Sex Differences in Long COVID

Living With Long COVID: Everyday Experiences, Health Information Barriers and Patients' Quality of Life

BACKGROUND

Long COVID has considerably impacted patients' daily lives, yet qualitative insights in Spain are still scarce. This study seeks to (1) explore patients' experiences and the barriers they face, (2) analyse challenges in accessing accurate information and (3) evaluate the effects on quality of life by examining its dimensions in detail.

METHODS

Semi-structured interviews were conducted with 23 participants in Spain with Long COVID. Thematic analysis was performed, investigating needs, obstacles in daily life, challenges in obtaining and understanding health knowledge and its effects on the quality of life.

RESULTS

The most frequent symptoms were chronic pain and postexercise fatigue. All individuals encountered restrictions in their daily lives, which often had financial consequences. A lack of recognition coupled with legal insecurity due to the absence of a formal diagnosis further compromised their economic stability. Stigmatisation and poor social understanding led to feelings of loneliness and distress, adding to the overall impact of the disease. Health fragmentation, lack of follow-up and absence of coordinated multidisciplinary treatment limited specialised treatment and health information. Therefore, many patients sought information and support from online communities. However, misinformation and information overload or contradictory information generated confusion, affecting decision-making about the management of their disease, affecting disease management and quality of life.

CONCLUSION

The impact of Long COVID transcends physical health, pointing to economic pressure, legal uncertainty and fragmentation of care. We reveal how misinformation and a lack of guidance intensify inequities in access to reliable information. These findings underscore the need for integrated models of care, policy recognition and targeted strategies to reduce socio-economic inequalities.

PATIENT OR PUBLIC CONTRIBUTION

This study expands knowledge about the experiences of people with Long COVID in Spain. Their journeys in the healthcare system and the challenges they face are key to the analysis and findings. Patient associations supported recruitment to ensure a broad range of viewpoints.

Physical Activity and Sedentary Behaviour in People with Long COVID: A Follow-Up from 12 to 18 Months After Discharge

Background/Objectives: Long-term effects of post-COVID-19 on several health outcomes remain unclear. We assessed PA and sedentary behaviour changes and explored behaviour-change factors twelve months post-COVID-19 in people with and without Long COVID. Methods: A prospective cohort study followed people treated for COVID-19 in different settings (home, hospital ward, intensive care unit) from twelve months to eighteen months post-COVID-19. Participants with and without Long COVID were identified. PA (Light PA-LPA, Moderate-to-Vigorous PA-MVPA, Steps·day-1), sedentary time, functional capacity (six-minute walk test-6MWT), muscle strength (quadriceps maximal voluntary contraction-QMVC), dyspnoea (modified Medical Research Council scale-mMRC), fatigue, symptoms of anxiety and depression, and health-related quality of life-HRQoL were assessed. Results: Among 148 participants (58 ± 15 years, 54% male), 101 had Long COVID. All remained physically inactive. People with Long COVID significantly increased LPA (LPALongCOVID +28 [1; 55] min·day-1; LPAControls +6 [-32; 45] min·day-1), and decreased MVPA (MVPALongCOVID -4 [-7; -2] min·day-1; MVPAControls -4 [-8; 1] min·day-1) and sedentarism (SedentarismLongCOVID -47 [-89; -4] min·day-1; SedentarismControls -30 [-88; 28] min·day-1). At eighteen months, higher proportions of individuals with Long COVID had impaired 6MWT (17% vs. 0%), reduced QMVC (25% vs. 6%), dyspnoea (24% vs. 0%), fatigue (67% vs. 13%), symptoms of anxiety (47% vs. 9%) and depression (26% vs. 0%) as well as poor HRQoL (50% vs. 6%). PA and sedentary behaviour changes at eighteen months were associated with dyspnoea and impaired QMVC at twelve months (LPA: mMRC ≥ 2: -41.56 [-129.30; 46.00] min·day-1, Steps·day-1: mMRC: -416.13 [-1223.83; 391.57]; QMVC ≤ 70% predicted: -1251.39 [-2661.69; 158.91], Sedentarism: mMRC ≥ 2: +47.21 [-90.57; 184.99] min·day-1; 0.24 ≤ R2 ≤ 0.32). Conclusions: PA and sedentary behaviour remain altered long after COVID-19, with people with Long COVID adjusting to fit lower PA levels, possibly driven by physical limitations and symptoms. Dyspnoea and muscle weakness may influence PA and sedentary behaviour.

