Wednesday, November 11, 2020

CDC: Late Sequelae of COVID-19 (Long COVID)

https://twitter.com/KartikSehgal_MD/status/1281695760879202304

#15,552

While the initial concerns with the COVID pandemic were handling acute illnesses and minimizing deaths, by early summer it had become apparent that some (perhaps many) COVID survivors were experiencing slow recoveries, and prolonged (and sometimes severe) sequelae. 

Some `recovered' patients have been left with lung, heart, or kidney damage while others have experienced lingering neurological manifestations ranging from relatively mild (headaches, dizziness, anosmia, mild confusion, etc.) to more profound (seizures, stupor, loss of consciousness, etc.) to potentially fatal (ischemic stroke, cerebral hemorrhage, muscle injury (rhabdomyolysis), etc.).

Some experts have suggested we may see huge increases in COVID-19 related heart failure and neurological diseases in the years ahead.

Emily A. Troyer, Jordan N. Kohn, and Suzi Hong 

Yesterday, in MMWR: Readmission Of COVID-19 Patients Within 2 Months Of Hospital Discharge, we looked at the likelihood of being readmitted to a hospital in the 60 days following release from a COVID diagnosis. 

While 3 weeks ago, in UK NIHR: Living With COVID-19 (Long COVID), we looked at the potential for many patients to develop a Post Viral Fatigue syndrome - similar to ME/CFS - that could cause permanent disability. 

The CDC has acknowledged these concerns in a number of MMWR & EID Journal articles, and by the following brief statement which has been on their COVID-19 website (Wayback Machine link) since September:

Long-Term Effects of COVID-19
Updated Sept. 16, 2020 

CDC is actively working to learn more about the whole range of short- and long-term health effects associated with COVID-19. As the pandemic unfolds, we are learning that many organs besides the lungs are affected by COVID-19 and there are many ways the infection can affect someone’s health.

One of the health effects that CDC is closely watching and working to understand relates to COVID-19 and the heart. Heart conditions associated with COVID-19 include inflammation and damage to the heart muscle itself, known as myocarditis, or inflammation of the covering of the heart, known as pericarditis. These conditions can occur by themselves or in combination. Heart damage may be an important part of severe disease and death from COVID-19, especially in older people with underlying illness. Heart damage like this might also explain some frequently reported long-term symptoms like shortness of breath, chest pain, and heart palpitations.

The risk of heart damage may not be limited to older and middle-aged adults. For example, young adults with COVID-19, including athletes, can also suffer from myocarditis. Severe heart damage has occurred in young, healthy people, but is rare. There may be more cases of mild effects of COVID-19 on the heart that can be diagnosed with special imaging tests, including in younger people with mild or minimal symptoms; however, the long-term significance of these mild effects on the heart are unknown. CDC will continue to assess and provide updates as new data emerge.
Yesterday, the CDC updated and expanded this statement and added a new web page addressing Late Sequelae of COVID-19:  

First the update. 

Updated Nov. 10, 2020

CDC is actively working to learn more about the whole range of short- and long-term health effects associated with COVID-19. As the pandemic unfolds, we are learning that many organs besides the lungs are affected by COVID-19 and there are many ways the infection can affect someone’s health.

While most persons with COVID-19 recover and return to normal health, some patients can have symptoms that can last for weeks or even months after recovery from acute illness. Even people who are not hospitalized and who have mild illness can experience persistent or late symptoms. Multi-year studies are underway to further investigate. CDC continues to work to identify how common these symptoms are, who is most likely to get them, and whether these symptoms eventually resolve.

The most commonly reported long-term symptoms include:
  • Fatigue
  • Shortness of breath
  • Cough
  • Joint pain
  • Chest pain
Other reported long-term symptoms include:
  • Difficulty with thinking and concentration (sometimes referred to as “brain fog”)
  • Depression
  • Muscle pain
  • Headache
  • Intermittent fever
  • Fast-beating or pounding heart (also known as heart palpitations)
More serious long-term complications appear to be less common but have been reported. These have been noted to affect different organ systems in the body. These include:
  • Cardiovascular: inflammation of the heart muscle
  • Respiratory: lung function abnormalities
  • Renal: acute kidney injury
  • Dermatologic: rash, hair loss
  • Neurological: smell and taste problems, sleep issues, difficulty with concentration, memory problems
  • Psychiatric: depression, anxiety, changes in mood
The long-term significance of these effects is not yet known. CDC will continue active investigation and provide updates as new data emerge, which can inform COVID-19 clinical care as well as the public health response to COVID-19.
 
Preventing COVID-19

The best way to prevent these long-term complications is to prevent COVID-19. The best strategies for preventing COVID-19 infection in youth and adults are to wear a mask in public places, stay at least 6 feet away from other people, frequently wash your hands, and avoid crowds and confined or poorly ventilated spaces.

