Long COVID Hits Healthcare Workers

By Gary Evans, Medical Writer

Long COVID is a shapeshifter, a mystery almost by definition, with a broad panoply of symptoms and manifestations that have uncertain onset and duration.

A Government Accountability Office (GAO) report estimates long COVID has “potentially affected up to 23 million Americans, pushing an estimated 1 million people out of work.”¹ This population is a moving target — at any given time, some may be clearing it while others are just starting to succumb to its spiderweb of symptoms. Some have experienced long COVID since the beginning of the pandemic, and their return to baseline health is in question.

“This is a new illness with new constellations of symptoms that all seem to be attributable to that initial infection with COVID that are durable beyond at least 30 days after infection,” Bruce Levy, MD, director of the COVID Recovery Center at Brigham and Women’s Hospital in Boston, said during a recent webinar.² “We’ve learned that long COVID is more common in women than men at least two to one — and some studies show about a three-to-one ratio.”

Since women comprise an estimated three-fourths of all healthcare workers, they should be well represented in this ever-changing long COVID cohort. But that is just another of long COVID’s unknowns: How many healthcare workers have been affected?

A 2022 survey of nurses by National Nurses United (NNU) revealed 18% of 2,825 nurses polled nationwide were still reporting long COVID symptoms after 12 months (Sept. 22, 2021, to Nov. 28, 2022). Extrapolating that rate to 4 million RNs nationwide reveals hundreds of thousands of nurses could have experienced long COVID for more than one year. Overall, 16% of nurses reported long COVID for four to six months, 8% for seven to nine months, and 7% for 10 to 12 months.³

Moreover, there is emerging evidence suggesting those with long COVID who are reinfected with SARS-CoV-2 are likely to see symptoms worsen. “Overwhelmingly, reinfection worsened the symptoms of long COVID in most people who were still symptomatic,” according to a poll conducted in the UK and Europe.⁴

“We are concerned that every time you are reinfected, it increases the likelihood of more severe symptoms of long COVID,” says Deborah Burger, RN, co-president of NNU. “This is a profession that works with COVID daily. The fact that we are no longer testing patients puts nurses at more risk. Some hospitals have essentially backed off supplying sick time for COVID because it is endemic in the population. That also means you can no longer say you got it at work, which is unlike the life-long protections provided for fire and police. They are assumed to have acquired their disabilities on the job.”

The NNU survey revealed 60% of nurses took time off to recover from post-COVID or long COVID symptoms. Most took less than a month off, but 3% took three to four months, and 3% did not return. Even back on the job, 38% said long COVID has affected their work.

Seventy-eight percent of NNU survey respondents experiencing long COVID have not sought treatment. Many of those who have sought treatment reported disbelief of symptoms was a major barrier. They are understandably frustrated, as the phenomenon of long COVID was initially met with skepticism by some until there were so many cases and medical complaints that it became clear something was happening.

“If you have this syndrome, you are not lazy, you are not crazy, you are not a bad person. You’re ill with a syndrome caused by the virus,” says Michael Crane, MD, MPH, an occupational medicine physician at Mount Sinai in NYC. “This has caused a tremendous amount of anxiety because people don’t know what the heck is wrong with them. There was anxiety, and not a lot of help from us for a while because we really didn’t recognize that this syndrome was connected to the coronavirus. We learned quickly, but not quickly enough for some of our patients, who felt sort of abandoned.”

The Long Tail of Symptoms

The CDC — not exactly known for inflammatory headlines — featured this one on a report late last year: “One in Five American Adults Who Have Had COVID-19 Still Have Long COVID.”⁵

“Overall, 1 in 13 adults in the U.S. (7.5%) have ‘long COVID’ symptoms, defined as symptoms lasting three or more months after first contracting the virus, and that they didn’t have prior to their COVID-19 infection,” the CDC reported. “Nearly three times as many adults ages 50-59 currently have long COVID than those age 80 and older. Women are more likely than men to currently have long COVID (9.4% vs. 5.5%). Nearly 9% of Hispanic adults currently have long COVID, higher than non-Hispanic white (7.5%) and Black (6.8%) adults, and over twice the percentage of non-Hispanic Asian adults (3.7%).”

