Long COVID: Challenges for prevention and measures to diminish the effects on OSH

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Professor Ewan Macdonald, University of Glasgow

Background and Scope of Guidance

On 11 March 2020, the World Health Organisation (WHO) declared the coronavirus COVID-19 outbreak as a pandemic. Vaccination is proving to be effective against the pandemic, however it is increasingly being recognised that infection due to COVID-19 can result in a number of longstanding impacts on the health of the individual with potentially debilitating effects in some. Symptoms lasting more than four weeks are generally called Long Covid. This lingering impact upon the health of those with experience of COVID-19 has also been designated post-COVID-19.

This guidance provides advice to employers and businesses in non-healthcare settings on:

  • Long Covid – what is it and how it is currently understood?
  • What are or could be the effects on workers’ safety?
  • What are the implications for work ability?
  • Focus on policy at the employer and country levels.
  • Conclusionary points on preventing future pandemics.

It is important to only follow guidance that has been issued by reputable sources when determining the risk and impact of COVID-19 / Long Covid. Decisions about risk should not be made based on race or country of origin; confidentiality of people with confirmed COVID-19 / Long Covid should be maintained and there should be awareness about persons who may be at particular risk (those aged over 60, or who have an underlying condition or chronic disease, or who are pregnant).

Long Covid, Post-COVID-19

Information about Long Covid

Patient groups define Long Covid as symptoms lasting longer than four weeks. The WHO has defined post-COVID-19 as a condition that occurs in individuals with a history of probable or confirmed SARS-CoV-2 infection, usually three months from the onset of COVID-19,with symptoms that last for at least two months and cannot be explained by an alternative diagnosis[1]

Long COVID can affect nearly every organ system with effects including disorders of the respiratory system and the nervous system, neurocognitive disorders, mental health disorders, metabolic disorders, cardiovascular disorders, gastrointestinal disorders, malaise, fatigue, musculoskeletal pain and anaemia. COVID-19 can therefore be defined as a new disease that can affect any organ in the body. While the mechanism behind its effect is still uncertain, it is probably due to inflammation of the lining of the blood vessels (endotheliitis), which means that it can affect any organ[2].

Signs and symptoms of Long Covid

Workers who are experiencing Long Covid may have any one or more of a number of symptoms, including:

  • Extreme tiredness (fatigue)
  • Shortness of breath
  • Chest pain or tightness
  • Problems with memory or concentration (‘brain fog’)
  • Difficulty sleeping
  • Heart palpitations
  • Dizziness
  • Pins and needles
  • Joint pain
  • Depression and anxiety
  • Tinnitus, earaches
  • Nausea, gastric symptoms, stomach ache
  • Postural dizziness
  • Loss of taste and smell
  • Skin rashes
  • Exacerbation of pre-existing conditions

How long will Long Covid last?

The time it takes to recover from COVID-19 is different for different individuals. Anecdotal evidence estimates that in a population of Long Covid patients who had been hospitalised, about half will recover within three months. Generally, Long Covid represents symptoms that have been present for more than two months, though there is no reason to believe that this choice of cut-off is specific to infection with the SARS-CoV-2 virus. Most people will recover within six months, and very few are still unfit to work after two years. Where there has been severe damage to an organ, such as the lungs because of scarring, the changes (in this case in the function of the lungs) may however be permanent even if the other Long Covid symptoms have disappeared.

Long Covid and Worker Health and Safety

What are or could be the effects on workers’ safety?

The impact of Long Covid is particularly concerning for workers as many symptoms and physical limitations recorded as a result of the disease could significantly impair a worker’s ability.

In the Long Covid population, fatigue, breathing issues and cognitive dysfunction remain the most recurrent debilitating symptoms listed by patients. Research has demonstrated that musculoskeletal, cardiovascular, gastrointestinal, pulmonary and neuropsychiatric symptoms were prevalent in about 85% of participants[3]. A further complication of Long Covid can be postural orthostatic tachycardia syndrome (POTS), which combines the difficulty in standing because of a sudden fall in blood pressure with a fast heart rate and a feeling of profound fatigue. These symptoms may be episodic and, in these workers, further occupational medical assessment and advice is required.

