(Art design: Jean-Dominique Lavoix-Carli)

More than 110 million people have experienced or still suffer from Long COVID since the start of the pandemic (Chen Chen et al., full references and detail of calculation below). This is the number that follows from the findings of a study systematically reviewing the research done on Long COVID until August 2021 and published on 16 November 2021 (Ibid).

This staggering figure highlights that the condition known as “Long COVID” must be taken into account if we are to fully understand what it means to “live with the COVID-19”. More particularly, to estimate the multiple impacts of the fifth wave of the COVID-19 pandemic, we need to integrate Long COVID and its effects. Long COVID could well be, and this increasingly so, a key aspect of the pandemic, even though it has rarely been accounted for initially.

Thus, in this article in two parts, we focus on Long COVID. The first part reviews current knowledge. We try to comprehend in which way this aspect of the pandemic may impact security, understood in the broadest meaning of the word. We thus look first at what is Long COVID, its many names, its definitions, the number of people experiencing it, who is at risk in terms of age notably, how long Long COVID lasts and its intensity. We then turn to the vaccines and Long COVID. Finally, we start highlighting possible impacts, at individual and collective level. With the next part, we shall seek to assess more specifically Long COVID in the framework of the fifth wave.

We looked at the potential global lethality of the fifth wave with the previous article, after having focused on contagion and the shape the fifth wave could take, globally.

What is “Long COVID”?

Introduction to Long COVID

“Long COVID” is also known as “Post-Acute Sequelae of COVID-19 (PASC)”, “Chronic COVID-19”, “post-COVID condition”, and “Long Haul COVID-19”.

Long COVID means that, after having been infected with the SARS-CoV-2, one suffers for an indeterminate length of time, from three to nine months according to the WHO, or more according to the United Kingdom Office for National Statistics (see below), of some symptoms, among the 200 symptoms that have been identified (WHO Science conversation, “Post COVID-19 condition“, 30 July 2021).

The illness is commonly defined as “new or persistent symptoms at four or more weeks from infection with SARS-CoV-2” (e.g. UK U.S. CDC; United Kingdom Office for National Statistics, Prevalence of ongoing symptoms following coronavirus (COVID-19) infection in the UK: 4 November 2021).

The WHO suggests, for its part, the following definition:

Post COVID-19 condition occurs in individuals with a history of probable or confirmed SARS CoV-2 infection, usually 3 months from the onset of COVID-19 with symptoms and that last for at least 2 months and cannot be explained by an alternative diagnosis.

WHO, “A clinical case definition of post COVID-19 condition by a Delphi consensus”, 6 October 2021, WHO/2019-nCoV/Post_COVID-19_condition/Clinical_case_definition/2021.1

Long Covid does not include COVID-19 complications, defined as “any secondary disease that manifests after the acute phase of a COVID-19 infection. Multisystem Inflammatory Syndrome in Children (MIS-C), Chronic Kidney Disease (CKD), myocarditis/pericarditis, Chronic Fatigue Syndrome (CFS) or myalgic encephalomyelitis, and Kawasaki disease are complications known to be associated with COVID-19” (Chen Chen et al., “Global Prevalence of Post-Acute Sequelae of COVID-19 (PASC) or Long COVID: A Meta-Analysis and Systematic Review“, MedRxiv [not yet peer-reviewed], 16 November 2021, doi: https://doi.org/10.1101/2021.11.15.21266377).

How many people experience Long COVID?

A study, published on 16 November 2021, reviewed all current scientific research written in English on Long COVID up to 12 August 2021. It sought notably to find out the prevalence of Long COVID and how many people could have suffered from or still are prey to Long COVID (Chen Chen et al., “Global Prevalence of Post-Acute Sequelae of COVID-19 (PASC) or Long COVID: A Meta-Analysis and Systematic Review“, Ibid.).

According to Chen Chen et al.’s findings, globally, we can estimate that 43% of all COVID-19 tested positive cases develop long-COVID. Prevalence is worse for people who are hospitalised and reaches, in that case, 57%.

