Socioeconomic inequalities of Long COVID: a retrospective population-based cohort study in the United Kingdom

Lost and changed meaning in life of people with Long Covid: a qualitative study

Long Covid (LC) has been called the greatest mass-disabling event in human history. For patients, LC not only has implications for quality of life but also for meaning in life: how one's life and the world are understood and what is seen as valuable in one's life. This qualitative empirical study used a Constructivist Grounded Theory approach to investigate the meaning in life of people struggling with LC through ten patient interviews. This study shows that patients lose their prior understanding of life and come to a changed meaning in life, in part due to the experienced (social) isolation and loss of (both physical and cognitive) abilities caused by LC. Moreover, patients struggled with acceptance, uncertainty, and the inherent incomprehensibility and uncontrollability that living with LC entails, though this simultaneously co-existed with hope, optimism and acceptance. Additionally, dimensions of meaning intersect; a patient having some understanding of their illness (dimension of meaning: comprehension) required an understanding Other (dimension of meaning: connection). Emerging from lockdown brought the challenge and isolation of adjusting to chronic illness in society as usual (albeit divided about COVID-19 measures). This study thus offers novel insights regarding changed, present, and sought meaning in life for LC patients.

Physical, cognitive, and social triggers of symptom fluctuations in people living with long COVID: an intensive longitudinal cohort study

Background

Symptom fluctuations within and between individuals with long COVID are widely reported, but the extent to which severity varies following different types of activity and levels of exertion, and the timing of symptoms and recovery, have not previously been quantified. We aimed to characterise timing, severity, and nature of symptom fluctuations in response to effortful physical, social and cognitive activities, using Ecological Momentary Assessments.

Methods

We recorded activity, effort, and severity of 8 core symptoms every 3 h for up to 24 days, in cohorts from both clinic and community settings. Symptom severities were jointly modelled using autoregressive and moving average processes.

Findings

Consent was received from 376 participants providing ≥1 week's measurements (273 clinic-based, 103 community-based). Severity of all symptoms was elevated 30 min after all categories of activity. Increased effort was associated with increased symptom severity. Fatigue severity scores increased by 1.8/10 (95% CI: 1.6-1.9) following the highest physical exertions and by 1.5 (1.4-1.7) following cognitive efforts. There was evidence of only mild delayed fatigue 3 h (0.3, 0.2-0.5) or one day later (0.2, 0.0- 0.5). Fatigue severity increased as the day progressed (1.4, 1.0-1.7), and cognitive dysfunction was 0.2 lower at weekends (0.1-0.3).

Interpretation

Cognitive, social, self-care and physical activities all triggered increased severity across every symptom, consistent with associated common pathways as potential therapeutic targets. Clear patterns of symptom fluctuations emerged that support more targeted self-management.

Funding

National Institute for Health and Care Research.

People from ethnic minorities seeking help for long COVID: a qualitative study

BACKGROUND

People from ethnic minority groups are disproportionately affected by COVID-19, less likely to access primary health care, and have reported dissatisfaction with health care. Although the prevalence of long COVID in ethnic minority groups is unclear, such populations are underrepresented in long-COVID specialist clinics and long-COVID lived-experience research, which informed the original long-COVID healthcare guidelines.

AIM

To understand the lived experiences of long COVID in people from ethnic minority groups.

DESIGN AND SETTING

Qualitative study of people living with long COVID in the UK.

METHOD

Semi-structured interviews with people who self-disclosed long COVID were conducted between June 2022 and June 2023 via telephone or video call. Thematic analysis of the data was conducted. People who were living with long COVID, or caring for someone with long COVID, advised on all stages of the research.

RESULTS

Interviews were conducted with 31 participants representing diverse socioeconomic demographics. Help-seeking barriers included little awareness of long COVID or available support, and not feeling worthy of receiving care. Negative healthcare encounters were reported in primary health care; however, these services were crucial for accessing secondary or specialist care. There were further access difficulties and dissatisfaction with specialist care. Experiences of stigma and discrimination contributed to delays in seeking care and unsatisfactory experiences, resulting in feelings of mistrust in health care.

CONCLUSION

Empathy, validation of experiences, and fairness in recognition and support of healthcare needs are required to restore trust in health care and improve the experiences of people with long COVID.

Prevalence of COVID-19 and Long COVID by industry and occupation: Behavioral Risk Factor Surveillance System 2022

BACKGROUND

Workers in healthcare and other essential occupations had elevated risks for COVID-19 infection early in the pandemic. No survey of U.S. workers to date has comprehensively assessed the prevalence of both COVID-19 and Long COVID across industries and occupations (I&O) at a detailed level.

METHODS

Behavioral Risk Factor Surveillance System data for 2022 from 39 states, Guam, and the U.S. Virgin Islands were used to estimate prevalence of self-reported history of COVID-19 and Long COVID, as well as the prevalence of Long COVID among those reporting prior COVID-19, by broad and detailed I&O. Adjusted prevalence ratios were used to compare outcome prevalence in each I&O to prevalence among all other workers combined.

RESULTS

By broad I&O, workers in healthcare, protective services, and education had elevated prevalences of COVID-19. The prevalence of Long COVID was elevated in healthcare and protective service but not education workers. Detailed I&O with significantly elevated prevalences of COVID-19 but not Long COVID included Dairy Product Manufacturing industry workers and subsets of mining workers. Both COVID-19 and Long COVID were elevated among bartenders/drinking places and personal care and appearance workers. The prevalence of Long COVID was elevated among farmworkers who reported having had COVID-19.

CONCLUSIONS

Industries and occupations with elevated levels of COVID-19 or Long COVID in this study may warrant increased measures to prevent transmission of airborne respiratory viruses. Accommodations are a key component for supporting workers in all workplaces. This new information about the distribution of Long COVID by I&O suggests where employer understanding and implementation of tailored workplace supports and accommodations are most needed to support continued employment of affected workers.

