Post-COVID-19 assessment may be needed in some high-hazard workers before return to work
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The Aviation and Occupational Cardiology Task Force of the European Association of Preventive Cardiology issued a statement on the post-COVID-19 infection evaluation of high-hazard workers prior to return to dangerous work.
The task force defined high-hazard workers as pilot and non-pilot aircrews, drivers of heavy goods vehicles, train drivers, professional taxi services, fire crew, police, divers, military, mountaineers, polar workers, offshore workers, and astronauts and space workers.
Published in the European Journal of Preventive Cardiology, the position statement includes a decision pathway for cardiopulmonary assessment for occupationally informed physicians based on high-hazard worker COVID-19 symptom severity as well as recommendations for testing modalities.
Challenges in assessing long COVID
The task force reported that most individuals with symptomatic COVID-19 recover within a few weeks, with no ongoing clinical disease manifestations, but approximately 10% of individuals have residual symptoms, sometimes referred to as “long COVID.”
“The challenge in assessing patients with ongoing symptoms following COVID-19 infection is the requirement to discriminate symptoms caused by organ pathology, from those caused by a more typical post-viral syndrome, documented in many well-characterized viral diseases,” Rienk Rienks, MD, PhD, cardiologist at the Central Military Hospital, University Hospital Utrecht, the Netherlands, and colleagues wrote. “This challenge is often compounded by health anxiety, which is particularly pertinent to employees undertaking high-hazard work due to additional concerns regarding future employment. Whilst the overall likelihood of significant pathology in this cohort may be low, employers need to be able to sign off an employee to undertake their high-hazard (and high risk) employment, and to ensure risk is mitigated. Even those who are asymptomatic may need investigation, given that subclinical disease may be occupationally significant.”
COVID-19 assessment tool
The position statement included a COVID-19 assessment tool, a flow chart to assist clinical risk triage based on COVID-19 symptoms, hypoxia and ECG findings.
High-hazard workers with a critical care hospitalization at any time for COVID-19, symptoms of breathlessness at rest or during exertion and/or chest pain, palpitations and dizziness since COVID-19 illness should be referred to exclude underlying pathology, according to the document.
The task force added that those who are unable to return to pre-COVID-19 infection symptom-onset levels of physical fitness should be referred for rehabilitation.
“For employees undertaking high-hazard work and presenting with cardiopulmonary symptoms (such as dyspnea and chest pain), occupational health physicians should be provided with occupationally contextualized clinical data,” the task force wrote. “After consultation with specialist clinicians, this will enable them to reassurance the patient and to give appropriate risk advice to the employer and to ensure that employees are fit for exercise rehabilitation and graduated or managed return to work.”
Despite low likelihood for significant cardiopulmonary pathology after symptomatic COVID-19 infection, high-hazard workers with high-risk characteristics and/or peripheral oxyhemoglobin desaturation should be referred for further assessment before return to work, according to the statement.
Such further assessment included peak exercise capacity measured using cardiopulmonary exercise testing.
The task force added that echocardiography, spirometry and 6-minute walk tests may not add value in risk assessment after symptomatic COVID-19 infection in high-hazard workers and should be reserved until they are clinically indicated.
“Careful discussion between occupationally informed clinicians is required to put the imaging, clinical and physiological data, and occupational risk into context and to determine whether an organization’s risk threshold has been exceeded,” the task force wrote. “It is likely that noncardiopulmonary symptoms, such as fatigue and cognitive impairment, may have a greater impact on return to work for high-hazard employees than those due to underlying cardiopulmonary pathology.”
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