Comment
Does post COVID-19 characterize new diseases and disabilities?
Sonjit Kumar Chakrovorty,a,d K. M. Amran Hossain,b,d Rubayet Shafin,c Shameem Ahammad,a and Iqbal Kabir Jahida,∗
a
Department of Microbiology, Jashore University of Science and Technology (JUST), Jashore, Bangladesh
b
Department of Physiotherapy and Rehabilitation, Jashore University of Science and Technology (JUST), Jashore, Bangladesh
c
Handicap International-Humanity & Inclusion, Bangladesh Program, Cox’s Bazar, Bangladesh
The clinical definition of symptom sequelae of COVID-
19 changed over time. Till March 2021, ongoing symp-
toms for more than four weeks were classified as post-
COVID-19 symptoms (PCS),1 later, on October 2021,
the WHO working group defines post-COVID-19 con-
dition (PCC)2 as the ongoing symptoms of COVID-19 or
newly developed symptoms noted after twelve weeks of
initial SARS-CoV-2 infection and these symptoms
persist for a minimum of two months, and no other
medical diagnosis can explain these symptoms. Several
studies have demonstrated the prevalence of PCS as
22.4%, 51%, and 43%, in Bangladeshi,3 Asian4, and
Global4 populations respectively. The prevalence of PCC
is still in a dilemma because none of the reported
symptoms matches WHO criteria.2 A meta-analysis4 of
symptoms diagnosed PCC as symptoms persistent after
4 weeks of COVID-19, other Epidemiological studies
from Bangladesh,3 India,5 United Kingdom,6 and the
United States7 diagnosed PCC with symptoms noted
after 12 weeks of COVID-19 but not persistent for a
minimum of two months duration. So, there is a
research gap in the epidemiology of PCC according to
WHO criteria. PCC causes relapsing, remittent episodes
of symptoms causing episodic disabilities,4,6 but the
interaction between disease and disability induced by
PCC is still unclear.
To figure out the real scenario of PCC and to char-
acterize the disease and episodic disabilities induced by
PCC, a large-scale population-based household
screening of 12,628 retrieved contacts of 12 weeks old
COVID-19 cases confirmed by Real-time polymerase
chain reaction test (RT-PCR) was conducted between
July and December 2021 in Bangladesh. Diagnosis of
PCC was performed according to WHO criteria.2 The
COVID-19 Yorkshire Rehabilitation Scale (C19-YRS)8
was used to elucidate the clinical scenario
(Supplementary File 1) and the International Classifi-
cation of Disease (ICD-10) was used to determine the
disease induced by PCC. Additionally, to determine the
spectrum of disability according to the International
Classification of Functioning, Disability, and Health
(ICF), 19 indicators under five ICF domains were
*Corresponding author.
E-mail address: ikjahid_mb@just.edu.bd (I.K. Jahid).
© 2023 The Author(s). Published by Elsevier Ltd. This is an open access
article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).
d
These authors contributed equally as the first author.
www.thelancet.com Vol 15 August, 2023
assessed through the sub-scales of six structured and The Lancet Regional
validated outcome tools (Supplementary File 2). Health - Southeast
The study revealed higher PCS 0.19 [95% CI: Asia 2023;15: 100234
0.19–0.20] (N = 2507) compared to PCC 0.04 [95% CI: Published Online 10 June
2023
0.041–0.048] (N = 563) in Bangladeshi people. Fifteen
https://doi.org/10.
symptoms were found as PCS in our study, and thirteen of
1016/j.lansea.2023.
them were diagnosed as PCC according to WHO clinical 100234
case definition.2 Major clinical symptoms associated with
PCC (with ICD-10 code) was fatigue (R53. 83) .221,
depression (F32.9) .218, cough (R05. 9) .219, pain (R52)
.219, weakness (R53) .217, anxiety (F40) .214, insomnia
(G47) .211, dyspnea (R06.0) .208, cognitive problems (R41.
84) .201, dizziness (R42) .172, PTSD (F43) .147, and
palpitation (R00.2) .147. The population proportion of
these PCC is supplied in Supplementary File 3. These
symptoms are also evident in previous studies,3–7 so the
ICD-10 codes of these symptoms can be sub-categorized
under PCC, which has been coded as “U-09” by the
WHO.9
In the ICF lens, functional disability was significant in
breathlessness, cough, fatigue, pain, anxiety, depression,
and insomnia. People with poor physical health, psycho-
logical health, and social participation in WHOQoL- Bref
had breathlessness, cough, pain, anxiety, depression, and
insomnia. The inter-relationship of Post-COVID-19 Con-
dition (PCC), episodic functional disability, and quality of
life is supplied in Supplementary File 4. For detailed
investigation, structural equation modeling (SEM) was
performed to find out the interaction among ICF domains
with PCC (Fig. 1). SEM showed a significant association
among the domains of the ICF model, which was not
observed in earlier studies. The impairments in body
structure and function directly affect the activity limitation
and participation restriction for a person having PCC or
long COVID. With this consequence, the significant im-
pairments in activity limitations and participation re-
strictions can affect the person’s personal and
environmental factor domains in ICF.
