Policy Planning for the Post-Pandemic World: The Chronic Illness and Mental Health Needs of Tens of Millions of COVID-19 Survivors

The novel coronavirus (COVID-19) has infected nearly 70 million people worldwide in the 11 months since its emergence, causing 1.5 million deaths.¹ Some of the tens of millions of COVID-19 survivors will live with long-term chronic illnesses, such as chronic fatigue, psychiatric illness, stigma, and injuries to the lung, heart, or other organs. Chronic illness resulting from COVID-19 will require rehabilitation, disease management, job accommodation such as gradual return to previous work schedules or telework, and/or disability insurance. All of these resources are more available in high-income countries than low- and middle-income countries (LMICs). That said, all countries can build on existing programs to improve mental health access and improve chronic disease management. Using evidence from previous coronavirus outbreaks and emerging evidence from COVID-19, this paper will describe the long-term health effects of COVID-19 and policy needs.

The acute symptoms of COVID-19 have been well-documented. Mild cases may include fever, cough, shortness of breath, headaches, muscle aches, fatigue, and loss of smell/taste. Severe illness may progress to bilateral pneumonia, acute respiratory distress syndrome, and even multi-organ failure. Neurologic effects may include encephalitis, causing mental status changes, and there have been some reports of brain demyelination and new-onset seizures.² COVID-19 was first identified less than a year ago, so the long-term effects are unknown, but seventeen years of research about two similar coronaviruses—SARS and MERS—may be applicable. Severe Acute Respiratory Syndrome (SARS), which was caused by the SARS-associated coronavirus (SARS-CoV), originated in 2003 in Guangdong, China, infecting over 8000 people globally and killing 774.³ Middle East Respiratory Syndrome (MERS), which was caused by the Respiratory Syndrome Coronavirus (MERS-CoV), originated in 2012, infecting 2000 globally and killing 842.⁴

Long-term effects of COVID-19

Among patients hospitalized with SARS and MERS, the most common long-term effects were new-onset psychiatric illness and fatigue.⁵ Some studies found many post-SARS and post-MERS patients met diagnostic criteria for chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME).⁶ These effects can be debilitating and prevent usual functioning at work. Less common long-term effects are changes to blood coagulation and injuries to various organs that could result in organ failure. About a third of mild cases have loss of smell or taste, which implies brain involvement; loss of smell or taste may be due to the virus affecting lymphatic drainage from the brain,⁷ the virus traveling through the nasal cavity into the brain, or to the virus binding directly to receptors in the brain,⁸ raising the possibility of later neurological disease. Some theorize that the same process responsible for loss of smell or taste can also lead to the other long-term post-COVID-19 neurologic and psychiatric effects, including CFS/ME.⁹

Chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME)

CFS/ME appears after viral illnesses or other acute stresses and was evident after SARS. The CFS/ME diagnostic criteria include a substantial reduction in usual activities for at least six months, exhaustion after exertion, non-refreshing sleep, and either cognitive impairment (“brain fog”) or feeling light-headed while standing.¹⁰ Historical research has found that similar symptoms were noted among survivors of the 1918 influenza pandemic.¹¹ CFS/ME has been noted one year¹² and three years¹³ after SARS infection and one year after MERS.¹⁴ A large study of middle-aged SARS survivors in Hong Kong four years after infection found 27% met chronic fatigue syndrome criteria.¹⁵ Initial reports of post-COVID-19 illness include symptoms such as extreme fatigue, concentration difficulties, memory lapses, and muscle weakness that are consistent with CFS/ME,^16,17 as well as short-term reduced cognitive ability.¹⁸

Damage to organs throughout the body

COVID-19 also damages organs throughout the body, creating potentially life-long physical health impacts, even for low-risk populations that were not hospitalized.^19...