Support measures for persons affected by long COVID

• Post COVID-19 conditions, also known as "long COVID" and scientifically named "Post-Acute Sequelae of SARS-CoV-2 infection", refer to symptoms that last for months after a COVID-19 infection.^{1Legend symbol denoting There is no internationally agreed definition of long COVID. The World Health Organization describes the symptoms as occurring "usually within three months from the onset of COVID-19" and lasting for "at least two months." In the US, the Centers for Disease Control and Prevention states that when an individual experiences new, returning, or continuing health problems for four weeks or more after the date of initial COVID-19 infection, they are experiencing post-COVID conditions. See World Health Organization (2021a) and Centers for Disease Control and Prevention (2022b).} Symptoms include fatigue, shortness of breath, joint pain, and problems with memory and concentration (commonly known as "brain fog"), among others. According to the World Health Organization ("WHO"), approximately 10%-20% of individuals previously infected with COVID-19 developed long COVID symptoms, but emerging evidence indicates possibility of much higher prevalence.^{2Legend symbol denoting For example, a systemic review of 45 research studies finds that the median proportion of individuals who experienced persistent post COVID-19 symptom was 73%. Another meta-analysis covering 50 studies showed that the estimated global prevalence of long COVID was 43%. See JAMA Network (2021) and University of Minnesota (2022).} Long COVID presents various challenges to patients, both physically and emotionally, potentially requiring multidimensional supports. For some patients, long COVID conditions impact their ability to work, study and even everyday functioning, thereby putting them at disadvantaged positions in their workplace, schools and/or daily life scenarios.^{3Legend symbol denoting See European Agency for Safety and Health at Work (2022).} Therefore, long COVID not only has implications on the health system, but also livelihood of long COVID patients and their employers' operations and manpower planning. For the economy in particular, high prevalence of long COVID might even be a cause for shrinkage in the labour force and worsened productivity.^{4Legend symbol denoting See Brookings Institution (2022) and Bank of England (2022).}
• In Hong Kong, with infection cases registered at over 1.3 million (18% of population) as at end-July 2022, there are often reported cases of long COVID, though there is no official estimation on the extent of its prevalence. At present, long COVID cases are mainly cared for under existing healthcare services, where patients are referred to specialized medical services as determined on a case-by-case basis by their primary care doctors. In view of the multifaceted nature of long COVID, there have been calls from society demanding better and more personalized support to long COVID patients, such as provision of specialized medical services and protection of rights of those whose abilities to work are affected.^{5Legend symbol denoting For example, see 文匯報(2022a) and 香港新聞網(2022).}
• This issue of Essentials aims to review WHO's guidance on long COVID management with a global overview of the common measures implemented. It will then review Hong Kong's support measures, followed by an examination of those in England of the United Kingdom ("UK") and the United States ("US"). The two places have relatively long experiences in addressing long COVID given their large number of infections early in the pandemic. The former has provided targeted healthcare services to support long COVID patients, whereas the latter has put in place guidance/measures in non-medical aspects to help long COVID people restore normal work/school life to the extent possible and provide protections to their rights where necessary.

• Scientists and medical professionals generally agree that there is yet any specific cure for long COVID. Various publications issued by WHO, therefore, focus on setting out principles on how to manage patients' care after a COVID-19 infection, as well as other policy recommendations on addressing long COVID.^{6Legend symbol denoting See World Health Organization (2021b, 2021c).} Major recommendations are highlighted as follows:
  • (a)
    increasing awareness by providing information to the general public to facilitate patients' access to healthcare, to foster self-care and self-help, and to reduce stigma about the condition;
  • (b)
    developing coordinated care pathways and guidelines to enable primary care providers to tailor case management to the conditions of individual patients, for example with prescriptions of rehabilitation programmes, and/or specialty management;
  • (c)
    taking multidisciplinary, multispecialty approaches to assessment and management that involve primary care providers (i.e. general practitioners), relevant specialists, rehabilitation professionals, mental health and psychosocial providers, and social care services to provide care that is personalized according to individual patients' needs;
  • (d)
    tackling the wider consequences of post-COVID conditions, such as patients' reduced ability to return to work, which may entail support measures outside the arena of healthcare, addressing employment rights, sick pay policies, and access to disability benefits; and
  • (e)
    implementing patient registers and other surveillance systems and following up with patients to support the research that is critical to understanding and treating long COVID.
• Various overseas places have measures in place to support the recovery and well-being of persons suffering from long COVID. Despite variations in breadth and depth, the support measures are generally in line with WHO's principles. Figure 1 lists some examples of measures implemented in overseas places:
  Figure 1 – Examples of measures implemented in overseas places

