Prognostic factors for persistent fatigue after COVID-19

British Journal of General Practice | February 2023 | BJGP.2022.0158. DOI: https://doi.org/10.3399/BJGP.2022.0158

Persistent fatigue after COVID-19 is common; however, the exact incidence and prognostic factors differ between studies. Evidence suggests that age, female sex, high body mass index, and comorbidities are risk factors for long COVID. The aim of this study was to investigate the prevalence of persistent fatigue after COVID-19 in patients with a mild infection (managed in primary care) during the first wave of the pandemic and to determine prognostic factors for persistent fatigue.

Prognostic factors for persistent fatigue included low education level, absence of a partner, high neuroticism (using the Eysenck Personality Questionnaire Revised-Short Form), low resilience, high frequency of GP contact, medication use, and threatening experiences in the past. The latter three factors appeared to be prognostic factors for persistent fatigue specifically after COVID-19 infection.

The study concludes that GP patients with COVID-19 (who were not admitted to hospital with COVID) have a fourfold higher chance of developing persistent fatigue than GP patients who had not had COVID-19. This risk is even higher in psychosocially vulnerable patients who had COVID-19.

Full paper: Prognostic factors for persistent fatigue after COVID-19: a prospective matched cohort study in primary care

Prevalence of ongoing symptoms following coronavirus infection in the UK

Estimates of the prevalence of self-reported long COVID and associated activity limitation, using UK Coronavirus (COVID-19) Infection Survey data. Experimental Statistics | Office for National Statistics

Main points:

• An estimated 2.0 million people living in private households in the UK (3.1% of the population) were experiencing self-reported long COVID as of 31 July 2022.
• Long COVID symptoms adversely affected the day-to-day activities of 1.5 million people, with 384,000 reporting that their ability to undertake their day-to-day activities had been “limited a lot”.
• Fatigue continued to be the most common symptom reported by individuals experiencing long COVID (62% of those with self-reported long COVID), followed by shortness of breath (37%), difficulty concentrating (33%), and muscle ache (31%).

Full detail: Prevalence of ongoing symptoms following coronavirus (COVID-19) infection in the UK | ONS

Healthwatch: What people told us about Long Covid

Healthwatch looked at a sample of 122 people’s experiences, shared with them between September 2020 and March 2022, to explore what it is like for people seeking help with symptoms of Long Covid.

Key findings:

• GPs are unsure of the symptoms of Long Covid – people often felt that their GP did not understand Long Covid. We also heard that many felt their GPs dismissed their symptoms and their experiences were not listened to, making it difficult to access help and support.
• GPs are unaware of what support is on offer or how to access it – even if GPs acknowledged symptoms, they were not always clear what support for Long Covid was available. Some people told us that it felt like their GP simply didn’t know what to do with them. Some GPs were unaware of the existence of Long Covid clinics. We also heard that GPs did not know how to refer people to a Long Covid clinic.
• People have mixed experiences of Long Covid support – we heard that people are waiting months for appointments at Long Covid clinics. People’s opinions are mixed, with some people finding the clinics not very helpful and others who said they helped them cope with their symptoms.  
• Long Covid can affect every aspect of life, but patients are not being offered holistic support – when people could access support, it mainly focused on physical symptoms, despite Long Covid also affecting people’s mental health and cognitive abilities.
• Some people struggled to access support more than others – people with pre-existing conditions told us that doctors often didn’t consider how conditions such as MS and chronic fatigue syndrome affected Long Covid. We also heard from many older women who felt that doctors used their age to dismiss their concerns

As a result of these issues, people are often left to manage their symptoms themselves and may be unsure of what support is available.

Full briefing: What people have told us about Long Covid

Long COVID in general practice: an analysis of the equity of NHS England’s enhanced service specification

British Journal of General Practice | February 2022 | vol. 72 (715): 85-86. DOI: https://doi.org/10.3399/bjgp22X718505

On 5 September 2021, 1.7% of the UK population reported suffering from prolonged symptoms 4 weeks after COVID-19 infection, the syndrome becoming known as long COVID, most commonly causing fatigue, headaches, and attention difficulties.

Despite the vaccination programme, in the autumn of 2021 approximately 40 000 COVID-19 cases were still being recorded daily, of which an estimated 3.0–11.7% will subsequently develop long COVID. Therefore, long COVID will continue to be a problem into the future.

