|
 
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| REVIEW ARTICLE |
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| Year : 2022 | Volume
: 3
| Issue : 2 | Page : 149-154 |
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Post and long-COVID conditions: Epidemiology, clinical symptoms and the prevention and treatment
Pooja Chauhan1, Vineet Kumar Pathak2, Dewesh Kumar3, Anita Upadhyay4, Anirban Chatterjee5, Chandrakant Lahariya6
1 Department of Community Medicine, NAMO Medical Education and Research Institute, Silvassa, UT of Daman and Diu and Dadra and Nagar Haveli, India
2 Integrated Department of Preventive Medicine and Pediatrics, Foundation for People-Centric Health Systems, New Delhi, India
3 Department of Community Medicine, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
4 Director- Projects, Human Capital Lighthouse Consulting Pvt Ltd, New Delhi, India
5 Department of Community and Family Medicine, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
6 Founding Director, Foundation for People-Centric Health Systems, New Delhi; Adjunct Professor, SD, Gupta School of Public Health, IIHMR University, Jaipur, Rajasthan, India
| Date of Submission | 05-Jul-2022 |
| Date of Decision | 20-Jul-2022 |
| Date of Acceptance | 26-Jul-2022 |
| Date of Web Publication | 29-Aug-2022 |
Correspondence Address:
Dr. Chandrakant Lahariya
Founding Director, Foundation for People-Centric Health Systems, B-2/105, Safdarjung Enclave, New Delhi - 110 029
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/JME.JME_83_22
A proportion of individuals affected with severe acute respiratory syndrome coronavirus 2 continue to have COVID-19 symptoms even after recovering from illness. These are termed as post-COVID condition (PCC)/long-COVID. Evidence suggests that symptoms of COVID-19 along with other generalised sequelae may persist in some patients with severe and very severe disease, as well as in patients who had mild or no symptoms. The management of PCC is a challenge as there is limited understanding about the issue even in healthcare professionals. Then, there is not enough documentation of post-COVID and long-COVID in India. From public health perspective, the health services and facilities have not been re-designed to tackle the situation. This review article aims to explore PCC and compilation of current international and national public health response along with recommendations to identify and manage the PCC at the primary. The article concludes the urgent need to document the burden of PCCs in India, develop standard case definition and equip primary healthcare facilities and providers with the requisite skills to manage the PCC. The governments, health care providers and facilities and public health bodies should also encourage and foster continuing country specific data, analysis and research into the determinants, duration and probable treatment modalities of PCC. The post and long-COVID conditions would require sustained policy and programmatic attention in all countries with special focus in low and middle income country settings.
Keywords: COVID-19, long-COVID, pandemic, post COVID, India, SARS CoV-2
How to cite this article:
Chauhan P, Pathak VK, Kumar D, Upadhyay A, Chatterjee A, Lahariya C. Post and long-COVID conditions: Epidemiology, clinical symptoms and the prevention and treatment. J Med Evid 2022;3:149-54 |
How to cite this URL:
Chauhan P, Pathak VK, Kumar D, Upadhyay A, Chatterjee A, Lahariya C. Post and long-COVID conditions: Epidemiology, clinical symptoms and the prevention and treatment. J Med Evid [serial online] 2022 [cited 2023 Jun 3];3:149-54. Available from: http://www.journaljme.org/text.asp?2022/3/2/149/354994 |
| Introduction | |  |
The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which causes coronavirus disease-19 (COVID-19) results in both acute and chronic health conditions.[1] A majority of those who get SARS-CoV-2 infection remain asymptomatic and then those who develops symptoms also recover within days; however, some people have been known to experience symptoms for a prolonged period of time, a condition termed as post-COVID condition (PCC).[1],[2] PCC remains a partially incompletely understood condition with no standard case definition. According to the Centers for Disease Control and Prevention (CDC), 'PCCs are a wide range of new, returning or ongoing health problems people can experience more than 4 weeks after first being infected with the virus that causes COVID-19'.[3] However, the definitions have mostly varied on how long symptoms are supposed to persist for it to be diagnosed as PCC. There are other terminologies which are interchangeably used include post-COVID syndrome and long-COVID. In short, anyone who has been previously infected with SARS-CoV-2 can manifest symptoms consistent with PCC. These conditions are typified by different types and combinations of health problems for different lengths of time.[4],[5] This review article aimed to explore PCC and compilation of current international and national public health response along with recommendations to identify and manage the PCC at the primary care level.
