Self-reported long COVID-19 symptoms are rare among vaccinated healthcare workers

Abstract

Introduction

COVID-19 pandemic adversely affected healthcare workers (HCWs). Here, we evaluate the occurence of long-COVID-19 symtoms among HCWs.

Methods

This is a questionnaire-based study of HCWs who had COVID-19 in two medical centers in Saudi Arabia and were mostly vaccinated.

Results

The study included 243 HCWs with a mean age (+ SD) of 36.1 (+ 7.6) years. Of them, 223 (91.8%) had three doses of COVID-19 vaccine, 12 (4.9%) had four doses, and 5 (2.1%) had two doses. The most common symptoms at the start of the illness were cough (180, 74.1%), shortness of breath (124, 51%), muscle ache (117, 48.1%), headache (113, 46.5%), sore throat (111, 45.7%), diarrhea (109, 44.9%) and loss of taste (108, 44.4%). Symptoms lasted for< one week in 117 (48.1%),> one week and< 1 month in 89 (36.6%),> 2 months and< 3 months in 9 (3.7%), and> 3 months in 15 (6.2%). The main symptoms present> 3 months were hair loss (8, 3.3%), cough (5, 2.1%), and diarrhea (5, 2.1%). A binomial regression analysis showed no relationship between persistence of symptoms for> 3 months and other demographic or clinical symptoms characteristics.

Conclusion

The study showed a low rate of the occurence of long-COVID> 3 months during the Omicron-wave among mostly vaccinated HCWs with no significant comorbidities. Furhter studies are needed to examine the effect of different vaccines on long-COVID-19 among HCWs.

Introduction

Coronavirus disease-19 (COVID-19), is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and was declared a global pandemic by the World Health Organization on March 11, 2020 [1]. The COVID-19 pandemic adversely affected healthcare workers (HCWs) and had added an extra-burden on healthcare organizations around the globe [2]. Of particular concern is the fact that HCWs were at increased risk of acquiring SARS-CoV-2 infection from caring for patients as well as the risk from the community [3]. HCWs had to learn and apply the ever changing medical guidelines [4].

Long-term outcomes of people infected with SARS-CoV-2 have been estimated to be 9–63% and the prevalence is up to 6–times higher than other post-viral conditions [5]. Those patients with post-COVID may have a diverse spectrum of symptoms affecting any organ with a prevalence of 35–90.5% [6]. The most common symptoms were: fatigue, dyspnea, neuropsychological disorders, and pain [6]. Al-Oraibi et al. presented a protocol of meta-analysis to examine the prevalence of long COVID-19 among HCWs [7]. One study in mid-2020 showed that long-COVID was present in in 45% of 138 HCW responding to a questionnaire after the first wave of COVID-19 [8]. In another study, 1123 (44%) of the included HCWs were vaccinated and the prevalence of long-COVID-19 was present in 73% of patients who had SARS-CoV-2 compared to 52% in those who were not infected [9]. However, that study did not examine the development of long-COVID in individuals who were vaccinated then had SARS-CoV-2 infection [9]. In the study by Peters et al., authors examined the occurrence of long COVID-19 in 2020 before the widespread use of vaccines. The authors found that 73% of 2053 participants had persistent symptoms for> 3 months and it was suggested to have follow up studies to examine impact of COVID-19 vaccination on the consequences of COVID-19 among HCWs and authors suggested to have further studies to examine the effect of vaccination on long-COVID-19 [10]. An additional study by Mohr et al. reported that 71% of 419 HCWs had one or more COVID-like symptoms 6 weeks after illness onset, with a lower prevalence among vaccinated participants (60.6%) compared with unvaccinated participants (79.1%) [11]. Thus, previous studies examined the occurrence of long-COVID-19 symptoms at different time of the pandemic and different countries than Saudi Arabia.

In Saudi Arabia, there is sparse of data regarding long-COVID among HCWs. A previous study in 2021 among the general population showed about half of 327 participants had persistent symptoms [12] and another study showed 351 (47.2%) of SARS-CoV-2 patients recovered more than 6 months [13]. A larger study among cases with SARS-CoV-2 infection showed that 225 (22·5%) patients had late symptoms [14]. The present study evaluates the prevalence of post-COVID-19 symptoms among highly vaccinated HCWs at the time of the Omicron wave in Saudi Arabia. In addition, the study adds to previous studies in relation to vaccination as previous studies showed no effect of SARS-CoV-2 immunization (given after SARS-CoV-2 infection) on the number of long-COVID symptoms [9] or studies that were done among non-vaccinated HCWs [10].

