#16,784
While somewhere between 98%-99% of those infected with COVID-19 survive their illness, we continue to see anecdotal reports and studies suggesting that many survivors come away with lingering - sometimes permanent - sequelae.
The notion that COVID (even Omicron) is no worse than the `flu' ignores both the severity of influenza, and the potential long-term impacts of SARS-CoV-2 infection.
Whether you call it `Long COVID' or `Post-COVID Syndrome', these persistent after-effects can range from mild or moderate - to disabling - and may even contribute to an early death months or years after the the initial infection.
The CDC has held several COCA Calls for clinicians on these post-COVID syndromes, including:
COCA Call: May 5, 2022: Evaluating and Supporting Patients Presenting with Cognitive Symptoms Following COVID
And we've looked at a number of studies, including:
There are also concerns that other, longer-term impacts, may arise in COVID survivors in the years ahead, including increased incidence of heart failure, and neurological manifestations, including Parkinson's syndrome.
Yesterday the MMWR carried the following report that found - among COVID survivors - that 1 in 5 adults (18-64), and 1 in 4 ≥ 65 experienced at least one incident condition that might plausibly be attributable to previous COVID-19 infection.
Post–COVID Conditions Among Adult COVID-19 Survivors Aged 18–64 and ≥65 Years — United States, March 2020–November 2021
Early Release / May 24, 2022 / 71
Lara Bull-Otterson, PhD1; Sarah Baca1,2; Sharon Saydah, PhD1; Tegan K. Boehmer, PhD1; Stacey Adjei, MPH1; Simone Gray, PhD1; Aaron M. Harris, MD1 (View author affiliations)View suggested citation
Summary
What is already known about this topic?
As more persons are exposed to and infected by SARS-CoV-2, reports of patients who experience persistent symptoms or organ dysfunction after acute COVID-19 and develop post-COVID conditions have increased.
What is added by this report?
COVID-19 survivors have twice the risk for developing pulmonary embolism or respiratory conditions; one in five COVID-19 survivors aged 18–64 years and one in four survivors aged ≥65 years experienced at least one incident condition that might be attributable to previous COVID-19.
What are the implications for public health practice?
Implementation of COVID-19 prevention strategies, as well as routine assessment for post-COVID conditions among persons who survive COVID-19, is critical to reducing the incidence and impact of post-COVID conditions, particularly among adults aged ≥65 years.
A growing number of persons previously infected with SARS-CoV-2, the virus that causes COVID-19, have reported persistent symptoms, or the onset of long-term symptoms, ≥4 weeks after acute COVID-19; these symptoms are commonly referred to as post-COVID conditions, or long COVID (1). Electronic health record (EHR) data during March 2020–November 2021, for persons in the United States aged ≥18 years were used to assess the incidence of 26 conditions often attributable to post-COVID (hereafter also referred to as incident conditions) among patients who had received a previous COVID-19 diagnosis (case-patients) compared with the incidence among matched patients without evidence of COVID-19 in the EHR (control patients).The analysis was stratified by two age groups (persons aged 18–64 and ≥65 years). Patients were followed for 30–365 days after the index encounter until one or more incident conditions were observed or through October 31, 2021 (whichever occurred first). Among all patients aged ≥18 years, 38% of case-patients experienced an incident condition compared with 16% of controls; conditions affected multiple systems, and included cardiovascular, pulmonary, hematologic, renal, endocrine, gastrointestinal, musculoskeletal, neurologic, and psychiatric signs and symptoms.By age group, the highest risk ratios (RRs) were for acute pulmonary embolism (RR = 2.1 and 2.2 among persons aged 18–64 and ≥65 years, respectively) and respiratory signs and symptoms (RR = 2.1 in both age groups). Among those aged 18–64 years, 35.4% of case-patients experienced an incident condition compared with 14.6% of controls. Among those aged ≥65 years, 45.4% of case-patients experienced an incident condition compared with 18.5% of controls. These findings translate to one in five COVID-19 survivors aged 18–64 years, and one in four survivors aged ≥65 years experiencing an incident condition that might be attributable to previous COVID-19.Implementation of COVID-19 prevention strategies, as well as routine assessment for post-COVID conditions among persons who survive COVID-19, is critical to reducing the incidence and impact of post-COVID, particularly among adults aged ≥65 years (2).
