The long-term health impacts of the coronavirus

Dr Tariq Jagnarine
BSc, MD, MMed FAM Medicine, CCFP

There is growing concern about the potential long-term consequences of COVID-19, with reports of symptoms lingering for weeks and even months. Survivors want to know how long these afflictions will last or if they will ever completely go away, not to mention what might be waiting around the corner in the months and years to come.

While it might feel like we have been in collective quarantine forever, COVID-19 is still a very new disease that has only been present in humans for over six months. That means long-term studies of the SARS-CoV-2 virus and subsequent infection are in their infancy. However, experts can take clues from other viral illnesses to try to predict how survivors might fare one, two, five, or 10 years from now.

Lungs
One of the primary concerns after a respiratory infection like COVID-19 is whether lung function will be permanently altered. Whether it is a typical pneumonia, an influenza pneumonia, or even a COVID-19 pneumonia, once persons were not sick enough to be hospitalized, there is the likelihood that they are going to bounce back to a normal pre-illness status. It may take four to six weeks even after the recovery has begun for the X-ray to get back to normal, but very often it will in those more mild and moderate cases.
However, there is a risk of scarring and more permanent lung damage in people who are hospitalized and ventilated. Many times, the post-recovery chest X-ray and CAT scans of the chest will show areas of scarring that may never really completely improve. That is going to have to be taken as a potential sign that they will not be able to get back to the lung function they had prior to the illness, leaving a fair amount of impairment.

Heart
Over the past two months, one of the deadliest effects of COVID-19 that has emerged is its impact on the heart. Research indicates that 20% to 30% of hospitalized patients experience heart problems, and cardiovascular complications contribute to 40% of all deaths.
It is unclear of the cause of the different cardiovascular symptoms such as: heart failure, heart attacks, myocarditis, and treatment are undiscovered as well. In some cases, the persons who are experiencing heart problems with COVID-19 already had underlying high blood pressure or heart disease issues, but in other instances, there were no known risk factors.
Cardiovascular complications are not unique to COVID-19. Many viral infections can cause myocarditis — the technical name for inflammation of the heart — which is typically thought to be a side effect of the body’s inflammatory immune response. Most people recover from myocarditis on their own, but some people do experience permanent damage to the heart muscle.
There is also a known link between heart disease and respiratory infections, with a 2-6 fold increase in the risk for heart attack and stroke up to a month after having the flu, although the risk is highest in the first week. Even blood clots are not unheard of with other viruses, doctors saw similar evidence of blood clotting during the 2003 SARS outbreak. Once caught early, these complications can be treated with medication. However, another follow-up study of recovered SARS patients showed that 44% had various cardiovascular abnormalities 12 years after infection.

Immune system
Another consideration is the impact of SARS-CoV-2 on a person’s risk for other infections. In a recent study, researchers found that 20% of people with COVID-19 were also infected with other viruses, including influenza, rhinovirus, and respiratory syncytial virus.
Typically, the presence of one virus decreases a person’s risk of another infection because the immune system is already activated. A type of protein called interferon is released with the first wave of the immune response and interferes with the virus’s ability to replicate and fight off other viral infections.
One reason the novel coronavirus is so pernicious is that it appears to suppress these interferons, meaning that not only is the COVID-19 infection worse, but there may also be a heightened risk for future infections. The virus teaches the cells, to stop making interferon, and so it actually reduces ones immunity either to second infections [of SARS-CoV-2] or potentially to even other viruses. While the research on the novel coronavirus’s impact on interferons is preliminary, SARS and MERS had a similar effect on the immune system, and there are several cases of people infected with MERS also contracting influenza and tuberculosis.