Material and methods

We conducted a questionnaire-based study of HCWs in two medical centers in Saudi Arabia, amd all included HCWs had COVID-19. We collected demographics, clinical presentation, underlying comorbidities, initial presenting symptoms and progression of these symptoms overtime. We included HCWs who were SARS-CoV-2 positive more than three months and less than 6 months and were positive between May 2022 and August 2022. The diagnosis was confirmed by SARS-CoV-2 rRT-PCR as described previously [15]. The institutional board (IRB 2022–034) approved this study.

Statistical analysis

We summarized the characteristics for continuous and categorical data as numbers and percentages. Characteristics were compared using descriptive statistics, and categorical data were compared using a chi-square test, whereby p < 0.05 was considered to indicate statistical significance. Statistical analysis was performed using the Statistical Package for the Social Sciences Program (SPSS), version 25. All statistical tests have been used with two-sided. A P value of ≤ 0.05 was considered for statistical significance.

Results

During the study period, 243 HCWs were included with a mean age (+ SD) of 36.1 (+ 7.6) years and a female to male ratio of 2.4:1. The baseline characteristics of the included HCWs are shown in Table 1. Of the participants, 223 (91.8%) had three doses of COVID-19 vaccine, 12 (4.9%) had four doses, 5 (2.1%) had two doses, and only 3 (1.2%) were not vaccinated. The most common symptoms at the start of the illness were: cough (180, 74.1%), shortness of breath (124, 51%), muscle ache (117, 48.1%), headache(113, 46.5%), sore throat (111, 45.7%), diarrhea (109, 44.9%) and loss of taste (108, 44.4%) (Table 1). Presence of comorbidities was uncommon and the top condition was hypertension (28, 11.5%) (Table 1). Symptoms lasted for< one week in 117 (48.1%),> one week and< 1 month in 89 (36.6%),> 2 months and< 3 months in 9 (3.7%) and> 3 months in 15 (6.2%) ( Fig. 1). The main symptoms that were present> 3 months were: hair loss (8, 3.3%), cough (5, 2.1%), diarrhea (5, 2.1%), headache (4, 1.6%), fatigue (3, 1.2%), palpitation (3, 1.2%) ( Table 2). In a binomial regression analysis, there was no relationship between persistence of symptoms> 3 months and clinical or demographic characteristics ( Table 3).

Table 1.

Base lien characteristics of the included healthcare workers and the presence of symptoms at the start of the SARS-CoV-2 infection.

Baseline Characteristics	Frequency	Percentage
Gender
Male	72	29.6
Female	171	70.4
Number of Vaccines
0	3	1.2
2	5	2.1
3	223	91.8
4	12	4.9
Diabetes Mellitus	14	5.8
Hypertension	28	11.5
CVS	10	4.1
Lung Disease	12	4.9
Post-transplant	7	2.9
Immunosuppressant drugs	2	0.8
Fever	67	27.6
Sore Throat	111	45.7
Cough	180	74.1
Shortness of breath	124	51
Loss of taste	108	44.4
Loss of Smell	55	22.6
Runny Nose	76	31.3
Chest Pain	77	31.7
Headache	113	46.5
Muscle ache	117	48.1
Diarrhea	109	44.9

Fig. 1.

Percent of Healthcare Workers with Symptoms at the Specified Duration after COVID-19.

Table 2.

Presence of Specific Symptoms at the specified time after infection with SARS-CoV-2.