  Raising public awareness on long COVID	•Centrally disseminating information on long COVID through the Internet, including symptoms and directions for further help (e.g. South Australia and Oslo in Norway), and/or self-management strategies (e.g. the UK).
  Issuing coordinated care pathways and guidelines to healthcare workers	•Alberta Province (Canada): Post COVID-19 Rehabilitation Response Framework (March 2021). •Malaysia: Post COVID-19 Management Protocol (July 2021). •Japan: Medical guidelines for post COVID-19 conditions (April 2022).
  Taking multidisciplinary, multispecialty approaches to assessment and management	•Government-funded multidisciplinary long COVID clinics in Europe (e.g. Belgium, France, the UK), Thailand and some states/provinces in Australia and Canada. •Rehabilitation clinics/services for long COVID patients in Germany and Malaysia.
  Tackling the wider consequences of post-COVID conditions	•The US: explicitly recognizing long COVID as a possible cause of disability, opening up long COVID patients to disability rights. •New Zealand: advising employers to treat long COVID employees in the same way they would respond to any long-term illness. •Australia: providing workers' compensation to people who catch COVID-19 while at work and subsequently suffer from long COVID.(*)
  Implementing surveillance systems to support research	•The UK: collecting data through ongoing nationwide COVID-19 Infection Survey and online follow-up questionnaires for families of children who have tested COVID-19 positive. •The US: collecting and analysing data through partner organizations (i.e. universities and local healthcare systems) and surveys.

  Note: (*)New South Wales, for example, has amended its workers' compensation laws to include a "presumption" for certain occupations that catching COVID-19 is a result of their work. For a prescribed list of occupations, including retail, health, education, hospitality, emergency services and other jobs that cannot feasibly be done at home, if an employee catches COVID-19, he/she is presumed to have caught it at work. See NSW Government (2022).
  Sources: Alberta Health Services (2021), Ministry of Health Malaysia (2021b), NHK World-Japan (2022), 厚生勞動省(2022), BMJ (2022), Thai PBS World (2022), RACGP (2022), SPOR Evidence Alliance (2021), Deutsche Rentenversicherung (2022), Ministry of Health Malaysia (2021a), Employment New Zealand (2022), The Sydney Morning Herald (2021), Office for National Statistics (2022a), Public Health England (2021), and Centers for Disease Control and Prevention (2022c).

