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Objectives To evaluate health outcomes and identify risk factors for reinfection and persistent symptoms among COVID-19 survivors 4 years after hospital discharge.Design Longitudinal cohort study.Setting Two hospitals in Wuhan, China.Participants 1076 COVID-19 survivors discharged from hospital.Outcome measures Self-reported symptom questionnaire, Chronic Obstructive Pulmonary Disease Assessment Test, Hospital Anxiety and Depression Scale and Checklist Individual Strength (CIS) fatigue subscale. Long covid was defined according to WHO criteria.Results Median age was 58 years and 50.2% were male. Reinfection during December 2022–April 2023 occurred in 36.1%; 21 developed pneumonia and 14 required hospitalisation. At least 12 months after reinfection, 12.1% reported sequelae compared with 46.9% after the initial infection. At 4 years, 16.7% reported long covid symptoms, commonly fatigue, chest tightness, cough and dyspnoea. In multivariable analysis, risk factors for abnormal fatigue (CIS ≥27) included age (OR 1.020, 95% CI 1.007 to 1.034; p=0.003), reinfection (OR 2.393, 95% CI 1.708 to 3.352; p<0.001), severe disease (OR 1.553, 95% CI 1.088 to 2.218; p=0.015) and tumour (OR 3.420, 95% CI 1.177 to 9.936; p=0.024).Conclusions At 4 years post discharge, symptom burden was lower than at earlier follow-up time points for most survivors. Reinfection and older age were associated with persistent symptoms.