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COVID-19 wrap: the long-haulers, aiming for zero, the future of air travel, and the merits of international cooperation

In the latest edition of the COVID-19 wrap, public health researcher Alison Barrett reports on emerging evidence around the needs of COVID “long-haulers” and other recent publications on pressing policy questions, including how to promote mask-wearing.


Long-Haul COVID

Nath, A and Billioux, BJ, World Neurology, 27 July 2020

Much of the focus during the pandemic has been on the immediate impacts of COVID-19 cases and deaths, although there has been some discussion about the long-term effects of the virus (including at Croakey).

While some COVID-19 patients appear to recover from the coronavirus without any long-term symptoms, others –  the COVID “long-haulers” – report persistent symptoms lasting weeks or months. And, as with the symptoms of the acute phase of the virus, the symptoms of the chronic/long-term phase seem to vary greatly.

Patients report symptoms including fever, headaches, brain fog, breathlessness, chest pain and fatigue. An Italian study found that 55 percent of post-acute COVID-19 patients experienced three or more persistent symptoms up to two months after the first symptoms appeared. Fatigue, breathlessness, joint pain and cough were the most common persistent symptoms reported.

Many “long-haulers” describe symptoms similar to those of myalgic encephalomyelitis/ chronic fatigue syndrome (ME/CFS). Dr Anthony Fauci, head of the United States National Institute of Allergy and Infectious Diseases, said about those recovering from COVID-19:

It’s extraordinary how many people have a post viral syndrome that’s very strikingly similar to myalgic encephalomyelitis/ chronic fatigue syndrome.”

ME/CFS is a long misunderstood illness and the cause is still unknown despite decades of research; however, many ME/CFS patients say their symptoms are triggered from a viral infection. A study found that over one-quarter (27.1%) of people recovering from the 2003 SARS-CoV outbreak met the diagnostic criteria for ME/CFS four years after the initial illness; and another study found that after the 2009 H1N1 (influenza A) outbreak, the rate of ME/CFS had increased two-fold.

It is important not to draw conclusions that COVID-19 “long-haulers” have ME/CFS as other outcomes from COVID-19, such as impaired heart function or fibrosis in lungs, may also result in persistent fatigue and other ME/CFS-like symptoms.

But, given the commonality in symptoms and evidence of ME/CFS occurring after SARS-CoV, H1N1 and other viral infections, the COVID-19 pandemic provides “an excellent opportunity to study the pathophysiology of ME/CFS that may have broader implications,” Nath and Billioux wrote. Several prospective studies are underway.

In the meantime, while this research is being done, COVID-19 “long-haulers” want to be seen and heard and it is important to provide them with guidance and support as they recover.

The tweets below are by former US health administrator, Andy Slavitt. See the full thread on Twitter.

Professor Paul Garner wrote for the BMJ on 4 September, after living with post-COVID-19 symptoms for six months:

I agree we need research, but we urgently need guidance right now. The guidance should not be contingent on the research being completed. The guidance should be developed rapidly and updated in real time.”


Management of post-acute COVID-19 in primary care

Greenhalgh, T et al, the BMJ, 11 August 2020

As discussed above, limited evidence exists about the post-acute phase of COVID-19. Likewise, evidence is limited about the management of patients, the “long-haulers,” in this phase. The authors wrote this article for primary care clinicians to help them manage patients suffering from long-term symptoms of COVID-19.

Firstly, the authors define post-acute COVID-19 as “extending beyond three weeks from the onset of first symptoms and chronic COVID-19 as extending beyond 12 weeks.” As many people were not tested for COVID-19, the authors say that a positive test is not necessary for diagnosis.

The article summarises clinical tests that may be required and recommendations for supporting the patient’s recovery from COVID-19 symptoms, including breathlessness, pulmonary rehabilitation, fatigue, chest pain, thromboembolism and mental health.

Greenhalgh and colleagues note that while it is still unclear if the long-term phase of COVID-19 affects the poor, elderly and other vulnerable populations disproportionately as in the acute phase, it is important to consider social and cultural factors in supporting patients in recovery.

The full recommendations for managing the longer-term care of COVID-19 patients can be viewed here.


Most Approve of National Response to COVID-19 in 14 Advanced Economies

Devlin, K and Connaughton, A, Pew Research Centre, 27 August 2020

A survey by Pew Research Centre has found the majority of people report that their country has dealt well with the COVID-19 outbreak.

Of 14 countries that took part in the survey, nearly all Danish (95%) and Australian (94%) respondents approved of their countries’ response, compared to 47 percent of Americans and 46 percent of British people.

Most respondents (across all countries surveyed) approved of their national response to the pandemic, and 46 percent reported that their country was more united now than before the pandemic. Fifty-four percent of Australians said the country was more united now.

