The later arrival of Omicron in Aotearoa means we have watched the impact of long Covid in other countries including Australia.
Developing after Covid-19 infection and lasting for three months or more, Long Covid is thought to affect 10 to 20 per cent of people based on research to date. As our country experiences higher numbers of Covid-infected people, what are the longer-term consequences for adults and children, and could New Zealand limit its impact?
The SMC asked experts to comment.
Dr Mona Jeffreys, Senior Research Fellow and co-lead of “Impacts of Covid-19 in Aotearoa” study, Health Services Research Centre, Victoria University of Wellington, comments:
What is known about the risks of long Covid from Omicron?
“From an epidemiological point of view, it is too early to tell whether Omicron will cause long COVID to the same or a greater or lesser degree than other strains of SARS-CoV-2. My understanding of the immunological data is that there is no reason to suggest that this will not occur.
“What is, of course, much more of a worry, is the magnitude of the problem. If, say, 10% of people have COVID symptoms that persist beyond one month, we would expect about 1,000 people in Aotearoa New Zealand to be in this group, based on pre-Omicron data. Based on current numbers (over 260,000 currently), we will be looking a huge case-load of people.”
What support is available for people with long Covid in New Zealand?
“At this stage, there is very little available. Health professionals are woefully uninformed, and patients are being left uncared for. There are some moves to change this. We are running a study (see covidaotearoa.com) to ask people what support would have been helpful, and what additional needs they had that were not met, etc. Partly stemming from this, we are forming a Long COVID Collective, to bring together people with Lived Experience, researchers and clinicians, to ensure that Aotearoa New Zealand remains at the forefront in the provision of the best care for people with Long COVID.”
How could NZ limit the impact of long Covid through policy measures?
“There is no current advice to people about how to reduce their risk of Long COVID. I would want everyone to know, in the same way that we all know about using masks, washing hands etc, that if you get COVID, please rest until all symptoms are gone. At this stage, this is the only measure that we know can reduce your risk. Other than, of course, getting vaccinated and boosted, so as to reduce your risk of getting COVID in the first place.”
What is the advice for individuals and families who are infected with Covid-19 to help mitigate the risks and severity of long Covid?
“While you are ill, rest. If you do have symptoms of Long COVID (ongoing, or newly developing symptoms), please seek help. There is information available from Te Rōpū Whakakaupapa Urutā and the National Institute for Health Innovation.
“Most importantly, if you have fatigue, muscle weakness, etc, do not ‘push through’. Do not think that you can exercise your way out of this. Do not believe that this is all in your mind. It is real, and with time and care, your symptoms can improve.”
What is your advice for communicating to the public on long Covid?
“There seems to be very little evidence-based information for the public or health professionals. We are looking to address this in the coming weeks and months.”
No conflict of interest declared.
Professor Harvey White, Cardiologist and Director of the Green Lane Cardiovascular Research Unit, Auckland City Hospital, comments:
What is known about the risks of long Covid from Omicron?
“Omicron was only reported to WHO on 24th November. The WHO definition of Long COVID is symptoms after 3 months, so there has been no opportunity yet to follow-up patients beyond that time.”
What is the research saying about the potential protective effect of vaccination against long Covid?
“Vaccination decreases the severity of COVID with decreased admissions to hospital What is notable about the Veterans study on heart health risks – which is a very good study – is that patients with mild symptoms (defined as not hospitalised) also got long COVID. Surprisingly in recent reports (e.g. last week) patients with severe long COVID symptoms have had them stop shortly after having a vaccination.”
How could NZ limit the impact of long Covid through policy measures?
“To take it seriously. It is real and anybody can get it. The best way to avoid it is to not get COVID in the first place. Don’t trivialize getting it, you could have heart attacks or strokes in the future, or brain fog affecting your memory and thinking, or fatigue affecting your ability to work or take part in recreation.”
What is the medical advice for individuals and families who are infected with Covid-19 to help mitigate the risks and severity of long Covid?
“Take it seriously. Don’t trivialize it. Avoid giving it to others, avoid crowds, social distance by 2 metres, wear masks, if inside make sure its well-ventilated. If you have symptoms of heart disease; chest discomfort related to exercise, shortness of breath, faintness, or palpitations, see your GP, it could be serious.”
No conflict of interest declared.