Understanding long COVID: prevalence, characteristics, and risk factors in the Eastern Province of Saudi Arabia

Background

The COVID-19 pandemic has significantly raised public health concerns and efforts to limit its spread, impacting societies and health systems worldwide. As challenges persist, the emergence of Long COVID (LC) marks a turning point in understanding the pandemic's long-term effects.

Aim

This study aimed to determine the prevalence of LC in the Eastern Province of the Kingdom of Saudi Arabia (KSA) and explore factors contributing to its persistence.

Methods

This descriptive, cross-sectional, questionnaire-based study was carried out between December 1, 2023, and March 1, 2024, involving 1,355 patients who recovered from COVID-19. Participants were conveniently chosen and information was gathered through in-person interviews in public settings after obtaining consent.

Results

A majority of the patients (N = 1,355; 47.5% female; 93.8% Saudis; mean Age ± SD 33.13 ± 12.60 years) had received three COVID-19 vaccine doses (89.5%). Women experienced 17.4% more LC symptoms than men (p < 0.001). The risk of having a higher symptom count increased by 42.5% 12 months after acute COVID-19 infection compared with baseline (<3 months, p < 0.001). A higher body mass index (BMI) was associated with more symptoms (1.1% increase per unit, p = 0.004). More acute-phase symptoms correlated with more LC symptoms (p < 0.001). Higher educational attainment reduced LC risk by 33% (p < 0.001). Finally, age and vaccination status had no effect on LC symptoms count (p > 0.05).

Conclusion

Sociodemographic and clinical factors contribute differently to the chances of having LC and the count of symptoms. Awareness of such factors could provide insight into improving management, leading to better health outcomes.

Prevalence, risk factors and characterisation of individuals with long COVID using Electronic Health Records in over 1.5 million COVID cases in England

OBJECTIVES

This study examines clinically confirmed long-COVID symptoms and diagnosis among individuals with COVID in England, aiming to understand prevalence and associated risk factors using electronic health records. To further understand long COVID, the study also explored differences in risks and symptom profiles in three subgroups: hospitalised, non-hospitalised, and untreated COVID cases.

METHODS

A population-based longitudinal cohort study was conducted using data from 1,554,040 individuals with confirmed SARS-CoV-2 infection via Clinical Practice Research Datalink. Descriptive statistics explored the prevalence of long COVID symptoms 12 weeks post-infection, and Cox regression models analysed the associated risk factors. Sensitivity analysis was conducted to test the impact of right-censoring data.

RESULTS

During an average 400-day follow-up, 7.4% of individuals with COVID had at least one long-COVID symptom after acute phase, yet only 0.5% had long-COVID diagnostic codes. The most common long-COVID symptoms included cough (17.7%), back pain (15.2%), stomach-ache (11.2%), headache (11.1%), and sore throat (10.0%). The same trend was observed in all three subgroups. Risk factors associated with long-COVID symptoms were female sex, non-white ethnicity, obesity, and pre-existing medical conditions like anxiety, depression, type II diabetes, and somatic symptom disorders.

CONCLUSIONS

This study is the first to investigate the prevalence and risk factors of clinically confirmed long-COVID in the general population. The findings could help clinicians identify higher risk individuals for timely intervention and allow decision-makers to more efficiently allocate resources for managing long-COVID.

Prevalence and impact of persistent symptoms following SARS-CoV-2 infection among healthcare workers: A cross-sectional survey in the SIREN cohort

INTRODUCTION

Following SARS-CoV-2 infection, some patients experience a range of long-lasting symptoms, with a specific burden on their lives and ability to work.

AIM

We describe the prevalence and impact of persistent symptoms pre-/post-vaccination in SIREN study participants.

METHODS

A cross-sectional study of SARS-CoV-2 positive participants was carried out within SIREN, a frequently tested UK healthcare worker cohort with vaccination and demographic data available. Participants with a SARS-CoV-2 positive PCR or anti-SARS-CoV-2 sample between 01 March 2020 and 31 September 2022 were asked via a questionnaire about symptoms and days absent from work following infection. Responses were excluded if infection dates were inconsistent with study records or missing key data. Symptom type/duration and whether infection occurred pre-/post-vaccination and during which variant period were described. Logistic regression was used to estimate factors associated with persistent symptoms (>12 weeks), adjusting for vaccination and demographic factors. The median days absent from work were also determined.

RESULTS

Of 16,599 invitations, 6677 participants responded, and 5053 were included in the analysis. The prevalence of persistent symptoms (symptoms lasting over 12 weeks) differed by infection episode; highest for first infections (32.7%; 1557/4767) compared to second (21.6%; 214/991) and third infections (21.6%; 16/74). Most frequently reported symptoms were fatigue, tiredness, shortness of breath and difficulty concentrating. A higher prevalence of persistent symptoms was reported during the Wild-type variant period compared to the other variant periods (52.9% Wild-type vs. 20.7% Omicron, for any symptom reported during their first infection). Overall, persistent symptoms were higher among unvaccinated participants (unvaccinated 38.1% vs vaccinated 22.0%). Multivariable analysis showed that participants were less likely to report persistent symptoms in infections occurring after vaccination compared to those with an infection before vaccination in the Alpha/Delta and Omicron periods (Alpha/Delta: adjusted Odds Ratio (aOR) 0.66, CI 95% 0.51-0.87, p = aOR 0.07, CI 95% 0.01-0.65, p = 0.02). About half of participants reported that their persistent symptoms impacted their day-to-day (51.8%) and work-related (42.1%) activities 'a little', and 24.0% and 14.4% reported that the impact was 'A lot'. 8.9% reported they had reduced their working hours, and 13.9% had changed their working pattern.

DISCUSSION

Persistent symptoms were frequent in our cohort, and there was a reduction in symptom duration in those with multiple infection episodes during later variant periods and post-vaccination. The impact of persistent symptoms resulting in reducing working hours or adjusting working patterns has important implications for workforce resilience. UK healthcare workers were highly exposed during the pandemic, demonstrating a significant burden.

Interaction between economic status and healthy lifestyle in long COVID among Chinese older population: a cross-sectional study

OBJECTIVES

To estimate the interaction between economic status (ES) and healthy lifestyle in long COVID among Chinese older people infected with SARS-CoV-2.

