Long-Haul Covid

Long-Haul Covid

Before discussing long-haul issues, I just wanted to highlight the fact that as of today (Jan 4, 2021) overall, we are at the second highest peak of hospitalizations today as we were at any point in this pandemic. Pediatric hospitalizations are at an all time high. Again, although Omicron may cause more mild disease, it’s all about the numbers. Massively greater numbers of infections leads to significant increases in numbers of seriously sick people, hospitalizations and deaths. A small percentage of a big number, is still a big number. Over 1 million new cases were diagnosed in the US just yesterday. And, as you will read below, even in mild cases of Covid, long-haul symptoms.

Back to Long-Haul.

Although essentially all infections or diseases can result in prolonged, even lifelong symptoms and problems, somehow with Covid-19, the concept has taken on new meaning. For no other disease has the term “long-hauler” been applied or used to describe people who suffer symptoms long after a disease has been diagnosed, has run its course or has been cured. 

Even the flu, the infection which is the most relatable to the Covid-19 infection, has a significant amount of residual symptoms in people. Autoimmune conditions like hepatitis, chronic coughing or lung scarring and even other organ damage from a more serious infection. And certainly some die from the flu, as many as 80,000 in the 2018-19 season. A simple case of Strep tonsillitis, which used to kill people regularly before the advent of antibiotics, still results in chronic kidney, heart and joint problems (Scarlet Fever). I see a few cases every year. There is even a behavioral syndrome, PANDAS, which stands for Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections, associated with apparently uneventful strep infections. 

As far as post Covid-19 symptoms go, up to 50 different symptoms in many combinations, impacting on every organ system, have been identified. This is essentially because the ACE-2 receptor, the one to which the SARS-Cov-2 virus attaches allowing it to enter our cells, is located on almost all cells, in every organ in the human body, not just the lungs. Today, there are dedicated clinics in most major medical institutions treating only long-haul Covid patients. And they are all expressing concern about the future, particularly when it comes to the potential impact on cognitive and behavioral development of kids who get infected.

In addition to the virus attacking many organ systems, the virus can live much longer in our tissues than we first thought, even months after an active infection resolves. Tissue biopsies reveal persistent, live, active SARS-Cov-2 virus in many tissues. These viruses are no longer causing transmission from person to person, but they continue to cause tissue and organ damage in the infected person. It goes from an active, rapidly resolving infection, to a long-term, slowly simmering inflammatory process, much like diabetes or hypertension.

Some examples of Long-haul issues include:

• Brain. Headaches, concentration and memory issues and “brain fog”. Many patients also complain of out-of-proportion anxiety and depression.
• Heart and Vascular System. Heart arrhythmias, and again, the issues are worse and more frequent than those which rarely occur after vaccination. Blood pressure has also been elevated because of the impact on our vascular system. We heard of “Covid Toes”, which seems to be a vascular inflammation.
• Pancreas. Diabetes occurs since the virus destroys the cells which make insulin, and those cells do not regrow. The pancreas also produces digestive enzymes which can be impaired as well.
• Lung. Scarring and inflammation leading to breathing difficulties, necessitating oxygen use and in some cases transplants. Chronic coughing and mucus clearing are other complaints.
• Upper Airway. Loss of smell. Altered taste. Chronic sinus infections.
• GI. Both diarrhea and constipation from abnormal autonomic (both sympathetic and parasympathetic) nerve function. Microbiome alterations leading to a leaky gut, causing generalized inflammation and malabsorption leading to various nutritional deficiencies.
• Other organs involved include the thyroid, kidneys, liver, skin as well as both the male and female reproductive systems.

Studies indicate that at least 10% and as many as 40% of those who have had Covid, even asymptomatically, will develop some kind of long-term complaints or organ problems. Females seem to be affected a little more. It’s not clear why. In the US, over 15 million “long-haulers”, as they are now referred to, have been treated already in Covid-19 clinics.

TREATMENT.

Organ specific treatments are well established. Insulin for diabetes, blood pressure and antiarrhythmic meds for the heart issues, inhalers for breathing issues… As far as generalized treatment is concerned, there is evidence that vaccination can actually improve or eliminate long-haul symptoms, another reason to get vaccinated, even if you have had Covid. 

Some other medications presently being used include 

• Steroids, which generally decrease inflammation. There is a fine line however between enough steroids for long enough and too much steroid, since these meds also have a slew of side effects which include actually impairing your immune system, making you more prone to other infections. Other side effects include raising blood pressure and blood sugar, inducing anxiety and sleeplessness and rare joint issues. They also lead to fluid retention and increased appetite so weight gain is common.
• Statins. In addition to lowering cholesterol, some statins also have the ability to lower inflammation of arteries, improving blood flow to various organs.
• Antivirals. Specifically, a class of antivirals called CCR5-inhibitors, now used to treat HIV infection.

Other general measures include those geared towards lowering inflammation in general and improving our innate immune system. 

• Proper nutrition. Eliminate added sugars, processed foods and add as many whole fruits and vegetables as you can into your diet. And YES, eliminating dairy and limiting other animal products is also helpful since these are well established to cause inflammation. The fiber from plants also significantly improves GI function and 70% of our immune system resides in our gut. Targeted supplementation also helps. The same standards used in prevention and treatment of acute Covid still apply. These include vitamin D, C, Zinc, Quercetin, Melatonin (watch the dose which should be no greater than 3 mg) as well as other potent antioxidants like NAC (N-Acetylcysteine) and Alpha Lipoic Acid.
• Sleep.This is the missing key in most people’s general health improvement plan, including mine. Proper sleep is linked to all kinds of health benefits including improved immune functions. Plenty of studies have demonstrated how even one night of poor sleep results in a significantly blunted immune response to various other vaccinations as well as increased potential of getting sick from various cold viruses. Whoever volunteered to be knowingly infected with a virus, is quite brave, or short on cash.
• Stress Management. Chronic cortisol production, our stress hormone, suppresses our immune system. Managing excessive stress comes in many forms like exercise, meditation, prayer, pets, being with people… I love the Buddhist saying that “Everyone should meditate once a day. If you don’t have time to meditate once a day, you should meditate twice a day”.
• Exercise. In addition to its impact on stress, constant movement and exercise also improve immune function and lower generalized inflammation. But don’t look only to exercise to lose weight. You can’t out-exercise your mouth!
• Community. We are social creatures and need each other to survive. Zoom is better than nothing, but in person communication is crucial. Just be careful and know your audience!

