Management of Post-COVID Conditions
Evaluating and Caring for Patients with Post-COVID Conditions: Interim Guidance
For most patients, the goal of medical management of post-COVID conditions is to optimize function and quality of life. Ideally, healthcare professionals, in consultation with the appropriate specialists, should develop a comprehensive management plan based on their patients’ presenting symptoms, underlying medical and psychiatric conditions, personal and social situations, and their treatment goals. Setting achievable goals through shared decision-makingexternal icon can be beneficial. Transparency is important for the process of goal setting; healthcare professionals should advise patients that post-COVID conditions are not yet well understood, and assure them that support will continue to be provided as new information emerges. Healthcare professionals and patients should continue to discuss progress and challenges and reassess goals as needed. Symptoms not explained by, or out of proportion to, objective findings are not uncommon after COVID-19 and should not be dismissed even if there is not yet a full understanding of their etiology or their expected duration.
Many post-COVID conditions can be improved through already established symptom management approaches (e.g., breathing exercises to improve symptoms of dyspnea). Creating a comprehensive rehabilitation plan(48, 49) may be helpful for some patients and might include physical and occupational therapy, speech and language therapy, vocational therapy, as well as neurologic rehabilitation for cognitive symptoms. A conservative physical rehabilitation plan might be indicated for some patients (e.g., persons with post-exertional malaise); consultation with physiatry for cautious initiation of exercise and recommendations about pacing may be useful. Gradual return to exercise as tolerated could be helpful for most patients.(50) Optimizing management of underlying medical conditions might include counseling on lifestyle components such as nutrition, sleep, and stress reduction (e.g., meditation).
Patient diaries and calendars might be useful to document changes in health conditions and symptom severity, especially in relation to potential triggers such as exertion (physical and cognitive), foods, menstruation, and treatments or medications. Such diaries and calendars can provide greater insight into patients’ symptoms and lived experience for healthcare professionals. Healthcare professionals should encourage patients to report any new or changing symptoms and to discuss any changes in activities or routines.
Patients with post-COVID conditions may share some of the symptoms that occur in patients who experience myalgic encephalomyelitis/chronic fatigue syndrome, fibromyalgia, post-treatment Lyme disease syndrome, dysautonomiaexternal icon, and mast cell activation syndromeexternal icon. Symptom management approaches that have been helpful for these disorders may also benefit some patients with post-COVID conditions (e.g., activity management (pacing) for post-exertional malaise).
FDA-approved or over the counter medications as well as vitamin or electrolyte supplements may be helpful for indicated illnesses (e.g., headache, anxiety) or documented deficiencies (e.g., vitamin deficiency) after carefully weighing the benefits and risks of pharmaceutical interventions. Some treatments have been offered that lack evidence of efficacy or effectiveness, and could be harmful to patients. Healthcare professionals should inquire about any unprescribed medications, herbal remedies, supplements, or other treatments that patients may be taking for their post-COVID conditions.
Follow-up visits with a healthcare professional might be considered every 2–3 months, with frequency adjusted up or down depending on the patient’s condition and illness progression.
Holistic Support for Patients with Post-COVID Conditions
Evidence indicates that holistic support for the patient throughout their illness course can be beneficial.(32-38) Recognizing and validating the impact of illness on quality of life should be part of the ongoing healthcare professional and patient interaction. Healthcare professionals can provide information on peer support resources (e.g., patient support groups, online forums). Support groups are connecting individuals, providing support, and sharing resources for persons affected by COVID-19 (see Resources). When material, employment or other social support needs are identified, healthcare professionals should consider referral themselves (if they are knowledgeable and able) and engaging a social worker, case worker, community health worker, or similarly trained professional to assist.
