Differences in incidence, nature of symptoms, and duration of long COVID among hospitalised migrant and non-migrant patients in the Netherlands: a retrospective cohort study

Factors affecting the impact of COVID-19 vaccination on post COVID-19 conditions among adults: A systematic literature review

This systematic literature review summarizes the evidence across 56 publications and pre-prints (January 2020-July 2023) with low-risk of bias based on JBI critical appraisal, that report adjusted estimates for the relationship between COVID-19 vaccination and Post-COVID-19 Condition (PCC) by timing of vaccination relative to infection or PCC-onset. Comparisons of adjusted vaccine effectiveness (aVE) against ≥1 PCC (vs. unvaccinated) across study characteristics known to impact PCC burden or VE against other COVID-19 endpoints were possible for 31 studies where vaccination preceded infection. Seventy-seven percent of pre-infection aVE estimates were statistically significant (range: 7%-95%). Statistically significant pre-infection aVE estimates were slightly higher for mRNA (range: 14%-84%) than non-mRNA vaccines (range: 16%-38%) and aVE ranges before and during Omicron overlapped. Our findings suggest that COVID-19 vaccination before SARS-CoV-2 infection reduces the risk of PCC regardless of vaccine type, number of doses received, PCC definition, predominant variant, and severity of acute infections included.

Novel biomarkers of mitochondrial dysfunction in Long COVID patients

Coronavirus disease 2019 (COVID-19) can lead to severe acute respiratory syndrome, and while most individuals recover within weeks, approximately 30-40% experience persistent symptoms collectively known as Long COVID, post-COVID-19 syndrome, or post-acute sequelae of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (PASC). These enduring symptoms, including fatigue, respiratory difficulties, body pain, short-term memory loss, concentration issues, and sleep disturbances, can persist for months. According to recent studies, SARS-CoV-2 infection causes prolonged disruptions in mitochondrial function, significantly altering cellular energy metabolism. Our research employed transmission electron microscopy to reveal distinct mitochondrial structural abnormalities in Long COVID patients, notably including significant swelling, disrupted cristae, and an overall irregular morphology, which collectively indicates severe mitochondrial distress. We noted increased levels of superoxide dismutase 1 which signals oxidative stress and elevated autophagy-related 4B cysteine peptidase levels, indicating disruptions in mitophagy. Importantly, our analysis also identified reduced levels of circulating cell-free mitochondrial DNA (ccf-mtDNA) in these patients, serving as a novel biomarker for the condition. These findings underscore the crucial role of persistent mitochondrial dysfunction in the pathogenesis of Long COVID. Further exploration of the cellular and molecular mechanisms underlying post-viral mitochondrial dysfunction is critical, particularly to understand the roles of autoimmune reactions and the reactivation of latent viruses in perpetuating these conditions. This comprehensive understanding could pave the way for targeted therapeutic interventions designed to alleviate the chronic impacts of Long COVID. By utilizing circulating ccf-mtDNA and other novel mitochondrial biomarkers, we can enhance our diagnostic capabilities and improve the management of this complex syndrome.

Cost-effectiveness Analysis of Nirmatrelvir/Ritonavir for COVID-19 Among Individuals at High Risk: A Modeling Study

Background

To prevent severe disease, nirmatrelvir/ritonavir (nirmatrelvir/r) is administered to individuals infected with SARS-CoV-2 who are at high risk, and it is currently priced at approximately $1375 in the Netherlands. We aim to evaluate the health outcomes and cost-effectiveness of nirmatrelvir/r among patients with high risk of severe disease.

Methods

We used a decision-analytic model parameterized with clinical and health care utilization data from individuals at high risk who were infected with SARS-CoV-2 between September 2021 and November 2023. We assumed baseline event rates of 1% for hospitalization and 0.05% for intensive care unit admission. Nirmatrelvir/r-related factors were varied. Costs were collected from a third-party payer's perspective, and the cost-effectiveness threshold was <$88 000 per quality-adjusted life-year gained. Sensitivity analyses were performed to account for uncertainties.

Results

This study included 949 individuals at high risk who were infected with SARS-CoV-2. The sample had a median age of 65 years (IQR, 53-75), and 416 (44%) participants were female. Comorbidities included obesity (25%), hematologic malignancy (21%), solid organ/stem cell transplantation (17%), and immunosuppressive medication use (47%). With an assumed low effectiveness, nirmatrelvir/r could reduce hospitalizations and deaths (relative risk reduction, 21% and 44%, respectively). With high effectiveness, relative risk reductions of 89% and 90% were calculated for hospitalizations and deaths. Higher baseline rates for intensive care unit and hospital admission positively influenced cost-effectiveness thresholds. Nirmatrelvir/r is cost-effectively priced at <$512 with low effectiveness and <$1071 with high effectiveness.

Conclusions

With current low baseline event rates for hospitalization, nirmatrelvir/r has the potential, not only to reduce hospitalizations and deaths in individuals with COVID-19 who are at high risk, but to do so cost-effectively with a drug price reduction of 22% to 63%. These findings are relevant for policy makers and physicians and emphasize the importance of reevaluating current drug pricing.

Clinical Trials Registration

NCT05195060 (ClinicalTrials.gov).

Role of toll-like receptors in post-COVID-19 associated neurodegenerative disorders?

