Cape Town — Much has been said about the long-term effects of Covid-19 on people who contracted the virus, but whose symptoms continue to persist long after the initial infection has passed. The World Health Organisation (WHO) addressed questions around the implications of Long Covid hosted by WHO Social Media Manager Aleksandra Kuzmanovic, with Dr. Maria Van Kerkhove, WHO Technical Lead on Covid-19, and Dr. Janet Diaz, Clinical Management Lead, WHO Health Emergencies Programme.
What is Long Covid?
The National Library of Medicine defines Long Covid as "coronavirus disease 2019 (Covid-19) related symptoms that persist more than 28 days from the onset of acute infection". It estimated that 10% of people with acute Covid-19 infections will develop Long Covid symptoms. According to the Centers for Disease Control (CDC), post-Covid conditions are a wide range of new, returning, or ongoing health problems that people experience after first being infected with the virus that causes Covid-19. While most patients recover between several days and two weeks after infection, some may find symptoms up to four weeks which is when a post-Covid condition may be identified.
Most people with post-Covid conditions experience symptoms days after their SARS CoV-2 infection when they knew they had Covid-19, but some people with post-Covid conditions did not notice when they first had an infection. Identification of Long Covid is made additionally difficult by the fact that there is currently no test to diagnose the condition. People may experience multiple symptoms that could also be the result of other health problems, making it more difficult for healthcare providers to identify post-Covid conditions in patents.
Study of Long Covid sheds light on condition
But what data is there to support these findings? The Lancet, a weekly peer-reviewed general medical journal, produced a study which aimed to establish how Long Covid patients in South Africa have been affected by the condition and which age groups were most at risk.
The study focused on cases reported between Dec 1, 2020, and Aug 23, 2021, and used the daily hospital surveillance (DATCOV) system. Created in 2020, it sought to create a daily excel spreadsheet of Covid-19 admissions based on the information submitted from more than 300 hospitals - both private and public - in South Africa's nine provinces. The Lancet study focused on patients aged 18 years or older who had been hospitalised with laboratory-confirmed SARS-CoV-2 infections. They were then assessed with follow-up visits spaced between one and three months after hospital discharge. They had to answer a questionnaire detailing their symptoms functional status, health-related quality of life, and occupational status.
Only 3,094 patients out of an initial total target of 241,159 Covid-19 admissions were able to be contacted to provide data. Of these, 1,873 were contacted for their follow-up assessment three months after hospital discharge. They had a median age of 52 and ethnicity was determined by self-identification and categorised in line with the Statistics South Africa classification, including Black, White, Mixed, Indian, and other.
A total of 1,249 (66.7%) of the patients reported new or persistent symptoms three months after hospital discharge. This echoes similar findings made by the National Library of Medicine which found that 60% of patients with mild Covid-19 had ≥ 1 long Covid symptom, while 35% had ≥ 3 ongoing symptoms for two months.
The most common symptoms reported were fatigue, shortness of breath, confusion or lack of concentration, headaches and vision problems. Additionally, these patients suffered great impact to their quality of life as well as their careers. In its conclusion, the study recommended the clinical guidelines and training of healthcare workers for identifying, assessing, and caring for patients affected by Long Covid.
Experts take a deeper look at Long Covid and its effects
WHO Social Media Manager Aleksandra Kuzmanovic said that one million deaths due to the virus have been reported for 2022 as of August 30, while Dr. Maria Van Kerkhove said a decline in the number of cases is being reported. "This is a good sign. However, we do know that surveillance capacities have declined, testing policies have changed and we're not seeing what we believe are the actual number of cases that are occurring being reported to the WHO because there's more self-testing," said Van Kerkhove, adding that trends had to be considered when evaluating case numbers.
Van Kerkhove said a rise in deaths was noted by the WHO over the past week. "We've seen an 8% increase in the last seven days". However, while this was the case, it also had to be factored into an overall lower mortality rate recorded over the past month. "Three years into the pandemic, these deaths were largely preventable because we have access to diagnostics and earlier clinical care, we have trained health workers who have experience with Covid-19 and we have safe and effective vaccines that work against these variants that have been circulating for several years now."