General practice is the first point of contact of the NHS for these patients. Therefore, the commissioning and funding of services in general practice for patients with long COVID needs to take account of these factors to prevent a continuation or exacerbation of the disproportionate COVID-19 impact on deprived populations.

Full detail: Long COVID in general practice: an analysis of the equity of NHS England’s enhanced service specification

See also: Recognising and bearing the burden of long COVID-related disability

Recognition, diagnosis, and management of long COVID

Guidelines | British Journal of General Practice

This Guidelines summary of Recommendations for the recognition, diagnosis, and management of long COVID: a Delphi study covers key recommendations to provide a rapid expert guide for GPs and clinical services in the recognition, diagnosis, and management of post-COVID-19 syndrome, also known as long COVID.

The Delphi method was used to derive 35 clear and practical recommendations by UK clinicians with an interest in and lived experience of long COVID.

Further information and full guideline: Recognition, diagnosis, and management of long COVID

Related: Recommendations for the recognition, diagnosis, and management of long COVID: a Delphi study | British Journal of General Practice

Long covid cases are underreported in GP records, research suggests

GPs may be underreporting long covid say researchers who analysed 58 million patients’ primary care records and found a much lower prevalence than previous survey estimates | BMJ | 2021; 374: n1685

An analysis of pseudonymised electronic health records of patients in England found only 40 cases of long covid reported per 100 000 people. This is a much lower prevalence than estimates using questionnaire research methods such as the React-2 study which estimated that around two million people have the condition.

The analysis, published in the British Journal of General Practice, also found wide variation in reporting of long covid by GP practice, geographic region, and electronic notes systems doctors used.

Further detail: Long covid cases are underreported in GP records, research suggests

Related research: Clinical coding of long COVID in English primary care: a federated analysis of 58 million patient records in situ using OpenSAFELY | British Journal of General Practice

Enhanced service specification: Long COVID 2021/22

NHS England

General practice plays a key role in supporting patients, both adults and children, with long term symptoms of COVID-19. This includes assessing, diagnosing, referring where necessary and providing longer term holistic support of patients. This enhanced service specification aims to support general practice in managing Long COVID.

Full detail: Enhanced service specification: Long COVID 2021/22

Long COVID: the NHS plan for 2021/22

NHS England

The Long Covid Plan 2021/22 builds on the previous five-point plan announced in October 2020 and outlines 10 key next steps to be taken by the NHS to support people living with Long Covid. The plan highlights the need for equity of access, outcomes and experience in Long Covid support, as well as committing to extending the Your COVID Recovery website, collecting and publishing data.

At the NHS Confederation Conference on the 15 June 2021 Sir Simon Stevens, Chief Executive of the NHS, announced a further package of support for Long Covid for 2021/22. This includes a £100 million investment, £30 million of which will go towards an enhanced service for general practice to support Long Covid care. The remaining £70 million will be used to expand other NHS Long Covid services and establish 15 ‘paediatric hubs’ to coordinate care for children and young people.

This investment underpins The Long Covid Plan 21/22. This outlines 10 key next steps to be taken to support people living with Long Covid:

1. £70 million to expand Long Covid services to add to the £24 million already spent on Post-Covid Assessment Clinics.
2. £30 million for the rollout of an enhanced service for general practice to support patients to be managed in primary care, where appropriate, and enable more consistent referrals to clinics for specialist assessment and treatment.
3. Care coordination.
4. Establish 15 Post-Covid assessment children and young people’s hubs across England in order to coordinate care across a range of services.
5. Develop standard rehabilitation pathway packages to treat the commonest symptoms of Long Covid.
6. Extend the use of the Your Covid Recovery online rehabilitation platform.
7. Collect and publish data to support operational performance, and clinical and research activities.
8. Focus on equity of access, outcomes and experience.
9. Promote good clinical practice through the national learning network on Long Covid for healthcare professionals.
10. Support our NHS staff suffering from Long Covid.

 Full document: Long Covid: the NHS plan for 2021/22

Long COVID and the importance of the doctor–patient relationship

British Journal of General Practice | February 2021

One of the RCGP’s current priorities is ‘relationship-based care’, and this BJGP editorial discusses how the patient–doctor relationship is vital in the management of people with long COVID. It states that GPs need to listen to people with persisting symptoms following acute-COVID infection, offer empathy and support, and most importantly, help them to navigate the developing referral pathways — acknowledging that currently this may involve referrals to different specialties.

