https://www.nature.com/articles/s41467-022-33415-5

Abstract

With increasing numbers infected by SARS-CoV-2, understanding
long-COVID is essential to inform health and social care support. A
Scottish population cohort of 33,281 laboratory-confirmed SARS-CoV-2
infections and 62,957 never-infected individuals were followed-up via
6, 12 and 18-month questionnaires and linkage to hospitalization and
death records. Of the 31,486 symptomatic infections,1,856 (6%) had not recovered and 13,350 (42%) only partially. No recovery was associated
with hospitalized infection, age, female sex, deprivation, respiratory
disease, depression and multimorbidity. Previous symptomatic infection
was associated with poorer quality of life, impairment across all
daily activities and 24 persistent symptoms including breathlessness
(OR 3.43, 95% CI 3.29–3.58), palpitations (OR 2.51, OR 2.36–2.66),
chest pain (OR 2.09, 95% CI 1.96–2.23), and confusion (OR 2.92, 95% CI 2.78–3.07). Asymptomatic infection was not associated with adverse
outcomes. Vaccination was associated with reduced risk of seven
symptoms. Here we describe the nature of long-COVID and the factors
associated with it.
Introduction

Whilst most people recover fully from severe acute respiratory
syndrome coronavirus-2 (SARS-CoV-2) infection, some develop
long-COVID. With increasing numbers of people having been infected
since the start of the pandemic, attention is shifting from managing
the acute infection to understanding long-COVID in order to inform the
health and social care response. The WHO defined long-COVID as “a
history of probable or confirmed SARS-CoV-2 infection … with symptoms
that last for at least 2 months and cannot be explained by an
alternative diagnosis”1. The imprecision of this, and other,
definitions reflects our poor understanding of the nature of
long-COVID and its underlying mechanisms.

A meta-analysis of 63 studies pooled symptom prevalence following laboratory-confirmed SARS-CoV-2 infection2. The sample size ranged
from 58 to 1733 (16,336 in total), with most studies containing fewer
than 200 participants. Overall, 53% of people reported one or more
symptoms beyond 12 weeks following infection. The most common were
fatigue, pain/discomfort, shortness of breath, cognitive impairment,
and mental health problems. Eighteen studies were judged to be at high
risk of bias, and the remaining 45 were at moderate risk, due to
convenience sampling and unrepresentative study populations. Half of
the studies investigated hospitalised cohorts. The only two studies
with more than 1000 participants were a hospitalised cohort and a
cohort of health-care workers with mild infection. In a subsequent meta-analysis of 18 studies with at least 12 months follow-up, study
samples ranged from 51 to 2433 (8591 in total) and 28% of participants
reported fatigue/weakness, 22% anxiety, 18% breathlessness, 19% memory
loss, 18% concentration difficulties and 12% insomnia3. The authors
highlighted a small sample size, lack of representativeness and low
response rate as limitations. Whilst many long-COVID studies have
focused on patients hospitalised with more severe infections, a
meta-analysis of 9 studies reported persistent symptoms in up to
one-third of people following mild SARS-CoV-2 infection4.

This study aimed to address some of the limitations of existing
studies by determining the frequency, nature, determinants and impact
of long-COVID in the general population using a largescale, nationwide
study, including people who had severe, mild and asymptomatic
infections and a never infected comparison group, and measuring serial self-reported outcomes as well as outcomes obtained from linkage to
routine health records. Here we show that the long-term sequelae of
COVID-19 are wide-ranging and impact on all aspects of daily living,
are specific to symptomatic infections and more likely following
severe infections requiring hospitalisation, and in older, female and
more deprived patients with pre-existing health problems but
vaccination appears to confer some protection.
Results
Cohort characteristics

Overall, 102,473 (16%) of the 638,125 people invited consented and
completed at least one questionnaire: 33,281 (20%) of the 162,957
people who had a positive test, and 69,192 (15%) of the 475,168
invited following only negative tests. Completion rates were 14% (90,578/625,315), 9% (21,963/242,412) and 11% (934/8625) for the 6, 12
and 18 month follow-up questionnaires respectively (Supplementary
Table 1). Compared with those who did not provide consent, responders
were more likely to be female (60.9% vs 51.2%; p-value < 0.001), were
older (>40 years 59.5% vs 46.0%; p-value < 0.001) and less deprived
(most deprived SIMD quintile 24.0% vs 27.0%; p-value <0.001).