Dr Anna Brooks, Senior Lecturer and Cellular immunologist, University of Auckland, comments:
What is known so far about long Covid?
“Research is starting to uncover some of the possible biological causes of the constellation of symptoms experienced by those with Long Covid. Although triggers are not completely understood, onset is likely due to both direct viral infection of cells and indirect unresolved inflammation. What we do know is that it is a complex, multi-system illness largely driven by dysfunction of the immune, nervous and circulatory systems leading to a spectrum of debilitating symptoms.
“Nervous system disruption (dysautonomia) is fairly common in people with Long Covid – ie a disruption of our “autopilot” functions such as heart rate, breathing, and digestion. Complications of Covid-19 illness likely evolve due to unresolved or persisting inflammation associated with widespread blood vessel damage (endotheliopathy) and disrupted blood clotting pathways (coagulopathy). Leading hypotheses of the cause of persisting inflammation include the development of a damaging autoimmune response and in some cases, perhaps incomplete clearance of the virus (either viral persistence or debris).”
What do we know about the risks of developing long Covid from Omicron infection?
“Unfortunately, very little. Since Omicron emerged 3-4 months ago, the countries where it hit first will only be starting to see cases emerge. Bearing in mind, the UK is the only country attempting to track incidence via the Office for National Statistics (ONS). Early indicators suggest an uptick in overall prevalence of Long Covid, however the most up-to-date data does not yet include the impact of Omicron. We are likely to see updates in coming weeks.
“Although vaccination, especially when recently boosted, has proven protective against hospitalisation and severe illness, we know that Omicron is able to partially evade our immune defence, which means there are much higher rates of symptomatic, or breakthrough infections. In fact, we don’t often hear the term “breakthrough” like we did for Delta, given it is now relatively common following exposure to Omicron. Earlier studies suggested vaccination reduced the risk for developing Long Covid, however there is no data yet to suggest the same for Omicron. While vaccination remains critical for protection, when symptomatic infections are common, the risk of Long Covid likely remains. We have no insight as to how prevalent Long Covid will be (currently estimated at 10-30%), all we know is that this is starting to emerge internationally.”
What support is available in NZ for people with long Covid?
“To date there have been no official channels for support, and therefore has largely been facilitated though our Patient-Led support group on Facebook. Access to medical care has been challenging, whereby people with Long Covid regularly report a lack of understanding of the condition or knowledge to assist. Notwithstanding, medical management guidelines are still emerging, and we hope that in due course dedicated Long Covid services will be implemented. NZ also urgently needs a national survey (similar to the UK ONS database) to allow self-monitoring of wellbeing including post-acute symptoms.”
What is the advice for anyone with Covid-19 to help mitigate the risks of long Covid?
“Recovery time is different for everyone but for most people who get COVID-19, their symptoms will resolve by 12 weeks. Long Covid, when symptoms persist, is not linked to severity of the initial COVID-19 illness and often develops following mild, or even asymptomatic infection. Caution must be taken to be mindful of new or ongoing symptoms that can fluctuate and affect people in different ways at different times.
“It is important to recognise the signs of an incomplete recovery. The most common being breathlessness/cough, fatigue, headaches, racing heart, and general aches and pains. Symptoms may also manifest differently in children and may be more difficult to spot. Children often complain of tiredness, sore tummy, headaches and aches and pains. When experiencing these symptoms, it is important to rest and not “push through”. It is incredibly important to avoid Graded Exercise Therapy (GET) – or any over exertion or stressors too soon, as this may exacerbate symptoms and cause further damage. Long Covid is not the result of deconditioning, and this is now deemed harmful.
“It is important to seek medical care to rule out any serious organ damage, after which symptom management can be sought. It will also be common for clinical tests to come back normal – this does not mean the patient is not unwell – it just means we don’t have the right tests yet – and is currently the focus of urgent research.
“For Racing heart: POTS (Postural orthostatic tachycardia syndrome) – a condition that affects blood flow, ie part of our autopilot function – is often the cause of unexplained heart rate fluctuations (tachycardia), and a common feature of post-viral illnesses. And for Shortness of breath: Seek guidance from physiotherapists experienced in Long Covid rehabilitation to assist with breathlessness.”
What is your advice for communicating to the public on long Covid?
