Factors associated with long COVID in sub-Saharan Africa: a scoping review

Abstract

Background

Long COVID is a condition characterized by persistent symptoms of COVID-19 that continue to occur in patients after apparent recovery. Given that, these symptoms may vary from person to person due to clinical, demographic, and genetic factors as well as comorbidities, our review aims to identify and analyze risk factors associated with persistent symptoms of COVID-19 (long COVID) in the specific context of sub-Saharan Africa.

Methods

Article searches were conducted in the PubMed, Scopus, African Journals Online (AJOL), Science Direct and Google Scholar databases using the keywords “long COVID” or “long-term COVID-19” or “post-COVID condition” or “post-acute sequelae of COVID-19” and “sub-Saharan Africa” or “sub-Saharan Africans”. The obtained data were entered into software for duplication checking. Two reviewers selected and extracted the data. Due to substantial heterogeneity in definitions and study designs, a narrative synthesis approach was adopted. Fifteen studies were included in this review, totaling 8,233 participants previously infected with SARS-CoV-2, with approximately 2,011 patients with long COVID from six countries. Six studies were cross-sectional, three were retrospective, three were cohort studies, two were case-control, and one was a case report.

Results

The review found that the prevalence of long COVID in sub-Saharan Africa ranged from 2% in Ghana to 66.7% in South Africa. The persistent COVID-19 symptoms most commonly experienced by people living in sub-Saharan Africa were fatigue (reported in 12 studies, 25–66% of patients), cough (7 studies, 9–86%), chest pain (9 studies, 9%-29%), dyspnea (10 studies, 15–45%), palpitations (4 studies, 10–30%), headache (9 studies, 12–38%), and cognitive impairment (6 studies, 8–20%). The main risk factors for the occurrence of persistent COVID-19 symptoms were older age (˃ 60 years), female sex, low education level, hypertension, type 2 diabetes, cardiovascular disease, length of hospitalization during the acute episode, number of initial COVID-19 symptoms, and initial disease severity.

Conclusion

Long COVID is a reality in sub-Saharan Africa. Fatigue and hypertension have proven to be the most common symptom and risk factor, respectively. The heterogeneity of long COVID definitions across studies limits direct prevalence comparisons. Given the socio-economic challenges, pre-existing comorbidities and differences in health systems in the sub-Saharan region, it is therefore necessary to develop new strategies for care, rehabilitation and treatment (specific to the realities of the sub-Saharan region) targeted at each persistent symptom of COVID-19 in order to resolve this emerging problem and allow patients to have a good quality of life.

Clinical trial number

Not applicable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-026-12942-2.

Background

Coronavirus disease (COVID-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that spread to all corners of the globe starting in late December 2019 from Wuhan city in China [1–4]. This pandemic has caused more than 6.5 million confirmed deaths and more than 600 million cases globally, with significant impacts in sub-Saharan Africa despite mortality initially being reported as lower than in other regions [5–7]. While attention initially focused on the acute phase of infection and associated mortality, it is now established that a substantial number of patients estimated at between 10% and 30% depending on the study continue to experience persistent symptoms well after acute infection, a condition now recognized as “long COVID”, “post-COVID-19 syndrome” or “post-acute sequelae of SARS-CoV-2 infection” (PASC) [8–10]. In sub-Saharan Africa, data on the prevalence and characteristics of long COVID remain fragmentary, but emerging studies suggest that this condition represents a considerable and underestimated health burden in the region [11].

Long COVID is characterized by the persistence of symptoms or the appearance of new symptoms beyond the acute phase of SARS-CoV-2 infection [12, 13]. According to the World Health Organization (WHO), long COVID is defined as a condition that occurs in individuals with a history of probable or confirmed SARS-CoV-2 infection, usually 3 months after the onset of COVID-19, with symptoms that persist for at least 2 months and cannot be explained by another diagnosis [14]. However, operational definitions vary across studies and health organizations. The National Institutes of Health (NIH) uses the term PASC (Post-Acute Sequelae of SARS-CoV-2) to refer to long-term effects appearing or persisting beyond 4 weeks after initial infection [15]. Whereas, the UK National Institute for Health and Care Excellence (NICE) distinguishes ongoing symptomatic COVID-19 (4–12 weeks) from “post-COVID-19 syndrome” (> 12 weeks) [16]. The United States CDC defines long COVID as the persistence of symptoms beyond 12 weeks after initial infection [17]. This variety of definitions complicates the comparison of studies and highlights the importance of harmonizing diagnostic criteria, particularly in the African context where diagnostic resources may be limited. The clinical picture of long COVID is heterogeneous, with more than 200 documented symptoms affecting virtually all organ systems [18]. The most frequently reported manifestations include persistent fatigue, shortness of breath, cognitive impairment (brain fog), chest pain, headache, myalgia, sleep disturbances, persistent anosmia/ageusia, gastrointestinal disturbances, and neuropsychiatric symptoms such as anxiety and depression [19, 20].

Sub-Saharan Africa has unique characteristics that may influence the epidemiology, clinical manifestations and management of long COVID, namely, a very youthful population (median age of 19.7 years compared with 38.4 years in Europe) that may potentially modify the prevalence and presentation of long COVID, a high prevalence of chronic infectious comorbidities (HIV/AIDS, tuberculosis, malaria) and an ever-increasing prevalence of non-communicable diseases (hypertension, diabetes, cardiovascular diseases), the coexistence of malnutrition and obesity as well as high exposure to environmental factors (air pollution, occupational exposure) [21–25]. Most of sub-Saharan Africa appears to be escaping COVID-19 despite health systems considered fragile [21] and facing many challenges, including access to primary health care with an average of 2 doctors per 10,000 inhabitants, compared with 35 per 10,000 in Europe [26]. The other challenges included the limited availability of diagnostic tests for SARS-CoV-2 limiting the identification of confirmed cases, limited capacity for patient follow-up after the acute phase (less than 30% of countries have post-COVID rehabilitation programs), insufficient resources for epidemiological surveillance of long COVID, lack of personnel trained in the recognition and management of post-COVID sequelae, fragmentation of health systems and poor coordination between different levels of care [27–29].

