Five years on and we're still unclear about long Covid

Long Covid still lacks standardised diagnostic criteria, which may be partly due to its effects on multiple organs, including the lungs. This has resulted in patient stigma and discrimination, as well as uncoordinated treatment. — dpa

Recent events involving candidates for the American presidential elections have brought attention to a number of issues, including Covid-19.

The Republican nominee, Donald Trump, was caught on camera sharing vaccine scepticism with independent candidate Robert Kennedy Jr.

The sitting President of the United States Joe Biden, who was until recently the Democratic nominee, was quarantined as he nursed himself back to health after contracting Covid-19.

While many of us would prefer to forget the pandemic period, it has only been less than five years since the SARS-CoV-2 virus was introduced to humankind.

In just a matter of months, it spread from China to the rest of the world, eventually leading to a pandemic that brought the world to a standstill.

The level of severity and risk of complications from Covid-19 are higher in the elderly and those with co-morbidities (concurrent illnesses) such as diabetes, kidney disease, heart failure, cancer and obesity.

Symptoms related to Covid-19 manifest in different ways, and the duration differs between individuals.

As is common with respiratory pathogens, the virus mutated over time.

The Delta variant was memorable for being particularly lethal.

Mortality (death) rates would have been higher were it not for the infection control measures and vaccination programmes that took place.

The virus eventually mutated to the Omicron variant, which has been the predominant viral variant for the past couple of years.

Prolonged disease

I am grateful that the days in which my Category 5 Covid-19 patients had a 50-50 chance of surviving admission into the ICU (intensive care unit) are in the rearview mirror.

These days, the prognosis is much better and the availability of antivirals help reduce symptoms and risk of escalation.

Some patients do have persistent problems however – prolonged symptoms are part of the post-viral syndrome known as post acute sequelae of SARS-CoV-2 infection (PASC) or “long Covid”.

A study published this month (July 2024) in the New England Journal of Medicine looked at the health records of approximately half a million patients with SARS-CoV-2 infections in an effort to determine the factors that predicted long Covid.

The authors showed that the cumulative frequency of long Covid decreased over the course of the pandemic, from a high of 10.4 cases per 100 persons at one year after infection, to a low of 3.5 cases per 100 persons at one year among vaccinated persons who had SARS-CoV-2 infection during the Omicron phase.

Although significantly lower, it is worth highlighting the fact that long Covid still does occur despite the widespread belief that the Omicron variant is “just like the common cold”.

Despite more than 24,000 publications on long Covid, it is safe to say that nobody truly knows why only some individuals get this chronic condition.

It is a blanket term used for many manifestations that may or may not have a common root cause (and suffers from the absence of standardised diagnostic criteria).

The majority of clinicians and scientists believe that it is related to antibodies and dysregulation of the body’s autoimmune system.

What is both perplexing and worrying is that the majority of long Covid cases stem from what was initially a mild infection.

These long-term effects can manifest in myriad ways.

The US National Academies of Sciences, Engineering and Medicine published a report concluding that long Covid is a complex chronic condition that can result in more than 200 health effects, affecting multiple body systems.

Some of these include severe exhaustion (young patients with the ability to run marathons have been known to struggle with household chores), dysregulation of the body’s ability to control the heart rate, cognitive impairment or “brain fog”, and difficulty breathing, among others.

Lack of coordinated management

Various studies have shown that the risk of developing long Covid is decreased by vaccination, as well as the appropriate use of antivirals.

Conversely, there appears to be an increase in the risk when an individual contracts the SARS-CoV-2 virus multiple times.

The treatment of long Covid very much depends on its manifestations.

In an ideal world, multidisciplinary long Covid clinics would bring together relevant clinical specialists, physiotherapists, psychologists and clinical scientists to not only address the symptoms effectively, but to also take the opportunity to conduct more research.

In reality, most symptoms are treated in isolation.

A patient with brain fog is likely to be seen by a neurologist, a patient with new-onset asthma by a respiratory specialist, and so on.

Malaise and fatigue appear to improve with structured pacing and any significant life changes will benefit from mental health support.

There are numerous studies looking into treatment options: from melatonin to assist with sleep disturbances to using medication to reduce levels of interferon gamma – a molecule that induces inflammation in the lungs.

Being aware and prepared

Patients with long Covid face the additional burden of having to “prove” that they are not well to the sceptics around them.

Having an ailment that is not physically obvious can lead to unsympathetic remarks and treatment by friends and colleagues.

It is worth reminding the public every so often – as this column aims to do – that long Covid is still a scourge in our society, and that empathy goes a long way in improving outcomes.

Besides ensuring that adequate treatment options are made available to patients with long Covid, it is also imperative that we do not rest on our laurels in preparing for the next pandemic, which is a question of when, not if.

Improving the country’s diagnostic and therapeutic capabilities, having an institutionalised framework and working at a regional level for pandemic preparedness are all steps that need to be taken to reduce the short-term and long-term damages of current and future respiratory pathogens.

Dr Helmy Haja Mydin is a consultant respiratory physician and Social & Economic Research Initiative senior policy advisor. For further information, email [e-mail]. The information provided is for educational and communication purposes only. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.