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INTERNATIONAL JOURNAL OF HEALTH & MEDICAL RESEARCH
ISSN(print): 2833-213X, ISSN(online): 2833-2148
Volume 02 Issue 07 July 2023
10.58806/ijhmr.2023.v2i7n03DOI :
Page No.-172-181
IJHMR, Volume 2 Issue 7 July 2023 www.ijhmr.com Page 172
The Prevalence of Dysphagia in Patients with Covid-19: A Systematic Review
and Meta-Analysis
Akbar Banari1, Alireza Aghaz2, Arash Shahriyari3, Fatemeh Fakhimi4, Mohadeseh Khoshgoftar5
1Department of Speech Therapy, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.
ORCID: 0000-0001-8432-6435
2 Department of Speech Therapy, School of Rehabilitation Sciences, Isfahan University of Medical Sciences, Isfahan, Iran.
ORCID: 0000-0002-6183-0214
3Department of Speech Therapy, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran.
ORCID: 0000-0003-1989-2101
4Department of Speech Therapy, School of Rehabilitation Sciences, Isfahan University of Medical Sciences, Isfahan, Iran.
ORCID: 0000-0003-0260-7458
5PhD Student in Health Education and Health promotion, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran.
ORCID: 0000-0002-6870-3920
ABSTRACT: The world has been suffering from COVID-19 since 2019. It is thought that there’s a high risk of dysphagia in
patients with COVID-19. Therefore, the purpose of this study was to estimate the prevalence of dysphagia in patients affected by
COVID-19 in admission (day 0), discharge, and 3-6 months post-discharge. Only English papers reporting dysphagia in COVID-
19 patients were included. Case reports and review studies were excluded. The authors searched Web of Science, Google Scholar,
Scopus, and PubMed from January 1, 2020, until July 1, 2022. In this study, the effect sizes and standard errors were used to estimate
the amount of dysphagia in these patients. Random effects were used for statistical analysis. Of the 2736 identified studies, 19
articles (n = 5334 patients) were included in the meta-analysis. The pooled prevalence of dysphagia in COVID-19 patients at
admission (n=643 patients), discharge (n=2286 patients), long-term (n=2405 patients), and the total was 32% (SE=0.13), 29%
(SE=0.04), 14% (SE=0.03), and 24% (SE=0.03), respectively. About a quarter of COVID-19 patients may have dysphagia during
the acute phase and/or also in the post-acute phase of the disease. Therefore, one should be aware of the symptoms of dysphagia
and treat it in time.
KEYWORDS: Prevalence; Dysphagia; Swallowing; COVID-19; Meta-analysis; Review
INTRODUCTION
The Coronavirus disease-2019 (COVID-19), caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) has
resulted in a worldwide catastrophic healthcare issue, with serious social, economic, and health problems [1]. The high number of
COVID-19 patients has caused a great number of hospital and intensive care unit (ICU) admissions [2]. The SARS-CoV-2 virus
causes damage to the heart, digestive system, lungs, peripheral and central nervous system, and other tissues in some diseased people
[3, 4]. Its transmission through contact, fomites, respiratory droplets, and aerosols has facilitated the quick spread worldwide [1].
The most common manifestations appear to be sore throat, fever, cough, fatigue, and breathing difficulties [5-7]. COVID-19 can
cause life-threatening conditions in older patients or those with respiratory or cardiac diseases, which can result in the development
of Acute Respiratory Distress Syndrome (ARDS) [1, 6]. Besides these common manifestations of COVID-19, a few studies on
clinical features of these patients have reported a number of symptoms and disorders related to speech and swallowing, such as
dysphagia and dysphonia [3, 4, 6, 8-10].
Dysphagia in patients affected by COVID-19 seems to result from breathing-swallowing incoordination [11]. A study examined the
relationship between COVID-19 and dysphagia exhibited that the manifestations of COVID-19, like ARDS, neurological
manifestations, loss of taste, dyspnea, and tachypnea, as well as treatment actions for this disease, including oxygen therapy, non-
invasive mechanical ventilation, intubation, tracheostomy, and drugs used in the ICUs setting, affect swallowing efficiency
Negatively [12]. However, there is still much unknown about the underlying processes of COVID-19-related swallowing disorders,
and further research is needed [13, 14].
