COVID-19 illness is caused by the betacoronavirus SARS-CoV-2. Cases of SARS-CoV-2 infection can be classified into at least four distinct classes: asymptomatic, upper respiratory tract infection, lower respiratory tract infection (eg, pneumonia), and acute respiratory distress syndrome (ARDS). Additionally, the virus can affect the cardiovascular, liver, kidneys, skin, gastrointestinal, hematological, and central nervous systems.1
Since the virus can be contracted from other people anywhere and a direct attribution is often difficult, classifying COVID-19 as an occupational illness can be controversial. Some US states (eg, AK, MN, UT, WI) have passed legislation granting the rebuttable presumption of causation by workplace exposure for select occupations. Many other states have taken executive or administrative actions to institute such presumptions (eg, AR, CA, FL, KY, ND, NH, NM, WA).2–4 See Table 1 for workers covered and definitions by each of these states. Who is covered differs considerably, with various combinations including first responders, corrections officers, military/national guard, nursing personnel, other healthcare personnel, grocers, and postal workers. In no case has the issue of a worker's prior comorbidities or apportionment been thus far directly incorporated into these new legislative and executive actions, although some states may have apportionment separately addressed in non-COVID regulations. This area of law is changing quite rapidly.
Qualifications for coverage also differ, such as whether a positive test is required for presumption. The degree and extent of coverage differs somewhat among these states, with some limiting the extent and duration of coverage (eg, through the duration of an emergency declaration).
Cases which clearly meet the requirements of the presumptive rules may not require any further evaluation to determine work-relatedness. However, there are many situations which may require formal evaluations to determine work-relatedness. These include: (1) cases occurring in states without presumptive rules, (2) cases claimed outside of the presumptive rules (eg, workers not directly covered), (3) those occurring among individuals who claim to have had COVID-19, but who tested negative for the virus by polymerase chain reaction (PCR), and (4) those occurring in individuals who state they were ill and were not permitted to be tested, may likely have the causation question formally adjudicated.
Those cases either accepted by a workers’ compensation insurer or administratively adjudicated as work compensable, may require an evaluation for issues such as ongoing treatment, Maximal Medical Improvement (MMI), Permanent and Stationary status (P and S), or Permanent Physical Impairment (PPI). The AMA Guides to the Evaluation of Permanent Impairment,5 which is used to guide ratings in the majority of States, does not address “COVID-19” or “SARS CoV-2.”
Several scenarios may help illustrate issues to consider for workers with administratively accepted work-related cases for which a rating is requested. These scenarios are sequenced from mild to more severe presentations. Regardless of the scenario below, appropriate quarantining or self-isolation as per the local (or state) health department's directives should be observed if the individual is believed to be contagious to help limit the spread of the virus.
Scenario No. 1: There are asymptomatic individuals who are tested only because they have had contact(s) with a known, positive case. Examples include a paramedic responding to a call or a health care worker inside a nursing home with known cases. Such workers are often tested despite the absence of any symptoms. If this individual remains asymptomatic, but did test positive on PCR for having “live” virus, there are no known long-term complications in those with subclinical infection. These individuals are considered to be at MMI a few weeks after the positive test, and there is no permanent impairment.
Scenario No. 2: For those who are pre-symptomatic (had not yet become symptomatic at the time of testing, but later become symptomatic) the average onset of illness is about 5 days (range 2–14) after exposure.6–9 These people would be rated similar to the scenarios below.
Scenario No. 3: There are individuals who test positive and who have mild disease. They are typically not hospitalized, and they recover at home. Few will have become significantly dyspneic that requires hospitalization. Once recovered they are asymptomatic. There are currently rare case reports of individuals with mild disease, who recover at home, and yet who have persisting symptoms suggesting possible permanent consequences. Thus, when the majority back to normal activity without symptoms, they can be declared to be at MMI and without impairment (0%). If necessary, this can be verified by Stress Echocardiography (Stress Echo) and full Pulmonary Function Testing (PFT)-especially DLCO. Individuals with mild persistent symptoms may require a longer period up to 6 months before being declared permanent and stationary.
Scenario No. 4: There are individuals who have moderate disease (test positive, are hospitalized, and treated with supplemental oxygen, but are not put in the ICU or on a ventilator). They usually have abnormal chest CT scans, and generally have abnormal nonspecific findings on chest x-rays. In these cases, review of hospital records is required to objectively document the organ systems involved. The most common concern in these cases will be residual pulmonary or cardiac pathology either from the virus or from the ventilator. There may also be cases in which significant pulmonary involvement was documented by outpatient or emergency room imaging, and the person convalesced at home. Pulmonary Function Testing is generally required to evaluate these individuals. In some cases, Stress Echocardiography is also needed.
