Session Date: January 6 , 2021
Stephen Scholand, MD; Infectious Disease Physician, Midstate Medical Center
Emma Kaplan-Lewis, MD; Clinical Quality Director HIV Services, NYC Health + Hospitals
Dr. Durrance, MD; Pulmonologist, NYC Health + Hospitals
To view the infographics in the presentation, visit: https://www.bmj.com/infographics
To view the specific Long Hauler infographic, visit: https://www.bmj.com/content/370/bmj.m3026/infographic
Below are some answers to questions posed during the session (posted 1/11/21, information may have been updated since posting):
If COVID antibodies are present, at what level does it reduce risk of reinfection among long haulers and their capacity to transmit to others? Should they receive the vaccine if it is over 6-8 months after they recovered from acute and subacute phases?
This is currently being evaluated and is not entirely known. antibody profiles don’t seem to be different in long haulers compared to other people who have recovered from COVID. There is one hypothesis that autoantibodies in the aftermath of severe covid may be leading to the long hauler symptoms (https://www.medrxiv.org/content/10.1101/2020.12.10.20247205v3), and a preprint study showed increased autoantibody reactivity among people recovering from COVID, however in my personal opinion this may just reflect the significant endothelial activation and dysfunction in severe COVID which would make the chance of having autoantibodies in the convalescent period more likely (similar to how HIV is associated with autoantibodies- both related to immune dysfunction as well as endothelial dysfunction). We do know that having antibodies after COVID greatly reduces the risk of reinfection (https://www.nejm.org/doi/full/10.1056/NEJMoa2034545) and a study of healthcare workers showed those who were antibody negative for anti spike IGG had PCR + test rate of 1.09/10,000 days at risk compared to 0.13/10,000 for those who were antibody positive. Because antibodies tend to last approximately 3 months ( if not longer) I believe it makes sense to vaccinate long haulers the same as any other individual at approximately 3 mo from the incident infection. If it is less than 3 months and there is concern for lost to follow up I would recommend vaccinating the patient as long as it has been at least 3 weeks from the most acute symptoms to avoid missing the opportunity.
Given the findings of susceptibility to microvascular blood vessel damage in the brains of COVID-19 patients, do we anticipate significantly increased rates of neurocognitive disorders in “recovered” and long-haul patients?
It is hard to say what the long term impact will be neurologically, however it should definitely be on our radar to detect neurocognitive dysfunction- particularly for individuals who had severe covid and especially if they had acute and/or persistent neurocognitive symptoms. We also don’t know what is unique to covid’s impact on cerebral microvasculature in comparison to other viral systemic infections- HIV for example and Varicella both impact microvasculature (and microvasculature) in different ways as well.
Given what we know so far, and in the context of a severe and inflammatory critical illness, it is something that we must keep in the front of our mind during visits. Evidence to this point is observational and retrospective. However, failing to adequately address issues of PTSD, Depression, Anxiety will undoubtedly increase the odds of developing long-term sequelae. While it appears to be intuitive at this time to suspect an increase in neurocognitive dysfunction, the magnitude of what that will be is yet to be determined.
Given these enormous periods of supine positioning and sedentism – are you recommending any preventive in bed strength training( isometrics) and baseline osteoporosis and muscle mass measurements- given expected osteopenia and sarcopenia?
Proning has been used in the hospital setting (either awake or when intubated with a proning team) to help with lung recruitment in severely hypoxic patients. I don’t have any data specifically on this but to me it makes a lot of sense to ambulate early and involve PT and OT early on in the process while patients are hospitalized as well as post discharge including utilizing telehealth with PT/OT. In terms of osteoporosis and sarcopenia I can’t answer in terms of COVID but for my personal practice I would follow routine guidelines for osteoporosis screening unless the patient had been hospitalized/bed ridden for > 1 month and then would see if insurance would cover a baseline DEXA.