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Table of Contents
REVIEW ARTICLE
Year : 2020  |  Volume : 17  |  Issue : 5  |  Page : 32-35

Long-term health consequences of COVID-19 disease


1 Department of Trauma and Orthopaedics, Southport and Ormskirk NHS Trust, Southport, UK
2 Department of Orthopaedics, Indraprastha Apollo Hospital, New Delhi, India

Date of Submission23-Aug-2020
Date of Decision24-Aug-2020
Date of Acceptance24-Aug-2020
Date of Web Publication09-Sep-2020

Correspondence Address:
Karthikeyan P Iyengar
Southport and Ormskirk NHS Trust, Southport, PR8 6PN
UK
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_109_20

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  Abstract 


The effects of novel coronavirus Severe Acute Respiratory Syndrome-CoV-2 outbreak until now have been dramatic on public health with widespread disruption of daily life and health care systems across the world. As we understand the new COVID-19 better, it is becoming apparent that the disease is far more complex. The extent and severity of the long-term health consequences remain uncertain, but emerging data suggest persistent, substantial morbidity of the population is likely. Long-term consequences are expected to have lasting physical, mental, and social health impact along with global economic effects.

Keywords: Coronavirus, COVID-19, lung diseases, mental disorders, neurodegeneration, pandemics


How to cite this article:
Iyengar KP, Vaishya R. Long-term health consequences of COVID-19 disease. Apollo Med 2020;17, Suppl S1:32-5

How to cite this URL:
Iyengar KP, Vaishya R. Long-term health consequences of COVID-19 disease. Apollo Med [serial online] 2020 [cited 2020 Nov 25];17, Suppl S1:32-5. Available from: https://www.apollomedicine.org/text.asp?2020/17/5/32/294562




  Introduction Top


The new novel Coronavirus Severe Acute Respiratory Syndrome (SARS)-CoV-2 outbreak was declared a pandemic by the World Health Organization (WHO) on March 11, 2020. COVID-19 is predominantly a respiratory illness and a highly contagious disease spread by droplet transmission. It causes a spectrum of illnesses from a mild sore throat to serious viral pneumonia requiring hospitalization.[1]

Currently, attention has been focused on the management of critical cases with the patients of mild symptoms being managed in the community and serious illness necessitates hospital care. It is estimated that about 80% of people infected with COVID-19 have a mild illness and recover well, but the remaining patient's require acute medical care.[2] However, it has been increasingly recognized, a sizeable group of patients seem to be experiencing persistent long-term consequences pertaining to COVID-19 either following initial recovery or due to aftereffects of exacerbation of underlying health condition.[3] This has raised concern amongt the health community with an anticipated long-term effect on health care systems soon. We explore the extended impact of the novel Coronavirus SARS-CoV-2 outbreak, how it affects patients, and strategies that can be undertaken to mitigate long-term consequences of COVID-19.


  Long-Term Health Consequences of Covid-19 Top


Prevalence

COVID-19 is an evolving disease. The exact incidence and prevalence are unknown. The signal for possible long-term implications arise from the understanding of acute manifestations of COVID-19, reports in current literature, along with experiences from the previous outbreak of SARS (2003) and Middle East Respiratory Syndrome (MERS) (2012).[4] A team of researchers from Italy reported that nearly nine in 10 patients (87%) discharged from a Rome hospital after recovering from COVID-19 were still experiencing at least one symptom 60 days after onset.[5]


  Long-Term Systemic Consequences of Covid-19 Top


Several long-term systemic consequences of COVID-19 are being seen and are expected to be seen more often, even after this pandemic is over. These sequelae of SARS-CoV-2 infection are seen involving multiple body organs and systems [Figure 1].
Figure 1: Long term health consequences of COVID-19

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Respiratory system

COVID-19 essentially being a respiratory illness, the evidence is gathering about the extent and severity of the long-term respiratory complications of COVID-19 infection.[3],[6] The pathophysiology seems to suggest the role of inflammation and injury to alveolar epithelial cells leading to fibrosis ad several forms of interstitial lung disease.[6] Besides the well-described symptoms of COVID-19, the British Lung Foundation and Asthma UK's post-COVID survey of over 1000 patients, of which over 800 had not been admitted to hospital, found that many patients experience persistent respiratory symptoms months after their initial illness with 90% reporting breathing problems.[7] Tiredness and fatigue were other confounding symptoms. From previous studies in China following the SARS outbreak (2003) it has been found that though most recover well from the acute respiratory illness, long-term effects on pulmonary function, exercise capacity, and lung fibrosis can still be present.[8] Follow-up serial computed tomography in this Beijing study revealed features of parenchymal abnormalities (e.g., “Ground-glass opacity.”) Management of persisting respiratory symptoms is likely to be less straightforward and the British Thoracic Society has published guidelines recommending chest radiography 3 months after discharge for all patients admitted to hospital with COVID-19.[9] The optimal management of long-term respiratory complications is unclear and probably requires a multidisciplinary approach with clinical review and further investigations in appropriate patients.[6]

