We Shouldn’t be Surprised If Long-Covid Will Last for Years
…if the same pattern repeats with SARS-1. That said, what can be done to aid recovery?
Regrettably, for patients with Covid-19, being released from the hospital or testing negative SARS-CoV-2 does not always mean a full recovery. It’s estimated that 10–30% of cases will turn into long-Covid, where symptoms such as dyspnea (shortness of breath), fatigue, cognitive problems, joint pain, myalgia, and gastrointestinal and cardiac issues persist for a month or more. But in my own research review posted as pre-print, the actual prevalence of long-Covid may be higher than the estimated 10–30%.
Strangely, long-Covid can happen to anyone who got infected by SARS-CoV-2, even children, students, and those who only had mild-to-moderate Covid-19. “Most of the patients that I see who are suffering from [long-Covid] syndrome were not hospitalized,” said Jessica Dine, MD, a pulmonary specialist and associate professor at the University of Pennsylvania. “They were pretty sick, but still at home.”
Long-Covid can last for 6 months or more
Some recovered with time, but a few did not. Studies have reported long-Covid symptoms — such as fatigue, dyspnea, memory problems, etc. — in about one-third of survivors that had been released from the hospital three months ago. Their lung and brain scans also showed abnormal radiograph results indicative of some level of organ damage.
In a more recent study published in the Journal of Infection, researchers at the Research Institute of Santiago in Spain performed a 6-month follow study on 183 survivors (mean age = 66; 18.2% admitted to ICU) of Covid-19. Results were as follows:
- 44.3% reported no limitations in everyday life.
- 31.1% reported persistent symptoms but no limitations in everyday life.
- 14.8% reported evident limitations in everyday life.
- 6.6% were unable to perform all everyday activities.
- 3.3% were dependent on a caregiver for everyday activities.
This means that, in these survivors, long-Covid was still on-going for six months. But how many more months will these people suffer? Just a few weeks or months more, or years? It’s still early to tell at this point, so perhaps we can infer clues from a similar post-coronavirus syndrome in the past.
Post-SARS syndrome or long-SARS
Severe Acute Respiratory Syndrome (SARS) was first detected in February of 2003 in China, which later spread to other countries. While SARS has a higher case fatality rate than SARS-CoV-2, its transmissibility is much lower. So, SARS was successfully contained within a year. In the end, a total of 8,096 SARS cases with 774 deaths happened across 29 countries.
While the outbreak ended, a proportion of SARS survivors developed a post-SARS syndrome that can last for years. We can call this syndrome long-SARS.
After six months, 30% of SARS survivors (out of 100; mean age = 35.6) in Hong Kong still showed abnormal lung scan results, of which 15% was severe enough to render their lungs unable to exchange gas properly. Their exercise capacity and quality of life declined substantially as a result.
The same research group followed the previous Hong Kong cohort up to two-year. This time, only 55 SARS survivors (mean age = 44.4) participated. Results found that half of them still had reduced lung capacity. Their walking mobility test improved from the 3rd to 6th month but plateaued after that.
At the 24th month, their overall mobility and self-rated quality of life were still much lower than the general population. And nearly one-third of survivors were still unable to return to work due to their illness.
A separate research group did a 4-year follow-up study on 181 SARS survivors (mean age = 43.3) from Hong Kong. Results found 40% of participants had persistent fatigue, of which 27.1% met the CDC’s criteria for chronic fatigue syndrome — a condition where people suffer disabling fatigue that may come with sleep and cognitive problems for six months or more, despite ample rest.
As equally unsettling, in this study, 42.5% of survivors had at least one psychiatric disorder — most commonly posttraumatic stress disorder, depression, and somatoform pain disorder. These psychiatric disorders were diagnosed in a semistructured clinical interview according to the Diagnostic and Statistical Manual of Mental Disorders (fourth edition).
There were no differences in sex, socioeconomic status, initial SARS severity, and medical comorbidities between survivors who developed psychiatric disorder and survivors who did no. This indicates that these variables do not influence who will develop psychiatric long-SARS.
