García M/ Enfermería Investiga Vol. 9 No. 2 2024 (April – June)

STUDY OF PERSISTENT COVID CASES IN HEALTH WORKERS

Mercè García Grau1 https://orcid.org/0009-0004-3439-966X, Joan InglésTorruella1 https://orcid.org/0000-

0002-3302-4274, Rosa Gil Soto1https://orcid.org/0000-0001-8981-6273, Esther Sabaté Águila1

https://orcid.org/0000-0002-9719-5857, Miriam Bandera Báez1 https://orcid.org/0009-0007-5620-8870,

Gustavo Moreno Martín1 https://orcid.org/0000-0002-3335-787X.

1Health Surveillance Unit of the Prevention Service of EDP Salut Sant Joan Reus - Baix Camp (EDPSALUT SANT JOAN

REUS-BAIX CAMP) (EDPSSBC). Sant Joan University Hospital. Reus. Spain.

distributed under the terms of the Creative Commons License, which permits unlimited use, distribution, and reproduction in any medium,

provided the original work is properly cited.

Corresponding Author: Esp Mercè Garcia Grau. Email:mariamerce.garcia@salutsantjoan.cat

Received: January 20, 2024

Accepted: March 28, 2024

ABSTRACT

Introduction: The COVID-19 disease presents an

acute affectation that can continue in a sustained

manner beyond 12 weeks from the onset of the initial

symptoms, being called Persistent COVID (Post

COVID, Long COVID). Objective: Assess the

incidence of Persistent Covid that the workers at the

Sant Joan de Reus Hospital and Reus-Baix Camp

Primary Care (EDPSSJRBC) have presented,

during the period from March 2020 to November

2022, predominant clinical, work impact. Methods:

Descriptive observational study of active workers on

9/30/2022, who after COVID-19 developed

Persistent Covid during 2020 to 2022. Study by

survey of workers with COVID-19 with Persistent

Covid symptoms and subsequent in-person

evaluation through questionnaires, health

examinations and complementary tests. Final

assessment of work capacity against Persistent

Covid in the context of the Health Surveillance of the

Occupational

Risk Prevention Service. Results: The profile of the

worker affected by Persistent Covid in our study is

characterized by: female sex, over 40 years of age,

care work profile, with predominant symptoms of

sleep disorder, memory disorder, difficulty

concentrating, changes in mental status, mood,

arthralgia, fatigue and headache. They presented

abnormal results in the tests: Post COVID-19

Functional Scale, Insomnia Severity Index and

Montreal Cognitive Assessment Test.Conclusions:

Clinical impact of Persistent Covid of the workers in

our study who improved over time and after

cognitive rehabilitation treatments in the Cognitive

Impairment Unit and regular physical exercise

prescribed by the Sports Medicine Unit. Persistent

Covid did not prevent the development of their work

activity

Keywords: Post-Acute COVID-19 Syndrome;

COVID-19; Health Personnel; Work Capacity

Evaluation.

INTRODUCTION

COVID-19 disease due to infection with the SARS-

CoV-2 Coronavirus (1,2) presents an acute clinical

picture, which can persist over time, which has been

called Persistent COVID (Post COVID, Long

COVID). The definition of Persistent COVID

includes a patient diagnosed with COVID-19

through PCR tests and/or serology who, after 12

weeks from the onset of the first symptom, presents

symptoms that were part of the acute phase of the

SARS-CoV-2 infection and that persists today (3,4).

The symptomatic picture of Persistent COVID may

include respiratory, rheumatic, neurological,

digestive, otorhinolaryngological, cardiological

and/or general symptoms (3-6). Exacerbations or

reactivations of previous pathologies and symptoms

that appear after the initial clinical presentation will

García M/ Enfermería Investiga Vol. 9 No. 2 2024 (April – June)

be excluded from the diagnosis of Persistent

COVID. In the Health Surveillance Unit of the

EDPSSJRBC Prevention Service, a medical

procedure was implemented for the detection,

assistance and monitoring of workers with

Persistent COVID symptoms.