Superficial Neuromodulation in Dysautonomia in Women with Post-COVID-19 Condition: A Pilot Study

Post-COVID-19 condition involves persistent symptoms after acute infection, often linked to dysautonomia, which affects heart rate variability, pain perception, fatigue, and sleep. Superficial neuromodulation has been proposed as a treatment. Objective: To assess the effects of superficial neuromodulation on symptoms, sleep quality, and autonomic function in post-COVID-19 condition patients. Methods: A pilot study was conducted based on a triple-blind randomized controlled trial methodology involving 16 female participants. The experimental group received neuromodulation, while the control group used a placebo device. The intervention spanned 15 sessions over two months. Primary outcomes included heart rate variability, pain threshold, cortisol levels, fatigue, sleep quality, and quality of life, analyzed using repeated-measures ANOVA. Results: Both groups improved over time. Heart rate variability (SDNN) increased in the experimental group (30.42 to 39.11 ms) but decreased in controls (31.88 to 28.73 ms) (p < 0.05). Pain threshold at C5-C6 improved in the experimental group (2.1 to 3.5 kg/cm2) but remained stable in controls (p = 0.032). Fatigue decreased significantly in both groups (p = 0.002). Sleep quality improved, with Pittsburgh Sleep Quality Index scores decreasing similarly in both groups. Cortisol levels increased, with a non-significant trend favoring controls. Conclusions: While improvements were seen, both groups benefited, suggesting a possible placebo effect. Superficial neuromodulation appears safe, but further studies with larger samples are needed to confirm efficacy.

Post-Discharge COVID-19 Symptoms Predict 1-Year Functional Decline, Falls, and Emergency Department Visits: A Cohort Study

BACKGROUND

Hospitalization frequently results in persistent symptoms among older adults, raising concerns about the long-term impacts of acute events-a problem amplified by COVID-19. We investigated the effects of persistent symptoms on functional decline and unplanned events over 1 year in older patients recovering from COVID-19 hospitalization.

METHODS

This prospective cohort included patients aged ≥ 50 years who survived COVID-19 hospitalization between March and December 2020 as part of the CO-FRAIL study at Brazil's largest academic medical center. Persistent symptoms were defined as those reported at admission and continuously present at one-, three-, six-, nine-, and 12-month post-discharge, covering 16 symptoms. Outcomes included functional decline in basic activities of daily living (ADL), mobility activities, instrumental activities of daily living (IADL), number of falls, emergency department (ED) visits, and hospital readmissions. Associations between persistent symptoms and outcomes were examined using mixed-effects negative binomial regression models adjusted for sociodemographic, clinical, hospitalization-related factors, and post-discharge rehabilitation.

RESULTS

Among 1019 patients (mean age = 65 ± 10 years; women = 45%; White = 62%), 324 (32%) experienced persistent symptoms throughout the year. Fatigue (28%), myalgia (19%), and dyspnea (13%) were the most common. Patients with ≥ 2 symptoms had an increased risk of functional decline in mobility activities (IRR = 2.11; 95% CI = 1.50-2.96), IADL (IRR = 2.00; 95% CI = 1.44-2.79), falls (IRR = 2.56; 95% CI = 1.14-5.75), and ED visits (IRR = 2.69; 95% CI = 1.27-5.70), but not readmissions. Among women, ≥ 1 persistent symptom was associated with a twofold increased risk of ADL decline. One year after discharge, patients with ≥ 2 persistent symptoms developed 1.27 more new disabilities (3.26 vs. 1.99 on a 15-point functional scale) and had 31 more unplanned events per 100 person-years (54.3 vs. 23.2) than those without symptoms.

