Residual pandemic: After effects of COVID-19 pervasive in India, thousands living with new ailments

Around 40 per cent patients who recovered from the novel coronavirus disease (COVID-19) suffer from long COVID, according to a November 2021 study. Close to 3.4 million people in India have recovered from COVID-19 so far. 

Long COVID is extremely deadly and its aftereffects are still not documented. Compared to post-COVID, acute mortality contributes only a small share of total COVID-19 morbidity, according to a research paper published October 26, 2021 in the Journal of Clinical Epidemiology. 

“Healthy years lost per COVID-19 case ranged from 0.92 (male in his 30s) to 5.71 (girl under 10) and were 3.5 and 3.6 for the oldest females and males,” the paper stated. But India still does not track post-COVID-19 cases. There are a few small-sample studies that indicate its prevalence. 

In July 2021, a study on 990 COVID-19 patients from three hospitals in north India by Max Healthcare showed about 40 per cent of them suffered from at least one post-COVID-19 symptom for up to a year. The manifestation of post-COVID-19 complications in many patients is fourfold higher in the second wave compared to the first wave, found the study.

A random online survey by the Asian Institute of Gastroenterology (AIG), Hyderabad on 5,347 individuals (of which 2,038 infected patients responded) found that 41.8 per cent patients complained of persistent symptoms. These were fatigue (64.15 per cent), body pain (31 per cent) and gastrointestinal problems (25 per cent). 

It was found that fatigue, weakness and sleeplessness were reported not only in serious cases but also in mild cases. Around 51 per cent of those who had milder forms of the disease had also developed long COVID, according to the data.

One of Kerala’s leading environmentalists, Sridhar Radhakrishnan, tested positive for COVID-19 towards the end of January 2021 and recovered by February 7. He said: 

After recovery, my biggest challenge was brain fog. No post-COVID advice is given either by the hospital or the state’s health department. I had to Google and find the confirmation of my worries. 

Sridhar started experiencing leg pain and breathing problems by the end of July. Doctors found he had heart ailments and recommended angioplasty to remove the blockage. After angioplasty, his breathing problem and leg pain also vanished. “In the post-COVID situation, what you have to fight is the engulfing paranoia and draining self-confidence,” said Sridhar. “Mental health is the prime area to be focused on.”

In the 12 months till June 18, 2021, as many as 2,142 people have complained of psychological symptoms after recovery to doctors in Kerala, said Rajan Khobragade, principal secretary (health), Kerala. “Stress due to fear of contracting COVID-19 again is also high, leading to sleep disorders,” said Bipin Gopal, nodal officer, Non-Communicable Diseases, Kerala. 

The increasing numbers of deaths and fear of oxygen shortage add to the stress, the officer added. The Kerala government said post-COVID complications are increasing among children and adults in the state. Some symptoms may have existed in the patients before they contracted the infection, but in a majority of cases the symptoms started after COVID-19.

Kerala has directed setting up of separate post-COVID clinics in all healthcare facilities in mid-December 2021. The state’s health minister Veena George said one major post-COVID-19 challenge is the rise in cases of diabetes among the infected young people, who are either getting it for the first time or reporting early onset of the disease. 

Pre-COVID-19 studies show that diabetes in Kerala is as high as 20 per cent. The national average is 8 per cent. New-onset diabetes in COVID-19 patients might be due to plausible interaction of the virus with receptors in essential metabolic tissues, including the pancreas, small intestine and kidneys, according to doctors. 

Another possible factor is the indiscriminate use of steroids. The minister said separate committees have been formed at the district and state levels to manage post-COVID-19 clinics. Private hospitals have been advised to designate nodal officers for the same.

Across the state, 185,059 people have reached primary health centres, community health centres and family health centres, seeking post-COVID-19 services so far, said Khobragade. A total of 30,147 patients approached taluk hospitals, district hospitals and general hospitals, while 174,393 had used the telemedicine facility. 

The doctors at the clinics were given refresher training in May last year, while a sensitisation session was conducted earlier for Accredited Social Health Activists (ASHA) workers, since they interact more closely with patients.

P Krishna Prasanthi, a physician based in Tirupati, Andhra Pradesh, and also the chairperson of the Academy of Medical Specialities, Indian Medical Association, is overwhelmed with the number of long COVID patients. The major complications were diabetes, cardiac problems and extreme fatigues, she said. 

“Ten per cent people (from her treatment pool) fell sick and needed treatment in ICUs for a long time — three to four weeks,” she said. 

Prasanthi described how she heard the scary news of her patients dropping dead due to cardiac arrest. She said: 

Eighty per cent of the patients reported heart palpitations. ECG done on even those who were young showed abnormalities. Patients, who did not have high blood pressure, developed it. It would then stabilise in one or two months. Even heart rates stabilised but sugar levels persisted for six months. Ten per cent of the patients with high sugar levels became permanently diabetic. But in 80-90 per cent cases diabetes was reversed.

We still do not know whether it is the severity of the disease or their pre-existing complications, or some other factor, that is making a difference, she said. “We do not have answers to these questions.”

Alladi Mohan, head of the department of medicine at Sri Venkateswara Institute of Medical Sciences, Tirupati, warns that there is more to come since the behaviour of the virus and the disease is still not fully deciphered. He and his team treated some 12,498 moderate, severe and critical COVID-19 patients between April 2020 and November 2021. 

“Roughly 10 per cent had persistence of some symptoms after surviving COVID-19. We called all the patients to visit us once after three months, then at six months and then at one year to understand whether they were symptomatic or not,” he said. Nearly all the recovered patients reported persistent breathlessness and cough for up to three-five months. 

