Policy makers, employers and occupational health and safety professionals need to prepare for the health impacts of long covid, which is affecting up to 1 in 10 people who have had Covid-19, is limiting employees’ ability to work and increasing absences.
Long covid, or post-Covid 19 condition as it was recently named by the World Health Organisation (WHO), has already affected more than half a million people in Britain. According to a report in The Economist, the vast majority are in their working age prime.
Symptoms can include fatigue, restlessness and ‘brain fog’ for up to six months after the initial Covid-19 infection. Symptoms can last up to a year or more. Research shows that one in five of those affected are unable to do even a part-time or a desk-based job. As of yet, long covid has no definitive cure, although a multi-disciplinary medical approach is recommended to treat this disease.
The response by the HSE is currently focused on the need for further research and guidance. It acknowledges this is a new disease and there is a lot of uncertainty about the scale of it in Ireland, as new information is emerging daily. Speaking at a HSE press briefing on May 13th, Dr Colm Henry, chief clinical officer, said that 10% of cases have symptoms longer than 10 weeks, and another 10-15% have symptoms longer than this again.
Expanding on the model of care proposed by the HSE to treat the condition, Dr. Henry explained it would be “largely community-based in supporting general practice and supporting people to manage their own symptoms and then setting up a limited number of specialist pathways for those people who require specialist services”.
Diagnosis and Treatment
When recently by HSR asked about methods of diagnosis, Dr. Martin Hogan, managing director of Corporate Health Ireland and former Dean of the Faculty of Occupational Medicine, explained the challenge is there is no one test which can diagnose it. “What is most important is getting a full medical history of the individual, including symptoms, age profile, occupation and previous Covid-19 infections.
Professor John Gallagher, chief medical officer of Cognate Health, former Dean of the Faculty of Occupational Medicine and a specialist in occupational medicine with the Health Services Executive (HSE), also recommends that anyone who has symptoms should attend their general practitioner (GP) initially. “The GP can organise baseline examinations, including chest x-rays or an ECG if needed. Referrals for respiratory, cardiology or neurological services can also be made”.
“In most cases people will get better of their own accord with rest, graded exercise and the passage of time”, advises Professor Gallagher. Unfortunately for others it may be more difficult. “You cannot say definitively when or how long it will take to get better”, cautions Dr. Hogan.
Long Covid Myths
Speaking about some of the common misperceptions related to the condition, Professor Gallagher explained it is not known why some people develop the condition and others do not. “Long covid can develop even if you had mild symptoms of Covid-19”, he clarified.
Elaborating on this point, Dr Hogan said that “in some cases it can be linked to the severity of the initial infection” and he discussed the higher viral load to which many healthcare workers were initially exposed, due to shortages or incorrect personal protective equipment at the start of the pandemic.
One myth which was discounted by Dr. Nisreen Alwan at a recent WHO webinar was that only women suffer from the disease. According to the UK Office for National Statistics, it is most common in working age adults, including men and women, but more women tended to develop it. This may be due to their predominance in roles such the healthcare professions and social care which have carried the greatest burden of the disease so far.
Another misperception is that depression and anxiety are common symptoms of the condition. But according to The Economist, many sufferers’ mental health is impacted because they are bounced from one specialist to another in search of a diagnosis, or struggle to have their symptoms acknowledged by their employer. Dr. Hogan recommends that employers should believe their employees and Professor Gallagher suggests that individuals should be made aware of any Employee Assistance Programme (EAP) e.g., counselling services, to support them.
For many workers suffering with the symptom of chronic fatigue, there is a real and legitimate fear of not being believed by their employer. When asked about this by HSR, Dr. Hogan explained: “This is a real condition which is poorly understood and the frequency of it is something we haven’t seen before”.
Irish nurses with lived experience of the condition, speaking at a recent Irish Nurses and Midwifes Organisation (INMO) conference confirmed some of these fears, as well as the concern they were being rushed back to work and encouraged to resume ‘normal levels of activities’ as quickly as possible. This can be difficult for some, in particular those impacted by chronic fatigue.
During a conversation with HSR, Dr Robert Ryan, Dean of the Faculty of Occupational Medicine, specialist occupational physician and managing partner of Medmark Occupational Healthcare, acknowledged another historic cohort of patients who suffer from chronic fatigue caused by other conditions. These patients experience chronic debility, with symptoms not dissimilar to patients with long covid, he explained.