There are so many symptoms expressed in long COVID that some scientists theorize SARS-CoV-2 can cause post-infection damage that can disrupt or deregulate the immune system, triggering inflammatory and autoimmune manifestations. Long COVID patients test negative for the virus, raising the question of whether it lingers in the body, finding some safe harbor where it remains possibly malevolent but undetectable. This was seen in the Ebola virus, which has been found in the cerebrospinal fluid, placenta, eyes, and testes — areas the immune system is unlikely to aggressively attack.⁶ Indeed, the ability to cause post-infection illness is commonly seen in other viruses, including adenoviruses, herpesviruses, enteroviruses, paramyxoviruses, and orthomyxoviruses.⁷

According to a Yale Medicine overview, “Long COVID can affect anyone, including children, and it can develop in people who had asymptomatic, mild, or severe COVID-19. It is not yet known why long COVID affects some people and not others. However, a recent study found that the condition is more common among older people, women, and those who had six or more symptoms during the first week of COVID-19.”⁸

There are around 70 symptoms, including hair loss, but these are some of the most commonly reported:

• chest pain or discomfort;
• shortness of breath;
• cough;
• fatigue;
• headache;
• joint pain, muscle aches, and pain/weakness;
• sore throat;
• persistent loss of smell and/or taste;
• brain fog;
• memory loss;
• depression;
• anxiety;
• PTSD;
• insomnia.

The Unknowns

Long COVID presents a litany of unknowns and problems yet to be overcome.

“We have no medicinal therapy to offer. There’s no evidence that any medicinal therapy is effective yet in long COVID,” Levy said. “We are left with a lot of questions: What is the case definition for long COVID? What are the disease-driving mechanisms? What’s caused by the virus itself vs. those who have severe illness? Who is at greatest risk? What’s the prognosis? We have a lot of challenges in front of us. This is really a public health crisis.”

Some answers may come from an ambitious research project called Researching COVID to Enhance Recovery (RECOVER), wherein Levy’s group will join 16 other research consortiums under a long COVID initiate led by the National Institutes of Health.

Cognitive impairment has raised concerns when seen in healthcare workers, perhaps due to the striking contrast with their former selves.

“Nursing is a highly educated profession,” Burger says. “You can’t afford a minute of inattention because people’s lives are at stake. When you have long COVID, the foggy brain, the inability to concentrate, all those mental symptoms — it’s a very demanding job.”

A Canadian study revealed the persistence of brain fog in healthcare workers particularly concerning. “The prognosis of these cognitive dysfunctions is unknown, but the lack of decline in prevalence over 4-28 weeks is worrisome,” the authors noted. “If persisting over the long term, this not-infrequent sequela of COVID-19 could become both personally and professionally impactful on a significant scale among the highly infected population of HCWs.”⁹

Asked by Hospital Employee Health to elaborate on this point, the lead author would only say further research is needed to clarify the meaning of this finding and downstream effects like long-term prognosis and staffing woes.

The authors went a little farther in concluding the paper by noting long COVID “may be a frequent sequela of ambulatory COVID-19 in working-age adults, with important effects on cognition. With so many HCWs infected, the implications for quality healthcare delivery could be profound if cognitive dysfunction and other severe [long COVID] symptoms persist in a professionally disabling way.”

In contrast, the authors of a recently published study in Israel concluded, “Although the long COVID phenomenon has been feared and discussed since the beginning of the pandemic, we observed that most health outcomes arising after a mild disease course remained for several months and returned to normal within the first year.”¹⁰

An outlier group of 5% still experienced symptoms after a year. A clinician who was not involved in the study said that still represents a significant amount of people.

“The spin is mainly positive, and I think that’s supported by other studies and with what we’re seeing. But, unfortunately, [long COVID recovery] is not for everyone and not for all the issues,” said Daniel Griffin, MD, a clinician who treats SARS-CoV-2 patients at Columbia University in New York City.

In the study, the hazard ratios still showed fairly significant risks for cognitive impairment, dyspnea, and weakness.

“Weakness really seems like it gets better and then comes back, unfortunately,” Griffin said in a webcast. “We see that cognitive impairment, memory impairment, [and] concentration are persisting out. It is true that 95% of people are going to be better at a year, but you still have that chunk of individuals who continue to suffer, and that’s real.”

Griffin also treats patients with long COVID, including some who have had the condition for the pandemic duration. One of these “long-haulers” told him she seemed to be crying at inappropriate times, and remaining unemotional at events that normally would induce tears. A few weeks later, Griffin asked her about it, and she had no memory of the conversation.

“Here’s a high-functioning individual, a healthcare professional, who now, almost three years later, is having cognitive impairment,” Griffin said. “Not everyone gets better.”

Haves and Have Nots

Levy described a fit patient in her late 20s or early 30s who exercised multiple times a week. She contracted acute COVID-19 and experienced a severe flu-like illness. Thankfully, she did not need to be hospitalized, but six months after her initial infection, she still could not work.

