Young COVID Long-haulers?
What Is a Long-Hauler?
In the US, we have coined the term “COVID Long-Hauler”. In the UK this is called “Long COVID”. The general concept is that these people don’t die, but they develop protracted symptoms after the cough and breathlessness have abated which can include brain fog and fatigue.
This is a tricky one to research as we’ve known for decades that anyone placed on a ventilator for weeks for any reason and who survives will likely have a post-ARDS syndrome (1). Meaning that many become permanently disabled. Given that these patients who we expect to have problems are mixed in in the discussions of long-haulers, we need to be cautious. Hence, for this discussion, we’re focused on people who get COVID, have symptoms, have those primary symptoms resolve within a few weeks, and then have lingering secondary symptoms.
To answer the question of how many young “long-haulers” are out there and to compare that to other common forms of disability in the young, I’ll first have to review the few studies we have on the syndrome. We’re looking for some idea of how many people under the age of 44 get COVID-19 and develop chronic symptoms. However, as you’ll see, the existing studies don’t tell us much.
The Harvard Newsletter
One of the prime hits on Google on this topic is the Harvard Newsletter (4), which opens with the following article title: “The tragedy of the post-COVID “long haulers”. The piece makes the case that this is an increasingly common public health issue. What references do they provide to back up that claim?
First up is an Italian study from early in the pandemic (5). This is a small case series of patients who were hospitalized that were older than our target group here (56 years of age). Three quarters were hospitalized with pneumonia and on average these people spent two weeks in the hospital. About half of these patients still had symptoms 60 days after their first COVID symptom appeared. However, regrettably, this one doesn’t tell us much about the average young person who gets COVID, has mild symptoms, but then develops long-term issues. It also doesn’t tell us much about what happened to these older and sicker patients at 3 or 4 or 6 months after getting COVID.
The next one is a Vanderbilt University study that sampled people with a positive COVID PCR test in the Emergency Room or in a clinic and who were not admitted to the hospital (3). A tad under 300 patients were interviewed on average 16 days after their test. The good news is that the average age was younger her at 43. By day 16, 65% had returned to normal health with 35% still feeling unwell. The people who didn’t get well quickly were heavier, crazier (they had a diagnosed psychiatric condition), had other medical conditions, and were older. Again, we know nothing from this study about people who have symptoms beyond a few weeks.
Hence, neither of these studies cited in the Harvard Newsletter is able to support the idea that a COVID long-hauler syndrome is common in younger patients. Perhaps there is other data out there?
UC Davis Health
UC Davis health is another common top Google hit on this subject (2). They cite “two studies”, but neither is an actual peer-reviewed publication of data. One is clearly a news article, so we’ll throw that one out. So let’s review the UK article they cite.
This article makes the following statement:
“Around 10% of patients who have tested positive for SARS-CoV-2 virus remain unwell beyond three weeks, and a smaller proportion for months (see box 1).7 This is based on the UK COVID Symptom Study, in which people enter their ongoing symptoms on a smartphone app. This percentage is lower than that cited in many published observational studies,89 whose denominator populations were those admitted to hospital or attending specialist clinics.”
Lots of issues here. Regrettably, any smartphone app data is junk data. Why? It’s ripe with severe selection bias, meaning sicker patients are more likely to want to go through the hassle of wanting to download an app on their phone and track their symptoms. So this is a trash reference. How about references 8 and 9 above, maybe there’s something there?
Reference 8 is a paper on the rehabilitation of severely impacted survivors of COVID who have the medically well-known medical condition of post-ARDS (6). Meaning patients who have been on a ventilator for any respiratory virus (long before COVID) may never fully recover function. Reference 9 brings us right back to the Italian paper I have discussed above. Hence, the UC Davis article is as poorly referenced as the Harvard Newsletter.
PubMed
Not being able to trust Dr. Google on this one, I next performed a US National Library of Medicine search. There were only 8 results. Some of these were just more news articles and not any published data. There was an opinion piece on long-term neurologic symptoms with again, no data. There was a case report. Basically, this search returned nothing with any data on how prevalent the long-hauler syndrome is in younger people.
Injury and Disease Disability in the Young
As I demonstrated in a prior blog, for people 44 and under, the leading causes of death are injuries, young heart disease, or cancer. First, for every traffic or shooting death, there are many more people who survive who are paraplegic, quadraplegic, or disabled in some way for life. The same holds true that for every young heart patient that dies there are many more who have heart disease and are disabled. The same holds true for those who survive cancer and lost a limb. These are the “long-haulers” of the more common diagnoses that people die of while young.
So given that there are no “long haul” statistics published for the young, I think it’s safe to say that given the low death rates, that the “long-haul” numbers are more likely than not lower than the more common causes of permanent disability in the young.
The upshot? Until we get some actual clinical data, the “long-haul” syndrome in younger people who get COVID symptoms and are diagnosed with the same is largely a rumor or at least the lowest quality medical data we have called “opinion”. Hence, if you’re young, you’re still much more likely to become disabled for life while driving than you are to get a COVID long-haul syndrome.
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References:
(1) Herridge MS, Moss M, Hough CL, Hopkins RO, Rice TW, Bienvenu OJ, Azoulay E. Recovery and outcomes after the acute respiratory distress syndrome (ARDS) in patients and their family caregivers. Intensive Care Med. 2016 May;42(5):725-738. doi: 10.1007/s00134-016-4321-8. Epub 2016 Mar 30. PMID: 27025938.
(2) UC Davis Health. Long haulers: Why some people experience long-term coronavirus symptoms. https://health.ucdavis.edu/coronavirus/covid-19-information/covid-19-long-haulers.html Accessed
(3) Tenforde MW, Kim SS, Lindsell CJ, et al. Symptom Duration and Risk Factors for Delayed Return to Usual Health Among Outpatients with COVID-19 in a Multistate Health Care Systems Network – United States, March-June 2020. MMWR Morb Mortal Wkly Rep. 2020;69(30):993-998. Published 2020 Jul 31. doi:10.15585/mmwr.mm6930e1
(4) Harvard Health Publishing: Harvard Medical School. The tragedy of the post-COVID “long haulers”. https://www.health.harvard.edu/blog/the-tragedy-of-the-post-covid-long-haulers-2020101521173 Accessed 12/29/20
(5) Carfì A, Bernabei R, Landi F; Gemelli Against COVID-19 Post-Acute Care Study Group. Persistent Symptoms in Patients After Acute COVID-19. JAMA. 2020 Aug 11;324(6):603-605. doi: 10.1001/jama.2020.12603. PMID: 32644129; PMCID: PMC7349096.
(6) Sheehy LM. Considerations for Postacute Rehabilitation for Survivors of COVID-19. JMIR Public Health Surveill. 2020 May 8;6(2):e19462. doi: 10.2196/19462. PMID: 32369030; PMCID: PMC7212817.
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