PASC (Long COVID-19) – Emerging Evidence and Management

By now we all know someone who has dealt with COVID-19. Whether the disease was mild, moderate or severe, the effects of long COVID-19 continue to plague many survivors. A nurse manager friend who had COVID-19 early in the pandemic still reports chronic fatigue, memory and word-finding issues. Another nurse friend who had COVID-19 in late 2020 continues to persevere in her journey to manage the many issues attributed to the syndrome known as post-acute sequelae of SARS-CoV-2 infection (PASC), aka "long COVID-19" or chronic COVID-19. PASC (long COVID-19) may occur following recovery from mild, moderate or severe forms of the disease. Ever since the issue of persistent symptoms post-COVID-19 emerged, I've been following the literature to learn more.

What are the symptoms of PASC (long COVID-19)?

The Centers for Disease Control and Infection (CDC) estimates that for survivors of COVID-19, one in five adults ages 18-64 years and one in four ages 65 years and older have at least one condition that could be attributed to a previous COVID-19 infection. Long-term or persistent symptoms occur four weeks or more after COVID-19 infection, and women are affected more often than men. Patients may experience one or more signs and symptoms with multiple systems affected, including:

• Cardiovascular
• Pulmonary
• Neurologic (including neurocognitive)
• Hematologic
• Renal
• Endocrine
• Gastrointestinal
• Musculoskeletal
• Psychiatric

Pulmonary embolism and respiratory signs and symptoms have the highest risk ratios for both age groups listed above. The CDC site's table-2 lists 26 conditions linked to post-COVID-19.

Are there guidelines to manage long COVID-19?

The CDC offers guidance for healthcare providers on the management and treatment of post-COVID-19 conditions. The American Academy of Physical Medicine and Rehabilitation (AAPM&R) offers a PASC Dashboard that estimates trends over time and the number of people affected by state and county. AAPM&R convened a PASC collaborative that includes patients, clinicians and multidisciplinary physicians to focus on the need for guidance, resources and formal education to improve nationally the care and health equity for patients with long COVID-19. The PASC collaborative is developing and publishing consensus guidance statements in order to establish standards of care for persons experiencing long COVID-19. New statements are linked on their dashboard as they become available.

Consensus guidance statements are available:

• Cardiovascular complications
• Breathing discomfort
• Fatigue
• Cognitive symptoms
• Neurological symptoms
• Autonomic dysfunction
• Pediatrics
• Mental Health

What is being done to research long COVID-19?

AAPM&R and others continue to call for more research on the issue of long COVID-19. Survivor Corps advocates on behalf of patients with COVID-19 and provides links to register for clinical trials and medical studies. The National Institutes of Health created the Recover Initiative to learn about the long- term effects of COVID-19 and to encourage participation in research. I've participated in the COVID Symptom Study now known as the Zoe Health Study, which is a simple, voluntary daily check-in app. The self-reported data is used to study the symptoms and track the spread of the SARS-CoV-2 virus as well as other health issues.

Does vaccination reduce the incidence of long COVID-19?

More research is needed regarding the incidence of long COVID-19 following vaccination, as data on vaccination benefits has been conflicting. A recent study that reviewed records from the U.S. Department of Veterans Affairs' national healthcare database showed vaccination before breakthrough COVID-19 infection offers only partial protection against the post-acute phase. The study analyzed the records of 34,000 vaccinated people who had a breakthrough case of COVID-19, 113,000 who had been infected but not vaccinated, and 13 million people who had not had COVID-19. An accompanying news story reported vaccination lowered the risk of long COVID-19 by about 15%.

Is the cause of long COVID-19 known?

There are multiple theories regardIng the cause of PASC (long COVID-19). Researchers continue to study both humans and animals in their quest to find a cause. Currently, the most common theories are as follows:

• Immune system remains triggered - Olfactory bulb inflammation may be the cause of "brain fog"
• Cell damage from the virus
• Microcirculation clotting
• Persistent viral mRNA and/or viral proteins despite recovery from initial COVID-19

What's next?

Research continues to evolve on the management and cause of PASC (long COVID-19). So keep reading, participate in research as you are able, and offer support to those who are reporting persistent symptoms following COVID-19.

Share with us what you have learned about the management and treatment of long COVID-19.