https://www.bmj.

com/content/378/bmj-2022-072117

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Referência: Greenhalgh T, Sivan M, Delaney B, Evans R, Milne R. Long covid—an

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update for primary care BMJ 2022; 378 :e072117 doi:10.1136/bmj-2022-072117

1 Nuffield Department of Primary Care PRACTICE POINTER

Health Sciences, University of Oxford,
Oxford, UK

2 Leeds Institute of Rheumatic and

Long covid—an update for primary care
Musculoskeletal Medicine, University Trisha Greenhalgh, 1 Manoj Sivan, 2 Brendan Delaney, 3 Rachael Evans, 4 Ruairidh Milne5
of Leeds, Leeds, UK
What you need to know 2000) has around 65 patients with long covid, 27 of
3 Institute of Global Health Innovation,
whom will have been unwell for more than a year,
Imperial College London, London, UK
• Long covid (prolonged symptoms following covid-19 and 12 for more than two years. Most general practices
4 Institute for Lung Health, Department infection) is common have far fewer patients with a long covid diagnostic
of Respiratory Sciences, University of • The mainstay of management is supportive, holistic code on their electronic health record9 for a
Leicester, Leicester, UK
care, symptom control, and detection of treatable combination of reasons, including lack of
5 School of Healthcare Enterprise and complications presentation, lack of recognition, and inadequate
Innovation, University of • Many patients can be supported effectively in primary coding. These figures do not cover children, who are
Southampton, Southampton, UK outside the scope of this article.
care by a GP with a special interest
Correspondence to T Greenhalgh
trish.greenhalgh@phc.ox.ac.uk Rates of long covid are lower in people who are triple
Cite this as: BMJ 2022;378:e072117
This article updates and extends a previous BMJ vaccinated, but prevalence of long covid (persistent
http://dx.doi.org/10.1136/bmj-2022-072117
Practice Pointer published in August 2020 when symptoms at 12-16 weeks after laboratory confirmed
Published: 22 September 2022 almost no peer reviewed research or evidence based SARS-CoV-2 infection) remains high at 5% for the
guidance on the condition was available.1 In this delta variant and 4.2% for omicron BA.2.10
update we outline how clinicians might respond to
the questions that patients ask. Symptoms and case definition
Long covid may be diagnosed late or not at all,11 -13
Definition
so both generalists and specialists should be alert to
The term “long covid”2 refers to prolonged symptoms it as a differential, while also being aware that
following infection with SARS-CoV-2 that are not patients can develop other persistent symptoms
explained by an alternative diagnosis. It embraces following acute covid-19 that are not necessarily
the National Institute for Health and Care Excellence caused by covid-19. Long covid is characterised by a
(NICE)’s terms “ongoing symptomatic covid-19” constellation of general and organ specific symptoms,
(symptoms lasting 4-12 weeks) and “post covid-19 the commonest of which are summarised in the
syndrome” (symptoms beyond 12 weeks),3 the US infographic. These multiple manifestations lead to
Centers for Disease Control and Prevention’s group difficulties with daily activities such as washing and
of “post-covid conditions,”4 and the World Health dressing, low exercise tolerance, and impaired ability
Organization’s “post covid-19 condition.”5 to work (either at all or partially), and result in
reduced quality of life.5 14 -19
Epidemiology
Symptoms typically occur across multiple systems
In mid-2022, approximately 70% of the UK adult
concurrently but sometimes one organ system (eg,
population had been infected with SARS-CoV-2.6 Of
cardiovascular) dominates. Phenotyping studies have
these, almost 2 million report covid-19 symptoms
identified several symptom clusters (table 1), with
persisting for more than four weeks; 807 000 (41%
severe cases characterised by greater number and
of all people with long covid) for more than a year;
intensity of symptoms and greater functional
and 403 000 (19%) for more than two years.7 Based
impairment.33 -35 Some patients’ long covid follows
on workforce data from the British Medical
a fairly constant course, while others experience
Association,8 a full time equivalent general
relapsing and remitting symptoms, sometimes with
practitioner with an average list size (approximately
particular triggers.36

