Ethnic minorities and COVID-19: examining whether excess risk is mediated through deprivation

Mortality from COVID-19 in Amazonian and Andean original indigenous populations of Peru

OBJECTIVE

To compare the mortality rates from COVID-19 among indigenous populations of the Amazon and Andean regions of Peru during the years 2020, 2021 and 2022.

METHODS

Secondary analysis of 33,567 data from the COVID-19 Notification System of the National Epidemiology Center, Prevention and Control of Diseases (CDC-Peru), from the years 2020-2022. The variables were age, sex, belonging to the Andean or Amazonian ethnic group, number and type of symptoms and risk conditions, abnormal findings in chest X-rays, year of data collection for hospitalization and death from COVID-19. Poisson family generalized linear regression models with logarithmic linkage and robust variance were used to establish differences in mortality between ethnic groups. Crude and adjusted risk ratio (RR) with 95 % confidence intervals (CI) were calculated.

RESULTS

33,567 participants with an average age of 33.6 years were included, 44.4 % were men and 70.2 % belonged to the Amazonian ethnic group. Most of those affected by COVID-19 presented 2 symptoms (38.8 %), 4.8 % presented some risk condition, 1451 (4.3 %) were hospitalized, and 433 (1.3 %) died. The adjusted analysis showed that the Andean group, compared to the Amazonian, tended to have a higher probability of death, and this association was statistically significant, RR =7.6, 95 % CI (5.5-10.5).

CONCLUSIONS

Patients from Andean indigenous communities had an almost 8 times higher risk of death from COVID-19.

Views and experiences of primary care among Black communities in the United Kingdom: a qualitative systematic review

BACKGROUND

In the United Kingdom, people with non-white ethnicities are more likely to report being in worse health conditions and have poorer experiences of healthcare services than white counterparts. The voices of those of Black ethnicities are often merged in literature among other non-white ethnicities. This literature review aims to analyse studies that investigate Black participant experiences of primary care in the UK.

METHODS

We conducted a systematic literature review searching Medline, Web of Science, EMBASE, SCOPUS, Social Policy and Practice, CINAHL plus, Psych INFO and Global Health with specific search terms for appropriate studies. No publish date limit was applied.

RESULTS

40 papers (39 articles and 1 thesis) were deemed eligible for inclusion in the review. A number of major themes emerged. Patient expectations of healthcare and the health seeking behaviour impacted their interactions with health systems in the UK. Both language and finances emerged as barriers through which some Black participants interacted with primary care services. (Mis)trust of clinicians and the health system was a common theme that often negatively impacted views of UK primary care services. The social context of the primary care service and instances of a cultural disconnect also impacted views of primary care services. Some papers detail patients recognising differential treatment based on ethnicity. The review included the voices of primary care professionals where descriptions of Black patients were overwhelmingly negative.

CONCLUSION

Views and experiences of Black groups may be radically different to other ethnic minorities and thus, should be teased out of broader umbrella terms like Black and Asian Minority Ethnic (BAME) and Black Minority Ethnic (BME). To address ethnicity-based health inequalities, culturally sensitive interventions that engage with the impacted community including co-designed interventions should be considered while acknowledging the implications of being racialised as Black in the UK.

Association between ethnic background and COVID-19 morbidity, mortality and vaccination in England: a multistate cohort analysis using the UK Biobank

OBJECTIVES

Despite growing evidence suggesting increased COVID-19 mortality among people from ethnic minorities, little is known about milder forms of SARS-CoV-2 infection. We sought to explore the association between ethnic background and the probability of testing, testing positive, hospitalisation, COVID-19 mortality and vaccination uptake.

DESIGN

A multistate cohort analysis. Participants were followed between 8 April 2020 and 30 September 2021.

SETTING

The UK Biobank, which stores medical data on around half a million people who were recruited between 2006 and 2010.

PARTICIPANTS

405 541 subjects were eligible for analysis, limited to UK Biobank participants living in England. 23 891 (6%) of participants were non-white.