• As at end-July 2022, there had been about 1.3 million reported cases of COVID-19 infection in Hong Kong. Currently, there are no official statistics on how many of these cases were affected by long COVID, and estimates made by various institutions so far showed great variations. The estimated proportion of previous COVID-19 patients suffering from long COVID varies from 40% to 75% according to three different studies^{7Legend symbol denoting Institutions that have published estimates on long COVID prevalence in Hong Kong include New Century Forum (see 文匯報(2022b)), the Chinese University of Hong Kong (see 香港01(2022)) and the Hong Kong Polytechnic University (see香港理工大學(2022)).}, while reportedly one public hospital registered that less than 3% of recovered patients suffered from long COVID.^{8Legend symbol denoting It should be noted that the figure covered patients who were infected with COVID-19 before the 5th wave of epidemic that occurred in 2022. See 明報(2022b).} Among children who had been infected with COVID-19, 10% were suspected to be suffering from long COVID.^{9Legend symbol denoting See 星島日報(2022).}
• Unlike overseas places with massive outbreaks early in the pandemic, 99% of Hong Kong's infection cases occurred during the fifth wave of pandemic in early 2022, when most cases were believed to be attributable to the Omicron variant of COVID-19. Scientists are still studying the risk of long COVID after infection with the Omicron variant.^{10Legend symbol denoting See Scientific American (2022).} Also, as infection cases continued to occur in the past few months, with about 88 000 additional cases reported from April to June 2022, more people may start worrying about whether they are suffering from long COVID as related symptoms persist. For some recovered patients, they may even become concerned that long COVID conditions may affect their performance in workplace.^{11Legend symbol denoting See 東方日報(2022b).}
• At present, the Government disseminates little advisory information to the public focusing on long COVID.^{12Legend symbol denoting There is little information on long COVID on the Government's COVID-19 online portal, coronavirus.gov.hk.} The absence of reliable information would impede self-management of the conditions by patients, potentially leading to issues down the road. While some District Health Centres ("DHC") have hosted seminars offering advice and information on long COVID, such events are largely only targeted at the DHCs' existing user base.^{13Legend symbol denoting For example, the Sham Shui Po District Health Centre ("DHC") hosted online seminars, and the Central and Western DHC Express hosted face-to-face workshops on long COVID. Under the purview of the Health Bureau, DHCs provide a variety of primary healthcare services, including health promotion, disease prevention, chronic disease management and community rehabilitation. There are currently six DHCs and 11 DHC Expresses.}
• Based on public information, currently there is no dedicated care pathway or specific clinical guidance in Hong Kong for people suspected to be affected by long COVID. However, such patients may receive medical care from the public healthcare system. According to Hospital Authority ("HA"), follow-up medical appointments would be arranged for recovered COVID-19 patients who have been hospitalized in public hospitals and those who have received medical consultation at government designated clinics for COVID-19 confirmed cases. Depending on the conditions of each case, referral to specialist care and/or rehabilitation services may be offered.^{14Legend symbol denoting See 香港經濟日報(2022) and Food and Health Bureau (2022).}
• While there is no standardized clinical arrangement to deal with long COVID, HA's "Special Chinese Medicine Out-patient Programme for COVID-19 infected persons" is considered a key element in the Government's support to long COVID patients, though not a targeted measure to tackle long COVID. Launched in April 2020, the Programme provides Chinese medicine ("CM") out-patient services as part of rehabilitation for persons previously infected with COVID-19 at 18 tripartite CM Clinic cum Training and Research Centres ("CMCTRs") across the territory.^{15Legend symbol denoting Launched in 2003, CMCTRs all operate on a tripartite collaboration model involving HA, a non-governmental organisation ("NGO") and a local university. NGOs are responsible for the running and day-to-day operation of the CMCTRs. See Hospital Authority (2021).} Eligible persons, even without long COVID symptoms, can receive up to 10 free-of-charge general consultations at one of the CMCTRs within six months from their hospital discharge date or date of completion of isolation. As of 28 June 2022, the programme had served over 38 000 patients (5% of whom below age 18), providing a total of over 134 600 consultations.^{16Legend symbol denoting See Health Bureau. (2022).} The Government is considering expanding the Programme to private CM practitioners through the Chinese Medicine Development Fund.^{17Legend symbol denoting See Legislative Council (2022).}
• Universities and their associated institutions have also initiated treatment or rehabilitative programmes either at charge or on an experimental basis. CUHK Medical Centre, a non-profit private hospital (also the teaching hospital of The Chinese University of Hong Kong) has set up a COVID Recovery Clinic to serve patients with at least one persistent symptom for four weeks or more after clearance of COVID-19 infection. It offers symptoms assessment, further specialty investigations and treatments in CM, mental health, sleep health and physiotherapy, as well as a treatment programme focusing on gut microbiome. The Department of Rehabilitation Science of Hong Kong Polytechnic University ("PolyU") has developed a six-week physical training programme called "3R Rehabilitation Programme" (where "3R" refers to "Rebuild fitness", "Regain confidence" and "Resume normal life") to improve lung capacity and muscle strength of recovered patients through different forms of fitness exercise. Hong Kong Baptist University also offered a rehabilitation programme integrating cardiorespiratory and resistance exercise training with the use of Chinese medicine. It is worth noting that both CUHK Medical Centre's gut microbiome programme and PolyU's 3R Rehabilitation Programme are results of research funded by the Government.^{18Legend symbol denoting See The Chinese University of Hong Kong (2022a) and The Hong Kong Polytechnic University (2022).}
• Indeed, the Government has approved a total of HK$545 million to support 70 COVID-19 related research studies since April 2020. Together with the Health & Medical Research Fund's annual open call for investigator-initiated projects, there are seven research studies specifically related to long COVID, covering the physical and mental impact of COVID-19 on recovered patients.^{19Legend symbol denoting See GovHK (2022a).} While these studies are important in generating insights on long COVID, some considered that the Government should also provide imminent support to people affected by long COVID, such as establishing specialized long COVID clinics utilizing existing facilities.^{20Legend symbol denoting For example, see 東方日報(2022a) and 香港01周報(2022).} Recently, with support from HA, CUHK launched Hong Kong's first large-scale survey of long COVID in July 2022, in an effort to offer information to the Government regarding the needs for providing special medical care for people debilitated by long COVID.