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Table 1 | Symptoms, investigation, and management of long covid
Symptom cluster Description and impact on daily life Investigations (in addition to full clinical Management
examination)
Fatigue, low exercise tolerance, deconditioning “Battery flat,” unable to do usual activities. Bloods as appropriate (eg, full blood count, urea Holistic management is key. Self-management
(eg, post-ICU) Trying to do more may worsen symptoms. In and electrolytes, renal, thyroid, vitamin D, C to function within available energy limits (eg,
some cases, fatigue does not improve with rest reactive protein, B12, ferritin). Exclude other prioritising, planning, building in breaks and
causes of fatigue. Monitor symptom severity rests, knowing when to stop20). Signpost to
and frequency and pattern of relapses (eg, resources (see box, Resources for patients)
using the C19-YRS outcome measure). Consider
autonomic dysfunction (see below)
Post-exertional symptom exacerbation (PESE) “Crash,” “relapse” worsening of symptoms Monitor symptom severity and frequency and Signpost to resources. Pacing in phases (see
(physical, cognitive, or emotional), or new pattern of relapses (eg, using C19-YRS). A WHO self-management booklet, box, Resources
symptoms, following exertion patient activity diary can record triggers (for for patients)
relapse)
Exertional breathlessness Short of breath predominantly with physical Guided by specific symptoms. Assess impact Refer according to clinical concern (eg,
activity on function (eg, using item 1 of C19-YRS). worsening symptoms, resting or exertional
Haemoglobin, spirometry, full lung function hypoxia, unexplained abnormal spirometry,
tests as indicated. Natriuretic peptides and abnormal chest x ray image)
echocardiogram as indicated if heart failure
suspected. Pulse oximetry and sit-to-stand test
for exertional hypoxia.21 Chest x ray image
(especially if patient was hospitalised) if
persistent lung damage suspected and to
exclude other causes.22 D dimer if acute
pulmonary embolism suspected (note that a
negative result does not exclude chronic
pulmonary emboli23)
Altered breathing/breathing pattern disorder Pressure in chest (“covid squeeze”), shallow Exclude other causes of breathlessness as Recommend breathing control exercises,
breathing, breathlessness with or without listed above, especially causes of episodic signpost to online resources for breathing
exertion, sense of needing to work harder to breathlessness such as asthma or recurrent pattern disorder (box, Resources for patients),
take a breath, or air hunger (“can’t get enough pulmonary embolism and if no improvement refer to specialist
air”)
Chest pain Pain in specific positions, pain on exertion, “lung Guided by specific symptoms. Chest pain may Chest pain with angina-like features warrants
burn,” pressure (“like an elephant sitting on indicate microvascular angina, myocardial referral to a rapid access chest pain clinic.
my chest”) infarction, myo- or pericarditis, pulmonary Consider colchicine or anti-inflammatory
embolism or costochondritis. ECG, troponin, D analgesics for inflammatory type pain once
dimer, oximetry (including sit-to-stand test), other causes excluded
vitamin D, imaging as indicated
Throat and voice symptoms “Covid strangle”—sore or dry throat with Full history and assessment to explore If not improving, refer to ear, nose, and throat
sensation of choking; altered voice differential diagnosis (eg, covid related vocal or speech and language therapist as
cord pathology, gastro-oesophageal reflux, appropriate
sinus disease, strained voice, dehydration)
Autonomic dysfunction Palpitations, dizziness, orthostatic tachycardia, NASA 10-minute lean test to check for postural Fluids, electrolytes, compression garments,
gastro-intestinal disturbance, generalised pain orthostatic tachycardia syndrome (POTS)24 lifestyle adaptation, and specialist rehabilitation
(protocol in supplementary file).25 if tolerated. Various drugs are under
Investigations for other causes of autonomic investigation.26 Specialist referral if symptoms
dysfunction/POTS if positive. 24 hour ECG and severe or diagnosis in doubt
blood pressure
Neurocognitive dysfunction “Brain fog” (poor short term memory, Brief cognitive screening test (eg, mini mental Strategies of pacing and energy conservation,
concentration, problem solving, and executive state examination27). Fatigue investigations as to-do list diary, avoid multitasking. If unable to
function). Mental fatigue above. If memory loss pre-dated covid-19 and work or have a safety critical occupation, refer
is now worsening, follow usual investigations for formal neuropsychological testing
and pathway
Dizziness and vertigo Unpleasant episodes, “room spinning,” nausea Full history to identify timing and triggers and Precautionary measures to avoid falls, head tilt
ascertain if resolving. Clinical examination (eg, and balance exercises, encouraging movement
nystagmus, other neurological signs, postural and activity focusing on environmental cues.
drop in blood pressure) Refer to audiology if indicated
Loss of smell Loss of enjoyment of food and mealtimes. Clinical examination to exclude nasal polyps, Smell training (see box, Resources for patients).
Phantosmia (a persistent, disagreeable chronic sinusitis, and rare inflammatory or Experiment with different foods and menus to
background smell) or parosmia (distorted sense neoplastic conditions of nasal cavity and cranial find palatable options. Steroid nasal spray may
of smell)28 nerves help in some cases
Allergic-type symptoms Skin rashes (eg, urticaria), conjunctivitis, Confirm urticaria clinically (eg, dermographism). Antihistamines (obtainable over the counter)
abdominal bloating, regurgitation If present, may indicate mast cell overactivity. may help. A clinical trial of specific
Resurgent atopy (eg, hay fever recurring after antihistamines is underway
many years) is common post covid (STIMULATE-ICP).29 Allergy or immunology
referral if fulfils local criteria (eg, anaphylaxis)

