New Global Pandemic Recognized by Few (revised)

After COVID came long COVID

The COVID pandemic meanders on with many people still becoming infected, hospitalized and even dying.  And despite all of its shortcomings and dangers COVID vaccines are still pushed by the medical and public health establishments and government agencies as the solution.  New variants of the virus keep emerging, making vaccines increasingly ineffective.  But meanwhile the new global pandemic becomes more and more prevalent with hardly any help for victims from the medical world.  What is the new pandemic?  The long COVID pandemic.

Long COVID hits many millions of people who were infected, regardless of whether they were asymptomatic, very ill, young or old, and got COVID vaccines.  Victims usually have a large number of debilitating symptoms affecting their behavior, organs and cognitive capabilities.  All the medical world is doing is sending victims to many specialists who only try to address their symptoms.  But there are no cures.  In many ways the new pandemic is worse than the original one.  Because victims have little reason to be hopeful of regaining their normal lives.  They may suffer for years.

Also to be noted are some findings that COVID vaccines themselves may cause long COVID.  This article is worth serious attention: “In rare cases, coronavirus vaccines may cause Long Covid–like symptoms.”  Limited evidence may not be compelling but also cannot be ignored.

A related issue is whether COVID vaccines reduce the probability of getting long COVID.  This article targets this question: “Long COVID risk falls only slightly after vaccination, huge study shows.”  It noted; “Vaccination against SARS-CoV-2 lowers the risk of long COVID after infection by only about 15%, according to a study of more than 13 million people1. That’s the largest cohort that has yet been used to examine how much vaccines protect against the condition, but it is unlikely to end the uncertainty.”

This is good article on the long term significance of long COVID: “Vaccines are no match for long Covid. Treating it is science’s next great challenge.  -Failure to recognize the need for a response could be a blunder we rue for decades to come.”  “Whatever your standpoint on whether the pandemic is over, or what “living with the virus” should mean, it is clear some manifestation of Covid-19 will be with us for some time to come. Not least for the estimated 1.7 million people in the UK living with long Covid.”

“And lest any who made a full and rapid recovery from infection still wonder whether long Covid might be a self-reported creation of the indolent, this is a now a large, well-documented, convergent cluster of clear physiological symptoms, and it is common to every part of the globe affected by Covid-19. Many sufferers of my acquaintance were keen cyclists, runners, skiers and dancers, but are now disabled and deprived of their former passions, while some are unable to resume their former professions. Doctors and scientists the world over now consider this a recognized part of the Sars-CoV-2 symptom profile.”

Here are some important findings from several recent articles.

Lingering Brain Problems Common After COVID - — Can new initiative point to long COVID therapies?

From MedPage Today June 29, 2022

At least one neuropsychiatric symptom has been reported in up to 90% of patients 6 months after COVID-19 hospitalization and in about 25% of non-hospitalized adults with COVID-19, a targeted rapid literature review showed.

Sequelae rates differed depending on the spectrum of post-COVID complications evaluated, the severity, course, and time window from initial infection, and the methodology used to assess symptoms, reported Naomi Simon, MD, MSc, and Jennifer Frontera, MD, both of New York University (NYU) Grossman School of Medicine in New York City.

Commonly reported neuropsychiatric events that occurred 4 or more weeks after acute SARS-CoV-2 infection were cognitive impairment, sleep problems, anxiety, depression, post-traumatic stress disorder (PTSD), fatigue, and headache, Simon and Frontera wrote in a special communication in JAMA Psychiatry.

Diverse reports about symptoms and prevalence rates have made it hard to pinpoint COVID's persistent sequelae, Simon and Frontera noted.

"The current literature describing neuropsychological events following SARS-CoV-2 infection is limited by ascertainment biases, variable definitions of long COVID, conflation of neurological symptoms, signs, and diagnoses, and lack of adequate control populations," Frontera told MedPage Today.

For their review, Simon and Frontera assessed articles about long COVID or post-acute sequelae of COVID-19 (PASC) published on PubMed and PsycInfo between January 2020 and February 1, 2022. The researchers used the CDC definition of long COVID, which included symptoms that were present 4 weeks or longer from index infection.

Post-infection sequelae rates varied widely across studies. One analysis of people hospitalized with COVID-19 from March to May 2020 showed more than 90% had functional and cognitive problems 6 months later. A 2021 survey of COVID-positive people suggested 25% had lingering cognitive or psychological symptoms that lasted a median of 4 months.

