Associate Professor Anthony Byrne, St Vincent’s Hospital Sydney thoracic physician and UNSW researcher speaks with AP Editor Jennifer Cooke.
Q: I’m interested if you have a long COVID, post-discharge clinic in any fashion at St Vincent’s Hospital?
A/Prof Byrne: We’ve got plans to establish one. So, we presented to the executive leadership team at St Vincent’s Hospital last week [mid-November 2021] to establish one. And in the meantime, we have been following up some of the patients, but not in a coordinated, specific, long COVID clinic, which acquires additional resourcing.
Q: So, this clinic involving long COVID that you’re seeking approval for, is that for long COVID specifically?
A: Well, it’s called a ‘Post-acute COVID clinic’. So that pertains to beyond 28 days from the onset of the illness, after the acute illness (and the infectiousness period). The definition of long COVID includes the persistence of symptoms for more than 3 months. So, the post-acute [COVID] clinic would include both long COVID and, post-acute patients.
Q: And what’s happened to the post-COVID people to date? Do they go back into the community?
A: I see a lot of them in my private consulting rooms. I have rooms here at the [St Vincent’s] clinic and I’ve also got rooms in Leichhardt [Sydney]. Many post-COVID patients are referred to see me by their GPs.
There are also some of the patients from the ADAPT study that are referred to see me for a Respiratory Specialist review due to the severity of their ongoing symptoms. The ADAPT study follows COVID-positive patients from St Vincent’s Hospital for up to 24 months post infection to better understand the immunological and chronic effects of the SARS-CoV-2 virus.
Participants complete a range of assessments including questionnaires, blood collection, imaging and lung function testing. There are times when those assessments identify abnormalities that require specialist medical interpretation, explanation and management. These are referred to the relevant specialist physician.
And some of them have significant ongoing need with both lung function impairment but other problems as well that have been detected post their COVID infection. For example, one of them was being followed and had, as part of the study, a cardiac MRI which detected abnormalities. Subsequent investigations were done to see that she actually had triple vessel disease and needed life-saving coronary artery bypass grafting.
That all came about because of the investigations initiated both by ADAPT and then clinically following up this patient. If that didn’t happen, she probably wouldn’t have had a triple vessel disease detected and she might not be walking and talking now.
Q: But it was it was basically the COVID that led you to that conclusion?
A: It was a comprehensive assessment post-COVID that led to that assessment.
Q: But COVID didn’t necessarily cause that?
A: Well, there is no way of knowing that no. But there is data from other studies demonstrating an increased cardiovascular risk following an episode of community-acquired pneumonia. That is, the pneumonia that required a hospital admission appeared to be an independent risk factor for cardiovascular events in the 12 months following the infection. And it would be not surprising to me at all to see in the coming months, data coming out to show that patients that survive COVID also have an increased risk of cardiovascular events and death. Because of what we already know about SARS-CoV-2 itself, with increased clotting risk and vascular damage. So, it would make infinite sense logically.
Q: Yes, I was thinking of plaque there, but yes, clotting it’s the problem, isn’t it?
A: Yep, vascular damage, inflammation.
Q: So that particular patient, and others, they come to you for follow up etc. Is there any involvement for pharmacists in this sort of area? I’ve spoken to a person with long COVID who was discharged from hospital in Melbourne and she’s got fatigue and has trouble sleeping and anxiety.
Q: And she had to suggest everything to the healthcare professionals like, ‘Do I need some more vitamins? Do I need magnesium?’ which may not necessarily help, but it helps as she’s doing something …
A: One thing worth saying about that and where the pharmacist might come into it, is say for example, sleep disturbance. Sleep disorders among COVID patients is an interesting one. So, as part of the ADAPT study, we performed diagnostic sleep studies on all patients that were admitted to hospital (in the post recovery phase). And we found that in that small number of patients from the first and second waves last year, that 100% of them had sleep apnoea – of those that were admitted to hospital. It was a small sample size and there was a varying severity of sleep apnoea – mild, moderate and severe. But the point is that, yes, sleep disturbance and even sleep disorders appear to be really common in these post-COVID survivors.