CONCLUSIONS

Persistent symptoms after hospitalization are common and contribute to functional decline, falls, and ED visits in older COVID-19 survivors. These findings suggest that greater attention to symptom burden may support risk identification and improve post-discharge care planning.

Prevalence of Long COVID in Mycobacterium tuberculosis-exposed Groups in Peru and Kenya

Background

Long COVID (LC), also referred to as post-COVID condition, refers to new or worsening symptoms lasting more than three months after SARS-CoV-2 infection. The prevalence of LC, and the impact of co-infection with prevalent pathogens such as Mycobacterium tuberculosis (Mtb), in low- and middle-income countries remain unclear. We aimed to address these gaps in two Mtb-exposed populations.

Methods

We recruited HIV-uninfected pulmonary tuberculosis (TB) patients (n=36) and their household contacts (n=63) in Peru, and healthcare workers (n=202) in Kenya. We collected clinical data using study instruments adapted from a United States based study of LC. Participants were sampled within 2 years of SARS-CoV-2 diagnosis.

Results

In Peru, 41.4% participants reported LC symptoms, with no TB-associated significant differences in the prevalence or clinical phenotypes of LC. The most common LC symptoms were neurological (e.g., headache and trouble sleeping) and musculoskeletal (e.g., back pain). Kenyan participants reported acute, but no LC symptoms, and reported a decline in the quality of life during acute infection. In Peru, the post-COVID-19 period was associated with a significant decline in all quality-of-life dimensions (p<0.01), except depression and anxiety (p=0.289).

Conclusion

This study shows that LC prevalence was high in Peru, where TB status was not linked to LC symptoms. Those with LC reported high levels of musculoskeletal and neurological symptoms. Unexpectedly, healthcare workers in Kenya denied the presence of LC symptoms. These findings highlight the need for long-term follow-up and larger studies in different geographic settings to dissect the impact of TB comorbidity on LC.

Multidisciplinary collaborative guidance on the assessment and treatment of patients with Long COVID: A compendium statement

BACKGROUND

In 2021, the American Academy of Physical Medicine and Rehabilitation established the Multi-Disciplinary Post-Acute Sequelae of SARS-CoV-2 Infection Collaborative to provide guidance from established Long COVID clinics for the evaluation and management of Long COVID. The collaborative previously published eight Long COVID consensus guidance statements using a primarily symptom-based approach. However, Long COVID symptoms most often do not occur in isolation.

AIMS

This compendium aims to equip clinicians with an efficient, up-to-date clinical resource for evaluating and managing adults experiencing Long COVID symptoms. The primary intended audience includes physiatrists, primary care physicians, and other clinicians who provide first-line assessment and management of Long COVID symptoms, especially in settings where subspecialty care is not readily available. This compendium provides a holistic framework for assessment and management, symptom-specific considerations, and updates on prevalence, health equity, disability considerations, pathophysiology, and emerging evidence regarding treatments under investigation. Because Long COVID closely resembles other infection-associated chronic conditions (IACCs) such as myalgic encephalomyelitis/chronic fatigue syndrome, the guidance in this compendium may also be helpful for clinicians managing these related conditions.

METHODS

Guidance in this compendium was developed by the collaborative's established modified Delphi approach. The collaborative is a multidisciplinary group whose members include physiatrists, primary care physicians, pulmonologists, cardiologists, psychiatrists, neuropsychologists, neurologists, occupational therapists, physical therapists, speech and language pathologists, patients, and government representatives. Over 40 Long COVID centers are represented in the collaborative.

