iQ&A Update March 2022

24 Mar 2022

The IPCRG iQ&A releases more evidence based answers and updates to your questions

As our IPCRG Sentinel Network continues to update us on key issues in primary care, the IPCRG iQ&A service has developed new and updated answers to help colleagues tackle some of these issues. The 34 answers provide a valuable primary care specific library of desktop helpers, which can be used for quick reference to update you on the latest evidence.

As Omicron variants have become dominant in many countries, we have updated our answers to keep up with the fast moving pace of emerging evidence. Updated answers include COVID-19 treatments, while answers on the use of nebulisers and flu vaccination have proved to be the most popular with several hundred views each.

In 2022 we expect COVID-19 questions to remain important to our network, but we also want to hear more about the respiratory issues that are prominent. If you wish to contribute questions, please join our IPCRG Sentinel Network.

The latest answers and updates are:

What should we advise patients regarding fourth and subsequent SARS-CoV-2 vaccine doses?

SARS-CoV-2 vaccine effectiveness declines with time since primary vaccination as antibody levels decline (WHO 2021). As a result, the protection offered against severe COVID-19 illness decreases by ~8% over a period of six months; this decrease in protection is higher among those over 50 (~10%; WHO 2021). The degree of waning depends on the vaccine product, the population considered, the level of circulating virus and the predominant variants of concern, as well as the extent of prior infection in the community and primary vaccination schedule (dose interval). Loss of protection against symptomatic disease is higher, estimated at around ~32% in those >50 years; WHO 2021).

Third dose booster vaccination has been shown to be safe and to increase antibody levels (Munro et al 2021) and to reduce both the rate of infection and the rate of severe illness (Bar-On et al 2021). Data on the duration of protection from infection, symptomatic disease and severe illness following booster vaccination is currently limited. An early study of booster vaccination with the Pfizer BioNTech vaccine suggests a rapid decline in protection from infection with implications for ongoing community spread of the virus (Levine-Tiefenbrun et al 2021). Data on loss of protection against severe illness are lacking although studies are ongoing and early indications suggest this may be markedly slower than for protection against infection/mild COVID-19 illness.

The emergence of the more transmissible Omicron variant has prompted many countries to increase the rate and shorten the interval for booster vaccination as this variant becomes dominant. For example, a fourth dose booster for individuals at high risk for severe COVID-19 illness is now recommended in some countries. However, a clear evidence base to support a broad-based booster program is lacking. The WHO continues to recommend targeted booster (third dose) programs for those most at risk for severe illness, particularly in light of low primary vaccination rates in low income countries. In addition, the WHO continue to emphasise the need to focus of delivering primary vaccinations to the entire global adult population before extending booster vaccinations beyond high risk groups.

The effectiveness of current vaccines against severe COVID-19 illness caused by the Omicron variant remains under evaluation and it may be that alternative vaccines specific for this and any future variants will be needed. The WHO states that booster doses of current vaccines are not a viable long term solution and specific vaccines against specific SARS-CoV-2 variants will likely be needed.

What do we know about the effect of long COVID and its impact on asthma or COPD patients?

Estimated prevalence of long-COVID (symptoms 12+ weeks following acute COVID-19 illness) vary considerably, ranging from <5% to >80% of patients following acute COVID-19 illness (Cabrera Martimbianco et al 2021). In a UK-based longitudinal study of 6899 adults who self-reported acute COVID-19 illness, long-COVID (symptoms beyond 12 weeks) increased with age from ~7.8% (mean age 28 years) to ~17% (mean age 58 years) (Thompson et al 2021). Among those hospitalised with COVID-19, between 50% and 89% have been reported to have at least one enduring symptom after 2 months after discharge (NIHR 2021). These estimates are based on the situation when the predominant SARS-CoV-2 variant was Delta and the picture may change once data for periods when the Omicron variant data was dominant.

Symptoms associated with long-COVID may impair an individual’s ability to function in their daily lives including performing activities of daily living and work. The most common symptoms include: fatigue, dyspnoea, cardiac abnormalities, cognitive impairment, sleep disturbances, symptoms of post-traumatic stress disorder, concentration problems, muscle pain and headache (Crook et al 2021).

A higher risk for long-COVID has been reported for those with asthma (as much as 32% increased risk reported in one study; Thompson et al 2021). In a UK-based survey of 4500 individuals with asthma 10.5% reported COVID-19 illness. Of these, 56% reported having long-COVID and were more likely than those without long-COVID to describe their breathing as worse/much worse, reported increased inhaler use and worse or much worse asthma management (Philip et al 2022).

In a UK-based primary care population, COPD, bronchitis and emphysema was not associated with an increased risk for long-COVID (defined as symptoms ≥4 weeks) (OR 1.53; 95% CI [0.84–2.72]; Jones et al 2021). In a prospective single-center study COPD was associated with symptom persistence at 12 months following discharge from hospital for acute COVID-19 illness (Fumagalli et al 2021). No systematic data on the risk factors and symptom profile of long-COVID among patients with COPD are yet available.

What this means for your clinical practice:

• Continue to follow-up with patients once they recover from acute COVID-19 illness of any severity, with particular vigilance for symptoms persisting beyond 12 weeks from onset of the acute illness
• For patients with asthma or COPD, review regularly

With grateful thanks to Karin Lispers, Associate Professor (Family Medicine and Preventive Medicine, Uppsala University, Sweden) for and on behalf of the IPCRG practice driven answers review group.

Useful links and supporting references:

Cabrera Martimbiano AL, et al. Frequency, signs and symptoms, and criteria adopted for long-COVID-19: A systematic review. Int J Clin Pract 2021;75:e14357.

Crook H, et al. Long covid – mechanisms, risk factors, and management. BMJ 2021;374:n1648.

Fumagalli C, et al. Factors associated with persistence of symptoms 1 year after COVID019: A longitudinal, prospective phone-based interview follow-up cohort study. Eur J Intern Med 2021; S0953-6205(21)00405-2.

Jones R, et al. Risk predictors and symptom features of long COVID within a broad primary care patient population including both tested and untested patients. Prag Obs Res 2021;12:93–104.

NIHR. Living with COVID19 – Second review. March 2021. Available at: https://evidence.nihr.ac.uk/themedreview/living-with-covid19-second-revi.... Accessed February 2022.

Perez Gonzalez A, et al. Long COVID in hospitalized and non-hospitalized patients in a large cohort in Northwest Spain, a prospective cohort study. 2021. Preprint not yet peer reviewed. Available at: https://www.medrxiv.org/content/10.1101/2021.08.05.21261634v1. Accessed January 2022.

Philip KEJ, et al. Impact of COVID-19 on people with asthma : A mixed methods analysis from a UK wide survey. BMJ Open Respir Res 2022;9:e001056. Available at: https://bmjopenrespres.bmj.com/content/9/1/e001056/. Accessed January 2022

Thompson EJ, et al. Risk factors for long COVID: analyses of 10 longitudinal studies and electronic health records in the UK. 2021. Pre-print (not yet per-reviewed). Available at: https://www.medrxiv.org/content/10.1101/2021.06.24.21259277v2. Accessed January 2022

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iQ&A Update March 2022

The IPCRG iQ&A releases more evidence based answers and updates to your questions

The latest answers and updates are:

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