Ask the Pharmacist

Q) If I should become infected with COVID-19, how long should I expect to feel sick?

A) Like so many questions in medicine, this answer is far from black and white. There seems to be an extremely wide degree of variability not only in the severity of the symptoms but also in their duration.

For some lucky individuals, they’ll never even know they were ever infected (we call these people asymptomatic). Just what percentage of individuals fall into this category is a number that is hotly debated with estimates widely varying (there’s that word again) anywhere from 6% (from a study done at a nursing home) all the way up to 96% (from a study looking at 3277 prison inmates).

However, most experts would put the true percentage that seem to escape this infection relatively unscathed in the low 40 percentiles as 3 studies reported by the WHO put the numbers at 42, 43 and 45 percent of the population. For the rest who get at least mildly ill, they can expect to feel under the weather for 1 to 2 weeks which is not a lot different from your run of the mill cold or flu which typically present with symptoms for 3 to 7 days.

However, there seem to be a number of people who have been, or at least are suspected to have been, infected with COVID-19 who remain unwell for many months. The exact percentage that seems to suffer from long-term effects once again is an unknown but it is common enough that they have started up several popular social media support groups and have now acquired their own unique moniker, known as the “long-haulers”. Their numbers are also significant enough to have caused clinicians and researchers who have been strictly focussed on the acute stage of this infection to start paying attention to the long term complications of COVID-19.

“Long- haulers” can roughly be defined as people who remained ill for weeks to months following their initial infection, and in some cases, still show no signs of being fully recovered. One study conducted in Rome checked in on 143 previously hospitalized patients (with an average age of 56.5 years) some months after they were discharged. The findings were, to be frank, disturbing. Only 12.6% of the 143 patients were completely symptom free. In other words, 87.4% of these still had at least one persistent symptom 2 months or longer after the initial onset of the virus and 55% of the 143 were in fact still coping with three or more persistent symptoms making many of them unable to work or even fully engage in the activities of daily living (this is the term we use for being able to perform routine chores like cooking, cleaning, grabbing groceries…).

The chief complaint was fatigue (with some describing even climbing a single flight of stairs to be an exhausting challenge) in 53.1 % of the patients, 43.4% had dyspnea (the medical term for shortness of breath), 27.3% had joint pain and 21.7% complained of ongoing chest pain. Interestingly, none of the 143 still exhibited a fever or many of the other common signs and symptoms of an acute infection.

The scary part is that long lasting symptoms is not a fate only reserved for those who were initially sick enough to require hospitalization. Many who are complaining of ongoing symptoms were only mildly ill during the initial phase and as such, never required medical treatment, and in many cases, were never tested due to the severe shortage of available tests back in March and April.

Body Politic, a popular COVID-19 support group, surveyed 640 of their “long-haulers” to get a better handle on the characteristics of this group. The range of symptoms reported consisted not only of the ones noted above but many others as well including a cough, fever, body aches, headache, brain fog (a word we use when your ability to think is impaired), gastrointestinal issues, dizziness, chills, sweats and insomnia. That is a startling array of symptoms but one that should not surprise us given that we now know that the coronavirus is a multi-system disease that can damage not only the lungs but also the heart, brain, nervous system, kidneys, liver, gastrointestinal tract and the skin.

Surprisingly, this same survey found that the majority of respondents were rather young, between the ages of 30 and 49 (62%) and that almost half of them were either denied a COVID-19 test or didn’t test for some other reason. Of the rest, quite a few of these patients who were tested for COVID came back with negative results but this does not necessarily mean that their symptoms cannot be attributed to the coronavirus.

The timing of a test can be critical with one study reporting that the chances of a false negative is more likely if a patient was tested a week after their symptoms first appeared. In the Body Politic survey, the patient’s tests that came back negative were on average tested 6 days later into their illness than those who tested positive. Another possible reason some tested negative was that our tests currently only check for the virus in our nasal cavity via a swab. It is entirely possible that by the time they are tested, the virus had already hit that area and had subsequently moved on to other areas of the body.

As Dr. Doris Gorfinkel, a Toronto family doctor and researcher puts it, “there could be like tons of virus that’s like two inches below that”. Regardless, there are a multitude of people who continue to be ill long after they were expected to recover. Why these symptoms continue in some, but not all, is also puzzling researchers. They know, as we stated earlier, it doesn’t seem to be related to the initial severity of the acute stage. It also doesn’t seem to be clearly linked to the general health of the individual as many of those who seem to remain sick are relatively young and healthy without pre-existing co-morbidities (this is the medical term we use for other diseases you may also have) such as diabetes or hypertension.

Researchers, including Rob Kozak, a clinical micro-biologist at Sunnybrook, believe the answer may lie within our immune system. One theory that he espouses is that during the initial stage, our immune system ramps up to fight off the virus in just about everybody, and then it shuts down after we recover. However, in some people, the system doesn’t seem to realize that the fight is over and it continues to attack remnants of genetic material from the virus that remains in the body or our own normal proteins that look somewhat similar to the virus. The result is an ongoing internal inflammatory response that damages the tissues within which it is occurring.

Another possible contributing reason behind these lingering symptoms is that a COVID-19 infection is a very traumatizing event for many of us, regardless of how sick we initially get. When we are suffering psychologically, there is a world of evidence that proves physical symptoms such as exhaustion and pain can often go hand in hand with the mental aspects of these disorders.

This disease has received so much press coverage, some of it overzealous to say the least, that it is no wonder that, in one study conducted by Dr. Paul Clavario from Italy, 50% of the 55 patients his team visited had lingering psychological problems afterwards. In fact, he felt that a full 15% met the criteria for a diagnosis of post traumatic stress disorder (PTSD). As seems to be the norm, we don’t have firm answers to how many of us are likely to become “long-haulers” or why. Experts do now recognize this is a major problem to the extent that two of the European countries worst hit by the virus (the U.K. and Italy) are starting to offer rehabilitation services to COVID- 19 survivors and the U.K. has just announced a major study into the long-term health effects of this virus.

Hopefully, with time, we can offer these poor people answers to their questions, and even better, a proven path towards a full recovery. For more information about this or any other health related questions, contact your pharmacist.