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\title{Post-COVID Syndrome in Healthcare Workers}



\author[1]{MERVE KAPLAN}%
\author[2]{Aysegul Akkol Camurcu}%
\author[3]{Serpil  Erol}%
\affil[1]{İstanbul Haydarpaşa Numune Eğitim ve Araştırma Hastanesi}%
\affil[2]{Istanbul Haydarpasa Numune Egitim ve Arastirma Hastanesi}%
\affil[3]{Department of Infectious Diseases and Clinical Microbiology, Health Sciences University, Haydarpasa Numune Training and Research Hospital}%


\vspace{-1em}



  
  \date{June 05, 2024}


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\selectlanguage{english}
\begin{abstract}
AIM: Some of the patients with COVID-19 disease have persistent symptoms
and there is limited information about the long-term health consequences
of those who have recovered. The aim of this study is to investigate
persistent symptoms of health care workers after COVID-19 disease and
the relationship with demographic and clinical characteristics of the
patients. METHOD: Healthcare workers who had symptomatic COVID-19
disease proven by RT-PCR and were diagnosed at least 12 weeks ago were
included in the study. Demographic characteristics, comorbidities,
symptoms at time of diagnosis and symptoms that persisted more than 3
weeks were examined in detail with a conducted questionnaire. RESULTS:
Of 121 patients included in the study, the mean age was 33.5 (22-59) and
the mean time since participants were diagnosed with COVID-19 disease
was 30.3 weeks (12.7-56.9). 92\% (n=112) of the participants were
followed up as outpatients. 63.6\% (n=77) of our patients had symptoms
lasting more than 3 weeks and the most common symptom were fatigue ,
loss of smell and attention deficit/concentration disorder. 19 of 77
patients (24.6\%) stated that their persistent symptoms lasted longer
than 24 weeks, with the most common symptoms being loss of smell.
CONCLUSION: All these findings show that even in young patients with
mild and moderate COVID-19 infection, post-COVID symptoms are at a rate
that will affect their quality of life and health services should be
planned for the rehabilitation of these patients. WHAT'S KNOWN? The
initial symptoms and clinical course of COVID-19 are well known, but
information about the long-term follow-up post-COV\selectlanguage{polish}İ\selectlanguage{english}D symptoms,
especially in mild and moderate patients, is limited. WHAT'S NEW? Our
study contributes to the literature on the frequency of long-term
symptoms at 3 months and 6 months in most young patients with mild
COVID-19.It also provides data on the situation of post-COVID syndrome
in Turkey.%
\end{abstract}%



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\textbf{POST-COVID SYNDROME IN HEALTHCARE WORKERS}

1-INTRODUCTION

COVID-19 disease which is caused by severe acute respiratory syndrome
coronovirus-2 (SARS-CoV2) and resulted in pandemic, is a disease that
can present in different clinical spectrums from asymptomatic infection
to critical illness and death. According to the World Health
Organization data stated in June 2021, COVID-19 disease has caused over
181 million recorded cases and over 3 million deaths worldwide (1).
Aside from severe cases that result in death, the vast majority of those
infected recover from the disease. Number of studies have reported that
some of the patients with COVID-19 disease have persistent symptoms.
This condition is named as ''Post-COVID Syndrome'', ''Long COVID'' or
''Long Haul Syndrome''.

WHO reported that the recovery time is approximately 2 weeks for mild
cases, and 3 to 6 weeks for patients with severe or critical illness
(2). However, it was later revealed that symptoms persisted for weeks or
even months in some patients who were not severely or critically ill.
The term ''Long COVID'' was first used in the Lombardy region of Italy
by Dr. Elisa Perego in line with the information obtained from the
follow-up of her patients. Later on, thousands of people around the
world who were unable to do their daily activities due to persistent
symptoms raised awareness of the symptoms of Long-COVID on social media
using the hashtag \#Long-COVID (3).

There is no consensus of the definition of post-COVID syndrome yet.
Greenhalgh et al. defined in their study that the symptoms persist
between 3 weeks and 12 weeks as post-acute COVID and symptoms that last
longer than 12 weeks as post-COVID syndrome (4). In various studies,
different durations of persistent symptoms have been evaluated (5-8).

Although the initial symptoms and clinical course of COVID-19 are well
known, there is limited information about the long-term health
consequences of those who have recovered. Because of the new cases that
still emerging around the world, it is important to understand the
long-term effects of COVID-19, risk factors and predictors of persistent
symptoms in order to eliminate those effects and plan health services.

