Assessment of Persistence Symptoms in Recovered COVID-19 Patients by Yorkshire Rehabilitation Scale (C19‐YRS): A Cross-Sectional Study from Qassim Region, Saudi Arabia ()
1. Introduction
At the beginning of 2020, a Chinese-originated contagious viral infection was rapidly spread worldwide, which was declared by the world health organization (WHO) a global pandemic [1] - [8].
This pandemic has greatly impacted people’s lives not only medically but at different levels of communities. Up to date, there are almost one billion confirmed cases and 7 million deaths globally specifically in the Kingdom of Saudi Arabia. More than 800 thousand cases were confirmed and almost 9 thousand plus deaths were reported [9].
Despite those years have passed and the pandemic in the waning phase, multiple persistent symptoms were reported post-recovery of acute infection.
Indeed, various authors have used different names such as “post-COVID-19 syndrome”, “long COVID-19”, “long-term COVID-19 effects”, “long haulers” and “persistent COVID-19 symptoms” [10], which refer to various conditions such as lasting inflammation, sequelae of organ damage, hospitalization and social isolation. [11] However, the WHO has established a clinical case definition of the post-COVID-19 syndrome: “it occurs in individuals with a history of 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” [12].
The original cause of the persistence of symptoms is not well defined, but several hypotheses have been produced [13]: aberrant immune responses, virus-specific pathophysiological alterations, inflammatory damage in response to the acute infection [14], and mechanisms of viral persistence in certain tissues [15] [16], SARS-CoV-2 interactions with host microbiome/virome communities, clotting or coagulation issues [17].
Furthermore, underlying risk factors can be involved: severity of early COVID-19, including symptom load, level of hospital care and the necessity for mechanical ventilation [18], female gender [18], age [19] [20] [21] [22], presence of comorbidity [21] [22] [23] [24] [25] and minority ethnicity [25] [26] foster the development of long COVID.
Moreover, COVID-19 vaccines decrease the risk of contracting infection; however, studies disagree on their protective effect against long COVID [27].
The respiratory system is known to be the most frequently affected by the COVID-19 acute illness phase, which is prolonged in the post-COVID-19 phase after patients’ recovery [10]. However, it is now well recognized that extrapulmonary systems such as the cardiovascular (CV) and nervous systems are also affected [10], producing symptoms such as cough, shortness of breath, fatigue, headache, chest pains, gastrointestinal issues, joint pains and loss of taste and smell, along with neuropsychiatric symptoms, for instance, insomnia, delirium, depression, and anxiety [28] - [36].
As all that has been said, these long-term effects of COVID-19 will have a great impact on the future of the country’s public health by causing permanent disabilities and maximizing the burden of chronic diseases [37]. Hence, the aim of this paper is to fulfill the knowledge gap in the literature by providing information regarding the persistence of symptoms in COVID-19 recovered patients in Qassim Region, Saudi Arabia, as we didn’t find a similar study had been conducted in Qassim Region. Additionally, it provided an in-depth study regarding the identification of persistency of symptoms or multi-organ dysfunction in recovered confirmed cases.
2. Materials and Methods
2.1. Study Design, Setting, and Population
This cross-sectional study was carried out between 1st January 2021 to 31st March 2022 in Qassim Region, Saudi Arabia, which is located in the central part of Saudi Arabia with an estimated population of 1.5 million in 2020 [38]. There are 19 Governmental hospitals and 165 PHCCs providing health care services under different specialties in the region. The target population was patients who were diagnosed with positive PCR of COVID-19 in the Qassim region.
2.2. Sample Size
The sample size was calculated using the Epi Info Stat calculator. According to the Saudi CDC, the total number of reported positive cases of COVID-19 in the Qassim region was 14,129 cases (2d February 2021). We assumed the prevalence rate of COVID-19, 50% for the calculation of the sample size in this study. At 95% confidence level, 5% margin of error, and a design effect of 2.0. So, the required sample size was 375 participants. Assuming the non-response rate of participants was 10% (38 cases), in addition to 375, it gave a total of 413 participants needed to be invited to achieve the required sample.
2.3. Sampling Procedure
Convenience sampling was applied for the selection of positive PCR Covid-19 cases. The enrolled participants were obtained from the official governmental registered system (HESN surveillance program of COVID-19. Inclusion criteria were adult confirmed COVID-19 patients with +ve PCR results registered in the surveillance system. After explaining the purpose of the study and getting approval from the administration, participants were contacted and invited to participate in this study. A total of 413 respondents filled the questionnaire through a telephone survey.