In sub-Saharan Africa, 40% of the population lives below the poverty line [30]. There is also a high population density in urban areas with overcrowded housing limiting isolation, a predominant informal economy (62% of jobs) limiting the ability to take time off work, limited access to health information and variability of beliefs about COVID-19, with traditional medicine playing an important role in treatment pathways [31–33]. The consequences that arise from these problems are numerous. For example, there is the possibility of significant under-diagnosis due to constraints in access to care and testing, challenges in professional reintegration of people affected by long COVID as well as the need for approaches adapted to the local context for the identification and management of patients [34, 35].

This scoping review aims to: (1) identify risk factors associated with the development of persistent COVID-19 symptoms in sub-Saharan Africa; (2) analyze how these risk factors differ from those identified in other regions of the world; (3) examine the implications for clinical management and public health policy; and (4) identify gaps in current knowledge requiring further research.

Methods

Conceptual framework

This review follows the methodological framework for scoping reviews proposed by Arksey and O’Malley, with improvements suggested by Levac et al., and the Joanna Briggs Institute [36–38].

Research questions as the prevalence and manifestation, then risk factors then comorbidities

These studies were selected based on the following key research questions:

• How do the prevalence and manifestations of long COVID differ in sub-Saharan Africa compared with other regions?

• Which are the risk factors associated with the development of persistent symptoms of COVID-19 in sub-Saharan Africa?

• What are the specific comorbidities that increase the risk of long COVID in this region?

Search strategy

Databases and sources

Searches were conducted in the Pubmed, Scopus, African Journals Online (AJOL), Science Direct, and Google Scholar databases. While Science Direct (Elsevier) is a publisher platform and Google Scholar is a search engine rather than bibliographic databases, they were included to maximize capture of relevant literature, particularly grey literature and regional publications that may not be indexed in traditional databases.

Search strategies and terms

The research was conducted in English and French. In order to address the research questions raised, we conducted searches in the PubMed, Scopus, AJOL, Science Direct, and Google Scholar databases. Comprehensive search equations were developed for each database, tailored to their specificities, using the following MeSH Terms and keywords: “COVID-19” OR “SARS-CoV-2” OR “coronavirus” OR “corona virus” OR “2019-nCoV” OR “novel coronavirus” OR “coronavirus disease 2019” OR “coronavirus outbreak” OR “pandemic” AND “long COVID” OR “post-COVID syndrome” OR “post-acute COVID-19” OR “post-acute sequelae of SARS-CoV-2” OR “PASC” OR “persistent symptoms” OR “prolonged symptoms” OR “chronic COVID” OR “long-haulers” OR “long-term effects” OR “long-term sequelae” OR “post-viral fatigue” OR “post-infectious syndrome” OR “convalescence” OR “persistent illness” OR “chronic symptoms” OR “post-acute” OR “post-discharge” OR “sequelae” AND “Sub-Saharan Africa” ​​OR “African countries” OR “Angola” OR “Benin” OR “Botswana” OR “Burkina Faso” OR “Burundi” OR “Cabo Verde” OR “Cameroon” OR “Central African Republic” OR “Chad” OR “Comoros” OR “Congo” OR “Côte d’Ivoire” OR “Ivory Coast” OR “Djibouti” OR “Equatorial Guinea” OR “Eritrea” OR “Eswatini” OR “Ethiopia” OR “Gabon” OR “Gambia” OR “Ghana” OR “Guinea” OR “Guinea-Bissau” OR “Kenya” OR “Lesotho” OR “Liberia” OR “Madagascar” OR “Malawi” OR “Mali” OR “Mauritania” OR “Mauritius” OR “Mozambique” OR “Namibia” OR “Niger” OR “Nigeria” OR “Rwanda” OR “São Tomé and Príncipe” OR “Senegal” OR “Seychelles” OR “Sierra Leone” OR “Somalia” OR “South Africa” ​​OR “South Sudan” OR “Sudan” OR “Tanzania” OR “Togo” OR “Uganda” OR “Zambia” OR “Zimbabwe” AND “risk factors” OR “risk assessment” OR “predictors” OR “determinants” OR “comorbidities” OR “associated factors” OR “prognostic factors” OR “epidemiology” OR “disease susceptibility” OR “vulnerability” OR “predisposition” OR “characteristics” OR “correlates” OR “prevalence” OR “incidence” OR “mortality” OR “morbidity” OR “outcomes” OR “prognosis” OR “severity”.

Reference management

All references were imported into the bibliographic management software Zotero (version 7.0), for duplicate removal and screening. References were formatted according to Vancouver style, with platform-specific details (URLs, access dates) removed except for online-only sources.

Inclusion and exclusion criteria

Inclusion criteria

Included in this scoping review were studies on persistent COVID-19 symptoms conducted in sub-Saharan Africa or including data from these countries, and published in English, French, or other languages with available translation. Also included were studies identifying risk factors, predictors or determinants of long COVID or studies published between January 2021 and October 2024 as well as primary research articles, conference abstracts, meta-analyses, and health agency reports. Study designs included were: cross-sectional studies, prospective and retrospective cohort studies, case-control studies, and case reports. The target population consisted of adults (≥ 18 years) with confirmed or probable SARS-CoV-2 infection. The primary outcome was the presence of persistent symptoms at least 4 weeks after acute infection.

Exclusion criteria

Studies that were not conducted in a sub-Saharan African (SSA) country or that focused solely on the acute phase of COVID-19 were not included in our review. Comments, editorials or practice guidelines were also excluded.

