Justification for a living guideline for Long Covid in primary care
Increasing Covid+ Patients and estimated Long Covid
The MoH reported covid-19 patient numbers have now passed the 500,000 mark [HPB]. The real-number of Covid-19 patients is at least 25-50% more according to the consensus of most healthcare sources because the number of PCRs done by the MoH has been decreasing and even only a small percentages of the RAT done in private sector is being reported to the Ministry.
According to the current estimates from US, UK and WHO, 10% of all Covid positive patients will progress to a ‘Long Covid’ (Ref definitions) phase with continued symptoms. Therefore at this point in time there are at least 50,000 patients according to the MoH patients numbers or 75,000 according to more pragmatic estimates.
Sri Lankan factor of illness sensitivity
There is an added ‘Sri Lankan’ factor that can increase this ‘10%’ percentage to even more. This is due to the increase in illness sensitivity in Sri Lankan population. The landmark study published in the NEJM in 1962 and 2001 of Ecology of Healthcare it was reported that in a population of 1000 people in US, 80% will have symptoms and 32% will consult a healthcare provider. In a study that ascertained ecology of healthcare in a population of 1000 people in Gampaha district, over a period of one month, 94% will have symptoms and 45% will consult a healthcare facility. There is a high probability of having more Covid-19+ patients seeking healthcare due to persisting symptoms after covid.
Increase workload for OPD in public and private sectors
This will increase the already overworked /understaffed healthcare provision in both the public and private sector. One contributing factor is the Covid+ healthcare providers including doctors. Yesterday recoded the 4th doctor death was reported.
Highlighting of cardiac, respiratory and neurological symptoms
A significant issue with Long Covid is the small percentage of serious side effects in patients present with chest pain, headache and breathlessness. Some examples are with myocarditis in patients presenting with chest pain and pulmonary fibrosis with patients presenting with persisting breathlessness. The Sri Lankan newspapers have highlighted these during the past few weeks when domain specialists highlight the symptoms and the relevant diseases.
Some of the leading articles that appeared to focus attention
Breathlessness by Chest Physicians – link
Depression in Long Covid – link
However none (at least to my knowledge) have discussed the natural progression of Long Covid and its positive outlook for majority of patients and how they can be managed and helped with measures that can pickup the red flags and refer for appropriate management.
Encouraging prognosis of Long Covid from primary care
There is encouraging news of the natural prognosis of Long Covid. The April 2021 national survey from UK reported that 21% of people with confirmed covid-19 still have symptoms at 5 weeks and 13.7% at 12 weeks. (Ref) However, a recent population based longitudinal study from Australia reported high rates of recovery among adults with confirmed covid-19 (20%, 80%, 93%, and 96% at 10, 30, 90, and 120 days respectively) (Ref). This indicates that, however distressing the symptoms, most people meeting NICE criteria for long covid are on a path, albeit often fluctuating, to natural recovery.
Primary care clinic should handle Long Covid
A BMJ 2021 August editorial (Ref) by two primary care doctors suggest that ‘Long covid clinics should be run as research hubs’ and goes on to suggest that ‘multidisciplinary care is not magically beneficial and can exclude patients from decisions.’ and goes on to elaborate that ‘timely use of the skills and knowledge of different specialist professionals is helpful, but improved decisions require an evidence base showing meaningful benefit for patients and cost effectiveness. Without this evidence, there is the potential for harm through routine imaging and associated overdiagnosis, ineffective or harmful treatment, and wastage of resources through duplication of effort.14 Inconsistent advice is also a danger: without evidence based interventions people attending new clinics may be no better off, and may be worse of.
Current research in Sri Lankan Long Covid
In addition at the CNTH OPD we have seen the increase number of patients presenting with Long Covid symptoms for the past 1-2 months. We have now commenced a descriptive study of presentations of Long Covid at the CNTH OPD, UFMC-Ragama with approval of the ERC at Ragama. From next week the divisional hospital will be joining the study. This study is managed by two Post MD Trainees Dr Chandima and Dr Shalini. It is hoped that more primary care facilities may join this study under the same protocol so only addition of sites will be necessary without going in to a full ERC application. We use the same forms and patient information sheets. The data collection is online so that we are ready with the analysis at any given moment with how our patients present with Long Covid.
We also are following them to see the natural progression of disease. The stage II study will commence as soon as we have a significant number of patients which will be assigned to a two arm study in ascertaining whether mindfulness meditation or psychiatric first aid is more effective.
Need for a living Long Covid Guideline from Primary Care
Therefor this primary care living guideline for Long Covid will have our own patients presenting complains and also take into consideration the current patterns from NICE, CDC, WHO especially related to management.
All references will be available to in the section below to read and download.