Question Period Note: POST COVID-19 CONDITION

• While, the typical duration of acute COVID-19 illness is two to six weeks, some patients have described debilitating symptoms persisting or recurring for weeks or months after their initial infection.

• The Government recognizes that some of the Canadians who contracted COVID-19 are facing a long recovery. While our understanding of the long-term health effects of COVID-19 is building, there is still much that is unknown about post COVID-19 condition.
• The Government of Canada is actively working with national and international experts to build the evidence base on post COVID-19 condition to support Canadians experiencing longer-term effects.
• Budget 2022 proposes $20 million over five years, starting in 2022-23, for the Canadian Institutes of Health Research to support additional research on the long-term effects of COVID-19 infections on Canadians, as well as the wider impacts of COVID-19 on health and health care systems.
• Budget 2022 also includes a new investment of $17.3 million over 3 years through the Public Health Agency of Canada to implement additional surveillance activities to examine post COVID-19 condition in Canada, including the development of a follow-up population-based survey on post COVID-19 condition, and to provide guidelines and supports for health professionals and for Canadians who are affected by post-COVID-19 condition.
• This will include funding for data and public health surveillance activities, including the development of a follow-up population-based survey on post COVID-19 condition, as well as the development and dissemination of evidence-based clinical guidelines on post COVID-19 condition that are adapted to the Canadian context.
• This is in addition to previously announced federal investments in research, through the Canadian Institutes of Health Research, of $328.8 million in COVID-19 research, of which $17.7 million was to study post COVID-19 condition.

If pressed on the prevalence of post COVID-19 condition in Canada
• There are currently insufficient data available to determine the percentage of the Canadian population experiencing post COVID-19 condition. The Federal government has recently funded and launched a population-based survey to estimate the prevalence of post COVID-19 condition among adults in Canada, and provide information on symptoms, risk factors and impacts on daily functioning. Results are expected in early 2023.
• Studies are underway that follow COVID-19 patients over time, from their initial diagnosis. These studies will provide high quality evidence upon which to make decisions for Canadians.
• The Government of Canada will continue to work with the provinces, territories and other domestic and international partners to monitor and better understand the long-term effects of COVID-19.

The typical duration of acute COVID-19 illness is two to six weeks. However, some patients have described debilitating symptoms persisting or recurring for weeks or months after acute illness. The World Health Organization (WHO) has developed the first version of a clinical case definition of post COVID-19 condition in adults, which reads as follows:
“Post COVID-19 condition 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. Common symptoms include fatigue, shortness of breath, cognitive dysfunction but also others and generally have an impact on everyday functioning. Symptoms may be new onset following initial recovery from an acute COVID-19 episode or persist from the initial illness. Symptoms may also fluctuate or relapse over time.”

The WHO is in the process of developing a separate clinical case definition for children, which they expect to complete in the coming months.

The range of symptoms reported is broad – they can vary from mild to severe, fluctuate in intensity and can sometimes disappear and reappear over time. Post COVID-19 condition can affect both adults and children, regardless of the severity of their initial COVID-19 symptoms in the acute stage, although studies in adults have reported that those who were hospitalized or needed intensive care during recovery are at increased risk of experiencing longer-term effects

It is anticipated that post COVID-19 condition will have a long-term impact on public health in Canada. The Government of Canada is actively monitoring the latest research and information related to the long-term effects and symptoms of COVID-19, as well as engaging with academic experts and policy makers from across the country, and internationally, to help inform public health action.

National Surveillance and Research

Since March 2020, the Canadian Institutes of Health Research (CIHR) has invested approximately $328.8 million in more than 800 COVID-19 research projects, of which $17.7 million was for targeted research studies on post COVID-19 condition. These projects span everything from diagnostics and potential treatments to public health responses and communication strategies. This funding includes post COVID-19 condition as an area of focus, e.g. for the Canadian COVID-19 Prospective Cohort Study (CANCOV), which aims to examine recovery trajectories and the determinants of longer-term outcomes. At the international level, CIHR is a member of the Global Research Collaboration for Infectious Disease Preparedness, an alliance of research funding organizations on a global scale that facilitates rapid and effective research responses to support new, urgent scientific priorities related to COVID-19.

In addition, Budget 2022 proposes $20 million in funding over five years, starting in 2022-23, for the Canadian Institutes of Health Research to support additional research into the long-term effects of COVID-19 infections on Canadians, as well as the broader impacts of COVID-19 on health and health care systems.

Based on early published reports in 2020, the World Health Organization estimates that at least 10-20% of people who had a COVID-19 infection will later experience one or several symptoms past 12 weeks after their initial illness. The Public Health Agency of Canada (PHAC) is regularly updating a review of worldwide studies on the prevalence of post COVID-19 condition, including the prevalence of the various symptoms and sequelae, and the proportion of individuals reporting difficulties in being able to carry out usual activities. Based on the global evidence reviewed by PHAC (peer-reviewed studies published up to April 2021) and findings from a recent peer-reviewed study, it is estimated that the proportion is 30-40% in individuals who were not hospitalized for their initial COVID-19 infection. Current evidence suggests that the prevalence is higher among those who were hospitalized during the acute phase compared to those who were not hospitalized. PHAC will continue to update this systematic review to capture results from high-quality studies currently underway. The studies reviewed by PHAC so far predate the last wave of infections associated with the Omicron variant.