PRIMARY AND SECONDARY OUTCOME MEASURES

The associations between ethnic background and testing, testing positive, hospitalisation and COVID-19 mortality were studied using multistate survival analyses. The association with single and double-dose vaccination was also modelled. Multistate models adjusted for age, sex and socioeconomic deprivation were fitted to estimate adjusted HRs (aHR) for each of the multistate transitions.

RESULTS

18 172 (4.5%) individuals tested positive, 3285 (0.8%) tested negative and then positive, 1490 (6.9% of those tested positive) were hospitalised, and 129 (0.6%) tested positive at the moment of hospital admission (ie, direct hospitalisation). Finally, 662 (17.4%) died after admission. Compared with white participants, Asian participants had an increased risk of negative to positive transition (aHR 1.24 (95% CI 1.02 to 1.52)), testing positive (95% CI 1.44 (1.33 to 1.55)) and direct hospitalisation (1.61 (95% CI 1.28 to 2.03)). Black participants had an increased risk of hospitalisation following a positive test (1.71 (95% CI 1.29 to 2.27)) and direct hospitalisation (1.90 (95% CI 1.51 to 2.39)). Although not the case for Asians (aHR 1.00 (95% CI 0.98 to 1.02)), black participants had a reduced vaccination probability (0.63 (95% CI 0.62 to 0.65)). In contrast, Chinese participants had a reduced risk of testing negative (aHR 0.64 (95% CI 0.57 to 0.73)), of testing positive (0.40 (95% CI 0.28 to 0.57)) and of vaccination (0.78 (95% CI 0.74 to 0.83)).

CONCLUSIONS

We identified inequities in testing, vaccination and COVID-19 outcomes according to ethnicity in England. Compared with whites, Asian participants had increased risks of infection and admission, and black participants had almost double hospitalisation risk, and a 40% lower vaccine uptake.

Socioeconomic inequalities of Long COVID: a retrospective population-based cohort study in the United Kingdom

OBJECTIVES

To estimate the risk of Long COVID by socioeconomic deprivation and to further examine the inequality by sex and occupation.

DESIGN

We conducted a retrospective population-based cohort study using data from the ONS COVID-19 Infection Survey between 26 April 2020 and 31 January 2022. This is the largest nationally representative survey of COVID-19 in the UK with longitudinal data on occupation, COVID-19 exposure and Long COVID.

SETTING

Community-based survey in the UK.

PARTICIPANTS

A total of 201,799 participants aged 16 to 64 years and with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

MAIN OUTCOME MEASURES

The risk of Long COVID at least 4 weeks after SARS-CoV-2 infection by index of multiple deprivation (IMD) and the modifying effects of socioeconomic deprivation by sex and occupation.

RESULTS

Nearly 10% (n = 19,315) of participants reported having Long COVID. Multivariable logistic regression models, adjusted for a range of variables (demographic, co-morbidity and time), showed that participants in the most deprived decile had a higher risk of Long COVID (11.4% vs. 8.2%; adjusted odds ratio (aOR): 1.46; 95% confidence interval (CI): 1.34, 1.59) compared to the least deprived decile. Significantly higher inequalities (most vs. least deprived decile) in Long COVID existed in healthcare and patient-facing roles (aOR: 1.76; 95% CI: 1.27, 2.44), in the education sector (aOR: 1.68; 95% CI: 1.31, 2.16) and in women (aOR: 1.56; 95% CI: 1.40, 1.73) than men (aOR: 1.32; 95% CI: 1.15, 1.51).

CONCLUSIONS

This study provides insights into the heterogeneous degree of inequality in Long COVID by deprivation, sex and occupation. These findings will help inform public health policies and interventions in incorporating a social justice and health inequality lens.

