DOCUMENT 25 FOI 25/26-1343 Research Paper

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Post-COVID syndrome

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1. Contents

Post-COVID syndrome 1

 Contents ....................................................................................................................... 1

Summary .................................................................................................................     3

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 Review, October 2025 .................................................................................................. 4
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3.1 The Trajectory of Post-COVID Syndrome 4

3.2 Diagnosing Post-COVID Syndrome 5

3.3 Treating Post-COVID Syndrome 7

3.4 The Prognostic Indicators for Post-COVID Syndrome 9

3.5 The Multidisciplinary Team and Post-COVID Syndrome 9

3.6 Post-COVID Syndrome and Chronic Fatigue 10

3.7 Psychosocial Impairments of Post-COVID Syndrome 11
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 Review, September 2023 .................................................................................           12
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4.1 Prolonged disability 12

4.2 Treatment and management 13

What is post-COVID syndrome-19? .................................................................           13

What is the prevalence of post-COVID syndrome-19? .................................              14

What are the most common symptoms of post-COVID syndrome-19? .................      15

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8. What is the current management for post-COVID syndrome-19? …………………………. 16

Permanence of post-COVID syndrome-19 ................................................................. 17

References ………………………………………………………………………………………………….. 20

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2. Summary

Update (October, 2025): The symptoms of post-COVID syndrome have diverse trajectories. While evidence is emerging that some symptoms may last for 2 years or more, many symptoms do attenuate over time. Understanding of symptom trajectory is limited by a lack of long-term studies that include symptom measures before the onset of COVID-19.

Post-COVID syndrome is not diagnosed via a single test. It requires symptoms to be present for at least 12 weeks (although some consider 4 weeks sufficient), the patient’s functioning to be impacted and alternative diagnoses to be excluded. Additionally, a patient’s medical history should be taken, their symptoms considered and a variety of test run e.g., x-rays, blood tests. Treatment is based on the symptoms present in the patient and is therefore highly individualised. There is no pharmacological treatment for post-COVID syndrome although symptoms can be treated with medication. There is limited evidence that therapy and exercise may improve some symptoms.

There is evidence that female gender, a longer hospital stay during COVID-19 infection, no COVID-19 vaccination, multiple COVID-19 infections, increased number and severity of symptoms during the infection, intensive care admission, older age, prior comorbidities and elevated Body Mass Index may be associated with post-COVID syndrome, although some sources disagree about the role of multiple infections and hospitalisation. Sources do agree that a multidisciplinary team should be involved in the rehabilitation process of post-COVID syndrome and the services of a multidisciplinary team should be offered any time from 4 weeks after the start of acute COVID-19 if rehabilitation is required.

Individuals with post-COVID syndrome often report decreased smell and taste, hair loss, rash and respiratory issues. These symptoms are less common in individuals with myalgic encephalomyelitis/chronic fatigue syndrome. Research is still underway to determine the exact relationship between these two conditions.

Psychological support, mindfulness-based approaches, peer support groups, antidepressants and, if safe, physical exercise training may be recommended for managing the long-term mental health symptoms of post-COVID syndrome based on their effectiveness in treating mental health symptoms in other conditions. The efficacy of these interventions in treating mental health symptoms in post-COVID syndrome is supported by a small amount of low- quality non-generalisable evidence.

Update (September, 2023): Heterogeneity of research data is still a significant barrier to determining the prevalence and incidence of post-COVID syndrome, the persistence of disability associated with post-COVID syndrome and any effective treatment and management techniques. Estimates of activity limitation for people with post-COVID syndrome vary between 16% and 80%. Estimates of prevalence vary considerably, though studies coalesce around estimates in the range of either 10%-20% or 40%-55%. The evidence base for treatment and management techniques is growing with some evidence supporting physical therapy,

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multimodal and personalised approaches. No pharmacological or non-pharmacological technique has emerged as a preferred pathway.

Post-COVID syndrome-19 is a collection of symptoms that persist after the initial acute phase of COVID-19 infection. While some consider 4 weeks the start of prolonged symptomology, 12 weeks is emerging as the point where post-COVID syndrome-19 can be diagnosed. The prevalence of post-COVID syndrome-19 is difficult to determine due to heterogeneity in the research data, however it is suggested to effect between 10-20% of people who survive a COVID-19 infection.

Management of post-COVID syndrome-19 will likely follow the management protocols for other post-viral syndromes, such as myalgic encephalitis/chronic fatigue syndrome, or critical illness recovery paths, for example post-intensive care syndrome.

Permanence of post-COVID syndrome-19 is difficult to determine at this point as the disease is in its infancy, however most people are expected to make a recovery over many months. Nonetheless, it is expected some people will continue to have physical and/or mental impairment that significantly impacts their functional capacity. As a consequence, the United States Department of Health and Human Services advises that post-COVID syndrome-19 can be considered a disability after patients complete an individualised assessment that indicates they have severely impaired functional capacity.

