Long Covid: A hidden pandemic

Tuesday July 27 2021
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Health workers attend to a Covid-19 patient in the ICU at Mulago National Referral Hospital in June. PHOTO/ FILE

By GILLIAN NANTUME

When Olivia Komugisha, a journalist, got Covid-19 in early June, she did not visit a hospital for treatment because her symptoms were mild.
 
“That was the time when hospitals around Kampala were full and the doctors were encouraging home-based care. I had flu, cough and fever, but I wasn’t really feeling so sick. However, the chest pain I experienced every night left me breathless. The only time I got relief was when I steamed,” she says. 
Since the country was hit by a second wave of Covid-19 in May 2021, social media has been awash with remedies to “prevent” the disease – and for those who contract it – to decongest the chest. One such remedy involves putting an assortment of herbs in a basin, pouring boiling water over them, and then, bending over the basin and inhaling the steam.
 
After two weeks, Komugisha tested negative for Covid-19. However, the effects of the disease still linger, especially in her ears. 
“My inner ears are itchy and painful. I constantly hear buzzing sounds. I still suffer stuffiness in my chest, and sometimes, breathlessness. A friend told me about some tablets I could take for my ears, but the medication worked for only a moment. Someone told me about a clinic I can visit at Mulago Hospital, but I haven’t been there because of the restrictions on transportation,” she says.
 
Komugisha still takes a blend of ginger, lemon and garlic for her chest pain. However, recently, a doctor she called advised her to go for a chest scan to assess the damage the disease could have done to her lungs. 
Komugisha is not alone. A growing number of Covid-19 survivors still have long-term health complications after they have recovered from the original infection. Some of these people did not really have severe Covid-19.

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Symptoms of long Covid
Dr Frederick Nakwagala, a senior consultant physician at Mulago National Referral Hospital in Kampala, and the Head of the Mulago Covid-19 Treatment Unit, says most of the people coming in for post-Covid care had fallen ill with mild symptoms of the disease. 
“About five percent of the recoveries come back with persistent symptoms. The commonest symptoms are fatigue, muscle pains that cannot be explained, difficulty in breathing, and tightness of the chest. Five percent is not a huge number, but it is significant. Interestingly, those who were treated at home are more likely to come to hospital with long Covid,” Dr Nakwagala says.  
 
Covid-19 statistics released by the Ministry of Health on July 20, show that there were 1,231 new Covid recoveries. This means that of these, 61 survivors (five percent) will return to hospital with long Covid.  If, according to statistics, on average, about 60 new people every day, are logging in with symptoms of long Covid, since the second wave hit the country. 

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Uganda has three clinics – in Mulago, Entebbe General Hospital, and at the Namboole Covid-19 Treatment Centre – that treat post-Covid recovery patients.  Although Dr Nakwagala will not commit to numbers, sources at the post-Covid clinic in Mulago Hospital say before the lockdown was imposed, about 30 people were coming in daily with long Covid. 
On June 19, President Yoweri Museveni imposed a 42-day lockdown to curb the spread of the coronavirus. Now, because of the ban on public and private transport, the clinic is seeing only half that number daily. 
 
Causes of long Covid
Ordinarily, while it would be expected that those who suffered severe disease are more prone to long Covid, Dr Nakwagala says those who suffered mild disease are sometimes, disadvantaged by their strong antibodies. 
“These people were never hospitalised because their bodies produced a high number of autoantibodies which successfully fought off the disease. However, these strong autoantibodies sometimes end up becoming a liability to the body,” Dr Nakwagala says. 
A study, Autoantibodies stabilize neutrophil extracellular traps in Covid-19, has found that these autoantibodies may be harmful to patients with Covid-19 if they persist for a long time, and thus, may contribute to the development of long Covid.
 
“So, you can imagine, you got a simple flu, didn’t go to hospital but treated it at home like any other ordinary flu. But then, you are now being told that your lungs have all along been suffering from pulmonary fibrosis,” Dr Nakwagala says. 
Pulmonary fibrosis is a is a form of lung disease where the normally thin, lacy walls of the air sacs in the lungs are no longer thin and lacy, but get thick, stiff and scarred, which is also known as fibrotic. With this scarring, the architecture of the lung gets stiffer and is less efficient in the ability to get oxygen into the bloodstream. In addition, the stiffness or fibrosis of the tissue makes it more difficult to expand the lungs and breathe.  
There are many causes of pulmonary fibrosis and with many recovered Covid-19 patients who are suffering from continuing symptoms of the disease, a number are being found to be afflicted with varying severities of pulmonary fibrosis. Pulmonary Fibrosis is difficult to treat, and it can take from three months to a year for the lungs to get back to pre Covid-19 levels.

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“The world can crush on you. This is a disability of sorts. When you get this condition, you can develop right heart failure (cor pulmonale), which you have to live with for the rest of your life,” Dr Nakwagala adds. 
Some Covid-19 survivors have gone on to develop post-Covid chronic medical complications that they previously did not have, such as, diabetes, hypertension, kidney disease, and blood clots.
 
