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Covid-19. Three years after the first case in Portugal, persistence of symptoms leads to thousands of consultations

Covid-19. Three years after the first case in Portugal, persistence of symptoms leads to thousands of consultations

Flat lay top view coronavirus concept.

Not all were hospitalized or had severe symptoms during the infection, but many continue to have symptoms, especially respiratory ones, and some even have to undergo physical rehabilitation. The aftermath of Covidia is still varied, and public and private hospitals are trying to respond to a situation that is still hostage to uncertainty and that has led thousands to seek help.

 

The estimates are frightening: between 10% and 20% of people infected with covid-19 can develop a long-lasting covid, characterized by persistent symptoms after 12 weeks, a condition that science is still studying but that is already considered disabling and ready to put even more pressure on the NHS. In Portugal, the number of people with long-term covid could reach 400 thousand. Some hospitals have already taken the initiative to create consultations dedicated to these cases, but the offer is still limited and confusing. Experts call for more attention to this issue and advocate the creation of an organized network to deal with this sequel of covid-19.

CNN Portugal contacted the different hospitals that offer this consultation and it is possible to see that the post-covid follow-up goes at two paces: some public and private health units, such as Centro Hospitalar Universitário Lisboa Norte and Hospital da Luz (still in a PPP with Hospital Beatriz Ângelo), for example, created the consultation in 2020, very focused on the post-discharge, but now open also to those who were not hospitalized. Other units did it in 2021 or only in 2022.

As far as numbers are concerned, there is no official count of people infected with SARS-CoV-2 who, 12 weeks later, still have symptoms and have sought help to get rid of them, but the data provided to CNN Portugal by some public hospitals show a total of 1,345 patients followed up in consultation during these three years of the pandemic – a number that will certainly be higher, since some hospitals have not responded.

In the private sector, both the Hospital da Luz and the CUF have provided only “round numbers” that, when added up, represent more than four thousand patients who have been followed due to the persistence of symptoms.

Gustavo Tato Borges, president of the National Association of Public Health Physicians, considers the issue of long-term covid with concern, not only from a medical and symptomatic point of view, sometimes disabling, but especially from the point of view of treatment and access to treatment – after all, there are not so many hospital units with specialized consultations, and primary health care is still fragile, with a shortage of family doctors able to deal with a condition where uncertainty still reigns and which science itself continues to study.

“There is a lot of uncertainty about post-Covid, there are a lot of studies being done to understand the size of the problem and the ramifications of the problem, but we are not prepared, we don’t know what’s coming, we have no idea how many people will need support, fortunately it will be fewer than those who had covid-19, but it can be a challenge because of the duration of the symptomatology,” he warns, lamenting the fact that “we don’t have much therapeutic supply for some of these situations”.

But it is not only a question of therapy, which can and will be adapted to each case, to each symptom that persists. The problem is that not all Portuguese hospitals offer this type of follow-up.

“It would always be interesting to have an organized plan for these issues, so that citizens, wherever they are, know what to do and where to go. This implies training in hospitals and general practitioners so that they know how to recognize what is happening to users,” emphasizes the public health doctor.

Manuel Carmo Gomes, epidemiologist and one of the experts who worked closely with the DGS during the pandemic, believes that the number of people with prolonged covid is high, but not necessarily serious, because it all depends on the symptoms that persist.

“On a conservative estimate,” he tells us, “at least 10% of infected people are considered to develop long-term covid,” so he challenges: “Just think, we’ve had about four million people infected at least once, and a 10% estimate gives you an idea of how many people.

That would be 400,000 in Portugal alone. “This puts pressure on the hospital system,” warns the epidemiologist, stressing the importance of organizing a “consultation and support network” for these cases.

The persistence of symptoms after acute SARS-CoV-2 infection was already noticed in the summer of 2020, weeks after the first cases of covid-19 in the world. At that time, it mainly affected those who developed severe illness, were hospitalized and even intubated. Today, the scenario is different: even those who had a mild infection can develop prolonged symptoms. And three years after the first case of covid-19 was reported in Portugal, on March 2, 2020, there are still people who feel the effects of the pandemic in their bodies.

Hospitals create multidisciplinary teams for thousands of patients

According to The Health Overview 2022 report by the European Commission and the OECD, some, but not all, EU countries have created consultations for so-called post-covid or long covid. “Portugal, Austria and Latvia have developed national clinical algorithms, patient pathways and treatment recommendations for suspected and confirmed long covid patients,” the document states.

