COVID-19 Long-Haul Effects
CRL Chief Scientific Officer Dr. Robert Stout discusses the lasting impact of COVID-19 infection in both symptomatic and asymptomatic patients. With symptoms impacting all patients, the “long-hauler” survivors will likely impact insurers’ decisions into the future.
Life insurance is about the financial protection of families over the long term. While short-term catastrophe may unexpectedly end or shorten a projected life expectancy, most are infrequent and priced into our life insurance products. But occasionally, events occur that impact most of the population; the SARS-CoV-2 epidemic has been such an occasion.
The global short-term cost of the pandemic is enormous, with projections of sixteen trillion dollars¹. While the impact for insurance claims is high, they fall within the capital reserves that our industry maintains. However, the short-term losses may only be a small portion of the future cost of SARS-CoV-2.
When cases first occurred, the clinical picture was elderly patients hospitalized with severe life-threatening respiratory lung disease. As our understanding of the underlining mechanism evolved, it soon became apparent that the infection was far more widespread than the lungs. Additional affected organs included the heart, liver, kidneys, brain, and the endothelial lining of the vascular system. It now appears that any tissue with ACE2, type 2 angiotensin receptor were targets of infection.
Survivors of symptomatic COVID-19 infection originally introduced the name “long-hauler.” It is now apparent that the term also applies to a much larger group that was asymptomatically infected. The clinical basis for long-haulers is the constellations of poorly understood symptoms that may persist for months after the resolution of the infection. Those symptoms include:
- Fatigue
- Shortness of breath or difficulty breathing
- Cough
- Joint pain
- Chest pain
- Memory, concentration, or sleep problems
- Muscle pain or headache
- Fast or pounding heartbeat
- Loss of smell or taste
- Depression or anxiety
- Fever
- Dizziness when you stand
- Worsened symptoms after physical or mental activities
Clinically, months after clearance of the virus, magnetic resonance imaging (MRI) studies demonstrate structural damage to the heart in 78/100 (78%) patients². These findings occur independently of the severity of the infection and clinical course. In addition, endomyocardial biopsy in patients with abnormal MRI documents lymphocytic inflammation in the myocardium of 60% of patients³. These findings are a significant concern in the future management and potential changes in the mortality of these patients.
Mental fog is another common complaint without a clear explanation; this includes cognitive dysfunction, including memory loss with loss of concentration, anxiety, depression, loss of taste and smell. After clearing the COVID-19 infection, the ongoing inflammatory and vascular changes that persist may provide the molecular mechanism for the neuropsychiatric symptoms. This proposal is speculation and requires research to determine its correctness.
CRL Research Summary
We examined the seroprevalence of COVID-19 in the insurance applicant population. Serum samples for 138,696 insurance applicants were analyzed for antibody to COVID-19 nucleocapsid protein (NC) with the Roche SARS-CoV-2 test. Antibody to Nucleocapsid documents infection, not vaccination. Testing was at approximately three-month intervals. We have previously published parts of this data⁴⁵.
Table 1. Seroprevalence of COVID-19 by applicant sex at four time periods.
Table 2. Seroprevalence of COVID-19 by age band and test period.
Conclusions: Currently, more than 25% of the insurance applicant population is seropositive for antibodies to COVID-19, indicating prior infection. In contrast to hospitalized patients, the highest prevalence is in the younger age group, under age 50. In addition, the long-term cardiovascular, cerebrovascular, and chronic inflammatory risk in recovered applicants is currently unknown. With this in mind, those “long-hauler” applicants present a tough underwriting challenge.
References
1. The COVID-19 Pandemic and the $16 Trillion Virus. David M. Cutler, Ph.D.; Lawrence H. Summers, Ph.D. JAMA. 2020;324(15):1495–1496. doi:10.1001/jama.2020.19759
2. Outcomes of Cardiovascular Magnetic Resonance Imaging in Patients Recently Recovered From Coronavirus Disease 2019 (COVID-19) Valentina O. Puntmann, MD, Ph.D.; M. Ludovica Carerj, MD; Imke Wieters, MD; et al. JAMA Cardiol. 2020;5(11):1265–1273. doi:10.1001/jamacardio.2020.3557
3. 6-month consequences of COVID-19 in patients discharged from hospital: a cohort study. Chaolin Huang, Lixue Huang, Yeming Wang, Xia Li, Lili Ren, Xiaoying Gu, Liang Kang, Li Guo, Min Liu, Xing Zhou, Jianfeng Luo et al. Lancet 2021 Jan 16;397(10270):220–232. doi: 10.1016/S0140–6736(20)32656–8. Epub 2021 Jan 8.
4. The Silent Pandemic COVID-19 in the Asymptomatic Population. Robert L. Stout, Ph.D.; Steven J. Rigatti, MD doi: https://doi.org/10.1101/2020.12.29.20248985 January 04, 2021 DOI: 10.23880/Epidemiology International Journal-16000175
5. Seroprevalence of SARS-CoV-2 Antibodies in the US Adult Asymptomatic Population; Robert L. Stout Ph.D; Steven J. Rigatti, MD https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2777502 Mar 16, 2021
About the Author
Dr. Robert Stout serves as Chief Scientific Officer and Laboratory Director for CRL’s General Laboratory. He provides scientific direction and research leadership for all of CRL with particular focus on research for CRL’s Insurer Services business. Dr. Stout, who has been with CRL since 1983, holds more than ten U.S. Patents in science, including one for immunoassay method and apparatus development (U.S. Patent #4,414,324) and one for methods of determining chronic Hepatitis C infection (U.S. Patent #10,051,253). He is the author of numerous research and review articles and is a regular presenter at scientific meetings and conferences. Dr. Stout holds a B.S. in Biochemistry from California State University and a Ph.D. in Biological Chemistry from U.C.L.A. School of Medicine.