RESULTS

Long COVID is defined by the National Academies of Sciences, Engineering, and Medicine as "an IACC that occurs after SARS-CoV-2 infection and is present for at least 3 months as a continuous, relapsing and remitting, or progressive disease state that affects one or more organ systems." The current global prevalence of Long COVID is estimated to be 6%. Higher prevalence has been identified among female gender, certain racial and ethnic groups, and individuals who live in nonurban areas. However, anyone can develop Long COVID after being infected with the SARS-CoV-2 virus. Long COVID can present as a wide variety of symptom clusters. The most common symptoms include exaggerated fatigue and diminished energy windows, postexertional malaise (PEM)/postexertional symptom exacerbation (PESE), cognitive impairment (brain fog), dysautonomia, pain/myalgias, and smell and taste alterations. Holistic assessment should include a traditional history, physical examination, and additional diagnostic testing, as indicated. A positive COVID-19 test during acute SARS-CoV-2 infection is not required to diagnose Long COVID, and currently, there is no single laboratory finding that is definitively diagnostic for confirming or ruling out the diagnosis of Long COVID. A basic laboratory assessment is recommended for all patients with possible Long COVID, and consideration for additional labs and diagnostic procedures is guided by the patient's specific symptoms. Current management strategies focus on symptom-based supportive care. Critical considerations include energy conservation strategies and addressing comorbidities and modifiable risk factors. Additionally, (1) it is essential to validate the patient's experience and provide reassurance that their symptoms are being taken seriously because many patients have had their symptoms dismissed by loved ones and clinicians; (2) physical activity recommendations must be carefully tailored to the patient's current activity tolerance because overly intense activity can trigger PEM/PESE and worsened muscle damage; and (3) treatment recommendations should be delivered with humility because there are many persistent unknowns related to Long COVID. To date, there are limited data to guide medication management specifically in the context of Long COVID. As such, medication use generally follows standard practice regarding indications and dosing, with extra attention to prioritize (1) patient preference via shared decision-making and (2) cautious use of medications that may improve some symptoms (eg, cognitive/attention impairment) but may worsen other symptoms (eg, PEM/PESE). Numerous clinical trials are investigating additional treatments. The return-to-work process for individuals with Long COVID can be challenging because symptoms can fluctuate, vary in nature, affect multiple functional areas (eg, physical and cognitive), and often manifest as an "invisible disability" that may not be readily acknowledged by employers or coworkers. Clinicians can help patients return to work by identifying suitable workplace accommodations and resources, providing necessary documentation, and recommending occupational or vocational therapy when needed. If these efforts are unsuccessful and work significantly worsens Long COVID symptoms or impedes recovery, applying for disability may be warranted. Long COVID is recognized as a potential disability under the Americans with Disabilities Act.

CONCLUSION

To contribute to the overall health and well-being for all patients, Long COVID care should be delivered in a holistic manner that acknowledges challenges faced by the patient and uncertainties in the field. For more detailed information on assessment and management of specific Long COVID symptoms, readers can reference the collaborative's symptom-specific consensus guidance statements.

Long COVID and Associated Factors Among Chinese Residents Aged 16 Years and Older in Canada: A Cross-Sectional Online Study

As the COVID-19 pandemic evolved, long COVID emerged as a significant threat to public health, characterized by one or more persistent symptoms impacting organ systems beyond 12 weeks of infection. Informative research has been derived from assessments of long COVID among the Chinese populace. However, none of these studies considered the COVID-19 experience of Chinese residents in Canada. Objectives: We aimed to fill this literature gap by delineating the long COVID experience, prevalence, and associated factors among a sample of Chinese residing in Canada during the pandemic. Methods: The present study employed a cross-sectional online survey questionnaire distributed to a sample of Canadian Chinese using a convenience sampling procedure from 22 December 2022 to 15 February 2023. Respondents were probed for sociodemographic background and health-, COVID-, and vaccine-related characteristics. Logistic LASSO regression was used for model building, and multivariate logistic regression was used to identify factors associated with developing long COVID. Results: Among 491 eligible participants, 63 (12.83%) reported experiencing long COVID with a mean duration of 5.31 (95% CI: 4.06-6.57) months and major symptoms including difficulty concentrating (21.67%), pain/discomfort (15.00%), as well as anxiety/depression (8.33%). Our final model identified significant associations between long COVID and two or more COVID-19 infections (OR = 23.725, 95% CI: 5.098-110.398, p < 0.0001), very severe/severe symptoms (OR = 3.177, 95% CI: 1.160-8.702, p = 0.0246), over-the-counter medicine (OR = 2.473, 95% CI: 1.035-5.909, p = 0.0416), and traditional Chinese medicine (OR = 8.259, 95% CI: 3.016-22.620, p < 0.0001). Further, we identified a significant protective effect of very good/good health status (OR = 0.247, 95% CI: 0.112-0.544, p = 0.0005). Conclusions: Long COVID effected a notable proportion of Canadian Chinese for a prolonged period during the COVID-19 pandemic. Our findings underscore the importance of preexisting health status and reinfection prevention when managing long COVID. Moreover, our work indicates an association between using over-the-counter medicine or traditional Chinese medicine and long COVID experience among Canadian Chinese.