Cardiovascular system

Underlying cardiovascular disease is associated with severe COVID-19 infection and adverse clinical outcomes.[10] While the exact mechanisms remain uncertain, angiotensin-converting enzyme 2 plays a pivotal role as a link between COVID-19 and the cardiovascular system. There is evidence of myocardial injury as a possible mechanism of cardiac events in COVID-19 patients. In addition to its acute complications, COVID-19 is likely to be associated with long-term cardiovascular damage. Consequently, for a subgroup of patients, a long-term management strategy is needed.

Neurological system

Currently, the long-term consequences of SARS-CoV-2 neuro-infection are unknown. However, it is anticipated potential chronic changes to the central nervous system in relation to accelerated brain aging and age-related neurodegenerative disorders is a future possibility. A high level of pro-inflammatory cytokines, direct negative effects of the immune reaction, acceleration or aggravation of preexisting cognitive deficits, or de novo induction of a neurodegenerative disease is an idea put forward Heneka et al.[11]

Metabolic system

It has been postulated that SARS-CoV-2 may cause alterations of glucose metabolism that could complicate the pathophysiology of preexisting diabetes or lead to new mechanisms of disease.[12] However, whether these alterations of glucose metabolism that occur with a sudden onset in severe COVID-19 persist or remit when the acute infection resolves is unclear.

Musculoskeletal system

Recovery from COVID-19 is associated with tiredness, fatigue and reports of myalgia, joint pains, and small joint arthritis. Some of the most severe sequelae after rehabilitation from SARS are femoral head necrosis and pulmonary fibrosis from the experience of the SARS epidemic in 2003.[8] Avascular necrosis of the femoral head is thought to be secondary to the use of steroids to manage COVID-19. As dexamethasone and methylprednisolone are being increasingly used during the current pandemic, bone health needs to be monitored as one of the long-term side-effects of these medications.[13]

Long COVID

“Long COVID” is a term being used to describe the long-term effects of COVID-19 in people who have either suspected or confirmed COVID-19.[14] There is growing evidence that in some patients, the symptoms persist longer than expected.

Mental health

The current COVID-19 pandemic is leading to additional health problems such as stress, anxiety, depressive symptoms, insomnia, denial, anger, and fear globally.[15] Financial insecurity and job loss caused by COVID-19 pandemic may exacerbate symptoms of depression, anxiety, distress, and psychosomatic symptoms, as noted by the United Kingdom–”UK-COVID-19 Social Study.” Posttraumatic Stress Disease is reported and may need frequent clinical contact to avoid exacerbations and hospitalizations. Uses of telemedicine where possible, is recommended to monitor mental illness and provide support.

Effect of COVID-19 on the diagnosis of other conditions

Concerns have been raised that the diagnosis and treatment of other non-COVID-19 related medical conditions may be delayed due to the current pandemic. Due to fear of contracting, COVID-19 patients are avoiding attending hospitals for other emergencies such as stroke, myocardial infarctions, and other cardiorespiratory diseases. Cancer care and elective orthopedic services have been suspended to various degrees. As this resume, it is expected a tsunami of non-COVID-19 diseases are going to inundate the already stretched health care system.


  Social Health and Effect on Health Care Systems Top


The WHO says mild illness from COVID-19 takes about 2 weeks to recover, while severe illness can take up to 3–6 weeks to improve. However, since COVID-19 is a new disease, no studies about the long-term trajectory of COVID-19 is available to plan forward.

The UK-National Health Service (NHS) assumes that of the COVID-19 patients who have required hospitalization, 45% will need ongoing medical care, 4% ill require in-patient rehabilitation, and 1% will permanently require acute care. The NHS has recently launched The posthospitalization COVID-19 study (PHOSP-COVID) to recruit 10,000 patients in the UK to identify the medical, psychological, and rehabilitation needs of patients admitted to hospital with COVID-19 and to provide a comprehensive picture of the longer-term effects of infection.[16]


  Strategies to Support Patients With Long-Term Consequences of Covid-19 Top


  • COVID-19 recovery programs: As we learn about the long-term complications of COVID-19, health-care systems will have to establish COVID-19 recovery programs to support, expand and provide access to COVID-19 rehabilitation treatments for those who have survived the virus but still have problems with breathing, mental health problems, or other complications.
  • Speciality support: As recommended by the British Thoracic Society guidelines for patients experiencing persistent problems with respiratory symptoms, various specialty, and medical organizations will have to set-up support mechanisms to assess these patients with regular clinical reviews and further investigations.
  • Community support: Peer-to-peer community and mental support groups will have to be been developed, for example, Long Covid.org to provide online resources and exercise tutorials to help in the Post-COVID recovery.



