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BackgroundLong Covid occurs in those infected with SARSCoV2 whose symptoms persist or develop beyond the acute phase. We conducted a systematic review to determine the prevalence of persistent symptoms, functional disability or pathological changes in adults or children at least 12 weeks post-infection. MethodsWe searched MEDLINE (Ovid), Embase (OVID), the Cochrane Covid-19 Study register, WHO ICTRP, medRxiv, Cochrane CENTRAL, MEDLINE (PubMed), ClinicalTrials.gov, and the WHO Global research on coronavirus disease (COVID-19) database from 1st January 2020 to 2nd November 2021, limited to publications in English. We included studies with at least 100 participants. Studies where all participants were critically ill were excluded. Articles were screened independently by two reviewers, with disagreements resolved by a third. Long Covid (primary outcome) was extracted as prevalence of at least one symptom or pathology, or prevalence of the most common symptom or pathology, at 12 weeks or later. Heterogeneity was quantified in absolute terms and as a proportion of total variation and explored across pre-defined subgroups (PROSPERO ID CRD42020218351). FindingsIn total 120 studies in 130 publications were included. Length of follow-up varied from 12 weeks to over 12 months. Few studies had low risk of bias. All complete and subgroup analyses except one had I2 [≥] 90%, with prevalence of persistent symptoms ranging between 0% and 93%. Studies using routine healthcare records tended to report lower prevalence of persistent symptoms/pathology than self-report. However, studies systematically investigating pathology in all participants at follow up tended to report the highest estimates of all three. Studies of hospitalised cases had generally higher estimates than community-based studies. InterpretationThe way in which Long Covid is defined and measured affects prevalence estimation. Given the widespread nature of SARSCoV2 infection globally, the burden of chronic illness is likely to be substantial even using the most conservative estimates. Fundingthis systematic review received no specific funding. Panel: Research in contextO_ST_ABSEvidence before this studyC_ST_ABSThe chronic effects of COVID19 were accounted for in relation to the health, social and economic impacts at the start of the pandemic in 2020. Long Covid is now established as a serious outcome of infection with SARSCoV2 that influences the daily lives of many. To estimate the population-level burden, the prevalence of prolonged health effects from SARSCoV2 infection needs to be quantified. We conducted a systematic review of published studies to determine the prevalence of persistent symptoms, functional disability or pathological changes in adults or children at least 12 weeks post-infection. Added value of this studyWe included 120 studies assessing Long Covid symptoms, functional status, or pathology published up to November 2021. There was significant heterogeneity between studies and wide variation in Long Covid prevalence estimates ranging between 0-93%. This is due to differences in Long Covid definition, required threshold of severity or impact on daily activities, study designs, sources of study samples, how the initial infection was defined, number of assessed symptoms and method of assessment. Despite large between-study heterogeneity, the studies with lowest risk of bias estimated prevalence between 3% and 37%. For studies that included comparison of cases to controls, there were significant methodological considerations to the choice of control groups including difficulty ascertaining the absence of exposure (SARSCoV2 infection). The review search timeline meant Long Covid prevalence in vaccinated populations could not be assessed. Implication of all the available evidenceEven with the most conservative estimates of prevalence among those infected, the chronic disease burden generated by SARSCoV2 infection seems substantial, particularly in countries where community transmission of SARSCoV2 is high.
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Background and aimLong Covid is a significant public health concern with potentially negative implications for health inequalities. We know that those who are already socially disadvantaged in society are more exposed to COVID-19, experience the worst health outcomes and are more likely to suffer economically. We also know that these groups are more likely to experience stigma and discrimination and have negative healthcare experiences even before the pandemic. However, little is known about disadvantaged groups experiences of Long Covid and preliminary evidence suggests they may be under-represented in those who access formal care. We will conduct a pilot study in a defined geographical area (Camden, London, UK) to test the feasibility of a community-based approach of identifying Long Covid cases that have not been formally clinically diagnosed and have not been referred to Long Covid Specialist services. We will explore the barriers to accessing recognition, care and support, as well as experiences of stigma and perceived discrimination. MethodsThis protocol and study materials were co-produced with a Community Advisory Board (CAB) made up primarily of people living with Long Covid. Working with voluntary organisations, promotional material are co-developed and will be distributed in the local community with engagement from key community organisations and leaders to highlight Long Covid symptoms and invite those experiencing them to participate in the study if they are not formally diagnosed and accessing care. Awareness of Long Covid and symptoms, experiences of trying to access care, as well as stigma and discrimination will be explored through qualitative interviews with participants. Upon completion of the interviews, participants will be offered referral to the local social prescribing team to receive support that is personalised to them potentially including, but not restricted to, liaising with their primary care provider and the regional Long Covid clinic run by University College London Hospitals (UCLH). Ethics and disseminationEthical approval has been obtained from the Faculty of Medicine Ethics Committee and Research Integrity and Governance, University of Southampton. (reference number 72400). Findings will be reported in a report and submitted for peer-reviewed publication. Definitive methods of dissemination will be decided by the CAB. Summaries of the findings will also be shared on the STIMULATE-ICP website, locally in the study area and through social media. We will specifically target policy makers and those responsible for shaping and commissioning Long Covid healthcare services and social support such as NHSE England Long Covid Group.
