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      Factors associated with the spatial heterogeneity of the first wave of COVID-19 in France: a nationwide geo-epidemiological study


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          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.


          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.


          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.


          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.



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                Author and article information

                Lancet Public Health
                Lancet Public Health
                The Lancet. Public Health
                The Author(s). Published by Elsevier Ltd.
                6 February 2021
                6 February 2021
                [a ]Aix Marseille University, National Institute of Health and Medical Research (INSERM), Institute of Research for Development (IRD), Economic and Social Sciences for Health and Medical Information Processing (SESSTIM), UMR1252, Marseille, France
                [b ]Public Assistance Marseille Hospitals (APHM), Biostatistics and Information and Communication Technologies Service (BioSTIC), Marseille, France
                [c ]Luxembourg Institute of Health, Luxembourg
                [d ]Internal Medicine and Clinical Research Unit, European Hospital Marseille, Marseille, France
                [e ]Research Centre for Epidemiology, Biostatistics, and Research Clinic, School of Public Health, Free University of Brussels, Brussels, Belgium
                [f ]University Grenoble Alpes, AGEIS EA 7404, La Tronche, France
                [g ]Sorbonne University, INSERM, Pierre-Louis Institute of Epidemiology and Public Health (IPLESP), AP-HP, Laboratory of Parasitology and Mycologie, Pitié-Salpêtrière Hospital, Paris, France
                [h ]European Hospital Marseille, Aix-Marseille University, INSERM, IRD, SESSTIM, IPLESP, Marseille, France
                Author notes
                [* ]Correspondence to: Prof Jean Gaudart, Aix Marseille University, INSERM, IRD, SESSTIM, UMR1252, Marseille 13005, France
                © 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.



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