Managing post-Covid complications essential

It is more than two years that the world saw the emergence of the Covid-19 pandemic, a hundred years after the Spanish flu had afflicted mankind. Like other countries, India has gone through recurrent waves due to different variants of the SARS-CoV-2 virus, with the Delta variant being the most lethal. There are reports of occurrence of new cases in many countries even now, attributed to a hybrid of Delta and Omicron. There does remain a likelihood of another wave in India too, but hopefully, with widespread vaccination, we could be spared of last year’s ravages.

Moreover, 40 per cent of those treated with oxygen support, complained of long-hauler symptoms. Women are twice more likely to report long Covid symptoms. Individuals with co-morbidities also have more ‘long Covid’. On the other hand, vaccinated individuals are reported to develop ‘long Covid’ less frequently than those who are unvaccinated.

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Patients with acute illness due to SARS-CoV-2 virus commonly develop symptoms 4-5 days after exposure. These symptoms include fever, throat pain, cough, body ache, loss of taste or smell and diarrhoea. Typically, recovery occurs within 7-10 days after the onset of symptoms in mild disease; it could take 3-6 weeks in severe/critical illness. However, one or more symptoms persist in a substantial percentage of people, even weeks or months after acute infection. “Long Covid” is a term used to describe such symptoms. It is also called “post-Covid syndrome”. It can be continuous or relapsing and remitting in nature.

The term “long Covid” was first used on social media to denote the persistence of symptoms weeks or months after the initial SARS-CoV-2 infection and the term ‘long-haulers’ was used by preschool teacher Amy Watson and science journalist Ed Yong.

“Post-acute Covid-19”, “Persistent Covid-19 symptoms”, “Post Covid-19 manifestations”, “Long-term Covid-19 effects” and “Post Covid-19 syndrome” are the other terms used by different people to describe the same. A majority of the people with post-Covid syndrome are PCR negative, indicating microbiological recovery. Depending upon the duration of symptoms, post Covid or long Covid can be divided into two stages: “post acute Covid” where symptoms extend beyond three weeks, but less than 12 weeks, and “chronic Covid” where symptoms extend beyond 12 weeks.

It has been reported that 50-80% of Covid survivors may have long-term symptoms for a variable period of time, some of them may be troublesome and affect the quality of life. Over 50 such symptoms have been identified with persistent fatigue being the commonest, followed by headache, lack of concentration, loss of smell or taste, difficulty in breathing and cough. Some patients have brain fog, sleep disturbances, chest discomfort, digestive problems, hair loss, weight loss and memory loss. Patients with lung involvement can have resultant fibrosis, limiting their effort tolerance. There are instances of lung abscesses getting complicated by bleeding.

Cardiovascular sequelae not only occur in symptomatic Covid patients but have also been reported in asymptomatic patients. Up to 20-30% of patients hospitalised with severe Covid have evidence of myocardial involvement. Long-term effects include increased cardio-metabolic demands, myocardial fibrosis or myocardial scar, persistent left ventricular dysfunction, heart failure, arrhythmias and autonomic dysfunction. Chest pain, shortness of breath and fatigue are frequent aftermaths in such patients. One of the great concerns of long Covid is its mental health consequences, such as depression, stress, anxiety and sleep disorders. The survivors are also at risk of chronic fatigue syndrome, post-traumatic stress disorder (PTSD), substance/drug abuse and a feeling of living with uncertainty, helplessness and fear, particularly over whether or not recovery is possible. Those who have endured difficulties in procuring hospital beds or drugs or have undergone the stress of being treated in crowded ICUs can have long-lasting effect on their minds. Some individuals develop thromboembolic complications during or after Covid infection, resulting in stroke or heart attack generating a debate on the need for prophylactic use of anticoagulants.

Development of diabetes after the coronavirus disease is another concern. Cases of new Type 2 diabetes being diagnosed have also been reported in people who have had Covid. This could be related to the effects of the virus on the pancreas, or the effects of drugs like steroids. Another theory suggests that when coronavirus infects the pancreas, it could trigger the immune system to attack and destroy the insulin producing beta cells, a key feature of Type 1 diabetes. Post Covid, control of diabetes also becomes erratic in some. Renal complications can also compound long Covid. Severe Covid disease with manifest organ dysfunction can in the long run, be complicated by residual disease or aggravation of pre-existing diseases like diabetes, chronic obstructive pulmonary disease or chronic renal disease.

Studies have found that individuals with severe cases, who were treated with immunosuppressant drugs, complained of long Covid symptoms, six times more than those who did not have severe disease. Moreover, 40 per cent of those who were treated with oxygen support, complained of long- hauler symptoms. Women are twice more likely to report long Covid symptoms. Individuals with co-morbidities like hypertension, obesity and diabetes mellitus also have more long Covid. On the other hand, vaccinated individuals are reported to develop long Covid less frequently than those who are unvaccinated. Moreover, even in individuals who have had Covid, vaccination helped prevent development of persistent symptoms.

Research into long Covid could unravel problems like blood clotting, myalgic encephalomyelitis, chronic fatigue syndrome and other conditions associated with the virus. The Covid pandemic has also led to trans-border research and given impetus to newer preventive and therapeutic strategies. In contrast to decades of research needed to launch a new vaccine, the world saw a number of vaccines within a year of description of genomic structure of SARS-CoV-2. No product based on mRNA technology had ever been approved before 2020. But within two years, the success of mRNA jabs against Covid has paved the way for more research into this technology. For India as well, development of indigenous vaccines has been gratifying.

It is not yet exactly known how long does it take for some symptoms of “long Covid” to resolve. There could be some permanent structural damage as in lung fibrosis, or development of auto-immunity. Long-term follow-up studies would throw light on these. In the meantime, such patients need care. Since there may not always be objective evidence of disease many times, such persons fail to seek or get attention. Many such patients are told, “It’s in your head only” as some doctors are themselves not aware of the sequelae. The Ministry of Health and Family Welfare has to be complimented for issuing the National Comprehensive Guidelines for Management of Post-Covid Sequelae for doctors. There is also a need for more support groups like the India Covid Survivor Group for people with persistent symptoms.