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BackgroundStigma can be experienced as perceived or actual disqualification from social and institutional acceptance on the basis of one or more physical, behavioural or other attributes deemed to be undesirable. Long Covid is a predominantly multisystem condition that occurs in people with a history of SARSCoV2 infection, often resulting in functional disability. AimTo develop and validate a Long Covid Stigma Scale (LCSS); and to quantify the burden of Long Covid stigma. Design and SettingFollow-up of a co-produced community-based Long Covid online survey using convenience non-probability sampling. MethodThirteen questions on stigma were designed to develop the LCSS capturing three domains - enacted (overt experiences of discrimination), internalised (internalising negative associations with Long Covid and accepting them as self-applicable) and anticipated (expectation of bias/poor treatment by others) stigma. Confirmatory factor analysis tested whether LCSS consisted of the three hypothesised domains. Model fit was assessed and prevalence was calculated. Results966 UK-based participants responded (888 for stigma questions), with mean age 48 years (SD: 10.7) and 85% female. Factor loadings for enacted stigma were 0.70-0.86, internalised 0.75-0.84, anticipated 0.58-0.87, and model fit was good. The prevalence of experiencing stigma at least sometimes and often/always was 95% and 76% respectively. Anticipated and internalised stigma were more frequently experienced than enacted stigma. Those who reported having a clinical diagnosis of Long Covid had higher stigma prevalence than those without. ConclusionThis study establishes a scale to measure Long Covid stigma and highlights common experiences of stigma in people living with Long Covid.
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IntroductionIndividuals with Long Covid represent a new and growing patient population. In England, fewer than 90 Long Covid clinics deliver assessment and treatment informed by NICE guidelines. However, a paucity of clinical trials or longitudinal cohort studies means that the epidemiology, clinical trajectory, healthcare utilisation and effectiveness of current Long Covid care are poorly documented, and that neither evidence-based treatments nor rehabilitation strategies exist. In addition, and in part due to pre-pandemic health inequalities, access to referral and care varies, and patient experience of the Long Covid care pathways can be poor. In a mixed methods study, we therefore aim to: (1) describe the usual healthcare, outcomes and resource utilisation of individuals with Long Covid; (2) assess the extent of inequalities in access to Long Covid care, and specifically to understand Long Covid patients experiences of stigma and discrimination. Methods and analysisA mixed methods study will address our aims. Qualitative data collection from patients and health professionals will be achieved through surveys, interviews and focus group discussions, to understand their experience and document the function of clinics. A patient cohort study will provide an understanding of outcomes and costs of care. Accessible data will be further analysed to understand the nature of Long Covid, and the care received. Ethics and disseminationEthical approval was obtained from South Central - Berkshire Research Ethics Committee (reference 303958). The dissemination plan will be decided by the patient and public involvement and engagement (PPIE) group members and study Co-Is, but will target 1) policy makers, and those responsible for commissioning and delivering Long Covid services, 2) patients and the public, and 3) academics.
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BackgroundIt is unclear whether receiving two COVID-19 vaccinations before SARS-CoV-2 infection reduces the risk of developing Long Covid symptoms. We examined whether the likelihood of symptoms 12 weeks after infection differed by vaccination status. MethodsWe included COVID-19 Infection Survey participants aged 18-69 years who tested positive for SARS-CoV-2 between 26 April 2020 and 30 November 2021; we excluded participants who, before their first test-confirmed infection, had suspected COVID-19 or Long Covid symptoms, or were single-vaccinated. Participants who were double-vaccinated [≥]14 days before infection were 1:1 propensity-score matched, based on socio-demographic characteristics and time from infection to follow-up for Long Covid, to those unvaccinated at time of infection. We estimated adjusted odds ratios (aOR) of Long Covid symptoms [≥]12 weeks post-infection, comparing double-vaccinated with unvaccinated (reference group) participants. ResultsThe study sample comprised 3,090 double-vaccinated participants (mean age 49 years, 54% female, 92% white, median follow-up from infection 96 days) and matched control participants. Long Covid symptoms were reported by 294 double-vaccinated participants (prevalence 9.5%) compared with 452 unvaccinated participants (14.6%), corresponding to an aOR for Long Covid symptoms of 0.59 (95% CI: 0.50 to 0.69). There was no evidence of heterogeneity by adenovirus vector versus messenger ribonucleic acid vaccines (p=0.25). ConclusionsCOVID-19 vaccination is associated with reduced risk of Long Covid, emphasising the need for public health initiatives to increase population-level vaccine uptake. Longer follow-up is needed, as is the assessment of further vaccine doses and the Omicron variant.
