Question Period Note: Post COVID-19 Condition

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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”.

Key Messages
• The Government recognizes that many Canadians who contract COVID-19 face a prolonged recovery, with symptoms that persist 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 PCC.
• In addition, earlier this month, Canada’s Chief Science Advisor (CSA), Dr. Mona Nemer, released her PCC Task Force report, Post-Covid-19 Condition in Canada: What we know, What we don’t know and a framework for action.
• Officials from across the Health Portfolio are reviewing findings from the CSA report, which will inform future government action in responding to PCC.
• Work has already started to respond to the Task Force’s recommendations:
o The Government has provided funding and scientific support for the development of Canadian evidence-based PCC guidelines for Canadians, and the establishment of a pan-Canadian PCC Research Network.
o Additionally, the Public Heath Agency of Canada has established a PCC Secretariat to bring greater coordination and strategic direction to the on-going work relating to the condition.

If pressed on the PCC Task Force Report
• I would like to thank Dr. Nemer, and all the members of the Task Force for their exceptional work. This report outlines the breadth, scope and complexity of issues surrounding PCC. It covers areas related to labour and the economy, clinical practice and research, data collection, coordination and infrastructure, impacts on individuals and communities.
• The recommendations will provide an invaluable source of information to help inform government actions to address PCC.
If pressed on govt actions
• The Government of Canada has made significant investments to build the evidence-base to better understand PCC. Since March 2020, the Canadian Institutes of Health Research has invested $394.3 million into COVID-19 research, and partner organizations have added another $20.5 million. Of this $414.8 million total, $17.7 million has been funding targeted to the study of PCC.
• In addition, the Government of Canada has established a PCC Secretariat within PHAC to coordinate a whole-of-government approach to address evidence and data gaps around the condition, along with supporting Canadians in managing and eventually recovering from it.
• Through Budget 2022, the government is investing $20 million over five years, to enable the Canadian Institutes of Health Research to establish a new Canadian PCC Research Network, called Long COVID Web, dedicated to understanding and addressing the biological, clinical, mental health, and health system and population health impacts of the condition.
• Budget 2022 also included $9 million over 3 years for PHAC to support the development, dissemination, and evaluation of Canadian evidence-based guidelines and tools for the identification, prevention, self-management, and clinical treatment of PCC. PHAC is providing this funding to the team of expert methodologists at the Cochrane Canada and GRADE centres at McMaster University who will develop the guidelines.

If pressed on the prevalence or impacts of PCC in Canada
• PHAC 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.
• Results from the October 2022 release by Statistics Canada of provisional data, from the Canadian COVID-19 Antibody and Health Survey, indicated that 14.8% of Canadian adults who self-reported a COVID-19 infection reported longer-term symptoms 3 or more months after the acute infection.
• PHAC is currently reviewing evidence on the global prevalence of PCC and potential risk factors. Results are expected later this year.
• Understanding the socio-economic impacts of PCC in Canada and its potential implications for the health care system and the broader economy is important. A review commissioned by PHAC found that approximately 17-19% of workers miss work due to PCC. A Canadian study also has found that PCC patients have about a 50% increase in health care utilisation.
• These endeavours will help refine our understanding of the prevalence and risk factors of PCC in Canada, as well as its potential impacts.
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 PCC if individuals become infected.
• The best way to prevent PCC is to take measures to avoid getting infected in the first place. This includes following personal preventive practices, such as staying up to date with your COVID-19 vaccinations and paying attention and taking precautions in response public health alerts and signals in your area.
If pressed on clinical services and supports available to Canadians with PCC
• The provincial 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 PCC. This includes specialized clinics dedicated to PCC recovery.

In October 2021, the World Health Organization (WHO) released a clinical case definition of PCC (PCC) in adults as follows: “PCC 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 that last for at least 2 months and cannot be explained by an alternative diagnosis.” In February 2023, WHO released a clinical case definition for children and adolescents as follows: “PCC in children and adolescents occurs in individuals with a history of confirmed or probable SARS-CoV-2 infection, when experiencing symptoms lasting at least 2 months which initially occurred within 3 months of acute COVID-19”.

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. Although, a large number of therapeutics are being assessed in clinical trials, none are currently approved by any international medical regulators. Due to a lack of PCC diagnostic tests, patients are diagnosed based on clinical assessment. Given the broad range of PCC symptoms, there is evidence that models of care based on a multi-disciplinary approach offer the most benefits to patients.

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 females, those with underlying conditions, and those who were hospitalized or needed intensive care during recovery are at increased risk of experiencing longer-term effects and PCC.

The impacts of PCC on public health and the health care system in general, are anticipated to be significant and long-term. 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 Health Portfolio 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 data collection for the survey is now complete.
• 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, 2022, this first release highlighted the proportion of Canadian’s self-reporting positive cases for COVID-19, as well as self-reported suspected infections.
• 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. This represents approximately 1.4 million Canadian adults, or 4.6% of the adult population. Data were collected from April 1 to August 15, 2022.

