A recent study reported prolonged symptoms of COVID-19 and found that severe disease during hospitalization was a risk factor for more symptoms and higher chronic obstructive pulmonary disease assessment test scores.
This retrospective, multicenter cohort study was conducted at 2 designated hospitals, Huoshenshan Hospital and Taikang Tongji Hospital, both in Wuhan, China. All adult patients with COVID-19 discharged between February 12 and April 10, 2020, were screened for eligibility. Of a consecutive sample of 3988 discharged patients, 1555 were excluded (796 declined to participate and 759 were unable to be contacted) and the remaining 2433 patients were enrolled. All patients were interviewed via telephone from March 1 to March 20, 2021. Statistical analysis was performed from March 28 to April 18, 2021.
All patients participated in telephone interviews using a series of questionnaires for evaluation of symptoms, along with a chronic obstructive pulmonary disease (COPD) assessment test (CAT). Logistic regression models were used to evaluate risk factors for fatigue, dyspnea, symptom burden, or higher CAT scores.
COVID-19 has spread rapidly into a global pandemic ever since the initial reports in December 2019 in China, which has caused millions of deaths.1 The disease affects multiple systems of the body in the acute phase, represented by acute pneumonia. With the increasing number of patients recovered, postinfection health consequences have been recognized. The first survivors in Wuhan, China, have now lived for 1 year, which provides an opportunity to address the long-term sequelae of COVID-19 in a large population sample.
Several studies have reported that COVID-19 survivors might have persistent symptoms, impaired lung function, and chest imaging abnormalities. At 6 months after symptom onset, 76% of patients reported at least 1 symptom, the most common being fatigue, muscle weakness, and sleep difficulties. In a prospective cohort study of 83 patients with COVID-19, dyspnea scores and exercise capacity improved at 1 year after hospital discharge, whereas radiological changes persisted in 20 (24%) patients. In another study of COVID-19 survivors 1 year after hospital discharge, post–COVID-19 symptoms included fatigue, dyspnea, chest pain, and cough. There are currently no agreed-upon measures to assess the symptom burden of COVID-19. However, the Chronic Obstructive Pulmonary Disease (COPD) Assessment Test (CAT), an 8-item questionnaire designed to quantify health status impairment in COPD patients, demonstrated a high CAT score in patients with COVID-19 in the weeks following their admission. However, the long-term symptom burden and health outcomes remain largely unknown. This study aimed to determine the long-term health outcomes associated with COVID-19 in a group of patients discharged from 2 designated hospitals of Wuhan one year after discharge.
This study reports the long-term health outcomes of COVID-19 survivors at 1-year after hospital discharge in a large cohort of patients. We found that 1095 patients (45.0%) reported at least 1 symptom, and the most common symptoms were fatigue, sweating, chest tightness, anxiety, and myalgia. Older age, female gender, and severe disease were associated with higher risks of fatigue or more symptoms. In total, 161 patients (6.6%) had CAT total scores of at least 10, for which the risk factors included severe disease during hospital stay or coexisting cerebrovascular diseases. Taken together, our study found that patients with severe disease had increased risks of more symptoms and higher CAT scores at 1-year follow-up.
COVID-19 can affect multiple organs, which leads to both acute organ damage and long-term sequelae, with the latter effects gaining increasing concerns. We found that fatigue was the most commonly reported symptom, which is consistent with previous studies. Fatigue is common after acute lung injury and is associated with substantial impairments in physical function and quality of life. High percentage of fatigue was possibly due to multiple organ injury following infection of SARS-CoV-2. Fatigue occurred in 27.7% of individuals in this study, which is lower than the 53% to 71% as reported by other studies. This is likely to be due to longer follow-up time, allowing the patients to gradually recover from previously existing symptoms.
Compared with male individuals, female patients had a significantly higher percentage of anxiety, myalgia, and headache. In a 3-month follow-up survey of patients with COVID-19, women were found to have higher percentages of fatigue, postactivity polypnea, and alopecia. Similarly, higher levels of stress, depression, and anxiety were also found in female SARS survivors. These studies all suggest that women are at greater risk of long-term symptomatic sequelae. Because anxiety was one of the most common symptoms at 1-year follow-up, the need for mental health assessment in COVID-19 survivors may be considered to help identify patients requiring psychological intervention.
In the present study, 4.2% of patients reported palpitations, which may point to long-term damage of COVID-19 to the cardiovascular system. Previously, cardiac involvement was found in 78% of German patients recovered from COVID-19 and ongoing myocardial inflammation in 60% of patients, but these cases were reported shortly after the acute illness. Also, cardiac injury was associated with an increased risk of in-hospital mortality. Because COVID-19 is still rapidly spreading over the world, more attention should be paid to cardiac damage in both the acute and postinfection phase of the disease. Changes in taste and smell were reported by a considerable proportion of patients, and these were also frequently reported in the acute phase of the disease, which suggests that COVID-19 may impact multiple sensory modalities and result in disruption of chemosensory function. In a series of mild-to-moderate symptomatic patients with COVID-19, 21.3% of patients reported persistent altered sense of smell or taste 1 year after disease onset. Taken together, our research suggests that the health consequences of COVID-19 extend far beyond acute infection.
Currently there’s no consensus on how to quantify the burden of COVID-19 symptoms. The 8-point differential item response scale of CAT—including cough, sputum, chest tightness, breathlessness, activity limitation, confidence leaving the home, sleep, and energy—had a significant overlap with the commonly reported COVID-19–related symptoms. The CAT conducted via telephone interview had a high validity and was comparable to face-to-face interviews,33 so CAT scoring may be a simple and useful tool to assess symptom burden of patients with COVID-19. In the present study, a total of 6.6% of patients had CAT total scores of at least 10, which was much lower than that reported by a previous study conducted at shorter follow-up time. In a study of 481 people in Canada without COPD, the mean (SD) CAT score was 6.9 (6.2). This indicates that the symptom burden decreased dramatically at 1-year follow-up and few people have substantial respiratory health status impairment, as measured by the CAT. In such individuals, we have found that severe disease during the acute illness and coexisting cerebrovascular diseases are risk factors. This study was done at 1 year, so further studies with longer follow-up time are still needed.
This study found that among patients who had been hospitalized with COVID-19 in Wuhan at the beginning of the pandemic, the most common symptoms at 1-year after discharge were fatigue, sweating, chest tightness, anxiety, and myalgia. Patients with severe disease had more postinfection symptoms and higher CAT scores. The findings provide valuable information about the long-term health outcomes of COVID-19 survivors and identify risk factors for sustained symptoms and poor respiratory health status, which is of importance with the coming of the post-COVID-19 era.