ABSTRACT
Introduction:
We undertook the first study from India to evaluate the long-term health effects of coronavirus disease 2019 (COVID-19).
Methods:
The patients enrolled in our post-COVID-19 clinic were followed up for assessment at 1, 3, 6 and 12 months after recovery from acute disease prospectively.
Results:
200 patients with mean age of 50.72 years and 57.5% males were analysed. 42.5% had severe and 17% had moderate disease at the time of diagnosis. The persistence of symptoms beyond 1 month of diagnosis was seen in 72.5% (145/200) patients. 8% (16/200) of the patients had post-COVID-19 complications that required rehospitalisation after discharge or recovery from acute COVID-19. The complications included respiratory failure (2%), lung cavities (3.5%), fungal infection, pericardial effusion, pneumothorax and death. The symptoms were persistent beyond 3 months in 51% (102/200) and beyond 6 months in 17.5% (35/200) of cases. The patients with persistent symptoms beyond 3 months and 6 months had significantly higher intensive care unit (ICU) admission during acute COVID-19, severe disease during acute COVID-19, and higher prevalence of comorbidities compared to the recovered patients. The clinical recovery was attained in 95.5% (91/200) patients, and the radiological recovery was attained in 97.92% patients at 1 year. The mean duration to clinical recovery was 174.2 days.
Conclusions:
COVID-19 recovery takes longer time. However, clinico-radiological recovery is attained in >95% cases by one year.
KEY WORDS: Long COVID, post-COVID complications, post-COVID-19 effects, post-COVID syndrome
INTRODUCTION
Coronavirus disease 2019 (COVID-19) is caused by a novel respiratory virus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It was first reported from Wuhan, China in December 2019.[1] The virus had spread rapidly and COVID-19 was declared a global pandemic by the World Health Organization (WHO) on 11th March 2020.[1] The disease was noticed first in India on 27 January 2020.[2] There are more than 750 million cases with more than 6 million deaths reported across the globe.[3] When the battle of acute COVID-19 was ongoing, there were reports of prolonged symptoms and various complications following recovery. Also, there were initial reports of COVID-19 behaving like an immunological disease with long-term complications and sequelae extending several months beyond the initial diagnosis.[4] However, the evidence regarding the clinico-radiological course of the disease beyond 1 year is sparse.
A meta-analysis of the studies limited to a few countries on post-COVID-19 effects found that there is a significant bias and inconsistent methodologies in most of the studies.[5] To the best of our knowledge, no study from India has followed up COVID-19 patients till 1 year to find out the time to clinical recovery and radiological resolution. Thus, we undertook “Follow-up Study of COVID-19 Sequelae (FOSCO study)”, first of its kind from India to comprehensively evaluate the long-term health effects of COVID-19 for 1 year from the initial diagnosis with the following objectives.
Objectives
Primary Objective: To study the prevalence and types of post-COVID-19 complications (PCC) among patients attending post-COVID-19 clinic.
Secondary Objectives:
To study the prevalence of persistent symptoms at 1, 3, 6 months and one year following the initial diagnosis of COVID-19.
To evaluate the factors affecting post-COVID-19 persistent symptoms.
To find out the time to clinical recovery from acute COVID-19.
MATERIAL AND METHODS
This was a prospective follow-up study conducted on all the patients presenting to the “post-COVID-19 clinic” of a tertiary care centre in Northern India from December 2020 to December 2021. Our institution was running a “post COVID-19 clinic” from Monday to Saturday from 9 a.m. to 12 p.m. along with routine respiratory out-patient department (OPD). The patients from the post-COVID-19 clinic were taken up for the FOSCO study if they satisfied the inclusion and exclusion criteria.
Inclusion criteria
History of confirmed diagnosis of COVID-19 (positivity by rapid antigen test or reverse transcriptase polymerase chain reaction)
Symptomatic patients
Adults having age >18 years.
Exclusion criteria
Asymptomatic COVID-19 cases.
Clinically diagnosed COVID-19 in the absence of laboratory confirmation.
Presence of significant systemic illness and moribund patients.
Presence of severe psychiatric illness that would hamper the follow-up clinical assessment.
