might lead to
mental health problem or mental illness. It is worth to discuss all these
one by one for us to gauge the management level and interven"on that
need to be introduced in order to op"mize the service that we
provided. In view of majority of the cases will end up in primary care
as their first point of contact post discharge, it is impera"ve for us to
make sure that there will be a guideline to help them managing or
referring the case accordingly.
1.4 These are 5 iden"fied domains of mental health issue Post COVID19:
5 DOMAINS OF MENTAL HEALTH ISSUES POST COVID19
Figure 10.1:
5 Domains of
Mental Health
Issues Post
COVID19
2.0 Trauma Related Issue
2.1 Trauma related issues associated with COVID19 occur in a spectrum

ranging from psychological distress to a more severe symptomatology
fulfilling the criteria of diagnosing a psychiatric disorder.
2.2 While some may be more resilient, others might be more vulnerable
due to mul"ple factors such as gene"c factors, personality traits,
underlying co morbidi"es, psychosocial factors etc. Thus, early
recogni"on of symptoms is important in order to provide necessary
care.
A. Adjustment disorder
a. This pandemic causes an unprecedented impact on the economy,

health, social and poli"cal sectors worldwide. The majority are
not ‘threatened’ per se by this illness like in posttrauma"c stress
disorder, but experience a huge life stressor due to financial
insecuri"es, social restric"on, future uncertain"es etc., which
some may present with significant emo"onal or behavioural
symptoms.
b. According to DSM5, to diagnose adjustment disorder, there has

to be distressing symptoms which are out of propor"on to the
severity and intensity of the stressor which occur within 3 months
of the onset of stressor. It also causes impairment in func"oning.
The symptoms resolve within 6 months a'er the stressor, or its
consequences have ceased.
c. Psychological interven"on is the treatment of choice and should

be tailored to the pa"ent. For example, providing suppor"ve
psychotherapy by enhancing coping and problemsolving skills to
deal with life stressors, behaviour approaches to manage
maladap"ve behaviour etc. Medica"on may be prescribed to
alleviate symptoms.
d. Pa"ents should be referred to a psychiatric unit when there is

presence of suicidality, causes significant impairment in func"on
or diagnosis of a more severe psychiatric disorder is suspected.
B. Posttrauma"c stress disorder (PTSD) & acute stress disorder (ASD)
a. Looking at past infec"ous disease outbreaks (Middle East

respiratory syndrome (MERS) & severe acute respiratory
syndrome (SARS), there would be increased prevalence of post
trauma"c stress symptoms and posttrauma"c stress disorder
(PTSD) among COVID19 survivors. Current available data on
prevalence of PTSD symptoms in MERS outbreak were 36%, SARS
18% and COVID1919 9%. Among those, healthcare workers had
the highest prevalence, followed by infected cases, and the
general public.
b. Extreme stressors associated with COVID19 include treatment of

the disease (e.g., fear of death from lifethreatening illness, pain
from medical interven"ons such as endotracheal intuba"on,
limited ability to communicate, and feelings of loss of control),
witnessing severe illness or death of close family members.
c. Diagnosing PTSD (based on DSM5) requires:
i. Exposure to the threat

ii. Having intrusive symptoms (e.g., distressing memories/
dreams/ having flashbacks/ psychological distress or
marked reac"ons when exposed to cues)
iii. Avoidance of s"muli associated with the trauma"c event
(distressing memories, thoughts, or feelings/ external
reminders)
iv. Nega"ve altera"ons in cogni"ons and mood (e.g.,
dissocia"ve reac"ons/ exaggerated nega"ve beliefs/
persistent nega"ve emo"ons/ marked reduced in interest/
feelings of detachment/ inability to experience posi"ve
emo"ons)
v. Marked altera"on in arousal and reac"vity (irritability/
recklessness/ hypervigilance/ exaggerated startle response/
poor concentra"on/ sleep disturbance)
d. These symptoms were present at least for a month and cause

significant distress and impairment in func"oning.
e. Meanwhile, acute stress disorder (ASD) is diagnosed when

symptoms were present between 3 days to 1 month post
trauma"c event exposure.
f. Risk factors which may contribute to increased risk of developing