The Prevalence of Dysphagia in Patients with Covid-19: A Systematic Review and Meta-Analysis
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Dysphagia prevalence in patients diagnosed with COVID-19 ranges from 7% [7] to 90% in different studies [8]. Martin-Martinez
et al. [15] in 2021, investigated the prevalence of dysphagia in 205 patients affected by COVID-19 admitted to the ward of a hospital
placed in Spain. The study reported that the prevalence of dysphagia at admission was 51.7% according to Volume-Viscosity
Swallowing Test (V-VST) and Eating Assessment Tool-10 (EAT-10). Mallart et al. [9] in France, conducted a cohort study of
patients with COVID-19 admitted to the ICU to explore the prevalence of dysphagia. The study found 22% of the patients had
dysphagia on discharge. Other researchers discovered a different dysphagia prevalence due to COVID-19, with Regan et al.
reporting a prevalence of 84% and Cerutia et al. reporting 54.8% [4, 16].
In some cities, sometimes because of the lack of diagnostic kits, COVID-19 diagnosis relies on evaluating the main clinical
symptoms [17]. Although some COVID-19 patients might not visit a physician, so Speech and Language Pathologists (SLPs) should
be completely aware of these symptoms in order to be capable of taking the necessary actions. As the number of COVID-19 patients
increases around the world [3], it is necessary for all clinicians, including SLPs, to be informed about the leading clinical
manifestations of COVID-19 patients. Based on the previous data, some researchers have reported dysphagia along with other
common symptoms of this disease, but these studies’ results are contradictory. On the other hand, dysphagia may lead to
complications such as pneumonia, malnutrition, dehydration, increased length of hospitalization, and mortality and a negative
impact on quality of life [13, 18]. So, it is needed that the impact of COVID-19 on this function be studied so early identification
and management can be provided. The available studies have investigated different strains of COVID-19 and different strains have
different effects on organs such as the brain and human functions. However, these studies were carried out at different time points
after the infection of these patients. These are reasons for the difference in reported dysphagia rates. To the best of the author's
knowledge, no meta-analysis study reported the presence of dysphagia in COVID-19 patients admitted to hospitals and during the
follow-up time. This may give us a view of the period of time (admission to hospital, discharge, or long-term) in which the
prevalence of dysphagia is higher in these patients. Therefore, the present study was designed to estimate the prevalence of dysphagia
in COVID-19 patients at three different time points: at admission, at discharge, and 3-6 months post-discharge or after their positive
SARS-CoV-2 test result.
MATERIALS AND METHODS
Search strategy
The authors reported this research based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)
statement and with PROSPERO registration number: CRD42023405377 [19]. For finding relevant studies, four famous medical
databases, including PubMed, Web of Science, Scopus, and Google Scholar were searched from January 1, 2020, until July 1, 2022.
The search terms were applied according to English MeSH keywords: [COVID-19 AND dysphagia] OR [COVID-19 AND
Deglutition] OR [SARS-CoV-2 AND Swallowing disorder] OR [Coronavirus AND Prevalence] OR [Coronavirus AND Incidence]
OR [Wuhan Coronavirus AND Characteristics] OR [new coronavirus AND characteristics]. Furthermore, the Centers for Disease
Control and Prevention (CDC) and the World Health Organization (WHO) portals were appraised as national public health
organizations.
Inclusion and exclusion criteria
Any related paper that reported dysphagia in patients affected by COVID-19 at the time of admission, at the time of hospital
discharge, or 3-6 months post-discharge or after their positive SARS-CoV-2 test result, was entered into this analysis. All article
designs (cross-sectional studies, case-control studies, non-randomized controlled trials, and randomized controlled trials) were
entered. Only articles in English were entered and reviewed. Review studies were excluded from this study. Since the sample
numbers are important in meta-analysis research, case report articles were excluded too. Only the characteristics of adult patients
were included.
