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Introduction: A proportion of people develop Long Covid after acute COVID-19, but with most studies concentrated in high-income countries (HICs), the global burden is largely unknown. Our study aims to characterise long-term COVID-19 sequelae in populations globally and compare the prevalence of reported symptoms in HICs and low-income and middle-income countries (LMICs)., Methods: A prospective, observational study in 17 countries in Africa, Asia, Europe and South America, including adults with confirmed COVID-19 assessed at 2 to <6 and 6 to <12 months post-hospital discharge. A standardised case report form developed by International Severe Acute Respiratory and emerging Infection Consortium's Global COVID-19 Follow-up working group evaluated the frequency of fever, persistent symptoms, breathlessness (MRC dyspnoea scale), fatigue and impact on daily activities., Results: Of 11 860 participants (median age: 52 (IQR: 41-62) years; 52.1% females), 56.5% were from HICs and 43.5% were from LMICs. The proportion identified with Long Covid was significantly higher in HICs vs LMICs at both assessment time points (69.0% vs 45.3%, p<0.001; 69.7% vs 42.4%, p<0.001). Participants in HICs were more likely to report not feeling fully recovered (54.3% vs 18.0%, p<0.001; 56.8% vs 40.1%, p<0.001), fatigue (42.9% vs 27.9%, p<0.001; 41.6% vs 27.9%, p<0.001), new/persistent fever (19.6% vs 2.1%, p<0.001; 20.3% vs 2.0%, p<0.001) and have a higher prevalence of anxiety/depression and impact on usual activities compared with participants in LMICs at 2 to <6 and 6 to <12 months post-COVID-19 hospital discharge, respectively., Conclusion: Our data show that Long Covid affects populations globally, manifesting similar symptomatology and impact on functioning in both HIC and LMICs. The prevalence was higher in HICs versus LMICs. Although we identified a lower prevalence, the impact of Long Covid may be greater in LMICs if there is a lack of support systems available in HICs. Further research into the aetiology of Long Covid and the burden in LMICs is critical to implement effective, accessible treatment and support strategies to improve COVID-19 outcomes for all., Competing Interests: Competing interests: JTS was Co-Chair of the ISARIC COVID Global follow up group. NL received a grant from the Italian Ministry of Health to support this work and received support from the National Congress of the Italian Society of Anesthesia and Critical Care Medicine SIAARTI for travel and accommodation expenses to attend a meeting. MoH Trustee is a Trustee of Long Covid Support., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Cylindrospermopsin (CYN), a cyanotoxin produced by harmful algal blooms, has been reported worldwide; however, there remains limited understanding of its potential risks to surface water quality. In the present study, we critically reviewed available literature regarding the global occurrence, bioaccumulation, and toxicity of CYN in aquatic systems with a particular focus on freshwater. We subsequently developed environmental exposure distributions (EEDs) for CYN in surface waters and performed probabilistic environmental hazard assessments (PEHAs) using guideline values (GVs). PEHAs were performed by geographic region, type of aquatic system, and matrix. CYN occurrence was prevalent in North America, Europe, and Asia/Pacific, with lakes being the most common system. Many global whole water EEDs exceeded guideline values (GV) previously developed for drinking water (e.g., 0.5 μg L -1 ) and recreational water (e.g., 1 μg L -1 ). GV exceedances were higher in the Asia/Pacific region, and in rivers and reservoirs. Rivers in the Asia/Pacific region exceeded the lowest drinking water GV 73.2% of the time. However, lack of standardized protocols used for analyses was alarming, which warrants improvement in future studies. In addition, bioaccumulation of CYN has been reported in mollusks, crustaceans, and fish, but such exposure information remains limited. Though several publications have reported aquatic toxicity of CYN, there is limited chronic aquatic toxicity data, especially for higher trophic level organisms. Most aquatic toxicity studies have not employed standardized experimental designs, failed to analytically verify treatment levels, and did not report purity of CYN used for experiments; therefore, existing data are insufficient to derive water quality guidelines. Considering such elevated exceedances of CYN in global surface waters and limited aquatic bioaccumulation and toxicity data, further aquatic monitoring, environmental fate and mechanistic toxicology studies are warranted to robustly assess and manage water quality risks to public health and the environment., Competing Interests: Declaration of competing interest The authors declare no conflicts of interest., (Copyright © 2020 Elsevier B.V. All rights reserved.)