PHAC continues to monitor the latest scientific literature on post COVID-19 condition in children and is working with the Canadian Paediatric Society to assess options to study post COVID-19 condition among children in Canada. At this time, the prevalence of this condition in children is not yet well-established, with high variability in estimates being observed from only a small number of studies. These estimates will become more precise as more studies are conducted and new evidence emerges.

As the prevalence of post COVID-19 condition in Canada is unknown, PHAC worked with Statistics Canada during fiscal year 2021-2022 to launch a second cycle of the Canadian COVID-19 Antibody and Health Survey (CCAHS). The survey will be used to estimate the prevalence of post COVID-19 condition in Canada and provide information on risk factors, symptoms (including severity and duration), and impacts on daily functioning. The first wave of survey invitations was mailed out on April 1st, 2022, and the second and third waves are scheduled for release on May 1st and June 1st, 2022, respectively. Preliminary results are expected between August and October 2022, and the final results will be released in early 2023.

While this survey will provide some general prevalence estimates, it does not fill all the evidence gaps associated with post COVID-19 condition in the Canadian context. Building on this initial survey, a follow-up survey will be conducted by PHAC in collaboration with Statistics Canada to obtain more detailed information from the respondents of the initial survey. In addition, PHAC will collaborate with other organizations in order to investigate existing sources of data that can be used to provide further evidence related to post COVID-19 condition in Canada. An investment of $1.3 million over three years was approved to undertake this work (2022-2023: $400 000; 2023-2024: $800 000; 2024-2025: $100 000).

PHAC continues to work with partners such as Statistics Canada, academic and professional organizations and the provinces and territories to explore the development and implementation of other public health surveillance activities to examine post COVID-19 condition. PHAC is also reviewing the evidence from countries that have implemented large population-based studies with data collection related to post COVID-19 condition.

Findings from the PHAC evidence brief on the efficacy of COVID-19 vaccines to lower the risk of post COVID-19 condition suggest that COVID-19 vaccination may decrease the risk of developing post COVID-19 condition. However, the small number of studies and the high risk of bias from retrospective studies lower our certainty in these conclusions. These findings could change in the future as the evidence from additional studies becomes available.

The evidence from worldwide and Canadian studies will help to determine the burden and urgency of this public health priority, as well as what mitigation measures are needed to support the recovery of those experiencing post COVID-19 condition. It will also help with anticipating and planning for longer-term burdens on healthcare systems, patients and their families, and society at large.

Support for Canadians with Post COVID-19 condition

It is clear that some of the symptoms reported by those with post COVID-19 condition affect their ability to work. Based on limited evidence from reviews conducted by PHAC and NICE, between 9%-22% of individuals were not working 3 months or more after acute COVID infection. Additionally, between 10%-46% of individuals reported working reduced hours approximately 7 months after acute infection. These results continue to undergo scientific evaluation to assess their validity and improve the level of certainty associated with this evidence.

Canadians suffering from post COVID-19 condition who are unable to work because of their symptoms may be eligible for support through Employment and Skills Development Canada’s Employment Insurance program and the Canada Pension Plan Disability benefits.

The provinces and territories are responsible for the management and delivery of health care services for their residents, including rehabilitation and treatment services for people with post COVID-19 condition. There are a number of public and private clinics that provide care to individuals with post COVID-19 condition across Canada, with a clear focus on interdisciplinary care.

PHAC is also engaging with national and international experts involved in clinical and health services research studies in order to inform public health decision-making and the development of evidence-based clinical guidelines. PHAC is also regularly updating the web content on post COVID-19 condition available on Canada.ca.

As part of Budget 2022, PHAC would receive $16 million over the next three years (2022-2023: $5.3 million; 2023-2024: $5.3 million; 2024-2025: $5.4 million) to develop and disseminate evidence-based guidelines on post COVID-19 condition. Potential topics may include guidance for the identification, prevention and management (including models of care) of post COVID-19 condition. PHAC is collaborating with partners to:
• scope guidelines and evidence that are already available;
• prioritize guideline topics and focus;
• identify knowledge gaps and priority areas; and,
• establish a guideline panel of experts.

These guidelines will consider the Canadian context, however, special populations (e.g. Indigenous, racialized, etc.) will also be taken into consideration.

Key Facts
• Whereas most people with COVID-19 recover fully from their illness, some, including those with milder illness, may experience symptoms for weeks or months after their initial infection. These longer-term symptoms are often referred to as “post COVID-19 condition”, “long COVID” and “post-acute sequelae of SARS-CoV-2 infection”. The condition can affect both adults and children. Affected individuals are commonly referred to as COVID-19 long-haulers.