Long Covid: The Long Road Ahead - Amazon AWS
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Long Covid: The Long Road Ahead
Rachel Coomey
Fourth year medical student, Trinity College Dublin
Word count: 2,096
1Introduction
The Covid-19 pandemic has dominated news headlines and public discussion for the past two years.
We have been inundated with information about positivity rates and death rates, numbers in intensive
care and economic impact. One aspect that has remained relatively underreported, however, is “Long
Covid”, the persistence of symptoms in the weeks or months after SARS-CoV-2 infection (1). Long
Covid rose to prominence due to social media, and its exact pathophysiology and long-term
implications are yet to be fully understood (2). 2% of the UK population reported themselves to
currently be suffering from Long Covid in January 2022, with 63% of those stating that the condition
was adversely impacting their day-to-day activities (3). One in four UK employers report that Long
Covid is a major cause of employee absence in their companies (4). While, thankfully, death rates due
to Covid are decreasing and fewer people are being admitted to intensive care in recent months, we
are yet to fully come to terms with many after-effects of the pandemic, including Long Covid. Given
that many effects of Long Covid may negatively affect ability to drive safely, I believe this issue is
hugely important, and pertinent to medical fitness to drive.
While the pathophysiology of Long Covid has not been fully elucidated, many possible contributing
factors have been suggested. These include inflammation (including auto-immune action) and
neuroinflammation, hypercoagulable state leading to microthrombi and ischaemia, mitochondrial
dysfunction, disruption of the autonomic nervous system, lung fibrotic remodelling, and leucocyte
infiltration in the gastrointestinal mucosa (5). Symptoms associated with Long Covid are many and
varied, with fatigue often featuring as the most common (3)(6). A systematic review of over 10,000
people in 12 countries found that other symptoms frequently reported include weakness, general
malaise, impaired concentration, and breathlessness (7), all of which may negatively impact ability to
drive. In total, over 60 physical symptoms and signs were demonstrated to be widely prevalent. This
essay will discuss some of these symptoms and their impact on driving, using other diseases with
similar manifestations as reference points where needed.
Symptoms and driving
Fatigue and cognitive impairment
Fatigue is a common symptom reported to remain after Covid-19 infection. In fact, the Health Service
Executive have published a webpage dedicated to fatigue after Covid, where specific advice is given
2regarding driving: “If you feel drowsy when driving, stop, park in a safe place and take a nap for 15
minutes” (8). Is this advice sufficient?
Fatigue is a concept that is easily understood at a basic level, but it is not clearly defined. While
discussion over the precise definition continues, one posited meaning is “a biological drive for
recuperative rest”, (9) which recognises the multi-faceted nature of the fatigued state. Fatigue has
been called a “silent killer” in road safety (10). It is estimated that around 20% of road traffic accidents
are related to sleepiness or fatigue (11)(12). In a survey of truck drivers in Colombia, risk factors for
crashes included extended periods of driving before the collision, fewer breaks, and less than four
hours of sleep the night before, all of which were thought to contribute to a fatigued state (13). It has
been well established that fatigue is exacerbated by longer driving times. Excessive driving times have
been shown to increase reaction times, unstable driving performance, and sleepiness scores (14).
Furthermore, cognitive fatigue and impairment- colloquially termed “brain fog”- is a commonly
reported feature of Long Covid (15), and has been shown to be associated with female sex, severity of
respiratory symptoms, and ICU admission (16), although patients who were never hospitalised have
also displayed cognitive impairment after Covid-19 (17). While little data is available regarding Long
Covid-associated cognitive impairment and driving, numerous studies have investigated the effect on
driving caused by cognitive impairment in other diseases. In multiple sclerosis (MS), people with MS-
associated cognitive impairment perform worse in several different driving skills compared to people
both people with MS but without cognitive impairment and healthy controls (18). People with MS-
associated cognitive impairment were much more likely to be rated as having a high probability of
crashing than people in either of the control groups. The Mild Cognitive Impairment (MCI) associated
with increased age has also been shown to affect driving. People with age-related MCI display lower
performance in driving generally and in discrete driving manoeuvres compared to healthy controls
(19). Poor performance was seen in left turns and lane control, as well as a global rating of driving.
The authors clarified that the performance of subjects with cognitive impairment was “less than
optimal”, rather than completely impaired, but cautioned that vigilance is needed. Of course, this
vigilance is needed partly because people with MCI have a high risk of progression to dementia.
However in the case of Long Covid, the long-term effects are as yet unknown, so I believe this is also
an area in which we need to be vigilant.