We excluded 6235 participants who had only negative tests recorded but self-reported they had tested positive. Therefore, the study cohort
comprised 96,238 participants. Their median age at baseline was 45
(IQR 31–56) years, 39% were male, 91% white, 30% had at least one
pre-existing health condition and 16% at least two; 4% had received at
least one COVID-19 vaccination dose prior to their index test (Table
1).
Table 1 Characteristics of study participants by infection status and symptomatology
Full size table
Symptoms during acute infection

Among the 33,281 participants who had a positive test, 31,486 (95%)
were symptomatic at the time of infection; 1208 (4%) had one symptom,
1999 (6%) had two, 2493 (8%) had three, and 25,786 (82%) had more than
three. Overall, 83% reported fatigue at the time of acute infection,
64% headache, 63% change in taste, 63% myalgia, 60% change in smell,
54% cough, 52% fever, 45% breathlessness, 41% loss of appetite, 38%
joint pain, 31% sore throat, 23% diarrhea, 21% chest pain, 20% runny
nose, 15% abdominal pain, 13% confusion, 13% hoarse voice, 9% hair
loss, 8% ear pain, 2% reduced consciousness, and 0.3% seizures. Of
those who reported symptom duration, 7259 (23%) reported <1 week,
13,710 (44%) 1–4 weeks, and 10,489 (33%) >4 weeks.
Outcomes

Of the 31,486 people who had had symptomatic infections, 1856 (6%)
reported that they had not recovered at all on their most recent
follow-up questionnaire, and 13,350 (42%) that they had only partially recovered. Among the 1342 people whose infection required
hospitalization, the figures were 217 (16%) and 797 (59%),
respectively, and among the 30,096 managed in the community, they were
1639 (5%) and 12,553 (42%), respectively.

For the 3941 with serial questionnaire data there was little change in
the overall breakdown; at their first follow-up, 316 (8%) had not at
all recovered and 1866 (47%) had only partially recovered, compared to
324 (8%) and 1806 (46%), respectively, at their most recent follow-up.
However, there was some cross-over between groups; 1453 (37%) remained
fully recovered, 1372 (35%) remained partially recovered, and 175 (4%) continued to report no recovery, while 494 (13%) reported delayed
recovery (improvement over time), and 447 (11%) reported relapse
(deterioration over time).

The results were similar when specific follow-up periods were
compared. In the sub-group of 3744 participants who had symptomatic
infections and who completed questionnaires at both 6 and 12 months
follow-up, the breakdown by no, partial and full recovery was 295 (8%)
1766 (47%), and 1683 (45%) at six months and 303 (8%), 1705 (46%) and
1736 (46%) at 12 months (Supplementary Table 2). Similarly, in the 197 participants who completed questionnaires at both 12 and 18 months
follow-up, the figures were 21 (11%), 100 (51%) and 76 (39%), and 21
(11%), 101 (51%) and 75 (38%) at 12 and 18 months, respectively.