In China, researchers followed 127 SARS survivors (mean age = 32), who also developed osteonecrosis of the femoral head (ONFH), for seven years. Notably, these survivors were in good health before they had SARS and SARS-induced ONFH. ONFH happens when there’s inadequate blood flow to the hip’s femoral head bone — which can happen following a severe lung disease — leading to gradual bone collapse.
At baseline, the study obtained 211 MRI scans of the hip from 127 survivors. Seven years later, 50 hips had collapsed despite surgical attempts to preserve the bone, and 66 hips produced a pain sensation. Age, sex, initial SARS severity, and total steroid dose received did not predict which SARS survivors will develop hip deterioration.
Another study published recently followed 71 SARS survivors in China from 2003 to 2018. At baseline, a hip joint injury was evident in 32% of them from MRI scans. Most recovered, leaving only four (5.6%) with a hip injury at 15-year follow-up. These four participants also showed severe deterioration in hip joint mobility at 15-year. And the rest managed to recover.
Only 35 completed both a lung CT scan and lung function test in the 15th year. In 13 of them (37%), total lung capacity and gas exchange efficiency improved within the first year of SARS diagnosis but plateaued and remained impaired for 14 years after that. In contrast, the remaining 22 (63%) whose lung scans showed normal results saw gradual lung function improvement over the years.
In this study, over 80% of the participants were younger than 40 years; only 7% were older than 50 years. As also evident in the mean ages of participants in the studies described above, long-SARS sufferers are typically middle-aged adults.
What has worked for long-Covid?
While long-SARS and long-Covid appear to be different conditions, they are both post-coronavirus syndromes. One commonality between the two is long-term lung injury and neurological health problems such as fatigue and psychiatric disorders. In contrast, hip deterioration is seen with long-SARS but not long-Covid, at least not now. So, we should be prepared if long-Covid will last for years — like long-SARS — although we should hope otherwise.
Fortunately, some guidance on long-Covid management has been published in the British Medical Journal. Herein, Trisha Greenhalgh, a professor of primary care health sciences at the University of Oxford, and colleagues detailed a rehabilitation training guide that has helped improve symptoms of long-Covid within 4–6 weeks.
The rehabilitation combines light aerobic and breathing exercises that should be done throughout the day — in 5–10 minutes sessions — every day. In those with severe long-Covid, such rehabilitation may need to be monitored by a healthcare provider. Light aerobics can be walking or Pilates, which should be performed within tolerance levels. The intensity is raised slowly and gradually without significant exertion — just like pacing. The rehabilitation also involves controlling breathing patterns to avoid shallow breaths. Breathing should be show and inhaled through the nose — expanding the tummy — and exhale via the mouth with a relaxed chest and shoulders.
The National Institute for Health and Care Excellence (NICE) has also developed guidelines for clinicians to aid long-Covid recovery. The NICE cautions that overlooked underlying medical conditions — such as cardiac, respiratory, renal, hepatic, gastrointestinal, neurological, endocrine, and mast cell disorders — may have contributed to the development of long-Covid. “Missing these complications could result in serious adverse outcomes for patients,” the NICE stated. Only when any underlying medical conditions are addressed, then the rehabilitation can start.
Plus, several medical organizations are forming research groups dedicated to investigating the long-term outcomes and potential remedies of long-Covid. With such a collective effort, hopefully, the same pattern with long-SARS will not happen with long-Covid.
In the early pandemic, hardly anyone expected that long-Covid can happen to so many people, especially those in the younger age groups. Studies have found that long-Covid can persist for up to 3–6 months and counting. Symptoms of long-Covid include shortness of breath, fatigue, cognitive difficulties, and others. It’s 3–6 months and counting, so how many more months? The current data is insufficient to make conclusions. If long-Covid follows the trajectory of long-SARS, then we shouldn’t be surprised if it lasts for years. But we can hope otherwise; efforts are being made to find solutions for long-Covid, and there’s already evidence that rehabilitation can work.