Our collective, pandemic focus continues to vacillate with the news of the day, but if it has settled anywhere, it has settled of late on the toll of so-called “long COVID,” now known medically as PASC: Post Acute Sequelae of SARS-CoV-2.
That topic is of interest to me for many reasons, not the least of which being: I have it.
To be fair, my version of “long COVID,” like my COVID infection itself, is seemingly mild. So while I can say I have PASC, it is an entry-level case. I am now about 2 months post infection, with IgG to corroborate my past bout and immunity- and still subject to waxing and waning fatigue, and recurrent headaches of a unique (and rather creepy) character. My olfaction, which I lost completely, is at best about 50% back now, and also waxes and wanes.
So, as noted, entry level, compared to those with far more severe symptoms going on for many more months. But then again, I don’t know yet how long all this will last; time will tell. I am trying to be patient, not one of my best attributes. I am hopeful that the single-dose vaccine I eventually receive (only one dose of any COVID vaccine is recommended post-infection) may help banish residual symptoms; there are some early indications of that effect.
For now, we are unsure of the remedies, but know for sure that long COVID is real; what are the major implications?
First, while PASC is garnering a unique level of attention as all things associated with the pandemic do, this syndrome is not unique to COVID. Many illnesses, and most injuries engender their own suite of “post acute sequelae.”
In my nearly 30 years rendering patient care, it was more norm than exception to see persistent symptoms months out from any moderately severe infection. Community acquired pneumonia, for instance, is deemed mild when it does not require hospitalization- but that doesn’t mean it disappears when the course of antibiotics ends. Patients routinely take months to feel back to baseline.
So, too, for any of the other infections that assault a vital organ, from pyelonephritis, to septic arthritis, to prostatitis, and perhaps even to cellulitis- infection of the skin. I am not aware of a national survey exploring residual symptoms, local or systemic, following these and various other infections- but my clinical experience says they are common.
As for viruses, many are notoriously “long.” Varicella, the virus that gives us chickenpox, resides within for decades, emerging to cause shingles. Herpes simplex never goes away, and can cause recurrent cold sores for a lifetime. These and other common viral exposures may even cause a long-form illness much like PASC, which we call by other names: chronic fatigue syndrome, or fibromyalgia. I have treated many patients with these conditions over the years, and at a frequency that makes coincidence unlikely, symptom onset followed some acute viral illness.
And then there is a notorious “long” infection that has itself attracted considerable attention, if altogether too little respect: chronic Lyme Disease. This is not at all likely to be chronic “infection” any more than PASC is, but rather a chronic symptom complex that all too often follows infection with the agent of Lyme disease, Borrelia burgdorferi.
My hope, then, is this: the population impact of PASC will cause the medical establishment to revisit a generally dismissive attitude toward other “long” post-infectious syndromes, including the possible inclusion of chronic fatigue and fibromyalgia among them.
There is another relevant consideration. We routinely say “illness and injury” as if the two are mutually exclusive. They are not. Many illnesses, SARS-CoV-2 clearly among them, cause tissue injury. Injured tissue takes time to heal.
If we think of the injuries we know best - fractured bones, torn ligaments - they offer an orienting primer to the phases, and timeline of recovery. As equestrian, skier, and one-time martial artist, I know this space all too well- having recovered from some number of ligament reconstructions (thanks again, Dr. Ruwe!), and literally dozens of fractures.
As with infection, an injury has an acute phase. Then, there is an inflammatory response as repair begins- and then subsiding inflammation as repair continues. Generally, about 6 weeks are required for basic, initial repair- with some variation based on the nature of the injury, age, nutritional status, and general health. After that initial repair, months are generally required for full recovery- and sometimes, years. Sometimes, episodic pain and tenderness never go away fully- and again, I can attest to this from personal experience as well as professional knowledge.
Thinking about the “injury” model, involving acute phase, repair, and then a long bout of physical therapy and rehabilitation, is helping me be patient with my own PASC symptoms, and also making me wish we knew more about the underlying mechanisms. Is PASC about tissue injury, and if so- what tissues are involved? We don’t have these answers yet- and need them both to understand PASC, and know best how to overcome it.
To sum up, then: long COVID is, of course, real and important- but like so much else in the pandemic, presented to us in a manner that maximizes drama, and minimizes context. The relevant context is that many other illnesses have comparably long tails, and almost all injuries do.
The distinction between illness and injury is far from absolute, and perhaps much of the reason for lengthy recovery is when the former causes the latter. We have much to learn about mechanisms of long COVID- there are important gaps in the tale thus far- and we should apply these lessons to other infections, too.
If the medical community learns to be more uniformly compassionate and respectful when patients complain of symptoms long after the “disease” is over, that will be a welcome advance- and the COVID19 pandemic will have done us at least this one favor.
Dr. David L. Katz is a board-certified specialist in Preventive Medicine/Public Health
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Some might wonder if my personal experience has altered my view about the best pandemic response policy. Not at all- but not because I am unwilling to change my mind. I do that routinely, whenever there is a good reason. Rather, PASC is simply one more reason why a risk-stratified response to COVID makes, and always made, the most sense.
Our “one size fits all” approach to COVID failed to protect many who most needed meticulous protection, over-protected many at very low risk of bad outcomes including PASC, and misallocated vital resources. I stand by my prior petitions for a strategy of total harm minimization by means of risk-stratified interdiction policies, or what colleagues have since called “focused protection.”
Risk-stratified exposures to COVID on our way to herd immunity facilitated by fast-track vaccine development would inevitably have resulted in some harm, including cases of PASC. But in a pandemic, there are no completely risk-free options- the goal is not unrealistic avoidance of all harm, but realistic minimization of total harms.
The path we did take through the pandemic resulted in massive exposure among the most vulnerable, a terrible and largely preventable casualty toll, and a high burden of PASC into the bargain. Selective exposure, based on knowledge of risk tiers, would have been far better and far less costly than the haphazard exposure our population has suffered.
Three of my adult children went through COVID when my wife and I did. They recovered quickly, and completely, with no hint of PASC. That syndrome can occur in young, healthy people, but as is generally true for SARS-CoV-2, risks rise with both age and infirmities. My wife and I are fortunate to have no infirmities, but age alone puts us in a higher risk group than our adult children- and our somewhat protracted recoveries are consistent with that.
David L. Katz, MD, MPH, FACPM, FACP, FACLM, is the Founding Director (1998) of Yale University’s Yale-Griffin Prevention Research Center, and former President of the American College of Lifestyle Medicine. He has published roughly 200 scientific articles and textbook chapters, and 15 books to date, including multiple editions of leading textbooks in both preventive medicine, and nutrition. He has made important contributions in the areas of lifestyle interventions for health promotion; nutrient profiling; behavior modification; holistic care; and evidence-based medicine. David earned his BA degree from Dartmouth College (1984); his MD from the Albert Einstein College of Medicine (1988); and his MPH from the Yale University School of Public Health (1993). He completed sequential residency training in Internal Medicine, and Preventive Medicine/Public Health. He is a two-time diplomate of the American Board of Internal Medicine, and a board-certified specialist in Preventive Medicine/Public Health. He has received two Honorary Doctorates.