Risk of long COVID increases with social and economic hardship
Mass General Brigham investigators led a nationwide study that found that financial hardship, food insecurity, lack of healthcare access, and other social risk factors are linked to higher risks of long COVID
Mass General Brigham investigators led a nationwide study that found that financial hardship, food insecurity, lack of healthcare access, and other social risk factors are linked to higher risks of long COVID
Long COVID includes a wide range of symptoms that present or persist three or more months after SARS-CoV-2 infection. Although in recent years researchers have gained greater insight into the prevalence, symptoms and effects of long COVID through the longitudinal Researching COVID to Enhance Recovery (RECOVER) Initiative, social risk factors for developing long COVID remain incompletely understood. In a new analysis of the RECOVER-Adult cohort, Mass General Brigham researchers found a two- to three-times higher risk of long COVID in those with social risk factors, including financial hardship, food insecurity, experiences of medical discrimination, and skipped medical care due to cost. Findings are published in Annals of Internal Medicine.
“During the pandemic, we saw the overwhelming role that social risk factors played in determining who was infected with COVID-19 and what the severity and mortality from disease was,” said lead author Candace Feldman, MD, MPH, ScD, of the Division of Rheumatology, Inflammation and Immunity at Brigham and Women’s Hospital (BWH), a founding member of the Mass General Brigham healthcare system. “We wanted to understand whether those risk factors also play a significant role in the longer-term, chronic symptoms that can affect people months and even years after SARS-CoV-2 infection.”
In this study, the researchers analyzed 3,700 participants from the RECOVER-Adult cohort, who had a SARS-CoV-2 infection during the Omicron variant outbreak, completed a baseline survey about social and economic factors at the time of infection, and completed a six-month follow-up survey assessing long COVID symptoms. The RECOVER-Adult participants were from 33 states, Washington, D.C., and Puerto Rico, and joined the study between October 2021 and November 2023.
In the baseline survey, the researchers assessed four major individual-level social risk factors: economic instability, education and language access barriers, health care access and quality challenges, and lack of social and community support using a series of questions and previously validated surveys. They also used ZIP code data to study area-level measures of risk, like household crowding.
After adjusting for variables including hospitalization for SARS-CoV-2 infection (as a marker of disease severity), vaccination history, pregnancy status, age, sex, race and ethnicity, the researchers found significant associations between nearly all the individual-level social risk factors studied and increased risk of developing long COVID. Furthermore, a greater number of social risk factors conferred a higher risk of long COVID. Living in areas with more household crowding was also associated with a greater risk of long COVID.
There was a significantly higher burden of social risk factors among racially or ethnically minoritized groups. However, the researchers found that social risk factors appeared to affect white, Black and Hispanic people’s risks of long COVID similarly.
Going forward, RECOVER Initiative researchers hope to determine whether these findings extend to children with long COVID and whether certain long COVID symptoms may be linked to specific social risk factors. They also hope to study symptoms of COVID-19 lasting a year or longer to better understand how social factors might contribute to these symptoms’ persistence.
“While rates of COVID-19 have decreased, long COVID is a chronic disease that many people still suffer from,” said senior author Elizabeth Karlson, MD, MS, of the Division of Rheumatology, Inflammation and Immunity at BWH. “As with other chronic diseases, many different parts of people's social environment influence long COVID risk. Future interventions must address these factors to effectively reduce adverse outcomes among people with high burden of social risk factors.”
Authorship: In addition to Feldman and Karlson, Mass General Brigham authors include Leah Santacroce, Ingrid V. Bassett, Tanayott Thaweethai, Yuri Quintana, Bruce D. Levy, and Cheryl R. Clark.