Case reports were included given the limited evidence base on long COVID in SSA. They contribute important clinical observations about atypical presentations that may not be captured in larger studies. However, findings from case reports are clearly distinguished from higher-quality evidence throughout the results and their limitations are acknowledged in the interpretation.

Data extraction and synthesis

Data extraction was performed by a first reviewer and verified by a second reviewer. We created a data extraction table to extract data from the included articles. The data collected consisted of study characteristics (authors, year of publication, country, study type), study population (sample size, demographic characteristics), definition used for long COVID, identified risk factors (demographic, clinical, socioeconomic), strength of associations (odds ratios, relative risks) and main findings. Due to substantial heterogeneity in long COVID definitions, study designs, follow-up periods, and outcome measures across included studies, a narrative synthesis approach was adopted rather than quantitative meta-analysis. Themes and patterns were identified by tabulating findings across studies and grouping them by risk factor category (demographic, clinical, comorbidity-related).

Quality assessment

Methodological quality of included studies was assessed using the Joanna Briggs Institute (JBI) critical appraisal tools appropriate for each study design: the JBI checklist for analytical cross-sectional studies (8 items), the JBI checklist for cohort studies (11 items), the JBI checklist for case-control studies (10 items), and the JBI checklist for case reports (8 items) [39, 40]. Two reviewers independently assessed each study, with disagreements resolved through discussion. Studies were categorized as low, moderate, or high risk of bias based on the proportion of criteria met. Results are presented in Supplementary Table S1.

Results

Overview of included studies

The systematic search identified 925 records: PubMed (n = 245), Scopus (n = 189), Science Direct (n = 156), AJOL (n = 23), and Google Scholar (n = 312). After removing 287 duplicates, 638 records were screened by title and abstract, of which 589 were excluded for not meeting inclusion criteria (wrong geographic region, focus on acute COVID-19 only, or wrong study type). Full-text review of 49 articles led to exclusion of 34 studies, leaving 15 studies for inclusion in the final synthesis.

The 15 included studies comprised: 6 cross-sectional studies, 3 retrospective studies, 3 cohort studies, 2 case-control studies, and 1 case report. Studies originated from 6 countries: South Africa (n = 6), Nigeria (n = 3), Zambia (n = 2), Ghana (n = 2), Ethiopia (n = 1), and Uganda (n = 1). The total sample size across all studies was 8,233 participants, of whom approximately 2,011 had long COVID.

Selection of studies

The figure below shows the study selection flowchart inspired by the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) model [41] (Fig. 1).

Fig. 1.

PRISMA 2020 flow diagram showing number of records identified from each database: PubMed (n = 245), Scopus (n = 189), Science Direct (n = 156), AJOL (n = 23), Google Scholar (n = 312). Records excluded after title/abstract screening (n = 589); full-text articles excluded with reasons (n = 34)

Characteristics of the included studies

The representation of studies according to country of origin, study design, study settings, and information on participants’ vaccination status is represented in the Fig. 2 below.

Fig. 2.

Geographical breakdown of studies (A). Proportion of studies by country of origin (B), by study design (C), by recruitment settings (D), and by information on vaccination status (E). The included studies originated from six countries (red). No studies were reported in the other countries, including Cameroon in Central Africa (grey)

The definitions of long COVID varied across studies. This heterogeneity reflects the evolving understanding of the condition and different time points of study conduct relative to consensus definitions.

Prevalence of long COVID

The prevalence of long COVID varied substantially across studies, ranging from 2% in Ghana [42] to 66.7% in South Africa [43]. This wide range reflects differences in: (1) operational definitions used (symptom duration thresholds of 14 days to 12 weeks), (2) study populations (hospitalized vs. non-hospitalized patients), (3) follow-up periods (2 months to 2 years), and (4) ascertainment methods (self-report vs. clinical assessment). Studies using the WHO definition (symptoms ≥ 12 weeks) generally reported prevalences of 17–41%, while those using shorter thresholds (≥ 14 days or ≥ 4 weeks) reported higher prevalences (40–67%).

Symptomatic profile

The main symptoms mentioned in our review were fatigue, cough, dyspnea, headache [42–53]. Fatigue was the most consistently reported symptom, documented in 12 of 15 studies with prevalence ranging from 25% to 66% among long COVID patients. Dyspnea was reported in 10 studies (15–45% prevalence), followed by headache (9 studies, 12–35%), chest pain (8 studies, 10–27%), cognitive impairment including memory difficulties and concentration problems (6 studies, 8–20%), sleep disturbances (6 studies, 10–25%), and persistent cough (7 studies, 9–37%). Apart from these, a case report in a Ugandan woman presented polyphagia as an atypical presentation; however, this represents a single observation and should be interpreted with caution [54].

Table 1 below presents the main persistent symptoms experienced by participants.

Table 1.

