Artigos

1. Introduction

According to the recent World Health Organization (WHO) definition, long COVID is
defined as the onset or persistence of a variety of symptoms occurring for more than 12 weeks
after acute SARS-CoV-2 infection, without an alternative diagnosis. This condition is
characterized primarily by many reported symptoms such as fatigue, dyspnea, and neurological
and cognitive impairment and affects multiple organs and systems1

. The etiology of long
COVID is still poorly understood; hence, treatments focus only on symptom relief.
Furthermore, the consequences of this syndrome are still unknown, as is the epidemiology of
long COVID, which remains debated in the scientific community and among policy makers2
.
Multiple hypotheses regarding the pathophysiology of long COVID, including virus
persistence in tissues, host mitochondrial dysfunction, immune system dysregulation, persistent
vascular injuries, preexisting comorbidities, and the clinical evolution of acute infection, have
emerged and have recently been described in the literature3

. However, the pathophysiology of

long COVID remains an unanswered question in the academic world.
The delineation of this syndrome is complex, and epidemiological studies and clinical
trials aiming to better understand it face substantial challenges. This complexity stems from the
diversity of symptomatic manifestations among affected individuals, which hinders the
development of an effective therapeutic approach and specific guidelines to guide clinical
management. Nevertheless, the most frequently reported symptoms of long COVID include
fatigue, dyspnea, altered senses of smell and taste, cognitive impairments such as memory loss
and insomnia, and systemic impairments across multiple organs 4,5. Studies have shown that
even mild COVID-19 infections can lead to what is known as "brain fog," which includes
memory lapses and issues with executive functions. These impairments have persisted for up
to 7 months post-infection, directly affecting patients' quality of life and work performance6
.

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Recent studies have shown that among survivors of the acute phase of the pandemic
between 2020 and 2021, 6.2% reported experiencing at least one long COVID symptom three
months after acute infection. A recent study conducted in Brazil7

indicated that 80% of the
sample experienced persistent symptoms from the acute phase of COVID-19, with most
patients reporting more than one symptom for at least 120 days after the acute phase.
Unfurtunately, it is estimated that up to 20% of SARS-CoV-2 patients in the world experienced
persistent symptoms after the acute phase of the infection, underscoring the importance of
understanding the underlying factors of this prolonged symptomatology and appropriately
guiding ongoing medical care8
.

Some studies have reported strong correlations between the persistence of symptoms
after the acute phase of the disease with groups that are more adversely affected during the
initial phase, such as elderly individuals or those with preexisting conditions such as

hypertension, diabetes, or heart disease. On the other hand, the long-term symptoms of COVID-
19 also appear in patients whose acute disease phase is characterized as mild or asymptomatic

across all age groups and even in the absence of preexisting conditions 9
.

A prospective study conducted in Brazil in 2023 analyzed the prevalence of factors
associated with Long COVID, highlighting that three out of four adult participants continued
to experience long-term symptoms from the acute phase. The study strongly associated this
condition with being female, a sedentary lifestyle, and found an inverse relationship between
COVID-19 vaccination and the prevalence of Long COVID 10
.

Unfortunately little is being talked about the effects of long COVID in the population
and there are only few countries stablishing public policies to combat the long-term symptoms
of COVID-19. In addition, public perception of population might be evaluated to understand if
there is a clear awareness about the risks of long COVID and how much it affect the lives of

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millions of people around the world. Furthermore, it is necessary to know what are the gaps
among the medical doctors and the understanding on the efects of long COVID.
Brazil was strongly affected by COVID-19 and the pandemics have made more than
than 700.000 deaths, 250.000 people hospitalized and 39 milion people infected11. There are
few studies on epidemiology of the long-term symptoms of long COVID in Brazil and few
studies are being conducted now using retrospective data analyzes and artifitial intelligence
(AI) 2.
When searches concerning participants perception of long COVID are conducted in
databases such as the PubMed, EMBASE, and Latin American and Caribbean Health Sciences
Literature (LILACS) databases, the results are always the same: there are no studies on the
public's knowledge about the long-term symptoms after the acute phase of COVID-19.
Therefore, given the current lack of comprehensive studies on this in the literature as well as in
relation to the public perception of this health condition, this study aimed to estimate and
analyze the public perception of posCOVID long-term symptoms in the Brazilian adult
population. For this purpose, a national opinion survey was conducted and data were compiled
among people who reported infection by COVID-19 and the posCOVID symptoms after the
acute phase of infection. These perception was evaluated on the light of recent studies showing
that characteristic symptoms of long COVID and brings several worries to the health system
and the need to the reabilitation.

