Jaipur: For more than a month after recovering from Covid-19, pulmonologist and intensivist Abhishek Prajapati could not take on surgeries that needed extreme precision, such as lung biopsies. The 37-year-old who works at the Shree Krishna Hospital in Anand, Gujarat simply did not feel confident enough. He also complained of exhaustion, palpitations and an unusual pain in the calves that he feared was deep vein thrombosis (DVT).

"I was quite scared and even got a 2D echocardiography twice and a sonography of my calves to make sure all was okay," he said. Prajapati, who lost 4 kg during his illness, said his hospital supported him and gave him time to recover.

Like Prajapati, many who have recovered from Covid-19 face what is popularly referred to as 'long Covid'--new or existing symptoms that sometimes last for months. These include minor symptoms such as headaches and fatigue or moderate ones--recurring respiratory illness, persistent bodyache and temporary cognitive impacts. The disease can also lead to multiorgan impacts, formation of blood clots resulting in pulmonary embolism or stroke, and nascent diabetes.

There is also the psychological impact of the disease such as depression and anxiety. "It's like this fear settles in the hearts of those who have recovered," said Prajapati. He adds that many Covid-19 recovered patients often call him, worried about even minor symptoms such as a stomach ache or headache.

In varying degrees, all these symptoms affect the Covid survivors' ability to work, we found. Doctors and patients we interviewed said these after-effects impacted productivity at work and people feared the economic consequences of long Covid. Some of those we interviewed said they could not return to work for months after recovery. It is thus important that companies formulate special policies and support systems for "long haulers" or those dealing with long Covid, they said.

The companies we spoke to mostly reported exhaustion, headaches and poor energy levels among recovered employees. Some said that their revised HR policies, formed in response to the pandemic, are enough to take care of long Covid too.

The World Health Organization describes long Covid as "persistent state of ill health" and adds that there is no agreed international definition of it. And it can follow mild, moderate or severe infections. It is still unclear why some people suffer from long Covid.

Theories variously include post-traumatic stress, lasting lung damage, dysfunction of endothelial cells (that line the interior of blood vessels), or multisystem inflammatory system (a disease in which the immune system attacks healthy cells).

Doctors told IndiaSpend that given the high caseload in India, the second wave is likely to result in more cases of long Covid than the first. Prajapati, for instance, estimated that almost 1 of every 15 (6%) of his Covid patients show long Covid symptoms. Children can also be impacted by long Covid.

Covid hit at least 1.4% of India's working-age population

Research conducted in the US showed that recovered Covid-19 patients are more likely to be at risk of death and use health resources, such as medication. In the UK, 22% of 9,063 patients who were no longer infected had at least one symptom after five weeks of recovery and 10% had one symptom after 12 weeks. Similarly, a Chinese study found signs of lung damage in 24% of 83 patients 12 months after hospital discharge. Estimates from the UK say that around a million people, including 120,000 health workers, suffer from some form of long Covid.

Long Covid could impact India's demographic dividend--the growth opportunity from its large working-age population. At least 2.9 million Indians between the ages of 20 and 60 years--73% of all Covid-19 cases--contracted Covid-19 in less than four months to April 21, 2021, as per the data presented by the health secretary at a press briefing. Another 3.6 million in this age group had contracted Covid-19 in 2020. Together, these 6.5 million make for 1.4% of the 469 million Indians in the 15-59 age group that participates in its labour force. [These data do not cover all of India's Covid-19 cases and the working age population affected is likely to be larger.]

Researchers and doctors believe that India is likely undercounting its Covid-19 cases. Further, the proportion of those who could face long Covid is unknown as there is a lack of publicly available data on long Covid in India.

Little research is being done in India on long Covid or its impact on health or quality of life. "Currently in India recovery means not dying of Covid-19," said Somashekhar Nimbalkar, a neonatologist and associate dean of research services at the Pramukhswami Medical College in Karamsad, Gujarat. "They say that what doesn't kill you, makes you stronger but in the case of Covid it is 'what doesn't kill you, makes you weaker'," said Nimbalkar, who has applied for a grant to study long Covid. He suggested that patients be followed up for a year to evaluate whether they make a complete recovery.

IndiaSpend wrote to the country's premier research institution, the Indian Council of Medical Research, requesting data on long Covid collected through the National Clinical Registry from the post-Covid-19 Outpatient Departments (OPD) set up last year. The response was that the subject comes under the purview of the health ministry. IndiaSpend has reached out to the Ministry of Health and Family Welfare and the Director General of Health Services and the story will be updated if and when they respond.

'I feared I was losing my cognitive skills'

Body Politic, a US-based online international support group for Covid-19 patients, especially for those who have long Covid, found in a survey of its members that three of the most common symptoms after six months of Covid-19 were fatigue (77.7%), post-exertional malaise (72.2%) and cognitive dysfunction (55.4%). Of the total of 7,000 responses they received by mid-May 2021, 35 came from India, said US-based Hannah Davis, who is involved with Body Politic's survey. The survey is ongoing and the survey form can be accessed here.

Ritu* is a social science researcher who was working with a health firm when she contracted Covid-19 in April 2020. Two months later, she was still struggling through Covid-induced brain fog--lack of clarity in thoughts--every morning from 5.30 a.m. to 7.30 a.m., to complete a book she was working on. Ritu also complained of sleeplessness, anaemia and a feeling of tightness in her chest.