• According to official estimate, 1.7 million people in England, or 9.4% of those who had been infected with COVID-19, experienced or were experiencing self-reported long COVID. Of these, 324 000 people reported that long COVID adversely affected their day-to-day activities "a lot" while another 854 000 said the conditions affected their day-to-day activities "a little".^{21Legend symbol denoting As at 1 June 2022. See Office for National Statistics (2022c).} As early as October 2020, England's public healthcare system National Health Service ("NHS") already set out a five-point plan as an initial response to the challenge. This includes:
  • (a)
    launching an online hub "Your COVID Recovery" providing general information and advice as well as tailored rehabilitation plans;^{22Legend symbol denoting While clinical assessment services require referrals and thus may not be directly accessible, NHS offers the "Your COVID Recovery" platform to support patients' self-management. The platform consists of two components: (i) a publicly open website containing information on recovering from COVID-19 and long COVID including physical, emotional and psychological wellbeing; and (ii) an interactive recovery platform, available upon referral by general practitioners or long COVID clinics, to enable patients to contact a healthcare professional for rehabilitation advice and/or join an online forum for peer-to-peer support. Meanwhile, long COVID patients can also access the UK government's one-stop online guidance on the range of support available to them. See NHS (2021a, 2022c).}
  • (b)
    issuing clinical guidance and educational materials for general practitioners and other health professionals to help them refer patients to the right support;
  • (c)
    setting up designated post-COVID assessment clinics ("long COVID clinics") offering one-stop and multidisciplinary services;
  • (d)
    establishing an NHS England Long COVID taskforce comprising patients, medical specialists and researchers to oversee NHS' support for long COVID; and
  • (e)
    researching on long COVID to better understand the condition and refine appropriate treatment.
• NHS further expanded the long COVID plan for 2021-2022 with further commitments, including establishment of 15 long COVID hubs that cater specifically for children and young people ("paediatric hubs"). The initiatives and designs relating to long COVID clinics and paediatric hubs are discussed below.