This study presented a hypothetical relationship be-
tween disease course and episodic disability in PCC. We
have identified 13 diseases having ICD-10 codes which
can be categorized as PCC under U-09. Though the
study is not conclusive and the result might not be
generalized because of low ICC values and Deff in
sample size calculation, the clinical implication out-
weighs the limitations. Future systematic reviews or
meta-analyses might consider using the cut-off duration
≥12 weeks Post-COVID and individual symptom dura-
tion ≥2 months for defining PCC or long COVID. We
1
 Comment
Fig. 1: Structural equation modeling (SEM) of interaction among ICF domains with Post-COVID-19 condition (PCC).
also highlight the need for future studies on the disease
burden of PCC addressing the existing research gap10 on
its episodic pattern, longitudinal disease course, and
outcome of multidisciplinary rehabilitation.
Contributors
S.K.C., K.M.A.H, R.S, I.K.J.: concept, design, definition of intellectual
content, analysis of data, interpretation of data, manuscript preparation,
manuscript editing, manuscript review, final approval, and guarantor.
S.K.C., K.M.A.H, R.S, S.A, I.K.J.: literature search, manuscript editing,
manuscript review, data acquisition, data analysis, and final approval.
Data sharing statement
Relevant data is available in the paper, the additional request for data should
be addressed to the corresponding author (ikjahid_mb@just.edu.bd).
Declaration of interests
None.
Acknowledgments
We acknowledge Tofajjal Hossain Tuhin and Ahamadullah-hil-Galeb for
their contribution to preparing the manuscript. We also acknowledge
the Directorate General of health services (DGHS) of Bangladesh for the
permission support in conducting the household survey.
Appendix A. Supplementary data
Supplementary data related to this article can be found at https://doi.
org/10.1016/j.lansea.2023.100234.
References
1 Fernández-de-las-Peñas C. Long covid: current definition. Infection.
2021;50(1):285–286. https://doi.org/10.1007/s15010-021-01696-5.
2 www.thelancet.com Vol 15 August, 2023
2 World Health Organization. A clinical case definition of post covid-
19 condition by a Delphi Consensus, 6 October 2021. https://apps.
who.int/iris/handle/10665/345824; 2021.
3 Hossain MA, Hossain KM, Saunders K, et al. Prevalence of long
covid symptoms in Bangladesh: a prospective inception cohort
study of covid-19 survivors. BMJ Glob Health. 2021;6(12). https://
doi.org/10.1136/bmjgh-2021-006838.
4 Chen C, Haupert SR, Zimmermann L, Shi X, Fritsche LG,
Mukherjee B. Global prevalence of post-coronavirus disease 2019
(COVID-19) condition or long covid: a meta-analysis and systematic
review. J Infect Dis. 2022;226(9):1593–1607. https://doi.org/10.
1093/infdis/jiac136.
5 Ayoubkhani D, Bermingham C, Pouwels KB, et al. Trajectory of
long covid symptoms after covid-19 vaccination: community based
cohort study. BMJ. 2022:377. https://doi.org/10.1136/bmj-2021-
069676.
6 Sivan M, Parkin A, Makower S, Greenwood DC. Post-COVID
syndrome symptoms, functional disability, and clinical severity
phenotypes in hospitalized and nonhospitalized individuals: a
cross-sectional evaluation from a community COVID rehabilitation
service. J Med Virol. 2022;94(4):1419–1427. https://doi.org/10.
1002/jmv.27456.
7 Bull-Otterson L, Baca S, Saydah S, et al. Post–COVID conditions
among adult COVID-19 survivors aged 18–64 and≥ 65 years—
United States, March 2020–November 2021. Morb Mortal Wkly Rep.
2022;71(21):713.
8 Sivan M, Halpin S, Gee J. Assessing long-term rehabilitation needs
in COVID-19 survivors using a telephone screening tool (C19-YRS
tool). Adv Clin Neurosci Rehab. 2020;19(4):14–17. https://doi.org/10.
47795/nele5960.
9 Diaz JV, Herridge M, Bertagnolio S, et al. Towards a universal
understanding of post COVID-19 condition. Bull World Health
Organ. 2021;99(12):901. https://doi.org/10.2471/BLT.21.286249.
10 O’Mahoney LL, Routen A, Gillies C, et al. The prevalence and long-
term health effects of long Covid among hospitalised and non-
hospitalised populations: a systematic review and meta-analysis.
eClinicalMedicine. 2023;55:101762. https://doi.org/10.1016/j.eclinm.
2022.101762.