| Epidemiology of Post-COVID Conditions | | |
The prevalence of PCC impinges on how it is defined. The growing evidence suggest that a significant number of patients of COVID-19 subsequently experience prolonged symptoms consistent with the condition. Data from the COVID symptom study in the United Kingdom indicated that around 10% of individuals who have tested positive for SARS-CoV-2 virus may remain unwell beyond 3 weeks, and a smaller proportion may continue exhibiting symptoms for months.[6] A study from the United States of America found that as many as 65% of people had returned to their previous level of health 2–3 weeks after a positive test.[7],[8] A team from Italy, one of the earliest affected countries reported that 87% of people discharged from a Rome hospital were still experiencing at least one symptom 2 months after testing COVID-19 positive and 55% had three or more symptoms including fatigue (53%), difficulty in breathing (43%), joint pain (27%) and chest pain (22%) with 40% saying it had reduced the quality of their life.[9] Another multicountry study with data from 56 countries found that PCC may persist beyond 4 weeks in as many as 93% of those who had been diagnosed with COVID-19.[10] In general, it has been found that the incidence of PCC may be lower in those who were not hospitalised (around 25%),[11] and higher in previously hospitalised patients of COVID-19 (as high as 85%).[10],[12],[13] There have been wider variations in PCC prevalence in low- and low-middle-income countries and in high-income countries. However, this could partly be linked to insufficient research and documentation from low-income and low-middle-income countries about post- and long-COVID-19 situation.
| Risk Groups for Post-Covid Condition | | |
Very few studies have tried to assess the predictors of PCC/long-COVID. It has been seen that increasing age, female gender, increased BMI, longer duration of the disease, living in deprived areas, working in health or social care and experiencing more than five symptoms in the 1st week of illness are all associated with an increased risk of long-COVID.[8],[14],[15] However, persistent viraemia due to weak or absent antibody response, relapse or reinfection with COVID-19, inflammatory and other immune reactions, deconditioning and mental factors such as post-traumatic stress may all play a role. Long-term respiratory, musculoskeletal and neuropsychiatric sequelae have been described for other coronaviruses (SARS and MERS)[16] and these might have pathophysiological parallels with COVID-19.[15]
| Clinical Signs and Symptoms | | |
Almost all systems of the body seem to be affected by PCC, and even those who had mild to no symptoms seem to get affected.[11],[13],[17] Patients diagnosed with long-COVID have reported as many as 205 symptoms across ten systems.[10] Another way of looking at it is that the symptoms of PCC/long-COVID may be characterised into neuropsychiatric or non-neuropsychiatric. The most common non-neuropsychiatric symptoms included fatigue, headache, dyspnoea and anosmia, while common neuropsychiatric symptoms included anxiety, dizziness, brain fog and insomnia. Comparatively rarer but serious manifestations of long-COVID have included cardiac arrhythmias, myocarditis/pericarditis and interstitial lung disease.[8],[10],[13],[18],[19],[20] A detailed list of symptoms of long-COVID is presented in [Box 1].