The 43% estimate corresponds almost perfectly to the prevalence rate for long COVID found in the United Kingdom Office for National Statistics “Coronavirus (COVID-19) Infection Survey (CIS)”, i.e. 41,84% (Prevalence of ongoing symptoms following coronavirus (COVID-19) infection in the UK: 1 April 2021 – first release – table 9).

This is far from the “approximately 10–20% of COVID-19 patients” suggested by the WHO in its report grounded in a Delphi survey (WHO, “A clinical case definition of post COVID-19 condition by a Delphi consensus”).

Among others, this shows, once more, the danger of using the Delphi method, as Theodore Gordon highlighted (“The Delphi Method”, The Millennium Project: Futures Research Methodology,Version 3.0, Ed. Jerome C. Glenn). Incidentally, these dangers are repeatedly ignored. The methodology continues being promoted without users seeking to remedy problems. It is thus used again and again, most often without caution by many actors, including within governments.

The low prevalence selected by the WHO survey also shows, once more, that the WHO is first and foremost an international political body, thus an arena for diplomatic and normative struggles. Furthermore as an institution, the WHO also has its own agenda (see Helene Lavoix, The Coronavirus COVID-19 Epidemic Outbreak is Not Only about a New Virus, The Red Team Analysis Society, 12 February 2020). Hence, the WHO definitions and recommendations must always be seen and understood in their context.

Following Chen Chen et al., on 22 November 2021, this means that 110,5 million people have suffered or still suffer, globally, from Long COVID since the start of the pandemic (estimates of infection: 257,015 million on 22 November 2021, Reuters). This number rises every minute.

Always according to Chen Chen et al., the prevalence of long COVID varies according to regions with 49% for Asia, 44% for Europe, and 30% for North America.

These results are still estimates as studies differ widely in their designs, regarding for example the type of patients studied, when the research was done, or the type and length of symptoms considered. For example, Chen Chen et al. highlight that for global prevalence, “Estimates ranged widely from 0.09 to 0.81” (Ibid.). Furthermore, to have a better grasp of the prevalence, we would need to be able to consider evolution and changes according to variants.

Unfortunately, long COVID cases are hardly monitored throughout the world, a situation that should change if we want to address it properly. This monitoring is more than necessary considering the staggering amount of people concerned, the sufferings the disease entails and the various direct and indirect impacts of long-COVID, as we shall see below.

From Table 12: Time series of estimated number of people living in private households with self-reported long COVID of any duration, UK: four week periods – United Kingdom Office for National Statistics; “Prevalence of ongoing symptoms following coronavirus (COVID-19) infection in the UK: 4 November 2021

Since 3 February 2021, the United Kingdom has started monitoring regularly Long COVID using self-reported declaration in the United Kingdom Office for National Statistics “Coronavirus (COVID-19) Infection Survey (CIS)” (Prevalence of ongoing symptoms following coronavirus (COVID-19) infection in the UK: 1 April 2021 – first release). It publishes new updates regularly, e.g. Prevalence of ongoing symptoms following coronavirus (COVID-19) infection in the UK: 4 November 2021“. As a result, we now have a regular estimate of real cases of long COVID in the United Kingdom, as shown in the graph.

How and why does one experience Long Covid?

So far, we do not know exactly why someone develops long COVID. Indeed, the disease is not yet understood (e.g. WHO Science conversation, “Post COVID-19 condition“, 30 July 2021). Nonetheless, we start having some potential knowledge about the condition, that must still be considered very cautiously.

According to Chen Chen et al., women tend to be more at risk of long COVID than men: the prevalence in females is of 49% (95% CI: 0.35, 0.63), and in males of 37% (95% CI: 0.24, 0.51) (Ibid: 13). Pre-existing asthma seems also to heighten the risks to experience long COVID (Ibid.). However, as the authors highlight, these conclusions resulted from less than five studies and thus should be considered with caution. Other “pre-existing conditions such as obesity, comorbidity, and hypothyroidism” were also singled out as favouring long COVID (Ibid.), but such findings do not seem to sit well with the very high prevalence.

By the end of 2021, thus almost two years after the start of the pandemic, we are only certain of one thing: if we are infected by the SARS-CoV-2, even if we are asymptomatic, then we can experience Long COVID and the odds this happen are rather high.

