Investigating Long Covid in Africa and South America with Gina Perez-Giraldo, MD

• Perez-Giraldo says her motivation to study medicine is a bit uncommon; she was intrigued after watching a TV show about researching the soul through the nervous system. She completed her medical school training in her home country of Colombia and then came to the United States for further training.
• Perez-Giraldo had an interest in global health early on in medical school and says transitioning from an environment of limited access to healthcare to a wealthy country like the U.S., with different access to medical care and research, motivated her to do global health research.
• She completed her residency at the University of Oklahoma, where she developed a strong interest in autoimmune diseases and neuro infectious diseases. She furthered her training at Northwestern University as a neuro-immunology fellow and global neurology fellow.
• She arrived at Northwestern in July 2021 and began work in the Neuro COVID-19 Clinic there, led by Dr. Igor Koralnik, seeing patients and working on research.
• Perez-Giraldo says research shows that in the United States, about 30% of the COVID 19 survivors will have persistent lingering symptoms and Long COVID is now the third leading cause of consultation to see a neurologist in the United States. Brain fog is the most common symptom followed by headache and fatigue . 
• Some people can recover from Long COVID in three months, but she says there's other people who are still affected two years later. 
• Up to 40% of individuals who had Long COVID took more than 10 days off work and had persistent cognitive symptoms, which could be potentially disabling. With cognitive rehabilitation there is a trend towards improvement over time, though it is unknown how Long it will last for each person. It's more likely that women and those with autoimmune conditions will develop it. 
• While most studies on Long COVID have only taken place in the U.S., Europe and Asia, investigators suspect Long COVID is not just limited to high-income countries and also exists in low and middle-income countries.
• Perez-Giraldo worked on a research project in Nigeria that identified around 6.7% of patients with persistent neurological symptoms of Long COVID. Symptoms reported in Nigeria were similar to those found in the US, including brain fog, fatigue, and headaches. Rates of depression and anxiety were lower in Nigeria, but this may be due to cultural perceptions and underreporting.
• She is now expanding this research into her home country of Colombia, to determine the prevalence and impact of Long COVID on cognitive function there. Both sites in Nigeria and Colombia are working to establish NeuroCOVID clinics that also conduct research, such as the one at Northwestern does.

Rob Murphy, MD [00:00:06] Welcome to the Explore Global Health Podcast. I'm Dr. Rob Murphy, executive director of the Havey Institute for Global Health here at Northwestern University Feinberg School of Medicine. Long COVID syndrome or Long COVID, also known as the post-acute sequelae of COVID 19, is being studied throughout the United States, Europe and Asia. But there have been less than five studies per continent on this condition in Africa, Oceania and South America. So it's been much more heavily studied in the higher income countries than in the West. Today's guest is working to change that. Dr. Gina Perez Giraldo is a second year neuro immunology fellow and global neurology fellow here at Northwestern University, and she's been working on establishing neuro COVID 19 programs in Nigeria and in Colombia and collecting data to help characterize this debilitating syndrome around the world. She joins me today to talk about this work and the path she has carved out in global health. Gina, welcome to the podcast. 

Gina S. Perez Giraldo, MD [00:01:13] Yeah, of course. And thank you. Dr. Murphy. Thank you for having me. 

Rob Murphy, MD [00:01:17] You began your career in global health in your home country of Colombia as a medical student. Can you tell me what was your motivation to study medicine and then what was your motivation to come to the United States for further training? 

Gina S. Perez Giraldo, MD [00:01:29] Well, my motivation to study medicine was a little different to what you typically hear in Colombia, South America, in general. We don't do college like we go straight from high school to whatever you want to do as a career. So when now I was supposed to be a lawyer because my parents are both lawyers, but at the end of high school, I saw this TV show talking about neuro philosophy and looking at trying to research the soul through the nervous system. And that's when I was like, "Oh, that's really cool." I decided I wanted to study medicine to eventually learn about the nervous system and definitely was very different to why you hear why people go into medicine. But as I started medical school and did my electives in neurology confirmed that that was the right decision and here I am. 

Rob Murphy, MD [00:02:20] What made you come to the United States for further training? How did that happen? 

