We begin with Dr. Jason Maley, who explains what Long COVID is and the processes that may be involved.

Dr. Maley discusses his and his team's clinical experiences of providing care to Long COVID sufferers, we also touch on the US national Recover research project that he is involved with.

Professor Amitava Banerjee is our second guest, he talks about the UK STIMULATE-ICP Long COVID research project we discuss the importance of illness prevention and his study findings on the organ damage linked with LONG COVID, as well as the research he is conducting looking into potential treatments.

[01:29] - Dr Jason Maley

[59:55] - Professor Amitava Banerjee

https://recovercovid.org/

https://www.theguardian.com/commentisfree/2022/jan/12/long-covid-trial-britain-short-term-virus

https://www.stimulate-icp.org/

https://www.bmj.com/content/372/bmj.n693

https://bmjopen.bmj.com/content/11/3/e048391

Kojala medical presents COVID 19 the answers the  show that delivers the scientific evidence-based

knowledge that can safely return us all to our  pre-COVID lives my name is Dr Funmi Okunola and

I'll be hosting the show every week you can listen  to me interview a highly respected professional

about the science that can reduce your risk  of becoming infected with this coronavirus

Hello and welcome to episode 3 of COVID 19 the  answers today I would like to introduce you to

Dr Jason Maley. Dr Maley is an epidemiologist  and specialist physician in pulmonary care

and critical medicine he is director of  Beth Israel Deaconess Medical Center's

critical illness and COVID 19 survivorship program  in Boston in the United States he is an instructor

in medicine at Harvard Medical School and co-chair  of the American academy of physical medicine and

rehabilitation post-acute sequelae of SARS COV-2  collaborative he has come to talk to us today

about long COVID. Welcome Jason, would you like to  tell us a bit about yourself, your resume is quite

diverse how did you come to be an epidemiologist  and also a physician for COVID 19 survivors?

Sure, thank you for having me, so I came to be  focused on this really initially through my work

at in the intensive care unit following patients  and families after they survived critical illness

before the pandemic and had an interest in both  understanding the challenges of recovering from

especially a respiratory illness like a  pneumonia and how to help people recover best

and with the pandemic and the number  of people we were seeing in the ICU

and then recognizing this entity long COVID the  sequelae that people were having even after mild

COVID we knew that there was an important need  to help these patients recover and the need to

understand it better and to get to the bottom  of why people were experiencing this so it was

kind of a natural extension of my pre-pandemic  outcomes work shifting into now understanding

recovery from COVID 19. That's fantastic and  I must say just thank you for all that you do.

We across the world truly appreciate physicians  such as yourself that have approached this whole

sort of pandemic disaster with such bravery and  focus. Really appreciate that thank you. So,

I'm going to now get down to the questions and  we're going to really talk about long COVID.

So long COVID is estimated to affect 15 to  30 percent of all non-hospitalized people

that get COVID 19 and around 80 percent  of people hospitalized with COVID 19.

to give the audience an idea on numbers with over  3 million Canadians infected with COVID 19 to date

we would expect around half to 1 million people  to develop long COVID in the USA nearly 78

million people have tested positive for COVID  19. This would equate to around 12 to 23

million people developing long COVID  staggering figures so after a viral

illness we can expect to be a little run down  for a few weeks as our immune systems recover

bearing this in mind what is long COVID and  how does it differ from this presentation

great so after you're right after  having a typical virus having a cold

or even having the flu most people will feel kind  of run down for days to weeks but then they'll

recover and they'll feel essentially like they  get back to their normal routine their energy

is normal their sleep normalizes they're  able to work their thinking hasn't changed

and certainly they're not having new unexplained  symptoms like pains or changes in their taste

and smell that has not returned those types  of things so where long COVID differs is as

people are recovering from the  initial illness the acute illness

having COVID 19 in the weeks to months after that  usually people recognize around four to 12 weeks

they haven't recovered the way they would expect  or there are new things that they're noticing

such as the shortness of breath that they had when  they first had COVID hasn't gone away and they

were previously athletic and active and now they  feel short of breath walking around their house

or their heart races when they walk around or  they haven't been able to return to work because

their thinking and their memory and their  ability to multitask and organize and focus is

completely off and they really can't function so  those along with many other things head to toe

are persisting in a way that you wouldn't  expect for someone who had recovered

from a virus and whose body had returned to normal  so there's clearly a change that hasn't returned

proportion of chronic illness in a  population in recorded medical history?