Study Method: The FOSCO study was approved by the Institutional Ethics committee. A written and informed consent was taken from all the patients. The details of date of diagnosis, demographic parameters, clinical symptoms, disease severity at diagnosis, comorbidities, treatment used were recorded from the history and previous medical records. The details of medication used, requirement of intensive care unit (ICU) admission or non-invasive or invasive ventilation were checked from discharge certificate of patients admitted during acute illness. The laboratory investigations, findings of the chest radiograph and high resolution computed tomography (HRCT) of the chest and computed tomography severity score (CTSS) during acute COVID-19 were also recorded. The patients were classified into severities of disease at diagnosis based on the criteria advocated by WHO: mild COVID-19- SpO2 >94%, moderate - SpO2 90%–94%, and severe - SpO2 <90%.[6] All the patients were followed up at 1, 3, 6 months and 1 year after the initial diagnosis either via visit to the post-COVID-19 clinic or via telephonic interview. During the follow-up in post-COVID-19 clinic, the patients were evaluated for any clinical symptoms, dyspnea grade, SpO2, functional status and any other complications. The functional status was assessed using post COVID-19 functional status (PCFS) scale. The PCFS scale is a patient-reported outcome measure to evaluate the effect of COVID-19 on functional status.[7] The entire range of functional limitations is graded from 0 (no functional limitation) to 4 (severe functional limitations) (Box 1).
Box 1.
Post COVID-19 functional status (PCFS) scale
| PCFS score 0- No functional limitations |
| There is absence of symptoms, pain, depression or anxiety |
| PCFS score 1- Negligible functional limitations |
| There are some symptoms, pain, depression or anxiety but all usual activities at home or work can be carried out at the same level of intensity. |
| PCFS Score 2- Slight functional limitations |
| The usual activities at home or work are carried out at a lower level of intensity or are occasionally avoided due to symptoms, pain, depression or anxiety. |
| PCFS Score 3- Moderate functional limitations |
| The usual activities at home or work are reduced due to symptoms, pain, depression or anxiety. |
| PCFS Score 4- Severe functional limitations |
| There is need of assistance for the usual activities due to symptoms, pain, depression or anxiety or need of nursing care and attention. |
| PCFS score 5- Death |
The moderate and severe cases were additionally evaluated with 6-minute walk test (6MWT), spirometry, and HRCT of chest during the follow-up. If follow-up HRCT chest was not possible, chest radiograph was performed to evaluate the response. The patients were managed conservatively. The time to achieve clinical recovery was noted as per our definition. The data were recorded in the proforma.
Definitions used for the FOSCO Study
PCC: Any worsening of symptoms that required rehospitalisation after being discharged from hospital or after recovery from the acute COVID-19 in non-hospitalised cases. The rehospitalisation could be due to respiratory or non-respiratory causes leading to worsening of symptoms.
Clinical recovery: The patient became symptom free or had minimal symptoms with SPO2 >96% for >3 months. For those with underlying chronic respiratory disease, clinical recovery was defined when the patient returned to pre-COVID-19 clinical status and maintained the same for at least 3 months.
Radiological resolution: The resolution of pulmonary parenchymal and interstitial changes on HRCT thorax or chest radiograph by >80% were compared to findings during initial diagnosis. During the later part of study, repeated HRCT scans were avoided so as to reduce the risk of radiation exposure, and radiological resolution was compared with chest radiographs alone.
Statistical Analysis: The data were tabulated on MS-Excel® (2010). The statistical analysis was done using SPSS software version 16.0 (IBM, Chicago, USA). The continuous variables were presented as mean ± standard deviation or median (interquartile range) as applicable. The categorical variables were presented as n (%). The various parameters were compared between two groups: patients who developed the post-COVID-19 effects and who did not develop. The univariate analysis was done using the independent sample student’s t-test for continuous variables and the Fisher exact test or Chi-square test for the categorical variables wherever applicable. The parameters with P value of <0.2 were subjected to multiple logistic regression analysis to find out the significant predictors of post-COVID-19 effects at 3 and 6 months follow-up. The P value of <0.05 was considered to be statistically significant.