Ultimately, remember that you do not want to get this disease, as benign as the Omicron variant might be. Please don’t let up on your vigilance and care to avoid getting infected or to allow those around you to get infected.

Stay safe and be well.

AC

As the incredibly transmissible variant Omicron spreads through our communities, it continues to be imperative to continue vigilant behavior to protect ourselves and our loved ones. Although it continues to appear that Omicron infection results in a milder Covid-19 course, again it is about the numbers. Record numbers. The highest since the start of the pandemic 2 years ago. More infected adults and kids inevitably leads to more hospitalization and death. In addition, long haul symptoms will occur to a greater degree (more on long-haul problems later). And YES, the vast majority of the sickest Covid patients are not vaccinated, or are not fully vaccinated (not boosted). In addition, repeat “natural” infections are occurring at a greater rate. Previous infection is not the answer.

The single most important healthcare measure we can take to protect ourselves and slow down Covid-19, is vaccination. Although not perfect, they are amazing and have saved a lot of lives. They are effective and they are safe. Billions of doses have proven it. The fact that most people hospitalized and dying from Covid-19 are unvaccinated also proves it. They are not a force field however, so other behaviour practices are also crucial. 

Masking is the second most important practice. The problem is, most people are not doing it and those who are, are doing it ineffectively. Part of the concern with the CDCs recommendation to shorten isolation with asymptomatic Covid is that they also recommend 5 additional days of masking. Most people won’t do it.

Again masks are not perfect, but they help.

First, by wearing a mask, any mask, as crappy as it may be, you are reminding yourself as well as those around you that there is a pandemic going on. Others around you may also be concerned that you may be infected and keep their distance, another important behavior to limit spread and infection. It’s like behaving like a crazy person so you get a seat on the bus or train. But by wearing a crappy mask, don;t delude yourself that you are being protected.

How you wear a mask is also important. If it’s under your nose, it’s useless. The virus lives and replicates in your nose. If the mask is below it, you’re just expelling, and breathing in viruses. If you keep lifting it to talk, you are also allowing ambient air to enter and exit your mouth and nose, not to mention the fact that you are touching the front, where the virus is filtered out. We know that the virus can survive many hours on cotton and other surfaces. Don’t wear it upside down. If it has a metal piece on one end, it’s to make the fit more snug on your nose, not under your chin. I’ve stopped correcting people since probably 1/3rd of the people I see wearing such a mask are wearing it upside down.

The fit of a mask is important. If it’s loose, and air can get around the mask, it defeats the purpose of wearing it. It should be snug all the way around.

QUALITY MATTERS. All masks are NOT created equal. Many repeated studies over the last 2 years have revealed the benefits, as well as the lack of benefit, of different kinds of masks.

A doyley, or mesh mask (yes, some people try to get into my office wearing these), are obviously completely useless. Can a mesh strainer hold water? 

Spandex, nylon and other synthetic materials, such as the ones gaiter-style are made of, are also pretty ineffective and can even aerosolize secretions more, spreading more virus than actually wearing nothing. 

Cotton masks, both commercial and home made, are the next best thing, but are also relatively ineffective unless they are thick. Multiple layers and insertable filters definitely help. The thicker the cotton, the better. They are washable which also is an advantage.

Surgical masks. Better than cloth but they are much less effective than most people think. Someone recently sent me a video from a mask-making facility in Indonesia and it was pretty sad. Clearly no sterility. Using a sewing machine with bare hands. Folding the pleats by hand, barefoot, sitting on the floor of an overcramped facility. Hopefully, the masks you are using are not from this vendor. Ideally, you want a 3-ply surgical mask, the standard in hospitals. They can be used for a few days and then must be discarded. If wrinkled up, they lose their filtration ability so don’t reuse them for too long.

N95 / KN95. These are the gold standard. The difference is essentially where they were certified. In the US, they are called N95, R95 or P95. In China, they are referenced as KN95 and in Europe they are called FFP2. They provide the most robust protection and are the gold standard, especially if made to fit an individual face. They are readily available online and I would strongly recommend wearing one of these when travelling or when spending any significant amount of time indoors with large numbers of people.

Face shields are NOT masks. They can be used with a mask, but they essentially only protect your eyes.

As for the health impact of wearing masks, there are none. Sure they’re uncomfortable and they cause your mouth to dry out since we tend to mouth-breathe more with masks, but that is about it. If your glasses fog up, improve the seal and/or, deal with it. If you have such mad lung disease that you can’t breathe with a mask, re-consider where you go, who you interact with and your vaccination status. These people are few and far between however.

Mouth breathing, by the way, is a chronic issue I deal with in the office. The nose is for breathing and the mouth is for eating. You lose 40% more moisture by mouth breathing and lose most filtration the nose provides.  We very quickly get acclimated to mouth breathing and simply need to practice nasal breathing. It’s much healthier for you. A great book discussing this topic is “The Oxygen Advantage” by by Patrick G. McKeown.

Have a safe and happy 2022.

It will be interesting to see how things continue to evolve.

Stay safe and be well.

AC