long term covid effects: commentary on yelin et al. (2020)

On this blog, we’ve had a debate over my opinions on COVID policy. To summarize, here is my view:

1. Most of the damage from COVID is disproportionately shouldered by the elderly.
2. Harm from COVID is relatively rare among non-elderly adults and young people.
3. It is possible to reduce transmission to elderly people with relatively simple policies like age screening, increased testng for care givers and encouraging the elderly to reduce contacts with younger people who have been out in the community.
4. Widespread lockdowns and closure have some very damaging effects such as unemployment, mental health problems, and erosion of the community.

Points #1 and #2 are very much the consensus. Most people seem to accept #4. #3 is more contended – but I am puzzled about why focusing on at risk people is seen as such a misguided policy. It’s what we do for other illnesses (e.g., if your family doesn’t have a history of sickle cell anemia, we won’t monitor you for it). The conclusion , however, is pretty simple: a relatively “open” policy – relase the young, protect the elderly. There are a growing number of epidemiologists who are moving toward this position. Even the WHO is backing off on lockdowns as a default method for COVID mitigation.

In the comments of my blog posts on the “open” position, people told me I am severly misunderstanding things or misrepresenting things. For example, people will link to a news article reporting that a young person died from COVID. This evidence is not what is needed to reverse my position. I have never said that young people are immune from COVID or that they don’t get infected. Rather, my point – which is the consensus – is that the damage from COVID is much, much more rare among the young than the elderly. Thus, if you point to an article about a single college student succumbing to COVID, that doesn’t undermine the major point. Policy is about larger trends, not rare cases. Also, news about infection rates should not change the position because infections by themselves are not the issue. Hospitalization and death is the issue. I also note here that I focus on death rates because infection rates are tough to interpret – an increase in public funding for test may increase *reporteed* cases, not actual cases.

Now, I want to turn to an issue that people brought up. People claimed that my “open” position is untenable because of the possibility of “long haul” COVID effects. In other words, COVID may have lingering and highly damaging effects on people and I don’t factor that in. Remember, when dealing with public policy, you are usually trying to deal with larger trends and allocating resources to people who need it. A small handful of cases will not change the argument. Thus, my argument about the “open” position for COVID stands if the people who get long term effects are the same people who were initially hospitalized or died – the elderly, mainly. If people who do not initially show symptoms, but are infected, still end up getting long terms effects, then that’s a chance to revise the police.

In arguing for a more “closed” position because of “long haul” effects, one commenter linked to this article in Lancet: Infectious Disease by Yelin et al., as a way of criticizing my point. So remember: if long haul effects are mainly concentrated among people who showed symptoms early on, then that reinforces my point becuase long haul effects would be an issue affecting a very specific group that we can protect (the elderly). If long haul effects appear in asymptomatic people (mainly younger people), then it would undermine my point because the assumptions behind the trade-off involved in an “open” position are incorrect.

So here is what the article says. Let’s start with the first sentence:

Weeks and months after the onset of acute COVID-19, people continue to suffer.

Right there, this article is about people who showed acute symptoms from the start. It’s about comorbidity conditioned on breathing problems and other severe symptoms. How can we tell? Here is the data that motivates the article: “78 of 100 patients in an observational cohort study who had recovered from COVID-19 had abnormal findings on cardiovascular MRI (median of 71 days after diagnosis) and 36 of those reported dyspnoea and unusual fatigue.” Severe breathing problems. Who were these 100 patients? A recent JAMA article (Pentmann et al. 2020) on *hospitalized* COVID patients. How sick were they? “This is a prospective observational cohort study of 100 patients diagnosed with severe acute respiratory syndrome coronavirus 2 by reverse transcription–polymerase chain reaction on swab test of the upper respiratory tract who fulfilled inclusion criteria for this CMR investigation.”

Let’s look at Table 1. in Pentmann et al. (2020). This table describes the 100 people who had severe COVID induced breathing problems. Look at the 1st column. What do we see? Average age 49. 18% had diabetes. 22% had hypertension. BMI? 25 vs. 23 in the control group. Blood pressure? 129 v. 122 for the control group. Pentmann et al. also created a group of 57 people who were risk matched, in order to compare equally ill people who did and did not have *acute* COVID.

Not suprisingly, the group of more obese, more diabetic and older acute COVID patients have more cardiac problems post-COVID than people who did not have acute COVID. Also, not surprisingly, COVID victims compared to “risk matched” non-COVID individuals did worse. But Yelin at al. (2020) put this in the proper perspective. They do not estimate the population level frequency of long haul effects among acute COVID victims, nor do they say anything about their appearance in otherwise low risk population.

Rather, they correctly, note that many infectious diseases can have catastrophic long terms effects: “Rare long-term sequelae can result after other viral infections—eg, infectious mononucleosis, measles, and hepatitis B.” They also note that since COVID is novel, we’ll need to conduct more research on what such long term effects are:

1. “The number of people affected by COVID-19 is unprecedented. We owe good answers on the long-term consequences of the disease to our patients and health-care providers. The obvious answer is in research.”
2. “Careful recording of symptoms and patient examination should allow understanding of which part of the sequelae is common to all severe infections, which symptoms might be explained by the anxiety caused by a new disease and by the isolation,⁹ and which symptoms are secondary to a complicated form of COVID-19 (eg, pulmonary involvement during the acute disease).”

Yelin et al. 2020 have a simple and important message: if you have acute COVID, you may have lingering side effects, just like other infectious diseases. Also, we need to figure out which problems are due to infectious disease generally, anxiety, and isolation. Notice, that nowhere in this article do Yelin et al. fundamentally take issue with the disease burden. In fact, the big study they describe (and others in the references) confirms what we know about COVID – it’s harms are way, way more focused on the elderly, and that’s the group we should help.

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