Managing essential post-Covid complications: The Tribune India


Rakesh Kochar


Former President, Indian Society of Gastroenterology

It has been more than two years since the world saw the emergence of the Covid-19 pandemic, a hundred years after the Spanish flu afflicted humanity. 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 deadliest. There are reports of new cases emerging in many countries even now attributed to a hybrid of Delta and Omicron. There also remains a chance of another wave in India, but hopefully with widespread vaccination we could be spared the ravages of last year.

Additionally, 40% of those treated with oxygen support complained of long-distance symptoms. Women are twice as likely to report long Covid symptoms. People with comorbidities also have more “long Covids”. On the other hand, vaccinated people would develop “long Covid” less frequently than those who are not vaccinated.

Patients with acute illness due to the SARS-CoV-2 virus typically develop symptoms 4-5 days after exposure. These symptoms include fever, sore throat, cough, body aches, loss of taste or smell, and diarrhea. Typically, recovery occurs within 7 to 10 days of the onset of symptoms of mild illness; this may 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 an 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 refer to the persistence of symptoms weeks or months after initial infection with SARS-CoV-2 and the term “long haul” 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 describe the same. A majority of people with post-Covid syndrome are PCR negative, indicating microbiological recovery. Depending on the duration of symptoms, post Covid or long Covid can be divided into two stages: “Acute post Covid” where the symptoms extend beyond three weeks, but less than 12 weeks, and “Chronic Covid” where the 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 these may be bothersome and affect quality of life. More than 50 of these symptoms have been identified, with persistent fatigue being the most common, followed by headaches, lack of concentration, loss of smell or taste, difficulty breathing and coughing. Some patients suffer from brain fog, trouble sleeping, chest discomfort, digestive problems, hair loss, weight loss, and memory loss. Patients with lung involvement may have resultant fibrosis, limiting their exercise tolerance. There are cases of lung abscesses that are complicated by bleeding.

Cardiovascular sequelae not only occur in symptomatic Covid patients but have also been reported in asymptomatic patients. Up to 20 to 30% of patients hospitalized with severe Covid show signs of myocardial damage. Long-term effects include increased cardio-metabolic demands, myocardial fibrosis or myocardial scarring, persistent left ventricular dysfunction, heart failure, arrhythmias, and autonomic dysfunction. Chest pain, shortness of breath and fatigue are common sequelae in these patients. One of the big concerns of the long Covid is its mental health consequences, such as depression, stress, anxiety and sleep disturbances. Survivors are also at risk for chronic fatigue syndrome, post-traumatic stress disorder (PTSD), substance abuse, and a sense of uncertainty, helplessness, and fear, particularly about whether recovery is possible or not. Those who have experienced difficulty obtaining hospital beds or medication or who have endured the stress of being treated in crowded intensive care units can have a lasting effect on their minds. Some individuals develop thromboembolic complications during or after Covid infection, resulting in stroke or heart attack generating debate about the need for prophylactic use of blood thinners.

Another concern is the development of diabetes after coronavirus disease. Cases of newly diagnosed type 2 diabetes have also been reported in people who have had Covid. It could be related to the effects of the virus on the pancreas or the effects of medications like steroids. Another theory suggests that when the coronavirus infects the pancreas, it could trigger the immune system to attack and destroy insulin-producing beta cells, a key feature of type 1 diabetes. Post Covid, diabetes control also becomes erratic in some. Kidney complications can also make long Covid worse. Severe Covid disease with overt organ dysfunction may, in the long term, be complicated by residual disease or worsening of pre-existing conditions such as diabetes, chronic obstructive pulmonary disease or chronic kidney disease.

Studies have shown that people with severe cases, who were treated with immunosuppressive drugs, complained of prolonged Covid symptoms, six times more than those without severe illness. Additionally, 40 percent of those who were treated with oxygen support complained of long-haul symptoms. Women are twice as likely to report long Covid symptoms. People with comorbidities like hypertension, obesity and diabetes mellitus also have longer Covid. On the other hand, vaccinated individuals would develop long Covid less frequently than those who are not vaccinated. In addition, even in people who have had Covid, vaccination has prevented the development of persistent symptoms.

Long Covid research could solve problems such as blood clotting, myalgic encephalomyelitis, chronic fatigue syndrome and other conditions associated with the virus. The Covid pandemic has also led to cross-border research and given impetus to new preventive and therapeutic strategies. Unlike the decades of research needed to launch a new vaccine, the world has seen a number of vaccines within a year of describing the genomic structure of SARS-CoV-2. No product based on mRNA technology had ever been approved before 2020. But in two years, the success of mRNA jabs against Covid has paved the way for more research into this technology. For India too, the development of indigenous vaccines has been rewarding.

It is not yet known exactly how long it takes for some “long Covid” symptoms to disappear. There could be permanent structural damage as in pulmonary fibrosis or the development of autoimmunity. Long-term follow-up studies would shed light on them. In the meantime, these patients need care. Since there is not always objective evidence of the disease, these people do not seek or get attention. Many of these patients are told: “It’s only in the head”, because some doctors themselves are not aware of the sequelae. The Department of Health and Family Welfare is to be commended for issuing the Comprehensive National Guidelines for the Management of Post-Covid Sequelae for Physicians. There is also a need to create more support groups like the India Covid Survivor Group for people with persistent symptoms.

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