Covid-19 restrictions: An opportunity to highlight the effect of neighbourhood deprivation on individuals' health-related behaviours

RATIONALE

Neighbourhood socio-economic deprivation is strongly related to health-risk behaviours, which are predictors of overall health and mortality. During the Covid-19 pandemic, individuals have been forced to spend more time within their residential areas, which might have had an effect on health-risk behaviours.

OBJECTIVE

We assess the consequences of living in a more or less deprived neighbourhood during the pandemic on individual behavioural changes in four health-related outcomes: smoking, drinking, physical activity and healthy eating. We hypothesise that the pandemic and related lock-downs had negative effects on health-related behaviours, but that this negative effect had been stronger for people living in more deprived areas. We additionally explore sex and ethnicity as sources of heterogeneity in these effects.

METHODS

We use data from four nationally representative cohort studies in England. We perform longitudinal individual and neighbourhood fixed effects estimations focusing on comparing the pre-pandemic period with the first lockdown (May 2020) period and up to one year after the outbreak of the pandemic (March 2021).

RESULTS

During the first lockdown, as compared to pre-pandemic levels, on average, people smoked more, drunk more and did more physical activity. However, compared to people in less deprived neighbourhoods, people living in more deprived areas showed a smaller increase in their levels of physical activity, consumed less fruit and vegetables and increased the number of cigarettes smoked. We additionally find that the combined effect of Covid-19 and area deprivation varies significantly by both sex and ethnicity.

CONCLUSION

Results add to evidence on the impact of the Covid-19 pandemic and associated lockdowns on health-risk behaviours, highlighting the relative contribution of the neighbourhood environment and individual characteristics. We argue that reducing levels of neighbourhood deprivation may contribute to positively influence behaviours, especially for some sub-groups of the population, leading to a reduction of social inequalities in health.

COVID-19 vaccination uptake amongst ethnic minority communities in England: a linked study exploring the drivers of differential vaccination rates

BACKGROUND

Despite generally high coronavirus disease 2019 (COVID-19) vaccination rates in the UK, vaccination hesitancy and lower take-up rates have been reported in certain ethnic minority communities.

METHODS

We used vaccination data from the National Immunisation Management System (NIMS) linked to the 2011 Census and individual health records for subjects aged ≥40 years (n = 24 094 186). We estimated age-standardized vaccination rates, stratified by ethnic group and key sociodemographic characteristics, such as religious affiliation, deprivation, educational attainment, geography, living conditions, country of birth, language skills and health status. To understand the association of ethnicity with lower vaccination rates, we conducted a logistic regression model adjusting for differences in geographic, sociodemographic and health characteristics. ResultsAll ethnic groups had lower age-standardized rates of vaccination compared with the white British population, whose vaccination rate of at least one dose was 94% (95% CI: 94%-94%). Black communities had the lowest rates, with 75% (74-75%) of black African and 66% (66-67%) of black Caribbean individuals having received at least one dose. The drivers of these lower rates were partly explained by accounting for sociodemographic differences. However, modelled estimates showed significant differences remained for all minority ethnic groups, compared with white British individuals.

CONCLUSIONS

Lower COVID-19 vaccination rates are consistently observed amongst all ethnic minorities.

Ethnic disparities in COVID-19 outcomes: a multinational cohort study of 20 million individuals from England and Canada

BACKGROUND

Heterogeneous studies have demonstrated ethnic inequalities in the risk of SARS-CoV-2 infection and adverse COVID-19 outcomes. This study evaluates the association between ethnicity and COVID-19 outcomes in two large population-based cohorts from England and Canada and investigates potential explanatory factors for ethnic patterning of severe outcomes.

METHODS

We identified adults aged 18 to 99 years in the QResearch primary care (England) and Ontario (Canada) healthcare administrative population-based datasets (start of follow-up: 24th and 25th Jan 2020 in England and Canada, respectively; end of follow-up: 31st Oct and 30th Sept 2020, respectively). We harmonised the definitions and the design of two cohorts to investigate associations between ethnicity and COVID-19-related death, hospitalisation, and intensive care (ICU) admission, adjusted for confounders, and combined the estimates obtained from survival analyses. We calculated the 'percentage of excess risk mediated' by these risk factors in the QResearch cohort.

