A healthcare worker in protective gear collects a blood sample from a man, who has recovered from COVID-19, during a plasma donation camp in Mumbai, July 2020. Photo: Reuters/Hemanshi Kamani/Files.
With improved survival of critically ill patients thanks to expanded healthcare resources and more appropriate therapies, the world’s focus has been shifting from ‘short COVID-19’ – where patients usually recover from their symptoms in two or three weeks – to ‘long-haul COVID-19‘, in which patients experience symptoms for more than four weeks.
Doctors and researchers initially thought COVID-19 to be marked by a certain constellation of symptoms like profound fatigue, breathlessness and muscle ache. But recent evidence has encouraged a more refined understanding of the problem.
Although 10% of COVID-19 patients experience symptoms beyond three weeks, only 2% continue to be ill at three months. Around 5% of patients have reported experiencing symptoms for eight weeks or more. These outcomes may seem arbitrary but researchers have been able to elucidate some underlying patterns, and have divided them into four groups:
* Those who were critically ill (especially those on the ventilator) are at risk of post-intensive care syndrome (or PICS), associated with cognitive disturbances (issues with memory, concentration and attention), post-traumatic stress disorder and muscle weakness
* Others have symptoms consistent with post-viral fatigue syndrome – exhaustion, sleep disorders and joint pain
* Some patients manifest symptoms associated with permanent organ damage following COVID-19, such as heart attacks, lung fibrosis and stroke; the extent to which this is reversible remains to be seen
* Another group of patients have vague symptoms affecting multiple organ systems, including the gastrointestinal tract, lungs, the heart, kidneys and the brain, that may wax and wane. Up to 10% of people have also reported rashes on the skin.
‘Long COVID’ has been found to be more common among women, the elderly and those with moderate symptoms in the first week: cough, hoarseness of voice, headache, diarrhoea, loss of appetite and smell, and shortness of breath. It is also reportedly more common among obese people and those with asthma. The exact reasons are unclear, but it may be related to antibody- or immunity-related reactions or associated with mental factors.
However, we don’t test routinely for complications. The possible consequences of COVID-19 are diverse and variable, and routinely testing for all of them could cost lakhs of rupees. Given that those experiencing ‘long COVID’ are still in the minority, and some of the tests are invasive and potentially dangerous, we must pay attention to the risk-benefit ratio. We need to be selective when ordering tests, and make sure they are specifically based on each patient’s history and the results of their examination.
For those who are critically ill, close and regular follow-ups are essential to ensure organ functions don’t deteriorate and the infection has no new consequences. Although potentially devastating, cases of thrombosis – which is the propensity to develop blood clots in the legs, lungs, heart and brain – following non-critical cases of COVID-19 are rare. Critically ill patients are most often discharged with anticoagulation drugs to prevent this. And most often, these patients will and do need a structured, long-term rehabilitation process.
For those with mild or no symptoms, there is no recommended follow-up schedule. Those who have prolonged periods of fatigue are commonly required to undertake complete blood-count and inflammatory markers (like C reactive protein and ferritin) tests. For those who had significant respiratory symptoms but were not admitted to intensive care, the British Thoracic Society recommends a chest X-ray at 12 weeks to screen for lung damage, along with a thorough clinical assessment to identify new, persistent or progressive symptoms.
The danger of over-investigating these patients is clear. With no frame fixed of reference, disruptions in lab results without accompanying symptoms can result in unnecessary treatments or interventions.
Tracking your health
A large part of the road to recovery is self-care, and this suffices for the vast majority of survivors. A keen attention to your health, a nutritious diet, adequate rest and relaxation, and a graduated return to a busy routine allows for the convalescence required while recovering from any major viral illness.
If you were breathless or had other respiratory issues, the daily use of a pulse oximeter may help you determine when to seek further care. Patients with previously diagnosed health issues like diabetes and hypertension need to monitor these conditions closely as they may worsen.
But whatever happens – please don’t panic because of the hype or hysteria surrounding COVID-19. Often, small studies with unintended bias are quoted without context, resulting in widespread fear and anxiety. It is reassuring that researchers are accruing a large volume of high-quality data. So over time, as in the acute setting, the effectiveness of our treatment will improve.
Researchers have already described effective healthcare delivery models for post-COVID-19 care, which is typically a combination of virtual and in-person visits. The physician is the best point-of-contact as there can be multiple organ systems involved and that requires well-coordinated care.
Given how variable the disease’s symptoms can be, there is growing consensus that physicians must acknowledge and incorporate patients’ perspectives to plan their treatment for optimal results. It is imperative for patients to comply with rehabilitation programmes. Breathing exercises and physical therapy could help reverse organ damage associated with the virus. A mental health screen is important as well: these symptoms are not readily demonstrable and often neglected.
In India, there have been calls to decentralise this care, ensuring that it is available at the community-level rather just in private hospitals, and only to patients who can afford it. These interventions are much more cost-effective to the healthcare system than paying for treatment after complications kick in.
The pandemic’s implications
Given the reports of reinfection around the globe, COVID-19 survivors are also understandably concerned. It’s important to remember that reinfection remains rare: only a handful of cases have been reported in spite of there having been nearly 43 million cases. Since our understanding COVID-19 immunity is still evolving, it is prudent to continue universal precautions until we have a robust way to measure immunity against the virus.
Unfortunately, for a section of survivors, the socio-economic cost of COVID-19 will stretch beyond a few weeks or months. Research into ‘long COVID’ is imperative to mitigate at least some of these effects, which – like COVID-19’s epidemiology – may be region-specific.
The pandemic has also reiterated that young, fit and healthy individuals are not ‘safe’ by virtue of the low mortality rate, and that herd immunity is untenable, especially in a population like India’s. We must continue to observe precautions, listen to each other, work together and replace data with better data to see this through.
Dr Narayana Subramaniam is a head and neck surgical oncologist at the Mazumdar Shaw Medical Centre, Bengaluru.