  Future Directions Top


As we deal with the acute effects of the current pandemic, strategies will have to be put in place and will require a coordinated response from the government, public health bodies, healthcare systems, scientists, and medical society to manage long-term consequences of COVID-19. Prospective studies and research to evaluate complications further and identify people at risk are necessary. The PHOSP-COVID study being planned to assess long-term effects of COVID-19 in hospitalized patients should be extended to milder cases to understand the full spectrum of the disease.


  Conclusion Top


It is important to acknowledge that the effects of COVID-19 are just not acute, but the disease has long-term consequences as well. Raising awareness, recognition, research, and multidisciplinary involvement will be the cornerstones to manage long-term sequelae of COVID-19 effectively. Lesson learnt from the previous SARS and MERS epidemic should be accelerated in planning future care of our patients and the health of our community.

Author's statements

Author's contributions

KPI and RV are involved in conceptualization, design, literature search, manuscript writing, references, and editing. Both authors have read and agreed the final draft submitted.

Statement of ethics

The current submitted article is not a clinical study and does not involve any patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al. A novel coronavirus from patients with pneumonia in China. N Engl J Med 2019;382:727-33.  Back to cited text no. 1
    
2.
The Centre for Evidence-Based Medicine (CEBM). COVID-19: What proportions are asymptomatic? Available from: https://www.cebm.net/covid-19/covid-19-what-proportion-are-asymptomatic/(20). [Last accessed on 2020 August 20].  Back to cited text no. 2
    
3.
Ngai JC, Ko FW, Ng SS, To KW, Tong M, Hui DS. The long-term impact of severe acute respiratory syndrome on pulmonary function, exercise capacity and health status. Respirology 2010;15:543-50.  Back to cited text no. 3
    
4.
Centers for Disease Control and Prevention. 2017. Severe acute respiratory syndrome (SARS). Available from: https://www.cdc.gov/sars/index. html.(20). [Last accessed on 2020 August 20].  Back to cited text no. 4
    
5.
Carfì A, Bernabei R, Landi F. Gemelli Against COVID-19 Post-Acute Care Study Group. Persistent Symptoms in Patients After Acute COVID-19 [published online ahead of print, 2020 Jul 9]. JAMA 2020;324:603-5.   Back to cited text no. 5
    
6.
Fraser E. Long term respiratory complications of covid-19. BMJ 2020;370:m3001.  Back to cited text no. 6
    
7.
8.
Zhang P, Li J, Liu H, Han N, Ju J, Kou Y, et al. Long-term bone and lung consequences associated with hospital-acquired severe acute respiratory syndrome: a 15-year follow-up from a prospective cohort study. Bone Res 2020;8:8.  Back to cited text no. 8
    
9.
British Thoracic Society. Guidance on respiratory follow up of patients with a clinico-radiological diagnosis of covid-19 pneumonia; 2020. Available from: www.brit-thoracic.org.uk. [Last accessed on 2020 August 20].  Back to cited text no. 9
    
10.
Li M, Dong Y, Wang H, Guo W, Zhou H, Zhang Z, et al. Cardiovascular disease potentially contributes to the progression and poor prognosis of COVID-19. Nutr Metab Cardiovasc Dis 2020;30:1061-7.  Back to cited text no. 10
    
11.
Heneka MT, Golenbock D, Latz E, Morgan D, Brown R. Immediate and long-term consequences of COVID-19 infections for the development of neurological disease. Alzheimers Res Ther 2020;12:69.  Back to cited text no. 11
    
12.
Rubino F, Amiel SA, Zimmet P, Alberti G, Bornstein S, Eckel RH, et al. New-onset diabetes in covid-19. N Engl J Med 2020;383:789-90.  Back to cited text no. 12
    
13.
Horby P, Lim WS, Emberson JR, Mafham M, Bell JB, Linsell L, et al. RECOVERY Collaborative Group, Dexamethasone in Hospitalized Patients with Covid-19 - Preliminary Report [published online ahead of print, 2020 Jul 17]. N Engl J Med 2020;NEJMoa2021436. doi:10.1056/NEJMoa2021436.  Back to cited text no. 13
    
14.
Mahase E. Covid-19: What do we know about “long covid?” BMJ. 2020;370:m2815.  Back to cited text no. 14
    
15.
Torales J, O'Higgins M, Castaldelli-Maia JM, Ventriglio A. The outbreak of COVID-19 coronavirus and its impact on global mental health. Int J Soc Psychiatry 2020;66:317-20.  Back to cited text no. 15
    
16.
The Posthospitalisation COVID-19 Study (PHOSP-COVID). Available from: https://www.phosp.org. [Last accessed on 2020 Aug 23].  Back to cited text no. 16
    


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