In the intricate realm of interactions between hosts and pathogens, Toll-like receptors (TLRs), which play a crucial role in the innate immune response, possess the ability to identify specific molecular signatures. This includes components originating from pathogens such as SARS-CoV-2, as well as the resulting damage-associated molecular patterns (DAMPs), the endogenous molecules released after cellular damage. A developing perspective suggests that TLRs play a central role in neuroinflammation, a fundamental factor in neurodegenerative conditions like Alzheimer's and Parkinson's disease (PD). This comprehensive review consolidates current research investigating the potential interplay between TLRs, their signaling mechanisms, and the processes of neurodegeneration following SARS-CoV-2 infection with an aim to elucidate the involvement of TLRs in the long-term neurological complications of COVID-19 and explore the potential of targeting TLRs as a means of implementing intervention strategies for the prevention or treatment of COVID-19-associated long-term brain outcomes.

Association between Mexican vaccination schemes and the duration of long COVID syndrome symptoms

The COVID-19 pandemic had a profound global impact, characterized by a high fatality rate and the emergence of enduring consequences known as Long COVID. Our study sought to gauge the prevalence of Long COVID syndrome in northeastern Mexico, correlating it with patients' comorbidities and vaccination records. We carried out an observational cross-sectional approach, by administering a comprehensive questionnaire covering patients' medical history, demographics, vaccination status, COVID-related symptoms, their duration, and any treatment received. Our participant cohort included 804 patients, averaging 41.5 (SD 13.6) years in age, with 59.3% being women. Notably, 168 individuals (20.9%) met Long COVID criteria. Our analysis of COVID-19 long lasting compared vaccination schemes, unveiling a significant difference between vaccinated and unvaccinated groups (p =  < 0.001). Through linear regression model, we found male gender (β = - 0.588, p < 0.001) and vaccination status (β = 0.221, p = 0.015) acted as protective factors against Long COVID symptom duration, while higher BMI was a risk factor (β = - 0.131, p = 0.026). We saw that the duration of Long COVID was different within vaccinated patients, and we did not find any association of comorbidities with an increase in the presence of symptoms. Even three years after the pandemic, a significant prevalence of Long COVID persists, and there is still a lack of standardized information and any possible treatment regarding this condition.

One-year trajectories of physical and mental health-related quality of life, fatigue and dyspnoea in COVID-19 survivors

PURPOSE

A substantial number of people experience a persisting impact on health-related quality of life (HRQoL) after COVID-19. The current study aims to identify different trajectories of physical and mental HRQoL, fatigue severity, and dyspnoea severity following hospitalisation with COVID-19, and associated factors of these trajectories.

METHODS

500 patients with COVID-19 were followed for one year in a longitudinal cohort study. Self-reported outcomes were measured at 3, 6, 9, and 12 months after hospitalisation. Distinct trajectories were characterised using Growth Mixture Modelling. Sociodemographic and clinical correlates of trajectories were investigated using multivariable (multinomial) logistic regression analyses.

RESULTS

Three trajectories ('stable high' (16%), 'improving' (40%), and 'stable low' (44%)) were found for physical HRQoL, and four ('stable high' (43%), 'improving' (14%), 'middle declining' (17%), and 'low' (26%)) for mental HRQoL. Older age, overweight and obesity, lower education, and comorbidities were associated with 'low' physical HRQoL. Younger age was associated with 'low' mental HRQoL. Four fatigue trajectories ('no fatigue' (15%), 'improving' (40%), 'low-severe' (27%), and 'high-severe' (18%)) were found. Participants either experienced almost never ('no dyspnoea', 75%) or almost always ('severe', 25%) dyspnoea. High co-occurrences between low HRQoL and severe fatigue and dyspnoea symptom trajectories were found.

CONCLUSION

A substantial number of COVID-19 survivors continue to struggle with reduced HRQoL over time. However, large variations in these physical and mental HRQoL trajectories exist, and trajectories are associated with persisting COVID-19-related symptoms or pre-hospitalised health status. Regular measurement of HRQoL and post-COVID symptoms may help identify those that may benefit from timely interventions.

Human herpesvirus reactivation and its potential role in the pathogenesis of post-acute sequelae of SARS-CoV-2 infection

The emergence of SARS-CoV-2 has precipitated a global pandemic with substantial long-term health implications, including the condition known as post-acute sequelae of SARS-CoV-2 infection (PASC), commonly referred to as Long COVID. PASC is marked by persistent symptoms such as fatigue, neurological issues, and autonomic dysfunction that persist for months beyond the acute phase of COVID-19. This review examines the potential role of herpesvirus reactivation, specifically Epstein-Barr virus (EBV) and cytomegalovirus (CMV), in the pathogenesis of PASC. Elevated antibody titers and specific T cell responses suggest recent herpesvirus reactivation in some PASC patients, although viremia is not consistently detected. SARS-CoV-2 exhibits endothelial trophism, directly affecting the vascular endothelium and contributing to microvascular pathologies. These pathologies are significant in PASC, where microvascular dysfunction may underlie various chronic symptoms. Similarly, herpesviruses like CMV also exhibit endothelial trophism, which may exacerbate endothelial damage when reactivated. Evidence suggests that EBV and CMV reactivation could indirectly contribute to the immune dysregulation, immunosenescence, and autoimmune responses observed in PASC. Additionally, EBV may play a role in the genesis of neurological symptoms through creating mitochondrial dysfunction, though direct confirmation remains elusive. The reviewed evidence suggests that while herpesviruses may not play a direct role in the pathogenesis of PASC, their potential indirect effects, especially in the context of endothelial involvement, warrant further investigation.

