Pandemic inequity in a megacity: a multilevel analysis of individual, community and health care vulnerability risks for COVID-19 mortality in Jakarta, Indonesia

Principal Investigator: Henry Surendra
Study location: Jakarta
Collaborators: Jakarta Health Agency, Faculty of Medicine Universitas IndonesiaThere are currently 33 megacities, defined by the United Nations Department of Economic and Social Affairs as cities with a population of at least 10 million persons. Megacities comprise 8% of the global population, yet account for approximately 20% of all COVID-19 deaths. Megacities often contain high levels of inequity with regard to income, housing, sanitation, transportation, population density, basic health care, and other factors. The important role of health inequity in the spread and mortality of epidemics has been known from influenza in 1918 to Ebola in 2014. The severity of illness and clinical outcomes can be affected by the concentration of comorbidities in susceptible groups in communities, and through disparities of access to health care for preventive measures or prompt diagnosis and treatment. Ensuring health equity, especially in megacities experiencing massive urbanization and mobility is essential for the current and future global health threats.

Importance
In the context of the ongoing pandemic, understanding community-level risk factors associated with the mortality is very important to guide policymaking and target public health and clinical interventions, particularly in the context of fragile public health systems. At individual-level, older age and pre-existing chronic comorbidities have been consistently reported as the main risk factors of COVID-19-related mortality across different settings. At the community-level, recent findings in US, Chile and Brazil suggested that COVID-19 mortality was concentrated in groups with higher socio-demographics vulnerability. However, there is a general scarcity of data in LMIC assessing the influence of community-level socio-demographics factors on COVID-19-related mortality.
Indonesia, the world’s fourth most populous country (population 274 million), is a lower-middle income country (LMIC) featuring great geographic, cultural and socio-economic diversity across the archipelago. Indonesia has suffered the highest number of COVID-19 confirmed cases and deaths in Southeast Asia, second only to India in all of Asia, at 4,253,598 cases and 143,744 deaths (3·4% case fatality rate (CFR)) up to November 22, 2021, of which 20% (863,482) of cases and 9·4% (13,574) of deaths occurred in its capital Jakarta, a megacity that features stark health inequalities and socio-demographic heterogeneity.

Objective
In this retrospective cohort study, we assessed individual, community-level and health care vulnerability among the 44 sub-districts of DKI Jakarta and how those factors were associated with COVID-19-related mortality during the first 18 months of the epidemic in that province (March 2020 through August 2021).

Results
This retrospective population-based study of the complete epidemiological surveillance data of Jakarta (N=705,503 cases) during the first eighteen months of the epidemic is the largest studies in LMIC to date, that comprehensively analysed the individual, community, and healthcare vulnerability associated with COVID-19-related mortality among individuals diagnosed with PCR-confirmed COVID-19. The overall case fatality rate among general population in Jakarta was 1·5% (10,797/705,503). Individual factors associated with risk of death were older age, male sex, comorbidities, and, during the first wave, age <5 years (adjusted odds ratio (aOR) 1·56, 95%CI 1·04-2·35; reference: age 20-29 years). The risk of death was further increased for people living in sub-districts with high rates of poverty (aOR for the poorer quarter 1·35, 95%CI 1·17-1·55; reference: wealthiest quarter), high population density (aOR for the highest density 1·34, 95%CI 1·14-2·58), and low COVID-19 vaccination coverage (aOR for the lowest coverage 1·25, 95%CI 1·13-1·38; reference: the highest). Implications
Differences in socio-demographics and access to quality health services, among other factors, greatly influence COVID-19 mortality in low-resource settings. This study affirmed that in addition to well-known individual risk factors, community-level socio-demographics and healthcare factors further increase the vulnerability of communities to die from COVID-19 in urban low-resource settings. These results highlight the need for accelerated vaccine rollout and additional preventive interventions to protect the urban poor who are most vulnerable to dying from COVID-19.