DESIGN

A cross-sectional study based on the Peking University Health Cohort in Anning, Yunnan.

SETTING

All primary health institutions in Anning, Yunnan Province, China, from April to May 2023.

PARTICIPANTS

A total of 4804 people aged 60 and older infected with SARS-CoV-2 were included in this study.

PRIMARY AND SECONDARY OUTCOME MEASURES

Long COVID was measured by participants' self-reported symptoms using structured questionnaires. ES was measured by last-month personal income, and participants' ES was defined as low if their income was below the per capita monthly income of local residents. Lifestyle score was equal to the number of healthy behaviours (including smoking, drinking, weight, exercise and diet) and grouped using the median score as the cut-off point. Univariate and multivariate logistic models were employed to estimate the association of ES with long COVID. Interaction between ES and lifestyle in long COVID was assessed by multiplicative interaction term.

RESULTS

We enrolled a total of 4804 participants infected with SARS-CoV-2, of whom 57.3% (2754 of 4804) had at least one long COVID symptom. Fatigue (1546, 56.1%), cough (1263, 45.9%) and muscle pain (880, 32.0%) were the top three common symptoms. Patients with low ES had a 48% (adjusted OR: 1.48; 95% CI 1.22, 1.82) increased risk of long COVID. A significant interaction was observed between ES and lifestyle (p value for interaction <0.001) in long COVID.

CONCLUSION

The interaction between ES and healthy lifestyle in long COVID was prominent. Comprehensive strengthened economic support for patients recovering from COVID-19, especially for those with low healthy lifestyle, should be implemented to prevent and manage long COVID symptoms.

Modeling the relative influence of socio-demographic variables on post-acute COVID-19 quality of life

Importance

Post-acute sequelae of SARS-CoV-2, referred to as "long COVID", are a globally pervasive threat. While their many clinical determinants are commonly considered, their plausible social correlates are often overlooked.

Objective

To compare social and clinical predictors of differences in quality of life (QoL) with long COVID. Additionally, to measure how much adjusted associations between social factors and long COVID-associated quality of life are unexplained by important clinical intermediates.

Design Setting and Participants

Data from the ISARIC long COVID multi-country prospective cohort study. Subjects from Norway, the United Kingdom (UK), and Russia, aged 16 and above, with confirmed acute SARS-CoV-2 infection reporting >= 1 long COVID-associated symptoms 1+ month following infection.

Exposure

The social exposures considered were educational attainment (Norway), employment status (UK and Russia), and female vs male sex (all countries).

Main outcome and measures

Quality of life-adjusted days, or QALDs, with long COVID.

Results

This cohort study included a total of 3891 participants. In all three countries, educational attainment, employment status, and female sex were important predictors of long COVID QALDs. Furthermore, a majority of the estimated relationships between each of these social correlates and long COVID QALDs could not be attributed to key long COVID-predicting comorbidities. In Norway, 90% (95% CI: 77%, 100%) of the adjusted association between the top two quintiles of educational attainment and long COVID QALDs was not explained by clinical intermediates. The same was true for 86% (73%, 100%) and 93% (80%,100%) of the adjusted associations between full-time employment and long COVID QALDs in the United Kingdom (UK) and Russia. Additionally, 77% (46%,100%) and 73% (52%, 94%) of the adjusted associations between female sex and long COVID QALDs in Norway and the UK were unexplained by the clinical mediators.

Conclusions and Relevance

This study highlights the role of socio-economic status indicators and female sex, in line with or beyond commonly cited clinical conditions, as predictors of long COVID-associated QoL, and further reveal that other (non-clinical) mechanisms likely drive their observed relationships. Our findings point to the importance of COVID interventions which go further than an exclusive focus on comorbidity management in order to help redress inequalities in experiences with this chronic disease.

Baseline socioeconomic status predicting post-COVID-19 symptoms: Results from Isfahan COVID Cohort (ICC) study

Objectives

Patients experience complications following their recovery from COVID-19, known as post-COVID-19. This study aimed to investigate the association between baseline socioeconomic status (SES) and post-COVID-19 symptoms among hospitalized and non-hospitalized patients.

Methods

In the study, we used data from the Isfahan COVID Cohort (ICC) study, a 5-year longitudinal cohort study started from March 10, 2020. SES was measured using short form of SES questionnaire (SES-SQ), consisting of employment status, house room number, the number of trips taken, and using notebooks, laptop, or tablet in the house. Cox proportional hazard analysis was used to examine the association between baseline SES and post-COVID-19 symptoms including general, cardiovascular and respiratory systems, adjusting for potential confounders.

Results

Out of the 3912 patients included in the study, 66.4 % reported post-COVID-19 symptoms. There was an association between low SES and increased risk of post-COVID-19 cardiovascular symptoms in the whole population (HR = 1.15; 95 CI, 1.01-1.31, p = 0.039). Considering the hospitalization status revealed that hospitalized patients with low SES had a higher risk of experiencing post-COVID-19 cardiovascular symptoms (HR = 1.96; 95 CI, 1.23-3.12, p = 0.004), while in non-hospitalized, low SES patients a lower risk was observed (HR = 0.82; 95 CI, 0.70-0.97, p = 0.017). No significant association was found between SES and other post-COVID-19 symptoms including general and respiratory symptoms.

Conclusions

We concluded an association between higher SES and increased post-COVID-19 cardiovascular symptoms. Low SES was associated with higher risk of post-COVID-19 cardiovascular symptoms in hospitalized patients, while in non-hospitalized, it was associated with a lower risk.

An investigation into General Practitioners' experience with Long Covid

BACKGROUND

Long Covid (LC) is the continuation or development of new symptoms after initial COVID-19 infection. Little is known about General Practitioners' (GP) experience of managing patients with LC.

AIMS

The aim of this study is to establish GP experiences with LC.

METHODS

A survey was designed and piloted in three training practices prior to distribution. The survey was completed by doctors working in GP training scheme practices in Cork, Ireland.