Young people and even children increasingly experience Long COVID

Long COVID affects mainly adults aged 35 to 69 years, however young adults, aged 17 to 24 years old, are far from being exempt of long COVID (United Kingdom Office for National Statistics; “Prevalence of ongoing symptoms following coronavirus (COVID-19) infection in the UK: 4 November 2021“).

Taking the British monitoring as indication, worryingly, long COVID seems to be spreading with time among the younger population. In November 2021 the percentage of the British people aged 17 to 24 years who had long COVID was “comparable to people aged 35 to 69 years” (Ibid.).

Furthermore, children also develop Long COVID. The British November 2021 survey highlighted that the percentage of long COVID increased among people aged 12 to 16 years, from 0,89% of the total UK population on 2 September to 1,27% on 2 October 2021 (Ibid, Table 4).

This corresponds to what was found in Israel. According to a mid-September 2021 survey by Israel Health Ministry,

Ongoing symptoms (long-COVID) exist among infected children in the state of Israel: 11.2% of all children experienced some symptoms after recovery, and about 1.8%-4.6% of them, depending on their age, continue to experience long-COVID symptoms after 6 months from the time of acute illness, as of the time of the survey. …

Ministry of Health Updates, “Results of the Long-COVID Survey Among Children in Israel“, 14.09.2021

According to the same survey, the older the child, the higher the chance to experience long-COVID. Symptomatic children have a higher chance to develop the illness. Nonetheless, asymptomatic children also develop long-COVID:

“Among teenagers aged 12-18 who developed symptomatic illness, 5.6% experienced long-COVID compared to 3.5% among those who experienced no symptoms when confirmed as coronavirus positive. A similar situation has been observed among other age groups.”

Ministry of Health Updates, “Results of the Long-COVID Survey Among Children in Israel“, 14.09.2021

How long does Long COVID last?

According to Chen Chen et al. Meta-Analysis and Systematic Review (Ibid.), global prevalence of long COVID according to time since “index date”, which is the date for the positive COVID-19 test, but should ideally be the time of infection, evolves as in the following table:

Follow up time after index date (in days)30 60 90 120
global pooled prevalence of long COVID36%24%29%51%
Global Prevalence of Long Covid according to time after positive test (from Chen Chen et al.)

Researchers explain the increased rates with time by an overrepresentation of hospitalised patients in studies of reference and drop out of people as they get better, both possibly distorting results.

If we turn to the UK ONS ongoing survey, we have the following figures. In October 2021, 1,2 million people reported they had long COVID (United Kingdom Office for National Statistics; “Prevalence of ongoing symptoms following coronavirus (COVID-19) infection in the UK: 4 November 2021). Out of these, “426.000 (35%) first had (or suspected they had) COVID-19 at least one year previously“; 204.000 (17%) thought they had COVID 19 between 39 and 52 weeks before (9,75 months and 1 year); 172.000 (14%) thought they had COVID 19 between 26 and 39 weeks (6,5 and 9,75 months) before; 46.000 (4%) thought they had COVID 19 between 12 and 26 weeks before (3 months and 6,5 months), 240.000 (20%) thought they had COVID 19 less than 12 weeks (3 months) before (Ibid).

It is difficult to compare the results of the two studies because the first considers the length of long COVID according to prevalence and the second according to long COVID patients. Furthermore, the first study only covers 120 days, i.e. 17,14 weeks, while the second goes beyond 52 weeks.

Both approaches are nonetheless informative and highlight the long length of time during which people suffer, while their family and society is also impacted.

How many of the people suffering of Long COVID are incapacitated by their symptoms

The symptoms of Long COVID are often incapacitating. Unfortunately, there is so far no treatment against Long COVID because the illness is not yet understood (WHO Science conversation, “Post COVID-19 condition“, 30 July 2021; Long Covid Diagnosis and Treatment by Dr. Seheult of Medcram – 5 June 2021: some data notably on prevalence are outdated).

