A significant number of individuals infected by Covid-19 develop “post-acute sequelae” (commonly termed long Covid). The World Health Organization (WHO) define long Covid as “the continuation or development of new symptoms three months after the initial SARS-CoV-2 infection, with these symptoms lasting for at least 2 months with no other explanation”. However, definitive diagnostic criteria have yet to be determined.
Covid-19 affects most organ systems in the body. Long Covid often comprises symptoms that follow an acute infection with substantial effects on sufferers’ daily wellbeing and functions.
It has been estimated that at least 65 to 130 million individuals have long Covid globally, based on a conservative estimated incidence of 10 to 20 per cent of infected individuals and more than 651 million documented Covid-19 cases to date globally.
The incidence of long Covid is estimated at 10 to 30 per cent of non-hospitalised cases, 50 to 70 per cent of hospitalised cases, and 10 to 12 per cent of vaccinated cases. The number is likely to be much higher due to many undocumented cases.
Published data on long Covid in Malaysia is limited. According to the Ministry of Health’s (MOH) Sungai Buloh Covid-19 Rehabilitation Outpatient Specialized Services databases, 474 (63.6 per cent) of 745 survivors experienced long Covid 12 weeks after acute infection.
The five most commonly reported symptoms were fatigue (73.4 per cent), exertional dyspnoea (19.4 per cent), insomnia (13.9 per cent), cough (9.7 per cent), and pain (7.3 per cent).
However, there were no reports of psychological symptoms such as anxiety, depression, and stress; whether it affected those who had mild acute symptoms or were not admitted to hospital; and the factors associated with long Covid.
A study done by researchers at the University of Malaya (UM) and International Medical University (IMU) published in August 2022 reported on an online survey of Covid-19 survivors conducted from July to September 2021 when there was a nationwide lockdown (Accessed January 19, 2023).
Of the 732 who responded, 56 per cent were without or with mild symptoms during their acute infection. Almost half were on home quarantine, with the rest admitted to Covid-19 centres or hospitals.
Of those hospitalised, 20 per cent were ventilated, while another 23 per cent were admitted to intensive care units. The mean duration of hospital stay was 10.9±8.2 days, with a minimum of two days and maximum of 52 days.
The limitations of the study included possible recall and/or selection bias, no assessment of whether the symptoms were intermittent or continuous, and no evaluation of the effect of vaccination.
Features Of Long Covid
More than 100 symptoms have been reported in long Covid. Fatigue, breathlessness, and neurocognitive difficulties are common symptoms. Fatigue is associated with diminished activity tolerance and post-exertional malaise and symptom exacerbation. Symptoms of anxiety and depression are common.
One in five Covid-19 survivors in the UM/IMU study reported of experiencing long Covid. The most commonly reported symptoms were fatigue, brain fog, depression, anxiety, and insomnia.
Women had 58 per cent higher odds of experiencing long Covid. Patients with moderate and severe acute infection had increased odds of 3.01 and 3.62 times respectively for long Covid.
Of the 550 who were working, 194 (35.3 per cent) reported that their work performance was affected, with 142 (73 per cent) reducing their working hours, while 46 (23.9 per cent) took leave or resigned from their jobs. More than 40 per cent had anxiety or depression.
Only 494 (67.5 per cent) of the 732 in the cohort were perceived to be in good health at the time of the survey compared to before they were infected. (Accessed January 19, 2023).
If the UM/IMU findings are extrapolated nationally, about a million Malaysians would have long Covid, considering that the reported number of Covid-19 cases exceeded 5 million on December 4, 2022. The actual number would be higher because of unreported Covid-19 cases.
There is limited data on how common the stigma of long Covid is. A United Kingdom study to develop and validate a Long Covid Stigma Scale; and to quantify the burden of long Covid stigma, published in November 2022, reported that of 966 participants, the prevalence of experiencing stigma at least ‘sometimes’ and ‘often/always’ was 95 per cent and 76 per cent respectively.
The prevalence of stigma was higher in those who had a clinical diagnosis of long Covid, i.e. 97.5 per cent sometimes and 82.5 per cent often/always. (Accessed January 19, 2023)
Going Forward
Scientific opinions diverge on some basic long Covid issues, which include:
- Cause: The cause(s) is unknown with various theories cited in the journals.
- Clinical features: Long Covid has been linked to more than 200 symptoms, with some sufferers having organ damage to the heart, lungs, kidneys, skin and brain.
- Duration: There is no universally agreed definition of how long symptoms must persist for a diagnosis of long Covid. The WHO and the MOH state that a person has Long Covid if symptoms persist three months after an initial infection. On the other hand, the United States’ Centre for Disease Control (CDC) barometer is four weeks.
- Management: The clinical guidelines on the management of long Covid have been evolving and will continue to change with time with the increasing knowledge about the condition. There is as yet no evidence-based treatment options. The current clinical guidelines focus on diagnosis and symptom management with various treatment options being evaluated.
The MOH’s guidelines on the management of long Covid were published in June 2021 (Annex 50, accessed January 19, 2023) with no updating since then. The public information on long Covid, published in February 2022, listed long Covid features and the health care facilities where medical attention can be sought. (Accessed February 19, 2023)
Patients and patient advocacy groups, globally, have been reporting on the absence of poor recognition of long Covid and timely support. This has been partly attributed to knowledge gaps about and evidence of long Covid, as well as overwhelmed health care systems.
The insufficient support of long Covid has led to disappointment and loss of faith and trust in health care service delivery, with many sufferers feeling frustrated and isolated in their search for therapies, resulting in their seeking alternative support and/or treatment.
The potential risks of self-medication like inappropriate treatments and harmful drug interactions are real.
Likewise, health care professionals, who have to manage long Covid sufferers daily, are also frustrated with the non-updating of the MOH’s management guidelines and lack of empathy by some employers towards sufferers.
The reader can protect oneself and others from long Covid by protecting oneself from Covid-19 in the first place. The simple, proven measures recommended by the WHO to help do this are:
- Taking up offers of Covid-19 vaccines and boosters.
- Wearing well-fitted masks.
- Cleaning hands regularly.
- Avoid catching coughs and colds.
- Ensuring indoor spaces are well-ventilated.
The WHO Clinical Management of Covid-19 Living guidelines from January 13, 2023, contain 16 new recommendations for rehabilitation of adults with long Covid, i.e. a strong recommendation that exertional desaturation and cardiac impairment following Covid-19 should be ruled out and managed before consideration of physical exercise training, and 15 conditional recommendations on rehabilitation services and interventions as well as patient education and skills training. (Accessed February 19, 2023).
Malaysia is a Vice President of the 75th World Health Assembly, the governing body of the WHO. Health care professionals who provide care to Covid-19 and Long Covid patients are awaiting the MOH’s response to WHO’s latest guideline with bated breath.
Dr Milton Lum is a Past President of the Federation of Private Medical Associations, Malaysia and the Malaysian Medical Association. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.
