Manifestations and risk factors of post COVID syndrome among COVID-19 patients presented with minimal symptoms – A study from Kerala, India

Myalgic Encephalomyelitis/Chronic Fatigue Syndrome After SARS-CoV-2 Infection

Importance

Chronic symptoms reported following an infection with SARS-CoV-2, such as cognitive problems, overlap with symptoms included in the definition of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS).

Objective

To evaluate the prevalence of ME/CFS-like illness subsequent to acute SARS-CoV-2 infection, changes in ME/CFS symptoms through 12 months of follow-up, and the association of ME/CFS symptoms with SARS-CoV-2 test results at the acute infection-like index illness.

Design, Setting, and Participants

This prospective, multisite, longitudinal cohort study (Innovative Support for Patients with SARS-CoV-2 Infections Registry [INSPIRE]) enrolled participants from December 11, 2020, to August 29, 2022. Participants were adults aged 18 to 64 years with acute symptoms suggestive of SARS-CoV-2 infection who received a US Food and Drug Administration-approved SARS-CoV-2 test at the time of illness and did not die or withdraw from the study by 3 months. Follow-up surveys were collected through February 28, 2023.

Exposure

COVID-19 status (positive vs negative) at enrollment.

Main Outcome and Measures

The main outcome was the weighted proportion of participants with ME/CFS-like illness based on the 2015 Institute of Medicine clinical case definition using self-reported symptoms.

Results

A total of 4378 participants were included in the study. Most were female (3226 [68.1%]). Mean (SD) age was 37.8 (11.8) years. The survey completion rates ranged from 38.7% (3613 of 4738 participants) to 76.3% (1835 of 4738) and decreased over time. The weighted proportion of participants identified with ME/CFS-like illness did not change significantly at 3 through 12 months of follow-up and was similar in the COVID-19-positive (range, 2.8%-3.7%) and COVID-19-negative (range, 3.1%-4.5%) groups. Adjusted analyses revealed no significant difference in the odds of ME/CFS-like illness at any time point between COVID-19-positive and COVID-19-negative individuals (marginal odds ratio range, 0.84 [95% CI, 0.42-1.67] to 1.18 [95% CI, 0.55-2.51]).

Conclusions and Relevance

In this prospective cohort study, there was no evidence that the proportion of participants with ME/CFS-like illness differed between those infected with SARS-CoV-2 vs those without SARS-CoV-2 infection up to 12 months after infection. A 3% to 4% prevalence of ME/CFS-like illness after an acute infection-like index illness would impose a high societal burden given the millions of persons infected with SARS-CoV-2.

Prevalence of long COVID symptoms in Haryana, India: a cross-sectional follow-up study

Background

Emerging research indicates growing concern over long COVID globally, although there have been limited studies that estimate population burden. We aimed to estimate the burden of long COVID in three districts of Haryana, India, using an opportunity to link a seroprevalence study to follow-up survey of symptoms associated with long COVID.

Methods

We used a population-based seroprevalence survey for COVID-19 conducted in September 2021 across Haryana, India. Adults from three purposively selected districts (Rohtak, Gurugram, and Jhajjar) were eligible to participate; 2205 of 3213 consented to participate in a survey on health status. Trained investigators administered a structured questionnaire that included demographic characteristics, self-reported symptoms of illness in the last six months before the survey, mental health, and history of COVID-19.

Findings

Unadjusted regression estimates indicated positive correlations between symptomatic complaints and COVID-19 exposure, suggesting lingering effects of COVID-19 in this population. The overall physical morbidity index was higher among those who tested positive for COVID-19, as was the incidence of new cases. However, both morbidity and incidence became statistically insignificant after adjustment for multiple comparisons. Cough emerged as the only statistically significant individual persistent symptom. Sex-stratified analyses indicated significant estimates only for physical morbidity in women.

Interpretation

This study is one of the first from India that uses a large population-based sample to examine longer term repercussions of COVID infections. The burden of long COVID should primarily be addressed in clinical settings, where specialised treatment for individual cases continues to evolve. Our analyses also provide insight into the size and nature of studies required to assess the population-level burden of long COVID.