So, we it's it's tough to say

exact numbers but one first reference  point is prior to this pandemic

this type of syndrome post acute infection post  acute viral syndromes causing impairments like

long COVID have been described for centuries  actually they were given a variety of different

names because the farther back in time you go  the less understanding they had of medicine and

similar unfortunately to what we're seeing with  Long COVID at that time people were also kind

of brushed aside as this isn't real or you're  just you need to get over this type of mentality

but people having changes in cognition persistent  fatigue unexplained pains and other symptoms like

we're seeing with long COVID has been described  with other viral pandemics and after other

infections so it's hard to know if we're simply  recognizing it and it's getting this attention

because of the scale of the pandemic and the  fact that so many people are being affected

and we're in the age of modern medicine and  communication and connectivity across the world

so that we can actually see that scale in a way  that wouldn't have been possible during a pandemic

at the beginning of the 20th century or during  pandemics at other times so I don't know the exact

comparison to others I think it's been seen before  but certainly the scale is something that we've

never at least had recorded in medical history.

with a myriad of symptoms, over 200  symptoms in a paper I read last year

ranging from fatigue, to heart arrhythmias.  In your clinical experience as a physician

closely working with this patient group. What  are the most serious and concerning symptoms?

The most common symptoms we see and what people  most often come to us concerned about are

debilitating fatigue. In many people, that's  associated with something called post-exertional

malaise, or post-exertional symptom exacerbation.  Which means you feel an intense exhaustion.

Some patients describe as if every part of  their body is completely drained of energy

after sometimes minimal activity. So  someone will wake up in the morning go

to make breakfast and after doing that they have  to lie down and they feel almost incapacitated.

There are others who feel fatigued that they're  able to do their normal activities, but the next

day after having a busy day, they feel a physical  illness which is that post-exertional malaise.

Many people actually think they got COVID  again or they think they've been infected,

so fatigue is a very common one the cognitive  changes, changes in thinking, memory, focus and

attention that impact people's ability to to work.  Sometimes to do common things around the house

like remember that they're cooking. They walk away  and forget that they're cooking. That's a common

symptom. The racing heart and feeling those types  of symptoms which we classify as dysautonomia,

an issue with the autonomic nervous system likely,  is a common area and then some other ones include

pains like burning, sharp pains, numbness tingling  nerve type pains. Changes in digestion Shortness

of breath I should say. Shortness of breath is a  very common one and we see people also who their

primary issue has been their taste and smell has  never returned. They otherwise feel recovered but

everything tastes rotten to them, or tastes  like metal and they're not able to enjoy foods,

So I'd say that's probably the handful  of most common things people come with,

although like you said, there are many things  people have experienced head to toe which I think

each one could be equally distressing or equally concerning, so it's not that one is more

is there a difference in the terms post-acute  sequelae of SARS-COV 2 and long COVID?

To give you an idea of what I mean. A person who's  been hospitalized with severe COVID and develops

kidney failure as a result. Would that person on  return in home who might remain in kidney failure,

be labeled as suffering from long COVID,  or do those that suffer from long COVID

have their own unique signs and symptom?  That's a great question. I think the terms

came from different sources so long  COVID arose within the patient community

as a term that emphasized the fact that it  wasn't necessarily that this was post COVID that

they were experiencing issues from COVID that  could represent a continuation of that disease

and was a slight change in labeling from  calling something a post-COVID condition

which was one of the terms used in the scientific  community post acute sequelae of SARS-COV 2 was

I think, originated from the National Institutes  of Health in the US and is essentially getting at

is a scientific label for an illness,  after the acute phase of the illness,

which I think from a historical perspective is  appropriate because there's also other post-acute

infectious syndromes that fit with what we're  seeing. So it's kind of easy to refer to that,

but I frequently just use long COVID because  it's simpler people are very familiar with it

in terms of your question about people  who have been very sick in the hospital

and have persistent health impairments afterwards  there is a distinction because whether it's from

COVID from the flu from a bacteria causing  pneumonia or other infection we've known for

a very long time people who become very ill  especially from infections in the hospital

suffer long-term consequences in their health  and it could be because their kidneys failed

because they were bed bound for weeks and  they have to recover from that or it could be

changes in cognition thinking and memory just  like we see with long COVID but it's probably

a slightly different process within the body  to become this sick after a mild virus versus

to have difficulty recovering because you were  severely sick in the ICU or in the hospital

being severely sick is probably regardless of  the cause the reason why you have difficulty

recovering whereas long COVID for the most part  is being used to refer to what could be the

underlying biological reason that after getting  a virus even a mild infection you begin to have

a host of new health issues throughout your  body and I think that's a different process.