“We need widespread awareness. The narrative that omicron is “mild” is dangerous and misleading. “Mild” inferred there would be less mortality from the acute infection, and less serious disease requiring hospitalisation, all largely due to high rates of vaccination. Vaccinations are critical but are just one layer of protection, and an imperfect one at that. Time since vaccination/boosting and the emergence of new variants will continue to impact the risk of long Covid. So, emphasis on infection prevention should be maintained to reduce infection transmission through vaccination (including boosting), mask wearing and adequate indoor ventilation. Even a small percent of widespread infection is going to lead to a significant health and economic burden.”
No conflict of interest declared.
Dr Amanda Kvalsvig, Epidemiologist and Senior Research Fellow, Department of Public Health, University of Otago, Wellington, comments:
“Longer term (post-acute) effects occur in all infectious diseases of childhood of public health significance, and Covid-19 is no different.
“In our Public Health Expert blog published today we present findings from a review of the evidence around post-acute effects of Covid-19 and children. These effects range from a rare but severe multisystem inflammatory syndrome that is unique to Covid-19, to more common symptoms grouped together as ‘long Covid’. Other findings include evidence of inflammation and abnormal blood clotting occurring in children that may indicate a potential risk of developing chronic conditions in future.
“There is still a big question-mark about how rare or common these impacts will be in Aotearoa New Zealand. We can expect impacts to be less severe for children than for adults, but we can also expect that the risk will be spread unevenly in our populations.
“What this means is that an individual child is likely to have a good outcome from Covid, but the size of the risk for *all children* (a whole generation) from this new pathogen is still unknown.
“In view of this uncertainty we recommend a precautionary approach in the current Omicron outbreak with a shift to greater efforts to protect children from infection.
“Findings from this review indicate a need to move to a whānau-centred approach, not a school-system-centred one, to protect children’s health and wellbeing during the Omicron outbreak whether they are in school or at home. That will mean intensifying messaging and resources to support ventilation and mask use, and resourcing community providers to address vaccine inequities experienced by Māori and Pacific children. The findings also suggest setting a lower threshold for closing schools and early childhood facilities, with greater flexibility from the education system to enable families to keep children at home if they wish to when school case numbers are high.”
No conflict of interest declared.
Dr Bronwyn Lennox Thompson, Senior Lecturer, Academic Coordinator Postgraduate Programmes in Pain & Pain Management, University of Otago, Christchurch, comments:
What support is available for people with long Covid in New Zealand?
“People in Aotearoa New Zealand with long Covid are likely to have great difficulty accessing rehabilitation services, particularly to support them to resume work, manage daily life occupations such as parenting, and return to their usual leisure activities. Currently rehabilitation services such as occupational therapy, physiotherapy and social work are not funded consistently across the country in primary health care.
“Given the Government has placed most Covid management into the hands of primary care general practitioners, this means that most people with long Covid will struggle to obtain the rehabilitation they need. While some people in a good financial position may be able to see an allied health clinician, long Covid requires a multidisciplinary approach within a team, and this is unavailable in most areas of the country while also being very expensive. Those people who are financially disadvantaged will struggle to access the level of rehabilitation support they need.
“Long Covid will highlight the disparity between people receiving ACC-funded rehabilitation and those who need rehabilitation for other health conditions. This needs to change.”
What is the advice for people with persisting post-Covid symptoms?
“The main advice for recovering from long Covid appears to be:
- Don’t overdo it – if you feel you need rest, rest.
- When starting to resume daily life occupations such as preparing meals, grocery shopping, meeting with friends, plan to do no more than one new activity a day. Begin with a very low level of activity, and very slowly increase – interspersed with regular planned breaks throughout the day. At first you may need to rest before you think you need to, but avoiding a “boom and bust” cycle of overdoing then having to rest is crucial.
- Begin with some fun things, and things that won’t matter if you stop for a break.
- Maintain a healthy diet.
- Ask for help from friends and family – let them know what you’d like them to do, don’t make them guess! They may question your motivation because your recovery is slow, and you may question your own motivation. Be prepared to say what it’s like for you, but most of all, tell people what you think they can do to help.
- Recovery can be slow and demoralising. You may question your mental health, and feel low in mood – make some room to have these feelings because rehabilitation is hard work. Cultivate some time for yourself, connection with at least one good friend, and consider using a form of meditation or relaxation practice. Reach out for counselling or talk therapy if you need it.
