In a span of four months, the Sree Avittom Thirunal Hospital, the maternal and child health wing of Government Medical College, Thiruvananthapuram, reported a rise of multisystem inflammatory syndrome in children (MIS-C), a serious but otherwise rare condition. While the hospital had earlier recorded at least one case every one or two months, between September 2020 and January 2021, the Sree Avittom Thirunal Hospital alone saw 48 MIS-C cases. Doctors say that the rise of such cases is associated with COVID-19, and is a result of the effect of the immune response of children to the novel coronavirus. While studies have shown that young children are better equipped to fight the SARS-CoV-2 virus that causes COVID-19, with the majority having mild or asymptomatic infections, Dr A Santhosh Kumar, the Kerala Medical Board Chairman, says that in a small percentage of children the immune system overreacts. “The immune system starts attacking parts of the body where remnants of the virus are present,” says Dr Santhosh. Sree Avittom Thirunal Hospital, however, isn’t alone in seeing a sudden rise of multisystem inflammatory syndrome cases among children. A study in the peer-reviewed medical journal 'The Lancet' in May 2020, found a 30-fold increase in Kawasaki disease, a multisystem inflammatory disease, among children in Bergamo, which was the epicentre of the COVID-19 epidemic in Italy. The study had warned that a similar outbreak could be expected in countries which are affected by COVID-19. And although a spike in such cases is worrying, Dr Santhosh, who is also the superintendent of Sree Avittom Thirunal Hospital, says that all children admitted at the hospital so far have recovered after treatment. “Though MIS-C cases are potentially life threatening, all affected children have made a recovery,” he says. While 70% of children with MIS-C have redness in their eyes, Dr Santhosh says other symptoms include redness in mouth and diarrhea. Though most of the children were asymptomatic for COVID-19, they later started experiencing fatigue. Unexplained fatigue, rash, inflammation in hands or legs, joint pain, diarrhea and shortness of breath are some of the common symptoms found in the children, who were later diagnosed with MIS-C. “Most of the children developed issues within one to three months after COVID-19 infection,” he notes. Kerala state medical board chairman and superintendent of SAT hospital Dr A Santhosh Kumar explains on the post Covid issues, especially the rising cases of multi system inflammatory syndrome in children (MIS-C) pic.twitter.com/qs6dRBLO2K — Jisha Surya (@jishasurya) February 20, 2021 Dr Santhosh observes that treating MIS-C is a tricky task as the focus is to suppress the immune system from overreacting. “Since antibiotics won’t work on the coronavirus, our immune system will have to handle it. Due to this, immunosuppressants cannot be provided. However, here we have to use our discretion over when to provide immunosuppressants and when not,” Dr Santhosh explains. He goes on to say, “Around 30 % of children diagnosed with MIS-C during the September – January period had cardiac dysfunction due to coronary dilatation (dilation of arteries supplying blood to the heart resulting in reduced pumping or blood clotting in that area). However, the condition was normalised through appropriate medication. Sometimes, we have to give anti-clotting medication to prevent thrombus (clot) in arteries due to coronary dilatation.” While the effects of COVID-19 on children are still being investigated, adults are experiencing different kinds of complications. Long COVID-19 Thirty-four-year-old media professional Kripa Narayanan tested positive for the coronavirus on October 14. And although ten days later her test returned negative for the coronavirus, officially marking her recovery, she soon began to suffer from a number of post-COVID-19 issues. “I joined work a week after my COVID-19 test returned negative. But even a 10-minute walk from home to office was highly tiring that I wanted to lie down immediately after reaching the office. I was also experiencing headaches. So I extended my leave for one more week. Now, the headache has turned into an everyday affair, so is drowsiness. I had breathing issues in the past and COVID-19 has aggravated it. It is difficult to climb stairs due to palpitations and shortness of breath. Other symptoms, including lack of smell, are persisting even after three months,” says Kripa, who is among a growing number of people suffering from post-COVID-19 issues. With the support of ASHA (Accredited Social Health Activist) workers and health staff, the state Health Department has launched a massive task of identifying patients with post-COVID-19 syndrome. While post-COVID-19 clinics were opened across the world, Kerala has started screening patients from the primary level. Decentralised approach Dr Bipin Gopal, nodal officer, non-communicable diseases and post-COVID-19 syndrome, says that a total of 1284 post-COVID-19 clinics were started in the state till January 29. Clinics were started at primary health centres, taluk and general hospitals and medical colleges. “ASHA workers and local health workers have data of the COVID-19 affected persons. All of them, whether they have post-COVID-19 symptoms or not, will be asked to undergo a screening at the nearby PHC,” he says. Post Covid clinic in Pulayanarcota in Trivandrum, Kerala. The state health department