October 17, 2022
Admiral Rachel L. Levine, MD, FAAP
Assistant Secretary of Health
U.S. Department of Health and Human Services
200 Independence Ave., SW
Washington, DC 20201
Dear Admiral Levine:
On behalf of the American College of Occupational and Environmental Medicine (ACOEM), thank you for the opportunity to respond to the Department of Health and Human Services’ (HHS) National Research Action Plan on Long COVID.1
ACOEM is the nation’s largest medical society dedicated to promoting the health of workers through preventive medicine, clinical care, research, and education. Our membership is comprised of 3,500 physicians, nurses, physician assistants, nurse practitioners, and other health care professionals who specialize in occupational and environmental medicine (OEM). We are in a unique position to reach American workers in a variety of settings due to our members’ leadership positions at hospitals and clinics, colleges and universities, large corporations, factories and industrial sites, law and safety enforcement organizations, government agencies, and the military. OEM clinicians are the only health care providers who focus on returning workers to work throughout the spectrum of their care.
Functional recovery and return to work are crucially important outcomes of interest for long COVID and are among the foundations of our specialty. OEM is the medical field that concentrates on the impact of work on health and the impact of health on the ability to work. Our members strive to optimize worker wellbeing and workplace safety and have expertise in employee return-to-work issues and disability.
ACOEM members have not only been treating employees with post-acute sequelae of COVID-19 (aka long COVID), but they have served as leaders in educating other medical professionals on COVID-19 and its related issues, including safely returning to work and long COVID. In addition, ACOEM has presented a number of educational offerings that address long COVID.*
Data from the U.S. Census Bureau’s June 2022 Household Pulse Survey show that roughly 1 in 13 adults in the U.S. (7.5%) currently have long COVID symptoms.2
A case of long COVID often presents with multi-system morbidity, and it has been estimated that 80% of patients with COVID-19 developed one or more long-term symptoms.3
Strikingly, the data also show that the prevalence is greatest among younger, working-age adults.2
Given these factors, the impact on both workability and the economy may be profound. Recent findings indicate that of 1,250 people infected in early 2020, only 8% reported being back to work at their pre-COVID level.4
Another random sample of 292 affected individuals showed that 20% of previously healthy young adults were not back to their usual health 14-21 days after testing positive, potentially leading to prolonged absence from work.5
Despite these observations, there is currently a paucity of quality data on return to work, short-term disability, and long-term disability. Given the potentially large impacts long COVID may have on disability rates, lost time, and the economy, a deeper understanding of the effects of long COVID on workability and return to work is crucial.
Much of the recent NIH Researching COVID to Enhance Recovery (RECOVER) initiative6
focuses on the need to decrease disability and increase the quality of life for patients suffering from long COVID. Occupational medicine research has demonstrated that chronic cases of disability are strongly influenced by many factors outside of the central physiological findings. They include psychological and social factors, biophysical factors, as well as comorbidities and genetic factors.7-9
We expect all these factors will contribute to disability from long COVID. Therefore, it will be extremely important for research to address currently accepted early interventions for return to life functions.
ACOEM recommends that the following areas be considered in research priorities for long COVID.
- Focus on assessing the patient’s function. When the provider is focused on determining what areas of function are most affected by the diagnosis, and what areas of function are of largest concern to the patient, the treatment plan can proceed more efficiently and is more likely to result in increased quality of life for the individual patient. Thus, future research needs to focus on function as an integral part of the treatment plan. Function should be assessed in the broadest terms to include not only physical ability but also participation in social functions including work and social activities.10,11 In order to make reasonable comparisons between various treatment plans and interventions, it is important that all research use functional patient reported outcome measures (PROMs) as a primary or secondary outcome measure to assess populations across all studies. The PROMs used in research should be reliable, valid, and comparable. Therefore, we recommend that PROMIS-29, originally developed by the U.S. federal government, is likely the best tool to evaluate the quality of life for multiple types of diagnosis and to assist providers in improving quality of life throughout the treatment plan. The use of one well-validated tool, specifically developed for research, which provides an appropriate reference point to the general population will allow for an improved global evaluation of treatments and a comparison between various studies.
- Include educational/outreach interventions aimed at decreasing disability. The Centers of Occupational Health & Education (COHE) in Washington State have identified best practices to prevent injury and work disability. These are fundamental practice tools for occupational medicine providers which are less familiar to primary care providers, who may inadvertently exacerbate work disability. These practices help to restore workers to productivity regardless of the nature or cause of the injury or illness. The national long COVID research portfolio should include studies designed to test educational/outreach interventions to discover how to effectively disseminate best practices for providers to prevent needless work disability. Our experience suggests that working directly with both the employee and employer is the best way to assure safe return to work. For example, the extensive use of return-to-work programs already in existence and those created under the Retaining Employment and Talent After Injury/Illness Network (RETAIN) grants should be part of the long COVID treatment projects. A review of the results from the first round of RETAIN grants shows the need for a “navigator” to assist both the worker and medical provider in obtaining an appropriate return to work. The navigator may be a vocational rehabilitation specialist, a nurse, PT, or another individual knowledgeable regarding physical impairment and return-to-work regulations. We strongly recommend this type of outreach be a required portion of future research projects.
