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Long COVID

Long Covid describes a longer , more complex course of illness than that emerging from initial formal reports from Wuhan ( The Novel Coronavirus Pneumonia Emergency Response Epidemiology Team 2020 ; WHO , 2020a )It must be noted that this is a new subject which is likely to change and evolve as more studies are done and what we know is derived from reports which are currently available ie long term data is missing No international consensus about the definition and lot of uncertainties persist Various terms are used in literature to describe the condition as
○ long haulers
○ long term effects of COVID 19
○ post-COVID syndrome & chronic COVID syndrome
 NICE opted for post covid syndrome and proposed three phases based on time after disease onset.

 

Acute phase – up to 4 weeks
Ongoing symptomatic COVID 19 – from 4 to 12 weeks
post covid 19 syndrome – more than 12 weeks

 

Timing of assessment of chronic symptoms varies and remains heterogenous and unstandardized A duration of more than 4 weeks is generally called as long covid ( until international consensus is reached ) and no evidence of any physiological change at 12 weeks to predict chronicity is currently available.

 

How common -Data on prevalence of long covid ( LC ) is still emerging and essentially this is work in progress , never we can draw some conclusions from what we already know In the UK the Office of National Statistic ( ONS ) has estimated that in during the week commencing 22nd November 2020 , around 186,000 people in private households in England were living with symptoms that had persisted for between 5 – 12 weeks with a confidence interval of 153,000 to 221,000 ONS estimates that 1 in 5 people have symptoms that persist after 5 weeks and 1 in 10 for 12 weeks or longer Zapatero et al ( Jan 2021 ) report that the prevalence of LC varies between 5 % and 50.9 % BMJ reported ( Dec 20 ) that LC is thought to occur in about 10 % of people Kings College London reported in October 20 that LC affects around 10 % of 18-49 yrs old rising to 22 % in over 70s

 

Possible risk factors -Older people Women ( 50 % more likely to suffer with LC than men ) Asthma Higher BMI Greater number of symptoms.

 

Cause -The cause of LC is not known , inflammatory reaction may play a role.

 

Identifying people with ongoing symptomatic COVID -19 or post COVID 19 syndrome NICE recommends this for all HC professionals in any setting for people who had suspected or confirmed acute COVID 19 irrespective of if they were hospitalised or had a positive or negative SARS -CoV-2-Test ( PCR , antigen or antibody )

 

Advice -about the most common new or ongoing symptoms
( see below )
 about recovery
○ may differ from person to person but for many people symptoms will resolve by 12 weeks
○ severity of the illness or hospitalization is not a determining factor contributing towards the likelihood of developing ongoing symptomatic COVID 19 or post COVID-19 syndrome
○ new symptoms if they happen can change unpredictable and can affect them in different ways at different times
 information on self management and what symptoms to look out for which they should seek medical advice
( including who to contact )

 

Common symptoms of ongoing symptomatic COVID 19 and post- COVID-19 syndrome –

 

Respiratory -breathlessness cough
CV- chest tightness chest pain palpitations
General -fatigue fever pain
Neurological -cognitive impairment
○ brain fog , loss of conc or
○ memory issues
Gastroenterology -abdominal pain nausea diarrhoea anorexia and ↓ appetite ( in older populations )
MSK-joint pain muscle pain
Mental -symptoms of depression symptoms of anxiety
ENT-tinnitus earache sore throat dizziness loss of taste and / or smell
Skin- rashes

 

Following acute COVID suspect the previous COVID 19 as the cause of new or ongoing symptoms.

if within 4-12 weeks – ongoing symptomatic COVID 19
if not resolved 12 weeks after the start of acute COVID 19 – post-COVID-19 syndrome.

 

Mode of consultation –people who remain concerned about new / ongoing symptoms after 4 weeks or more- offer a consultation it can be by video / phone or face to face

 

Screening questionnaire -NICE suggests that you may use a screening questionnaire as part of the initial consultation ( in conjunction with clinical assessment ) Currently Post COVID-19 functional status scale is the most common search result on Google

 

Symptoms may vary -The guideline suggests that not all will suffer with the most commonly reported symptoms.

 

Shared decision -discuss if they need further assessment and how based upon symptoms decide if they need investigation in person or require urgent secondary care referral

 

Under-served or vulnerable groups provide extra support consider f/u by primary care or community services for people in vulnerable groups and black , Asian and minority ethnic groups

 

The guideline recommends that for those who have been hospitalised – a video or tel f/u consultation should be held at 6 weeks by a healthcare professional in secondary care

 

Assessment -use holistic , person centered approach obtain a comprehensive clinical history
○ history of suspected or confirmed
 acute COVID -19
○ nature and severity of previous and current symptoms
○ timing and duration of symptoms
○ history of other health conditions
 appropriate examination which covers
○ physical
○ cognitive
○ psychological
○ psychiatric
 Symptoms can fluctuate widely and can change in nature over time
 Assess the impact of the illness on the person for e.g life and activities , work , education , mobility and independence
 Discuss the person’s concerns , experience , worries and distress & include a family member to help describe their symptoms if the person agrees
 Do not try to predict if the person is likely to develop post COVID 19 syndrome ( based on if they had certain symptoms or cluster of symptoms or if they were admitted to hospital during the acute COVID -19 period )
 Be mindful that in older people signs of ongoing symptomatic COVID 19 or suspected COVID- 19 syndrome can include
○ gradual decline
○ deconditioning
○ worsening frailty or dementia
○ loss of interest in eating and drinking
 New cognitive symptoms should be evaluated using a validated screening tool to measure any impairment and impact.