The continuity of Persistent COVID symptoms, apart

from the possible impact on workers' daily activities,

may have an implication on the development of their

work activity, with the need for temporary or

permanent work disability or adaptations to their job,

to be assessed by the Health Surveillance Services

(7-9).

The purpose of this study is to record the symptoms

presented by the workers at the Sant Joan de Reus

Hospital and Primary Care of Reus and Baix Camp,

the healthcare, rehabilitation and follow-up care

provided to the workers in the period from March

2020 to November 2022. Since the study has been

carried out within the framework of the Health

Surveillance Unit, the work impact of the workers

derived from Persistent COVID and the need for

functional adaptation that they may have required in

their work place has also been assessed during the

study period.

METHODS

This is an observational, descriptive study of the

workers of the EDPSSJBC company, in September

2022, who suffered from COVID-19 and the

symptoms of Persistent COVID developed in the

period 2020 to 2022. The workers who were

excluded: not belonging to EDPSSJBC; workers in

a situation of incapacity for work and those who did

not complete all phases of the study.

To evaluate the Persistent COVID clinic from the

Health Surveillance Unit of the Occupational Risk

Prevention Service, the Procedure for care action in

workers with Persistent COVID (2021), in force at

EDPSSBC, was applied.

This procedure consists of: sending a survey of

symptoms compatible with Persistent COVID

(Fever, low-grade fever or chills, fatigue that

prevents daily activity, myalgia at rest or daily

activity, arthralgia of extremities at rest, dyspnea at

rest or daily activities, persistent cough, chest pain

at rest or daily activity, anosmia or ageusia,

headache, diarrhea, memory loss, changes in

mood, sadness, crying, nervousness, insomnia,

alopecia) to workers who had suffered from COVID-

19. Those who responded affirmatively to Persistent

symptoms of more than 12 weeks were scheduled

to undergo a health examination. This health

examination included a nursing part with the

completion of a new Persistent COVID symptoms

questionnaire at the time of the visit, application of

different tests and scales, all with validity and

reliability (10,11).

These scales include: EQ5D functional quality of life

scales (EuroQol) (Cronbach 0.75) (12.13), mMRC

Test for evaluation of dyspnea (Pearson coef 0.92)

(14.15), Test Hamilton anxiety/depression scale

(HAD) (Cronbach 0.89) (16.17), Post COVID-19

Functional Status Scale (PCFS) ((kappa 0.63))

(18.19), Modified Impact of Fatigue (MFIS)

(Cronbach 0.81) (20.21), Sleep Scale: Insomnia

Severity Index (Cronbach 0.82) (22.23), Pain

Assessment Questionnaire (Bpi) (Cronbach 0.82)

76) (24.25) and Montreal Cognitive Assessment

(MOCA) (Cronbach's 0.891) (26.27). In addition, the

specific analytical determination was carried out:

total SARS CoV-2 antibodies (Ab), blood count,

ESR, albumin, total and direct bilirubin, serum

calcium, total cholesterol and cholesterol fractions,

complement CH50, C3, C4, creatinine, glomerular

filtration rate , rheumatoid factor, ferritin, iron, folate,

alkaline phosphatase, phosphorus, GGT, GOT,

GPT, glucose, glycosylated hemoglobin, ionogram

(sodium and potassium), C-reactive protein, total

proteins, transferrin, triglycerides, urea, vitamin B12,

vitamin D, antithrombin III, prothrombin time,

activated partial thromboplastin, antinuclear

antibodies, DNA autoantibodies, TSH, T3 and T4,

apoprotein, creatine kinase, fibrinogen, lactic

dehydrogenase, and antiphospholipid syndrome.

Anthropometric data were recorded: weight, height

and abdominal circumference. Measurement of

blood pressure, pulse, oxygen saturation, body

temperature was carried out. And a spirometry and

an electrocardiogram were performed.

