Prevalence of chronic fatigue syndrome and its related factors in covid- 19 patients discharged from at northwest of Iran hospitals in 2022

doi:10.21203/rs.3.rs-5305350/v1

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Research Article

Prevalence of chronic fatigue syndrome and its related factors in covid- 19 patients discharged from at northwest of Iran hospitals in 2022

https://doi.org/10.21203/rs.3.rs-5305350/v1

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Introduction:

The COVID-19 pandemic has been a tragedy. It has devastated the health and financial well-being of many people around the world. Fatigue is one of the common symptoms and complications of covid-19, which can continue in patients for a long time after infection. The present study was also conducted with the aim of determining the prevalence of chronic fatigue syndrome and associated risk factors in covid-19 patients discharged from at northwest of Iran hospitals in 2022

Methods

This cross-sectional study was performed between May 2021 and January 2022 at northwest of Iran. 422 patients who had been discharged from hospital with COVID-19 were enrolled in our study. Chalder fatigue Assessment Scale (FAS) was used to measure post-COVID-19 chronic fatigue syndrome. Central and dispersion indicators were used to describe clinical and sociodemographic characteristics of patients. The chi-square test and person correlation were used to examine the statistical association between the CFS score and other clinical and sociodemographic factors.

Results

in overall, 72% of patients were female. The mean ± SD of the CFS score was 21.2 ± 9.0. The prevalence of post-COVID-19 CFS among our studied sample was %12.64. The findings showed that the prevalence of chronic fatigue and fatigue scores were higher in women (%13) than in men (%12.3) and this difference was statistically significant (P < 0.04). The findings showed that the prevalence of chronic fatigue with history of previous disease (P = 0.04), history of drug use (P = 0.01), history of smoking (P = 0.04), history of mechanical ventilation (P = 0.05) and age (P = 0.001) has a significant relationship.

Conclusion

Post-COVID-19 fatigue is a major issue following the initial acute illness with COVID-19, with a prevalence of %12.64. Therefore, the implementation of standardized measures for the screening of chronic fatigue after covid-19 and planning by the health staff in order to help these patients especially among female patients Seems necessary.

COVID-19 Patient

Prevalence

chronic fatigue syndrome

The coronavirus outbreak is a public health emergency of international concern (1). The corona virus disease started from the city of Wuhan in China and quickly spread other countries. So that the World Health Organization has reported the number of people suffering from this disease by the end of 2023, about 770 million people, and the death of almost seven million patients has been confirmed (2). The most common symptoms of patients with covid-19 are fever, cough, shortness of breath and myalgia/fatigue (1). Recovery from covid-19 does not guarantee a return to normal health, and patients do not return to full health for weeks and months after recovery (3). Peng Fei Sun set al.'s meta-analysis analysis showed that in 10 articles studied among 50,466 patients with Covid-19, the incidence rate of fever was 89.1%, cough was 72.2%, and muscle pain or fatigue was 42.5% (4). A study of more than 4 million people in the US, UK and Sweden, in which people entered their ongoing symptoms into a smartphone app, found that about 10% of patients tested positive for the Covid-19 virus., remain symptomatic for more than 3 weeks and fewer were symptomatic for months(5).

The Centers for Disease Control and Prevention (CDC) followed nearly 300 patients for several weeks. Three weeks after testing positive, almost half of the patients still had symptoms such as fatigue and cough (6).Irish researchers studied 128 infected patients and found that in an average of 10 weeks after initial symptoms of Covid-19, 52% reported persistent fatigue and 31% did not return to work (7).The results of an online survey completed by 3,762 patients from 56 countries showed persistent fatigue, post-exercise weakness and cognitive dysfunction (all core symptoms of myalgic encephalomyelitis/CFS/ME) at 7 months after disease onset., in the majority of the remaining patients and 67.5% were unable to work or needed to reduce work (8, 9). Considering that (CFS/ME) as a post-Covid-19 syndrome, is a concern regarding the long-term consequences of this disease (10) and can negatively affect personal and social life (11) and additional burden on the system Imports health care (12). Understanding the risk factors and signs and symptoms of long-term outcomes after recovery from covid-19 allows for proper follow-up and management of the disease after recovery.