Additional authors include Radica Alicic, Rachel Atchley-Challenner, Alicia Chung, Mark P. Goldberg, Carol R. Horowitz, Karen B. Jacobson, J. Daniel Kelly, Stacey Knight, Karen Lutrick, Praveen Mudumbi, Sairam Parthasarathy, Heather Prendergast, Nasser Sharareh, Judd Shellito, Zaki A. Sherif, Brittany D. Taylor, Emily Taylor, Joel Tsevat, Zanthia Wiley, Natasha J. Williams, Lynn Yee, Lisa Aponte-Soto, Jhony Baissary, Jasmine Berry, Alexander W. Charney, Maged M. Costantine, Alexandria M. Duven, Nathaniel Erdmann, Kacey C. Ernst, Elen M. Feuerriegel, Valerie J. Flaherman, Minjoung Go, Kellie Hawkins, Vanessa Jacoby, Janice John, Sara Kelly, Elijah Kindred, Adeyinka Laiyemo, Emily B. Levitan, Jennifer K. Logue, Jai G. Marathe, Jeffrey N. Martin, Grace A. McComsey, Torri D. Metz, Tony Minor, Aoyjai P. Montgomery, Janet M. Mullington, Igho Ofotukun, Megumi J. Okumura, Michael J. Peluso, Kristen Pogreba-Brown, Hengameh Raissy, Johana M. Rosas, Upinder Singh, Timothy VanWagoner.
Disclosures: Feldman receives grant support to her institution for health equity research and consults for several organizations on unrelated content. Knight receives research funding from Janssen. Alicic, Parthasarathy, Aponte-Soto, Singh, Levitan, and Mullington receive NIH or other research funding or consulting support unrelated to this manuscript.
Funding: This study was funded in part by the National Institutes of Health (OTA OT2HL161841, OTA OT2HL161847, and OTA OT2HL156812).
Paper cited: Feldman CH et al. “Social Determinants of Health and Risk of Long COVID in the U.S. RECOVER-Adult Cohort” Annals of Internal Medicine DOI: 10.7326/ANNALS-24-01971
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About Mass General Brigham
Mass General Brigham is an integrated academic health care system, uniting great minds to solve the hardest problems in medicine for our communities and the world. Mass General Brigham connects a full continuum of care across a system of academic medical centers, community and specialty hospitals, a health insurance plan, physician networks, community health centers, home care, and long-term care services. Mass General Brigham is a nonprofit organization committed to patient care, research, teaching, and service to the community. In addition, Mass General Brigham is one of the nation’s leading biomedical research organizations with several Harvard Medical School teaching hospitals. For more information, please visit massgeneralbrigham.org.
Journal
Annals of Internal Medicine
Method of Research
Survey
Subject of Research
People
Article Title
Social Determinants of Health and Risk of Long COVID in the U.S. RECOVER-Adult Cohort
Article Publication Date
28-Jul-2025
COI Statement
Feldman receives grant support to her institution for health equity research and consults for several organizations on unrelated content. Knight receives research funding from Janssen. Alicic, Parthasarathy, Aponte-Soto, Singh, Levitan, and Mullington receive NIH or other research funding or consulting support unrelated to this manuscript.
Economically disadvantaged patients at greater risk for long COVID
Below please find summaries of new articles that will be published in the next issue of Annals of Internal Medicine. The summaries are not intended to substitute for the full articles as a source of information. This information is under strict embargo and by taking it into possession, media representatives are committing to the terms of the embargo not only on their own behalf, but also on behalf of the organization they represent.
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1. Economically disadvantaged patients at greater risk for long COVID
Abstract: https://www.acpjournals.org/doi/10.7326/ANNALS-24-01971
URL goes live when the embargo lifts
A prospective observational cohort study determined the associations between social determinants of health (SDoH) at the time of SARS-CoV-2 infection and subsequent risk for long COVID. The study found that people with social risk factors including economic instability and food insecurity at the time of COVID-19 infection were at greater risk for long COVID. The results suggest policy efforts are essential to dismantle the systemic drivers of social risk factors and address the disparities exacerbated by the COVID-19 pandemic. The study is published in Annals of Internal Medicine.
