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Federal Register / Vol. 86, No. 116 / Monday, June 21, 2021 / Rules and Regulations
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not hospitalized CDC, February 16, 2021, and their effects are not fleeting and often linger. In a multistate telephone survey of 292 adults with COVID19, the majority of whom did not eventually require hospitalization, 274 94% of the survey respondents were symptomatic at the time of their SARSCoV2 test, reporting illness for a median of three days prior to the positive test Tenforde et al., July 24, 2020. Around one third of symptomatic respondents 95 of 274 reported that they still had not returned to their usual state of health 23 weeks after testing positive. Even among the young adults aged 1834 years with no chronic medical conditions, nearly one in five had not returned to their usual state of health 23 weeks after testing.
Even though these cases rarely result in hospitalization, individuals with mild to moderate cases of COVID19 are also significantly impacted by their illness as a result of CDC isolation recommendations. According to the current CDC criteria, a person with symptomatic COVID19 should generally discontinue isolation only when all three of the following conditions have been met: 1 At least 10 days have passed since symptom onset; 2 at least 24 hours have passed since experiencing a fever without the use of fever-reducing medications; and 3 other symptoms have improved other than loss of taste or smell CDC, February 18, 2021. And the CDC notes with respect to the first criteria that individuals with severe illness or with compromised immunity might require up to 20 days of isolation. Even those with mild or moderate cases of COVID
19 may be prevented by their illness from working from home during the period of isolation.
Longer-Term Health Effects Recovery from acute infection with the SARSCoV2 virus can be prolonged. Three categories of patients in particular are known to require ongoing care after resolution of their acute viral infection: Those with a severe illness requiring hospitalization especially ICU care; those with a specific medical complication from the infection, such as a stroke; and those with milder acute illnesses who experience persistent symptoms such as fatigue and breathlessness. The lingering of, or development of, related health effects after a SARSCoV2
infection is known as post-acute sequelae. Dr. Francis Collins, Director of the National Institutes of Health, testified that recovery can be prolonged even in previously healthy young adults with milder infections. Some people
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experience persistent symptoms for weeks or even months after the acute infection Collins, April 28, 2021. PostAcute COVID19 syndrome has been proposed as a diagnostic term for these patients, although the term long COVID is more common outside the medical community. According to the CDC, the most common symptoms of Post-Acute COVID19 syndrome are fatigue, shortness of breath, cough, and joint and chest pain CDC, April 8, 2020. Other symptoms reported by these patients include decreased memory and concentration, depression, muscle pain, headache, intermittent fever, and racing heart CDC, April 8, 2021. Additional common symptoms, as reported by Dr. Collins, are abnormal sleep patterns and persistent loss of taste or smell Collins, April 28, 2021.
The cause of these long-term effects and effective treatments have yet to be established. The report from the Pulmonary Breakout Session of the National Institute of Allergy and Infectious Diseases NIAID Workshop on Post-Acute Sequelae of COVID19
stated that the burden of post-acute sequelae overall could be enormous NIAID, December 4, 2020. Dr. John Brooks, the chief medical officer for the CDCs COVID19 response, said he expected long-term symptoms would affect on the order of tens of thousands in the United States and possibly hundreds of thousands Belluck, December 5, 2020. Dr. Collins testified that longer-term health impairments may occur in up to 30% of recovered COVID19 patients Collins, April 28, 2021.
Prolonged illness is common in patients who required hospitalization because of COVID19, and particularly in those who required ICU admission. In a large nationwide U.S. study, 18.5% of hospitalized patients were discharged to a long-term care or rehabilitation facility Rosenthal et al., December 10, 2020. Of 1,250 patients in a Michigan study, 12.6% were discharged to a skilled nursing or rehabilitation facility and 15.1% of hospital survivors were rehospitalized within 60 days of discharge Chopra et al., November 11, 2020. Of the 195 who were employed prior to hospitalization, 23% were unable to return to work due to health reasons and 26% of those who returned to work required reduced hours or modified duties Chopra et al., November 11, 2020. Those who returned to work did so a median of 27 days after hospital discharge Chopra et al., November 11, 2020. Existing evidence indicates that COVID19 patients requiring ICU care and mechanical ventilation may
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experience Post Intensive Care Syndrome PICS, which is a constellation of cognitive dysfunction, psychiatric conditions, and/or physical disability that persists after patients leave the ICU Society of Critical Care Medicine, 2013. In a study at 3 months post-discharge of 19 COVID19 patients who required mechanical ventilation while hospitalized, 89% reported pain or discomfort, 47% experienced decreased mobility, and 42%
experienced anxiety/depression Valent, October 10, 2020. The authors noted that these results are similar to those reported in follow-up studies of patients who survived ARDS due to other viral infections. Many employees hospitalized with COVID19 may require a long period of recovery should this trajectory continue to hold. In a 5year follow-up of 67 previouslyemployed ARDS survivors, 34 had not returned to work within one year of discharge and 21 had not returned at five years Kamdar, February 1, 2018.
ARDS is a serious complication that may have an impact on employees ability to return to work after a COVID
19 diagnosis.
Several studies conducted outside the U.S. have also noted the persistence of COVID19 symptoms after hospital discharge. In a study of 1,733
discharged patients in China, 76%
reported at least one symptom of COVID19 six months after hospital discharge with 63% experiencing persistent fatigue or muscle weakness Huang et al., January 8, 2021.
Similarly, an Irish study found 52% of 128 patients reported persistent fatigue a median of 10 weeks after initial symptoms first appeared Townsend et al., November 9, 2020. A study of 991
pregnant women 5% hospitalized in the U.S. found that the median time for symptoms to resolve was 37 days and that 25% had persistent symptoms mainly cough, fatigue, headache, and shortness of breath eight weeks after onset Afshar et al., December, 2020. A
study of 86 previously-hospitalized Austrian patients observed that 88%
had CT scans still indicating lung damage at 6 weeks after their hospital discharge; at 12 weeks, 56% of CT scans still revealed damage European Respiratory Society, September 7, 2020.
A study of 152 previously-hospitalized patients with laboratory-confirmed COVID19 disease who required at least 6 liters of oxygen during admission found that 30 to 40 days after discharge, 74% reported shortness of breath and 13.5% still required oxygen at home Weerahandi et al., August 14, 2020. A
UK study found that among 100

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