Relevance of a Covid-19 infection and its long-term consequences
The COVID-19 pandemic has fundamentally changed the world since 2019 and continues to shape the lives of many people today. Although the immediate threat posed by the virus has now been brought under control in many parts of the world, it remains an issue of ongoing relevance. By 2024, the landscape of protective measures, testing requirements, and the management of long-term effects, such as Long COVID, has evolved significantly.
Gone are the days of widespread lockdowns and ubiquitous mask mandates, yet the virus remains a reality we must live with. Protective measures have become more nuanced and are tailored more closely to local conditions and individual risk factors. Testing strategies have also changed: While regular testing has been scaled back in many places, access to rapid tests and PCR tests remains crucial in certain situations.
Advances in research and treatment are particularly crucial for those affected by Long COVID, whose numbers are still growing. New therapeutic approaches and specialized rehabilitation programs offer hope, but many affected individuals continue to struggle with the long-term effects of the disease. The question of how we as a society deal with these challenges remains highly relevant and calls for an informed and nuanced look at the developments of recent years.
Below, we take a closer look at current developments in the response to COVID-19 and examine how protection and care for those affected have changed since the early days of the pandemic. Stay tuned to find out what you need to know right now.
Long and Post-COVID Symptoms
The terms “acute COVID-19 infection,” “Long COVID,” and “post-COVID” refer to different phases and aspects of the disease caused by the SARS-CoV-2 virus and have specific definitions:
Acute COVID-19 infection: This describes the initial phase of the disease following infection with the SARS-CoV-2 virus. The acute infection typically lasts up to four weeks and includes symptoms directly associated with the viral infection, such as fever, cough, shortness of breath, loss of taste and smell, and, in severe cases, pneumonia and other complications. The acute phase ends when the symptoms subside and the patient recovers.
Long COVID: This phase describes the presence of symptoms that persist for more than four weeks after the acute infection. These symptoms can be varied and affect different organ systems, such as fatigue, shortness of breath, cognitive impairments (“brain fog”), as well as muscle and joint pain. Long COVID is still considered a diagnosis of exclusion and is diagnosed when symptoms persist without interruption after the acute phase and last for at least four weeks. The term “Long COVID” is often used synonymously with “Post-COVID.” This is not entirely accurate, so it is important to distinguish between the two terms in medicine, even though the distinction is fluid.
Post-COVID: In medicine, Post-COVID is defined as the phase in which symptoms persist after 12 weeks, and it becomes clearer that they may be long-term or chronic. Post-COVID encompasses both the longer-term symptoms of Long COVID and chronic conditions that may develop from a COVID-19 infection.
Chronicity of the Clinical Picture
A clinical picture is considered to have become chronic when symptoms persist for more than three months and a return to normal health appears unlikely. This applies to both Long Covid and other chronic conditions such as Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS). Chronic conditions often require long-term and comprehensive care to manage symptoms and improve the quality of life for those affected.
Current Prevalence
The epidemiological situation in Germany shows that COVID-19 continues to circulate, even though most people are either vaccinated or have already been infected. In the summer of 2024, an increase in COVID-19 incidence was observed in Germany. This increase is attributable to several factors:
- New virus variants: Since the beginning of the year, new variants have spread and are responsible for a significant proportion of new infections. Some of these variants exhibit increased transmissibility and can, in some cases, evade existing immunity, leading to a higher infection rate.
- Seasonal effects: Although summer is normally a time when respiratory infections decline, there was an unusually high number of COVID-19 cases this year. This could be related to increased travel and large-scale events that took place during the summer months. Such activities promote close contact between people and facilitate virus transmission. In addition, travel rates are highest in the summer, meaning that people are once again spending more time abroad and in potential COVID-19 hotspots.
- Waning vaccine protection: For many people, the effectiveness of the vaccine or a previous infection is waning, making them more susceptible to reinfection. Although vaccination campaigns are still ongoing, the willingness to receive booster shots is lower than in previous years, which contributes to the spread of the virus.
- Reduced protective measures: With the lifting of many government protective measures, such as mask mandates and restrictions on public life, conditions for the spread of the virus have improved. At a time when the public feels safer, vigilance is declining, which increases the risk of infection.
The prevalence of Long COVID varies depending on the study, but general estimates suggest that about 10–20% of those infected with COVID-19 are affected. Accordingly, about 65 million people worldwide are affected by post-COVID symptoms.
