Background

The inverse care law states that disadvantaged populations need more health care than advantaged populations but receive less. Gaps in COVID-19-related health care and infection control are not well understood. We aimed to examine inequalities in health in the care cascade from testing for SARS-CoV-2 to COVID-19-related hospitalisation, intensive care unit (ICU) admission, and death in Switzerland, a wealthy country strongly affected by the pandemic.

Methods

We analysed surveillance data reported to the Swiss Federal Office of Public Health from March 1, 2020, to April 16, 2021, and 2018 population data. We geocoded residential addresses of notifications to identify the Swiss neighbourhood index of socioeconomic position (Swiss-SEP). The index describes 1·27 million small neighbourhoods of approximately 50 households each on the basis of rent per m², education and occupation of household heads, and crowding. We used negative binomial regression models to calculate incidence rate ratios (IRRs) with 95% credible intervals (CrIs) of the association between ten groups of the Swiss-SEP index defined by deciles (1=lowest, 10=highest) and outcomes. Models were adjusted for sex, age, canton, and wave of the epidemic (before or after June 8, 2020). We used three different denominators: the general population, the number of tests, and the number of positive tests.

Findings

Analyses were based on 4 129 636 tests, 609 782 positive tests, 26 143 hospitalisations, 2432 ICU admissions, 9383 deaths, and 8 221 406 residents. Comparing the highest with the lowest Swiss-SEP group and using the general population as the denominator, more tests were done among people living in neighbourhoods of highest SEP compared with lowest SEP (adjusted IRR 1·18 [95% CrI 1·02–1·36]). Among tested people, test positivity was lower (0·75 [0·69–0·81]) in neighbourhoods of highest SEP than of lowest SEP. Among people testing positive, the adjusted IRR was 0·68 (0·62–0·74) for hospitalisation, was 0·54 (0·43–0·70) for ICU admission, and 0·86 (0·76–0·99) for death. The associations between neighbourhood SEP and outcomes were stronger in younger age groups and we found heterogeneity between areas.

Interpretation

The inverse care law and socioeconomic inequalities were evident in Switzerland during the COVID-19 epidemic. People living in neighbourhoods of low SEP were less likely to be tested but more likely to test positive, be admitted to hospital, or die, compared with those in areas of high SEP. It is essential to continue to monitor testing for SARS-CoV-2, access and uptake of COVID-19 vaccination and outcomes of COVID-19. Governments and health-care systems should address this pandemic of inequality by taking measures to reduce health inequalities in response to the SARS-CoV-2 pandemic.

Funding

Swiss Federal Office of Public Health, Swiss National Science Foundation, EU Horizon 2020, Branco Weiss Foundation.

中文翻译：

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瑞士的社会经济地位和从检测到死亡的 COVID-19 护理级联：基于人口的分析

 背景

逆向医疗法规定，弱势群体比优势群体需要更多的医疗保健，但获得的医疗保健却较少。与 COVID-19 相关的医疗保健和感染控制方面的差距尚不清楚。我们的目的是研究瑞士这个受疫情严重影响的富裕国家，从 SARS-CoV-2 检测到与 COVID-19 相关的住院、重症监护病房 (ICU) 入住和死亡等一系列护理中的健康不平等现象。

 方法

我们分析了2020年3月1日至2021年4月16日向瑞士联邦公共卫生办公室报告的监测数据以及2018年的人口数据。我们对通知的住宅地址进行地理编码，以识别瑞士社区社会经济地位指数 (Swiss-SEP)。该指数根据每^平方米租金、户主的教育和职业以及拥挤程度描述了 1·2700 万个小社区，每个社区大约有 50 户家庭。我们使用负二项式回归模型来计算由十分位数（1=最低，10=最高）和结果定义的 Swiss-SEP 指数十组之间关联的 95% 可信区间 (CrIs) 的发病率比 (IRR)。模型根据性别、年龄、所在州和疫情波次（2020年6月8日前后）进行了调整。我们使用了三个不同的分母：总人口、检测数量和阳性检测数量。

 发现

分析基于 4,129,636 例检测、609,782 例阳性检测、26,143 例住院治疗、2432 例 ICU 入住、9383 例死亡和 8,221,406 名居民。比较最高和最低瑞士 SEP 群体并使用总人口作为分母，与最低 SEP 社区相比，对居住在最高 SEP 社区的人们进行了更多测试（调整后的 IRR 1·18 [95% CrI 1·02–1 ·36]）。在受测人群中，SEP 最高的社区的测试阳性率低于 SEP 最低的社区 (0·75 [0·69–0·81])。在检测呈阳性的人群中，住院治疗的调整后 IRR 为 0·68 (0·62–0·74)，入住 ICU 的调整后 IRR 为 0·54 (0·43–0·70)，入住 ICU 的调整后 IRR 为 0·86 (0·76– 0·99) 死亡。在较年轻的年龄组中，社区 SEP 与结果之间的关联更强，我们发现区域之间存在异质性。

 解释

在 COVID-19 疫情期间，瑞士的逆向护理法和社会经济不平等现象十分明显。与居住在高 SEP 地区的人们相比，生活在低 SEP 社区的人们接受检测的可能性较小，但检测结果呈阳性、入院或死亡的可能性更高。必须继续监测 SARS-CoV-2 检测、COVID-19 疫苗接种的获取和接种情况以及 COVID-19 的结果。各国政府和卫生保健系统应采取措施减少健康不平等，以应对 SARS-CoV-2 大流行，从而解决这一普遍存在的不平等问题。

 资金

瑞士联邦公共卫生办公室、瑞士国家科学基金会、欧盟地平线 2020、布兰科·韦斯基金会。