The story so far Months after the first cases of COVID-19 were detected in the world outside China, concerns about persistent symptoms post infection cropped up. Systems were then set up to study this phenomenon and provide possible solutions to those suffering from sequalae related to their COVID infection. The Lancet’s May 11 publication (https://doi.org/10.1016/ S2213-2600(22)00126-6 ) has provided more grist to the mill for those calling for greater attention to Long COVID, establishing that the burden of symptomatic sequelae remained fairly high even two years after COVID. Pandemic survivors also had a remarkably lower health status than the general population at two years, it said.
What is long COVID?
With the ongoing COVID-19 pandemic, evidence showed that a considerable proportion of people who have recovered from COVID-19 continue to face long-term effects on multiple organs and systems. These sequelae have been noticed in people who did not exhibit any symptoms during their infection stage. In the absence of a universally-accepted definition, post-COVID Syndrome, by consensus, is defined as signs and symptoms that develop during or after an infection consistent with COVID-19 which continue for more than 12 weeks and are not explained by alternative diagnosis. Technically, post Covid defines symptoms that persist four weeks after infection and Long Covid, 12 weeks past a COVID-19 infection.
The effects range from skin rash, sleep difficulties fatigue or muscle weakness, hair loss, joint pain, palpitations, dizziness, cough, headache, sore throat, to chest pain, smell and taste disorders, anxiety disorders and mobility issues. The Lancet paper chronicled these and many more side effects, but only in patients who were hospitalised for COVID.
How long does long COVID last for?
The study, perhaps for the first time, described Long COVID for the longest time possible – two years. It characterises the longitudinal evolution of health outcomes in hospital survivors with different initial disease severity throughout the two years after an acute COVID-19 infection. A matched control group of adults without a COVID-19 infection were studied against patients who tested positive for SARS-CoV-2, and had been discharged from Jin Yin-tan Hospital in Wuhan, China, between January 7 and May 29, 2020. Health outcomes were measured at six months, 12 months and two years after symptom onset.
The study did note that the proportion of individuals with at least one sequelae symptom decreased significantly from 68% at six months to 55% at two years, (with fatigue or muscle weakness being the most frequently reported symptom throughout follow-up). The scene continued to improve in almost all domains, especially in terms of anxiety or depression, with the proportion of participants reporting symptoms of anxiety or depression dropping significantly from 23% at six months to 12% at two years. About 89 % of those who had been hospitalised for COVID had returned to their regular work at the end of two years. At the two-year follow-up, notably, long COVID symptoms were related to a decreased health-related quality of life and exercise capacity, psychological abnormality, and increased use of health care after discharge.
COVID-19 survivors still had more prevalent symptoms and more problems with pain or discomfort, as well as anxiety or depression, at two years, than did the control group, as per the study. Additionally, a significantly higher proportion of survivors who had received higher-level respiratory support during hospitalisation continued to have lung issues. The study findings indicate that there was an urgent need to explore the pathogenesis of Long COVID and develop effective interventions to reduce the risk of such side effects.
What is the status in India?
The government of India developed its own National Comprehensive Guidelines for the management of post-COVID sequelae. This document sets out detailed techniques to treat post-COVID complications affecting cardiovascular, gastrointestinal, nephrological, neurological and respiratory systems. Several hospitals, both government and private, set up COVID wards to treat persons who complain of what seemed like post-COVID symptoms.
In January 2022, Indraprastha Apollo Hospital, New Delhi, reported that people infected in the second wave of COVID have experienced four times more Long COVID conditions than those from the first wave. According to doctors at the hospital, people who contracted the virus in the second wave showed multiple symptoms including high grade fever, diarrhoea and severe lung infection. They added that even after a year of testing positive, the road to recovery for patients had been very difficult, with acute weakness and fatigue plaguing their everyday lives.
But, said Jacob John, senior virologist, formerly with the Christian Medical College, Vellore, there was very little evidence for Post Covid or Long Covid in India, “As far as I know, for some reason, we have not seen it so much in India,” he told this writer.
Chandrakanth Lahariya, epidemiologist and public policy and health systems specialist, said it appeared that both Post Covid and Long Covid had fewer numbers in India. “We need to remember,” he hastened to explain to this correspondent, “Post covid and Long Covid are realities. A small proportion of people will continue to have symptoms, beyond four weeks, and beyond 12 weeks.”
The broader principles of immunology – how the immune system works, how vaccination helps – are universal principles -- they worked the same way, largely, in any part of the world, Dr. Lahariya explained. This was not the same for Long Covid, because these were health conditions, and these need not necessarily be the same across the world.
“In the absence of the data, from India, it is difficult to say exactly what the situation is, we can only make inferences on empirical understanding. Long Covid is a reality, it is likely in all settings, but it is very possible that numbers will vary from setting to setting. The rates of Post Covid and Long Covid seem lower, in India, but only data can answer this confidently. We need a more systematic, robust study to generate such data, and we cannot base it merely on anecdotes or people visiting the health care facility.”
How should we prepare for the future?
Dr. Lahariya pointed out that in the last two years, the focus, quite naturally, was in taking care of people who were ill, and very little research, and therefore data, existed on Long Covid from a longitudinal basis (multiple engagements over a long period of time, as in the case of The Lancet paper). But since the world seems to be at the fag end of the pandemic, it is necessary for every health system to gear up to deliver both Post Covid and Long Covid services, irrespective of the number of people who might require them, he added.