Incidence of SARS-CoV-2 Infection and Related Mortality by Education Level During Three Phases of the 2020 Pandemic: A Population-Based Cohort Study in Rome

Background: The SARS-CoV-2 infection is likely to hit harder disadvantaged people. Quantitative evidence on social determinants of health in the risk of infection and adverse outcomes is still limited. The aim of this work was to investigate the effect of educational disparities on the incidence of infection and mortality within 30 days of the onset of infection in Rome in three different phases of the epidemic.Methods: A population-based cohort of all 1,538,231 residents in Rome at 1/1/2020, aged 35+, and surveyed at 2011 census, was considered. All SARS-CoV-2 cases for the period 1/03/2020-31/12/2020 were selected. Cumulative incidence and mortality risk by education were estimated. Multivariable log-binomial and Cox regression models were used to investigate educational disparities in incidence of SARS-CoV-2 infection and mortality, during the entire study period and in the three phases of pandemic.Findings: In the study period there were 47,736 incident cases and 2,281 deaths. The 2020 pandemic was characterised by two waves before and after the summer period, the first characterized by high mortality risk and the second by a large number of cases. There was evidence of socioeconomic inequalities in incidence of infection and mortality, particularly in the second wave. From September to December low educated adults had 25% higher risk of infection, and 43% higher mortality risk, compared to high educated.Interpretation: Our results show the existence of social inequalities in COVID-19 incidence and mortality. These results strengthen the need for monitoring inequalities emerging from this pandemic.Funding Information: Italian Ministry of Health (COVID-2020-12371675).Declaration of Interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no support from any organization for the submitted work (except the research grants listed in funding); no financial relationships with any organizations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.