3. Review, October 2025

Long COVID is also known post-acute sequelae of COVID-19 (PASC), post-COVID-19 condition (PCC) and post-COVID syndrome (PCS). For the purpose of this review the term post-COVID syndrome will be used.

3.1 The Trajectory of Post-COVID Syndrome

NSW Health states that a small number of people may have symptoms of post-COVID syndrome for 12 or more months (2025, p. 2). A Queensland Health living evidence summary on Long COVID states it is very rare that lingering symptoms do not resolve. It reports a study in Victoria showing that 2% of hospitalised and 0.09% of non-hospitalised adults with COVID- 19 develop post-COVID syndrome (2024b, pp. 5/10). It also references data from the Centre for Disease Control (CDC) published in 2023 which found that the persistence of symptoms at 12 months was not statistically significant different between COVID test-positive and COVID test-negative participant groups. It reports that 1,288 COVID-positive participants completed the full 12 months of the study including all quarterly surveys, and 18.3% of COVID–positive participants reported persistent symptoms of any type through the 12 months.

According to the living evidence summary, many studies are poorly designed and overestimate the threat of post-COVID syndrome (2024b, p. 10). It is also acknowledged that there is a lack of large studies on post-COVID syndrome symptoms with symptom measures before the onset of COVID-19, resulting in post-COVID syndrome still being poorly defined (Ellingjord-Dale et

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al., 2024; Santoro et al., 2025). Recent longitudinal studies have shown mixed results, and the trajectory appears to be highly individual, varying for different symptoms in different people.

A 2024 Norwegian study compared persistent symptoms in COVID-positive and COVID- negative adults. The study found higher levels of persistent symptoms such as memory- and concentration problems, anosmia and dysgeusia, dyspnoea, fatigue and self-assessed worsening of overall health in COVID-positive patients. The cognitive symptoms and self- assessed worsening of overall health did not attenuate over time, with the symptoms of memory and concentration problems persisting for at least 22 months (the time of the final follow-up in the study) while other symptoms peaked during the acute phase and then exhibited a downward trend. These results held true even when correcting for symptoms before the onset of COVID-19 (Ellingjord-Dale et al., 2024). Another study comparing COVID- positive and COVID-negative individuals A 2025 study by Yeung et al. compared COVID- positive and COVID-negative patients in majority English-speaking countries. They found that, over a 9 month period, non-cognitive symptoms improved but cognitive and neurological symptoms and memory function did not change significantly in their study’s participants. For COVID-positive participants, symptoms of ongoing gastrointestinal/autoimmune/fatigue and mood symptoms appeared to reduce and cardiopulmonary symptoms also improved compared to the COVID-negative group.

Santoro et al. (2025) found evidence that, while many symptoms attenuated over time, some participants continued to experience symptoms for 2 years or longer. Predominant long-term symptoms include fatigue, respiratory sequalae and brain fog (Santoro et al., 2025, p. 6). Becker et al. (2025) found that cognitive measures of attention, working memory, processing speed, executive function and verbal learning and memory improved progressively through 42 months post-COVID. However, the measures of processing speed and executive functioning still remained below the normative mean at the end of the study (Becker et al., 2025, p. 1). Fischer et al. (2025) also identified elevated and persisting symptoms in individuals for up to 24 months after COVID infection. They identified that individual symptoms have multiple possible trajectories including remaining at a low level, increasing over time, and decreasing over time (Fischer, 2025). The variety of trajectories for each symptom is also shown by Badinlou et al. (2024). They report that most symptoms (mental functions, sensory functions, pain and body system functions) decrease over time, with a slight increase or stabilisation towards the end of the study, 12 months after infection. However, the quality of these studies is affected by the lack of control groups, different durations and follow-up time points, and decreasing number of participants with each follow-up.

3.2 Diagnosing Post-COVID Syndrome

According to the National Institute for Health and Care Excellent (NICE) Rapid Guidelines, the CDC and the World Health Organisation (WHO), post-COVID syndrome may be suspected if the person’s symptoms have not resolved 12 weeks after the start of acute COVID-19 (Queensland Health, 2024b, p. 3; NICE, 2024, p. 9). However, some consider that ongoing

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health issues 4 weeks after COVID-19 constitutes post-COVID syndrome e.g., the UK Office of National Statistics. Some also refer to an intermediary phase called ongoing symptomatic COVID for symptoms lasting between 4 and 12 weeks e.g., the NICE Rapid Guidelines (Queensland Health, 2024b, p. 3).

According to Queensland Health, to meet the criteria for post-COVID syndrome, symptoms must meet the duration criteria described above and must:

be unable to be explained by an alternative diagnosis
impact on the patient’s function (i.e. affecting their ability to perform everyday functions) (Queensland Health, 2024a).

However, there is currently no one test that can be used to diagnose post-COVID syndrome. Diagnosis is performed by a doctor based on symptoms, medical history and tests which may include:
blood pressure checks
heart rate checks
blood tests
exercise tests — including a one-minute sit-to-stand test
x-rays
lung function tests
an electrocardiogram (ECG) (HealthDirect, 2024).