RESULTS

There were 9.83 million adults in the QResearch cohort (11,597 deaths; 21,917 hospitalisations; 2932 ICU admissions) and 10.27 million adults in the Ontario cohort (951 deaths; 5132 hospitalisations; 1191 ICU admissions). Compared to the general population, pooled random-effects estimates showed that South Asian ethnicity was associated with an increased risk of COVID-19 death (hazard ratio: 1.63, 95% CI: 1.09-2.44), hospitalisation (1.53; 1.32-1.76), and ICU admission (1.67; 1.23-2.28). Associations with ethnic groups were consistent across levels of deprivation. In QResearch, sociodemographic, lifestyle, and clinical factors accounted for 42.9% (South Asian) and 39.4% (Black) of the excess risk of COVID-19 death.

CONCLUSION

International population-level analyses demonstrate clear ethnic inequalities in COVID-19 risks. Policymakers should be cognisant of the increased risks in some ethnic populations and design equitable health policy as the pandemic continues.

Risk Factors of Severe COVID-19: A Review of Host, Viral and Environmental Factors

The clinical course and outcome of COVID-19 are highly variable, ranging from asymptomatic infections to severe disease and death. Understanding the risk factors of severe COVID-19 is relevant both in the clinical setting and at the epidemiological level. Here, we provide an overview of host, viral and environmental factors that have been shown or (in some cases) hypothesized to be associated with severe clinical outcomes. The factors considered in detail include the age and frailty, genetic polymorphisms, biological sex (and pregnancy), co- and superinfections, non-communicable comorbidities, immunological history, microbiota, and lifestyle of the patient; viral genetic variation and infecting dose; socioeconomic factors; and air pollution. For each category, we compile (sometimes conflicting) evidence for the association of the factor with COVID-19 outcomes (including the strength of the effect) and outline possible action mechanisms. We also discuss the complex interactions between the various risk factors.

Mitigating COVID-19 Risk and Vaccine Hesitancy Among Underserved African American and Latinx Individuals with Mental Illness Through Mental Health Therapist-Facilitated Discussions

Background

Underserved ethnic minorities with psychiatric disorders are at an increased risk of COVID-19. This study aims to examine the effectiveness of one-to-one counseling on COVID-19 vaccination and vaccination readiness among underserved African American and Latinx individuals with mental illnesses and adult caregivers of children with mental illness.

Methods

Through an academic-community partnered collaboration, a multidisciplinary and culturally sensitive training on COVID-19 was co-developed and delivered to 68 therapists from January to March 2021. Mental health clients and their caregivers were recruited to participate in pre- and post-intervention surveys to evaluate the impact of the intervention on their perceptions of COVID-19 public health guidelines, testing, and vaccination. Mental health therapists delivered four lessons of the COVID-19 educational intervention with 254 clients from March to June 2021, when vaccine availability was widely available. Of those clients, we collected 180 baseline and 115 follow-up surveys. The main outcome was the uptake in COVID-19 vaccine.

Results

There was a positive shift in participant vaccine acceptance and receptivity. Pre-intervention survey shows that only 56% of adult clients and 48% of caregivers had indicated a likelihood of getting the vaccine for themselves at baseline. Post-intervention documented that more than 57% of each group had been vaccinated, with another 11–15% of the unvaccinated individuals reporting that they were somewhat or very likely to get the vaccine.

Conclusion

This study demonstrated that multidisciplinary academic-community and theoretical-based educational intervention delivered by mental health therapists is an effective strategy in increasing COVID-19 vaccine acceptance and reducing the negative impact and disruption that COVID-19 caused in the daily life of mental health patients and caregivers.