Of the 21,525 people with ongoing symptoms following symptomatic
infection, the most common were tiredness, headache and muscle
aches/weakness (Table 2). However, symptoms were also common among
people never infected. Compared with the latter, people who had
previous symptomatic infection were significantly more likely to
report 24 of the 26 symptoms at follow-up after adjusting for
potential confounders (Table 3). After changes in smell and taste, the
largest effect sizes were observed for symptoms that were potentially cardiovascular in origin (breathlessness, chest pain and palpitations)
and confusion (Table 3). People with previous symptomatic infection
were also more likely to have multiple (=3) symptoms than people never
infected (14,236 (45%) vs 19,613 (31%)). There was weak evidence of
clustering of musculoskeletal and neuropsychological symptoms
following previous symptomatic infection (Supplementary Fig. 2). Among
the participants who completed serial questionnaires, there was
evidence of improvements in taste and smell between 6 and 12 months
follow-up but increased reporting of a dry or productive cough between
6 and 18 months (Supplementary Table 3).
Table 2 Crude outcomes of participants by infection status and
symptomatology
Full size table
Table 3 Univariate and multivariate binary logistic regression
analyses of the associations between previous symptomatic SARS-CoV-2
infection and current symptoms, referent to people never infected
Full size table

Routine data were available until January 2022, providing a median
(IQR) of 7 (6–8) months follow-up. People who had previous symptomatic infection were not at significantly increased risk of all-cause
hospitalization (fully adjusted OR 1.02, 95% CI 0.97–1.07, p?=?0.386),
ICU admission (fully adjusted OR 1.21, 95% CI 0.86–1.70, p?=?0.267) or all-cause mortality (fully adjusted OR 0.64, 95% CI 0.39–1.05,
p?=?0.076). However, they had a median EQ-5D score of 75 (IQR 60–89)
in their most recent follow-up questionnaire compared with 80 (IQR
63–90) for people never infected (p?<?0.001). People who had previous symptomatic infection had significantly lower EQ-5D scores in both the univariate Poisson model (coefficient 0.96, 95% CI 0.96–0.96,
p?<?0.001) and in the fully adjusted model (coefficient 0.95, 95% C I 0.95–0.95, p?<?0.001). Similarly, people who had had symptomatic
infection were significantly more likely to report impaired mobility, housework/chores, working/studying, washing/dressing, exercise/sport,
hobbies and relationships after adjusting for potential confounders
(Table 4). Asymptomatic SARS-CoV-2 infection was not associated with
increased risk of current symptoms, impaired daily activities, reduced
quality of life, hospitalization, ICU admission or death.
Table 4 Univariate and multivariate binary logistic regression
analyses of the associations between previous symptomatic SARS-CoV-2
infection and current difficulties in activities of daily living,
referent to people never infected
Full size table
Factors associated with outcomes

Following previous symptomatic infection, lack of complete recovery
was associated with more severe (hospitalized) initial infection,
older age, female sex, deprivation, white ethnicity, and pre-existing
health conditions, including respiratory disease and depression (Table
5). Compared to unvaccinated people, people vaccinated prior to
symptomatic infection were less likely to report persistent change in
smell (OR 0.58, 0.45–0.76), change in taste (OR 0.61, 95% CI
0.46–0.79), problems hearing (OR 0.60, 95% CI 0.44–0.83), poor
appetite (OR 0.72, 95% CI 0.53–0.99), balance problems (OR 0.71, 95%
CI 0.53–0.95), confusion/difficulty concentrating (OR 0.72, 95% CI
0.58–0.89), and anxiety/depression (OR 0.76, 95% CI 0.64–0.92) at
their latest follow-up after adjustment for potential confounders.
Table 5 Multivariate logistic regression analysis of the factors
associated with no or partial recovery, referent to full recovery,
among people with previous symptomatic SARS-CoV-2 infection
Full size table
Discussion

Between 6 and 18 months following symptomatic SARS-CoV-2 infection,
almost half of those infected reported no, or incomplete, recovery.
Whilst recovery status remained constant over follow-up for most, 13%
reported improvement over time and 11% deterioration. Symptomatic
SARS-CoV-2 infection was associated with a wide range of persistent
symptoms, impaired daily activities and reduced health-related quality
of life, independent of sociodemographic factors and pre-existing
health conditions. The strongest associations were observed for
symptoms that were potentially cardiovascular in origin
(breathlessness, chest pain and palpitations) and confusion. Lack of
recovery was associated with more severe infection, older age, female
gender, black and South Asian ethnic groups, deprivation, pre-existing respiratory disease and multimorbidity but pre-infection vaccination
was associated with reduced risk of some persistent symptoms. We found
no evidence of sequelae following asymptomatic infection.

