At the time of this discussion, on 31 May 2023, the WHO website showed 767,364,883 cases of COVID-19 and 6,938,353 deaths globally. In addition, 13,375, 580,553 vaccine doses have been administered (3). COVID-19 has been reported as one of the most highly contagious pandemic infections and is the most common infection in the new era, causing a variety of changes in health systems, general public health and society (21).
By reviewing an article carried out by Z. Mohammed et al. (2021), they reported that many recovered COVID-19 patients face a variety of long-term complications (22). Therefore, in-depth investigations of the long-term effects of COVID‐19 infection will help in the appropriate analysis, evaluation and management of persistent or emerging health consequences.
Hence, the possible pathophysiological mechanisms of long-term complications should be considered. The main mechanism includes direct viral tissue damage; the presence of the receptor angiotensin-converting enzyme 2 (ACE2); and entry of the virus into target cells through activation of its spike protein in a variety of locations in the body. Therefore, direct tissue damage may be a primary mechanism involved in the pathogenesis of SARS-CoV-2 infection, which may also contribute to its longer-term complications (23, 24).
In the present study, the long-term consequences of COVID-19 among COVID-19 survivors in the Hail region, KSA, were assessed, and the results revealed that 60% of participants were experiencing intermittent or continuous fatigue for more than 6 months after COVID-19. In addition to fatigue, arthralgia, and myalgia, which are common long-term consequences, these three common symptoms may occur due to disability and impaired daily activities. Similarly, in various studies, musculoskeletal symptoms were defined as complaints of COVID-19, both at the acute and postacute phases. The presence of ACE 2 receptors in skeletal muscle and synovial tissue suggested that viral invasion causes these symptoms. Even though arthritis is common with many viral illnesses, COVID-19 more typically causes myalgia and arthralgia without true inflammatory arthritis (12, 25, 26).
Similarly, moderate to severe levels of fatigue were reported among 61% of the participants in the study conducted by Halpin. et al. (2020) (27). Similarly, Jacobs et al. (2020) reported that fatigue is the most common symptom (56.8%) occurring one month postdischarge, followed by other symptoms, such as shortness of breath (51.4%), cough (40.4%), lack of taste (21.9%), muscular pain (20.2%), diarrhea (15.8%), lack of smell (15.3%), production of phlegm (13.7%), and headache (13.1%) (28).
The second most common complaint in the present study was headache; 60% of participants complained of headache frequently, and 14% of them still complained of headache during the time of data collection. Similarly, headache is one of the most commonly reported symptoms among the neuropsychiatric long-term complications of COVID-19 (18). Headache may be an iceberg symptom of neurocognitive complications due to systemic inflammatory damage, although pathological studies of the brain and real-time PCR have failed to detect coronavirus in cerebrospinal fluid (29). On the other hand, some studies did not report headache as a long-term complaint (30). Regarding gastrointestinal alterations, the present study revealed that more than half of the participants complained of loss of appetite, and this persistent complaint may be related to the replication of the virus within the digestive tract (31).
Researchers have reported dyspnea, shortness of breath or breathlessness as common long-term pulmonary complications after COVID-19 (1). Mandal et al. (2021) reported that 53%, 43%, and 69% of participants complained of dyspnea, cough, and fatigue, respectively (32). Similarly, Weerahndi et al. (2021) reported that 74% of overall postdischarge patients complained of shortness of breath for more than one month (33). In addition, Halpin et al. (2020) reported that two-thirds of postdischarge ICU patients complained of breathlessness, whereas two-fifths of ward patients complained about breathlessness (27). In this study, 45% of participants complained of frequent and continuous dyspnea episodes for more than 6 months after discharge. The respiratory system is the primary site of coronavirus infections; thus, long-term complaints such as cough and chest pain, which can accompany dyspnea, may be related to frequent exposure to viruses during subsequent waves of pandemics.
