Pandemic inequity in a megacity: a multilevel analysis of individual, community and health care vulnerability risks for COVID-19 mortality in Jakarta, Indonesia
Authors: Surendra Henry , Salama Ngabila , Lestari Karina D , Adrian Verry , Widyastuti  , Oktavia Dwi , Lina Rosa N , Djaafara Bimandra A , Fadilah Ihsan , Sagara Rahmat , Ekawati Lenny L , Nurhasim Ahmad , Ahmad Riris A , Kekalih Aria , Syam Ari F , Shankar Anuraj H , Thwaites Guy , Baird J. Kevin , Hamers Raph L. , Elyazar Iqbal RF 
Published: November 2021

AbstractBackgroundThe 33 recognized megacities comprise approximately 7% of the global population, yet account for 20% COVID-19 deaths. The specific inequities and other factors within megacities that affect vulnerability to COVID-19 mortality remain poorly defined. We assessed individual, community-level and health care factors associated with COVID-19-related mortality in a megacity of Jakarta, Indonesia, during two epidemic waves spanning March 2, 2020, to August 31, 2021.MethodsThis retrospective cohort included all residents of Jakarta, Indonesia, with PCR-confirmed COVID-19. We extracted demographic, clinical, outcome (recovered or died), vaccine coverage data, and disease prevalence from Jakarta Health Office surveillance records, and collected sub-district level socio-demographics data from various official sources. We used multi-level logistic regression to examine individual, community and sub-district-level health care factors and their associations with COVID-19-mortality.FindingsOf 705,503 cases with a definitive outcome by August 31, 2021, 694,706 (98·5%) recovered and 10,797 (1·5%) died. The median age was 36 years (IQR 24–50), 13·2% (93,459) were <18 years, and 51·6% were female. The sub-district level accounted for 1·5% of variance in mortality (p<0.0001). Individual-level factors associated with 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). Community-level factors associated with death were 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; reference: the lowest), low vaccine coverage (aOR for the lowest coverage 1·25, 95%CI 1·13-1·38; reference: the highest).InterpretationIn addition to individual risk factors, living in areas with high poverty and density, and low health care performance further increase the vulnerability of communities to COVID-19-associated death in urban low-resource settings.FundingWellcome (UK) Africa Asia Programme Vietnam (106680/Z/14/Z).Research in contextEvidence before this studyWe searched PubMed on November 22, 2021, for articles that assessed individual, community, and healthcare vulnerability factors associated with coronavirus disease 2019 (COVID-19) mortality, using the search terms (“novel coronavirus” OR “SARS-CoV-2” OR “COVID-19”) AND (“death” OR “mortality” OR “deceased”) AND (“community” OR “social”) AND (“healthcare” OR “health system”). The 33 recognized megacities comprise approximately 7% of the global population, yet account for 20% COVID-19 deaths. The specific inequities and other factors within megacities that affect vulnerability to COVID-19 mortality remain poorly defined. At individual-level, studies have shown COVID-19-related mortality to be associated with older age and common underlying chronic co-morbidities including hypertension, diabetes, obesity, cardiac disease, chronic kidney disease and liver disease. Only few studies from North America, and South America have reported the association between lower community-level socio-economic status and healthcare performance with increased risk of COVID-19-related death. We found no studies have been done to assess individual, community, and healthcare vulnerability factors associated with COVID-19 mortality risk, especially in lower-and middle-income countries (LMIC) where accessing quality health care services is often challenging for substantial proportions of population, due to under-resourced and fragile health systems. In Southeast Asia, by November 22, 2021, COVID-19 case fatality rate had been reported at 2·2% (23,951/1,104,835) in Vietnam, 1·7% (47,288/2,826,853) in Philippines, 1·0% (20,434/2,071,009) in Thailand, 1·2% (30,063/2,591,486) in Malaysia, 2·4% (2,905/119,904) in Cambodia, and 0·3% in Singapore (667/253,649). Indonesia has the highest number of COVID-19 cases and deaths in the region, reporting 3·4% case fatality rate (143,744 /4,253,598), with the highest number of cases in the capital city of Jakarta. A preliminary analysis of the first five months of surveillance in Jakarta found that 497 of 4265 (12%) hospitalised patients had died, associated with older age, male sex; pre-existing hypertension, diabetes, or chronic kidney disease; clinical diagnosis of pneumonia; multiple (>3) symptoms; immediate intensive care unit admission, or intubation.Added value of this studyThis retrospective population-based study of the complete epidemiological surveillance data of Jakarta 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 of all available evidenceDifferences 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.