2. Methods
A quantitative sample study was conducted, consisting of a public opinion survey
carried out from July 5 to July 10, 2023, by the SoU_Ciência Study Center and the Idea Institute.
The survey was conducted using a structured questionnaire with 53 questions, targeting a

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representative sample of the Brazilian population, comprising 1,295 respondents of both sexes,
residing throughout the country, aged 16 and older, with diverse demographic characteristics.
The sample was organized by variable quotas in line with the country's population
distribution across each region, with proportions defined by data from the 2021 PNAD survey
and the 2010 IBGE Census. Respondents were segmented by demographic characteristics
(gender, age, ethnicity, region, education, social class, income, religion, municipality, and
political orientation). A national sample of 1,250 to 1,300 interviews, with a 95% confidence
interval, has a margin of sampling error of plus or minus 2.85 to 3 percentage points. Public
opinion samples for national elections, for example, are composed on a similar scale. At the
beginning of the questionnaire, we ask whether the participant consents to take part in the study.
Both the control of inconsistencies and the breakdown of sociodemographic data are conducted
daily throughout the data collection period.
All the selected participants stated that they had been previously diagnosed (between
2020 and 2023) with COVID-19, accounting for 40.6% of the initial sample. 661 (51%)
participants reported not having been diagnosed with the disease, and 108 (8.3%) stated that
they did not know whether they had the disease; therefore, these participants were excluded
from the next step analysis of the results.
The results obtained were analyzed categorically, considering such variables. The
quantitative questions allowed only one response, whereas the qualitative questions allowed
more than one response. The study was based on self-reported data, which may be subject to
errors in memory or interpretation.
Participation in the survey was voluntary, and no financial incentives were offered to
the participants. The project was conducted following Brazilian ethical norms for studies
involving human subjects (Resolution CNS 466/12) and was registered with the Ethics and
Research Committee (CEP/UNIFESP) under number 1309/2021.

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3. Results
Between July 5th and 10th, 2023, 1295 individuals were interviewed via telephone to
complete a questionnaire. From this pool, 526 participants reported to have had COVID-19 and
then were considered for this study. This included 302 women (57.4%) and 224 men (42.6%).
Among the participants, 240 (45.7%) were aged 45 years or older, 126 (24%) were between 35
and 44 years old, 107 (20.3%) were between 25 and 34 years old, and 57 (10%) were between
18 and 24 years old. Concerning the region of residence, 197 (37%) participants were residents
of the Southeast Region; the percentages for the Northeast, South, North, and Midwest Regions
were 28.9% (152 respondents), 12.6% (66), 12.3% (67), and 9.2% (48), respectively. The
subjects answered to several questions related to the COVID-19, the symptoms reported and
the duration of them after the infection. Questions on the number of infections were also
included. Table 1 shows the main persistent symptoms reported by the participants after
COVID-19 and which might be related to the long COVID.

Tab.1
Regarding the need for hospitalization in the acute phase of the infection, 41 (7.8%)
participants who diagnosed with COVID-19 required hospitalization, while 341 (64.8%) sought
outpatient medical care, and the remaining 138 (26.3%) abstained from seeking medical help
during the infection. Additionally, questions were asked regarding the persistence of symptoms
for more than 12 weeks and/or the appearance of symptoms perceived by the individual. A total
of 52.5% (276 individuals) of the participants reported that they experienced mild symptoms,
40.4% (212) reported experiencing moderate symptoms, and only 33 (6.2%) reported
experiencing severe symptoms (Figure 1). Among the 526 study participants who have
contracted COVID-19, 66% (348) reported to have been infected only once; 25% (131) were
infected twice; 7.5% (39) were infected at least three times, and 1% (5) did not remember,

indicating a reinfection rate of approximately 32.5% among patients with a history of COVID-
19 (Figure 2).