Gina S. Perez Giraldo, MD [00:02:25] I always knew that I wanted to do my training somewhere else.  I had a great life in Colombia, like, all my family's there and everything was great. I have no complaints. I just always knew that I wanted to get out of my comfort zone. I feel like every time that you get out of your comfort zone, do something different. You grow, you evolve. So I always knew that I wanted to do that, that I wanted to train somewhere else. My medical school had a strong affiliation with the University of San Antonio, Texas, in San Antonio. So I did an internship there when I was in medical school, and I decided to do it to just go to a new place, a new language. 

Rob Murphy, MD [00:03:07] How Long were you in San Antonio? 

Gina S. Perez Giraldo, MD [00:03:08] I was there for six months and there was some sort of medical school there, so I thought it would be fun to just do something completely different and decided to start all the process to do my residency here. And that's how I ended up here. 

Rob Murphy, MD [00:03:22] So how did you end up at Northwestern? 

Gina S. Perez Giraldo, MD [00:03:24] I did my residency first at the University of Oklahoma. Those were my first four years of training. Once I did neurology, I got very interested in autoimmune diseases and neuro infectious diseases. And Northwestern specifically has a great neurology program with the addition of having a neuro infectious diseases program too. So I applied and here I am. 

Rob Murphy, MD [00:03:51] Have you always wanted to focus on global health as part of your training, or was that something that evolved later, or did it started early in medical school or even before medical school? 

Gina S. Perez Giraldo, MD [00:04:02] I think that that's something that started early in medical school. That's part of the reason why I also knew that I wanted to do my training somewhere else wanted to see other places, see how the health care systems were in different places. And I think that being from a third world country and being exposed and seeing patients that beLonged to underserved areas, like knowing that there's a limit of access to certain resources, makes you have some certain sensitivity to it. And specifically, once you transition from that environment to wealthy countries like the US that has such different access to medical care, such different access to just like diagnostics and treatments, and you know that that is not the case everywhere in the world. And you know that there's not that access to research in other places. I think that that's what got me specifically motivated to do global health. I'm in a position now that I'm working here in the U.S. I think it's great to give back to not only my country but other places that don't have such access to health care and research and hopefully help decrease that gap that definitely exists. 

Rob Murphy, MD [00:05:18] You completed your residency training in neurology at University of Oklahoma, like you said, and then you started your neuro immunology training at Northwestern in July 2021 during the COVID pandemic. Northwestern Fellowship focuses on multiple sclerosis and neuro immunology. But then during the pandemic, there was this pivot and you started caring for patients with Long COVID and publishing studies about these patients, and that became a big part of the fellowship. Can you elaborate a little bit more on that? You really adapted your training to accommodate what was going on all around you and all around the world. 

Gina S. Perez Giraldo, MD [00:05:59] Once I arrived in July 2021, the Dr. Koralnik, he had already started the clinic. Dr. Koralnik has had like the experience and neuro HIV in the past, and then they started seeing patients that were just consulting in the clinic because even though they didn't have severe COVID infection, they were having this persistent lingering neurological symptoms. So he created the clinic and gave the opportunity to the fellow to be involved. That's how it all got started. Then he also opened the doors because he was doing research already. The group already had publications before I joined the team, but he opened the doors for me to be part of his research project and that's when I joined and have been working now for over a year and have almost two years. We have a weekly clinic which we only see neuro ID, but we mostly see neuro COVID patients. 

Rob Murphy, MD [00:06:51] Yeah, and you mentioned Dr. Igor Koralnik and the pretty well known clinic that he started about Long term neurologic complications of covid. Dr. Koralnik is the program director of our global Health Program in neurology, and so he's been with us since the beginning, which was only 2019, actually just a year before the pandemic started. Can you give us a little information about the overall prevalence of Long COVID in the United States, and particularly the proportion of people that have neurologic symptoms and what kind of symptoms they have In. 