RESULTS

Fifty-three of one hundred and sixty invited GPs completed the survey, indicating a 33% response rate. 8% (4/53) of participants agreed and 0% (0/53) strongly agreed with the statement they were "confident in diagnosing Long Covid". 81% (43/53) were not confident in treating patients with LC. 70% (37/53) were unaware of indications for referral to secondary care. 38% (20/53) were aware of the referral pathways to local LC clinics. 93% (49/53) agreed there were educational deficits regarding LC.

CONCLUSIONS

There was a lack of confidence in the diagnosis and management of LC, and in the interface with secondary care. There is demand for educational interventions to assist GPs with their care of patients with this emerging condition.

Socio-economic conditions affect health-related quality of life, during recovery from acute SARS-CoV-2 infection : Results from the VASCO study (VAriabili Socioeconomiche e COVID-19), on the "Surviving-COVID" cohort, from Bergamo (Italy)

BACKGROUND

Recovery from acute COVID-19 may be slow and incomplete: cases of Post-Acute Sequelae of COVID (PASC) are counted in millions, worldwide. We aimed to explore if and how the pre-existing Socio-economic-status (SES) influences such recovery.

METHODS

We analyzed a database of 1536 consecutive patients from the first wave of COVID-19 in Italy (February-September 2020), previously admitted to our referral hospital, and followed-up in a dedicated multidisciplinary intervention. We excluded those seen earlier than 12 weeks (the conventional limit for a possible PASC syndrome), and those reporting a serious complication from the acute phase (possibly accounting for symptoms persistence). We studied whether the exposition to disadvantaged SES (estimated through the Italian Institute of Statistics's model - ISTAT 2017) was affecting recovery outcomes, that is: symptoms (composite endpoint, i.e. at least one among: dyspnea, fatigue, myalgia, chest pain or palpitations); Health-Related-Quality-of-Life (HRQoL, as by SF-36 scale); post-traumatic-stress-disorder (as by IES-R scale); and lung structural damage (as by impaired CO diffusion, DLCO).

RESULTS

Eight-hundred and twenty-five patients were included in the analysis (median age 59 years; IQR: 50-69 years, 60.2% men), of which 499 (60.5%) were previously admitted to hospital and 27 (3.3%) to Intensive-Care Unit (ICU). Those still complaining of symptoms at follow-up were 337 (40.9%; 95%CI 37.5-42.2%), and 256 had a possible Post-Traumatic Stress Disorder (PTSD) (31%, 95%CI 28.7-35.1%). DLCO was reduced in 147 (19.6%, 95%CI 17.0-22.7%). In a multivariable model, disadvantaged SES was associated with a lower HRQoL, especially for items exploring physical health (Limitations in physical activities: OR = 0.65; 95%CI = 0.47 to 0.89; p = 0.008; AUC = 0.74) and Bodily pain (OR = 0.57; 95%CI = 0.40 to 0.82; p = 0.002; AUC = 0.74). We did not observe any association between SES and the other outcomes.

CONCLUSIONS

Recovery after COVID-19 appears to be independently affected by a pre-existent socio-economic disadvantage, and clinical assessment should incorporate SES and HRQoL measurements, along with symptoms. The socioeconomic determinants of SARS-CoV-2 disease are not exclusive of the acute infection: this finding deserves further research and specific interventions.

Exploring the Complexities of Long COVID

Since the emergence of the SARS-CoV-2 virus in 2019, nearly 700 million COVID-19 cases and 7 million deaths have been reported globally. Despite most individuals recovering within four weeks, the Center for Disease Control (CDC) estimates that 7.5% to 41% develop post-acute infection syndrome (PAIS), known as 'Long COVID'. This review provides current statistics on Long COVID's prevalence, explores hypotheses concerning epidemiological factors, such as age, gender, comorbidities, initial COVID-19 severity, and vaccine interactions, and delves into potential mechanisms, including immune responses, viral persistence, and gut dysbiosis. Moreover, we conclude that women, advanced age, comorbidities, non-vaccination, and low socioeconomic status all appear to be risk factors. The reasons for these differences are still not fully understood and likely involve a complex relationship between social, genetic, hormonal, and other factors. Furthermore, individuals with Long COVID-19 seem more likely to endure economic hardship due to persistent symptoms. In summary, our findings further illustrate the multifaceted nature of Long COVID and underscore the importance of understanding the epidemiological factors and potential mechanisms needed to develop effective therapeutic strategies and interventions.

Prevalence of Post-COVID conditions among Mexican COVID-19 survivors: a nationwide cross-sectional study

BACKGROUND

There are limited population-representative data that describe the potential burden of Post-COVID conditions (PCC) in Mexico. We estimated the prevalence of PCC overall and by sociodemographic characteristics among a representative sample of adults previously diagnosed with COVID-19 in Mexico. We additionally, characterized the PCC symptoms, and estimated the association between diagnosed type-2 diabetes and hypertension with PCC.

METHODS

We used data from the 2021 National Health and Nutrition Survey in Mexico, a nationally and regionally representative survey, from August 1st to October 31st, 2021. Using the WHO definition, we estimated the prevalence of PCC by sociodemographics and prevalence of PCC symptoms. We fit multivariable log-binomial regression models to estimate the associations.

RESULTS

The prevalence of PCC was 37.0%. The most common persistent symptoms were fatigue (56.8%), myalgia or arthralgia (47.5%), respiratory distress and dyspnea (42.7%), headache (34.0%), and cough (25.7%). The prevalence was higher in older people, women, and individuals with low socioeconomic status. There was no significant association between hypertension and PCC or diabetes and PCC prevalence.

CONCLUSIONS

About one-third of the adult Mexican population who had COVID-19 in 2021 had Post-COVID conditions. Our population-based estimates can help assess potential priorities for PCC-related health services, which is critical in light of our weak health system and limited funding.

Using co-design methods to develop new personalised support for people living with Long Covid: The 'LISTEN' intervention

INTRODUCTION

Many Covid-19 survivors are living with unresolved, relapsing and remitting symptoms and no 'one size' of treatment is likely to be effective for everyone. Supported self-management for the varied symptoms of Long Covid (LC) is recommended by the National Institute for Health and Care Excellence in the United Kingdom. We aimed to develop a new personalised support intervention for people living with LC using a structured co-design framework to guide replication and evaluation.

