What are the long-term health symptoms of COVID-19?

Summary

The following is a summary of evidence sources that provide information on the longer-term symptoms of COVID-19. For additional information about each of the sources, see the Table below.    For additional information about each of the sources, see the Table below.

In its September update #36, What we know about long-term effects of COVID-19, the World Health Organization (WHO) states that people typically recover from COVID-19 after two to six weeks. However, for some, their symptoms may persist for weeks or months following initial recovery, although they are not likely to be infectious to others during this time [3]. The WHO and the US Centers for Disease Control and Prevention (CDC) note that these symptoms, of what now is called or known as ‘long COVID’, include fatigue, cough, congestion or shortness of breath, loss of taste or smell, headache, body aches, diarrhea, nausea, confusion and chest pains. Further, these agencies report the potential long-term health problems to include: 1) damage to heart muscles and heart failure; 2) damage to lung tissue and longer-term respiratory problems; 3) loss of smell, stroke and cognitive impairment; 4) anxiety, depression, post-traumatic stress disorder and sleep disturbance; and 5) pain in joint and muscles and fatigue causing reduced exercise capacity [3,4]. High blood pressure, obesity and mental health conditions may be risk factors for persistence of symptoms [3].  
 
The CDC indicates in its Long-Term Effects of COVID-19 report that COVID-19 symptoms are more common among middle-aged and older adults but may still occur in young, healthy people [4]:, as noted by the WHO, 20% of 18-34 year old adults with COVID-19, otherwise in good health, reported prolonged symptoms [3]. 
 
One meta-analysis and one literature review state that based on known evidence surrounding other viruses such as SARS, MERS, and seasonal influenzas, many of the aforementioned long-term symptoms can be anticipated for COVID-19 [1,2]. The authors of a systematic review and meta-analysis on long-term clinical outcomes in survivors of SARS and MERS coronavirus outbreaks after hospitalisation or ICU admission found that stress, anxiety and depression have been observed in up to one-third of survivors at 6 months post-recovery from MERS and SARS and should be anticipated among COVID-19 survivors [1]. There is limited evidence to date regarding the longer-term effects of COVID-19, why certain people experience long-term symptoms, and the optimal care for those experiencing long COVID. This is currently an important focus for research around the world. Guidance on Management of post-acute covid-19 in primary care notes that weak or absent antibody response, relapse or reinfection, inflammatory and other immune reactions, deconditioning and mental factors such as post-traumatic stress may all contribute to persistent symptoms [6]. This primary care guidance also describes how long COVID patients should be managed pragmatically, based on a patient evaluation and with an emphasis on a multidisciplinary intervention that includes education, exercise training and behavioural modification (e.g., teaching breathing techniques for persistent breathlessness and coughing or using of pulse oximetry to self-monitor oxygen saturation) [6]. One expert commentary in the Lancet, has offered a list of questions yet to be answered (e.g. can we predict during the acute disease which patients will develop long term consequences?) [7], and another commentary notes the challenges for patients and providers in the face of this uncertainty, and points to the emergence of patient-organized long COVID groups [8].  In a recent evidence submission to the UK government, “Long Covid”: evidence, recommendations and priority research questions , a team of clinicians and researchers proposed a four-tier approach to organizing services for patients with long COVID [5].   

Evidence

What‘s Trending on Social Media and Media

In this article a young woman describes the frustration of doctors not knowing how to treat her disease after she tested negative for COVID-19 and had long-term symptoms that were not commonly documented. The woman writes that the most frustrating part is that some medical doctors dismiss her complaints as psychological. She calls for more action and support to “long-haulers” like her.  
 
The COVID Long Haulers Support Group Canada is a Facebook Group for Canadians and have had more than 4,200 members join since the group started in June 2020. The aim of the group is to share information and stories for people affected by long-term symptoms of COVID-19, to discuss available treatments and to provide a list of doctors who are treating their cases.  
 
A CNN article describes the preliminary finding from a study presented at the European Respiratory Society International Congress on September 4th, 2020. This study states that moderate improvement of persisting lung impairment was detectable among patients with long-term COVID-19 symptoms. This article calls for patients to start pulmonary rehabilitation as soon as they are physically fit to do so.  

Organizational Scan

The National Institutes of Health describes the Body Politic COVID-19 Support Group that was set up through the Slack platform where researchers can ask “long-hauler patients” about their symptoms, recovery and patient experiences. Another initiative, The Patient-led Research for COVID-19, brought together scientists from different disciplines who have also been affected by long-term symptoms to work on further questions [9]. 