Higher risk, higher protection. COVID-19 risk among immigrants in France: results from the population-based EpiCov survey

Background

Immigrants and ethnic/racialized minorities have been identified as being at higher risk of coronavirus disease-19 (COVID-19) infection, but few studies report on their exposures and prevention behaviours. This study aims to examine the social distribution of COVID-19 exposure (overcrowding, working outside the home, use of public transport to go to work) and prevention behaviours (use of face masks, washing hands, respect for physical distance) in France during the first wave of the epidemic.

Methods

We used the EpiCov population-based survey from a random sample of individuals aged 15 years or more. We determined the distribution of the self-reported outcomes according to migratory status and sex, using χ² tests. We modelled the probability of outcomes with logistic regression. Finally, we focused the analysis on the Greater Paris area and accounted for neighbourhood characteristics.

Results

A total of 111 824 participants were included in the study. Overall, immigrant groups from non-European countries were more exposed to COVID-19-related factors and more respectful of prevention measures. The probability of overcrowding and the use of public transport was higher for immigrants from sub-Saharan Africa [adjusted odds ratio (aOR) = 3.71 (3.19; 4.32), aOR = 6.36 (4.86; 8.32)] than for the majority population. Immigrant groups were less likely to have a non-systematic use of face masks and to breach physical distancing than the majority population [for immigrants from sub-Saharan Africa, aOR = 0.32 (0.28; 0.37) and aOR = 0.71 (0.61; 0.81), respectively]. Living in a neighbourhood with a higher share of immigrants was associated with higher exposure and better prevention behaviours.

Conclusions

In France, immigrants had a higher exposure to COVID-19-related factors and more systematic prevention behaviours.

COVID-19 vaccination coverage in deprived populations living in segregated colonies: A nationwide cross-sectional study in Hungary

The segregated colonies (SCs) in Hungary are populated mainly but not exclusively by Roma. Their health care use is restricted in many respects. It has not been studied yet, whether fair COVID-19 vaccination coverage achieved in Hungary is accompanied with fair effectiveness in SCs. Using census data, the vaccination coverage in SCs and the complementary areas (CAs) in the same settlements of the country was determined. To describe the settlement level differences, the vaccination coverage (until June 30, 2021) in SCs were compared to those in CAs by age, sex, and eligibility for exemption certificate standardized measures. Aggregating settlement level data, the level of geographic discrimination in Hungary was also determined. According to nationwide aggregates, crude vaccination coverage was significantly lower in SCs (40.05%, 95% CI 39.87%-40.23%) than in CAs (65.42%, 95% CI 65.37%-65.46%). The relative standardized vaccination coverage was 0.643 (95% CI 0.639-0.647) in SCs. A total of 437 of the 938 investigated settlements showed significant local vaccination disparities. Hungarian citizens living in SCs, mainly of Roma ethnicity, are a distinct high-risk group. Special intervention adapted to SCs is needed to mitigate inequality in vaccination coverage and further consequences of the pandemic.

Assessing the Acceptability of a Co-Produced Long COVID Intervention in an Underserved Community in the UK

BACKGROUND

The COVID-19 pandemic has disproportionately affected people from more deprived communities. The experience of Long COVID is similarly distributed but very few investigations have concentrated on the needs of this population. The aim of this project was to co-produce an acceptable intervention for people with Long COVID living in communities recognised as more deprived.

METHODS

The intervention was based on a multi-disciplinary team using approaches from sport and exercise medicine and functional rehabilitation. The co-production process was undertaken with a stakeholder advisory group and patient public involvement representation. This study identified participants by postcode and the indices of multiple deprivation (IMD); recruitment and engagement were supported by an existing health and wellbeing service. A virtual 'clinic' was offered with a team of professional practitioners who met participants three times each; to directly consider their needs and offer structured advice. The acceptability of the intervention was based on the individual's participation and their completion of the intervention.