The international survey was conducted over the phone between 10 June and 3 August with adults in United States, Canada, Belgium, Denmark, France, Germany, Italy, Netherlands, Spain, Sweden, United Kingdom, Australia, Japan and South Korea.

Other key findings from the survey are that more than half (58%) of respondents report their lives changing a ‘fair amount or great deal’ as a result of COVID-19, and 59 percent believe that more international cooperation would have helped to reduce the number of COVID-19 cases in their country.


German Experiment Tests How the Coronavirus Spreads at a Concert

Raphelson, S, NPR, 24 August 2020

Researchers at Martin Luther University Halle-Wittenberg in Germany conducted an experiment in August to gain an understanding of how COVID-19 might spread in large gatherings and social events, and how best to prevent it.

Approximately 1,500 volunteers participated in the experiment that simulated three different concert scenarios:

1) an event with no social distancing;

2) multiple entry points, less crowding and more space between participants; and

3) smaller audience and strict enforcement of social distancing, with participants required to stand five-feet apart from each other.

All participants had to test negative for the coronavirus 48 hours prior to the event, have shown no symptoms of the virus within 48 hours before the start, and were required to wear a respiratory protection mask during the whole event. Participants were provided with hand sanitiser, and alcohol was not permitted.

While the experiment did not fully reflect the true conditions of a concert where people may drink alcohol and sing without a mask, lead researcher, Michael Gekle, “hopes the data will contribute to national decisions as to whether an event should take place or not, thanks to reliable predictions as to the risk of additional infections related to such an event”.

Results are expected to be made public in September.


Air travel in the time of COVID-19

Editorial, The Lancet Infectious Diseases, 1 September 2020

The COVID-19 pandemic has changed how much and the way we travel this year, and in some countries, largely stopped travel completely. It is unclear what the future of travel will look like.

Country-wide lockdowns and movement restrictions to minimise SARS-CoV-2 infections have dramatically impacted the airline and travel industries, resulting in massive economic loss and job losses.

By mid-April, more than two-thirds of the worlds’ passenger aircrafts had been grounded. For a visual view of the difference in air traffic between early March and early April, see these flight map images from Flight Radar.

While some countries are now reopening, people thinking about travel need to consider the risks of travelling, what measures are in place to minimise the risk of COVID-19 infection both during their journey and at their destination, and what requirements are required for arriving travellers.

While cruise ships are still not operating, the main form of international travel is by air.

As discussed in a previous COVID-19 Wrap, reported infections of SARS-CoV-2 on passenger aircraft have been minimal. Air ventilation and filtering systems onboard remove most bacteria and other virus particles. Airlines have also introduced new in-flight guidelines including mask wearing, more cleaning and hand sanitising; and, some have reduced the number of passengers on board and/or stopped selling food and drink.

For the future of travel, rapid testing for crew and passengers might be implemented and travel bubbles might be introduced between countries with minimal COVID-19 risk.

The Editors see that a “COVID-19 vaccine will be instrumental in reinstating confidence in travellers”.


Go for zero: How Australia can get to zero COVID-19 cases

Duckett, S, Mackey, W & Chen, T, Grattan Institute, 3 September 2020

Stephen Duckett and colleagues from the Grattan Institute published this report outlining how Australia can get to zero COVID-19 cases, saying:

COVID is a classic case of short-term pain for long-term gain.

Getting cases down to zero, and keeping them there, will be hard work – but it will save lives and enable the economy to recover more quickly.”

The report details a four-point plan:

  • Governments need to be clear about their goal for zero active COVID-19 community cases, and their plans to reach this goal
  • Governments should be clear to the public about conditions under which restrictions will be phased out or reinstated
  • Governments need to improve public health efforts, by increasing testing and contact tracing capabilities
  • Once Australia reaches zero cases, governments should use frequent testing and international quarantine with the aim of remaining at zero cases.

The report also summarises Australia’s COVID-19 strategy to date, and health, social and economic costs of the pandemic. See it here.


COVID-19 Resources: Mask Guidance Playbook

Prevent Epidemics, 27 August 2020

Prevent Epidemics has published a report to aid policymakers in promoting mask-wearing. It includes evidence on, and best-practices for mask-wearing.

Image sourced from PreventEpidemics.org, for non-commercial use.

More COVID-19 resources developed by Prevent Epidemics can be found here.


Alison Barrett is a Masters by Research candidate and research assistant at University of South Australia, with interests in public health, rural health and health inequities. Follow on Twitter: @AlisonSBarrett. Croakey thanks her for providing this column as a probono service to our readers.

See previous editions of the COVID wrap.

COVID-19 Twitter lists

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