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Table 1 | Symptoms, investigation, and management of long covid (Continued)

Symptom cluster Description and impact on daily life Investigations (in addition to full clinical Management
examination)
Poor sleep Unrefreshing sleep, exhaustion, exacerbation Assess daytime somnolence (eg, using Epworth Sleep hygiene measures (eg, structured
of fatigue and brain fog, vivid dreams or sleepiness scale30); exclude underlying causes routines, exercise as able, avoid shift work if
nightmares (eg, obstructive sleep apnoea using possible, avoid caffeine and alcohol), short
STOP-Bang questionnaire31). Assess daytime naps. Melatonin may help restore
psychological health. Covid related sleep circadian rhythms in some cases (exclude other
disorder often overlaps with autonomic causes before prescribing)32
dysfunction and mast cell disorder
Mental health Anxiety, depression, post-traumatic stress Full history (hear the patient’s story; witness Whole person care. Adjusting to illness. Talking
disorder (PTSD). Loss of identity and purpose their experience; affirm their lived experience). therapy, meditation, and medication if
Carefully distinguish anxiety from POTS (see indicated. Mental health referral or social
above). Assess risk of self-harm and risk to any prescribing if appropriate
dependents
Joint and muscle pain Generalised, focal, or regional pain. May be in Investigations guided by history and clinical Non-steroidal anti-inflammatory drugs.
“coat hanger” distribution. May progress to examination. C reactive protein (if inflammatory Mobilisation within personal limits. Consider
chronic pain disorder suspected), creatine kinase (if trial of neuropathic agents (amitriptyline,
myositis suspected). Additional tests as gabapentin, pregabalin) in chronic cases,
indicated for rheumatological disorders especially if neuropathic symptoms