Predominant symptoms and comorbidities

Authors	Predominant symptoms	Comorbidities
Elias et al. [44]	Fatigue (27.5%), Cough (15.3%)	Not reported
Malambo et al. [45]	Cough (38.7%), fatigue (38.5%), shortness of breath (26.5%), chest pain (20.9%), headache (14.8%), muscle aches/pain (14.1%), palpitations (12.5%), joint aches/pain (11.9%), and forgetfulness or brain fog (8.0%)	Hypertension (71.1%), diabetes (26.3%), HIV (25.2%) and cardiovascular disease (11.2%)
Nuamah et al. [42]	Cough (64.0%), headache (38.7%), and chest pain (28.1%)	Hypertension (39.8%)
Seyoum et al. [46]	Cough (86.9%), easy fatigability (69.4%), loss of appetite (54.8%), and fever (53.1%)	Diabetes Mellitus and hypertension were the most common comorbid illnesses during the time of admission, being present in 35.3% and 30.4% of participants respectively
Crankson et al. [55]	Not reported	Hypertension (2.5%), diabetes mellitus (4.3%), hypertension and diabetes mellitus (8.7%), and neurological diseases (50%)
Dryden et al. [47]	Fatigue (50.3%), shortness of breath (23.4%), confusion or lack of concentration (17.5%), headaches (13.8%) and vision problems/blurred vision (10.1%)	Hypertension (35.7%), obesity (25.3%), diabetes mellitus (22.3%), HIV (5.1%)
Kinge et al. [48]	Fatigue (42%), anxiety (34%), difficulty sleeping (31%), chest pain (24%), muscle pain (21%), and brain fog (21%)	The most frequently reported comorbid condition was hypertension, particularly among workers aged 45 to 55 years.
Kruger et al. [49]	Fatigue (74%), cognitive impairment (71%), dyspnea (59%), depression and anxiety (30%), arthralgia/myalgia (49%), sleep disturbance (34%), palpitations (30%), chest pain (29%), anosmia (25%), dysgeusia (25%), hypoxemia (13%)	Hypertension (24%), hyperlipidemia (19%), type 2 diabetes mellitus (6%), thrombosis (3%), cardiovascular diseases (3%), psoriasis (2%), rheumatoid arthritis (2%), myocardial infarction (1%)
Mendelsohn et al. [43]	Dyspnea (20.1%), fatigue (34.5%), ageusia (19.5%), anosmia (18.4%), headache (15.5%), body aches (14.9%), chest pain (10.9%), gastrointestinal disturbances (12.1%), palpitations (10.3%), rash (6.3%)	Diabetes (22.0%), hypertension (48.4%), ischemic heart disease (4.4%), chronic obstructive pulmonary disease/asthma (6.3%), history of tuberculosis (0.6%), HIV (0.6%), other (4.4%)
Pretorius et al. [50]	Fatigue, brain fog, loss of concentration and forgetfulness, shortness of breath, joint and muscle pain	Hypertension, dyslipidemia, cardiovascular diseases, type 2 diabetes mellitus
Walker et al. [71]	Not reported	Not reported
Zulu et al. [51]	Cough (37%), headache (26%), chest pain (22.2%), rhinorrhea (18.5%), fatigue (14.8%), appetite (14.8%), arthralgia (14.8%), myalgia (7.4%), abdominal pain (11.1%)	HIV (7.4%)
Kaggwa et al. [54]	Polyphagia and weight gain	Not reported
Ogoina et al. [52]	Cough (n = 9), fatigue (n = 8), shortness of breath (n = 5), chest pain (n = 4), palpitations (n = 2), anxiety (n = 3), anorexia (n = 3)	History of diabetes (66.7%), history of hypertension (66.7%) The occurrence of persistent COVID-19 symptoms was increased according to the initial severity of COVID-19 disease (mild COVID-19) (p = 0.029)
Osikomaiya et al. [53]	Easy fatigue (12.8%), headache (12.8%), chest pain (9.8%), insomnia (9.8%), myalgia (8.8%), cough (9.2%), dyspnea (9.5%), loss of appetite (8.8%)	Hypertension (72.9%) and diabetes (15.3%)

Demographic risk factors

Age

Age has been mentioned as a risk factor for the occurrence of long COVID in several studies in our review [43, 44, 46, 47]. The study by Seyoum et al. found advanced age (˃ 60 years) to be a risk factor for the occurrence of long COVID [aOR = 4.405, 95% CI (1.52–12.5), p < 0.01] [46]. Similarly, Elias et al. showed that older age was a risk factor [aOR = 1.04, 95% CI (1.02–1.07), p = 0.001] [44]. The study by Dryden et al. also indicated that patient age (≥ 65 years) was a risk factor for the occurrence of long COVID [47]. On the other hand, Zulu et al. did not show that age was a risk factor for the occurrence of long COVID but in their study, they noted that the median age of participants with persistent symptoms was 33 years (IQR: 25–42) [51]. Median ages across the six studies reporting this variable ranged from 32 years [51] to 55 years [48], with four studies reporting medians above 45 years.

Sex

Some studies have found female sex to be a risk factor associated with symptom persistence after acute COVID-19 [44, 47]. These include studies by Elias et al., and Dryden et al [44, 47]. One study found that female sex increases the risk of developing post-acute COVID-19 syndrome (aOR = 1.82, 95% CI 1.00–3.29, p = 0.05), and another showed that being a woman is a factor associated with the persistence of symptoms after acute COVID-19 (aOR = 1.20, 95% CI 1.04–1.38, p = 0.01) [44, 47]. Some articles in our review nevertheless did not find sex to be a risk factor for the occurrence of persistent symptoms of long COVID but found that in the population of symptomatic patients (n = 27), a large proportion were female (17 or 63%) [43, 51].

Other demographic factors

Apart from the demographic risk factors mentioned, the level of education of patients is one. Crankson et al., showed that the risk of long COVID decreased with increasing patient education level (primary OR = 0.73, p = 0.02; secondary/professional OR = 0.26, p = 0.02; higher education OR = 0.23, p = 0.01) [55]. Indeed, patients with primary (OR = 0.73, 95% CI 0.01–0.66, p = 0.02), secondary/vocational (OR = 0.26, 95% CI 0.09–0.77, p = 0.02) and higher (OR = 0.23, 95% CI 0.07–0.72, p = 0.01) education levels had lower risks of a long COVID diagnosis compared to those with no formal education [55].

Clinical risk factors

Severity of initial infection

Initial disease severity, length of hospital stay, and number of symptoms were reported by some studies in our review as clinical risk factors for the occurrence of persistent COVID-19 symptoms [42–45, 51–53, 55]. Mendelsohn et al., Malambo et al., Osikomaiya et al., Ogoina et al., mentioned in their studies that the occurrence of long COVID increased with the initial severity of COVID-19 disease [43, 45, 52, 53]. For Ogoina et al., and Osikomaiya et al., for example, the presence of persistent COVID-19 symptoms was significantly associated with mild COVID-19 and moderate COVID-19 respectively [52, 53].