Researchers from Brigham and Women’s Hospital, Harvard Medical School, and colleagues studied data from 3,787 adults enrolled in the RECOVER-Adult study between October 2021 and November 2023 who had acute SARS-CoV-2 infection with the Omicron variant. Participants completed comorbidity and SDoH surveys at baseline and long COVID symptom surveys at six-month follow-up. The researchers used the Healthy People 2030 categorizations for SDoH to consider four domains of individual-level social risk factors (economic instability, education and language access barriers, health care access and quality challenges, and lack of social or community support) and two area-level measures from ZIP code data (neighborhood poverty and household crowding). The outcome measured was meeting the criteria for likely long COVID from the 2024 update of the RECOVER-Adult Long COVID Research Index (LCRI) based on the 6-month patient-reported symptom survey. The researchers found that persons with financial hardship, food insecurity, less than a college education, and health care access challenges were at higher risk for developing long COVID. Living in a ZIP code with higher household crowding was also associated with greater risk of long COVID. Secondary analyses found that a greater number of social risk factors within most domains conferred higher risk for long COVID. The findings show the lasting contribution of social risk factors to the disparities exacerbated by the COVID-19 pandemic.
Media contacts: For an embargoed PDF, please contact Gabby Macrina at gmacrina@acponline.org. To contact corresponding author Candace H. Feldman, MD, MPH, ScD, please email Tori Roberts at vroberts1@mgb.org.
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2. Asian Indian, Chinese, and Filipino Americans have distinct cardiovascular mortality risk profiles
Abstract: https://www.acpjournals.org/doi/10.7326/ANNALS-25-00108
URL goes live when the embargo lifts
A brief research report assessed cardiovascular risk factor and disease mortality among Asian Indian, Chinese, and Filipino American subgroups in the United States. The findings revealed that each subgroup has distinct cardiovascular challenges, with Filipino Americans having the highest mortality across most cardiovascular conditions. Asian Indian Americans had especially high mortality rates form heart disease and diabetes, while Chinese Americans had high rates of stroke and hypertension mortality. The results can inform tailored screening, diagnosis, and prevention strategies to the unique risk profiles of Asian Indians, Chinese, and Filipino Americans. The study is published in Annals of Internal Medicine.
Researchers from Brigham and Women’s Hospital, Beth Israel Deaconess Medical Center, and Mount Sinai Fuster Heart Hospital studied death certificate data from the Centers of Disease Control and Prevention’s WONDER database of adults aged 18 and older who were identified as Asian Indian, Chinese, or Filipino between 2018-2023. The researchers found that cardiovascular related age-standardized mortality rates (ASMRs) were highest among Filipino American females and males. Asian Indian American and Chinese American females had similar cardiovascular ASMRs, while Asian Indian American males had higher cardiovascular ASMRs than Chinese American males. When stratified by cardiovascular subtypes, Asian Indian Americans had higher rates of heart disease and diabetes mortality, whereas Chinese Americans had higher burdens of stroke and hypertension mortality. The findings suggest that targeted public health efforts to reduce cardiovascular mortality are necessary.
Media contacts: For an embargoed PDF, please contact Gabby Macrina at gmacrina@acponline.org. To contact corresponding author Deepak L. Bhatt, MD, MPH, MBA please email Ilana Nikravesh at ilana.nikravesh@mountsinai.org.
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3. High tibial osteotomy may modify natural course of knee osteoarthritis in middle-aged adults
Abstract: https://www.acpjournals.org/doi/10.7326/ANNALS-25-00920
URL goes live when the embargo lifts
A randomized trial with a parallel preference arm evaluated the efficacy of medial opening wedge high tibial osteotomy (HTO) compared with nonsurgical management in patients with symptomatic medial compartment knee osteoarthritis and varus alignment (bowed legs). The study found that medial opening wedge HTO slows the progression of structural joint damage and improves clinical outcomes in these patients, and these findings were consistent across the randomized and preference trial arms. The study is published in Annals of Internal Medicine.