Fatigue has been somewhat normalised in modern society, which may cause people to be less cautious
about its adverse effects. In a Spanish survey, almost 40% of drivers considered themselves to be in
3good condition to drive even when displaying symptoms of fatigue (20). In Ireland, 28% of motorists
admit having fallen asleep while driving- a worryingly high figure (21). While current HSE campaigns
regarding driver fatigue are commendable, they may not be sufficient. Regarding fatigue after Covid-
19, we must consider what to advise patients. While some patients with Long Covid report to being
much too weak to consider driving (22), many others feel capable of driving. As demonstrated above,
many motorists display poor judgement regarding their ability to drive while fatigued. So, what should
our response be? Many regions in the USA have established Medical Advisory Boards (MABs) to
provide guidance on policy around drivers with cognitive impairment (23). Should we consider a MAB
for Long Covid-associated cognitive impairment, or even Long Covid generally? I believe this may be
beneficial. In Ireland currently, an ‘on-road’ driving assessment is sometimes administered to people
with dementia (24). Perhaps a modified version of this may be helpful in assessing people with Long
Covid and their ability to drive. This may not be logistically feasible or even necessary for everyone
with Long Covid-associated fatigue or cognitive impairment, but it could be a useful tool for specific
cohorts, such as people for whom driving is an occupational necessity or those who request it. As
mentioned earlier, long journeys considerably increase unstable driving performance and sleepiness
scores. This may be helpful information to publicise through the media and to ask medical
professionals to warn their Long Covid patients. Knowledge of the dangers of longer journeys might
encourage people with Long Covid to take public transport, such as inter-city trains, or to make
frequent use of rest stops if they do need to take a long drive.
While Long Covid-associated fatigue and cognitive impairment are common and worrying issues, there
are feasible solutions. Public information campaigns regarding safe driving, informing medical
practitioners, particularly primary care practitioners, on how best to advise patients, and putting in
place driving safety assessments for those who need them will help keep road users safe without being
overly restrictive.
Chest pain and breathlessness
Chest pain and breathlessness are also two of the most common symptoms reported in Long Covid
(25). While the exact aetiology of these has yet to be elucidated, it has been posited that the chest
pain is due to microvascular ischaemia (26). Historically, people who have angina, particularly angina
that is provoked by driving, have been advised not to drive (27). However, given that efficacious
treatment methods are now available, the HSE and NDLS advise that most people can keep driving,
unless their angina is unstable or triggered by emotion (28). If Long Covid patients experience
4unpredictable angina, it may be prudent to advise them to refrain from driving until their symptoms
improve, or, if symptoms are not improving, until an effective treatment for Long Covid-associated
chest pain is recognised. As angina pectoris has been shown to significantly decrease patients’ road
usage (29), it is imperative that an effective medication is found.
Breathlessness, another common symptom of Long Covid, improves after breathing exercises, and all
patients with breathlessness should be appropriately supported with these (30). Patients with chronic
breathlessness have expressed that driving is a means of maintaining their independence, with some
saying it is the only out of home activity they can still perform (31). This demonstrates the importance
of supporting patients with breathlessness after Covid-19 in maintaining their ability to drive, if
possible and safe. Most patients and their caregivers don’t believe that breathlessness negatively
impacts driving skills (31). If a Long Covid patient’s breathlessness is sufficiently severe to inhibit
driving, they should be asked to refrain from driving and referred to a respiratory specialist, as this
would indicate quite severe disease.
Other symptoms
While fatigue, cognitive impairment, chest pain, and breathlessness are some of the most commonly
reported symptoms of Long Covid, a wide array of other symptoms exist. These affect many systems,
including the cardiopulmonary, upper respiratory, gastrointestinal, musculoskeletal, neurological, and
psychological systems (7), with over 60 individual symptoms being noted. It would be neither possible
nor beneficial to examine each symptom individually, as these will vary in both temporality and
severity from one individual to another. Some of these symptoms can be looked at through the lens
of similar, well-established conditions. For example, joint pain is a common symptom in Long Covid
patients, with 44% of patients suffering from joint pain in one study (6). While Long Covid-associated
joint pain has not been studied in relation to driving, extensive research has been carried out regarding
the relationship between rheumatoid arthritis and driving (32). Many recommendations regarding
rheumatoid arthritis patients may be applicable to Long Covid patients suffering from joint pain. Other
symptoms may be less well researched, and might need to be considered on a case-by-case basis. The
‘on-road’ driving assessments mooted earlier may be beneficial here.
5Looking forward
Does Long Covid increase a person’s risk of being in a road traffic accident? Empirical evidence does
not yet exist due to the novelty of the condition. However, it is known that a diagnosis of fibromyalgia,
which shares several symptoms with Long Covid, has been associated with increased risk of road traffic
accident, although very few patients’ physicians had given any warning regarding this (33). As
described in this essay, many common symptoms of Long Covid could increase risk of unsafe driving.