Neuropsychological functioning after COVID-19: Minor differences between individuals with and without persistent complaints after SARS-CoV-2 infection

Objective: It is unclear how self-reported severe fatigue and difficulty concentrating after SARS-CoV-2 infection relate to objective neuropsychological functioning. The study aimed to compare neuropsychological functioning between individuals with and without these persistent subjective complaints. Method: Individuals with and without persistent severe fatigue (Checklist Individual Strength (CIS) fatigue ≥ 35) and difficulty concentrating (CIS concentration ≥ 18) at least 3 months after SARS-CoV-2 infection were included. Neuropsychological assessment was performed on overall cognitive functioning, attention, processing speed, executive functioning, memory, visuo-construction, and language (18 tests). T-scores -1.5 SD below population normative data (T ≤ 35) were classified as "impaired". Results: 230 participants were included in the study, of whom 22 were excluded from the analysis due to invalid performance. Of the participants included in the analysis, 111 reported persistent complaints of severe fatigue and difficulty concentrating and 97 did not. Median age was 54 years, 59% (n = 126) were female, and participants were assessed a median of 23 months after first infection (IQR: 16-28). With bivariate logistic regression, individuals with persistent complaints had an increased likelihood of slower information processing speed performance on the Stroop word reading (OR = 2.45, 95%CI = 1.02-5.84) compared to those without persistent complaints. Demographic or clinical covariates (e.g. hospitalization) did not influence this association. With linear regression techniques, persistent complaints were associated with lower t-scores on the D2 CP, TMT B, and TMT B|A. There were no differences in performance on the other neuropsychological tests. Conclusions: Individuals with subjective severe fatigue and difficulty concentrating after COVID-19 do not typically demonstrate cognitive impairment on extensive neuropsychological testing.

Cerebromicrovascular mechanisms contributing to long COVID: implications for neurocognitive health

Long COVID (also known as post-acute sequelae of SARS-CoV-2 infection [PASC] or post-COVID syndrome) is characterized by persistent symptoms that extend beyond the acute phase of SARS-CoV-2 infection, affecting approximately 10% to over 30% of those infected. It presents a significant clinical challenge, notably due to pronounced neurocognitive symptoms such as brain fog. The mechanisms underlying these effects are multifactorial, with mounting evidence pointing to a central role of cerebromicrovascular dysfunction. This review investigates key pathophysiological mechanisms contributing to cerebrovascular dysfunction in long COVID and their impacts on brain health. We discuss how endothelial tropism of SARS-CoV-2 and direct vascular infection trigger endothelial dysfunction, impaired neurovascular coupling, and blood-brain barrier disruption, resulting in compromised cerebral perfusion. Furthermore, the infection appears to induce mitochondrial dysfunction, enhancing oxidative stress and inflammation within cerebral endothelial cells. Autoantibody formation following infection also potentially exacerbates neurovascular injury, contributing to chronic vascular inflammation and ongoing blood-brain barrier compromise. These factors collectively contribute to the emergence of white matter hyperintensities, promote amyloid pathology, and may accelerate neurodegenerative processes, including Alzheimer's disease. This review also emphasizes the critical role of advanced imaging techniques in assessing cerebromicrovascular health and the need for targeted interventions to address these cerebrovascular complications. A deeper understanding of the cerebrovascular mechanisms of long COVID is essential to advance targeted treatments and mitigate its long-term neurocognitive consequences.

Exercise rehabilitation in post COVID-19 patients: a randomized controlled trial of different training modalities

BACKGROUND

Long-lasting symptoms (>12 weeks) following a COVID-19 infection are defined as the post-COVID-19 syndrome (PCS), often manifesting as fatigue and reduced exercise capacity. Thus, exercise has been suggested as a non-pharmacological therapy.

AIM

To investigate the effects of endurance vs. concurrent exercise on physical function, symptoms and quality of life in individuals with PCS, that did not need hospital admission during acute COVID-19.

DESIGN

Parallel-group, single-center, randomized controlled trial.

SETTING

This study was conducted at the University of Vienna.

POPULATION

Adult individuals with a SARS-CoV-2 infection at least 12 weeks prior to enrollment who reported at least one symptom specific to PCS and did not experience post-exertional malaise.

METHODS

Participants were randomized to either 12 weeks of supervised endurance training (ED) or concurrent training (CT), or a non-exercising control group (C). As the primary outcome, VO2peak was assessed pre and post intervention. Secondary outcomes were handgrip and lower body strength, heart rate variability, symptoms, health-related quality of life (HRQoL) and concentration performance. The main effects for time and group as well as the time*group interaction were assessed via a 2x2 analysis of variance. Additionally, within-group pre-post testing was performed.

RESULTS

Taking the study protocol into account, 42 subjects could be included in the analysis (N.=14 in each group). A significant time*group interaction favoring both exercise conditions was found for VO2peak (partial Eta2=0.267; ED: +3.9 mL/min/kg; CT: +3.2 mL/min/kg). The Fatigue Severity Score significantly decreased in ED (Hedges' g=0.63) and CT (Hedges' g=0.82) from pre to post, but not in C. Breathlessness and lower body strength improved most in CT. Significant within-group improvements in HRQoL and the number of PCS symptoms occurred in all groups.

CONCLUSIONS

Both exercise regimes led to increases in VO2peak and lower fatigue scores in subjects with PCS. Improvements in HRQoL occurred in all groups, however more pronounced after the exercise interventions. No definite conclusion about the superiority of either training modality can be drawn.

CLINICAL REHABILITATION IMPACT

The results show that in this population both exercise regimes are feasible and safe and lead to improvements in various health domains.

Long COVID and its risk factors in migrants: a nationwide register study from Sweden

BACKGROUND

Many studies have found more severe COVID-19 outcomes in migrants and ethnic minorities throughout the COVID-19 pandemic, while recent evidence also suggests higher risk of longer-term consequences. We studied the risk of a long COVID diagnosis among adult residents in Sweden, dependent on country of birth and accounting for known risk factors for long COVID.

