COVID Recovery
The Implications of COVID and LONG COVID on Physical and Mental Health
I am now in the majority of people who survived COVID. Perhaps I have God to thank or maybe it’s my own genetic immunity, or luck, or fate, or destiny. Either way, I’m alive and that’s why I’m grateful.
After such an ordeal, one would hope that contracting and surviving COVID would be a badge of immunity. Certainly not a badge of courage because you can’t run from COVID once you’ve got it.
Unfortunately, this is not the case. COVID remains infectious (even to those previously infected) and just because you contract it once doesn’t mean you won’t get it again. I’ve talked to people, many of them my own clients. What I’ve learned is that it’s still possible to be re-exposed and contract COVID a second time, or a third or even fourth time.
Re-occurring COVID infection is known in public health, epidemiological lingo as an “endemic” disease. In fact, I’ve wondered what endemic means and what its implications are for someone trying to stay protected from COVID infection and re-infection.
Endemic, defined in our common language is: Characteristic of or prevalent in a particular field, area, or environment. Endemic, used in a sentence is: “Malaria is endemic in many of the hotter regions of the world.” The key word in this sentence is “hotter regions” for obvious reasons (see “particular… area” in the previous definition).
Endemic, defined as a medical or epidemiological term, is: A disease that is constantly present in a certain geographic area or in a certain group of people. This definition denotes a temporal disease occurrence pattern in a population (or group) where the disease manifests with predictable regularity and only minor fluctuations in its frequency over time.
If COVID has become “endemic” then, by replacing the word “COVID” for “disease” in the endemic definition, you get this statement:
COVID is constantly present in a certain geographic area or in a certain group of people. In the case of COVID, “certain” group of people happens to be you and I, and geographic area is the entire world. I’m not sure why COVID is not called “panendemic,” but I’m not in the business of creating new words.
This clarification of endemicity is for general knowledge, but it does not describe the implications of an endemic disease on a population or group.
If it is endemic, What are the implications of COVID?
Addressing this question involves examining an existing, and somewhat parallel, disease such as influenza or the common flu. Clearly, flu is endemic.
The flu is endemic. Our public health system tracks the flu. There is a period of time called “the flu season” when the flu virus is at its highest contagion rate. That’s roughly when we get flu shots (or at least some people get flu shots) to protect those vaccinated against a particular strain of flu. Our medical system has developed experimental treatments, as well, to diminish flu symptoms (or even flu effects) when people, early on, contract the flu (oseltamivir (Tamiflu) is one of those drug treatments).
NOTE: This is how oseltamivir (Tamiflu) works: Flu virus spreads by locally infecting a host cell (say, some lung cells), then virus particles break off the infected cells and travel to other lung cells throughout the entire respiratory tract, spreading the flu. Aseltamivir works by interrupting the function of the enzyme neuraminidase that creates these virus particles. So, the drug literally stops the production of virus break-off particles. The local virus infection remains, but it cannot spread, and eventually your body’s immune system (not the drug) kills the virus at the local infection site.
We expect to eventually contract the flu, perhaps multiple times, during our lifetime. No one gets too worried about flu season even though people die every year from flu. Life simply goes on without fuss except, of course, if you are that person who dies from flu virus.
McKinsey & Company (a world-wide social-welfare consulting firm) has come up with a set of society guidelines as COVID-19 becomes endemic. I won’t copy their entire set of guidelines in this blog, these are available at: https://www.mckinsey.com/industries/public-and-social-sector/our-insights/pandemic-to-endemic-where-do-us-public-health-systems-go-from-here
I abstract two sections from these guidelines that telegraph the COVID-19 social-endemic mindset.
Developing a set of vital signs to track the health of society. As the pandemic becomes endemic, evaluating the public-health system could extend beyond current key COVID-19-related measures, which include excess mortality, hospitalization, case fatality, and transmission rates…now may be the time to broaden…attention to a set of measures that encompasses broader societal healthcare outcomes (such as maternal and infant health, behavioral health, communicable disease, chronic disease, and environmental health)…
Integrating COVID-19 boosters into annual vaccination campaigns. While vaccines bolster immune defense against COVID-19…this immunity wanes over time. …The US Centers for Disease Control and Prevention (CDC) has recommended booster vaccinations for the general population. As [COVID] variants continue to evolve…periodic booster shots may provide an effective public-health tool to anticipate and control future outbreaks…Ensuring access to both COVID-19 and flu vaccines at dispensing locations…. Longer-term, combination vaccines across multiple respiratory illnesses are in development…
What about Long COVID?