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ObjectiveTo estimate associations between COVID-19 vaccination and Long Covid symptoms in adults who were infected with SARS-CoV-2 prior to vaccination. DesignObservational cohort study using individual-level interrupted time series analysis. SettingRandom sample from the community population of the UK. Participants28,356 COVID-19 Infection Survey participants (mean age 46 years, 56% female, 89% white) aged 18 to 69 years who received at least their first vaccination after test-confirmed infection. Main outcome measuresPresence of long Covid symptoms at least 12 weeks after infection over the follow-up period 3 February to 5 September 2021. ResultsMedian follow-up was 141 days from first vaccination (among all participants) and 67 days from second vaccination (84% of participants). First vaccination was associated with an initial 12.8% decrease (95% confidence interval: -18.6% to -6.6%) in the odds of Long Covid, but increasing by 0.3% (-0.6% to +1.2%) per week after the first dose. Second vaccination was associated with an 8.8% decrease (-14.1% to -3.1%) in the odds of Long Covid, with the odds subsequently decreasing by 0.8% (-1.2% to -0.4%) per week. There was no statistical evidence of heterogeneity in associations between vaccination and Long Covid by socio-demographic characteristics, health status, whether hospitalised with acute COVID-19, vaccine type (adenovirus vector or mRNA), or duration from infection to vaccination. ConclusionsThe likelihood of Long Covid symptoms reduced after COVID-19 vaccination, and the improvement was sustained over the follow-up period after the second dose. Vaccination may contribute to a reduction in the population health burden of Long Covid, though longer follow-up time is needed. Summary boxWhat is already known on this topic O_LICOVID-19 vaccines are effective at reducing rates of SARS-CoV-2 infection, transmission, hospitalisation, and death C_LIO_LIThe incidence of Long Covid may be reduced if infected after vaccination, but the relationship between vaccination and pre-existing long COVID symptoms is unclear, as published studies are generally small and with self-selected participants C_LI What this study adds O_LIThe likelihood of Long Covid symptoms reduced after COVID-19 vaccination, and the improvement was sustained over the follow-up period after the second dose C_LIO_LIThere was no evidence of differences in this relationship by socio-demographic characteristics, health-related factors, vaccine type, or duration from infection to vaccination C_LIO_LIAlthough causality cannot be inferred from this observational evidence, vaccination may contribute to a reduction in the population health burden of Long Covid; further research is needed to understand the biological mechanisms that may ultimately contribute to the development of therapeutics for Long Covid C_LI
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Many people are not recovering for months after being infected with SARS-CoV-2. Long Covid has emerged as a major public health concern that needs defining, quantifying, and describing. We aimed to explore the initial and ongoing symptoms of Long Covid following SARS-CoV-2 infection and describe its impact on daily life in people who were not admitted to hospital during the first two weeks of the illness. We co-produced a survey with people living with Long Covid. We collected the data through an online survey using convenience non-probability sampling, with the survey posted both specifically on Long Covid support groups and generally on social media. The criteria for inclusion were adults with lab-confirmed (PCR or antibody) or suspected COVID-19 managed in the community (non-hospitalised) in the first two weeks of illness. We used agglomerative hierarchical clustering to identify specific symptom clusters, and their demographic and functional correlates. We analysed data from 2550 participants with a median duration of illness of 7.7 months (interquartile range (IQR) 7.4-8.0). The mean age was 46.5 years (standard deviation 11 years) with 82.8% females and 79.9% of participants based in the UK. 89.5% described their health as good, very good or excellent before COVID-19. The most common initial symptoms that persisted were exhaustion, chest pressure/tightness, shortness of breath and headache. Cough, fever, and chills were common initial symptoms that became less prevalent later in the illness, whereas cognitive dysfunction and palpitations became more prevalent later in the illness. 26.5% reported lab-confirmation of infection. The biggest difference in ongoing symptoms between those who reported testing positive and those who did not was loss of smell/taste. Ongoing symptoms affected at least 3 organ systems in 83.5% of participants. Most participants described fluctuating (57.7%) or relapsing symptoms (17.6%). Physical activity, stress and sleep disturbance commonly triggered symptoms. A third (32%) reported they were unable to live alone without any assistance at six weeks from start of illness. 16.9% reported being unable to work solely due to COVID-19 illness. 66.4% reported taking time off sick (median of 60 days, IQR 20, 129). 