Question Period Note: Post-COVID condition

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• While the typical duration of a COVID-19 episode ranges from two to six weeks, many infected individuals experience new or persisting symptoms for weeks or months after the acute phase.
• The Government recognizes that many Canadians who contract COVID-19 face a prolonged recovery, with symptoms that endure for some time after their infection.
• While our understanding of the long-term health effects of COVID-19 is building, there is still much that is unknown. The Government of Canada is actively working with national and international experts to build the evidence base on post COVID-19 condition, to inform and identity strategies to improve the prevention, diagnosis and treatment.
• The Chief Science Advisor of Canada, Dr. Mona Nemer, has convened a Task Force to develop a scientific roadmap that will provide a comprehensive framework for addressing post COVID-19 condition. Once released, it will inform decision-making going forward to address its health and socioeconomic impacts in Canada.
• Statistics Canada and the Public Health Agency of Canada recently provided the first Canadian data that provides insight into the magnitude and impacts of post COVID-19 condition on the Canadian population. The reports, based on data from the Canadian COVID-19 Antibody and Health Survey Cycle 2, will help inform our way forward in supporting Canadians living with post COVID 19 condition and will help to prevent future cases.

If pressed on federal actions to address PCC and on details of PCC funding for research, surveillance and evidence-based guidelines in Canada
• The Government of Canada is making significant investments to build the evidence-base to better understand post COVID-19 condition.
• Since March 2020, our Government has invested $414 million for COVID-19 research through the Canadian Institutes of Health Research, including $17.7 million in targeted funding to study post COVID-19 condition.
• We have also continued to build on these investments. Budget 2022 provided $20 million over five years, starting this year, for the Canadian Institutes of Health Research that will support a new research network dedicated to understanding and addressing the long-term impacts of COVID-19 infections on people living in Canada and Canadian health systems.
• Budget 2022 also included $10 million over 3 years for the Public Health Agency of Canada to develop evidence-based guidelines and tools for the identification, prevention, self-management, and clinical treatment of post COVID-19 condition, and to undertake additional surveillance activities

If pressed on the prevalence or impacts of PCC in Canada
• The Public Health Agency of Canada continues to monitor developments on scientific evidence nationally and internationally. This includes working with the provinces and territories to better understand the long-term effects of COVID 19.
• Research in Canada and around the world is underway to better understand post COVID-19 condition and its impacts. Numerous studies have reported the estimated prevalence of post COVID-19 condition in different populations, though these estimates range considerably for several reasons, including differences in when and where the studies were conducted.
• Results from the limited provisional release, on October 17th, 2022, of the Canadian COVID-19 Antibody and Health Survey by Statistics Canada, including some results on longer-term symptoms present for 3 months or more following an acute COVID-19 infection.
• The preliminary findings indicate that 14.8% of Canadian adults who reported a COVID-19 infection reported longer term symptoms 3 or more months after the acute infection.
• In addition, new data published on October 20th by the Public Health Agency of Canada show that the impacts of these longer term symptoms are significant. Almost half (47.3%) experienced symptoms for a year or longer, and 21.3% said that their symptoms often or always limited their daily activities.
• These symptoms also had an important impact on employment or school attendance. Among adults with longer-term symptoms who were employed or attending school, approximately three-quarters (74.1%) missed some work or school due to their symptoms. On average, they missed 20 days.
• This study and others to follow will help to refine our understanding of the prevalence of post COVID-19 condition in Canada, as well as potentially relevant risk factors.
• The Public Health Agency of Canada is also undertaking efforts to understand the socio-economic impacts of post COVID-19 condition in Canada, and its potential implications for the health care system, and the broader economy.

If pressed on the impact of vaccination on PCC in Canada
• Early evidence suggests that vaccination with two or more doses of COVID-19 vaccines helps to reduce the risk of developing post COVID-19 condition if individuals become infected.
• The best way to prevent post COVID-19 condition is to take measures to avoid getting infected in the first place. This includes following public health measures, reducing the risk of COVID-19 complications by getting vaccinated, and remaining up to date on booster doses.

If pressed on clinical services and supports available to Canadians with PCC
• Given the complexity of post COVID-19 condition, we recommend that Canadians experiencing a delayed recovery from COVID-19 maintain an ongoing dialogue with their health care providers about possible ways to manage their symptoms.
• The provinces and territorial governments are responsible for the management, organization and delivery of health care services for their residents. Many jurisdictions have developed local resources on post COVID-19 condition. This includes specialized clinics dedicated to post COVID-19 condition recovery.