which brings me to my next question with  so many symptoms associated with long COVID

do you believe that as research progresses we will  find that COVID 19 has led to a cluster of disease

processes rather than just one termed long COVID  I think from what I see with different patterns in

patients the different types of symptoms and the  different what we might use the term phenotype

which is kind of a description of certain patterns  of symptoms we may see 10 percent of our patients

have this pattern 20 percent have a different  pattern we certainly see that's what we're

observing that's what I see as I see now having  seen many hundreds of people with this there

are some with very distinct clusters and respond  to specific medications well others who have no

response to those medications and have a different  cluster so I think at the very basic level

it may relate what we're learning at  least to a change in the immune system

the immune system is becomes active to fight  the infection but doesn't shut off as it should

but within each person there may be a different  way that that manifests there may be specific

immune cells that are more  active in one person than another

that could lead to impairments in one area in  response to one set of medications versus another

so I think it's it seems to be diverse enough  that we'll learn from the initial injury of COVID

the body responds in slightly different  pathways and that could lead to these different

clusters of symptoms and different responses to  treatments which is unfortunately it's common

for almost all diseases and what makes medicine  challenging is that even one drug for one disease

can cure one person of it and not help another?

suffering. What is remarkable to me is that  people who have never had any COVID symptoms,

i.e those who have tested  positive but are asymptomatic,

can also go on to develop long COVID.  Do you have a theory as to why?

That's a great question. I don't know  the exact answer to why that's the case

and just by the nature of people recognizing  long COVID as being associated with having had

coveted with at least some symptoms almost  everyone we see had a period of time where

they felt ill and then the long COVID followed  that it's less common that people come to us,

having had a positive COVID test, no symptoms and  then later on develop symptoms. So I don't know

how common long COVID is after a symptomatic  infection, but for the same reasons that it's

causing this in mild infection it could simply  be that the virus is stimulating a change in

the immune system. Not to the degree that causes  severe illness, but persists at a low level say,

and causes other health impairments because  it doesn't shut off appropriately. So I think

it's possible that it could be after asymptomatic  infection though most of the patients we see did

have, can point to some symptoms, even if it's a  very mild illness when they were initially sick.

Has there been any definitive research  that indicates for how much time

an individual would be expected  to suffer with long COVID? This

goes back to that the different clusters of  patients or buckets people seem to fall into

there are we see certainly very distinct  groups in terms of people who have similar

long COVID issues they feel short of breath  or they have brain fog yet when we follow them

by nine months they feel back to normal versus  people who have no change over time or a group

of people. I would say it's not uncommon  for people who have had very long symptoms

that they have ups and downs they have a period  where they thought they were completely over this

and then something happened they may have gotten  COVID again, or they may have had a stressful

time in their life, or had some other illness  and their symptoms flare back. So there's that

group that has kind of a roller coaster of ups and  downs. So it kind of depends on what group someone

falls into in terms of guessing when they might  feel better, or at least very close to normal.

And as we follow people over the first six months  or so, it gives us a fairly good understanding of

which group they might fall into because their  people know themselves well and they can say

compared to three months ago. I feel so  much better, I'm not back to normal but I'm

dramatically better. That's much more reassuring  than seeing someone who every month has an up

and down and we can't quite get a grasp on what's  causing these continued flares of their symptoms.

Is there any evidence-based research to show

long-COVID patients that have had  significant improvement in their symptoms

can completely recover or will long  COVID stay with them for life?

There lots of the research has focused  on different symptoms over time

it's been fairly limited in that it  has done surveys or other ways of

engaging patients to describe what they're  experiencing. There haven't been as many

studies that have very rigorously  followed people systematically,

say every month, or every few months. That's  actually something that we're involved in right

now is this large national study throughout the US  that intends to follow people over years. But what

i've seen so far, for specific symptoms are things  like people, who even by four to six months still

have changes in smell and taste. Most of them have  recovered when they're followed up at one year.

For people who have very fast heart rate in the  early months after COVID, which is a common thing

we see the heart is going faster than expected of  activity. Most by six to nine months seem to have

resolved that symptom. For other symptoms like  fatigue and brain fog cognitive changes, those

appear to be the most persistent among people who  have persistent symptoms. Fatigue and brain fog

or cognitive changes tend to be two of the ones  that are experienced by most people in that group

so it really seems to vary by by the individual  symptom and we've seen at least that it definitely

seems to vary by when people are able to get care  whether it's medications to treat their symptoms,

or rehabilitation to help their shortness  of breath, or other forms of treatment there

certainly seems to be a benefit that we're finding  in our patients and patients when they enter into

our clinic I feel are continuing on the path of  recovery even if they're not fully back to normal

it's uncommon for people to be worsening or  not feeling better over time most people do

every few months say that they're continuing to  recover and they're continuing to feel better

that's really good to hear actually so I  may be a bit presumptive with this question

but from your own encounters as a physician caring  for this patient group have you experienced a

patient fully recovering from long COVID that can  be declared cured of long COVID. Yeah I think

so. I have certainly have had patients who  feel fully recovered. They generally fall

into that group who by, I would say, 6 to  12 months are experiencing that recovery.