For the studies of Elias et al., Malambo et al., the duration of hospitalization was found to have an impact on the development of persistent symptoms of long COVID [44, 45]. Elias et al., in their study, just indicated that a long hospital stay increases the chances of developing persistent symptoms of COVID-19 (aOR 1.06, 95% CI 1.02–1.10, p = 0.003) without specifying the duration of hospitalization [44]. Malambo et al., went further by specifying that this duration of hospitalization is greater than or equal to 15 days (aOR 5.37; 95%, 95% CI 2.99–10.0, p < 0.001) [45]. Elias et al., on the other hand indicated that the average number of days of hospitalization for patients with persistent symptoms was 14 days [44]. Admission of patients to the intensive care unit (ICU) also increased their chances of presenting persistent symptoms of long COVID (aOR 1.17, 95% CI 1.01–1.37, p = 0.04) [47].

The number of symptoms experienced during the acute episode of the disease was another risk factor for the occurrence of long COVID [51]. Individuals with five or more symptoms at the onset were nearly three times more likely to report persistent symptoms than other symptomatic participants [51]. A particularity on certain symptoms was observed in some studies in our review. Indeed, according to Zulu et al., participants with loss of appetite at the onset of symptoms had higher odds of reporting persistent symptoms [51]. Nuamah et al. in turn, show that the odds of having persistent symptoms beyond 14 days are 98% higher in patients who experienced chest pain compared to those who did not [42].

Pre-existing comorbidities specific to the sub-Saharan context

Infectious diseases

Several infectious diseases were reported in the studies in our review. The most recurrent were HIV and tuberculosis [45, 48, 51]. Malambo et al., for example, showed that the presence of comorbidities including HIV was longitudinally associated with an odds ratio increased by 1.67 (95% CI 1.02–2.75, p = 0.04) [45].

Non-communicable diseases

Comorbidities encountered in the studies in our review were hypertension, diabetes mellitus, cardiovascular diseases, both hypertension and diabetes mellitus, tumors, neurological diseases, asthma, arthritis, renal failure, dyslipidemia [45, 48, 50, 55]. The presence of comorbidities was longitudinally associated with an increase in the odds ratio of long COVID by a factor of 1.67 (95% CI 1.02–2.75) in the study by Malambo et al [45]. For Crankson et al., regression analyses showed that on average, COVID-19 patients with hypertension and diabetes mellitus spent almost 2 days longer in the hospital (p = 0.00, 95% CI 1.42–2.33) and had 4 times the risk of long COVID (95% CI = 1.61–10.85, p = 0.003) compared to those without comorbidities [55]. In the Kinge et al. study, the most frequently reported comorbid condition was hypertension, especially among workers aged 45–55 years [48].

Table 2 summarizes the studies included in our scoping review, presenting the risk factors and prevalence of long COVID.

Table 2.