37.0% reported loss of income due to illness, and 64.4% said they were unable to perform usual activities/duties. Acute systems clustered broadly into two groups: a majority cluster (n=2235, 88%) with cardiopulmonary predominant symptoms, and a minority cluster (n=305, 12%) with multisystem symptoms. Similarly, ongoing symptoms broadly clustered in two groups; a majority cluster (n=2243, 88.8%) exhibiting mainly cardiopulmonary, cognitive symptoms and exhaustion, and a minority cluster (n=283, 11.2%) exhibited more multisystem symptoms. Belonging to the more severe multisystem cluster was associated with more severe functional impact, lower income, younger age, being female, worse baseline health, and inadequate rest in the first two weeks of the illness, with no major differences in the cluster patterns when restricting analysis to the lab-confirmed subgroup. This is an exploratory survey of Long Covid characteristics. Whilst it is important to acknowledge that it is a non-representative population sample, it highlights the heterogeneity of persistent symptoms, and the significant functional impact of prolonged illness following confirmed or suspected SARS-CoV-2 infection. To study prevalence, predictors and prognosis, research is needed in a representative population sample using standardised case definitions (to include those not lab-confirmed in the first pandemic wave).
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BackgroundExploring transmission and symptoms of COVID-19 in children is vital, given that schools have recently fully reopened. ObjectivesThis study aimed to characterise the nature and duration of symptoms suggestive of COVID-19 in UK households, and examine whether the symptoms varied between households with and without children and between adults and children from March to May 2020 in the UK. MethodsAn online questionnaire posted on social media (Mumsnet, Twitter, Facebook) was used to gather demographic and symptom information within UK households. ResultsResults from 508 households (1057 adults and 398 children) were available for analysis. 64.1% of respondent households with children and 59.1% of households without children had adults with symptoms suggestive of COVID-19. The proportion of adults that reported being symptomatic was 46.1% in households with children (and 36.7% in households without children. In 37.8% of households with at least one adult and one child with symptoms, the childs onset of symptoms started before the adult. Of all children, 35.7% experienced symptoms, with almost a quarter experiencing fluctuating symptoms for more than 2 weeks compared to almost half of symptomatic adults. In general, children had a shorter (median 5 days) and milder illness course than adults (median 10 days). Fatigue was the most common symptom in adults (79.7%) and cough was the most common symptom in children (53.5%). Chest tightness, shortness of breath, fatigue, muscle ache and diarrhoea were more common in adults than children, while cough and fever were equally common. ConclusionChildren had shorter and milder illness than adults, but in almost a quarter of children symptoms lasted more than 2 weeks. In over a third of both adult-child symptomatic households, the child was the first to become ill. Child to adult transmission and clinical presentation in children need to be further characterised. SynopsisO_LIStudy question. What is the nature and duration of symptoms suggestive of COVID-19 in UK households with and without children during March and May 2020? Do the symptoms vary between adults and children? C_LIO_LIWhats already known. There has been uncertainty about the extent to which children get and transmit SARS-CoV-2 within households. Symptoms associated with SARS-CoV-2 infection are well described in adults but symptoms and their duration are less well-characterised in children. C_LIO_LIWhat this study adds On average, children had shorter and milder illness than adults, but still symptoms lasted more than 2 weeks in a significant proportion of children. In over a third of both adult and child symptomatic households, the child was the first to become ill. C_LI
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The benefits, both in terms of productivity and public health, are investigated for different levels of engagement with the test, trace and isolate procedures in the context of a pandemic in which there is little or no herd immunity. Simple mathematical modelling is used in the context of a single, relatively closed workplace such as a factory or back-office where, in normal operation, each worker has lengthy interactions with a fixed set of colleagues. A discrete-time SEIR model on a fixed interaction graph is simulated with parameters that are motivated by the recent COVID-19 pandemic in the UK during a post-peak phase, including a small risk of viral infection from outside the working environment. Two kinds of worker are assumed, transparents who regularly test, share their results with colleagues and isolate as soon as a contact tests positive for the disease, and opaques who do none of these. Moreover, the simulations are constructed as a "playable model" in which the transparency level, disease parameters and mean interaction degree can be varied by the user. The model is analysed in the continuum limit. All simulations point to the double benefit of transparency in maximising productivity and minimising overall infection rates. Based on these findings, public policy implications are discussed on how to incentivise this mutually beneficial behaviour in different kinds of workplace, and simple recommendations are made.