Patients who are seeing us who are 18 months out,  I guess the nature of them seeing us is because

they still have symptoms. So there's a bias to who  we're seeing, but we certainly have seen people

who feel fully recovered. I guess the term cured  may depend on us understanding what the actual

cause of long COVID is and being able to test that  which is something that we we don't currently know

and can't do, so I'm hopeful that we'll learn  through these studies what to follow and what

to test for, that will help us know the body is no  longer having the problem that caused long COVID.

We do have a concern sometimes when people  feel much better, that there could be a risk

of symptoms flaring in the future and that could  happen if they got a new infection. I've had

people with who have felt cured and then had a  second infection with COVID and their symptoms

returned to some degree, so that makes me think  if it is something such as the immune system

that has not properly regulated itself they  could be at risk for that with future infections

So that's kind of where I stand on cured, but  people recovering from symptoms we certainly

have seen and we've seen people who without new  infections or new triggers have felt completely

back to normal that's encouraging do  you have any idea of what proportion

that is of the people you see it's going to be  slightly biased because people with the worst

symptoms come to us and there's also unfortunately  a long wait for all COVID clinics because of just

the sheer volume of people experiencing this  so we do see the sickest of the sick people

I would say probably a third of the people  we see fall into that category of they come

with bad symptoms yet we can tell as we follow  them with time and we look back in time they're

clearly improving and they get back to a place  where they feel say 95/ 97% back to themselves

probably a third of the people we see. And  the other two thirds were either seeing

slower progress, or they may feel better and  then have a future flare and have more of that

up and down coming and going  aspect to their long COVID.

Numerous important studies have been launched  to look at how COVID 19 leads to long COVID.

This has resulted in a range of hypotheses being  proposed as a cause of long COVID. And to give

just a few examples, a change in gut microbiome  its classification as an autoimmune disease

one really interesting one to me recently  was latent viruses in the body such as the

Epstein-Barr virus which causes mono or glandular  fever being re-triggered by SARS-CoV-2 and so on

so what in is in your opinion the most  likely cause or causes of this syndrome?

In my opinion the most likely theory to  bear out as being true, is a change in

the immune system after having COVID 19 that's  leading to persistent low level inflammation or

injury in different parts of the body what's  triggering that we don't know there are

even below that level of theory there are theories  that it could be persistence of at par parts

of the virus that the body is still feeling  although there's not active infection going on

that viral remnants are still triggering the  immune system or that in autoimmunity meaning that

the body's immune system is in a sense attacking  itself has been triggered there have been some

clues to those to that type of process but nothing  definitive but I think it all centers around

an inappropriate response of the immune  system being persistently abnormal for

much longer than you would expect after  a virus I think other things like finding

Epstein-Barr virus which is a very common virus  that people may have latent in their bodies.

It doesn't point to that being the cause  necessarily because it's quite common that

that's found in different infections in different  inflammatory states. So I think it's probably just

a clue to the fact that the immune system is  not properly regulating itself more so than that

abstinent viral virus itself being the explanation  for long COVID it's probably just a sign of the

issue within the body. Right, okay, so when you  term viral remnants, you actually mean viral

remnants of SARS-CoV-2 rather than viral remnants  of something else that we may well have caught

yes yeah that's one of the theories  is that that that could be a trigger

and it's very tough to to answer that theory  because the only way to really look for virus

in detail is if someone has unfortunately died  and we can do an autopsy and those are usually

people who get very sick in the hospital not  people who are young and otherwise healthy

and then got COVID and are living with  long COVID but but it's hard to understand

within their body what could be going  on without getting the right tests.

Long COVID is known to disproportionately  affect women more than men.

Do you have any idea why this could be?

So I think telling the demographics has been tough  because in some cases the surveys have engaged

social media groups or other groups who may skew  towards a different demographic depending on who

is most engaged in that group and who is searching  for answers as part of that group. So I don't,

we certainly see a spectrum men and women and  all races and ethnicities affected by this and

I think that makes sense to me. There are parts  of long COVID like having a very fast heart rate

with activity that has been seen after other  viruses or as part of a syndrome called POTS

austral orthostatic tachycardic syndrome that has  tended to be younger women more often than men.

