Long COVID and Occupational Medicine Practice

Some individuals with COVID-19 do not recover to their usual state of health, experiencing a broad array of new or continuing debilitating symptoms collectively referred to as “long COVID.”  Long COVID can have a significant impact on a worker’s return to work. In June 2023, the Centers for Disease Control and Prevention hosted the webinar Evaluating and Supporting Patients with Long COVID in Returning to Work.  As an extension of the webinar, we recently published an article in the Journal of Occupational and Environmental Medicine discussing best practices for occupational medicine (OM) physicians to handle the return to work of long COVID patients.

Medical Aspects

While a single case definition has not been widely accepted, the World Health Organization has defined long COVID as “the continuation or development of new symptoms 3 months after the initial SARS-CoV-2 infection, with these symptoms lasting for at least 2 months with no other explanation.”[1] The US Department of Health and Human Services emphasizes that “long COVID is not one condition. It represents many potentially overlapping entities, likely with different biological causes and different sets of risk factors and outcomes.”[2]  More than 200 different symptoms associated with long COVID have been identified from all 12 organ systems of the body.[3]  These symptoms can include breathlessness after exertion, cognitive impairment or “brain fog,” headache, fatigue, dysautonomia (damage to the nerves of the autonomic nervous system), and gastrointestinal symptoms.[4] [5]

A heterogeneous set of hypotheses have been proposed to explain the pathophysiology of long COVID involving viral factors, host factors, and tissue damage.[6] Prominent causal hypotheses include the following:

(1) viral persistence, either of infectious virions, viral RNA or viral proteins [7] [8];

(2) reactivation of latent viruses[9];

(3) immune dysregulation and autoimmunity triggered by the infection [6]; and

(4) chronic tissue and organ damage characterized by thrombotic endothelialitis, endothelial inflammation, hyperactivated platelets, and fibrinaloid microclots.[10]

Because of the absence of a widely accepted case definition and diagnostic criteria for long COVID, national prevalence estimates can range anywhere from 5% to 50%.[11] [12]  No definitive treatment exists for long COVID.[4] Studies have shown that receiving COVID-19 vaccination prior to contracting the virus resulted in a significant reduction in post-COVID conditions.[13] [14] New research may indicate biomarkers for diagnosis and treatment of Long COVID. [15] Recommendations exist for occupational medicine (OM) physicians seeing patients presenting with new or continuing symptoms post-acute COVID.[16] [17] Currently, therapeutic care is directed at symptom management, especially reduction in sympathetic hyperactivity, rehabilitation, and reassurance and support.[16]

Occupational Aspects

Although information regarding the impact of long COVID on the working population is still developing,[18] it is generally accepted that long COVID symptoms can impact the activities of daily living, including the ability to maintain employment.[3] Effects on the labor market may be significant with estimates that long COVID may account for 15% to 18% of unfilled jobs. [19] [20] Issues related to return to work, reasonable accommodation, modified work schedules, impairment, and disability are vital areas affecting working adults with long COVID.[21]

To prevent long COVID from becoming a disabling condition, the treating OM physician should prioritize functional-outcome measures together with clinical process measures in caring for a worker with long COVID.[22] The importance of work to worker well-being is key in the clinical approach to preventing work disability in workers with long COVID.[23] Helping workers stay at work or return to work is critical to preventing disability and an OM physician’s role in treating workers with long COVID.[23]

Some considerations for the OM physician follow.

Preventing Work Disability: Preventing work disability requires attention to both the impairment—the objective deficits in body function or structure—and all other factors that threaten optimal participation in work. Nonclinical factors can include social system impediments, such as lack of work accommodations, limited access to vocational rehabilitation, and individual difficulty overcoming health challenges.

Evaluating Function: Function should be assessed at every visit, with questions about how the condition has impacted an individual’s functioning at work and at home, exploring how exactly the individual’s symptoms interfere with work activities. There are many different patient-reported outcome measure tools that can be used to systematically track baseline against progress in functional outcomes.[22] Functional limitations should be assessed in relation to work requirements.