In Portugal, post-covid consultations follow therapeutic and assessment strategies defined internally in each hospital unit, whether public or private, in accordance with the guidelines of the Directorate General of Health, which a year ago issued a standard that defines the guidelines for diagnosis and clinical approach to the post-covid 19 condition.

Doctor Margarida Serrado is at the post-covid consultation at the Pulido Valente Hospital, in the Lisboa Norte Hospital Center, which receives patients not only from Santa Maria, but also from other hospital units in the capital. As in the Hospital da Luz, the follow-up consultation was created in 2020, initially focused on pulmonary issues, but now adapted to the new reality of post-covid.

“There was a need to organize a consultation for the follow-up of the most serious patients. In the beginning, we weren’t focused on the follow-up and treatment of the entire post-covid, but that doesn’t mean we didn’t do it,” he explains, stressing that several medical specialties are involved.

In the nearly three years of follow-up after the acute infection, the doctor continues, 1,192 consultations, both initial and follow-up, have been performed, and “416 patients” have been evaluated. “The minority are patients who were not hospitalized, the majority are patients with severe pathology,” she continues.

It was in March 2021 that the covid-19 post-pneumonia pulmonology consultation was created at the Cova da Beira University Hospital Center. In total, 162 users were followed in 332 consultations, but this hospital unit in Beira Interior also created, at the same time, the Post-Covid Medicine consultation, more comprehensive in the typology of symptoms, with 31 users already followed in a total of 61 consultations.

At the Barreiro Montijo Hospital Center, the Post-Covid consultation was created in April 2021, and by the end of last year, 235 patients had been followed, in a total of 591 consultations. A total of eight specialists in internal medicine and pulmonology are involved in this consultation, which takes place every two weeks. At the Centro Hospitalar de Leiria, the post-covid consultation focuses on the respiratory part and is the responsibility of the Pneumology Department. 204 patients have already been followed up. But, as happens in other hospitals, in Leiria there is also a Covid Medicine consultation that involves other areas and specialties, including psychiatry.

Miguel Toscano Rico, a specialist in internal medicine and director of the Post-Covid Outpatient Clinic (CAP-Covid) at the Centro Hospitalar Universitário de Lisboa Central (Central Lisbon University Hospital Center), has been providing post-infection care since the beginning of the pandemic, but it was only in March 2021 that this clinic was created, having already “seen around 450 patients, referred from inpatient care (70%), other hospital specialties (20%) and general practice (10%),” he points out.

The team that makes up this clinic is diverse, as is the case with most post-operative consultations in public and private hospitals. In addition to pulmonology and internal medicine, there are specialists in neurology, cardiology, physical medicine and rehabilitation, psychiatry, nutrition and psychology.

The University Hospital Center of Coimbra created the consultation on March 15 last year and since then “85 patients have been referred until the end of 2022, with 145 consultations having been performed”. At the end of last year, the Cardiorespiratory Rehabilitation Unit was also inaugurated at the General Hospital of the Coimbra Hospital and University Center (CHUC), a space focused on the specialties of physiatrics, cardiology and pulmonology, where some patients with post-covid symptoms are monitored and undergo rehabilitation, as reported by TSF.

As for the private sector, since its creation in 2021, “at the CUF Tejo Hospital alone, thousands of patients have been evaluated” in the post-covid consultation “with the aim of identifying potential consequences and rehabilitation needs after infection,” reveals Vanessa Mendes, coordinator of General and Family Medicine at this hospital. Other units of the group also offer this consultation, with synergy between medical specialties depending on the symptoms that persist.

“In 2020, [Hospital] Beatriz Ângelo had a very large abundance of patients with covid-19, it was a brutal abundance, we quickly realized that we needed to respond to the post-discharge and we began to set up the consultation there,” says physician Sofia Furtado.

Sofia Furtado is now director of pneumology at Hospital da Luz Lisboa, but at the start of the pandemic she was also at Hospital Beatriz Ângelo, then a public-private partnership with the Luz Saúde group. She was in charge of organizing the post-pandemic response and is now the head of the private unit’s consultation.

