It is a bright Wednesday morning in the second week of September and about a dozen men and women wait in a Covid-appropriate queue to see a doctor at RML Hospital in New Delhi. All of them have one thing in common: they have beaten the Covid-19 virus. But that feeling of getting back on one’s feet is yet to sink in for them.

Some have complaints related to the chest and lungs, almost everyone feels “extremely tired” most of the time, and there are those who feel all these and more. “I feel breathless after walking for just 2 minutes. Before Covid, I used to walk and workout almost an hour everyday,” says a patient in his late 30s, who declined to be identified.

So far, India has registered more than 59 lakh Covid-19 cases and over 48 lakh clinical recoveries. While this can be seen as a positive on the recovery rate front, what is worrying the medical fraternity is the increasing complaints of ailments, some severe, among those who have recovered. This remains a serious cause of concern because it shows a much longer recovery period than anticipated and the likelihood of additional pressure on the healthcare system even if recoveries rise. Reinfection is another problem that could get out of control.

At least a dozen recovered patients ET Magazine spoke to across the country complained of fatigue, memory lapses, inability to concentrate, loss of sense of smell or taste, shortness of breath and poor heart function. No one seems to be sure if and when the ailments would go away.

The premier All India Institute of Medical Sciences (AIIMS) is now turning its attention to such cases through teleconsultation. AIIMS Director Randeep Guleria says there have been several types of complaints from recovered patients. “These range from extreme fatigue, dry persistent cough, breathing difficulty to even, in some cases, heart dysfunction, neurological complications and lung psoriasis.”

Such symptoms leave people like Jitendra Kumar, 49, confused. His test shows he doesn’t have Covid anymore but he is not sure if he has recovered fully. “I have these bouts of cough that fail to subside.” About 45 days after being discharged from a hospital in Lucknow, Kumar has developed lung issues, bronchitis, extreme fatigue and has mood swings.

It is not just physiological issues people like him have to deal with. “The sight of dying patients, and doctors and nurses going around in personal protective equipment refuses to fade from my memory. I can’t sleep. I feel counselling must be made mandatory for all recovered patients, especially for those who were hospitalised,” says Kumar, who is a general manager at UP Rajkiya Nirman Nigam, Lucknow.

Another emerging trend that has shocked experts is the sudden death of patients who have tested negative, as pointed out by Assam Health Minister Himanta Biswa Sarma in the first week of September.

Principal Secretary-Health of Assam Samir K Sinha says, “We have not compiled the numbers but there has definitely been deaths among recovered patients. A lot of people are coming back to hospitals with post-Covid complications in the kidneys, lungs or liver. It is a very deadly disease and the fact that a majority are asymptomatic is bad advertisement — in the sense, people are not taking it very seriously.”

Several hospitals such as RML and Rajiv Gandhi Super Specialty Hospital have now started post-Covid clinics, including teleconsultation sessions, to address these symptoms. Most of these clinics have experts from multiple verticals: physicians, respiratory medicine, pulmonary specialists, general medicine, psychiatry and physiotherapy, among others.

Guleria of AIIMS says while the initial part of the pandemic was about saving lives, six months later, the focus is on recovered patients due to residual illness. “This may last for weeks or months; sometimes the damage may be lifelong.”

Like the disease itself, there are a lot of unanswered questions around life-after-Covid as well that researchers and scientists across the world are exploring. “We do not know why so many people have Covid symptoms for so long even after recovery,” says Akiko Iwasaki, Waldemar Von Zedtwitz Professor of Immunobiology and Molecular, Cellular and Developmental Biology, Yale School of Medicine, in an email response. “It is possible that there is a persistent viral infection that cannot be detected by nasal swabs. It is also possible there is persistent viral RNA or antigens driving immune responses. Finally, it is possible that some form of autoimmune response is induced in these long haulers.”

Nobody really knows what the long-term effects of having Covid is going to be. “Some argue that this may last for 6-9 months. I have a feeling it varies from person to person depending on the immune response of the body,” adds Guleria.

While experts try to figure out the new puzzle, another issue is raising its ugly head: reinfection.

Reinfection Worry
Instances of coronavirus reinfection have been reported from Hong Kong, Belgium, the UK and India. “There are just 4-5 instances of documented reinfection across the world,” says Sridhar Sivsubbu, senior scientist at Institute of Genomics & Integrated Biology (IGIB), New Delhi. But the lack of understanding about the virus adds an element of volatility to the issue.

For Arun Makwana, a physician at Civil Hospital, Ahmedabad, the disease returned after five months. His first positive test result came in late April. He was asymptomatic and recovered after a while. In September, he developed fever, headache, bodyache and muscle pain. “I could barely walk.” He was shocked when he tested Covid-positive again. “Reinfection cases are rare. But it is a myth that recovering from Covid gives immunity from reinfection,” Makwana tells ET Magazine over phone from Ahmedabad, where he is in home isolation.

Establishing a case of reinfection requires sequencing the viral genome of the first infection in the patient, and then sequencing the viral genome of the second infection in the patient and proving that the two are different. “In two of the four cases that we investigated,” says Sivsubbu, “we found slightly different variations in the genetic composition between the two episodes of infection.”

The National Institute of Virology-Pune, IGIB, Indian Council of Medical Research and the Council of Scientific and Industrial Research are sequencing the genomes to answer questions on the longevity of infection-induced immunity, causes of reinfection and the long-term impact of the virus on humans.

Reinfections will also have a bearing on vaccine development. If there are significant reinfections — as pointed out by Guleria — it makes the vaccine development procedure all the more complex. This is because it is easy to develop vaccines for a disease where an infection results in lifelong immunity, or at least for a significant period. For example, polio and tuberculosis vaccines offer lifelong immunity, while for SARS & MERS, the antibody levels wane significantly in a year or two.

Given the rising cases of reinfection world over, researchers say the only safe way to achieve herd immunity is through large-scale administration of vaccines.

“Reinfection cases tell us that naturally acquired immunity against SARS-CoV-2 may not last long or be effective in some. We may see many more reinfection cases. This is why we need a vaccine to establish herd immunity. Immunity from natural infection is not sufficient,” adds Iwasaki of Yale School of Medicine.





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