Intended for healthcare professionals

Rapid Response:

FROM DOCTORS AS PATIENTS: A MANIFESTO FOR TACKLING PERSISTING SYMPTOMS OF COVID-19

We write as a group of doctors affected by persisting symptoms of suspected or confirmed COVID-19. We aim to share our insights from both our personal experiences of the illness and our perspective as physicians.

Tackling this issue will involve collaboration between politicians, healthcare services, public health professionals, scientists and society as a whole. We call for the following principles to be used so that the best possible outcomes can be achieved for all people affected by persisting symptoms of COVID-19:

1) Research and surveillance: Persisting symptoms of COVID-19 should be dealt with using a scientific methodology and without bias. People experiencing them should be counted.

The effects of the virus should be studied in the way that any other disease would be, with thorough attention paid to epidemiology, pathophysiology and management. “We still know very little about COVID-19, but we do know that we cannot fight what we do not measure.”[1] Research and surveillance needs to capture the full spectrum of disease, including in those not hospitalised and not tested, in order to build an accurate picture of COVID-19 phenotypes. A clear definition for recovery from COVID-19 is required. Whilst further evidence is awaited clinicians should “be open about uncertainty, and transparent in the ways in which we acknowledge the limitations of the imperfect data we have no choice but to use”.[2] We argue this means accepting an emerging picture that prolonged symptoms are having a substantial impact on a significant minority of people and acknowledging that death is not the only outcome to measure. We argue that further research into chronic COVID-19 symptoms is essential. Failure to understand the underlying biological mechanisms causing these persisting symptoms risks missing opportunities to identify risk factors for developing them, prevent chronicity and find treatment approaches both for people suffering now as well as any future patients.

2) Clinical Services: Services need to be timely, tailored to individuals’ presentations, and involve investigating and treating pathology, as well as the functional recovery of individuals.

Many patients who may, under normal circumstances, have been admitted to hospital instead managed their extremely difficult symptoms at home during this crisis. We should not assume that pathology is different between hospitalised and non-hospitalised patients. Before any active rehabilitation can start organic pathology needs to be detected and managed with appropriate investigations. A rehabilitation prescription can then be made for the individual. As Prof. Turner-Stokes (Consultant in Rehabilitation Medicine) warned in a recent RSM Webinar,[3] “… before we get people exercising, it’s important to be sure that it’s going to be safe. We need proper evaluation of cardiac and respiratory function, and we need to take things slowly and in a paced measure.” A recent study in JAMA [4] of 100 patients (67 of whom had not been admitted to hospital) undergoing cardiac MRI after COVID-19 demonstrated “cardiac involvement in 78 patients (78%) and ongoing myocardial inflammation in 60 patients (60%)”. The authors discuss that “…participants… with mostly home-based recovery had frequent cardiac inflammatory involvement, which was similar to the hospitalized subgroup with regards to severity and extent.”

The establishment of one-stop clinics will allow pattern recognition and expertise to develop amongst clinicians identifying and managing sequelae of COVID-19. These clinics should reflect the multi-system nature of COVID-19 and involve multidisciplinary teams with access to relevant investigations to detect known complications of COVID-19 as indicated after clinical review. A reliance on “one-size fits all” online rehabilitation services risks serious harm to patients if pathology goes undetected, and is a missed opportunity for clinicians to develop their experience with the sequelae of this virus that is set to be an ongoing presence in our clinical practice. Where current guidance has been issued, such as the statement from NICE [5] cautioning against Graded Exercise Therapy in the context of COVID-19, it should be communicated quickly to clinicians on the frontline.

3) Patient involvement: Patients must be involved in the commissioning of clinical services and the design of research studies.

‘No decision without me’[6]- Lessons learnt from other illnesses have demonstrated the importance of involving those most affected. Patients experiencing persisting symptoms of COVID-19 [7] have a great deal to contribute to the search for solutions. Involving patients in research design [8] and the commissioning of clinical services will ensure that the patient perspective is listened to and will optimise the development of such studies and clinical services. This may take the form of representatives from patient-formed groups, which may include signatories of this letter, liaising with policy makers, researchers and healthcare leaders.

4) Clinical services commissioned should not unfairly discriminate against those with negative tests and a clinical diagnosis should be adequate for accessing any appropriate services.