RESULTS

Ten participants were recruited with eight completing the intervention. The partnership with an existing community health and wellbeing service was deemed to be an important way of reaching participants. Two men and six women ages ranging from 38 to 73 were involved and their needs were commonly associated with fatigue, anxiety and depression with overall de-conditioning. None reported serious hardship associated with the pandemic although most were in self-employment/part-time employment or were not working due to retirement or ill-health. Two older participants lived alone, and others were single parents and had considerable challenges associated with managing a household alongside their Long COVID difficulties.

CONCLUSIONS

This paper presents the needs and perspectives of eight individuals involved in the process and discusses the needs and preferences of the group in relation to their support for self- managed recovery from Long COVID.

Association Between Accelerometer-Assessed Physical Activity and Severity of COVID-19 in UK Biobank

OBJECTIVE

To quantify the association between accelerometer-assessed physical activity and coronavirus disease 2019 (COVID-19) outcomes.

METHODS

Data from 82,253 UK Biobank participants with accelerometer data (measured 2013-2015), complete covariate data, and linked COVID-19 data from March 16, 2020, to March 16, 2021, were included. Two outcomes were investigated: severe COVID-19 (positive test result from in-hospital setting or COVID-19 as primary cause of death) and nonsevere COVID-19 (positive test result from community setting). Logistic regressions were used to assess associations with moderate to vigorous physical activity (MVPA), total activity, and intensity gradient. A higher intensity gradient indicates a higher proportion of vigorous activity.

RESULTS

Average MVPA was 48.1 (32.7) min/d. Physical activity was associated with lower odds of severe COVID-19 (adjusted odds ratio per standard deviation increase: MVPA, 0.75 [95% CI, 0.67 to 0.85]; total, 0.83 [0.74 to 0.92]; intensity, 0.77 [0.70 to 0.86]), with stronger associations in women (MVPA, 0.63 [0.52 to 0.77]; total, 0.76 [0.64 to 0.90]; intensity, 0.63 [0.53 to 0.74]) than in men (MVPA, 0.84 [0.73 to 0.97]; total, 0.88 [0.77 to 1.01]; intensity, 0.88 [0.77 to 1.00]). In contrast, when mutually adjusted, total activity was associated with higher odds of a nonsevere infection (1.10 [1.04 to 1.16]), whereas the intensity gradient was associated with lower odds (0.91 [0.86 to 0.97]).

CONCLUSION

Odds of severe COVID-19 were approximately 25% lower per standard deviation (∼30 min/d) MVPA. A greater proportion of vigorous activity was associated with lower odds of severe and nonsevere infections. The association between total activity and higher odds of a nonsevere infection may be through greater community engagement and thus more exposure to the virus. Results support calls for public health messaging highlighting the potential of MVPA for reducing the odds of severe COVID-19.

Differences in Accelerometer-Measured Patterns of Physical Activity and Sleep/Rest Between Ethnic Groups and Age: An Analysis of UK Biobank

BACKGROUND

Physical activity and sleep are important for health; whether device-measured physical activity and sleep differ by ethnicity is unclear. This study aimed to compare physical activity and sleep/rest in white, South Asian (SA), and black adults by age.

METHODS

Physical activity and sleep/rest quality were assessed using accelerometer data from UK Biobank. Linear regressions, stratified by sex, were used to analyze differences in activity and sleep/rest. An ethnicity × age group interaction term was used to assess whether ethnic differences were consistent across age groups.

RESULTS

Data from 95,914 participants, aged 45-79 years, were included. Overall activity was 7% higher in black, and 5% lower in SA individuals compared with white individuals. Minority ethnic groups had poorer sleep/rest quality. Lower physical activity and poorer sleep quality occurred at a later age in black and SA adults (>65 y), than white adults (>55 y).

CONCLUSIONS

While black adults are more active, and SA adults less active, than white adults, the age-related reduction appears to be delayed in black and SA adults. Sleep/rest quality is poorer in black and SA adults than in white adults. Understanding ethnic differences in physical activity and rest differ may provide insight into chronic conditions with differing prevalence across ethnicities.