Fatigue—described by one patient as “like the most severe jet lag disease.34 44 It is more common in people who were hospitalised,
and hangover I’ve ever had”37—is the commonest symptom and aged 35 to 69, female, living in deprived areas, working in
may be associated with severe functional impairment; reduced healthcare, social care, or education, with high body mass index,
exercise tolerance is also common. Some patients develop and with more than one pre-existing, activity limiting health
post-exertional malaise (PEM) or post-exertional symptom condition.7 34 44 -46
exacerbation (PESE),11 defined as worsening of symptoms following
The underlying cause of long covid is not fully known, but several
physical or mental exertion, typically 12 to 48 hours after activity
interacting mechanisms likely contribute.47 -49 A chronic, low grade
and lasting days or (rarely) weeks.38 Long covid has evident (but
inflammatory response is correlated with the severity of ongoing
under-researched) overlaps with chronic fatigue and myalgic
symptoms in patients who were hospitalised.33 Some patients have
encephalomyelitis.39Box 1 gives examples of patients’ accounts.
evidence of multi-organ microvascular disease characterised by
Box 1: Patients’ accounts of long covid symptoms and accessing services, immunothrombosis and endothelial dysfunction,47 48 and some
show an autoimmune response, where the body starts to recognise
from research interviews with people with long covid13 40 41
its own tissues and organs as foreign.50 Some patients have covid
“I had an odd rash for quite a while; it kept coming and going … very itchy induced neurological damage, particularly to the autonomic nervous
cough ... very mild asthma … I started getting the odd headache again system, which controls involuntary functions like heart rate.35 46 51
.... Pins and needles, feet going completely numb ... all sorts of odd
Being chronically ill and with unpredictable relapses may lead to
symptoms, I just kept putting it down to grief until a couple of months
in, a friend said, ‘Look, do you think this could be covid?’”
loss of work, income, and social interaction, which in turn can lead
to poor mental health.14 Structural inequalities such as poverty,
“The fatigue is literally like hitting a wall. I can’t stay awake any more.
It’s just like, wow, I have to go to bed.” overcrowding, poor working conditions, and inability to access
services are important in the development and course of covid-19
“I’d had 11 days of feeling great. And after [a particular] weekend I crashed
again. And again it seemed to last for weeks of having these waves of and may form an important context for long covid.52 -54
symptoms: shortness of breath, diarrhoea, muscle aches, complete What can my primary care team do for me?
fatigue.”
“I think it [consultation with general practitioner] was a really positive Patients with long covid greatly value input from their primary care
experience and I felt really listened to, and she was able to be honest at clinician. Notwithstanding prevailing uncertainties and the lack of
that point and said I don’t really know what I can do to help you but you definitive curative therapies, generalist clinicians can help patients
can phone me or email me at any point.” considerably by
“My last interaction with my GP was in June. I asked about my lungs, and
he said, ‘What do you want me to do about it? You tell me. I have no idea.’ • Hearing the patient’s story and validating their experience
It felt very dismissive […]. ‘Nothing’s got any evidence so, yeah sorry, I
• Making the diagnosis of long covid (which does not have to be
can’t help.’ I went back to work after five weeks still very unwell because
nobody believed in long covid in May, they just didn’t believe it.” by exclusion) and excluding alternative diagnoses

• Providing holistic, relationship based care through continuity

Questions patients ask of care with a sympathetic clinician who knows the patient
Why did I get long covid, and what caused it? • Conducting a full examination in a face-to-face appointment
Symptoms (especially fatigue) may persist after many infectious • Encouraging self-management and directing to resources (box,
illnesses, including other coronaviruses such as SARS and MERS.42 Resources for patients)
But no clear explanation exists for why a particular individual
• Managing specific symptoms (table 1)
develops long covid while another recovers quickly.
• Detecting and actioning “red flag” symptoms (infographic)
Long covid is more common in those who had more severe acute
disease43 but may occur after mild or even asymptomatic

