Emily Headrick, Clinical Technical Advisor, FHI 360 

While the worst phases of the COVID-19 pandemic are now years behind us, the people of the Pacific Islands continue to live with the fall-out of the unprecedented global crisis. Some of the consequences of the COVID-19 outbreak in Fiji are obvious: lost loved ones; a crippled workforce straining with the loss of a significant proportion of its nurses through resignation or emigration; and economic strain from the abrupt interruption of tourism, which has been slow to reactivate. Other effects are more subtle and are only now emerging as causes of concern, long COVID being one of them.  

Long COVID refers to a diverse range of conditions that remains a complex health area to manage, despite affecting health and quality of life for up to 30% of the nearly 1 billion people around the world who contracted COVID-19. Dwindling research efforts have left us with only a slightly clearer understanding of the pathophysiology of these conditions, but there are still no reliable diagnostics or reliable treatment options for millions of people around the world. Care is even more fractured in places with low awareness of post-COVID health conditions like long COVID, and there is no clear protocol for where patients with potential long COVID can go for care within a health system. This begs the question of public health stakeholders around the world: How do we plan to take care of people affected by a disease outbreak, not only during the outbreak itself, but long after its initial effects have waned? 

As clinicians and community leaders in Fiji emerged from the worst waves of COVID-19 cases, some noticed their patients complaining of prolonged symptoms including shortness of breath, weakness, joint pain, and fatigue. Except for a small group of dedicated clinicians, the concept of long COVID was not commonly known in communities, primary health care services, or in the public health system.  

In 2022 and 2023, EpiC partnered with the Fijian Ministry of Health and Medical Services (MHMS) and the Ministry of Wellness to develop a training package for primary health care clinicians for post-COVID conditions (PCCs), which includes the most well-known group of conditions known as long COVID. The challenge of this endeavor was two-fold. First, there was virtually no awareness of long COVID in the community. However, there was an enormous amount of COVID-19 vaccine-related mistrust —subsequently eroding trust in the health system — and a prevailing social understanding that any unexplained symptomology was attributed to vaccine injury. Second: clinical management is challenging. PCCs, including long COVID, are complex to diagnose and manage. Long COVID can present differently with every person, affecting different organ systems and presenting with different degrees of severity. Furthermore, there is no validated screening tool (largely due to the heterogeneity of symptom presentation), and there are no objective diagnostics that can determine if the symptoms are post-COVID physiological processes.   

To face these challenges, the USAID-funded Meeting Targets and Maintaining Epidemic Control (EpiC) project tailored its training approach to meet people where they were and ground the initiative in local value systems, world views, and lived experiences of communities and the clinicians caring for them. A family nurse practitioner and a clinical technical advisor with the EpiC project used her bedside experience to tailor the content for local clinicians who were facing burnout, overwork, and patient mistrust. EpiC drew on the expertise of local Pasifika nurse practitioner Catherine Soana Latailakepa-Tu’akalau to imbue culturally informed perspectives into this training initiative and ensure that the training workshops were anchored in Pasifika value systems and concepts of health and illness.  

The first series of training workshops focused on clinical case management of PCCs, targeted to clinicians working in Fiji’s primary health care system – including general practitioners and nurses, and specialists like physiotherapists, cardiologists, mental health specialists and diabetes educators. The essential concepts of PCC clinical management were shared with clinicians, but most of the two-day workshops were grounded in the Fijian principle of talanoa, or discussion. Using case-based scenarios, clinicians worked in groups to apply their learning to develop real plans of care that included clinical, psychosocial and social support management strategies. During these discussions, feedback and local perspectives were shared about what was or was not feasible for both clinical and operational case management in local settings. Innovative solutions to meet these local challenges were also proposed.  

These clinical case management workshops informed the discussions in a separate workshop (called the SOP Co-Design Workshop) attended by elected champions from each clinical workshop, as well as policy makers, MHMS representatives, and director-level leaders in the Fijian health system. This workshop was intended to clearly define a case definition for PCC that aligns with the Fijian context and to begin drafting standard operating procedures (SOPs) and clinical guidelines for identification, diagnosis, and management of suspected long COVID in the Fijian Primary Care System. A technical working group composed of health leaders and a team of multidisciplinary clinicians was also established during this event to move the effort forward.  

Workshop participants work together to come up with a case definition for long COVID. (Photo credit: Emily Headrick, FHI 360)

While the final decision for long COVID patients’ optimal care pathway was to be determined in future sessions with the technical working group, one innovative recommendation emerged from the group. All participants recognized the need for a dedicated care pathway for any survivor of a public health emergency. The creation of a post-public health emergency care pathway in the existing system has the potential to streamline resources, signpost clear access points for patients and overburdened primary health care clinicians, and earmark financial resources for any novel research efforts, diagnostic needs, or treatment modalities for survivors of any future potential outbreak (not limited to COVID-19, or PCCs). Similar post-epidemic care models exist from other settings such as the Ebola Survivor Program designated clear pathways, financing mechanisms, and support structures for the complex health needs of Ebola survivors in Sierra Leone after the 2014-2016 outbreak. However, to our knowledge, there is no other instance of a general post-public health emergency clinical care pathway.  

The workshops represented the first of many evolving conversations to create, at minimum, an awareness of PCCs that didn’t exist before. Fijian health leaders taught us that this situation is challenging but worth finding solutions, not only for survivors of COVID-19 but for any future public health emergency. The PCC Technical Working Group has continued to refine and finalize the SOPs, national guidelines, and implementation of post-COVID care in Fiji, in alignment with other national health priorities, such as non-communicable disease care and public health emergency preparedness. With support from EpiC, health leaders in Fiji are taking necessary steps to strengthen local systems and are serving as examples for the rest of the world.  

Featured image: Catherine Soana Latailakepa-Tu’akalau, a nurse practitioner and Pasifika health consultant, presents to workshop participants. (Photo credit: Emily Headrick, FHI 360)