Association of COVID-19 symptoms and functional status of the COVID-19 survivors in a tertiary health care center in a developing country

Introduction

The COVID-19 pandemic has swept across the globe, affecting millions of people in 231 countries, areas, and territories and overwhelming healthcare systems. Bangladesh is one of the countries that has been severely affected by the pandemic, with 2.37 million cases and 29,445 deaths reported up to 26^th March, 2023 (Worldometer). Coronaviruses are a family of enveloped viruses known as Coronaviridae. They are large, positive single-stranded RNA viruses that can be transmitted from human to human through respiratory secretions.¹

COVID-19 is characterized by a range of clinical symptoms that appear 2-14 days after exposure to the virus, such as fever, cough, nasal congestion, fatigue, dyspnea, and severe chest symptoms consistent with pneumonia.^2,3 The most common COVID-19 symptoms were fever (83%–98%), dry cough (57%–82%), and dyspnea (18%–55%), with a median duration of 5–8 days after the infection. Anosmia also presented in the early stages of the disease in the absence of other symptoms.³

It is expected that COVID-19 will have a noteworthy impact on physical, cognitive, mental, and social health, even among patients with mild illness.¹ Previous studies on the long-term consequences of severe acute respiratory distress syndrome (ARDS) have shown negative effects on pulmonary function and overall health status that can persist for several years after the onset of the disease.⁴ A large proportion of patients experience fatigue, which reduces both physical and mental performance.⁵

According to the World Health Organization (WHO), quality of life (QOL) refers to an individual’s perception of their position in life within the context of the cultural and value systems they live in and their goals, expectations, standards, and concerns.⁶ Standard indicators of QOL include wealth, employment, physical and mental health, education, environment, leisure and recreational activities, social connections, religious beliefs, safety, security, and freedom. In patients who have recovered from COVID-19, their mental health may require a long-term recovery process, which can significantly impact their overall quality of life.^1,7

A study found that general, respiratory, and gastrointestinal symptoms were associated with an increased risk of death due to COVID-19. Additionally, pre-existing conditions such as diabetes, cardiovascular diseases, and respiratory disease had a statistically significant association with the hospitalization of patients.³ Another study noted that many COVID-19 hospital survivors face adverse effects even six months after hospital discharge in terms of the level of physical activity and functional level decline in older adults.⁸

Functional capacity refers to an individual’s maximal ability to perform daily activities across various domains of life, such as physical, psychological, social, and spiritual. Meanwhile, functional performance refers to the actual activities that individuals carry out during their daily lives.¹

Bangladesh is a developing country that has been severely affected by the pandemic, with thousands of cases and deaths reported.⁹ With the given number of COVID-19 survivors and their associated disabilities and financial constraints, their quality of life in terms of functional status in Bangladesh is negatively impacted.^9,10 Like other low resource countries, in Bangladesh the healthcare system is underdeveloped where rehabilitation is not a health priority, and so COVID-19 survivors added an extra burden over healthcare delivery system.¹⁰

While many individuals have been able to recover from the disease, it is essential to understand the impact that COVID-19 can have on survivors’ functional status. This study aims to investigate the association between COVID-19 symptoms and functional status among COVID-19 survivors in a tertiary healthcare center in Bangladesh. By examining the functional status of survivors, this study seeks to shed light on the impact of COVID-19 on the physical, mental, and social wellbeing of those who have contracted the virus. These findings emphasize the importance of providing a comprehensive care and support to COVID-19 survivors beyond the acute phase of the illness to improve their functional outcomes and quality of life. Hence, an attempt was made to determine the association between COVID-19 symptoms and functional status among COVID-19 survivors in a tertiary health care center in a developing country.

Methods

Results

Within the specified time frame, a total of 280 participants agreed to participate in the study. However, 36 participants were subsequently excluded for various reasons. Specifically, 20 of them did not present their COVID-19 test result during the interview, 12 withdrew from the study due to time constraints or feeling unwell during the interview, and 4 were missing data. Among the 244 participants, 57.4 percent were male and 42.6 percent were female. The mean (SD) age of the patients was 44.6 (±14.7) years, where 37.7 percent were from 20-35 years age group. Again, the majority of the patients have above secondary level education (82), work as a service holder (56.6%) and came from nuclear family (67.2%). 63.9 percent of the patients had a monthly family income between 31000-60000 BDT. The mean duration of suffering, on the basis of how long patients had COVID-19 symptoms, was 15.9 (±6.1) days where 61.5 percent of the patients had a duration of 11-20 days (Table 1).

Out of the 244 patients, 40 (16.4%) patients had no functional limitation (grade 0 functional status in PCFS scale) while 100 (40.9%) had negligible functional limitation and 14 (5.7%) had severe functional limitation (Figure 1).

