COVID-19 - Quality of Life After Infection

Nearly two million cases have been documented, and thousands have died of the 2019
coronavirus disease (COVID-19). Hong Kong has seen nearly 1,000 documented cases of COVID-19
as of April 11, 2020. Potentially many more cases have gone unreported. The virus that causes
the COVID-19 disease, SARS-CoV2, is a coronavirus, from the same group of viruses as the SARS
virus from 2003. Worldwide, COVID-19 has killed many more patients than SARS, yet the two
viruses share a similar background.

As the peak of viral infections begins to recede, however, the main priority will shift to
the process of recovery. Over the past 17 years, Professor David SC HUI has published
multiple follow-up examinations of SARS patients conducted at the Prince of Wales Hospital
(PWH) outpatient clinics. He found that SARS patients suffered serious long-term effects
after ostensibly recovering from their illnesses. Moreover, healthcare workers, who were
disproportionately affected by SARS infections in 2003 were also disproportionately affected
by long-term disability. Like SARS, many COVID-19 patients require intensive care,
intubation, and aggressive medical therapy. One of the treatments tried for SARS patients was
high-dose corticosteroids, which has been associated with avascular necrosis of major joints
and long term disability. As the COVID-19 pandemic only started a few months ago, it is still
unknown if COVID-19 patients will suffer the same fate as SARS survivors.

Recent COVID-19 research has logically focused on the acute diagnosis and treatment of
affected patients in order to avoid short -term morbidity and mortality. Past research
looking at SARS outcomes showed that both the six month exercise capacity and health status
of SARS survivors was lower than that of normal controls. Sepsis patients also experience
serious disease caused by infection, and long-term reductions in quality of life have been
described in survivors of sepsis. Patients who survive intensive care go on to show deficits
in verbal learning and memory, resulting in limitations in returning to work or school. Many
SARS survivors developed post-traumatic stress disorder and other debilitating psychological
illnesses. Based on the Hong Kong experience with SARS, the investigators are concerned that
COVID-19 survivors are at risk for similar challenges in quality of life after discharge from
acute care.

The Accident and Emergency Medicine Academic Unit of the Chinese University of Hong Kong
based at PWH has worked on multiple studies involving quality of life. In particular, the
investigators have previously collaborated with Professor Hui and the CUHK Department of
Medicine and Therapeutics (M&T) on a quality of life follow-up study on SARS patients. As for
studying health related quality of life, the investigators currently have an ongoing project
examining the subject in trauma patients after discharge.

Several instruments have been widely used in quality of life research, including the 36-Item
Short Form Health Survey (SF-36), the 12-Item Short Form Health Survey (SF-12), the World
Health Organization Quality of Life Instruments (WHOQOL-BREF), EuroQoL-5D (EQ-5D-5L) and the
Short-Form Six-Dimension (SF-6D). Our team has experience using the SF-36, SF-12v2(HK) and
the EQ-5D-5L survey instruments for monitoring quality of life in research subjects in Hong
Kong. For example, the investigators found that trauma patients in Hong Kong scored
significantly worse on the SF-36 twelve months after injury. The investigators also found the
most dramatic improvements happened in the first one to six months post-injury, and that 45%
of subjects had achieved an excellent outcome by four years post-injury. The SF-12v2(HK) with
four week recall is a modified version of the SF-36 to be shorter and quicker to use, while
also already translated and validated in Hong Kong. The investigators aim to combine our
experience with conducting quantitative quality of life studies with the CUHK Department of
M&T's expertise in coronavirus treatment and followup to explore the quality of life of
COVID-19 patients in recovery.

The reported mortality rates for COVID-19 has so far been lower than SARS, although the
higher absolute numbers of COVID-19 patients mean worldwide deaths are overall much higher.
Trauma, sepsis and SARS survivors have all experienced significant long-term morbidity and
decreased quality of life as a result of their injuries or infections. A previous study of
patients infected with SARS-CoV-1 in 2003 at PWH showed that significant numbers of
recovering patients had impaired long-term health status. The question this study hopes to
answer is to what degree do COVID-19 patients suffer a similar fate? Has the knowledge gained
from the SARS experience led to improved quality of life outcomes compared to SARS survivors?
Or do the similarities between the viruses that cause SARS and COVID-19 extend to a reduced
quality of life after recovery as well?