There are many possible mechanisms that contribute to the
pathophysiology of prolonged symptoms. Sequelae due to organ damage,
different duration required for recovery of each organ system, chronic
inflammation or immune response/autoantibody production, rare
persistence of the virus in the body, effects of hospitalization and
critical illness, post intensive care syndrome, complications due to
coronavirus infection, comorbidities and drugs, psychological and social
issues such as post-traumatic stress disorder are among the reasons that
play a role in the development of prolonged symptoms(9).

The aim of this study is to investigate persistent symptoms of health
care workers after COVID-19 disease with a questionnaire and the
relationship of the persistent symptoms with demographic and clinical
characteristics of the patients.

2-METHOD

A questionnaire was conducted to determine post-COVID symptoms of health
workers at our hospital who were diagnosed with COVID-19 disease.

In order to evaluate the long-term effects of the COVID-19 disease,
healthcare workers who had symptomatic disease proven by RT-PCR and were
diagnosed at least 12 weeks ago were included in the study.

Demographic characteristics (age, sex, body mass index (BMI),
occupation), comorbidities, symptoms at time of diagnosis and symptoms
that persisted more than 3 weeks were examined in detail with the
questionnaire. Post-COVID symptoms and their relations with the
demographic characteristics were analyzed.

In addition, the effects of COVID-19 disease on participants' quality of
life were investigated by evaluating the EuroQoL five-dimension
five-level (EQ-5D-5L) questionnaire and the EuroQoL visual analog scale
(EQ-VAS) filled by the participants themselves.

The data of our study was analyzed with IBM SPSS Statistics 23 (IBM
SPSS, Turkey). Descriptive statistics stated as frequency, mean,
standard deviation, minimum and maximum values. Categorical variables
were analyzed with Chi-square test. Risk factors of symptoms that last
more than 3 weeks were determined with logistic regression analyze.
Statistical significance was determined as p values below 5\%.

3-RESULTS

Of the 121 patients included in the study, 39 (32.2\%) were male and 82
(62.8\%) were female. The mean age was 33.5 (22-59, SD=8.23). There were
82 people (67.8\%) between the ages of 18-34, 31 people (25.6\%) between
the ages of 35-49, and 8 people (6.6\%) over the age of 50. When the
chronic diseases of the participants were questioned, 80 (66.1\%) had no
disease, while 41 (33.9\%) had a known chronic disease. Nine (7.4\%) of
the participants were hospitalized and 112 (92.6\%) were followed up as
outpatients (Table 1).

When the symptoms of the patients at the time of diagnosis were
questioned, the most common symptoms were fatigue (n=95, 78.5\%), joint
pain (n=77, 63.6\%), headache (n=72, 59.5\%), loss of smell (n=60,
49.6\%), loss of taste (n=57, 47.1\%), sore throat (n=53, 43.8\%), cough
(n=52, 43\%), fever (n=44, 36.4\%) (Table 2).

The mean time since participants were diagnosed with COVID-19 infection
was 30.3 weeks (12.7-56.9, SD=12.6 weeks). Patients were asked whether
they had symptoms lasting longer than 3 weeks. 77 (63.6\%) had symptoms
lasting more than 3 weeks after COVID-19 infection. Fatigue (n=40,
33\%), loss of smell (n=27, 22.3\%), attention deficit/concentration
disorder (n=25, 20.7\%), dyspnea (n=24, 19.8\%), myalgia (n=24, 19.8\%),
loss of taste (n=23, 19\%), cough (n=19, 15.7\%), joint pain (n=18,
14.9\%), sleep disturbance (n=14, 11.6\%), memory difficulties (n=13,
10.7\%) were the most common symptoms (Figure 1 \& Figure 2).

When patients with dyspnea for more than three weeks (n=24) rated their
dyspnea, 1 (4.2\%) had dyspnea at rest, 2 (8.3\%) had dyspnea while
dressing, and 20 (83.3\%) had dyspnea on stairs. When the participants
(n=40) who complained of fatigue for more than three weeks rated their
fatigue complaints, 29 (72.5\%) said they could carry out their daily
work, 5 (12.5\%) spent less than 50\% of the day in bed, 3 (7.5\%)
stated that they spent more than 50\% in bed. No participant stated that
they were totally confined to bed (WHO performance score) (10).