Gina S. Perez Giraldo, MD [00:07:26] The United States, about 30% of the COVID 19 survivors will have persistent lingering symptoms. So of all the millions of people that have been infected in the US, 30% of those will have some lingering symptoms, which is a pretty high number. And then we know now that neurological Long-covid or neurological sequelae out of COVID 19, it's now the third leading cause of consultation to see a neurologist in the United States. Like this was declared last year by the president of the American Academy of Neurology. So it became a very prevalent condition and a very common cause of consultation. The most common ideological symptom as well, people called brain fog. Brain fog means different things for different people. Some people describe brain fog and they mean having memory problems or other people is attention problems, or other people just feel like they're in a daze, that they feel like they are out of it. And that's the most common we have seen in our research over 80% of the patients that come to see us in our clinic report some degree of brain fog. Other common symptoms that we see are headaches. About 70% of the patients describe that they have headaches. Patients say that they have depression, anxiety as well, related to either people that never had depression and anxiety and after COVID, they noticed that they definitely had new and say they've never had or they already had it but it got worse after the infection. We hear that very often. Other common symptoms are myalgia, like pain in the muscles or people lose their sense of taste and smell never comes back or they develop parotid mass meaning smells. Now things smelled badly or they cannot enjoy foods because they taste horrible. Those are common ringing in your ears, blurry vision, a lot of pain and neuropathy, like feeling like pins and needles. Hands and feet is also commonly described. So it's this variety of symptoms that affect the nervous system in different, different ways. But the most common one, it's definitely brain fog. That's what we hear about the most. 

Rob Murphy, MD [00:09:47] It's incredibly common, as you mentioned. How debilitating actually can it be? I mean, are these people working? Are they able to work or they can't work anymore? Is this really disabling? And and if so, how Long does this last? Do they get better on their own or is it chronic? 

Gina S. Perez Giraldo, MD [00:10:07] We actually have tried to look into that in one of the earlier publications that Dr. Koralnik and colleagues had once the clinic started was trying to characterize the patients that were never hospitalized that develop Long covid and to try to see how disabling it was. They actually found that about 48% of those patients had to take some more than ten days out of work. It definitely affects the workforce. Very commonly, people have to take leaves. They cannot go back to work, that there's their disability. Up to 40% that we saw in the research took more than 10 days off of work. So we have a young population that are in their prime while still productive life that now have this disabling, potentially disabling cognitive symptoms that are not allowing them to work very well. They also have a little fatigue that also interferes with their daily routine, daily lifestyle. We don't really know how Long is going to last. We have tried to look into that as well. There's actually a paper notice published looking at the evolution of symptoms, and there was a follow up. The first patients that we're seeing in the clinic and the median time in which they were seen was about nine months later. And really, the only symptoms that got significantly better where the loss of sense of taste and smell. Otherwise, patients continued to have their brain fog sensation, the fatigue and the other things that I just mentioned. So it seems to be that the symptoms persist over time. However, we are not able to say how Long is going to last for each person. There's people that get better in three months and there's people that it's been two years and they're still affected. And we have not been able to predict who is going to be the one that gets better, quicker and who's going to be the one that takes them Longer. But we do see as a whole that people tend to get better over time. 

Rob Murphy, MD [00:12:08] Well, that's encouraging. 

Gina S. Perez Giraldo, MD [00:12:09] Yeah. In this study specifically, we saw that the first visit people felt that there were about 65% back to baseline. And the follow up, they said they felt they felt that there were about 75% back to baseline and this was statistically significant. So overall, there is a trend to improvement, but there is definitely presence of persistent symptoms over time. We just everybody just follows our own trajectory. Everybody goes at their own pace. 

Rob Murphy, MD [00:12:36] Have you been able to identify what puts somebody at risk for a Long COVID? Is the gender based, age based severity of disease, no vaccine, vaccine? What are some of the risk factors? 