Summary of studies in the scoping review

Author (country)	Study period	Study Design	Sample Size	Long COVID Prevalence	Follow-up Window	Population Characteristics	Operational definitions of long COVID	Risk factors	Main Findings
Elias et al., 2024 (Ethiopia)	12 June 2020-1st November 2021	Cross-sectional	340	NR	25.6 months	Out of the 400 patients, 20 patients were dead, 14 patients refused to give consent, and 26 patients couldn’t be reached because their phones weren’t working. Finally, 340 were included in the study. The majority (68.5%) were male and the mean age was 53.9 (± 13.3 SD) years.	Persistence of any sign or symptom that was developed during the acute COVID-19 illness for more than twelve weeks after hospital discharge.	Older age (aOR 1.04, 95% CI 1.02–1.07, p < 0,01), female sex (aOR 1.82, 95% CI 1.00–3.29, p = 0,04), presence of comorbidity (aOR 2.38, 95% CI 1.35–4.19, p < 0,01), alcohol use (aOR 3.05, 95% CI 1.49–6.26, p < 0,01), fatigue at presentation (aOR 2.18, 95% CI 1.21–3.95, p < 0,01), and longer hospital stay (aOR 1.06, 95% CI 1.02–1.10, p = 0,01) were found to increase the odds of developing post-acute COVID-19 syndrome. Higher hemoglobin level was found to decrease the risk of subsequent post-acute COVID-19 syndrome (aOR 0.84, 95% CI 0.71–0.99, p = 0,04).	Nearly half of survivors experience long COVID for up to 2 years, dominated by fatigue, dyspnea, and cognitive impairment.
Malambo et al., 2024 (Zambia)	August 2020-January 2023	Cross-sectional	1,359	377/1359 (27.7%)	7 weeks (IQR 4–12 weeks)	Out of a total 1359 PAC-19 clinical patients in the cross-sectional analysis, 548 (40.3%) patients with ≥ 2 PAC-19 clinic visits were included in the longitudinal sub-analysis. Patients’ median age was 53 (IQR: 41–63) years, and 693 (52.9%) were female.	Presence of new, relapsing, or persistent COVID-19 symptoms.	Patients with hospital length of stay ≥ 15 days (aOR 5.37, 95% CI 2.99–10.0, p < 0,001), severe acute COVID-19 (aOR 3.22, 95% CI 1.68–6.73, p < 0,001), and comorbidities (aOR 1.50, 95% CI 1.02–2.21, p = 0,041) had significantly higher chance of long COVID.	Prolonged severe symptoms, predominantly fatigue and dyspnea
Nuamah et al., 2023 (Ghana)	1st April 2020-31 March 2022	Retrospective	350	NR	NR	Of the 350 participants, 253 (72.3%) presented with one or more symptoms of COVID-19 upon admission.	Symptoms of COVID-19 persisting beyond 14 days after symptom onset.	The odds of patients presenting with COVID-19 symptoms that persist beyond 14 days are 98% higher among patients who experienced chest pain compared to those who did not (aOR 1.98, 95% CI 1.10–3.55, p = 0.02) and 2% increased for each additional year of their age (aOR 1.02, 95% CI 1.00-1.04, p = 0.02).	Common respiratory and neurological symptoms
Seyoum et al., 2023 (Ethiopia)	January 2021-January 2022	Cross-sectional	405	NR	3 months	405 participants were randomly selected, 256 (63.2%) were male. The median age was 57 (43.0, 65.0) years.	Presence of 2 or more of persistent cough, persistent shortness of breath, increased respiratory rate (> 22 breaths per minute) and requirement of oxygen support (SpO2 < 90% on room air) was used to define post COVID-19 pulmonary complication during 3rd month visit.	Older age (aOR 0.227, 95% CI 0.08–0.66, p = 0,006) and consolidation (aOR 0.497, 95% CI 0.258–0.957, p = 0,036) were shown to have significant association with post COVID-19 pulmonary complications.	Prevalence of post-COVID-19 pulmonary complication in recovered COVID-19 patients was 14.1% (95% CI 10.8%, 17.8%).
Crankson et al., 2022 (Ghana)	March 2020-August 2021	Cross-sectional	2,334	50/2334 (2%)	NR	2334 participants, among them 50 had long COVID. 60.1% were men and 39.9% were women. The majority were aged from 30–59 years (57.5%).	Patients who still exhibited COVID-19 symptoms 4 weeks after the initial illness, without any other medical diagnosis.	COVID-19 patients with hypertension and diabetes mellitus spent nearly 2 days longer in the hospital (p = 0.00, 95% CI 1.42–2.33) and had four times the risk of developing long COVID (95% CI 1.61–10.85, p = 0.003) than those without comorbidities. Increasing patient education level decreased risk of long COVID.	Prolonged hospitalization is a major determinant of long COVID.
Dryden et al., 2022 (South Africa)	1st December 2020-23 August 2021	Cohort	1,873	1249/1873 (66.7%)	3 months	1873 participants hospitalized with COVID-19 were followed up 3 months after hospital discharge. 960 (53.1%) were women and 913 (48.8%) were men, the median age was 52 years (41–62).	Symptoms that generally appear within three months following the actual COVID-19 infection and last for at least two months.	Female sex (aOR 1.20, 95% CI 1.04–1.38, p < 0,05) and intensive care unit admission (aOR 1.17, 95% CI 1.01–1.37, p < 0,05).	Two-thirds of patients have at least one persistent symptom at 3 months.
Kinge et al., 2022 (South Africa)	5 January 2020-7 February 2021	Cross-sectional	62	15/62 (24,2%)	NR	62 frontline healthcare workers who have recovered from the acute phase of the disease. The median age was 33,5 years (IQR 30–44 years).	The presence of symptoms for four weeks and beyond in 2020 or the presence of symptoms lasting usually three months on from the onset of the COVID-19 with symptoms that last for at least two months and cannot be explained by an alternative diagnosis.	NR	Fatigue, cognitive impairment, and anxiety are common among healthcare workers.
Kruger et al., 2022 (South Africa)	NR	Case-control	99	NR	NR	99 participants with long COVID and 29 healthy controls. Median age: 51 years (40–60 years).	NR	NR	Long COVID is associated with persistent coagulopathy.
Mendelsohn et al., 2022 (South Africa)	15 December 2020-31 January 2021	Cross-sectional	174	172/653 (35%)	Approximately 2 months	174 participants with long COVID among 653 patients infected with COVID-19. The mean age of participants was 50.3 years (13.6 years); 62% were women.	Symptoms related to Coronavirus Disease 2019 (COVID-19) that persist for more than 28 days after the onset of the acute infection.	Self-reported non recovery (OR 14.99, 95% CI 5.94–37.84, p < 0.001)	A significant proportion of patients who had non-critical COVID-19 still have persistent symptoms two months after infection.
Pretorius et al., 2022 (South Africa)	NR	Cohort	845	NR	NR	845 participants. Gender balance (70% women) and most reported COVID-19/PASC symptoms. The majority (76%) of participants were aged 31–40, 41–50, and 51–60.	Persistent symptoms and new symptoms that were not present before the acute COVID-19 infection and that last for at least 2 months after recovery from the acute (infectious) COVID-19.	NR	Microclot and platelet pathologies were associated with long COVID/PASC symptoms that persisted after the recovery from acute COVID-19.
Walker et al., 2022 (South Africa)	NR	Case-control	60	NR	NR	30 matched healthy participants and 30 participants with long COVID.	NR	NR	Significant microclot load was observed in the Platelet poor plasma of participants with PASC
Zulu et al., 2022 (Zambia)	July 2020	Cohort	27	27/182 (37%)	54 days (IQR 46–59 days)	27 participants with long COVID. The mean age was 32 years (range 1–85 years). 17 (63.0%) were women.	Persistent symptoms ongoing since the diagnosis of SARS-CoV-2 infection, lasting for more than 4 weeks.	People with five or more symptoms at baseline were nearly three times more likely to report persistent symptoms than other symptomatic participants (OR 2.87, 95% CI 1.09–7.56, p = 0.03) as well as participants with loss of appetite at symptom onset (OR 3.40, 95% CI 1.30–8.86, p = 0.01).	Significant early symptom persistence
Kaggwa et al., 2021 (Uganda)	NR	Case report	1	NR	NR	1 Adult with post-COVID	Symptom that persisted 6 months after recovery from COVID-19.	NR	Unusual polyphagia and weight gain
Ogoina et al., 2021 (Nigeria)	April-December 2020	Retrospective	30	9/51 (17.65%)	7-238 days	30 participants were eligible for inclusion out of 51 previously hospitalized COVID-19 patients (median age: 46 years (32.5 years − 53 years). 66.7% were men.	Persistent or new COVID-19-related symptoms observed after discharge and at least 3 weeks after the initial COVID-19 symptoms.	NR	Frequent persistent symptoms after hospitalization
Osikomaiya et al., 2021(Nigeria)	April-June 2020	Retrospective	274	112/274 (40.9%)	15 days (IQR 14–17 days)	274 participants were included in the study. The majority were in the 35–49 age group (38.3%) and were male (66.1%).	The term persistent symptoms refers to self-reported COVID-19-like symptoms noted by patients during clinical examination and physical assessment at the post-COVID-19 clinic.	Moderate versus mild symptomatic COVID-19 disease was a predictor of persistent COVID-like symptoms after discharge, (aOR 2.03, 95% CI 1.19–3.47, p < 0,05).	High prevalence of fatigue and dyspnea