Funding

This paper was produced under the auspices of the Lancet COVID 19 Commission India Task Force, which was supported financially by the Reliance Foundation. The Lancet COVID 19 Commission was set up in July 2020 and submitted its final report by October 2022. This report by the India Task Force was prepared during the same period.

Melatonin: a ferroptosis inhibitor with potential therapeutic efficacy for the post-COVID-19 trajectory of accelerated brain aging and neurodegeneration

The unprecedented pandemic of COVID-19 swept millions of lives in a short period, yet its menace continues among its survivors in the form of post-COVID syndrome. An exponentially growing number of COVID-19 survivors suffer from cognitive impairment, with compelling evidence of a trajectory of accelerated aging and neurodegeneration. The novel and enigmatic nature of this yet-to-unfold pathology demands extensive research seeking answers for both the molecular underpinnings and potential therapeutic targets. Ferroptosis, an iron-dependent cell death, is a strongly proposed underlying mechanism in post-COVID-19 aging and neurodegeneration discourse. COVID-19 incites neuroinflammation, iron dysregulation, reactive oxygen species (ROS) accumulation, antioxidant system repression, renin-angiotensin system (RAS) disruption, and clock gene alteration. These events pave the way for ferroptosis, which shows its signature in COVID-19, premature aging, and neurodegenerative disorders. In the search for a treatment, melatonin shines as a promising ferroptosis inhibitor with its repeatedly reported safety and tolerability. According to various studies, melatonin has proven efficacy in attenuating the severity of certain COVID-19 manifestations, validating its reputation as an anti-viral compound. Melatonin has well-documented anti-aging properties and combating neurodegenerative-related pathologies. Melatonin can block the leading events of ferroptosis since it is an efficient anti-inflammatory, iron chelator, antioxidant, angiotensin II antagonist, and clock gene regulator. Therefore, we propose ferroptosis as the culprit behind the post-COVID-19 trajectory of aging and neurodegeneration and melatonin, a well-fitting ferroptosis inhibitor, as a potential treatment.

Prevalence and determinants of post-COVID-19 syndrome among patients 6 months post-discharge from a teaching hospital in South India

Background

The coronavirus disease 2019 (COVID-19) infection has affected millions of people worldwide in the last 4 years. Among those infected, the long-term COVID-19 syndrome, in which symptoms of COVID-19 persist for a variable period, is posing new challenges to the health system, but few studies are available in India that examine the post-COVID-19 syndrome, that is, 6 months and beyond COVID-19 infection. This study aimed to find the prevalence and determinants of post-COVID-19 syndrome among patients 6 months and beyond their infection.

Methodology

This cross-sectional study was conducted among 300 patients who were admitted and discharged from Government Medical College, Thrissur, at least 6 months before with a diagnosis of COVID-19 infection. The data collection was performed using a semi-structured interview schedule through a telephonic interview. The analysis was performed using the Statistical Package for the Social Sciences (SPSS) software.

Results

21% of the patients studied had at least one persistent symptom at the end of 6 months, and 4.1% had more than one symptom. Among the symptoms persisting most commonly were fatigue (11%) and dyspnea (7.7%). Other than persisting symptoms, 21% of patients developed exertional dyspnea and 19% developed sleep disturbances during the 6 months after discharge. The factors that were associated with persistent symptoms in univariate analysis were increasing age, presence of chronic obstructive pulmonary disease (COPD), presence of chronic kidney disease (CKD), and admission to the intensive care unit (ICU).

Conclusion

The study concludes that one-fifth of the patients still suffer from post-COVID-19 syndrome even 6 months after the COVID-19 infection. Our health systems should be prepared for the long-term management of COVID-19-infected people and prepare policies for the same.

A cross-sectional and population-based study from primary care on post-COVID-19 conditions in non-hospitalized patients

BACKGROUND

Current research on post-COVID-19 conditions (PCC) has focused on hospitalized COVID-19 patients, and often lacks a comparison group. This study assessed the prevalence of PCC in non-hospitalized COVID-19 primary care patients compared to primary care patients not diagnosed with COVID-19.

METHODS

This cross-sectional, population-based study (n = 2539) analyzed and compared the prevalence of PCC in patients with a positive COVID-19 test (n = 1410) and patients with a negative COVID-19 test (n = 1129) never hospitalized for COVID-19 related conditions. Participants were identified using electronic health records and completed an electronic questionnaire, available in English and Spanish, including 54 potential post COVID-19 symptoms. Logistic regression was conducted to assess the association of PCC with COVID-19.

