Covid: No short solution to long term side effects

On the night of December 31, 2021, Sukumaran (82) from Kolathur developed a mild fever. It could be the chill weather, the fully vaccinated man told his family members when they pressed for a Covid-19 test. By dawn, he developed severe chills and fever. The chills were so intense that he thought he wouldn’t survive. “But, the chills and fever disappeared the next morning and I was just fine. It was just a one-day affair and I forgot about it soon,” Sukumaran said.

By end of February, the octogenarian felt a slight pain in his right inner thigh. Over the next few days, the pain spread to his lower hips and he could barely move. The orthopaedic surgeon he consulted, told him it could a case of muscle spasm or sprain, typical for that age, and prescribed standard painkillers and anti-inflammatory medication. Two weeks later, Sukumaran was back at the clinic with no relief from the pain although he was popping three pain killers every day for the past fifteen days. An MRI scan revealed that Sukumaran was suffering from avascular necrosis of the femoral head, a condition where the blood supply to the ball-and-socket joint had been cut off and needed hip replacement surgery.

Orthopaedic surgeon L Narayanan who treated Sukumaran immediately identified him as a consequence of Covid-19 as he had performed at least a dozen surgeries for patients of different ages over the last six months alone and all of them had recovered from Covid-19 within three months. Before the pandemic, he used to diagnose just one or two cases a year.

Among the dozens and dozens of symptoms associated with the post-Covid-19 condition also known as Long Covid, avascular necrosis is one of the less prevalent. The most common are dyspnea (breathlessness), fatigue, cough, muscle and joint pain, sleep problems, loss of smell or taste, low mood or depression, anxiety and brain fog (loss of the ability to think clearly). According to the John Hopkins Medicine Centre in the United States, some of the less common Long Covid symptoms are heart inflammation, kidney damage, Postural orthostatic tachycardia syndrome (POTS) and even post-Covid Diabetes have been identified.

While medical professionals across the world began to receive patients with all the above-mentioned ailments, as with every other development in the Coronavirus-triggered pandemic, there was no clear consensus. Following the overwhelming evidence presented to them, the WHO in October 2021 a clinical case definition of the Post Covid condition which is: Post COVID-19 condition occurs in individuals with a history of probable or confirmed SARS CoV-2 infection, usually 3 months from the onset of COVID-19 with symptoms and that last for at least 2 months and cannot be explained by an alternative diagnosis. Common symptoms include fatigue, shortness of breath, cognitive dysfunction but also others and generally have an impact on everyday functioning. Symptoms may be new-onset following initial recovery from an acute COVID-19 episode or persist from the initial illness. Symptoms may also fluctuate or relapse over time.’

Since then, several hundred studies have been conducted across the world to understand this Post Covid condition, technically known as post-acute sequelae SARS-CoV-2 Infection (PASC) or Long Covid. Most studies conclude that a large number of patients who suffered from Covid-19 have some form of Long Covid resulting in decreased health parameters.

A recent study published in the Lancet Journal titled ‘Health outcomes in people 2 years after surviving hospitalization with Covid: a longitudinal cohort study in May 2022 concluded that ‘regardless of initial disease severity, Covid survivors had longitudinal improvements in physical and mental health, with most returning to their original work within 2 years; however, the burden of symptomatic sequelae remained fairly high. Covid survivors had a remarkably lower health status than the general population at 2 years. The study findings indicate that there is an urgent need to explore the pathogenesis of long Covid and develop effective interventions to reduce the risk of long Covid.’

Doctors who have been treating patients in the post-Covid wards of government hospitals here concur that the health status of post-Covid-19 patients was considerably lower even in India and that domain-specific studies need to be conducted on whether vaccination helps with long Covid-19 or not.

Another study published again last month in the Annals of Internal Medicine journal on ‘A Longitudinal Study of Covid-19 Sequelae and Immunity: Baseline Findings’ also concluded that 'a high burden of persistent symptoms was observed in persons after Covid-19. An extensive diagnostic evaluation revealed no specific cause of reported symptoms in most cases. Antibody levels were highly variable after Covid-19.’

However, long-term consequences of post-viral symptoms are not subjected to Covid-19 alone as the diseases caused by the previous two Coronaviruses, SARS (Severe Acute Respiratory Syndrome) and MERS (Middle East Respiratory Syndrome), also showed similar symptoms that lasted several years.

According to a study published in PubMed Central titled ‘Long-term sequelae following previous coronavirus epidemics’ research had revealed that most post-SARS problems settled in time, there were ongoing issues with persistent shortness of breath, fatigue, reduced quality of life and a significant burden of mental health problems over fifteen years. Similarly, the condition of patients who have survived MERS is likely to be similar to SARS survivors and based on fatigue, pulmonary rehabilitation, mental health support and post-intensive care management.

Back home, the Union Ministry of Health and Family Welfare released the National Comprehensive Guidelines for Post-Covid Sequelae in September 2021 taking into consideration the gravity of the situation especially post the second wave of the Covid-19 pandemic. The document detailed diagnostic and treatment protocols for post-Covid Cardiovascular Sequelae, post-Covid Gastrointestinal Sequelae, Nephrological Sequelae, Neurological Sequelae and long-term respiratory effects.

However, doctors here point out that while a vast majority of the Long Covid cases have been identified and treated, the situation continues to be evolving with the new variants and sub-variants emerging at regular intervals. Besides, the effect of vaccination i.e. the various types of vaccines including mRNA vaccines, DNA vaccines etc. and their effect on the immune system and thereby Long Covid also needs to be studied in detail.

With a vast majority of the population vaccinated, understanding the impact of Long Covid on Breakthrough Infections (BTI) following vaccination becomes a necessity. A study published in Nature Medicine on May 25, 2022, concludes that ‘Compared to people with SARS-CoV-2 infection who were not previously vaccinated, people with BTI exhibited lower risks of death and incident post-acute sequelae. Altogether, the findings suggest that vaccination before infection confers only partial protection in the post-acute phase of the disease; hence, reliance on it as a sole mitigation strategy may not optimally reduce long-term health consequences of SARS-CoV-2 infection. The findings emphasize the need for continued optimization of strategies for primary prevention of BTI and will guide the development of post-acute care pathways for people with BTI.’

According to a study published in PubMed Central titled ‘Long-term sequelae following previous coronavirus epidemics’ research had revealed that most post-SARS problems settled in time, there were ongoing issues with persistent shortness of breath, fatigue, reduced quality of life and a significant burden of mental health problems over fifteen years.

In short, while the pandemic might finally be coming under some form of control in India and across the world, the war against Covid-19 is likely to be a long and tiresome one where only conclusive research and scientific evidence can help things get better.