Figure 1. Functional status of the respondents on post-COVID-19 PCFS scale (N = 244).

This study revealed that grade 0 was found to be statistically significant with fever, cough, respiratory distress, weakness or numbness of limbs, joint pain and skin rash or discoloration of fingers and toes. Grade 1 was found to be statistically significant (p < 0.001) with only respiratory distress and Grade 2 with weakness or numbness of limbs (p < 0.001). Grade 3 was found to be statistically significant (p < 0.001) with fever, cough, loss of taste, respiratory distress, and sore throat. Grade 3 was also found to be statistically significant (p < 0.05) with weakness or numbness of limbs and skin rash or discoloration of fingers and toes. Grade 4 was found to be statistically significant at p < 0.001 level with the symptoms of fever, fatigue, chest pain, and skin rash or discoloration of fingers and toes, whereas loss of taste, respiratory distress, sore throat, weakness or numbness of limbs were found statistically significant at p < 0.05 level (Table 2).

Patients with symptoms lasting 14 days or more had a higher percentage of functional limitations. The statistical analysis of the data revealed that there was a significant association between the duration of COVID-19 symptoms and post-COVID-19 functional status for patients who experienced symptoms for 14 days or more. Specifically, there was a statistically significant difference in the proportion of patients with grade 1, grade 3, and grade 4 functional status compared to those with symptoms lasting less than 14 days, with p-values of less than 0.05. However, for patients with symptoms lasting less than 14 days, there was no statistically significant association with post-COVID-19 functional status. Overall, these findings suggest that a longer duration of COVID-19 symptoms is associated with a higher risk of functional limitations in post-COVID-19 recovery (Table 3).

The majority of individuals aged 50 and below are in lower grades of PCFS (Grade 0 and 1), suggesting they have better functional status compared to those above age 50. Notably, 95% of those in Grade 0 and 72% in Grade 1 are under 50 years old. For the older group (Above 50), a significant percentage (85.7%) falls in Grade 4, indicating poorer functional status. The presence of significant p-values (p < 0.001 in Grade 4) highlights a statistically significant worse outcome in functional status among older individuals. A higher percentage of individuals in paid occupations tend to have better functional outcomes in the lower grades (Grade 0 and 1), with 70% in Grade 0 and 80% in Grade 1.

Conversely, individuals in unpaid occupations show higher frequencies in higher grades (Grade 3 and Grade 4), indicating poorer functional status. The difference in Grade 1 and Grade 3 is statistically significant with p < 0.05 and p < 0.001 respectively, suggesting that occupation type has a meaningful impact on functional status post-COVID-19. Non-smokers generally report better functional status, with 80% in Grade 0 and 90% in Grade 1. Smokers show a higher percentage in higher grades, such as Grade 3 (22.7%) and Grade 4 (28.6%). The difference in Grade 1 for non-smokers is statistically significant (*p < 0.05), indicating that smoking status may negatively impact post-COVID-19 recovery (Table 4).

Discussion

Our study investigated the association between COVID-19 symptoms and functional status among survivors in a tertiary health care center in Bangladesh, revealing insights into the post-recovery experiences of patients. The mean age of our cohort was 44.6 years, with a significant representation from the 20-35 age group, indicating a notable impact of COVID-19 across a younger demographic than typically emphasized in existing literature. This age group was considered to be relatively less vulnerable to COVID-19, and the high representation of this group might suggest a higher prevalence of the virus in the younger population of the studied area. The average age of the patients was found in earlier investigations to be 33.09 ± 12.09 years and 38.48 ± 16.20 years old respectively.^9,13

There are differences in the clinical and demographic traits of COVID-19 individuals in a given population. Male patients make up 57.4% of the total population, with female patients making up the remaining 42.6%. These results were in line with some earlier research and global trends^6,13–15 which represented both developed and developing nations. The study also sheds light on the diverse socio-economic backgrounds of COVID-19 survivors, revealing that a majority, or 56.6%, were employed individuals, and a substantial 82% had attained an education level beyond secondary school. This data suggests that COVID-19 affected a wide array of individuals, not limited by educational attainment or professional standing. Furthermore, the majority of participants, 67%, resided in nuclear families, in contrast to 37% who lived in extended (joint) family settings. On the economic front, a notable share of patients (63.9%) reported a monthly family income ranging from 31,000 to 60,000 Bangladeshi Taka. This group particularly experienced heightened financial strain during the pandemic due to considerable out-of-pocket healthcare expenses, which constituted roughly two-thirds of the total health expenditure in Bangladesh.¹⁶ Previous reports also showed that “vulnerable non-poor” families in Bangladesh have a monthly income between 35,000-70,000 BDT.