	Time after infection with SARS-CoV-2
	< 1 week		1 week-1 month		1–3 months		> 3 months
Symptoms	Frequency	Percentage	Frequency	Percentage	Frequency	Percentage	Frequency	Percentage
Fatigue	11	25.6	20	46.5	5	11.6	7	16.3
Myalgia	4	19	9	42.9	3	14.3	5	23.8
Chest Pain	2	6.5	22	71	2	6.5	5	16.1
Cough	10	17.2	35	60.3	5	8.6	8	13.8
Wheezing	6	27.3	9	40.9	5	22.7	2	9.1
Palpitation	1	3.3	18	60	6	20	5	16.7
Headache	6	24	10	40	4	16	5	20
Hypersomnia	1	7.7	6	46.2	3	23.1	3	23.1
Depression	0	0	4	36.4	3	27.3	4	36.4
Anxiety	1	5.9	10	58.8	2	11.8	4	23.5
Poor Concentration	1	6.3	7	43.8	3	18.8	5	31.3
Memory Deficit	1	4.5	11	50	5	22.7	5	22.7
Hair Loss	2	6.9	10	34.5	12	41.4	5	17.2
Diarrhea	2	9.1	12	54.5	5	22.7	3	13.6
Constipation	0	0	13	81.3	1	6.3	2	12.5
Weight Loss	4	57.1	2	28.6	0	0	1	14.3
Loss of Taste	2	15.4	9	69.2	1	7.7	1	7.7
Loss of Smell	2	13.3	12	80	1	6.7	0	0

Table 3.

Binomial Logistic regression analyses to test the independent relationship between duration of symptoms and other clinical variables.

Clinical Characteristics	P-value	Odds Ratio	95% C.I. for odds ratio
			Lower	Upper
Number of vaccines received	0.25	0.53	0.18	1.56
Gender (Male)	0.87	0.88	0.19	4.03
Diabetes Mellitus	1	.	0	.
Hypertension	0.76	1.44	0.14	14.53
Cardiovascular system disease	0.54	0.45	0.03	5.95
Lung disease	0.80	1.61	0.03	69.17
Post-transplant	0.31	0.25	0.02	3.66
Immunosuppressant drugs	1	0	0.000	.
Fever	0.17	0.34	0.071	1.61
Sore Throat	0.04	0.18	0.032	0.96
Cough	0.43	1.72	0.44	6.83
Shortness of breath	0.32	2.04	0.50	8.30
Loss of taste	0.33	0.52	0.14	1.96
Loss of smell	0.12	3.91	0.69	22.02
Runny nose	0.13	0.33	0.08	1.37
Chest pain	0.865	0.87	0.18	4.23
Headache	0.73	1.31	0.29	6.02
Muscle ache	0.15	3.05	0.68	13.67
Diarrhea	0.16	0.34	0.07	1.56

Discussion

In this study, we evaluated self-reported post-COVID-19 symptoms among vaccinated HCWs who were infected with SARS-CoV-2 between May 2022 and August 2022, coinciding with the Omicron wave in Saudi Arabia [16], [17]. We evaluated the persistence of symptoms among 243 HCWs and the rate was 13 (5.3%) at> one month and< 2 months, 9 (3.7%) at> 2 months and< 3 months, and 15 (6.2%)> 3 months. According to the WHO, “post-COVID-19 occurs in those with probable or confirmed SARS CoV-2 infection, usually 3 months from the onset of COVID-19 with symptoms and that last for at least 2 months and cannot be explained by an alternative diagnosis” [18]. The prevalence of post-COVID-19 symptoms was thought to be 10–20% of patients 3 weeks after SARS-CoV-2 infection among non-hospitalized patients [19], [20]. In a previous study, associated factors with long-COVID-19 occurring at 6 months were the presence of severe acute illness, higher Charlson Comorbidity Index (CCI) score, and non-vaccination [21]. Before the COVID-19 vaccination, long-COVID-19 was reported in one third of surveyed HCWs in mid-2020 [8] and the occurrence was associated with the need for rehabilitation [10]. However, the low occurrence of long-COVID-19 among HCWs in this study points to the potential value of COVID-19 vaccination and the possible change in the virus behavior overtime due to the different variants.

This study was conducted during the Omicron wave and there could be a relationship between the different variants of SARS-CoV-2 and the occurrence of long-COVID. In a large study of 2560 participants, the rates of long COVID in the different waves were: 48.1% (95% CI, 39.9%−56.2%) in wave 1, 35.9% (95% CI, 30.5%−41.6%) in wave 2, and 16.5% (95% CI, 12.4%−21.4%) in wave 3 [22]. However, another study showed no difference in the occurrence of post-COVID among wild-type, alpha and delta variants with the exception of the occurrence of few general symptoms and sleep disturbance [23]. A third small study of 53 patients showed that post-COVID occurred in 5% of the included patients during the Omicron wave [24]. Thus, the data suggest that the rate of long-COVID-19 decreased overtime with the emergence of different SARS-CoV-2 variants.