2.4. Data Collection Procedure and Instrument
A structured questionnaire [COVID-19 Yorkshire Rehabilitation Scale (C19-YRS)] was used for collecting the data [39]. Patients over 18 years old who were diagnosed as positive COVID-19 (WHO criteria) in Tetamman clinics and registered in the records, were interviewed by telephone survey. The questionnaire contained 35 items divided into three sections. Questions in the first section collected information about patients’ age, gender, nationality, education, family size, history of comorbidity, smoking status, and regular exercise. The second section collected the clinical characteristics of the patients, including symptoms at the beginning of the disease and after 2 weeks, medication vaccination status, and duration of isolation. The third part assessed the patient’s clinical status by using the C19-YRS checklist [40]. The checklist was administered by telephone and guided the interview. It aimed to underline the persistent symptoms and their intensities concerning the pre-infection condition in a bio-psycho-social way. Moreover, it highlighted three different classes of Post Covid Syndrome (PCS) severity for each symptom (<3 = mild; 3 - 5 = moderate; 6 - 10 = severe). [40] The clinical assessment through the C19-YRS application covered all the domains according to the International Classification of Functioning (ICF), thus investigating symptoms related to body functions and structures, limitations to activities, and participation restrictions considering personal and environmental factors. We selected 10 of the 22 items, the ones directly or indirectly measurable through validation. In the tests and questionnaires, thus we were concerned with: breathlessness at rest, during dressing and stairs, fatigue, pain/discomfort anxiety, depression, communication, mobility, personal care, usual activities, and global health.
2.5. Data Analysis
The collected data were entered and analyzed in SPSS (version 21) Chicago, IL, USA. Descriptive statistics (mean, standard deviation, and frequency) were calculated for all clinical parameters and C19-YRS items for ICU-hospitalized, Ward-hospitalized patients, and Home isolated patients. The Chi-Square test was used for between-groups differences. C19-YRS outcomes have been examined considering frequency and intensity in the answers given. The scale’s internal consistency has been checked by Cronbach’s alpha coefficient, a magnitude index for the between-items coherence, where values of >0.70 represent high consistency. The level of significance will be p < 0.01.
2.6. Ethical Considerations
The ethical approval was taken from the Regional Research Ethics Committee, Qassim region (Approval #: 1442-1459584). A permission letter was obtained from the regional director of the Qassim MOH before starting the data collection. Verbal Informed consent was obtained from each participant before commencing the data collection. The researcher preserved the participants’ confidentiality at all steps of the study for the data collection, analysis, and results.
3. Results
3.1. Sample Characteristics
A total of 413 confirmed COVID-19 patients were enrolled in this study; their data was obtained from the HESN surveillance program of COVID-19, Qassim Health Cluster. The personal characteristics of COVID-19 Patients are given in Table 1.
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Table 1. Socio-demographic characteristics of the study population, Qassim, KSA 2021.
Male patients were 219 (53.0%) while females were 194 (47.0%). Their average age was 38.7 (±14.97) years. All of them were of Saudi nationality. More than half of the patients had college and postgraduation education 270 (65.4%). The reported patients were from different geographical areas in the Qassim region but the bulk of cases was from Buraydah city153 (37.0%). More than two-thirds of the patients were non-smokers 330 (79.9%) and didn’t practice regular physical exercise 297 (71.9%), Table 1.
3.2. Patients’ Clinical Profile
One hundred and sixty-six (40%) COVID-19 patients had a history of chronic diseases. Among them, Diabetes 64 (15.5%) and hypertension 60 (14.5%) were the dominant co-morbidity. Table 2 Majority of the covid-19 patients 371 (89.8%), were isolated at home, and of them, 37 (9.0%) were admitted to the hospital, and only 5 (1.2%) cases were treated in the Intensive Care Unit (ICU). Most of the surveyed patients 382 (92.5%) had been covered with the 1st dose of the COVID-19 vaccine at the moment of the data collection; while a few of them 60 (14.5%) had taken the Flu vaccine. The average duration of patients’ isolation was 14.8 (±5.53) days. The patients’ treatment is mentioned in Table 2.
Table 3 shows the patients’ symptoms at the beginning of the COVID-19 infection, fever was the most common complaint 332 (80.4%), with 267 (64.6%) of patients reporting fatigue of varying severity, followed by loss of smell 230 (55.7%). Near half of the patients felt body ache and muscle pain 202 (48.9%), followed by loss of taste 197 (47.7%). Among the respiratory symptom, Cough
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Table 2. History of Chronic diseases and vaccination status of COVID-19 patients, Qassim, KSA 2021, (n = 413).