And more often than older people and I don't think  it's very well understood why that's the case the

MECFS is another component a syndrome that we see  reflected in long Covid which stands for myalgic

encephalomyelitis chronic fatigue syndrome that  has also been described for a long time after

other infections and also sometimes for  unknown reasons people develop this but

they frequently are able to point to some  initial illness and initial infection.

In studies of that disease that  have gone on prior to the pandemic,

there have been clues that there may be genes.  Genetics that make one person more susceptible

after an infection to developing it compared  to others, so I think probably the reason

that so many people are having the same virus  infect them and some recover and some develop

long COVID would have to do with differences in  the genetics and how the bodies are responding,

which could then translate into differences  among demographics. So that's interesting. So you

actually think there's likely a genetic rather  than a sex or gender difference that could be

leading to an exacerbation of symptoms I think  probably for for the same infection to lead to

such varied responses in the body the genetics or  something we call epigenetics things that also not

just your genes but modify the activity of genes  there could be so many reasons why one person is

prone to having this completely different  response to the virus than another and we see that

in acute COVID too some people get very sick  and die from Covid and someone else who seems

to be the same age the same gender otherwise  seems exactly the same has a mild illness

so there are a lot of factors related to  how the immune system responds to infection

that differ between people and there  are things such as genetics and other

factors that modify the activity of genes that  could be why there's such a different response

I guess it would be really interesting to do  some twin studies to back up that argument do you

know of anybody who's doing that yeah that's an  interesting point I don't know off the top of my

head about twin studies but that is an area where  people can use identical twins and understand

and also can use people adopted at birth who  are twins to understand the relationship between

environment versus genetics on illness but I  don't know of that in long COVID thank you.

Long COVID seems to affect one or many different  parts of the body involving potentially

many medical specialists becoming  involved in the sufferers treatment

and recovery can you please tell us about your  approach to providing care for these patients

because it affects so many parts of the body  and we recognized even early on from patients

surviving the ICU that there were many different  areas affected that know one doctor or one

therapist or clinician or nurse could help address  a loan our approach was to put together a team of

people who really act as a group centered around  the patient's needs and we modify who's involved

with each patient depending on the individual  patient's needs so some people may primarily have

issues with their thinking and memory and they  need to focus on seeing our cognitive neurologist

and our occupational therapist  who specializes in brain rehab

and a neuropsychiatrist who also specializes in  brain rehabilitation all of those people are kind

of part of the core team and then you can easily  streamline patients getting into each one of them

much more than you could if you were just refer  you're a primary care doctor in a health system

and you're just trying to refer patients to  different areas and then the second benefit of

creating that team is that you begin by virtue of  specializing in this seeing a very high volume of

patients and you gain a level of experience  quickly that other people just simply don't

have because they're not focused solely on this  and so your our practice and how we treat patients

begins to be informed on a week-to-week basis by  what we're learning from seeing so many patients

and it's a feedback where we can develop  processes of care and see what's working

and what's not in a way that wouldn't be possible  if we didn't have a high volume specialized team

that's fantastic so I guess it's what's  called a multi-disciplinary team with many

different I guess medical specialists  and and other medical professionals

being involved yes yeah that's right we have very  important outside of physicians social workers

physical and occupational therapists  a nurse who coordinates all of this

the staff in our clinics who help to coordinate  the care as well and then researchers and people

who are doing things like breathing therapy with  patients who have backgrounds in yogic breathing

people who are helping with their  research to understand what's going on

so many areas of the team and many different  disciplines involved that's fantastic this

virus is a new discovery in medicine and science  your experience with post-intensive care syndrome

must have been invaluable to the work you  are doing today on long COVID please explain

post-intensive care syndrome to our audience  and could you relate how this clinical and

research experience fed into your clinical  care and research of long-COVID sufferers?

Yes, thank you. So over 20 plus years research  had been showing that people surviving being

an intensive care unit on breathing machines,  on ventilators or having severe infections in

the intensive care unit were leaving and  suffering from changes to their thinking.

They were testing on the level of people with  dementia at times, in terms of their thinking.

They were physically debilitated because they  were bed bound and for so long and they were

sick and their muscles had wasted and they may  have other injuries and they were suffering from

post-traumatic stress disorder, anxiety,  depression. They may have had continued shortness

of breath because their pneumonia had scarred  their lungs, so all of these issues became termed

post-intensive care syndrome which refers  to these persistent health impairments that

occur after being in the ICU and  persist after leaving the hospital

and they generally fall into those buckets of  physical impairments, mental health impairments,

and cognitive impairments although there are  now many other things layered on top of that

that issue post-intensive care syndrome was  at least in the US not very well addressed

by health systems. There were only a few clinics  that existed prior to the pandemic that were

focused on ICU recovery and it was so is very,  very limited getting actual specialized access

the pandemic was a catalyst for many of these  clinics opening up including ours because

suddenly health systems saw the issue and it  was being recognized by the public and they were

motivated to to invest and to support these  whereas prior to this a lot of it fell into the

research domain and didn't make it over into the  space of actually helping patients clinically.