Facility-measured nocturnal hypoxemia and sleep among adults with long COVID versus age- and sex-matched healthy adults: a preliminary observational study

Study Objectives

Persistent post-acute sequelae of SARS-CoV-2 infection, i.e. long COVID, impacts multiple organ systems. While lower blood oxygen is expected when SARS-CoV-2 infects the lungs, hypoxia without pulmonary symptoms may continue after the acute phase. Ventilation and blood oxygen are more vulnerable during sleep, but nocturnal hypoxemia hasn't been studied in people with long COVID in a facility setting using gold-standard polysomnography (PSG).

Methods

We conducted an observational study with 50 participants (25 long COVID, 25 age-sex-matched healthy controls) using in-laboratory overnight PSG. We calculated the average SpO2, average SpO2 after removing desaturations, the respiratory rate in different sleep periods, and the hypoxic costs using all desaturations.

Results

We found that average SpO2 was lower in participants with long COVID: 1.0% lower after sleep onset (p = .004) and 0.7% lower during REM (p = .002); average SpO2 after removing desaturations was also lower in participants with long COVID: 1.3% lower after sleep onset (p = .002), 0.9% lower during REM (p = .0004), and 1.4% lower during NREM (p = .003); and respiratory rate was 1.4/minute higher in participants with long COVID during REM (p = .005). There were no significant differences in SpO2 and respiratory rate before sleep onset, the within-participant change from before to after sleep onset, or hypoxic costs.

Conclusions

The results suggest that long COVID had a persistent lower nocturnal blood oxygen saturation, and support the need for a large-scale study of nocturnal hypoxemia in people with long COVID compared to the general population.

'We Don't Have to Prove to People How We're Feeling': Understanding the Role of Peer Support Groups in Countering Epistemic Injustices in Long COVID at a US Centre

BACKGROUND

Long COVID, an infection-associated chronic condition characterised by new or worsening signs or symptoms for more than 3 months after a SARS-CoV-2 infection, is a chronic debilitating illness which remains poorly understood. Epistemic injustice in healthcare describes the unique harms or wrongs done to a person in their capacity to share and acquire knowledge about their illness. Although the concept of epistemic injustice has been described in other chronic conditions, few studies have explored these concepts in Long COVID.

OBJECTIVES

(1) To understand the lived experience of epistemic injustice in adults with Long COVID who were participating in a peer support group intervention and (2) to describe the potential impact of the support group on these experiences in participants.

METHODS

Qualitative analysis utilising inductive analysis of semi-structured individual interviews of patients with Long COVID who participated in a peer support group intervention at an academic medical centre in Oregon, USA.

RESULTS

We identified three themes that captured the lived experiences of epistemic injustice in Long COVID support group participants: (1) dismissal and disregard; (2) episodic and unpredictable symptoms and impairment, and (3) knowledge and interpretation practices. We also found that the peer support potentially impacted these experiences of epistemic injustice through (1) recognition and validation; (2) solidarity and community, and (3) information exchange and expectation setting.

CONCLUSIONS

Long COVID patients are at risk of experiencing epistemic injustice in seeking healthcare for this complex condition. Peer support programmes may be one approach to help counter these experiences and should be further studied as a complex intervention for improving patient-centred care in Long COVID.

