Could ‘long Covid’ become the biggest return-to-work challenge yet for OH?

Covid-19 is not just a discussion about those who recover from the virus and those, sadly, who do not. A significant minority of patients are reporting often debilitating symptoms for weeks, even months, after having notionally ‘recovered’. For occupational health practitioners, the worry is what this ‘long Covid’ will mean for many in terms of returning to work post virus, and whether hard-pressed employers will be up to the challenge. Nic Paton reports.

“6.5 months of #LongCovid and struck by the realisation that I have no formal diagnosis, no treatment and no prognosis. Still off work.”

So said “Secretlonghauler” in September, one of a growing number of people on social media, notably Twitter, sharing their stories of chronic and often debilitating symptoms months after having notionally ‘recovered’ from Covid-19, symptoms that increasingly are being bundled together under the umbrella term “long Covid”.

Because Covid-19 is such a new disease, our knowledge and understanding of it is still very much evolving. Yet how worried should occupational health practitioners be about long Covid? After all, this appears to a condition (or combination of conditions) that often follows a relatively mild bout of the disease itself.

It also often appears – but again the emphasis is on “appears” – to be something that more commonly affects younger people or those of working age. Yet it can result in individuals being off work – even sometimes completely incapacitated – for weeks or even months on end.

A recent article in the BMJ suggested what it termed “post-acute covid-19” appears to be a multisystem disease that sometimes occurs in those who have had Covid-19 that was either managed within the community or on a standard hospital ward.

Its symptoms can vary widely but appear (again, emphasis on “appear”) to include regular relapsing over long periods of the cough, fever and fatigue associated with the virus itself.

“Other reported symptoms include shortness of breath, chest pain, headaches, neurocognitive difficulties, muscle pains and weakness, gastrointestinal upset, rashes, metabolic disruption (such as poor control of diabetes), thromboembolic conditions, and depression and other mental health conditions,” the BMJ said. It also highlighted the possibility of ongoing skin rashes and lesions, or what is sometimes now being referred to as “Covid toe”.

Around 10% of patients who had tested positive for the SARS-CoV-2 virus remained unwell beyond three weeks, with a smaller proportion for months, the BMJ added, from data based on the UK Covid Symptom Study. However, it also highlighted a recent US study which had found that only 65% of people had returned to their previous level of health 14-21 days after a positive test.

Others within the medical profession, notably Professor Devi Sridhar, professor and chair of global public health at Edinburgh University, have been pushing hard for the conversation around Covid-19 ‘outcomes’ to be shifted from the somewhat binary focus, if understandable in the midst of a public health emergency, on either deaths or ‘recovery’.

As she put it on Twitter back in the summer: “Emerging story of COVID is not only the deaths but the morbidity in healthy, young people, called ‘long-haulers’. Not just about dying but what it means to suffer for months with post-COVID complications. This is a new virus & doctors learning how to best care for COVID patients.”

Occupational Health & Wellbeing asked OH practitioners for their thoughts on this condition, and the return-to-work ramifications this potentially chronic side-effect of Covid-19 may pose.

Risk of rising ill health retirements

“In my opinion, ‘long Covid’ is going to be a challenge in so much as we can only advise on symptoms and thus accommodations as they are presented to us,” said Diane Romano-Woodward, president of the Faculty of Occupational Health Nursing.

“As it is a new disease we don’t know how long the symptoms will last, so it will be a challenge to advise on the application of the Equality Act. That is unless there is an obvious long-term issue like heart damage, which is not going to go away.

“I also anticipate that, with the reductions in posts and redundancies, most employers won’t have a lot of capacity to provide alternative duties or redeployment. So we may see more ill health retirement applications and, for all those with long-term impairments of whatever cause, dismissal on grounds of capability,” Romano-Woodward added, somewhat pessimistically.

“Many of our clients (SMEs) may well struggle to wait for employees to have the opportunity for treatment in order to plan a return, and financially the situation is damaging for both the employee and the employer,” agreed OH specialist practitioner Lesley Clarke.

“I think it is going to push a lot of businesses to terminate on the grounds of ill health when, in a more stable financial state, they may have waited those extra few months to gauge recovery extent and likelihood of return to work of their employee.

“I also have concerns that, where employers would previously have been open to suggestions for adjustments/restrictions to enable an individual to stay in a role whether this is on a permanent basis or temporarily while the health situation is improved upon, a lot of this goodwill (and patience) might not be so forthcoming any more.

“This could well then leave an individual feeling undervalued that their company can’t – or won’t – accommodate them and us in OH, I imagine, will find the situation very frustrating. Our ability to support the employee to remain or return to work in a supportive/successful manner might have much more limited options in terms of ‘negotiating’ to achieve good outcomes for all parties,” Clarke added.