PTSD and chronic psychological distress:
i. Sociodemographic factors (e.g., gender female, age – older

adults)
ii. Exposurerelated factors (e.g., living in highly affected areas,
knowing, or having a close rela"onship with someone
infected with COVID19, becoming infected with COVID19,
being quaran"ned, or hospitalized for COVID19, and
working on the front line of the COVID19 pandemic)
iii. Loss of a loved one
iv. Pandemicrelated worries and stressors (e.g., fear of being
infected, concerns about family members’ health and safety,
financial losses, job loss, housing problems, social isola"on,
and lack of support)
g. In addi"on, some popula"ons, such as individuals with certain

disabili"es may experience unique challenges.
h. It is important to have a high index of suspicion to be able to

detect the symptoms early and referral should be made to a
psychiatric unit for a formal evalua"on and early interven"on.
Treatment consists of traumabased psychotherapy and/or
pharmacotherapy i.e., selec"ve serotonin reuptake inhibitors or
serotonin norepinephrine reuptake inhibitors.
3.0 Grief & Loss
3.1 Assessment can be based on the 5 stages of grief by Kubler Ross, it is

an objec"ve assessment of grief stages that can be used especially
when none of the psychiatric diagnosis criteria can be fulfilled during
ini"al assessment at primary care. What are the stages?
a. Denial: Pa"ent will experience a mixture of emo"on and behavior

such as avoidance behavior of treatment and follow up, confusion
of situa"on, inappropriately elated, shock and fear
b. Anger: Frustrated pa"ent, easily irritated and anxious
c. Bargaining: Struggling to find meaning and reaching out to others
d. Depression: Overwhelmed and helpless
e. Acceptance: Exploring op"ons to move forward
3.2 Grief and loss can be managed by counsellors who are trained in grief
work or a clinical psychologist where available. To refer to these 2
services in ter"ary centers, it must be done thru the psychiatry clinic
and need to be discussed with psychiatrist of the respec"ve hospital.
4.0 Underlying Mental Health Issues
4.1 There is pa"ent under primary care follow up and there will be pa"ent
who come to primary care for other issues but has underlying mental
illness which was previously stabile. The main concern in this cohort of
the pa"ent is the emergence of relapse symptoms that can be triggered
by many reasons including nonadherence to psychiatry medica"on
during quaran"ne or admission, the use of steroid that might increase
risk of relapse or emergence of new psychiatric symptoms or
neurological sequelae of COVID19.
4.2 Management of relapses can be managed as usual unless there are

suspicion of other coexist or comorbid issues.
5.0 S"gma & Isola"on
5.1 Infec"ous diseases are known to bring about s"gma an a&ribute

linking a person to a set of nega"ve or undesirable characteris"cs,
leading them to be prejudiced or discriminated against9. In this context,
people are labelled, stereotyped, discriminated against, treated
separately, and/or experience loss of status because of a perceived link
with a disease (e.g., COVID19)10. The psychological sequelae of
COVID19 commonly seen in COVID19 survivors, health care workers
and other frontliners include grief, fear, depression, anxiety, post
trauma"c stress disorder and s"gma, 11,12. S"gma or ‘Hidden threats’
in the form of fear of seeking medical care would lead to
underrepor"ng and under tes"ng of cases, compromising efforts to
provide effec"ve health care, thus increasing the spread, morbidity and
mortality of COVID19 cases 12,13.
5.2 Why is there Social S"gma?
Due to reports of COVID19 being associated with severe morbidity and

mortality, there is a fear of being infected or being in contact with those
poten"ally affected 10,11. Studies have found that misinforma"on,
false news and rumors related to COVID19 circula"ng through social
media caused unfounded fears and confusion amongst the people14.
5.3 Approaches in Comba"ng S"gma
Several approach can be done by the Family Medicine Specialists (FMS)