“She was sleeping a good portion of the day,” Levy recalled. “She had significant post-exertional malaise. Her life was really torn apart by this. We did an extensive evaluation to make sure nothing else was going on, and we could not find any other explanation for her symptoms. At the time, now six months after her acute illness, all testing for acute COVID was negative.”

The patient was given “non-medicinal therapies” in conjunction with a focus on mental health, physical rehabilitation, nutrition, and sleep therapy. “She slowly did start to improve, but it took her about a year to get better,” Levy said.

Citing all the progress made against COVID-19 since it first appeared, Levy said long COVID has brought the medical community back to square one.

“Long COVID can be thought of as the post-pandemic pandemic,” he said. “Well, I’m not sure we’re really in a post-pandemic, but long COVID is now front and center. We really need a similar public health approach to fully understand and address long COVID.”

The hospital gets as many as 150 new patients a month coming to the COVID Recovery Center. “We’re up to over 2,500 patients,” Levy said. “This is truly a prominent health crisis. Equity is important for all we do at the center, and we know that vulnerable populations were drastically impacted by acute COVID. It’s our sense that they’re similarly impacted by long COVID.”

Linda Sprague Martinez, PhD, a social worker and co-speaker at the webinar, reported that is indeed the case. She offered some of her impressions of visiting long COVID clinics and some of the low income and primarily ethnic areas around Boston.²

Not surprisingly, most of the long COVID clinics were clustered in Boston, but Martinez interviewed clinic directors and canvassed the minority communities. Many of the latter were unaware of long COVID, demonstrating a lack of health literacy that puts them at an immediate disadvantage to receive care. “Picture if you’re having symptoms that persist over time, but you haven’t heard this term ‘long COVID’ — you’re wondering what’s going on with your body,” Martinez said.

In several focus groups with eight to 10 people, many reported they are working through long COVID symptoms. “‘People are going into work not feeling well and are just not well, but you have to keep pushing,’” one community member told Martinez. “One of our recommendations is that there needs to be support groups available for people with long COVID. We heard from participants with diabetes that they were not able to manage their insulin levels as well as they had managed them pre-COVID.”

One described the feeling of long COVID as “It’s like I’m here, but I’m not here.” Another community member told Martinez she was going to make tortillas, and she took out the sugar instead of corn flour. “I said to myself, ‘What is wrong with me?’” she told Martinez.

The communities need help with affordable healthcare, mental healthcare, paying off medical debt, and understanding what conditions qualify as a disability.

Under the Americans with Disabilities Act (ADA), workers with long COVID are entitled to reasonable accommodations if they are diagnosed with a mental or physical impairment that meets the definition of disability, are qualified for the job, and work for an employer with at least 15 employees, a labor law firm reported.¹¹

“People diagnosed with long-haul COVID-19 are entitled to the same protections from discrimination as any other person with a disability under the ADA,” the author of the legal opinion noted, adding the caveat, “Long-term effects of COVID-19 do not always qualify as a disability under the ADA. An individualized assessment, taking into account an employee’s specific symptoms and the effect those symptoms have on the employee’s major life activities, is necessary to determine whether a person’s long-haul COVID-19 condition meets the requirements for application of the ADA.”

REFERENCES

1. Government Accountability Office. Science and Tech Spotlight: Long COVID. March 2022.
2. Public Health Institute of Western Massachusetts. Webinar: Long COVID. Jan. 20, 2023.
3. National Nurses United. NNU COVID Survey #8: Year Three: Acute and long COVID, a double public health and occupational health crisis. Dec. 13, 2022.
4. Joi P. New survey suggests reinfection worsens long COVID. Gavi. Sep.15, 2022.
5. Centers for Disease Control and Prevention. Nearly one in five American adults who have had COVID-19 still have “long COVID.” June 22, 2022.
6. Centers for Disease Control and Prevention. Ebola. Transmission. Page last reviewed Jan 14, 2021.
7. Children’s Hospital of Philadelphia. SARS-CoV-2 is not the only virus to cause lingering effects. Jan. 26, 2023.
8. Yale Medicine. Long COVID. 2023.
9. Carazo S, Skowronski DM, Laforce Jr. R, et al. Physical, psychological, and cognitive profile of post-COVID conditions in healthcare workers, Quebec, Canada. Open Forum Infect Dis 2022;9:ofac386.
10. Mizrahi B, Sudry T, Flaks-Manov N, et al. Long covid outcomes at one year after mild SARS-CoV-2 infection: Nationwide cohort study. BMJ 2023;380:e072529.
11. Culley SR. Long haul COVID-19 and the ADA: What employers should know. Rumberger Kirk. Jan. 7, 2022.