Widespread testing was not available during the early days of the pandemic. The timing of tests for active COVID-19 infection (such as RT-PCR tests) affects test performance and even if performed at an optimal time, the test is associated with a considerable risk of false negatives.[9] We know antibody tests have mainly been validated on hospitalised patients and are poorly sensitive early in the illness.[10] There is little data regarding testing later in the disease course, and false negatives appear common. Some individuals do not seroconvert [11] despite having previously tested positive. Thus, adherence to positive test results as a criterion for access to medical services or specific COVID-19 sick pay arrangements with employers is unacceptable in the context of a clinical diagnosis of COVID-19.

We welcome increasing awareness of the problem of persisting symptoms of COVID-19.[12] As politicians, scientists and doctors attempt to tackle this issue, these principles can act as a guide enabling the experiences of those living with the condition to inform the efforts of experts and lead to improved research and clinical care, benefiting those affected and society as a whole.

References
1) Alwan N. What exactly is mild covid-19? https://blogs.bmj.com/bmj/2020/07/28/nisreen-a-alwan-what-exactly-is-mil...
Date last updated: July 28 2020. Date last accessed: August 21 2020.

2) Rutter H, Wolpert M, Greenhalgh T. Managing uncertainty in the covid-19 era. https://blogs.bmj.com/bmj/2020/07/22/managing-uncertainty-in-the-covid-1...
Date last updated: July 22 2020. Date last accessed: August 21 2020.

3) RSM COVID-19 Series | Episode 32: Rehabilitation after the viral infection. https://www.youtube.com/watch?v=KW1Gdw9D_Pk
Date last updated: July 21 2020. Date last accessed: August 21 2020.

4) Puntmann VO, Carerj ML, Wieters I, et al. Outcomes of Cardiovascular Magnetic Resonance Imaging in Patients Recently Recovered From Coronavirus Disease 2019 (COVID-19). JAMA Cardiol. Published online July 27, 2020. doi:10.1001/jamacardio.2020.3557.

5) Torjesen I. NICE cautions against using graded exercise therapy for patients recovering from covid-19. BMJ 2020;370:m2912.

6) Department of Health. Liberating the NHS: No decision about me, without me – Government response to the consultation. https://assets.publishing.service.gov.uk/government/uploads/system/uploa...
Date published: December 13 2012. Date last accessed: August 21 2020.

7) Lokugamage A, Taylor S, Rayner C. Patients’ experiences of “longcovid” are missing from the NHS narrative. https://blogs.bmj.com/bmj/2020/07/10/patients-experiences-of-longcovid-a...
Date published: July 10 2020. Date last accessed: August 21 2020.

8) NIHR. PPI (Patient and Public Involvement) resources for applicants to NIHR research programmes. https://www.nihr.ac.uk/documents/ppi-patient-and-public-involvement-reso...
Date last updated: December 18 2019. Date last accessed: August 21 2020.

9) Watson J, Whiting PF, Brush JE. Interpreting a covid-19 test result. BMJ 2020; 369 :m1808.

10) Deeks JJ, Dinnes J, Takwoingi Y, Davenport C, Spijker R, Taylor-Phillips S, Adriano A, Beese S, Dretzke J, Ferrante di Ruffano L, Harris IM, Price MJ, Dittrich S, Emperador D, Hooft L, Leeflang MMG, Van den Bruel A. Antibody tests for identification of current and past infection with SARS‐CoV‐2. Cochrane Database of Systematic Reviews 2020, Issue 6. Art. No.: CD013652. DOI: 10.1002/14651858.CD013652.

11) Staines HM, Kirwan DE, Clark DJ, Adams ER, Augustin Y, Byrne RL, Cocozza M, Cubas-Atienza AI, Cuevas LE, Cusinato M, Davies BMO, Davis M, Davis P, Duvoix A, Eckersley NM, Forton D, Fraser A, Garrod G, Hadcocks L, Hu Q, Johnson M, Kay GA, Klekotko K, Lewis Z, Mensah-Kane J, Menzies S, Monahan I, Moore C, Nebe-von-Caron G, Owen SI, Sainter C, Sall AA, Schouten J, Williams C, Wilkins J, Woolston K, Fitchett JRA, Krishna S, Planche T. Dynamics of IgG seroconversion and pathophysiology of COVID-19 infections. (Preprint)
medRxiv 2020.06.07.20124636; doi: https://doi.org/10.1101/2020.06.07.20124636.