Decline in Testing and Its Impact
A key factor influencing the current COVID-19 situation is the decline in testing. Since the peak of the pandemic, many countries, including Germany, have adjusted their testing strategies and reduced the number of tests conducted. This leads to lower detection rates and potentially an underestimation of actual infection numbers. According to the European Centre for Disease Prevention and Control (ECDC), the reduction in testing has impaired the ability to closely monitor the spread of new variants and the overall epidemiological situation. Regular at-home coronavirus testing allows for the early detection of a potential COVID-19 infection. It is therefore recommended to always keep rapid tests on hand at home. By doing so, you not only safeguard your own health but also protect those around you from new infections. This can help protect particularly vulnerable groups.
Common Symptoms of Long and Post-COVID
The most common symptoms of Long Covid include a wide range of complaints that affect various organ systems and can significantly impair the quality of life of those affected.
- Fatigue and exhaustion: Persistent, often overwhelming tiredness that is scarcely alleviated by rest is one of the most characteristic and severely debilitating symptoms of Long COVID. This debilitating exhaustion currently has no known treatment.
- Cognitive impairments (brain fog): Those affected often report problems with concentration, memory disturbances, and a slowing of mental processes, which can make daily life very difficult.
- Respiratory symptoms: Persistent shortness of breath, coughing, and chest pain indicate lung involvement, even in cases of previously mild COVID-19.
- Musculoskeletal symptoms: Pain in muscles and joints, as well as general weakness, can significantly impair mobility and well-being.
- Neurological symptoms: In addition to cognitive problems, headaches, dizziness, and sensory disturbances such as tingling or numbness often occur.
- Mental health issues: Depression, anxiety, and sleep disturbances are common side effects that can arise from the sudden onset of a serious illness.
- Cardiovascular symptoms: Arrhythmias, palpitations, and occasional chest pain or tightness may indicate ongoing strain on the cardiovascular system.
- Worsening of existing conditions: Long COVID and post-COVID can permanently worsen pre-existing conditions such as asthma, cardiovascular diseases, or neurological disorders. Patients often report an increase in symptoms of these underlying conditions, which were triggered or exacerbated by the COVID-19 infection.
| Category | Symptoms |
|---|---|
| Autonomic symptoms | Fatigue, sleep disturbances |
| Cardiac symptoms | Chest pain, palpitations, chest tightness, postural orthostatic tachycardia syndrome |
| Cognitive symptoms | Brain fog, memory problems, difficulty concentrating, depression, anxiety |
| Dermatological symptoms | Hair loss |
| Gastrointestinal symptoms | Digestive problems |
| Immunological symptoms | Fever |
| Muscle and joint symptoms | Muscle pain, joint pain |
| Neurological symptoms | Headaches, loss of sense of smell, tingling sensations |
| Pulmonary symptoms | Shortness of breath, cough, sore throat |
| Post-Exertional Malaise (PEM) |
Pathomechanisms of Post-COVID
The exact pathomechanisms of Long COVID are not yet fully understood, but current research points to several possible causes:
- Persistent viral components: It is believed that parts of the virus may remain in the body and cause a persistent inflammatory response.
- Autoimmune reactions: COVID-19 can trigger autoimmune reactions in which the immune system mistakenly attacks the body’s own tissues.
- Immune system dysfunction: Dysregulation of the immune system can lead to persistent inflammation and symptoms.
- Organ damage: Damage to organs during the acute phase can have long-term effects that contribute to the symptoms of Long COVID.
Challenges in the Daily Lives of People with Long COVID
Long COVID presents significant challenges for those affected in their daily lives. These challenges span various areas, including social interactions and overall participation in social life.
Isolation and social stigma:
- Isolation: Many people with Long COVID experience involuntary social isolation because their persistent symptoms make it difficult for them to participate in social activities. They often require support in the form of physical care or assistive devices.
- Stigmatization: There is still a lack of understanding and acceptance of Long COVID. Those affected may be stigmatized and not taken seriously because of their symptoms, which are often invisible. Due to the complexity of the condition, there is a lack of specialized care providers and medical centers. Those that do exist have extremely long wait times of 12–24 months or have had to close again due to a lack of start-up funding. As a result, those affected and their loved ones feel left to cope with the condition on their own and remain in the dark.
Mental Health:
- Depression and Anxiety: Persistent health problems and the inability to lead a normal life can lead to depression and anxiety. Uncertainty about how long the symptoms will last and a lack of recognition by insurance providers and the public health system also contribute to these psychological burdens.