METHODS

We used linked Swedish administrative registers between March 1, 2020 and April 1, 2023, to estimate the risk of a long COVID diagnosis in the adult population that had a confirmed COVID-19 infection. Poisson regressions were used to calculate incidence rate ratios (IRR) of long COVID by country/region of birth. The contribution of sex, preexisting health status, disease severity, vaccination status, and socioeconomic factors to differences in long COVID diagnosis by country/region of birth were further investigated.

RESULTS

Of the 1,869,188 persons diagnosed with COVID-19 that were included, 7539 had received a long COVID diagnosis. Compared with residents born in Sweden, we found higher risks of long COVID among migrants from East Europe (IRR: 1.44 CI: 1.29-1.60), Finland (IRR: 1.36 CI: 1.15-1.61), South Asia (IRR: 1.28 CI: 1.03-1.59), Other Asia (IRR: 1.35 CI: 1.13-1.62), Other Africa (IRR: 1.48 CI: 1.17-1.87), and the Middle East (IRR: 1.43 CI: 1.27-1.63) in models adjusted for age and sex. We discovered that disease severity, i.e., whether the person was hospitalized (IRR: 18.6 CI: 17.3-20.0) or treated in an intensive care unit (IRR: 120.5 CI: 111.7-129.8), primarily contributed to the higher risk of long COVID found in migrants while the contribution of vaccinations and social conditions were moderate. Preexisting health problems did not contribute to the increased risk of long COVID in migrants.

CONCLUSIONS

The greater exposure and impact of the COVID-19 virus among migrants also affected longer-term consequences. Disease severity was the most important risk factor for long COVID in migrants. The findings emphasize the need for targeted health interventions for migrant communities during an infectious disease pandemic, such as strategic vaccination campaigns and extending social insurance schemes, focusing on reducing disease severity to mitigate the longer-term health consequences of an infection.

Temporal changes in the risk of six-month post-COVID symptoms: a national population-based cohort study

It is unclear how the risk of post-COVID symptoms evolved during the pandemic, especially before the spread of Severe Acute Respiratory Syndrome Coronavirus 2 variants and the availability of vaccines. We used modified Poisson regressions to compare the risk of six-month post-COVID symptoms and their associated risk factors according to the period of first acute COVID: during the French first (March-May 2020) or second (September-November 2020) wave. Nonresponse weights and multiple imputation were used to handle missing data. Among participants aged 15 years or older in a national population-based cohort, the risk of post-COVID symptoms was 14.6% (95% confidence interval [CI], 13.9%-15.3%) in March-May 2020, vs 7.0% (95% CI, 6.3%-7.7%) in September-November 2020 (adjusted relative risk [RR], 1.36; 95% CI, 1.20-1.55). For both periods, the risk was higher in the presence of baseline physical condition(s), and it increased with the number of acute symptoms. During the first wave, the risk was also higher for women, in the presence of baseline mental condition(s), and it varied with educational level. In France in 2020, the risk of six-month post-COVID symptoms was higher during the first than the second wave. This difference was observed before the spread of variants and the availability of vaccines.

People from ethnic minorities seeking help for long COVID: a qualitative study

BACKGROUND

People from ethnic minority groups are disproportionately affected by COVID-19, less likely to access primary health care, and have reported dissatisfaction with health care. Although the prevalence of long COVID in ethnic minority groups is unclear, such populations are underrepresented in long-COVID specialist clinics and long-COVID lived-experience research, which informed the original long-COVID healthcare guidelines.

AIM

To understand the lived experiences of long COVID in people from ethnic minority groups.

DESIGN AND SETTING

Qualitative study of people living with long COVID in the UK.

METHOD

Semi-structured interviews with people who self-disclosed long COVID were conducted between June 2022 and June 2023 via telephone or video call. Thematic analysis of the data was conducted. People who were living with long COVID, or caring for someone with long COVID, advised on all stages of the research.

RESULTS

Interviews were conducted with 31 participants representing diverse socioeconomic demographics. Help-seeking barriers included little awareness of long COVID or available support, and not feeling worthy of receiving care. Negative healthcare encounters were reported in primary health care; however, these services were crucial for accessing secondary or specialist care. There were further access difficulties and dissatisfaction with specialist care. Experiences of stigma and discrimination contributed to delays in seeking care and unsatisfactory experiences, resulting in feelings of mistrust in health care.

CONCLUSION

Empathy, validation of experiences, and fairness in recognition and support of healthcare needs are required to restore trust in health care and improve the experiences of people with long COVID.

Long COVID in healthcare workers: longitudinal mixed-methods study

BACKGROUND

Healthcare workers (HCWs) report higher rates of long coronavirus disease (COVID) (LC) than other occupational groups. It is still unclear whether LC is a lifelong condition. Workforce shortfalls are apparent due to sick leave, reduced hours and lower productivity.

AIMS

To investigate the lived experience of LC on a range of HCWs, including impact on health-related quality-of-life (HRQL), use of health services, working and personal lives and household finances.

METHODS

Longitudinal mixed methods with online surveys and qualitative interviews 6-months apart. HCWs including healthcare professionals, ancillary and administration staff who self-report LC were recruited through social media and National Health Service channels. Interviewees were purposively sampled from survey responses.