Job Accommodations: Some workers with long COVID cannot work at all, whereas others can with employer-provided job accommodations. Workers with long COVID symptoms that last for months or years may be covered by the Americans with Disabilities Act (ADA).[24] The ADA applies to individuals with long COVID if their condition “substantially limits one or more major life activities.” [21][25] [26] Workers who do not meet the ADA definition of disability may be protected by the Family and Medical Leave Act of 1993 (FMLA).[27] [21]

Under ADA or FMLA , when the treating OM physician determines there may be job accommodations that would permit the individual to perform his/her essential job duties, the Job Accommodation Network is a source of assistance in prescribing specific accommodations.[28] Job accommodations for workers with long COVID can help employers retain workers in a tight labor market.[29] Long COVID may be covered by applicable state or federal workers’ compensation insurance systems.[30] [31]

Occupational Medicine Practice

Experience in caring for workers with long COVID to recover function and livelihood is accumulating, primarily in large academic medical centers. The following OM practice recommendations for caring for workers with long COVID are based on a large, self-insured, medical center’s experience with hundreds of workers with the signs and symptoms of long COVID.

Return to Work

It has been well documented that returning to work as early as possible is beneficial for recovery and long-term health. However, for workers with long COVID, returning to work too early, as is true with exercise, can result in health deterioration.[32]  Because of the prolonged reconditioning and frequent tiredness after physical effort associated with long COVID, one return-to work strategy used in a large hospital-based OM practice for long COVID workers is to gradually reintroduce them back into the workplace also called gradual work titration.

Gradual work titration is a long-standing OM strategy used in a variety of conditions to support a worker in adjusting to their work environment whether the work involves physically demanding tasks. Gradual reintroduction into the workplace as a part of a return-to work plan starts with collaboration between the employee and the OM physician.[33] It can include reduced tasks, reduced length of shift, or other modifications. Currently, there is no standard protocol to guide the OM physician in developing a gradual work titration plan for long COVID because the efficacy of gradual work titration in long COVID has not been shown. Given that each worker with long COVID presents a unique grouping of symptoms, gradual work titration should be pursued only when both the patient and the OM physician believe it is appropriate.

Communication

The best outcomes occur when OM physicians foster ongoing communication among the worker, employer, and the OM physician. Workers are only required to share their OM physician’s work recommendations with their employers. However, if a worker shares additional details about the specific symptoms they are experiencing, this additional information may help employers understand a worker’s unique return-to-work needs. Occupational medicine physicians can contribute to optimal communication by using more frequent follow-up visits and by providing frequent updated work restrictions and accommodation prescriptions.

Remote Work

When available, access to remote work arrangements can further optimize a worker’s long COVID treatment plan. Many workers with long COVID suffer from physical and cognitive sensitivity to environmental conditions such as heat and noise. Working from home allows greater control of a worker’s environment and may increase work ability. When feasible, the opportunity for remote work can allow for more effective rest periods.

Work Task Prescriptions

An OM physician provides a prescription to the worker and employer to address the medical condition.  Tailoring a work task prescription to a worker’s job tasks can optimize their return to health and work ability. For example, individuals with fatigue may need to be restricted to work that is not highly paced or work that does not involve extreme physical exertion. Workers with sleep disturbances can be prescribed a later start time. Specific work task prescriptions may be necessary to keep long COVID workers safe at work and during any rehabilitation program. Workers with cognitive impairment may need to be restricted from operating heavy machinery. Workers with disturbed smell can be at risk in a job where olfactory function is crucial for safety. Consultation with the worker and the employer who together know the inherent risks of a particular job can help the OM physician develop the best work task prescription.

This blog post summarizes the more detailed article “Long COVID and Occupational Medicine Practice”.  This information can help OM physicians evaluate a worker with symptoms of long COVID despite the absence of a definition, or a pathophysiological explanation of long COVID. When meeting with a worker exhibiting long COVID symptoms, it is critical for the OM physician to understand the medical aspects of long COVID, ways to use functional measures to prevent a long COVID impairment from becoming a disabling condition, and practical approaches to assist the worker in maintaining employment.

