Expert Forum on secondary COVID-19 impacts

Agenda, presentations & recordings - Day 1

Agenda, presentations & recordings - Day 2

I've been able to attend several of these export forums in the past and the level of insight is always staggering.

The event, featuring a total of eleven external experts from various fields, was a fantastic opportunity for our own experts to expand their knowledge and help Swiss Re stay at the top of the game. With this many speakers, it won't surprise that this will be a slightly longer post. Still, I'll just try to give a sense and a few glimpses at the many insights – for full details, we'll link to the presentation slides and video recordings.

What is the "Post-COVID-19 Syndrome"

It essentially refers to signs and symptoms, developed during or after COVID-19 infection, that continue for more than 12 weeks and are not explained by an alternative diagnosis. A current estimate suggests that between five and ten percent of patients are affected by Long-COVID – and there is a higher prevalence among older patients and women. At current, the most common Long-COVID symptoms are fatigue, shortness of breath as well as joint and chest pains.

Michael Sharpe, Professor of Psychological Medicine at Oxford University, reported on initial findings from the post-COVID clinic that has been set up in Oxford. This notion of dedicated multi-disciplinary post-COVID clinics was echoed by several other speakers over the course of the two-day exchange. While Long-COVID research is still in its infancy, there is already agreement on a number of things, among them: fatigue is the most common symptom; the syndrome has no single cause and is no single condition; and a considerable number of Long-COVID patients are unable to go back to work.

Scientists are looking at three areas as possible causes for the syndrome – they are biological, psychological and social. Physical and mental health are firmly linked. Heightened anxieties can lead to unhealthy coping behaviors, and social factors are known to worsen already fragile conditions. Among these, unsurprisingly, is the negative impact by news – whether factual or misinformation. As we learned, even support groups, while well-intentioned, may cause more harm than good. The reason being that those on the mend will likely leave the group again, while those still affected, remain and continue to share in an increasingly unhealthy cycle.

What can be done

As always, there is such as thing as too much and too little. As Long-COVID isn't easily defined, what's required by care staff is an open mind, and a pragmatic approach. Professor Sharpe explained that, first and foremost, patients need to feel listened to and believed. Physicians must then identify and treat what is treatable – and with positive messaging help patients toward rehabilitation.

As we're still in the midst of the pandemic, there are not yet a great many answers to the long-term outcome for patients affected by the Post-COVID Syndrome. For now, research suggests that most improve over time, and that psychologically informed rehabilitation is the best treatment. There is, based on what is known at this time, an expectation that one percent of affected people will have long-term disability.

In a next part of the afternoon, three experts talked about the state of research into the effects and long-term consequences of COVID-19 on the heart and lung; in addition a hospitalist shared his learnings on patient recovery and readmission; and findings from a Boston U collaboration about COVID-19 mortality across sociodemographic and health characteristics was shared. While some research does not yet benefit from large-scale studies, what scientists agree on even now is that lack of capacity by hospitals around the world, due to COVID spikes, had multiple negative side-effects as many tests were delayed and surgeries postponed.

Ashwani Bhatia, Chief Medical Officer at BayCare Clinic, talked about his experiences as a hospitalist. While acknowledging that hospitals are still busy dealing with the immediate effects of the pandemic, he urged that now is the time to look at long-term effects. As we all know, this wasn't the first pandemic, and it won't be the last. Now's the time to learn and prepare for that next time. Bhatia highlighted some of the COVID-19 long-term effects he has observed and said that one in ten discharged patients was readmitted within two months – something he attributed to sending people home too early because of hospital space shortages.

The long-term strain on mental health

The psychological impact on patients and healthcare workers is often talked about – and is intensively studied by the experts. Bhatia showed that the overall working population (people aged 18-64) is experiencing a considerable decline in emotional health and wellbeing. In healthcare workers, he pointed out a rise in feelings of burnout by physicians by almost 20% (compared with 2018), and that almost 40% of physicians would like to retire in the next year – a clear reminder that every system has it's breaking point, and COVID-19 brought the healthcare system all-too-close to that point.

The effects of the Post-COVID syndrome will continue to put a stress on the system long after the immediate crisis is over. To help society navigate the next months and years, vaccination, to prevent transmission and achieve herd immunity, is essential. Long-COVID also requires the launch of post-COVID clinics with multi-disciplinary approaches. To monitor and learn, a registry for high-risk COVID-19 survivors is envisioned. In a sense, COVID-19 survivors become a frontline in the fight against the next pandemic – through them, with them, we can learn and better prepare.

If you're interested in the topic from a mental health perspective, I particularly recommend the three sessions on day two, with Heather Haq, Chief Medical Officer at Baylor College of Medicine; Tom Heffernan, Senior Lecturer at Northumbria University; and Neil Greenberg, Professor of Defence Mental Health at King's College London. They offer great insights into the impact of lockdowns, quarantine and self-isolation; PTSD in medical workers; and the impact on children. This last topic was especially revealing as, because COVID-related deaths and/or severe outcomes in children are rare, the focus on children is often neglected.

