Preprint Prevalence and Functional Outcomes of Post-Exertional Malaise among Adults with prior COVID-19…, 2026, Packard et al.

[SNT Gatchaman]

Prevalence and Functional Outcomes of Post-Exertional Malaise among Adults with prior COVID-19: Results from a Representative Survey of New York City Residents
Samuel E Packard; Therese Russo; Jannae Parrott; Julia Sisti; Amanda Lans

OBJECTIVE
To estimate the prevalence of Post-Exertional Malaise (PEM) among adults with prior COVID-19 and associated mental health and disability outcomes.

METHODS
We conducted a cross-sectional analysis of data from a survey of 9,620 adults with prior COVID-19 in New York City, collected May – June 2024. PEM was measured with the DePaul Symptom Questionnaire – Post Exertional Malaise, categorized by symptom duration (< 14 vs. ≥14 hours). Weighted prevalence estimates were stratified by socio-demographic and clinical characteristics. Modified Poisson regression was used to assess the association of PEM with depression, anxiety, and disability.

RESULTS
The prevalence of PEM symptoms was 20.9% overall and 4.0% with symptom duration ≥ 14 hours, representing over 800,000 New Yorkers affected and over 150,000 who meet a diagnostic criterion for ME/CFS. PEM prevalence was higher among women, transgender and non-binary adults, people of color, and lower educational attainment, chronic comorbidities, or disabilities. PEM was associated with 3 - 4 times higher prevalence of mental health outcomes and 4 - 5 times higher disability scores.

CONCLUSIONS
PEM symptoms were common and strongly associated with disability and adverse mental health. Screening, pathways to care, and supportive policies are needed to mitigate long-term consequences, particularly among marginalized populations.

Web | DOI | PDF | Preprint: MedRxiv | Open Access

 

[Axel]

The PEM criteria seem rather lenient.
It all depends on what is meant by ‘minimal activity’ and the exacerbation of a single symptom.
Plus those very strange 14 hours.

 

[Peter T]

Previously we have discussed concerns that the DePaul tool is not a reliable measure of PEM, that it fails adequately to distinguish between rapid fatiguability, post exertion symptom exacerbation and PEM.

Though it is likely to include what we consider as PEM it will generate false positives by including what we have described as rapid fatiguability, which though potentially part of PEM, is not the full picture of ME/CFS PEM that includes features not part of the exaggeration of the normal fatigue process found in other conditions.

We desperately need more work on developing an operationalised definition of PEM that can be used for research purposes.

 

[Andy]

The DSQ-PEM ascertains self-reported frequency and severity of five symptoms experienced after exertion over the past six months: Dead, heavy feeling after starting to exercise; Next day soreness or fatigue after non-strenuous, everyday activities; Mentally tired after the slightest effort; Minimum exercise makes you physically tired; Physically drained or sick after mild activity.
PEM was defined as reporting at least one of the five symptoms at both a severity of moderate or greater and a frequency of about half the time or more 18.
Symptom duration following a triggering activity was dichotomized as mild/moderate (<14 hours) and prolonged (≥14 hours). Prolonged symptom duration is relevant as a diagnostic criterion of ME/CFS 18.

So we have concerns here that the DSQ-PEM may pick up people who experience a normal reaction to exercise, this research team then reduced PEM down to, potentially, only one part of the DSQ-PEM. No wonder they found so many people 'with' PEM.