Urban-rural disparities in COVID-19 hospitalisations and mortality: A population-based study on national surveillance data from Germany and Italy

Abstract

Purpose Recent literature has highlighted the overlapping contribution of demographic characteristics and spatial factors to urban-rural disparities in SARS-CoV-2 transmission and outcomes. Yet the interplay between individual characteristics, hospitalisation, and spatial factors for urban-rural disparities in COVID-19 mortality have received limited attention. Methods To fill this gap, we use national surveillance data collected by the European Centre for Disease Prevention and Control and we fit a generalized linear model to estimate the association between COVID-19 mortality and the individuals’ age, sex, hospitalisation status, population density, share of the population over the age of 60, and pandemic wave across urban, intermediate and rural territories. Findings We find that in what type of territory individuals live (urban-intermediate-rural) accounts for a significant difference in their probability of dying given SARS-COV-2 infection. Hospitalisation has a large and positive effect on the probability of dying given SARS-CoV-2 infection, but with a gradient across urban, intermediate and rural territories. For those living in rural areas, the risk of dying is lower than in urban areas but only if hospitalisation was not needed; while for those who were hospitalised in rural areas the risk of dying was higher than in urban areas. Conclusions Together with individuals’ demographic characteristics (notably age), hospitalisation has the largest effect on urban-rural disparities in COVID-19 mortality net of other individual and regional characteristics, including population density and the share of the population over 60.