Our study’s findings reveal that older individuals, defined as those aged 50 and above, are disproportionately represented in the higher (more severe) grades of the PCFS which is consistent with an Egyptian study where age was found to be a significant risk factor for PCFS.¹⁷ This pattern suggests that older adults face a greater risk of poorer functional recovery, indicating a need for tailored medical and supportive interventions to improve their recovery prospects. Additionally, our analysis shows a clear disparity in functional outcomes based on occupational status. Individuals in unpaid occupations, which may include retirees, housewives, or the unemployed, tend to experience worse functional outcomes. In contrast, those in paid occupations, such as service holders and business owners, generally report better functional status. This distinction underscores the potential impact of economic activity and possibly socioeconomic status on recovery from COVID-19. Smoking status also appears to influence functional outcomes significantly. Smokers are less frequently found across all PCFS grades but are more concentrated in the severe impairment categories. Specifically, 28.6% of smokers are categorized under Grade 4, which represents a severe level of impairment. On the other hand, non-smokers are primarily found in the lower impairment grades, with 80% classified under Grade 0, indicating milder or no functional impairment. This distribution suggests that smoking may exacerbate the risk of severe post-COVID-19 functional impairments.

The average duration of COVID-19 symptoms among the participants indicated that the population experienced a form of the disease that was generally mild and consistent with standard infection periods. In contrast, Jradi et al.’s study reported a longer (35.31 ± 18.75) mean duration than the results of the current investigation.¹⁵ This long duration might be due to the impairment in physical activities, the long duration of confinement and the extreme doubt during the COVID-19 disease had generated remarkable mental and attitude disorders.¹⁸

In our study, a considerable number of the patients experienced varying degrees of functional limitation following COVID-19, with most facing mild to negligible impacts on their daily activities. However, a smaller subset encountered severe limitations, significantly hindering their daily functionality. The analysis did not cover the functional status of a portion of the participants. Similar results were mentioned by Machado et al.¹³ In similar study, Hussein et al., reported that most of participants (63.1%) had a trivial limitation in activities after recovery from COVID-19 (Grade 1), 14.1% had slight (Grade 2), 2.5% had moderate (Grade 3), and only 0.5% had severe functional limitation (Grade 4). However one fifth of the participants had no functional limitations (Grade 0).¹⁵ Another study conducted by Pant et al. showed negligible functional limitation (PCFS grade 1) among nearly one fourth (27.3%) of the patients, 13 (12.3%) patients had slight functional limitation (PCFS grade 2), and a negligible portion of the patients had moderate (PCFS grade 3) and severe functional limitations (PCFS grade 4).¹⁴

The present study describes the relationship between the functional status of patients and various symptoms they experienced. According to the statement, grade 0 functional status was statistically significant with fever, cough, respiratory distress, weakness or numbness of limbs, joint pain, and skin rash or discoloration of fingers and toes. This suggests that patients with grade 0 functional status were less likely to experience these symptoms compared to patients with higher functional status grades. Grade 1 functional status was found to be statistically significant with only respiratory distress, and grade 2 was found to be statistically significant with weakness or numbness of limbs. This indicates that patients with higher functional status grades were more likely to experience these symptoms compared to patients with lower functional status grades. Grade 3 functional status was statistically significant with fever, cough, loss of taste, respiratory distress, sore throat, weakness or numbness of limbs, and skin rash or discoloration of finger toes. Similarly, grade 4 functional status was statistically significant with fever, fatigue, loss of taste, respiratory distress, sore throat, weakness or numbness of limbs, chest pain, and skin rash or discoloration of fingers and toes. This suggests that patients with higher functional status grades were more likely to experience these symptoms compared to patients with lower functional status grades.

In a notable fraction of COVID-19 survivors, persistent symptoms have been linked to a progression toward low functional status.¹⁹ A higher percentage of people in a different study by Machado et al., who present a symptom-based COVID-19 diagnosis and have a lower functional level, such as living alone, have symptoms.¹⁴ Among individuals who had symptoms for at least 14 days, there was a significant correlation between the length of COVID-19 symptoms and post-COVID-19 functional status (p < 0.05). Longer symptom duration was linked to worse functional status in research by Huang et al., including decreased mobility and greater fatigue, discomfort, and depressive illness.²⁰ The limitations of this study were firstly, the study used a convenience sampling technique, which may limit the generalizability of the findings. Secondly, the study relied on self-reported information, which may be subject to recall bias. Finally, the study was conducted in a single tertiary healthcare center, which may limit the generalizability of the findings to other settings.

Conclusion

This research will provide valuable insights into the association between COVID-19 symptoms and functional status of survivors in a developing country. The findings will be useful in developing effective rehabilitation programs for COVID-19 survivors and improving their quality of life.