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Table 3. Comparison between patients’ symptoms before and after 15 days from the beginning of COVID-19 disease, (n = 413).
158 (38.3%) was the commonest followed by shortness of breathing (SOB) 129 (31.2%), congestion or running nose 97 (23.5%), sore throat 88 (21.3%), and chest pain or pressure 75 (18.2%). Approximately one-third of patients also experienced nausea (32.0%) and other Gastrointestinal symptoms such as diarrhea 70 (16.9%) and vomiting 55 (13.3%). A few patients had psychological problems such as anxiety 23 (5.6%) and depression 14 (3.4%). Other symptoms also reported such as dizziness, sweating, skin rash, Hair falling, Bad dreams, and Hallucinations were troublesome for very few of the respondents, Table 3.
We compared the patients’ symptoms at the beginning of covid-19 and after 15 days from the onset. We found the majority of the patients’ symptoms decreased or subsided. But still, some patients suffered from persistent symptoms. Among the highest percentage of the patient’s symptoms at the beginning, it’s found loss of smell 89 (21.5%) was the commonest continued symptom followed by tiredness 69 (16.7%), cough 59 (14.3%), and loss of taste 58 (14.0%). Moreover, the average duration of patients’ COVID-19 Symptoms was 8.0 (±7.2) days. In less than half of the patients 174 (42.1%) the disease symptoms continued for more than 14 days, Table 3.
3.3. Assessment of Clinical Symptoms by C19-YRS Checklist
In this study, the severity and persistence of COVID-19 symptoms were assessed by the C19-YRS checklist, in Figure 1.
The Patients’ symptoms scores and sub-scales are presented in mild, moderate, and severe categories. Among the Body Functions and Structures items, we found the severity of the breathlessness on walking was the prominent symptom compared to other examined symptoms. Followed by breathlessness symptoms during patients’ rest and dressing. The severity of depression and anxiety were also highly reported during the disease, followed by fatigue and loss of appetite. Among the activity items, Mobility intensity and unusual activities were similar in the degree of severity, but the personal care intensity was the least, Figure 1.
Patients who were admitted to an intensive care unit (n = 5) were significantly elderly patients (P < 0.001), with chronic diseases (P < 0.01) mainly Diabetes Mellitus (P < 0.01) and Hypertension (P < 0.01). However, Gender, education, family size, smoking status, and physical exercise had no significant effects on the patient’s type of admission or isolation, Table 4.
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Figure 1. Patients’ COVID-19 symptoms severity phenotypes (mild, moderate, severe) based on C19-YRS items score.
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Table 4. Correlation between COVID-19 patients’ characteristics and admission to ordinary wards and intensive care units or in-home isolation, Qassim, KSA, (n = 413).
Abbreviations: ICU = Intensive Care Unit; DM = Diabetes Melilites HTN = Hypertension.
Furthermore, the researchers assessed the intensity and severity of the patient’s symptoms after 4 weeks concerning the types of admission shown in Table 5; 100% breathlessness was reported in patients admitted to the ICU, 89.1% in patients admitted in the word, and 25% in home isolated patients. (P < 0.01). About 60%, pain or discomfort, 40.5% Fatigue, and 32.4% loss of appetite (Body Functions and Structures). Breathlessness was more present during highly demanding tasks, such as climbing stairs, with a C19-YRS reported intensity of 7.6 (2.5) for those who had a history of admission to ICU. Similarly, the laryngeal complication was rated with an intensity of 7.6 (2.5). Finally, anxiety and depression were scored with 0.6 (1.8) and 0.6 (1.7) intensity. Among Activities, reduced mobility was the most significant limitation highlighted (35.1%) after 12 weeks, with a significant influence on usual activities (27%) and personal care (8.1%) (history of word admission), Table 5.
3.4. Persistent Symptoms over Times
Among the Body Functions and Structures items, the correlations were high between breathlessness, fatigue, pain or discomfort, loss of appetite, voice changes symptoms, and hospital admission (p < 0.01). At the same time, 2 items from activities had a significant statistical correlation between mobility, unusual activities, and history of hospital admission. The Global Health perception was also highly significant (p < 0.01), Table 6.
Further correlations were reported in Table 6. Symptoms after 4 weeks, except for anxiety and bladder continence, all the Body Functions and Structures items, symptoms were still present but significantly reduced except for laryngeal complication and swallowing changes which were slightly increased after 2 weeks (P < 0.01). Physical symptoms such as breathlessness improved by 19.1%, and depression by 6.7%, whereas the variation in intensity such as fatigue means and SD 0.9 (1.4) was less pronounced. Conversely, pain (+6.8%) and loss of appetite (+4%) were more represented evidencing persistence over time. Among activities, a significant improvement in usual activities (11.5%) and personal care (2%), were found, whereas mobility became worse (+7.8%). The variation of intensities and the distribution-based measures of responsiveness were reported in Table 6.