Neurocognitive and mental health impacts
COVID-19 also seems to affect the central nervous system, with potentially long-lasting consequences. In one study from China, more than a third of 214 people hospitalized with confirmed COVID-19 had neurological symptoms, including dizziness, headaches, impaired consciousness, vision, taste/smell impairment, and nerve pain while they were ill. These symptoms were more common in patients with severe cases, where the incidence increased to 46.5 percent. Another study in France found neurologic features in 58 of 64 critically ill COVID-19 patients.
Looking back to SARS and MERS suggests that COVID-19 patients may have slightly delayed onset of neurological impacts. Which appeared in patients 2 to 3 weeks into the course of the illness. These included muscular weakness, burning or prickling, and numbness, and the breakdown of muscle tissue into the blood. Neurological injuries, including impaired balance and coordination, confusion, and coma, were also found with MERS.
Long-term complications of COVID-19 — whether caused by the virus itself or the inflammation it triggers — could include decreased attention, concentration, and memory, as well as dysfunction in peripheral nerves.
There are other cognitive implications for people who receive intensive treatment in hospitals. For example, delirium, which is an acutely disturbed state of mind that can result in confusion and seeing or hearing things that are not there. It affects a third or more of ICU patients, and research suggests the presence of delirium during severe illness predicts future long-term cognitive decline.
Previous research on acute respiratory distress syndrome (ARDS) more generally may also provide clues to what neurological issues critically ill COVID-19 patients might see after leaving the hospital.
Research shows one in five ARDS survivors experiences long-term cognitive impairment, even five years after being discharged. Continuing impairments can include short-term memory problems and difficulty with learning and executive function. These can lead to challenges like difficulty working, impaired money management, or struggling to perform daily tasks.
ARDS survivors frequently have increased rates of depression and anxiety, and many experience post-traumatic stress. Although it is still too early to have much data on COVID-19, during the SARS outbreak, former patients struggled with psychological distress and stress for at least a year after the outbreak.
Childhood inflammation, male infertility, and other possible lasting effects
The novel coronavirus continues to frustrate scientists and patients alike with its mysteries. One of these is a small but growing number of children who recently began showing up at doctors’ offices in Britain, Italy, and Spain with strange symptoms, including a rash, a high fever, and heart inflammation.
On May 4, the New York City Health Department noted that at least 15 children with these symptoms had been hospitalized there, too. These cases present like a severe immune response called Kawasaki disease, where blood vessels can begin to leak, and fluid builds up in the lungs and other major organs. Children who survive the Kawasaki-like conditions can suffer from myocardial and vascular complications in adulthood. Nevertheless, it is too early to know how —COVID-related cases will develop. Many of the small number of reported cases appear to be responding well to treatment.
Researchers are now, suggesting that COVID-19 may pose particular problems for men beyond their disproportionate mortality from the illness. The testicles contain a high number of ACE2 receptors resulting in a theoretical possibility of testicular damage and subsequent infertility following COVID-19 infection.
A recent study shows that in 81 men with COVID-19, male hormone ratios were off, which could signal trouble for fertility down the line. After recovery from COVID-19, young men who are interested in having children should receive a consultation regarding their fertility.
Moreover, it is just the beginning of figuring out what this complex infection means for other organ systems and their recovery.

Overall well-being
A final consideration is the consequence of hospitalization or weeks of being bed-bound on the body’s recovery. The consensus is that people with weak health systems prior to contracting COVID-19, will be more severely affected and take longer to recover and regain strength.
Post-viral fatigue syndrome is one potential explanation for the chronic fatigue, headaches, joint and muscle pain, and cognitive fuzziness that can linger after a viral illness.
Post-intensive care syndrome and post-viral fatigue syndrome are general terms for the physical and cognitive impairment, that can follow serious illnesses, which are both concerns with COVID-19. With post-intensive care syndrome, being sedated and bed-bound in the ICU can result in muscle atrophy, problems with memory and concentration, and even emotional issues similar to post-traumatic stress syndrome.
Even in people who were not hospitalized for COVID-19, recovery can be a long, slow journey, as indicated by the experiences of post-infected persons. Post-viral fatigue syndrome is one potential explanation for the chronic fatigue, headaches, joint and muscle pain, and cognitive fuzziness that can linger after a viral illness. Doctors are not entirely sure what causes the syndrome, naming a lingering infection, inflammation in the brain, or an overreaction of the immune system as possible sources. There are also no real treatments for the condition, and while symptoms often resolve after a few months, some cases may be permanent.
Since so little is unknown about the novel coronavirus, its symptoms, and the potential for long-term consequences. It is imperative that survivors volunteer to be part of scientific studies about the illness. We are still in the early phase of understanding this virus and its impact on the growing number of COVID-19 survivors and symptoms they might expect to have, how long it might take them to get back to feeling normal or if they ever will, and other precautions that might need to be in place.