According to a Swedish study, carried out between 15 April 2020 and 8 May 2020, among health care professionals after mild COVID-19, thus prior to the Alpha and Delta variants, 8 to 15% of people suffering of Long COVID saw their symptoms interfering with their daily lives (Havervall S, Rosell A, Phillipson M, et al., “Symptoms and Functional Impairment Assessed 8 Months After Mild COVID-19 Among Health Care Workers“, JAMA, 2021;325(19): 2015–2016, doi:10.1001/jama.2021.5612).

However, if we consider the ongoing monitoring carried out in the UK, by 4 November 2021, the proportion of people suffering from incapacitating symptoms is much higher:

“Symptoms adversely affected the day-to-day activities of 780,000 people (65% of those with self-reported long COVID), with 233,000 (19%) reporting that their ability to undertake their day-to-day activities had been “limited a lot”.

United Kingdom Office for National Statistics; “Prevalence of ongoing symptoms following coronavirus (COVID-19) infection in the UK: 4 November 2021

The variations between the two studies may stem from a host of reasons, the most worrying being an increasingly worse outcome because of variants, as well as, possibly, a repetition of infection creating some type of fragility.

Vaccination and Long COVID

What is the impact, if any, of current vaccination on Long COVID? Here again, we are faced with uncertain knowledge.

A 26 October 2021 study “reviewed data on nearly 20,000 U.S. COVID-19 patients, half of whom had been vaccinated (Maxime Taquet, Quentin Dercon, Paul J Harrison, “Six-month sequelae of post-vaccination SARS-CoV-2 infection: a retrospective cohort study of 10,024 breakthrough infections, medRxiv, [not yet peer-reviewed], 26 October 2021, doi: 2021.10.26.21265508). The researchers looked at “confirmed SARS-CoV-2 infection (recorded between January 1 and August 31, 2021), thus probably including Alpha and Delta variants. Considering the importance of the findings, I quote them at length:

This study… confirm[s] that vaccination protects against death and ICU admission following breakthrough SARS-CoV-2 infection [i.e. infection after vaccination]. … Our study also shows that vaccination against COVID-19 is associated with lower risk of additional outcomes … namely respiratory failure, hypoxaemia, oxygen requirement, hypercoagulopathy or venous thromboembolism, seizures, psychotic disorder, and hair loss.
On the other hand, previous vaccination does not appear to be protective against several previously documented outcomes of COVID-19 such as long-COVID features, arrhythmia, joint pain, type 2 diabetes, liver disease, sleep disorders, and mood and anxiety disorders.
The absence of a protective effect against long-COVID features is concerning given the high incidence and burden of these sequelae of COVID-19.
… our results highlight that some post-acute outcomes of SARS-CoV-2 (and notably long-COVID presentations) are likely to persist even after successful vaccination of the population, so long as breakthrough infections occur.

Maxime Taquet, Quentin Dercon, Paul J Harrison, “Six-month sequelae of post-vaccination SARS-CoV-2 infection: a retrospective cohort study of 10,024 breakthrough infections, medRxiv, [not yet peer-reviewed], 26 October 2021, doi: 2021.10.26.21265508

Another study has shown contradicting results. The research was realised on self-declaring people in the UK and its results were much more optimistic. It looked also at the impact of vaccination on Long Covid, with data covering variants between 8 December 2020, and 4 July 2021, thus mixing both the Alpha and Delta variants, and suggested that the odds to develop a Long Covid after vaccination was lowered by 50% (Steves, “Long COVID: double vaccination halves risk…; Antonelli M, Penfold RS, Merino J, et al. Risk factors and disease profile of post-vaccination SARS-CoV-2 infection in UK users of the COVID Symptom Study app: a prospective, community-based, nested, case-control study. Lancet Infect Dis. 2021;0(0), doi:10.1016/S1473-3099(21)00460-6).

Taquet et al. address the difference between their results and the UK study on self-declaring patients, highlighting among others that self-declaration may introduce biases. The 26 October study, being done in the U.S., does not include ChAdOx1 nCov-19 (‘Oxford/AstraZeneca’) vaccine, while the second does, as it was realised in the UK (Taquet et al. Ibid.). Further research would be needed, especially considering the positive potential of the ChAdOx1 nCov-19 (‘Oxford/AstraZeneca’) vaccine for Long COVID. However, if we look at the ongoing monitoring of Long COVID done in the UK, we still have significant figures for patients suffering of Long COVID, when the population is largely vaccinated. This would thus tend to suggest that even if the Oxford/AstraZeneca vaccine offers some modicum of protection, it is insufficient regarding the prevalence of long COVID and its intensity.