Fig.1
Figure 1 Participants perceptions of symptoms reported by people who were infected by SARS-
CoV-2 during the analyzed period. The histogram shows the results of the responses to the

question "What were the symptoms you experienced when you contracted COVID-19?" of
patients who had mild, moderate or severe symptoms related to COVID-19.

Figure 2: Participants perceptions of symptoms reported by people who were infected with
SARS-CoV-2 one, two, three, four or more than five times during the analyzed period. The
histogram shows the results of the responses to the question "How many times have you had
COVID-19?"

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All responses in this topic were considered regardless of the time of symptom onset
after the acute phase, and this interval was distributed among participants as follows: Regarding
the temporality of the clinical picture, 176 (33.4%) participants reported having symptom onset
and/or persistence for at least three months, as follows: 52 (30%) participants stated that their
symptoms persisted for two weeks after the end of the acute infection, followed by 35 (19.9%)
who reported a duration of four weeks, 15 (8.5%) with a duration of two months, 9 (5.4%) with
a duration of three months, 5 (2.8%) with a duration of four months, 2 (0.9%) with a duration
of five months, 5 (2.7%) with a duration of six months, and 38 (21.6%) with a duration of more
than 6 months (Figure 3).

Figure 3: Participants perceptions of the duration of symptoms reported by people with
a history of COVID-19. The histogram shows the results of the responses to the question
"How long (approximately) do you think the symptoms lasted after COVID-19?"

4. Discussion
The study presents some important limitations, mainly due to the methodology of
telephone interviews. Among the limitations are information bias from participants and
selection bias, as only individuals with access to telephones who were available to respond to

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the survey were included. Additionally, it is not possible to objectively verify the information
provided, as the questions relied on the participants' perception and memory without
considering positive tests or medical records. We do not know the interval until the symptoms
were investigated, only the perception of how long after the acute phase the symptoms persisted
or appeared.
Proceeding with the analysis of the previously documented data obtained through the
research conducted by the SoU_Ciência Center, it is possible to establish congruence between
the literature and the responses provided by the participants in the present study. It is important
to note that according to the WHO, long COVID is defined as the persistence or emergence of
symptoms for at least three months after COVID-19 with a duration of at least two months
without any other explanations or diagnoses9

. On the basis of the definition of long COVID,
the present study shows that approximately 33.4% (176) of the sample participants who
reported symptoms after the acute phase of the disease, would be classified as long COVID
subjets according to the WHO criteria.
A recent study revealed that 54% of patients diagnosed with COVID-19 experienced at
least one symptom of long COVID which persists for one month13, these results are consistent
with the Centers for Disease Control and Prevention (CDC) definition, which considers long
COVID as symptoms lasting from 4 weeks onward3

similar to what is observed in the present
study, in which 49.9% of the patients experienced symptoms of long COVID for up to one
month. Moreover, the appearance of symptoms related to the postacute sequelae of COVID-19
does not appear to be linked to the need for hospitalization during the acute phase of the
infection, although it is considered a high risk factor5

. This is evidenced by the fact that 54.2%
of the interviewed patients who had been diagnosed with COVID-19 reported the persistence
or emergence of symptoms after acute infection, whereas only 7.8% were hospitalized during
the initial phase of the disease. Once again, participants perception reported in the present study

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aligns with the known literature, since studies estimate that the incidence of long COVID in
adults who do not require hospitalization during the acute phase of COVID-19 ranges from
7.5% to 41%5

. These data reveal a scenario of extreme heterogeneity and inconclusiveness in
previous studies regarding hospitalization rates, which has significant implications for public
health actions due to the wide variation in the results. It also demonstrates a concerning level
of uncertainty about this matter in the literature which shows that is necessary to further
investigate this problem14
.