has started 1284 post Covid clinics to identify, screen and address the issue of long Covid among the Covid patients. ASHA workers, local health employees help in tracking the patients. pic.twitter.com/1gTeqBY3P0 — Jisha Surya (@jishasurya) February 20, 2021 As per data from the Health Department, a total of 1,45,188 patients (15% of the total COVID-19 cases) were followed up for screening, out of which 51,508 persons were screened through eSanjeevani, the telemedicine programme. Out of the total screened, patients with respiratory problems topped the list. Around 5% of the screened patients, which is 7409 persons, had respiratory issues as a post-COVID-19 complication, while 1649 persons had cardiac problems. There were 3341 patients with musculoskeletal symptoms. Around 1400 persons had neurological issues and 812 had psychological problems. While 882 persons were referred to higher centres for detailed review, 123 patients required hospital admission. Fatigue to lung damage Dr A Fathahudeen, Vice Principal and Head of Department of Pulmonolgy and Critical Care at Government Medical College, Ernakulam details the case of a 60-year-old patient who developed pneumonia post COVID-19. The condition of the patient, who was obese, soon worsened into respiratory failure. “He was given mask ventilation for four weeks and later put on mechanical ventilator support for another two weeks. An effect of long active COVID-19, he died on the 50th day after testing positive. The virus attack is like a hit and run case. The test returned negative on the eighth day after onset of symptoms, but effects of the virus lingered on,” he recalls. Dr Fathahudeen says that the term ‘post-COVID-19 syndrome’ is not right as the health issues vary from individuals to individuals. “It should be long active COVID-19 as it lasts from three weeks to three months. The most severe issue is lung damage, which is an active process. It affects the gas exchange due to the development of a large number of micro vascular clots in the blood vessels in lungs. That is the reason why patients require continued mask ventilation and oxygen support. In my experience, less than 3% of the patients will experience irreversible lung damage that demand continued ventilator support and many will succumb,” says Dr Fathahudeen. Many other patients, he says, experience anxiety, depression, unexplained fatigue, shortness of breath, cough and even an early onset of diabetes due to the changes in the beta cells of the pancreas due to the involvement of the virus. Dr Fathahudeen says, “Most of these conditions are reversible and only less than 3% will experience irreversible lung damage and eventually death.” Impact on health workers Dr S S Santhosh, Deputy Superintendent of Government Medical College, Thiruvananthapuram, was a frontline warrior who led missions to various places, including Mumbai, to set up COVID-19 hospitals from scratch. Like other health workers, Santhosh also underwent periodic COVID-19 tests. A few months ago, Santhosh experienced some uneasiness and after an ECG test, it was found to be a case of myocardial infarction (heart attack). He immediately underwent an angioplasty. Dr Santhosh, who had no history of any comorbidities, said that he decided to do an antibody test and his suspicions were confirmed. “The antibody test was positive and I had an asymptomatic COVID-19, which went unnoticed. I think I survived because I was able to get the medical attention on time,” he says. Dr R Aravind, Head of Department of Infectious Diseases, Medical College Hospital, Thiruvananthapuram and member of state medical board, says that the percentage of patients who are affected by long COVID-19 might vary based on the sampling population. “As per an ongoing study conducted among health workers, around 20% have their symptoms persist even after 21 days and 4% have these persisting for more than three months. Incidentally, most of these health care workers were either asymptomatic or mildly symptomatic for COVID-19,” he says. As per the preliminary assessment of this ongoing study among health workers, who have had COVID-19, in Kerala, 60% have excessive fatigability, 30 % have breathlessness, 24% altered sleep rhythm (also called COVID-19 insomnia), 20% have excessive hair loss, 15% muscle pain and headache and 10% suffer from multiple joint pain. Inability to concentrate or lack of attention for a prolonged time, known as brain fogging, was experienced by around 10 %. Around 10% and 2% health workers have reported anxiety and depression respectively. “Though these may not come in the category of severe health issues, it is devastating for health workers. A study conducted after severe acute respiratory syndrome (SARS) in Hong Kong found that excessive fatigability continued in SARS-affected health workers for around three-and-half years and many had to discontinue works,” says Dr Aravind, pointing to the possible socio-economic impacts of the Long COVID-19. Dr Bipin Gopal says that the Health Department is planning to submit a consolidated report on post- COVID-19 issues within a few months. “As a way ahead in tackling the issue of post-COVID-19 issues or Long COVID-19, priority will be given to setting up specialty hospitals, which can address issues ranging from physical to psychological,” he says. Jisha Surya is an independent journalist living in Kerala. This story was reported under NFI Fellowships for independent journalists.