Long COVID in Pakistan, India, and Bangladesh: a review of its spread, symptoms, and healthcare responses

Despite South Asia containing 54.3 million affected individuals, representing 12.8% of the global burden, no prior systematic synthesis has integrated evidence across all three major South Asian countries (Pakistan, India, and Bangladesh). Existing reviews have either focused on individual countries or global estimates without stratifying South Asian data by sex, age, urban-rural setting, and pandemic wave. This critical knowledge gap prevents the development of evidence-based, region-specific policies for post-COVID syndrome management in a population already strained by limited healthcare resources (4, 15–18).

This systematic narrative review aims to (1) synthesize and compare post-COVID syndrome prevalence data across Pakistan, India, and Bangladesh; (2) identify gender-specific, age-stratified, and urban-rural patterns in post-COVID syndrome burden; (3) document and categorize clinical manifestations by organ system across the region; (4) assess healthcare system responses, capacity gaps, and rehabilitation outcomes; and (5) provide actionable, evidence-based recommendations for clinicians, policymakers, and researchers to mitigate the post-COVID syndrome burden in South Asia.

This comprehensive review employed a systematic narrative review methodology following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines (Supplementary File 1: PRISMA-ScR Checklist), which is ideal for mapping heterogeneous evidence landscapes where traditional meta-analyses are infeasible due to inconsistent definitions, diverse study designs, and high statistical heterogeneity across global and regional post-COVID syndrome studies (10, 21, 22). This approach enabled synthesis of diverse study designs, heterogeneous South Asian populations, and varied outcome measurements while permitting nuanced discussions of methodological variations, regional contextual factors, healthcare system differences, and cultural influences (8, 9, 23–27). Full Boolean search strategies for each database (PubMed, Scopus, and Google Scholar) are provided in Additional File 2: database search strategies.

On November 19, 2025, searches of PubMed yielded 3,847 articles, Scopus identified 2,134 articles, and Google Scholar located 1,256 publications (28, 29). The combined initial yield was 7,237 records. Following systematic deduplication using EndNote X20, 5,812 unique articles were retained. A quality-control audit of 50 removed duplicates confirmed an accuracy of 98% (30). Screening was conducted by two independent reviewers, with a third reviewer resolving disagreements (22, 30). PubMed, Scopus, and Google Scholar were selected because together they provide broad, complementary coverage of biomedical and public-health literature relevant to South Asia, with PubMed offering optimal indexing for clinical topics, Scopus adding extensive international and regional journal coverage, and Google Scholar improving capture of gray and regionally indexed literature. CINAHL, Embase, and Web of Science were not searched because our focus was epidemiological and clinical rather than nursing-specific, and because these subscription databases are not consistently accessible across collaborating South Asian institutions; current evidence-based guidance recommends tailoring database selection to both content coverage and feasibility in resource-constrained settings.

A total of 5,812 unique records underwent title and abstract screening. The inter-rater reliability was substantial, with a raw concordance rate of 87.3%. Consequently, 1,043 articles underwent full-text evaluation. Author contact for clarification was pursued in 12 articles, yielding responses from 10. Ultimately, 388 articles satisfied the inclusion criteria, equating to 38.8% of the full-text reviews and 6.7% of the deduplicated initial yield.

Inclusion criteria: original peer-reviewed research; cohort studies, cross-sectional surveys, case series, systematic reviews, or meta-analyses; confirmed post-COVID syndrome lasting ≥4 weeks; South Asian population focus; measurement of post-COVID syndrome manifestations, prevalence, risk factors, or management approaches.

Exclusion criteria: opinion pieces, editorials, and commentaries lacking original data; case series with < 10 cases; non-English publications; preprints without peer review; non-South Asian populations; acute COVID-19 treatment studies; and duplicate datasets.

