Mohit Bhandari MD FRCSC PhD
Ayesha Siddiqua Msc PhD
- Recovering from COVID-19 does not bring an end to the health impact of the disease.
- There is emerging evidence and hypotheses regarding the long-term sequelae of COVID-19.
- A wide range of complications involving the following organ systems may develop post-recovery: neurological, pulmonary, cardiovascular, as well as renal and hepatic systems.
- The long-term impact on mental health may be the next big health crisis after the COVID-19 pandemic.
- Even among individuals without the disease, there can be a lasting mental health impact due to the life changes experienced as a result of the pandemic.
- The long-term health consequences may be worse for some groups than others, notably older individuals, those with underlying medical conditions, racial and ethnic minorities, as well as those who are socioeconomically disadvantaged.
“If we have learned anything over the past couple of months, it is that this disease, COVID-19, is extremely heterogeneous in presentation…we’ve now learned that the disease affects many
different organ systems: patients can die not only from lung failure, but also kidney failure, blood clots, liver abnormalities, and neurological manifestations.” – Dr. Robert Stevens
Associate Professor of Anaesthesiology and Critical Care Medicine, Johns Hopkins Medicine (1)
The Initial Experience with COVID-19
Since the beginning of the COVID-19 pandemic, SARS-CoV-2 has rapidly spread globally with more than 20 million confirmed cases and over 700,000 deaths. The common symptoms of COVID-19 include fever, dry cough, and tiredness, whereas the less common symptoms include aches, pains, nasal congestion, headaches, conjunctivitis, sore throat, diarrhea, loss of taste or smell, skin rash, or discolouration of fingers or toes. The clinical manifestation of COVID-19 can vary among infected individuals – some people have only mild symptoms while others become seriously ill and require hospitalization. Individuals at high risk of infection and serious illness include older people and those with other medical conditions including heart and lung problems, diabetes, or cancer. The median time from onset to recovery for mild illness is about 2 weeks, whereas it is three to six weeks for serious illness (Source: World Health Organizaon).
Although majority of the infected people recover from COVID-19, there is now growing recognition of the long-term health impact of the disease. This impact is not limited to the respiratory system and can have diverse physical and mental health consequences. In this context, a secondary pandemic of a wide variety of medical concerns is a real possibility. Understanding the aftermath of COVID-19 from a clinical perspective is necessary for health care systems to prepare for a future with many unknown challenges.
“Cardiovascular, pulmonary and other neurological sequelae may be expected based on the pathophysiology of COVID-19 or what is known regarding other infectious diseases.” — Ontario Agency for Health Protection and Promotion (Public Health Ontario) 2020 (2)
“Even though neurological symptoms are less common in COVID-19 than lung problems, recovery from neurological injuries is often incomplete and can take much longer compared
to other organ systems (for example, lung), and therefore result in much greater overall disability, and possibly more death.” — Dr. Sherry Chou, Associate Professor of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh (1)
Long-Term Impact on Physical Health: What We Know So Far
Since the recovery from COVID-19 can take up to six weeks, the long-term impact can be conceptualized as symptoms that develop after six weeks or persist longer than six weeks after COVID-19 symptom onset, except symptoms and complications that emerge during the acute stage of the infection (2). Given the persistent nature of the pandemic and the urgency to manage the current public health crisis, there is little empirical evidence available on the long-term impact of COVID-19. Much of what is currently known is based on findings from few small studies, hypotheses generated based on the pathophysiology of COVID19 and the consequences of infection observed from other coronaviruses (such as SARS-CoV-1 and MERSCoV), as well as anecdotes shared by patients and clinicians working on the front lines. The National Heart, Lung, and Blood Institute is currently conducting the COVID-19 Observational Study (CORAL Study) to further examine the clinical characteristics of the disease, its underlying biology, as well as short and longterm health outcomes (3). Exhibit 1 shows an overview of current understanding of the long-term physical
impact of COVID-19, which highlights that even though the acute complications of the disease are successfully treated, there may be a wide range of complications that may emerge in the future.