RESULTS

The first survey was completed by 471 HCWs (S1) and 302 (64%) the follow-up (S2). A total of 50 HCWs were interviewed initially and 44 at second interview. All participants experienced various relapsing, remitting, changing and prolonged LC symptoms (mean 7.1 [SD 4.8] at S2) and a third reported day-to-day activities 'limited a lot'. Most participants were working in a reduced capacity: reduced hours, different role or location. Healthcare was limited, and often unsatisfactory. Participants feared reinfection, their future, ability to work and financial security (59% (n = 174) at S2). They experienced stigma, distress, grief for their former self and some felt unsupported, however, as awareness of LC grew some experienced improved understanding and support.

CONCLUSIONS

Most participants continued working, managing complex and dynamic symptoms effecting their everyday life and ability to work. Most did not report significant improvements over time and feared for their future and financial security.

Mitochondrial dysfunction in long COVID: mechanisms, consequences, and potential therapeutic approaches

The COVID-19 pandemic, caused by the SARS-CoV-2 virus, has introduced the medical community to the phenomenon of long COVID, a condition characterized by persistent symptoms following the resolution of the acute phase of infection. Among the myriad of symptoms reported by long COVID sufferers, chronic fatigue, cognitive disturbances, and exercise intolerance are predominant, suggesting systemic alterations beyond the initial viral pathology. Emerging evidence has pointed to mitochondrial dysfunction as a potential underpinning mechanism contributing to the persistence and diversity of long COVID symptoms. This review aims to synthesize current findings related to mitochondrial dysfunction in long COVID, exploring its implications for cellular energy deficits, oxidative stress, immune dysregulation, metabolic disturbances, and endothelial dysfunction. Through a comprehensive analysis of the literature, we highlight the significance of mitochondrial health in the pathophysiology of long COVID, drawing parallels with similar clinical syndromes linked to post-infectious states in other diseases where mitochondrial impairment has been implicated. We discuss potential therapeutic strategies targeting mitochondrial function, including pharmacological interventions, lifestyle modifications, exercise, and dietary approaches, and emphasize the need for further research and collaborative efforts to advance our understanding and management of long COVID. This review underscores the critical role of mitochondrial dysfunction in long COVID and calls for a multidisciplinary approach to address the gaps in our knowledge and treatment options for those affected by this condition.

Exploring the dynamics of COVID-19 in a Greenlandic cohort: Mild acute illness and moderate risk of long COVID

Objectives

This study aimed to explore how the Greenlandic population experienced the course of both acute and long-term COVID-19. It was motivated by the unique epidemiologic situation in Greenland, with delayed community transmission of SARS-CoV-2 relative to the rest of the world.

Methods

In a survey among 310 Greenlandic adults, we assessed the association between previous SARS-CoV-2 infection and overall health outcomes by administering three repeated questionnaires over 12 months after infection, with a response rate of 41% at the 12-month follow-up. The study included 128 individuals with confirmed SARS-CoV-2 infection from January/February 2022 and 182 test-negative controls. Participants were recruited through personal approaches, phone calls, and social media platforms.

Results

A total of 53.7% of 162 participants who were test-positive recovered within 4 weeks and 2.5% were hospitalized due to SARS-CoV-2. The most common symptoms were fatigue and signs of mild upper respiratory tract infection. Less than 5% reported sick leave above 2 weeks after infection. Compared with participants who were test-negative, there was an increased risk of reporting fatigue (risk differences 25.4%, 95% confidence interval 8.8-44.0) and mental exhaustion (risk differences 23.4%, 95% confidence interval 4.8-42.2) up to 12 months after a positive test.

Conclusions

Our results indicate that during a period dominated by the Omicron variant, Greenlanders experienced a mild acute course of COVID-19, with quick recovery, minimizing the impact on sick leave. Long COVID may be present in Greenlanders, with symptoms persisting up to 12 months after infection. However, it is important to consider the small sample size and modest response rate as limitations when interpreting the results.

Predictors of somatic symptoms during the COVID-19 pandemic: a national longitudinal survey in Japan

OBJECTIVES

The COVID-19 pandemic has highlighted the long-term consequences of SARS-CoV-2 infection, termed long COVID. However, in the absence of comparative groups, the differentiation of disease progression remains difficult, as COVID-19 symptoms become indistinguishable from symptoms originating from alternative etiologies. This study aimed to longitudinally investigate the association between COVID-19 exposure and the somatic symptoms in the Japanese general population.

DESIGN

This was a longitudinal cohort study with 1-year follow-up.

SETTING AND PARTICIPANTS

Longitudinal data from 19 545 individuals who participated in the Japan Society and New Tobacco Internet Survey (JASTIS) 2022 and 2023 were included. In this study, we used data from the 2022 JASTIS as baseline data and the 2023 JASTIS as follow-up data. Based on questionnaire responses, respondents were classified into three categories of exposure to COVID-19.

OUTCOME MEASURES

The somatic symptoms were assessed by the Somatic Symptom Scale-8 (SSS-8). Using generalised linear models adjusted for baseline covariates, we calculated the ORs of having very high somatic symptoms assessed by SSS-8, attributable to COVID-19 exposure (no COVID-19 cases as the reference group).

RESULTS

Follow-up completers were divided into three groups according to COVID-19 exposure (no COVID-19, n=16 012; COVID-19 without O2 therapy, n=3201; COVID-19 with O2 therapy, n=332). After adjusting for all covariates, COVID-19 cases with O2 therapy had a significant positive association (OR 7.60, 95% CI 5.47 to 10.58) with a very high somatic symptoms burden while other COVID-19 exposure groups did not. Pre-existing physical and psychological conditions were also associated with increased risk of somatic symptoms.