12) Greenhalgh T, Knight M, A’Court C, Buxton M, Husain L. Management of post-acute covid-19 in primary care. BMJ 2020; 370 :m3026.

Competing interests: Dr Daniel Campion reports personal fees from Emergent BioSolutions, outside the submitted work; Dr Nathalie MacDermott reports grants from National Institute for Health Research (NIHR) UK , grants from Wellcome Trust, outside the submitted work; Dr Margarita Thomson is Cancer Clinical lead South West London CCG (Merton).

11 September 2020
Jake C Suett
Staff Grade Anaesthetist and Intensive Care Doctor
Dr Nisreen A Alwan, Associate Professor in Public Health, University of Southampton; Dr Emily Attree, Salaried GP, London; Dr Jennifer Mary Blair, Consultant Anaesthetist & Trust Lead for Simulation and Human Factors, Epsom & St Helier University Hospitals NHS Trust; Prof Debby Bogaert, Chair of Paediatric Medicine, Professor of Paediatric Infectious Diseases, Honorary Consultant Paediatric Infectious Diseases, Center for Inflammation Research, University of Edinburgh, Edinburgh; Dr Mary-Ann Bowen, GP Partner, West Midlands; Dr John Boyle, Consultant Psychiatrist, Belfast; Dr Madeleine Bradman, GP, North Yorkshire; Dr Tracy Ann Briggs, Senior Lecturer and Honorary Consultant in Clinical Genetics, University of Manchester; Dr Sarah Burns, GP, Southampton; Dr Daniel Campion, Travel Health Physician, London; Dr Katherine Cushing, GP and CCG Clinical Lead for CYP & Families, Newcastle; Prof Brendan Delaney, Chair in Medical Informatics and Decision Making, Imperial College London; Dr Chris Dixon, Full time GP partner, Bexhill on Sea; Dr Grace E. Dolman, Hepatology ST7, Cambridge University Hospitals NHS Foundation Trust; Dr Caitriona Dynan, Consultant Radiologist, Antrim Area Hospital Northern Ireland; Dr Ian M Frayling, Honorary Consulting Genetic Pathologist to St Mark's Hospital, Harrow & St Vincent's Hospital, Dublin, President Elect, Association of Clinical Pathologists; Dr Nell Freeman-Romilly, Foundation Doctor, Oxford; Dr Iulia Hammond, GP ST1, Greater Manchester; Dr Jenny Judge, Consultant Forensic Psychiatrist, Surrey and Borders NHS Trust; Dr Linn Järte, CT2 Anaesthetist, South Wales; Dr Amali Lokugamage, Consultant Obstetrician & Gynaecologist and Honorary Associate Professor, UCL; Dr Nathalie MacDermott, NIHR Academic Clinical Lecturer & ST7 Paediatric Infectious Diseases, King's College London; Dr Mairi MacKinnon, General Practitioner, Inverness; Dr Visita Majithia, Salaried GP, London; Dr Tanya Northridge, GP Partner, Brixton Hill Group Practice; Dr Laura Powell, Anaesthetics CT1, Severn Deanery; Dr Clare Rayner, Consultant Occupational Physician, North-West; Dr Ginevra Read, ST8 Psychiatry, Severn Deanery; Dr Ekta Sahu, Speciality Doctor, Paediatrics, Coventry; Dr Claudia Shand, Retired GP, Hook, Hampshire; Dr Amy Small, GP Partner Prestonpans Group Practice, Member of BMA Scottish Council and Scottish GP Committee; Dr Cara Strachan, East Lothian; Dr Jake Suett, Staff Grade Anaesthetist and Intensive Care Doctor; Dr Becky Sykes, Salaried GP, Bristol; Dr Sharon Taylor, Consultant Child and Adolescent Psychiatrist, London; Dr Kevin Thomas, GP Pontcae Medical Practice, Merthyr Tydfil; Dr Margarita Thomson, GP, London; Dr Alexis Wiltshire, Locum GP, Liverpool; Dr Victoria Woods, GP, Wessex.
The Queen Elizabeth Hospital Kings Lynn
c/o Anaesthetic Department Secretary, The Queen Elizabeth Hospital Kings Lynn, Gayton Rd, King's Lynn PE30 4ET