PHAC is also collaborating with Statistics Canada on a crowdsourcing survey that uses the CCAHS-Cycle 2 electronic questionnaire. Launched on February 14, 2023, the Canadian Health and COVID-19 Survey (CHCS) is being used by participating jurisdictions to better understand the health impacts of the COVID-19 pandemic, including PCC, on subpopulations of interest in their jurisdictions.
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.

Through Budget 2022, PHAC received $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. Aligned with the PCC Task Force’s recommendation, PHAC is providing funding to the team of expert methodologists at the Cochrane Canada and GRADE centres at McMaster University who are leading the development, dissemination, and evaluation of evidence-based guidelines for Canadians, including patients, health practitioners, and decision-makers. 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 both general and some specific population subgroups, where feasible. The guidelines will begin to be released in early 2024.
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 $394.3 million COVID-19 research, to which partner organizations have added $20.5 million, and resulted 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, including scientific findings on the clinical management and treatment of individuals 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 Canadian PCC Research Network, called Long Covid Web, focussed on improving the understanding of the clinical, mental health, health systems, and biological impacts of PCC. The competitive funding opportunity was launched on October 19, 2022, with an announcement of the successful team in March 2023. In early February 2023, CIHR organized a kick-off meeting to introduce the successful team to key policy players in the Health Portfolio and to enable and facilitate coordination and cohesion across various Government of Canada initiatives and investments on PCC.
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 coordinated investment to improve preparedness and a rapid research response to epidemics and pandemics.
Office of the Chief Science Advisor of Canada
In the summer of 2022 the Chief Science Advisor of Canada, Dr. Mona Nemer, convened a Task Force on post COVID-19 condition. With a focus on the Canadian context, the key objectives of the Task Force were to summarize evidence that could inform the management of PCC, and to identify knowledge gaps in order to address the health and socioeconomic impacts of PCC in Canada. The Task Force released its recommendations in a pre-report disseminated on December 14 2022, and the full report was released at the beginning of March 2023.

Since this time, the Government of Canada has established a PCC Secretariat within PHAC to coordinate a whole-of-government approach to address evidence and data gaps around the condition. Health Portfolio officials will review all recommendations to help inform future government action in responding to PCC.
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.
Some preliminary evidence, including from the October 17, 2022 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.
PHAC is currently undertaking a review to synthesise the available evidence on the global prevalence of PCC and potential risk factors for the condition. Results are expected later in 2023.
Socioeconomic impacts of PCC
The socioeconomic impacts of PCC are emerging, 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).
• In the US, estimates of the total economic burden vary between $50-$600 billion/year.

Estimates extrapolated from US results suggest that the economic burden to Canada could range from $5-$60 billion/year. In addition, job loss (including retirement and long term disability) is estimated to be 1-3%.

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 treatment and production loss due to reduced labour force participation among those with PCC. The results from the modelling work will be published in 2023.

In addition, PHAC has commissioned a living evidence review with COVID-END that synthesizes the available evidence addressing the impact of PCC on return to work, productivity loss, and the overall economic burden of PCC, including economic impacts directly related to mental health symptoms associated with PCC. The recently published report has found that the proportion of workers who experience substantial absence from work due to PCC varies, but is likely around 17-19%. One Canadian study has found that PCC patients have about a 50% increase in health care utilisation compared to patients who did not have COVID-19. At this stage, there is no significant evidence on the impact of PCC on productivity loss and none of the key studies reported the economic impact which might be attributed to mental health conditions in those with PCC.

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 helps to 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 income support through Employment Insurance (EI) Sickness Benefits. In recognition that some individuals require more time to recover from an illness or injury, the Government of Canada permanently extended EI sickness benefits from 15 weeks to 26 weeks. Those extra weeks are available for new EI claims established on or after December 18, 2022.

To align with this change, the maximum length of unpaid sick leave available to federally regulated private sector employees was also increased from 17 to 27 weeks under the Canada Labour Code. This change also came into effect on December 18, 2022 to ensure that employees have the right to take unpaid job-protected leave while receiving the extended EI sickness benefits.

• 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. Known risk factors include female sex, hospitalization due to COVID-19, pre-existing chronic health conditions, and repeated SARS-CoV-2 infection.
• 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.
• The best way to currently prevent PCC is to take measures to avoid getting infected with COVID-19. This includes getting vaccinated and continuing to take personal protective measures.
• Emerging evidence suggests that COVID-19 vaccination with two or more doses helps to reduce the risk of developing PCC among individuals who get vaccinated prior to a COVID-19 infection. Early treatment with safe and effective COVID-19 therapies may also help reduce the risk of developing PCC.