Mental health is also really important for good sleep, and post-COVID patients appear to suffer in this regard after their acute illness. They might have post-traumatic stress. They might have anxiety. They might have depression. And one of the medications that’s available in pharmacies is melatonin. And as a respiratory and sleep physician, we prescribe melatonin, not uncommonly. And, as you know, it’s available without prescription from your pharmacist and in discussion with the pharmacist. So, I think that would be something to consider.
Melatonin is an important hormone that helps regulate the sleep wake cycle and maintain the circadian rhythm. In those post-COVID patients that have poor sleep, a pharmacist could potentially recommend melatonin, but with the caveat that ‘look, here’s this medication that you could have because you’ve sleeping poorly but if this doesn’t help you, then really the next step would be to talk to a GP and consider a referral to see a sleep physician’. Because sleep-disordered breathing is, I think, common in those people with long COVID, particularly if they required a hospital admission for their acute COVID illness. We know that sleep apnoea is a risk factor for severe COVID illness. It’s a risk factor for an admission to hospital when somebody is diagnosed with COVID.
Q: Okay, so there’s also that recent study that was published in Critical Care by the Monash people led by Professor Hodgman. They did a study of people who had been severely ill in intensive care. And 70% of them came out with a disability, if not multiple. And she says that basically these patients afterwards, who develop long COVID need referrals to GPs for screening for new disabilities, they need further management potentially by physiotherapists, by speech therapists, by dieticians, which is sort of like rehabilitation basically, after a terrible illness, which it is. And, also, psychological referral.
A: Absolutely 100% agree. So, that’s why, in fact, our post-acute COVID clinic that we’re planning, is in conjunction with respiratory physicians and also Professor Steven Faux, who’s the head of rehabilitation at St Vincent’s for that very reason, because they do have needs that are pulmonary, but also extra-pulmonary. I mean, there are muscular weaknesses in these people. There is post-traumatic stress, psychological dysfunction with anxiety and chronic fatigue-type symptoms. It’s very much a multisystem disease.
Q: It’s a new disease, isn’t it?
A: It is well, I mean, it’s a novel virus. But then we do have some data on other viruses like SARS-Cov-1 and MERS which have been in the past – smaller numbers of patients. But the difference here is that and I think this is the big deal and the advantage, which probably [Prof] Gail [Matthews] told you in the ADAPT study, 90% of the cohort are non-hospital-admitted patients. So, for example, we recently did a small, randomised controlled trial in long COVID sufferers. A lot of them were not admitted to hospital and suffered symptoms up to a year after their infection. And we found in that population that they had measurable weakness to muscles – a year later – in these patients that were not admitted to hospital.
Q: And this is from infection last year?
A: Yeah. A year ago. So those people with long COVID compared to those people that did not have long COVID all had the virus were weaker at 12 months and more disabled by virtue of, say, St George’s Respiratory Questionnaire or other disability fatigue scales. But this is a point of difference, because in some of the larger studies that you’ll read in Europe and the one [Monash University study lead by Prof Hodgman] you are quoting in Melbourne, they are telephone reviews. But what we’ve done here is actually a physical face-to-face review. We’ve measured, we’ve done grip strength, we’ve done sit-to-stand measurements. So, these are actual measurements, they’re not just necessarily
A: Yes, exactly. In the non-admitted cohort, you know if you were to extrapolate this to the millions of people that have had COVID and a small percentage of them having residual symptoms, that’s a big deal globally.
Q: Do you think it’s likely to be a major public health problem?