Custom extraction forms standardized per the PRISMA-ScR and JBI guidelines documented study characteristics, population demographics, and post-COVID syndrome outcomes (30–33). Data extraction was performed independently by two reviewers using Excel templates, with discrepancies resolved by consensus, yielding a 94.1% concordance (34, 35). The GRADE framework was used to assess the certainty (36–38). The methodological quality was evaluated using the JBI Critical Appraisal Checklist for Studies Reporting Prevalence Data (22). Statistical analyses were performed using Comprehensive Meta-Analysis V3 software with random-effects models and 95% confidence intervals (21). Heterogeneity was quantified using the I² statistic and Cochran's Q–test (39, 40). Publication bias was assessed using funnel plots and Egger's regression test (41–43).

The prevalence of South Asian post-COVID syndrome ranges from 11.2 to 34.2% depending on geographic location, viral variant, healthcare infrastructure, and demographic factors (15, 16, 18, 44) (Table 1, Figure 3).

Pakistan shows a modest urban-rural disparity of 3.1 percentage points, reflecting intermediate healthcare infrastructure development (70). India demonstrated the most substantial disparity at 11.8 percentage points, representing a 2.4-fold higher urban prevalence, driven by healthcare infrastructure concentration, where 80% of diagnostic facilities are in urban centers, occupational exposure patterns, and differences in healthcare-seeking behavior (71, 72). Bangladesh shows moderate disparity of 6.1 percentage points, with 80% of healthcare resources concentrated in Dhaka and major cities (24, 73, 74). These urban-rural disparities correlate directly with healthcare infrastructure metrics rather than infection rates or disease severity (24, 75).

The prevalence of post-COVID syndrome demonstrated a declining trend across successive pandemic waves, from 32.1% during the wild-type wave to 14.2% during Omicron XBB (Table 3, Figure 4).

Female predominance persisted across all waves but gradually attenuated. Vaccination was associated with substantial prevalence reductions of 32% during Omicron BA.1 and 42% during Omicron XBB compared to pre-vaccine baselines (56, 76, 77) (Figure 5).

The findings of this review position the post-COVID syndrome burden in South Asia within the global context. While the pooled regional prevalence of 9.4%−22.5% under the WHO criteria appears moderate, this translates to 54.3 million affected individuals due to the region's large population base. Comparatively, South America has the highest global pooled prevalence at 51%, followed by Europe at 39%, Australia at 42.4%, Asia at 35%, and North America at 30% (10, 22). South Asia's apparently lower prevalence likely reflects substantial underdetection in rural areas, where limited diagnostic capabilities and healthcare-seeking behavior differences mask the true disease burden rather than indicating genuinely lower rates (8, 9, 23, 24, 48) (Table 4, Figure 6).

The consistent female predominance across all three countries (F:M ratios 1.41:1–1.81:1) suggests both biological susceptibility through estrogen-dependent immune responses, X-linked immune gene expression, and ACE2 receptor patterns, and social determinants, including caregiving roles and informal employment without health protections. This pattern mirrors global trends where female predominance transcends socioeconomic development levels (10, 78, 79). The peak burden in the 35–54 age group, corresponding to peak employment and family caregiving roles, carries profound economic implications for a region where this demographic constitutes the primary workforce.

Urban-rural disparities (Pakistan 3.1 pp, Bangladesh 6.1 pp, India 11.8 pp) correlated more strongly with healthcare infrastructure metrics than with infection severity. India's 11.8 percentage point gap the largest in the region reflects 80% concentration of diagnostic facilities in urban centers, higher urban healthcare utilization rates (3–4 × rural), and potential rural survivor bias where higher acute COVID-19 mortality may select for milder post-COVID syndrome cases (8, 9, 23, 24, 48). Bangladesh's divisional variations, with Khulna at 51.6% vs. Sylhet at 1.7%, further underscore the localized transmission dynamics shaping the burden distribution (12, 19).

The multisystem nature of post-COVID syndrome, with fatigue (58.3%), brain fog (52.1%), and dyspnea (42.3%) as the leading manifestations, necessitates multidisciplinary management approaches. The discordance between subjective dyspnea (42.3%) and objective lung function decline (28.4%) indicates that rehabilitation must address both pulmonary and psychological components including anxiety, deconditioning, and sensory hyperawareness (54, 59, 80). Structured rehabilitation programs demonstrated significant improvement in 67.3% of patients, with telehealth approaches achieving 84% adherence and 40%−50% cost reduction, offering a viable model for rural healthcare delivery (81–85).