RESULTS
Among all the patients presenting to our post-COVID-19 clinic, 248 fulfilled the inclusion/exclusion criteria. Around 200 patients who completed follow-up for 1 year of diagnosis were included in the final analysis. We could not collect follow-up data of 48 patients as telephonic contact with some patients was not possible and some did not respond properly to our telephonic interview. Table 1 describes the demographic, clinical and laboratory parameters of the 200 patients during the active disease. The mean age of the patients was 50.72 ± 13.70 years. There were 57.5% (115/200) males and 42.5% females. Their mean body mass index (BMI) was 25.49 ± 4.93 kg/m2. Comorbidities were present in 59% of the patients. The most common comorbidities were hypertension (24%) and diabetes (22%). Coexisting obstructive lung diseases were present in 18% (36/200) of patients. None had pre-existing diffuse parenchymal lung disease except for one patient who had right upper lobe fibrosis due to old tuberculosis. Among 200 patients included in the final analysis, 42.5% had severe disease during acute COVID-19. During the active disease, 48.5% patients required hospitalisation and 11.5% required ICU care. Their mean duration of admission was 19.54 ± 21.57 days. Oxygen therapy was given in 43.5% of the cases during the active phase of disease while 54% had received systemic steroids. Chest radiograph was available in 48% of patients during acute disease. A total of 30.5% patients had undergone HRCT chest with the mean CTSS of 14.56 ± 5.82.
Table 1.
Demographic, clinical and laboratory parameters of patients during active COVID-19
| Demographic Parameters | n=200 |
|---|---|
| Age | 50.72±13.70 |
| Gender (male %) | 115 (57.5%) |
| BMI | 25.49±4.93 |
| Smoking history | 31 (15.5%) |
| Vaccinated against COVID-19 | 58 (29%) |
| Comorbidities | 118 (59%) |
| Hypertension | 48 (24%) |
| Diabetes | 44 (22%) |
| Chronic obstructive airway disease | 36 (18%) |
| Hypothyroidism | 13 (6.5%) |
| Cardiovascular disease | 13 (6.5%) |
| Obstructive sleep apnoea | 4 (2%) |
| Clinical parameters | |
| Severity of disease | |
| Mild disease | 81 (40.5%) |
| Moderate disease | 34 (17%) |
| Severe disease | 85 (42.5%) |
| Presence of fever (%) | 175 (87.5%) |
| Mean duration of fever (days) | 6.38±5.57 |
| Presence of hypoxia (SpO2 <90%) | 86 (43%) |
| Mean SpO2 (%) | 87.42±12.5 |
| Admission rate | 97 (48.5%) |
| ICU admission | 23 (11.5%) |
| Mean duration of admission | 19.54±21.57 |
| Use of medication during acute COVID-19 | |
| Remdesivir | 31 (15.5%) |
| Tocilizumab | 2 (1%) |
| Systemic steroids | 108 (54%) |
| Pulse methylprednisolone | 8 (4%) |
| Anticoagulant use | 75 (37.5%) |
| Plasma therapy | 3 (1.5%) |
| Oxygen therapy | 87 (43.5%) |
| Non-invasive or invasive ventilation use | 14 (7%) |
| Chest X-ray done | 96 (48%) |
| CT chest done | 61 (30.5%) |
| Mean CT severity score | 14.56±5.82 |
| Discharge parameters | |
| Mean SpO2 (%) | 93.54±5.72 |
| Use of oxygen support | 28 (14%) |
| Use of steroids | 45 (22.5%) |
| Use of antifibrotics | 11 (5.5%) |
| Use of anticoagulants | 40 (20%) |
BMI- Body mass index. ICU- Intensive care admission. CT- Computed tomography
The admitted patients had a mean SpO2 of 93.54 ± 5.72% at discharge. Out of the total cohort, 14% required oxygen support at discharge. The steroids and antifibrotics were prescribed in 22.5% and 5.5%, respectively. The antifibrotics received were either pirfenidone or nintedanib at suboptimal doses and none had received for more than a month. The steroids used at discharge also had a variable dosing regimen.
In our study, PCC was seen in 8% (16/200) of the patients during follow-up [Figure 1]. Most had respiratory complications except for one with pericardial effusion. Among the total study population, 2% (4/200) were readmitted with respiratory failure. Secondary infections and pulmonary embolism were ruled out in them and they improved with systemic corticosteroids. The other PCC seen were pulmonary cavitation in 3.5% (7/200), fungal infection in 1% (2/200), pericardial effusion in 0.5% (1/200) and pneumothorax in 0.5% (1/200) patients. Out of the total cohort, one patient died after readmission with respiratory failure. The cause of death could not be confirmed but likely to be related to a delayed immune response related to the virus. Among those who had PCC in terms of cavitation, three patients had tuberculosis, one had aspergillosis, one had bacterial abscess, and two had no definite etiology for the cavitation. All our patients with cavity had improved outcome with appropriate management. Figure 2 shows the radiology of the patients with post-COVID-19 cavity.