The symptoms of confusion, memory loss, and depression are related mainly to neuropsychiatric status. High levels of stress, extreme anxiety, and apprehension may aggravate symptoms and long-term complaints, particularly when individuals have a low level of knowledge about the novel cause of COVID-19 and when there is controversy among health agencies and many governments. The present study revealed that 43.7%, 28.2%, and 28.1% of participants complained of frequent episodes of confusion, memory alterations, and depression, respectively. Many studies have reported similar findings; Lopaze et al. (2021), in a systemic review and meta-analysis study, reported that attention disorders, memory loss, and depression were 26%, 16%, and 12%, respectively, among COVID-19 survivors (34). Similarly, a cohort study was carried out to investigate the 6-month psychiatric outcomes among COVID-19 patients; 46.2% of the hospitalized patients had neuropsychiatric problems, whereas 33.6% of the overall participants had neuropsychiatric problems (30).
The effect of COVID-19 on quality of life has been assessed in many studies worldwide. Garrigues, E. et al. (2020), in their study of postdischarge persistent symptoms and related quality of life, showed that five dimensions of quality of life were altered with slight significance among ICU patients, while the overall index of the EQ-5D was 0.86. They also found that approximately one-third of participants who were active workers had not returned to their work at the time of data collection (35). However, et al. (2020) indicated that persistent symptoms for 35 days after discharge were significantly related to impaired ability to perform activities of daily living and impaired mental, social, and physical functions (28).
To the best of our knowledge, no study has evaluated how COVID-19 infection affects patients' quality of life in Saudi Arabia and the Arabian Peninsula. The mean quality of life score among participants in this study was 11.9 ± 3.71, while pain and discomfort, anxiety/depression, and daily activities were the most common. Furthermore, we found that anxiety and depression were the most common sequelae among patients who received ICU intervention, while pain and discomfort were the most persistent postdischarge sequelae among ward-admitted patients. These findings are in agreement with those of Malik et al. (2021) in a systematic review of post-acute COVID‐19 syndrome (PCS) and health‐related quality of life (HRQoL) data; they concluded that 58% of post‐COVID‐19 patients had poor quality of life. A total of 41.5% of the participants had pain/discomfort, 37.5% had anxiety/depression, 36% had problems with mobility, 28% had problems with usual activities, and only 8% had self‐care problems. These results indicate that the majority of COVID‐19 survivors have a poor quality of life, which ultimately results in challenges for patients, healthcare providers, and public health providers (36). Along the same line, Poudal. AK et al. [2021] summarize similar results from a structured review of five studies from different countries (37).
Furthermore, the current study revealed that post-COVID-19 quality of life was significantly affected by infection; anxiety/depression and unexplained pain and discomfort were the most apparent deficits in the quality-of-life dimensions. This study revealed significant relationships between marital status and family size and quality of health; single participants experienced lower quality of life than married participants did. Moreover, an increased number of family members significantly improves quality of life. Family and social support in Arabian society are important, and most people live in homogenous close families and tribes; this may explain these significant relationships. Moreover, COVID-19 patients were more dependent on their relatives because of quarantine and preventive measures. Concurrently, Emrani et al. (2020) studied the effect of sociodemographic characteristics on quality of life in Iran. They found that increased age and marital status are associated with low quality of life (38); although their study was not focused on COVID-19, it coincides with our findings regarding the effect of sociodemographic factors on quality of life among COVID-19 survivors.
This study investigated the factors that predict quality of life among COVID-19 survivors. The quality of life was significantly affected by the level of activity/exercise and smoking history. A lack of exercise activities (e.g., walking) has been related to poor quality of life after discharge, which may be related to muscular resilience after COVID-19. Smoking leads to poor quality of life as a result of the systemic effects of smoking, impaired oxygen supply, and accumulation of carbon monoxide. Other factors that affect quality of life were associated with the severity of symptoms and the level of medical intervention during the acute phase. These findings correspond with those of Garrigues, E. et al. (2020), who indicated that quality of life was influenced by the most common persistent symptoms, such as fever, cough, fatigue, length of stay, and type of oxygen supply. The authors suggested that patients who experienced one or more of these symptoms reported poor quality of life after recovery (35). Another recent systemic review of quality-of-life post-COVID-19 discharge concluded that quality-of-life post-COVID-19 was significantly impacted regardless of the duration of acute infection. It has been shown that advanced age, comorbidities, patients who need ICU treatment, prolonged length of study, and mechanical ventilation are associated with a greater risk of poor quality of life postdischarge (39).