and people from various agencies to combat this.
5.4 COVID19 survivors
a. COVID19 survivors go through a different kind of loneliness and

isola"on a'er being quaran"ned and recovering from COVID
1915. These survivors are at "mes accused of being negligent and
ignorant, thereby held responsible for contrac"ng the virus,

causing them to discriminated by society16. People keep their
distance from them in fear of contrac"ng the infec"on from
them15.
b. The issues that are commonly seen among the survivors are17,
confusion about COVID19 informa"on and its vague prognosis,
the fear of imminent mortality, the psychological distress in
isola"on (dull isola"on days), psychological problems among
family members, the psychological burden of being a carrier and
fear of transmi$ng the disease or being rejected16.
c. Screening these survivors for grief, depression and anxiety would

be of benefit. Using screening tools like the Depression Anxiety
Stress Scale 21 (DASS21) would be useful to assess the current
condi"on of the survivor. Allow these people to speak about their
feelings by providing them a safe space and "me when talking
about their feelings14. Monitor their emo"onal states regularly.
Assure them that their feelings are a normal reac"on to adversity
and uncertain"es14. At all "mes, confiden"ality must be
maintained.
d. Psychological interven"ons like grounding, relaxa"on techniques

and mindfulness would help these pa"ents concentrate on being
in the present (‘here and now’).
e. Peer emo"onal groups, psychological support, counselling or

social engagement would proof beneficial and helpful14. COVID
19 survivors can share their experiences and issues with the
public. S"gma can be reduced by highligh"ng and praising
survivors who adhere to the government protocol. By educa"ng
the public, s"gma and discrimina"on towards these survivors can
be reduced.
f. However, if these survivors do not improve, they should be guided

to seek help from counsellors or the Mental Health and
Psychological Support Services (MHPSS), a hotline that delivers
psychosocial services available to everyone14.
5.5 Advocate for COVID19 survivors10
a. Awareness through all forms media pla)orm should be done with

cau"on without increasing fear. For example: Use appropriate
terms like COVID19 or people who may have COVID19, speak
accurately about the risk of COVID19 using evidencebased
research and talk posi"vely while emphasizing the effec"veness
of preven"on and treatment measures
b. Encourage responsible handling of informa"on via social media

while challenging myths and stereotypes
c. Providing emo"onal support to affected people during different

stages of isola"on/treatment can help them overcome the
psychological impact of s"gma
5.6 There is no health without mental health. Therefore, if the

individual needs further assistance with regards to mental health,
it is impera"ve that said individual be referred to the nearest
psychiatric department for further assessment and treatment.
6.0 Emergence of Mental Health Disorder
6.1 Anxiety Disorders (Generalized Anxiety Disorder, Panic Disorder, Specific

Phobia)
The diagnos"c criteria of the said diagnoses are not changed despite
its onset are post COVID19 infec"on. However, working diagnoses of
the said disorders should be enough to trigger the management of the
pa"ent.
6.2 Soma"c Symptoms & Related Disorders (Soma"c Symptoms Disorder,

Illness Anxiety Disorders, PFAOMC)
a. These are a set of mental disorders that is not familiar in primary

care and usually diagnosed in consulta"on liaison (CL) se$ng. In
view of limited numbers of CL psychiatrist in Malaysia, the
diagnosis and management of the illnesses can be done with the
local psychiatrist. Diagnoses and managements are more
complicated.
b. The diagnoses are usually related to and will influence pa"ent

behavior towards treatment, adherence and possible disease
complica"on
6.3 Major Depressive Disorders
a. This is one of the iden"fied mental illness post COVID19 with

more data emerged from other countries. The management is the
same as per Clinical Prac"ce Guideline of Major Depressive
Disorder that is available. There is new recommenda"on for
managing Post COVID19 depression and this can be discussed
with the psychiatrist
6.4 Neuropsychiatric Sequelae of COVID19
a. Central Nervous System manifesta"on of COVID19 can be debilita"ng