aOR: adjusted Odds Ratio, CI: Confidence Interval, NR: Not Reported, IQR: Interquatile Range

Vaccination Status

Only three studies (representing 20%) reported the COVID-19 vaccination status of patients [44, 45, 47]. In the study by Malambo et al., among patients with persistent COVID-19 symptoms, 21.9% were vaccinated and 78.1% unvaccinated; meanwhile, 75.8% of unvaccinated patients and 24.2% of vaccinated patients had no persistent COVID-19 symptoms [45]. In contrast, the study by Elias et al. reported that 34.1% and 39.7% of patients who had been vaccinated at least once and those who were unvaccinated, respectively, presented with persistent COVID-19 symptoms [44]. In the same study, 65.9% of unvaccinated patients had no persistent symptoms, compared to 60.3% [44]. Dryden et al. only presented the vaccination status of patients according to sex, showing that 49.8% of women and 50.8% of men had received at least one dose of a COVID-19 vaccine [47]. None of the cited studies provided the names of the vaccines received by the patients, limiting the ability to assess vaccine-specific effects on long COVID risk.

Discussion

This scoping review identified and analyzed risk factors associated with long COVID in sub-Saharan Africa based on 15 studies comprising 8,233 participants across six countries. The prevalence of long COVID ranged widely (2–67%), reflecting heterogeneity in definitions and study populations. The results of the different studies show that persistent symptoms of COVID-19 affect several body systems, the major ones being the central nervous, respiratory, digestive, musculoskeletal and cardiovascular systems. The chances of suffering from persistent symptoms of COVID-19 were increased in the presence of high blood pressure (hypertension), diabetes and depending on the length of hospitalization during the acute phase, the number of initial symptoms of COVID-19, and the initial severity of the disease. Besides these clinical risk factors, age, sex and education level were the main sociodemographic risk factors associated with the occurrence of persistent symptoms of long COVID.

Comparison with global findings

The risk factors identified in this review show both similarities and differences compared to global literature. Similar to findings from high-income countries, female sex, older age, and pre-existing comorbidities (hypertension, diabetes, cardiovascular disease) emerged as consistent risk factors across SSA studies. Two meta-analyses from global data [56, 57] identified these same factors, suggesting biological mechanisms that transcend geographic boundaries [56, 57]. However, several features distinguish the SSA context: (1) the potential role of HIV co-infection as a risk factor, which is rarely examined in studies from other regions; (2) the younger overall population in SSA, which may modify the age-risk relationship; (3) limited access to healthcare and follow-up, which may lead to underdiagnosis of milder cases; and (4) higher prevalence of infectious disease comorbidities that may interact with SARS-CoV-2 infection.

According to the studies in our review [43, 47], women have been shown to be more predisposed to developing long COVID compared to men, even though women generally have stronger initial immune responses that may protect against severe acute infection [56, 58]. The sex-based difference in long COVID risk may be explained by differential T-cell activity. Women typically show more robust early T-cell responses, which while protective during acute infection, may paradoxically contribute to prolonged inflammation and viral persistence in tissues, leading to long-term symptoms [59]. Similar results were shown by Zemni et al., in North Africa [60]. They found that female sex was a risk factor for the occurrence of long COVID. Two meta-analyses also identified female sex as a risk factor for persistent COVID-19 symptoms [57, 61].

The level of education was also identified as a risk factor associated with persistent symptoms of COVID-19. Indeed, the more knowledge one has about a disease, the better-informed one is about prevention and protection measures, which in turn saves the sick person from developing a chronic form. This was verified in the study by Crankson et al.; This study showed that the more the patient’s level of education increased, the risk of presenting persistent symptoms of COVID-19 decreased [55].

Age emerged as a significant risk factor in multiple studies, with patients over 60 years showing substantially higher odds of developing long COVID. The median ages reported across six studies ranged from 32 years [51] to 55 years [48]. A Danish cohort study showed that the risk of long COVID diagnosis is higher in individuals from sub-Saharan Africa aged over 60 years compared to those from North Africa, Asia, Central and Eastern Europe [62].

Cardiovascular diseases, hypertension, and type 2 diabetes mellitus were the main comorbidity-related risk factors for long COVID in the included studies. Zemni et al., Moyo et al., and Salukhov et al. have also reported similar associations in Tunisian, South African and Russian studies respectively [60, 63, 64]. The mechanistic link between cardiovascular disease and long COVID may relate to shared pathophysiology: ACE2 expression is upregulated in failing human hearts, potentially explaining both higher acute infectivity and persistent cardiovascular symptoms in patients with pre-existing heart disease [65, 66].