Dr Janet Diaz presented data on Long Covid, raising the question of whether the estimate of roughly 4 million people living with the condition is accurate. "Making the estimate is complicated", citing a recent non-peer-reviewed report by the Institute of Health Metrics and Evaluation which found "worrying" data gathered between 2020 and 2021. The report estimated that 144 million people are affected with Long Covid.
Based on that figure, Diaz said that 4% of people who have been infected with the virus may have Long Covid, though this may be even higher since many do not get tested for Covid-19. Kuzmanovic asked how one may be able to recognise the symptoms of post-Covid conditions. Diaz responded: "If you've had Covid-19 and your symptoms have not gotten better after about three months, then that is the trigger to seek care. Symptoms to watch for are shortness of breath, cognitive dysfunction or 'brain fog', which is how it's commonly described, and symptoms around fatigue."
While those are the three major clusters of infections to watch for, Diaz noted that others like chest pain, and loss of taste and smell have also been reported.
Answering a question on the kinds of neurological conditions caused by Long Covid that have been reported, Diaz said: "First, I want to give the reassurance that patients do get better.; seeking coordinated care is quite important. On neurological symptoms, patients have reported difficulty concentrating and difficulty sleeping (along with loss of taste and smell), some reported getting dizzy when they stand up and hopefully healthcare specialists can work with patients with those symptoms to keep them functional and active."
She said that it seems to largely to affect women and adults rather than children.
"From what we know so far, it is more common in women than in men, it is more common in adults than in children. While children can still get Long Covid, they are less at risk. Aside from that, it does seem to affect patients who had more severe Covid-19 symptoms than those who had mild ones, but it's much more common to have mild Covid based on the absolute numbers.
According to Van Kerkhove, how long people are infectious varies.
"We do look at the infectiousness of patients and we do look at how long people are infectious with the virus and it does depend on age, the severity you might have - people who are asymptomatic versus those that have very few symptoms versus those who have been vaccinated or not, the number of vaccines you've had or been boosted, your underlying conditions, etc. We do know that people who are immunocompromised can be infectious for quite long periods of time and some studies have found that may be the case for up to several hundred days in some individuals, but, typically, people are most infectious around the time that they develop symptoms."
"That is a general overview but it also depends on the variants that have been circulating, as you know. We've had alpha, beta, gamma, delta, now we have omicron and we have some variants of omicron and we have variants of some variants of omicron - the virus is evolving so every time we get an answer on infectiousness, we have to evaluate it again."
Diaz added that a diagnosis of Long Covid is generally made if symptoms persist for more than three months.
"To make a diagnosis of Long Covid in a patient, they must have had Covid-19 - the acute illness, and if you had symptoms for more than three months… We don't have a diagnostic test for Long Covid. That is something we really need to accelerate our understanding of - what kind of test would be helpful. It's not a PCR (polymerase chain reaction) test because these patients are not infectious with the post-Covid-19 condition so I would disaggregate that. I want to give a caveat to that - what's causing the post-Covid-19 condition? What's the mechanism? There's one hypothesis that the virus is persisting somewhere in the body and maybe that's what's causing the continued inflammatory response in your brain or your lungs, etc, but that doesn't mean you're infectious with the virus, I just want to be clear on that."
The other hypothesis is that this inflammation is just your body reacting in a residual way to the virus you had before. Another is clotting - we know that clotting during the acute illness is a big complication and perhaps there are micro clots causing these symptoms. There are also reports of patients out of the acute illness in the first year that have more cardiac complications, so there's lots to still disentangle."
Diaz's theory of a potential inflammatory response was the subject of a January 2022 article by Forbes. It wrote that an analysis by researchers at the University of New South Wales' Kirby institute and St Vincent's Hospital Sydney pointing to uncovered evidence of sustained inflammation along with activation of the immune response persisting for at least eight months after the initial acute Covid-19 infection. Inflammation is critical in the recovery of from an infection. It assists the body by ridding it of the source of the damage and by repairing injured tissue.
