Caring for patients with post–COVID-19 conditions

Introduction

Introduction

Evidence regarding the incidence and spectrum of post–COVID-19 illness and management is evolving and will continue to develop in years to come.

The National COVID-19 Clinical Evidence Taskforce continues to monitor and review latest research in this space.


Defining post–COVID-19 conditions

The World Health Organization recently developed a clinical case definition for ‘post–COVID-19 condition’:

Post COVID-19 condition occurs in individuals with a history of probable or confirmed SARS CoV-2 infection, usually 3 months from the onset of COVID-19 with symptoms and that last for at least 2 months and cannot be explained by an alternative diagnosis. Common symptoms include fatigue, shortness of breath, cognitive dysfunction but also others and generally have an impact on everyday functioning. Symptoms may be new onset following initial recovery from an acute COVID-19 episode or persist from the initial illness. Symptoms may also fluctuate or relapse over time.1 

Another suggested definition that describes a range of post-acute COVID-19 symptoms is ‘chronic COVID-19’ or ‘post–COVID syndrome’; that is, illness extending beyond 12 weeks from initial symptoms.2,3

The term ‘long COVID’ has been commonly used to describe COVID-19 symptoms following acute illness, irrespective of how long the symptoms take to resolve, and could be used to refer to either of the above two conditions.4

This guide contains information for general practitioners (GPs) and their teams, who are providing care for patients who have previously tested positive to COVID-19 or have a history suggestive of undiagnosed COVID-19 and have – or are at risk of – post– COVID-19 conditions at any point after the initial acute infection. 

Incidence of post–COVID-19 sequelae

The incidence of post–COVID-19 sequelae in those who have tested positive and who have been managed in an outpatient setting (such as management in the home) is thought to be between 10% and 35%, but for those admitted to hospital, this could be closer to 85%.5 The incidence of prolonged illness significantly increases with age, comorbidities and initial severity of the acute illness.

In a UK study of 20,000 people who had tested positive to COVID-19, 13.7% reported having symptoms 12 weeks after acute infection.6 In an Australian study of 3000 people, 80% reported full recovery within one month, and 5% reported experiencing symptoms after three months.7 Other studies reported significantly higher prevalence of symptoms at both time points.3

Studies indicate that the risk of post–COVID symptoms in people who contract COVID-19 after their second dose of COVID-19 vaccine is approximately halved.8 

Management of post–COVID-19 conditions

Global experience with the epidemics of severe acute respiratory syndrome coronavirus 1 (SARS-CoV-1) in 2003 and Middle Eastern respiratory syndrome (MERS) in 2012 has added to the evidence used in current recommendations in post–COVID-19  management.9

General practice presentations in a post-acute COVID-19 scenario are likely to be based on:

  • non-specific post-viral symptoms, particularly fatigue, breathlessness, persistent cough and cognitive dysfunction10
  • specific serious sequelae resulting from the acute infection, or as delayed complications
  • recovery following severe illness that required intensive care management
  • mental health impacts of the acute illness, stigma, ongoing symptoms and functional impairment.

For patients with ongoing symptomatic COVID-19 or suspected post–COVID-19 conditions, a holistic, person-centred approach should be used, including a comprehensive clinical history and appropriate examination that involves assessing physical, cognitive, psychological and psychiatric symptoms, as well as functional abilities.4 

This resource

The purpose of this resource is to provide advice and support to GPs and their teams when caring for patients with post–COVID-19 conditions, and to encourage the development of individualised plans for their ongoing management.

This document provides generic guidance and should be used to support any local or other more contemporaneous advice, such as the National COVID-19 Clinical Evidence Taskforce guidelines and clinical flowcharts for the care of people with post–COVID-19 and local HealthPathways, acknowledging that uncertainties remain in our understanding of the sequelae of COVID-19 and its management.

This guide can be used in conjunction with the patient resource, Managing post–COVID-19 symptoms.

