CMAAO CORONA FACTS and MYTH : Rapid Guideline on Long COVID

Author : Dr K Aggarwal , President CMAAO, HCFI, With input from Dr Monica Vasudev

India

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New Delhi, December 26, 2020 :

The National Institute for Health and Care Excellence (NICE) Issued Rapid Guideline on Long COVID

1. People may have ongoing symptomatic COVID-19 if they present with symptoms 4 to 12 weeks after the start of acute symptoms
2. People may have post-COVID syndrome if their symptoms have not resolved after 12 weeks
3. The rapid guideline on managing the long-term effects of COVID-19, also known as ‘long COVID’, was produced by NICE in collaboration with the Scottish Intercollegiate Guidelines Network (SIGN) and the Royal College of General Practitioners (RCGP).
4.  It was published as the NHS announced that patients with long-term symptoms of COVID-19 could now access specialist help at a growing number of clinics in England.
5.  1 in 5 people with COVID-19 develop longer term symptoms. Around 186,000 people experience health problems for up to 12 weeks, according to the Office for National Statistics.
6.  The ONS estimated that 9.9% of people who had COVID-19 remained symptomatic after 12 weeks.
7.  The most common symptoms were fatigue, cough, and headache.
8.  The NICE guidance covers the care of people who have signs and symptoms that develop during or after an infection consistent with COVID-19, that continue for more than 4 weeks, and are not explained by an alternative diagnosis. It provides recommendations based on current evidence and expert consensus.
9.  The guideline makes recommendations in a number of other key areas, including: Assessing people with new or ongoing symptoms after acute COVID-19; Investigations and referral; Planning care; Management, including self-management, supported self-management, and rehabilitation; Follow-up and monitoring; Service organisation

To develop the recommendations, we have used the following clinical definitions for the initial illness and long COVID at different times:

• Acute COVID-19: signs and symptoms of COVID-19 for up to 4 weeks.
• Ongoing symptomatic COVID-19: signs and symptoms of COVID-19 from 4 to 12 weeks.
• Post-COVID-19 syndrome: signs and symptoms that develop during or after an infection consistent with COVID-19, continue for more than 12 weeks and are not explained by an alternative diagnosis.

Common symptoms of ongoing symptomatic COVID-19 and post-COVID-19 syndrome

Symptoms after acute COVID-19 are highly variable and wide ranging. The most commonly reported symptoms include (but are not limited to) the following.

Respiratory symptoms

• Breathlessness
• Cough

Cardiovascular symptoms

• Chest tightness
• Chest pain
• Palpitations

Generalised symptoms

• Fatigue
• Fever
• Pain

Neurological symptoms

• Cognitive impairment (‘brain fog’, loss of concentration or memory issues)
• Headache
• Sleep disturbance
• Peripheral neuropathy symptoms (pins and needles and numbness)
• Dizziness
• Delirium (in older populations)

Gastrointestinal symptoms

• Abdominal pain
• Nausea
• Diarrhoea
• Anorexia and reduced appetite (in older populations)

Musculoskeletal symptoms

• Joint pain
• Muscle pain

Psychological/psychiatric symptoms

• Symptoms of depression
• Symptoms of anxiety

Ear, nose and throat symptoms

• Tinnitus
• Earache
• Sore throat
• Dizziness
• Loss of taste and/or smell

Dermatological

• Skin rashes

Investigations and referral

These recommendations are for healthcare professionals carrying out initial investigations in primary care or community services for people with new or ongoing symptoms 4 weeks or more after the start of suspected or confirmed acute COVID-19.

Refer people with ongoing symptomatic COVID-19 or suspected post-COVID-19 syndrome urgently to the relevant acute services if they have signs or symptoms that could be caused by an acute or life‑threatening complication, including (but not limited to):

• Severe hypoxaemia or oxygen desaturation on exercise
• Signs of severe lung disease
• Cardiac chest pain
• Multi system inflammatory syndrome (in children).

Offer tests and investigations tailored to people’s signs and symptoms to rule out acute or life‑threatening complications and find out if symptoms are likely to be caused by ongoing symptomatic COVID‑19, post‑COVID‑19 syndrome or could be a new, unrelated diagnosis.

If another diagnosis unrelated to COVID-19 is suspected, offer investigations and referral in line with relevant national or local guidance.

Offer blood tests, which may include a full blood count, kidney and liver function tests, C‑reactive protein test, ferritin, B‑type natriuretic peptide (BNP) and thyroid function tests.

If appropriate, offer an exercise tolerance test suited to the person’s ability (for example the 1‑minute sit‑to‑stand test). During the exercise test, record level of breathlessness, heart rate and oxygen saturation. Follow an appropriate protocol to carry out the test safely (see the rationale section on investigations and referral  for suggested protocols). For advice on sharing skills between services to help community services manage these assessments, see the recommendation on sharing skills and training in the section on service organisation.

For people with postural symptoms, for example palpitations or dizziness on standing, carry out lying and standing blood pressure and heart rate recordings (3‑minute active stand test, or 10 minutes if you suspect postural tachycardia syndrome, or other forms of autonomic dysfunction).

Offer a chest X-ray by 12 weeks after acute COVID-19 if the person has not already had one and they have continuing respiratory symptoms. Chest X-ray appearances alone should not determine the need for referral for further care. Be aware that a plain chest X-ray may not be sufficient to rule out lung disease.

Refer people with ongoing symptomatic COVID-19 or suspected post‑COVID‑19 syndrome urgently for psychiatric assessment if they have severe psychiatric symptoms or are at risk of self‑harm or suicide.

Follow relevant national or local guidelines on referral for people who have anxiety and mood disorders or other psychiatric symptoms. Consider referral:

• for psychological therapies if they have common mental health symptoms, such as symptoms of mild anxiety and mild depression or
• to a liaison psychiatry service if they have more complex needs (especially if they have a complex physical and mental health presentation).

3.10After ruling out acute or life-threatening complications and alternative diagnoses, consider referring people to an integrated multidisciplinary assessment service (if available) any time from 4 weeks after the start of acute COVID‑19.

Do not exclude people from referral to a multidisciplinary assessment service or for further investigations or specialist input based on the absence of a positive SARS‑CoV‑2 test (PCR, antigen or antibody).

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