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Letters Management of long covid

From doctors as patients: a manifesto for tackling persisting symptoms of covid-19

BMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m3565 (Published 15 September 2020) Cite this as: BMJ 2020;370:m3565

Rapid Response:

Are Health Professionals at higher risk for Long covid: Need for comprehensive surveillance to ensure occupational health and safety?

Dear Editor,

A group of health professionals affected by persisting symptoms of suspected or confirmed Covid-19 have called for further research into chronic Covid-19 symptoms (1). Earlier another health professional described experiencing a seven weeks long roller coaster of ill health, extreme emotions and utter exhaustion (2). Increasing attention is being drawn to a relatively under recognized condition labelled as “Long covid” to describe illness in people who have either recovered from Covid-19 but are still reporting lasting effects of the infection or have had the usual symptoms for far longer than would be expected. Many people, including several health professionals who have been infected, have been sharing their symptoms and experience through various channels (3).

The exact definition of “Long covid” is still evolving, in a recent online webinar on the diagnosis, management, and prognosis of “Long covid”, the expert panel used a working definition as " not recovering [for] several weeks or months following the start of symptoms that were suggestive of Covid-19, whether the person was tested or not" (4).

Recent studies from the UK and US have reported increased risk for SARS-CoV-2 infection among front-line health-care workers compared with the general community, using either self-reported data on COVID-19 testing positivity or a symptom-based predictor of positive infection status (5). A report based on a global survey by the International Council of Nurses estimate that infection rates among healthcare workers are likely to be in the range of 10% and an estimated 3 million healthcare professionals across the globe likely to be infected with COVID-19. This survey also revealed that less half the countries surveyed classify COVID-19 as an occupational disease (6). Emerging evidence suggests that healthcare workers are prone for reinfections and these could easily be missed when they are asymptomatic (7).

The underlying patho-physiological mechanisms in "Long covid" are not yet described. Anecdotal reports indicate that most persons experiencing chronic symptoms that qualify to be labelled as "Long covid" often experience mild symptoms or are asymptomatic when first infected with SARS-COV2 virus.

It has been reported that among children recovering after a mild attack of SARS-COV2 infection, a small percentage develop Multisystem Inflammatory Syndrome in Children (MIS-c) about 4-6 weeks after infection. It is postulated that prior immunity to other viruses trigger an enhanced immune response when these children are infected with SAR COV2 virus giving rise to hyper inflammation presenting as MIS-c (8).

Considering reports from healthcare professionals experiencing mild symptoms during their initial infection with SARS COV2 and thereafter a prolonged course of symptoms of fatigue, dyspnoea, joint pain, and chest pain, many of which are characteristic of autoimmune mediated responses, further research into the role of repeated exposure to SARS COV2 virus in a healthcare delivery setting and or in the community, and role of the repeated exposures leading to autoimmune mediated responses warrant urgent evaluation.

As health professionals are overwhelmed with a surge in workload posed by the rise in cases and growing demand on the health systems that have limited capacity, symptoms of chronic fatigue, joint pains and dyspnoea could easily be attributed to the additional workload or accompanying work related stress. Healthcare workers are likely to be silently suffering while experiencing “Long covid” even while continuing save lives during the ongoing pandemic.

As WHO launches the Patient Safety 2020 campaign on 17 September 2020 with a special focus on Health worker safety(9), creating global awareness on health worker safety by recognizing the immense burden that health professionals are likely to be experiencing due to the limited understanding, scant evidence and lack of coordinated mechanisms to diagnose, monitor and respond comprehensively to “Long covid” among health workers is an emerging occupational health priority of immediate global significance.

Digital health tools routinely used by healthcare workers in health services delivery could incorporate mechanisms for symptom tracking and contextual support for health-workers if adapted appropriately. The recently launched WHO Mobile Academy app (10) could incorporate specific modules on recognition and response to “Long covid” and offer opportunities for peer to peer support and pathways seek rehabilitative support. Where feasible national helplines for health workers to report occupation health and safety related matters will build confidence and provide reassurance to the millions of health workers who are risking their lives and serving their fellow citizens during this pandemic.

While we embark to light up monuments and public places in “orange” in solidarity with the health worker safety campaign, ensuring that healthcare workers are in the "pink of health" calls for concerted action from all stakeholders.

References:

1 Alwan NA, Attree E, Blair JM, et al. From doctors as patients: a manifesto for tackling persisting symptoms of covid-19. BMJ2020;370:m3565
2 Garner P. For 7 weeks I have been through a roller coaster of ill health, extreme emotions, and utter exhaustion. BMJ Opinion. 5 May 2020. https://blogs.bmj.com/bmj/2020/05/05/paul-garner-people-who-have-a-more-....
3 Mahase E. Covid-19: What do we know about “long covid”?. bmj. 2020 Jul 14;370.
4 Nabavi N. Long covid: How to define it and how to manage it. https://www.bmj.com/content/370/bmj.m3489
5 Nguyen LH, Drew DA, Graham MS, Joshi AD, Guo CG, Ma W, Mehta RS, Warner ET, Sikavi DR, Lo CH, Kwon S. Risk of COVID-19 among front-line health-care workers and the general community: a prospective cohort study. The Lancet Public Health. 2020 Jul 31.
6 https://www.icn.ch/news/new-icn-report-shows-governments-are-failing-pri...
7 Gupta, V., Bhoyar, R. C., Jain, A., Srivastava, S., Upadhayay, R., Imran, M., … Sivasubbu, S. (2020, September 15). Asymptomatic reinfection in two healthcare workers from India with genetically distinct SARS-CoV-2. https://doi.org/10.31219/osf.io/4fmrg
8 Consiglio CR, Cotugno N, Sardh F, Pou C, Amodio D, Rodriguez L, Tan Z, Zicari S, Ruggiero A, Pascucci GR, Santilli V. The immunology of multisystem inflammatory syndrome in children with COVID-19. Cell. 2020 Sep 6.
9 https://www.who.int/campaigns/world-patient-safety-day/2020
10 https://www.who.int/about/who-academy/the-who-academy-s-covid-19-mobile-...

Competing interests: No competing interests

16 September 2020
Oommen John
Internal Medicine, Public Health Research
George Institute for Global Health, University of New South Wales, New Delhi, India
New Delhi