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• Managing comorbidities (especially diabetes and cardiovascular disability and overall health state, known as the Covid-19 Yorkshire
disease and risk factors) Rehabilitation Scale (C19YRS), has been developed and validated
(see multimedia appendix).60 61 This instrument, which is less
• Sharing the uncertainties of prognosis
burdensome for patient and clinician than multiple condition
• Helping set realistic goals for recovery (including pacing to avoid specific scales, is available in document format (see bmj.com) and
PESE) as a smartphone app for the patient linked to a web portal for the
Considering referral to other members of the primary care team clinician (https://c19-yrs.com/).60 It can be completed at intervals
• over time to chart the patient’s recovery (or lack of it).
(eg, pharmacist, advanced clinical practitioner, community
physiotherapist) or social support services as appropriate When will I get better?
• Monitoring progress The time course of recovery is extremely variable. Approximately
Assessing mental wellbeing and managing depression and two thirds of patients who have persisting symptoms at four weeks
• can expect to be recovered by 12 weeks.43 Those still unwell at 12
anxiety as needed
weeks may benefit from specialist multidisciplinary care. They may
• Providing sickness certification still improve, albeit at a slower rate, but many patients appear to
Supporting self-advocacy (eg, with employer when returning to plateau and their illness course may fluctuate with exacerbations
• triggered by physical or mental stress.7 33 62 It is currently not
work)
possible to predict which patients will recover within weeks and
• Entering the correct code for long covid on the electronic patient which will develop a long term condition.
record.55
Do I need to see a specialist?
All this takes time, and several consultations may be needed. Many people with long covid can be managed effectively in primary
What investigations should I have? care, but “red flag” symptoms (infographic) require urgent referral
and action. Additionally, some patients—those with multiple severe
Long covid affects patients in different ways and to different degrees.
symptoms (especially if both physical and mental health are
Because a key component of care is investigating and managing
affected), symptoms persisting after a severe acute illness (eg, a
risk factors and comorbidities, no standard protocol exists for
period in intensive care), atypical symptoms, profound functional
assessment. Ideally, every patient should have an in-person
impairment (eg, unable to work or attend college), and those
consultation including a full history, clinical examination, and
needing confirmation that self-management or supported
review of comorbidities and social circumstances.
rehabilitation is safe and appropriate—benefit from specialist
Initial investigations are guided by the predominant symptoms referral.63 Ideally, this should occur in a dedicated “single point of
(table 1) and are primarily directed at excluding serious alternative entry” long covid clinic. These integrated clinics spanning primary
diagnoses. Patients may have heard about tests for immunological and secondary care give patients access to additional investigations
and clotting function; such tests are the subject of intense research and other specialists (typically including respiratory medicine,
currently, but they do not yet have an established role in clinical cardiology, neurology, rehabilitation medicine, therapists, and
practice. psychologists). Not all localities have such services, and in their
absence, a thorough history and clinical assessment should enable
What treatments are available?
a referral to be made to the most appropriate secondary care service.
As with investigations, no standard protocol exists for treating long Table 1 and the infographic provide some indicators.
covid. Recovery programmes have been designed and implemented
Because health services in many areas are currently very stretched,
with the aim of improving physical health and mental wellbeing.56
some patients may experience considerable delays even when their
The optimal content, delivery method, and duration of these
referral meets local criteria. Supportive care and symptom control
programmes is currently unknown, but under investigation (see
from the primary care team may be helpful in the interim.
EPPIcentre resource, box, Resources for healthcare professionals).
Programmes to date have been modelled on successful examples What if I’m not getting better?
such as pulmonary and cardiac rehabilitation, but with substantial
Early research on management of post-acute covid-19 assumed
modification for adults with long covid who are particularly
(explicitly or implicitly) that patients would recover, albeit slowly.
managing fatigue and PESE.57
Long covid specialist services in the UK were designed around this
Much current medication is directed at symptom control assumption and focused on assessment, rehabilitation, occupational
(paracetamol or non-steroidal anti-inflammatory drugs for fever therapy, and psychological support. Thirty months into the
and pains, antihistamines for allergic symptoms). Table 1 lists other pandemic, it is clear that this approach helps many but not all
specific medications for different symptom clusters. Covid vaccines patients, and that for a substantial minority, “recovery” currently
may help long covid symptoms and should be discussed with all means developing the ability to manage limited energy, continuing
those without contraindications who are not already fully pain, cognitive limitations, and ongoing flare ups in what has
vaccinated; they should be told that improvement may be modest become a long term condition.36 In addition to research to
and not all patients benefit (indeed, some may experience worsening characterise persisting forms of long covid and test targeted
of symptoms).33 58 59 therapies, models of integrated ongoing care more akin to those for
other long term conditions such as diabetes, heart failure, or chronic
How will I know if I’m getting better?
pain are needed, including evaluating and costing the contribution
The best guide to whether a patient is getting better is whether they of primary care to any such service. Community based
feel better (and if they do, whether this reflects permanent recovery interdisciplinary services and adequate support and training for
or temporary remission). A patient reported outcome measure that healthcare professionals are needed to rapidly improve care and
measures symptom severity across 10 domains as well as functional services for the growing numbers of people living with long covid.