Effects of covid-19 pandemic on life expectancy and premature mortality in 2020: time series analysis in 37 countries

OBJECTIVE

To estimate the changes in life expectancy and years of life lost in 2020 associated with the covid-19 pandemic.

DESIGN

Time series analysis.

SETTING

37 upper-middle and high income countries or regions with reliable and complete mortality data.

PARTICIPANTS

Annual all cause mortality data from the Human Mortality Database for 2005-20, harmonised and disaggregated by age and sex.

MAIN OUTCOME MEASURES

Reduction in life expectancy was estimated as the difference between observed and expected life expectancy in 2020 using the Lee-Carter model. Excess years of life lost were estimated as the difference between the observed and expected years of life lost in 2020 using the World Health Organization standard life table.

RESULTS

Reduction in life expectancy in men and women was observed in all the countries studied except New Zealand, Taiwan, and Norway, where there was a gain in life expectancy in 2020. No evidence was found of a change in life expectancy in Denmark, Iceland, and South Korea. The highest reduction in life expectancy was observed in Russia (men: -2.33, 95% confidence interval -2.50 to -2.17; women: -2.14, -2.25 to -2.03), the United States (men: -2.27, -2.39 to -2.15; women: -1.61, -1.70 to -1.51), Bulgaria (men: -1.96, -2.11 to -1.81; women: -1.37, -1.74 to -1.01), Lithuania (men: -1.83, -2.07 to -1.59; women: -1.21, -1.36 to -1.05), Chile (men: -1.64, -1.97 to -1.32; women: -0.88, -1.28 to -0.50), and Spain (men: -1.35, -1.53 to -1.18; women: -1.13, -1.37 to -0.90). Years of life lost in 2020 were higher than expected in all countries except Taiwan, New Zealand, Norway, Iceland, Denmark, and South Korea. In the remaining 31 countries, more than 222 million years of life were lost in 2020, which is 28.1 million (95% confidence interval 26.8m to 29.5m) years of life lost more than expected (17.3 million (16.8m to 17.8m) in men and 10.8 million (10.4m to 11.3m) in women). The highest excess years of life lost per 100 000 population were observed in Bulgaria (men: 7260, 95% confidence interval 6820 to 7710; women: 3730, 2740 to 4730), Russia (men: 7020, 6550 to 7480; women: 4760, 4530 to 4990), Lithuania (men: 5430, 4750 to 6070; women: 2640, 2310 to 2980), the US (men: 4350, 4170 to 4530; women: 2430, 2320 to 2550), Poland (men: 3830, 3540 to 4120; women: 1830, 1630 to 2040), and Hungary (men: 2770, 2490 to 3040; women: 1920, 1590 to 2240). The excess years of life lost were relatively low in people younger than 65 years, except in Russia, Bulgaria, Lithuania, and the US where the excess years of life lost was >2000 per 100 000.

CONCLUSION

More than 28 million excess years of life were lost in 2020 in 31 countries, with a higher rate in men than women. Excess years of life lost associated with the covid-19 pandemic in 2020 were more than five times higher than those associated with the seasonal influenza epidemic in 2015.

Unequal burden of COVID-19 in Hungary: a geographical and socioeconomic analysis of the second wave of the pandemic

Introduction

We describe COVID-19 morbidity, mortality, case fatality and excess death in a country-wide study of municipalities in Hungary, exploring the association with socioeconomic status.

Methods

The spatial distribution of morbidity, mortality and case fatality was mapped using hierarchical Bayesian smoothed indirectly standardised ratios. Indirectly standardised ratios were used to evaluate the association between deprivation and the outcome measures. We looked separately at morbidity and mortality in the 10 districts with the highest and 10 districts with the lowest share of Roma population.