RESULTS

Post-COVID-19 conditions are prevalent in both groups, and significantly more prevalent in patients with COVID-19. Strong significant differences exist for the twenty most reported conditions, except for anxiety. Common conditions are fatigue (59.5% (COVID-19 positive) vs. 41.3% (COVID-19 negative); OR 2.15 [1.79-2.60]), difficulty sleeping (52.1% (positive) vs. 41.9% (negative); OR 1.42 [1.18-1.71]) and concentration problems (50.6% (positive) vs 28.5% (negative); OR 2.64 [2.17-3.22]). Similar disparities in prevalence are also observed after comparing two groups (positive vs. negative) by age, sex, time since testing, and race/ethnicity.

CONCLUSIONS

PCC is highly prevalent in non-hospitalized COVID-19 patients in primary care. However, it is important to note that PCC strongly overlaps with common health symptoms seen in primary care, including fatigue, difficulty sleeping, and headaches, which makes the diagnosis of PCC in primary care even more challenging.

A landscape on disorders following different COVID-19 vaccination: a systematic review of Iranian case reports

There have been massive studies to develop an effective vaccine against SARS-CoV-2 which fortunately led to manage the recent pandemic, COVID-19. According to the quite rapidly developed vaccines in a fast window time, large investigations to assess the probable vaccine-related adverse events are crucially required. COVID-19 vaccines are available of different platforms and the primary clinical trials results presented acceptable safety profile of the approved vaccines. Nevertheless, the long-term assessment of the adverse events or rare conditions need to be investigated. The present systematic review, aimed at classification of probable vaccine-related unsolicited adverse events in Iranian population through the data collection of the published case report studies.The related published case reports were explored via PubMed, Web of Science and Google scholar according to the available published data up to 14th Dec, 2022 using PRISMA guideline. Out of 437 explored studies, the relevant data were fully investigated which totally led to 40 studies, including 64 case reports with a new onset of a problem post-vaccination. The cases were then classified according to the various items, such as the type of adverse event and COVID-19 vaccines.The reported COVID-19 vaccines in the studied cases included BBIBP-CorV, ChAdOx1-S, Sputnik V and COVAXIN. The results showed that the adverse events presented in 8 different categories, including cutaneous involvements in 43.7% (n = 28), neurologic problems (n = 16), blood/vessel involvement (n = 6), cardiovascular involvement (n = 5), ocular disorders (n = 4), liver disorder/failure (n = 2), graft rejection (n = 2) and one metabolic disorder. Notably, almost 60% of the cases had no comorbidities. Moreover, the obtained data revealed nearly half of the incidences occurred after the first dose of injection and the median duration of improvement after the symptom was 10 days (range: 2-120). In addition, 73% of all the cases were either significantly improved or fully recovered. Liver failure following ChAdOx1-S vaccination was the most serious vaccine adverse event which led to death in two individuals with no related medical history.Although the advantages of COVID-19 vaccination is undoubtedly significant, individuals including with a history of serious disease, comorbidities and immunodeficiency conditions should be vaccinated with the utmost caution. This study provides a comprehensive overview and clinical implications of possible vaccine-related adverse events which should be considered in further vaccination strategies. Nevertheless, there might be a bias regarding potential under-reporting and missing data of the case reports included in the present study. Although the reported data are not proven to be the direct vaccination outcomes and could be a possible immune response over stimulation, the people the population with a medium/high risk should be monitored after getting vaccinated against COVID-19 of any platforms. This could be achieved by a carefull attention to the subjects ' medical history and also through consulting with healthcare providers before vaccination.

The Burden and Characteristics of Post-COVID-19 Conditions Among Laboratory-Confirmed Delta and Omicron COVID-19 Cases: A Preliminary Study From Maharashtra, India

BACKGROUND

Post-COVID-19 conditions (PCC) have emerged as a significant global health concern due to their potential impact on patients' quality of life and healthcare resources. The present study aims to understand the burden and characteristics of PCC in Maharashtra, India, and compares its prevalence among cases infected with Delta and Omicron variants.