Gina S. Perez Giraldo, MD [00:12:51] Yeah, that's a great question. So we have been able to identify some things. For example, we have been able to identify that people that have a history of autoimmune conditions, they are more likely to develop Long COVID that we identified and also women are more likely to develop Long-covid. In all of the studies that we have done Long COVID is always more prevalent in women as compared to men. And this has led us to think, as we know, that women have a higher tendency to develop autoimmune diseases. And we know that people that have autoimmune diseases at baseline have a higher likelihood of developing of COVID. We think that Long COVID likely represents some sort of autoimmune dysregulation and some of autoimmune conditions, and we think that that is one of the risks will be being a woman having autoimmune conditions at baseline. We also recently, this was one of my fellowship projects that just recently got accepted in Annals of Neurology. We wanted to compare being hospitalized and not be hospitalized like somebody that had COVID that was severe enough to have to be in the hospital and somebody that didn't have severe COVID. And but both groups developed Long COVID wanting to compare them and see what they had in common or what are they different. We found that the neurological symptoms overall were similar, like the brain fog. And overall things were about the same between the two groups. The exception were that patients that were not hospitalized had more muscle pain like more myalgins. And also more loss of sense of taste and smell. But other ways the brain fog was similar between the two groups. However, we did find which was interesting, is that the patients that were in the hospital because we once we see the patient in our clinic, we do a cognitive tests, the patient perceives their memory problems as brain fog, but we want to be able to determine exactly what the problem is. So we do a task that is called image toolbox, in which we test different aspects of cognition, attention, executive function, working memory. And then we're able to, once we're able to identify what the problem is, we need the patients cause we know what is expected out of them. We send them to cognitive rehab, we have our cognitive rehab program at Shirley Ryan. So what we found is that the specialists that were hospitalized had a significant decrease in cognition executive function at. And working memory in this was statistically significant. And the patients that were not hospitalized only had decreased attention. Now, the other domains. So it looks like the patterns of cognitive dysfunction are different between those two groups, which lets us think that the etiology of Long-covid is different for those two groups. They're not apples and apples, they're different. That's what we're working on now, trying to see like what is would think that perhaps patients was in the hospital with acute illness, perhaps had some sort of neurological damage. That leads to a specific pattern of cognitive deterioration that the non-hospitalized situation didn't have. So that is what we're working on right now as well. 

Rob Murphy, MD [00:16:06] What do we know about Long COVID in low and middle income countries? I mean, most of the reports I've seen, it's they're all from the U.S. or Europe. 

Gina S. Perez Giraldo, MD [00:16:15] That is a great question, and that is why they as well has inspired us to expand our research to other middle income and low income countries. In Nigeria, we have there's a group of Nigerian collaborators in Lagos, Nigeria. They're incredibly proactive, incredibly hardworking, and they're also launching a neuro covid clinic. They already have preliminary data that we share that global health they with you guys in because they didn't have any information. First of all, the real burden of just COVID infection itself in Nigeria is not accurately known because many patients didn't really get tested or went to the hospital. They suspect that the real burden of COVID and then COVID is higher than what we actually even think. What they have found in their studies, they have done a great work and researchers have identified around 3000 patients that had COVID, they called them see them in the clinic, and of those a small amount reported having persistent neurological symptoms. It wasn't 30% like we have heard here in the US. For them, the number went down to only 91 patients, which was like 6.7%. And then they saw that,  they also try to compare those that were in the hospital, those that were not in the hospital, and they said that both groups had persistent neurological symptoms and they found very similar symptoms to what we have found here in the U.S. Like about 60% of the patients reported having brain fog, fatigue, headaches were common for them to. And something that is interesting is that the rates of depression and anxiety were much lower than what we had seen in the US. But they suspect that this is more due to the cultural perception that you don't really talk about depression, that anxiety, or he don't really report having depression or anxiety. So they suspect that this is much higher than what we're seeing. So basically this preliminary data is showing us that Long-covid does exist in Nigeria. They have cognitive symptoms to like. People have come to the US and the extent of how much it affects them, it's something that we still need to investigate, but we have been able to determine that it does exist in Nigeria too. We are interested in knowing how much does it affect South Americans, and that's where we decided to manage this project in Colombia too, which is where I'm from originally, because we don't know really what our numbers are people being affected by neurological sequenza of COVID 19 in Colombia? So that inspired us to do this and this now we're finally at the point that we're ready to start recruiting patients and talking like there's been a lot of conversations with neurologists and everybody. They tell us that they definitely, definitely have very frequent consultations from patients saying after I had COVID my memory's not the same, after I had COVID I couldn't concentrate after I had COVID my performance of work is not the same. So it sounds like it's it's present there, but we still don't have numbers to know how prevalent that is and how disabling it is. 

Rob Murphy, MD [00:19:34] How did you jump from Nigeria to Colombia? 