Some individuals may also have inflammation of the heart muscle (myocarditis), or even have had a heart attack, which could also affect their ability to undertake physical work. Some of these individuals can suddenly experience a rise in their heart rate from the normal level of around 70 beats per minute up to levels of 100-140 beats per minute. A further common symptom (occurring in around 10% of workers) that can occur is the condition called ‘brain fog’, a neurocognitive effect of COVID-19 infection, when a worker has difficulty with concentration and memory, usually a temporary effect.

Long Covid and implications for work ability

When considering the size of the potential Long Covid population and the fact that most of this group are workers, Long Covid presents a considerable challenge for employers because key workers may have difficulty returning to their normal jobs within usual timescales.

There remain important questions for workers, employers and their occupational health advisors:

  • What are the functional limitations of an individual worker with any condition including Long Covid?
  • What are the task requirements of their job?
  • What are their specific limitations in relation to their job?
  • What is the likely trajectory of their recovery?
  • What kind of flexibility, adjustments or modifications can be made to the job or the working hours?
  • Does the work organisation provide access to occupational health and/or rehabilitation services such as physiotherapy or mental health support?
  • Are there any safety-critical issues that need to be considered?

Assessing and supporting workers with Long Covid

If a worker with Long Covid has complex health issues that are preventing their return to work, an occupational diseases assessment will be necessary to identify their work ability and their limitations.

Key aspects of worker support and assessment could include:

  • reassessment of company sickness absence triggers and policies to accommodate the unique needs of the worker mandated by Long Covid;
  • phased return programmes to enable workers to return to work effectively;
  • programmes of temporarily decreased hours or limited duties pertaining to the needs of the worker as they recover; and
  • communication with the worker’s personal physician – providing there is consent given to do so.

Working within capacity

Phasing of work

  • Particularly important: to reduce the risk of relapses, workers should not be doing more than 70% of what they feel capable of doing at any time in order to avoid fatigue. Becoming fatigued can cause relapses in their condition and further delay their recovery.

Worker knowledge and self-assessment

  • The worker is the person who can best assess their own level of fatigue and regular discussion between worker and manager is important to guide the successful rehabilitation of workers affected by Long Covid.

Avoidable work losses

  • A small number of Long Covid workers have had to retire from work on the grounds of ill health, as a result of routine application of existing policies, but who with more time may have been rehabilitated to work.

Challenges for Prevention and Management of the Occupational Safety and Health Risks Related to Long Covid and Possible Hazards

Safety in the workplace

It is important to minimise the risks of infection and reinfection in the workplace. The SARS-CoV-2 virus is frequently changing its infectivity and all workplaces should have undertaken a risk assessment for COVID-19 infection[4], and instituted control measures.

Key actions by the employer can include:

  • Regularly update the risk assessment to account for changes in infectivity or in knowledge about infection risk.
  • Training of all workers in COVID-19 safety. This should be refreshed regularly.
  • Home working should be encouraged where possible.
  • For travelling to work, training in the assessment of the risks and implementation of control measures is advised.
  • Where necessary, risk assessment should be undertaken for workers who have underlying conditions that make them more vulnerable.
  • Workers with cognitive symptoms, sometimes called ‘brain fog’, require careful assessment if they are undertaking safety-critical tasks. This also applies to any other symptoms that could potentially affect functioning of the worker. Advice may be required from an occupational physician who may need to communicate with the worker’s personal physician.

Support of individuals with Long Covid

For workers returning to work with Long Covid, it is important that the manager regularly enquires about the employees’ health, to be aware of the limitations imposed by safety-critical symptoms and to ensure that the workers are not putting themselves, co-workers or customers at risk.

This will require actions such as:

  • regular meetings with the employee;
  • risk assessments and safety at work investigations;
  • responsibility training outlining roles of staff, management and any external engagement policies;
  • temporary redeployment to part-time work or alternative work based on the level of fatigue and symptoms experienced by the worker; and
  • for workers with complex problems, regular review by the occupational physician or the occupational health service may be necessary in relation to safety-critical tasks.

Ultimately, the prognosis is improvement of function and the objective should be to try and return the worker to full duties safely for the individual, fellow workers and the organisation as a whole.

What Measures at the Policy, Research and Practice Levels are Expected to be Effective in Diminishing the Unwanted Side Effects of Long Covid on Occupational Safety and Health?