On the other hand, another point showed an important similarity with the literature. The
interviews revealed the following temporal distribution in terms of the duration of symptoms
after the acute phase of infection: symptoms lasting for two weeks (30%), symptoms lasting for
one month (19.9%), or symptoms lasting for more than six months (21.6%). This finding is
corroborated by others14, in which a pattern or temporal trend for the persistence of long COVID
symptoms has not been established; in the refered study, the persistence of symptoms was
reported to last for two, five, and eight months. When long-term symptoms are analyzed by
organ systems, the risks of pulmonary, gastrointestinal, and musculoskeletal impairments
remain high even two years after acute SARS-CoV-2 infection 15
.

In terms of general and respiratory symptoms, the results of the present study differ from
those reported in the literature, as the percentages of patients who reported experiencing
respiratory symptoms and fatigue after the initial SARS-CoV-2 infection (52.5% and 72.4%,
respectively) are greater than those reported in previously published studies (39% and 49.6%)13
.
This highlights that fatigue is one of the most prevalent symptoms in patients experiencing long
COVID, surpassing even common respiratory symptoms, such as cough and dyspnea, in the
acute phase of the infection. In contrast to other long-term symptoms, some studies have noted
that fatigue and neurocognitive impairment persist longer and may even worsen over time16
.
The same study revealed that, between hospitalized and nonhospitalized individuals, there was

14
no statistically significant difference among those who reported some level of fatigue after the
acute phase of the disease.
Finally, with respect to cognitive symptoms, it is known from preexisting studies that a
subjective cognitive impairment (SCI) is reported globally among patients experiencing long
COVID, meaning that patients experience a subjective change in their own performance, with
areas such as memory, concentration, orientation, and language affected17. In the present study,
the majority of participants (55.6%) who had been infected with COVID-19 reported
experiencing persistent subjective cognitive symptoms after the initial infection; 64.6% of the
patients reported experiencing memory loss, 53.5% reported experiencing difficulty
concentrating, and 20.7% reported experiencing mental confusion, which is in line with the
conclusions of the listed studies2, 17. Consequently, depending on symptoms, the cognitive
aspect may be affected in the majority of people, implying a long-term need for specific
attention to the neuropsychological system in each individual affected by COVID-19.
Some published studies have aimed to relate long COVID to some specific antiviral
medications for COVID-19 that combines nirmatrelivir and ritonavir. Certain publications from
early 2023 indicate that this medications is associated with a 26% lower risk of developing
long COVID over a 6-month period, in addition to reduced risks of hospitalization and death
after the acute phase of the infection - 24% and 47%, respectively 15. However, more recent
studies from 2024 revealed that, on the basis of a specific sample analyzed, the likelihood of
developing postacute symptoms was 16% among patients who used the antiviral during the
acute phase of infection, whereas it was 14% among those who had long COVID but did not
use the medication18. There is still not enough scientific consensus on the efficacy of this
medication in treating, preventing, or minimizing the effects of long COVID; more studies are
needed to better understand the long-term effects of this medication.

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It is important to mention that Long COVID has been studied for many authors by using
retrospective data analyzes and Artificial Intelligence (AI) to achieve a accurate analysis of the
symptoms. In a recent study11, our group developed a method that allows analysis from medical
records our University Hospital in São Paulo, Brazil. This tool showed excellent performance
in investigating the effects of Long COVID on patients admitted to this hospital and followed
up for several months after discharge. It is interesting to note that the analyses of the collected
data from patients, showed that dyspnea is a prevalent symptom which is similar to what we
observed among the participants of the present study. These facts, reinforce the idea that the
perception of the Long COVID symptoms might became a very important element to identify
the possible long-term symptoms associated with post COVID-19 and to prospect the seek for
treatment and to prepare the health system for rehabilitation programs.