Chronic fatigue is a debilitating chronic disease with a global prevalence of 0.3 to 0.8% (13). The effects of this syndrome on work are costly and cause a decrease in production, efficiency, motivation and increase in absenteeism and unemployment(14).Mezza et al. (2022) reported that 22, 27, 30, and 34 percent of patients experience chronic fatigue in the pathological range after one, three, six, and twelve months have passed since the recovery of acute symptoms.[7] Koenig et al. (2023) in their study on general practitioner referrals, stated that 35% of patients suspected of covid-19 and 13% of patients not suspected of covid-19 had symptoms of persistent fatigue, and the prognostic factors of persistent fatigue included low education., the absence of a life partner, low flexibility, depression, history of drug use, and threatening experiences in the past (15, 16). The important point is that chronic fatigue with changes in mental health can affect the activity and function of the immune system of people with this disease and make them susceptible to other diseases. Paying attention to effective factors and treatments can play an important role in improving the health of people with chronic fatigue syndrome (11).

It appears that the current coronavirus pandemic could trigger a global spike in CFS/ME within 6 to 18 months of discharge. Preventing the continuation of chronic fatigue and controlling its adverse consequences can be achieved by examining and intervening in the factors that determine the occurrence of this syndrome and the effective factors in reducing the quality of life of these patients (17, 18).

Given that the occurrence of chronic fatigue in discharged Covid-19 patients, it can affect various aspects of the patients' personal and social life and their quality of life. On the other hand, the review of the literature indicates the lack of investigation of the prevalence of this syndrome and its related risk factors in Iranian society, especially in Ardabil city. Therefore, the present study was conducted with the aim of investigating the prevalence of chronic fatigue syndrome and associated risk factors in covid-19 patients discharged from at northwest of Iran hospitals in 2022

This cross-sectional study was performed between May 2021 and January 2022 at northwest of Iran. The study population was the patients of Covid-19 who were discharged from hospitals in the northwest of Iran in 2022. The sample size was estimated to be 384 people, taking into account the proportion of the studied trait of 50%, accuracy of 5% and confidence interval of 95%. Considering the probability of 10% dropout, the final sample size was estimated to be 422 people that were studied by simple random sampling method. First, the data of patients with a definite diagnosis of Covid-19 (PCR+) was obtained. Then the patients were contacted by the hospital and after coordination, the questionnaire was completed in person.

The inclusion criteria include covid-19 patients admitted to Ardabil hospitals in the northwest of Iran 2022 with a definite diagnosis (definite diagnosis of covid-19 disease by a specialist doctor and PCR + test), willingness to cooperate, at least 3 months and a maximum of 9 months have passed since at the time of discharge, the patients were alert, able to understand Farsi language, and completed the research ethics form. The exclusion criteria were the death of the patient, lack of access, diagnosis of physical and mental diseases that justify chronic fatigue in patients (infectious diseases, thyroid, depression, psychosis, etc.).

It should be noted that due to the lack of access to samples (for example, cases living in villages) and the unwillingness of patients to participate in the study, the response rate and participation of people in the study was 80.56%. In other words, the presented results are related to the information of 340 patients.

The data collection tool was a two-part questionnaire:

Demographic information questionnaire: consisting of 25 questions such as gender, age, weight, height, level of education, occupation, marriage, number of family members, way of life, economic status of the family, history of chronic illness, history of drug use, history of smoking, history of drug and psychoactive use, History of alcohol consumption, hospitalization history, duration of hospitalization, blood oxygen saturation level, examination of symptoms of shortness of breath, pain, fatigue, memory and concentration disorders.

Chalder Chronic Fatigue Questionnaire: This questionnaire is a 14-question scale in which answers are collected on a 4-point Likert scale, where the lowest score (score 0) is for the answer that is much less than the usual level and the highest score (score 3) is for the answer that is more than the usual level. The score range of this questionnaire is 0 to 42, and a score equal to or higher than 22 is considered chronic fatigue syndrome (19). CFS is a reliable and valid tool that can be used in different populations to assess fatigue (internal consistency α = 0.863 and test-retest reliability ICC = 0.76) (20). Validity and reliability of the instrument have been confirmed in the study of the instrument designer (19). This tool has been psychometrically evaluated in Iran by Rahimian and internal consistency has been reported with Cronbach's alpha of 0.91(21). In the present study, the reliability of the tool was obtained using Cronbach's alpha technique of 0.96.