• NHS has invested a total of £94 million (HK$906 million) in 2021-2022 to establish a network of long COVID clinics. There are currently 90 long COVID clinics across England,^{23Legend symbol denoting See UK Parliament (2022).} some of which operate as virtual clinics without a physical location.^{24Legend symbol denoting An example is The Suffolk and North East Essex Long COVID Assessment Service. See NHS North East Essex CCG (undated).} The clinics are implemented by local healthcare systems in accordance with the National Guidance for Post-COVID Syndrome Assessment Clinics issued by NHS and have the following salient features:
  • (a)
    NHS has issued a detailed guidance to enable consistent referrals to long COVID clinics (Figure 2), and the system relies on general practice to support patients to be managed in primary care, where appropriate, and to make consistent referrals for specialist assessment and treatment;
  • (b)
    In view of the key role of general practitioners, NHS has allocated funding for their professional education, training and pathway development that will enable clinical management in primary care;
  • (c)
    Referrals from hospitals and primary care providers are reviewed by the respective local NHS service providers (known as NHS trusts), which may accept a referral (NHS statistics show that about 85%-90% of the referrals were accepted) or reject it as clinically inappropriate based on the medical evidence submitted;
  • (d)
    Upon acceptance to the long COVID clinic system, patients receive initial specialist assessments including a physical assessment (to identify any potential chronic health issues), a cognitive assessment (to assess any memory, attention and concentration problems) and a psychological assessment (to assess potential depression, anxiety or other mental health condition);
  • (e)
    Long COVID clinics act as one stop shops which provide specialist assessment, diagnosis and treatment. The clinics are staffed by multidisciplinary teams including respiratory physicians, nurses, physiotherapists, occupational therapists, sports therapists, psychologists, speech and language therapists, dietitians, and social workers;
  • (f)
    Long COVID clinics in some regions have developed tailored rehabilitation packages for patients, which are delivered by therapists working in the long COVID clinics; and
  • (g)
    Depending on needs, long COVID clinics may refer patients into specialists for advanced diagnosis and treatment, such as lung disease services, sleep clinics, cardiac services, rehabilitation services, and/or mental health services.

    Figure 2 – Clinical pathways for assessment and intervention for post COVID-19 syndrome

    

    Source: NHS (2022c).

• Apart from long COVID adults, about 1.8% of primary school students and nearly 4.8% secondary school students in England are estimated to have long COVID.^{25Legend symbol denoting Latest statistics as at March 2022. See Office for National Statistics (2022b).} As of May 2022, NHS has set up 14 paediatric hubs across England providing non-clinical services dedicated to children and young people (aged 0-18 years) suffering from symptoms and had a likely or proven COVID-19 infection over 12 weeks ago. Salient features of the paediatric hubs are as follows:
  • (a)
    As for the long COVID clinics for adults, patients require referrals by their primary care providers (general practitioners or paediatricians) before accessing service at the paediatric hubs;
  • (b)
    Patients undergo assessments by a multidisciplinary team at the paediatric hubs either face-to-face or virtually. Composition of the multidisciplinary teams of the hubs vary by location, but generally include paediatrician, adolescent medicine, respiratory, infectious diseases, rheumatology, cardiology, neurology, psychiatry, psychology, physiotherapy, occupational therapy and clinical nurse specialist;
  • (c)
    Yet unlike long COVID clinics for adults, the hubs generally do not provide treatment, but are instead focusing on assessing clinical needs and coordinating care of children and young people. Depending on the outcome of assessments, the hubs provide further referral to appropriate treatment and specialist support to other clinicians; and
  • (d)
    The hubs also serve the purpose of gathering evidence on long COVID's manifestation in children and young people, potentially contributing to the development of a case definition for this group of patients.

• Statistics show that there has been solid demand for NHS' long COVID services. During the four-week period between 9 May and 6 June 2022, long COVID clinics in England had accepted about 4 600 referrals and provided about 4 100 initial assessments and over 12 200 follow-up consultations (Figure 3), averaging about 180 cases handled by each clinic during the period. A healthcare service provider reportedly said that patient feedback was generally positive because different aspects of their illness could be assessed under one roof by a multidisciplinary team, and that many long COVID patients required therapy-led care to support their recovery more than medical interventions.^{26Legend symbol denoting See BHR University Hospitals NHS Trust (2021), Banbury Guardian (2021) and The News, Portsmouth (2021). Having said that, there have also been issues over variations in the services among the long COVID clinics. For example, some paediatric hubs were said to only provide treatment for fatigue but not other health problems. See UK Parliament (2022).}
  Figure 3 – Service statistics of long COVID clinics in England
  
