Long Covid’s Advent Calendar of Symptoms

Posted by John Mooney FFPH, Locum Consultant in Public Health, NHS Highland @StandupforPHlth

I should really start this piece with both a declaration of personal interest and a confession. Firstly, I can unfortunately count myself among the many thousands of people affected by what is being referred to as ‘long covid’. Secondly, I have shamelessly borrowed my title analogy from a fellow sufferer and infectious disease academic, Professor Paul Garner whose highly engaging and informative BMJ blogs^(1,2) on the subject have helped many to realise that they are not alone or imagining things. With another prominent ‘patient-advocate’ for the disease being the University of Southampton’s Dr Nisreen Alwan, (associate professor and consultant in public health), you might be forgiven for thinking that this is a virus with a special affinity for public health professionals! Now that would be clever but regrettably it is clearly far less discerning.

Image credit: The Spectator magazine and the illustrator Richard Jolley

In keeping with the spirit of the season, my own advent calendar of symptoms has popped open several new windows this week, most notably ‘pins and needles’ and joint pains. Both have arrived on top of the commonly experienced and more worrying long-term chest pains (eight months in my case) and irregular erratic heart rate (managing over 200bpm at rest on one occasion (the normal range for healthy adults is between 60 and 100 bpm). This combined with a rogue ECG readout (Electrocardiograms test the heart's rhythm and electrical activity) in a local A&E department earned me an unscheduled two-night stay in hospital six weeks ago. Seemingly intractable tinnitus has become another constant ‘companion’.

Resting heart rate over 200 bpm &
 oxygen saturation below optimal 

Thanks to my local NHS Hospital, my symptoms were comprehensively investigated and I continue on the ‘recovery’ journey - if recovery is not too optimistic a label. Recent findings from several studies on the longer term complications of the disease have however made for uncomfortable reading, all the more so for being carried out in people whose symptoms had generally not been particularly severe.

In the first of these, a Frankfurt based cardiac MRI study⁽³⁾ recruited 100 cases of non-hospitalised patients in whom 78% were found to have disruption to heart muscle function and 60% ongoing heart tissue inflammation. Given that the number of ‘milder’ cases will always inevitably far outweigh the numbers hospitalised or who tragically do not survive, the sheer scale of the potential public health disease and premature death burden (if heart health is undermined), begins to look very concerning⁽⁴⁾.

Receiving supplemental oxygen in A&E 6 months after
 initial symptoms (mask displaced to drink)

Perhaps more worrying still, ‘long covid’ does not seem to restrict its attentions to the heart and lungs, with another study finding evidence of multiple organ damage in 201 people with a largely mild course of disease, 70% of whom had damage in one or more organs, including kidneys (12%), liver (10%), pancreas (17%) and spleen (6%), as well as heart (32%) and lungs (33%) four months after initial symptoms⁽⁵⁾. 

Adding further to this complex picture was a news release about a study this week of ten patients at Oxford University in which a novel scanning technique was used to successfully identify damage not picked up by conventional scans⁽⁶⁾. Eight of the ten patients still experiencing shortness of breath three months after infection (none severe enough to be hospitalised), had evidence of hidden lung damage. The new technique will now be repeated with a much larger sample.

These worrying findings about potential long-term damage are already prompting some big-picture questions: What proportion of people who only had very mild disease will go on to develop organ damage? Proportions like 60% and 70% could potentially translate into a staggering public health disease burden with very substantial implications for health services. Devastating though the considerable loss of life has been, the eventual population impact clearly has the potential to be far greater⁽⁴⁾. 

As always with such matters however, it is never especially helpful or productive to dwell too long on ‘worst case scenarios’. For my own part, I am fortunate to be in a non-physically demanding job with an understanding employer. The prospect of accommodating such an unwelcome guest as long covid in a physically strenuous job or on a zero hours contract (or both) does not bear thinking about. Long covid clearly has the potential to further exacerbate the substantial inequalities in health and social outcomes that have so clearly characterised the current pandemic.

Significant unanswered questions also remain around which population groups are most likely to be affected by long covid: do they correspond for instance to those most at risk of not surviving? Early indications are that this might not be the case, at least as far as age or gender is concerned: while there has been no systematic population prevalence study, long covid seems to disproportionately affect younger and middle-aged adults, and females over males. For some this latter observation lends credence to long covid being ‘auto-immune’ in origin since women tend to be at higher risk of such diseases (lupus and rheumatoid arthritis being two prominent examples).

Would vaccination be helpful for those affected? Or might it be dangerous given the likely involvement of a misdirected immune response as the basis for the condition? In these respects it’s extremely encouraging that long covid is receiving high level research attention that seems to be already helping to unravel its impact, causes and effects. Such efforts may ultimately be at least as valuable as the impressive progress with vaccine development.

Returning to the advent calendar of the title, the wonderful thing about advent is that there is a season of joy and festivity at the end of a dark midwinter month. Here’s hoping that there is an end in sight also for the many afflicted by long covid.