It is important that when discussing and researching Long Covid, we do not forget about road safety.
We must ensure that road users- both Long Covid patients and road users generally- are kept safe.
Equally, we must not be overly restrictive, and unnecessarily take away people’s ability to drive, which
to many is synonymous with their freedom. Freedom is more valuable than ever after the last two
years. Another commonly reported aspect of Long Covid is worsened quality of life (6), and to restrict
people’s permission to drive without adequate cause would likely further disimprove the quality of
life of Long Covid patients. If some restrictions must be made, we should consider restrictive driving
licenses- which regulate drivers in certain aspects of driving, such as speed or geographical restrictions
(34)- where possible, rather than unnecessarily impeding people from driving altogether.
Furthermore, I believe this issue is of sufficient importance that numerous stakeholders must work
together to further study Long Covid and road safety. These stakeholders include but are not limited
to the NDLS, the RCPI’s National Office for Traffic Medicine, the Irish College of General Practitioners,
and the Association of Occupational Therapists in Ireland. These groups can together form an advisory
board and write policy regarding Long Covid and driving, and educate the nation’s general
practitioners and occupational therapists about Long Covid. These health professionals will, yet again,
be at the forefront of a new aspect of the pandemic. Given the many varied symptoms associated with
Long Covid, the heterogeneity of presentations, and the many things still unknown, they must look
holistically at each individual who presents.
In summary, Long Covid is sufficiently common, severe, and pertinent to traffic medicine to warrant
collaboration of multiple groups and guidelines to be put in place. Large prospective cohort studies
will be helpful in learning more about Long Covid generally, and driving simulation studies will
demonstrate Long Covid’s effects on driving. Beneficial measures might include ‘on-road’ driving
safety assessments, public information campaigns about driver fatigue, guidance for general
6practitioners about symptoms such as angina and breathlessness, and restrictive driving licenses
rather than driving bans, where possible.
Abbreviations
MAB- Medical Advisory Board
MCI- Mild Cognitive Impairment
MS- Multiple Sclerosis
NDLS- National Driver License Service
References
1. BMJ. 370:m3489. 2020.
2. Callard F, Perego E. How and why patients made Long Covid. Social Science and Medicine.
2021 Jan 1;268.
3. Ayoubkhani D, Pawelek P. Prevalence of ongoing symptoms following coronavirus (COVID-19)
infection in the UK. 2022.
4. Quarter of UK employers cite long COVID as driving absences - survey. Reuters. 2022 Feb 8;
5. Castanares-Zapatero D, Chalon P. COVID 19-KCE Contributions Pathophysiology of Long
Covid: A Preliminary Report. 2021.
6. Carfì A, Bernabei R, Landi F. Persistent symptoms in patients after acute COVID-19. Vol. 324,
JAMA - Journal of the American Medical Association. American Medical Association; 2020. p.
603–5.
7. Michelen M, Manoharan L, Elkheir N, Cheng V, Dagens A, Hastie C, et al. Characterising long
COVID: A living systematic review. Vol. 6, BMJ Global Health. BMJ Publishing Group; 2021.
8. Health Service Executive. Fatigue after COVID-19.
9. Williamson A, Lombardi DA, Folkard S, Stutts J, Courtney TK, Connor JL. The link between
fatigue and safety. Accident Analysis and Prevention. 2011 Mar;43(2):498–515.
710. Zhang G, Yau KKW, Zhang X, Li Y. Traffic accidents involving fatigue driving and their extent of
casualties. Accident Analysis and Prevention. 2016 Feb 1;87:34–42.
11. Garbarino S, Nobili L, Beelke M, de Carli F, Ferrillo F. Analysis of the Role of Sleepiness on the
Distribution of Accidents not Directly Ascribed to Sleepiness. Sleep [Internet].
2001;24(2):203–6. Available from:
https://academic.oup.com/sleep/article/24/2/201/2749988
12. Horne J, Reyner L. Sleep related vehicle accidents. BMJ. 1995;310(565).
13. Torregroza-Vargas NM, Bocarejo JP, Ramos-Bonilla JP. Fatigue and crashes: The case of
freight transport in Colombia. Accident Analysis and Prevention. 2014;72:440–8.
14. Ting PH, Hwang JR, Doong JL, Jeng MC. Driver fatigue and highway driving: A simulator study.
Physiology and Behavior. 2008 Jun 9;94(3):448–53.