CONCLUSION

The findings of our study suggest that the severity of COVID-19 symptoms requiring O2 therapy in the acute phase led to high somatic symptoms. Pre-existing conditions were also associated with a subsequent risk of somatic symptoms.

Barriers to healthcare access and experiences of stigma: Findings from a coproduced Long Covid case-finding study

BACKGROUND AND AIM

Long Covid is often stigmatised, particularly in people who are disadvantaged within society. This may prevent them from seeking help and could lead to widening health inequalities. This coproduced study with a Community Advisory Board (CAB) of people with Long Covid aimed to understand healthcare and wider barriers and stigma experienced by people with probable Long Covid.

METHODS

An active case finding approach was employed to find adults with probable, but not yet clinically diagnosed, Long Covid in two localities in London (Camden and Merton) and Derbyshire, England. Interviews explored the barriers to care and the stigma faced by participants and were analysed thematically. This study forms part of the STIMULATE-ICP Collaboration.

FINDINGS

Twenty-three interviews were completed. Participants reported limited awareness of what Long Covid is and the available pathways to management. There was considerable self-doubt among participants, sometimes reinforced by interactions with healthcare professionals (HCPs). Participants questioned their deservedness in seeking healthcare support for their symptoms. Hesitancy to engage with healthcare services was motivated by fear of needing more investigation and concerns regarding judgement about the ability to carry out caregiving responsibilities. It was also motivated by the complexity of the clinical presentation and fear of all symptoms being attributed to poor mental health. Participants also reported trying to avoid overburdening the health system. These difficulties were compounded by experiences of stigma and discrimination. The emerging themes reaffirmed a framework of epistemic injustice in relation to Long Covid, where creating, interpreting and conveying knowledge has varied credibility based on the teller's identity characteristics and/or the level of their interpretive resources.

CONCLUSION

We have codeveloped recommendations based on the findings. These include early signposting to services, dedicating protected time to listening to people with Long Covid, providing a holistic approach in care pathways, and working to mitigate stigma. Regardless of the diagnosis, people experiencing new symptoms must be encouraged to seek timely medical help. Clear public health messaging is needed among communities already disadvantaged by epistemic injustice to raise awareness of Long Covid, and to share stories that encourage seeking care and to illustrate the adverse effects of stigma.

PATIENT OR PUBLIC CONTRIBUTION

This study was coproduced with a CAB made up of 23 members including HCPs, people with lived experience of Long Covid and other stakeholders.

Patients' evaluation of aftercare following hospitalization for COVID-19: satisfaction and unmet needs

BACKGROUND

Patient experiences with COVID-19 aftercare remain largely unknown. We evaluated COVID-19 aftercare from a patient perspective one year after hospitalization, assessing satisfaction and its associated factors, and unmet needs.

METHODS

The Satisfaction with COVID-19 Aftercare Questionnaire (SCAQ) was developed as part of a multicenter prospective cohort study and administered one year after hospital discharge. The SCAQ assesses (1) patient satisfaction, comprising information provision, rehabilitation, follow-up by hospitals and general practitioners (GPs), the most important aftercare topics, and overall satisfaction, and (2) unmet needs.

RESULTS

487/561 (87%) COVID-19 patients completed the SCAQ, all had been discharged from the hospital between March 2020 and May 2021. Among responders, the median age of patients was 60 (IQR 54-67) years, 338 (69%) were male, and the median length of stay in the hospital was 13 (6-27) days. Patients were least satisfied with information on who could be contacted with questions when health problems arise (59% satisfied or very satisfied). Many patients (75%) received rehabilitation, most frequently community-based (70%). Across the different community-based therapies, ≥ 60% of patients were satisfied with shared-decision making and ≥ 70% with the received therapy; a majority (≥ 79%) indicated a preference for receiving the same therapy again if needed. Regarding follow-up by hospitals, 86% of patients received this follow-up, most frequently visiting a pulmonologist (96%), being generally satisfied with the received aftercare. Aftercare from GPs was received by 39% of patients, with 88% being satisfied with the GP's availability and 79% with referral to appropriate aftercare providers. Patients (> 50%) considered information-related items most important in aftercare. Overall, patients rated their satisfaction with aftercare 8/10 (7-9) points. Those who received medical rehabilitation (versus no rehabilitation, adjusted beta 0.61 [95%CI 0.11 to 1.11], p = 0.02) or aftercare by a hospital medical specialist (1.1 [0.46 to 1.64], p < 0.001) or GP (0.39 [0.053 to 0.72], p = 0.023) reported significantly higher satisfaction than those without such aftercare. Unmet needs were reported by 35% of patients, with lack of information (20%) and lack of additional aftercare and/or involvement of their GP (19%) being the most frequently reported.

CONCLUSION

Despite the forced quick development of COVID-19 aftercare, patients were generally satisfied. Follow-up by healthcare professionals and information provision is important to meet patients' aftercare needs.

Communicating without a Shared Language: A Qualitative Study of Language Barriers in Language-Discordant Cancer Communication

We use language to achieve understanding, and language barriers can have major health consequences for patients with serious illness. While ethnic minorities are more likely to experience social inequalities in health and health care, communicative processes in language-discordant cancer care remain unexplored. This study aimed to investigate communication between patients with cancer and limited Danish proficiency and oncology clinicians, with special emphasis on how linguistic barriers influenced patient involvement and decision-making. 18 participant observations of clinical encounters were conducted. Field notes and transcriptions of audio recordings were analyzed, and three themes were identified: Miscommunication and uncertainty as a basic linguistic condition; Impact of time on patient involvement; Unequally divided roles and (mis)communication responsibilities. The results showed that professional interpreting could not eradicate miscommunication but was crucial for achieving understanding. Organizational factors related to time and professional interpreting limited patient involvement. Without professional interpreting, patients' relatives were assigned massive communication responsibilities. When no Danish-speaking relatives partook, clinicians' ethical dilemmas further increased as did patient safety risks. Language barriers have consequences for everyone who engages in health communication, and the generated knowledge about how linguistic inequality manifests itself in clinical practice can be used to reduce social inequalities in health and health care.