A: Oh, it absolutely is. I mean, I know that to be the case. We’re currently planning studies on other diseases including chronic obstructive pulmonary disease (COPD), and … we spoke to an Australian, actually, Theo Vos, [Theo Vos, Professor of Health Metrics Sciences at the Institute for Health Metrics and Evaluation (IHME) at the University of Washington] who’s been involved with the global burden of disease studies… And so he … was involved in disability weights for COVID with other researchers in Europe – he’s currently based in Europe – on the burden of trying to estimate this as a disease burden globally. You can do that for other diseases – COPD, for example. You can allocate a disability weight based on the severity of lung function. So, it’s a bit tricky to do that with COVID but that’s what they are attempting to do. So, there are people that are looking at this already.
Q: So long COVID is potentially a very severe public health threat. Could it be, as someone was quoted today, I think somewhere in The Age I think it was, could it be worse than the current death toll from COVID? Because it’s a public health issue, there will be ongoing …
A: I guess in terms of morbidity. We talk about mortality and morbidity. It depends on how it’s affecting the individual. The definition in the WHO for long COVID is that you’ve got an impairment that persists beyond 3 months from the diagnosis of COVID and you haven’t returned to your baseline level. And so, depending on what your baseline level is, that could be significant, particularly if it’s affecting a young, working-age population and causing a significant reduction to quality of life. We know that chronic pain and chronic mental illness contribute enormously to the global burden of disease. And so, if these symptoms are experienced by long COVID survivors and persist for some time, then COVID will contribute to health care utilisation and therefore be important for public health in the years to come.
Q: So, just to finish off, how do you think a pharmacist could help a long COVID patient who has ongoing symptoms including temporary hair loss, severe fatigue, sleep disturbances and anxiety? So, melatonin is one thing. Is there anything else that, you know, pharmacologically or even, I suppose, they could just refer her to her GP and say that you really should see someone about this?
A: Yeah, I think GP and specialist referral, I think that’s key. But on the upstream, you know, the prevention is worth more than a pound of cure, you know, sort of thing – like the vaccine. There are a lot of vaccine-hesitant people still out there. And I guess the pharmacists’ role is to say, ‘look you’re hesitant about the vaccine’ as people quoting unreliable sources about symptoms after the vaccine, but just to put that all in context and say, ‘Look, if you actually get the virus, and you’re unvaccinated, and you’ve got long COVID, that’s a lot more to be worried about’.
Q: I suppose there’s, you know, younger people who would not have been eligible until relatively recently to get it as well. And now there’s reports coming out saying, you know, the younger people, even though they might not have many symptoms at all, they’re still having them a long time afterwards, which is also a bit of a worry, I suppose, too. I just wanted to know of what support to long COVID patients that pharmacists could be?
A: It’s a multi system thing – sleep disturbance, mental health, obviously I’m a respiratory physician, so respiratory is really important. But also, cardiovascular disease – pharmacists can check blood pressure [for] all these cardiovascular risk factors, cardiovascular health. So, it’s also an opportunity to look at other health-related potential problems that are age appropriate.
Q: And if they have shortness of breath, certainly that would have to be a GP and onward to other specialties?
A: That’s an obvious one. And, also, chronic cough, fatigue, like these [symptoms]. These are a bit nebulous.
Q: What do you do for fatigue?
A: Well, that’s the thing. This why you need a specialist comprehensive assessment. Because then we could say, ‘Is this a cognitive thing? Or is this a physical thing? Or are you fatigued because in fact you’ve got heart failure that’s unrecognised? Or are you fatigued because you’ve got severe sleep apnoea that’s unrecognised?’
Q: So, then there’s a, like a constellation of specialists that you need referral to?
A: Absolutely. And that’s why a GP is a good person to start with because they’re looking at the whole person. And then appropriate referral. And that’s one of the reasons why I think having a coordinated approach to this is really important with a multi-system disease.
Q: What about long COVID clinics, at hospitals where some of these people would have been?
A: I think that’s something that’s being looked at. It’s a matter of resourcing to it. At the end of the day, we’re very lucky here in Australia that we’ve got a highly functioning health service. Because in a lot of settings where I am involved in research, that’s not the case. So, I think we’re quite lucky to have primary care and others, so you don’t necessarily need that when you’ve got a GP who’s well informed.