- When starting exercise, begin well below what you think you “ought” to do. The form of movement practice doesn’t matter: do the kind of movement you enjoy, they’re all good. Be aware that your tolerance will be low – so begin low and be consistent. Walking is good, so is yoga, tai chi, qi gong, but if these don’t float your boat, do what does make you feel good. If you overdo it one day, give yourself a break for a day – then don’t do as much the next time!”
No conflict of interest declared.
Professor Kurt Krause, Infectious Diseases Physician; Professor of Biochemistry, University of Otago, comments:
“The 2% brain shrinkage finding announced yesterday is potentially quite a big deal, bolstered by the lack of similar findings in influenza. This could mean that “long Covid” is an even bigger deal than other post-viral syndromes.”
No conflict of interest declared.
Emeritus Professor Warren Tate, biochemist, molecular biologist and ME/CFS expert, Brain Health Research Centre, University of Otago, comments:
What support is available in NZ for people with long Covid?
“There are initiatives occurring like the ‘Impacts of Covid-19′ study that has established the need for support for Long COVID sufferers, and the Waitemata District Health Board is setting up a Long COVID clinic. Researchers have highlighted the need for a formal network of health providers to provide better support for the Long COVID group of sufferers in New Zealand.”
As an ME/CFS expert, what could help individuals and families with Covid-19 to help mitigate the risks of long Covid?
“Without specific therapies that benefit the ME/CFS community collectively this is a difficult question. For people with post-viral fatigue, management strategies that have proved helpful to people with ME/CFS include: mitigating life stresses wherever possible, and acknowledging the core symptom of “post-exertional malaise” that can arise from physical, mental, or emotional exertions, leading to debilitating relapses. Those clinicians with an excellent understanding of ME/CFS have management strategies that may translate to Long COVID.”
How could NZ limit the impact of long Covid through policy measures?
“There is a history of much variety in the knowledge and understanding of ME/CFS among health practitioners that has impacted – often negatively – on patients’ care and support. There is a need for education in the medical schools to ensure all graduating doctors have a clear understanding of the illnesses and the physiological dysfunctions for both ME/CFS and Long COVID. Consistent evidence-based management of these conditions will ultimately benefit patients and make their lives better supported.”
What is your advice for communicating to the public on long Covid?
“Currently the messaging is very mixed. Some senior clinicians have said the current Omicron pandemic is just a mild flu-like illness while others have warned not to be complacent about the potential serious health consequences, even if for a minority. There are also messages that it would be good for us all to get Omicron as though that might provide long-term immunity, but there is no reference to long-term risks.
“There is virtually no messaging reminding people of Long COVID as we in New Zealand get more cases than we have ever had, and what that could mean for a future health burden to individuals, families, communities, and our health system. This is not a call for fear-mongering but there is a need to remind all to take personal measures to minimise infection – so we not only mitigate immediate problems for our hospital system but future burdens on our health system as a whole.”
No conflict of interest.
Dr Stephen Ritchie, Infectious Diseases Specialist and Senior Lecturer – Clinical, Molecular Medicine and Pathology, University of Auckland, comments:
“It is too early in the Omicron surge globally to determine the risk of long COVID related to Omicron. As many as one in three people infected with earlier variants of COVID-19 during 2021 developed serious symptoms that lasted for more than 3-6 months. Long COVID often occurs after more severe disease, although it can occur after very mild disease. Because the majority of people affected by the Omicron variant have mild disease I expect the risk of long COVID to be much lower with Omicron. Furthermore, as studies have shown, the exceptionally high vaccination rate in NZ provides protection against severe disease and also against long COVID. However, because so many NZers have and will become unwell with Omicron, a large number of people will still develop long COVID symptoms.
“Unfortunately, there are no specific treatments to fix long COVID, but many sufferers have improved over time. The Ministry of Health has funded research to determine the unmet needs of NZers with long COVID and some regions have set up clinics or other pathways for GPs to help people suffering with long COVID. It is likely that with further research in NZ and overseas that measures to reduce the impact of long COVID will become available.
