Since the previous rapid review, a large amount of new research and reviews are available to draw upon. Many studies have addressed aspects previously identified as limitations such as the use of validated questionnaires, documenting pre-COVID health status, and control cohorts. Many studies now include only participants with RT-PCR verified infections and also focus on a range of disease severities from severe (hospitalized) to mild (managed in the community); PCR-validated infections ensure a higher quality of comparison between test-positive and control groups. Studies involving control groups contributed illuminating findings about prevalence and incidence of long COVID, which is lower than previous thought when compared to control groups. Comorbidities/factors that potentially indicate increased risk of developing long COVID-19 have been identified and widely agreed-upon, such as diabetes, cardiovascular diseases, obesity, and gender (female).
A case definition for long COVID has yet to be adopted but is commonly defined as COVID-related symptoms that persist or emerge beyond 4 weeks of infection with two subsequent phases: “ongoing symptomatic COVID-19 (OSC; signs and symptoms from 4 to 12 weeks from initial infection) and 2) post-COVID-19 syndrome (PCS; signs and symptoms beyond 12 weeks) with respect to symptomatology, abnormal functioning, psychological burden, and quality of life”. Long COVID includes both OSC and PCS.
It is estimated that 32% of non-hospitalized and 51% of hospitalized people experience Long COVID symptoms within 12 weeks of infection; however, higher estimates up to 92% have been reported in studies with a greater proportion in persons who were previously hospitalized. More than 200 symptoms affecting 10 organ systems have been identified in various reports or systematic reviews. Many patients (49%), experience at least one COVID-related symptom 12 months after infection (compared to 68% at 6 months).
For many persons, symptoms improve over time while others experience persistent and/or new symptoms. At 3 months post-infection the most frequently reported symptoms are fatigue (up to 98%), dyspnoea (up to 88%), headache (up to 91%) and taste/smell disorders (up to 58%).
Mechanism(s) leading to long COVID remain unclear, but these comorbidities/factors have been found to indicate potentially increased risk of developing long COVID:
o Age (60+)
o Greater number of symptoms during the acute phase of illness (typically 5+)
o Manifestation of specific symptoms
o Cardiovascular disease
o Obesity or high BMI
o Gender (female)
There is limited evidence to support the contention that vaccination lowers incidence of long COVID.
July 9, 2021
The frequency of Long COVID symptoms varies widely across studies based on populations studied, duration of follow up and methods of assessment of symptoms.
It is estimated that 1 in 50 persons experience Long COVID symptoms after 12 weeks; however, higher estimates up to 80% have been reported in studies with a greater proportion of persons who were previously hospitalized. A recent study of a mixed cohort of 96 persons found that only 22.9% had no symptoms at 12 months post diagnosis.
A wide range of symptoms affecting multiple organ systems has been reported. For many persons symptoms improve over time while others experience persistent and/or new symptoms. Among studies with the longest duration of follow up, the most frequently reported symptoms included fatigue (up to 65%), dyspnea (up to 50%), headache (up to 45%), anosmia/ageusia (up to 25%), cognitive memory/concentration (up to 39.6%) and sleep disorders (up to 26%).
Few studies estimated the duration of symptoms with estimates ranging from 2.2% for 6 months and 27% for 7-9 months.
The mechanism(s) leading to Long COVID remain unclear but those experiencing post acute sequelae tend to be older, have a greater number of symptoms during the acute phase of illness or manifest specific symptoms and live with multiple comorbid conditions such as obesity.
The lack of consensus on a definition of Long COVID contributes to marked variations in robust prevalence estimates.
A significant amount of evidence was produced since the previous review. This updated review was rewritten with extensive changes which have not been identified in red.
Hammond, B; Badea, A; Groot, G; Reeder, B; Howell-Spooner, B; Mueller, M. What is the incidence and duration of long COVID cases? 2022 Mar 31, Document no.: EPM210601v2 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2022. 18 p. (CEST rapid review report).
There exists some ambiguity across jurisdictions and thus there is no clear universal case definition of COVID-19 hospitalization.
Public Health Ontario measures hospitalization as “the number of confirmed COVID-19 cases that reported ever being hospitalized during their infection”- i.e., all cases reported as ever being hospitalized during their infection.
The category “incidental COVID-19 hospitalizations” has been proposed. This refers to patients who are primarily admitted for other ailments and test positive as part of routine screening.
Some jurisdictions and health agencies have started differentiating between those who were admitted for COVID-19-related illness and incidental admissions. Ontario and Saskatchewan have begun using this category in their regular reporting of COVID-19 statistics.
New data from Australia, New Zealand, the US, and Canada indicate that 30 to 50 percent of COVID-19 hospitalizations are “incidental COVID-19 hospitalization” – 46% of COVID-19 hospitalizations in Ontario (as of January 11th, 2022) and 40% in Saskatchewan (as of January 26th, 2022)
Some expert opinions caution that such binary categorization may oversimplify clinical reality, and suggests also employing an ‘indeterminate’ category
Asamoah, G; Badea, A; Reeder, B; Groot, G; Muhajarine, N; Howell-Spooner, B; Young, C. What is the (case) definition of hospitalization for COVID-19 in similar jurisdictions? 2022 Feb 10. Document no.: CAC220101 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2022. 9 p. (CEST rapid review report).
Long COVID-19 is likely to increase healthcare demands across the health system, including emergency departments, hospital admissions, primary care visits, specialists appointments, and home care and rehabilitation services.