Policy – Company level

Long Covid is currently a poorly understood condition because of the variable symptoms. Workers may be greatly affected, for example, by fatigue, but may look quite normal to their work colleagues and not get much support from their treating doctors because of the more acute patient care issues associated with the pandemic.

It is therefore important that employers:

  • recognise the importance of Long Covid for the affected individual and the organisation, identify the major symptoms experienced by the worker, and manage the worker optimally to rehabilitate them to their job, or provide alternative work.
  • establish dedicated policies within the organisation or at least have an explicit recognition of Long Covid within existing sickness absence policies.

Policy – Country level

All EU national health services have been under pressure because of the pandemic, and the care available to Long Covid workers has been variable and, in some cases, very poor because of other demands. As a result, workers who may have been very fit and may not have required hospital care but did develop Long Covid can experience poor healthcare support and feel relatively abandoned if the health service system has been overloaded by sicker people.

Due to the compartmentalising of medicine within the modern world, much national healthcare is segmented and based on disease due to single-system failures, for example, mental health, musculoskeletal, respiratory, cardiac, dermatological, neurological and so on. As such, workers may be treated by different specialists or specialised services without coordination, leading them to navigate a healthcare system that is fragmented and complex.

Workers with Long Covid whose specific health problems have been identified and treated are in need of holistic care and access to

vocational rehabilitation services. Most countries are developing one-stop clinics and rehabilitation facilities designed to rehabilitate individuals with multiple symptoms with the aim of improving their functioning and helping them return to work, but these developments have been very slow and must be a priority in the longer term.

Research needs

To improve knowledge on the specific workplace issues and improve management at the workplace level, further research is needed with occupational health academic organisations to identify:

  • the occupational needs of these workers;
  • the impact of Long Covid on the workplace and for employers;
  • the relevance for safety-critical work; and
  • the most effective workplace-based interventions that maximise work ability.

Conclusion: Preventing Future Pandemics

Breakdowns in occupational safety and health are central factors in the history of this pandemic. The origin of the SARS-CoV-2 virus is obscure, with initial reports pointing to transmission from animals in a live market. Whatever the situation, the importance of biosecurity and effective segregation of potential sources of infection has been reinforced. This increase in focus upon health and safety includes the principles of control or avoidance of hazards and best practice, including risk assessment, elimination, substitution and containment. In this pandemic, failures have been noted within the provision and adequacy of effective personal protective equipment as well as the hierarchy of prevention measures and processes; this has resulted in increased risks to workers in occupational settings as diverse as healthcare, food processing, transport and public-facing roles.

After the gruelling experiences and losses of the last two years under the pandemic, it is important that future epidemics be prevented. It is essential that employers understand that they have a responsibility to address risks from exposure to biological agents, as well as to employees for the right to safe working environments. To achieve this, it is essential to normalise hygiene and sanitation practices within the public domain, as well as to build stronger links between employers and occupational health services within a programme of assessment, employee support and effective safeguards to remain vigilant against rising infections.

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References

  1. Soriano J. B., Murthy, S., Marshall, J. C., Relan, P., Diaz, J. V., & WHO Clinical Case Definition Working Group on Post-COVID-19 Condition. (2021). A clinical case definition of post-COVID-19 condition by a Delphi consensus. The Lancet Infectious Diseases, 22(4), e102-e107. https://doi.org/10.1016/S1473-3099(21)00703-9. p. 1
  2. Varga, Z., Flammer, A. J., Steiger, P., Haberecker, M., Andermatt, R., Zinkernagel, A. S., Mehra, M. R., Schuepbach, R. A., Ruschitzka, F., & Moch, H. (2020). Endothelial cell infection and endotheliitis in COVID-19. The Lancet, 395(10234), 1417-1418. https://doi.org/10.1016/S0140-6736(20)30937-5
  3. Davis, H. E., Assaf, G. S., McCorkell, L., Wei, H., Low, R. J., Re’em, Y., Redfield, S., Austin, J. P., & Akrami, A. (2021). Characterizing long COVID in an international cohort: 7 Months of symptoms and their impact. EClinicalMedicine, 38, Article 101019. https://doi.org/10.1016/j.eclinm.2021.101019
  4. https://oiraproject.eu/en/oira-tools?search_api_fulltext=covid&sort_by=field_publication_date

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