"I was afraid I would lose my cognitive abilities if I didn't work through it," Ritu said, adding how critical these skills were in her line of work. "It is almost like a disability but it is not recognised at the workplace."

Ritu finally had to give up her consulting job in June 2020 because her employers did not allow her paid leave and refused to budge on its standard HR rules. For women who have to juggle responsibilities at home and work, long Covid can be particularly hard, she pointed out. Ritu, who could once do a brisk 45-minute walk or carry kilos of groceries on her back without much effort, found that she could not even bathe her two-year-old daughter.

"It might not be visible from the outside, but Covid-19 ravages the bodies on the inside," said Prajapati, who said the disease demands at least 2-3 months of rest. Those in competitive and stressful roles at work, such as sales, deserve even more compassion and flexibility at work, he pointed out, adding that stress could worsen long Covid.

Ritu could afford to drop out of the workplace because her husband holds a well-paying job. But for many workers, especially those in the informal sector or on daily wages, quitting work might not be a choice.

"We've heard of those who had been fired because they could not do their job or work long hours," said Davis, who is involved with Body Politic and is a freelancer working on machine learning. She has not been able to take up freelance assignments since she got Covid-19 in April 2020 in New York because of several symptoms including serious memory loss and cognitive dysfunction.

"I lost so much energy that it is hard to explain what that feels like. Even being in a room with someone for five minutes or a phone call would wipe me out. There was a loss of friendships and relationships that come with any disability," she said. In New York currently, all post-Covid facilities have a waiting list, Davis said.

Flexi options, counselling

Wipro Limited provides financial support for recurring medical expenses such as OPD fees and has enhanced insurance coverage for additional expenses arising due to long Covid, a company representative said in an email response. Currently only about 2% of the company's staff is required to report to the office. The company is also exploring flexible working options for employees suffering from long Covid and their Employee Assistance Program (EAP) offers 24x7 counselling sessions for those who might need it.

Since the start of the pandemic, Urban Company, a gig platform for beauticians, carpenters, electricians and so on, has had a policy of unlimited leaves for the staff. "We encourage employees to take a day off if they are feeling unwell," said Raghav Chandra, its co-founder and technology head. As most of its employees are currently working from home, the company also insists that no one works on weekends.

The only post-recovery symptom employees have reported so far is fatigue, Chandra said. Gig workers who sign up for Urban Company can mark themselves off work for as long as they wish. They can also seek help from the company's relief fund that covers medical, hospital and bereavement expenses borne by gig workers. Those who work with the group's beauty segment in lockdown areas are offered interest-free loans.

Factories struggle to cope

Manufacturing units have a bigger problem at hand--work from home is not an option for most workers. Take the example of Noida-based Deki Electronics Limited, which manufactures capacitors. In the second surge, upto 50-60% of its employees have either contracted Covid-19 or need time off to care for sick family members, said the company's managing director, Vinod Sharma. Some employees who have recovered from Covid and are back at work are complaining of weakness and fatigue, he said. A 62-year-old vice-president, who had contracted Covid-19 in 2020, is still not back to his pre-Covid health.

Currently, 700 employees are at work at the factory but the company will need to hire nearly 200 more if the staff who are on Covid leave do not return to work or if their productivity is impaired, said Sharma, who is also the chairman of the Confederation of Indian Industries' (CII) National Committee on Information Communication Technology & Electronics Manufacturing. Deki's factory workers are free to choose their shift duration, based on their physical ability. "The energy-level is a problem. I hope it comes back to normal soon," Sharma said. The company encourages yoga and deep breathing sessions at home and work and has made its factory meals more nutritious to help convalescent workers.

Little attention to long Covid

India, which had record-breaking caseloads and fatalities in the pandemic, had put out generic guidelines on post-Covid management in 2020.

Post-viral complications are not new: Post-infection fatigue was observed after the onset of the 2003 SARS-CoV epidemic. In 2009, researchers found chronic fatigue in those who had recovered from H1N1 influenza. And another study found that 28% of those who recovered from the Ebola virus experienced unusual levels of fatigue.

Yet, back in June 2020, after her recovery, when Ritu started reporting long Covid symptoms, even doctors had no idea what she was dealing with. "It is almost a kind of surreal feeling, you keep asking yourself whether you are imagining this or is this actually happening," she said. Joining Body Politic helped her psychologically as she found others who were going through the same kinds of experiences; some were recovering, others not.

Now that long Covid has been recognised internationally, we need to…."learn how to better look after people with long-term complications after acute Covid-19", wrote Piero L Olliaro of the Centre for Tropical Medicine and Global Health at the Nuffield Department of Medicine at Oxford University.

On August 11, 2020, the health ministry said that an expert group on long Covid had been set up, headed by the Director General of Health Services. A guidance note released by the health ministry on September 13, 2020, said that "recovered patients may continue to report [a] wide variety of signs and symptoms including fatigue, body ache, cough, sore throat, difficulty in breathing, etc." It recommended steps such as drinking lots of warm water, taking "immunity promoting AYUSH medicine" prescribed by a qualified practitioner, mild and moderate exercise, a balanced, nutritious diet, adequate sleep, psychosocial support from peers, the community or a counsellor.

Other countries have invested in research on long Covid. The UK, for instance, has provided £8.4 million (Rs 86 crore) for studying the subject, giving an ongoing post-Covid hospitalisation study "urgent public health research status". The US has provided $1.15 billion (Rs 8,392 crore) over four years to its National Institutes of Health to research into the prolonged health consequences of Covid-19.

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