As the global COVID-19 pandemic has progressed, evidence has emerged that some patients
are experiencing prolonged multiorgan symptoms and complications beyond the initial
period of acute infection and illness. The list of persisting
and new symptoms reported by patients is extensive, including chronic cough, shortness
of breath, chest tightness, cognitive dysfunction, and extreme fatigue. Termed long
COVID or post-COVID-19 syndrome, the implications and consequences of such ongoing
clinical manifestations are a growing health concern.
In the UK, as of Jan 10, 2021, there have been around 3·02 million confirmed cases
of COVID-19. As the scope of testing widens, the number of patients reporting long
COVID symptoms is also increasing. In a survey by the UK Government's Office for National
Statistics in November, 2020, around one in five people who tested positive for COVID-19
had symptoms that lasted for 5 weeks or longer, and one in ten people had symptoms
that lasted for 12 weeks or longer. These figures equate to an estimated 186 000 individuals
(95% CI 153 000–221 000) in England who had symptoms persisting between 5 and 12 weeks.
Clearly, a large number of resources will be needed to help patients and clinicians
understand and manage long-term COVID-19 sequelae. In the UK, 68 clinics have been
set up so far by the National Health Service to assess long-term post-COVID-19 effects.
Additionally, in December, 2020, the National Institute for Health and Care Excellence
(NICE) in partnership with the Scottish Intercollegiate Guidelines Network and the
Royal College of General Practitioners published a guideline for clinicians on the
management and care of people with long-term effects of COVID-19.
In the guideline, two definitions of postacute COVID-19 are given: (1) ongoing symptomatic
COVID-19 for people who still have symptoms between 4 and 12 weeks after the start
of acute symptoms; and (2) post-COVID-19 syndrome for people who still have symptoms
for more than 12 weeks after the start of acute symptoms. The guideline also makes
recommendations for clinical investigations of patients presenting with new or ongoing
symptoms 4 weeks or later after acute infection. The recommended investigations include
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 O2
saturation). They also recommend that a chest x-ray should be offered to all patients
by 12 weeks after acute infection if they have continuing respiratory symptoms.
As COVID-19 (and post-COVID-19 syndrome) are still such new conditions, the guideline
is adaptive and will be updated as new evidence becomes available from scientific
and clinical studies. Recommended key areas of research into post-COVID-19 syndrome
include risk factors for developing the syndrome (including its prevalence in different
populations), clinically effective interventions, screening, and the natural history
of the disease; large ongoing studies in this field include PHOSP-COVID, an 18-month
study that is assessing the long-term health outcomes for 10 000 people who have been
admitted to hospital with COVID-19.
The NICE guideline has been welcomed by health-care professionals, but certain gaps
are evident and it will be crucial to fill them as soon as possible. For example,
although the guidance acknowledges the importance of multidisciplinary rehabilitation
for the management of patients post COVID, Sally Singh (University of Leicester, Leicester,
UK) points out that “rehabilitation programmes should be individualised and adapted
to accommodate the needs of the patient”. The British Lung Foundation also call for
more detail in the guideline about rehabilitation resources since these will play
a crucial role in recovery, commenting “we particularly need details on who would
benefit from rehabilitation, and what kind they should have. We [also] need to ensure
there is capacity in community rehabilitation services to help people with long COVID,
since existing services might struggle to meet extra demand”. They continued, “it's
important the guideline continues to evolve so we can ensure the best possible care
for anyone struggling.”
Chris Brightling (National Institute of Health Research, Leicester, UK) highlighted
that the guideline will need to include a comprehensive review of the symptoms and
pathology of long COVID as more evidence becomes available. Preliminary pulmonary
findings include extensive lung thrombosis and persistence of viral RNA and syncytia
in pneumocytes in an analysis of 41 post-mortem samples, and weakened lung function
and lung damage in a scanning study of 40 patients who have persisting shortness of
breath. But, as Brightling emphasises, our gaps in knowledge remain considerable.
He comments, “we need to understand why following COVID-19 infection, the impact varies
from full recovery to severe, persistent debilitating symptoms affecting multiple
organs and mental health”. Updating guidance with understanding of the biological
basis of post-acute COVID-19 clinical symptoms, and details on recovery and rehabilitation
services will be essential to providing personalised, evidence-based care for these
patients.
© 2021 Tim Vernon/Science Photo Library
2021
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