“Many reported fatigue, exhaustion, tiredness and postural autostatic hypertension syndrome, where they feel giddy, a feeling of being in the air,” Mohan said. According to this observation, 8-10 per cent of the patients reported paralysis, stroke, heart attacks and issues related to blood vessels getting blocked.

Complications unrelated?

In many cases doctors do not find any correlation between post-COVID-19 complications and the viral infection itself. Still, for COVID-19 recovered people, it is a life with new morbidities. 

Most of them say they have new health issues. Take the case of Sukanta Tripathy, a 55-year-old officer in the Odisha government. Tripathy has been struggling with a series of medical problems though his doctors say the complications are not connected to COVID-19.

Tripathy contracted COVID-19 in August 2020. After recovering, he developed severe weakness, fungal infection in his mouth and faced intermittent memory loss, which continued for months. 

Tripathy’s sugar levels rose from 110-115 mg/dL to 400-500 mg/dL even after taking insulin. It took a lot of medication to control the blood sugar level. A year later, on September 20, 2021, he suffered a brain stroke and remained in hospital for around 20 days. 

Now posted in Sambalpur as additional commissioner of consolidation and settlement, Tripathy said the fungal infection in his mouth was painful and lasted for a year. He survived on a diet of just sattu (powdered grains), grounded pakhal (watered rice) with lemon juice and Horlicks. He could not touch onion, chili, garlic, ginger, carrot, papad or any food that needed chewing. “Since I could not eat properly, it aggravated my weakness,” Tripathy said.

Though doctors treating him have ruled out a link between his current health condition and COVID-19, Tripathy believed otherwise and said his immune system, strength and stamina have been affected. “People know instinctively when health issues that were not present earlier appear after they get COVID-19. People are not uniformly affected,” he said.

There are also many cases in Odisha where children developed complications, though many were not infected with the virus. The complications included persistent fever and vomiting, the reasons for which are yet to be ascertained.

Some patients, who do not wish to be identified, said doctors told them COVID-19 acted as a trigger to make them more susceptible to the ailments. Some said they were told their liver infection was due to the side-effects of high doses of medicines.

Viral persistence

The novel coronavirus is barely two years old and its behaviour during and after the infection is still a subject of study. People with risk factors (high blood pressure, smoking, diabetes and obesity) and those without any comorbidity are reporting the same long COVID symptoms. 

It is also evident that long COVID patients have multi-organ complications. Does this mean patients have the novel coronavirus still circulating in their organs after the clinical recovery? Or, are the remains of the virus still in some organs, and the body’s immune system is fighting them, resulting in long COVID symptoms? This has led to many studies on this aspect, medically known as the ‘viral persistence’.

“SARS-CoV-2 is like a nuclear bomb in terms of the immune system. It just blows everything up,” Steven Deeks, a physician and infectious-disease researcher at the University of California, San Francisco, US, was quoted by the journal Nature in an article dated June 9, 2021. 

“Some of those changes might linger — as has been seen in the aftermath of other viral infections,” the article says. “It’s still early days. But we believe that long COVID-19 is not caused by one thing. That there are multiple diseases that are happening,” the article quoted Akiko Iwasaki, a professor of immunobiology at Yale University, US.

The world has seen viruses that offer some clues for long COVID. For instance, the genome of the novel coronavirus is made of RNA (not DNA) — just like the genome of the virus that causes Hepatitis C. Persistent Hepatitis C infection leads to liver disease and cancer, long after the infection. 

“Where there is long-term persistence, there can be long-term consequences,” said Mary F Kearney in a webinar in December 2021. Kearney is a scientist who studies HIV drug resistance at the National Cancer Institute’s Center for Cancer Research at the National Cancer Institute in Maryland, US.

A study by the University Hospital Frankfurt, Germany, published in JAMA Cardiology in July 2020, offers some insight into post-recovery health complications. It found that around 80 of the 100 patients whose cardiovascular MRIs were examined after they recovered from COVID-19, had some structural changes in their heart. 

It also found that the disease inflicted damage on the organ long after the patient had recovered and in cases where the infection was not even severe to begin with. MRIs of the 100 infected patients were compared with those who did not carry the infection two months after the first group recovered from the disease. 

Another study, also published in JAMA Cardiology in July 2020, analysed autopsy results of 39 people who died of COVID-19 and whose average age was 85. It found high levels of the virus in the hearts of 24 patients.

In an article dated July 31, 2021 published in The Conversation, William Petri, a physician-scientist researching COVID-19 at the University of Virginia, US, said that “an unanswered question is the extent to which the virus can ‘hide out’ in seemingly recovered individuals. If it does, could this explain some of the lingering symptoms of COVID-19 or pose a risk for transmission of infection to others even after recovery?”

Some studies indicate that the coronavirus causing COVID-19 could be found in places earlier considered safe. For instance, SARS-CoV-2 could infect the foetus via the placenta. It has also been found in the blood, the nasal cavity and palate for up to a month after infection.

“The mounting evidence suggests that SARS-CoV-2 can infect immune privileged sites and, from there, result in chronic persistent — but not latent — infections,” Petri wrote. 

K Srinath Reddy, president of the Public Health Foundation of India, a public-private initiative registered in Delhi, told DTE: We do not yet know how those who recover behave. The recent German study published in JAMA talks about heart infection post recovery, that too in young people. And this is just the beginning of our understanding. 

Assuming that all the patients, including asymptomatic ones, gain full recovery is not correct, he said.

The story is the second of a two-part series first published in the 1-15 January, 2022 print edition of DTE. Read the first part here

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