Gina S. Perez Giraldo, MD [00:19:38] The Institute of lower held Northwestern is funding not only my fellowship and the second year, but also I was given a grant to start a project. Since I am from Colombia and I had my medical school like that. Well, maybe we can do it there. We started talking with them since January of 2022. We have had to overcome several obstacles to be able to establish the collaboration. It hasn't been a very straightforward thing to do and it definitely has taking a lot of conversations. I think that it's been interesting learning how every country has their own limitations. Like even though I like the institution that we're working on, which is my medical school I know is extremely serious. It's excellent institution, but there's regulations that they need to pass. Like they, for example, needed a lot of forms and extra things that we were not expecting and must be, "Why do we need all this?" And they told me, Well, it's because there's such high corruption in the country that we're highly regulated so we need to take all this extra steps because that's just the regulations that they have that we don't have those kind of states in the United States. So that has been interesting to navigate through. But fortunately now we're at a place I would ready to start recruiting patients. But that's what led us to Colombia, because that's where I'm from. And the Institute of Global Health funded, the project there, Nigeria in the Dr. Koralnik currently had already established the collaboration before I started my fellowship. He already had contacted the people in Lagos. He had already set that before I arrived. And you'll be interested in knowing this, but the next fellow who's coming the next neurology fellow, she's going to be here in July. She was listening to one of our talks and she's saying maybe we can start one in Bangladesh. She has contacts in Bangladesh and she's interested in why not just state setting a clinic there. So maybe we will have another continent that can join our projects. 

Rob Murphy, MD [00:21:39] What kind of cultural barriers did you run into? 

Gina S. Perez Giraldo, MD [00:21:44] I think that the biggest one has been the population will not seek for help unless like for something that is not perceived as disabling, like the population will not seek, for they will not go to a doctor or a hospital for chronic fatigue or feeling like they cannot concentrate because that is not unless you're seriously dying from something, you're not going to go ask for help. And that leads to under detection of the problem and that really people are suffering in silence without really getting help. And I think that that's similar in Colombia, too, honestly, because I went to visit home just last summer and I was talking with my uncle who was driving me to all these places and his like, you know, after I had COVID yeah, kind of not as sharp, but, you know, that's just life. And, you know, it's just a very different perception of when I go look for help. That's what it is here in higher income countries. I think it's a shame because everybody should get access to help and everybody should, especially for something that can be potentially disabling or interrupted your performance. So I think that that has been the biggest cultural barrier and just people admitting to feeling anxious or depressed. Our collaborators will tell us that in Nigeria you will really have to dig really hard asking the patient about mental health for them to acknowledge that they do have depression and anxiety which is also different to what the culture is in the US as well. 

Rob Murphy, MD [00:23:14] Gina, you're almost at the end of your fellowship here after two years. What's the next what's next for you? 

Gina S. Perez Giraldo, MD [00:23:23] Well, when I have a baby. 

Rob Murphy, MD [00:23:24] Congratulations, by the way. 

Gina S. Perez Giraldo, MD [00:23:26] Thank you. Thank you. I'm going to start my first official job, a faculty position in July at the Medical University of South Carolina MUSC in Charleston, South Carolina. I definitely plan to keep Global Health as of my career. The Medical University of South Carolina also has a globla health institute I plan to be a part of. I already contact with them. I plan to continue to be involved with Northwestern. With Dr. Koralnik we plan to continue to collaborate. We started this project in Columbia and I definitely want to continue to be a part of it. Even if I'm in a different institution. I feel like once we have started one project, we're opening doors for other projects in the future. So I'm sure that we'll be able to collaborate with Columbia, Nigeria and many other places in the future with other projects as well and really excited for the future. 

Rob Murphy, MD [00:24:20] Any advice you could give for students, both U.S. and non-U.S., who want to take on global health? 

Gina S. Perez Giraldo, MD [00:24:28] I think that my advice would be that just having an idea and finding people that share the passion that you have, your idea, it's really the most important thing. There's going to be obstacles. As I said, the Colombia project is taking us time to go to be at the place that we're at today. But you just keep finding people that share the interest that you have and people will try in places like Colombia or Africa that don't have access to such support in their regular lives. They're very interested. I mean, they'll try to overcome the obstacles like the obstacles that we went through. They were the ones that were trying to find the solutions, like they're very resourceful. So I think it's just having the idea and the passion and just keep insisting. And things will happen. Just having to support a circus like this one thinks can really happen. 

Rob Murphy, MD [00:25:28] Gina, thank you very much. 

Gina S. Perez Giraldo, MD [00:25:29] Thank you very much. Thank you for having me. And thank you for all your support. 

Rob Murphy, MD [00:25:38] Follow us on Apple Podcasts or wherever you listen to podcasts to hear the latest episodes and join our community that is dedicated to making a lasting positive impact on global health.