Diaz and Van Kerkhove also touched on what training would be needed by healthcare workers to support patients with Long Covid.
"That's a complex question; we try to tackle it in many different ways at the same time. One is developing norms and standards for clinical care so we do have clinical management guidelines and that's meant to empower clinicians, healthcare providers to know what to do. We have the Living Covid-19 Guideline - one aspect focuses on therapeutics for acute Covid-19, the other on clinical care. In the clinical care one we have a chapter (that's growing) on the management of patients after the acute illness and for post-Covid-19 conditions so that's one of the things we do because we have to translate evidence into policy.
"We also need to support research and, in a way, what we are missing are active clinical trials to assess treatments for long Covid; there's just not a lot out there. There are some hypotheses of different types of treatments but none of them have gone to clinical trials. We need funders to fund these trials, these studies. People want to do them - there are patients, clinicians, patient-led research movements so there are possibilities for community-based research to do studies but I am concerned there is not enough interest to support these studies through the donor community for all that can be done", Diaz said.
Van Kerkhove added that "we've started to see how countries are starting to deal with these rehab centres in providing that care. In a recent trip I made to Brazil, for example, I visited three post-Covid-19 facilities - one was in a hospital, one was in an old school that was turned into a rehab centre and one was in a community and there are these novel approaches to how this is being done and what I was struck by was the comprehensive nature in which the delivery of the rehab, the care was provided. It was not just for the lungs or for helping to walk again or mental conditioning. In the community one, for example, it was about the family coming in to say 'we have been impacted by this'."
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Van Kerkhove's reference to rehabilitation centres is based on the WHO's aim to assist individuals suffering from Long Covid. The global body said in a document on Covid-19 rehabilitation training that due to the new, fluctuating and protracted course of the after-effects of Covid-19, the need for rehabilitation services in a population may persist beyond the pandemic.
Diaz and Van Kerkhove also spoke about medications being used to treat Covid-19.
"For Covid-19, the acute illness, if you have non-severe disease, we have recommendations for three different anti-virals; you only need to use one, not all three at the same time. The options are Nirmatrelvir (also known as Paxlovid), the other is Molnupiravir and the third one is Remdesivir. When you use them early, as in the first five days you find a symptom - when you test and find it positive - then you have a reduced risk of getting hospitalised."
According to Diaz, these treatments are most effective in high-risk patients, specifically, those hose who are immuno-suppressed or who have malignancy or cancer or untreated HIV. They also may also benefit unvaccinated individuals. "These drugs are very good at reducing the risk but you need an early test and to take the treatment as early as possible", Diaz said.
Van Kerkhove emphasised the importance of vaccination. "I just want to add, as Janet just gave a brilliant overview of the therapeutics that we have and there are many, as you heard, for the full course of the disease, but I also just want to make a plug for vaccination. So what we want to do as much as we can is prevent these infections in the first place, prevent the opportunity for the virus to become severe and our vaccines are working incredibly well. It is still astonishing that we have so many safe and effective vaccines that are accessible.
Van Kerkhove's plea comes with the fact that vaccine equity has still not been reached around the world. The problem of vaccine hesitancy and resistance has been persistent since the availability of the first preventative treatments for the virus. This has been compounded by the fact that vast amounts of fake news on vaccines spread around the Internet. World leaders, including U.S. President Joe Biden, reportedly said in July 2021 that social media platforms were largely responsible for people's scepticism in getting vaccinated by spreading misinformation, and appealed for them to address the issue.
Van Kerkhove went on to urge people to get vaccinated whether it be their first dose or a booster shot if only to prevent contracting post-Covid-19 conditions. She added that highly exposed individuals like teachers, healthcare workers and essential workers had to prioritise getting vaccinated based on their roles and their exposure to others. "We need vaccine coverage in those groups at 100% and we will not stop until that is reached."