The World Health Organization (WHO) developed the first version of a clinical case definition of post COVID-19 condition (PCC) in adults 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.” The WHO is exploring the possibility of developing, in the coming months, a separate clinical case definition for children.
There are currently many scientific uncertainties related to PCC and the evidence is slowly evolving. PCC can affect many different organs, including the brain, the heart, and the lungs. The reported range of symptoms is broad, varying from mild to severe, and can fluctuate in intensity and sometimes disappear and reappear over time. Common PCC symptoms include fatigue, cough, shortness of breath, brain fog, intolerance to physical activity, and others. Often these symptoms have a significant impact on everyday functioning and quality of life. PCC can affect both adults and children, regardless of the presence and/or severity of their initial COVID-19 symptoms. 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 and PCC.

PCC will have a significant long-term impact on public health and the health care system in general. At this point, there is insufficient evidence to determine the socio-economic impacts of PCC in Canada, and its potential burden on the health care system, or the broader economy. The Government of Canada is actively monitoring the latest research, as well as engaging experts and policy makers (domestic and international) to help inform public health action.
National Surveillance and Research
Public Health Agency of Canada (PHAC) and partners
Statistics Canada, in partnership with PHAC and in consultation with the COVID-19 Immunity Task Force have been working on the Canadian COVID-19 Antibody and Health Survey (CCAHS – Cycle 2). The first wave of the survey was launched in April 2022 and the collected data will be used to estimate the prevalence of PCC in adults in Canada.
• On September 6th, 2022, Statistics Canada released preliminary results from the CCAHS – Cycle 2 via “The Daily” page on the Statistics Canada website. Using responses received as of July 15th, this first release will highlight the proportion of self-reported positive tests for COVID-19, as well as self-reported suspected infections, and symptom prevalence.
• On October 17, 2022, further preliminary results about adults reporting longer-term symptoms following a SARS-CoV-2 infection were released by Statistics Canada. Data from the CCAHS estimate that 14.8% of Canadian adults who contracted COVID-19 experience longer-term symptoms 3 months or more after initial COVID-19 infection.

The Canadian Paediatric Surveillance Program (CPSP), a joint project of PHAC and the Canadian Paediatric Society, launched a new two-year surveillance study of PCC in children and youth in Canada in early September 2022. The CPSP study will also provide information on risk factors, symptoms, and impacts on daily functioning. Preliminary results are not anticipated before early 2023.

Through Budget 2022, PHAC will receive $9 million over the next three years (2022-2023: $1 million; 2023-2024: $4 million; 2024-2025: $4 million) to develop and disseminate evidence-based guidelines on PCC. Potential topics may include guidance for the identification, prevention, self-management, and clinical treatment of PCC. 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, and special populations (e.g. Indigenous, racialized, etc.) will also be taken into consideration.
Budget 2022 also includes another $1 million to undertake additional surveillance activities.
Canadian Institutes of Health Research (CIHR)
Since March 2020, the Canadian Institutes of Health Research (CIHR) has invested $414 million in 965 COVID-19 research projects, including $17.7 million to fund 41 targeted research studies on PCC. Spanning a wide range of research interests the funded projects across Canada will yield important results to inform how to manage and treat people with PCC.
Budget 2022 also provided an additional $20 million over five years, starting in 2022-23, for CIHR that will support the creation of a research network on the long-term effects of COVID-19 infections on people living in Canada and Canadian health systems. The funding opportunity was launched on October 19, 2022, and it is anticipated that the successful network will be notified on January 12, 2023.
At the international level, CIHR is a member of the Global Research Collaboration for Infectious Disease Preparedness. This global initiative is an alliance of research funding organizations that facilitates rapid/effective research responses.
Office of the Chief Science Advisor of Canada
The Chief Science Advisor of Canada, Dr. Mona Nemer, has convened a Task Force on post-COVID-19 condition. With a focus on the Canadian context, the key objectives of the Task Force are to summarize evidence that can inform the management of PCC, and to identify knowledge gaps in order to address the health and socioeconomic impacts of PCC in Canada. To help meet these objectives, the taskforce held a series of round tables with different stakeholders. The Task Force’s report is anticipated in November 2022.