with possible short and longterm neuropsychiatric sequelae. Among
the iden"fied CNS manifesta"on are headache and dizziness,
cerebrovascular events, meningoencephali"s and encephalopathy and
seizures.
b. These sequelae might end up with mul"ple psychological and

behavioral manifesta"on that needs psychiatric interven"on in short
term or long term. These cohort of pa"ents need to be referred to
psychiatry based on several red flags in order for us to not miss anything
during regular follow up in primary care. What are the red flags?
c. History of intensive care unit admission and/or prolonged ven"la"on
d. History of delirium/ disorganized behavior/psychosis
e. Cogni"ve issues including poor memory and concentra"on Post COVID

19 infec"on
7.0 Psychiatry condi"ons that require Psychiatry Referral
Pa"ent may present to primary care facili"es with nonspecific psychological and/or
behavioral issues. The symptoms may or may not fulfil any specific psychiatric
diagnosis but it is very important to discuss with the nearest psychiatrist in order
to stra"fy care and management of the pa"ent as the following. However, pa"ents
who come with delirium or disorganised behaviour (red flag symptoms) require
urgent referral to the nearest hospital.
a. Prolonged and persistent mood and/or behavioral changes for more

than 2 weeks
b. History of intensive care unit admission and/or prolonged ven"la"on
c. Relapse of the underlying psychiatric disorder
d. Sleep disturbance: difficulty to ini"ate sleep, difficulty maintaining or
early morning awakening
e. Cogni"ve issues including poor memory and concentra"on in non
geriatric popula"on
f. Background history of steroid use during COVID19 management
References:
1. Roy D, Ghosh R, Dubey S, Dubey MJ, BenitoLeón J, Kan" Ray B.

Neurological and Neuropsychiatric Impacts of COVID1919 Pandemic. Can
J Neurol Sci. 2021;48(1):924. doi:10.1017/cjn.2020.173
2. American Psychiatric Associa"on (2013) Diagnos"c and sta"s"cal manual
of mental disorders (5th edi"on). American Psychiatric Publishing.
3. Erin T. Kaseda & Andrew J. Levine (2020) Posttrauma"c stress disorder: A
differen"al diagnos"c considera"on for COVID1919 survivors, The Clinical
Neuropsychologist, 34:78, 14981514, DOI:
10.1080/13854046.2020.1811894
4. Evaldas Kazlauskas & Soledad Quero. Adjustment and Coronavirus: How to
Prepare for COVID1919 Pandemic Related Adjustment Disorder
Worldwide? Psychological Trauma: Theory, Research, Prac"ce, and Policy.
2020, Vol. 12, No. S1, S22–S24. h&p://dx.doi.org/10.1037/tra0000706
5. Güler Boyraz & Dominique N. Legros (2020) Coronavirus Disease (COVID
1919) and Trauma"c Stress: Probable Risk Factors and Correlates of
Pos&rauma"c Stress Disorder, Journal of Loss and Trauma, 25:67, 503522,
DOI: 10.1080/15325024.2020.1763556
6. Mona Salehi, Man Amanat, Mohammadreza Mohammadi, Maryam
Salmanian, Nima Rezaei, Amene Saghazadeh, Amir Garakani (2021) The
prevalence of posttrauma"c stress disorder related symptoms in
Coronavirus outbreaks: A systema"creview and metaanalysis.
h&ps://doi.org/10.1016/j.jad .2020.12.188
7. Yuan et al (2021) Prevalence of pos&rauma"c stress disorder a'er
infec"ous disease pandemics in the twentyfirst century, including COVID
1919: a metaanalysis and systema"c review. Molecular Psychiatry
8. h&ps://doi.org/10.1038/s4138002101036x
9. Mak WW, Cheung F, Woo J, Lee D, Li P, Chan KS, Tam CM. A compara"ve
study of the s"gma associated with infec"ous diseases (SARS, AIDS, TB).
Hong Kong Med J. 2009; 15:347.
10.World Health Organiza"on. A guide to preven"ng and addressing social
s"gma associated with COVID1919. Retrieved from (20th March 2021) :
h&ps://www.who.int/publica"ons/m/item/aguidetopreven"ngand
addressingsocials"gmaassociatedwithCOVID1919
11.Yau EK, Ping NP, Shoesmith WD, James S, Hadi NM, Loo JL. The behaviour
changes in response to COVID1919 pandemic within Malaysia. The
Malaysian Journal of Medical Sciences: MJMS. 2020 Mar;27(2):45.
12.Lau H, Khosrawipour T, Kocbach P, Ichii H, Bania J, Khosrawipour V.
Evalua"ng the massive underrepor"ng and undertes"ng of COVID1919
cases in mul"ple global epicenters. Pulmonology. 2021 Mar 1;27(2):1105.
13.Abdelhafiz AS, Alorabi M. Social s"gma: the hidden threat of COVID1919.
Fron"ers in public health. 2020;8.
14.Gao J, Zheng P, Jia Y, Chen H, Mao Y, Chen S, Wang Y, Fu H, Dai J. Mental
health problems and social media exposure during COVID1919 outbreak.
Plos one. 2020 Apr 16;15(4): e0231924.
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discrimina"on. Retrieved from (20th March 2021):
h&ps://www.nst.com.my/news/na"on/2021/02/667544/malaysiasex
COVID1919pa"entsgrapples"gmadiscrimina"on
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COVID1919 pandemic. Fron"ers in Public Health. 2020; 8:829.
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Appendix 1
POST COVID19 (CATEGORY 4 AND 5) MANAGEMENT FLOW CHART AT