| Laboratory Investigations | | |
The investigations recommended are based on the symptoms and body organ thought to be affected. A chest skiagram may be advised in patients with dyspnoea. Anaemia also needs to be ruled out in dyspnoea. Elevated biomarkers may be indicative of underlying acute or chronic conditions – natriuretic peptides for heart failure, ferritin for inflammation and continued prothrombotic state, troponin for acute myocardial infarction, etc.[21],[22]
The British Thoracic Society recommends differential assessment of COVID-19 patients in the weeks and months following recovery from COVID-19. Patients who had been managed in the Intensive Care Unit/High Dependency Unit or who suffered from severe COVID-19 are recommended for undergoing a clinical review after 4–6 weeks post-discharge.[23] This follow-up should be employed for comprehensive examination of the patient. NICE guidelines in the UK, on long-COVID recommend investigations including a full blood count, kidney and liver function tests, a C-reactive protein test and an exercise tolerance test (recording level of breathlessness, heart rate and SpO2). A chest skiagram is also recommended for all patients by 12 weeks after acute infection if they have continuing respiratory symptoms.[24] Guidelines issued by the Government of India for managing long-COVID stipulate that the first follow-up should preferably be after 7 days of discharge either telephonically or in-person, preferably at the place the patient had been admitted or hospital closer to their homes.[25]
It is expected that further research into manifestations of, indications for and interpretation of diagnostic and monitoring tests would refine and crystallise investigation guidelines. Specially in the epidemics and pandemic where local settings and context determine the clinical features and outcomes, every country need to collect its own detailed clinical/case data and conduct analytical studies on these aspects.
| Clinical Management | | |
The symptomatic approach to the management of long-COVID is advised with holistic, longitudinal follow-up in primary care, multidisciplinary rehabilitation services and the empowerment of affected groups.[26] In addition to the investigations as advised, following aspects need to be considered:[13],[26],[27]
- Long-term dyspnoea: If dyspnoea persists as the main symptom, and after ruling out all complementary tests for alternative diseases, the so-called respiratory burn syndrome or chronic inflammation of the respiratory tract may be suspected, and referral to pulmonology or otorhinolaryngology may be considered
- Long-term anosmia/dysgeusia: Referral to otorhinolaryngology is indicated for long-term multimodal treatment
- Long-term headache: Not much is known about the characteristic of headache associated with long-COVID – although it has been observed that in many cases, these headaches might be refractory and not respond to commonly administered NSAIDs. In fact, in many cases, headache might be among the first PCC symptoms which can lead to visit healthcare facilities; hence, history of COVID from patients visiting the outpatient department is important. Similarly, the duration and intensity might vary case to case basics. Many patients have reported tension type headache up to 2 weeks post-recovery. It may be included among the primary headaches, diagnosed according to symptoms in the absence of organic or structural alterations. Hence, a possible neurology consultation in case of intractable headaches is recommended. Apart of headache as a new symptom, PCC patients might feel the aggravation of already diagnosed causes of chronic headache like migraine. Also, patient counselling on headache aggravating factors like lack of sleep, adequate diet, smoking and alcohol intake should be done
- Neuropsychiatric complications – such as anxiety, depression and brain fog. Early, comprehensive and all-rounded intervention is needed to counter and neuropsychiatric manifestations of long-COVID. Although psychiatrist consultation is imperative, but for the comprehensive care, family and caregiver support is also necessary.
- Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) – ME/CFS is a common complication of many acute viral illnesses.[28] It is characterised by respiratory symptoms, fever, adenopathy, myalgias and other symptoms,[29] which lasts for more than 6 months with or without an acute phase preceding it.[30] Since CFS is not characterised by any specific symptoms or signs, it often goes undiagnosed.[31] It is being speculated that in many cases, PCC may evolve into CFS, in which case a multidisciplinary, sustainable approach will need to be implemented.[32]
| Holistic Case Management | | |
In addition to the treating the symptoms, PCC demands for a multidisciplinary rehabilitation service, which entail a cohesive and integrated approach towards symptomatic management of persistent long-COVID manifestations. An integrated pathway to permanent resolution of symptoms would encourage adherence and uniformity of intervention.
There are a few innovative approaches in PCC management in India. As an example, the Guidelines issued by the Government of Kerala envisage integration of post-COVID management in the existing National health mission framework, with the engagement of frontline workers as links between the community and nearest healthcare services to facilitate access to healthcare for patients of long-COVID. It also instructs setting up of long-COVID clinics in all primary health centres (PHCs), community health centres (CHCs), district hospitals (DHs) and medical colleges.[33]
The PCC management is also another opportunity to strengthen engagement with peer, family and community support in health services. The support from family, peers and the community are needed to provide a supportive environment for patients suffering from long-COVID. Patients and healthcare providers may also be organised into peer groups, which can be instrumental in disseminating tips and information on how to better manage symptoms of long-COVID.[25],[34] Long-COVID may be associated with profound and significant stigmatisation.[35],[36] Rallying the family, peers and community into support groups would also help in dispelling much of this stigma.