4. Discussion
This is the first study in the Qassim Region that applied the C19-YRS in positive
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Table 5. COVID-19 Patients’ symptoms and their relationship to the types of admission and isolation.
Abbreviations: ICU = Intensive Care Unit.
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Table 6. Responsiveness of COVID-19 symptoms before and after 4 weeks.
Abbreviations: M = Mean, SD = Standard Deviation.
PCR COVID-19 patients to report the responsiveness of the scale in Post COVID-19 Syndrome (PCS).
This study demonstrated that this scale could be a valuable tool in detecting the multidimensional nature of Post-COVID Syndrome, characterized by physical, cognitive, and psychological symptoms that persist longer than 4weeks from the acute infection [36] [41]. Our sample reported persistent symptoms related to Body Functions and Structures, such as laryngeal complications (50%), Swallowing changes (43.8%), fatigue (31.3%), pain (18.8%), loss of appetite (18.8%), breathlessness (12.5%), and depression (6.3%), and Activities such as reduced mobility (18.8%) after 4 weeks. These findings are consistent with previous studies that reported the persistence of symptoms in post-COVID patients [32] [35] [42] [43].
Furthermore, our findings supported that COVID-19 severity or intensive care hospitalization directly influenced the persistence of symptoms after 4 weeks [32] [40]. Differences in symptoms severity have been found among patients admitted to the ICU, Ward, or in-home isolation in our cohort. This can be explained by factors, such as age, and co-morbidities with chronic diseases, which may influence COVID severity on PCS (P < 0.01). Our ICU patients were significantly older than ward patients and with diabetes Mellitus, and hypertension (P < 0.01). This established a positive relation to PCS [44] [45].
After 4 weeks, the more common PCS physical symptoms, such as breathlessness and fatigue, were significantly less represented, but laryngeal complications and Swallowing changes were significantly represented. Similarly, the severity of phenotypes was changed, with a small portion of patients with persistent severe symptoms. The symptoms’ entity may be related to several factors such as the extent of organ damage, duration of hospital admission, the difference in recovery time, and complications related to co-morbidities [46].
Psychological distress was less pronounced in the study group; only depression was still present after 4 weeks with less severity. These findings in recovery profiles for physical and psychological functions might reflect the need for long-term management for both psychological and physical well-being in COVID-19 patients. We highlighted a significant improvement in personal care and usual activities regarding Activities. However, change in mobility was still a severe phenotype after 4 weeks.
Limitations of the Study
This study has several limitations. Firstly, this was an observational study where patients were assessed through a telephone survey; recall memories can be considered a bias for detecting responsiveness. Secondly, we included only COVID-19 patients who registered in the Qassim Surveillance system. Thirdly, symptoms and their severity were self-reported by COVID-19 patients, leading to a possible degree of subjectivity in their reporting. For these reasons, the results cannot be generalized to all Saudi post-COVID populations.
Despite these limitations, we are confident that the C19-YRS will turn out to be a useful addition to current assessments of post-COVID-19 in clinical studies and could be used to complement clinician-rated measures of symptoms.
5. Conclusion
The C19-YRS was a valuable patient-reported outcome for screening, assessing severity, and monitoring the persistence of symptoms after 4 weeks from the onset of COVID-19 in a cohort of Saudi patients. The study examined the post covid syndrome and its severity by patients’ responsiveness to the scale items in C19-YRS. The Body Functions and Structures such as laryngeal complications, swallowing changes, fatigue, pain, breathlessness, and depression were persistent after 4 weeks also change in mobility was reported in the activities. Follow-up of the physical and psychological condition of hospitalized and non-hospitalized patients is highly needed. Finally, this study highlighted the importance of rehabilitation and long-term management of the persistent symptoms in post-COVID patients.
Availability of Data and Material
Data generated during this study are available from the corresponding author on request.
Funding
The authors did not receive support from any organization for the submitted work.
Authors’ Contributions
All authors contributed to Conceptualization and Methodology, carried out the formal analysis, arranged resources, collected data, supervised the project, was involved in project administration, wrote the initial draft, and critically reviewed and edited the manuscript. All authors approved the final draft for publication.
Acknowledgements
We are thankful for the generous contributions of the research participants and the MOH staff who assisted in the study’s data collection.