Also published yesterday is the following review of what is currently known about the late sequelae of COVID-19. 
Late Sequelae of COVID-19
Updated Nov. 10, 2020

The identification of the novel coronavirus SARS-CoV-2 in December 2019 has led to a growing and continually evolving body of knowledge about the virus and the disease it causes, COVID-19.

In peer-reviewed literature and public discussion, persistent symptoms are being reported among COVID-19 survivors, including individuals who initially experience a mild acute illness. These persistent symptoms pose new challenges to patients, healthcare providers, and public health practitioners. The natural history of SARS-CoV-2 infection and COVID-19 is a current area of investigation, and the prevalence, type, duration, and severity of persistent symptoms following resolution of acute SARS-CoV-2 infection, as well as risk factors associated with their development, are currently being studied.

While older patients may have an increased risk for severe disease, young survivors, including those physically-fit prior to SARS-CoV-2 infection, have also reported symptoms months after acute illness (Assaf, Asthma UK and British Lung Foundation, Godlee). Research is underway to differentiate symptoms of a prolonged course of COVID-19 illness from sequelae following resolution of acute SARS-CoV-2 infection, achieve consensus on the time period at which to define the post-acute and long-term phases of COVID-19, and distinguish health effects exclusively related to infection with SARS-CoV-2 from consequences of procedures and treatments required for care of persons with severe disease of any etiology.

Characterization of the etiology and pathophysiology of late sequelae is underway, and may reflect organ damage from the acute infection phase (Ngai), manifestations of a persistent hyperinflammatory state (Yende, Tay), ongoing viral activity associated with a host viral reservoir (Hartley), or an inadequate antibody response (Wu). Factors in addition to acute disease that may further complicate the picture include physical deconditioning (Gemelli) at baseline or after a long disease course (Thornton), pre-COVID-19 comorbidities (O’Keefe), and psychological sequelae following a long or difficult disease course (Yende) as well as those relating to lifestyle changes due to the pandemic (Galea). Likely, the persistent sequelae of COVID-19 represent multiple syndromes resulting from distinct pathophysiological processes along the spectrum of disease.

Though there is limited information on late sequelae of COVID-19, reports of persistent symptoms in persons who recovered from acute COVID-19 illness have emerged (Tenforde, Carfi, Halpin, COVID Symptom Study, Greenlaugh, del Rio). The most commonly reported symptoms include fatigue, dyspnea, cough, arthralgia, and chest pain (Tenforde, Halpin, O’Keefe, Calfi, Assaf, Banda, Lambert). Other reported symptoms include cognitive impairment, depression, myalgia, headache, fever, and palpitations (Tenforde, Halpin, O’Keefe, Calfi, Assaf, Banda, Lambert). More serious complications appear to be less common but have been reported. These complications include:
  • Cardiovascular: myocardial inflammation, ventricular dysfunction (Sardari, Puntmann, Rajpal)
  • Respiratory: pulmonary function abnormalities (Huang, Zhao)
  • Renal: acute kidney injury (Peleg)
  • Dermatologic: rash, alopecia (Lambert)
  • Neurological: olfactory and gustatory dysfunction, sleep dysregulation, altered cognition, memory impairment (Otte, Paderno, Halpin, Lambert, Assaf, Banda)
  • Psychiatric: depression, anxiety, changes in mood(Halpin, Lambert, Singh)
Post-COVID-19 care centers are opening at academic medical centers in the United States, bringing together multidisciplinary teams to provide a comprehensive and coordinated treatment approach to COVID-19 aftercare. The National Institutes of Health have published interim guidelines for the medical management of COVID-19, including a section on persistent symptoms or illnesses after recovery from acute COVID-19. These guidelines will be updated as new information emerges.
Survivor support groups are connecting individuals, providing support, and sharing resources with survivors and others affected by COVID-19 (Body Politic, Survivor Corps). Multi-year studies will be crucial in elucidating longer-term sequelae. CDC continues active investigation into the full spectrum of COVID-19 to establish a more complete understanding of the natural history of SARS-CoV-2 infection and COVID-19 related illnesses, which can inform care strategies as well as the public health response to this virus.
Ongoing research
National Institutes of Health, National Institute of Allergy and Infectious Diseases. A longitudinal study of COVID-19 sequelae and immunity. https://clinicaltrials.gov/ct2/show/NCT04411147
University of California, San Francisco. Long-term impact of infection with novel coronavirus (COVID-19) (LIINC). https://clinicaltrials.gov/ct2/show/record/NCT04362150

This early acknowledgement of long-term impacts from COVID-19 is encouraging, and it hopefully means these patients will be treated better than the millions of ME/CFS, Post Lyme Disease Syndrome, and Gulf War Illness patients that have too often been marginalized and/or ignored by the medical system over the past few decades.

It is even possible that what we learn from Post-COVID Syndrome may aid in the treatment of these other illnesses.

While its burden may not become fully apparent for years, Long COVID is something that individuals, and society as a whole, will have to deal with long after the pandemic has ended. 

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