Scenario No. 5: There are individuals who have severe disease (test positive, are hospitalized, and are typically treated in an ICU with either non-invasive ventilation or mechanical ventilation). These individuals require careful review of the medical records to ascertain which organ systems were affected. Most of these cases require Pulmonary Function Testing to evaluate the person's pulmonary status. In many cases, Stress Echocardiography is also needed. Depending on the extent of any identified impairment(s), subsequent evaluations may be required to ascertain maximum medical improvement and remaining permanent impairment.
Scenario No. 6: There are individuals who have severe disease such as that in scenario No. 5, but who also have one or more other end organ dysfunctions. These other disorders may include congestive heart failure, myocardial infarction, dysrhythmias, stroke, renal failure, psychological illness, myopathy, and coagulopathies. Thorough medical records evaluation is required. The evaluations of these individuals are typically quite complex and require testing of the relevant affected organs (eg, Stress Echocardiography, Pulmonary Function Testing, renal studies, functional capacity evaluation, and psychometric testing). Additionally, since the time to recover may be measured in many months to years, multiple assessments may be required to assess the attainment of maximum medical improvement and the permanent impairment.
If these individuals have persisting complaints of dyspnea on exertion or fatigue (or other residual impairment of another organ system), the first assessment should be “face-to-face” in an office setting (ie, not telemedicine). Using release of information forms to obtain records from all recent clinical encounters before the onset of COVID-19 as well as the inpatient and outpatient medical records during treatment of COVID-19 is an essential first step. Obtaining these records from health care providers and hospitals will provide objective evidence of illness, potential organ system sequelae, and help with questions about pre-existing status. Records should include evidence of a positive PCR test for the presence of the virus. Chest x-ray or chest CT scan results would confirm pulmonary involvement occurred, as would measures of oxygen saturation level below 90% to 95% on room air in previously healthy individuals. A complete review of systems is needed. Suggested COVID-19 specific questions are provided in Table 2. Finally, a formal activities of daily living questionnaire should be used (see Table 3 for an example).
The physical examination should address all affected organ systems. Typically, this would especially focus on the pulmonary and cardiovascular system examinations. Vital signs and pulse oximetry are helpful. Examination may also require attention to one of the less common complications described previously. A simple in-office screening test to potentially include is the 6-minute walk test while wearing a pulse oximeter. Norms for distance walked by age are available.10 Also, important information would include a change in pulse from sitting to walking, and whether desaturation (oxygen level on pulse oximeter) occurs during walking. Tachycardia (pulse more than 100) and less than normal distance walked with preserved oxygen saturation may suggest deconditioning, and not permanent impairment. However, the concern is that they have had a heart injury resulting in lowered ejection fraction.
The American College of Occupational and Environmental Medicine (ACOEM) Guidelines on COVID-19 (June 17, 2020 update)11 contains a section on Disability and Return to Work. It states that based on prior experience with other similar viral illnesses, patients who recovered without hospitalization will generally be adequately recovered from post-infection fatigue, and be ready to return to work after 2 to 3 weeks. This is about the time when some patients may be retested to see if they are still shedding the virus if required by their employer. The clinical significance of a recovered patient still having viral shedding is unclear and may not be a barrier to work especially if the work can be performed without close contact with others (eg, telework). For patients with documented pneumonia or who required supplemental oxygen therapy, recovery would be estimated to be 4 to 8 weeks after hospitalization or clinical recovery based on analogies to other viral pneumonias.
For patients who required mechanical ventilation for an Acute Respiratory Distress Syndrome (ARDS) illness, past experience has been that 50% of survivors may not have returned to work by 1 year from hospital discharge.12–16 Lung volumes often show about a 20% reduction that frequently resolves in 6 months. Thus, it would be logical to wait until hospitalized survivors are 6 months from discharge before attempting to perform an initial evaluation for MMI and PPI. The ACOEM guideline points out that lung diffusion abnormalities, if present, may take 5 years to resolve after ARDS. The diffusion capacity for carbon monoxide (DLco) is the test that best reflects diffusion abnormalities. There are no published studies yet of spirometry results in COVID-19 survivors, but the pathophysiology so far appears to be predominantly Diffuse Alveolar Damage, Hyaline Membranes, and microangiopathic processes.17 Thus, the DLco, which can be difficult to obtain, may be anticipated to be the most sensitive test to assess impaired pulmonary function.
Blood testing for Complete Blood Count, Comprehensive Metabolic Panel should be obtained unless recent results from prior convalescent testing are available and normal. This testing should include renal function, albumin, and at least one or more hepatic enzymes. Testing should also include any abnormal findings during prior treatment to document return to normalcy (eg, coagulation studies).
