Factors associated with the spatial heterogeneity of COVID-19 in France: a nationwide ecological study

Like in many countries and regions, spread of the COVID-19 pandemic has exhibited important spatial heterogeneity across France, one of the most affected countries so far. To better understand factors associated with incidence, mortality and lethality heterogeneity across the 96 administrative departments of metropolitan France, we thus conducted a geo-epidemiological analysis based on publicly available data, using hierarchical ascendant classification (HAC) on principal component analysis (PCA) of multidimensional variables, and multivariate analyses with generalized additive models (GAM). Our results confirm a marked spatial heterogeneity of in-hospital COVID-19 incidence and mortality, following the North East – South West diffusion of the epidemic. The delay elapsed between the first COVID-19 associated death and the onset of the national lockdown on March 17 th , 2020, appeared positively associated with in-hospital incidence, mortality and lethality. Mortality was also strongly associated with incidence. Mortality and lethality rates were significantly higher in departments with older population, but they were not significantly associated with the number of intensive-care beds available in 2018. We did not find any significant association between incidence, mortality or lethality rates and incidence of new chloroquine and hydroxychloroquine dispensations in pharmacies either, nor between COVID-19 incidence and climate, nor between economic indicators and in-hospital COVID-19 incidence or mortality. This ecological study highlights the impact of population age structure, epidemic spread and transmission mitigation policies in COVID-19 morbidity or mortality heterogeneity.