Journal of Current Research in Scientific Medicine

EDITORIAL
Year
: 2020  |  Volume : 6  |  Issue : 2  |  Page : 71--72

Long COVID – Need for follow-up clinics


Aneesh Basheer 
 Department of Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India

Correspondence Address:
Aneesh Basheer
Department of Medicine, Pondicherry Institute of Medical Sciences, Puducherry
India




How to cite this article:
Basheer A. Long COVID – Need for follow-up clinics.J Curr Res Sci Med 2020;6:71-72


How to cite this URL:
Basheer A. Long COVID – Need for follow-up clinics. J Curr Res Sci Med [serial online] 2020 [cited 2021 Apr 21 ];6:71-72
Available from: https://www.jcrsmed.org/text.asp?2020/6/2/71/304211


Full Text



Our understanding of SARS-CoV-2 infection has evolved considerably in the past few months, with the world witnessing a hitherto unseen pace of research on its pathogenesis, molecular biology, epidemiology, treatment options, and preventive strategies. With new information on COVID-19 disease came the bitter realization that it is not a garden variety influenza-like viral infection – in more than one way. The infectivity of the virus, frequency of asymptomatic infection, subclinical lung involvement, relatively high mortality among high-risk subgroups, and possible long-term sequelae have all stood out as stark contrasts to the “common cold” viral infections. The term “Long COVID” appeared first in a Twitter post by a COVID-19 survivor and subsequently accepted widely to signify the long-term sequelae of COVID-19. Data from different cohorts from different parts of the world indicate that long-term complications could involve many organ systems.

While standard definitions have not yet been developed, experts agree that illness beyond 3 weeks of first symptoms could be termed postacute COVID-19 and anything more than 12 weeks termed chronic COVID-19.[1] Long COVID, however, is used in a broader sense to encompass all of these. It is estimated to affect approximately 10% of those tested positive for the SARS-CoV-2.[2] This could well be an underestimate since many people are not tested, and several others may be asymptomatic. One study reported that at the end of 2–3 weeks after a positive test, fewer than 65% of the patients perceived regaining baseline health status.[3]

The major presentations of long COVID relate mostly to the respiratory system, although neurological, hematological, and immunological derangements have been reported. Persistent cough, breathlessness, fatigue, and myalgia are common. Lung fibrosis and pulmonary thromboembolism have been reported with increased frequency among those who survive severe COVID pneumonia. In an Italian cohort of survivors of moderate-to-severe COVID illness, the most frequent sequelae were fatigue (53%) followed by persistent breathlessness (43%).[4] However, data on how and when these sequelae could resolve are not available at present. Venous thromboembolism, including pulmonary embolism, appears to be a major problem during the acute phase, with rates as high as 25%–31%.[5],[6] Whether survivors are at increased risk of thromboembolic events remains uncertain at this point in time. Cardiovascular complications such as myocarditis, myocardial infarction, and arrhythmias have been reported several weeks after acute COVID-19.[7],[8],[9],[10] Transient cognitive derangement (brain fog) is a troublesome nonspecific neurological sequela well noted in long COVID syndrome.[11] Above all, the impact of acute COVID on mental health is obvious, and several studies report high levels of anxiety, low mood, insomnia, social isolation, and posttraumatic stress disorder among survivors.[12],[13],[14]

Nonetheless, the fact remains that we do not have sufficient information at present on potential long-term sequelae. Neither are we sure of the trajectory and natural history of the observed components of long COVID in survivors. Using other SARS viral infections as a reference, it is likely that most of these could be self-limiting and inconsequential in the long run. Yet, we need to address the concerns and apprehensions of persons with these symptoms since some of them could be potentially troublesome and debilitating. Setting up of COVID-19 follow-up clinics is an important step in this direction. These clinics could have multiple utilities. First, they provide a mechanism by which patients can interact with the care providers outside of the barriers and suffocating environment of a secluded ward inhabited only by COVID-19 patients and staff in personal protective equipment. Second, these clinics are likely to be a major source of data on the long-term sequelae of COVID-19, aiding us in developing effective mechanisms to detect and manage them. Third, they provide a vital opportunity to reinforce healthy habits developed during this pandemic, including hand hygiene, cough etiquette, use of masks, and social distancing. These survivors and their relatives are more likely to imbibe and disseminate such health promotion advocacies, having gone through the trauma of the infection. Fourth, persons in need of medical and/or surgical attention for potential issues can be identified at such clinics and promptly referred. Fifth, several COVID-19 patients have comorbidities such as diabetes, hypertension, and heart disease. These clinics could be an important opportunity to provide continued care for these comorbidities that might have been neglected during and after the acute COVID illness. Finally, they could strengthen the trust and bond created between the healthcare professionals and patients during the tough times of this pandemic. This could very well be our chance to rebuild the sacred relationship that was on the verge of crumbling.

