Long COVID More Common Among Socially Vulnerable Individuals

People experiencing social risk factors at the time of COVID-19 infection had a greater risk of developing long COVID, according to a study published today in Annals of Internal Medicine.¹

The researchers explained that individual- and area-level social risk factors have been associated with higher COVID-19 infection rates and greater mortality.² Some individuals infected with COVID-19 go on to develop long COVID, defined as clusters of neurologic, cardiovascular, pulmonary, gastrointestinal, and otolaryngologic symptoms that persist, relapse, or progress 3 or more months after infection.¹ Previous research has linked long COVID to demographic factors, underlying health conditions, infection severity, and exposure to air pollutants.

However, no longitudinal studies to date have evaluated whether social risk factor exposures at the time of COVID-19 infection independently increase the risk for long COVID while accounting for comorbidities, demographics, infection severity, and vaccination status. To address this gap, the researchers conducted a prospective observational cohort study using data from the longitudinal RECOVER-Adult cohort.

Social risk factors significantly increase the likelihood of developing long COVID, highlighting the urgent need for equitable health care and support systems. | Image Credit: Parradee - stock.adobe.com

The study included adults 18 years or older who were within 30 days of COVID-19 infection between October 31, 2021, and November 14, 2023. Participants were recruited from 33 states, the District of Columbia, and Puerto Rico and were required to complete baseline questionnaires on social determinants of health, comorbidities, and pregnancy status. The researchers followed eligible participants prospectively.

The primary outcome was meeting the criteria for likely long COVID 6 months post infection, based on the 2024 RECOVER-Adult Long COVID Research Index. It was defined as a symptom score of 11 or more on a weighted index that includes symptoms such as brain fog, change in sense of smell or taste, and chronic cough.

The researchers used the Healthy People 2030 framework to assess 4 domains of individual-level social risk: economic instability; barriers to education and language access; health care access and quality challenges; and lack of social or community support. Additionally, they used zip code–level data to assess neighborhood poverty and household crowding, defined by the percentage of residents living below the federal poverty line and the percentage of overcrowded households, respectively.

Of the 15,160 people in the full cohort, 3787 met the inclusion criteria. The mean (SD) age was 49 (16) years, and most participants (n = 260; 69%) were female. As for race and ethnicity, 2267 (60%) identified as White, 534 (14%) as Black, 478 (13%) as Hispanic, and 275 as Asian (7%).

Social risk factor prevalence was high across the cohort. More than one-third (n = 1315; 35%) had at least 1 measure of economic instability, with financial hardship being most common (n = 1088; 29%). Also, 29% (n = 1096) faced barriers to health care access or quality, including 18% (n = 679) who reported discrimination in a medical setting. Additionally, about 28% (n = 1053) had less than a college education.

Social or community support challenges were also widespread, as 73% reported at least 1 related issue, with 22% (n = 852) lacking social support and 28% (n = 1050) reporting poor neighborhood cohesion. Zip code–level data were available for 3772 people (99.6%), with 20% (n = 797) living in areas with the highest poverty rates and 17% (n = 658) in areas with the highest household crowding.

Overall, 418 participants (11%) developed long COVID. In adjusted models, those with economic instability were significantly more likely to develop long COVID. For example, people experiencing financial hardship had 2.36 (95% CI, 1.97-2.91) times the risk, and those with food insecurity had 2.39 (95% CI, 1.83-2.98) times the risk.

Elevated risks were also observed among participants with lower educational attainment and across all health care access and quality barriers. The highest risk was among those who skipped medical care due to cost (adjusted marginal risk ratio [ARR], 2.98; 95% CI, 2.22-3.70).

In addition, all measures of poor social or community support were linked with heightened long COVID risk, with the strongest association seen in those without social support (ARR, 1.79; 95% CI, 1.50-2.17). Lastly, living in areas with the highest vs lowest levels of household crowding was associated with 1.36 (95% CI, 1.05-1.71) times the risk for long COVID.

“These findings demonstrate the lasting contribution of social risk factors to the disparities exacerbated by the COVID-19 pandemic,” the authors wrote.

The study had several limitations, including possible selection bias and differential loss to follow-up, which could affect its generalizability. Also, because this was an observational study, the associations observed do not imply causation. Still, the researchers emphasized the importance of their findings and outlined areas for future action.

“Efforts are urgently needed to build infrastructure to address current inequities in social risk factor distribution and to ensure access to high-quality, multidisciplinary long COVID care for persons with the greatest burden,” the authors concluded. “…From a policy perspective, advocacy is essential to dismantle the upstream systemic and structural drivers of social risk factors and area-level adverse exposures to address the profound disparities exacerbated by the COVID-19 pandemic.”

References

1. Feldman CH, Santacroce L, Bassett IV, et al. Social determinants of health and risk for long COVID in the US RECOVER-adult cohort. Ann Intern Med. Published online July 28, 2025. doi:10.7326/ANNALS-24-01971
2. Magesh S, John D, Li WT, et al. Disparities in COVID-19 outcomes by race, ethnicity, and socioeconomic status: a systematic-review and meta-analysis. JAMA Netw Open. 2021;4(11):e2134147. doi:10.1001/jamanetworkopen.2021.34147