Another study at 120 days, but not considering the variant Delta, suggests that vaccination improves the condition of Long COVID patients (Viet-Thi Tran et al., “Efficacy of COVID-19 Vaccination on the Symptoms of Patients With Long COVID…“, SSRN/Preprints with The Lancet, 29 Sept 2021). Meanwhile, “the proportion of patients with an unacceptable symptom state” was reduced to 38.9% from 46.4% (Ibid.). Note that 38.9% people “with an unacceptable symptom state”, is still very high indeed.

As a summary, waiting for further research and bearing in mind the precaution principle, it appears wise to contemplate that the current existing vaccines, possibly, hardly have any positive effects on long COVID.

Furthermore, we know first that, considering the current state of knowledge, it is so far infection that triggers long COVID. Second, vaccines seem to have, at best, only a limited positive effect on infections (see Helene Lavoix, “Towards a Covid-19 Fifth Wave“, The Red team Analysis Society, 27 October 2021). Third, whatever protection current vaccines offer in terms of contagion, it is lowered in time as immunity wanes (Ibid). Thus, so far, the only certain means we have to fight and prevent long COVID are non-pharmaceutical interventions (face masks, distance, quarantines, lockdowns etc.).

Individual and collective impacts

Actually, for our purpose, the UK ONS gives us some very interesting data, as it also breaks down the intensity of incapacitation created by Long COVID according to length of illness, as shown in the graph below:

People with long COVID according to activity limitation and length of condition
From Table 9: “Estimated number of people living in private households with self-reported long COVID by subsequent activity limitation, UK: four week period ending 2 October 2021”, United Kingdom Office for National Statistics; “Prevalence of ongoing symptoms following coronavirus (COVID-19) infection in the UK: 4 November 2021

This graph shows possibly also how debilitating long COVID can be as the longer people suffer, the more limited they are in their activities.

The figure of people being severely limited in their day to day activities and having started experiencing symptoms more than 52 weeks ago is substantial. It represents almost one mid-sized city.

In terms of impacts, it should be taken into consideration that one person who experiences a strongly limiting long COVID means that it is the entire family that will be impacted. Indeed, the person limited in her activities must be cared for, while the psychological impact on the family must also be taken into account. If ever the person who is suffering of Long COVID is the care taker and the resource provider, then the consequences are even more dramatic. One person with a partially or severely limiting long COVID thus actually means far more people being directly impacted.

As a result, the graph above highlights that a relatively considerable number of people will be “removed” from society as they will be unable to carry out their work. As the family is also impacted, this will also imply milder but nonetheless most probably perceptible impacts on society stemming from the increased burden and worry on the family.

Notably for small and medium size companies the impact of Long COVID can be disastrous. Indeed, the absence of one person may endanger the very survival of the company. For larger companies, which nonetheless have chosen tight employment policies, the impact of long COVID may also be very serious. Collectively, the severity of the impact will vary according to sectors, and analyses per sector of activity should be made urgently..

For example, it would be very interesting to estimate how much of the current ongoing disruptions of the global supply chain (e.g. Judy Greenwald, “Port logjams exacerbate supply chain risks“, Business Insurance, 1 Novembre 2021) can also be related to long COVID.

As a summary, it is obvious Long COVID is a serious condition, impacting many people and with many and possibly cascading consequences. Next, we shall turn to estimates regarding the future to have a better vision of what long COVID could entail for the fifth wave.

Published by Dr Helene Lavoix (MSc PhD Lond)

Dr Helene Lavoix, PhD Lond (International Relations), is the President/CEO of The Red Team Analysis Society. She is specialised in strategic foresight and warning for national and international security issues. Her current focus is on the rise of China, the COVID-19 Pandemic, the methodology of SF&W, radicalisation as well as new tech and security.

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