For people with ongoing symptomatic COVID-19 or suspected post-COVID syndrome, the NICE Rapid Guidelines (2024) recommend a comprehensive clinical history and appropriate examination that involves assessing physical, cognitive, psychological and psychiatric symptoms, as well as functional abilities.

The comprehensive clinical history should include the following:

history of acute COVID-19 (suspected or confirmed)
the nature and severity of previous and current symptoms
timing and duration of symptoms since the start of acute COVID-19
history of other health conditions
exacerbation of pre-existing conditions (NICE 2024, p. 13).

The NICE Rapid Guidelines also recommend offering tests and investigations tailored to patients’ signs and symptoms to rule out acute or life-threatening complications and to determine if symptoms are likely to be caused by ongoing symptomatic COVID-19, post- COVID syndrome or a new, unrelated diagnosis (NICE, 2024, p. 15).

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Queensland Health’s living evidence summary (2024, p. 9) for Long COVID recommends The Post COVID Functional Scale (PCFS) and the Post-Covid-19 Yorkshire Rehabilitation Screen (C19-YRS) for the assessment and management of post-COVID syndrome (Queensland Health, 2024b, p. 9).

3.3 Treating Post-COVID Syndrome

There is no single treatment for post-COVID syndrome. Treatment aims to manage symptoms and any complications (NSW Health, 2025). As such, the treatment for post-COVID syndrome depends on the symptoms experienced by the patient. Treating doctors may refer patients to a variety of allied health specialists including:

a respiratory specialist
a cardiologist
a physiotherapist
an occupational therapist
a dietitian
a speech pathologist
a psychologist (HealthDirect, 2024).

There are currently no recommended medicines for treating post-COVID syndrome (HealthDirect, 2024). However, medications may be prescribed for symptomatic relief as needed (WHO, 2025b). General advice includes:

eat a healthy diet
stay well hydrated by drinking plenty of fluids
keep your social connections — reach out to family and friends
practise mindfulness techniques, such as breathing exercises and meditation
quit smoking or vaping
reduce how much alcohol you drink (HealthDirect, 2024).

According to HealthDirect (2024), treatments that are currently showing positive results for people with post-COVID syndrome are:

physical activity
inspiratory muscle training and pulmonary rehabilitation (types of breathing exercises)
hyperbaric oxygen therapy
physical and mental health rehabilitation programs.

The 3 Ps are also recommended:

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Pace: save your energy by breaking up your daily activities into smaller, more manageable tasks. Rest often.

Plan: spread activities that need more energy, such as gardening, food shopping and laundry, across the whole week. Plan for plenty of rest in between these tasks. If you can, ask family members or friends to help you. Consider other options like grocery delivery services.

Prioritise: only do essential tasks and activities. If you can, ask a family member or friend to help with these tasks (HealthDirect, 2024).

At the present time, there remains limited research on treatments and a lack of large studies to understand the most effective treatments. However, doctors and their patients may make individualised treatment decisions based on knowledge from similar medical conditions (WHO, 2025b).

A WHO Guideline Development Group is currently working on guidelines on diagnosis, treatment and rehabilitation in post-COVID syndrome (WHO, 2025b). A living guideline for the clinical management of COVID-19 is available and includes information about rehabilitating post-COVID syndrome (WHO, 2025a). It provides conditional recommendations for managing symptoms such as post-exertional symptom exacerbation, arthralgia, breathing impairment, cognitive impairment, fatigue, mental health, olfactory impairment, orthostatic intolerance, swallowing impairment and voice impairment. See the living guideline for more information (WHO, 2025a, pp. 81 – 92).

The current NICE Rapid Guidelines for managing the long-term effects of COVID-19 emphasise the role of self-management, a personalised rehabilitation and management plan and a multidisciplinary approach to rehabilitation including physical, psychological and psychiatric aspects (NICE, 2024, pp. 20-22).

A living systematic review by Zeraatkar et al. (2024) investigates the interventions for managing post-COVID syndrome. Results show that cognitive behavioural therapy (CBT) and physical and mental health rehabilitation are likely effective for the treatment of post-COVID syndrome with moderate certainty evidence. In particular, CBT may reduce fatigue and improve concentration, while combined programmes of physical and mental health may increase the proportion of patients who experience recovery or important improvements, and may improve quality of life and reduce symptoms of depression. However, no such evidence for physical and cognitive function, anxiety, fatigue, pain or dyspnoea was found. Moderate-certainty evidence also showed that intermittent aerobic exercise probably improves physical function compared with continuous aerobic exercise. Other interventions included pharmacological treatments (vortioxetine, leronlimab, a synbiotic (SIM01), coenzyme Q10, amygdala and insula retraining, combined L-arginine and vitamin C), inspiratory muscle training, transcranial direct current stimulation, hyperbaric oxygen, and a mobile application providing education on post-COVID syndrome (telerehabilitation mobile app). Evidence for these treatments was of low or very low certainty.