If residual pulmonary impairment is plausible, then full spirometry (including measurement of the DLco, full lung volumes, impendence testing, or nitrogen washout) should be obtained. The test results should be evaluated to verify that they meet ATS criteria for full effort and reliability.18–20
Pulmonary impairment is rated from Tables 5–4 (6th ed., p88). In jurisdictions using the AMA Guides 5th edition, ratings come from Table 5–12 (5th ed., p. 107). Cardiovascular injuries that may come to attention as well as the relevant sections of the AMA Guides are included in Table 4. Desaturation during exercise with normal spirometry could suggest impaired cardiac output (decreased left ventricle ejection fraction by Echocardiogram) or interstitial lung disease. If the echo is normal, then other systemic illness such as anemia or lung abnormalities are most likely.
For most cases the spirometry, echocardiogram, and possibly routine Bruce-protocol treadmill testing will be sufficient for rating the pulmonary and/or cardiac consequences of moderate to severe COVID-19. For less common cases in which the reported fatigue and or dyspnea appear out of proportion to the spirometry and echocardiogram results, metabolic cardiopulmonary exercise stress testing21 is the gold standard for evaluation.
COVID-19 patients can have cardiac complications. Some COVID-19 patients have ST segment elevation on EKG with corresponding clots in major epicardial coronary arteries attributed to a hypercoagulable state seen in these patients.22 Some COVID-19 patients have viral myocarditis/cardiomyopathy without large artery induced infarcts.23 These patients can be rated as for any other cardiomyopathy patient. Left ventricle ejection fraction (EF by Echo or cardiac catheterization), Brain Natriuretic Peptide level (BNP), and/or METs of exertion achieved on a Stress Echo, are the test results that guide this evaluation.
Pulmonary emboli may occur due to either a hypercoagulable state that may be related to the viral infection and/or prolonged inactivity.24 Impairment would be evaluated by spirometry (infarction reduced forced vital capacity—FVC) and by echocardiogram or Stress Echocardiogram showing pulmonary hypertension.
There are patients having large vessel strokes, presumably due to the hypercoagulable state known to occur in some patients with COVID-19.25 These would be rated like any other large vessel stoke, and if cranial nerve or visual impairment is present, they would be rated from Chapters 11 and 12 in either Guides edition.
Guillain-Barré syndrome and its variants have been reported during and just after COVID-19 illness,26,27 and these are ratable from the Guides 5th and 6th edition The Central and Peripheral Nervous System chapter. This diagnosis should not be used for subjective complaints of weakness and fatigue with no objective documentation of Guillain-Barré actually having been present, by accepted criteria.28
An unusual symptom in COVID-19 is anosmia, ie, loss of sense of smell. Early reports do not clarify if this is only loss of smell, or whether there is also loss of taste. Most of the sense of the taste of food is determined by the sense of smell. Subjective loss of sense of smell is not always validated on testing. Recovery of sense of smell lost from viral disease is known to recover in 32% to 66% of cases,29 but it may take up to a month to recover. If persistent, olfaction should be tested with the UPSIT or Sniffin Sticks. This is given a rating of 1% to 5% based on the Guides 5th ed. Page 262 or 6th ed. Page 270.
Note that the central and peripheral nervous system chapter also has a rating methodology for myopathy30 or for generalized peripheral neuropathy (Sections 13–9 in either edition). However, myopathy is usually reversible with a physical therapy and home exercise treatment course that focuses on active progressive exercises.
While COVID-19 patients may have a hypercoagulable state (elevated D-dimer, etc) there are no current reports of a hypercoagulable state persisting after recovery.
Providing care to COVID-19 patients can be stressful.31,32 There are individuals who present with Post Traumatic Stress Disorder symptoms. Some had actual COVID-19, some were first responders or health care workers,33–35 and some had both of these experiences. Some states have created a legal presumption that PTSD in these situations is presumed to have been caused by COVID-19. Modern systematic reviews indicate cognitive behavioral therapy (CBT) has better outcomes compared with medications36–38 and therefore 12 to 18 sessions of CBT should have been provided before MMI is established. A further consideration is the stability of employment. If the individual is still in a “temporary” off work status, the outcome of PTSD with a change in employment is not known. Thus, if a health care worker is still unwilling to return to work after CBT, an alternate career choice may need to be made, and PPI should logically be assessed after re-employment in a different career (removal from exposure) results in improvement.
In summary, there is preliminary evidence and advice for the scientific approach to workers who need to have evaluations for the permanent consequences of COVID-19 illness in those with either administratively accepted or adjudicated cases. With further clinical experiences with this unique viral infection, the approach to rating may need to be modified slightly. However, the suggestions and general approach outlined here should remain applicable for the foreseeable future.
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