Figure 1.
Pie chart showing the prevalence and types of various post COVID-19 complications
Figure 2.
Radiological data of some patients with post COVID-19 cavity. Patient 1: 1A and B - Chest radiograph and CT scan showing right middle lobe cavity due to aspergillus, CT also shows residual bilateral lower lobe opacities due to COVID-19 pneumonia. 1C- Chest radiograph after 2 months of voriconazole therapy, 1D- Chest radiograph after 4 months of treatment, shows complete resolution. Patient 2: 2A and B - Chest radiograph and CT scan showing right middle lobe and lower lobe lung abscess due to E. coli, CT scan also shows left lower lobe opacities due to COVID-19 pneumonia. 2C and D- Chest radiographs after 2 months and 4 months respectively showing complete resolution with residual plural thickening. Patient 3: 3A- Chest CT scan at 2 months follow-up after resolution of COVID-19 pneumonia, 3B shows development of a new cavity in right lower lobe at 3 months follow-up without any obvious cause. Patient 4: 4A- Chest CT scan during COVID-19 diagnosis, 4B- Follow-up CT scan after 3 months showing resolution of initial ground glass opacities and a new cavity in left lingular lobe due to tuberculosis
All the patients were followed up at 1, 3 and 6 months and at the end of 1 year after the initial diagnosis of COVID-19. Table 2 shows the follow-up data of the patients. At 1 month follow-up, 72.5% (145/200) patients had long COVID-19. The residual symptoms included dyspnea, cough, fever, chest pain and hemoptysis. Their mean SpO2 at 1 month follow up was 94.97 ± 5.08%. Hypoxemia (SpO2 <90%) was seen in 10.25% (21/200) of patients at 1 month follow-up. A poor quality of life with PCFS score of 3 and 4 was observed in 20.5% patients. At three months follow-up, 51% (102/200) of patients had persistent symptoms among which 12.5% had hypoxemia. The mean SpO2 at the end of 3 months was 95.68 ± 4.69 and only 11% had poor quality of life. The persistence of symptoms beyond 6 months was found in 17.5% patients. Only 3% of the patients had residual hypoxemia. At 1 year follow-up, 95.5% of the patients had attained clinical recovery while only 4.5% did not improve. On analysis of the radiological data available in 48.5% (96/200) patients, only 9.37% had radiological resolution at 3 months while it increased to 25% at 6 months and 97.91% at 1 year. The timeline of the patients is graphically shown in Figure 3. It is evident that long-term symptoms up to 3 months were seen in about 50% of cases but complete recovery was seen in >80% cases in 6 months and in >95% cases in 1 year. We found the mean time to clinical recovery was 174 days.
Table 2.
Follow up data of the patients
| Parameters | 1 month follow up | 3 month follow up | 6 month follow up | 1 year follow up |
|---|---|---|---|---|
| Residual symptoms | 145 (72.5%) | 102 (51%) | 35 (17.5%) | 9 (4.5%) |
| Outcome (improved) | 55 (27.5%) | 98 (49%) | 165 (82.5%) | 191 (95.5%) |
| SpO2 (mean) | 94.97±5.08 | 95.68±4.69 | 97.14±2.92 | 97.33±0.88 |
| Hypoxia (SpO2<90%) | 36 (18%) | 25 (12.5%) | 6 (3%) | 2 (1%) |
| Mean mMRC grade | 1.275 | 0.89 | 0.43 | 0.176 |
| Significant dyspnea (mMRC grade 3 & 4) | 32 (16%) | 17 (8.5%) | 6 (3%) | 0 |
| Functional status (Mean PCFS score) | 1.3 | 0.82 | 0.405 | 0.12 |
| PCFS score 3 & 4 | 41 (20.5%) | 22 (11%) | 7 (4.43%) | 1 (0.5%) |
| Return to work | 112 (56%) | 140 (70%) | 187 (93.5%) | 197 (98.5%) |
| Radiological recovery (Out of 96 patients) | Nil | 9/96 (9.37%) | 24/96 (25%) | 94/96 (97.91%) |
| 6MWD (mean) | 382.7±108.14 (Done in 15 subjects) | 414.66±92.39 (Done in 12 subjects) | 385±42.88 (Done in 8 subjects) | N/A |
| FEV1 (mean) | N/A | 1.81±0.67 (Done in 14 subjects) | 1.79±0.65 (Done in 12 subjects) | N/A |
mMRC- Modified medical research council. PCFS- Post COVID-19 functional status. 6MWD- 6 minute walk distance. FEV1- Forced expiratory volume in 1st second. N/A- Data not available
Figure 3.