Full editorial: Long COVID and the importance of the doctor–patient relationship

6-month consequences of COVID-19 in patients discharged from hospital: a cohort study

Background

The long-term health consequences of COVID-19 remain largely unclear. The aim of this study was to describe the long-term health consequences of patients with COVID-19 who have been discharged from hospital and investigate the associated risk factors, in particular disease severity.

Methods

We did an ambidirectional cohort study of patients with confirmed COVID-19 who had been discharged from Jin Yin-tan Hospital (Wuhan, China) between Jan 7, 2020, and May 29, 2020. Patients who died before follow-up, patients for whom follow-up would be difficult because of psychotic disorders, dementia, or re-admission to hospital, those who were unable to move freely due to concomitant osteoarthropathy or immobile before or after discharge due to diseases such as stroke or pulmonary embolism, those who declined to participate, those who could not be contacted, and those living outside of Wuhan or in nursing or welfare homes were all excluded. All patients were interviewed with a series of questionnaires for evaluation of symptoms and health-related quality of life, underwent physical examinations and a 6-min walking test, and received blood tests. A stratified sampling procedure was used to sample patients according to their highest seven-category scale during their hospital stay as 3, 4, and 5–6, to receive pulmonary function test, high resolution CT of the chest, and ultrasonography. Enrolled patients who had participated in the Lopinavir Trial for Suppression of SARS-CoV-2 in China received severe acute respiratory syndrome coronavirus 2 antibody tests. Multivariable adjusted linear or logistic regression models were used to evaluate the association between disease severity and long-term health consequences.

Findings

In total, 1733 of 2469 discharged patients with COVID-19 were enrolled after 736 were excluded. Patients had a median age of 57·0 (IQR 47·0–65·0) years and 897 (52%) were men. The follow-up study was done from June 16, to Sept 3, 2020, and the median follow-up time after symptom onset was 186·0 (175·0–199·0) days. Fatigue or muscle weakness (63%, 1038 of 1655) and sleep difficulties (26%, 437 of 1655) were the most common symptoms. Anxiety or depression was reported among 23% (367 of 1617) of patients. The proportions of median 6-min walking distance less than the lower limit of the normal range were 24% for those at severity scale 3, 22% for severity scale 4, and 29% for severity scale 5–6. The corresponding proportions of patients with diffusion impairment were 22% for severity scale 3, 29% for scale 4, and 56% for scale 5–6, and median CT scores were 3·0 (IQR 2·0–5·0) for severity scale 3, 4·0 (3·0–5·0) for scale 4, and 5·0 (4·0–6·0) for scale 5–6. After multivariable adjustment, patients showed an odds ratio (OR) 1·61 (95% CI 0·80–3·25) for scale 4 versus scale 3 and 4·60 (1·85–11·48) for scale 5–6 versus scale 3 for diffusion impairment; OR 0·88 (0·66–1·17) for scale 4 versus scale 3 and OR 1·77 (1·05–2·97) for scale 5–6 versus scale 3 for anxiety or depression, and OR 0·74 (0·58–0·96) for scale 4 versus scale 3 and 2·69 (1·46–4·96) for scale 5–6 versus scale 3 for fatigue or muscle weakness. Of 94 patients with blood antibodies tested at follow-up, the seropositivity (96·2% vs 58·5%) and median titres (19·0 vs 10·0) of the neutralising antibodies were significantly lower compared with at the acute phase. 107 of 822 participants without acute kidney injury and with estimated glomerular filtration rate (eGFR) 90 mL/min per 1·73 m² or more at acute phase had eGFR less than 90 mL/min per 1·73 m² at follow-up.

Interpretation

At 6 months after acute infection, COVID-19 survivors were mainly troubled with fatigue or muscle weakness, sleep difficulties, and anxiety or depression. Patients who were more severely ill during their hospital stay had more severe impaired pulmonary diffusion capacities and abnormal chest imaging manifestations, and are the main target population for intervention of long-term recovery.

Funding

National Natural Science Foundation of China, Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences, National Key Research and Development Program of China, Major Projects of National Science and Technology on New Drug Creation and Development of Pulmonary Tuberculosis, and Peking Union Medical College Foundation.

Reference: The Lancet,  VOLUME 397, ISSUE 10270, P220-232, JANUARY 16, 2021