Haq called it a "dual pandemic" – COVID on one hand, pediatric mental health on the other. She showed that emergency visits for mental health crises for 12-17-year-olds were up by 31%. There's an increase in suicide ideation and attempts – and underlying mental health issues are exacerbated by the pandemic. Haq alerted to another dramatic side-effect that's likely not the radar of many, namely that many of the COVID-19 deaths leave behind children who find themselves suddenly single or even double orphans.

It has become clear that, during this pandemic, psychiatric institutions also reached their limits. With no beds available, mental health patients, in need of a secure environment, had to be sent to medical hospitals instead. And those were, of course, equally strained.

Science is the way out and forward

I invite you to immerse yourself in these recordings. While some may be too technical for laypeople, most help us better understand what's behind us, where we are now, and what we can and must expect in the coming months and years. One presentation slide offered a quote, by Dr. Jeremy Farrar, that perfectly illustrates the importance of this expert forum, and that of every other collaborative effort by scientists around the world:

Swiss Re Institute: Dr. Haq , thank you for joining us. Your insights as a hospitalist pediatrician shine an important light on children's health, an area that's been neglected in the past year as we've rushed to contain the pandemic.
Dr. Haq (find her on LinkedIn): Glad to be with you to share some of what we've learned over the course of the past year as frontline workers at Texas Children's Hospital. We all know that COVID-19 rarely leads to severe outcomes in children and teens – most infected children experience only mild to moderate symptoms. For this reason, both the physical and psychological impact on children is often overlooked. The numbers, however, are telling us that there needs to be a far greater focus on children. In the beginning of the pandemic it was estimated that around 2% of diagnosed cases were children and teens. But as testing has expanded the estimate has risen to 8-10%. While there are few deaths, we do see a number of worrying trends.

Swiss Re Institute: Before we look at the longer-term impacts of COVID-19 on children, can you tell us a bit more about children's symptoms as they come to your hospital?
Dr. Haq: There's neonatal fever, fever, vomiting, diarrhea, dehydration. We see cases of kidney injury and pneumonia, but not as much as in adults. And then there's MIS-C, the multi-system inflammatory syndrome in children. We find that one in three children requires critical care.

Swiss Re Institute: Can you elaborate on MIS-C?
Dr. Haq: It's basically a combination of fever, lab evidence of inflammation, and multiple organ systems involved – and a history of recent or current COVID infection. We have seen a large number of these cases here in Texas. These tend to happen in adolescents, previously healthy. And we've found that cases of MIS-C usually lag behind COVID surges by about three to four weeks.

Swiss Re Institute: What are the long-term sequelae of both acute COVID and MIS-C in children?
Dr Haq: We have set up a post-COVID clinic, focused on examining heart function of children who were diagnosed with either acute COVID disease or MIS-C. A lot of these kids have structural changes in their hearts, or heart function, that need to be observed closely over time. We are concerned that these children could have lifelong impacts.

With regard to psychological impacts, we see an alarming trend, you might call it a pediatric mental health tsunami. Many children experience heightened levels of anxiety. These are children who have lost family members or have family members impacted by COVID-19 and so require care long after a diagnosis. Children, in their developmental stages, also struggle with disrupted schooling, loss of peer interactions, loss of routine, economic changes at both the family and community level. In the United States we've found that emergency room visits for mental health crises among 12 to 17-year olds is up more than 30% compared to the prior year. Children are presenting to the ER with suicidal ideation, following suicide attempts and both intentional and unintentional overdoses. We see another disturbing trend in that the pre-teen age group also presents these types of issues.

Swiss Re Institute: Are the rise of suicide ideation and attempts tied to pandemic waves?
Dr. Haq: That's what we see. At the beginning of last year, the data was comparable to 2019. But already in February and March we saw a rise in suicidal ideation rates, as well as an increase of children presenting for suicide attempts to pediatric emergency departments. We saw a next surge in the summer. As far as actual suicide attempts, there's been an increase, compared to the prior year, throughout the pandemic. These trends in our teenage and pre-teen populations indicate a widespread mental health impact of the pandemic on this age group.

Swiss Re Institute: Are mental health institutions ready to cope with the increase?
Dr. Haq: We see shortages of community mental health resources. With psychiatric institutions overflowing because of increased demand, patients are sent to medical hospitals, such as Texas Children's. Across the US we seen an increase in number of mental health admissions into hospitals. These are children without medical issues but suffering from severe depression and suicidal thoughts.

It is difficult to predict the long-term sequelae of the mental health challenges in this age group. But I think we're going to be seeing reverberations of this mental health pandemic amongst children for a long time to come. Finally, allow me to add one more area of concern that requires attention, study and care: orphans, left in the wake of the pandemic. The many adult deaths due to COVID-19 leave behind an even greater number of single or double orphans. It must be expected that these millions of bereaved teens and pre-teens will add to the increasing demands put on our care institutions.