  Source: NHS (2022b).
• Despite resources dedicated to boosting the capacity of England's long COVID clinics, given an estimated 1.7 million long COVID patients, there remains a sizable backlog, as evident from the gap between accepted referrals and initial assessments conducted during each of the four-week periods (Figure 3), with a range of about 500-1 300 cases per period.^{27Legend symbol denoting See The Guardian (2022).} Of the patients who received their initial specialist assessments between 9 May and 5 June 2022, 29% had waited for 15 weeks or more (another 38% had waiting time between 6 and 14 weeks).^{28Legend symbol denoting Moreover, there are considerable variations among regions, with the longest waiting time in South East England (where 39% of those who received initial specialist assessment during the period from 9 May to 5 June 2022 had waited for at least 15 weeks).} To improve the long COVID services, NHS has pledged to reduce the waiting time as one of the organization's priorities for 2022-2023.^{29Legend symbol denoting See NHS (2022a).}
• The UK government also acknowledged that long COVID would likely increase demand for manpower in healthcare – not just for its long COVID clinics but also across a range of services. Hence, it has committed to make recruiting overseas less costly and more attractive for healthcare talents to come to work in the UK, among other measures to strengthen healthcare manpower.^{30Legend symbol denoting The UK has in place the Health and Social Care Visa scheme to allow medical professionals to come to or stay in the UK to do an eligible job with NHS, an NHS supplier or in adult social care. See Gov.UK (2022).}

• In the US, the government estimated that 7.6% of the adult population were experiencing long COVID during 29 June to 11 July.^{31Legend symbol denoting The data is based on periodic household surveys conducted by the Centers for Disease Control and Prevention. See Centers for Disease Control and Prevention (2022a).} The US government has been continuously reviewing and developing its plan in addressing long COVID, with the launch of targeted healthcare programmes. In view of widespread effects of long COVID on lives and society, it has further laid out its latest direction in a presidential memorandum published in April 2022^{32Legend symbol denoting See The White House (2022b).}, giving a strong focus on research to understand the causes of post COVID-19 conditions and potential prevention and treatment options.
• Although the US has also launched designated long COVID clinical services as part of their response actions in 2020,^{33Legend symbol denoting Currently there are at least one long COVID clinic in each of the states in the US providing treatment and rehabilitation services, with its design and operation varied from state to state. More recently, the national health agency, Centers for Disease Control and Prevention, has released an interim guidance for healthcare providers treating patients with post-COVID conditions, which among others, advises that "based on current information, many post-COVID conditions can be managed by primary care providers, with the incorporation of patient-centered approaches to optimize the quality of life and function in affected patients". See Centers for Disease Control and Prevention (2021).} considering the uniqueness of the US healthcare system in terms of funding structure and public/private market share, this section will not examine in detail its care model in treating long COVID conditions. Instead it will focus on non-medical support measures for long COVID people, including the requirement to provide reasonable accommodation in workplace and school, as well as the programmes of assistive technologies.