METHODS

We used the improvement methodology, Experience-Based Co-Design, in an accelerated form to harness the collective experiences of people with LC. Incorporating evidence from 'Bridges Self-Management' (Bridges) an approach in which healthcare professionals (HCPs)are trained to support knowledge, confidence and skills of individuals living with long term conditions. Co-designed resources are also central to Bridges. Adults who self-identified as living with or recovered from LC, from England or Wales, aged 18 years and over were recruited, and HCPs, with experience of supporting people with LC. Participants took part in a series of small co-design group meetings and larger mixed meetings to agree priorities, core principles and generate resources and intervention content.

RESULTS

People with LC (n = 28), and HCPs (n = 9) supported co-design of a book (hard-copy and digital form) to be used in 1:1 support sessions with a trained HCP. Co-design stages prioritised stories about physical symptoms first, and psychological and social challenges which followed, nonlinear journeys and reconceptualising stability as progress, rich descriptions of strategies and links to reputable advice and support for navigating healthcare services. Co-design enabled formulation of eight core intervention principles which underpinned the training and language used by HCPs and fidelity assessments.

CONCLUSION

We have developed a new personalised support intervention, with core principles to be used in one-to-one sessions delivered by trained HCPs, with a new co-designed book as a prompt to build personalised strategies and plans using narratives, ideas, and solutions from other people with LC. Effectiveness and cost effectiveness of the 'LISTEN' intervention will be evaluated in a randomised controlled trial set within the context of the updated Framework for Developing and Evaluating Complex Interventions.

PATIENT AND PUBLIC CONTRIBUTION

The LISTEN Public and Patient Involvement (PPI) group comprised seven people living with LC. They all contributed to the design of this study and five members were part of a larger co-design community described in this paper. They have contributed to this paper by interpreting stages of intervention design and analysis of results. Three members of our PPI group are co-authors of this paper.

Disparities by Social Determinants of Health: Links Between Long COVID and Cardiovascular Disease

Long COVID has been defined by the World Health Organisation as "continuation or development of new symptoms 3 months after the initial SARS-CoV-2 infection, with these symptoms lasting for at least 2 months with no other explanation." Cardiovascular disease is implicated as a risk factor, concomitant condition, and consequence of long COVID. As well as heterogeneity in definition, presentation, and likely underlying pathophysiology of long COVID, disparities by social determinants of health, extensively studied and described in cardiovascular disease, have been observed in 3 ways. First, underlying long-term conditions, such as cardiovascular disease and its risk factors, are associated with incidence and severity of long COVID, and previously described socioeconomic disparities in these factors are important in exacerbating disparities in long COVID. Second, socioeconomic disparities in management of COVID-19 may themselves lead to distal disparities in long COVID. Third, there are socioeconomic disparities in the way that long COVID is diagnosed, managed, and prevented. Together, factors such as age, sex, deprivation, and ethnicity have far-reaching implications in this new postviral syndrome across its management spectrum. There are similarities and differences compared with disparities for cardiovascular disease. Some of these disparities are in fact, inequalities, that is, rather than simply observed variations, they represent injustices with costs to individuals, communities, and economies. This review of current literature considers opportunities to prevent or at least attenuate these socioeconomic disparities in long COVID and cardiovascular disease, with special challenges for research, clinical practice, public health, and policy in a new disease which is evolving.

Inferring community transmission of SARS-CoV-2 in the United Kingdom using the ONS COVID-19 Infection Survey

Key epidemiological parameters, including the effective reproduction number, R ( t ) , and the instantaneous growth rate, r ( t ) , generated from an ensemble of models, have been informing public health policy throughout the COVID-19 pandemic in the four nations of the United Kingdom of Great Britain and Northern Ireland (UK). However, estimation of these quantities became challenging with the scaling down of surveillance systems as part of the transition from the "emergency" to "endemic" phase of the pandemic. The Office for National Statistics (ONS) COVID-19 Infection Survey (CIS) provided an opportunity to continue estimating these parameters in the absence of other data streams. We used a penalised spline model fitted to the publicly-available ONS CIS test positivity estimates to produce a smoothed estimate of the prevalence of SARS-CoV-2 positivity over time. The resulting fitted curve was used to estimate the "ONS-based" R ( t ) and r ( t ) across the four nations of the UK. Estimates produced under this model are compared to government-published estimates with particular consideration given to the contribution that this single data stream can offer in the estimation of these parameters. Depending on the nation and parameter, we found that up to 77% of the variance in the government-published estimates can be explained by the ONS-based estimates, demonstrating the value of this singular data stream to track the epidemic in each of the four nations. We additionally find that the ONS-based estimates uncover epidemic trends earlier than the corresponding government-published estimates. Our work shows that the ONS CIS can be used to generate key COVID-19 epidemiological parameters across the four UK nations, further underlining the enormous value of such population-level studies of infection. This is not intended as an alternative to ensemble modelling, rather it is intended as a potential solution to the aforementioned challenge faced by public health officials in the UK in early 2022.

Impact of long COVID on health-related quality-of-life: an OpenSAFELY population cohort study using patient-reported outcome measures (OpenPROMPT)

Background

Long COVID is a major problem affecting patient health, the health service, and the workforce. To optimise the design of future interventions against COVID-19, and to better plan and allocate health resources, it is critical to quantify the health and economic burden of this novel condition. We aimed to evaluate and estimate the differences in health impacts of long COVID across sociodemographic categories and quantify this in Quality-Adjusted Life-Years (QALYs), widely used measures across health systems.

Methods

With the approval of NHS England, we utilised OpenPROMPT, a UK cohort study measuring the impact of long COVID on health-related quality-of-life (HRQoL). OpenPROMPT invited responses to Patient Reported Outcome Measures (PROMs) using a smartphone application and recruited between November 2022 and October 2023. We used the validated EuroQol EQ-5D questionnaire with the UK Value Set to develop disutility scores (1-utility) for respondents with and without Long COVID using linear mixed models, and we calculated subsequent Quality-Adjusted Life-Months (QALMs) for long COVID.