Illustrative image showing timeline of clinical parameters during COVID-19
Our study compared various factors between the patients who improved versus those who did not improve at the end of follow-up of 3 and 6 months [Table 3]. In the univariate analysis among subjects having symptoms beyond 3 months versus those improved, it was found that there was statistically significant difference in parameters like presence of comorbidities, duration of fever, severity of disease, requirement of steroids, anticoagulants, oxygen and ICU admission. The univariate analysis among subjects having symptoms beyond 6 months and those who improved after 6 months showed that those with presence of comorbidities, severe disease, steroids/oxygen and ICU requirement were significantly more likely to have prolonged symptoms. Paradoxically, those with post-COVID-19 long-term symptoms had significantly higher use of antifibrotics compared to those who improved. The multiple logistic regression analysis did not find any factor to be a significant predictor for the persistent symptoms at 3 and 6 months.
Table 3.
Univariate analysis to find out predictors of post COVID-19 effects at 3-months follow up and 6-month follow up
| Parameters | Predictors of post COVID-19 effects at 3-months follow up | Predictors of post COVID-19 effects at 6-months follow up | ||||
|---|---|---|---|---|---|---|
|
|
|
|||||
| Persistence of post COVID-19 effects (102) | Improved (98) | P | Persistence of post COVID-19 effects (n=35) | Improved (n=165) | P | |
| Age | 51.2±12.5 | 50.1±14.8 | 0.304 | 52.03±11.76 | 49.50±14.57 | 0.175 |
| Gender M: F | 61: 41 | 54: 44 | 0.501 | 19: 16 | 93: 72 | 0.821 |
| BMI | 25.86±5.22 | 25.04±4.54 | 0.133 | 25.94±5.39 | 25.18±4.76 | 0.214 |
| Smoking history | 18 (17.6%) | 13 (13.2%) | 0.392 | 7 (20%) | 25 (15.15%) | 0.478 |
| Vaccination yes: no | 28: 74 | 30: 68 | 0.622 | 10: 25 | 60: 105 | 0.379 |
| Presence of comorbidities | 65 (63.7%) | 49 (50%) | 0.049 | 26 (74.2%) | 85 (51.51%) | 0.014 |
| Severity of disease | ||||||
| Mild | 32 | 49 | 0.001 | 7 | 74 | 0.014 |
| Moderate | 14 | 20 | 6 | 28 | ||
| Severe | 56 | 29 | 22 | 63 | ||
| Requirement of steroids | 60 (58.8%) | 41 (41.83%) | 0.016 | 23 (65.7%) | 76 (46.06%) | 0.035 |
| Requirement of anti-coagulants | 46 (45.09%) | 29 (29.59%) | 0.023 | 14 (40%) | 54 (32.73%) | 0.409 |
| Oxygen requirement | 55 (53.92%) | 30 (30.6%) | <0.001 | 19 (54.28%) | 58 (35.15%) | 0.034 |
| ICU requirement | 17 (16.66%) | 4 (4.08%) | 0.003 | 8 (22.8%) | 10 (16.5%) | 0.002 |
| Use of antifibrotics | 10 (9.80%) | 1 (1.02%) | 0.006 | 7 (20%) | 4 (2.42%) | <0.0001 |
BMI- Body mass index. ICU- Intensive care unit
DISCUSSION
There is growing evidence that COVID-19 is beyond an acute disease. Over the course of the pandemic, various terminologies have been used for the post-COVID-19 long-term effects.[8,9,10,11] The burden of various post-COVID-19 health effects is variable from 10% to 80% depending on multiple factors. As per the estimates by the Institute for Health Metrics and Evaluation, by the end of 2021, 3.7% out of total 3.92 billion infected cases developed post-COVID-19 condition as defined by the WHO (persistent or new symptoms after 3 months). Also, 15.1% out of those with post-COVID-19 condition had persistent symptoms at 12 months.[8] To the best of our knowledge, there are no studies on long-term morbidity following COVID-19 in the Indian subcontinent, which was one of the worst affected during the first and second waves caused by one of the worst variants called kappa and delta variants.[12,13] We for the first time from India followed up COVID-19 patients for 1 year to find out the various complications and other health effects.