HOSPITALS/INSTITUTIONS
Category 4 and 5 Post

COVID19 Pa"ent
Teleconsulta"on at 2
weeks (for the need of
earlier review)
Referral by appointment at
4 weeks
Post COVID19 Clinic

(PC19 Clinic)
Assessment and Inves"ga"on

1. Comprehensive clinical history
2. Appropriate examina"on
3. Appropriate inves"ga"on
• Look for presence

of Red Flag Manage accordingly
symptoms and
manage accordingly (Refer respec"ve sec"on for
• Refer to hospital if management)
indicated
1. Breathlessness or
hypoxia
2. Syncope Con"nue management and
3. Unexplained chest
pain palpita"ons or
assessment
arrhythmias
4. Delirium, or focal
neurological signs
or symptoms.
5. Persistent fever / No
gastrointes"nal Residual medical
symptoms impairment or physical Discharge
6. Mul"system
inflammatory disability?
syndrome (in
children) Yes
Appendix 2
MANAGEMENT FLOW CHART FOR WALKIN POST COVID19 PATIENTS
Post COVID19 Pa"ent

(any category)
Walkin to Emergency and Trauma

Department (ETD) or Primary Care
*Presence of NO
Manage
Red Flags symptoms?
accordingly
YES
Stabilize pa"ent
NO
Pa"ent requires
Refer Appendix 1 hospital admission?
• Look for presence YES

of Red Flag
symptoms and
manage accordingly Admit for further
• Refer to hospital if
indicated
management
1. Breathlessness or
hypoxia
2. Syncope
3. Unexplained chest Follow up at Post COVID19 Clinic:
pain palpita"ons or
arrhythmias
4. Delirium, or focal • For pa"ents with appointment
neurological signs
or symptoms.
date
5. Persistent fever / • Refer if no appointment date
gastrointes"nal and if necessary
symptoms
6. Mul"system
inflammatory
syndrome (in
children)
Appendix 3
Appendix 4
MINISTRY OF HEALTH MALAYSIA

