Background

The objective of this study was to better understand the factors associated with the heterogeneity of in-hospital COVID-19 morbidity and mortality across France, one of the countries most affected by COVID-19 in the early months of the pandemic.

Methods

This geo-epidemiological analysis was based on data publicly available on government and administration websites for the 96 administrative departments of metropolitan France between March 19 and May 11, 2020, including Public Health France, the Regional Health Agencies, the French national statistics institute, and the Ministry of Health. Using hierarchical ascendant classification on principal component analysis of multidimensional variables, and multivariate analyses with generalised additive models, we assessed the associations between several factors (spatiotemporal spread of the epidemic between Feb 7 and March 17, 2020, the national lockdown, demographic population structure, baseline intensive care capacities, baseline population health and health-care services, new chloroquine and hydroxychloroquine dispensations, economic indicators, degree of urbanisation, and climate profile) and in-hospital COVID-19 incidence, mortality, and case fatality rates. Incidence rate was defined as the cumulative number of in-hospital COVID-19 cases per 100 000 inhabitants, mortality rate as the cumulative number of in-hospital COVID-19 deaths per 100 000, and case fatality rate as the cumulative number of in-hospital COVID-19 deaths per cumulative number of in-hospital COVID-19 cases.

Findings

From March 19 to May 11, 2020, hospitals in metropolitan France notified a total of 100 988 COVID-19 cases, including 16 597 people who were admitted to intensive care and 17 062 deaths. There was an overall cumulative in-hospital incidence rate of 155·6 cases per 100 000 inhabitants (range 19·4–489·5), in-hospital mortality rate of 26·3 deaths per 100 000 (1·1–119·2), and in-hospital case fatality rate of 16·9% (4·8–26·2). We found clear spatial heterogeneity of in-hospital COVID-19 incidence and mortality rates, following the spread of the epidemic. After multivariate adjustment, the delay between the first COVID-19-associated death and the onset of the national lockdown was positively associated with in-hospital incidence (adjusted standardised incidence ratio 1·02, 95% CI 1·01–1·04), mortality (adjusted standardised mortality ratio 1·04, 1·02–1·06), and case fatality rates (adjusted standardised fatality ratio 1·01, 1·01–1·02). Mortality and case fatality rates were higher in departments with older populations (adjusted standardised ratio for populations with a high proportion older than aged >85 years 2·17 [95% CI 1·20–3·90] for mortality and 1·43 [1·08–1·88] for case fatality rate). Mortality rate was also associated with incidence rate (1·0004, 1·0002–1·001), but mortality and case fatality rates did not appear to be associated with baseline intensive care capacities. We found no association between climate and in-hospital COVID-19 incidence, or between economic indicators and in-hospital COVID-19 incidence or mortality rates.

Interpretation

This ecological study highlights the impact of the epidemic spread, national lockdown, and reactive adaptation of intensive care capacities on the spatial distribution of COVID-19 morbidity and mortality. It provides information for future geo-epidemiological analyses and has implications for preparedness and response policies to current and future epidemic waves in France and elsewhere.

Funding

None.

中文翻译：

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与法国第一波 COVID-19 的空间异质性相关的因素：一项全国范围的地理流行病学研究

背景

本研究的目的是更好地了解与法国各地院内 COVID-19 发病率和死亡率异质性相关的因素，法国是大流行最初几个月受 COVID-19 影响最严重的国家之一。

方法

这项地理流行病学分析基于 2020 年 3 月 19 日至 5 月 11 日期间法国本土 96 个行政部门的政府和行政网站上公开的数据，包括法国公共卫生署、地区卫生机构、法国国家统计局和卫生部。利用多维变量主成分分析的层次上升分类和广义加性模型的多变量分析，我们评估了几个因素之间的关联（2020年2月7日至3月17日期间疫情的时空传播、国家封锁、人口结构、基线重症监护能力、基线人口健康和医疗保健服务、新的氯喹和羟氯喹配药、经济指标、城市化程度和气候概况）以及院内 COVID-19 发病率、死亡率和病死率。发病率定义为每 10 万居民中累计住院 COVID-19 病例数，死亡率定义为每 10 万居民中累计住院 COVID-19 病例数，病死率定义为每 10 万居民中累计住院 COVID-19 病例数。医院内 COVID-19 死亡人数与住院 COVID-19 病例累计数之比。

发现

2020年3月19日至5月11日，法国本土医院共报告了100 988例COVID-19病例，其中16 597人入住重症监护室，17 062人死亡。总体累计院内发病率为每 10 万居民 155·6 例（范围 19·4–489·5），院内死亡率为每 10 万居民 26·3 例死亡（1·1–119·5）。 2），院内病死率为16·9%（4·8–26·2）。随着疫情的蔓延，我们发现院内 COVID-19 发病率和死亡率存在明显的空间异质性。经过多变量调整后，首例与 COVID-19 相关的死亡与全国封锁开始之间的延迟与院内发病率呈正相关（调整后的标准化发病率 1·02，95% CI 1·01–1·04） 、死亡率（调整后的标准化死亡率 1·04、1·02–1·06）和病死率（调整后的标准化死亡率 1·01、1·01–1·02）。人口老龄化部门的死亡率和病死率较高（调整后的标准化比率，其中年龄大于 85 岁的人口比例较高，死亡率为 2·17 [95% CI 1·20–3·90]，死亡率为 1·43 [95% CI 1·20–3·90]）。 1·08–1·88]病死率）。死亡率也与发病率相关（1·0004、1·0002–1·001），但死亡率和病死率似乎与基线重症监护能力无关。我们发现气候与院内 COVID-19 发病率之间或经济指标与院内 COVID-19 发病率或死亡率之间没有关联。

解释

这项生态研究强调了流行病传播、国家封锁和重症监护能力的反应性适应对 COVID-19 发病率和死亡率空间分布的影响。它为未来的地理流行病学分析提供信息，并对法国和其他地方当前和未来流行病浪潮的准备和应对政策产生影响。

资金

没有任何。