Wow that's something positive to come out of all  of this really yes that's really cool you treat

both hospitalized and non-hospitalized  long-COVID sufferers the presentation

of symptoms for long-COVID and post-intensive  care syndrome is similar how do you distinguish

between the symptoms caused by long COVID from the  symptoms caused by post-intensive care syndrome

yeah for post-intensive care syndrome because  there's a fair amount of experience with it

prior to COVID we tend to really if people are  coming out of the ICU focus on those issues

which do have some overlap with long COVID so  there are people who have changes in cognition

there are people who are physically debilitated  and need very intense physical therapy and then

others with mental health issues or shortness  of breath so we tend after the ICU to really

focus on the big steps of recovery going from

someone who has been in the hospital bed  bound on life support to it walking around

basic functioning at home those types of things  and then over the coming months we're able to see

is someone kind of continuing to  progress and recover in the expected way

or are there other unique aspects to what  they're experiencing that we see with long

COVID like the taste and smell haven't returned  that's something that we wouldn't routinely

expect with post-intensive care syndrome and is  more unique to this virus that they're having

unexplained pains throughout their body that's  something again we see commonly with the virus

and there are some other examples of things  that wouldn't you wouldn't simply expect

related to being critically ill and  maybe more unique to long COVID itself

but the approach is generally get the big picture  of recover recovery settled out which is largely

post-intensive care syndrome issues addressed and  then over time understand is they're recovering

are there new issues emerging or are some of the  issues persisting that we think we wouldn't expect

to persist in this way if it was just critical  illness alone and not long COVID so in actual fact

you're in a very good position because you see  those two different groups to sort of tease out

so the two different types of symptoms it's  actually a very good position that you're in from

what I can ascertain am I correct? Yes I think so.  And it's a bit up to the individual patient how I

think long COVID has gotten so much recognition.  People may feel more support if they're labeled,

or they self-associate as having long COVID and  there are other people experiencing these things

post-intensive care syndrome though it was known  in the medical world was not really known to the

public and even not known to most doctors so I  think there is a also benefit in just the commun

community of support that you get from being  someone who has long COVID whether it's we think

it falls more into a post-intensive care syndrome  bucket or it's more of a long-COVID bucket.

Could you please share with us the specific  research that you're doing with respect to long

COVID? So our research spans a few areas with  long COVID early on as we began to see people

with shortness of breath many of whom were having  normal testing performed and we couldn't find an

issue with the lung lungs themselves that fully  explain this we were wondering how we could help

people rehabilitate from that knowing that they  were safe to do so because their lung function was

was preserved so we've been doing a randomized  study of specific types of breathing exercises

to improve the breathing comfort for patients  to improve their strength of breathing

and to improve their ability to  breathe comfortably while active.

More recently this extensive study across the  the US through the national institutes of health

is called recover and it's going to be  enrolling people who either have long COVID

or are at the time of having their COVID infection  are acutely sick or people who have not had COVID

as far as they know and are healthy and so we  can use them for comparison and we're doing

detailed testing blood testing questionnaires  as well as potentially depending on symptoms

tests head to toe like brain MRi lung function  tests, other things to get at what exactly is

causing these symptoms and what could explain  long COVID and how do people recover in these

different groups so how as we test them  over time are their symptoms changing.

Recent studies in Israel and the  US have indicated that vaccination

possibly prevents long COVID, or reduces the  severity of long-covered symptoms. In your opinion

when we are vaccinated against SARS-CoV-  what is happening in the body to cause this

so when we're vaccinated against SARS-CoV-  2 or pretty much any vaccination the idea

is to produce a memory within our immune system  for that infection so that the infection for in

the case of this virus which may be in your nose  along the lining of your nose as as you breathe it

in can only get that far and when it enters the  body it's cleared quickly because your body has

a memory of this infection and it removes it  it has antibodies which are things that attach

and remove infection and activate a process that  ultimately removes the infection from your body

so the biggest difference in someone vaccinated  versus unvaccinated from that perspective

is really the body entering and the virus  entering and spreading throughout the body

in a way that can be harmful if you're  vaccinated you can still be exposed to

the virus you can still breathe it in it can  still get on the lining of your nose and that's

why you can still test positive potentially  at the time that you're exposed from a swab

but it won't successfully get in and spread  throughout your body and it won't make you sick