| Vaccination and Post-COVID Condition | | |
It is not fully understood if people who have been vaccinated and subsequently end up contracting acute COVID-19 suffer from PCC or not and to what extent. However, evolving evidence strongly suggests that vaccination after recovering from acute COVID-19 may cut down the duration of PCC. An international survey on 900 people found that being administered even a single dose of COVID-19 vaccine lead to an improvement in post-COVID symptoms in more than half the participants.[37] Therefore, although there still is no conclusive evidence about the impact that vaccination might have on shortening the duration of PCC, getting vaccinated is strongly advised. Not only would it reduce the chances of contracting COVID-19 again,[38] it may also act to alleviate symptoms of PCC.
| Discussion | | |
India has reported the second highest numbers of COVID patients in the world. Assuming that the reported prevalence of PCC in India is the same as that in the Western countries or even lower, there would be a sizeable number of patients in need of such services. Then, one of the impacts of COVID-19 pandemic has been that people have been identified with health conditions which they had even before the pandemic; however, diagnosis was made during them being tested COVID-19 positive. The pandemic has made major impact on mental health of people. Therefore, there is a clear need for implementing the public health approach to various aspects of COVID-19 including PCC.
In PCCs, a majority of the symptoms can be managed at home or at the primary care level.[12] Establishing post-COVID clinics at PHCs, CHCs, DHs and medical colleges need to be considered for providing comprehensive, escalating care to patients of PCC. There is every merit in integrating the care for PCC into our healthcare delivery system at every level (primary, secondary, tertiary). Early identification and timely referral of post-intensive care syndrome which results in extreme weakness and post-traumatic stress disorder can enhance the quality of life of the patient.
The training and equipping our human resources with the skillset needed to accurately diagnose and treat PCC is necessary next step. Strengthening healthcare systems by training healthcare providers at every level would allow for early detection and effective management of long-COVID. To facilitate this process, an operational definition of PPC at the level of primary setting can be implemented to identify the common symptoms along with red flag signs for immediate referral and manage the PCC as early as possible. As first point of contact for most of the PCC patients will be primary health centres hence proper screening protocol and training of healthcare staffs plays a crucial role in the management of PCC at that level.
Healthcare Workers at the primary level along with community-based agencies such as Village Health Sanitation and Nutrition Committee (VHSNC) and Mahila Arogya Samiti (MAS)[39] need to be sensitised to act as a community-based support for self-management and self-monitoring of PCC and would also act as referral linkage to nearest healthcare facility for ancillary management when needed. The care seeking for PCC also need to be encouraged at community level. The frontline workers as well as doctors and nurses need to be sensitised and trained on various aspects of PCC.
In addition, telehealth and mobile health platforms may also be engaged to reach out to patients of PCC and follow them up regularly.[40] In resource-limited settings such as rural and tribal areas of India, the community health workers can act to provide telehealth and mobile health services by connecting beneficiaries to doctors via their handheld devices. Various initiatives in two arms of Ayushman Bharat Program:[41] The Pradhan Mantri Jan Arogya Yojana and Health and wellness centres[42] need to be tweaked and aligned to facilitate the process. India has recently announced public health and management cadre.[43] The strengthening and capacity building of public healthcare systems to tackle the impending epidemic of PCC would also have long-term positive ramifications on the public healthcare landscape. With making PHCs into HWCs, the current health system has the potential to provide services to mild PCC patients at the primary level. Since Sub Health Centre (SHC)-HWC are the closest to the community (first point of care), their role in knowledge dissemination is key component against PCC. The specific measures and interventions at various levels are summarised in [Box 2]. There are a few specific roles which can be assigned to this workforce in PCCs [Box 3]. Finally, there is a need for research and data documentation process for PCC and medical colleges and academic facilities need to take lead in this wok. The lack of COVID specific data on patient profile, comorbid condition, severity of COVID infections etc., act as a major constraint for PCC understanding and management.