Findings

The total OpenPROMPT cohort consisted of 7575 individuals who consented to data collection, with which we used data from 6070 participants who completed a baseline research questionnaire where 24.6% self-reported long COVID. In multivariable regressions, long COVID had a consistent impact on HRQoL, showing a higher likelihood or odds of reporting loss in quality-of-life (Odds Ratio (OR): 4.7, 95% CI: 3.72-5.93) compared with people who did not report long COVID. Reporting a disability was the largest predictor of losses of HRQoL (OR: 17.7, 95% CI: 10.37-30.33) across survey responses. Self-reported long COVID was associated with an 0.37 QALM loss.

Interpretation

We found substantial impacts on quality-of-life due to long COVID, representing a major burden on patients and the health service. We highlight the need for continued support and research for long COVID, as HRQoL scores compared unfavourably to patients with conditions such as multiple sclerosis, heart failure, and renal disease.

Funding

This research was supported by the National Institute for Health and Care Research (NIHR) (OpenPROMPT: COV-LT2-0073).

Barriers to healthcare access and experiences of stigma: Findings from a coproduced Long Covid case-finding study

BACKGROUND AND AIM

Long Covid is often stigmatised, particularly in people who are disadvantaged within society. This may prevent them from seeking help and could lead to widening health inequalities. This coproduced study with a Community Advisory Board (CAB) of people with Long Covid aimed to understand healthcare and wider barriers and stigma experienced by people with probable Long Covid.

METHODS

An active case finding approach was employed to find adults with probable, but not yet clinically diagnosed, Long Covid in two localities in London (Camden and Merton) and Derbyshire, England. Interviews explored the barriers to care and the stigma faced by participants and were analysed thematically. This study forms part of the STIMULATE-ICP Collaboration.

FINDINGS

Twenty-three interviews were completed. Participants reported limited awareness of what Long Covid is and the available pathways to management. There was considerable self-doubt among participants, sometimes reinforced by interactions with healthcare professionals (HCPs). Participants questioned their deservedness in seeking healthcare support for their symptoms. Hesitancy to engage with healthcare services was motivated by fear of needing more investigation and concerns regarding judgement about the ability to carry out caregiving responsibilities. It was also motivated by the complexity of the clinical presentation and fear of all symptoms being attributed to poor mental health. Participants also reported trying to avoid overburdening the health system. These difficulties were compounded by experiences of stigma and discrimination. The emerging themes reaffirmed a framework of epistemic injustice in relation to Long Covid, where creating, interpreting and conveying knowledge has varied credibility based on the teller's identity characteristics and/or the level of their interpretive resources.

CONCLUSION

We have codeveloped recommendations based on the findings. These include early signposting to services, dedicating protected time to listening to people with Long Covid, providing a holistic approach in care pathways, and working to mitigate stigma. Regardless of the diagnosis, people experiencing new symptoms must be encouraged to seek timely medical help. Clear public health messaging is needed among communities already disadvantaged by epistemic injustice to raise awareness of Long Covid, and to share stories that encourage seeking care and to illustrate the adverse effects of stigma.

PATIENT OR PUBLIC CONTRIBUTION

This study was coproduced with a CAB made up of 23 members including HCPs, people with lived experience of Long Covid and other stakeholders.

Delayed Antibody Response in the Acute Phase of Infection Is Associated with a Lower Mental Component of Quality of Life in Survivors of Severe and Critical COVID-19

Background: The long-term sequelae of coronavirus disease 2019 (COVID-19) significantly affects quality of life (QoL) in disease survivors. Delayed development of the adaptive immune response is associated with more severe disease and a worse prognosis in COVID-19. The effects of delayed immune response on COVID-19 sequelae and QoL are unknown. Methods: We conducted a prospective study to assess the relationship between the delayed antibody response in the acute phase of infection in naïve unvaccinated patients suffering from severe or critical COVID-19 and their QoL 12 months after hospital discharge. The 12-item Short Form Survey (SF-12) questionnaire was used for assessment of QoL. The SF-12 evaluates both mental and physical components of QoL, incorporating a mental component score (MCS-12) and a physical component score (PCS-12). A delayed antibody response was defined as testing negative for anti-spike SARS-CoV-2 antibodies at the time of hospital admission. Results: The study included 274 patients (154 men and 120 women). Of the enrolled patients, 144 had a delayed immune response. These patients had a significantly lower MCS-12 (p = 0.002), but PCS-12 (p = 0.397) was not significantly different at the 12-month follow-up compared to patients with positive anti-spike SARS-CoV-2 antibodies. The MCS-12 at the time of follow-up was negatively associated with delayed antibody response irrespective of possible confounders (p = 0.006; B = 3.609; ηp2 = 0.035; 95% CI = 1.069-6.150). An MSC-12 below 50 points at the time of follow-up was positively associated with delayed antibody response (p = 0.001; B = 1.092; OR = 2.979; 95% CI = 1.554-5.711). Conclusions: This study confirmed that, in patients with severe and critical COVID-19, a negative result for anti-spike SARS-CoV-2 antibodies at the time of hospital admission is associated with a lower mental component of QoL in unvaccinated patients naïve to COVID-19 one year after hospital discharge.

Baseline Characteristics in the Remote Diet Intervention to REduce long-COVID Symptoms Trial (ReDIRECT)

Background

The persistence of symptoms for ≥12 weeks after a COVID-19 infection is known as Long COVID (LC), a condition with unclear pathophysiology and no proven treatments to date. Living with obesity is a risk factor for LC and has symptoms which may overlap with and aggravate LC.

Methods

ReDIRECT is a remotely delivered trial assessing whether weight management can reduce LC symptoms. We recruited people with LC and BMI >27kg/m 2. The intervention was delivered remotely by dietitians, with online data collection (medical and dietary history, COVID-19 infection and vaccination, body composition, LC history/symptoms, blood pressure, quality of life, sociodemographic data). Participants self-selected the dominant LC symptoms they most wanted to improve from the intervention.