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Greenhalgh et al. (2024) include in their clinical update of post-COVID syndrome information on recommended approaches for symptom-specific treatment. It includes information on fatigue, breathing issues, chest pain, throat and voice symptoms, orthostatic intolerance, neurocognitive dysfunction, pain, poor sleep, mental health and more (see pp. 715-716 for more information).

3.4 The Prognostic Indicators for Post-COVID Syndrome

There is evidence that female gender, a longer hospital stay during COVID-19 infection, no COVID-19 vaccination, multiple COVID-19 infections, increased number and severity of symptoms during the infection, intensive care admission, older age, prior comorbidities and elevated Body Mass Index may be associated with post-COVID syndrome (Allard et al., 2022; Fischer et al., 2025, p. 1; NSW Health, 2025, p. 20; Santoro et al., 2025, p. 2). Badinlou et al. (2024, p. 1) report that initial infection severity, education and work status were significantly associated with post-COVID syndrome impairment levels in their participants in Sweden, with those with lower levels of education and those who were not employed at baseline more likely to experience a deterioration of post-COVID impairments over time (p. 4).

Importantly, Queensland Health (2024b, p. 6) report that risk of post-COVID syndrome decreases with subsequent infections, and the NICE Rapid Guidelines advise not to predict whether a person is likely to develop post-COVID syndrome based on whether they had certain symptoms (or clusters of symptoms) or were in hospital during acute COVID-19 (NICE, 2024, p. 14).

QLD Health discuss the effects of negative messaging and the media, and their implication on the recovery from post-COVID syndrome. They present the argument that negative public health messaging has induced fear of post-COVID syndrome in the population which has increased risks of functional somatic symptom disorders and of the ‘nocebo effect’ whereby “the expectation of a negative future outcome causes the very physiologic negative outcome to occur.” What is more, the hypervigilance caused by negative messaging also causes hyper-attentiveness to symptoms which further delays recovery (2024b, p. 10).

We did not find any information regarding the expected duration of post-COVID syndrome beyond what is discussed in section 3.1 above.

3.5 The Multidisciplinary Team and Post-COVID Syndrome

Multidisciplinary teams are consistently recommended in the management of post-COVID syndrome (Allard et al., 2022; NICE, 2024, pp. 21-22 WHO, 2025a, pp. 77).

As discussed above in section 3.2 patients may be referred to a variety of clinicians depending on the symptoms they are experiencing. The Australian Guidelines for the Clinical Care of People with COVID-19 state that patients with persistent symptoms or functional impairment following COVID-19 should begin rehabilitation as soon as possible in a way that is appropriate to their circumstance, setting and tolerance. Where appropriate, treatment may

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involve physical and occupational therapy, speech and language therapy, vocational therapy, as well as neurological rehabilitation and dietary intervention (National Clinical Evidence Taskforce, 2023, pp. 451/456).

The NICE Rapid Guidelines state that after ruling out acute or life-threatening complications and alternative diagnoses, practitioners should consider referring people to an appropriate service, such as an integrated multidisciplinary assessment service, any time from 4 weeks after the start of acute COVID-19 (p. 17). They recommend providing integrated, multidisciplinary rehabilitation services, based on local need and resources. According to the guidelines, healthcare professionals should have a range of specialist skills, with expertise in managing fatigue and respiratory symptoms (including breathlessness). They go on to explain that additional expertise may be needed depending on the age and symptoms of the person. The core team may include, but should not be limited to, the following specialist areas:

occupational therapy
physiotherapy
clinical psychology and psychiatry
rehabilitation medicine (NICE, 2024, p. 27).

The WHO living guidelines (2025a, p. 75) state that multidisciplinary rehabilitation professionals, mental health and psychosocial providers should be included in the national (local), coordinated care pathways for individuals who have had suspected or confirmed COVID-19 (of any disease severity) who have persistent, new, or changing symptoms. A workforce for the rehabilitation of adults with post COVID-19 condition may include but is not limited to physiotherapists, occupational therapists, nurses, psychologists, speech and language therapists, physicians, social workers and community health care workers depending on local needs (WHO, 2025a, p. 81).

A 2023 randomised controlled study with 96 ICU patients found that the intervention group, who had received medical, nursing, physiotherapy and occupational therapy interventions, had significantly better muscular strength and respiratory capacity, and significantly fewer days of hospitalisation, than the control group who received care as usual (Carvalho et al., 2023).

3.6 Post-COVID Syndrome and Chronic Fatigue

Myalgic encephalomyelitis/chronic fatigue syndrome (ME-CFS) often follows an “infectious-like” illness. Post-COVID syndrome, by definition, follows in the wake of acute infection with SARS-CoV-2 (Komaroff & Lipkin, 2023, p. 3).

Some individuals with post-COVID syndrome may have symptoms similar to those reported by individuals with ME-CFS (CDC, 2025). It has been theorised that, given the similarities between ME-CFS and post-COVID syndrome in their post-viral clinical course, overlapping symptoms, and idiopathic aetiology, post-COVID syndrome may represent another post-viral

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example of ME-CFS (Dehlia & Guthridge, 2024, p. 2). Research in this area is ongoing with no definitive answer available at this time.