“We would say that perhaps between 30% and 50% of people with a [SARS-CoV-2] infection that has clinical manifestations are going to have some form of mental health issues…that
could be anxiety or depression but also nonspecific symptoms that include fatigue, sleep, and waking abnormalities, a general sense of not being at your best, not being fully recovered in
terms of the abilities of performing academically, occupationally, potentially physically.” — Dr. Teodor Postolache, Professor of Psychiatry, University of Maryland School of Medicine (18)
“Stress is usually a function of two factors – the intensity of the demands placed on us, as well as our control over those demands…A big part of what’s tough during the pandemic is the lack of control.” — Dr. Hilary Bergsieker, Associate Professor of Psychology, University of Waterloo (19)
Long-Term Impact on Mental Health: The Next Big Crisis?
Given the current scope of the pandemic, debilitating physical consequences of COVID-19 among those at higher risk of the disease as well as those severely impacted, the mental health consequences of this disease have not been extensively studied. There is now growing recognition that there can be lasting mental health impact on those who recovered from COVID-19. Previous pandemics have demonstrated that a wide range of neuropsychiatric symptoms, such as encephalopathy, mood changes, or psychosis may occur alongside acute viral infection, or may emerge after weeks, months, or longer in patients who have recovered (20). A study from China showed that after patients recovered from SARS-CoV-1 during the 2003 epidemic, they were diagnosed with post traumatic stress disorder (54.5%), depression (39%), pain disorder (36.4%), panic disorder (32.5%), and obsessive compulsive disorder (15.6%) at 31 to 50 months after infection, which represents a significant increase from their pre-infection prevalence of any psychiatric diagnoses (3%) (21). It is hypothesized that similar impact may be observed for COVID-19 as well, which requires long term follow up of survivors of this disease.
At a broader level, regardless of whether individuals had COVID-19, the pandemic has been a direct and indirect source of distress and traumatization for everyone. Dr. Karestan Koenen, Professor of Psychiatric Epidemiology at the Harvard T.H. Chan School of Public Health, explained that “initially for all of us, there [was] a lot of uncertainty and people feeling out of control…events that are threatening, are uncontrollable, and have a lot of uncertainty are really toxic to mental health” (22). Indeed, a recent study from China showed that after the declaration of the COVID-19 pandemic, negative emotions (such as anxiety, depression and indignation) and sensitivity to social risks increased, while the scores of positive emotions and life satisfaction decreased among Weibo users, which is a popular platform to discuss individual information and life activities (23). Furthermore, the pandemic has taken a tremendous toll on economies of numerous countries around the world – with many people who have lost their jobs as a result. Unemployment over a prolonged period of time can introduce a variety of stressors to an individual’s life and can lead to depression (22). The economic fallout and recession due to COVID-19 can leave lasting impact on the mental health of the general population.
While front line healthcare workers are working hard to protect the health of their patients, they are required to quarantine and maintain social distancing at a greater level than the general population since they have a higher risk of contracting COVID-19, which can negatively impact their mental health (22). Since the beginning of the pandemic, healthcare workers have been labelled as heroes and commended for their resiliency. Yet, the price they are paying to care for patients during these truly unprecedented times has not received adequate attention. There is considerable evidence from the SARS epidemic that suggests the COVID-19 pandemic can be particularly detrimental for healthcare workers’ mental health. After the SARS epidemic, the effect of being quarantined was a predictor of post traumatic stress symptoms in hospital staff even after three years (24). Another recent study from China shows that nurses and physicians caring for patients with COVID-19 reported significantly more depression, anxiety, insomnia and distress than providers who did not care directly for these patients (25). Just as patients who survived this disease, healthcare workers should also continue to be monitored even when the public health crisis has been averted.