First, all the data were entered into SPSS software version 26.0. Then, for quantitative variables such as height, weight, age, etc., central and dispersion indices were calculated and qualitative variables were shown as percentages and frequencies. The average overall and item-by-item scores of chronic fatigue syndrome were calculated and the prevalence of chronic fatigue syndrome in the samples was determined by considering the cut-off point of 22. Pearson's correlation coefficient and chi-square test were used to investigate the relationship between the prevalence of chronic fatigue and demographic characteristics and related factors.

Among the 422 cases of patients who were randomly selected, 340 people agreed to cooperate (RR = 80.56). The results showed that 51.8% of the examined patients were female and 36.5% of them were illiterate. Of them, 6.5% had a history of smoking and 80.6% had a history of chronic disease. The mean age of patients was 60.18 ± 19.5 years and the mean length of hospital stay was 6.70 ± 2.59 days. Other demographic characteristics is shown in Table 1. (place of Table 1).

Table 1

Distribution of sociodemographic characteristics of patients
frequency Variable		Number (%)	Variable		Mean ± SD
gender	Male Female	164(48.2) 176(51.8)	O2 Saturation during discharge		88.36 ± 6.08
Education	Uneducated reading / writing diploma Higher Education	124(36.5) 63(18.5) 44(12.9) 109(32.1)	O2 Saturation during study		93.63 ± 608
job	Employed Non-employed Retired	103(30.3) 204(60) 33(9.7)	BMI		23.64 ± 1.18
Marriage status	Single married	88(25.9) 252(74.1)	Systolic blood pressure		129.79 ± 19.29
Housing	private house Rented house father's house etc	105(30.88) 106(31.17) 85(25) 1(0.29)	Diastolic blood pressure		77.12 ± 11.20
life style	Singly with family	4(1.2) 336(98.8)	Age		60.18 ± 19.5
The economic situation	Favorable unfavorable	53(15.6) 287(84.4)	family members		7.10 ± 1.78
Chronic disease	yes no	274(80.6) 66(19.4)	Length of hospital stay		6.70 ± 2.59
Smoking	yes no	22(6.5) 318(93.5)	hospitalization in ICU	yes	25(7.4)
Smoking	yes no	22(6.5) 318(93.5)	hospitalization in ICU	no	315(92.6)
alcohol use	yes no	1(0.29) 339(99.71)	Mechanical ventilation	yes	49(14.4)
alcohol use	yes no	1(0.29) 339(99.71)	Mechanical ventilation	no	291(85.6)
History of drug use	yes no	1(0.29) 339(99.71)	Duration of mechanical ventilation		1.5 ± 0.58
Previous hospitalization	yes no	99(29.1) 241(70.9)

As shown in Table 2, 75.29% of patients experienced headache, 99.41% experienced chronic pain, and 60% experienced fatigue within 3 months after discharge. Other signs and symptoms experienced by the patients are shown in Table No. 2. (place of Table 2).

Table 2

Frequency distribution of symptoms and signs experienced by patients during 3 months later
frequency Variable		Number (%)
dyspnea	yes no	185(54.41) 152(44.7)
Headache	yes no	256(75.29) 84(24.70)
chronic pain	yes no	338(99.41) 2(0.58)
Severe temporary pain in the limbs	yes no	336(98.82) 4(1.18)
muscle cramp	yes no	69(20.29) 271(79.70)
Taking painkillers and sedatives	yes no	217(63.82) 123(36.17)
tiredness	yes no	204(60) 136(40)
depression	yes no	115(33.82) 225(66.17)
Trouble sleeping	yes no	236(69.41) 104(30.58)

The results showed that 61.47% of the participants reported that they were more sleepy or dull than usual. Among them, 51.17% had problems with fatigue and 46.47% had problems concentrating more than usual. Also, 42.05% felt weak more than usual. (place of Table 3).