The clinical care burden of long COVID-19 is the greatest in the first 3 months after testing and is likely to place the greatest demand on primary care services.
Patients with severe COVID-19 illness are more likely to place longer-term demands (4-6 months) on specialist care due to respiratory, circulatory, endocrine, metabolic, psychiatric and unspecified conditions.
McLean, M; Williams-Roberts, H; Reeder, B; Howell-Spooner, B; Ellsworth, C. What are long COVID's demands on the healthcare system, and its severity of the illness? 2021 Jul 12, Document no.: EPM210602 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2021. 23 p. (CEST rapid review report).
McCarron, M; Lee, S; Takaya, S; Howell-Spooner, B; Dalidowicz, M. Is there increased morbidity or mortality peri-operatively for symptomatic, asymptomatic, post-COVID patients? 2020 Oct 15; Document no.: INF092801 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2020. 27 p. (CEST rapid review report)
· The terms cluster and outbreak both describe the occurrence of new disease cases within a particular location and time period. The number of cases within a cluster are not necessarily greater than what is expected, however in an outbreak the number of cases does exceed the usual norm.
· In an outbreak the cases are confirmed to be epidemiologically linked while in a cluster an epidemiological connection is only suspected.
· Not all clusters are outbreaks, however each cluster needs to be investigated
· Understanding how to characterize COVID-19 cases based on a suspected or proven epidemiological link can better guide prevention of disease spreading
Radu, L; Badea, A; Groot, G; Ellsworth, C; Young, C. What is the definition of an outbreak versus a cluster for COVID-19 in different clinical and community settings in Canada, the US, and the UK? 2020 Jul 27; Document no.: EOC071001 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2020. 11 p. (CEST rapid review report)
Core concepts of family engagement include dignity and respect, information sharing, participation in care and decision making, and collaboration (Hart 2020).
A careful balance needs to be maintained between attending to patients’ physical and psychological needs and adhering to infection control guidelines, while offering psychological support to family members (Chan 2006).
The word ‘visitation’ does not adequately describe family members’ involvement. Family presence is a more suitable term as it redefines families as partners in care (Hart 2020). However, it is important to recognize that family presence is not a substitute for adequate staffing levels.
Very little guidance is provided in the literature on innovative or specific approaches engage family care providers during a pandemic. The literature mainly focuses on supporting alternate forms of communication such as telephone calls, or technology assisted communication through social media or video/voice calls.
Enhanced communication strategies that provide regular information to a primary family contact on the patient/resident condition and allow chosen care partners to contribute to decision making as much as possible are recommended (Koller 2006).
The negative impact of visitation restrictions places increased stress on patients/residents and families who are unable to provide or receive non-healthcare specific supportive care. Those with neurocognitive disorders or communication barriers are more significantly impacted.
Staff also report increased stress during family visitation restrictions due to the additional time required to take on a “familial role” for the patient/resident. These roles may include providing a supportive environment, social interaction, information sharing, and opportunities for play (Koller 2006a – pediatric hospital setting).
The search question did not specifically look at impact of visitation on infection rates; therefore, there is insufficient information to determine if visitation policies affect infection rates. However, a systematic review in pediatric hospital setting in Ontario found no connection between liberal visiting hours and increased SARS infection rates (Smith 2009).
When facilitating sibling visitation in the NICU, a pre-visit education process is recommended. Maternity settings may wish to consider a 'combination' policy, where the women's partners and/or significant other would have open visiting (all day), with restricted visiting for others. In other general hospital ward settings, open visiting with a 'quiet hour' is suggested (Smith 2009).
Tupper, S; Ward, H; Dalidowicz, M; Boden, C; Ellsworth, C; What are best practices for engaging family care providers during a pandemic? 2020 Apr 16; Document no.: LTC042401 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2020. 22 p. (CEST rapid review report)
Visitor restrictions in long-term care (LTC) during an outbreak or pandemic are implemented due to the perceived risk of transmission between residents or staff and visitors.
· Social isolation and possible loss of care resulting from visitor restrictions in LTC may place residents at risk of poorer outcomes in terms of both physical and mental health, as well as distress to families and staff (see Saskatchewan LTC Network Family Perspective).
· Visitor restriction policies typically allow visits for compassionate reasons that include end of life, critical care, and support of persons who require assistance beyond that provided by healthcare e.g. support for feeding, mobility, or behaviors, but specific detail on these is not consistent or clear.
· Recent changes to visitation policies in Australia are less restrictive and allow brief visitations (end of table 1, noted in red font).
· Although the majority of policies describe a need for flexibility and case-by-case assessment of visits deemed “essential”, the majority of policies are not clear in who is to conduct this analysis or the criteria that should be used to make these decisions.
Visitation policies differ in detail regarding the number of visitors allowed at one time, total number of visitors allowed, visit duration, mobility within the home and location of the visit.
· Remote and technology assisted visits are to be facilitated by LTC staff.
· Infection control practices are enforced for visitors, and may include screening (e.g. temperature, symptoms, travel and contact history), prohibiting ill visitors, use of personal protective equipment (PPE), hand and cough hygiene.
· Education of visitors and support for proper infection control practices is encouraged in the majority of policies.
Tupper, S; Ward, H; Howell-Spooner, B; Dalidowicz, M; Boden, C. How is "compassionate visit" defined and operationalized in the context of an infectious outbreak or pandemic in long-term care? 2020 May 1; Document no.: LTC042402
RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2020. 17 p. (CEST rapid review report)