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

  1. Henry Surendra
  2. Ngabila Salama
  3. Karina D Lestari
  4. Verry Adrian
  5. Widyastuti Widyastuti
  6. Dwi Oktavia
  7. Rosa N Lina
  8. Bimandra A Djaafara
  9. Ihsan Fadilah
  10. Rahmat Sagara
  11. Lenny L Ekawati
  12. Ahmad Nurhasim
  13. Riris A Ahmad
  14. Aria Kekalih
  15. Ari F Syam
  16. Anuraj H Shankar
  17. Guy Thwaites
  18. J Kevin Baird
  19. Raph L Hamers
  20. Iqbal R F Elyazar

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Abstract

Worldwide, the 33 recognised 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 healthcare factors associated with COVID-19-related mortality in a megacity of Jakarta, Indonesia, during two epidemic waves spanning 2 March 2020 to 31 August 2021.

Methods

This retrospective cohort included 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 subdistrict level sociodemographics data from various official sources. We used multilevel logistic regression to examine individual, community and subdistrict-level healthcare factors and their associations with COVID-19 mortality.

Results

Of 705 503 cases with a definitive outcome by 31 August 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 subdistrict level accounted for 1.5% of variance in mortality (p<0.0001). Mortality ranged from 0.9 to 1.8% by subdistrict. Individual-level factors associated with death were older age, male sex, comorbidities and age <5 years during the first wave (adjusted OR (aOR)) 1.56, 95% CI 1.04 to 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 to 1.55; reference: wealthiest quarter) and high population density (aOR for the highest density 1.34, 95% CI 1.14 to 2.58; reference: the lowest). Healthcare factor associated with death was low vaccine coverage (aOR for the lowest coverage 1.25, 95% CI 1.13 to 1.38; reference: the highest).

Conclusion

In addition to individual risk factors, living in areas with high poverty and density, and low healthcare performance further increase the vulnerability of communities to COVID-19-associated death in urban low-resource settings.

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  1. Version published to 10.1136/bmjgh-2021-008329
  2. ScreenIT

    SciScore for 10.1101/2021.11.24.21266809: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    EthicsField Sample Permit: This study is reported as per Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Ethics: This study was approved by the Health Research Ethics Committee of the National Institute of Health Research and Development, Ministry of Health Indonesia (LB.02.01/2/KE.643/2021).
    IRB: This study is reported as per Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Ethics: This study was approved by the Health Research Ethics Committee of the National Institute of Health Research and Development, Ministry of Health Indonesia (LB.02.01/2/KE.643/2021).
    Consent: The requirement for patient consent was waived as this was a secondary analysis of anonymised routine surveillance data21.
    Sex as a biological variablenot detected.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.

    Table 2: Resources

    Software and Algorithms
    SentencesResources
    All statistical analyses were done in Stata/MP 17.1 (StataCorp, College Station, TX, USA).
    StataCorp
    suggested: (Stata, RRID:SCR_012763)

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    This study had some limitations. The retrospective design and reliance on routine surveillance data meant that, for some key baseline variables, data were incomplete or uniformly unavailable (e.g., type of comorbidities and disease severity classification). As in many other settings, the individual-level socio-demographics data were not recorded in the current Indonesia’s national database22. Comorbidities were often self-reported or could be under-diagnosed, potentially resulting in underreporting and hence underestimation of effect sizes. Details on supportive care and treatment received were also not available for this analysis. There are several other relevant socio-demographics variables such as human development index and public health development index that may represent population and health system vulnerability24 but were only available at the district level, and were not included in our analysis. However, our analysis included all available key variables that compose those indicators (prevalence of infectious and non-communicable diseases, health care workers-population ratio, universal child immunization, and all-cause mortality among under 5 years old population), therefore enhancing credibility of our findings. In conclusion, individual-level risk factors associated with COVID-19 mortality in DKI Jakarta, Indonesia are broadly similar to those in more developed settings, dominated by advanced age and comorbidities. At the community-level, our analysis suggested t...

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    Results from scite Reference Check: We found no unreliable references.

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  3. Version published to 10.1101/2021.11.24.21266809v1 on medRxiv