We would like to hear from workers, employers, and OM physicians with input on what has helped workers return or remain in the workplace while battling long COVID.

The American College of Occupational and Environmental Medicine offers continuing education credits based on the content of the full article.

John Howard, MD, is the Director of the National Institute for Occupational Safety and Health.

Marianne Cloeren, MD, MPH, FACOEM, FACP, is an Associate Professor in the Division of Occupational and Environmental Medicine at the University of Maryland School of Medicine.

Greg Vanichkachorn, MD, MPH, is an Occupational Medicine physician at the Mayo Clinic in Rochester, Minnesota.

References

[1] World Health Organization. Post COVID-19 condition (long COVID). December 7, 2022. Available at: https://www.who.int/europe/news-room/fact-sheets/item/post-covid-19-condition. Accessed August 3, 2023.

[2] Centers for Disease Control and Prevention. Long COVID or post-COVID conditions. December 16, 2022. Available at: https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects/index.html/. Accessed July 5, 2023.

[3] Davis HE, Assaf GS, McCorkell L, et al. Characterizing long COVID in an international cohort: 7 months of symptoms and their impact. EclinicalMedicine 2021;38:101019.

[4] Davis HE, McCorkell L, Vogel JM, Topol EJ. Long COVID: major findings, mechanisms and recommendations. Nat Rev Microbiol 2023;21:133–146.

[5] Parotto M, Gyöngyösi M, Howe K, et al. Post-acute sequelae of COVID-19: understanding and addressing the burden of multisystem manifestations. Lancet Respir Med 2023;11:739–754.

[6] Iwasaki A, Putrino D. Why we need a deeper understanding of the pathophysiology of long COVID. Lancet 2023;23:393–395.

[7]Stein SR, Ramelli SC, Grazioli A, et al. SARS-CoV-2 infection and persistence in the human body and brain at autopsy. Nature 2022;612:758–763..

[8] Swank Z, Senussi Y, Manickas-Hill, Z et al. Persistent circulating severe acute respiratory syndrome coronavirus 2 spike is associated with post-acute coronavirus disease 19 sequelae. Clin Infect Dis. 2023:76:e487–e490.

[9] Peluso MJ, Deveau T-M, Munter SE, et al. Chronic viral coinfections differentially affect the likelihood of developing long COVID. J Clin Invest 2023;133:e163669.

[10] Turner S, Khan MA, Putrino D, Woodcock A, Kell DB, Pretorius E. Long COVID: pathophysiological factors and abnormalities of coagulation. Trends Endocrinol Metab 2023;34:321–344.

[11] Ledford H. How common is long COVID? Why studies give different answers. Nature 2022;606:852–853.

[12] Hua MJ, Gonakoti S, Shariff R, et al. Prevalence and characteristics of long COVID 7–12 months after hospitalization among patients from an urban safety-net hospital: a pilot study [published online March 24, 2023]. AJPM Focus 2023;2:100091.

[13] Marra AR, Kobayashi T, Callado GY, et al. The effectiveness of COVID-19 vaccine in the prevention of post-COVID conditions: a systematic literature review and meta-analysis of the latest research. Antimicrob Steward Healthc Epidemiol 2023. doi: 10.1017/ash.2023.447

[14] Catala M. The effectiveness of COVID-19 vaccines to prevent long COVID symptoms: staggered cohort study of data from the UK, Spain, and Estonia. Lancet Respir Med Jan 11 2024. DOI: doi.org/10.1016/S2213-2600(23)00414-9.

[15] Cervia-Hasler C, et al. Persistent complement dysregulation with signs of thromboinflammation in active Long Covid. Science 383 (6680), DOI: 10.1126/science.adg7942

[16] Mueller MR, Ganesh R, Hurt RT, Beckman TJ. Post-COVID conditions. Mayo Clin Proc 2023;98:1071–1078.

[17] National Institute for Health and Care Excellence (NICE). COVID-19 rapid guideline: managing the longterm effects of COVID-19. Version 1.20. March 11, 2022. Available at: https://www.nice.org.uk/guidance/ng188/resources/covid19-rapid-guideline-managing-the-longterm-effects-of-covid19-pdf-51035515742. Accessed July 5, 2023.

