Clinical Characteristics and Factors Associated with Long COVID in Zambia, August 2020 to January 2023

Background Several seroprevalence studies in Africa documented the extent of spread of SARS-CoV-2, yet there is limited data on signs, symptoms and conditions that continue or develop after acute COVID-19 infection (long COVID). We sought to examine patient characteristics at post-acute COVID-19 (PAC-19) clinics in Zambia and assess factors associated with long COVID at first visit to a PAC-19 clinic and longitudinally among a cohort of patients. Methods Long COVID was defined, initially in the Zambia PAC-19 clinical guidelines, as new, relapsing or persistent symptoms lasting >4 weeks after an initial SARS-CoV-2 infection. Severe illness was defined as COVID-19 episode that required supplemental oxygen therapy, intensive care unit stay or treatment with steroids/remdesivir. We fitted logistic regression models with cross-sectional and longitudinal data and considered statistical significance at p<0.05. Results In total, 1,359 patients attended PAC-19 clinics and had data abstracted from Aug-2020 to Jan-2023; 548 (40.3%) patients with ≥2 visits were included in the longitudinal analysis. Patients’ median age was 53 (interquartile range [IQR]: 41-63) years, 919 (67.6%) were hospitalized for acute COVID-19, and of whom 686 (74.6%) had severe illness. Patients with hospital length of stay ≥15 days (adjusted odds ratio [aOR]: 5.50; 95% confidence interval [95% CI]: 3.06-10.3), severe illness (aOR: 3.23; 95% CI: 1.68-6.75), and comorbidities (aOR:1.51; 95% CI: 1.04-2.22) had significantly higher odds of long COVID.  Longitudinally, long COVID prevalence significantly (p<0.001) declined from 75.4% at the first PAC-19 visit to 26.0% by the fifth visit. The median follow-up time was 7 (IQR: 4-12) weeks. Conclusion Long COVID symptoms were common among patient presenting for care in PAC-19 clinics in Zambia, but most recovered within ~2 months. Despite potentially substantial morbidity due to long COVID, few patients overall with COVID-19 attended a PAC-19 clinic. Scaling up PAC-19 services and integrating into routine clinical care could improve access by patients. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study has been supported in part by the President's Emergency Plan for AIDS Relief (PEPFAR) through the Centers for Disease Control and Prevention (CDC) Grant number/CoAg ID number GH002234. The study sponsor or funder had no role, in the study design collection, analysis, and interpretation of data writing of the report and the decision to submit the article for publication. In addition, there is independence of researchers from funders and all authors, external and internal, had full access to all of the data (including statistical reports and tables) in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: This retrospective study obtained ethical clearance (waiver for informed consent) from the University of Zambia Biomedical Research Ethics Committee (Ref No. 2711-2022), approval from the Zambia National Health Research Authority (Ref No: NHRA0002/26/05/2022) and was determined to be non-research according to the U.S Centers for Disease Control and Prevention (CDC) policy and applicable federal law (See e.g., 45 C.F.R. part 46.102(l)(2), 21 C.F.R. part 56 42 U.S.C. §241(d) 5 U.S.C. 552a 44 U.S.C.3501 et seq.). CDC investigators did not interact with the patients or have access to personally identifiable information but participated in protocol development and analysis of anonymized data. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Data are not currently publicly available but may be obtained by a third party. The data are de-identified participant data, available with permission from the Government of the Republic of Zambia (GRZ) – Ministry of Health (MoH), info@moh.gov.zm. A request to access the data can be made to the corresponding author (ykh1@cdc.gov), who will need to get permission from GRZ (MoH) to avail the data. Protocols and statistical analysis information is available as per above.