so I think the biggest difference is early rapid  clearance of the virus within the body preventing

it from spreading throughout the bloodstream to  tissues and affecting tissues potentially with

inflammation and that seems to fit with the  idea that abnormal immune system activation

is explaining long COVID persistent inflammation  throughout the body could be explaining long COVID

if you prevent that from happening in the  first place by clearing the virus immediately

through the memory that your body has from  vaccination then you could prevent long COVID

and that's what we're seeing in these studies  that are early and there's, they're preliminary,

some are not yet fully reviewed by the journals  that they've they're submitting to but they

seem to be good quality and they suggest one  of the recent studies I've seen from Israel

that full vaccination is more protective than  single dose and is much more protective than

unvaccinated so it fits with this theory  and it kind of supports this idea that

clearing the virus quickly could prevent long  COVID that's an excellent explanation I can sort

of qualify that in my mind so when you say full  vaccination do you mean two shots three shots

so this test this study was done with two  shots I believe of the Pfizer vaccine

at this point I would consider someone  a full protected vaccination with three

shots and that's been shown very clearly with data

in with the Omicron variant that two shots are not  fully protective in the way that three shots are

and certainly for someone who is at higher  risk because of their age or other illnesses

or their immune system is compromised then they  they definitely need to have full vaccination

including booster shots to be protected.  Yeah, thank you for that excellent answer.

Despite the worldwide record-breaking number of  COVID infections caused by the recent Omicron wave

we have been told by politicians and some in  public health that we need to live with COVID

19. countries all over the world are rushing to  roll back public health infection control measures

such as requirements to wear masks or  to be vaccinated to enter public spaces

in some countries and regions access to testing  has been reduced contact tracing cathode and

cessation of the need to quarantine if you test  positive it appears with this approach that some

are advocating a policy of letting the virus  rip through our populations unobstructed what

is your opinion of this approach and what impact  do you see this having on long COVID so I think

we expect long COVID can continue to happen  unfortunately from this virus as it spreads and

so the decisions from a public health perspective  and for each individual person of how they want to

protect themselves could impact that you could  be at higher risk if you're not vaccinated and

you're in public places and you don't wear a mask  you would be at high risk of getting the virus and

then you could get long COVID if you're  fully vaccinated and you take measures to

avoid crowded spaces indoors or you wear  a mask indoors then you're at lower risk

the actual public policies that are decided  are are tough because everything in medicine

is a benefit of risk is a balance of risks and  benefits and people often outside of medicine

have a tough time conceptualizing that and  policies are kind of a blanket thing so everyone

is affected by them yet within even a state or  a town they're going to be people with polar

opposite views on this risk benefit some will be  more comfortable being more careful and some will

want to be less careful in terms of exposure to  the virus so I think the the main answer to the

changes is that we will unfortunately continue to  see mild infections that's going to be the reality

of the state of the virus and the rate of  vaccination in different regions will affect that

we're hopeful in the regions like I live in  where there's a very high vaccination rate

that that will be protective against Long  COVID in the same way it's protective against

COVID infection and severe illness from acute  coping so that will benefit those areas in areas

where the virus is spreading and there's a low  vaccination rate they're going to have I would

expect higher rates of long COVID as well and  in some of those areas unfortunately they may be

less prepared because they're not large cities  with long COVID clinics or they may be less well

resourced and so that will be a challenge  as well getting access to care for people

experiencing non-COVID who are in an area  that they don't have large hospitals or

this pandemic initially the medical community did  not believe people were suffering from long COVID

as a result people set up their own online support  groups some don't want to hear about long COVID or

acknowledge it exists as an important byproduct of  the COVID 19 pandemic yet we see numerous examples

of well-known individuals such as Olympic athletes  or professional athletes in their peak physical

condition who have had their career trajectory  altered and in some cases their career ending

because of long COVID why do you  think long COVID is being ignored

by so many when there is so much evidence to the  contrary showing it is doing damage to so many

yeah that's a great question I think  the why is tough to get to but is

unfortunately not too surprising that people  have been discounted for illnesses that

weren't clearly measurable or didn't clearly  show up on some test and even among people

who have illnesses who show up on some tests  they're discounted for a variety of reasons

so I think medicine had people skeptical as well  as outside of medicine and we see that we still

continue to see this people skeptical of well  is this real how much of the symptoms are people

exaggerating are this people who come to our  clinic even tell us among friends and family

sometimes they have a tough time with people  saying you know these other people were sick at

the same time and feel fine. Why do you still  feel this way? People have that problem with

employers sometimes as well as they are feeling  these changes in cognition, this exhaustion,

pains throughout their body and because it doesn't  manifest in a very easily measurable or tangible

thing, like a cat scan result, or a test for  cancer, or something like that. It's I think, it's

easier for people to be doubtful of it. Especially  if they're not deep within this work and clearly

seeing this is obviously an injury after the  virus this has been described for centuries.