  1. World Health Organization. A clinical case definition of post COVID-19 condition by a Delphi consensus, 6 October 2021. Geneva: WHO, 2021 int/publications/i/item/WHO-2019-nCoV-Post_COVID-19_condition-Clinical_ case_definition-2021.1 [Accessed 24 November 2021].
  2. Greenhalgh T, Knight M, A’Court M, Buxton M, Husain L. Management of post- acute covid-19 in primary care. BMJ 2020;370:m3026. [Accessed 24 November 2021].
  3. Nalbandian A, Sehgal K, Gupta K, et al. Post-acute COVID-19 syndrome. Nat Med 2021;27(4):601–15. [Accessed 24 November 2021].
  4. National Institute for Health and Care Excellence. COVID-19 rapid guideline: Managing the long-term effects of COVID-19. UK: NICE, 2021 [Accessed 6 December 2021].
  5. Pavli A, Theodoridou M, Maltezou H. Post-COVID syndrome: Incidence, clinical spectrum, and challenges for primary healthcare professionals. Arch Med Res 2021;52(6): 575–81. [Accessed 6 December 2021].
  6. Office for National Statistics. Prevalence of ongoing symptoms following coronavirus (COVID-19) infection in the UK: 1 April 2021. UK: Office for National Statistics, 2021 omsfollowingcoronaviruscovid19infectionintheuk/1april2021#measuring-the-data [Accessed 24 November 2021].
  7. Liu B, Jayasundara D, Pye V, et al. Whole of population-based cohort study of recovery time from COVID-19 in New South Wales Australia. Lancet Reg Health West Pac 2021;12:100193. [Accessed 24 November 2021].
  8. Antonelli M, Penfold R, Merino J, Sudre C. Risk factors and disease profile of post- vaccination SARS-CoV-2 infection in UK users of the COVID Symptom Study app: A prospective, community-based, nested, case-control study. Lancet Infect Dis 2021;S1473-3099(21)00460-6. [Accessed 24 November 2021].
  9. Barker-Davies R, O’Sullivan O, Senaratne K, et al. The Stanford Hall consensus statement for post-COVID 19 rehabilitation. Br J Sports Med 2020;54(16):949–59. [Accessed 24 November 2021].
  10. Venkatesan P. NICE guideline on long COVID. Lancet Respir Med 2021;9(2):129. [Accessed 24 November 2021].
  11. Australian Institute of Health and Welfare. The first year of COVID-19 in Australia: Direct and indirect health effects. Canberra: Australian Government, 2021 phe-287.pdf [Accessed 23 November 2021].
  12. National COVID-19 Clinical Evidence Taskforce. Care of people with post-COVID-19 (version 4.0). Melbourne: National COVID-19 Clinical Evidence Taskforce, 2022   [Accessed 5 May 2022].
  13. British Society of Rehabilitation Medicine. Rehabilitation in the wake of COVID-19 – A phoenix from the ashes. UK: BSRM, 2020 downloads/covid-19bsrmissue1-published-27-4-2020.pdf  [Accessed 23 November 2021].
  14. Selvaraj V, Dapaah-Afriyie K. Lung cavitation due to COVID 19 pneumonia. BMJ Case  Rep 2020;13(7):e237245. [Accessed 23 November 2021].
  15. Carfi A, Bernabei R, Landi R, Gemelli Against COVID-19 Post-Acute Study Group. Persistent symptoms in patients after acute COVID-19. JAMA 2020;324(6):603–05. [Accessed 23 November 2021].
  16. Spruit MA, Holland AE, Singh SJ, et al. COVID-19: interim guidance on rehabilitation in the hospital and post-hospital phase from a European Respiratory Society and American Thoracic Society-coordinated international task force. Eur Respir J 2020;56(6):2002197. [Accessed 23 November 2021].
  17. Rroku A, Kottwitz J, Heidecker B. Update on myocarditis – what we know so far and where we may be heading. Eur Heart J Acute Cardiovasc Care 2020 (ahead of print). [Accessed 23 November 2021].
  18. Firth J, Marx W, Dash S, et al. The effects of dietary improvement on symptoms of depression and anxiety: A meta-analysis of randomized controlled trials. Psychosom Med  2019;81(3):265–80. [Accessed 23 November 2021].
  19. National COVID-19 Clinical Evidence Taskforce. Management of adults with mild-COVID-19 (version 42). Melbourne: National COVID-19 Clinical  Evidence Taskforce, 2022  [Accessed 5 May 2022].
  20. National COVID-19 Clinical Evidence Taskforce. Australian guidelines for clinical care of people with COVID-19 (version 56.1) – Venous thromboembolism (VTE) prophylaxis. Melbourne: National COVID-19 Clinical evidence Taskforce, 2022 [Accessed 5 May 2022].
  21. American Society of Haematology. COVID-19 and VTE/anticoagulation: Frequently asked questions (version 12). Washington: American Society of Haematology, 2021 [Accessed 6 December 2021].
  22. Herrera JE, Niehaus WN, Whiteson J, et al. Multidisciplinary collaborative consensus guidance statement on the assessment and treatment of fatigue in postacute sequelae of SARS-CoV-2 infection (PASC) patients. PM R 2021;13(9):1027–43. [Accessed 6 December 2021].
  23. Thurber K, Barrett E, Agostino J, et al. Risk of severe illness from COVID-19 among Aboriginal and Torres Strait Islander adults: The construct of ‘vulnerable populations’ obscures the root causes of health inequities. Aust N Z J Public Health 2021;4(6):658–63. [Accessed 6 December 2021].
  24. Yashashana A, Pollard-Wharton N, Zwi A, Biles B. Indigenous Australians at increased risk of COVID-19 due to existing health and socioeconomic inequities. Lancet Reg Health West Pac 2020;1:100007. [Accessed 6 December 2021].
  25. Zimmermann P, Pittet L, Curtis N. How common is long COVID in children and adolescents? Pediatr Infect Dis J 2021;40(12):e482–87. [Accessed 6 December 2021].
  26. Murdoch Children’s Research Institute. Frequently asked COVID-19 questions. Melbourne: MCRI, 2021 [Accessed 24 November 2021].
  27. Australian Technical Advisory Group on Immunisation. Clinical guidance  for COVID-19 vaccine providers. Canberra; ATAGI, 2022  [Accessed 5 May 2022].
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