“As the COVID-19 pandemic has spread around the world, the virus that causes it has tended to prey on the most vulnerable. Outside of nursing homes, that means poor people who do essential work and live in overcrowded housing.” — Kelly Grant, The Globe and Mail, 2020 (26)
Long-Term Impact is Worse for Racial and Ethnic Minority Groups
In the beginning of the pandemic, older individuals and those with underlying medical conditions were recognized to be at greater risk for severe complications for COVID-19. There is now increasing recognition this risk may be exacerbated for racial and ethnic minority groups, as well as those who are socioeconomically disadvantaged. Recent evidence from Ontario, Canada shows after adjusting for differences in age structure between neighbourhoods, the rate of SARS-CoV-2 infections in the most diverse neighbourhoods was three times higher than the rate observed in the least diverse neighbourhoods (27). Individuals living in the most diverse neighbourhoods also experienced severe outcomes (including hospitalizations, ICU admissions, and deaths) at higher rates than those living in the least diverse neighbourhoods (27). Structural social inequalities experienced by minorities and their overrepresentation in essential service occupations, where they may not be able to practice physical distancing and may not have access to personal protective equipment, increase their risk for COVID-19 (28). Furthermore, racialized populations are more likely to have chronic health conditions and poor access to health care, which can set them on a negative trajectory for more severe outcomes. For example, in Canada, Black populations have higher risk of hypertension and diabetes, as well as difficulty accessing a regular doctor (29-31). Taken together, even if minority groups and those who are socioeconomically disadvantaged manage to survive COVID-19, their long-term health outcomes could look very different than the more advantaged groups in society. Several large cities in the U.S. and Canada have taken a short-term approach to protect their vulnerable communities. For example, governments in Toronto, Chicago, and New York offer hotel rooms and meals to low-income individuals so they do not spread the virus to their families and roommates if they live in crowded housing (26). However, this does not solve the problems postrecovery, many minority and socioeconomically disadvantaged groups may not be able to take time off from work or access necessary health care to address the wide range of long-term physical and mental health outcomes of COVID-19. This may lead to health problems being recognized when it is too late and they have become more severe.
“Living with SARS-CoV-2 by returning as closely as possible to “business as usual” is far from winning the bale. It rather looks like “giving in to the enemy” , while vaccine and drug development efforts only feed the dearest hope for a successful way out.” — Reperant and Osterhaus, 2020 (32)
Winning the Battle or Losing the War?
After six months of quarantine and lockdown and finally beginning to see declines in the COVID-19 cases in some countries around the world, many governing bodies are eager to reopen their
economies and return to “business as usual”. Yet, several key components continue to be missing or poorly planned in the preparation to reopen. Physical distancing measures that are necessary are often not strictly implemented, which has led to a surge of new cases in several settings after reopening. Additionally, there is little discussion about capacity building to monitor and manage the health of COVID-19 survivors and their healthcare providers – which is of paramount importance given the significant consequences for their physical and mental health. Without a comprehensive plan to cope with the aftermath of the pandemic according to the needs observed in different countries, we will win the temporary battle against COVID-19, but not the war.
Mohit Bhandari, MD, PhD
Dr. Mohit Bhandari is a Professor of Surgery and University Scholar at McMaster University, Canada. He holds a Canada Research Chair in Evidence-Based Orthopaedic Surgery and serves as the Editor-in-Chief of OrthoEvidence.
Ayesha Siddiqua MSc, PhD
Ayesha Siddiqua has a Masters and a PhD from the Health Research Methodology Program in the Department of Health Research Methods, Evidence, and Impact at McMaster University.