Table 3

Frequency distribution of chronic fatigue questions
Chronic fatigue syndrome questions	much worse than usual	Worse than usual	no more than usual	better than usual	Mean ± SD
Do you have problems with tiredness?	1(0.29)	154(45.29)	174(51.17)	11(3.23)	2.53 ± 0.56
Do you need to rest more?	1(0.29)	161(47.35)	153(45)	25(7.35)	2.52 ± 0.63
Do you feel sleepy or drowsy?	0	104(30.58)	29(61.47)	27(7.94)	2.39 ± 0.6
Do you have problems starting things?	46(13.52)	168(49.41)	114(33.52)	12(3.52)	2.21 ± 0.7
Do you start things without difficulty but get weak as you go on?	183(53.82)	26(7.64)	76(22.35)	55(16.17)	1.3 ± 0.67
Are you lacking in energy?	146(42.94)	64(18.82)	93(27.35)	37(10.88)	1.65 ± 0.81
Do you have less strength in your muscles?	75(22.05)	142(41.76)	112(32.94)	11(3.23)	2.09 ± 0.76
Do you feel weak?	40(11.76)	143(42.05)	143(42.05)	14(4.11)	2.33 ± 0.72
Do you have difficulty concentrating?	45(13.23)	135(39.70)	158(46.47)	2(0.58)	2.33 ± 0.7
Do you think as clearly as usual?	92(27.05)	168(49.41)	78(22.94)	2(0.58)	1.95 ± 0.71
Do 6 you make slips of the tongue when speaking?	214(62.94)	9.(27.35)	20(5.88)	13(3.82)	1.38 ± 0.6
Do you find it more difficult to find the correct word?	258(75.88)	57(16.76)	14(4.11)	11(3.23)	1.20 ± 0.45
Is your memory as good as usual?	262(77.5)	50(14.70)	14(4.11)	14(4.11)	1.92 ± 0.44
Are you still interested in the things you used to do?	262(77.5)	64(18.82)	7(2.05)	7(2.05)	1.20 ± 0.42
Mean ± SD	14.65 ± 4.69				1.92 ± 0.57

The prevalence rate of CFS was 12.64%. The mean total score in CFS was 14.65 ± 4.69 (range 0–42). The mean score of physical fatigue (9.45 ± 2.98) was higher than the mental dimension (5.19 ± 2.76). (place of Table 4).

Table 4

**Frequency** distribution and mean of CFS in discharged covid-19 patients
frequency chronic fatigue	N (%)
yes no	43(12.64) 297(87.6)
physical fatigue mental fatigue	9.45 ± 2.98 5.19 ± 2.76
CFS) total)	14.65 ± 4.69

The results showed that 14.3% of patients with a history of chronic disease and 27.3% of smokers had chronic fatigue and this difference was statistically significant (P < 0.04). The prevalence of chronic fatigue was higher in women (%13) than in men (%12.3) and this difference was statistically significant (P < 0.04). Also, 12.8% of patients with a history of drug use suffered from chronic fatigue and this difference was statistically significant. The prevalence of chronic fatigue in patients under mechanical ventilation was higher (20.4%) than other people and this difference was statistically significant (P < 0.04) (place of Table 5).

Table 5

The relationship between CFS and the sociodemographic characteristics of patients
CFS Variable		Yes N (%)	no N (%)	P- Value
gender	Male Female	23(13) 20(12.3)	154(87) 143(87.7)	0.04
Education	Uneducated reading / writing diploma Higher education	20(16.1) 9(14.3) 4(9.1) 10(9.2)	104(83.9) 54(85.7) 40(90.9) 99(90.8)	0.36
job	Employed Non-employed Retired	13(12.6) 24(11.8) 6(18.2)	90(87.4) 180(88.2) 27(81.8)	0.58
Marriage status	Single married	7(8) 36(14.3)	81(92) 216(85.7)	0.08
Housing	private house Rented house father's house	18(11.9) 17(15.9) 8(9.8)	133(88.1) 90(84.1) 74(90.2)	0.42
life style	Singly with family	- 43(12.8)	4(100) 293(87.2)	0.58
The economic situation	Favorable unfavorable	8(15.1) 35(12.2)	45(84.9) 252(87.8)	0.34
Chronic disease	yes no	39(14.2) 4(6.1)	235(85.8) 62(93.9)	0.04
smoking	yes no	6(27.3) 37(11.6)	16(72.7) 281(88.4)	0.04
History of drug Use	yes no	39(12.8) 4(5.3)	225(85.2) 72(94.7)	0.01
hospitalization in ICU	yes no	6(24) 37(11.7)	19(76) 278(88.3)	0.07
Mechanical ventilation	yes no	10(20.4) 33(11.3)	39(79.6) 258(88.7)	0.04
BMI	Slim Normal Overweight	- 40(13) 3(10.3)	32(100) 268(78) 26(89.7)	0.73
Month of study	3 months 6 months 9 months	4(10.3) 14(12.8) 25(13)	35(89.7) 95(87.2) 167(87)	0.89