Results

Compared with the national average, the relative incidence of cases was 30%–36% lower in the most deprived quintile but the relative mortality and case fatality were 27%–32% higher. Expressed as incidence ratios relative to the national average, the most deprived municipalities had a relative incidence ratio of 0.64 (CI: 0.62 to 0.65) and 0.70 (CI: 0.69 to 0.72) for males and females, respectively. The corresponding figures for mortality were 1.32 (CI: 1.20 to 1.44) for males and 1.27 (CI: 1.16 to 1.39) for females and for case fatality 1.27 (CI: 1.16 to 1.39) and 1.32 (CI: 1.20 to 1.44) for males and females, respectively. The excess death rate (per 100 000) increased with deprivation levels (least deprived: 114.12 (CI: 108.60 to 119.84) and most deprived: 158.07 (CI: 149.30 to 167.23)). The 10 districts where Roma formed the greatest share of the population had an excess mortality rate 17.46% higher than the average for the most deprived quintile.

Conclusions

Those living in more deprived municipalities had a lower risk of being identified as a confirmed COVID-19 case but had a higher risk of death. An inverse association between trends in morbidity and mortality by socioeconomic conditions should be a cause for concern and points to the need for responses, including those involving vaccination, to pay particular attention to inequalities and their causes.

Excess deaths associated with covid-19 pandemic in 2020: age and sex disaggregated time series analysis in 29 high income countries

OBJECTIVE

To estimate the direct and indirect effects of the covid-19 pandemic on mortality in 2020 in 29 high income countries with reliable and complete age and sex disaggregated mortality data.

DESIGN

Time series study of high income countries.

SETTING

Austria, Belgium, Czech Republic, Denmark, England and Wales, Estonia, Finland, France, Germany, Greece, Hungary, Israel, Italy, Latvia, Lithuania, the Netherlands, New Zealand, Northern Ireland, Norway, Poland, Portugal, Scotland, Slovakia, Slovenia, South Korea, Spain, Sweden, Switzerland, and United States.

PARTICIPANTS

Mortality data from the Short-term Mortality Fluctuations data series of the Human Mortality Database for 2016-20, harmonised and disaggregated by age and sex.

INTERVENTIONS

Covid-19 pandemic and associated policy measures.

MAIN OUTCOME MEASURES

Weekly excess deaths (observed deaths versus expected deaths predicted by model) in 2020, by sex and age (0-14, 15-64, 65-74, 75-84, and ≥85 years), estimated using an over-dispersed Poisson regression model that accounts for temporal trends and seasonal variability in mortality.

RESULTS

An estimated 979 000 (95% confidence interval 954 000 to 1 001 000) excess deaths occurred in 2020 in the 29 high income countries analysed. All countries had excess deaths in 2020, except New Zealand, Norway, and Denmark. The five countries with the highest absolute number of excess deaths were the US (458 000, 454 000 to 461 000), Italy (89 100, 87 500 to 90 700), England and Wales (85 400, 83 900 to 86 800), Spain (84 100, 82 800 to 85 300), and Poland (60 100, 58 800 to 61 300). New Zealand had lower overall mortality than expected (-2500, -2900 to -2100). In many countries, the estimated number of excess deaths substantially exceeded the number of reported deaths from covid-19. The highest excess death rates (per 100 000) in men were in Lithuania (285, 259 to 311), Poland (191, 184 to 197), Spain (179, 174 to 184), Hungary (174, 161 to 188), and Italy (168, 163 to 173); the highest rates in women were in Lithuania (210, 185 to 234), Spain (180, 175 to 185), Hungary (169, 156 to 182), Slovenia (158, 132 to 184), and Belgium (151, 141 to 162). Little evidence was found of subsequent compensatory reductions following excess mortality.

CONCLUSION

Approximately one million excess deaths occurred in 2020 in these 29 high income countries. Age standardised excess death rates were higher in men than women in almost all countries. Excess deaths substantially exceeded reported deaths from covid-19 in many countries, indicating that determining the full impact of the pandemic on mortality requires assessment of excess deaths. Many countries had lower deaths than expected in children <15 years. Sex inequality in mortality widened further in most countries in 2020.