Limitations in Daily Life:
- Performing Daily Tasks: Persistent fatigue and other symptoms such as shortness of breath and pain make it difficult for those affected to perform daily tasks. Even simple activities like grocery shopping, housework, or caring for children can become major challenges.
- Mobility: Many affected individuals have difficulty getting around, which further limits their participation in social and professional activities. As a result, many people are no longer able to live independently in a manner appropriate for their age. The problem is not accepting assistive devices as support, but rather that people are often not granted a disability rating (GdB) or recognized as requiring a care level. Here, too, there are too few guidelines that take COVID-19 into account in the categorization process.
Work-Related Challenges:
- Ability to Work: The symptoms of Long COVID can severely impair a person’s ability to work. Prolonged periods of illness and the inability to return to work are common problems. This not only leads to financial difficulties but can also undermine self-esteem and professional identity.
- Return to Work: Returning to the workplace is often difficult. Flexible work schedules and conditions are necessary but are not always offered. Measures such as the “Hamburg Model” for gradual reintegration can be helpful, but often require individual adjustments, as the reintegration period is insufficient for those with moderate to severe symptoms; thus, new approaches are needed to permanently reintegrate people with post-COVID conditions into the labor market.
- Long wait times: Due to high demand and limited capacity at specialized rehabilitation facilities, those affected often face long wait times. Furthermore, very few facilities specialize in Long and Post-COVID. Due to the lack of evidence, a rigid rehabilitation protocol should not be followed. Given the varied symptoms and different areas of focus, it is essential to assess each patient individually. Some patients are advised against rehabilitation due to post-exertional malaise, as the risk of triggering a persistent worsening of their condition is too great. Specialized post-COVID centers often have wait times exceeding 12 months. For patients, this is valuable time to initiate a diagnostic evaluation. Here, too, the advice is: wait and see.
- Multidisciplinary Approaches: Comprehensive rehabilitation requires multidisciplinary approaches that integrate not only specialized fields—such as physical and occupational therapy—but also exercise therapy, psychological support, targeted medical treatment, and medication therapy based on the latest research findings. However, such programs are not available everywhere.
Financial Burdens:
- Costs of treatment and rehabilitation: The costs of long-term treatments and rehabilitation can be substantial, especially if not all measures are covered by insurers such as health insurance, pension insurance, or workers’ compensation agencies. This means that people who already lack an income must finance their therapy out of pocket. This places an additional burden on those affected and their families. One reason for this is that medications are considered “off-label” until they have completed the clinical trial process. It can therefore take many years for a medication to receive official approval. Until then, these medications are not included in health insurance providers’ coverage catalogs and are therefore not reimbursable.
Long COVID has far-reaching effects on the daily lives of those affected and their social circles. It requires comprehensive recognition and support from society and the healthcare system to overcome these challenges and improve the quality of life for those affected.
Possible Treatment Approaches for Long COVID
Long COVID is a complex syndrome with a wide range of symptoms that can persist for weeks or months. Treatment requires a multidisciplinary approach. Here are some of the most important treatment approaches:
Symptomatic treatment:
- Fatigue: Pacing (managing activity and rest), energy conservation techniques, and physical rehabilitation are crucial for managing persistent fatigue.
- Respiratory symptoms: Respiratory therapy and targeted exercises to improve lung function can help restore breathing capacity.
- Cognitive symptoms: Cognitive rehabilitation and memory training can be used to alleviate problems with memory and concentration.
- Cardiovascular problems: Regular monitoring and treatment of arrhythmias or other cardiac issues by cardiologists.
- Neurological symptoms: Neurological examinations and treatments to address neurocognitive disorders.
- Physical therapy: Exercises to strengthen muscles and improve mobility to support physical functions.
- Occupational therapy: Support in managing daily activities and improving quality of life.
- Psychotherapy: Psychological support and counseling to help cope with the emotional and psychological stress associated with Long and Post-COVID.
- Self-help groups: Participation in groups where people affected by the condition can share their experiences and support one another.
- Pain management: Use of pain relievers and anti-inflammatory medications (NSAIDs) to alleviate pain and inflammation.
- Immune system modulation: In some cases, medications that modulate the immune system may be used to reduce autoimmune reactions.
Since the causes of Long COVID have not yet been sufficiently researched, treatment is exclusively symptomatic. The main goal is to alleviate symptoms and improve the quality of life for those affected. However, these interventions are not causal treatment approaches and are therefore not curative. Based on the current state of scientific knowledge, post-COVID cannot be cured. Time is an important factor in the course of the disease, and it is considered crucial for recovery from a post-infectious illness.