A systematic review and meta-analysis conducted by Dehlia and Guthridge in 2024 revealed that 51% of patients with post-COVID syndrome satisfied ME-CFS diagnostic criteria, with fatigue, sleep disruption, and muscle/joint pain being the most common symptoms. Importantly, post-COVID syndrome patients also experienced post-exertional malaise (PEM) which is a hallmark symptom of ME-CFS. Similar findings are reported in other studies (Goldenberg, 2024).

Individuals with post-COVID syndrome frequently report decreased smell and taste, hair loss, rash and respiratory issues, which are not as common in ME-CFS (Komaroff & Lipkin, 2023, p. 4; Moneer, 2024). On the other hand, individuals with ME-CFS frequently report painful lymph nodes, chemical sensitivities and tinnitus. These symptoms are rarely reported in individuals with post-COVID syndrome (Komaroff & Lipkin, 2023, p. 4).

The recommendations for managing post-COVID syndrome are discussed above section 3.3. The TAPIB research paper RES 338 ME/CFS discusses treatment for ME/CFS.

Similarities in treating the two conditions include symptom management, lifestyle changes (scheduling activities and rest, ensuring good sleep hygiene and appropriate diet), pacing, CBT, personalised exercise programs.

3.7 Psychosocial Impairments of Post-COVID Syndrome

Common complications of post-COVID syndrome include anxiety, depression and post-traumatic stress disorder. These complications may be from post-COVID syndrome or from the stress of having a chronic illness (HealthDirect, 2024; Santoro et al., 2025).

For the clinical rehabilitation management of anxiety and depression in adults with post-COVID syndrome, the WHO living guidelines include a condition recommendation for using psychological support and, in the absence of post-exertional symptom exacerbation (PESE), physical exercise training. In addition, mindfulness-based approaches and peer support groups may be useful to reduce distress in some people with post-COVID syndrome when managing long-term symptoms (p. 87). In addition, antidepressants (e.g. amitriptyline, fluoxetine) may be considered for depression in consultation with the individual and considering personal preferences, age, concurrent medical conditions, mental health conditions (e.g. bipolar disorder) and side-effects (p. 87). The interventions in the recommendation have been proposed considering evidence for interventions for rehabilitation of anxiety and depression in other health conditions and therefore their effectiveness for post-COVID syndrome is not stated (p. 88).

Greenhalgh et al. (2024) recommend whole-person care, talking therapy, meditation, and medication (if indicated) for depression, anxiety and PTSD associated with post-COVID syndrome (p. 716).

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A 2024 systematic review of interventions for mental health, cognition and psychological well-being in post-COVID syndrome included seven studies on psychosocial interventions including CBT, cognitive processing therapy, acceptance and commitment therapy and more (Hawke et al.). The RCTs included in this review showed differences in resilience and components of quality of life in the intervention group compared to the control group. However, this study did not control for pre-test scores. Another RCT found that fewer people in the intervention group reported psychological distress, post-traumatic stress disorder and anxiety at post-treatment compared with the control group. Other non-RCT studies showed significant effects on symptoms such as anxiety, rumination, social connection and mental well-being, and a reduction in post-traumatic stress disorder, depression and anxiety, an increase in quality of life and daily functional improvements. However, the results of these studies are unable to be generalised due to small participant numbers and lack of control groups (pp. 3-4). Overall, the review’s results show that interventions are highly heterogeneous and findings are inconclusive to date (Hawke et al., 2024, p. 1).

Another systematic review (Schurr et al., 2025) found 12 studies which included psychotherapeutic interventions. Interventions included CBT, Eye Movement Desensitisation and Reprocessing, psychoeducation, cognitive training, stress management and more. While most studies showed an improvement in a range of post-COVID syndrome symptoms (depression, anxiety, quality of life, fatigue, pain, memory and others) it is not possible to draw general conclusions regarding the efficacy of these interventions due to the nature of the studies (non-randomised, non-controlled).

4. Review, September 2023

4.1 Prolonged disability

Estimates of prevalence and incidence of post-COVID syndrome, and estimates of the presence of impairment or activity limitation still vary widely. Centers for Disease Control and Prevention found approximately one quarter of adults with post-COVID syndrome report significant activity limitations (Ford et al, 2023). Reviewing 35 studies, Oliveira-Almeida et al (2023) found activity limitations in between 16% and 80% of subjects.

The World Health Organisation still endorses a prevalence estimate of 10-20% (WHO, 2022). Woodrow et al (2023) reviewed 73 studies and found prevalence estimates between 0% and 93%. An international systematic review considered 194 studies including 735,006 participants and found 45% of COVID-19 survivors experience ongoing symptoms at 4 months (O’Mahoney et al, 2022). In a review involving 120,970 patients, Di Gennaro et al (2023) found an incidence of 56.9%. In contrast, 10 longitudinal studies from the UK found continuation of symptoms after 12 weeks in 8-17% of cases (Hallek et al, 2023). Hallek et al (2023) found 15% of unvaccinated adults infected with SARS-CoV-2 met criteria for post-COVID syndrome, with lower incidence among vaccinated COVID-19 survivors. Evidence from the US also supports the rate of around 15%. Between 14% and 16% of respondents to the Household

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Pulse Survey report experiencing post-COVID syndrome (National Centre for Health Statistics, 2023).