Patient Groups with Special Considerations
Persons who belong to racial and ethnic minority populations have experienced a higher burden of COVID-19 in part because of structural racism and longstanding disparities in social determinants of health, which could reasonably lead to a higher incidence of post-COVID conditions in these same populations.(51) COVID-19-related health disparities have also been reported for racial and ethnic minority employees of certain occupations (e.g., working in meat processing facilities).(52) Deploying resources to these communities can help ensure disproptionally affected residents are aware of post-COVID conditions and have access to needed services that may be lacking there.
People with disabilities may require close follow-up related to functional limitations. People experiencing homelessness or housing instability as well as people in correctional facilities may experience challenges accessing healthcare and other support services. People with pre-existing substance use disorder may be at risk for relapse.
Tools for cross-cultural communication and language access, including translated materials on post-COVID conditions and interpreter services, could help address health literacy and improve communication effectiveness.
People with barriers to accessing health care due to lack of health insurance, access to healthcare professionals who accept their health insurance, or lack of transportation, childcare, or paid sick leave may face additional challenges accessing healthcare. Telemedicine visits may be helpful for such patients who live in rural areas with access to broadband.
Lastly, patient advocacy groups have raised concerns that some post-COVID conditions have been either misdiagnosed as or misattributed to psychiatric causes, particularly among persons who belong to marginalized or vulnerable groups. Sensitivity to and awareness of stigma, completing a full clinical evaluation, and maintaining an attitude of empathy and understanding can help address these concerns.
- Nalbandian A, Sehgal K, Gupta A, Madhavan MV, et al. Post-acute COVID-19 syndrome. Nat Med. 2021 Apr;27(4):601-615. doi:10.1038/s41591-021-01283-zexternal icon
- Policy Brief 39 – In the Wake of the Pandemic Preparing for Long COVID. Accessed at: https://apps.who.int/iris/bitstream/handle/10665/339629/Policy-brief-39-1997-8073-eng.pdfexternal icon
- Huang Y, Pinto MD, Borelli JL, et al. COVID Symptoms, Symptom Clusters, and Predictors for Becoming a Long-Hauler: Looking for Clarity in the Haze of the Pandemic. medRxiv. 2021 Mar 5. doi: 10.1101/2021.03.03.21252086external icon
- Havervall S, Rosell A, Phillipson M, Mangsbo SM, Nilsson P, Hober S, Thålin C. Symptoms and Functional Impairment Assessed 8 Months After Mild COVID-19 Among Health Care Workers. JAMA. 2021 Apr 7. doi:10.1001/jama.2021.5612external icon
- Office of National Statistics. Prevalence of ongoing symptoms following coronavirus (COVID-19) infection in the UK: 1 April 2021. Accessed at: https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/bulletins/prevalenceofongoingsymptomsfollowingcoronaviruscovid19infectionintheuk/1april2021external icon
- Chevinsky JR, Tao G, Lavery AM, et al. Late conditions diagnosed 1-4 months following an initial COVID-19 encounter: a matched cohort study using inpatient and outpatient administrative data - United States, March 1-June 30, 2020. Clin Infect Dis. 2021 Apr 28. doi: 10.1093/cid/ciab338external icon