Swiss Re Institute: Professor Sharpe, thank you for giving us a bit of your valuable time. The 'Long COVID' diagnosis is relatively recent – can you offer a definition?
Professor Sharpe (find his CV here): The post-COVID-19 syndrome is defined by NICE (National Institute for Health and Care Excellence) as 'signs and symptoms that develop during or after an infection with COVID-19, continue for more than 12 weeks and are not explained by an alternative diagnosis.' This definition may not be universally accepted, but it does clarify what we are talking about.

Swiss Re Institute: As this is a new illness, what are the early research findings?
Professor Sharpe: This is a tough time for academics and a lot of the research has been done in the form of internet surveys. These give us some clues, but we are aware that there is a deluge of poor-quality research with unclear denominators. Better research is on the way but there simply hasn't yet been enough time for randomized trials. Based on current understanding, we think that 5 to 10% of patients, at three months, have some kind of severity of symptoms and disability. Many more may have lesser symptoms and lesser disability. These patients tend to be older, with a predominance of females, and pre-morbid vulnerabilities.

Swiss Re Institute: Tell us about the post-COVID clinic you helped set up in Oxford.
Professor Sharpe: Our clinic is a multi-disciplinary one-stop shop that initially focused on people admitted to hospital, but today the majority of patients are referrals from primary care. We have a multi-disciplinary team, where we can bring in cardiology, neurology, etc., as needed. These clinics have been a very interesting development and I think it is how medicine should be practiced. A major concern is that all of this is made possible through short-term funding. Long-term funding is promised, but we'll have to wait and see.

Swiss Re Institute: What can you tell us about the causes of Long-COVID?
Professor Sharpe: It is all-too easy to talk about post-COVID syndrome as if it were one thing, like lung cancer, for example. We must allow for the fact that it is heterogeneous and be wary of thinking in terms of a single cause. Based on our clinical experience, there are biological, psychological and social causal factors. Patients often have a lot of symptoms, as many as 20-30 – but we must remember that multi-symptom illness does not mean multi-symptom pathologies.

There are striking psychological factors, we might call it health anxiety. Some of our patients experience significant anxieties because of an understandable focus on their bodily symptoms, but about a third to half of our patients are negatively impacted by the media. Consumption of newspaper articles that proclaim 'Long-COVID could mean lifelong-COVID' and that 'the effects could be horrible,' can hinder patients' recovery. Another, perhaps surprising, social factor has to do with online support groups. These have proven to be of great benefit for many worried patients. However, people who recover tend to leave such groups, leaving the group with only people with poor prognosis. There's concern that such groups can then exacerbate pessimistic views of the illness and transfer those to vulnerable patients.

Swiss Re Institute: You mentioned those who recover – tell us about rehabilitation.
Professor Sharpe: Right now, with the many as-yet unknowns of this illness, there can be excessive investigation. While the intent may be noble, it won't necessarily be helpful to the patient as it can entrench them in worries and distract from the task of rehabilitation. Some of my colleagues are inclined to do as many tests as possible, while others simply treat for anxiety or chronic fatigue. I think one of the real challenges for managing Long-COVID is to find the right balance between the two.

When people come to our clinic, the crucial first step is that they are taken seriously. Patients must feel listened to and believed. From there, physicians have to manage the patient's uncertainty and their own uncertainty in deciding how many avenues to go down with possibilities and tests, and how much to be pragmatic. We must remember that is heterogeneous and we do find treatable conditions. I think what's really important is that, as far as we know, most people improve and so to give an overall positive message rather than this is a very worrying alarming condition that we don't understand and we don't know what's going to happen to you. At the moment, the best approach to post-COVID seems to accept that it will take time. Psychologically informed rehabilitation addresses patients' worries and helps them gently return to activity.

Swiss Re Institute: What are the challenges you see for the long term?
Professor Sharpe: Well, the obvious challenge is that there aren't many multi-disciplinary rehabilitation teams. They are being set up in some places in the UK – but it's patchy and made possible with short-term funding. The UK's National Health Service is generally good when it comes to acute illness, not quite as good when it comes to rehabilitation. There are currently also challenges with guidelines – these may complicate treatment for post-COVID patients.

Swiss Re Institute: What are your expectations with regard to chronic disabilities?
Professor Sharpe: The syndrome hasn't been around long enough, so we simply don't know. Still, our experiences to date show that most patients do improve – for many this means months, not weeks – but they do improve. In the absence of good data, physicians usually fall back on the rule of thirds. And so, if we say we've got 5% and we apply the rule of thirds, my guess would be that something like 1% of patients may have some long-term chronic disability and chronic work disability. Again, that is a guess, and it will depend on the care patients get, but given the number of people with COVID, that could potentially be quite a lot of people.