‘Awful’ long-term health effects

Other practitioners pointed to the “awful” long-term side effects they were seeing becoming apparent, including fatigue, reduced cognitive function, and muscle wasting. Some employees were reporting having difficulty being seen, or listened to, within primary care. Another concern was the effect such long-term debilitation could have in terms of a heightened risk of depression, mental ill health or even suicide.

“I was discussing this the other day with a colleague,” conceded OH and wellbeing manager Kate Kyne. “The biggest issue we currently face is HR and managers are referring and expecting more detailed information about the longer term fitness/capabilities. However, not having the crystal ball or magic wand, we can’t give them the answers they want.”

“I do feel for those unfortunate to be experiencing the effects of Covid, as it does appear to have multiple and complex health effects that will be difficult to come to terms with,” said OH practitioner Lorraine Leckie.

Echoing both Lesley Clarke and Diane Romano-Woodward, she added: “Personally, I think there will be an increase in ill health retirements for the severely affected. Those less severely affected but unable to remain/return to work for whatever reason will be ‘let go’ and left to claim benefits until they are well enough to find employment that fits with their abilities.”

Lack of access to care or support

Even when, to use Professor Sridhar’s term, Covid “long-haulers” do make it back into work, the current infection control restrictions in place in most workplaces may make it hard for OH to provide them with the support they need, worry other OH practitioners.

One practitioner pointed out to Occupational Health & Wellbeing that she was already coming across cases where employers were becoming frustrated about the fact employees were not getting ‘better’ after being off for coronavirus, and where managers were becoming impatient about when workers might be able to come back. “When these individuals do come back, it is going to be harder to support them due to social distancing and new safe working practices – short shifts, for example, are harder for managers to accommodate. They also won’t be able to get physical assistance from colleagues as easily as would have happened in the past,” she added.

However “long Covid” evolves, there does therefore appear to be a consensus, and a growing worry among OH practitioners, about the long-term workplace health ramifications of this condition. After all, if the 10% estimate is accurate, we could be talking about many thousands of people of working age being affected with some level of medium- to long-term fallout in terms of health or functional capacity from the virus.

In particular, it is the concern that, with many organisations under severe financial and operational pressure because of Covid-19, the wherewithal – and, indeed, the goodwill – of many employers to provide the sort of ongoing support, care and adjustment that Covid-19 long-haulers will need may be in much shorter supply than in more ‘normal’ times.

Just as worrying, occupational health practitioners – themselves under intense workload pressure as well as operationally restricted by Covid-19 in what they can deliver – may also be limited in their capacity or ability to provide the support these employees need. And the worry from here is what happens next, whether it will mean such employees are ‘encouraged’ to take ill health retirement, leave the workforce of their own volition, or are simply let go.

Finally, let’s also not forget the many millions of workers out there who do not have access to occupational health anyway, and so may end up reliant on hard-pressed (and potentially sceptical or dismissive) primary care professionals.

As OH nurse Jacinta Morassi highlighted to Occupational Health & Wellbeing: “I have had a few cases recently of employees who are customer-facing who were diagnosed with Covid in March and are still off sick with long-lasting problems such as extreme fatigue, numbness, tingling, kidney function issues, breathing problems and so on.

“These people were not hospitalised and therefore have had very little support, with GPs at a loss of how to treat them as, essentially, all test results are ‘normal’. There is definitely a lack of continuing support and it’s now massively affecting people’s mental health,” she added.

“For those who had Covid and were admitted to ICU or hospital they have had a medical review. But for those who stayed at home and were, perhaps, never formally diagnosed, some have only had a telephone review,” agreed OH nurse manager Jean Piernicki.

“No one has examined them, listened to their lungs and so on. Now, months down the line they remain unwell and in some cases neglected by their GP. Some are suicidal, think they are losing the plot. What do employees who do not have the benefit of access to OH do?” Piernicki added.

PHE ‘long Covid’ guidance and new NHS support

Growing recognition that long Covid does potentially pose a serious, long-term health challenge came in October when NHS chief executive Sir Simon Stevens pledged £10m for the setting up of specialist clinics for long Covid sufferers that are able to carry out physical, cognitive and psychological assessments.

Public Health England in September also published guidance around the long-term health effects of Covid-19. In line with the BMJ study, it highlighted that approximately 10% of those with mild coronavirus and who were not admitted to hospital have reported symptoms lasting more than four weeks. A number of hospitalised cases reported continuing symptoms for eight or more weeks following discharge, it added.