Review of Evidence

Resource	Type/Source of Evidence	Last Updated
Long-term clinical outcomes in survivors of SARS and MERS coronavirus outbreaks after hospitalisation or ICU admission: A systematic review and meta-analysis — Ahmed et al.	Meta-Analysis	This meta-analysis states that among survivors of MERS and SARS complications up to 6 months after discharge included lung function abnormalities, psychological impairment and reduced exercise capacity. Mental health problems include stress, anxiety and depression were observed in up to one-third of survivors at 6 months post recovery. Clinicians should therefore anticipate similar long-term outcomes for COVID-19 survivors and plan suitable and timely treatments to provide best possible recovery and quality of life.   Last Updated: May 30, 2020
The potential long-term impact of the COVID-19 outbreak on patients with non-communicable diseases in Europe: consequences for healthy ageing — Palmer et al.	Literature Review	Based on knowledge of how seasonal influenzas and community-acquired pneumonia are associated with pneumonia, this review calls for the need to monitor non-communicable disease symptoms and cognitive decline among COVID-19 patients.   The authors call for more longitudinal follow-up studies to determine the long-term neurological and neuropsychological consequences of this pandemic.  Last Updated: May 25, 2020
What we know about long-term effects of COVID-19 — WHO: World Health Organization	International Guidance	The WHO notes that although people typically recover from COVID-19 after two to six weeks, among some people symptoms may linger or recur for weeks or months following their initial recovery. This may also occur in people with mild disease and it is thought that people are not infectious to others during this time. Some of the symptoms that may persist are fatigue, cough, congestion or shortness of breath, loss of taste or smell, headache, body aches, diarrhea, nausea, confusion and chest pains. It is also thought that COVID-19 may increase the risk of the following long-term health problems: 1) damage to heart muscles and heart failure; 2) damage to lung tissue and restrictive lung failure; 3) loss of smell, stroke and cognitive impairment; 4) anxiety, depression, post-traumatic stress disorder and sleep disturbance; and 5) pain in joint and muscles and fatigue. Among 18-34 year old adults in good health, 20% reported prolonged symptoms. Some risk factors for persistence of symptoms include high blood pressure, obesity and mental health conditions.  Last Updated: September 8, 2020
Long-Term Effects of COVID-19 — CDC: Centers for Disease Control and Prevention	National Guidance	The CDC describes that COVID-19 affects many organs not only the lungs. Heart conditions associated with COVID-19 include inflammation and damage to the heart muscle itself and inflammation of the covering of the heart. Heart damage may explain some reported long-term symptoms like shortness of breath, chest pain and heart palpitations. These symptoms are more common among middle-aged and older adults but may still occur in young, healthy people.   Last Updated: September 15, 2020
“Long Covid”: evidence, recommendations and priority research questions — Greenhalgh et al.	Expert Advice to Government	This guidance recommends a four-tier approach to organizing services for patient care, including: 1) resources and support for self-care; 2) generalist care including therapeutic relationship in general practice and a community-based interdisciplinary rehabilitation service led by allied health professionals; 3) specialist care including system-based investigation, management and rehabilitation; and 4) specialist management of specific complications.   Last Updated: September 22, 2020
Management of post-acute covid-19 in primary care — Greenhalgh et al.	Primary Care Guidance	This primary care practice guidance notes that apart from serious ongoing complications or comorbidities, long COVID patients should be managed pragmatically and symptomatically with emphasis on holistic support. This emphasizes a multidisciplinary intervention based on patient evaluation that includes education, exercise training and behavioural modification such as breathing techniques or the use of pulse oximetry to self-monitor oxygen saturation.     This guidance also notes that weak or absent antibody response, relapse or reinfection, inflammatory and other immune reactions, deconditioning and mental factors such as post-traumatic stress may all contribute to persistent symptoms.   Last Updated: August 10, 2020
Long-term consequences of COVID-19: research needs — Yelin et al.	Commentary	This commentary focuses on the need for further investigation of the long-term impacts of COVID-19. Answers on the long-term consequences of the disease are needed to help patients and health-care providers. Careful recording of symptoms and patient examination is needed to understand what is common to all severe infections and which symptoms are secondary to a complicated form of COVID-19. The authors offer a list of research questions to be pursued.   Last Updated: September 30, 2020
As Their Numbers Grow, COVID-19 “Long Haulers” Stump Experts — Rita Rubin	News Item	This news item notes the frustration amongst patients and providers with the uncertainty around long-term symptoms, and management, given limited evidence to guide the care of “long-haulers”. It also notes the emergence of patient organized Facebook groups on long COVID in the US.   Last Updated: September 22, 2020
Citizen Scientists Take on the Challenge of Long-Haul COVID-19 — National Institutes of Health	Organizational Scan	Last Updated: September 2, 2020
Disclaimer: The summaries provided are distillations of reviews that have synthesized many individual studies. As such, summarized information may not always be applicable to every context. Each piece of evidence is hyperlinked to the original source.