The identification and acknowledgement of long covid may provide some degree of validation for such patients and he felt it is likely they will seek to access whatever assessment and treatment services that are to be made available to long covid patients.
Health Benefits of Work
When discussing what to do if workers are impacted by long covid in the context of carrying out their work, all of the occupational physicians stressed the importance of engaging with the employer as much as possible. They also agreed that the individual should receive a consultation with Occupational Health, who can provide guidance on any work adjustments which may be needed.
As the extent of the problem is still unknown for many employers, this will only become clearer in time, as more workers return to the work environment, explained Dr. Ryan. “Employees may be able to manage symptoms such as fatigue whilst home working, but this becomes more challenging when asked to return to the workplace”.
Dr. Ryan outlined the health benefits relating to work, including giving people structure, collegiality and purpose and that Occupational Health should be involved to help support the maintenance of employment where possible. This could include re-examining work tasks, staggering start or finish times and facilitating time off for medical appointments.
The Next Stage for Long Covid
Looking to the future, it is clear there is a need for “better research, recognition and rehabilitation”, according to WHO experts. Statements issued by the HSE also indicate there is still a lot of uncertainty around the scale of the disease and the complexity and duration of the symptoms.
In the UK, moves are afoot to have long covid recognised as an occupational disease and to compensate frontline health and other key workers, as recently reported in the British Medical Journal (BMJ). In Ireland, the issue of making Covid–19 cases reportable as a workplace occupational illness to the HSA has been debated by an Oireachtas Committee (HSR issue June 2021, link: https://www. healthandsafetyreview.ie/article/7485
From an employee perspective, the INMO, who represent many of the healthcare workers suffering with long covid, are calling for government and employer tailored medical supports, income security and flexible rehabilitation into work.
All of this research is prompting employers to rethink how they can accommodate workers with this disease, which can flare up in unpredictable bouts. This may mean offering home-working, flexible schedules, part-time work or alternative duties over a longer than normal basis, in order to support employees during their recovery.
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FAQ on long covid/post COVID-19 condition
(This information may be used to inform workplace risk assessments, procedures or training. Research on long covid is continuously evolving and information is based on current data at time of publication. Employers should seek specific advice where required).
1 What is long covid?
Long covid, also known as post-Covid-19 condition, is affecting up to 1 in 10 people whereby they still have symptoms post infection for up to 12 weeks and even up to a year. The majority of people improve in time but people may experience differences in the rate of improvement. (WHO, 2021).
2 Who does it impact?
Any person who has had actual or suspect Covid-19 is at risk of developing this condition. It affects people of any age. In some cases, it does not correlate with the severity of the acute infection (Rayner and Campbell, 2021) although other research indicates that those who were exposed to a high viral load during their initial infection are more at risk of developing it later e.g., those working with infected Covid-19 cases.
3 What are the symptoms?
The most common symptoms reported include physical and cognitive fatigue, shortness of breath, headaches and chest pain. Less common symptoms include joint pain, dizziness and a cough. Other symptoms may involve serious organ disease including cardiovascular symptoms, neurocognitive (memory and speech), neurological (stroke and migraines) and respiratory issues (lung disease and asthma). For some individuals, symptoms may overlap with post-infectious chronic fatigue syndrome, also called myalgic encephalomyelitis (ME).
4 Which work sectors are most at risk?
Healthcare workers, social care workers and those who are in contact with infected individuals or waste may be exposed to a greater viral dose than other workers and may be at greater risk.
5 How is it diagnosed?
To date, there is no single test for diagnosing this condition. Obtaining a full history from the individual is important, including age, occupation, general medical history and Covid-19 infection history. Guidelines produced by NICE in England (National Institute for Health and Clinical Excellence, 2020) advises the following criteria for diagnosing persistent symptoms of Covid-19:
1) Ongoing symptomatic Covid-19: if people present with symptoms 4 to 12 weeks after the start of the acute Covid-19 that are not explained by an alternative diagnosis.
2) Post Covid-19 syndrome/condition: if the person’s symptoms have not resolved 12 weeks after the start of acute Covid-19.