Hospital Beatriz Ângelo
Hospital Beatriz Ângelo

“I have the peculiarity of having seen the impact of the disease in both public and private hospitals, and I can say that in any hospital structure, the impact of COVID was absolutely dramatic,” he says.

The uncertainty and the increase in the number of patients with complaints – and all of them varied – led the Beatriz Ângelo Hospital to realize that “it would be necessary to structure this consultation” and did so “in December 2020”. “It was relatively early compared to most consultations. And we did it in a very structured way” and already in harmony with Hospital da Luz Lisboa, he explains, revealing that in the consultation there are several specialists who can be called to intervene and that there is now also a rehabilitation team focused on the most serious cases.

When asked about the numbers, Sofia Furtado says that in 2021, “almost two thousand patients were seen in the consultation at the Hospital da Luz Lisboa, and then, in 2022, they didn’t reach two thousand”, but she hastens to say that other units of the same group, spread throughout the country, also have this consultation, which immediately increases the numbers mentioned.

In the Lusíadas group, “about 1,500 consultations” have been performed, although the number of people served was not specified. Doctors from the specialties of general and family medicine, internal medicine, pulmonology, cardiology, infectious diseases, and physical medicine and rehabilitation are involved in the post-covid consultation.

Data were also requested from the District Hospital of Santarém and the University Hospital Center of São João, but no response was received at the time of publication. The post-covid consultation at the Hospital Prof. Doutor Fernando Fonseca (Amadora-Sintra) was closed in December 2022, and patients with sequelae are now followed in different specialties, depending on the symptoms that persist.

More than 200 symptoms that take months to resolve
According to science, more than 200 post-covidose symptoms have been reported, symptoms that affect every organ of the human body and are not limited to each other, knocking out even the strongest immune systems. Loss of taste and smell – which for some lasted only a few days, for others weeks – and a weakened mental health are examples of the complexity of this condition.

The Centro Hospitalar Barreiro Montijo cites “fatigue, dyspnea during small exertions, memory loss, hair loss” as some of the most common complaints in post-covid consultations.

Miguel Toscano Rico, a doctor at CHULC, says that in his clinic, “the sensation of chest pain/pressure, shortness of breath, asthenia (generalized weakness), and difficulty concentrating/memory loss,” the so-called “brain fog,” were also very common. “We also had a significant incidence of depressive symptoms and persistent cough, among other things,” he adds.

The variety of symptoms and their intensity means that treatment is often multidisciplinary, but always individualized, and the length of time a person is followed varies. In some cases, a few weeks are enough to understand what the sequelae or persistent symptom is and respond with an effective treatment; in others, it can take months.

At Centro Hospitalar Barreiro Montijo, for example, the average treatment time is five months. At CHULC, the average stay is three months, but there are cases that require more time to recover. “The patients in the first waves needed much longer follow-up, and between 5 and 10% of them are still being followed up,” says doctor Miguel Toscano Rico.

The Lusíadas group says that the recovery time has been “variable,” with some people being followed for three months and others for 12. “For example, the most seriously ill patients are still in the clinic, many of the asthmatics are still being followed, and the others have been discharged when they got better, although some return after the second infection,” she explains.

“I remember a lady who was waiting for her wedding day, but had to postpone it because of the severity of her covid. A young patient, very serious, who took about six months to rehabilitate from a motor point of view. She couldn’t do anything on her own, but then she got married and came back to me satisfied with her recovery,” says Margarida Serrado, from Pulido Valente, where several patients have passed through with different recovery times, some of them close to a year.

In Coimbra, according to the hospital, “38% of the patients were discharged after three months because they had improved and there were no recurrences, 5% were discharged after six months and the rest are still being followed up because they have important pathologies – chronic pulmonary thromboembolism (PTE), myopericarditis requiring follow-up, pulmonary fibrosis and/or bronchiectasis, pre-diabetes and high blood pressure (HTA). In Leiria, the estimate is “12 months” of follow-up for full recovery after Covidien.

Long-term Covid is not an old man’s thing

As for the type of patients with post-covid symptoms, the scenario is quite heterogeneous, and if many believe that only older people are affected, the data provided to CNN Portugal shows another reality: the average age is 50 years old, but there are cases of young people, 18 years old or younger, healthy and sporty people fighting against persistent symptoms caused by the infection.