Dr Robert Kalyesubula, a nephrologist, says for some people, the multiple drugs used in the treatment of Covid-19, are likely to cause kidney complications. 
“Kidney involvement in a Covid-19 survivor is a result of severe disease. Most of them do not make it out of the ICU. But, if they are discharged, about 20 percent return with kidney problems. The majority will have their kidneys recover over a period of three to six months, but a few will go on to have chronic kidney disease,” he says.
 
Dr Nakwagala, agrees, saying some antibiotics and anti-inflammation drugs could be linked to post-Covid chronic medical conditions. 
“Long Covid is a result of the disease. However, for post-Covid chronic conditions, there is one drug that is worrying us. We fear that dexamethasone can damage the body and cause diabetes and high blood pressure in people who previously did not have these conditions. Dexamethasone can also destroy the adrenal gland. So, we are trying to watch out for people who have been using it,” he says. 
According to the World Health Organisation, Dexamethasone is a corticosteroid used in a wide range of conditions for its anti-inflammatory and immunosuppressant effects. It was tested in hospitalised patients with COVID-19 in the United Kingdom’s national clinical trial RECOVERY and was found to have benefits for critically ill patients.
 
Dexamethasone is an over-the-counter drug in a number of pharmacies in Kampala and Wakiso, and as a result, a number of Ugandans have been using it a prophylaxis, and as treatment for Covid-19 at home.
 Last month, pharmacists warned against dexamethasone use as a Covid drug, urging doctors not to prescribe it for patients undergoing home-based care. They say dexamethasone lowers immunity yet people who have mild disease have to boost their immunity.
 
In an earlier interview with this newspaper, Dr Samuel Opio, the secretary of Pharmaceutical Society of Uganda (PSU), said although dexamethasone’s anti-inflammatory effect was useful in reducing mucus production, it should only be used on critically ill Covid-19 patients. 
Dr Charles Olaro, the head of clinical services at the Ministry of Health, said at the time that the ministry had not recommended the use of dexamethasone for home-based care, but did not comment on how the ministry is regulating its use.

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Available treatment options
Although long Covid can affect anyone, the people who are most at risk of contracting the coronavirus are the ones who are more likely to suffer. These include people above 65 years, people who are living with chronic respiratory illnesses like asthma, and people who are obese.   
Dr Ivan Kisuule, a physician and the Head of the Namboole Covid-19 Treatment Unit, says at his Unit, the majority of those with Long Covid have had severe disease.
 
“A month after discharge, eight out of every ten people are grappling with long Covid. At six weeks, we have about six people out of ten, and at eight weeks, we have five people coming back. Three months after recovery, there might be three people who still have symptoms, and these usually last a very long time. Long Covid is happening especially to people who required to be put on oxygen and as a result, they developed a bit of lung damage or fibrosis,” he says.
 
Dr Kisuule adds that lung damage is permanent and there is no cure for it. “We have had to discharge some patients who are on oxygen because their oxygenation has failed to improve due to the fibrosis. These people will have to use long-term oxygen therapy. They have to buy oxygen cylinders to use at home. Some may require being on oxygen for life,” he says. 
Currently, post-Covid care at the three clinics is free-of-charge. However, in most cases, doctors refer the patients to specialists. For a population of 43 million, Uganda has 12 adult cardiologists, 12 nephrologists, and six pulmonologists. Most of these specialists are based in Kampala.
 
Currently, there are no statistics on the impact of long Covid on the country’s healthcare system. Seeing a specialist is expensive. For instance, a chest scan costs between Shs200,000 (USD 56) and Shs500,000 (USD 140) in private facilities.  For those who develop kidney disease, the cost of dialysis can be prohibitive. 
“Those with mild injury of the kidneys may need Shs 200,00 (USD 56) a month for treatment. For moderate injuries – without dialysis – they could use Shs 3m (USD 848). However, those who need dialysis will spend about Shs 1m (USD 283) a week. They will need about Shs 12m (USD 3,392) to manage that kidney for three months, excluding the cost of drugs,” Dr Kalyesubula says.
 
Dr Nakwagala says besides medication, in most cases, the care for long Covid is psychotherapeutic. 
“Some people may lose jobs due to reduced work output, and they will become disinterested in life and embrace negativity. There may be instances of reduced sperm count and loss of sexual interest. In the long run, this will affect their social relationships. That is why psychological therapy is very important in treating long Covid,” he says.
 
Can vaccines help?

People with long Covid remain at risk of contracting Covid-19 again. Col Dr John Lusiba, a physician and cardiologist working with the Mulago Covid-19 Treatment Unit, says getting vaccinated might be the only hope for everyone. 
“The vaccine is still new and we do not know its long-term effects. Most experts probably believe vaccination prevents severe disease and the available information is that it can help one not to get long Covid,” he says. 
Dr Lusiba adds that people with long Covid should boost their immunity as they wait for vaccination. “Eat foods with zinc and Vitamin C, control your weight, and take your drugs on time if you have an underlying medical condition,” he says.
 
Dr Nakwagala, who is also the Pillar Head for the Case Management Pillar at the Ministry of Health, says there are ongoing discussions in the ministry about opening post-Covid-19 clinics countrywide to bring services closer to people. 
 
This article was produced by the Africa Women’s Journalism Project (AWJP) in partnership with The ONE Campaign and the International Center for Journalists (ICFJ).”

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