- Hernandez-Romieu AC, Leung S, Mbanya A, et al. Health Care Utilization and Clinical Characteristics of Nonhospitalized Adults in an Integrated Health Care System 28-180 Days After COVID-19 Diagnosis - Georgia, May 2020-March 2021. MMWR Morb Mortal Wkly Rep. 2021 Apr 30;70(17):644-650. doi: 10.15585/mmwr.mm7017e3external icon
- Lund LC, Hallas J, Nielsen H, Koch A, Mogensen SH, Brun NC, Christiansen CF, Thomsen RW, Pottegård A. Post-acute effects of SARS-CoV-2 infection in individuals not requiring hospital admission: a Danish population-based cohort study. Lancet Infect Dis. 2021 May 10. doi:10.1016/S1473-3099(21)00211-5external icon
- Huang C, Huang L, Wang Y, et al. 6-month consequences of COVID-19 in patients discharged from hospital: a cohort study. Lancet. 2021 Jan 16;397(10270):220-232. doi:10.1016/S0140-6736(20)32656-8external icon
- Pavli A, Theodoridou M, Maltezou HC. Post-COVID syndrome: Incidence, clinical spectrum, and challenges for primary healthcare professionals. Arch Med Res. 2021 May 4. doi:10.1016/j.arcmed.2021.03.010external icon
- Cabrera Martimbianco AL, Pacheco RL, Bagattini ÂM, et al. Frequency, signs and symptoms, and criteria adopted for long COVID: a systematic review. Int J Clin Pract. 2021 May 11:e14357. doi:10.1111/ijcp.14357external icon
- Rando HM, Bennett TD, Byrd JB, et al. Challenges in defining Long COVID: Striking differences across literature, Electronic Health Records, and patient-reported information. medRxiv. 2021 Mar 26. doi:10.1101/2021.03.20.21253896external icon
- Office of National Statistics. Update on long COVID prevalence estimate. Accessed at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/962830/s1079-ons-update-on-long-covid-prevalence-estimate.pdfexternal icon
- Buonsenso D, Munblit D, De Rose C, et al. Preliminary evidence on long COVID in children. Acta Paediatr. 2021 Apr 9. doi:10.1111/apa.15870external icon
- Say D, Crawford N, McNab S, et al. Post-acute COVID-19 outcomes in children with mild and asymptomatic disease. Lancet Child Adolesc Health. 2021 Apr 20. doi:10.1016/S2352-4642(21)00124-3external icon
- Osmanov I, Spiridonova E, Bobkova P, et al. Risk factors for long covid in previously hospitalised children using the ISARIC Global follow-up protocol: A prospective cohort study. medRxiv. 2021 Apr 26. doi:10.1101/2021.04.26.21256110external icon
- Assaf G, Davis H, McCorkell L, et al. What does COVID-19 recovery actually look like? An analysis of the prolonged COVID-19 symptoms survey by Patient-Led Research Team. Patient Led Research for COVID-19, 2020. external icon
- Lam MH, Wing YK, Yu MW, et al. Mental morbidities and chronic fatigue in severe acute respiratory syndrome survivors: long-term follow-up. Arch Intern Med. 2009 Dec 14;169(22):2142-7. doi:10.1001/archinternmed.2009.384external icon
- Lee SH, Shin HS, Park HY, et al. Depression as a Mediator of Chronic Fatigue and Post-Traumatic Stress Symptoms in Middle East Respiratory Syndrome Survivors. Psychiatry Investig. 2019 Jan;16(1):59-64. doi:10.30773/pi.2018.10.22.3.external icon
- Lambert N, Survivor Corps, El-Azab SA, et al. COVID-19 Survivors’ Reports of the Timing, Duration, and Health Impacts of Post-Acute Sequelae of SARS-CoV-2 (PASC) Infection. medRxiv 2021.03.22.21254026; doi:10.1101/2021.03.22.21254026external icon
- Colbenson GA, Johnson A, Wilson ME. Post-intensive care syndrome: impact, prevention, and management. Breathe (Sheff). 2019 Jun;15(2):98-101. doi:10.1183/20734735.0013-2019external icon
