COVID-19

In this guideline, we use the term “Long-COVID” to represent the spectrum of ongoing symptoms that impact people after an acute infection with the SARS CoV2 virus. This has also been referred to as “Post-COVID19 Syndrome” or “Long-haul COVID”.

In assessing pilots/air traffic controllers after COVID it is important to note the broad differential diagnosis and that Long COVID includes:

• Symptoms and signs that continue or develop eight or more weeks after acute COVID -19 infection and cannot be explained by an alternative diagnosis
• Symptoms and signs may affect several organ systems, occur in diverse patterns, and frequently get worse after physical or mental activity
• Symptoms and signs that may exacerbate pre-existing disease affecting organ systems.

Mild COVID disease may relapse and present as Long COVID, be significantly impactful and be exacerbated by stress, fatigue, and exercise. Please refer also to NICE guidelines.

Aeromedical Implications

Effect of aviation on condition

• Fatigue
• Sleep deprivation
• Increased cardiac workload during stressful phases of flight
• Hypoxic, hypobaric, low relative humidity flight environment
• Lowering of seizure risk threshold.

Effect of condition on aviation

• Overt incapacitation
  • Distracting pain
  • Acute shortness of breath
  • Syncope
  • Heart failure
  • Arrhythmia
  • Seizure
  • Sudden death
• Cognitive impairment “Brain fog”
• Mental Health including mood disorders newly acquired or exacerbated
• Post-traumatic stress disorder
• Fatigue
• Loss of sense of smell

Effect of treatment on aviation

• Neuropsychological impairment secondary to steroid treatment
• Side effects of medication such as protease inhibitors and other treatments

Risk Factors for Long COVID

• Age >65
• Immunocompromised
• Cardiovascular disease including hypertension
• Chronic lung disease including asthma
• Cancer
• Obesity
• Diabetes
• Chronic kidney disease
• Chronic liver disease
• Pregnancy

Approach to medical certification

Asymptomatic or mild initial COVID-19 illness (full recovery in 7 days, not hospitalised): return to normal duties with GP/DAME review

• This is not Long COVID
• Medical examiner (GP/DAME) should confirm absence of cardiac, respiratory, neurological or another organ involvement – please refer below and to NICE guidelines
• Reports and investigations will be dependent upon the medical history and results of any investigations. At the minimum the following should be undertaken:
  • Cardiorespiratory exam with normal vitals – BP, HR, SpO2 >95% in all cases
  • Neurological history and examination including:
    • evaluation for anosmia consideration of sense of smell – discussion regarding operational safety considerations and ability to reliably smell solvents, fumes and gasoline (JetA1) and consider appropriate testing if required.
    • assessment of cognitive function (MOCA, RUDAS, MMSE or TMT)
  • Consider the following tests:
    • Spirometry
    • ECG
    • Exertional pulse oximetry e.g. 1-min sit-to-stand test, 6-minute walk test where respiratory symptoms were prominent during the acute phase (please note exertional pulse oximetry should only be conducted where emergency medical care is immediately available)

Moderate to severe initial COVID-19 illness (symptomatic for longer than 7 days / Hospitalized) and /or confirmed Long COVID19 disease, or positive findings during “mild” workup: will require further assessment by DAME and referral to AvMed CASA

• Reports and investigations will be dependent upon the medical history and results of any investigations. At the minimum the following should be undertaken:
  • Cardiorespiratory exam to include vitals BP, HR, SpO2
  • Neurological history and examination including:
    • evaluation for anosmia consideration of sense of smell ability to reliably smell solvents, fumes and gasoline (JetA1) and consider appropriate testing if required.
    • assessment of cognitive function (MOCA, RUDAS, MMSE or TMT)
  • Office tests:
    • Resting ECG
    • Exertional pulse oximetry e.g. 1-min sit-to-stand test, 6-minute walk test (please note exertional pulse oximetry should only be conducted where emergency medical care is immediately available)
  • Referred tests:
    • Comprehensive lung function testing to include DLCO
    • Blood tests – Full blood count, kidney and liver function tests, C reactive protein
  • Further tests, as clinically indicated, may include:
    • Troponin (cTn I and T), B type natriuretic peptide (BNP) and thyroid function tests
    • Echocardiogram and/or Cardiac MRI (if cardiac dysfunction was suspected or present during the acute phase, or cardiac symptoms present in the Long COVID phase)