Centers for Disease Control and Prevention found approximately 16% of adults with COVID-like symptoms reported ongoing symptoms after 12 months (Montoy et al, 2023). In contrast, Woodrow et al (2023) found prevalence estimate of 48.5% after 12 months. Woodrow et al conclude that the way in which post-COVID syndrome is defined and measured affects prevalence estimates. Estimates are lower in studies using routine health records (13.6%) compared with self-report studies (43.9%). The highest estimates were found in studies systematically investigating pathology (51.7%).

4.2 Treatment and management

No pharmacological or non-pharmacological treatment or management strategy has emerged as the favoured method among researchers or clinicians (Chandon et al, 2023; Chee et al, 2023; Fawzy et al, 2023; Marshall-Andon et al, 2023; Hallek et al, 2023).

In their review of 37 practice guidelines, Marshall-Andon et al (2023) found some consensus around education, shared decision making and personalised care for patients with post-COVID syndrome, including tailoring the modality and setting of treatment or management to the patient’s situation.

A recent review of 12 studies found physical therapy (especially, moderate exercise and interventions related to respiratory muscles) was associated with a significant improvement in fatigue, dyspnea and quality of life in patients with post-COVID syndrome (Sánchez-García et al, 2023).

5. What is post-COVID syndrome-19?

There is no internationally agreed definition of post-COVID syndrome-19, however signs and symptoms beyond 4 weeks is considered ongoing COVID-19 (Molhave et al, 2022). The World Health Organisation (WHO) recognised the existence of continuing symptoms and effects of COVID-19 after the initial infection period in September 2020, stating post-COVID syndrome-19 is:

an illness that is that occurs in people who have a probable or confirmed SARS-CoV-2 infection; usually within 3 months of onset of the infection, with symptoms and effects that last for at least 3 months. These symptoms and effects cannot be explained by an alternative diagnosis (WHO, 2021a).

In the United States, Centers for Disease Control and Prevention (CDC) advise that post-COVID-19 conditions can be identified at least 4 weeks after the initial COVID-19 diagnosis (CDC, 2022). In the United Kingdom, the National Institute for Health Care and Excellence (NICE) proposes that ‘acute COVID-19’ is the period up to 4 weeks post infection diagnosis, ‘COVID in progress’ is the experience of signs and symptoms between 4-12 weeks post infection diagnosis, and post-COVID syndrome are signs and symptoms that continue for more

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than 12 weeks after the initial infection and are not attributable to another diagnosis (NICE, 2022). A formal definition of post-COVID syndrome-19 by the Australian Health Department could not be found.

The CDC suggests post-COVID syndrome-19 is more common for people who had severe symptoms of COVID-19 during their initial infection (CDC, 2022), however the WHO advise there is no clear evidence of a relationship between initial severity of COVID-19 infection and the likelihood of developing post-COVID syndrome-19 (WHO, 2021b). What is known, is people can suffer post-COVID syndrome-19 regardless of whether they had mild or severe symptoms with the initial COVID-19 infection (Berger et al, 2021).

While research is continuing to try to identify those most at risk of post-COVID syndrome-19, some risk factors may include (Berger et al, 2021; CDC, 2022):

people who were in intensive care units during their initial COVID-19 infection
people who have underlying health conditions prior to the infection including

diabetes, heart failure, asthma, hypertension and epilepsy
demographics with health inequities such as ethnic minority groups and people with

disability
people unvaccinated against COVID-19
adults appear more vulnerable to post-COVID syndrome-19 than children.

6. What is the prevalence of post-COVID syndrome-19?

Despite the body of research emerging around post-COVID syndrome-19, the prevalence is difficult to determine due to differences in study methodology, different outcome definitions and time frames, and different symptoms and levels of severity surveyed (Emecen et al, 2022). Additionally, prevalence is influenced by social determinants, such as poverty, racism and disability (Berger et al, 2021), therefore there is considerable inconsistency in the literature depending on participant demographics.

In one United Kingdom study, 18.2% of participants reported at least one symptom 6 months post initial COVID-19 infection (Emecen et al, 2022). This is in line with the WHO (2021b) estimate that around 10-20% of COVID-19 survivors experience mid- and long-term effects after the acute phase of illness has passed. However, a systematic review cited by Maglietta et al (2022), involving 57 studies and over 250,000 survivors of COVID-19, demonstrated more than half of these survivors experienced post-acute symptoms at 6 months post initial infection. I was unable to source clear data for the persistence of symptoms beyond this time point.

Further complicating prevalence data is the influence of different variants on recovery from COVID-19. Research from the United Kingdom comparing the Delta and Omicron variants

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suggests an increased risk of ongoing symptoms at 4 weeks post infection with Delta infection (10.8% participants) than an Omicron infection (4.5% participants) (Antonelli et al, 2022).