Participants were asked about the duration of their persistent symptoms.
Thirty-eight (31.4\%) of 121 participants had symptoms lasting longer
than 12 weeks. The most common symptoms lasting longer than 12 weeks are
loss of smell (n=16, 13.2\%), loss of taste (n=111, 9.1\%), fatigue
(n=10, 8.6\%), attention deficit and concentration disorder (n=9,
7.4\%), dyspnea (n=8, 6.6\%), sleep disturbance (n=7, 5.7\%), cough
(n=5, 4.1\%), chest pain (n=4, 3.3\%), memory difficulties (n=4, 3.3\%),
headache (n=3, 2.4\%), myalgia (n=3, 2.4\%), joint pain (n=1, 0.8\%),
sputum (n=1, 0.8\%), constipation (n=1, 0.8\%), back pain (n=1, 0.8\%).

At the time of the survey, 77 of the 121 participants were diagnosed
with COVID-19 before more than 24 weeks. There were 19 participants
(24.6\%, 19/77) who stated that their persistent symptoms lasted longer
than 24 weeks. The most common symptoms lasting more than 24 weeks are
respectively loss of smell (n=9, 11.6\%), loss of taste (n=5, 6.4\%),
dyspnea (n=5, 6.4\%), headache (n=3, 3.8\%), fatigue (n=2, 2.5\%), cough
(n=2, 2.5\%), attention deficit and concentration disorder (n=2, 2.5\%),
memory difficulties (n=1, 1.2\%), sleep disorder (n=1, 1.2\%), back pain
(n=1, 1.2\%) (Figure 3).

Fifty-seven (69\%) of the women and 20 (51.3\%) of the men had symptoms
lasting longer than 3 weeks. There was no statistically significant
difference between women and men (p=0.051). There was no statistically
significant correlation between age distribution, BMI and occupational
group, and symptoms lasting longer than 3 weeks (p\textgreater{}0.05).

Sixteen (55.2\%) smokers and 61 non-smokers (66.3\%) had complaints that
lasted longer than 3 weeks. No statistically significant correlation was
found between smoking and persistent complaints (p=0.277).

Forty-nine (61.3\%) of the participants without any chronic disease and
28 (68.3\%) of the participants with a known chronic disease had
symptoms lasting more than 3 weeks. There was no statistical difference
between those with and without chronic disease (p=0.446).

Because of the low number of hospitalized patients (n=7), statistical
difference of presence of persistent symptoms between hospitalized and
outpatients could not be evaluated.

When the relationship between the symptoms in the initial period of
COVID-19 infection and post-COVID syndrome was examined; the presence of
complaints of dyspnea (p=0.028, r=6.514 (confidence interval:
1.22-34.729)) and fatigue (p=0.010, r:4.313 (confidence interval:
1.411-13.181)) at baseline was associated with the occurrence of
complaints lasting more than 3 weeks. There was no significant
relationship between the presence of other complaints and the presence
of complaints lasting longer than three weeks.

When the EQ-5D-5L quality of life scale data was analyzed, 40 (33.1\%)
of the participants had worse health status than before (at least 1
dimension of deterioration and none of them improved), 72 (59.1\%)
identified their health status as the same before COVID-19 infection.
The Q-VAS score decreased from 83.116 (10-100, SD=15.78) to 80.438
(25-100, SD=15.36) after COVID-19 infection. The mean change was 2.68
(SD=6.51). In studies, the smallest decrease in the Q-VAS score that
constitutes clinical significance in respiratory diseases was determined
to be above 7 points (11). The number of people who had a decrease of
more than 7 points in the Q-VAS score of the participants was 19
(15.7\%) (Table 3).

4-DISCUSSION

This is the first clinical study to our knowledge conducted in Turkey on
post-COVID syndrome. In our study, 77 (63.6\%) of the participants were
found to have symptoms lasting longer than 3 weeks, after COVID-19
infection. In the study of Tenforde et al., 65\% of the patients stated
that they could not return to their normal health on the 14-21st day of
the disease (6). In another study, at least 1 symptom was found in 68\%
and 66\% of patients on the 30th and 60th days, respectively (7). In
both studies, patients with mild to moderate disease were evaluated
similar to our study. These results reveal that prolonged symptoms are
also seen at high rates in patients with mild COVID-19 disease. However,
in another study, it was revealed that these rates increased to 87\% in
patients with a more serious clinical picture (12).

Fatigue (63.6\%), loss of smell (22.3\%), attention
deficit/concentration disorder (20.7\%), and dyspnea (19.8\%) were the
most common persistent symptoms in our study. In many studies, the most
common persistent symptom in mild and severe disease was fatigue (5,
12-15). In our study, it was noteworthy that complaints such as
attention deficit/concentration disorder (\%20.7), sleep disorder
(\%11.6) and memory difficulties (\%10.7) were among the common
prolonged symptoms.

