Post-COVID-19 manifestations among college students: shedding the light on young adults’ health

Abstract

Background

Post-COVID-19 syndrome refers to a variety of symptoms that affect different organs in the body and can persist 28 days following exposure to COVID-19. Previous studies have shown that COVID-19 affects not only elderly individuals but also young adults. However, the influence of post-COVID-19 syndrome on young adults has not been studied sufficiently. Therefore, the aim of this study was to determine the prevalence and characteristics of post-COVID-19 manifestations in young adults.

Methods

An analytical cross-sectional online questionnaire was distributed from July 2022 to July 2023 to health sciences students in Saudi Arabia. The study used a non-probability convenience sampling technique, and the sample size was calculated to be 464. The survey included questions about the participants’ demographics, health records, COVID-19 results, duration of infection, and previous and current COVID-19 symptoms. Illness severity and management were evaluated using the COVID Experiences (COVEX) Symptoms and Diagnoses module, and Patient Health Questionnaire (PHQ-9) was used to assess depression.

Results

According to the inclusion criteria, 428 participants were divided into three groups: those who fully recovered within 14 days of the acute phase (76.4%), those with prolonged symptoms that resolved within 28 days (16.8%), and those with persistent symptoms for more than 28 days (6.8%). The symptom development frequency during the acute phase significantly differed among the three groups: headache (p = 0.038), loss of smell and taste (p = < 0.001), and fatigue (p = 0.009). The symptoms that significantly differed between the prolonged group and persistent group during the post-COVID-19 syndrome phase were loss of smell and taste (p = < 0.001) and shortness of breath (p = < 0.001). The study results revealed that females are susceptible to long-COVID-19. This study revealed that the overall severity of post-COVID-19 symptoms was mild in this age group. The PHQ-9 score when comparing the three groups showed a significant association with depression (p = 0.035).

Conclusion

The study results support the perception that not only can the geriatric population suffer from post-COVID-19 syndrome but also that young adults are prone to persistent symptoms such as loss of smell and taste, which may affect their mental health status.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-024-20925-8.

Introduction

The outbreak of coronavirus disease 2019 (known as COVID-19) which led to severe acute respiratory syndrome, was first detected in Wuhan, China in late 2019 [1, 2]. The number of patients affected by COVID-19 is increasing alarmingly; by April 2022, approximately 500,186,525 people were infected, and 6,190,349 died, according to the World Health Organization (WHO) report [3]. The primary transmission routes for COVID-19 include person-to-person contact and respiratory droplets formed by coughing or sneezing [4]. In addition, as per anecdotal reports of COVID-19 survivors, the infection phase lasts 2–3 weeks [2]. As a result, the outbreak of the pandemic has mandated dramatic lifestyle changes starting with social and economic conditions [4].

There is increasing evidence that COVID-19-exposed people may experience some long-term COVID-19 symptoms, or “long-COVID-19” or “long haulers”. Long-term COVID-19 refers to a variety of symptoms affecting various organs that people might suffer from following exposure to the virus [5]. Furthermore, according to a study conducted in South Africa, 28 days is a commonly accepted time range for distinguishing the duration of acute and post-acute infections from long-COVID-19 [6]. A recent study conducted in Saudi Arabia indicated that factors such as male gender, smoking, older age, existing health conditions, and previous COVID-19 infections could predispose individuals to long term symptoms like fatigue, general discomfort, muscle pain, joint pain, and depression [7]. A recent study reported that elderly COVID-19 patients might have some prolonged symptoms; the most common symptoms were muscle ache, headache, fatigue, anxiety, and loss of smell or taste [8]. Whereas the less common symptoms were sleep problems, tachycardia, dyspnea, dizziness, fever, cough, and chest pain [8]. Previous reports have shown that older people are more susceptible to hospitalization and are at higher risk of mortality and comorbidities, which might be attributed to the status of their immune system [9, 10]. In addition, according to the Centers for Disease Control and Prevention (CDC), the prevalence of infection, hospitalization, and mortality among adults is significantly lower based on age. Patients aged 30-39-year-olds have a 4-fold greater death rate than 18-29-year-olds, and 85-year-olds have a 340-fold greater death rate than 18-29-year-olds [11]. Another study carried out in Saudi Arabia found that over 80% of the participants were relatively young, aged between 20 and 50 years, and were in good health prior to contracting COVID-19. This suggests that weakness and fatigue are prominent symptoms following recovery from the virus [12].