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Resources for patients • Health Education England long covid e-learning modules for health
Books professionals. https://www.e-lfh.org.uk/programmes/long-covid/
• The Long Covid Self Help Guide37—written by specialists at a long Online resources
covid clinic offering lay explanations and self-management strategies • Living maps of covid-19 evidence, created by the UCL EPPI-centre,
for the different symptom clusters of long covid with long covid segment. http://eppi.ioe.ac.uk/cms/Projects/Depart-
• Support for rehabilitation: self-management after COVID-19 related mentofHealthandSocialCare/Publishedreviews/COVID-19Livingsys-
tematicmapoftheevidence/tabid/3765/Default.aspx
illness—a World Health Organization guide for patients20
• Living systematic review of long covid, which will be updated as new
• Long Covid Rehabilitation Booklet from NHS Hertfordshire.
evidence emerges64
https://www.hct.nhs.uk/media/4529/long-covid-rehabilitation-
booklet-july-2021.pdf. • Long covid physio: a resource site intended mainly for
Websites physiotherapists and their patients, set up by physiotherapists who
have (had) long covid. https://longcovid.physio
• Your Covid Recovery (https://www.yourcovidrecovery.nhs.uk/)—an
NHS England funded website with public facing resources (Phase I
resources). These offer helpful advice for specific symptoms, eg, How patients were involved in the creation of this article
dizziness (https://www.yourcovidrecovery.nhs.uk/covid-in-the-last-
Patients who were members of the LOCOMOTION quality improvement
4-weeks/effects-on-your-body/dizziness/). Phase II Your Covid
Recovery is a web based covid-19 rehabilitation programme with collaborative (see protocol paper for details65) contributed the comments
healthcare professional support for those referred into the scheme in box 1. RM has lived experience of long covid and co-chairs the patient
(usually by a rehabilitation professional) advisory group for LOCOMOTION. The paper was read by three additional
patients with long covid and modified in response to their feedback.
• Physiotherapy for Breathing Pattern Disorders (https://www.physio-
We considered patient led and professionally led research on their merits,
therapyforbpd.org.uk)—a patient facing site designed and run by
aware that many high quality studies on this condition were
specialist physiotherapists
conceptualised and undertaken by patient communities (who included
• Long Covid Work (https://longcovidwork.co.uk/)—a site for people scientists, social scientists and clinicians, who brought relevant research
returning to work after long covid. skills as well as lived experience of long covid).
Support groups
• Long Covid SOS (https://www.longcovidsos.org) and Long Covid How this article was created
Support (https://www.longcovid.org). Examples of resource and
This paper draws on three sources. The first was a literature search of
networking sites set up by and for people with long covid.
PubMed using the terms “post-acute covid-19 syndrome (MeSH)”, and
“long covid (title and abstract)” and including basic science studies and
Resources for healthcare professionals reviews,11 47 48 50 narrative reviews, and conceptual papers considering
Guidelines mechanisms,14 24 26 36 45 49 52 64 66 clinical trials (of which none had
reported at the time of writing), observational studies and reviews of
• Covid-19 rapid guideline: managing the long term effects of covid-19
these,15 -17 33 34 43 44 46 62 67 -70 systematic reviews of rehabilitation
(by NICE, Royal College of GPs, and Scottish Intercollegiate Guidelines
programmes,71 studies on outcome measures,35 60 61 72 -74 social science
Network)3 studies of long covid in vulnerable groups and underserved
• Faculty of Occupational Medicine guidance for health professional communities,52 -54 surveys12 18 75 and a Delphi study76 of patient
on return to work for patients with post-covid syndrome. priorities, and qualitative studies of the patient experience.2 13 40 41 77
https://www.fom.ac.uk/wp-content/uploads/FOM-Guidance-post- Secondly, the paper drew on group discussions with front line clinicians
COVID_healthcare-professionals.pdf
and patient partners (the LOCOMOTION consortium65) who are members
• Society of Occupational Medicine’s covid-19 return to work guide for of a national quality improvement collaborative for long covid clinics in
recovering workers. https://www.som.org.uk/COVID-19_re- the UK (these discussions prompted us to undertake further literature
turn_to_work_guide_for_recovering_workers.pdf searches where needed). Thirdly, we drew on “grey literature” including
• NICE guideline on chronic pain. service specifications,78 79 Office of National Statistics publications,6 7 80
E-learning courses guidelines, and policy documents from the UK and
internationally,3 5 56 57 63 81 and patient facing self-help literature.20 37
• Long term effects of covid-19 and post-covid-19 syndrome: an
e-learning resource from the UK Royal College of General Practitioners.
https://elearning.rcgp.org.uk/course/view.php?id=492

