Fatigue and shortness of breath persist in recovered Covid patients, study finds

A study by Italian researchers published in Journal of the American Medical Association finds that certain symptoms of Covid-19 persist much beyond a negative test.

A medical worker in PPE takes a nasopharyngeal swab sample from woman at a mobile sample-collection site in Moscow | Andrey Rudakov | Bloomberg

New Delhi: While ‘long-term’ for a seven-month-old virus may be a relative term, recent evidence on the multiple organs and systems the novel coronavirus affects raises lingering questions about how long does it really take for a person to heal after the infection — not just test negative.

This also has implications on how a death is categorised as a ‘Covid’ death — is it only till the virus lasts in the body or is it till the symptoms last?

In one of the first such studies, researchers in Italy studied patients who had ‘recovered’ from the infection over two months ago to find out what were the long-term effects of the coronavirus infection.

The study, published in the Journal of the American Medical Association (JAMA) last week, revealed that a majority of the patients reported fatigue and shortness of breath as persisting symptoms.

Shortness of breath is also counted as one of the danger signs of a Covid patient — when the person has to be rushed to hospital. The other common symptoms include cough, fever, dyspnea, musculoskeletal symptoms (myalgia, joint pain, fatigue), gastrointestinal symptoms, and anosmia/dysgeusia (loss of smell and taste). Loss of smell and taste have made late entrants in the list of Covid symptoms.

Interestingly, among the patients who were initially a part of the study, 14 per cent ended up testing positive again. However, the study does not clarify whether these were cases of re-infection or of false negatives during testing.

What the study found

The study started with 179 patients, who had met the World Health Organization criteria for discontinuation of quarantine. The criteria included no fever for three consecutive days, improvement in other symptoms, and two negative test results for SARS-CoV-2, 24 hours apart.

However, only 143 patients could be studied for the intended period of two months.

“Patients were assessed a mean of 60.3 days after onset of the first COVID-19 symptom; at the time of the evaluation, only 18 (12.6%) were completely free of any COVID-19–related symptom, while 32% had 1 or 2 symptoms and 55% had 3 or more. None of the patients had fever or any signs or symptoms of acute illness,” reported researchers from the Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome in the journal.

“Worsened quality of life was observed among 44.1% of patients…a high proportion of individuals still reported fatigue (53.1%), dyspnea (43.4%), joint pain, (27.3%) and chest pain (21.7%)…87.4% reported persistence of at least 1 symptom, particularly fatigue and dyspnea,” they added.

They also pointed out the limitations in their study. It was a single-centre study and information about the symptoms that patients had prior to the infection was not available.

Furthermore, there was no control group to compare to the trial group.

“Patients with community-acquired pneumonia can also have persistent symptoms, suggesting that these findings may not be exclusive to COVID-19,” the study noted.

Implications of the study

The long-term effects of Covid-19 have been a matter of much speculation, especially given the anecdotal evidence of recovered patients about the persistence of fatigue and other symptoms.

This also raises questions about what can be termed a ‘Covid death’.

Ordinarily, a death is categorised as a Covid death only till the person tests positive for the virus. That is why an Italian tourist who was hospitalised in Jaipur and eventually died was not counted as a Covid death as the person tested negative before his death, though he was never discharged from the hospital. There are many such instances across the country.

However, this principle is brought under the scanner if symptoms persist beyond a negative Covid test, as has been suggested by the JAMA study.

“While a large proportion of Covid-19 infected persons have been reported to be affected mildly with good recovery, many of the hospitalised persons with a more severe form of illness report residual symptoms contributing to chronic disability. The need for long-term follow-up and chronic ambulatory care in primary healthcare settings becomes very important,” said Dr K Srinath Reddy, president of the Public Health Foundation and member of the Executive Group of the International Steering Committee of WHO’s Covid-19 Solidarity Trial.

“Whether these residual features have a bearing on short or medium-term mortality needs be assessed. Effective rehabilitation services, to promote physical and mental health in Covid-19 survivors, will need to become an integral part of the health system response. As Prof. Peter Piot, who was affected by Covid-19, told me ‘this is a nasty virus’ with a long road to full recovery. We need to factor that as we provide post-hospitalisation care,” said Reddy, who is also a member of ICMR’s Covid-19 taskforce.

Medical literature is also available about the long-term effects of the SARS infection, another coronavirus that broke out in 2003 and is known to behave similar to SARS-CoV-2.

There is also talk of something that is being tentatively called a post-Covid lung disease that is similar to the effect reported in many recovered SARS patients of being unable to exercise for a prolonged period of time.

Furthermore, a study from Hong Kong reported that only 78 per cent of SARS patients were able to return to full‐time work, one year after infection.

In a paper, published last month on the long-term effects of Covid-19, the international health organisation GAVI – The Vaccine Alliance, wrote: “Given the multi-organ effect of COVID-19 on the body, survivors may have a variety of long-term effects on their organs, including what some doctors are calling ‘post-COVID lung disease’.”

“Looking at the organs that are affected during infection could give an idea of where the long-term effects on the body are likely to manifest. As we are still in the throes of the pandemic, and at a relatively early stage of a new disease, it is too early to tell what COVID-19 survivors are likely to experience in a year’s time.” the paper noted.