tetano
Editor, Senior Moderator
PLoS One
. 2026 Nov 3;21(11):e0345433.
doi: 10.1371/journal.pone.0345433. eCollection 2026.
Xinmeng Zhao 1 , Li Deng 1 , Nicole D Ford 1 , Sharon Saydah 1
Affiliations Expand
Background: Long COVID has emerged as a major public health concern in the United States, yet geographic variation in its prevalence remains poorly understood. This study examines how state-level differences in COVID-19 vaccination, SARS-CoV-2 infection burden, severity of acute COVID-19 (measured by hospitalization rates) and multimorbidity burden relate to adult Long COVID prevalence in the United States.
Methods: We conducted an ecological analysis using data from the 2023 Behavioral Risk Factor Surveillance System (BRFSS), from which we estimated state-level prevalence of self-reported Long COVID among adults. These estimates were linked with publicly available data on SARS-CoV-2 incidence, COVID-19 hospitalizations, COVID-19 vaccine coverage, and a multimorbidity indicator (defined as ≥3 chronic conditions associated with increased risk of severe COVID-19, e.g., diabetes, obesity, chronic kidney disease). Multivariable linear regression models were used to assess the association between these factors and Long COVID prevalence, adjusting for state age and sex distributions. Rubin's rules were applied to propagate the uncertainty in the estimates of Long COVID and COVID-19 vaccine coverage through regression analyses.
Results: All examined factors-including SARS-CoV-2 incidence, COVID-19 hospitalization, COVID-19 vaccine coverage, and multimorbidity prevalence-varied by state. In univariable analyses, vaccine coverage and multimorbidity prevalence were significantly associated with Long COVID prevalence. In the multivariable model, vaccine coverage and SARS-CoV-2 incidence were significant; however, after accounting for uncertainty in Long COVID and vaccine coverage estimates, only higher vaccine coverage remained significantly associated with lower Long COVID prevalence.
Conclusions: Higher State-level variation in COVID-19 vaccine coverage was consistently associated with lower adult Long COVID prevalence. These ecological findings support further investigation of vaccination and other state-level determinants of Long COVID burden and may inform population-level strategies for addressing Long COVID.
. 2026 Nov 3;21(11):e0345433.
doi: 10.1371/journal.pone.0345433. eCollection 2026.
Long COVID prevalence among U.S. adults: A state-level ecological analysis of associations with SARS-CoV-2 incidence, COVID-19 hospitalization rates, COVID-19 vaccine coverage, and multimorbidity
Xinmeng Zhao 1 , Li Deng 1 , Nicole D Ford 1 , Sharon Saydah 1
Affiliations Expand
- PMID: 42976189
- PMCID: PMC13730352
- DOI: 10.1371/journal.pone.0345433
Abstract
Background: Long COVID has emerged as a major public health concern in the United States, yet geographic variation in its prevalence remains poorly understood. This study examines how state-level differences in COVID-19 vaccination, SARS-CoV-2 infection burden, severity of acute COVID-19 (measured by hospitalization rates) and multimorbidity burden relate to adult Long COVID prevalence in the United States.
Methods: We conducted an ecological analysis using data from the 2023 Behavioral Risk Factor Surveillance System (BRFSS), from which we estimated state-level prevalence of self-reported Long COVID among adults. These estimates were linked with publicly available data on SARS-CoV-2 incidence, COVID-19 hospitalizations, COVID-19 vaccine coverage, and a multimorbidity indicator (defined as ≥3 chronic conditions associated with increased risk of severe COVID-19, e.g., diabetes, obesity, chronic kidney disease). Multivariable linear regression models were used to assess the association between these factors and Long COVID prevalence, adjusting for state age and sex distributions. Rubin's rules were applied to propagate the uncertainty in the estimates of Long COVID and COVID-19 vaccine coverage through regression analyses.
Results: All examined factors-including SARS-CoV-2 incidence, COVID-19 hospitalization, COVID-19 vaccine coverage, and multimorbidity prevalence-varied by state. In univariable analyses, vaccine coverage and multimorbidity prevalence were significantly associated with Long COVID prevalence. In the multivariable model, vaccine coverage and SARS-CoV-2 incidence were significant; however, after accounting for uncertainty in Long COVID and vaccine coverage estimates, only higher vaccine coverage remained significantly associated with lower Long COVID prevalence.
Conclusions: Higher State-level variation in COVID-19 vaccine coverage was consistently associated with lower adult Long COVID prevalence. These ecological findings support further investigation of vaccination and other state-level determinants of Long COVID burden and may inform population-level strategies for addressing Long COVID.