1.Cormier Z (2020, June 22). How Covid-19 can damage the brain. Retrieved from https://www.bbc.com/future/article/20200622-the-long-term-effectsof-covid-19-infection
2.Ontario Agency for Health Protection and Promotion (Public Health Ontario) (2020, July 10). Long-term sequelae and COVID-19 – What we know so far. Retrieved from https://www.publichealthontario.ca/-/media/documents/ncov/covid-wwksf/2020/07/what-we-know-covid-19-long-termsequelae.pdf?la=en
3.National Heart, Lung, and Blood Institute (2020, June 3). Looking forward: Understanding the long-term effects of COVID-19. Retrieved from https://www.nhlbi.nih.gov/news/2020/looking-forward-understanding-long-term-effects-covid-19
4. Abboud H, Abboud FZ, Kharbouch H, Arkha Y, El Abbadi N, El Ouahabi A (2020). COVID-19 and SARS-Cov-2 infection: Pathophysiology and clinical effects on the nervous system. World Neurosurgy; 140: 49-53. DOI: 10.1016/j.wneu.2020.05.193
5. Heneka MT, Golenbock D, Latz E, Morgan D, Brown R (2020). Immediate and long-term consequences of COVID-19 infections for the development of neurological disease. Alzheimer’s Research & Therapy; 12(1): 69. DOI: 10.1186/s13195-020-00640-3
6. De Felice FG, Tovar-Moll F, Moll J, Munoz DP, Ferreira ST (2020). Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the central nervous system. Trends in Neurosciences; 43(6): 355-357. DOI: 10.1016/j.tins.2020.04.004
7. Carsana L, Sonzogni A, Nasr A, Rossi RS, Pellegrinelli A, Zerbi P, et al. Pulmonary post-mortem findings in a series of COVID-19 cases from northern Italy: a two-centre descriptive study. Lancet Infectious Diseases. Published Online First. 2020, Jun 8. DOI: 10.1016/s1473- 3099(20)30434-5
8. Schaller T, Hirschbühl K, Burkhardt K, Braun G, Trepel M, Märkl B, et al (2020). Postmortem examination of patients with COVID-19. JAMA; 323(24): 2518-2520. DOI: 10.1001/jama.2020.8907
9. Driggin E, Madhavan MV, Bikdeli B, Chuich T, Laracy J, Biondi-Zoccai G, et al (2020). Cardiovascular considerations for patients, health care workers, and health systems during the COVID-19 pandemic. Journal of the American College of Cardiology; 75(18): 2352-2371. DOI: 10.1016/j.jacc.2020.03.031
10. Belot A, Antona D, Renolleau S, Javouhey E, Hentgen V, Angoulvant F, et al (2020). SARS-CoV-2-related paediatric inflammatory multisystem syndrome, an epidemiological study, France, 1 March to 17 May 2020. Euro Surveillance; 25(22): 2001010. DOI: 10.2807/1560- 7917.es.2020.25.22.2001010
11. Cheung EW, Zachariah P, Gorelik M, Boneparth A, Kernie SG, Orange JS, et al. Multisystem inflammatory syndrome related to COVID-19 in previously healthy children and adolescents in New York City. JAMA. Published Online First. 2020, Jun 8. DOI: 10.1001/jama.2020.10374
12. Pouletty M, Borocco C, Ouldali N, Caseris M, Basmaci R, Lachaume N, et al. Paediatric multisystem inflammatory syndrome temporally associated with SARS-CoV-2 mimicking Kawasaki disease (Kawa-COVID-19): A multicentre cohort. Annals of Rheumatic Diseases. Published Online First. 2020, Jun 11. DOI: 10.1136%2Fannrheumdis-2020-217960
13. Feldstein LR, Rose EB, Horwitz SM, Collins JP, Newhams MM, Son MBF, et al. Multisystem inflammatory syndrome in U.S. children and adolescents. New England Journal of Medicine. Published Online First. 2020, Jun 29. DOI: 10.1056/nejmoa2021680
14.Dufort EM, Koumans EH, Chow EJ, Rosenthal EM, Muse A, Rowlands J, et al. Multisystem inflammatory syndrome in children in New York State. New England Journal of Medicine. Published Online First. 2020, Jun 29. DOI: 10.1056/nejmoa2021756
15. Adapa S, Chenna A, Balla M, Merugu GP, Koduri NM, Daggubati SR, et al (2020). COVID-19 pandemic causing acute kidney injury and impact on patients with chronic kidney disease and renal transplantation. Journal of Clinical Medicine Research;12(6): 352-361. DOI: 10.14740/jocmr4200
16. Wang L, Li X, Chen H, Yan S, Li D, Li Y, et al (2020). Coronavirus disease 19 infection does not result in acute kidney injury: An analysis of 116 hospitalized patients from Wuhan, China. American Journal of Nephrology; 51(5): 343-348. DOI: 10.1159/000507471