- Lavery AM, Preston LE, Ko JY, et al. Characteristics of Hospitalized COVID-19 Patients Discharged and Experiencing Same-Hospital Readmission - United States, March-August 2020. MMWR Morb Mortal Wkly Rep. 2020 Nov 13;69(45):1695-1699. doi: 10.15585/mmwr.mm6945e2
- Chopra V, Flanders SA, O'Malley M, et al. Sixty-Day Outcomes Among Patients Hospitalized With COVID-19. Ann Intern Med. 2020 Nov 11. doi: 10.7326/M20-5661external icon
- Ayoubkhani D, Khunti K, Nafilyan V, et al. Post-covid syndrome in individuals admitted to hospital with covid-19: retrospective cohort study. BMJ. 2021 Mar 31;372:n693. doi:10.1136/bmj.n693external icon
- Atalla E, Kalligeros M, Giampaolo G, et al. Readmissions among patients with COVID-19. Int J Clin Pract. 2020 Sep 7:e13700. doi:10.1111/ijcp.13700external icon
- Donnelly JP, Wang XQ, Iwashyna TJ, et al. Readmission and Death After Initial Hospital Discharge Among Patients With COVID-19 in a Large Multihospital System. JAMA. 2021 Jan 19;325(3):304-306. doi:10.1001/jama.2020.21465external icon
- Somani SS, Richter F, Fuster V, et al. Characterization of Patients Who Return to Hospital Following Discharge from Hospitalization for COVID-19. J Gen Intern Med. 2020 Oct;35(10):2838-2844. doi:10.1007/s11606-020-06120-6external icon
- Jeon WH, Seon JY, Park SY, et al. Analysis of Risk Factors on Readmission Cases of COVID-19 in the Republic of Korea: Using Nationwide Health Claims Data. Int J Environ Res Public Health. 2020 Aug 12;17(16). doi:10.3390/ijerph17165844external icon
- Akinbami LJ, Petersen LR, Sami S, et al. COVID-19 symptoms and SARS-CoV-2 antibody positivity in a large survey of first responders and healthcare personnel, May-July 2020. Clin Infect Dis. 2021 Jan 30. doi:10.1093/cid/ciab080external icon
- Petersen LR, Sami S, Vuong N, et al. Lack of antibodies to SARS-CoV-2 in a large cohort of previously infected persons. Clin Infect Dis. 2020 Nov 4.
- American Academy of Pediatrics. COVID-19 Interim Guidance: Return to Sports and Physical Activity. Accessed at: https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/covid-19-interim-guidance-return-to-sports/external icon
- Greenhalgh T, Knight M, A’Court C, et al. Management of post-acute covid-19 in primary care. BMJ. 2020;370:m3026. doi:10.1136/bmj.m3026external icon
- COVID-19 Rapid Guideline: Managing the Long-Term Effects of COVID-19. Accessed at: https://www.nice.org.uk/guidance/NG188external icon
- Sisó-Almirall A, Brito-Zerón P, Conangla Ferrín L, et al. Long Covid-19: Proposed Primary Care Clinical Guidelines for Diagnosis and Disease Management. Int J Environ Res Public Health. 2021 Apr 20;18(8). doi:10.3390/ijerph18084350external icon
- Parkin A, Davison J, Tarrant R, et al. A Multidisciplinary NHS COVID-19 Service to Manage Post-COVID-19 Syndrome in the Community. J Prim Care Community Health. 2021 Jan-Dec;12:21501327211010994. doi:10.1177/21501327211010994external icon
- Brigham E, O'Toole J, Kim SY, et al. The Johns Hopkins Post-Acute COVID-19 Team (PACT): A Multidisciplinary, Collaborative, Ambulatory Framework Supporting COVID-19 Survivors. Am J Med. 2021 Apr;134(4):462-467.e1. doi:10.1016/j.amjmed.2020.12.009external icon
- Santhosh L, Block B, Kim SY, Raju S, Shah RJ, Thakur N, Brigham EP, Parker AM. How I Do It: Rapid Design and Implementation of Post-COVID-19 Clinics. Chest. 2021 Mar 31. doi:10.1016/j.chest.2021.03.044external icon