Long COVID has been around since COVID-19. The American Medical Association (https://www.ama-assn.org/delivering-care/public-health/what-long-covid) defines Long COVID as follows:
Most people recover from SARS-CoV-2, the virus that causes COVID-19, within a couple of weeks, but others may experience new or lingering symptoms, even after recuperating from COVID-19. Although, there is no universal clinical case definition for these lingering symptoms the CDC labels long COVID, also known as post-COVID conditions, as a wide range of new, returning or ongoing health problems people can experience four or more weeks after first being infected with SARS-CoV-2…According to the CDC, long COVID may also be referred to as long-haul COVID, post-acute COVID-19, long-term effects of COVID or chronic COVID.
The AMA Continues -
Patients with long COVID can be placed in one of three categories…
Patients with COVID-19 who do not recover completely and have ongoing symptoms because of direct cell damage from the virus.
Patients with symptoms related to chronic hospitalization such as when someone is in the hospital, ICU or is bed bound for weeks.
Patients with new symptoms that appear after recovery.
FACT: Those with “Long COVID” are a subset (or a subgroup) of those who have contracted COVID. In other words, you can’t get “Long COVID” unless you first get COVID-19.
CRITICAL POINT: The time of full recovery from the initial COVID-19 exposure differs across people (some recover in a few days, some recover in a few weeks a small minority take months). This seemingly obvious individual difference is important for different reasons.
You could have two people: Person 1: Takes a long time to recover from COVID (say 4 weeks). Person 2: Recovers from COVID quickly (say, a few days), but then gets Long COVID. Although these two people recover at roughly the same time, say 4 weeks, Person 2 had long COVID and would probably be diagnosed and treated differently than Person 1.
WHAT HAPPENED TO ME?
My initial COVID infection was approximately August 13, 2022. My story from there is articulated in a previous entry. I was physically sick with COVID through August 24, 2022 (or 11 days). I’m not sure when I tested negative for COVID, in fact, I never did take a test again, so I could still be positive. It is, however, unlikely that I am positive for COVID because I’m not experiencing any clear symptoms. Today, September 20, 2022 I feel fairly normal. I am, however, hyper-aware of anything that might mean I have Long COVID. I do feel fatigue still, when I walk for 30 minutes I feel fine, but over the course of the day I get, what I think, is more tired than prior to COVID, but I have know way, beyond my memory, to validate this difference. My fears/anxiety about COVID keep getting pushed into the background when I’m busy and likely sometime in October 2022 I won’t think about COVID symptoms anymore.
Perhaps, my story is a good one, perhaps it is not. Who knows, We have yet, as a society, refined our identification and tracking of the symptoms of what is elusively called, “Long-COVID Syndrome.”
LONG COVID OR NOT LONG COVID
This leads to an intriguing question. How do you know if you have: a) COVID or b) Long COVID. The simple answer is: If you are testing positive for COVID you have COVID. If you do not test positive for COVID, but you are having COVID-like symptoms, then you have Long COVID.
This answer seems easy and it is straight-forward, but it is incomplete and possibly wrong. Why?
The distinction between COVID and Long-COVID can only be determined by the measured presence or absence of COVID-19.
As of August 30, 2022 we didn’t have a test to confirm the existence of a “Long-COVID.” So, what might be Long-COVID could be any number of conditions including post-Lyme, ME-CFS, Fibromyalgia, or even the common cold. It could also be a brand new disease that infects a vulnerable host that gets triggered into symptom expression by COVID damage (a person’s arthritis flares up mimicking Long COVID).
CUTTING EDGE INFORMATION:
There is a new test on the visible horizon line. It is called “incellKine”. The name reflects the company that developed it. The incellKINE test claims to identify immune signatures unique to long COVID and use these to distinguish Long COVID from other diseases. An experimental test, IncellDx, claims to identify immune signatures called cytokines and chemokines. These are sources of inflammation. They are also unique to long COVID.
Whether this diagnostic Long COVID test proves to be a reliable and valid measure of the presence of Long COVID is still to be determined, but my reading of the early results are promising. We know a lot about COVID, how it infiltrates, how it proliferates, what residual it leaves behind. We have a good sense of the symptoms, and even how to treat it effectively. We still can’t eliminate it, but we are getting close. I imagine that this same trajectory will be seen for Long COVID as well. Unfortunately, when damage is done, damage can’t easily be reversed. So, the problems of Long COVID will likely linger for years and years.
