key: cord-1030043-s1lm0gy0 authors: Zhou, Min; Cai, Jing; Sun, Wenjie; Jing, Wu; Wang, Yidong; Gamber, Michelle; Fan, Lingyan; He, Guiqing title: Does Post-COVID-19 symptoms exist? A longitudinal study of COVID-19 sequelae in Wenzhou, China date: 2021-03-05 journal: Ann Med Psychol (Paris) DOI: 10.1016/j.amp.2021.03.003 sha: 9c9dca110f63c5c88dfdb15ca35db40e732182bc doc_id: 1030043 cord_uid: s1lm0gy0 Objective: We conducted a cohort of tracing discharge patients of COVID-19. Materials and methods: We used the Mann Whitney U test, χ² test, or Fisher’s exact test to compare differences between age groups and gender groups where appropriate. Results: Our study provides insights into the nature and severity of medical conditions specific to survivors of COVID-19. Conclusions: It also highlights the potential mental health issues resulting from infectious disease outbreaks within communities. The novel Coronavirus (COVID-19) outbreak occurred in Wuhan, China in December 2019 and spread to other countries. Most patient's symptoms have been mild to moderate and have resolved after receiving therapy. The outbreak of COVID-19 in China has been defined by the World Health Organization as a public health emergency of international concern. The epidemic not only causes social panic, but also causes physical and mental damage to people. However, little is known about the patient's health status or disease prognosis when the COVID-19 patients are discharged from hospitals. Moreover, recurrence of positive SARS-CoV-2 RNA has been reported (Chen, Xu, Lei, Huang, Liu, Gao and Peng, 2020) . Of note, post-traumatic stress disorder (PTSD) had been reported in other fatal virus infectious diseases (Group, 2019 , Lee, Kang, Cho, Kim and Park, 2018 , Mak, Chu, Pan, Yiu and Chan, 2009 .And most previous studies have focused on the effects of public health emergencies on post-traumatic stress disorder in medical staff in (PTSD), but there are few studies on traumatic stress disorder in patients. To the best of our knowledge, there are no studies reporting on the status of discharged COVID-patients. Hence, we conducted a prospective study on the COVID-19 patients from Wenzhou. Page 4 of 11 J o u r n a l P r e -p r o o f 4 Until February 14, 139 confirmed COVID-19 cases admitted in Wenzhou Sixth People's Hospital. Among them, 89 discharged patients were followed up at least 3 weeks with a semistructured questionnaire address on Post-COVID-19 symptoms and health status. The surveys collected information on symptoms and diagnostic testing occurring any time during the recovery period. Mental health status was also accessed by administering the PTSD Checklist-Civilian Version (PCL-C) (Wilkins, Lang and Norman, 2011) . The ethics commissions of Wenzhou Central Hospital Medical Group hospital approved the study. The participants responded to the PLC-C, which includes 17 items on a 5-point scale, ranging from 1 (not at all) to 5 (extremely) in three areas: Intrusion, avoidance and numbing, and hyperarousal. A PTSD severity-score was computed by summing up all symptom scores. Respondents indicated the extent to which they have been affected by symptoms over the past month. The PCL-C total score ranges from 17 to 85, with higher scores indicating greater PTSD symptom severity. It was recommended that, when the instrument was used as a continuous measure, a cut-off score of 50 is optimal for making the diagnosis of combat related PTSD. The scores that range from 38-49 suggest probable PTSD. The protocol was approved by the Review Board at the Wenzhou Central Hospital. Written informed consent was obtained from all participants. According to the national criteria, the discharge criteria were: (i) afebrile for at least 3 days, (ii) obvious alleviation of respiratory symptoms, (iii) improvement in radiological abnormalities on chest computed tomography (CT) or X-ray and (iv) two consecutive negative detections of SARS-CoV-2 at least 24 h apart(Zhao, Yan and Qu, 2020). Continuous and categorical variables were presented as median (IQR) and n (%), respectively. We used the Mann Whitney U test, χ² test, or Fisher's exact test to compare differences between age groups and gender groups where appropriate. The prevalence of the total prevalence of symptom or sign was estimated with 95% confidence intervals. All tests were 2-Page 5 of 11 J o u r n a l P r e -p r o o f 5 sided, and a p value less than 0.05 was considered statistically significant. All statistical analyses were performed by the SPSS software, version 19.0 (IBM Corp, Armonk, NY). Of 89 patients (median 43 years [IQR 31-52]), 43 were female (Table 1 ). Of note, six patients (6.7%) had recurrence of positive RNA at the three-week follow-up. Several symptoms were reported by the discharged patients, e.g. mild (e.g., fatigue) to more severe complications requiring rehospitalization or treatment. The most frequently reported symptoms were cough (46.1%), fatigue (36.0%), expectoration properties (24.7%) (coughing up or spitting up material from the respiratory track), chest tightness and insomnia ( Table 1 in the Supplementary Appendix). Six patients (6.7%) had