- O'Brien H, Tracey MJ, Ottewill C, et al. An integrated multidisciplinary model of COVID-19 recovery care. Ir J Med Sci. 2021 May;190(2):461-468. doi:10.1007/s11845-020-02354-9external icon
- Lopez-Leon S, Wegman-Ostrosky T, Perelman C, et al. More Than 50 Long-Term Effects of COVID-19: A Systematic Review and Meta-Analysis. Res Sq. 2021 Mar 1. doi:10.2139/ssrn.3769978external icon
- Al-Aly Z, Xie Y, Bowe B. High-dimensional characterization of post-acute sequalae of COVID-19. Nature. 2021 Apr 22. doi:10.1038/s41586-021-03553-9external icon
- Sudre CH, Murray B, Varsavsky T, et al. Attributes and predictors of long COVID. Nat Med. 2021 Apr;27(4):626-631. doi:10.1038/s41591-021-01292-yexternal icon
- Lund LC, Hallas J, Nielsen H, et al. Post-acute effects of SARS-CoV-2 infection in individuals not requiring hospital admission: a Danish population-based cohort study. Lancet Infect Dis. 2021 May 10. doi:10.1016/S1473-3099(21)00211-5external icon
- Carfì A, Bernabei R, Landi F, et al. Persistent Symptoms in Patients After Acute COVID-19. JAMA. 2020 Aug 11;324(6):603-605. doi:10.1001/jama.2020.12603external icon
- Cellai M, O'Keefe JB. Characterization of Prolonged COVID-19 Symptoms in an Outpatient Telemedicine Clinic. Open Forum Infect Dis. 2020 Oct;7(10):ofaa420. doi:10.1093/ofid/ofaa420external icon
- Logue JK, Franko NM, McCulloch DJ, et al. Sequelae in Adults at 6 Months After COVID-19 Infection. JAMA Netw Open. 2021 Feb 1;4(2):e210830. doi:10.1001/jamanetworkopen.2021.0830external icon
- del Rio C, Collins LF, Malani P. Long-term health consequences of COVID-19. JAMA. 2020. doi:10.1001/jama.2020.19719external icon
- Taquet M, Geddes JR, Husain M, et al. 6-month neurological and psychiatric outcomes in 236 379 survivors of COVID-19: a retrospective cohort study using electronic health records. Lancet Psychiatry. 2021 May;8(5):416-427. doi:10.1016/S2215-0366(21)00084-5external icon
- Barker-Davies RM, O'Sullivan O, Senaratne KPP, et al. The Stanford Hall consensus statement for post-COVID-19 rehabilitation. Br J Sports Med. 2020 Aug;54(16):949-959. doi:10.1136/bjsports-2020-102596external icon
- Li Z, Zheng C, Duan C, et al. Rehabilitation needs of the first cohort of post-acute COVID-19 patients in Hubei, China. Eur J Phys Rehabil Med. 2020 Jun;56(3):339-344. doi: 10.23736/S1973-9087.20.06298-X. PMID: 32672029. doi:10.23736/s1973-9087.20.06298-xexternal icon
- Daynes E, Gerlis C, Chaplin E, et al. Early experiences of rehabilitation for individuals post-COVID to improve fatigue, breathlessness exercise capacity and cognition - A cohort study. Chron Respir Dis. 2021 Jan-Dec;18:14799731211015691. doi:10.1177%2F14799731211015691external icon
- Berger Z, Altiery DE Jesus V, Assoumou SA, et al. Long COVID and Health Inequities: The Role of Primary Care. Milbank Q. 2021 Mar 30. doi:10.1111/1468-0009.12505external icon
- Waltenburg MA, Victoroff T, Rose CE, et al. Update: COVID-19 Among Workers in Meat and Poultry Processing Facilities ― United States, April–May 2020. MMWR Morb Mortal Wkly Rep 2020;69:887-892. Accessed at: https://www.cdc.gov/mmwr/volumes/69/wr/mm6927e2.htm
- DT Arnold, A Milne, E Samms, et al. Are vaccines safe in patients with Long COVID? A prospective observational study. medRxiv. 2021 March 11; 21253225. Accessed at: https://www.medrxiv.org/content/10.1101/2021.03.11.21253225v2external icon
- Santoli JM, Lindley MC, DeSilva MB, et al. Effects of the COVID-19 Pandemic on Routine Pediatric Vaccine Ordering and Administration - United States, 2020. MMWR Morb Mortal Wkly Rep. 2020 May 15;69(19):591-593.