Persistent fatigue following SARS-CoV-2 infection is common and independent of severity of initial infection July 2020 Townsend et al

Sly Saint

Sly Saint

Senior Member (Voting Rights)
Preprint
Abstract
Fatigue is a common symptom in those presenting with symptomatic COVID-19 infection. However, it is unknown if COVID-19 results in persistent fatigue in those recovered from acute infection. We examined the prevalence of fatigue in individuals recovered from the acute phase of COVID-19 illness using the Chalder Fatigue Score (CFQ-11). We further examined potential predictors of fatigue following COVID-19 infection, evaluating indicators of COVID-19 severity, markers of peripheral immune activation and circulating pro-inflammatory cytokines. Of 128 participants (49.5 ± 15 years; 54% female), more than half reported persistent fatigue (52.3%; 45/128) at 10 weeks (median) after initial COVID-19 symptoms. There was no association between COVID-19 severity (need for inpatient admission, supplemental oxygen or critical care) and fatigue following COVID-19. Additionally, there was no association between routine laboratory markers of inflammation and cell turnover (leukocyte, neutrophil or lymphocyte counts, neutrophil-to-lymphocyte ratio, lactate dehydrogenase, C-reactive protein) or pro-inflammatory molecules (IL-6 or sCD25) and fatigue post COVID-19. Female gender and those with a pre-existing diagnosis of depression/anxiety were over-represented in those with fatigue. Our findings demonstrate a significant burden of post-viral fatigue in individuals with previous SARS-CoV-2 infection after the acute phase of COVID-19 illness. This study highlights the importance of assessing those recovering from COVID-19 for symptoms of severe fatigue, irrespective of severity of initial illness, and may identify a group worthy of further study and early intervention.
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https://www.medrxiv.org/content/10.1101/2020.07.29.20164293v1
 
Many thanks for your very helpful feedback. Apologies if it seems as though we are proposing graded exercise for all; we mean to suggest a suite of interventions that will need to be individually tailored, rather than a blanket approach to all. Will clarify in published version.

So how do they know how to tailor interventions? Without any trials? He says he may identify a group worthy of further study and early intervention so what is the suite he prepare earlier?

Nul points I am afraid.
 
They have replied to my tweet saying they are aware of the limitations of the CFQ, but don't know of any better measure of fatigue.

Can someone suggest a better one for me to suggest to them, especially if they are using it for ongoing follow up of patients post treatment, as they need one that allows for worsening to show, and doesn't have the CFQ ceiling effect.
 
That fatigue is independent of infection severity seems unintuitive. Could this be due to inadequacies of the Chalder scale? Or is this a hint that fatigue is due to a somewhat different process than the infection, triggered by it but then continuing on its own?

Anyway I'm troubled by the observation that GET and CBT are still seen as important treatment for fatigue, including the authors of this paper. There is no good reason to think they work any better than a placebo. I also don't like the eagerness of the authors to intervene early. They appear convinced that they know how to help patients and don't seem to consider the possibility that they could cause harm by acting without having any real understanding of the problem. Making patients jump through extra hoops with the intent of helping them recover could delay or prevent their recovery.
 
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Midnattsol said:
Did they at least correct for the anxious/depression that would increase scores on the CFQ..?
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Depression/Anxiety was based on prior diagnoses or use of antidepressant medication.

The real problem is that caseness was based on the aforementioned crap questionnaire.

Notably, 86.6% of "Fatigued" participants did not have any prior depression/anxiety diagnoses, so this a weak predictor at most.
 
Trish said:
I have tweeted one of the authors:



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There are many better tools than CFQ. None are great but this is a disappointing answer, it's pretty much the worst one. Is it really the job of patients to point out to researchers that there are other tools? Did they simply not look? Over the years from papers I have seen several in use that are much better. Ugh.

Great replies everyone, though. But really using only one and the worst one of all? I repeat myself but: ugh.
 
Trish said:
They have replied to my tweet saying they are aware of the limitations of the CFQ, but don't know of any better measure of fatigue.

Can someone suggest a better one for me to suggest to them, especially if they are using it for ongoing follow up of patients post treatment, as they need one that allows for worsening to show, and doesn't have the CFQ ceiling effect.
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There are a bunch. Checklist Individual Strength, maybe? Fatigue Severity Scale? Any are better than the CFQ, I think, though all have problems.
 
There is a significant burden of fatigue at median follow up of ten weeks, with half of the patient cohort reporting severe fatigue. This has several profound implications. Firstly, 50% of the participants do not feel back to full health, despite being medically deemed recovered from their primary illness. Secondly, the impact of this fatigue on daily function is already evident, with almost one third (31%) having not returned to employment. This is of particular concern, given that it is recommended that post-viral infection return to work should take place after four weeks to prevent deconditioning (39). The high proportion of healthcare workers infected by COVID-19, not just in our cohort but internationally, means that this will have a significant impact on healthcare systems (38, 40, 41).
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Management of fatigue states requires multi-disciplinary input, and will not be appropriately addressed if follow up is by treating medical physicians alone. A suite of interventions, including graded exercise and cognitive behavioural therapy, are needed to manage CFS and may be relevant to post infectious fatigue. Furthermore, successful return to work will require ongoing input from occupational health departments and employers (60)
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Oh dear. I think the next link to offer them is to Mark Vink's latest paper deconstructing Cochrane and focusing on return to work.
 
Trish said:
Oh dear. I think the next link to offer them is to Mark Vink's latest paper deconstructing Cochrane and focusing on return to work.
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Actually, they do cite the latter...
Furthermore, successful return to work will require ongoing input from occupational health departments and employers (60).
[...]
60. Vink M, Vink-Niese F. Work Rehabilitation and Medical Retirement for Myalgic Encephalomyelitis/Chronic Fatigue Syndrome Patients. A Review and Appraisal of Diagnostic Strategies. Diagnostics. 2019;9(4):124.
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Not sure they read it!
 
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