Damien Ridge, Professor of Health Studies at the University of Westminster, reveals that long covid is a reality for 2.7 percent of people aged 17-24 and 3.6 percent of people aged 25-34 – in these cases, symptoms last beyond four weeks after infection.

“It’s obvious that in the first phase, in 2021, I saw more severe cases, I saw more difficult changes in the lungs, and I saw that in young adults. The thing that severe covid was only with patients with comorbidities and severe and older is also not true,” says Sofia Furtado, from Lisbon’s Hospital da Luz.

 

BUSINESS WOMAN COVID-19
BUSINESS WOMAN COVID-19

“What struck me was the number of patients with severe COPD that I had to follow for a long time because of the lung involvement of young people, even athletes, who took months to return to normal life,” recalls the doctor.

At the Centro Hospitalar Universitário Cova da Beira, for example, the post-pneumonia consultation has already seen one patient under the age of 19 and four under the age of 29. In total, there were 162, most of them over 60, an age group in which the likelihood of having other comorbidities increases with age. One person under the age of 19 was also included in the follow-up. In total, 31 people were followed up in this consultation. In the CUF Tejo consultation, for example, people between 30 and 50 years of age were followed.

The study COVID Longa in Children and Adolescents: Fiction or Reality?, carried out by specialists from the Maternal and Child Center of the North, of the University Hospital Center of Porto, combed through several studies on the subject and concluded that “the prevalence of Long Covid in children and adolescents was very variable among the studies, ranging from 2 to 66%, but the truth is that not all hospital units follow children and adolescents, which hinders the ability to have a real perception of the problem.

As the study itself points out, the evidence on long covid in children and adolescents is limited, but the World Health Organization itself has already included long covid in the Archives of Disease in Childhood. And it is suspected that symptoms may evolve over time.

As for gender, more women come to these consultations, according to the hospitals contacted.

Vaccine slows the pace and symptoms

In 2021, a study published in The Lancet already lifted the veil on the effect of the protective shield that the vaccine has against long-lasting covid. And what happened at the Hospital da Luz in Lisbon reflects this. If in that year “many patients with severe post-covid” came to our appointment, especially recovering from pneumonia, “in 2022 we already had many patients who had mild covid and came to our appointment because of a persistent cough, a worsening of their asthma,” says Sofia Furtado, stressing the role of vaccination and booster doses.

“We have noticed a decrease in the number of patients coming to the clinic,” says pneumologist Sofia Furtado, from the Hospital da Luz in Lisbon, for whom “this is due to the effect of the vaccine. “The disease is less severe and the symptoms after acute infection are also a little different,” she explains.

At the Pulido Valente Hospital, we can already see the difference, says Margarida Serrado. Currently, this consultation is still open, but the change in the post-vaccination framework may bring changes. “Now, due to the mass vaccination, the severe forms are less frequent” and, therefore, the hospital is “thinking about remodeling” the consultation, “because the needs for which it was created are less”, reveals the doctor, explaining that today “less severe patients” come to the consultation and, therefore, “the therapeutic approach has become different”.

The Lusíadas group also wanted to highlight the role of vaccination, saying that, in relation to pneumology, “there is a pre-summer 2021 and post-summer 2021 period, with a clear relationship with vaccination and the change in severity of the disease.

“In the pre-summer 2021 phase, patients with severe respiratory diseases predominated, with prolonged follow-up that lasted more than 1 year, in the post-summer 2021 patients, dragging cough, easy fatigue without structural lung damage predominate,” clarifies the Lusíadas group.

As early as 2022, Nature reported on a study indicating that the risk of developing long covid drops by 15% after vaccination. Also late last year, the University of Cambridge found that vaccination before and after covid-19 significantly reduced post-infection conditions, although the effectiveness varied.

“Today, we see that people mostly arrive with respiratory conditioning and fatigue, which has a psychological component,” says the Pulido Valente doctor, who also points out that sleep disturbances are also common and “are now more frequent”.

But Margarida Serrado doesn’t forget what she has seen, complex clinical cases, sometimes difficult to decipher. “We saw people in very serious conditions who took a long time to return to normal life”.

Source: Daniela Costa Teixeira

https://cnnportugal.iol.pt/covid-19/long-covid/covid-19-tres-anos-depois-do-primeiro-caso-em-portugal-persistencia-de-sintomas-leva-milhares-as-consultas/20230302/63f734790cf2665294d6f2a4

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