A COVID follow-up clinic needs to be run by a multidisciplinary team consisting of physicians, pulmonologists, psychiatrists, psychologists, and rehabilitation specialists. It would be good to have a brief clinical examination focused on the respiratory, cardiac, and nervous systems followed by a set of limited investigations. Several societies have provided guidance on possible workup to be done in post-COVID-19 patients. It may be both cost-effective and sensible to test based on clinical presentation, rather than a battery of all possible tests for all patients. However, a chest radiograph, pulmonary function tests, and a six-minute walk test would give a lot of information in most patients and could therefore be default. While most of the common long COVID symptoms such as fatigue, myalgia, and cough only require reassurance and symptomatic treatment, more ominous features such as fibrosis and thromboembolism will need a specialist referral and further evaluation for definitive management.

To conclude, long COVID is likely to a major reason for visits to hospitals in the coming months. Healthcare professionals and policymakers need to be aware of the potential issues and the need for quality data on long-term sequelae of COVID-19. COVID follow-up clinics run by multidisciplinary teams providing affordable care and testing are likely to be the best way to address long COVID.

References

1Greenhalgh T, Knight M, A'Court C, Buxton M, Husain L. Management of post-acute COVID-19 in primary care. BMJ 2020;370:m3026.
2How Long Does COVID-19 Last? Available from: https://covid.joinzoe.com/post/covid-long-term. [Last accessed on 2020 Nov 11].
3Tenforde MW, Kim SS, Lindsell CJ, Billig Rose E, Shapiro NI, Files DC, et al. Symptom duration and risk factors for delayed return to usual health among outpatients with COVID-19 in a multistate health care systems network-United States, March-June 2020. MMWR Morb Mortal Wkly Rep 2020;69:993-8.
4Carfì 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.
5Cui S, Chen S, Li X, Liu S, Wang F. Prevalence of venous thromboembolism in patients with severe novel coronavirus pneumonia. J Thromb Haemost 2020;18:1421-4.
6Klok FA, Kruip MJ, van der Meer NJ, Arbous MS, Gommers DA, Kant KM, et al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res 2020;191:145-7.
7Barker-Davies RM, O'Sullivan O, Senaratne KP, Baker P, Cranley M, Dharm-Datta S, et al. The Stanford Hall consensus statement for post-COVID-19 rehabilitation. Br J Sports Med 2020;54:949-59.
8Shi S, Qin M, Shen B, Cai Y, Liu T, Yang F, et al. Association of cardiac injury with mortality in hospitalized patients with COVID-19 in Wuhan, China. JAMA Cardiol 2020;5:802-10.
9Kochi AN, Tagliari AP, Forleo GB, Fassini GM, Tondo C. Cardiac and arrhythmic complications in patients with COVID-19. J Cardiovasc Electrophysiol 2020;31:1003-8.
10Madjid M, Safavi-Naeini P, Solomon SD, Vardeny O. Potential effects of coronaviruses on the cardiovascular system: A review. JAMA Cardiol 2020;5:831-40.
11What Does COVID-19 Recovery Actually Look Like? Patient Led Research. Available from: https://patientresearchcovid19.com/research/report-1/. [Last accessed on 2020 Nov 11].
12Garner P. COVID-19 at 14 weeks—Phantom speed cameras, unknown limits, and harsh penalties. BMJ. Available from: https://blogs.bmj.com/bmj/2020/06/23/paul-garner-covid-19-at-14-weeks-phantom-speed-cameras-unknown-limits-and-harsh-penalties/. [Last accessed on 2020 Nov 11].
13Forte G, Favieri F, Tambelli R, Casagrande M. COVID-19 pandemic in the Italian population: Validation of a post-traumatic stress disorder questionnaire and prevalence of PTSD symptomatology. Int J Environ Res Public Health 2020;17.
14Duan L, Zhu G. Psychological interventions for people affected by the COVID-19 epidemic. Lancet Psychiatry 2020;7:300-2.