Resources for the Recognition and Management of Long-COVID in Primary Care

Medical knowledge on the recognition and management of what is variously called “post-COVID syndrome”, “long COVID”, and multiple other descriptions is accumulating rapidly in response to an “epidemic within the pandemic”. In a retrospective study of electronic medical records of over 250,000 European symptomatic COVID cases, more than half of those surveyed reported symptoms either persisting or recurring within a six-month period after diagnosis and over one-third of those during the third to sixth month.1 The World Health Organization (WHO) has formally defined “long COVID” as a “Post COVID-19 condition occurs in individuals with a history of probable or confirmed SARS-CoV-2 infection, usually 3 months from the onset of COVID-19 with symptoms and that last for at least 2 months and cannot be explained by an alternative diagnosis…”.2 The constellation of findings associated with long COVID has been analyzed in a meta-analysis.3 As of July 2021, long COVID, also known as “post-COVID conditions”, can be considered a disability under the Americans with Disabilities Act (ADA). The guidance states “an individualized assessment is necessary to determine whether a person’s long COVID condition or any of its symptoms substantially limits a major life activity”. Those with long COVID that qualifies as a disability are entitled to the same protections from discrimination as any other person with a disability under the ADA, Section 504, and Section 1557.4

The evolution of published information on this topic is so rapid that any attempt to summarize it will be out of date by the time this blog is published. The focus here will be to identify useful resources for primary care. Many of these resources are being continuously updated as knowledge evolves.

The Centers for Disease Control and Prevention (CDC) is designated as the lead federal agency to advise health care providers. Their website has interim guidelines for evaluating and caring for patients with post-COVID conditions.5 The CDC also has a Clinician Outreach and Communication Activity (COCA) program which has produced several webinars on post-COVID conditions; these are archived for viewing and are eligible for continuing education credit.6,7

The National Institutes of Health (NIH) COVID-19 treatment guidelines website has an overview of resources for persistent symptoms or organ dysfunction after acute COVID-19. It includes links to other guidelines and clinical research resources.8

The National Institute for Health and Care Excellence (NICE) has rapid guidelines on managing the long-term effects of COVID-19. This guideline has been developed jointly by NICE, the Scottish Intercollegiate Guidelines Network (SIGN), and the Royal College of General Practitioners (RCGP).9

An editorial in the American Family Physician called for primary care to be the focus of initial management of long COVID in the US and has a primer on the topic.10

Another good introduction is an article in the British Medical Journal (BMJ) on the management of post-acute COVID-19 in primary care. Particularly useful in this article is a link to the BMJ podcast What Do We Know About Long Covid and a visual summary figure “Long COVID in Primary Care” which summarizes the key points of assessment and management in primary care.11

In Spain, the Catalan Society of Family and Community Medicine (CAMFiC) established a working group to develop clinical practice guidelines, consisting mainly of primary care professionals (90%), together with specialists in internal medicine, autoimmune diseases, infectious disease, epidemiology, and statistics. The article has a link to nine algorithms for managing the most common findings by their length of persistence.12

Because symptoms persisting or recurring after acute COVID-19 are difficult to evaluate, patients are often frustrated and believe that their complaints are not being addressed. The importance of addressing the emotional aspects of long COVID is emphasized in a UK study of patient satisfaction with their sources of primary care.13

The importance of multispecialty communication and cooperation is critical in the management of these patients.14

References (all links were accessed November 5-6, 2021):

  1. Taquet M, Dercon Q, Luciano S, Geddes JR, Husain M, Harrison PJ. Incidence, co-occurrence, and evolution of long-COVID features: A 6-month retrospective cohort study of 273,618 survivors of COVID-19. PLoS Med. 2021 Sep 28;18(9). PMID: 34582441. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8478214/
  2. World Health Organization: A clinical case definition of post COVID-19 condition by a Delphi consensus, 6 October 2021. https://www.who.int/publications/i/item/WHO-2019-nCoV-Post_COVID-19_condition-Clinical_case_definition-2021.1
  3. Michelen M, Manoharan L, Elkheir N, Cheng V, Dagens A, Hastie C, O’Hara M, Suett J, Dahmash D, Bugaeva P, Rigby I, Munblit D, Harriss E, Burls A, Foote C, Scott J, Carson G, Olliaro P, Sigfrid L, Stavropoulou C. Characterising long COVID: a living systematic review. BMJ Glob Health. 2021 Sep;6(9). PMID: 34580069. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8478580/
  4. Laws & Regulations/Civil Rights for Providers of Health Care and Human Services/Guidance on “Long COVID” as a Disability Under the ADA, Section 504, and Section 1557. https://www.hhs.gov/civil-rights/for-providers/civil-rights-covid19/guidance-long-covid-disability/index.html
  5. Evaluating and Caring for Patients with Post-COVID Conditions: Interim Guidance (CDC). https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-care/post-covid-workup.html
  6. Evaluating and Caring for Patients with Post-COVID Conditions (CDC COCA webinar) https://emergency.cdc.gov/coca/calls/2021/callinfo_061721.asp
  7. Evaluating and Supporting Patients Presenting With Fatigue Following COVID-19 (CDC COCA webinar) https://emergency.cdc.gov/coca/calls/2021/callinfo_093021.asp
  8. Persistent Symptoms or Organ Dysfunction After Acute COVID-19 (NIH) https://www.covid19treatmentguidelines.nih.gov/overview/clinical-spectrum/
  9. COVID-19 rapid guideline: managing the long-term effects of COVID-19 https://www.nice.org.uk/guidance/ng188
  10. Greenhalgh T, Knight M. Long COVID: A Primer for Family Physicians. Am Fam Physician. 2020 Dec 15;102(12):716-717. PMID: 33320511. https://www.aafp.org/afp/2020/1215/p716.html
  11. Greenhalgh T, Knight M, A’Court C, Buxton M, Husain L. Management of post-acute covid-19 in primary care. BMJ. 2020 Aug 11. PMID: 32784198. https://www.bmj.com/content/370/bmj.m3026
  12. Sisó-Almirall A, Brito-Zerón P, Conangla Ferrín L, Kostov B, Moragas Moreno A, Mestres J, Sellarès J, Galindo G, Morera R, Basora J, Trilla A, Ramos-Casals M, On Behalf Of The CAMFiC Long Covid-Study Group. Long Covid-19: Proposed Primary Care Clinical Guidelines for Diagnosis and Disease Management. Int J Environ Res Public Health. 2021 Apr 20;18(8). PMID: 33923972. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8073248/
  13. Kingstone T, Taylor AK, O’Donnell CA, Atherton H, Blane DN, Chew-Graham CA. Finding the ‘right’ GP: a qualitative study of the experiences of people with long-COVID. BJGP Open. 2020 Dec 15;4(5). PMID: 33051223. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7880173/
  14. Parker AM, Brigham E, Connolly B, McPeake J, Agranovich AV, Kenes MT, Casey K, Reynolds C, Schmidt KFR, Kim SY, Kaplin A, Sevin CM, Brodsky MB, Turnbull AE. Addressing the post-acute sequelae of SARS-CoV-2 infection: a multidisciplinary model of care. Lancet Respir Med. 2021 Nov;9(11):1328-1341. PMID: 34678213. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8525917/

Charles A. Sneiderman, MD, PhD, DABFM
Medical Director, Culmore Clinic
Bailey’s Crossroads, VA
charless@culmoreclinic.org

Published on 12/17/2021

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