MATERIAL AND METHODS

A retrospective observational study included 617 laboratory-confirmed Delta and Omicron variant cases. These cases were telephonically followed up to document persistent COVID-19 symptoms using a questionnaire based on the Post-COVID-19 Clinical Form from the Global COVID-19 Clinical Platform of the World Health Organization (WHO), and the results were analyzed.

RESULTS

Out of 617 laboratory-confirmed COVID-19 cases, 82.97% and 17.03% were Omicron and Delta cases, respectively. The mean follow-up period for Delta and Omicron cases was 78.05 and 21.56 weeks, respectively. A total of 40 (6.48%) cases reported persistent symptoms at follow-up, with a higher prevalence among those infected with the Delta variant (12.38%) compared to the Omicron variant (5.27%). The most common long COVID symptoms reported were malaise (25%), dyspnea (20%), post-exertional fatigue (17.5%), joint pain (15%), and frequent episodes of cough and cold (15%). Additionally, 1.94% of participants developed a new medical condition following COVID-19 infection, most commonly hypertension (25%), lung fibrosis (16.67%), and asthma (8.33%). Factors such as more than five acute symptoms, a moderate to severe disease, the need for hospitalization, and hospitalization for more than five days were significantly associated with PCC.

CONCLUSION

Long COVID results in extended disability and illness. The varying impacts of different COVID-19 variants highlight the complex nature of post-COVID-19 complications. Our findings highlight the need for strategic planning of healthcare resources to ensure optimal response and preparedness to manage the burden of PCC.

Health-related quality of life and long-term symptoms among patients with non-severe covid-19 - a prospective cohort study

BACKGROUND

The vast majority of covid-19 patients experience non-severe disease. Nonetheless, long-term symptoms may be common and the impact on quality of life is uncertain. This study aims to examine these aspects in a prospective, longitudinal cohort.

METHODS

Non-hospitalised patients with PCR-confirmed covid-19 were prospectively invited to self-report assessments of background data, symptoms and recovery, illness perception (BIPQ) and health-related quality of life (HR-Qol) measured by EQ5D-VAS.

RESULTS

154 patients were included (mean age 46 years, 69% female). The majority of participants (65%) had symptoms for 1-4 weeks and 12% more than 6 months. The most common symptoms were initially malaise, fatigue, headache, fever and cough and the most common long-term symptoms were impaired physical condition, fatigue, anosmia and headache. The BIPQ index had a negative correlation with the EQ5D-VAS score after the infection, but not with long-term symptoms. Mean differences in the EQ5D-VAS score were significantly lower after the infection and patients with long-term symptoms had a more pronounced negative effect in EQ5D-VAS scores.

CONCLUSION

We found that most patients with non-severe covid-19 reported symptoms for 1-4 weeks and approximately 10% developed long-term symptoms. Non-severe covid-19 seems to have a negative influence on HR-Qol, especially in patients with long-term symptoms and with a greater burden from the disease. None of the initial symptoms could predict the presence of long-term symptoms.

Characteristics and predictors of Long COVID among diagnosed cases of COVID-19

BACKGROUND

Long COVID or long-term symptoms after COVID-19 has the ability to affect health and quality of life. Knowledge about the burden and predictors could aid in their prevention and management. Most of the studies are from high-income countries and focus on severe acute COVID-19 cases. We did this study to estimate the incidence and identify the characteristics and predictors of Long COVID among our patients.

METHODOLOGY

We recruited adult (≥18 years) patients who were diagnosed as Reverse Transcription Polymerase Chain Reaction (RTPCR) confirmed SARS-COV-2 infection and were either hospitalized or tested on outpatient basis. Eligible participants were followed up telephonically after four weeks and six months of diagnosis of SARS-COV-2 infection to collect data on sociodemographic, clinical history, vaccination history, Cycle threshold (Ct) values during diagnosis and other variables. Characteristics of Long COVID were elicited, and multivariable logistic regression was done to find the predictors of Long COVID.