Data extraction and paper quality evaluation
The first and second authors separately extracted and evaluated the data. Two researchers separately extracted the country of
implementation, year of publication, sample size, average age, gender, dysphagia assessment method, and the number of patients
who had dysphagia from the articles that met the inclusion criteria and entered them into a table. After the completion of data
extraction, the two researchers shared their final tables and any disagreement between the judgments of the two was resolved by
consulting and discussing with the third author. The Newcastle-Ottawa scale (NOS) was used to evaluate all the included articles
[20], and the results were listed in Tables 1 & 2 & 3.
The Prevalence of Dysphagia in Patients with Covid-19: A Systematic Review and Meta-Analysis
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Table 1. The demographic data of the studies included in this meta-analysis showing the prevalence of dysphagia in COVID-19
patients at admission (day 0)
Study
Country
year
Sample
Size
Mean±S
D
age (y)
Sex
(male)
Method
Dysphag
ic (Total)
Redd et al.
[21]
United States
2020
318
1
Martin-
Martinez et
al. [22]
Spain
2021
205
69.3 (17.5)
98
Subj/
EAT-10
106
Cerutia et al.
[23]
Switzerland
2021
31
61 (12)
25
Subj/
GUSS
17
Ceriana et al.
[24]
Italy
2021
89
61.9 ±11.3
63
25
Total
643
186
149
Abbreviations: SD: Standard Deviation; Subj: Subjective; EAT-10: Eating Assessment Tool-10; GUSS: Gugging Swallowing
Screen
Statistical analysis
The meta-analysis was performed to estimate the pooled prevalence of dysphagia in COVID-19 patients. The effect sizes were
expressed as prevalence and also frequency at 95% confidence interval. Random effects were used for statistical analysis.
Table 2. The demographic data of the studies included in this meta-analysis showing the prevalence of dysphagia in COVID-19
patients at discharge
Study
Countr
y
year
Sample
Size
Mean±
SD
age (y)
Sex
(male)
Metho
d
Dyspha
gic
(Total)
Archer et al.
[13]
United Kingdom
2021
99
56.8(16.7)
Subj/
FOIS
29
Ceruti et al.
[16]
Switzerland
2021
31
61 (12)
25
Subj/
GUSS
7
Lima et al. [5]
Brazil
2021
101
53.4(15.9)
66
Subj/
ASHA NOMS
30
Mallart et al.
[25]
France
2022
43
62.9(10.9)
30
10
Martin-
Martinez et al.
[22]
Spain
2021
183
Subj/
EAT-10
82
Ramos et al.
[26]
Spain
2021
936
63.7 ± 15.3
558
Subj/
EAT-10
242
Regan et al.
[27]
Ireland
2021
95
62
69
Subj/
FOIS
26
The Prevalence of Dysphagia in Patients with Covid-19: A Systematic Review and Meta-Analysis
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Regan et al.
[28]
Ireland
2021
315
76
194
Subj/
FOIS
142
Reyes‐Torres
et al. [29]
Mexico
2021
112
54 (12)
92
Subj/
V-VST
46
Gonzalez
Lindh et al.
[30]
Sweden
2021
28
61 (11.9)
22
Subj/
FOIS
10
Hoyois et al.
[31]
Belgium
2021
15
60
10
9
Daunter et al.
[32]
United States
2021
239
66.80 (15.31)
166
29
Ceriana et al.