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The authors thank patient research participants for the descriptions in box 1, as well as Matthew Knight,
Contributorship and guarantor: The paper draws on the clinical experiences and wisdom of the Patient Advisory Group members Clare Rayner, Ian Tucker-Bell, and Nikki Smith, and five reviewers
LOCOMOTION consortium. All authors contributed to the literature search and synthesis of key findings (two patients and three clinicians) for helpful comments on an earlier draft.
from these. TG wrote the first draft, which was extensively amended by other authors. All authors
offered feedback on the infographic. All authors read and approved the final manuscript. Competing interests: TG is a member of Independent SAGE. MS is WHO Europe adviser on covid
rehabilitation policy and led the development of the C19-YRS (Yorkshire Rehabilitation Scale) outcome
measure for long covid. RE and TG are members of the NHS England Task Force for long covid.

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Provenance and peer review: commissioned; externally peer reviewed. 29 STIMULATE-ICP investigators. About the STIMULATE-ICP Study. University College London
Hospitals, 2022. https://www.stimulate-icp.org/about.
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primary care. BMJ 2020;370:. doi: 10.1136/bmj.m3026 pmid: 32784198 1991;14:-5. doi: 10.1093/sleep/14.6.540 pmid: 1798888
2 Perego E, Callard F, Stras L, etal. Why the patient-made term ‘long covid’ is needed. Wellcome 31 Chung F, Abdullah HR, Liao P. STOP-Bang questionnaire: a practical approach to screen for
Open Res 2020;5:doi: 10.12688/wellcomeopenres.16307.1. obstructive sleep apnea. Chest 2016;149:-8. doi: 10.1378/chest.15-0903 pmid: 26378880
3 National Institute for Health and Care Excellence (NICE) Scottish Intercollegiate Guidelines 32 Pataka A, Kotoulas S, Sakka E, Katsaounou P, Pappa S. Sleep dysfunction in COVID-19 patients:
Network. (SIGN) and Royal College of General Practitioners (RCGP). COVID-19 rapid guideline: prevalence, risk factors, mechanisms, and management. J Pers Med 2021;11:.
managing the long-term effects of COVID-19. NICE, 2022. https://www.nice.org.uk/guidance/ng188/ doi: 10.3390/jpm11111203 pmid: 34834555
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