Discussion
The findings from this analysis of a large EHR-based database of U.S. adults indicated that COVID-19 survivors were significantly more likely than were control patients to have incident conditions that might be attributable to previous COVID-19. One in five COVID-19 survivors aged 18–64 years and one in four survivors aged ≥65 years experienced at least one incident condition that might be attributable to previous COVID-19. Independent of age group, the highest RRs were for acute pulmonary embolism and respiratory symptoms.
These findings are consistent with those from several large studies that indicated that post-COVID incident conditions occur in 20%–30% of patients (6,7), and that a proportion of patients require expanded follow-up care after the initial infection. COVID-19 severity and illness duration can affect patients’ health care needs and economic well-being (8). The occurrence of incident conditions following infection might also affect a patient’s ability to contribute to the workforce and might have economic consequences for survivors and their dependents, particularly among adults aged 18–64 years (5). In addition, care requirements might place a strain on health services after acute illness in communities that experience heavy COVID-19 case surges.
COVID-19 survivors aged ≥65 years in this study were at increased risk for neurologic conditions, as well as for four of five mental health conditions (mood disorders, other mental conditions, anxiety, and substance-related disorders). Neurocognitive symptoms have been reported to persist for up to 1 year after acute infection and might persist longer (9). Overall, 45.4% of survivors aged ≥65 years in this study had incident conditions. Among adults aged ≥65 years, who are already at higher risk for stroke and neurocognitive impairment, post-COVID conditions affecting the nervous system are of particular concern because these conditions can lead to early entry into supportive services or investment of additional resources into care (10).
The findings in this study are subject to at least five limitations.
- First, patient data were limited to those seen at facilities serviced by Cerner EHR network during January 2020–November 2021; therefore, the findings might not be representative of the entire U.S. adult population or of COVID-19 case patients infected with recent variants.
- Second, the incidence of new conditions after an acute COVID-19 infection might be biased toward a population that is seeking care, either as a follow-up to a previous complaint (including COVID-19) or for another medical complaint, which might result in a “sicker” control group leading to underestimation of observed risk.
- Third, COVID-19 vaccination status was not considered in this analysis, nor were potentially confounding factors (e.g., SARS-CoV-2 variant, sex, race, ethnicity, health care entity, or geographic region), because data were not available, were inconsistent, or included a high proportion of missing or unknown values; for example, data were not matched by data contributors, so controls were not necessarily from the same health care entity or region of the country.
- Differences between the groups might influence the risks associated with survival from COVID-19 and incident conditions, which require further study. Fourth, International Classification of Disease, Tenth Revision, Clinical Modification (ICD-10-CM) codes were used to identify COVID-19 case-patients, and misclassification of controls is possible. However, the inclusion of laboratory data to identify case-patients and exclude controls helped to limit the potential for such misclassification.
- Finally, the study only assessed conditions thought to be attributable to COVID-19 or post-COVID illness, which might have biased RRs away from the null. For example, clinicians might have been more likely to document possible post-COVID conditions among case-patients. In addition, because several conditions examined are also risk factors for moderate to severe COVID-19, it is possible that case-patients were more likely to have had an existing condition that was not documented in their EHR during the year preceding their COVID-19 diagnosis, resulting in overestimated risk for this group.
As the cumulative number of persons ever having been infected with SARS-CoV-2 increases, the number of survivors suffering post-COVID conditions is also likely to increase. Therefore, implementation of COVID-19 prevention strategies, as well as routine assessment for post-COVID conditions among persons who survive COVID-19, is critical to reducing the incidence and impact of post-COVID conditions, particularly among adults aged ≥65 years (2). These findings can increase awareness for post-COVID conditions and improve post-acute care and management of patients after illness. Further investigation is warranted to understand the pathophysiologic mechanisms associated with increased risk for post-COVID conditions, including by age and type of condition.
Many people dismiss COVID infection as trivial since it is mostly mild, and point to the high survival rate - even among those hospitalized - as if that tells the whole story.
But as these studies continue to show - the long-term impacts of COVID infection can be serious and should not be underestimated - making this is an illness you really want to avoid if at all possible.