References:

1. Paul Garner on long haul covid-19—Don’t try to dominate this virus, accommodate it - The BMJ September 4, 2020. https://blogs.bmj.com/bmj/2020/09/04/paul-garner-on-long-haul-covid-19-dont-try-and-dominate-this-virus-accommodate-it/
2. Paul Garner: Covid-19 and fatigue—a game of snakes and ladders - The BMJ May 19 2020. https://blogs.bmj.com/bmj/2020/05/19/paul-garner-covid-19-and-fatigue-a-game-of-snakes-and-ladders/
3. Puntmann VO, Carerj ML, Wieters I, et al. Outcomes of cardiovascular magnetic resonance imaging in patients recently recovered from coronavirus disease 2019 (COVID-19). JAMA Cardiol. Published online July 27, 2020. doi:10.1001/jamacardio.2020.3557
4. Mooney, JD, Ling J. Long covid: a potential longer term morbidity time bomb?: Rapid response to: BMJ 2020; 371. doi.org/10.1136/bmj.m4470
5. Dennis A, Wamil M, Kapur S, Alberts J, Badley AD. Multi-organ impairment in low-risk individuals with long COVID. https://www.medrxiv.org/content/10.1101/2020.10.14.20212555v1.full.pdf
6. BBC News: Covid-19: Lung damage 'identified' in study: 1st Dec 2020 https://www.bbc.co.uk/news/health-55017301

Acknowledgement to high profile fellow awareness raisers of #LongCovid:

Professor Paul Garner: Liverpool School of Tropical Medicine: @PaulGarnerWoof

Dr Nisreen Alwan: University of Southampton @Dr2NisreenAlwan

Who wins: the tortoise or the hare in the race for health benefits?

Posted by Liane Azevedo, Fuse staff member and Senior Lecturer in Physical Activity and Public Health, Teesside University

At the 63rd American College of Sports Medicine Annual Meeting in Boston, USA this year, an interesting debate took place which was titled ‘Who Wins: the Tortoise or the Hare?'. The debate discussed the latest research findings on a hot topic in physical activity research: what is better for your health; high intensity exercise or reducing sedentary behaviour in favour of light to moderate exercise? I was expecting a heated debate; however, the session was quite balanced with both sides presenting the pros and cons of their approach, followed by a talk on the middle ground by Tim Church suggesting that the best is exercise in moderation (the benefits of regular moderate-intensity exercise).

Let’s start with the arguments for reducing sedentary behaviour. The sedentary behaviour ‘defence’ was presented by Genevieve Healy from the University of Queensland. She talked about a study which showed that a reduction in sitting, in favour of more standing or stepping, could both promote cardio-metabolic benefits (concerning heart disease and metabolic disorders such as diabetes) to improvements in glucose and lipid metabolism (the synthesis and breakdown of glucose and fatty acids). Similar results were shown in other presentations at the conference with a number of studies also showing that interrupted sitting with walking (rather than just standing) can improve insulin response, resting blood pressure and lipid concentration. Moreover, Genevieve provided a number of examples of interventions for the workplace and for older populations, such as Small Steps, Stand Up For Health and Stand Up Australia, which have all shown to be effective

I presented evidence of this argument myself at the conference in a poster about a systematic review which we conducted on sedentary behaviour interventions for children. We found that sedentary interventions are mostly ineffective to reduce BMI (body mass index) in a mixed-weight population but can be effective for treatment of an overweight or obese population.

In the case of sedentary behaviour major questions still remain, for instance, are the risks of sedentary behaviour for cardiovascular diseases independent of physical activity? In other words, if you have a job like mine that requires you to sit for long hours and you try to compensate for this behaviour at the end of the day by doing 30-40 mins of moderate to vigorous physical activity, does this mean that you still have the same cardiovascular disease risks as, for instance, someone who does not exercise? The answer appears to be no; the risk seems lower (phew … ). However, the data in the literature is still contradictory. But it was interesting to see well known scientists in the field like Charles Matthews recognising that these behaviours might not be as independent of each other as it was originally thought when it relates to health risks.

The case for the opposite argument - that high intensity exercise is more important for your health - was made by Professor Ulrik Wisløff from the Norwegian University of Science and Technology. He presented a number of studies which showed the additional benefits of vigorous activity compared to moderate or total physical activity on a number of health indicators, such as all-cause mortality, improvement of maximum aerobic capacity and in endothelial (the inner lining of blood vessels) function, and as an effective treatment of arterial fibrillation (abnormal heart rhythm) in unhealthy patients.

The audience questioned Professor Wisløff about the risk of injury when doing high intensity exercise, how to translate these findings into physical activity guidelines, and the long term sustainability of this type of exercise. Wisløff said that in their studies there were no report of injuries, but admitted that long term sustainability still needs to be investigated. A starting point for demonstrating the feasibility of high intensity exercise in a real-life setting can be found in the study completed by Dr Kathryn Weston at Teesside University. In the study she investigated the effect of a school-based high-intensity interval training on cardio-metabolic health. She found that the high intensity exercise did not only improve some cardio-metabolic parameters but was also delivered as intended.

Therefore, I would say that the answer to the question ‘who wins the tortoise or the hare?’ is that both are winners. For some people high intensity exercise can be the most exciting way to exercise, while for others just the substitution of sedentary to light and moderate is the suitable (also it doesn’t need to be one or the other). The most important point is to choose something that will encourage you to do physical activity, because the health benefit is there for both.

Acknowledgment: Liane Azevedo would like to thank Fuse and Teesside University for the support to attend this Conference.


Photo attribution: “Image from page 216 of "St. Nicholas [serial]" (1873)” by Internet Archive Book Images via Flickr.com: https://www.flickr.com/photos/internetarchivebookimages/14781657201