The present study was carried out with the aim of determining the prevalence of chronic fatigue syndrome and its related factors in covid- 19 patients discharged from at northwest of Iran hospitals in 2022. Regarding the signs and symptoms of covid-19 in our study, the most common symptom was chronic pain and about 54% of the participants reported shortness of breath. In a Norwegian study, nearly half of patients reported shortness of breath during activity 3 months after being hospitalized for Covid-19(22).But contrary to the findings of our study, in Deka et al.'s study, fatigue was the most common symptom and 72.4% did not report any symptoms of shortness of breath during the covid-19 disease(23).The reason for this difference may be due to the difference in the demographic variables of the participants in the study (for example, the age of the participants).

This study found that 12.64%. of patients experienced various fatigue levels. • Although the global prevalence (CFS/ME) is reported to be 1 to 2% (24). Contrary to the findings of our study, other studies have reported a prevalence of 43–45% (CFS/ME) in patients with covid-19(11, 25). Also, in the study of Simani et al., the prevalence of (CFS/ME) was reported as 2.5%, which is much lower than the findings of the present study (26). The higher prevalence of (CFS/ME) in the present study compared to the global prevalence of this syndrome, may be a confirmation of the increase in the prevalence of this syndrome after contracting the Covid-19 virus. As various studies have stated that infection and exposure to some viruses are one of the causes of CFS/ME (27–29). But the lower prevalence of (CFS/ME) in the present study compared to other studies may be due to the difference in the studied population, the time of the study and the way of measuring the level of fatigue in the studies. It should be noted that paying attention to the role of vaccination in different countries and the variety of vaccines available in countries can be one of the factors affecting the prevalence of post-Covid-19 symptoms and signs in infected people or the occurrence of chronic fatigue syndrome in infected people. This requires investigation by researchers and scholars.

The results showed that the mean and standard deviation of the dimension of physical fatigue in chronic fatigue syndrome is 9.54 ± 2.98. Various studies have reported the level of physical fatigue after covid-19 in patients with different grades. In consistent with our findings, in the study of Kodour et al. (2022), the average score of the physical fatigue dimension was 8 (5 to 10)(29). The results of Deka et al.'s study (2022) also showed that 20% of the participants had physical fatigue with a score of 10 (23). Unlike the results of the present study, in the study of Stavem et al. (2021), the mean score of the physical fatigue dimension was 0.66 (0.55 to 0.78) (30). Also, in Elanwar's study, the average value for physical fatigue was 4 (2–7) (31). The reason for the difference between the studies and the average scores of the present study may be the difference in the chronic fatigue measurement tool in the participants and the difference in the people participating in the study. Also, in the study of Herck et al. (2021) who evaluated fatigue three and six months after contracting Covid-19, the results showed that during the three-month follow-up, the average physical fatigue score was 19 points (16–20) and the average The mental fatigue score was 15 points (10 to 17) and these scores were lower for physical fatigue in the six-month follow-up, but did not decrease for mental fatigue (32). This shows the prevailing physical fatigue in the post-Covid-19 situation.

The results showed that mean of mental fatigue dimension was 5.19 ± 2.76 which is Consistent with the the study of Kedor et al. (2022), in there study the average score of mental fatigue dimension was 6 (4 to 10) (29). Whereas, contrary to the findings of the present study, in Elanor's study, the average value for mental fatigue was 2 (0–3) (31). In the study of Stavem et al. (2021), the mean score of the mental fatigue dimension was 0.47 (0.35 to 0.59) (30). Also, in the study of Deka et al. (2022), mental fatigue was found in only 2% of the study population (23).