Applicability and management of public policies:
Considering the entire context involving the perception of the participants of this study,
it is necessary to evaluate the conditions of the postCOVID symptoms, especially in basic
health units (UBSs) of the Health System in Brazil which may also be applicable in other
countries that were severely affected by the pandemics. It is clear by several studies that many
people have faced long-term symptoms or residual manifestations after COVID-19 and they are
unaware of the proper way to seek assistance. Thus, it is important to listen to the public need
accordingly to their perception. In light of this reality, it is crucial for healthcare professionals,
in collaboration with health managers from different government spheres, to develop strategies
to manage the care of these patients.
The first initiative of the Federal Government regarding long COVID was implemented
through GM/MS Ordinance 3872 in December 2021. This measure allocates specific resources
to patients affected by the syndrome while also disseminating guidelines aimed at ensuring

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follow-up care for those experiencing postacute infection sequelae, covering a period of six
months19. However, importantly, the limited understanding of the topic among professionals
still hinders the implementation of specific measures in the care of these patients.
In 2022, the Manual for Assessment and Management of Post-COVID Conditions in
Primary Health Care20 was released by the federal government, but the decentralization of
actions resulted in local initiatives at the state and municipal levels, causing care for these
patients to be uneven and ineffective across different territories. However, the mentioned
manual is outdated and does not align with the reality of UBSs in the country. This happens
because a significant portion of the guidelines require tests and consultations with specialists,
with notoriously long waiting lists, leading to prolonged waiting times for patients to receive
adequate treatment. Therefore, there is an urgent need to implement effective public policies
focused on primary care in integrated regional networks with other levels of health care, aiming
to encompass the significant portion of patients affected by post-COVID syndrome.
Additionally, it is important to increase awareness among the population about the existence of
long COVID, encouraging individuals to seek medical assistance and appropriate treatment.
The underreporting of COVID-19 cases in Brazil was a complex and heterogeneous
phenomenon throughout the pandemic. It is estimated that the average rate of actual cases is
3.4 times higher than the reported number21, meaning that approximately 130 million Brazilians
were infected, compared with the 38 million reported cases between 2020 and 2023. At the
beginning of the pandemic, underreporting was particularly high, estimated at a rate of 9.2%;
this means that for every 100 actual cases, only 9.2 were reported22, 23 . This underreporting
hindered the understanding of the true extent of the pandemic and the adoption of adequate and
effective control measures. In the present study, 40.6% of the respondents reported having been
previously infected with SARS-CoV-2, a number that may still be underestimated, reflecting
the underreporting of cases. These data reflect a total of 215 people who are subreporting in this

17
small universe, which, when expanded, aligns with the pandemic scenario in Brazil: the
reporting rate of COVID-19 cases in the country is extremely low, which indicates an important
lack of knowledge among government agencies on the real impact of the disease and the
persistence of the long-term symptoms. Notably, without case reporting and without knowledge
about acute infections among the population, the understanding of persistence and/or
emergence of new symptoms is hindered; thus, the perception of long COVID cases is
completely biased. Therefore, it is important to implement prevalence studies and measures to
reduce the underreporting of COVID-19 cases, as this will help public authorities make more
informed decisions and protect public health.
Finally, reinfection with SARS-CoV-2 is an important event to consider, as the number
of reinfections can worsen an individual's health condition. Previous studies have shown that
individuals who are reinfected with COVID-19 are at high risk of postacute symptoms,
including pulmonary, cardiovascular, hematological, gastrointestinal, renal, metabolic,
neurological, musculoskeletal, and psychological long-term symptoms24. These results indicate
that virus reinfection may contribute to the development of long COVID, with evident risk even
in vaccinated individuals. Furthermore, the collected data indicating a considerable reinfection
rate (171 participants) raise another concern because these patients are more likely to experience
long-term symptoms in the acute phase of the disease than those who contract the disease only
once.