[24]
Italy
2021
89
61.9 ±11.3
63
6
Total
2286
1295
668
Abbreviations: SD: Standard Deviation; Subj: Subjective; FOIS: Functional Oral Intake Status; GUSS: Gugging Swallowing
Screen; ASHA NOMS: American Speech-Language-Hearing Association National Outcome Measurement System; EAT-10: Eating
Assessment Tool-10; V-VST: Volume-Viscosity Swallow Test
Table 3. The demographic data of the studies included in this meta-analysis showing the prevalence of dysphagia in COVID-19
patients at 3-6 months post-discharge / positive SARS-CoV-2 test
Study
Coun
try
year
Samp
le Size
Mean
±SD
age
(y)
Sex
(male
)
Meth
od
Dysp
ha
gic
(Total
)
Ramos et al. [26]
Spain
2021
62
Subj/
EAT-10
3
Martin-Martinez et
al. [22]
Spain
2021
175
Subj/
EAT-10
42
Martin-Martinez et
al. [22]
Spain
2021
171
Subj/
EAT-10
40
Neevel et al. [33]
United States
2021
24
50
12
6
Allisan-Arrighi et
al. [34]
United States
2022
81
54.23(17.36)
49
16
Wahlgren et al. [35]
Sweden
2021
158
57.4(13.8)
97
13
Huang et al. [36]
China
2021
1655
57
897
69
Leis-Cofiño
et al. [37]
Spain
2021
79
64
48
Subj/
EAT-10
7
Total
2405
1103
196
Abbreviations: SD: Standard Deviation; Subj: Subjective; EAT-10: Eating Assessment Tool-10
Results
The Prevalence of Dysphagia in Patients with Covid-19: A Systematic Review and Meta-Analysis
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RESEARCH SELECTION
The present search found 2736 records, of which 2132 were duplicates. The authors reviewed the abstract of 604 articles. Out of
which, 42 studies met the inclusion conditions for full-text review. Finally, 19 articles entered the meta-analysis stage (Fig. 1). In
detail, four studies investigated the prevalence of dysphagia at admission [6, 16, 21, 24], 13 studies focused on the prevalence of
dysphagia at discharge [4-6, 8, 13, 14, 16, 24, 31, 32, 38-40], and the prevalence of dysphagia in the long-term was investigated in
eight studies [6, 33-37, 39]. In the studies that introduced dysphagia assessment tools, all studies used subjective tools to screen for
swallowing disorders (Tables 1 & 2 & 3).
Fig. 1 The PRISMA flowchart (2020) for the selection of the eligible studies for meta-analysis
Meta-analysis results
The study of the clinical data included 19 studies with a total of 643 COVID-19 patients at admission, 2286 COVID-19 patients at
discharge, 2405 COVID-19 patients at 3-6 months post-discharge or after their positive SARS-CoV-2 test result, and 5334 COVID-
19 patients in total. The demographic information of the studies included in this meta-analysis is shown in Tables 1 & 2 & 3. Forest
plot of the prevalence of dysphagia in COVID-19 patients at admission, discharge, and long-term is shown in Fig. 2 . As the results
of the meta-analysis show, the highest prevalence of dysphagia in COVID-19 patients was related to admission with 32%, and the
lowest prevalence of dysphagia in COVID-19 patients was related to 3-6 months later with 14% prevalence. Based on the meta-
analysis results, in total, the average age of these patients was 61.2 years. The average age of patients was different at the time
points. In detail, the mean age of patients at the time of admission, discharge, and 3-6 months post-discharge was 66.5 years, 64.28
years, and 57.11 years, respectively.
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Fig. 2 Prevalence of dysphagia in COVID-19 patients at admission (day 0), discharge, and long-term
Publication bias detection
The funnel plot based on the total studies is given in Fig. 3. The results show that the studies are asymmetric.