Results

Participants (n=234) in England (64%) and Scotland (30%) were mainly women (85%) of white ethnicity (90%), with 13% living in the 20% most deprived areas, a mean age of 46 (SD10) years, and median BMI of 35kg/m 2 (IQR 32-40). Before starting the study, 30% reported more than one COVID-19 infection (82% confirmed with one or more positive tests). LC Diagnosis was mainly by GPs (71%), other healthcare professionals (9%), or self-diagnosed (21%). The median total number of symptoms was 6 (IQR 4-8). Self-selected dominant LC symptoms included fatigue (54%), breathlessness (16%), pain (12%), anxiety/depression (1%) and "other" (17%). At baseline, 82% were taking medication, 57% reported 1+ other medical conditions. Quality of life was poor; 20% were on long-term sick leave or reduced working hours. Most (92%) reported having gained weight since contracting COVID-19 (median weight change +11.5 kg, range -11.5 to +45.3 kg).

Conclusions

Symptoms linked to LC and overweight are diverse and complex. Remote trial delivery enabled rapid recruitment across the UK yet certain groups (e.g. men and those from ethnic minority groups) were under-represented.

Trial registration

ISRCTN registry ( ISRCTN12595520, 25/11/2021).

Cross-sectional population-based estimates of a rural-urban disparity in prevalence of long COVID among Michigan adults with polymerase chain reaction-confirmed COVID-19, 2020-2022

PURPOSE

To (1) assess whether residential rurality/urbanicity was associated with the prevalence of 30- or 90-day long COVID, and (2) evaluate whether differences in long COVID risk factors might explain this potential disparity.

METHODS

We used data from the Michigan COVID-19 Recovery Surveillance Study, a population-based probability sample of adults with COVID-19 (n = 4,937). We measured residential rurality/urbanicity using dichotomized Rural-Urban Commuting Area codes (metropolitan, nonmetropolitan). We considered outcomes of 30-day long COVID (illness duration ≥30 days) and 90-day long COVID (illness duration ≥90 days). Using Poisson regression, we estimated unadjusted prevalence ratios (PRs) to compare 30- and 90-day long COVID between metropolitan and nonmetropolitan respondents. Then, we adjusted our model to account for differences between groups in long COVID risk factors (age, sex, acute COVID-19 severity, vaccination status, race and ethnicity, socioeconomic status, health care access, SARS-CoV-2 variant, and pre-existing conditions). We estimated associations for the full study period (Jan 1, 2020-May 31, 2022), the pre-vaccine era (before April 5, 2021), and the vaccine era (after April 5, 2021).

FINDINGS

Compared to metropolitan adults, the prevalence of 30-day long COVID was 15% higher (PR = 1.15 [95% CI: 1.03, 1.29]), and the prevalence of 90-day long COVID was 27% higher (PR = 1.27 [95% CI: 1.09, 1.49]) among nonmetropolitan adults. Adjusting for long COVID risk factors did not reduce disparity estimates in the pre-vaccine era but halved estimates in the vaccine era.

CONCLUSIONS

Our findings provide evidence of a rural-urban disparity in long COVID and suggest that the factors contributing to this disparity changed over time as the sociopolitical context of the pandemic evolved and COVID-19 vaccines were introduced.

Prevalence and determinants of post-acute sequelae after SARS-CoV-2 infection (Long COVID) among adults in Mexico during 2022: a retrospective analysis of nationally representative data

Background

Post-acute sequelae after SARS-CoV-2 infection (PASC) remains a concerning long-term complication of COVID-19. Here, we aimed to characterize the epidemiology of PASC in Mexico during 2022 and identify potential associations of covariates with PASC prevalence using nationally representative data.

Methods

We analyzed data from the 2022 Mexican National Health and Nutrition Survey (ENSANUT) from 24,434 participants, representing 85,521,661 adults ≥20 years. PASC was defined using both the National Institute for Health and Care Excellence (NICE) definition and a PASC score ≥12. Estimates of PASC prevalence were stratified by age, sex, rural vs. urban setting, social lag quartiles, number of reinfections, vaccination status and periods of predominance of SARS-CoV-2 circulating variants. Determinants of PASC were assessed using log-binomial regression models adjusted by survey weights.

Findings

Persistent symptoms after SARS-CoV-2 infection were reported by 12.44% (95% CI 11.89-12.99) of adults ≥20 years in Mexico in 2022. The most common persistent symptoms were fatigue, musculoskeletal pain, headache, cough, loss of smell or taste, fever, post-exertional malaise, brain fog, anxiety, and chest pain. PASC was present in 21.21% (95% CI 19.74-22.68) of subjects with previously diagnosed COVID-19. Over 28.6% of patients with PASC reported symptoms persistence ≥6 months and 14.05% reported incapacitating symptoms. Higher PASC prevalence was associated with SARS-CoV-2 reinfections, depressive symptoms and living in states with high social lag. PASC prevalence, particularly its more severe forms, decreased with COVID-19 vaccination and for infections during periods of Omicron variant predominance.

Interpretation

PASC remains a significant public health burden in Mexico as the COVID-19 pandemic transitions into endemic. Promoting SARS-CoV-2 reinfection prevention and booster vaccination may be useful in reducing PASC burden.

Funding

This research was supported by Instituto Nacional de Geriatría in Mexico.

Risk of long COVID and associated symptoms after acute SARS-COV-2 infection in ethnic minorities: A nationwide register-linked cohort study in Denmark

BACKGROUND

Ethnic minorities living in high-income countries have been disproportionately affected by Coronavirus Disease 2019 (COVID-19) in terms of infection rates, hospitalisations, and deaths; however, less is known about long COVID in these populations. Our aim was to examine the risk of long COVID and associated symptoms among ethnic minorities.