| Conclusion | | |
The COVID-19 pandemic should act as a wake-up call to the Indian healthcare establishment. The PCC scenario should be looked at as an opportunity to identify and address shortcomings in health systems. The need of the hour is to equip peripheral healthcare facilities and the providers with the requisite skills which would empower them to provide optimum care to the person with PCC. Developing simple evidence-based PCC management algorithms is needed. The government, clinicians, and public health bodies should also encourage and foster continuing country specific data, analysis and research into the determinants, duration and probable treatment modalities of PCC. Responding to the PCCs is integral part of overall response to the COVID-19 pandemic. The post and long- COVID conditions would require sustained policy and programmatic attention in all countries with special focus in low and middle income country settings.
Financial support and sponsorship
Dr Pooja Chauhan has written this article as part of her role as Fellow under Technical Writing in Public Health (TWPH) fellowship program, Cohort I in 2022 run by the Foundation for People Centric Health Systems, New Delhi.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Lahariya C, Kang G, Guleria R. Till We Win: India's Fight against the COVID-19 Pandemic. New Delhi: Penguin Random House India; 2020. p. 352.  |
| 2. | |
| 3. | |
| 4. | Sykes DL, Holdsworth L, Jawad N, Gunasekera P, Morice AH, Crooks MG. Post-COVID-19 symptom burden: What is long-COVID and how should we manage it? Lung 2021;199:113-9. |
| 5. | Lopez-Leon S, Wegman-Ostrosky T, Perelman C, Sepulveda R, Rebolledo PA, Cuapio A, et al. More than 50 Long-term effects of COVID-19: a systematic review and meta-analysis. Preprint. medRxiv. 2021;2021.01.27.21250617. Published 2021 Jan 30. doi:10.1101/2021.01.27.21250617. |
| 6. | |
| 7. | Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report. Symptom Duration and Risk Factors for Delayed Return to Usual Health Among Outpatients with COVID-19 in a Multistate Health Care Systems Network . Available from https://www.cdc.gov/mmwr/volumes/69/wr/mm6930e1.htm. [Last accessed on 2022 Aug 19]. |
| 8. | Sudre CH, Murray B, Varsavsky T, Graham MS, Penfold RS, Bowyer RC, et al. Attributes and predictors of long COVID. Nat Med 2021;27:626-31. |
| 9. | Carfì A, Bernabei R, Landi F; Gemelli against COVID-19 Post-Acute Care Study Group. Persistent symptoms in patients after acute COVID-19. JAMA 2020;324:603-5. |
| 10. | Davis HE, Assaf GS, McCorkell L, Wei H, Low RJ, Re'em Y, et al. Characterizing long COVID in an international cohort: 7 months of symptoms and their impact. EClinicalMedicine 2021;38:101019. |
| 11. | Augustin M, Schommers P, Stecher M, Dewald F, Gieselmann L, Gruell H, et al. Post-COVID syndrome in non-hospitalised patients with COVID-19: A longitudinal prospective cohort study. Lancet Reg Health Eur 2021;6:100122. |
| 12. | Pavli A, Theodoridou M, Maltezou HC. Post-COVID syndrome: Incidence, clinical spectrum, and challenges for primary healthcare professionals. Arch Med Res 2021;52:575-81. |
| 13. | Nalbandian A, Sehgal K, Gupta A, Madhavan MV, McGroder C, Stevens JS, et al. Post-acute COVID-19 syndrome. Nat Med 2021;27:601-15. |
| 14. | |
| 15. | Mahmud R, Rahman MM, Rassel MA, Monayem FB, Sayeed SK, Islam MS, et al. Post-COVID-19 syndrome among symptomatic COVID-19 patients: A prospective cohort study in a tertiary care center of Bangladesh. PLoS One 2021;16:e0249644. |
| 16. | O'Sullivan O. Long-term sequelae following previous coronavirus epidemics. Clin Med (Lond) 2021;21:e68-70. |