6 What should employees do if they suspect they have long covid?
According to the HSE, people with symptoms should initially attend their general practitioner (GP) for a general assessment, followed by referral onto specialist pathways for people who require specialist services. Examples of assessments may include clinical tests focusing on lung function impairment, reduced muscle strength, nerve damage, automic dysregulation and organ damage.
Employees are also encouraged to engage with their employer if they are diagnosed with the condition, to enable the employer to offer any supports and provide any work accommodations which may be needed. A consultation with an occupational health provider is also recommended, to ensure the best possible advice is given to the individual on the condition, the return-to-work options and any work adjustments needed to facilitate them in the work environment.
According to the Society of Occupational Medicine, patients with specific conditions, including myocarditis (inflammation of the heart muscle), problems with the autonomic nervous system (heart, bladder, intestines etc) and lung issues, may require specialist cardiorespiratory clearance before returning to strenuous work.
7 What treatments are available?
Treatment options vary depending on the symptoms being experienced. The model of treatment proposed by the HSE is based around supporting people to manage their own symptoms, and setting up a limited number of specialist pathways for those who require specialist services.
For those with improved symptoms, research suggests treatments may include speech therapy, antihistamines, dietary alterations, heart rate and angina control. Physiotherapy may be useful for those with Postural Tachycardia Syndrome (PoTS), which is an abnormal increase in heart rate that occurs after sitting up or standing (Rayner & Campbell, 2021).
8 What are the implications for employers?
Employers who have sickness absence policies may need to review these with regard to long covid. An international survey on behalf of the Society of Occupational Medicine found that over 20% of employees remained off work for up to 7 months after infection, and 45% were working at a reduced capacity. According to a report by The Economist recently, one in five people with long covid say they are unable to do even a part time, desk-based job.
Employers should consider flexible working policies, the provision of home-working where possible, reduced hours and be patient with those with the condition. A longer than normal phased return to work may be needed than with other conditions, as workers may appear fine one day and not another day.
9 What are the work implications for employees returning to work after long covid?
Long covid can have serious consequences on what an employee can and cannot do in the course of their job and each person’s symptoms should be assessed individually. Research shows there may be issues with prolonged standing due to autonomic dysfunction.
Ongoing fatigue can limit the length of time workers can stay at a task and also impact on work intensity. The use of certain meeting technologies e.g., Zoom and Teams technology can aggravate hoarseness due to over stimulation of the voicebox. Short-term memory, reading, naming objects, concentration and attention can all be impacted.
10 What are the implications for occupational health professionals?
The role of occupational health is to advise on fitness to work and make recommendations on any adjustments that are needed to facilitate a person remaining in work or returning to the workplace after a period of illness or absence. Post Covid-19 condition should be treated the same as any medical condition impacting on work and employees returning to work may require support or advice, including the offer of any Employee Assistance Programme (EAP), such as counselling services. Consideration should be given to a phased return to the workplace or altered duties if necessary. This should be done in consultation with the employer, occupational health and the employee.
11 What are the implications for health and safety professionals?
The health and safety professional, in conjunction with line management, should ensure that any person returning to work has had a fitness to work assessment completed by occupational health and the workplace risk assessment is updated.
The risk assessment should reflect any changes/ modifications required to facilitate the employee at work and ensure no other employees are placed at additional risk due to those changes. Further information on the HSA’s fitness to work guidance following Covid-19 absence is available at https:// tinyurl.com/3yspde5v. 12
12. Further sources of information:
The Health Services Executive (HSE) website has a dedicated section on recovering after Covid-19: https://bit.ly/3Ard0VJ.
The UK National Health Service (NHS) website at https://bit.ly/368o8sC.
Rayner, C & Campbell, R., 2021, Long Covid Implications for the workplace, Occupational Medicine, Link: https://doi. org/10.1093/occmed/kqab042
Sivan, S, Rayner C, Delaney, 2021, Fresh evidence of the scale and scope of long covid, British Medical Journal, 01st April 2021, link: https://bit.ly/2UlTysS.
The Economist, 2021, Long Covid, and now for the aftershock, 01st May 2021. World Health Organisation, 2021, In the wake of the pandemic: preparing for Long COVID, link: https://bit. ly/3hdfdfZ