7. What are the most common symptoms of post-COVID

syndrome-19?

It has been noted that symptoms of post-COVID syndrome-19 are similar to other post-viral fatigue syndromes such as myalgic encephalitis/chronic fatigue syndrome (Boaventrua et al, 2022; CDC, 2022), although the multisystem complications from post-COVID syndrome-19 maybe broader and more intense than other post-viral syndromes (Boaventrua et al, 2022).

The most common symptoms of post-COVID syndrome-19 reported in the literature include (Berger et al, 2021; CDC, 2022; Maglietta et al, 2022; Scordo et al, 2021; WHO, 2021b):

Physical and mental fatigue that interferes with daily life
Shortness of breath
Memory and concentration problems (‘brain fog’)
Headache
Mental health impairment (e.g., anxiety, depression, mood swings)
Abdominal pains
Muscle weakness and joint pain
Palpitations and chest pain
Dizziness
Gastrointestinal issues (e.g., diarrhea, stomach pain)
Sleep problems
Change in smell and/or taste
Pins and needles feeling
Skin lesions similar to chilblains

Post-COVID syndrome-19 may affect people differently as different organ systems become involved, and an individual’s symptoms may fluctuate or relapse over time (Berger et al, 2021; WHO, 2021b).

Figure 1 below, an excerpt from research by Yong and Liu (2021), highlights the different organ systems that may be affected by post-COVID syndrome-19:

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[Image not converted to Markdown – “Figure 1 Symptoms of the post-COVID-19 syndrome (PCS)” – check the source PDF page for the actual content]

FIGURE 1 Symptoms of the post-COVID-19 syndrome (PCS). Multiple organ systems are affected, such as psychological or psychiatric (insomnia, anxiety and depression), neurological (cognitive impairments involving memory and concentration, headache, dizziness and peripheral neuropathy), ear, nose, and throat (rhinorrhoea, smell and taste alterations, earache, tinnitus, cough, and sore throat), respiratory (dyspnoea and cough), cardiovascular (chest pain, palpitations and tachycardia), gastrointestinal (abdominal pain, nausea and diarrhoea), generalised (chills, pain and fever) and musculoskeletal (fatigue, myalgia and joint pain). Dyspnoea, fatigue, and cognitive impairments are among the topmost common PCS symptoms (references in Table 1), as reviewed in Shah et al.,³ Nasserie et al.,¹⁰ Michelen et al.¹¹ and Lopez-Leon et al¹⁹. (The human body vector was licenced from Freepik.com.)

8. What is the current management for post-COVID

syndrome-19?

There is no documented specific medication to treat post-COVID syndrome-19 (Molhave et al, 2022) and much of the current literature describes medical management of post-COVID syndrome-19. Effective management of post-COVID syndrome-19 involves symptom relief and rehabilitation (Molhave et al, 2022; WHO, 2021b), and involvement of a multidisciplinary team for patients with multiple organ systems impacted may be required (Berger et al, 2021; Kokhan et al, 2022; Molhave et al, 2022; Scordo et al, 2021; Sundar Srethstha & Love, 2021).

Particular rehabilitation programs mentioned in the literature include physical rehabilitation to improve respiratory and cardiovascular function, which is best performed within 2 months of initial diagnosis of COVID-19 (Kokhan et al, 2022; Molhave et al, 2022). Also, cognitive therapy has been shown to be effective for patients with mental fatigue (Molhave et al, 2022).

As the existence of post-COVID syndrome-19 is in its infancy, there is speculation, for example by Dr Anthony Fauci of the National Institute of Allergy and Infectious Diseases, that post-COVID syndrome-19 may have a similar aetiology to other post-infectious conditions such as myalgic encephalomyelitis/chronic fatigue syndrome (Scordo et al, 2021; Sundar Shrestha & Love, 2021). Therefore, exploring the aetiology and management of myalgic encephalomyelitis/chronic fatigue syndrome may give some insight into post-COVID syndrome-19 syndrome (Scordo et al, 2021). Current literature indicates cognitive behaviour therapy and graded exercise therapy are important in the management of myalgic encephalitis/chronic fatigue syndrome (Sharpe et al, 2021; Snook & Slowman, 2019).

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Cognitive behaviour therapy focusses on challenging fatigue related cognitions and planning social and occupational rehabilitation, while graded exercise therapy involves determining baseline ability and slowly increasing intensity and duration without exacerbating symptoms (Sharpe et al, 2021; Snook & Slowman, 2019).