Our finding of impaired daily activities is consistent with previous
studies. In a meta-analysis of 12 studies covering 4828 participants
previously infected by SARS-CoV-2, 35% had problems with mobility, 8%
with personal care, 42% pain/discomfort, and 38% anxiety/depression5. Similarly, in a global social media survey of 1020 confirmed and 2742
suspected previous COVID-19 cases, 45% reported an ongoing impact on
their ability to work6. In line with our findings, previous studies
have reported that women, older and more deprived people, and those
with pre-existing health problems were less likely to recover
completely from COVID-197,8,9.

Of eight studies that assessed the effectiveness of pre-infection
vaccination on long-COVID10, six (two cohort, two case-control, two cross-sectional) reported fewer symptoms 1–6 months following
infection among those fully vaccinated11,12,13,14,15,16, including
fatigue, headache, muscle weakness/pain, breathlessness, dizziness,
and change in smell13,16. Our findings differ from previous
studies12,13,14,16 in suggesting possible protection against
persistent symptoms from even partial vaccination. Three studies have
suggested that, among unvaccinated people, post-infection vaccination
may also reduce the risk or severity of long-COVID15,17,18,
especially, if given early following infection15.

As a general population study, our findings provide a better
indication of the overall risk and burden of long-COVID than
hospitalised cohorts. The inclusion of asymptomatic infections enabled
us to demonstrate that long-COVID is specific to people with
symptomatic infections. Incomplete ascertainment of all cases of
COVID-19 was inevitable due to the lack of PCR testing at the
beginning of the pandemic, followed by a gradual increase in testing
capacity and therefore changes in testing criteria. The risk of misclassification was reduced by using a composite definition of the
previous infection, requiring both laboratory confirmation and
self-report, and excluding people who reported a previous positive
test that was not on the database. The never-infected group will
include some people with asymptomatic infection or symptomatic
infection prior to testing becoming available. The latter could
potentially lead to under-estimation of the true magnitude of
association between SARS-CoV-2 infection and ongoing health problems.

Our cohort included a large sample (n?=?33,281) of people previously
infected and the response rate of 16% overall and 20% among people who
had symptomatic infection was consistent with previous studies that
have used SMS text invitations as the sole method of recruitment. For
example, in a study on the impact of COVID-19, an SMS text invitation
was sent to 7911 patients attending a rheumatology outpatient clinic,
of whom 21% responded and 20% completed the questionnaire19. In
another study, SMS text messages were sent to 350 cases recorded on a
COVID-19 contact tracing database. Of these 24% responded and 1%
provided the requested information on their contacts20. In our study, recruitment may have been lower in some sub-groups. For example, the questionnaire was written in English and accessed via a web-based app
and therefore may have been inaccessible to people without internet
access or without English as their first language. Formal and informal
carers were permitted to assist respondents in completing the
questionnaire. It is possible that people with persistent health
problems may have been more motivated to participate. Whilst reporting
of current symptoms will not be subject to recall bias, a potential
study limitation is that symptoms at the time of acute infections were
recalled at follow-up and, therefore, were potentially subject to
recall bias.

Symptoms are common in the general population. The three most common
symptoms among people previously infected were also reported by 16–32%
of people never infected. Therefore, the inclusion of an uninfected
comparison group enabled us to demonstrate that the outcomes were not
due to confounding. This is a major strength of our study compared
with other population cohort studies9,18. We matched our uninfected
comparison group 3:1 at the time of invitation; allowing for an
anticipated lower response rate among uninfected individuals and
attrition due to subsequent infection. Serial outcome measurements in
a sub-group of 3941 respondents enabled us to investigate the
trajectory of long-COVID over time. Very few people had been fully
vaccinated pre-infection. However, sufficient had received a single
dose to demonstrate some evidence of protection against persistent
symptoms. The non-significant lower risk of death following
symptomatic infection is likely to reflect the fact that our study
recruited people who had survived at least six months following
infection.