Implications for clinical practice

Given that our review identified hypertension, diabetes, cardiovascular disease, older age, and female sex as major risk factors for long COVID, clinical practice should focus on: (1) systematic screening of high-risk patients during and after acute COVID-19 infection; (2) early referral protocols for patients presenting with multiple initial symptoms or requiring prolonged hospitalization; (3) patient education on warning signs that should prompt medical consultation; and (4) follow-up scheduling based on individual risk stratification. Management of long-term COVID-19 patients must be multidisciplinary due to the multiple systems affected including pulmonology for respiratory symptoms, cardiology for cardiovascular complications, neurology for cognitive impairment, physical rehabilitation for fatigue and deconditioning, and mental health support for anxiety and depression [67]. The WHO rehabilitation guidelines provide a framework for post-COVID care that can be adapted to the SSA context [68]. The SPACO+ study represents a concrete example of an integrated educational intervention program being implemented in France and Cameroon [69].

Implications for public health policies

Given that our review identified hypertension, diabetes, and cardiovascular disease as major risk factors for long COVID in SSA, public health policies should prioritize integration of long COVID screening and management into existing chronic disease programs. Given the relatively insufficient number of doctors in the sub-Saharan context with an ever-growing population and in an effort to reduce their workload, paramedical staff should be trained in the detection and management of long COVID cases through task-shifting strategies that have proven effective for other chronic conditions in the region. Furthermore, given the sometimes less than ideal health system in some countries in sub-Saharan Africa, health policies should seek to improve access to health care for patients with long COVID and, above all, opt for international collaborations to share knowledge and experience.

Knowledge gaps and research priorities

This review identified several important gaps in the current literature on long COVID in SSA: (1) Absence of standardized long COVID definitions across studies, limiting prevalence comparisons and pooled analyses; (2) Lack of data on socioeconomic and environmental risk factors, despite their potential relevance in the SSA context; (3) Unknown impact of neglected tropical diseases (NTDs) on long COVID risk, particularly as certain NTDs are known to alter immune responses [70]; (4) Limited data on vaccination effects, with only three studies reporting vaccination status and none examining vaccine-specific effects; (5) Absence of longitudinal follow-up studies beyond 2 years, leaving the natural history of long COVID in SSA unknown; (6) No health economic assessments of the burden of long COVID in SSA. Future research should prioritize prospective cohort studies with standardized definitions, investigation of NTD interactions, and health economic evaluations to inform resource allocation.

Strengths and limitations

Strengths of this review include: comprehensive search strategy across multiple databases including regional African sources (AJOL); inclusion of studies in both English and French to capture francophone African literature; use of established scoping review methodology; and quality assessment of included studies. Our review had some limitations. The first limitation concerns the number of included studies and the fact that none addressed the influence of socioeconomic and environmental risk factors. The second concerns the investigation of a possible impact of neglected tropical diseases (NTDs) on the development of long COVID symptoms in sub-Saharan Africa, especially as certain NTDs are known to alter immune responses and thereby reduce immunity against tuberculosis, a comorbidity of long COVID [70]. Third, the heterogeneity of long COVID definitions across studies limits direct prevalence comparisons. Fourth, the use of Google Scholar, while useful for capturing grey literature, introduces potential limitations in reproducibility. Fifth, the quality assessment revealed that most studies had moderate risk of bias, primarily related to selection methods and incomplete outcome assessment. Finally, publication bias cannot be excluded, particularly given the challenges of publishing from resource-limited settings.

Conclusions

In this review, the results of which will be used for the SPACO+ study, allowed us to examine the risk factors for long COVID in sub-Saharan Africa, in addition to the fact that this continent was less affected than others by the pandemic [69]. Beyond their overall impact, cases of long COVID were not evenly distributed among populations. They were more frequent in people with underlying medical problems such as diabetes mellitus, hypertension, and cardiovascular disease. Fatigue, sleep difficulties, chest, joint, and muscle pain, dyspnea, palpitations, headaches, and cognitive impairment were, among others, the main persistent symptoms presented by patients during long COVID in sub-Saharan Africa. The heterogeneity of long COVID definitions across the included studies represents a significant limitation for direct prevalence comparisons and highlights the need for adoption of standardized diagnostic criteria in future research. Africa, along with South America, is one of the continents where the vaccination rate has been very low, which may have an impact on the number and symptoms of long COVID. For example, within the sub-Saharan region, Cameroon (which has only 4% of people vaccinated against COVID-19) is lacking data on long COVID. This review serves as a warning signal to encourage governments to be proactive in establishing care models for people with post-COVID-19 sequelae. Given this multi-systemic impact of long COVID and given that symptoms can vary from one patient to another, future research should focus on personal management, intervention and treatment strategies, similar to the SPACO+ study conducted jointly in France and Cameroon [69].

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

COVID

Corona Virus Disease

SARS-CoV-2

Severe Acute Respiratory Syndrome CoronaVirus 2

PASC

Post-Acute Sequelae of SARS-CoV-2

WHO

World Health Organization

NIH

National Institutes of Health

NICE

National Institute for Health and Care Excellence

CDC

Centers for Disease Control and Prevention

AJOL

African Journals Online

JBI

Joanna Briggs Institute

SSA

Sub-Saharan Africa

PRISMA

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

HIV

Human Immunodeficiency Virus

ACE2

Angiotensin-Converting Enzyme 2

NTDs

Neglected Tropical Diseases

SPACO+

Monitoring and Adapted Pathways for People Suffering from Persistent Symptoms of Covid-19

Author contributions

C.E.E.M., B.B., and S.H.M. supervised the study. V.J.N.H. searched for articles in various databases and performed data extraction. V.J.N.H. drafted the manuscript. O.L.K., E.G.E.S., E.C.B.L., Y.M.B., C.A.A., J.G., B.B., S.H.M., and C.E.E.M. revised the manuscript. All authors read and approved the final manuscript.

Funding

This study is part of the SPACO + project, which has received funding from ANRS - Agence Nationale de la Recherche / Emerging Infectious Diseases. (Grant number: ANRS283). The funders were not involved in the design of the study, the collection and analysis of the data, the decision to publish or the preparation of the manuscript.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.