Researchers from London Health Sciences Centre Research Institute (LHSCRI), Western University, Fowler Kennedy Sport Medicine Clinic, and colleagues studied data from 145 middle-aged adults at a tertiary care center with varus alignment and symptomatic medial compartment knee osteoarthritis. Patients who agreed to be randomly assigned were allocated to either receive nonsurgical management for three months followed by medial opening wedge HTO (HTO group) or nonsurgical management alone (control group). Patients who declined to be randomly assigned participated in the preference arm. Nonsurgical management was consistent with guideline recommendations and included exercise therapy, weight management, and pain medications when needed. The primary outcome was change in articular cartilage thickness in the medial tibiofemoral compartment from baseline to two years of follow-up. The suggested minimal clinically important difference (MCID) for the loss of medial tibiofemoral articular cartilage thickness is 6.3%. Secondary outcomes were patient-reported outcome measures using the Knee Injury and Osteoarthritis Outcome Score (KOOS) and gait biomechanics. A total of 30 HTO and 29 control participants in the randomized arm and 36 HTO and 29 control participants in the preference arm were assessed at two years of follow-up. In the HTO group, the mean 2-year change in medial tibiofemoral articular cartilage thickness was -0.07 mm (CI, -0.15 to 0.01mm), corresponding to a loss of 2%. In the control group, the change was -0.25 mm (CI, -0.33 to -0.17 mm), corresponding to a loss of 9% from baseline. These findings were consistent in the preference arm as well. Large improvements in pain, function and gait biomechanics also favored HTO in both the randomized and preference arms. The findings suggest that medial opening wedge HTO modifies the natural course of knee osteoarthritis among this subgroup of patients.
Media contacts: For an embargoed PDF, please contact Gabby Macrina at gmacrina@acponline.org. To contact corresponding author Trevor B. Birmingham, PhD, please email Celine Zadorsky at media@lhsc.on.ca.
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4. Rituximab not superior to glucocorticoids in inducing remission in patients with eosinophilic granulomatosis with polyangiitis
Abstract: https://www.acpjournals.org/doi/10.7326/ANNALS-24-03947
URL goes live when the embargo lifts
A phase 3, multicenter, randomized controlled trial compared rituximab with conventional strategy for the induction of remission in patients with eosinophilic granulomatosis with polyangiitis (EGPA). The trial found rituximab was not superior to the conventional strategy for inducing remission in patients with EGPA. As a result, the role of rituximab in guidelines and recommendations around the therapeutic management of EGPA has been updated. The study is published in Annals of Internal Medicine.
Researchers funded by the French Ministry of Health studied 105 patients aged 18 and older with a diagnosis of EGPA between December 2016 and October 2019. Patients were eligible if they had a diagnosis of EGPA regardless of antineutrophil cytoplasmic antibody (ANCA) status; had newly diagnosed or relapsing disease at the time of screening; had active disease defined as a Birmingham Vasculitis Activity Score (BVAS), version 3, of 3 or greater; and were within the first 21 days of initiating or increasing glucocorticoids at a dose of 1 mg/kg per day or less. Eligible patients were randomly assigned to either receive induction therapy with rituximab (experimental group) or a conventional five-factor score-based strategy (control group). The primary end point was the percentage of patients who achieved remission, defined as the absence of disease activity attributable to EGPA corresponding to a BVAS of 0 at prednisone dose of 7.5 mg/d or less, at 180 days after randomization. Secondary endpoints included duration of remission during the study, average daily glucocorticoid dose, and safety. 33 patients (63.5%) in the rituximab group and 32 patients (60.4%) in the conventional strategy group achieved remission at 180 days (relative risk, 1.05 [95% CI, 0.78 to 1.42, P¼ 0.75). Results were similar at day 360. The mean duration of remission was 48.5±6.51 weeks in the rituximab group and 49.1±7.42 weeks in the conventional strategy group. The number of adverse events was also similar between the two groups. The results show that rituximab was not superior to the conventional strategy in inducing remission in patients with EGPA. In nonsevere EGPA, glucocorticoids alone remain the standard of care, whereas cyclophosphamide remains the standard for patients with severe disease.
Media contacts: For an embargoed PDF, please contact Gabby Macrina at gmacrina@acponline.org. To contact corresponding author Pr. Benjamin Terrier please email benjamin.terrier@aphp.fr.
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Also new this issue:
The Risks of Risk Assessment: Causal Blind Spots When Using Prediction Models for Treatment Decisions
Nan van Geloven, PhD, et al.
Research and Reporting Methods
Abstract: https://www.acpjournals.org/doi/10.7326/ANNALS-24-00279
Journal
Annals of Internal Medicine
Method of Research
News article
Subject of Research
People
Article Title
Social Determinants of Health and Risk of Long COVID in the U.S. RECOVER-Adult Cohort
Article Publication Date
29-Jul-2025
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