Although it is widely believed that young adults have a low risk of experiencing significant COVID-19 symptoms, a recent study estimated that many children and young adults exposed to COVID-19 need hospitalization [13]. Surprisingly, COVID-19 has a considerable influence on the health of young adults [2]. According to the CDC, 21.5% of people aged 18-29-years-old were exposed to COVID-19 according to a sample size of 59,230,41. Moreover, of the total deaths of 766,584 people, approximately 0.8% were between the ages of 18 and 29 years old [14]. Furthermore, about 25% of young COVID-19 patients treated at the Children’s National Hospital in Washington, DC, between March 15 and April 30, 2020, required hospitalization, and 5% required critical care [13]. In addition, a study conducted in Jordan that utilized a survey with 990 participants found that participants between the ages of 18 and 34 had the highest rates of long-term COVID-19 symptoms [15]. An online survey about COVID-19 conducted with undergraduate students at a private midwestern university suggested that COVID-19 symptoms and post-COVID-19 health problems are protracted in young adults [2]. Moreover, among participants aged 18-34-years-old in the U.S. Multistate Health Care Systems Network in March–June 2020, approximately 19% reported not having returned to their normal health status after 14–21 days of a positive test [16]. However, the most commonly reported symptom among young adults was impaired concentration. In addition, neuralgia, rhinitis, exercise intolerance, dyspnea, insomnia, mental fog, anorexia, fatigue, and chest pain have been reported [2].

Even though young adults are prone to exposure to COVID-19, the focus has been more likely on their possibility of spreading the virus [14]. According to a recent study that compared seronegative young adults with seropositive young adults, seropositive young adults had approximately one-fifth of the chance of recurrent infection. Despite developing antibodies after the initial infection, seropositive young adults do not ensure sufficient SARS-CoV-2 neutralization or protection against subsequent infections [17].

This emphasizes the importance of considering young adults’ health, especially college bachelors, since they prefer to continue attending in-person rotations at the hospital and risking their health by socializing with possible COVID-19 patients who are preparing to risk infection with COVID-19 [18].

To the best of our knowledge, there is a lack of research investigating young adults’ complications after being exposed to COVID-19. This research aimed to determine the prevalence and characteristics of post-COVID-19 manifestations in health profession students at King Saud bin Abdulaziz University for Health Sciences (KSAU-HS) in Riyadh, Jeddah, and Al-Ahsa.

Methodology

Participants

The study was conducted at KSAU-HS on three campuses and the data collection period was between July 2022 and July 2023.

The study population included all years’ students at KSAU-HS on the three campuses. The inclusion criteria included enrolled students who tested positive for COVID-19 from July 2022 to July 2023 at KSAU-HS on the three campuses. The exclusion criteria consisted of students who were exposed to COVID-19 without confirmed polymerase chain reaction (PCR) tests and students with a recent COVID-19 positive PCR result < 28 days at the time of the survey. A total of 688 participants were contacted, and 428 participants were included according to the inclusion and exclusion criteria.

The participants were divided into 2 groups. The acute phase group and the post-COVID-19 group which consisted of 2 subgroups. The prolonged symptoms group (> 14, < 28 days) and the persistent symptoms group (> 28 days).

Measures

A descriptive cross-sectional study aided in assessing the prevalence of post-COVID-19 symptoms in KSAU-HS in the study participants.

Raosoft^®ฏ software was used to calculate the sample size [19]. The total number of undergraduate students enrolled from 2022 to 2023 on KSAU-HS in the three campuses is approximately 10,669. The required sample size was estimated at the 95% confidence level with an estimated 50% response distribution and a margin of error of ± 5%. The required sample size was determined to be 371. The final sample size was increased to 464, considering the 25% non-response rate.

The data collection method for the study was an online questionnaire. The first part included participant demographic and health data, such as COVID-19 results, duration of infection, management, previous and current COVID-19 symptoms such as fever, pharyngitis, lymphadenopathy, cough, dyspnea, rhinitis, myalgia, lethargy, diarrhea, constipation, decreased appetite, vomiting, emesis, migraine, and olfaction impairment appearance. The used instrument was adopted from previous valid and reliable questionnaires used in a single-center study that was conducted to investigate post-COVID syndrome [20]. In addition, illness severity and management were evaluated using COVID Experiences (COVEX) Symptoms and Diagnoses module [21] with only 2a, 2b, and 2c questions used as done previously [2]. Patient Health Questionnaire (PHQ-9) is a self-measured scale that is used to assess depression. The score of each of the nine questions ranges from “0” (not at all) to “3” (nearly every day), and the scale has been validated for use in primary care [22]. The studied variables included primary outcomes: the length of each symptom, COVID-19 illness severity in all phases. Additionally, secondary outcomes: included the presence of depression as a consequence of COVID-19 exposure.