Updated Clinical Practice Guidelines for the Diagnosis and Management of Long COVID

"Long COVID" is a term used to describe a condition when the symptoms and signs associated with coronavirus disease 2019 (COVID-19) persist for more than three months among patients infected with COVID-19; this condition has been reported globally and poses a serious public health issue. Long COVID can manifest in various forms, highlighting the need for appropriate evaluation and management by experts from various fields. However, due to the lack of clear clinical definitions, knowledge of pathophysiology, diagnostic methods, and treatment protocols, it is necessary to develop the best standard clinical guidelines based on the scientific evidence reported to date. We developed this clinical guideline for diagnosing and treating long COVID by analyzing the latest research data collected from the start of the COVID-19 pandemic until June 2023, along with the consensus of expert opinions. This guideline provides recommendations for diagnosis and treatment that can be applied in clinical practice, based on a total of 32 key questions related to patients with long COVID. The evaluation of patients with long COVID should be comprehensive, including medical history, physical examination, blood tests, imaging studies, and functional tests. To reduce the risk of developing long COVID, vaccination and antiviral treatment during the acute phase are recommended. This guideline will be revised when there is a reasonable need for updates based on the availability of new knowledge on the diagnosis and treatment of long COVID.

Risk of long COVID and associated symptoms after acute SARS-COV-2 infection in ethnic minorities: A nationwide register-linked cohort study in Denmark

BACKGROUND

Ethnic minorities living in high-income countries have been disproportionately affected by Coronavirus Disease 2019 (COVID-19) in terms of infection rates, hospitalisations, and deaths; however, less is known about long COVID in these populations. Our aim was to examine the risk of long COVID and associated symptoms among ethnic minorities.

METHODS AND FINDINGS

We used nationwide register-based cohort data on individuals diagnosed with COVID-19 aged ≥18 years (n = 2,287,175) between January 2020 and August 2022 in Denmark. We calculated the risk of long COVID diagnosis and long COVID symptoms among ethnic minorities compared with native Danes using multivariable Cox proportional hazard regression and logistic regression, respectively. Among individuals who were first time diagnosed with COVID-19 during the study period, 39,876 (1.7%) were hospitalised and 2,247,299 (98.3%) were nonhospitalised individuals. Of the diagnosed COVID-19 cases, 1,952,021 (85.3%) were native Danes and 335,154 (14.7%) were ethnic minorities. After adjustment for age, sex, civil status, education, family income, and Charlson comorbidity index, ethnic minorities from North Africa (adjusted hazard ratio [aHR] 1.41, 95% confidence interval [CI] [1.12,1.79], p = 0.003), Middle East (aHR 1.38, 95% CI [1.24,1.55], p < 0.001), Eastern Europe (aHR 1.35, 95% CI [1.22,1.49], p < 0.001), and Asia (aHR 1.23, 95% CI [1.09,1.40], p = 0.001) had significantly greater risk of long COVID diagnosis than native Danes. In the analysis by largest countries of origin, the greater risks of long COVID diagnosis were found in people of Iraqi origin (aHR 1.56, 95% CI [1.30,1.88], p < 0.001), people of Turkish origin (aHR 1.42, 95% CI [1.24,1.63], p < 0.001), and people of Somali origin (aHR 1.42, 95% CI [1.07,1.91], p = 0.016). A significant factor associated with an increased risk of long COVID diagnosis was COVID-19 hospitalisation. The risk of long COVID diagnosis among ethnic minorities was more pronounced between January 2020 and June 2021. Furthermore, the odds of reporting cardiopulmonary symptoms (including dyspnoea, cough, and chest pain) and any long COVID symptoms were higher among people of North African, Middle Eastern, Eastern European, and Asian origins than among native Danes in both unadjusted and adjusted models. Despite including the nationwide sample of individuals diagnosed with COVID-19, the precision of our estimates on long COVID was limited to the sample of patients with symptoms who had contacted the hospital.

CONCLUSIONS

Belonging to an ethnic minority group was significantly associated with an increased risk of long COVID, indicating the need to better understand long COVID drivers and address care and treatment strategies in these populations.

Norwegian "dugnad" as a rhetorical device in public health communication during the COVID-19 pandemic. A qualitative study from immigrant's perspectives

BACKGROUND

During the COVID-19 pandemic, the Norwegian government appealed to the term "national dugnad" in the communication of containment measures as a call for collective action to fight the spread of infection. "Dugnad" is traditionally associated with solidarity, social responsibility, and a communal spirit in the form of volunteer work carried out by a local community. Although the word "dugnad" is difficult to translate to other languages, it was used as a rhetorical device by the government to communicate health-related information during the pandemic. This study aims to explore how immigrants understood and related to the term "dugnad" as used in the context of the COVID-19 pandemic in Norway.

METHODS

We conducted 55 semi-structured interviews in 2020 with immigrants from Poland (10), Syria (15), Somalia (10), Sri Lanka (10), and Chile (10). Interviews were conducted in participants' mother-tongues. We used systematic text condensation following Malterud's four steps to analyze the data.

