Practice Resources

Recent literature indicates that symptoms of COVID-19 may persist for longer periods of time.  Authors of one study reported follow-up, at a mean of 60 days post symptom onset, of 143 patients who had been hospitalized for COVID-19. Of these patients, 72% of them were found to have interstitial pneumonia during hospitalization. At the time of follow-up, they found that “only 18 (12.6%) were completely free of any COVID-19–related symptoms, while 32% had 1 or 2 symptoms and 55% had 3 or more.”  Fatigue was the most common persistent symptom, present in 53% of the individuals.  Other common persistent symptoms included dyspnea and joint pain.  Cough was present in about 15% of the patients. Regarding limitations, the authors point out that this was a small study at a single institution.³  

An interview study of 274 symptomatic COVID-19 patients who had been treated as outpatients showed that 35% “reported not having returned to their usual state of health by the date of the interview (median = 16 days from testing date) . . .” The frequency of persistent symptoms increased with increasing age, such that nearly 50% of those 50 years or older had continued symptoms.  The authors found: “Among respondents reporting cough, fatigue, or shortness of breath at the time of testing, 43%, 35%, and 29%, respectively, continued to experience these symptoms at the time of the interview. These findings indicate that COVID-19 can result in prolonged illness even among persons with milder outpatient illness, including young adults . . . . Symptoms least likely to have resolved included cough (not resolved in 43% [71 of 166]) and fatigue (not resolved in 35% [68 of 192]) . . .”  The presence of prior chronic medical illnesses affected the percentage who had not returned to their usual state of health. Of 44 individuals who had 3 or more chronic medical conditions, 57% reported that they had not returned to their usual state of health by the date of the interview.  This study is limited by the relatively short duration of follow-up.⁴  These findings indicate that symptoms may persist well beyond the time that the individual is infectious and will likely affect the ability to return to work.

Despite increasing reports of post-acute COVID-19 symptoms, a universally accepted definition and treatment has yet to emerge.¹  At the same time, the CDC has placed greater emphasis on duration of symptoms (i.e., 10 days at a minimum), resolution of fever (i.e., 24 hours without fever-reducing medication at a minimum), and symptom improvement, as opposed to repeated negative RT-PCR testing (except in immunocompromised persons) to determine the period of potential infectiousness and isolation.  The CDC has recently published, “for patients with mild to moderate COVID-19, replication-competent virus has not been recovered after 10 days following symptom onset”; and, “recovery of replication-competent virus between 10 and 20 days after symptom onset has been documented in some persons with severe COVID-19 that, in some cases, was complicated by immunocompromised state.”²  Nevertheless, most individuals with COVID-19 are not likely to be infectious after ten days following the onset of symptoms. 

Extensive literature searches in PUBMED did not identify publications addressing the impact of or need for employer policies related to prolonged disability or delayed return to work. Relative to another employer policy, authors of an Israeli study reported that 94% of people who had paid sick leave indicated that they would follow guidance to not return to work when ill, while only 57% without paid sick leave would do so.⁵

In any case, one should anticipate that some patients with COVID-19 will have prolonged periods of partial and/or total disability impacting their return to unrestricted work. Employers should be prepared to address these situations with a uniform approach.  The occupational medicine provider is uniquely positioned to assist the employer and employee in managing a safe, compliant, and measured return to work for this population.  An interactive dialogue will be required between employer, employee, and medical provider to assure the employee is capable of performing the essential job functions, with or without reasonable accommodations, without posing a direct threat to the employee or others based on the individual situation.  Communication with the employee’s treatment team, a focused work-up, functional testing, and a work-site evaluation may be required. 

Ongoing monitoring may also be required after return to partial or full duty work.  Providing for short-term disability benefits may be important but may create negative incentives to return to work if not thoughtfully constructed.  Furthermore, state and/or federal accommodation rules specific to COVID-19 may need to be considered.  Some employees will have to care for ill family members for a prolonged period of time and may be eligible for FMLA leave.  Finally, given our current understanding surrounding COVID-19, employers should recognize that the majority of individuals with persistent cough are not likely to be infectious and should be allowed to return to work, if they are otherwise able to do so.