Even as the number of COVID19 cases are on a decline in India, patients who have successfully recovered from the virus are complaining of post COVID-19 complications.
One of the most common complaint is brain fog, where people who have recovered from Covid-19 sometimes experience lingering difficulties in concentration, as well as headaches, anxiety, fatigue or sleep disruptions.
Dr Tanu Singhal, an infectious diseases specialist from the London School of Hygiene and Tropical Medicine in an interview to Databaaz, said another most common post COVID-19 complication are infections.
"COVID itself lowers your immunity. And then on top of that, if you take steroids for COVID, your immunity goes down further. So we are seeing people coming with bad fungal infections, bad bacterial infections," said Dr Singhal.
For the patients that do develop thrombosis, cardiac issues, and other post COVID-19 complications, Dr Singhal points out that these were the patients that were not at risk for developing COVID-19 at all.
Dr Tanu Singhal elaborates, "The people who come back with these problems are those generally who never anticipated it, and they come with a stroke, and they have no risk factors. And then when you evaluate them, you find they had COVID, three, four weeks ago. So that is the pattern."
Excerpts of the interview
So before I ask you about post COVID-19 symptoms, can you tell us about where we stand today, or you feel we stand today in terms of our success in combating this virus?
So at a population level, we do see a decline in the number of cases in the country, which is a good thing, because at one point, we had a lakh case per day, and now we are about 30 to 40,000 cases per day. So there has been a decline. And it seems to be a true decline because testing hasn't gone down.
In fact, it has gone up, then as far as the outcome of patients with COVID is concerned, we are seeing better outcomes than what we were four or five months ago.This observation is based on experience from my own hospital, where the first three or four months of April, May, June were quite bad, and we were seeing mortality rates of 40 to 50% in our patients with severe disease. But after that, the mortality has come down. And I think this is because of many factors.
First is that patients are now coming in early, there is more awareness. Also, we are using Remdesivir, which as per US has made a difference in the outcome of patients, doctors have known how to treat it better, the use of Tocilizumab has come down which was actually causing problems. So overall, I think the outcomes have become better. So the number of cases are declining. And also the outcome of cases is better. So that is what I would say as far as COVID is concerned, we Mumbai actually saw a major decline. And now the cases have gone up again a bit but they haven't reached the peak levels yet.
Now let's talk about the post COVID 19 cases. There are two kinds — one is the kind where patients come to hospitals and come into your radar, so to speak. And there are others who perhaps may not even get tested, or even if they get tested are getting treated at home because the symptoms are mild to moderate. And yet many of these patients are now displaying or later displaying symptoms of or post COVID symptoms, including what in some places is being called the COVID-19 fog. How are you seeing this? And what have you been coming across?
So yes, we are seeing both types of patients. We are seeing mild patients as well because some of them are our own healthcare workers. And there are many people who do online consultations for COVID if they are mild, so we have experience with these patients as well. And the most common problem, which I come across is fatigue, you know, that, you know, even after recovery, they feel so weak, and they can't go back to their usual work. And we see that with health care workers also said they'd come and join work and then they say they're feeling very tired and they want to go back and rest.
So, that is one problem, we are seeing that we are seeing that the loss of sense of taste and smell take some time to come back and that actually causes patients distress, then we are also seeing this phenomenon very a low-grade fever persisting for a month and this is because these people have got so used to measuring their temperatures that you know, they keep measuring it and in the evenings if they get a little bit of 99 also they get burdened.
So, some of the problems may be more perceived than real. Right. We are seeing these cases of brain fog. And recently we had actually a person admitted with us who had mild COVID and didn't need any major treatment and then a month later started becoming forgetful and so much so that he used to forget everything and he was becoming very drowsy and withdrawn and he had to be admitted to hospital for that.
So this brain fog also has different spectrums. But one thing is very clear that COVID is not behaving like any other pathogen. It is breaking all the boundaries and the barriers and, name anything kind of complication post COVID. We have seen it. We've seen people coming with pancreatitis, strokes, myocardial infarctions, thrombosis, and so many other complications affecting almost every organ of the body.
We are now in December, which is almost the ninth month since this hit has in its full intensity. Now, are you saying that in some of these cases, for instance, fatigue, for instance, forgetfulness? Is there recovery after that? Or are you saying that this is almost like a, I mean, like a longer term, state?
No, they recover. All the people who were complaining of fatigue about a month or two ago, don't have it any longer. So I have not seen any patient who has had it permanently, it's just that it doesn't go away as soon as people expected to go away. But eventually they recover. So the long term outcomes, in terms of all these minor symptoms is quite good.
Is this true for all the symptoms that you just described earlier, whether it's to do with where you said, thrombosis, or myocardial infarctions?
That is a different thing. I can classify the post COVID problems as mild, and also as severe. Eventually these mild symptoms go away, it just takes some time.
Do the mild symptoms also relate to mild symptoms at the onset of the disease? Or are these two not related?
No, so they are not related. They are people who have had moderate to severe symptoms, they will not have serious problems, but they will continue to experience fatigue. But for the person who has been in hospital, who's been in the ICU, if they have fatigue and other problems after recovery, it's understandable. But for patients who have very mild symptoms in the beginning, it is unexpected.
And the other thing, which I know kind of wanted to say about this is mental health problems, we are seeing, you know, a lot of mental health problems triggered even with mild symptoms, because they they've had a lot of anxiety about their condition and social isolation, so many of them are coming with mental health problems later.
Is there any insight as to why this happens? I mean, why is there fatigue? Or why is there forgetfulness? What could be the triggers it or could be causing it?