CAN WE PUT COVID AND LONG COVID IN PERSPECTIVE
How do we put perspective around COVID and Long COVID. There are some challenges:
COVID is occurring right now and it is scaring every living person. Fear impacts how people view things.
Technically, COVID is somewhere between pandemic and endemic. We can’t agree on terms and labels. Long COVID has all kinds of names and descriptions.
COVID has been politicized, and anything politicized has an inflated perspective.
The world-wide COVID data is enormous, but still in 2022 highly disorganized and, in some regions of the world, spotty. We still, have no systematic way of organizing or collecting data beyond what is observed in the newspapers and this is haphazard. People don’t test, people don’t even reveal whether they’ve gotten COVID. So data integrity remains a big problem.
Even so, there are ways to look at COVID from the broader perspective. I like the graph below. The red box is the “approximate” area where a COVID dot will eventually fall.
The data for this graph comes from China. The raw data are death rates and disease transmission rates (communicability). Death rates are transformed to a logarithmic scale because some of the diseases at the top have an absolute death rate too small to fit into this box unless you transform this data to account for smaller numbers of absolute persons killed, for example, by Ebola. Take measles, as another example. Here is a really “fast” moving disease that tends to be associated with lower death rates. This graph is a distortion of reality, but it does show potential trends of COVID in relation to other communicable diseases.
I think COVID will go down in the history books as an “average” moving disease (as far a pure communicability is concerned). It is less likely (20% likely or less) you will die from COVID if you contract it; unlike Ebola, which is highly likely to kill you if you contract it.
A LESSON FROM THE CHART: Be grateful that a virus like Ebola is not highly communicable as well.
How Many Times Might I Get COVID?
This is a good question when a virus or related disease moves to an endemic state. In a recent New Yorker Article, How Many Times Will I Get COVID: When it comes to coronavirus infections, the third time is not the charm. What is?, Dhruv Khullar, October 8, 2022, Annals of Medicine:
…
Viruses have always caused a variety of immediate and lasting health problems. It’s just that “most people haven’t been paying attention,” Krammer said. Long before this pandemic, for example, viral infections were linked to diabetes, cancer, heart problems, and autoimmune conditions. Five years ago, in her book on the 1918 influenza pandemic, the journalist Laura Spinney wrote about people who suffered prolonged weakness, fatigue, brain fog, insomnia, and mood changes. “We were leaden-footed for weeks,” one woman recalled. “It also was very difficult to remember any simple thing, even for five minutes.” A train driver was “never . . . quite the same” after his illness, blacking out while driving and causing an accident. In parts of Africa, post-viral syndromes were so widespread among farmers that they’re thought to have triggered a famine. Recent research suggests that even non-pandemic influenza may be associated with protracted symptoms: according to researchers at Oxford, nearly a third of people who contract the flu virus today report symptoms that resemble long covid, and could be suffering what might be called “long flu.”
Doesn’t this mean that we should worry about a higher baseline of illness going forward—that the risks of coronavirus reinfections will be layered atop a pre-pandemic level of disease? “Not necessarily,” Krammer told me. “In fact, I think we’re going to get back to more or less the same state we were in before the pandemic.” Krammer argued that respiratory viruses often compete with one another; one kind of infection could make others less likely, at least in the short term. (During the 2020-21 influenza season, flu cases fell so steeply that the C.D.C. was unable to calculate the virus’s burden.) After an infection, the cells in your respiratory tract remain in an antiviral state for some time, making it harder for other viruses to take up residence. It’s also likely that, during and after an illness, people change their behavior. They stay home from work, skip dinner with friends, forgo concerts and conferences. “In the long run, sars-CoV-2 will be just another respiratory virus,” Krammer predicted…
Al-Aly was less sanguine. He sees little reason that covid risks will necessarily drop to the level of influenza… “We have to balance the need for normalcy with the need to protect the health of the people,” he said. Still, he agreed with Krammer and the other experts on one thing: the added burden of a third, fourth, or fifth infection will probably be lower than the first or second. … “There will come a point where reinfection will not add more risk,” Al-Aly said. “Whether that is the sixth or seventh or nth infection, we don’t know yet.”