Sleep and COVID: Sleep-related symptoms, ‘transient’ vaccine-related side effects and more

Indira Gurubhagavatula, MD, MPH, associate professor of medicine and director of the Sleep Medicine Fellowship at Penn Medicine, spoke with Healio about the relationship between COVID-19 and sleep.

Healio: What does current research say about the relationship between COVID-19 and sleep?

Gurubhagavatula: There is evidence of an association between COVID-19 infection and disordered sleep. We have seen data that suggest underlying sleep disorders may increase the likelihood of developing COVID-19 or having worse outcomes from the viral illness. Conversely, there is also evidence to suggest that COVID-19 itself can cause or worsen sleep disturbances.

In the initial days of the pandemic, social, economic and occupational stressors were present, which also contributed to a high prevalence of insomnia; this was experienced even more commonly among front-line workers, including those in health care. Some groups also had changes in health habits, with more consumption of alcohol and caffeine, greater use of screens, less physical activity due to the closure of gyms, and later bedtimes and rise times, which may have contributed to disordered sleep.

Healio: How are patients with sleep disorders affected if they contract COVID-19?

Gurubhagavatula: Sleep is an important modulator of the immune system; healthy sleep allows for a healthy balance between pro-inflammatory and anti-inflammatory molecules to generate a robust immune response to infection or vaccination. Sleep disorders, then, can impair our immune response.

Sleep apnea is a common sleep disorder in the general population. Data show that during the acute phase of infection, patients may not be able to tolerate continuous positive airway pressure therapy, which is the first-line treatment for sleep apnea. CPAP consists of a mask worn over the face, which is connected to a machine that blows a gentle stream of air into the throat to keep the airway open during sleep. During viral illnesses, some patients find it difficult to use CPAP; as a result, their sleep apnea symptoms come back and can include snoring, sleep fragmentation, daytime sleepiness, headaches and needing to urinate more frequently at night.

Data also show that people with sleep apnea who develop COVID-19 fare worse and are more likely to get admitted to the hospital, need a ventilator or require intensive care. COVID-19 is thought to be an inflammatory disease that can affect lung tissue and cause drops in oxygen levels; sleep apnea affects tissues similarly, by worsening inflammation and causing oxygen drops during sleep. So, the two together can lead to worse outcomes.

Other sleep disorders, such as chronically insufficient sleep, insomnia or shift work sleep disorder, also may increase the risk of contracting COVID-19 by impairing immune defense systems; they can similarly reduce the immune response to vaccination. There are data that show just one single night of insufficient sleep can reduce the immune response to influenza A and hepatitis A vaccinations.

The reverse association has also been found: Patients with COVID-19 experience a variety of sleep-related symptoms during their illness, including excessive daytime sleepiness, sleeping much longer hours than usual for them or the opposite — persistent insomnia. COVID-associated insomnia has been common enough that it has gotten its own name, called “coronasomnia” or “COVID-somnia.”

Even after recovery from acute illness, some patients continue to have lingering symptoms of COVID-19 that last for weeks to months, a condition called long COVID, chronic COVID, Post-Acute Covid-19 Syndrome (PACS) or long-haul COVID-19. Around one in five patients who get COVID-19 may end up with long COVID, sometimes called “long-haulers.”

Insomnia, daytime fatigue and “brain fog” are among the most reported symptoms of people who develop long COVID. Fatigue has been reported in up to two-thirds of long-haulers; in one series, sleep difficulties were seen in nearly 25% and are among the most common symptoms of long COVID, along with anxiety or depression (23% to 40% of patients), which themselves can contribute to insomnia and daytime fatigue.

Healio: How common are sleep-related side effects (with both having COVID-19 infection and COVID-19 vaccination)?

Gurubhagavatula: It is not at all unusual for patients with COVID-19 infection to sleep for longer hours while sick or in the first couple of days after vaccination, or to experience insomnia. Cytokines, which are the molecules responsible for immunity, can directly disrupt sleep, and some can promote sleep. Sleep changes that occur after vaccination or infection may be associated with the generation of fever, which is thought to promote survival from the infection.

Healio: How do you discuss COVID-19 vaccines and boosters with patients?

Gurubhagavatula: There is a lot of misinformation regarding vaccines and boosters; we know that vaccines and boosters work. We know that the most recent booster, the bivalent vaccine that targets the original virus as well as the omicron variant, is effective in reducing hospitalization rates by 50%. Yet only 14% of those eligible have received it.

One approach is to have an honest conversation with patients about what their concerns are about vaccinations and what has kept them from getting vaccinated. For some wage workers, finding time to leave work and get to a vaccination center has been a challenge. We find ways to troubleshoot by looking at local drug stores, urgent care clinics, doctor’s offices or other facilities they can access quickly and conveniently.

I also invite patients to do an honest assessment of their personal health and risk factors for getting severe COVID-19 or long COVID, and their living situation and who they are likely to encounter regularly. If there are vulnerable — such as pregnant women, older adults and those who are immunocompromised — we talk about the role of vaccination in protecting themselves and loved ones from getting very sick. If they already have risk factors for severe disease (not only sleep disorders such as sleep apnea, but also cardiovascular disease, diabetes, asthma or immune compromise), we talk about what that could mean.

Many patients have already had COVID-19 more than once; some have suffered severe symptoms, do not want to get that sick again and may be more open to considering vaccination. Many just do not have accurate information — they believe that if they know someone who had the vaccine and still got sick, then the vaccine did not work. We review the fact that vaccines may not prevent infection entirely but reduce the severity if one contracts the virus; prevention requires other strategies, such as wearing a well-fitting KN95 or N95 mask in indoor public settings and avoiding crowded areas.

When discussing vaccines, it is good to remind patients that it is important to maintain healthy sleep habits in the days leading up to the vaccine, as there is evidence that getting sufficient good-quality sleep beforehand boosts the immune response to vaccines. This means allow yourself enough time to get the sleep you need; if your doctor prescribed treatment for a sleep disorder, such as a positive airway pressure machine for sleep apnea, make sure you use it before and after vaccination. Limit alcohol, caffeine and anything that could disrupt your sleep in the days before the vaccine is given.

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There are also those eligible to get vaccinated or boosted, who would benefit from the vaccine, are at high risk of exposure and/or for severe disease, yet who simply cannot be convinced for a number of reasons, including disbelief that COVID-19 is in circulation; distrust of the vaccine formulation, the government, pharmaceutical companies or health workers; a misperception that it is “just a cold;” a personal preference; or because they believe that “natural immunity” is superior. Some express concern about missing work because of vaccine-related side effects.

Healio: What advice would you give people who might be hesitant to get vaccinated or boosted because they are concerned about sleep-related side effects?

Gurubhagavatula: Sleep-related side effects from a vaccine or booster dose are most often transient; they may last a day or two, then resolve. If fever, body aches or a sore injection site are preventing sleep, over-the-counter agents are available that can help relieve the symptoms and help with sleep.

Adequate hydration also helps with tolerating the side effects and improving sleep quality. Limiting the use of alcohol, caffeine, tobacco and recreational drugs around the time of the vaccine can help improve sleep quality at the time of vaccination.

Most people find side effects to be minor, and the benefit of protection to be worth the transient inconvenience.