fever (oral temperature higher than 37.4℃). Three patients (3.4%) complained poor appetite, while two patients (2.2%) complained of myalgia, arthralgia, oral ulcers and eye discomfort respectively. Totally, thirty-eight of the patients (42.7%) felt completely improved, and forty-two patients (47.2%) felt much improved, with one patient felt no improved and another patient felt even worse. There were no significant difference in symptoms, signs or RT-PCR conversion between the age and sex groups (p>0.05). Only 73 patients were assessed for psychological stress by administering the PTSD Checklist-Civilian Version (PCL-C) ( Table 2 ). There were sixteen patients who were more like to be females aged over 45 years did not participant the mental health assessment. There was 11.0% of the survivors had probable post-traumatic stress disorder (PTSD) and 13.7 % of the survivors who manifested high distress and with trauma exposure had PTSD. Female had a higher scores of PTSD than male (p=0.001), but there was no significant difference between age groups. Post-COVID-19 symptoms include, but are not restricted to, musculoskeletal pain, Recurrence of positive SARS-CoV-2 RNA is a unique phenomenon. It is different from coronaviruses, such as SARS and MERS, which do not similarly reported relapses in the literature resulting among discharged patients. In the presented study, there was 6 cases among 89 discharge patients (6.7% with 95% CI [1.4-12.1]). The mechanism is still unclear until now. The potential explanation is that health systems are being overwhelmed and are not able to adequately follow-up with patient's post-discharge. The hospitals are often forced to discharge these patients, even if they haven't fully recovered as the need for beds is immense. Future study on the clinical symptoms of those patients and pathology are warrant. COVID-19 pandemic has been associated with increases in mental health issues among COVID-19 patients. Typically, PTSD is triggered by a terrifying or traumatic event, which could result from either experiencing it or witnessing it. As for COVID-19, the emergency environmental conditions that have been induced with this infectious disease might produce unique characteristics that are resulting in PTSD among COVID-19 survivors. Of note, most COVID-19 patients are more likely to be infected by close contact such as from family members. As a result, those patients might be experiencing the impacts of both COVID-19 exposure in themselves as well as witnessing it in their family member. This could result in a double exposure effect and could have a more severe impact. Also, our resulting confirm that gender difference exists in PTSD (Kornfield, Hantsoo and Epperson, 2018) . It could be due to the hormone and neurosteroid/peptide differences from both preclinical and clinical research (Kornfield, Hantsoo, 2018) . Our study has several limitations. Dysfunctional information related with complained symptoms was not accessed. Most symptoms were self-reported and were not cross-checked against medical charts. Also, follow-up time since hospital discharge was short, and PTSD symptoms can manifest years after the traumatic situation has occurred. The pathogenesis of the symptoms reported by survivors of COVID-19 is unclear and requires further study. Our study provides insights into the nature and severity of medical conditions specific to survivors of COVID-19. It also highlights the potential mental health issues resulting from infectious disease outbreaks within communities. The long-term consequences may not just be physical symptoms, which could necessitate comprehensive and coordinated mental health responses. Lastly, this study has underscored the importance of better understanding the conditions that lead to reinfection and what this means for measures that are undertaken to decrease disease transmission. Long-term psychological support could be a crucial element aiding in reducing mortality and morbidity and promoting overall effectiveness of efforts to halt COVID-19 transmission. This study provides a reference for improving people's mental health and psychological adaptability during any future COVID-19-like pandemic. Recurrence of positive SARS-CoV-2 RNA in COVID-19: A case report A longitudinal study of Ebola sequelae in Liberia What does sex have to do with it? The role of sex as a biological variable in the development of posttraumatic stress disorder Depression as a mediator of chronic fatigue and post-traumatic stress symptoms in Middle East respiratory syndrome survivors Psychological impact of the 2015 MERS outbreak on hospital workers and quarantined hemodialysis patients Long-term psychiatric morbidities among SARS survivors Post-Ebola syndrome Coping with future epidemics: T ai chi practice as an overcoming strategy used by survivors of severe acute respiratory syndrome (SARS) in post-SARS H ong K ong Synthesis of the psychometric properties of the PTSD checklist (PCL) military, civilian, and specific versions Interpretations of "Diagnosis and Treatment Protocol for Novel Coronavirus Pneumonia (Trial Version 7 Acknowledgements: Not applicable.