RESULTS

We have analyzed 487 and 371 individual data with a median follow-up of 44 days (Inter quartile range (IQR): 39,47) and 223 days (IQR:195,251), respectively. Overall, Long COVID was reported by 29.2% (95% Confidence interval (CI): 25.3%,33.4%) and 9.4% (95% CI: 6.7%,12.9%) of participants at four weeks and six months of follow-up, respectively. Incidence of Long COVID among patients with mild/moderate disease (n = 415) was 23.4% (95% CI: 19.5%,27.7%) as compared to 62.5% (95% CI: 50.7%,73%) in severe/critical cases(n = 72) at four weeks of follow-up. At six months, the incidence among mild/moderate (n = 319) was 7.2% (95% CI:4.6%,10.6%) as compared to 23.1% (95% CI:12.5%,36.8%) in severe/critical (n = 52). The most common Long COVID symptom was fatigue. Statistically significant predictors of Long COVID at four weeks of follow-up were-Pre-existing medical conditions (Adjusted Odds ratio (aOR) = 2.00, 95% CI: 1.16,3.44), having a higher number of symptoms during acute phase of COVID-19 disease (aOR = 11.24, 95% CI: 4.00,31.51), two doses of COVID-19 vaccination (aOR = 2.32, 95% CI: 1.17,4.58), the severity of illness (aOR = 5.71, 95% CI: 3.00,10.89) and being admitted to hospital (Odds ratio (OR) = 3.89, 95% CI: 2.49,6.08).

CONCLUSION

A considerable proportion of COVID-19 cases reported Long COVID symptoms. More research is needed in Long COVID to objectively assess the symptoms and find the biological and radiological markers.

Patients' Health Experiences of Post COVID-19 Condition-A Qualitative Study

Patients who suffer from long-term symptoms of COVID-19, described as post COVID-19 condition, are a new and large group of patients. There is a lack of knowledge concerning health experiences in this patient group. The aim of this study was to explore patients' health experiences of post COVID-19 condition. Data collection was performed through 14 semi-structured interviews. The qualitative content analysis resulted in six sub-categories, three categories, and an overall theme. Patients experienced symptoms of varying duration-ranging from 5-21 months. The results showed that patients' health experiences of post COVID-19 condition moved between uncertainty and new insights. This was shown by patients experiencing: (1) loss of abilities, including losing smell and taste and lacking energy, (2) loss of control, including being foreign to oneself and seeking answers, and (3) revaluation of life, including accepting the transformed body and prioritizing health. This study illustrates that patients living with post COVID-19 condition need to be treated with flexibility, based on each individual's unique challenges and experiences of the symptoms and the consequences for their health.

Global prevalence of chronic fatigue syndrome among long COVID-19 patients: A systematic review and meta-analysis

Background

Chronic fatigue syndrome is a persistent and debilitating disorder. According to several studies, chronic fatigue syndrome has been identified among recovered COVID-19 patients as the most common symptom of long COVID. The aim of this systematic review and meta-analysis study was to obtain the prevalence of chronic fatigue syndrome in long COVID cases.

Methods

In this systematic review and meta-analysis, we analysed reported results of studies that assessed the occurrence of chronic fatigue syndrome among COVID-19 patients four weeks after the onset of symptoms. The study selection was commenced by searching PubMed, Web of Science, Science Direct, Scopus, Embase, and Google scholar using the keywords of Chronic fatigue syndrome, COVID-19, and post-COVID-19 syndrome. The searches were without a lower time limit and until April 2022. Heterogeneity of studies was assessed using the I² index, and a random effects model was used for analysis. Data analysis was performed within the Comprehensive Meta-Analysis software (version 2).

Results

The pooled prevalence of chronic fatigue syndrome four weeks after the onset of COVID-19 symptoms, in 52 studies with a sample size of 127,117, was 45.2% (95% CI: 34.1-56.9%). Meta-regression analysis in examining the effects of the two factors of sample size, and year of study on the changes in the overall prevalence, showed that with increasing sample size, and year of study, the prevalence of chronic fatigue syndrome among long COVID patients (p < 0.05).

Conclusion

Our results show that the overall prevalence of chronic fatigue syndrome as a long COVID symptom is 45.2%. Chronic fatigue after infection with COVID-19 can negatively affect personal and social lives. Given such significant negative consequences caused by the syndrome, it is recommended that health policymakers allocate funds to reduce the adverse effects of this syndrome, by creating programs to support long COVID patients.