Our finding of higher rates of recovery among black and South Asian participants is consistent with a previous study that observed a lower probability of persistent symptoms among Asian participants9.
Apparently better long-term prognosis contrasts with the known higher
risk of black and South Asian individuals during acute infection with SARS-CoV-221 and may reflect survival bias, since participants needed
to have survived at least 6 months following their acute infection to participate in our study. The Scottish population is 96% white22.
Therefore, it is important that ethnic-specific outcomes are reported
by other long-COVID studies with more ethnically diverse populations.

In conclusion, 6–18 months following symptomatic SARS-CoV-2 infection,
adults were at greater risk of a diverse group of symptoms, poorer
quality of life and wide-ranging impairment of their daily activities,
which could not be explained by confounding. Sequelae were more likely following severe infection and were not observed following
asymptomatic infection and pre-infection vaccination may be
protective.
Methods
Study design

Long-COVID in Scotland Study (Long-CISS) is an ambidirectional,
general population cohort. Every adult (>16 years) in Scotland with a
positive PCR test for SARS-CoV-2 from April 2020 was invited to
participate along with a comparison group who had had a negative test
but never had a positive test, matched 3:1 by age, sex, and area-based socioeconomic deprivation quintile. The National Health Service (NHS)
Scotland platform that provides PCR result notifications identified
eligible participants and invited them via automated SMS text
messages. The study commenced in May 2021 and was recruited both retrospectively and prospectively based on existing and new test
results, respectively. People in the comparison group were reallocated
to the infected group if, and when, they had a positive test. The
cohort included people with asymptomatic SARS-CoV-2 infection
detected, for example, during occupational or travel-related
screening. Participants provided electronic consent and study approval
was obtained from the West of Scotland Research Ethics Committee (ref. 21/WS/0020) and the Public Benefit and Privacy Panel (ref. 2021-0180).
Data sources

A self-completed online questionnaire (Supplementary Fig. 1) collected information on pre-existing health conditions at the time of the index
test (first positive test or, for the comparison group, most recent
negative test) as well as current symptoms, limitations in daily
activities and quality of life. Those who had tested positive also
provided information on symptoms during the initial infection and
current recovery status. Questionnaires were completed 6, 12 and 18
months after the index test. Additional data were obtained through
linkage to electronic health records both five years prior to their
index test and subsequent to the test (up to January 2022) on
hospitalizations (Scottish Morbidity Record 01/04), dispensed
prescriptions (Prescribing Information System), vaccinations, and
death certificates (General Registrar Office). Long-CISS is ongoing
and the findings in this manuscript relate to index tests performed up
to May 2021 and follow-up questionnaires up to November 2021.
Definitions

Infection was defined as a positive PCR recorded on the national
database and categorised as symptomatic or asymptomatic based on
self-report. Severe infection was defined as an admission to hospital
with ICD-10 code U07.1 on a date occurring between 1 day prior to the
test and 2 weeks after. Respondents who reported having had a positive
test that was not recorded on the database were excluded from the
study as we could not determine whether they were incorrect or had
taken the test outside Scotland.

