Alison Barrett writes:
Many concerns, questions and uncertainties surrounding long COVID were raised at a World Health Organization (WHO) webinar this week, featuring global experts.
Concerns were expressed about “the immense” economic costs of long COVID, as well as about its impact on safety in workplaces.
The webinar – the sixth on long COVID convened by the WHO – is timely, coming ahead of the release this month of a Federal Parliamentary inquiry into long COVID, as previously covered by Croakey.
“It’s clear that COVID-19 has had a huge impact around the world, not only in its direct impact from acute illness but in these long-lasting effects, which many people suffer,” said Dr Mike Ryan, Executive Director of WHO’s Emergencies Programme.
Patients have been critical in driving necessary research about the condition, Ryan told the webinar.
However, much is still unclear about long COVID in terms of pathophysiology, treatment and therapies to improve symptoms.
Dr Diego Castanares-Zapatero from the Belgian Health Care Knowledge Centre called for a clear research agenda to be set, to avoid duplications and increase joint efforts on the topic.
Professor Kamlesh Khunti from the University of Leicester in United Kingdom emphasised the importance of including patients in research at all stages from study design to the dissemination of results.
Long COVID researchers from the United States, United Kingdom, India, Belgium, Argentina and Mali presented at the webinar, which Ryan said was an opportunity to “expand our understanding” of the evolving research landscape.

Update on prevalence
During the webinar, wide ranges in long COVID prevalence – from three to 48 percent – were reported by different speakers.
Variances in prevalence estimates depend on a range of factors including where and/or when the studies were conducted (before or after vaccination, which variant was predominant at time) or in which population groups (people who had severe or mild case of acute COVID).
“We need good quality studies that have control groups or have robust exposure assessments such as confirmed diagnosis, COVID validated symptom assessments, because at the moment there’s huge differences in the way COVID is described, how they’ve included the patients and the symptoms that they are assessing,” Khunti said.
We also need more data, particularly from low-middle income countries, he said.

Khunti said that vaccination against COVID-19 with two doses reduces the risk of long COVID, referring to a systematic review by Dr Vasiliki Tsampasian and colleagues.
Professor Jill Pell from the University of Glasgow commented during her presentation that it also “depends how you ask the question as to what results you get” for prevalence.
Her research has found that 6.6 percent of people in Scotland who have been previously infected with COVID have “one or more new or persistent symptoms that can definitely be attributed to long COVID” at six months post COVID.

Using a validated tool to measure health-related quality of life – the EQ-5D – Pell and colleagues found that people with long COVID symptoms had poorer quality of life than people never infected with COVID.
Approximately three-quarters of people with long COVID reported no change in recovery six months after infection. Of the remaining cohort, 12 percent said they improved over time and 12 percent said they deteriorated.
Highlighting inequitable outcomes between population groups, Pell said the research found that “people who were affluent are more likely to improve and less likely to deteriorate, and people who had pre-existing depression and anxiety, again, were less likely to improve and more likely to deteriorate”.
Occupational health and safety
Many long COVID symptoms such as autonomic dysfunction, neurocognitive impairment and pain will “affect somebody’s endurance or cognitive or physical endurance at work”, according to Dr Clare Rayner, occupational physician and an honorary lecturer at the University of Manchester in the United Kingdom.
These symptoms have the potential to affect comfort, the ability to stand or sit for long periods, and safety in the workplace.
Cognitive impairments are “highly important factors when we’re thinking about safety in workplaces”, Rayner said.
Recent surveys by Rayner and colleagues show that 70 percent of British people with long COVID have reduced work status, either losing their jobs or working significantly reduced hours.
Employers can support people with long COVID back to work by having early and ongoing contact with employees, identifying priority work elements, having ‘COVID-centric’ work policies and environmental modifications, she said.
An individualised action plan to work will be most beneficial, with flexibility to gradually increase hours, according to Rayner.
Quoting Professor Ewan MacDonald, from the University of Glasgow, Rayner said “long COVID is the sting in the tail of the pandemic”.

Prevention and early intervention matters
Rayner said that it’s “extremely important” to treat some of the symptoms and sub-conditions such as autonomic dysfunction and tachycardia early with known treatments to enable “people to return to work and normal activities”.
“Don’t leave people with symptoms. Get in there early. Listen to what they’re saying, and their function will improve sooner,” she said.
“We should be thinking of work as a health outcome – by that, I mean that every healthcare professional should see it as something to aim for.”
Rayner also said we should avoid reinfections and overall “look at prevention”, which is “going to be the best option”, especially for people in insecure work conditions who do not receive sick pay or benefits.
“All of the things I’ve said are all very well, if you work in an employed setting and especially if you have pay and benefits, but many people across the world do not have these.”
Financial impact
Long COVID is likely to have a significant financial impact, according to Professor David Cutler from Harvard University in the US, including welfare loss from reduced health, earning losses and additional health spending, which will have individual and population impacts.
Cutler said that estimates for the US are that 500,000 to two million people “are out of work or working less because of long COVID”.
Based on the lower end of estimates about people out of work, they estimate long COVID cost the US “roughly 17 percent of GDP”.
The “economic costs of long COVID are just immense” and will have significant implications for governments on policy, medical spending, and disability insurance programs, he said.
Note, as with long COVID prevalence, the prevalence for people out of work may fluctuate between estimates depending on various factors.

Red flags
In caring for patients with long COVID, Dr Malachy Clancy from Thomas Jefferson University in the US, said “we must ensure that we first do no harm”.
Particular red flags include interventions that could cause deterioration in the patient, cardiac impairments and exertional oxygen desaturation, he said. Clinicians need to closely monitor and assess for any triggers.
Clancy discussed four concepts to consider in providing safe rehabilitation for patients with long COVID:
- identify red flags, as outlined above. The focus of rehabilitation is often on stabilising fluctuations and tolerance before building activity
- personalise rehabilitation according to individual patient’s symptoms, restrictions and needs
- expectations for rehab should be accurately managed from the beginning – returning to health “looks different for each person”
- rehab should be psychologically safe and supported.
“We need to recognise the lived experiences and unfortunate stigma associated with post COVID-19 condition,” Clancy said.
Dr Ariel Izcovich, from the Hospital Aleman de Buenos Aires, discussed a living review of interventions for long COVID by the Pan American Health Organization.
The most recent review includes 37 interventions, of which most have been found to have some effect but the certainty about the effectiveness is low – in terms of study quality.
They found that respiratory training for patients with respiratory symptoms post COVID is the only intervention included in the review that has moderate certainty of benefit. No interventions have high certainty.
Izcovich said many randomised trials on both pharmacological and non-pharmacological interventions were ongoing “so hopefully, we will have more certainty and more interventions” in our review in the future.

Also read this recent Croakey article: Putting homelessness on the agenda for long COVID policy
See Croakey’s archive of articles on COVID-19.