| 17. | Uzunova G, Pallanti S, Hollander E. Presentation and management of anxiety in individuals with acute symptomatic or asymptomatic COVID-19 infection, and in the post-COVID-19 recovery phase. Int J Psychiatry Clin Pract 2021;25:115-31. |
| 18. | Iqbal FM, Lam K, Sounderajah V, Clarke JM, Ashrafian H, Darzi A. Characteristics and predictors of acute and chronic post-COVID syndrome: A systematic review and meta-analysis. EClinicalMedicine 2021;36:100899. |
| 19. | Gorna R, MacDermott N, Rayner C, O'Hara M, Evans S, Agyen L, et al. Long COVID guidelines need to reflect lived experience. Lancet 2021;397:455-7. |
| 20. | Kamal M, Abo Omirah M, Hussein A, Saeed H. Assessment and characterisation of post-COVID-19 manifestations. Int J Clin Pract 2021;75:e13746. |
| 21. | Greenhalgh T, Knight M, A'Court C, Buxton M, Husain L. Management of post-acute COVID-19 in primary care. BMJ 2020;370:m3026. |
| 22. | Nabavi N. Long COVID: How to define it and how to manage it. BMJ 2020;370:m3489. |
| 23. | British Thoracic Society. British Thoracic Society Guidance on Respiratory Follow up of Patients with a Clinico-Radiological Diagnosis of COVID-19 Pneumonia. London, UK: British Thoracic Society (BTS). 2021. p. 15. |
| 24. | Venkatesan P. NICE guideline on long COVID. Lancet Respir Med 2021;9:129. |
| 25. | |
| 26. | Sisó-Almirall A, Brito-Zerón P, Conangla Ferrín L, Kostov B, Moragas Moreno A, Mestres J, et al. Long COVID-19: Proposed primary care clinical guidelines for diagnosis and disease management. Int J Environ Res Public Health 2021;18:4350. |
| 27. | Schreiber M. Treating patients with long COVID. Am Psychol Assoc 2021;52:62. |
| 28. | Lam MH, Wing YK, Yu MW, Leung CM, Ma RC, Kong AP, et al. Mental morbidities and chronic fatigue in severe acute respiratory syndrome survivors: Long-term follow-up. Arch Intern Med 2009;169:2142-7. |
| 29. | Komaroff AL, Bateman L. Will COVID-19 lead to myalgic encephalomyelitis/chronic fatigue syndrome? Front Med (Lausanne) 2020;7:606824. |
| 30. | Clayton EW. Beyond myalgic encephalomyelitis/chronic fatigue syndrome: An IOM report on redefining an illness. JAMA 2015;313:1101-2. |
| 31. | Griffith JP, Zarrouf FA. A systematic review of chronic fatigue syndrome: Don't assume it's depression. Prim Care Companion J Clin Psychiatry 2008;10:120-8. |
| 32. | Chaudhuri S. PostCOVID-19 syndrome – The new pandemic. Indian J Respir Care 2021;10:170. [Full text] |
| 33. | |
| 34. | |
| 35. | |
| 36. | Ballering A, Olde Hartman T, Rosmalen J. Long COVID-19, persistent somatic symptoms and social stigmatisation. J Epidemiol Community Health 2021; 75(6):603-604. |
| 37. | Strain WD, Sherwood O, Banerjee A, Van der Togt V, Hishmeh L, Rossman J. The Impact of COVID Vaccination on Symptoms of Long COVID: An International Survey of People with Lived Experience of Long COVID. Vaccines (Basel) 2022;10:652. |
| 38. | |
| 39. | Lahariya C, Roy B, Shukla A, Chatterjee M, De Graeve H, Jhalani M, et al. Community action for health in India: Evolution, lessons learnt and ways forward to achieve universal health coverage. WHO South East Asia J Public Health 2020;9:82-91. |
| 40. | Worsowicz G, Stone J. Post-COVID rehabilitation services emphasizing telemedicine. Mo Med 2020;117:319-20. |
| 41. | Lahariya C. 'Ayushman Bharat' program and universal health coverage in India. Indian Pediatr 2018;55:495-506. |
| 42. | Lahariya C. Health & wellness centers to strengthen primary health care in India: Concept, progress and ways forward. Indian J Pediatr 2020;87:916-29. |
| 43. | |
|
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