Socioeconomic deprivation was obtained from postcode of residence
using the Scottish Index of Multiple Deprivation derived from
aggregated data on: income, employment, education, health, access to
services, crime and housing23. SARS-CoV-2 variants were defined as
dominant if they accounted for =95% of cases genotyped that week (https://sars2.cvr.gla.ac.uk/cog-uk/). Pre-existing health conditions
were ascertained from self-report, previous hospitalizations and
dispensed prescriptions. Respiratory disease was defined as
International Classification of Diseases 10 (ICD10) codes J40-J47,
J98.2 or J98.3, or bronchodilators, inhaled corticosteroids,
cromoglycate, leukotriene or phosphodiesterase type-4 inhibitor
(British National Formulary (BNF) 3.1–3.3), or self-report. Coronary
heart disease was defined as ICD10 codes I11.0, I13.0, I13.2, I20-I25 (excluding I24.1), I50, T82.2, or Z95.5, or self-report. Depression
was defined as ICD10 codes F30-F33, or anti-depressant, hypnotic or
anxiolytic (BNF 4.1;4.3), or self-report. Diabetes was defined as
ICD10 codes E10-E14, G590, G632, H280, H360, M142, N083, O240-O243 or self-report24. The total number of self-reported health conditions was categorised as 0, 1, 2–3 or =4.
Outcomes

The outcomes measured were 26 symptoms (harmonised with the ISARIC questionnaire)25, limitations across 7 activities of daily living, health-related quality of life (using EQ-5D), hospitalization,
admission to an intensive care unit (ICU), and all-cause mortality in
the whole cohort, as well as self-reported recovery status (full,
partial or none) in the symptomatic infection group. Hospitalization
(as an outcome) was defined as admission to hospital on a date at
least two weeks following the index test, to exclude admissions
related to the acute infection. Delayed recovery was defined as
participants with previous symptomatic infection who reported no or
partial recovery at their first follow-up but an improvement at
subsequent follow-up; either from no to partial or full recovery, or
from partial to full recovery. Relapse was defined as participants
with previous symptomatic infections who reported full or partial
recovery at their first follow-up but a deterioration at subsequent
follow-up; either full to partial or no recovery, or from partial to
no recovery.
Statistical analyses

Baseline characteristics and crude outcomes broken down by infection
status (symptomatic, asymptomatic or never infected) were summarized
using frequencies/percentages and medians/inter-quartile ranges for
categorical and continuous variables and compared using chi-square
tests and Mann–Whitney U tests, respectively. A correlation matrix of
current symptoms was used to produce a heat map of symptom clustering
at follow-up. Separate binary logistic regression models were run in
the whole cohort to determine the association between infection status
and the outcomes of individual symptoms, limitations in daily
activities, hospitalization, ICU admission and death, using never
infected as the referent group. Poisson regression models were run for
the outcome of EQ-5D because it was a numeric variable and did not
satisfy the assumptions required for linear regression. All models
were run univariately, then adjusted incrementally for: socioeconomic
factors (age, sex, ethnic group, deprivation) and stage of follow-up
(6, 12 or 18 months); pre-existing health conditions (count,
respiratory and coronary heart disease, depression, diabetes);
vaccination status; and dominant SARS-CoV-2 variant. In the
symptomatic infection group, the same models were run to determine the
factors associated with these outcomes and recovery status. All
analyses were performed using Stata v16.
Reporting summary

Further information on research design is available in the Nature
Research Reporting Summary linked to this article.
Data availability

The datasets analysed during the current study are available in the
National Services Scotland National Safe Haven, https://www.isdscotland.org/Products-and-Services/eDRIS/Use-of-the-National-Safe-Haven/.
This protects the confidentiality of the data and ensures that
Information Governance is robust. Applications to access health data
in Scotland are submitted to the NHS Scotland Public Benefit and
Privacy Panel for Health and Social Care. Information can be found at https://www.informationgovernance.scot.nhs.uk/pbpphsc/.

Link to full-text including figures and references: https://www.nature.com/articles/s41467-022-33415-5

+++

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Suggested further reading: https://groups.google.com/g/sci.med.cardiology/c/5EWtT4CwCOg/m/QjNF57xRBAAJ

Shorter link:
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These "good works" (Ephesians 2:10) is what LORD Jesus means by His
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...because we mindfully choose to openly care with our heart,

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--
Andrew B. Chung, MD/PhD
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which is the only **healthy** cure for the U.S. healthcare crisis

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