Overall, prevalence rates ranged from 4% to 47% for cognitive abnormalities, 3% to 27% for sleep disturbances, 7% to 46% for anxiety, 3% to 20% for depression, 6% to 43% for PTSD, 5% to 32% for fatigue, and 5% to 12% for headache.

"These rates appear to be higher than rates observed in similar patient populations without COVID-19," Simon and Frontera wrote.

"Among 73,000 non-hospitalized patients 30 days or longer after infection, incident onset of anxiety and fear-related disorders and trauma- and stress-related disorders was significantly greater than among those without COVID-19," Simon and Frontera noted. "However, not all studies have found higher rates of mood and anxiety symptoms after COVID-19 hospitalization than among comparator groups, and substantial variability exists in study methods and quality."

Subjective symptoms, diagnosed syndromes, and objective testing abnormalities were conflated across studies, muddying a solid understanding of long COVID epidemiology, Simon and Frontera observed. Many studies reported cross-sectional data only. Even when associations between SARS-CoV-2 and neuropsychiatric disease seemed plausible, causality was difficult to verify without pathological evidence or robust biomarkers, the researchers pointed out.

What triggered post-COVID neuropsychiatric sequelae also was not clear. Proposed mechanisms included brain injury from acute COVID-19, neurodegeneration from secondary COVID effects, immune dysregulation and chronic inflammation, viral persistence in tissue reservoirs, and reactivation of other latent viruses, Simon and Frontera noted.  [This ignores sold research showing micro blood clots in long COVID victims.]

"Despite rapidly emerging data, many gaps in knowledge persist related to the variable definitions of PASC, lack of standardized phenotyping or biomarkers, variability in virus genotypes, ascertainment biases, and limited accounting for social determinants of health and pandemic-related stressors," the authors wrote.

Physician Group Releases Guidance on Cardiovascular Issues in Long COVID

From MedPage Today June 7, 2022

Risks for cardiovascular complications, including pulmonary embolism, arterial and venous thromboses, myocardial infarction, and stroke, are higher in patients with post-acute sequelae of SARS-CoV-2 (PASC), or long COVID, highlighting the need for greater awareness of these conditions among clinicians, according to a consensus statement released by the American Academy of Physical Medicine & Rehabilitation (AAPM&R).

Cardiovascular complications may arise weeks or months after a patient's initial COVID-19 infection, with severity of the symptoms ranging from "mild to incapacitating," according to the PASC Collaborative, a multidisciplinary group of physicians, clinicians, and patient advocates, who developed the statement. They noted that 5% to 29% of COVID-19 survivors complain of cardiovascular symptoms such as chest pain, dyspnea, or palpitations months after their recovery from the acute infection.

"Unfortunately, many people could have chronic cardiovascular conditions due to COVID-19 infection -- even patients without previous cardiovascular disease, comorbidities, and otherwise low risk of cardiovascular disease," said ​​lead author Jonathan Whiteson, MD, of NYU Langone Health in New York City, in a press release. "Because of the chronic nature of cardiovascular conditions, there will likely be long-lasting consequences for patients and health systems worldwide."

Whiteson and colleagues noted that the new consensus statement, the fourth in a series of guidance statements released by AAPM&R, was created to help improve awareness and understanding about this new and widespread condition. The PASC Collaborative was designed to share the best collective knowledge from across medical fields in one place for providers who are tasked with identifying long COVID and its many manifestations.

The goal of the consensus statement was to help providers address patient needs in whatever specialty they are practicing, explained co-author Alba Azola, MD, co-director of the Post-Acute COVID-19 Team at Johns Hopkins Medicine in Baltimore.

"We are not enough," Azola told MedPage Today. "In terms of the post-COVID clinics, there's just not enough for the millions and millions of Americans that are affected."

The guidance, in a nutshell, recommends that physicians become more vigilant about the potential for cardiovascular disease caused by long COVID, especially in patients with no history of cardiovascular complications, calling for targeted education of both healthcare professionals and patients with long COVID.

Whiteson and team advised that all stakeholders learn about the heterogeneity of long COVID symptoms, the likelihood of developing long COVID, the difference between expected symptoms and clinical red flags, lifestyle changes to help ease symptoms, and the connection between the cardiovascular and nervous systems.