Sequelae of COVID-19 among previously hospitalized patients up to 1 year after discharge: a systematic review and meta-analysis

OBJECTIVE

Although complications and clinical symptoms of COVID-19 have been elucidated, the prevalence of long-term sequelae of COVID-19 is less clear in previously hospitalized COVID-19 patients. This review and meta-analysis present the occurrence of different symptoms up to 1 year of follow-up for previously hospitalized patients.

METHODS

We performed a systematic review from PubMed and Web of Science using keywords such as "COVID-19", "SARS-CoV-2", "sequelae", "long-term effect" and included studies with at least 3-month of follow-up. Meta-analyses using random-effects models were performed to estimate the pooled prevalence for different sequelae. Subgroup analyses were conducted by different follow-up time, regions, age and ICU admission.

RESULTS

72 articles were included in the meta-analyses after screening 11,620 articles, identifying a total of 167 sequelae related to COVID-19 from 88,769 patients. Commonly reported sequelae included fatigue (27.5%, 95% CI 22.4-33.3%, range 1.5-84.9%), somnipathy (20.1%, 95% CI 14.7-26.9%, range 1.2-64.8%), anxiety (18.0%, 95% CI 13.8-23.1%, range 0.6-47.8%), dyspnea (15.5%, 95% CI 11.3-20.9%, range 0.8-58.4%), PTSD (14.6%, 95% CI 11.3-18.7%, range 1.2-32.0%), hypomnesia (13.4%, 95% CI 8.4-20.7%, range 0.6-53.8%), arthralgia (12.9%, 95% CI 8.4-19.2%, range 0.0-47.8%), depression (12.7%, 95% CI 9.3-17.2%, range 0.6-37.5%), alopecia (11.2%, 95% CI 6.9-17.6%, range 0.0-47.0%) over 3-13.2 months of follow-up. The prevalence of most symptoms reduced after > 9 months of follow-up, but fatigue and somnipathy persisted in 26.2% and 15.1%, respectively, of the patients over a year. COVID-19 patients from Asia reported a lower prevalence than those from other regions.

CONCLUSIONS

This review identified a wide spectrum of COVID-19 sequelae in previously hospitalized COVID-19 patients, with some symptoms persisting up to 1 year. Management and rehabilitation strategies targeting these symptoms may improve quality of life of recovered patients.

First insights from patients presenting with long/post-COVID syndrome in primary care: an exploratory report

Background

Following the global pandemic of coronavirus disease 2019 (COVID-19), the long COVID or post-COVID syndrome refers to a relatively complex novel clinical entity. We conducted this study to assess the primary epidemiological features, main symptoms, and comorbidities probably related to this syndrome in patients referred to our long/post-COVID primary care unit during the initial months of its operation.

Methods and Material

This single-center prospective observational study was conducted between April 2022 and December 2022 and enrolled 71 patients (33 men, 38 women) who were examined due to persisting symptoms after recovering from COVID-19 infection, with the mean time of the first visit estimated at 3.12 ± 2.41 months from their acute COVID-19 illness. A thorough medical history, clinical examination, laboratory, and any other tests were performed on all patients when necessary.

Results

The most common symptoms of long/post-COVID reported were fatigue (63.4 %), a persistent cough (45.1 %), stress manifestations (42.3 %), arthralgia or myalgia (33.8 %), tachycardia (32.4 %), depression manifestations (29.6 %), exertional dyspnea (28.2 %), and sleep disorders (25.4 %). Hypertension (in about 40 %) and the presence of five or more symptoms during the acute COVID-19 illness (in approximately 52 %) could be regarded as factors increasing the long/post-COVID appearance. The long/post-COVID syndrome affects even patients not experiencing severe COVID-19 illness. Unvaccinated patients are at higher risk of severe COVID-19 (p =0.014), higher risk of hospitalization (p =0.002), and in higher need of respiratory support with high flow (p =0.017) when compared to vaccinated ones. Hospitalized patients appear to be older than outpatients (59 ± 12.42 vs 52.78 ± 11.48 years of age; p =0.032.

Conclusion

The long/post-COVID syndrome is an established clinical entity, and several clinical features, symptoms, and patient profiles have to be assessed from the initial medical contact in primary care to exclude early any other clinical conditions and offer guided therapeutic strategies to those patients. HIPPOKRATIA 2022, 26 (4):138-142.