Another significant medical condition that may be relevant to the understanding and management of post-COVID syndrome-19 is post-intensive care syndrome (PICS) - the presence of health problems common to patients who have recovered from critical illness in intensive care units (Parker et al, 2021). Similar to post-COVID syndrome-19, cognitive impairment (’brain fog’), extreme fatigue, muscle weakness, and shortness of breath are among the most common symptoms of PICS (Parker et al, 2021). Parker et al (2021) suggests applying the PICS post-acute phase framework to post-COVID syndrome-19 patients could involve:

Occupational therapy – provide energy conservation and work simplification strategies; address impact of cognitive impairments on work performance; monitor for residual impairment in gross and fine motor function, sensory integration or pain related to positioning (such as prolonged proning in ICU); strengthening and fine motor training using writing aids or assistive technology.
Physical therapy – ICU acquired weakness can persist for years after the acute illness has resolved, therefore physical therapy can be beneficial to improve strength and physical function.
Speech therapy – intubation injuries can extend from the voice and airway to dysphagia; dysphagia can persist for months, but most patients will recover with support.
Social workers – many patients report persistent symptoms that impact their ability to return to work. Social workers can connect patients with job resources, conduct screening for mental health impairments, and provide psychoeducation and referrals.
Primary health care – primary health practitioners should provide aftercare and care coordination for post-COVID syndrome-19 patients.

9. Permanence of post-COVID syndrome-19

For most people, the natural history of post-COVID syndrome-19 appears to be a gradual improvement of symptoms over many months (Berger et al, 2021; CDC, 2022; WHO, 2021b). However, the long-term prognosis for some people is unknown, as it is not known whether damaged organ systems will fully recover or if there will be lasting effects (Berger et al, 2021; Scordo et al, 2021). Unfortunately, it appears some people with post-COVID syndrome-19 will continue to have long-term organ compromise, long-term complex immune and homeostatic dysfunction with disabling symptoms and impaired functional levels (Sundar Srethstha & Love, 2021).

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In July 2021, post-COVID syndrome-19 became a recognised disability under the Americans with Disabilities Act, Section 504 and Section 1557 (CDC, 2022; United States Department of Health and Human Services, 2021). In the United States, as post-COVID syndrome-19 causes physical and/or mental impairment, it can be considered a disability if it substantially limits one or more major life activities such as caring for oneself, performing manual tasks, eating, walking or concentrating. Table 1 summarises further information from the United States Department of Health and Human Services (2021) regarding post-COVID syndrome-19 as a disability.

However, whether post-COVID syndrome-19 can be considered a permanent disability requires an individualised assessment to determine if the post-COVID syndrome-19 symptoms and effects substantially impact the individual’s functional capacity (United States Department of Health and Human Services, 2021).

Table 1

Information regarding post-COVID syndrome-19 as a disability (United States Department of Health and Human Services, 2021)

ADA, Section 504, and Section 1557 if it substantially limits one or more major life activities. These laws and their related rules define a person with a disability as an individual with a physical or mental impairment that substantially limits one or more of the major life activities of such individual (“actual disability”); a person with a record of such an impairment (“record of”); or a person who is regarded as having such an impairment (“regarded as”). A person with post-COVID syndrome has a disability if the person’s condition or any of its symptoms is a “physical or mental” impairment that “substantially limits” one or more major life activities.

a. Post-COVID syndrome is a physical or mental impairment.

A physical impairment includes any physiological disorder or condition affecting one or more body systems, including, among others, the neurological, respiratory, cardiovascular, and circulatory systems. A mental impairment includes any mental or psychological disorder, such as an emotional or mental illness.

Post-COVID syndrome is a physiological condition affecting one or more body systems. For example, some people with post-COVID syndrome experience:

Lung damage

Heart damage, including inflammation of the heart muscle

Kidney damage

Neurological damage

Damage to the circulatory system resulting in poor blood flow

Lingering emotional illness and other mental health conditions

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Accordingly, post-COVID syndrome is a physical or mental impairment under the ADA, Section 504, and Section 1557.

b. Post-COVID syndrome can substantially limit one or more major life activities

“Major life activities” include a wide range of activities, such as caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, sitting, reaching, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, writing, communicating, interacting with others, and working. The term also includes the operation of a major bodily function, such as the functions of the immune system, cardiovascular system, neurological system, circulatory system, or the operation of an organ.

The term “substantially limits” is construed broadly under these laws and should not demand extensive analysis. The impairment does not need to prevent or significantly restrict an individual from performing a major life activity, and the limitations do not need to be severe, permanent, or long-term. Whether an individual with post-COVID syndrome is substantially limited in a major bodily function or other major life activity is determined without the benefit of any medication, treatment, or other measures used by the individual to lessen or compensate for symptoms. Even if the impairment comes and goes, it is considered a disability if it would substantially limit a major life activity when the impairment is active.

Post-COVID syndrome can substantially limit a major life activity. The situations in which an individual with post-COVID syndrome might be substantially limited in a major life activity are diverse. Among possible examples, some include:

A person with post-COVID syndrome who has lung damage that causes shortness of breath, fatigue, and related effects is substantially limited in respiratory function, among other major life activities

A person with post-COVID syndrome who has symptoms of intestinal pain, vomiting, and nausea that have lingered for months is substantially limited in gastrointestinal function, among other major life activities

A person with post-COVID syndrome who experiences memory lapses and “brain fog” is substantially limited in brain function, concentrating, and/or thinking.

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