5. Conclusion
As discussed earlier, to reduce the risk of long COVID after SARS-CoV-2 reinfection,
it is imperative that public authorities provide support to reinfected individuals, primarily
through comprehensive health care measures provided by multidisciplinary teams, aiming to
treat severe long COVID symptoms and improve patients’ quality of life, along with quality

18
rehabilitation, which can help individuals recover their physical and cognitive functions. In the
Brazilian context, public policies to support reinfected individuals are still in the early stages,
and it is necessary to ensure coverage and meet the specific needs of these individuals.
In this way, this study demonstrates it is importance in valuing public perception about
Long COVID. Thus, by investigating the social perception of symptoms, we highlight which
systems are most affected, allowing these patients to perceive the symptoms and seek
appropriate help. Furthermore, by increasing public perception on the subject, society is
allowed to cover public authorities from all spheres of power, demanding better care directed
to Long COVID, insisting on effective public policies so that the problem can be combated with
seriousness. Public agencies need to value public opinion, and studies that investigate social
perception of the consequences of COVID highlight the need for popular prestige, listening and
action aimed at the population. The importance of social education on the topic, therefore, is
the basis for a better health system aimed at caring for the population.

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References
1. Mantovani A, Morrone MC, Patrono C, Santoro MG, Schiaffino S, Remuzzi G and
Bussolati G (2022). Long Covid: where we stand and challenges ahead. Cell Death
Differ 29(10) : 1891-1900.
2. Global Burden of Disease Long COVID Collaborators; Hanson WS, Abbafati C, Aerts
JG, Al-Aly, Z, Ashbaugh C, et al. (2022) Estimated Global Proportions of Individuals
With Persistent Fatigue, Cognitive, and Respiratory Symptom Clusters Following
Symptomatic COVID-19 in 2020 and 2021. JAMA 328(16) : 1604-1615.
3. Davis HE, McCorkell L, Vogel JM and Topol EJ (2023) Author Correction: Long
COVID: major findings, mechanisms and recommendations. Nat Rev Microbiol, 21(6)
: 408. Erratum for: Nat Rev Microbiol 21(3): 133-146.
4. CDC. Post-COVID Conditions: Information for Healthcare Providers [Internet].
Centers for Disease Control and Prevention. 2020. Available from:

https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-care/post-covid-
conditions.html

5. Ford ND, Slaughter D, Edwards D, Dalton A, Perrine C, Vahratian A and Saydah S
(2023) Long COVID and Significant Activity Limitation Among Adults, by Age -
United States, June 1-13, 2022, to June 7-19, 2023. MMWR Morb Mortal Wkly Rep
72(32): 866-870.
6. Lopes-Santos LE, de Lacerda Ferreira D, de Angelis G, Foss MP, Trevisan AC, de
Lacerda KJCC, Tumas V, Bellissimo-Rodrigues F, Wichert-Ana L. How Mild Is the
Mild Long COVID? A Comprehensive Neuropsychological Assessment of Patients
with Cognitive Complaints. Arch Clin Neuropsychol. 2024 Sep 7:acae071. doi:
10.1093/arclin/acae071. Epub ahead of print. PMID: 39244203.

20
7. Bonifácio LP, Csizmar VNF, Barbosa-Júnior F, Pereira APS, Koenigkam-Santos M,

Wada DT, Gaspar GG, Carvalho FS, Bollela VR, Santana RC, Souza JP, Bellissimo-
Rodrigues F. Long-Term Symptoms among COVID-19 Survivors in Prospective

Cohort Study, Brazil. Emerg Infect Dis. 2022 Mar;28(3):730-733. doi:
10.3201/eid2803.212020. Epub 2022 Feb 8. PMID: 35133956; PMCID: PMC8888217.
8. Regunath H, Goldstein NM and Guntur VP (2023) Long COVID: Where Are We in
2023? Mo Med, 120(2) : 102-105.
9. World Health Organization (2023) Post-COVID-19 condition. Geneva: World Health

Organization. Available at: https://www.who.int/europe/news-room/fact-
sheets/item/post-covid-19-condition (Accessed: 18 March 2024).