Subsequently, it was scheduled for the medical

health examination to: evaluate the data collected by

the nursing staff, the analytical results and the tests

performed, as well as the tests completed by the

workers. A clinical history was taken: directed

anamnesis of the COVID-19 disease (onset,

symptoms, treatment performed, hospital/ICU

admissions, mechanical ventilation requirements...),

anamnesis of previous history, chronic treatments

and assessment of Persistent COVID symptoms. A

directed physical examination was performed:

neurological examination (cranial nerves,

coordination and balance tests, Romberg test...),

cardiorespiratory, oropharyngeal and abdominal

examination, lumbar fist percussion,

musculoskeletal examination, eye examination,

otoscopy, skin examination; assessment of the need

for treatment. Complementary tests were requested:

Chest radiology or lung CT, respiratory functional

tests, echocardiogram... or referrals to other medical

specialties: Sports Medicine and/or Physiotherapy

Unit, Cognitive Impairment Unit, Medicine Unit

Internal, Otorhinolaryngology Unit, Cardiology Unit,

Digestology Unit, Rheumatology Unit, Dermatology

Unit...

Subsequent follow-up visits were made to the

workers who required it with an in-person or

telephone appointment to evaluate the results of the

complementary tests requested, treatments

performed, consultations with other medical

specialties requested and/or relevant referrals to

other Hospital services. as well as assessment of

the health status of the professional.

The results of the workers who presented symptoms

of Persistent COVID and who participated in the

study of the EDPSSBC Health Surveillance Unit

were analyzed. The variables considered were: age,

García M/ Enfermería Investiga Vol. 9 No. 2 2024 (April – June)

sex, professional category, results of surveys and

tests, anthropometric data, analytical and physical

examination results, complementary tests

(electrocardiogram, spirometry, blood pressure),

referrals to medical specialties and possible work

impact.

The treatment and analysis of the data from the

study project is carried out by health personnel from

the EDPSSBC Health Surveillance Unit. Finally, an

assessment of the worker's work aptitude was made

considering the possible impact of Persistent

COVID. To compare the results, the categories have

been referenced: sex, age (in groups of 1-40 and

>40) and professional category (grouped into care

and non-care).

The incidence of the results and 95% confidence

interval (95%CI) were calculated. Differences

between variables were quantified using incidence

rates, odds ratio (OR) and 95% CI. To calculate the

demographic incidence rates, the population of

Hospital workers and the values of the variables

(COVID-19, Persistent COVID) detected

respectively based on gender, age and professional

group have been taken into account. To calculate

the incidence rates of the clinical variables (results

of tests, tests performed and physical examinations

performed), the results obtained for each variable

have been taken into account with respect to the

total number of Persistent COVID surveys per 100.

To calculate the incidence rates of interhospital

referrals, the number of referrals made to the

different medical services has been expressed, with

respect to the total number of referrals made

multiplied by 100. Regarding the functional impact

on work, the rate of incidence of occupational

impairment of workers affected by Persistent COVID

with respect to the total number of workers with

Persistent COVID studied. To calculate the 95%CI,

the Excel 365 statistical function was used for a Z

value of 1.96 and to calculate the OR, MedCalc

Statistical Software version 20.210 (Med-Calc

Software bv, Ostend, Belgium) was used;

https://www.medcalc.org; 2020).

BIOETHICAL COMMUNICATION

Approval of the EDP Salut Sant Joan de Reus-Baix

Camp Clinical Research Ethics Committee (IISPV

Drug Research Ethics Committee), which considers

that: -The necessary suitability requirements of the

protocol are met in relation to the objectives of the

study and the foreseeable risks and discomforts for

the subject are justified. -The capacity of the

researcher and the available means are appropriate

to carry out the study. -The proposed waiver of

consent for this study is accepted. -The scope of the

planned economic compensation does not interfere

with respect for ethical postulates. -This committee

in its meeting dated 06/27/2023, minute number

006/2023, has evaluated and decided to issue a

Favorable Report for the study to be carried out, and

accepts that said study be carried out at: Hospital

Universitari Sant Joan de Reus by GARCIA GRAU,

MERCE of the Health Surveillance Unit as main

researcher. (Code CEIm104/2023 final version:

Version 002 date: 6/13/2023)

RESULTS

The EDPSSBC staff workers as of September 2022,

who suffered from the COVID-19 disease in the

study period were 398 workers out of a total of 2,120

workers, representing 18.77%. In the resulting data

(Table 1), COVID-19 is observed in women with an

incidence rate of 18.90% (CI95:16.98-20.83%);

greater affectation in the age group under 40 years

(rate of 22.12) (OR 1.50; CI95:1.21-1.87%) and in

care workers (rate of 20.63) (OR 2.71; CI95:1.81-

4.02%), versus non-care

García M/ Enfermería Investiga Vol. 9 No. 2 2024 (April – June)

Thus, 158 workers (39.7%) also responded

affirmatively to the Persistent COVID

symptomatology screening surveys. Of those who

responded to the screening surveys, 70 workers

(44.30%) showed symptoms compatible with the

definition of Persistent COVID (Table 2).

The incidence of Persistent COVID in the study

population (Table 2) predominates in women at a

rate of 48.03%, with a higher rate of COVID-19 and

response to screening; in the population over 40

years of age (rate 49.40%) (population with a

greater response to screening and with the

presence of previous pathologies that may influence

the symptoms of Persistent COVID); and in the

healthcare population (rate 44.37%), front-line

personnel, with a higher response rate to screening.

Finally, 50 workers (71.42%) attended evaluation for

PERSISTENT COVID in the Health Surveillance

Unit (20 workers did not attend a medical

appointment and were excluded from the study). In

reference to the symptoms of Persistent COVID

(table 3): workers reported sleep disorders 32%

followed by memory loss or difficulty concentrating

30%, mood changes, sadness, crying or

nervousness 28%, pain joint pain at rest 28%,

feeling fatigue or tiredness in daily activities 24%

and headache 22%. If we analyze the pathological

results of the tests applied to the workers, we

observe: post-COVID functional status assessment

test 77.42% (although the majority indicate minimal

or mild functional limitation), insomnia test and

MOCA test (51 .61%; CI95: 34.02-69.21%) in both

respectively, followed by the pain test (45.16%;

CI95: 27.64-62.68%) and quality of life, sleep and

emotions. (45.16%; CI95:27.64-62.68%).

Of the tests carried out in the health examinations

carried out (Table 3), the majority of workers present

alterations in the analytical parameters 94.59%,

followed by a body mass index of Obesity in 45.16%

and alterations ECG 22.58% (left bundle branch

block, first degree atrioventricular block, left anterior

hemiblock, extrasystole, tachycardia, sinus

bradycardia and nonspecific repolarization

alteration). The most significant laboratory analytical

parameters detected are: Vitamin D deficiency

64.86%, dyslipidemia 51.35%, immunological

parameters 40.54% (positive antinuclear antibodies

and altered complement factors), followed by a

decrease in iron/ferritin 24. 32% and altered

coagulation parameters 21.62%. The most relevant

findings in the physical examination of the workers

(Table 3) were musculoskeletal involvement of the

spine in 73.08% and upper extremities: shoulders

(tendonitis)30.77% as well as venous vascular

insufficiency in lower extremities (venous

insufficiency)38.46%, not solely attributable to the

pathology of Persistent COVID.

García M/ Enfermería Investiga Vol. 9 No. 2 2024 (April – June)

Interhospital referrals were made (Table 4) mainly in the Cognitive Impairment Unit (Neurodegenerative)

34.62%, with a medical assessment that indicated “no significant impairment”; referrals to the Sports

Medicine Unit 26.92% with symptomatic improvement in fatigue symptoms and improvement in functional

capacity. To a lesser extent, referral to the Pulmonology Unit 7.69%.