“The main measure to prevent long COVID is via vaccination to reduce the risk of developing severe disease from COVID-19; several studies have shown that vaccination reduces the risk of long COVID considerably. If a person is still unwell during the recovery phase after COVID-19 infection it is good to only gradually get back into normal activities. People in this situation will often need to pace themselves and rest when they need to, but should aim to increase exercise and activities in a gradual way. Health Navigator has good advice for people during the recovery phase of COVID-19.”
No conflict of interest declared.
Exercise advice for anyone with Covid-19:
Dr Judikje Scheffer, Specialist General Practitioner in Chronic Fatigue Syndrome / Myalgic Encephalomyelitis and Medical provider HPSNZ / Rowing NZ, comments:
“Due to the rapidly-evolving strains of COVID-19 and the continuously ongoing research, best practice and guidelines are fluid and changeable. Local New Zealand guidelines for sport and exercise during and after COVID-19 infection are currently under development. The following information is based on overseas guidelines and current best practice advice.”
What are the medical recommendations on rest and physical activity / exercise during acute Covid infection?
“No person or clinical presentation is the same and specific advice will differ per patient. Factors to consider are all of these:
– whether you are symptomatic or not,
– the severity of your symptoms,
– general fitness,
– type of sport you are participating in (sports with high aerobic demand the return to sport may take longer than less aerobically demanding sports),
– underlying conditions/illnesses that can negatively impact recovery (heart disease, diabetes, COPD, etc).
“If you are infected with COVID-19 it is important not to exercise while being symptomatic and the current general advice is to rest for at least 10 days. Your body has only a certain amount of adaptive capacity. While you are unwell this needs to be directed to fighting the virus. If you overdo it when you are unwell, it will just drag your condition down and it will take you longer to get better. You can judge your recovery by:
1-Your resting pulse
2-How you are feeling generally [rated out of 10]
3-Any muscle and joint aches
“Even if you are positive and have no symptoms, it is advised not to exercise. Overseas guidelines advise you should be at least 7 days symptom free and able to complete normal daily activities of living and normal walking on flat ground before you start doing exercise again and when you do, you should monitor for symptoms like for example increased heart rate, shortness of breath, lightheadedness, chest pain, abnormal fatigue or an out of proportion muscle soreness. When you become symptomatic during or after doing exercise it is advised to see a medical doctor. Depending on the severity of symptoms, other underlying conditions and the aerobic demand in your sport, the period before you can resume a full return to sport can be weeks or longer.
“Serious COVID-19 infection has been found to have more detrimental effects to health, particularly to heart and lungs, and for example result in myocarditis or lung fibrosis. Therefore, after a severe COVID-19 infection, or if you have other health conditions that affect your recovery, it is advised to discuss your return to sport and activity plan with a medical doctor, like a sport and exercise physician.”
What are the medical recommendations on rest and physical activity / exercise for people who experience lingering or longer-term symptoms (long Covid)?
“If you do have lingering symptoms it is important to seek medical advice and not push through symptoms, thinking “exercise must be good for you”. Yes it is – if you are healthy and not infected with COVID-19, regular exercise can even help reduce the severity of COVID-19 illness. Several studies have found that active people have lower risk of COVID-19 infection, of severe COVID-19 related illness (including hospital/ICU admission) and COVID-19 related death.
“Especially if you experience ‘post exertional malaise’ (PEM), which is worsening of your symptoms (excessive fatigue, muscle soreness, shortness of breath, etc.) in the hours to days (!) after you have exerted yourself (even mildly), you should stop and rest instead. Long Covid resembles Chronic Fatigue Syndrome and PEM is a key factor in this prolonged illness and requires careful pacing to recover, just like with persistent fatigue after Glandular Fever. Exercise is not beneficial in this case!”
What is the medical advice for individuals and families who are infected with Covid-19 to help mitigate the risks and severity of long Covid?
“‘Long Covid’ should be considered when the effects of COVID-19 are causing ongoing symptoms weeks to months after the initial infection. Obviously, preventing COVID-19 infection would be the best way to avoid getting Long Covid. The next best thing to do is get vaccinated when you can. Vaccination will help reduce the risk of infection and reduce illness severity. If you do get infected it is important to listen to your body and rest as per above advice.”
No conflict of interest declared.
Dr Sarah Rhodes, Lecturer, School of Physiotherapy, University of Otago, comments:
From a physiotherapy perspective, what is the advice for individuals and families with Covid-19 to help mitigate the risks of long Covid?