We found PCC in 8% of total study population. Respiratory failure was seen in 2% and lung cavitation in 3.5%. The other causes of PCC were fungal infection, pericardial effusion and pneumothorax. One patient died due to PCC. The spectrum of complications seen in our study is similar to earlier reports.[12] The prior data shows that 10%–20% of patients of COVID-19 required rehospitalization after discharge.[14] Another study from UK found that one-third out of 47,780 patients were readmitted and >10% died after discharge.[15] The cause of rehospitalization after discharge in earlier studies is not explained.[16,17] We observed that all our respiratory failure patients improved with systemic corticosteroids except one. This could be related to the rebound phenomenon seen in some case of COVID-19. The causes of rebound are viral reactivation, prolonged cytokine release syndrome and secondary organising pneumonia due to immune dysregulation.[18] One of the patients even expired due to the same complication. Some of the patients developed PCC because of cavities. The cause of post-COVID-19 cavity in our study is similar to earlier reports with the most common being secondary infection.[19,20] The earlier reports have mentioned the natural course of these cavities in survivors to be uncertain. However, we have followed them up till one year and found that the some of the cavities are non-infectious and improve without any intervention.
We had a detailed analysis of the COVID-19 timeline. We found that the persistence of symptoms was seen in 72.5% of patients at 1 month, 51% of the patients at 3 months and 17.5% of the patients at 6 months. Our findings are in line with prior studies that shows a varied prevalence of persistent symptoms ranging from 9% to 80%.[5,13,21,22,23,24] This could be related to the difference in initial disease severity which included various studies. Also, studies included patients from different waves of COVID-19 caused by different variants of virus. Our study showed that progressively there was improvement in radiology, functional status and hypoxemia. We followed up the patients for 1 year and found that the most common radiological outcome is healing without fibrosis seen in 97.91% cases. It was believed that COVID-19 might cause pulmonary fibrosis, also referred to as post-COVID interstitial lung disease.[14,25] This made a lot of physicians prescribe antifibrotics or steroids. Almost all our patients recovered completely irrespective of antifibrotic use. Our study also found that the mean duration to clinical recovery was 174 days, that is, roughly around 6 months and clinico-radiological recovery is attained in >95% cases by 1 year. So, we can assume that healing is complete by 1 year. This brings hope that COVID-19 is not a chronic disease as predicted earlier. Those with residual symptoms should receive additional medical, psychological and rehabilitative support as part of a multidisciplinary approach to have a scar-free healing.
When we analyzed the factors affecting development of prolonged symptoms beyond 3 months, it was found that the presence of comorbidities, severity of initial disease, requirement of steroids, requirement of oxygen support and ICU admission were significant contributors in the univariate analysis but none was significant after multivariate analysis. The earlier studies have found that severity and ICU admission during acute COVID-19 is the strongest predictor of long-term post-COVID-19 effects. This is because severe disease is associated with acute respiratory distress syndrome (ARDS), which is likely to have long-term effects as with other critical illnesses. There are variable results of association of the patient’s demographic parameters, presence of comorbidities and initial symptoms with post-COVID-19 long-term effects. Thus, the predictability of these parameters for the post-COVID-19 effects is not accurate.[5,12,24] Our results also suggest that no single factor can predict the post-COVID-19 effects when confounders were removed. This is probably because COVID-19 itself is a very strong independent risk factor for the post-COVID-19 effects.[12,26] Though antifibrotics were predicted to prevent post-COVID-19 fibrosis, we observed a paradox that antifibrotics use was associated with higher prevalence of post-COVID-19 long-term effects. This was probably because the likelihood of using antifibrotic was higher in patients with severe disease. Thus, we can conclude that antifibrotics have no impact on long-term sequelae.
Our study has some limitations. We had a limited sample size from North India, but the results may be extrapolated. There was selection bias as we recruited patients presenting to the post-COVID-19 clinic only. The symptomatic patients are more likely to seek medical attention, hence it could be an overestimation of the actual burden. Our study recruited patients from different waves of the pandemic attributed to the kappa and delta variants, which could also affect the variability in results.
CONCLUSION
The recovery from COVID-19 is longer than other viral pneumonias but clinical and radiological recovery is attained in >95% cases by 1 year. Some of the PCC due to immune dysregulation require use of steroid. The development of long-term post-COVID-19 effects is affected by initial disease severity and ICU admission. The patients should receive a holistic care during the acute COVID-19 as well as recovery phase to minimize the PCC.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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