 

Urgent referral to acute services -Presentation raises suspicion of a
 life threatening complication as 
( but not limited to )
 severe hypoxaemia or O2 desaturation on exercise signs of severe lung disease cardiac chest pain multisystem inflammatory syndrome in children.

 

Investigate -based on signs and symptoms to r/o acute or life threatening complications try and find out if the symptoms are due to ongoing symptomatic COVID-19 , post COVID 19 syndrome or are due to a new unrelated diagnosis investigate and refer if another diagnosis is suspected in line with relevant national or local guidelines.

 

Blood tests -Offer blood tests as
 FBC ,Us & Es , LFT CRP , Ferritin Brain natriuretic peptide ( BNP ) TFT

 

Exercise tolerance -Panel suggests that the 1- minute sit-to-stand test ( if safe and appropriate ) would be useful for most people as it can be carried out in primary care along with blood tests. During the test
 record level of breathlessness heart rate and O2 saturation.

 

Postural symptoms -obtain lying and standing BP for people with postural symptoms as palpitations or dizziness on standing & heart rate recordings which can be 3 minutes active stand test or 10 minutes if you suspect postural tachycardia syndrome , or other forms of autonomic dysfunction.

 

CXR- offer a CXR by 12 weeks if not done already or if they have continuing respiratory symptoms CXR will not show all pathologies and do not base the decision to refer or not based on CXR findings alone.

 

Mental health services- refer to psychiatric services if they have severe psychiatric symptoms or are at risk of self-harm or suicide ( follow guidance on management for people with anxiety, mood disorders ) consider referral for psychological therapies if they have common mental health symptoms such as of mild anxiety or depression to liaison psychiatry for people with more complex needs.

 

A referral to multidisciplinary team or for further investigations should not be denied to those who have not tested positive for SARS-CoV-2 test ( PCR , antigen or antibody )

 

* This summary covers the sections from identification to investigations and referral – of the guideline only. Sections which are not covered include planning care , management , f/u and monitoring , sharing information and continuity of care & service organization. Please refer to the full guidance provided under links along with further resources.\

Resources – verified

Long Covid Support – peer and advocacy group Patients – Long Covid Support

NHS Long Covid support Your COVID Recovery | Supporting your recovery after COVID-19

Covid 19 Supporting your recovery NHS Lancashire Teaching Hospitals an excellent resource COVID-19: Supporting your recovery – Overview (lthtr.nhs.uk)

British Heart Foundation on Long Covid COVID-19: Supporting your recovery – Overview (lthtr.nhs.uk)

BMA – doctors with long COVID Doctors with long COVID (bma.org.uk)

Royal College of Occupational Therapists – How to manage post-viral fatigue after COVID 19 How to manage post-viral fatigue after COVID-19 – RCOT

Chartered Society of Physiotherapy COVID 19 : the road to recovery Covid-19: the Road to Recovery (csp.org.uk)

 

References

  1. The prevalence of long COVID symptoms and COVID-19 complications Office of National Statistics The prevalence of long COVID symptoms and COVID-19 complications – Office for National Statistics

  2. Long COVID guidelines need to reflect lived experience The Lancet Gorna et al Volume 397, Issue 10273 , P455-457 , February 2 , 2021 Long COVID guidelines need to reflect lived experience – The Lancet

  3. Sivan ManojTaylor SharonNICE guideline on long covid 
  4. COVID-19 rapid guideline: managing the long-term effects of COVID-19 NICE guideline [NG188]Published date: 

  5. Felicity Callard, Elisa Perego, How and why patients made Long Covid, Social Science & Medicine, Volume 268, 2021, 113426, How and why patients made Long Covid – ScienceDirect
  6. Greenhalgh TrishaKnight MatthewA’Court ChristineBuxton MariaHusain LaibaManagement of post-acute covid-19 in primary care 
  7. COVID 19 – KCE CONTRIBUTIONS EPIDEMIOLOGY OF LONG COVID: A
    PRAGMATIC REVIEW OF THE LITERATURE
    DIEGO CASTANARES ZAPATERO, GERMAINE HANQUET, KOEN VAN DEN HEEDE https://kce.fgov.be/sites/default/files/atoms/files/2020-04HSR_LongCOVID_COVID%20Contributions_01022021.pdf

 

 

 

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