Seán Dunphy discusses the long term impact of COVID-19 on patients and public health.
SARS-CoV-2, the virus responsible for COVID-19, was first identified at the end of 2019. Now, a year later, the long term health implications are becoming clearer. The high infection rate and immediate danger of the virus were apparent early in the pandemic, but even the most severe cases of COVID-19 lasted little more than two weeks. However, over time many patients have reported symptoms lasting for multiple weeks, even months.
Long term COVID-19 symptoms were first noted in Italy, where follow up appointments with COVID-19 patients revealed a group of patients who had symptoms after the two week infection. Long term studies like the COVID Symptom Study run by Kings College London, were quickly established to uncover the prevalence of these long term COVID-19 symptoms. They revealed that 10 per cent of COVID-19 patients will suffer from at least one of sixty-one reported long term symptoms. These symptoms span a broad spectrum, far beyond the characteristic cough, fever, and loss of taste/smell. The most frequently reported symptoms include fatigue, breathlessness, lack of concentration, brain fog, joint pain and muscle aches.
Although many scientists predicted that SARS-CoV-2 would have a long term effect based on knowledge of the original SARS coronavirus, there was little suggestion that so many would suffer from long term symptoms.
One of the earliest predictions was lasting heart damage since both SARS and MERS left patients with long term heart complications. Nearly half of all hospitalised SARS patients had cardiovascular abnormalities 12 years after first being infected. A similar trend is being uncovered in COVID-19 patients. A study at University Hospital Frankfurt’s Centre for Cardiovascular Imaging revealed that although most of the patients experienced mild symptoms, more than 75 per cent had unusual structural changes in their cardiac tissue. Lasting cardiovascular damage is even being identified in athletes. Ohio State University’s studies of post covid myocarditis (heart inflammation) in athletes revealed cardiac tissue damage in 30 per cent of its 26 participants. Myocarditis can account for many of the symptoms of long covid and is unsurprising in COVID-19 patients given it is most commonly caused by viral infection, but myocarditis alone cannot account for the 1 in 10 prevalence of long covid.
A review in The British Medical Journal suggests that “long covid” may be four separate syndromes: post viral fatigue syndrome (PVFS), post-intensive-care syndrome, permanent lung and heart damage or continuing COVID-19 symptoms. Of these contributing syndromes, organ damage is the most easily diagnosed because of the recognisable physiological and anatomical changes. For example, MRI has been used to identify myocarditis in some long covid patients. However, the other three syndromes are far more challenging to diagnose and can cause periodic symptoms which come and go.
Fatigue and difficulty concentrating are some of the most ubiquitous symptoms reported among long covid patients, symptoms characteristic of PVFS, a diagnosis which often precedes a chronic fatigue syndrome (CFS) diagnosis. As the name suggests PVFS is a collection of symptoms which some patients have reported following viral infections such as glandular fever and SARs. These long covid patients diagnosed with PVFS patients rarely display the organ damage identified in other “long haulers” supporting the argument that long covid has become a catch all term for a number of syndromes. Unlike organ damage there is little known of the biological changes which cause PVFS, and there are no characteristic physiological or anatomical changes, creating uncertainty when seeking a medical diagnosis.
This uncertainty coupled with the periodic absence of symptoms creates difficulties for patients when seeking medical help, with many patients being dismissed as suffering from physical symptoms of anxiety. Since these symptoms significantly impact the patient’s life and complicate return to work plans, this is a particularly frustrating conclusion to overcoming the challenges of seeking help for an illness which can feel elusive even to the patient.
To date, 75.5 million patients globally have tested positive for COVID-19, with nearly 2 million cases confirmed in the UK but it is estimated that the actual number of cases in the UK is much higher given the lack of testing during the initial wave in March. Recent estimates suggest that 10 per cent of these patients will experience long term symptoms. Chief executive of the NHS, Simon Stevens, is quoted by the BBC saying “tens of thousands, probably hundreds of thousands”of Britons will suffer from long covid. This message is echoed by The Royal College of General Practitioners, who expect waves of pressure on their practises in the form of long covid patients. The often periodic nature of the illness is expected to convey a degree of unpredictability to these waves because patients with less severe sporadic symptoms may not immediately seek medical help and may present at GPs at varying time points following SARS-CoV-2 infection.
In response to the already mounting toll of long covid on GPs, NHS England have launched an online portal to guide patients, whether hospitalized with COVID-19 or not, through a three month programme that gives access to on-demand clinical support. Equally, the NHS plans to open 40 long covid clinics where patients will be able to access GPs and other healthcare professionals, but these services are not accessible to patients who have not tested positive for COVID-19. This decision strands the many suspect COVID-19 cases who could not receive testing during the initial wave because of the inadequate response of the Westminster government to the emergence of SARS-CoV-2. To complement this medical care, the Post-Hospitalisation COVID-19 Study (PHOSP-COVID) has been announced. This 12-month study of 10,000 COVID-19 patients hopes to better assess the long term consequences of COVID-19, but will fall significantly short of providing a broad picture in its emission of COVID-19 patients who did not require hospitalisation.
As the development of vaccines brings the end of the COVID-19 pandemic into sight, its toll on the economy and public health lingers in the long covid patients who continue to suffer from fatigue and pain that often keeps them from work. In response to support and advocacy groups organised by long-haulers like LongCovidSOS, the British government have taken steps to ease the toll on the public healthcare system. However these advocates argue that these steps are too little and too late. Nisreen Alwan, a public-health professor at the University of Southampton who has had COVID-19, is quoted in the Atlantic arguing that more research is needed, that “we cannot fight what we do not measure,” that “death is not the only thing that counts. We must also count lives changed.” In light of this, the British government’s decisions to allow “low” levels of COVID-19 to spread amongst the “low” risk portions of the population may prove catastrophic in the resulting high numbers of lives changed by long covid.
Written by Seán Dunphy and edited by Ailie McWhinnie.