Statistical analysis

The data were entered and analyzed on SPSS version 20.0. For the analysis, frequency and percentage were computed for categorical variables such as gender, COVID-19 test results, COVID Experiences (COVEX), and Patient Health Questionnaire (PHQ-9) results. Mean and standard deviation were estimated for the quantitative variables as age. Frequencies and percentages are shown in tables and bar charts, and for mean and standard deviation, tables were used for display. For inferential statistics, t-tests and ANOVA were used for comparing numerical variables with categorical variables, and chi-square tests were used for the comparison of categorical variables. A P-value < 0.05 was considered to indicate statically significance.

Results

A total of 688 students completed the online survey, 428 students were included and (63.3%) of them were females. The participants were divided into two main groups, fully recovered from the acute phase group (76.4%), and post-COVID syndrome group after the acute phase which is only 14 days (23.6%). The post-COVID syndrome group (N = 101) was divided into two subgroups: Students with prolonged symptoms that eventually resolved within 28 days (16.8%) and students with persistent symptoms (6.8%) (Fig. 1).

Fig. 1.

Illustrates the number of participants included in each study group

In addition, statistical analysis revealed that 85.9% of the students may have depression according to the PHQ-9 survey outcomes and, 27 (6.3%) of the 368 students scored high which may indicate severe depression.

The symptoms severity, presence of comorbidities, depression level (Table 1), and symptoms prevalence (Fig. 2) were measured in both prolonged and persistent groups. Other comparisons were performed between the post-COVID-19 syndrome subgroups with these variables (symptoms severity, usage of medications). Means, standard deviations, and frequency counts for all demographic measures (Table 2).

Table 1.

Represents a comparison of the severity of the symptoms (from mild to critical illness) and the depression level (from non to severe depression) between the post COVID-19 syndrome groups

Fig. 2.

Represents the prevalence of the COVID-19 symptoms in the three groups. The highest significant symptoms were reported during the acute phase of COVID-19 by the recovered participants, the prolonged symptoms group, and those with the persistent symptoms. The bars represent the percentage of participants who reported the symptoms in each group

Table 2.

Represents the participants who fully recovered from the symptoms, who had prolonged symptoms and eventually recovered, and who had persistent symptoms, with clarification of these demographic measures and characteristics for each group (age, gender, long term medical condition, cigarette, and vaping use)

Symptoms prevalence and severity during the acute phase

During the acute phase of COVID-19, the most common symptoms reported by the recovered group participants were cough (68.5%), fever (65.7%), and headache (62.7%). The headache incidence was highly significantly different during the acute phase in the fully recovered group, the prolonged symptoms group, and the persistent symptoms group during the acute phase (p = 0.038). On the other hand, in the prolonged group, the most common symptoms were cough (79.1%), headache (77.2%), and loss of smell (76.4%). In the persistent group, the most commonly reported symptoms during the acute phase were loss of smell (82.7%), loss of taste (82.7%), and fatigue (82,7%). Importantly, loss of smell (p = < 0.001), loss of taste (p = < 0.001) and fatigue (p = 0.009) were highly significant in the whole population during the acute phase compared to the other symptoms. One participant reported that she experienced bone pain during COVID-19 incubation, which continued even after recovering (Fig. 2). (For further information. See Additional File 1).

A total of 56.2% of the recovered participants had a mild illness during the acute phase of the disease. Most of the participants with prolonged symptoms reported having a moderate illness (56.9%) during the acute phase. Additionally, 58.6% of the persistent symptoms group rated their acute illness as moderate. Importantly, there was a highly significant association between symptoms during the acute phase and severity (p = 0.003). (For further information. See Additional File 2).