15. Callan C, Ladds E, Husain L, Pattinson K, Greenhalgh T. ‘I can’t cope with multiple inputs’: a
qualitative study of the lived experience of ‘brain fog’ after COVID-19. BMJ Open [Internet].
2022 Feb 11;12(2):e056366. Available from:
https://bmjopen.bmj.com/lookup/doi/10.1136/bmjopen-2021-056366
16. Asadi-Pooya AA, Akbari A, Emami A, Lotfi M, Rostamihosseinkhani M, Nemati H, et al. Long
COVID syndrome-associated brain fog. Journal of Medical Virology. 2022 Mar 1;94(3):979–84.
17. Wild C, Norton L, Menon D, Ripsman D, Swartz R, Owen A. Seeing through brain fog:
disentangling the cognitive, physical, and mental health sequalae of COVID-19. Cell Reports
Medicine. 2022;
18. Schultheis MT, Garay E, DeLuca J. The influence of cognitive impairment on driving
performance in multiple sclerosis. Neurology. 2001;56:1089–94.
19. Wadley VG, Okonkwo O, Crowe M, Vance DE, Elgin JM, Ball KK, et al. Mild cognitive
impairment and everyday function: An investigation of driving performance. Journal of
Geriatric Psychiatry and Neurology. 2009 Jun;22(2):87–94.
20. Alonso F, Esteban C, Useche SA, López de Cózar E, Useche S. Prevalence of Physical and
Mental Fatigue Symptoms on Spanish Drivers and Its Incidence on Driving Safety Applied
Studies on Road Safety. Prevalence of Physical and Mental Fatigue Symptoms on Spanish
Drivers and Its Incidence on Driving Safety Advances in Psychology and Neuroscience
[Internet]. 2016;1(2):10–8. Available from: http://www.sciencepublishinggroup.com/j/apn
21. O’Mahony J. Driver Attitudes & Behaviour Survey 2020- Road Safety Authority. B&A Research
and Insight. 2020 Feb;
22. Selinger H. A world forever transformed: Life with Long COVID. Al Jazeera. 2021 Dec 26;
23. Eby DW, Molnar LJ. Driving Fitness and Cognitive Impairment Issues for Physicians. JAMA
[Internet]. 2010;303(16):1642–3. Available from: https://jamanetwork.com/
24. The Alzheimer Society of Ireland. Driving and Dementia Fact Sheet [Internet]. 2014 Sep.
Available from: www.ndls.ie
25. Yelin D, Margalit I, Yahav D, Runold M, Bruchfeld J. Long COVID-19—it’s not over until? Vol.
27, Clinical Microbiology and Infection. Elsevier B.V.; 2021. p. 506–8.
826. Vallejo N, Teis A, Mateu L, Bayés-Genís A. Persistent chest pain after recovery of COVID-19:
Microvascular disease-related angina? Vol. 5, European Heart Journal - Case Reports. Oxford
University Press; 2021.
27. Taggart P, Gibbons D, Walter Somerville M. Some Effects of Motor-car Driving on the Normal
and Abnormal Heart. British Medical Journal. 1969;4:130–4.
28. National Driver License Service. Cardiac Conditions and Driving [Internet]. 2017. Available
from: www.ndls.ie
29. Parmentier G, Chastang J-F, Nabi H, Chiron M, Lafont S, Lagarde E. Road mobility and the risk
of road traffic accident as a driver The impact of medical conditions and life events. Accident
Analysis and Prevention. 2005;37:1121–34.
30. Greenhalgh T, Knight M, A’Court C, Buxton M, Husain L. Management of post-acute covid-19
in primary care. The BMJ. 2020 Aug 11;370.
31. Ferreira DH, Boland JW, Kochovska S, Honson A, Phillips JL, Currow DC. Patients’ and
caregivers’ experiences of driving with chronic breathlessness before and after regular low-
dose sustained-release morphine: A qualitative study. Palliative Medicine. 2020 Sep
1;34(8):1078–87.
32. Zhou DJ, Mikuls TR, Schmidt C, England BR, Bergman DA, Rizzo M, et al. Driving Ability and
Safety in Rheumatoid Arthritis: A Systematic Review. Vol. 73, Arthritis Care and Research.
John Wiley and Sons Inc; 2021. p. 489–97.
33. Redelmeier DA, Zung JD, Thiruchelvam D, Tibshirani RJ. Fibromyalgia and the risk of a
subsequent motor vehicle crash. Journal of Rheumatology. 2015 Aug 1;42(8):1502–10.
34. O’Byrne C, Naughton A, O’Neill D. Is driver licensing restriction for age-related medical
conditions an effective mechanism to improve driver safety without unduly impairing
mobility? European Geriatric Medicine. 2015;6(6):541–4.
9You can also read