We know a fair amount about what how other viruses  have affected people in terms of syndromes and

we're learning a fair amount about the actual  changes with long COVID and I'm hopeful that the

recent research, especially this year as research  is really ramping up our understanding of the

biology of long Covid is ramping up. There will  be clear high impact studies that kind of wipe

away any doubt that people had, but as you've seen  and we've seen throughout the pandemic. Even very

obvious tangible things can be discounted,  or ignored by people and that's, I think,

part of human psychology and not necessarily  unique to any any virus or any illness.

In 2026 the first baby boomer turns 80. Our  medical systems are already stretched thin

with an aging population as a  certainty in the next few years

and the potential additional cost  burden on the medical system with

long COVID. How do you think we can  manage these pressures going forward?

So I think certainly investment in in  primary care and general medicine care

and investment in teams that manage illnesses in  ways that center around the patient's needs and

bring value to the patients rather than ways that  produce revenue through testing or treatments that

that type of focus which is kind of value-based  healthcare compared to what we call in the US

fee for service. Which is you have something  done and the insurance pays for that specific

thing to be done. Having a value-based mindset  and having insurance coverage that focuses on

patients outcomes rather than just services,  is gonna certainly serve patients well.

We're hoping at least from a long COVID  perspective to have investments through

Federal grants or other programs to support the  continued build up of long COVID clinics because

there are already too few were already  overwhelmed and if you rely on each COVID clinic

to try to support itself it's going to be quite  challenging so we're trying to advocate for some

organized national program that supports the  development and growth of long COVID clinics

both from a clinical and research perspective  but I think caring for an aging population will

hopefully require a continued shift in the  right direction of how we provide medicine

that we focus on prevention of disease not  treatment of illness once it's happened and

we actually truly put our money where our mouth  is in that because for the most part health care.

Things that treat more serious diseases, pay more  procedures are more desirable financially from

the global health care perspective,  than a preventative treatment

and we have to continue to shift to

value-based health care and preventive health care  for aging populations. Thank you for that answer.

Post-pandemic. Let's look at people that  have had COVID 19. About 400 million people

in the world to date which is likely to  be a an underestimate have had COVID 19

so from that figure around 60 to 120 million  people will be expected to develop long COVID

with this figure set to increase as more  people become infected do you believe that

long COVID will have a greater economic and  societal impact than the pandemic itself

it's hard to do a direct comparison  I think it will have a substantial

impact and it could be a very big enduring  impact in terms of employment joblessness because

tons of the patients we see have to  leave their jobs because they can't

function in the jobs so I think the workforce  issues will continue in part because of long COVID

those buckets of patience I talked about people  recovering versus having continued illness

it's hard to know amongst the the  millions of people having COVID

how many people will fall into each bucket so  we're I'm hopeful with vaccination and with what

we're learning about long COVID we'll be able  to help these patients in a way that we weren't

able to do at the very beginning when this was  first recognized and we knew nothing about it

but I think the the pandemic itself has had  catastrophic worldwide financial implications

I think the implications of long COVID will be  really on the workforce and on the quality of

life and the lives of all these people affected  which may not be easily reflected in a jobs number

or an economics number but will be people  living with these chronic illnesses that are

have changed the way they experience or enjoy  life and that in and of itself is a huge deal

and I know we've nearly run out of time so  this is a very last question I'd like to

end on a positive note what have been your  most uplifting experiences of this pandemic

I think the most uplifting thing from a long  COVID perspective is just how resilient people are

that people come to us with these intense  impairments and changes how they're feeling

and experiencing life yet they've continued to  go they're raising their kids they're at home

and even when we don't have an easy answer  and we listen to them just by developing

a relationship with them and having someone  listen people are so grateful and that is a

very simple thing that you can do it doesn't  take really any specific medical expertise

but it's something that for patients who are  being ignored is often not provided to them no

one is listening and so I think the simplicity of  developing relationships with people by listening

and believing their symptoms and by partnering  to help them feel better even if we don't have

a simple cure has been an uplifting part of  this and seeing the resilience that people have

thank you so much for such a fantastic interview  it's been very informative and we're so privileged

to have an expert such as yourself join  us today thank you for all that you do

your patients are very lucky to have  such a dedicated healthcare professional

looking after them thank you thanks it  was my pleasure thank for having me

Thanks for listening to this week's episode of  COVID 19 The Answers. If you enjoyed the episode

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