[18] Gallegos M, Morgan ML, Burgos-Videla C, Caycho-Rodriguez T, Martino P, Cervigni M. The impact of long COVID on people’s capacity to work. Ann Work Expos Health 2023;67:801–804.

[19] Bach K. New Evidence Is Showing That Long COVID Is Keeping as Many as 4 Million People Out of Work. Brookings. August 24, 2022. Available at: https://www.brookings.edu/articles/new-data-shows-long-covid-is-keeping-as-many-as-4-million-people-out-of-work/. Accessed July 5, 2023.

[20] New York State Insurance Fund. Shining a light on long COVID: an analysis of workers’ compensation data. January 24, 2023. Available at: https://ww3.nysif.com/en/FooterPages/Column1/AboutNYSIF/NYSIF_News/2023/20230124LongCovid/. Accessed July 5, 2023.

[21] US Department of Health and Human Services. Guidance on “Long COVID” as a Disability Under the ADA, Section 504, and Section 1557. July 26, 2021. Available at: https://www.hhs.gov/civil-rights/for-providers/civil-rights-covid19/guidance-long-covid-disability/index.html#footnote10_0ac8mdc. Accessed July 5, 2023.

[22] Mueller K, Konicki D, Larson P, Hudson TW, Yarborough C; the ACOEM Expert Panel on Functional Outcomes. Advancing value-based medicine: why integrating functional outcomes with clinical measures is critical to our health care future. J Occup Environ Med 2017;59:e57–e62.

[23] Jurisic M, Bean M, Harbaugh J, et al. The personal physician’s role in helping patients with medical conditions stay at work or return to work. J Occup Environ Med 2017;59:e125–e131.

[24] Americans with Disabilities Act of 1990, as amended. Available at: https://www.ada.gov/law-and-regs/ada/. Accessed August 3, 2023.

[25] Equal Employment Opportunity Commission. What you should know about COVID-19, the ADA, the Rehabilitation Act, and other EEO laws. Updated on May 15, 2023. Available at: https://www.eeoc.gov/wysk/what-you-should-know-about-covid-19-and-ada-rehabilitation-act-and-other-eeo-laws. Accessed August 3, 2023.

[26] Batiste LC; US Department of Labor. Workers with long COVID-19: you may be entitled to workplace accommodations. July 6, 2021. Available at: https://blog.dol.gov/2021/07/06/workers-with-long-covid-19-may-be-entitled-to-accommodations. Accessed August 3, 2023.

[27] Family and Medical Leave Act. 29 USC Section 2601 et seq. Accessed August 3, 2023. Available at: https://www.ecfr.gov/current/title-29/subtitle-B/chapter-V/subchapter-C/part-825.

[28] Job Accommodation Network. Accommodation and compliance: long COVID. Available at: https://askjan.org/disabilities/Long-COVID.cfm?csSearch=4456665_1/. Accessed August 3, 2023.

[29] Lowenstein F. How managers can support employees with long COVID. MIT Sloan Management Review March 14, 2022. Available at: https://sloanreview.mit.edu/article/how-managers-can-support-employees-with-long-covid/. Accessed August 3, 2023.

[30] Bernacki EJ, Hunt DL, Tsourmas NF, et al. Attributes of long duration COVID-19 workers’ compensation claims. J Occup Environ Med 2022;64:e327–e322.

[31] Zhang J, Chen L, Yu Y. Medical treatments and cost of COVID-19 claims and an early look at “long COVID” in the California workers’ compensation system. California Workers’ Compensation Insurance Rating Bureau 2022. Available at: https://www.wcirb.com/sites/default/files/documents/wcirb-longcovid-impactreport-ar-2.pdf.

[32] Wright J, Astill SL, Sivian M. The relationship between physical activity and long COVID: a cross-sectional study. Int J Environ Res Public Health 2022;19:5093.

[33] Gyllensten K, Holm A, Sanden H. Workplace factors that promote and hinder work ability and return to work among individuals with long-term effects of COVID-19: a qualitative study. Work 2023;75:1101–1112.