There’s still a lot to learn about Covid-19, but it’s clear that it is not simply a relatively short and mild viral infection. In October 2020, an analysis of data from the Covid Symptom Study app from health science company ZOE, led by researchers at King’s College London, revealed that many people are experiencing symptoms that last for many weeks or even months. This has been termed ‘long-Covid’. Often symptoms associated with long-Covid haven’t been severe enough to land people in hospital, and may even seem mild during the initial infection, but they have significantly affected, or continue to affect, people’s daily lives.
The NHS estimates that long-Covid affects as many as 60,000 people in the UK. Many of these people remain frustrated and exhausted, battling symptoms that show no signs of abating, or symptoms that keep coming back after a period of recovery. While some of these can be eased with self care measures and over-the-counter (OTC) products, it is important that pharmacy customers who are concerned about long-Covid consult their GP to make sure there are no underlying health problems.
“Pharmacies may be called on to help with long-lasting symptoms of Covid-19,” says Naresh Rallmil, Numark service development pharmacist. “Some of these symptoms can be quite severe and outside the pharmacy team’s clinical skills. If customers are suffering from some of the more severe symptoms, pharmacies should understand when and where to refer. For example, those suffering with prolonged coughs and breathlessness should be investigated and monitored in secondary care to ensure they are treated appropriately.”
The Covid Symptom Study data revealed that while most people with Covid-19 reported being back to normal in 11 days or less, around one in seven had symptoms lasting for at least four weeks, one in 20 suffered for more than eight weeks, and one in 50 suffered for longer than 12 weeks.
Older people were more likely to get long-Covid than younger people, and women were more prone than men. People developing long-Covid tended to have a slightly higher average BMI than those experiencing a shorter form of the virus. People with asthma were more likely to develop the long form, and also those with a greater number of symptoms in the first week of their illness.
“It’s important that as well as worrying about excess deaths, we also need to consider those who will be affected by long-Covid if we don’t get the pandemic under control soon,” says Professor Tim Spector, Covid Symptom Study lead and professor of genetic epidemiology at King’s College London. “Having such large numbers of people affected means specialist services need to be set up urgently with full financial help for hospitals and GPs.”
A survey published by the British Medical Association in August 2020 revealed that almost a third of doctors had seen or treated patients with symptoms they believed were the long-term effects of Covid-19. The symptoms most commonly reported included chronic fatigue, reduced exercise capacity, muscle weakness, memory loss, concentration difficulties and loss of sense of smell. Many other effects have been reported in other surveys and studies, including blood clots, poor diabetes control and mental health conditions.
“The symptoms are confusing and highly variable,” says Dr Emma Ladds, academic GP at the Nuffield Department of Primary Care Health Sciences, University of Oxford. “Most commonly patients with long-Covid report chest pains, breathlessness, myalgia and fatigue – particularly on exercise. However, many more are reported, including indigestion and reflux, skin rashes, numbness and tingling sensations, memory or attentional problems and mood problems. Symptoms often come in waves, with patients feeling recovered and then suffering relapses.”
The NHS estimates that long-Covid affects as many as 60,000 people in the UK
There is not yet an official definition of long-Covid, and it is still unclear why some people are developing this form of the disease. It is possible that a weak immune response, autoimmune reactions, excessive inflammation, viral persistence, post-viral stress and anxiety or even different viral strains may contribute. According to the British Society of Immunology, even people with mild or asymptomatic Covid-19 infections may experience long-term inflammatory consequences.
In October 2020, the Oxford University C-MORE study revealed that persistent or chronic inflammation may be the underlying factor in MRI changes in various organs. “These findings underscore the need to further explore the physiological processes associated with Covid-19 and to develop a holistic, integrated model of clinical care for our patients after they have been discharged from hospital,” says Dr Betty Raman, clinical research fellow at the Radcliffe Department of Medicine in Oxford.
In a recent British Medical Journal (BMJ) online webinar, Valentina Puntmann, co-author of a research paper in JAMA Cardiology, discussed the relatively high frequency of post-viral or inflammatory myocarditis (inflammation of the heart muscle) in people who have had Covid-19. “We were all focusing on the lungs and respiratory symptoms to begin with, but the virus attacks the same receptor that is in the heart too,” she says. “Many patients who have had heart failure in the past who have now been very unwell with Covid-19 symptoms have sustained arrhythmias, meaning their hearts were beating very fast whilst they were ill, and they then went on to develop heart failure.”