- Collect occupational demographics in studies. To assess the impact of long COVID on work disability, and the effectiveness of interventions designed to reduce work disability, studies must collect basic occupational demographics including employment status, occupation and industry if employed, and current work status. Knowledge of an individual’s industry and occupation is fundamental to decision-making about the return to work. For example, the functional demands of a construction worker differ dramatically from that of a high school teacher or a neurosurgeon. Fortunately, version 3 of the U.S. Core Data for Interoperability requires electronic health records (EHRs) to collect and store patients' industry and occupation and utilize a Work and Health Functional Profile. This information will be available to treating physicians to aid their return-to-work prescriptions.12 Therefore, ACOEM supports efforts to incorporate occupational demographics into electronic medical records in a standard, codified format to support future research efforts on the relationship between health, occupation, and work disability, regardless of the medical condition of interest.
ACOEM appreciates the opportunity to provide input on our recommendations for research priorities for patients with long COVID. Principles that occupational medicine physicians are familiar with can play a vital role in minimizing the impact of long COVID on workers and their ability to work and we hope that the Department of Health and Human Services will consider our recommendations in their research.
Douglas W. Martin, MD, FACOEM
Cc: Katherine Bruss, Public Health Analyst, Centers for Disease Control and Prevention
, MD, MPH, Rear Admiral and Deputy Assistant Secretary for Science and Medicine, Office of the Assistant Secretary for Health, Department of Health and Human Services
- Department of Health and Human Services, Office of the Assistant Secretary for Health. National Research Action Plan on Long COVID. 2022. Available at: https://www.covid.gov/assets/files/National-Research-Action-Plan-on-Long-COVID-08012022.pdf.
- National Center for Health Statistics. Long COVID Household Pulse Survey, Phase 3.5. Centers for Disease Control and Prevention: 2022. Available at https://www.cdc.gov/nchs/covid19/pulse/long-covid.htm.
- Lopez-Leon S, Wegman-Ostrosky T, Perelman C, et al. More than 50 long-term effects of COVID-19: a systematic review and meta-analysis. Sci Rep. 2021;11(1):16144.
- Medinger G, Altmann D. The Long COVID Handbook. Preprint: London, Penguin; 2022. Available at: https://www.penguin.co.uk/books/453380/the-long-COVID-handbook-by-altmann-gez-medinger-and-professordanny/9781529900125.
- Tenforde MW, Kim SS, Lindsell CJ, et al. Symptom duration and risk factors for delayed return to usual health among outpatients with COVID-19 in a multistate health care systems network — United States, March–June 2020. MMWR Morb Mortal Wkly Rep. 2020;69:993-998. DOI: http://dx.doi.org/10.15585/mmwr.mm6930e1
- Researching COVID to Enhance Recovery. Available at: https://recovercovid.org/.
- Hartvigsen J, Hancock MJ, Kongsted A, et al. What low back pain is and why we need to pay attention. Lancet. 2018;391(10137):2356-2367.
- Bruns D, Disorbio JM. Assessment of biopsychosocial risk factors for medical treatment: a collaborative approach. J Clinical Psychology Med Settings. 2009;16(2):127-147.
- Bruns D, Warren PA. Assessment of psychosocial contributions to disability. In Handbook of Behavioral Health Disability Management. 2018, Springer. p. 101-141.
- Mueller K, Konicki D, Larson P, Hudson TW, Yarborough C, ACOEM Expert Panel on Functional Outcomes. Advancing value-based medicine: why integrating functional outcomes with clinical measures is critical to our health care future. J Occup Environ Med. 2017.59(4):e57-e62.
- Mueller KL, Hudson TW III, Bruns D, et al. Recommendations from the 2019 Symposium on including functional status measurement in standard patient care. J Occup Environ Med. 2020;62(8):e457-e466.
- McLellan RK, Haas NS, Kownacki RP, Pransky GS, Talmage JB, Dreger M; RTW Subject Matter Expert Work Group. Using electronic health records and clinical decision support to provide return-to-work guidance for primary care practitioners for patients with low back pain. J Occup Environ Med. 2017;59(11):e240-244.
*ACOEM long COVID education offerings:
- Webinar: April 13, 2022: Long COVID
- Virtual Fall Summit: Friday, November 12, 2021
- Causation and Impairment Related to Post-Acute COVID
- Post-acute COVID and Chronic Fatigue
- Navigating a Post-Vaccine World: Virus, Vaccine, and Variants Virtual Symposium: June 12, 2021
- Evaluating the Patient with Post-COVID Symptoms
- Neuropsychology Issues related to Post-COVID Syndrome
- Treatment and Rehabilitation for Post-COVID Syndrome