South Asian healthcare systems face critical capacity gaps: primary care facilities serve one per 30,000–50,000 population in rural areas vs. one per 5,000–10,000 in urban areas; diagnostic capabilities including cardiac imaging, pulmonary function testing, and cognitive assessment are available in only 40%−60% of urban vs. less than 5% of rural facilities; and rehabilitation services address only 2%−5% of identified needs (27, 59, 75, 86, 87). These infrastructure limitations both underestimate the true rural prevalence and prevent the adequate management of identified cases.

The declining prevalence across pandemic waves (32.1%−14.2%), coupled with vaccination-associated reductions (32%−42%), suggests that ongoing vaccination campaigns remain essential. However, the persistent burden of 14.2% even during Omicron XBB indicates that post-COVID syndrome will remain a significant healthcare challenge, requiring sustained investment. Future research priorities include South Asian-specific genetic studies (currently only 12 published), prospective cohorts with follow-up exceeding 18 months, and standardized WHO-criteria prevalence studies to enable accurate cross-regional comparisons (52, 88–92).

Dedicated post-COVID syndrome clinics need to be established within existing tertiary care centers in major cities across Pakistan, India, and Bangladesh, staffed by multidisciplinary teams, including pulmonologists, cardiologists, neurologists, psychiatrists, and rehabilitation specialists, with standardized WHO-criteria diagnostic protocols. Primary care physician training programs should be developed and implemented through online continuing medical education modules focused on post-COVID syndrome recognition, initial management, and referral criteria, targeting the primary care workforce as the first point of contact for most affected individuals. Rehabilitation infrastructure should be expanded by integrating post-COVID syndrome rehabilitation services into existing community health centers, leveraging telehealth platforms to extend specialist access to rural populations where only 2%−5% of rehabilitation needs are currently met. Support for vulnerable populations, particularly women aged 35–54 in informal employment who demonstrate the highest post-COVID syndrome burden, through workplace accommodations, targeted health screenings, and social protection programs, needs to be prioritized. Investment should be made in South Asian population-specific genetic research examining ACE2 polymorphisms, HLA variants, and interleukin gene profiles to identify region-specific susceptibility markers that can inform personalized therapeutic approaches. Regional surveillance systems should be strengthened by implementing standardized post-COVID syndrome registries across all three countries using WHO diagnostic criteria, enabling accurate prevalence monitoring, resource allocation planning, and evaluation of intervention effectiveness.

This review represents the first systematic synthesis integrating all major South Asian countries encompassing 2.1 billion population with diverse healthcare contexts (18, 24, 75, 93). The large evidence base of 388 peer-reviewed publications spanning 5.8 years and encompassing over 1.2 million participants, with GRADE quality assessment, enabled the prioritization of robust findings. Sex-specific, age-stratified, urban-rural, and temporal stratifications identify specific vulnerable populations requiring targeted interventions (74, 86, 94). PRISMA-ScR framework compliance with 87.3% inter-rater reliability at screening and 94.1% data extraction concordance ensures methodological rigor. Analysis of definition inconsistency explaining approximately 60% of prevalence variation provides mechanistic understanding, and implementation-focused recommendations include precise resource requirements and feasibility assessments (87, 95–97).

Only 12 peer-reviewed studies have examined post-COVID syndrome genetic factors in South Asian populations despite 54.3 million affected individuals (52, 88–92). Pre-2023 studies employed variable case definitions contributing to approximately 60% of the 9.4%−34.2% variation; WHO 6-criterion definitions should be adopted in future research (10, 54, 98–101). Only 8.2% of the included studies provided follow-up data beyond 18 months, creating uncertainty regarding long-term disability trajectories. Vaccination during 2021–2025 complicates attribution of prevalence changes to viral variants vs. vaccination effects, although comparative studies suggest 40%−52% prevalence reduction with vaccination (56, 76, 77). English-language-only inclusion potentially excludes 5%−10% of relevant South Asian research, and indirect economic costs remain substantially underestimated (15, 24, 102–108).