17.Samidoust P, Samidoust A, Samadani AA, Khoshdoz S (2020). Risk of hepatic failure in COVID-19 patients. A systematic review and meta-analysis. Le Infezioni in Medicina; 28(Suppl 1): 96-103. Available from: https://www.infezmed.it/media/journal/Vol_28_suppl1_2020_15.pdf
18. Cooney E (2020, August 12). Long after the fire of a Covid-19 infection, mental and neurological effects can still smolder. Retrieved from https://www.statnews.com/2020/08/12/after-covid19-mental-neurological-effects-smolder/
19. Rooy NV (2020, August 13). Women’s mental health disproportionally affected by COVID-19 pandemic: study. Retrieved from https://kitchener.ctvnews.ca/women-s-mental-health-disproportionally-affected-by-covid-19-pandemic-study-1.5062616
20. Troyera EA, Kohna JN, & Hong S (2020). Are we facing a crashing wave of neuropsychiatric sequelae of COVID-19? Neuropsychiatric symptoms and potential immunologic mechanisms. Brain, Behaviour, and Immunity; 87: 34-39. DOI: 10.1016/j.bbi.2020.04.027
21. Lam MHB, Wing Y, Yu MW, Leung C, Ma RCW, Kong APS et al (2009). Mental morbidities and chronic fatigue in severe acute respiratory syndrome survivors. Archives of Internal Medicine; 169(22): 2142-2147. DOI: 10.1001/ archinternmed.2009.384
22.Wilson M (2020, June 8). 13 potential long-term effects the coronavirus pandemic could have on mental health. Retrieved from https://www.businessinsider.com/potential-mental-health-effects-of-coronavirus-pandemic-2020-6
23. Li S, Wang Y, Xue J, Zhao N, & Zhu T (2020). The impact of COVID-19 epidemic declaration on psychological consequences: A study on active Weibo users. International Journal of Environmental Research and Public Health; 17(6): 2032. DOI: 10.3390/ijerph17062032
24. Wu P, Fang Y, Guan Z, Fan B, Kong J, Yao Z et al (2009). The psychological impact of the SARS epidemic on hospital employees in China: Exposure, risk perception, and altruistic acceptance of risk. Canadian Journal of Psychiatry; 54(5): 302–11. DOI: 10.1177/070674370905400504
25.Lai J, Ma S, Wang Y, Zhongxiang C, Jianbo H, Wei N et al (2020). Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Network Open; 3(3): e203976. DOI: 10.1001/jamanetworkopen.2020.3976
26. Grant K (2020, July 2). Data show poverty, overcrowded housing connected to COVID-19 rates among racial minorities in Toronto. Retrieved from https://www.theglobeandmail.com/canada/toronto/article-data-show-poverty-overcrowded-housing-connected-to-covid-19-rates/
27.Ontario Agency for Health Protection and Promotion (Public Health Ontario) (2020, May 14). COVID-19 in Ontario – A Focus on Diversity: January 15, 2020 to May 14, 2020. Retrieved from https://www.publichealthontario.ca/-/media/documents/ncov/epi/2020/06/covid-19-epi-diversity.pdf?la=en
28.Ontario Agency for Health Protection and Promotion (Public health Ontario) (2020, May 24). COVID-19 – What we know so far about… social determinants of health. Retrieved from https://www.publichealthontario.ca/-/media/documents/ncov/covid-wwksf/2020/05/what-we-know-socialdeterminants-health.pdf?la=en
29.Ramraj C, Shahidi FV, Jr WD, Kawachi I, Zuberi D, & Siddiqi A (2016). Equally inequitable? A cross-national comparative study of racial health inequalities in the United States and Canada. Social Science & Medicine; 161: 19-26. DOI: 10.1016/j.socscimed.2016.05.028
30. Veenstra G & Patterson AC (2015). Black–White health inequalities in Canada. Journal of Immigrant and Minority Health; 18(1): 51-57. DOI: 10.1007/s10903-014-0140-6
31. Siddiqi AA, Wang S, Quinn K, Nguyen Q, & Christy AD (2016). Racial disparities in access to care under conditions of universal coverage. American Journal of Preventive Medicine; 50(2): 220-225. DOI: 10.1016/j.amepre.2014.08.004
32. Reperant LA & Osterhaus ADME (2020). COVID-19: losing battles or winning the war? One Health Outlook; 9. DOI: 10.1186/s42522-020-00019-2