Refer people with ongoing symptomatic COVID-19 or suspected post-COVID-19 syndrome urgently to the relevant acute services if they have signs or symptoms that could be caused by an acute or life‑threatening complication, including (but not limited to):

• severe hypoxaemia or oxygen desaturation on exercise (decline of 3% or more from resting level)
• signs of severe respiratory compromise
• cardiac chest pain, sustained palpitations or presyncope
• multisystem inflammatory syndrome

Based on Treatment

• Acceptable, stable treatment without significant side effects

Demonstrated Disease-free status

• 4 weeks of no aviation-related duties with assessment at least at day 1 and day 28
• Examination on day 28 to assess for absence of symptoms / complications for the 4 weeks immediately preceding the examination

Risk assessment protocol - Information required

New applicants and recertification for current certificate-holders meeting definition Long COVID

CASA requires a report from the relevant specialist(s) - e.g., Infectious diseases physician, Respiratory physician, Cardiologist, Psychiatrist, depending on system involvement, symptoms, and findings of preliminary investigations. The report(s) should detail:

• Confirmed diagnosis
• Clinical status
  • Presence, severity, and impact of ongoing symptoms (such as breathlessness, pain, palpitations, neurological symptoms
• Progress up to the date of review, and prognosis in the short, medium and longer term
• Management
  • treatment
  • side-effects
• Proposed monitoring and follow-up plan. Please detail periodic investigations required

The investigations listed above under the approach to medical certification “Moderate to severe initial COVID-19 illness” must be less than 1 month old at the time of review for certification. Additionally, detailed investigation reports (for relevant affected organs and systems) may include:

• Respiratory:
  • high-resolution CT lungs
• Cardiac:
  • SARS-CoV-2 / COVID -19 infection is associated with direct and indirect cardiotoxicity. Individuals who experienced cardiac symptoms (e.g. dyspnoea, exercise intolerance, chest pain, palpitations, syncope, etc.) during acute illness may be at higher risk for underlying cardiac dysfunction and warrant further evaluation. Any exertional assessments must be performed in a controlled environment with emergency medical care immediately available.
    • 24 hour Holter
    • If clinically indicated, stress test
    • If clinically indicated, for postural symptoms, for example palpitations or dizziness on standing, carry out lying and standing blood pressure and heart rate recordings (3‑minute active stand test, or 10 minutes if you suspect postural tachycardia syndrome, or other forms of autonomic dysfunction). POTS is described with COVID.
• Neurological assessment
  • Neuropsychometric testing acceptable to CASA
  • EEG
• Mental Health
  • Psychiatrist and /or Psychologist report including assessment scales.

Indicative outcomes

• Initial notification to CASA and grounding until demonstrated stability and absence of symptoms or complications (see above demonstrated disease free status for moderate to severe COVID-19 )
• Unrestricted certification is possible if asymptomatic with absence of or low risk of significant impairment.

Favourable

• Absence of symptoms
• Absence of side-effects from treatment
• Absence of cardiac, respiratory, neuropsychological or other organ system involvement.

Unfavourable

• Ongoing symptoms or abnormalities in any of the testing
• Headache, seizure, motor or sensory nerve impairment, cognitive impairment
• SpO2 <95% at rest
• Oxygen desaturation on exercise (3% or more)
• Evidence of rhythm disturbance
• Significant abnormality on assessment of cardiac function.

Pilot and Controller Information

• Annual review will be required for a minimum of 2 years after diagnosis. Ongoing annual review after 2 years will be dependent upon extent of organ involvement and improvements in understanding the risks associated with this new disease.
• Multi-crew restriction may be required for pilots
• Treatment may impact the ability to exercise the privileges of your medical certificate.