Prevalence of PCC
There is still uncertainty about the prevalence of PCC. Based on early published reports in 2020 and before the development of a first case definition, the WHO estimated that at least 10% to 20% of people would experience PCC after their initial COVID-19 infection. Several evidence reviews (including one led by PHAC) from the initial phase of the pandemic (prior to the Omicron variant and roll out of vaccination campaigns) found that about 30% to 40% of those not hospitalized still reported at least one symptom, whether it be mild or more severe, beyond 12 weeks since their initial COVID-19 infection.
In these reviews, the prevalence estimates of PCC vary wildly, ranging from below 5% in some studies to around 80% in studies among those with severe initial illness. The variation in estimates is likely due to differences in the definitions used for PCC, in the characteristics of the study populations (e.g. hospitalized for COVID-19 or outpatients), and in the methods and timing of assessment of PCC-related symptoms.
The first results from CCAHS, related to PCC were released in October, estimating that 14.8% of adults have longer term symptoms 3 months or more after initial COVID-19 infection. This represents approximately 1.4 million Canadian adults, or 4.6% of the adult population. Data were collected from April to August 2022.
Some preliminary evidence, including from the Oct 17th release from the CCAHS, suggests that infections caused by the Omicron variant may be less likely to lead to PCC compared to other variants. More research is needed to understand whether this is due to differences in variants or other factors such as increasing population immunity (from vaccination and/or infection), or a combination of both. The impact of multiple infections on the risk of PCC is also not yet well understood, but preliminary and limited evidence suggests that the risks of PCC may increase with the number of reinfections.
At this time, the prevalence of PCC 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, including the CPSP, are conducted and new evidence emerges.
Socioeconomic impacts of PCC
The socio-economic impacts of PCC bring emerging issues, for example in relation to the labour market. In the United States, for example:
• Around 16 million working-age Americans (those aged 18 to 65) presently have PCC;
• Of those, 2 to 4 million are out of work due to PCC; and
• The annual cost of those lost wages alone is around $170 billion a year (and potentially as high as $230 billion).

The volume of media stories highlighting the plight of individuals suffering from PCC continues to increase. These often focus on the dual barrier of accessing care, as well as the dire financial implications; including loss of homes, jobs, custody of children, and draining of personal pension funds.

We learned from CCAHS that among adults with longer-term symptoms, 21.3% said that their symptoms often or always limited their daily activities. Among adults with longer-term symptoms who were employed or attending school, approximately three-quarters (74.1%) missed some work or school due to their symptoms. On average, they missed 20 days. This loss of productivity results in adverse social and economic consequences (e.g. loss of income, loss of employment among those experiencing symptoms over a long time period)

PHAC is using modelling to quantify the economic impact of PCC cases averted due to vaccination (from December 2020 to March 2022), focusing on the economic costs associated with reduced productivity, and labour force participation among those with PCC. The results from the modelling work, generated through a partnership with Finance Canada, will be published in 2023.

In addition, PHAC’s Office of the Chief Science Officer has initiated a scoping project with COVID-END that will outline and synthesize the available evidence for these gaps.

Vaccination and post COVID-19 condition
PHAC continues to closely monitor the evidence for the impacts of vaccination on PCC. Findings from PHAC’s latest review of the evidence (published up to July 7, 2022) continue to suggest that COVID-19 vaccination with two or more doses may reduce the risk of developing PCC among individuals who get vaccinated prior to a COVID-19 infection. More research is needed to quantify the extent to which additional doses may provide additional protection.
Support for Canadians with PCC
In terms of financial support, Canadians suffering from COVID-19 or PCC, who are unable to work, may be eligible to receive up to 15 weeks of income support through the Employment Insurance (EI) Sickness Benefit. In recognition that some individuals require more time to recover from an illness or injury, ESDC is planning to extend the EI sickness benefit from 15 to 26 weeks. This change has not been implemented, and it is anticipated to be launched before year end.

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 PCC. There are a number of public and private clinics that provide care to individuals with PCC across Canada, with a focus on interdisciplinary care. As of August 19, 2022, four provinces have clinics: British Columbia, Alberta, Ontario, and Quebec.

• While most people with COVID-19 recover fully from their illness, many people, including some with a milder initial episode, report experiencing symptoms for weeks or months after their initial infection. These longer-term symptoms (often wide ranging and varying in severity) are referred to as “post COVID-19 condition” (PCC), or “long COVID”.
• PCC refers to symptoms that last for at least two months, that cannot be explained by an alternative diagnosis, and that are experienced at 12 weeks or more after the onset of COVID-19.
• PCC can affect both adults and children, with preliminary evidence suggesting it is more common among adults, and more common in those who experienced a severe COVID-19 illness.
• Based on new data from the Canadian COVID-19 Antibody and Health Survey (CCAHS) released on October 17, 2022 by Statistics Canada, an estimated 14.8% of adults who reported a previous COVID-19 infection experienced longer-term symptoms 3+ months after their initial infection. This translates to about 1.4 million Canadian adults or 4.6% of the Canadian adult population.
• There are many scientific uncertainties about PCC, including how it develops, who is most at risk, the effect of variants and the potential longer-term socioeconomic impacts.
• While clinical studies are underway in Canada and around the world, there is currently no universally agreed-upon approach to diagnose and treat PCC.
• The best way to currently prevent PCC is to take measures to avoid getting infected.
• Individuals vaccinated with two or more doses of COVID-19 vaccines may have a reduced risk of developing PCC if they become infected.