Management of SARS-CoV-2 Infection-Clinical Practice Guidelines of the Polish Association of Epidemiologists and Infectiologists, for 2025

The first Polish recommendations for the management of COVID-19 were published by the Polish Society of Epidemiologists and Infectiologists (PTEiLChZ) on 31 March 2020, and the last three years ago. The emergence of new SARS-CoV-2 variants, a different course of the disease, as well as new knowledge about therapies and vaccines, requires updating diagnostic, therapeutic, and prophylactic guidelines. Despite the reduction in the threat associated with COVID-19, there is a risk of another epidemic caused by coronaviruses, which was an additional reason for developing a new version of the guidelines. In preparing these recommendations, the Delphi method was used, reaching a consensus after three survey cycles. Compared to the 2022 version, the names of the individual stages of the disease have been changed, adapting them to the realities of clinical practice, and attention was paid to the differences observed in immunosuppressed patients and in children. Some previously recommended drugs have been discontinued, including monoclonal antibodies. In addition, general principles of vaccination were presented, as well as issues related to the post-COVID syndrome.

Real-World Experience with the Available Outpatient COVID-19 THErapies in Patients with canceR (CO.THER)

BACKGROUND/OBJECTIVES

Cancer represents an important risk factor for acquiring severe acute respiratory syndrome by Coronavirus-2 (SARS-CoV-2) and subsequent hospitalization. The utility of early antiviral therapies, including their protective effect on long COVID outcomes, in cancer patients has not yet been clearly demonstrated. We conducted the CO.THER study (COVID-19 THErapies in patients with canceR) to address this knowledge gap.

METHODS

We designed an ambispective single-center cohort study. We collected clinical and oncological data from the hospital's electronic patient records at the start of COVID-19 therapy (T0), seven days after T0 (T1), two weeks after T0 (T2), one month after T0 (T3), three months after T0 (T4), six months after T0 (T5), and twelve months after T0 (T6). The primary endpoint of this ambispective single-center cohort study was the rate of hospitalization for COVID-19 disease within 14 days in cancer patients using anti-SARS-CoV-2 early therapies. The proportion of hospitalizations within 14 days (primary endpoint) was computed together with its exact binomial 95% confidence interval (95%CI).

RESULTS

131 patients' records (53M [40.5%], 78F, [59.5%]; median age 62.45, interquartile range [IQR] 56-71) were enrolled. As shown by the Kaplan-Meier hospitalization-free estimate, only three patients (2.1%) were hospitalized for a COVID-19 related cause within 14 days of starting early treatment (95%CI 0.5-6.6%). The cumulative survival probability beyond 12 months in hospitalization-free patients was 98% (95%CI 93-99%). Twelve patients (9.2%) reported another COVID-19 infection during the follow-up and they were all retreated with Nirmatrelvir-Ritonavir. The cumulative reinfection-free survival was 90% at 12 months (95%CI 83-95%). Further, 15 patients of the 123 evaluable at 3 months (median age 51 years, IQR 40-68) reported long COVID symptoms (12.2%, 95%CI 7.0-19.3%).

CONCLUSIONS

Our data demonstrate a low rate of hospitalization and reassuring data on safety in this cohort of high-risk subjects.

Language Matters: What Not to Say to Patients with Long COVID, Myalgic Encephalomyelitis/Chronic Fatigue Syndrome, and Other Complex Chronic Disorders

People with Long COVID, myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), and other complex chronic disorders consistently report having difficulty obtaining effective and compassionate medical care and being disbelieved, judged, gaslighted, and even dismissed by healthcare professionals. We believe that these adversarial interactions and language are more likely to arise when healthcare professionals are confronting complex chronic illnesses without proper training, diagnostic biomarkers, or FDA-approved therapies. These problematic conversations between practitioners and patients often involve specific words and phrases-termed the "never-words"-can leave patients in significant emotional distress and negatively impact the clinician-patient relationship and recovery. Seeking to prevent these destructive interactions, we review key literature on best practices for difficult clinical conversations and discuss the application of these practices for people with Long COVID, ME/CFS, dysautonomia, and other complex chronic disorders. We provide recommendations for alternative, preferred phrasing to the never-words, which can enhance therapeutic relationship and chronic illness patient care via compassionate, encouraging, and non-judgmental language.