The results of this study showed that history of previous disease (P = 0.04), history of drug use (P = 0.01), history of smoking (P = 0.04), history of mechanical ventilation (P = 0.05) and Age (P = 0.001) is a risk factor associated with chronic fatigue. Consistent with the findings of our study, in the study of Al Johani et al. (2023), history of chronic disease was identified as an independent predictor of fatigue (33). Also, in the study of Deka et al. (2022), the total score of fatigue and smoking status had a significant relationship with CFS/ME (23). In a systematic review, which was conducted to describe the symptoms, etiology, potential risk factors associated with post-Covid-19 fatigue, and therapeutic approaches used to treat post-Covid-19 fatigue, the results showed that older age is a potential risk factor for fatigue. It is after covid-19(34). Also, in line with the findings of the present study, in Westerlin et al.'s study, education level had no significant relationship with chronic fatigue syndrome (35).

The prevalence of chronic fatigue and fatigue scores were higher in women than in men. Contrary to the findings of our study, in different studies gender (female gender) was associated with an increased risk of CFS/ME (26, 30, 33). CFS/ME is approximately 1.5 to 2 times more common in women than in men (36). Also, various studies reported the level of education among the variables related to CFS/ME (33, 37). Different studies reported a significant relationship between BMI and CFS/ME (30, 38). Hospitalization in the intensive care unit has also been reported as one of the risk factors for CFS/ME (6). The fact that some patients may experience debilitating chronic fatigue is worrisome and can have a large long-term impact on these individuals as well as on the health care system and society as a whole (39–41). Indeed, fatigue is strongly associated with health-related quality of life and aspects of daily life (42, 43) and its adverse consequences, leading to the use of sick leave, increased health care consumption and more hidden costs, and care by friends or family members (44, 45). Fatigue is a complex and challenging symptom, because several factors can contribute to the onset and maintenance of fatigue, as seen in other chronic diseases (46). This can manifest itself as mental fatigue, physical fatigue or both (30).

Many survivors did not want to come to the hospital and cooperate. Pre-Covid psychiatric status was not documented. We evaluated patients only for 9 months after discharge.

The results showed that some patients with Covid-19 suffer from chronic fatigue after being discharged from the hospital. Therefore, considering the significant negative consequences caused by this syndrome, it is recommended that health policy makers take measures to reduce the adverse effects of this syndrome by creating programs to support long-term Covid-19 patients.

Ethical Approval

Ethics approval and consent to participate. This study strictly followed the principles outlined in the Declaration of Helsinki. The present study is a project approved by the Student Research Committee of the School of Nursing and Midwifery, Ardabil University of Medical Sciences, with the code of ethics IR.ARUMS.REC. 1401.211. All participants provided written informed consent before the commencement of the study. The consent form gave the participants a clear understanding of the study’s purpose and methods. Participants were also informed of the researchers’ commitment to address any questions or concerns and the confidentiality of their information.

Consent for publication

Not applicable.

Conflict of Interest:

The authors declare that there is no conflict of interest.

Funding

This work was supported by Ardabil University of Medical Sciences (IR.ARUMS.REC. 1401.211.)

Author Contribution

Conceptualization: Mohammad Ali Mohammadi, Arman AlizadehData curation: Nasser MozaffariFormal analysis: Mohammad Ali MohammadiFunding acquisition: No FundingMethodology: Mohammad Ali Mohammadi, Behrouz DadkhahValidation: Arman Alizadeh, Behrouz. DadkhahWriting–original draft: Nasser Mozaffari, Behrouz Dadkhah, Arman AlizadehWriting–review & editing: Behrouz Dadkhah, Mohammad Ali Mohammadi

Acknowledgments:

The authors of this article express their gratitude to all the patients who participated in the research, the Vice President of Research and Technology of Ardabil University of Medical Sciences, and the management of Ardabil health service centers.

Data Availability

The datasets generated and/or analyzed during the current study are not publicly available but are available from the corresponding author on reasonable request.

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Prevalence of chronic fatigue syndrome and its related factors in covid- 19 patients discharged from at northwest of Iran hospitals in 2022

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