The Prevalence of Dysphagia in Patients with Covid-19: A Systematic Review and Meta-Analysis
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Fig. 3 Funnel plot of all studies
DISCUSSION
Based on the results of the present meta-analysis, the prevalence of dysphagia in COVID-19 patients at admission to the hospital is
32%. So, about one-third of COVID-19 patients may experience dysphagia as the only symptom. Ceriana et al. also reported a
similar rate (28%) [24]. Although, a considerable rate of dysphagia has been noted in two recent European studies, with Martinez
et al. reporting 51.7% of COVID-19 patients admitted to the ward and Cerutia et al. reporting 54.8% in COVID-19 patients admitted
to the ICU [6, 16]. According to the results of the present study, dysphagia prevalence in patients diagnosed with COVID-19 at the
time of discharge is very similar to the time of admission and equal to 29%. Similar studies by Archer et al. and Lima et al. reported
similar percentages, 29.2%, and 29.7%, respectively [5, 13]. Although a higher dysphagia rate at these patients’ time of discharge
has also been reported: 45% by Regan et al. and 50% by Reyes‐Torres et al. [4, 40]. Since the rate of dysphagia is almost the same
at the time of admission and discharge, it can be argued that swallowing therapy for these patients during their hospitalization has
not been attended to as much as necessary. Because Regan et al. showed that if these patients undergo swallowing therapy, the
results will be notable; They reported after treatment implementation in hospitalized patients the prevalence of dysphagia decreased
from 86% to 27% at the time of discharge [8]. However, In a study conducted by Cerutia et al. comparing the prevalence of dysphagia
between COVID-19 patients and Non-COVID-19 patients, a higher rate of dysphagia was observed in COVID-19 patients with
faster recovery [16]. Concerns regarding the transmission of the virus via aerosol-generating procedures in addition to the lack of
instrumental assessments might have resulted in the altered amount and varied forms of management provided during pandemic
waves. Other influencing issues may include SLP services in ICU settings, dysphagia training, and access to personal protective
equipment [8].
Many organs in the body in addition to the lungs can be impacted by COVID-19 and this damage increases the danger of long-term
health complications [7]. In the present study, the authors illustrated the prevalence of dysphagia in patients diagnosed with COVID-
19 in the long term. However, the prevalence (14%) in the analysis was small, it was not negligible and it required therapeutic
intervention; Because a study conducted by Martin-Martinez et al. demonstrated that dysphagia is relevant to increased 6-month
mortality [6]. According to Neevel et al.'s study, this prevalence goes up to 25% [33]. The form of pneumonia caused by COVID-
19 can result in long-term injury to the lungs’ air sacs. And the long-term breathing difficulties caused by the scar tissue can lead to
weak coordination of swallowing and breathing predisposing [7]. Furthermore, risks for developing swallowing impairments can
also occur due to other injuries caused by COVID-19. As Aoyagi et al. described the COVID-19 infection may cause damage to the
X and IX cranial nerves [41]. Post-acute COVID-19 Swallowing disorder is probably caused by a multiplicity of reasons [7].
However, this rate of dysphagia has been halved since hospital discharge. As found in studies, the prevalence of dysphagia is directly
related to the severity of the disease [38] and intubation [4]. Therefore, after the discharge and recovery from COVID-19 and
reducing the burden of the disease, the rate of dysphagia decreased. Also, by reducing the injuries caused by intubation, the rate of
dysphagia is expected to decline. Another potential reason for this reduction is post-discharge rehabilitation service delivery in the
community [35].
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As we have shown, the average age is the highest at the time of admission and decreases at the time of discharge and follow-up.
The decrease in the average age after discharge may be due to the death of very old patients after discharge from the hospital [6].
Perhaps older patients did not cooperate for re-testing of dysphagia after discharge and did not return for re-evaluation (due to old
age, comorbidities, or long-term complications of COVID-19) [6] and most of the younger patients have cooperated and returned
for re-examination. Another reason for this could be the small and limited number of studies that have included the average age for
day 0 [6, 16, 21].
In total, 24% of patients affected with COVID-19 suffer from dysphagia, which is a significant frequency. Data on swallowing
difficulties in these patients would inform inpatient and outpatient service delivery [4, 8]. The present data indicate that SLPs should
be included both in hospitals and outpatient multidisciplinary COVID-19 clinics in society [8]. Early evaluation of suspected
subjects is required for timely intervention to avoid further consequences [4].
CONCLUSION
About a quarter of patients with COVID-19 may have dysphagia (swallowing difficulties) during the acute phase and/or also in the
post-acute phase of the disease. Therefore, one should be aware of the symptoms of dysphagia and treat it in time. Hospitals,
multidisciplinary clinics, and SLPs will always play a vital role in evaluating, diagnosing, and treating people with COVID-19–related
swallowing disorders.
Compliance with Ethical Standards
Conflict of interest
The authors declared no conflict of interest.
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