10. Feter N, Caputo EL, Leite JS, Delpino FM, Silva LS da, Vieira YP, et al.. Prevalência e
fatores associados à COVID longa em adultos do Sul do Brasil: achados da coorte
PAMPA. Cad Saúde Pública [Internet]. 2023;39(12):e00098023. Disponível em:
https://doi.org/10.1590/0102-311XEN098023
11. Ranzani OT, Bastos LSL, Gelli JGM, Marchesi JF, Baião F, Hamacher S, et al.
Characterisation of the first 250 000 hospital admissions for COVID-19 in Brazil: a
retrospective analysis of nationwide data. The Lancet Respiratory Medicine [Internet].
2021 Jan 15;0(0). Available from:
https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30560-9/fulltext
12. Veras-Fiorentino P. et al Natural Language Processing method to Unravel Long
COVID's clinical condition in hospitalized patients. Preprint
https://doi.org/10.21203/rs.3.rs-4262099/v1
13. Bowe B, Xie Y, Al-Aly Z (2023) Postacute sequelae of COVID-19 at 2 years Nat Med
29(9) : 2347-2357.

21
14. Groff D, Sun A, Ssentongo AE, Ba DM, Parsons N, Poudel GR et al. (2021) Short-term
and Long-term Rates of Postacute Sequelae of SARS-CoV-2 Infection: A Systematic
Review. JAMA Netw Open 4(10): e2128568.
15. Nittas V, Gao M, West EA, Ballouz T, Menges D, Wulf Hanson S, et al. (2022) Long
COVID Through a Public Health Lens: An Umbrella Review, Public Health Rev 43:
1604501.
16. Xie Y, Choi T, Al-Aly Z (2023) Association of Treatment With Nirmatrelvir and the
Risk of Post-COVID-19 Condition. JAMA Intern Med 183(6) : 554-564
17. Ceban F, Ling S, Lui LMW, Lee Y, Gill H, Teopiz KM et al. (2022) Fatigue and

cognitive impairment in Post-COVID-19 Syndrome: A systematic review and meta-
analysis. Brain Behav Immun 101 : 93-135.

18. Kubota T, Kuroda N and Sone D (2023) Neuropsychiatric aspects of long COVID: A
comprehensive review. Psychiatry Clin Neurosci 77(2) : 84-93
19. Durstenfeld MS, Peluso MJ, Lin F, Peyser ND, Isasi C, Carton TW, et al. (2024)
Association of nirmatrelvir for acute SARS-CoV-2 infection with subsequent Long
COVID symptoms in an observational cohort study. J Med Virol 96(1): e29333.
20. Ministério da Saúde (BR). (2021) Portaria no 3.872, de 29 de dezembro de 2021.
Brasília: Diário Oficial da União. Available at:
https://bvsms.saude.gov.br/bvs/saudelegis/gm/2021/prt3872_29_12_2021.html.

21. Ministério da Saúde (BR). Manual de Avaliação e Manejo das Condições Pós-COVID-
19. Brasília: Ministério da Saúde. Available at:

https://bvsms.saude.gov.br/bvs/publicacoes/manual_avaliação_manejo_condições_cov
id.pdf.

22
22. Klein J, Wood J, Jaycox JR, Dhodapkar RM, Lu P, Gehlhausen JR, et al. (2023)
Distinguishing features of long COVID identified through immune profiling. Nature
623(7985) : 139-148.
23. Guyton AC, Hall JE (2017) Tratado de fisiologia médica, 13a ed. Rio de Janeiro:
Elsevier Ltda. Capítulo 77.

24. Palamim CVC, Siqueira BA, Boschiero MN, Marson FAL (2023) Increase in COVID-
19 underreporting among 3,282,337 Brazilian hospitalized patients due to SARS: A 3-

year report and a major concern for health authorities. Travel Med Infect Dis 54: 102616.
25. Lai CC, Hsu CK, Yen MY, Lee PI, Ko WC and Hsueh PR (2023) Long COVID: An
inevitable sequela of SARS-CoV-2 infection. J Microbiol Immunol Infect 56(1) : 1-9.
26. Prado MFD, Antunes BBP, Bastos LDSL, Peres IT, Silva AABD, Dantas LF, et al.
(2020) Analysis of COVID-19 under-reporting in Brazil. Rev Bras Ter Intensiva 32(2)
: 224-228.

27. Bowe B, Xie Y, Al-Aly Z (2022) Acute and postacute sequelae associated with SARS-
CoV-2 reinfection. Nat Med, 28(11) : 2398-2405.