It is clear that Covid-19 puts extra stress on many different organs. In October 2020, the COVERSCAN study, which assesses the impact of Covid-19 on the health of multiple organs using imaging technology, revealed that 50 per cent of patients recovering from Covid-19 have measurable organ damage, including those not hospitalised. The research programme, developed by digital technology company Perspectum, Oxford University Hospitals NHS Trust and the Mayo Clinic, mapped the effects of Covid-19 on the body’s key organs, and found that 50 per cent of patients have evidence of either heart, liver or kidney damage, with a median age of 43. Some 13 per cent had evidence of liver inflammation and 19 per cent had evidence of liver fat. Many patients had excess fat in their pancreas as well.
“These results provide early evidence showing that effects of the virus can have a potentially long-term impact on younger people who have not been hospitalised with Covid-19,” says Mary Xu, head of clinical affairs at Perspectum. “These findings are a first step in enabling clinicians to better understand the disease and, in doing so, aid them in monitoring and supporting their patients with any subsequent ongoing healthcare needs.”
Since Covid-19 is not only a new virus, but different to any other virus encountered before now, healthcare professionals have had to create new management guidelines from scratch. Dr Nisreen Alwan, associate professor in public health at the University of Southampton, who has personal experience of long-Covid, has been campaigning for more healthcare recognition of long-Covid patients. She stresses that the degree of Covid-19 severity isn’t simply about hospital admissions or deaths, but also about the duration of the disease, especially in young people who were previously healthy.
In August 2020, Trisha Greenhalgh, practising GP and professor of primary healthcare at the University of Oxford’s Nuffield Department of Primary Care Health Sciences, and Matthew Knight, a respiratory physician who ran a clinic for people recovering from long-Covid, co-authored a BMJ article on the management of post-acute Covid-19 in primary care.
The article reported that after serious underlying complications and conditions have been excluded, patients can be managed symptomatically in primary care. Most people don’t need to be referred to specialist rehabilitation services, and ongoing symptoms, such as breathlessness and low energy levels, will gradually improve. Fever, for example, may be treated symptomatically with paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen. Most, but not all, patients who weren’t admitted to hospital recovered well with four to six weeks of light aerobic exercise such as walking or Pilates, gradually increasing in intensity. However, any underlying conditions, such as diabetes, heart problems, respiratory problems and high blood pressure, must be controlled.
Customers with ongoing or severe symptoms should always be referred to their GP for a proper assessment. Dr Nisa Aslam, a GP in the London borough of Tower Hamlets, says red flags to watch out for include:
• Persistently high fever that’s not resolving
• Shortness of breath
• Chest pain
• Pain on taking a deep breath in
• Muscle or limb weakness
• Hearing loss.
Doctors have also found that Covid-19 can trigger anxiety and depression or make existing mental health problems worse. “Recovery can take its toll on those already suffering psychological issues,” says Naresh Rallmil, Numark service development pharmacist. “Customers can be advised on mental health issues or referred to their GP practice if required.”
Those suffering with prolonged coughs and breathlessness should be investigated and monitored in secondary care
Community pharmacies play an important role in identifying patients who need professional medical advice and signposting to further support. “Long-Covid covers a wide range of symptoms and it might signal underlying treatable pathologies, such as blood clots,” says Dr Alwan. “Pharmacies can’t clinically diagnose cases, but they should listen to customers and advise them to contact their GP for a medical assessment, if appropriate, rather than offering pharmacological solutions straightaway. Some people may need to have further investigations. Long-Covid must be taken seriously. Peer support groups can also be very helpful, so that patients realise they are not alone, and that other people are experiencing similar symptoms.”
In November 2020, NHS England announced the launch of more than 40 long-Covid specialist clinics to help patients deal with physical and psychological symptoms. GPs and other healthcare professionals will soon be able to refer patients, after ruling out other possible underlying causes such as suspected stroke, lung cancer or respiratory conditions.
“It isn’t yet clear which individuals with long-Covid have symptoms because of complications or organ damage,” says Dr Ladds. “It is important that all healthcare professionals look out for patients reporting persistent symptoms and encourage them to discuss these with their GP. There are a range of clinics now open, or in the process of being set up, which can offer investigations for these people to make sure they have no serious organ problems and help them manage their symptoms. Patients can also get advice and information from Your Covid Recovery.
See TM's feature on managing long-Covid for further information about tackling individual symptoms associated with the condition.