METHODS AND FINDINGS

We used nationwide register-based cohort data on individuals diagnosed with COVID-19 aged ≥18 years (n = 2,287,175) between January 2020 and August 2022 in Denmark. We calculated the risk of long COVID diagnosis and long COVID symptoms among ethnic minorities compared with native Danes using multivariable Cox proportional hazard regression and logistic regression, respectively. Among individuals who were first time diagnosed with COVID-19 during the study period, 39,876 (1.7%) were hospitalised and 2,247,299 (98.3%) were nonhospitalised individuals. Of the diagnosed COVID-19 cases, 1,952,021 (85.3%) were native Danes and 335,154 (14.7%) were ethnic minorities. After adjustment for age, sex, civil status, education, family income, and Charlson comorbidity index, ethnic minorities from North Africa (adjusted hazard ratio [aHR] 1.41, 95% confidence interval [CI] [1.12,1.79], p = 0.003), Middle East (aHR 1.38, 95% CI [1.24,1.55], p < 0.001), Eastern Europe (aHR 1.35, 95% CI [1.22,1.49], p < 0.001), and Asia (aHR 1.23, 95% CI [1.09,1.40], p = 0.001) had significantly greater risk of long COVID diagnosis than native Danes. In the analysis by largest countries of origin, the greater risks of long COVID diagnosis were found in people of Iraqi origin (aHR 1.56, 95% CI [1.30,1.88], p < 0.001), people of Turkish origin (aHR 1.42, 95% CI [1.24,1.63], p < 0.001), and people of Somali origin (aHR 1.42, 95% CI [1.07,1.91], p = 0.016). A significant factor associated with an increased risk of long COVID diagnosis was COVID-19 hospitalisation. The risk of long COVID diagnosis among ethnic minorities was more pronounced between January 2020 and June 2021. Furthermore, the odds of reporting cardiopulmonary symptoms (including dyspnoea, cough, and chest pain) and any long COVID symptoms were higher among people of North African, Middle Eastern, Eastern European, and Asian origins than among native Danes in both unadjusted and adjusted models. Despite including the nationwide sample of individuals diagnosed with COVID-19, the precision of our estimates on long COVID was limited to the sample of patients with symptoms who had contacted the hospital.

CONCLUSIONS

Belonging to an ethnic minority group was significantly associated with an increased risk of long COVID, indicating the need to better understand long COVID drivers and address care and treatment strategies in these populations.

Ethnic and racial differences in self-reported symptoms, health status, activity level, and missed work at 3 and 6 months following SARS-CoV-2 infection

Introduction

Data on ethnic and racial differences in symptoms and health-related impacts following SARS-CoV-2 infection are limited. We aimed to estimate the ethnic and racial differences in symptoms and health-related impacts 3 and 6 months after the first SARS-CoV-2 infection.

Methods

Participants included adults with SARS-CoV-2 infection enrolled in a prospective multicenter US study between 12/11/2020 and 7/4/2022 as the primary cohort of interest, as well as a SARS-CoV-2-negative cohort to account for non-SARS-CoV-2-infection impacts, who completed enrollment and 3-month surveys (N = 3,161; 2,402 SARS-CoV-2-positive, 759 SARS-CoV-2-negative). Marginal odds ratios were estimated using GEE logistic regression for individual symptoms, health status, activity level, and missed work 3 and 6 months after COVID-19 illness, comparing each ethnicity or race to the referent group (non-Hispanic or white), adjusting for demographic factors, social determinants of health, substance use, pre-existing health conditions, SARS-CoV-2 infection status, COVID-19 vaccination status, and survey time point, with interactions between ethnicity or race and time point, ethnicity or race and SARS-CoV-2 infection status, and SARS-CoV-2 infection status and time point.

Results

Following SARS-CoV-2 infection, the majority of symptoms were similar over time between ethnic and racial groups. At 3 months, Hispanic participants were more likely than non-Hispanic participants to report fair/poor health (OR: 1.94; 95%CI: 1.36-2.78) and reduced activity (somewhat less, OR: 1.47; 95%CI: 1.06-2.02; much less, OR: 2.23; 95%CI: 1.38-3.61). At 6 months, differences by ethnicity were not present. At 3 months, Other/Multiple race participants were more likely than white participants to report fair/poor health (OR: 1.90; 95% CI: 1.25-2.88), reduced activity (somewhat less, OR: 1.72; 95%CI: 1.21-2.46; much less, OR: 2.08; 95%CI: 1.18-3.65). At 6 months, Asian participants were more likely than white participants to report fair/poor health (OR: 1.88; 95%CI: 1.13-3.12); Black participants reported more missed work (OR, 2.83; 95%CI: 1.60-5.00); and Other/Multiple race participants reported more fair/poor health (OR: 1.83; 95%CI: 1.10-3.05), reduced activity (somewhat less, OR: 1.60; 95%CI: 1.02-2.51; much less, OR: 2.49; 95%CI: 1.40-4.44), and more missed work (OR: 2.25; 95%CI: 1.27-3.98).

Discussion

Awareness of ethnic and racial differences in outcomes following SARS-CoV-2 infection may inform clinical and public health efforts to advance health equity in long-term outcomes.

The Long-Term Impacts of COVID-19 on Physical and Psychological Health - Beijing Municipality, China, December 2022-April 2023

What is already known about this topic?

Reports detailing the clinical presentation of coronavirus disease 2019 (COVID-19) are extensive in China. However, data remains limited regarding the long-term effects of the 2022 outbreak on the community and healthcare workers (HCWs).

What is added by this report?

In the follow-up study conducted with 1,069 community members and 3,309 HCWs infected with COVID-19, we observed that five months post-outbreak, 39.2% of community members and 28.7% of HCWs reported experiencing at least one symptom. The symptoms most frequently reported included fatigue or muscle weakness, insomnia, cognitive dysfunction, hair loss, joint or muscle pain, and persistent cough. HCWs tended to experience fewer long-term physical consequences and their symptoms had an expedited recovery time compared to the community members. Nevertheless, HCWs displayed a higher prevalence of moderate to severe depression and anxiety.

What are the implications for public health practice?

The establishment of a public healthcare system dedicated to continual monitoring, prevention, and clinical treatment of persistent COVID-19 symptoms is imperative.