Prevalence and severity of symptoms post-COVID-19

Of the 72 participants who experienced prolonged symptoms, approximately half (48.6%) reported a loss of smell, and one-third (33.3%) had shortness of breath and reported a loss of taste after COVID-19 infection. On the other hand, the most commonly reported symptoms in the persistent group were loss of smell (41.3%) and continued experience of shortness of breath (37.9%). Two participants reported that they experienced smelling bad odors (2.7%). (For Further Information. See additional File 3). The participants who experienced prolonged symptoms and eventually recovered (58.3%) reported their post-COVID-19 illness as mild. As a result, there was a highly significant association between symptoms (loss of smell, shortness of breath, and loss of taste) and mild illness severity in the prolonged and persistent groups during the post-COVID-19 phase (p < 0.001). Additionally, one half (51.7%) of the persistent symptoms group reported post-COVID-19 illness as mild (Table 1). Moreover, approximately one-half of the participants in the prolonged symptoms group (50%) and in the persistent group (51%) used medication for post-COVID-19 symptoms. (For further information. See Additional File 4).

Depression severity among all groups

The depression scale showed a highly significant association with the three groups (p = 0.035). The majority of the participants in the recovered group (n = 104, 38.1%) had mild depression. Whereas lower mild depression scores were observed in the prolonged symptoms group (n = 20, 29.9%), and this was the most frequent depression level scored. However, the persistent symptoms group had moderate depression, and it was the most frequent depression level scored (35.7%). Which proved that the persistent symptoms group had a greater severity of depression than the recovered and prolonged symptoms groups. (For Further Information. See additional File 5)

Smoking cigarettes and using vape devices

The total participants who answered (yes, daily) to the question (Do you smoke cigarettes?) were 13 participants, and 9 of them were from the recovered group (69.2%), 1 (7.7%) from the prolonged symptoms group, and 3 (23.1%) from the persistent symptoms group. However, there was no significant association between smoking and post-COVID syndrome (p = 0.206). Furthermore, 41 of the participants answered (yes, daily) to the question (Do you use vaping devices?). 31 of them were in the recovered group (75.6%), 6 had prolonged symptoms but eventually recovered (14.6%), and 4 were in the persistent group (9.8%). The vaping did not demonstrate significant differences (p = 0.945).

Discussion

Understanding COVID-19 is crucial, as despite the announcement of the disease as a pandemic almost three years ago, the number of cases reported by the WHO continues to increase [3]. Although young adults are susceptible to COVID-19 complications, the majority of related research has investigated geriatric health. As stated by a recent study, the insufficiency of SARS-CoV2 neutralization in young adults leads to subsequent infections [17]. In particular, in health professions, students since they need to attend clinical rotations in the hospital [18]. There is a lack of research measuring the difficulties that young adults may experience after being exposed to COVID-19 globally, particularly in Saudi Arabia. Hence, this study shed light on young adults’ health regarding the prevalence and characteristics of post-COVID-19 manifestations and investigated the associations between post-COVID-19 symptoms with depression and severity. additionally, the prevalence of other comorbidities was determined among health profession students at King Saud bin Abdulaziz University for Health Sciences on the three campuses.

This study revealed evidence that young adults can also suffer from post-COVID-19 syndrome. In line with the study findings, 16.8% of the patient were included in the prolonged group, and approximately two thirds of those in this group continued to experience at least two symptoms. the persistent group accounted for 6.8%, and three quarters of the patients had at least two symptoms after the COVID-19 incubation period. A longitudinal study included 201 participants who supposedly recovered from COVID-19. A total of 98% of them still suffered.

from four months after COVID-19 onset. These symptoms included fatigue, myalgias, headache, and cardiorespiratory and gastrointestinal symptoms. Moreover, in 70% of the sample, impairment in one or more organs, including the heart, lungs, kidneys, liver, pancreas, and spleen, was identified using multiorgan magnetic resonance imaging (MRI). Fewer patients in this sample had a prior medical history, and only 18% needed to be admitted to the hospital during the acute phase of the disease [23]. However, it remains unknown whether some or all individuals with post-COVID-19 syndrome will eventually return to their pre-COVID-19 level of health and functioning.

The majority of the participants who experienced persistent symptoms were females, while males accounted for only 17% of the participants, similar to the findings of previous studies [2, 24]. Correspondingly, a previous study revealed that there was a sex difference in post-COVID-19 sequelae. Compared with males, female experienced more severe post-COVID-19 symptoms. The scientific justification behind this phenomenon is that females have low levels of SARS-CoV-2 antibodies, and males have more long-lasting SARS-CoV-2 antibodies in their saliva over time than females [25].