“The risk factors for developing long COVID are not yet fully understood but it is likely that some are modifiable. One factor that appears to increase the risk of developing long COVID is keeping going at all costs, after contracting the acute COVID infection. People with a less severe infection may be tempted to “push through” and carry on as normal. The best advice if you test positive for COVID-19 – even if your initial symptoms are mild – is to allow yourself time to rest both physically and mentally, to optimise your chance of a full recovery. Avoid doing anything strenuous and make resting a priority.
“Fatigue is a common symptom of many viral illnesses and a feature of both acute COVID-19 infection and long COVID. Fatigue is debilitating and can make previously simple tasks exhausting. If someone with a COVID infection is experiencing fatigue it is important to employ strategies such as ‘Prioritise, plan, pace’ to manage energy reserves appropriately and reduce the risk of persistent symptoms developing.
“Rehabilitation is an important part of recovery following acute COVID-19 infection. Screening of symptoms by a physiotherapist or other health professional is essential to assess risk factors for return to exercise. A safe approach to rehabilitation requires monitoring of symptoms in response to activity to ensure they are not worsened by over-exertion. The current consensus is that exercise should not be undertaken until the individual has been completely symptom-free for at least seven days. Commencing exercise too early may increase the risk of long COVID. When exercise is restarted it is advisable to ease back into it slowly.”
No conflict of interest declared.
Dr Adam Castricum, Sport and Exercise Physician, Axis Sports Medicine Specialists, and Chair of Australasian College of Sport and Exercise Physicians Exercise Medicine and Mental Health Advisory Groups, comments:
What is the sports medicine advice for returning to exercise after Covid-19 infection?
“Whilst most of us will at some stage get a COVID infection, fortunately the majority of people will have only mild symptoms due to a comprehensive and successful vaccination and mitigation programme in Aotearoa. These can range from upper respiratory tract symptoms such as runny nose, cough, hoarse voice, and for some loss of taste and smell, as well as fever, fatigue and brain fog. Some, unfortunately, will need further care and support in hospital.
“Generally, COVID infection symptoms settle over 3-7 days within the infectious period, but given the SARS-CoV-2 virus can also reach the heart, kidney, blood, brain and wider nervous system, resumption of activity must be slow and steady, at all times being guided by both physical and psychological factors. It is most important not to resume activity too quickly and too intensely, as this can prolong the fatigue and other symptoms, making getting back to even the most basic activities of daily living difficult and frustratingly slow.
“Fortunately, here in Aotearoa, we have the experience of clinicians managing return to activity, exercise and sport in overseas pandemic-ravaged countries that have helped to shape best practice and safe management here.
How long is the expected recovery from Covid-19? (for people in general, not long Covid)
“Returning to the full level of activity or sport generally takes about 3 weeks in athletes, but can often take 6 weeks and for some with more severe disease and those hospitalised, it can take longer. The important message is that returning to activity and exercise is important for recovery of physical and psychological wellbeing, but must be in a paced, very graded stepwise fashion, ensuring you are able to recover well from each exercise bout without ongoing symptoms before progressing to the next level. Adequate sleep, good nutrition, hydration and social connection are also vital to help you recover well.”
What support is available to assist people with Covid-19 recovery? (people in general, not long Covid)
“Wonderful resources outlining these steps can be found on the Moving Medicine website with an easy to follow set of COVID Recovery Tips detailing how to get back to what you love. For those wishing to get back to high-performance endurance sports and activities, there is an excellent Infographic in the British Journal of Sports Medicine outlining “Graduated Return to Play after COVID-19 infection”.
“Most importantly, if you feel that you need help resuming activity after your COVID infection please reach out to your local GP, physiotherapist or exercise physiologist, who can ensure you get the best and safest advice on getting back to the activities you love. Those who have a severe or more prolonged course, or have medical conditions such as diabetes, heart, lung or kidney disease, may need referral for further assessment with a Sport and Exercise Physician, Rehabilitation Physician or other relevant medical specialist prior to starting their graduated return to activity.
“So be kind to yourself, don’t be afraid to ask for help, and be patient with your recovery.”
No conflict of interest declared. Dr Castricum is employed by Axis Sports Medicine Specialists.