We had not identified any associated factors with the persistent of symptoms in relation to demographic characteristics, acute symptoms or vaccine status. Previous studies showed variable associated factors. One study showed that older age and presence of comorbidities were associated with increased risk [22]. Another study showed that female gender, ethnicity, socioeconomic status, smoking, obesity and the presence of other comorbidities to be associated with occurrence of long-COVID [25]. In a systematic review of patients with SARS-CoV-2, presence of comorbidities and previous hospitalization were associated with higher risk of post-COVID-19 condition [26]. Thus, the lack of specific contributing factors to long-COVID in this study might be related to the generally healthy HCWs in this study.

The relationship between COVID-19 vaccination and the occurrence of post-COVID symptoms was evaluated previously. The occurrence of breakthrough SARS-CoV-2 after vaccination might be due to reduction in anti-receptor binding domain immunoglobulin G (IgG) and anti-spike IgG overtime to 94–95% at 90–180 days and 55–85% at 140–160 days, respectively [27]. An additional study among HCWs showed that breakthrough SARS-CoV-2 infections correlated with neutralizing antibody titers before the infection [28]. Thus, it is important to evaluate the prevalence of post-COVID among vaccinated individuals. One study showed that two doses of COVID-19 vaccination lowered the risk of long-COVID [26]. An additional study showed a lower rate of post-COVID-19 with increasing number of COVID-19 doses with rates as follows: 41.8% (95% CI, 37.0%−46.7%), 30.0% (95% CI, 6.7%−65.2%), 17.4% (95% CI, 7.8%−31.4%), and 16.0% (95% CI, 11.8%−21.0%) in unvaccinated, 1, 2 and 3 doses of vaccines, respectively [22]. Additionally, a systematic review showed that two doses of vaccine were more effective than one dose in decreasing post-COVID-19 symptoms [29]. However, a systematic review showed a low level of evidence (grade III, case-controls, cohort studies) that vaccination before SARS-CoV-2 infection can reduce long-COVID prevalence [30]. Thus, it is not surprising to see a lower rate of post-COVID-19 in this study as most of our patients had been vaccinated.

The definition of long COVID includes persistent symptoms or appearance of new symptoms beyond a definite period such as four weeks from the diagnosis of primary COVID-19 as suggested previously [18], [31]. In this study, the percentage of patients who reported persistent or new symptoms was 3.7–6.2% over time. Of the reported symptoms> 3 months was hair loss in 3.3% of the HCWs. In a large study from the United Kingdom, hair loss was associated with the largest adjusted hazard ratio of (3.99: 95% CI 3.63–4.39) in those with COVID-19 compared to those without COVID-19 [25]. It was suggested that loss of hair (telogen effluvium) after COVID-19 may be the result of the use of more medications or the occurrence of increased stress [32].

There is a need to examine long-COVID among HCWs in different parts of the world and overtime and in relation to vaccine. This study examined the prevalence of long-COVID among highly vaccinated population of HCWs during the Omicron wave. Thus, this study attempts to fill the gap in knowledge about long-COVID among HCWs in Saudi Arabia. However, the study has few limitations including the fact that symptoms were self-reported based on a questionnaire, and the small number of included HCWs. Thus, the study might not accurately reflect clinical diagnoses and outcomes. The included HCWs might missed reporting minor long-term symptoms but unlikely to underestimate the occurrence of major symptoms. However, other unforeseen confounders could not be entirely excluded. The study also did not include a comparison group of HCWs who were infected but were not vaccinated. However, this issue was not possible at the time of the study due to the high rate of vaccination in Saudi Arabia in general and among HCWs in specific as they were prioritized early on during the COVID-19 vaccination campaigns [33].

In conclusion, this study showed a relatively low occurrence of long-COVID among highly vaccinated HCWs who also had a low prevalence of comorbidities. The fact that the study was done during the third-wave (Omicron) and that most HCWs were vaccinated may shed lights on these factors and the contribution to the occurence of long COVID-19.

Funding

No funding was received for this study.

Declaration of Competing Interest

All auhtors have no conflict of interest to declare.