While it was observed that in 31\% of the participants, symptoms lasted
longer than 12 weeks, it was found that the symptoms lasted longer than
24 weeks in 24\% of the 77 participants who were at least 24 weeks after
the diagnosis of COVID-19. In the study of Perez et al., post-COVID
symptoms were detected in 50.9\% of the patients on day 77. In this
study, when the frequency of post-COVID symptoms was evaluated
separately according to severity of the disease, it was reported as 36\%
in patients with mild pneumonia and 58\% in patients with severe
pneumonia (8). According to another study, 80.4\% of the hospitalized
patients had ongoing symptoms at the 7th month of follow-up (16). In
another study, 58\% of the patients evaluated on an average of 217 days
after discharge had at least one ongoing symptom (17). In the study of
Huang et al., 76\% of the patients had ongoing symptoms on the 186th day
(18). Our study contributes to the literature about the frequency of
symptoms lasting longer than 6 months in the long-term follow-up of
outpatients.

Fatigue and dyspnea were the most common symptoms lasting longer than 12
weeks in the hospitalized patient studies, in our study; the most common
symptoms lasting longer than 12 weeks were loss of smell (13\%), loss of
taste (9\%), fatigue (8\%), attention deficit and concentration disorder
(7\%) (8, 19). When the symptoms lasting longer than 24 weeks were
evaluated in our study, the most common symptoms were loss of smell
(11\%) and loss of taste (6\%). In the study of Vanichkachorn et al.,
the most common symptoms at 6 months were fatigue (80\%) and shortness
of breath (49\%) (20). In a study in which patients followed for 30-300
days (mean 169 days) were evaluated, loss of smell and taste was
reported at a rate of 13.6\%, similar to our study. However, fatigue
(13.6\%) was reported higher in this study than in our study (2.5\%)
(21).

We could not find a significant correlation between gender, age, BMI,
the presence of comorbidities and the presence of post-COVID symptoms.
This may be related to the fact that the participants were young
patients, did not have severe comorbidities, and the majority (92\%)
consisted of mild outpatients. In a study similar to our study no
significant correlation was found between the clinical characteristics
of the patients, gender, age, comorbidities, severity of acute
infection, intensive care unit (ICU) stay and length of stay in the
hospital or ICU, and post-COVID symptoms (8). In another multicenter
study, it was reported that there was a significant relationship between
female gender, length of hospital stays, number of comorbidities, and
number of acute COVID-19 symptoms and post-COVID symptoms (16). These
different results obtained from various studies reveal that there is a
need for more comprehensive studies with larger series on this subject.

When we examined the relationship between post-COVID symptoms and
smoking, 55\% of smokers and 66\% of non-smokers had complaints that
lasted longer than 3 weeks. There was no statistically significant
relationship between smoking and persistent complaints. When we reviewed
the literature, no other study was found that examined the relationship
between smoking and post-COVID syndrome.

In our study, it was determined that the complaints of dyspnea and
fatigue in the initial period of COVID-19 infection were associated with
persistent symptoms. In one study, it was determined that the number of
symptoms in the first week of the disease constitutes a risk factor for
post-COVID syndrome (22).

In our study, 72\% of the patients with fatigue lasting longer than 3
weeks stated that they were able to carry out their daily activities,
while 83\% of the patients who described dyspnea defined it as dyspnea
that increased with climbing stairs. In studies conducted with severe
disease, it was found that complaints of fatigue and shortness of breath
prevented patients from performing their daily work (5, 19). When
outpatients were evaluated in our study, it was found that although
these complaints were among the most common persistent symptoms, they
did not prevent the patients from doing their daily activities.

While 33\% of our participants defined their health status as worse than
before according to the EQ-5D-5L scale, it was determined that 15\% had
a decrease of 7 points or more in their EQ-VAS score (11). It has been
reported in some studies that the quality of life of patients with
severe COVID-19 disease was affected by COVID-19 infection, and a
decrease in the Q-VAS score to a clinical significance was observed (5,
19). The results of our study showed that the quality of life was
significantly affected in patients with mild to moderate COVID-19
disease.

There are some limitations of our study; it was carried out in a single
center and the sample size was relatively small, most of the patients
were outpatients and because of that our cohort was not reflect all
COVID-19 patients.

In conclusion, all these findings show that even in young patients with
mild and moderate COVID-19 infection, long-term post-COVID symptoms are
at a rate that will affect their quality of life and health services
should be planned for the rehabilitation of these patients.

\textbf{Hosted file}

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\textbf{Hosted file}

\verb`Tables_Post-COVID Syndrome in Healthcare Workers.docx`  available at \url{https://authorea.com/users/733422/articles/711122-post-covid-syndrome-in-healthcare-workers}

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