• In the US, individuals are entitled to protection from discrimination if their long COVID symptoms lead to a disability, even though it is just temporary. The US Department of Health and Human Services ("HHS") and the Department of Justice issued a joint guidance in July 2021 providing clarity that long COVID could be a disability under various federal civil right laws.^{34Legend symbol denoting The federal civil right laws covered include the American Disability Act (which applies to the government, schools, employers and anyone who offers goods or services to the public), Section 504 of the Rehabilitation Act (which applies to recipients of federal financial assistance), and Section 1557 of the Patient Protection and Affordable Care Act (which applies to health programmes and activities). See U.S. Department of Health and Human Services (2021).} According to the guidance, a person with long COVID is disabled if any of the symptoms is a physical or mental impairment that "substantially limits one or more major life activities".^{35Legend symbol denoting According to the American Disability Act, major life activities include functions such as caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, sitting, reaching, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, interacting with others, and working. Major life activities also include the operation of a major bodily function, such as functions of the immune system, normal cell growth, etc.} The recognition of long COVID conditions as potential causes for disability implies that various entities are obligated to make adjustments or modifications (or referred to as reasonable accommodations) for affected individuals, including in the workplace and school.^{36Legend symbol denoting Besides workplace and school, businesses that provide goods or services to the public are also required to provide reasonable adjustment to long COVID patients as the disability regulations apply to all places accessed and open to the public.}
• In the workplace, employers with 15 employees or more are obligated to provide adjustments or modifications to enable people with disabilities to enjoy equal employment opportunities, unless it can demonstrate that the accommodation would impose an undue hardship on the operation of the business. Employers determine the existence of disability on a case-by-case basis. He/she may require medical documentation detailing the disability with any restrictions or limitations, or request the employee concerned to give permission for the him/her to contact the employee's health care provider directly.^{37Legend symbol denoting If the employee does not cooperate in providing the requested reasonable medical information, the employer can lawfully deny the accommodation request. See U.S. Equal Employment Opportunity Commission (2022).}
• There is no exhaustive list of accommodations prescribed in the disability law. According to the Job Accommodation Network^{38Legend symbol denoting Funded by the US Department of Labor's Office of Disability Employment Policy, the Job Accommodation Network provides free, expert, and confidential guidance on job accommodations and disability employment issues.}, reasonable accommodations are determined through an interactive process between the employer and the employee rather than one-size-fits-all, and some commonly requested long COVID-related adjustments include telework (commonly in the format of "work from home") and equipment to enable telework, job restructuring (e.g. removing some job functions) and schedule modification (e.g. reduced or alternative hours).^{39Legend symbol denoting See Job Accommodation Network (2021b).} Further examples of accommodations for some of the common long COVID symptoms are listed in Figure 4. In the event that the employer has denied the request for an accommodation without a valid reason, the employee concerned may appeal the decision by filing a complaint with Equal Employment Opportunity Commission ("EEOC") or the state enforcing agency.^{40Legend symbol denoting For further details on employers' obligations, see U.S. Equal Employment Opportunity Commission (2022).}
  Figure 4 – Examples of workplace accommodations for common long COVID symptoms

  Workplace accommodations	Long COVID symptoms
  	Shortness of breath with exertion	Extreme fatigue	Brain fog	Joint pain and body aches
  Common examples	•Allow rest breaks •Allow telework •Restructure the job to remove marginal job functions
  Examples applicable to specific symptoms	•Allow removal of mask when appropriate •Allow time for medical treatment such as use of a nebulizer or inhaler	•Provide an ergonomic workstation •Allow flexible schedule	•Provide memory aids such as flowcharts and check lists •Provide a quiet workspace	•Provide an ergonomic workstation •Reduce the physical demands of the job •Allow flexible schedule

  Source: Job Accommodation Network (2021a).
• The requirements on employers to provide reasonable accommodations came against a backdrop of increasing acceptance of telework among US employers. Indeed, it has been reported that many US employers have been expanding and reforming employee benefits during the COVID-19 pandemic, with increased attention to employees' well-being and family caregiving duties.^{41Legend symbol denoting See Harvard Business Review (2021) and SHRM (2021).} Reportedly some US companies have already established disability accommodation policies and processes for employees impacted by long COVID.^{42Legend symbol denoting See Time (2022b).} Nevertheless, whether the accommodation is reasonable is considered subjective, and there are concerns that the ambiguity and complexity of diagnosis for long COVID may lead to workplace conflicts and even lawsuits.^{43Legend symbol denoting For example, see Fortune (2022) and Bloomberg Law (2021).} EEOC thus advises employers to engage in informal dialogue with employees concerned in determining whether a reasonable accommodation is possible, such that the accommodation will enable the employee to perform the essential function of the position.
• According to a survey on people who had contracted COVID-19, 55% said that their workplace had accommodated employees experiencing long COVID symptoms.^{44Legend symbol denoting See Power (undated).} While telework remains a common form of adjustment or modification, some companies reportedly have sought to minimize its operational impact with the offer of alternative accommodations, such as allowing the long COVID staff to sit instead of stand at reception desk; and inviting health coaches to provide one-on-one and tailored exercise training (e.g. breathing and stretchers) to address specific symptoms experienced by individual employees with long COVID.^{45Legend symbol denoting See Time (2022a).}
• Likewise, schools that receive federal financial assistance are required to provide students with disabilities with reasonable accommodations. With respect to long COVID, the Department of Education issued a guidance on the protections and services for children and students with long COVID.^{46Legend symbol denoting See United States Department of Education (2021).} This includes special education, academic adjustments, and reasonable modifications. For example, for children who suffer from chronic fatigue, adaptations that are oriented toward conserving energy, such as frequent rest breaks and permission to use elevators, may be reasonable accommodations.^{47Legend symbol denoting For further suggestions of accommodations for students suffering from long COVID, see the list provided by the Kennedy Krieger Institute (2021), a non-profit paediatric hospital which operates a pediatric post-COVID clinic and a nurse-education programme for schools.}
• According to the Department of Education's guidance, long COVID children experiencing difficulty concentrating and anxiety symptoms may need to receive counselling services, alongside behavioural interventions and supplementary aids to improve academic engagement, among other helping services. Despite the availability of guidance, there are views that figuring out the right framework for supporting students with long COVID would still be complicated, because the diagnosis is new and little is known about how symptoms may change over time. Thus, maintaining regular evaluations of students' needs and communications with parents are important.^{48Legend symbol denoting See Washington Post (2021).}