Moreover, this study revealed that the prolonged and the persistent groups showed a highly significant association between the following symptoms: loss of smell, shortness of breath, and loss of taste. A recent study suggested that 51% of the students who recovered from COVID-19 continued to suffer from persistent symptoms, including headache and shortness of breath [2]. Like in our study, a single-center questionnaire conducted on 1007 participants who recovered from COVID-19 reported that loss of smell, loss of taste, and shortness of breath were persistent even after COVID-19 acute illness [20]. A similar pattern of reported symptoms indicates a threatening health situation. Additionally, the overall severity of post-COVID-19 symptoms was described as a mild illness, although some participants had to seek healthcare advice regarding their protracted symptoms. However, in a similar study, the majority of participants described post-COVID-19 symptoms as moderate illness [2].

Furthermore, many studies have measured the depression levels among students during The COVID-19 pandemic. In this study, the depression scale score was strongly significantly associated with the scores of the recovered participants, the prolonged participants, and the persistent participants. Moreover, there are several participants who experienced severe levels of depression, in which they answered “Yes” to the question of (Thought that you would be better off dead, or of hurting yourself). Our results align with these of earlier study showing that the persistent group had the most severe level of depression [2]. Several studies have emphasized the association between poor academic performance and depression among students. Also, a study specified that low academic function and a drop in GPA are related to mental health problems and emotional problems [26]. Moreover, neither smoking cigarettes nor vaping devices demonstrate an association similar to the findings of a previous study [2].

Strengths

To the best of our knowledge, there is a lack of research investigating post-COVID-19 syndrome in the young adults in Saudi Arabia. Accordingly, the importance of this study is to focus specifically on young adults’ physical and mental health after being infected with COVID-19. Moreover, it measures the prevalence of the post-COVID-19 symptoms, severity and depression. Furthermore, the population of this study included students from three different campuses.

Limitation

The study utilized self-reported data, which may acquire some disadvantages, such as underreport or participants may be embarrassed to reveal some of the details. Moreover, some responses could be exaggerated, and response bias is one of the common phenomenon associated with self-reported data. Additionally, the cross-sectional design of the study may limit its ability to establish causality or track the progression of symptoms over time. Furthermore, the sample is homogeneous, consisting solely of health sciences students from a single university, which restricts the generalizability of the findings to other young adult populations. Thus, future studies are guaranteed to explore the post-COVID-19 syndrome in more diverse student populations with a longitudinal study design.

Recommendations

Further research regarding the long-term effect of COVID-19 involving other age groups, such as adolescents, is required. Furthermore, covering more diverse student populations to extend the generalizability of the findings to other young adult populations is highly suggested. Moreover, future research is encouraged to demonstrate the importance of longitudinal studies to detect any developments or changes in the characteristics of the target population. Importantly, future studies are guaranteed to investigate the role of pre-existing conditions or lifestyle factors, such as smoking or vaping in post-COVID-19 outcomes.

Additionally, the study outcomes demand that the medical and scientific communities to closely monitor the persistent symptoms of young adults who were exposed with COVID-19 infection, especially their mental health. In addition, to shed the light on the impact of post-COVID-19 symptoms on the academic performance.

Conclusion

Our results indicate that some of the participants had prolonged and persistent symptoms, which suggests of possible evidence that young adults could be long haulers. However, post-COVID-19 syndrome has been a subject of numerous researchers worldwide, so people should be enlightened about this syndrome. Moreover, people should be aware of follow up with doctors in case the symptoms of COVID-19 persist for a long period of time, as these symptoms may disturb the quality of life.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Abbreviations

SARS-CoV-2

Severe acute respiratory syndrome coronavirus 2

WHO

World Health Organization report

CDC

Centers for Disease Control and Prevention

COVID-19

The Novel Coronavirus Disease 2019

KSAU-HS

King Saud bin Abdulaziz University for Health Sciences

PCR

Polymerase chain reaction

COVEX

COVID Experiences

PHQ-9

Patient Health Questionnaire

SPSS

Statistical Package for the Social Sciences

Author contributions

AAA, RAA, MEA, YAD, and AYH conceptualized the project and collected the data. MAK conceptualized the project and analyzed the collected data. AAA, RAA, MEA, and YAD wrote the entire manuscript. AYH, MAK, and FFA reviewed, edited, and approved the final version of the manuscript.

Funding

None.

Data availability

Data is provided within the manuscript or supplementary information files. If any additional information is required please contact the corresponding author.

Declarations

Ethics approval and consent to participate

IRB approval was obtained prior the data collection from King Abdullah International Medical Research Center, SP22J/135/08 dated July 2022. Informed consent was obtained from all the participants. Subject confidentiality was maintained through the process of this research.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.