So it is the reason I think is because this COVID virus, it basically enters the body through an ACE-2 receptor. And these receptors are widely distributed all over the body. So that was that is why the virus can gain access to every system. And it is known that it gains access to the nervous system also, and that is the reason for the loss of sense of taste and smell. And probably that is the reason.
So one could be actual damage by the virus to these organ systems. And the second could be also a byproduct of the stress which a person undergoes, you know, during the whole COVID episode.
Right, and when you speak of thrombosis or cardiac issues, in the post-COVID phase, are these related to prior conditions? Or are these something that people in as you've observed, developed completely afresh?
So most of the times, they develop completely afresh. We have a cohort of about 600 or 700 patients with COVID, who were treated in our hospital for severe COVID, they are the ones who don't come back with these thrombotic problems because we are not even giving them anticoagulation at the time of discharge.
The people who come back with these problems are those generally who never anticipated it, and they come they come with a stroke, and they have no risk factors. And then when you evaluate them, you find they had COVID, three, four weeks ago.
So that is the pattern. So most of the patients who come to us with these kinds of COVID related thrombosis had mild illness earlier, but the number is very small, so that is why people shouldn't panic because that is a very common problem that everybody reads about thrombosis and COVID.
And then they feel that even if they are at home, they do their D-dimer levels and if the D-dimer is high, the same can be take anticoagulation? that is not recommended. Because if 1000 people have a mild COVID maybe there'll be one who will have a thrombotic complication.
But many more would have fatigue and let's say things like forgetfulness? I mean, I'm also saying from my own anecdotal experience from people that I've spoken to.
Yes, so serious complications are rare. There's nothing much one can do, to prevent these from happening, like the serious complications at least like thrombosis, because anybody who's had mild COVID would not be on anticoagulation, etc, to prevent this from happening. So I think it is just bad luck. It's only very few people who qualify for anticoagulation after they're discharged from the hospital.
Now, when someone is diagnosed, I mean, obviously, at that point, you don't know what's going to happen. Maybe you've caught it early. And it looks like it's mild. Is there anything you can do to prevent what could be more serious onset once you've recovered? Or like I asked you earlier, once you've got it, then it's pretty much in the hands of God. I mean, you don't know which way it's gonna go. And you just have to hope for the best.
No, there are some things which you can do and one of the very important things which people should do is to not take steroids if they have mild COVID because that is happening and do not take too many medications because that's also happening like you know, patients who have mild COVID, they are given azithromycin, HCQ, ivermectin doxycycline etc, for which there is no real scientific basis.
So, they should avoid that and stearoyl should definitely be avoided, because the most horrible complications that we are seeing post COVID are actually infections. I mean, because what happens is COVID itself lowers your immunity. And then on top of that, if you take steroids, your immunity goes down further. So we are seeing people coming with bad fungal infections, bad bacterial infections.
So that is the most common complication which we are seeing after COVID. And that is avoidable to a certain extent, by not taking medications, which are not indicated. Another thing is patients with severe COVID, you know, some of them are being treated with steroids for a very long time, which is not recommended, it's basically 7 to 10 days, which is recommended. But if they go on for long, then they come back with bad infections. So number one on the list of post COVID serious complication is infection.
So you're saying, therefore, you have to be very careful about not overdosing yourself or multiple dosing yourself at the time that you at the time that you've actually tested positive.
Yes. And also be careful for the next one month, after recovery also, and if you have any kind of thing, which is amiss, like don't ignore it. So suppose you know, you have recovered from COVID. And then suddenly, you start having some symptom, like you start having some chest pain, or you start having some weakness of a limb or you have something you get fever, again, don't ignore. Because once people have recovered from COVID, they think that all is well with us, we have recovered but you still have to be careful for the next month or two. And in case they have any of these problems, then they should immediately consult a doctor.
You said that Remdesivir is working, and Itolizumab are not working. Is the treatment protocol now more or less now remdesivir, and maybe whatever else that you may do, or other drugs that you're still working on.
So actually now our protocol for the past four months has become fairly standard, which includes remdesivir, steroids and low molecular weight heparin to prevent thrombosis and oxygen, these are the four cardinal things.
And this has remained more or less same for the next three to four months because there is nothing else which is there in the offing. Convalescent plasma has gone off. Similarly, tocilizumab has gone off the treatment schedule. And, and one of the reasons why tocilizumab has gone off is because of the serious infections we started seeing when we were using tocilizumab. So after the trial said that tocilizumab see doesn't help, we stopped using it.
Now, you might ask that the trials also said that Remdesivir doesn't work. So why are you still using it? So the reason is two, one is as personal experience, we felt that it works. And our outcomes have become better. And second is that there is no downside to using the drug except for the cost. Because we've used it in many patients and then no side effects whatsoever. It's a completely safe drug. So that makes doctors offer the drug to their patients because they feel that when there's nothing else that is at least offer something which is known to help. That is the reason why Remdesivir has still stayed in the protocols.
The city of Mumbai, for instance, has clearly seen fairly sharp reduction in cases compared to obviously the peak. Do you feel that there is much greater herd immunity now and seroprevalence?
Yes, it is, because studies also show the same. For example, in the slums, it may be around 50%. In housing societies, there was a study done at some time ago, which was about 15 to 20%. Even in health care workers, the antibody tests have shown the prevalence, so, I think, yes, I think the decline in cases is possibly because of herd immunity because the city has opened up much more than before. And in fact, a compliance to prevention has actually gone down, mask fatigue has set in, people don't no longer want to stay in their houses they want to go. The final message, which I would like to give people is that it's not over yet. It's not over yet. And this virus is very unpredictable. So, again, we should continue to follow those things like social distancing mask and hand hygiene advice. We don't know whether we will also face the same situation as Europe is undergoing right now.