• Long COVID patients in the US may also benefit from assistive technology ("AT") programmes under the existing Assistive Technology Act, which provides grants to improve access of individuals with disabilities to local AT programmes in each state and territory. Persons with disabilities may access the AT device suitable for their needs with additional support such as device demonstration, short-term device loans, financial loans and used devices at reduced costs. Although not specifically targeted at long COVID, many existing AT programmes are applicable to long COVID symptoms. For example, smart pens may help patients with cognitive or memory issues keep up with meetings, and certain gadgets may help those experiencing joint and muscle pain complete daily living tasks with reduced dexterity.^{49Legend symbol denoting The Assistive Technology Act Technical Assistance and Training Center published an issue brief providing insights on how long COVID patients may benefit from AT programmes. See AT3 Center (2021).} A state-run programme in Florida, for example, has made available AT through a library, providing schools, teachers, parents and therapists with trial, demonstration, loan and/or training services.^{50Legend symbol denoting See Florida Alliance for Assistive Services and Technology (2021) and Disability Rights Florida (2020).}

• Based on the experiences of other places, governments' support for long COVID patients largely consists of one or more of the following aspects recommended by WHO: (a) disseminating information to the public so that patients are aware of when and where they can seek help and how they may self-manage their symptoms; (b) making available guidelines and care pathways to help medical professionals direct patients to the appropriate services; (c) establishing special medical services such as long COVID clinics to provide specialist multidisciplinary assessment, treatment and/or rehabilitation; (d) putting forth measures to alleviate difficulties patients meet at work and school and in their daily lives; and (e) surveillance initiatives to assess the extent of long COVID's impact and to support relevant research.
• With over 1.3 million people being confirmed as infected by COVID-19 in Hong Kong, there are views that the Government should do more to support those suffering from long COVID. Yet there remains substantial uncertainty about the potential caseload, care demand arising from long COVID and effectiveness of various services especially given the fast-evolving nature of the disease. While experts and commentators could be holding very diverse views on these issues, there appears a general agreement that long COVID, if left unaddressed, could have significant ramifications on the local economy and society at large.
• England's experience demonstrates the merits of one-stop multidisciplinary healthcare facility for long COVID patients. The holistic assessments and individualized recovery programmes received positive feedback from those who were able to access the service. However, even with 90 long COVID clinics for a total of 56.6 million population, the capacity still falls behind the demand. Its online resources hub for recovered patients, combined with clearly defined care pathways, has in some way reduced the anxiety of some long COVID patients by empowering them with more information and choices in addition to facilitating patient self-management and community care which alleviated the pressure on the healthcare system to certain extent.
• The US, on the other hand, is a frontrunner in specifying long COVID patients' legal rights. Although the US has a very different baseline as Hong Kong, as the statutory rights of people with disabilities are much more complex and elaborated in the former, it provides insights on the areas in which employers and schools can provide reasonable accommodations to alleviate the difficulties faced by long COVID patients.