RESULTS

The results are organized into three themes corresponding to: (1) meaning making of the term "dugnad"; (2) attitudes towards the term "dugnad"; and (3) reactions to the use of "dugnad" in a public health context. Overall, participants were familiar with the term "dugnad" and positively associated it with volunteering, unity, and a sense of community. However, we found a variety of reactions towards using this term in a public health context, ranging from agreement to disagreement and irritation.

CONCLUSION

Health communication during pandemics is crucial for maximizing compliance and gaining control of disease spread. In multicultural societies, governments and authorities should be aware of the linguistic and cultural barriers to public health communication if they are to effectively reach the entire population. The use of culturally specific concepts in this context, specially as rhetorical devices, may hinder effective health communication and increase health inequalities.

Looking at the Data on Smoking and Post-COVID-19 Syndrome-A Literature Review

Long COVID is a recently described entity that is responsible for significant morbidity and that has consequences ranging from mild to life-threatening. The underlying mechanisms are not completely understood, and treatment options are currently limited, as existing data focus more on risk factors and predictors. Smoking has been reported as a risk factor for poor outcomes of acute SARS-CoV-2 infection and seems to also play a role in mediating post-COVID-19 symptoms. We aimed to review relevant work addressing the interaction between smoking and long COVID in order to characterize smoking's role as a risk factor and possibly identify new research directions. Methods: The PubMed/MEDLINE database was searched using the keywords 'smoking', 'long COVID', and 'post-acute COVID' to identify relevant English-language articles published up to October 2023. Results and conclusions: From the 374 initial hits, a total of 36 papers were deemed relevant to the aim of the review. There was significant variability concerning the ways in which tobacco usage was quantified and reported; still, there is compelling evidence linking smoking to an increased risk of developing manifestations of post-acute-COVID disease. Some clinical conditions, such as dyspnea, cardiovascular symptoms, and cognitive or mental-health impairment, seem to be relatively strongly associated with smoking, while the connection between smoking and upper-airway involvement seems less certain. The available data support recommending smoking cessation as a clinical tool for the prevention of long COVID.

Muscle abnormalities worsen after post-exertional malaise in long COVID

A subgroup of patients infected with SARS-CoV-2 remain symptomatic over three months after infection. A distinctive symptom of patients with long COVID is post-exertional malaise, which is associated with a worsening of fatigue- and pain-related symptoms after acute mental or physical exercise, but its underlying pathophysiology is unclear. With this longitudinal case-control study (NCT05225688), we provide new insights into the pathophysiology of post-exertional malaise in patients with long COVID. We show that skeletal muscle structure is associated with a lower exercise capacity in patients, and local and systemic metabolic disturbances, severe exercise-induced myopathy and tissue infiltration of amyloid-containing deposits in skeletal muscles of patients with long COVID worsen after induction of post-exertional malaise. This study highlights novel pathways that help to understand the pathophysiology of post-exertional malaise in patients suffering from long COVID and other post-infectious diseases.

Effectiveness of Antiviral Therapy on Long COVID: A Systematic Review and Meta-Analysis

Antiviral treatment reduces the severity and mortality of SARS-CoV-2 infection; however, its effectiveness against long COVID-19 is unclear. This study aimed to evaluate the effectiveness of antiviral drugs in preventing long COVID and related hospitalizations/deaths. Scientific and medical databases were searched from 1 January 2020 to 30 June 2023. We included observational cohort studies comparing individuals receiving early antiviral therapy for COVID-19 and those receiving supportive treatment. A fixed-effects model was used to merge the effects reported in two or more studies. The risk of post-acute sequelae of COVID-19 (PASC) was combined as an odds ratio (OR). Six studies were selected, including a total of 3,352,235 participants. The occurrence of PASC was 27.5% lower in patients who received antiviral drugs during the early stages of SARS-CoV-2 infection (OR = 0.725; 95% confidence interval [CI] = 0.409-0.747) than in the supportive treatment group. Moreover, the risk of PASC-associated hospitalization and mortality was 29.7% lower in patients receiving early antiviral therapy than in the supportive treatment group (OR = 0.721; 95% CI = 0.697-0.794). Early antiviral therapy was associated with a reduced risk of PASC and related hospitalization or death. Thus, early antiviral therapy is recommended for at-risk individuals.

Prevalence and Predictors of Long COVID in Patients Accessing a National Digital Mental Health Service

MindSpot is a national mental health service that provides assessments and treatment to Australian adults online or via telephone. Since the start of 2020, questions related to the mental health impacts of COVID-19 have been routinely administered. The objective of the current study is to report the prevalence and predictors of self-reported "long COVID" in patients completing an assessment at the MindSpot Clinic between 5 September 2022 and 7 May 2023 (n = 17,909). Consistent with the World Health Organization definition, we defined long COVID as the occurrence of ongoing physical or mental health symptoms three months after a COVID-19 infection. We conducted a descriptive univariate analysis of patients who reported: no COVID-19 diagnosis (n = 6151); a current or recent (within 3 months) COVID-19 infection (n = 2417); no symptoms three months post-COVID-19 infection (n = 7468); or COVID-related symptoms at least three months post-infection (n = 1873). Multivariate logistic regression was then used to compare patients with and without symptoms three months post-COVID to identify potential predictors for long COVID. The prevalence of long COVID was 10% of the total sample (1873/17909). Patients reporting symptoms associated with long COVID were older, more likely to be female, and more likely to be depressed and report a reduced ability to perform their usual tasks. Sociodemographic factors, including cultural background, education, and employment, were examined. These results provide evidence of the significant prevalence of symptoms of long COVID in people using a national digital mental health service. Reporting outcomes in an Australian context and in specific sub-populations is important for public health planning and for supporting patients.