According to the guidance, persistent health problems reported following acute Covid-19 have included:

• respiratory symptoms and conditions such as chronic cough, shortness of breath, lung inflammation and fibrosis, and pulmonary vascular disease;
• cardiovascular symptoms and disease such as chest tightness, acute myocarditis and heart failure;
• protracted loss or change of smell and taste;
• mental health problems including depression, anxiety and cognitive difficulties;
• inflammatory disorders such as myalgia, multisystem inflammatory syndrome, Guillain-Barre syndrome, or neuralgic amyotrophy;
• gastrointestinal disturbance with diarrhoea;
• continuing headaches;
• fatigue, weakness and sleeplessness;
• liver and kidney dysfunction;
• clotting disorders and thrombosis;
• lymphadenopathy; and
• skin rashes.

PHE emphasised research to evaluate the long-term health and psychosocial effects of Covid-19 is continuing. Major studies include the Post-Hospitalisation Covid-19 study in the UK and the International Severe Acute Respiratory and Emerging Infection Consortium (ISARIC) global Covid-19 long-term follow-up study.

PHE has recommended that patients struggling to recover from Covid-19 infection should speak to their GP “about local care pathways for support and assessment of any long-term symptoms or health problems”.

It highlighted that healthcare providers can also refer patients to its online ‘Your Covid Recovery’ programme. This was launched back in July and is aiming to support people with long-term breathing or mental health issues that had developed as a result of contracting the virus.

The PHE guidance largely tallies with more anecdotal findings from Professor Tim Spector, professor of genetic epidemiology at King’s College London, who is running the Covid Symptom Study app.

He argued in September that thousands people in the UK could be suffering from long Covid, with some 300,000 people having reported symptoms lasting longer than a month, and up to 60,000 people for more than three months.

Professor Spector warned there was a “big danger” that those with such long-term symptoms “might end up being forgotten”.

Support groups set up

As well as government and medical research and resources, there are community-based support groups that have been set up and which may be a valuable resource for OH to signpost to, both for employers and employees.

For example, the long Covid support group includes a range of personal stories, resources and awareness-raising tools. Its website can be found at https://www.longcovid.org/

Equally, a “long Covid ‘SOS’” campaign group has been set up to raise awareness of the condition among the general public and with employers. It is also working to put pressure on the government to do more to recognise the needs of those suffering long-term after-effects from the virus.

It has called for a working group to be set up to address the needs of all long-term Covid-19 sufferers and for more research to be carried out as a matter of urgency.

It has argued that healthcare providers need to be better educated and “empowered” to treat patients with the condition properly and for multi-disciplinary clinics to be set up to properly assess, test, diagnose and care for long Covid patients.

It has also said there needs to be a focus on the economic implications of long Covid, including the provision of long-term sick leave, financial support and take steps to ensure employers are made fully aware of the condition. Its website can be found at: https://www.longcovidsos.org/

Finally, social media is also active around long Covid. There is a Facebook support group, which can be found at https://www.facebook.com/groups/longcovid/ and on Twitter the hashtag #LongCovid will take you to many of those who are tweeting about their experiences with the condition.

References
Secretlonghauler, Twitter, September 28, 2020, https://twitter.com/Secretlonghaul1/status/1310514023671177221
Professor Devi Sridhar (https://twitter.com/devisridhar), July 09, 2020, https://twitter.com/devisridhar/status/1281273415694004224?lang=en
Management of post-acute covid-19 in primary care, BMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m3026 (Published 11 August 2020)
Covid-19: long-term health effects, Public Health England, September 2020, https://www.gov.uk/government/publications/covid-19-long-term-health-effects/covid-19-long-term-health-effects
Post-Hospitalisation Covid-19 study, https://www.phosp.org/
International Severe Acute Respiratory and Emerging Infection Consortium global Covid-19 long-term follow-up study, https://isaric.tghn.org/CCP/isaric-global-covid-19-long-term-follow-study/
UK Covid Symptom Study, https://covid.joinzoe.com/
Your Covid Recovery, https://www.yourcovidrecovery.nhs.uk/your-road-to-recovery/what-next/
Long Covid support group, https://www.longcovid.org/
Long Covid SOS, https://www.longcovidsos.org/
Facebook Long Covid support group https://www.facebook.com/groups/longcovid/
“Thousands still have Covid-19 complications months later”, Occupational Health & Wellbeing, September 2020, https://www.personneltoday.com/?p=257742
“NHS to launch coronavirus recovery support service”, Occupational Health & Wellbeing, July 2020, https://www.personneltoday.com/hr/on-demand-coronavirus-recovery-support-service-to-be-launched/