Overlap Between Post-COVID and Myalgic Encephalomyelitis (ME/CFS)
ME/CFS is a complex, severe neurological and chronic condition characterized by extreme fatigue that is not alleviated by rest and can be exacerbated by physical or mental exertion. The majority of those affected are permanently unable to work, dependent on care from others, and unable to lead an autonomous and self-determined life. The condition was first recognized as early as the 1950s. However, it has received little attention in recent decades because only a small minority of people were affected. Experts note that, particularly with ME/CFS, there is a very high number of undiagnosed cases and frequent misdiagnoses. It was not until the COVID-19 pandemic that the condition garnered attention, as the clinical presentations of the two conditions are highly similar in terms of symptoms. Accordingly, between 20 and 50% of post-COVID patients meet the diagnostic criteria for ME/CFS, depending on the study. People in their young to middle ages—between 20 and 40 years old—are particularly affected, including those without any apparent pre-existing conditions.
It is estimated that approximately 0.2 to 0.4% of the global population is affected by ME/CFS, although prevalence varies by region and diagnostic criteria. In Germany, prevalence prior to the COVID-19 pandemic was estimated at approximately 300,000. Experts report a high number of unreported cases. As a result of the COVID-19 pandemic, the number of affected individuals is expected to have at least doubled.
Pathomechanisms
The exact causes of ME/CFS are not yet fully understood, but it is believed that several factors play a role, including infections, immune disorders, neuroendocrine dysregulation, and genetic predispositions. There is evidence that viral infections may be a trigger, which is particularly significant in the context of post-COVID.
Similarities:
- Fatigue, exhaustion, and post-exertional malaise (PEM): Both conditions are characterized by severe, often debilitating exhaustion that worsens after even the slightest exertion.
- Severe physical limitations: The majority of those affected rely on outside help, have a care level designation, and require assistive devices; some are completely bedridden, while others can manage household chores with great difficulty.
- Sleep disturbances: Prolonged sleep episodes and the feeling of not waking up refreshed are typical of the clinical picture.
- Cognitive impairments: Difficulty concentrating and “brain fog” are common in both ME/CFS and post-COVID.
- Autonomic dysfunction: Symptoms such as dizziness, palpitations, and problems with temperature regulation occur in both conditions. As a result, there is also an overlap with what is known as postural orthostatic tachycardia syndrome (POTS). This condition often represents a complication of both post-COVID and ME/CFS.
Differences:
- Origin: ME/CFS can be triggered by various factors, whereas post-COVID specifically occurs following a SARS-CoV-2 infection.
- Course: ME/CFS is often a protracted, chronic condition, whereas with post-COVID, symptoms may subside after several months, although some cases can also become chronic.
- Classification: ME/CFS has its own clearly defined classification with diagnostic criteria (e.g., the Canadian Consensus Criteria), whereas post-COVID is a broader syndrome that does not yet have a standardized definition.
Comparison Table: ME/CFS vs. Post-COVID
| Characteristic | ME/CFS | Post-COVID |
|---|---|---|
| Origin | Various triggers, often following viral infections | Following an acute SARS-CoV-2 infection |
| Exhaustion (PEM) | Yes | Yes |
| Sleep disturbances | Yes | Yes |
| Cognitive symptoms | Yes (brain fog, trouble concentrating) | Yes (brain fog, difficulty concentrating) |
| Autonomic dysfunction | Yes (e.g., dizziness, tachycardia) | Yes (e.g., dizziness, tachycardia) |
| Duration of symptoms | Chronic, often lifelong | Variable; may subside or become chronic |
| Diagnostic criteria | Canadian consensus criteria, Fukuda criteria | No uniform criteria; often symptom-based |
Long COVID remains a serious challenge that significantly impairs the lives of many affected individuals even long after the acute COVID-19 infection. The persistent symptoms can substantially reduce quality of life and require targeted medical care. These long-term effects underscore that COVID-19 is not merely a temporary illness but can have long-term health consequences.
Given these risks, it remains crucial to protect oneself and others from reinfection. Rapid tests that are easily accessible and simple to administer are an effective means of curbing the spread of the virus. Regular testing, especially when symptoms are present or after contact with infected individuals, helps detect infections early and prevent the spread of the virus. This is particularly important for preventing the onset of Long COVID and protecting vulnerable populations.
At a time when many people consider the pandemic to be over, it is essential to remain cautious and take advantage of the available protective measures. In this way, we can work together to minimize the long-term health consequences of COVID-19 and safeguard the health of society as a whole.