This will help both physicians and patients identify the risk factors for cardiovascular complications related to long COVID, they said. Specifically, they noted that patients may experience shortness of breath, fatigue, chest pain, palpitations, dizziness, abdominal bloating, leg swelling, and reduced tolerance for exercise or activity.

To help physicians diagnose and treat patients with long COVID who may present with these symptoms, Whiteson and team outlined several best practices. First, they recommended that a full patient history be taken, including details about any previous COVID-19 infections, such as severity of initial infection and need for ventilator or extra-corporeal membrane oxygenation. Physicians should also note any common or worsening cardiac complaints. In addition, the authors recommended the use of all relevant testing, such as electrocardiograms, echocardiograms, cardiac stress tests, and standard lab tests.

The authors stressed that physicians should focus on modification strategies for risk factors, including hypertension, diabetes, obesity, tobacco use, and sedentary behavior. These modifiable risk factors are associated with greater morbidity and mortality in patients with COVID-19. New research is attempting to define their effects in patients with long COVID.

If patients are experiencing severe cardiovascular complications or disorders, such as arrhythmias, coronary artery disease, or ventricular dysfunction, the next recommended step would be to refer them to the appropriate specialist or a cardiac or long COVID rehabilitation center, the guidance states.

"I think the future will entail a state where we are talking about COVID as a risk factor," Whiteson said. "If someone has had COVID, they may develop cardiovascular disease even in the absence of other risk factors, so look carefully and interpret symptoms cautiously because it's not something you want to miss."

Long covid symptoms are often overlooked in seniors

From the Washington Post June 26, 2022

Nearly 18 months after getting the coronavirus and spending weeks in the hospital, Terry Bell struggles with hanging up his shirts and pants after doing the laundry.

Lifting his clothes, raising his arms, arranging items in his closet leave Bell short of breath and often trigger severe fatigue. He walks with a cane, and only short distances. He’s 50 pounds lighter than when he was struck by covid-19, the disease caused by the coronavirus.

Bell, 70, is among millions of older adults who have grappled with long covid — a population that has received little attention even though research suggests seniors are more likely to develop the poorly understood condition than younger or middle-aged adults.

Long covid refers to ongoing or new health problems that occur at least four weeks after a covid infection, according to the Centers for Disease Control and Prevention. Much about the condition is baffling: There is no diagnostic test to confirm it, no standard definition of the ailment and no way to predict who will be affected. Common symptoms, which can last months or years, include fatigue, shortness of breath, an elevated heart rate, muscle and joint pain, sleep disruptions, and problems with attention, concentration, language and memory — a set of difficulties known as brain fog.

Ongoing inflammation or a dysfunctional immune response may be responsible, along with reservoirs of the virus that remain in the body, small blood clots or residual damage to the heart, lungs, vascular system, brain, kidneys or other organs.

Effect on older adults

Only now is the impact on older adults beginning to be documented. In a study published in the journal BMJ, researchers estimated that 32 percent of older adults in the United States who survived covid infections had symptoms of long covid up to four months after infection — more than double the 14 percent rate an earlier study found in adults ages 18 to 64. (Other studies suggest symptoms can last much longer, for a year or more.)

Terry Bell, 70, who spent two weeks in an intensive care unit and has been diagnosed with long covid, says he now walks with a cane for only short distances and is 50 pounds lighter. He finds that hanging up his shirts and pants after doing the laundry leaves him short of breath and often triggers severe fatigue. (Bob McReynolds)

The BMJ study examined more than 87,000 adults 65 and older who had covid infections in 2020, drawing on claims data from UnitedHealth Group’s Medicare Advantage plans. It included symptoms that lasted 21 days or more after an infection, a shorter period than the CDC uses in its long covid definition. The data encompasses both older adults who were hospitalized because of covid (27 percent) and those who were not (73 percent).

A study released last month from the CDC found that 1 out of every 4 older adults who survived covid experienced at least 1 of 26 common symptoms associated with long covid, compared with 1 out of every 5 people between the ages of 18 and 64.

The higher rate of post-covid symptoms in older adults is probably because of a higher incidence of chronic disease and physical vulnerability in this population — traits that have led to a greater burden of serious illness, hospitalization and death among seniors throughout the pandemic.

“On average, older adults are less resilient. They don’t have the same ability to bounce back from serious illness,” said Ken Cohen, a co-author of the study and executive director of translational research for Optum Care. Optum Care is a network of physician practices owned by UnitedHealth Group.