García M/ Enfermería Investiga Vol. 9 No. 2 2024 (April – June)

The majority of the workers (90%) in the current study had a self-limiting COVID condition that allowed them

to carry out the activities of their workplace (table 5). It must be taken into account that the workers assessed

with Persistent COVID were actively working.

DISCUSSION

The strengths of this study to consider would be the

comprehensive assessment of the worker with

Persistent COVID with information collection,

medical health examinations, analytical and

complementary tests and with an assessment of

work capacity. The limitations in the study were a

low participation of workers with COVID-19, to

assess the symptoms of Persistent COVID. Some

workers with COVID-19 did not participate in the

study because they were in follow-up with other

medical specialties for Persistent COVID, others

because they were on temporary disability, and

others did not complete all phases of the study. The

active state of the COVID-19 pandemic must also be

taken into account, which implied coinciding with the

study of Persistent COVID, the care of new acute

episodes of COVID-19 and its subsequent study of

Persistent COVID.

The results of Persistent COVID obtained, with

respect to gender (mostly female), are referenced to

an initial population sample in number of female

workers that tripled that of male workers, and a

greater number of women with COVID-19 compared

to the number of men. In similarity with other studies

(28,29) where a predominance in women is also

observed. Likewise, this research, like other studies,

found a greater impact on older workers (28,29) who

were more predisposed to getting sick and with the

presence of previous pathologies that could

influence the manifestation of Persistent COVID.

Regarding the professional group, a greater impact

of Persistent COVID was observed in healthcare

workers (on the front line of health care, more

exposed to Sars-CoV-2 infection in this period),

versus non-care workers. The most prevalent

Persistent COVID symptoms were: sleep

impairment, memory loss, concentration difficulties,

mood changes, arthralgias, fatigue and headache,

observed in other Persistent COVID studies (30-33).

Regarding the results of the complementary tests,

analytical alterations were observed, highlighting

immunological parameters. The alterations in the

electrocardiogram are nonspecific, not attributable

to Persistent COVID exclusively. The findings in the

physical examination of the study participants are

not justified solely by the existence of Persistent

COVID. The persistence of muscle involvement in

the form of fatigue was observed in the study and

treatment was prescribed in the Sports Medicine

Unit. Through targeted physical exercise programs,

significant improvements in symptoms were

observed in the majority of workers, as in other

studies (34).

The Persistent COVID symptoms observed in this

study evolved favorably over time and with targeted

guidelines for physical exercise and cognitive

García M/ Enfermería Investiga Vol. 9 No. 2 2024 (April – June)

rehabilitation, in the majority of our cases. In a

minority, who are currently being monitored, some

symptoms persist, without it being disabling at work

(the workers are still active). Coinciding with other

investigations (35,36)

The fact of having suffered the COVID-19 disease

more than once improved the symptoms of

Persistent COVID, in one case of the current

investigation. It is expected that future research in

the field of Persistent COVID will allow progress in

the diagnosis, treatment and recovery of the

disease.

CONCLUSIONS

There was clinical involvement of Persistent COVID

among the workers in the current investigation. They

improved over time and after cognitive rehabilitation

treatments in the Cognitive Impairment Unit and

regular physical exercise prescribed by the Sports

Medicine Unit. The impact of Persistent COVID did

not prevent the development of their work activity

ACKNOWLEDGEMENT

To the participation of the EDPSSJBC Workers in

the study, the involvement of the medical Specialties

of the Sant Joan de Reus Hospital: Cognitive

Impairment Unit, Sports Medicine Unit; Pulmonology

Unit, Internal Medicine Unit, Cardiology Unit,

Digestology Unit, Otorhinolaryngology Unit,

Rheumatology Unit, Neurology Unit, Physiotherapy

Unit and others and, especially, to the EDPSSJBC

Health Surveillance staff.

CONFLICT OF INTERESTS

The authors declare that they have no conflicts of

interest.

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