Our study focused on understanding PCC among COVID-19 survivors in Uganda, with little known about the condition, its risk factors, and the aspect of post-COVID care. We identified a significant proportion of individuals experiencing PCC in both Wave 1 (16%) and Wave 2 (20%), translating into approximately 1 in 5 previously-hospitalized individuals. Having comorbidities during both waves and moderate and severe disease during Wave 1 were associated with PCC. Most individuals reported not seeking care for the condition, even when they needed it, with the most sighted reason being the belief that their symptoms would resolve.
Although the cause of PCC remains largely unknown [11], post-viral syndromes, with varied symptoms and some similar to those in our study, have been reported for viruses such as Ross River virus [18], Epstein-Barr virus [18, 19], Chikungunya virus [20] and Ebola virus [21]. The possible mechanisms that explain PCC, such as seen in our study, have been linked to endothelial dysfunction due to the effect of SARS-COV-2 on ACE2 inhibitors or vascular inflammation [22] or an over-immunosuppression [23] leading to multisystemic effects. The proportion of individuals experiencing PCC in our study is different from those in other African countries. A study in South Africa showed that 4 in 5 participants and 2 in 3 participants experienced new or persistent COVID-19 symptoms at 1 and 3 months following hospitalization [12], while another in Nigeria had a proportion of 4 in 10 participants expressing PCC symptoms [15]. The difference in these proportions being higher than those highlighted in our study might have been due to the prospective nature of the study compared to our retrospective study. Due to low levels of bias and confounding factors, prospective studies may be more reliable than retrospective studies [24, 25]. However, for the study in Nigeria, patients reported to the survivor’s clinic 2 weeks after hospitalization, and no time was allocated to gauge the persistence of these symptoms beyond 4 weeks for mild disease and beyond 8 weeks for severe disease, as was done for our study. The short period following hospitalization might have contributed to a higher prevalence than in our study. Overall, the varied proportions of PCC as seen in other studies outside Africa might have been due to a difference in case definitions, study populations, study design, or the period of follow-up after the initial acute phase of COVID-19.
Our study confirmed that individuals with a history of moderate or severe COVID-19 disease during Wave 1 and those with comorbidities were at a significantly higher risk of developing PCC. Comorbidities were previously associated with the condition in other studies [26, 27], while the severity of the disease has also been previously associated with PCC [15]. In contrast to our study, older age, female sex, and smoking were also found to be associated with PCC in one study [13], while another study in children and adolescents reported muscle pain at admission, older age, and intensive care admission [14]. The difference in these associations with PCC in different studies and in different time periods highlights the importance of continuous research and context-specific tailored post-discharge care plans for these vulnerable groups.
A substantial proportion of individuals who experienced PCC symptoms did not seek care from health workers, despite acknowledging the need for medical attention. Reasons for not seeking care included the expectation that symptoms would resolve and logistical barriers, such as not knowing where to seek care and financial constraints. Although PCC has been shown to impact health-related quality of life (HRQoL) [28–30], seeking care for individuals in African settings for PCC has been a problem, attributed to several factors, including lack of awareness, as evidenced in a study in Ethiopia [31]. The belief that symptoms may subside, findings similar to our study have also been highlighted [31]. Nevertheless, health-seeking for PCC has been a problem, even in advanced health systems such as in England, with approximately 1 in 4 seeking care, findings similar to our study [32]. These findings underscore the importance of public health campaigns and accessible healthcare services to address PCC-related health-seeking behaviors to raise awareness about the persistence of symptoms and the importance of seeking medical care, with the rehabilitation of PCC patients helping a return to normal health [33, 34].
This study has strengths and limitations. First, this is the first study in Uganda, to the best of our knowledge, that sought to understand PCC and its associated risk factors. However, several limitations should be considered when interpreting our findings. Firstly, the retrospective nature of the study and the use of self-reporting might have introduced social desirability and recall biases. Secondly, our study was conducted in two regional referral and urban hospitals, potentially limiting generalizability to other healthcare settings, most especially those in rural settings in Uganda. Thirdly, our study was conducted among previously-hospitalized individuals, as we could not find data on non-hospitalized individuals and the rapid nature of the study. This might have introduced a population bias due to the effects of hospital stay among some individuals. Comparative studies in a non-hospitalized population would have been ideal.