Long Covid: special consideration needed

Vaccination may be winning the war against the pandemic in some countries, but for those with Long Covid, the fight is only just beginning. How does it affect people, who are at risk, and how can OSH professionals help sufferers return to work? Dr Karen Michell answers these questions and more. 

Long Covid, also known as Long-haul Covid or post-acute sequelae of COVID, is a syndrome characterised by diverse symptoms in those who have tested positive for infection with SARS-Cov-2, and who still experience symptoms after 28 days. It is estimated that it affects 10% of people who contract COVID-19 (Office for National Statistics (ONS), 2020).

The UK’s NICE guideline gives two definitions of Long Covid: ongoing symptomatic COVID-19 for people who still have symptoms four to 12 weeks after the start of acute symptoms, and post-COVID-19 syndrome for people who have symptoms more than 12 weeks after the start of acute symptoms (Venkatesan, 2021). Long Covid symptoms are diverse, affecting multiple systems in the body (respiratory, cardiovascular, nervous system, musculoskeletal). Commonly reported symptoms include fatigue, shortness of breath, muscle pains, chest pain, cognitive impairment (‘brain fog’), headache and psychological disorders such as depression and post-traumatic stress disorder (Scherlinger et al, 2021; Sudre et al, 2020). Symptoms reflect systemic damage to the body rather than active infection. Patients describe exhaustion from simple daily activities and a devastating impact on their lives. The diverse nature of the symptoms means multiple strategies are required to address sufferers’ health and social needs.  

Who gets Long Covid and what are the risks?

It is not only those who were hospitalised with severe COVID-19 who develop Long Covid – even people with mild cases report symptoms weeks and months later. However, it is more likely in those with pre-existing health conditions such as diabetes, asthma or hypertension, those aged over 50, those with a high body mass index, and women (Chand and Meshram, 2021). Another predictive factor is the number of symptoms the sufferer experiences. In cases where five or more symptoms were experienced in the first week of COVID-19 infection, the person was significantly more likely to develop Long Covid (Sudre et al, 2020; Tenforde et al, 2020). The scale of the health and economic problem is evident when the duration and diversity of presentations are considered in relation to the number of positive cases. As of 25 May 2021, the World Health Organization reported 167,011,807 confirmed cases of COVID-19 globally (WHO, 2021). If 10% of cases progress to Long Covid, more than 16 million people will suffer the condition. In the UK alone, it is estimated that 1.1 million people are suffering varying degrees of Long Covid (ONS, 2021).  

How to manage Long Covid

The key to managing Long Covid is understanding that this is a debilitating and evolving condition. Our understanding of it will improve with research, and as we gain insights from patients’ experiences. Healthcare is based on rehabilitation and symptom management aligned to medical guidelines and government policies. Multiple body systems may be affected, requiring an adaptive approach. Treatment requires a multidisciplinary team including clinicians, physiotherapists, occupational therapists, psychologists, social workers, safety practitioners and occupational health (OH) professionals. A worker’s health may vary from one day to the next as symptoms progress or resolve, and particular attention should be given to workers with cardiac, respiratory or neurological symptoms that do not improve. The OSH professional needs to be aware of changes reported by workers who are also patients. UK NICE guidelines detail protocols to assist health professionals caring for people with Long Covid (Venkatesan, 2021), and OH organisations have developed guidelines to assist OH practitioners and managers with return-to-work (RTW) processes. In the UK the NHS has established 69 Long Covid clinics to address the health needs of these patients.

Is Long Covid an occupational disease?

To be termed an occupational disease, the health outcome must have a causative link to exposure in the workplace. Health workers who contract COVID-19 after treating a COVID-positive patient will be assessed as having contracted the disease as a direct consequence of their work. If they progress to Long Covid, it would be deemed a continuation of the COVID-19 and thus occupational. A person may argue that they acquired COVID-19 from a co-worker and so have an occupational disease. The difference is that you may have come across this same person in a supermarket queue and it would not be a consequence of your work.

'The key to managing long covid is understanding that this is a debilitating and evolving condition'

More important than determining if COVID-19 is occupational are efforts to prevent the virus spreading, through effective infection prevention and control measures. Co-workers may be concerned they will catch Long Covid from a sufferer who has returned to work. Typically, a person with COVID-19 is infectious for 10 days, and has a fever and persistent new cough. The majority of Long Covid patients test negative for the virus, despite symptoms, and are not infectious.

Returning to work

For many workers it is not a case of returning to work after Long Covid but with Long Covid, especially in countries lacking strong social security systems and where COVID-19 is both an economic and a health issue. In some cases, survival is dependent on ability to work. A US-based survey reported that 35% of COVID-positive patients had not returned to work 14 to 21 days after testing positive, with the highest rate of no return reported in those aged 50 and over (Tenforde et al, 2020). In another study (Alwan, 2021), 75% of those with Long Covid said it affected their work, and 60% reported taking time off because of ill health. The significance for OSH professionals is the potential for prolonged absence and the possible need to provide supportive and adaptive RTW processes. RTW may be complicated and require an individualised approach to accommodate a worker’s capabilities in relation to their job specifications.  

A worker whose job requires manual labour and who is experiencing fatigue and shortness of breath will tire easily and not cope with their job’s physical demands. An office worker may have to give constant attention to detail while suffering from headaches and brain fog. A worker with a respiratory deficit may be unable to wear a respirator while working in their usual dusty environment, and have to be transferred to another job profile where the need to wear a respirator is not a concern. Or you may have to manage a worker with more than one systemic effect of COVID-19, making these scenarios even more challenging.

In all of these cases, workers are unable to cope with their job for different reasons, showing the need for an individualised approach. Success will be based on a planned, coordinated response, addressing physical and cognitive limitations, sickness absence and presenteeism. 

The OSH role

Work is good for physical and mental health, and a worker does not need to be 100% fit to be able to work (Faculty of Occupational Medicine (FOM) of the Royal College of Physicians, 2021). OSH professionals are obliged to facilitate a timely but safe RTW for employees to retain their skills within the workforce. Considerations given to a worker’s return in the context of Long Covid must be consistent with those in normal circumstances: risk driven and based on the hierarchy of control (examples highlighted in Table 1).  

The most significant aspect of the RTW process for those with Long Covid will be the assessment of their ability to assume normal work based on the disease’s impact on their health. Symptoms affecting functionality and the ability to cope at work include shortness of breath, fatigue, brain fog and chest pain (FOM, 2021). An OH practitioner is best suited to assist with this assessment and, if given an accurate job specification, will be able to advise on adaptations required.  

A key issue is the inclusion of the line manager, who is responsible for the day-to-day safety and health of workers under their control, as well as a decision-maker. Ask the worker for suggestions on adjustments such as working from home, flexible or reduced hours and assistive equipment. Address mental health issues by listening to their concerns and fears, and providing realistic reassurances and advice. Case management must be based on the worker’s ability rather than their inability, with a focus on activities that can be performed and taking into account the impact and duration of the activity. This is particularly relevant in safety-critical tasks, where lapses in energy levels and/or concentration may be disastrous. Reallocation to tasks with reduced working hours, the ability to sit on the job, and more frequent rest breaks may be required. Workers will experience highs and lows, and may need to be monitored from day to day to accommodate these transitions.  

What next?

COVID-19’s impact has been massive, and continues through the effects of Long Covid. As an emerging syndrome, it is still unclear how long it will take workers to recover, and OSH professionals could be managing workers with Long Covid for years. Successful integration of sufferers into the workplace requires a coordinated and collaborative approach between safety and health professionals, at the centre of which is the worker’s wellbeing.

Dr Karen Michell is an IOSH researcher.

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