For older individuals affected by long covid, the consequences can be devastating: the onset of disability, the inability to work, reduced ability to carry out activities of daily life, and a lower quality of life.

Difficult to recognize

But in many seniors, long covid is hard to recognize.

“The challenge is that nonspecific symptoms such as fatigue, weakness, pain, confusion and increased frailty are things we often see in seriously ill older adults. Or people may think, ‘That’s just part of aging,’ ” said Charles Thomas Alexander Semelka, a postdoctoral fellow in geriatric medicine at Wake Forest University.

Ann Morse, 72, of Nashville, was diagnosed with covid in November 2020 and recovered at home after a trip to the emergency room and follow-up home visits from nurses every few days. She soon began having trouble with her memory, attention and speech, as well as sleep problems and severe fatigue. Although she has improved somewhat, several cognitive issues and fatigue still persist.

“What was frustrating was I would tell people my symptoms and they’d say, ‘Oh, we’re like that too,’ as if this was about getting older,” she told me. “And I’m like, but this happened to me suddenly, almost overnight.”

Bell, a singer-songwriter in Nashville, had a hard time getting adequate follow-up attention after spending two weeks in an ICU and an additional five weeks in a nursing home receiving rehabilitation therapy.

“I wasn’t getting answers from my regular doctors about my breathing and other issues,” he said. “They said take some over-the-counter medications for your sinus and things like that.” Bell said his real recovery began after he was recommended to specialists at Vanderbilt University Medical Center.

‘Significant differences’

James Jackson, director of long-term outcomes at Vanderbilt’s Critical Illness, Brain Dysfunction, and Survivorship Center, runs several long covid support groups that Morse and Bell attend and has worked with hundreds of similar patients. He said he estimates that about a third of those who are older have some degree of cognitive impairment.

“We know there are significant differences between younger and older brains,” Jackson said. “Younger brains are more plastic and effective at reconstituting, and our younger patients seem able to regain their cognitive functioning more quickly.”

In extreme cases, covid infections can lead to dementia. That may be because older adults who are severely ill with it are at high risk of developing delirium — an acute and sudden change in mental status — which is associated with the subsequent development of dementia, said Liron Sinvani, a geriatrician and an assistant professor at Northwell Health’s Feinstein Institutes for Medical Research in Manhasset, N.Y.

Older patients’ brains also may have been injured from oxygen deprivation or inflammation. Or disease processes that underlie dementia may already have been underway, and a covid infection may serve as a tipping point, hastening the emergence of symptoms.

Research conducted by Sinvani and colleagues, published in March, found that 13 percent of covid patients who were 65 and older and hospitalized at Northwell Health in March 2020 or April 2020 had evidence of dementia a year later.

Thomas Gut, associate chair of medicine at Staten Island University Hospital, which opened one of the first long covid clinics in the United States, observed that becoming ill with covid can push older adults with preexisting conditions such as heart failure or lung disease “over the edge” to a more severe impairment.

In older adults especially, he said, “it’s hard to attribute what’s directly related to covid and what’s a progression of conditions they already have.”

That wasn’t true for Richard Gard, 67, who lives just outside New Haven, Conn., a self-described “very healthy and fit” sailor, scuba diver, and music teacher at Yale University who contracted covid in March 2020. He was the first covid patient treated at Yale New Haven Hospital, where he was critically ill for 2½ weeks, including five days in intensive care and three days on a ventilator.

In the two years since, Gard has spent more than two months in the hospital, usually for symptoms that resemble a heart attack.

“If I tried to walk up the stairs or 10 feet, I would almost pass out with exhaustion, and the symptoms would start — extreme chest pain radiating up my arm into my neck, trouble breathing, sweating,” he said.

Life-changing infection

Erica Spatz, director of the preventive cardiovascular health program at Yale, is one of Gard’s physicians.

“The more severe the covid infection and the older you are, the more likely it is you’ll have a cardiovascular complication after,” she said. Complications include weakening of the heart muscle, blood clots, abnormal heart rhythms, vascular system damage and high blood pressure.

Gard’s life has changed in ways he never imagined. Unable to work, he takes 22 medications and can still walk only 10 minutes on level ground. Post-traumatic stress disorder is a frequent, unwanted companion.

“A lot of times, it’s been difficult to go on, but I tell myself I just have to get up and try one more time,” he said. “Every day that I get a little bit better, I tell myself I’m adding another day or week to my life.”