POST COVID19 REFERRAL LETTER/ SURAT RUJUKAN POST COVID19
1. NAME/ NAMA: 2. AGE/ UMUR:
3. IC NO. / PASSPORT/NO. KP: 4. GENDER/ JANTINA:
5. PHONE NO/ NO. TEL: 6. RN:
7. DATE OF ADMISSION/TARIKH 8. DATE OF DISCHARGE /TARIKH

KEMASUKAN: DISCAJ:
9. NOTES FOR REFERRAL / NOTA RUJUKAN
10. FINAL DIAGNOSIS/ DIAGNOSA AKHIR:
Highest Category: Please circle CAT 1/ CAT 2 / CAT 3 / CAT 4/ CAT 5
Comorbid:
Complica"ons:
Discharge medica"on:
Date of Posi"ve Swab Taken:
Date of 1st Symptoms /onset, if any:

1. RELEVANT INVESTIGATION RESULTS/ KEPUTUSAN UJIAN YANG BERKAITAN

(*please a&ached recent relevant results)
2. LATEST RADIOLOGICAL FINDINGS / KEPUTUSAN RADIOLOGI TERBARU

a. Date:
b. Findings:
3. LAST DATE OF QUARANTINE / TARIKH AKHIR KUARANTIN: ______________

( ) Home Quaran"ne ( ) Healthcare facility
14. DETAILS OF ATTENDING PHYSICIAN/ BUTIRAN PEGAWAI PERUBATAN
Signature/Tandatangan: _____________________________________________
Name of A&ending Physician/Nama Pegawai Perubatan: ___________________

Official Stamp/ Cop Rasmi:
Referral Facility / Fasili" yang Merujuk: __________________________________
Date/ Tarikh: _______________________________________________________

Appendix 5
CLERKING SHEET FOR POST COVID19 PATIENTs

Protocolo Post-Covid Malasia 2021

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Protocolo Post-Covid Malasia 2021

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1st Edition 2021

Tan Sri Dato’ Seri Dr Noor Hisham Abdullah

Dato’ Dr Norhizan Ismail

Datuk Dr Chong Chee Keong

Datuk Dr Hishamshah Mohd Ibrahim

Dr Ahmad Razid Salleh

Datuk Dr Norhaya" Rusli

Da"n Seri Dr Asmah Samat

Dr Nazrila Hairizan Nasir

Dr Nor’Aishah Abu Bakar

Dato’ Dr Mahiran Mustafa Dr Thahira A Jamal Mohamed

Dr Nor Zaila Zaidan Dr Elizabeth Chong Gar Mit

Dr Suraya Amir Husin

Dr Shahanizan Mohd Zin

Dr Nor Farah Bakh"ar

Dr Sara Sofia Yahya

Che Liza Che Abdullah

Chung Yun Mui @ Suzanna

Content: Chapters viii

List of Figures xii

List of Abbrevia"ons xiv

General Post COVID­19 Management 1

Post COVID­19 Management Protocol In Primary Care 14

Organizing Pneumonia In COVID­19 54

Post COVID­19 Management Protocol For 62

Post COVID­19 Management Protocol For 75

Post COVID­19 Management And Protocol In 91

Post COVID­19 Follow Up Rehabilita"on 106

Management Of Psychological Issues In 144

Table 1.1 COVID­19 infec"on further classified into clinical categories 2

ABG Arterial blood gas

CR2 Complete Remission 2

ILD Inters""al lung disease

PPE Protec"ve Personal Equipment

1.1 Coronavirus disease 2019 (COVID­19) is an infec"ous disease caused by

1.2 COVID­19 pandemic has resulted in a growing popula"on of individuals

1.3 Although the evidence base is limited, accumula"ng observa"onal data

This guidance is to ensure that pa"ents are followed up in a "mely manner

4.1 This guideline provides a pla)orm for a comprehensive and coordinated

4.2 It makes recommenda"ons about care in all healthcare se$ngs for

5.0 Opera"onal defini"ons

5.1 Case defini"ons

To eﬀec"vely diagnose, treat and manage a condi"on it needs to be

b. Ongoing symptoma"c COVID­19:

c. Post COVID­19 syndrome:

5.2 Follow­up loca"ons

a. Hospitals (preferably with specialist)

6.0 Symptoms of Post COVID­19 pa"ents

6.3 Meanwhile, of the 745 survivors a&ended physical review a'er 12

6.4 When assessing any pa"ent, it is important to have an awareness of

Organs aﬀected Sequelae

Organs aﬀected Sequelae

Organs aﬀected Sequelae

Less common symptoms include:

7.1 Assessment of Post COVID­19 pa"ents is as following:

a. All Category 4 and 5 of COVID­19 cases will be followed­up and

up (refer flow chart: Appendix 1) using recommended referral

b. Other categories of COVID­19 cases can be referred to Primary

c. Pa"ents with red­flag symptoms should be assessed and

7.2 Use a holis"c, person­centered approach to assess all cases. This

7.3 Include this point in the comprehensive clinical history2,4,8,9,10,11:

a. History of suspected or confirmed acute COVID­19.

b. The nature and severity of other health condi"ons and current

c. Timing and dura"on of symptoms since the start of acute COVID­

General Post COVID19 Management 1

Post COVID19 Management Protocol In Primary Care 14

Organizing Pneumonia In COVID19 54

Post COVID19 Management Protocol For 62

Post COVID19 Management Protocol For 75

Post COVID19 Management And Protocol In 91

Post COVID19 Follow Up Rehabilita"on 106

Table 1.1 COVID19 infec"on further classified into clinical categories 2

1.1 Coronavirus disease 2019 (COVID19) is an infec"ous disease caused by

1.2 COVID19 pandemic has resulted in a growing popula"on of individuals

b. Ongoing symptoma"c COVID19:

c. Post COVID19 syndrome:

5.2 Followup loca"ons

6.0 Symptoms of Post COVID19 pa"ents

7.1 Assessment of Post COVID19 pa"ents is as following:

a. All Category 4 and 5 of COVID19 cases will be followedup and

b. Other categories of COVID19 cases can be referred to Primary

c. Pa"ents with redflag symptoms should be assessed and

7.2 Use a holis"c, personcentered approach to assess all cases. This

a. History of suspected or confirmed acute COVID19.

c. Timing and dura"on of symptoms since the start of acute COVID

b. Be aware that people can have wideranging and fluctua"ng

f. Do not predict whether a person is likely to develop Post COVID

8.0 Iden"fy phases of Post COVID19 cases

Iden"fy the phases of Post COVID19 pa"ents (refer 5.0) to eﬀec"vely

10.1 Give advice and informa"on on selfmanagement to people with

e. Informa"on about new or con"nuing symptoms of COVID19 that

10.5 Pa"ent who developed Post COVID19 complica"ons will be referred

c. Considera"on for induc"on of diabetes remission in newonset

e. Eﬀec"ve screening and monitoring to detect diabetesrelated

d. Headaches, lowgrade fever and myalgia:

Pa"ent should be assessed for the improvement of Post COVID19 complica"ons.

1. Flow Chart of Post COVID19 Management at Ter"ary Centre (Category

2. Flow Chart of Post COVID19 Management for Walk in Cases

3. Discharge Note for COVID19 Pa"ents

4. Referral Le&er for Post COVID19 Pa"ents

5. Clerking Sheet for Post COVID19 Pa"ents

1. Clinical Management for confirm COVID19 in Adult and Pediatric: COVID

3.1 Post COVID19 pa"ents may be symptoma"c or asymptoma"c of

3.2 Symptoma"c Post COVID19 pa"ents may have new, ongoing or

*A cutoﬀ score 3 or more is posi"ve

DEPRESSION ANXIETY STRESS SCALE21 (DASS21)

Date Name________

• Assess pa"ent’s condi"on Post COVID19 infec"on by comparing with