{
  "abstract": "Background: Global evidence on COVID-19 related inequalities remains temporally fragmented. In this study we investigated how the associations of socioeconomic deprivation (SED) and country of birth with severe COVID-19 evolved in COVID-19 vaccinated persons residing in small/medium sized municipalities in Italy in 2021–2024.\n\nMethods: We retrospectively analysed data of 22,131,245 adults, living in municipalities with <50,000 residents, extracted from the national COVID-19 surveillance and vaccination databases. Using multivariable Cox regression we estimated annual hazard ratios (HRs) of COVID-19 hospitalisation and/or death by municipal SED quintile (Q) (relative to the least deprived Q1), and by country of birth (foreign-born vs. Italian-born). Our analyses, spanning periods with mobility restrictions (2021), and COVID-19 vaccination programs (2021–2024), were adjusted for demographic characteristics, high-risk conditions and COVID-19 vaccination, excluding the latter upon exploring the impact of the vaccine rollout on the observed associations.\n\nResults: Deprived areas experienced increased hazard of severe COVID-19 in 2021–2022, peaking in 2021 (Q5, HR: 1.74, 95% CI: 1.59–1.91). Socioeconomic deprivation inequalities attenuated in 2023 and reversed in the most deprived areas in 2024 (Q5, HR: 0.75, 95% CI: 0.63–0.88). Foreign-born persons were disproportionately affected in 2021 (HR: 1.54, 95% CI:1.44–1.65) and to a lesser extent in 2022, diminishing to non-significant inequalities in 2023–2024. Not accounting for COVID-19 vaccination in the analysis modestly altered the COVID-19 related inequalities in 2021 to the disadvantage of deprived areas (Q5, HR: 1.84, 95% CI: 1.67–2.02) and foreign-born individuals (HR: 1.75, 95% CI: 1.63–1.87).\n\nConclusions: Greater attention should be given to socioeconomically deprived areas and foreign-born people in future pandemic preparedness plans in Italy targeting small and medium sized municipalities, with particular focus on periods with mobility restrictions and initial phases of mass vaccine rollouts.\n\nSupplementary information: The online version contains supplementary material available at https://doi.org/10.1186/s12939-026-02976-y.",
  "abstract_shown": true,
  "affiliations": [
    "Department of Infectious Diseases, Istituto Superiore Di Sanità, Rome, Italy",
    "Center for Health Emergencies, Bruno Kessler Foundation, Trento, Italy",
    "National Institute for the Analysis of Public Policy, Rome, Italy"
  ],
  "article_type": "research article",
  "arxiv": null,
  "author_total": 6,
  "authors": [
    {
      "affs": [
        0,
        1
      ],
      "name": "Emmanouil Alexandros Fotakis"
    },
    {
      "affs": [
        0
      ],
      "name": "Alberto Mateo Urdiales"
    },
    {
      "affs": [
        2
      ],
      "name": "Aldo Rosano"
    },
    {
      "affs": [
        1
      ],
      "name": "Stefano Merler"
    },
    {
      "affs": [
        0
      ],
      "name": "Patrizio Pezzotti"
    },
    {
      "affs": [
        0
      ],
      "name": "Massimo Fabiani"
    }
  ],
  "bibtex": "https://research.draconitic.com/paper/bznfkazk1zjtm.bib",
  "cited_by": 0,
  "doi": "10.1186/s12939-026-02976-y",
  "fulltext_url": "https://pmc.ncbi.nlm.nih.gov/articles/PMC13733036/",
  "id": "bznfkazk1zjtm",
  "issns": [
    "1475-9276"
  ],
  "landing_url": "https://doi.org/10.1186/s12939-026-02976-y",
  "language": "en",
  "licence": "CC-BY-NC-ND-4.0",
  "licence_label": "CC BY-NC-ND 4.0",
  "licence_source": "article",
  "licence_url": "https://creativecommons.org/licenses/by-nc-nd/4.0/",
  "metadata_licence": null,
  "native_subjects": [
    [
      "heading",
      "Research"
    ],
    [
      "openalex",
      "2725|COVID-19 Clinical Research Studies"
    ]
  ],
  "openalex": "W7201871930",
  "pdf_url": null,
  "pmcid": "PMC13733036",
  "pmid": "42983532",
  "published": "2026-08-07",
  "publisher": "BMC",
  "ris": "https://research.draconitic.com/paper/bznfkazk1zjtm.ris",
  "sources": [
    {
      "first_seen": "2026-11-08T12:22:54Z",
      "native_id": "PMC13733036",
      "source": "pmc",
      "url": "https://doi.org/10.1186/s12939-026-02976-y"
    }
  ],
  "subjects": [
    {
      "field": "medicine",
      "origin": "openalex:2725|COVID-19 Clinical Research Studies",
      "subfield": "infectious-disease"
    }
  ],
  "title": "Inequalities in severe COVID-19 by socioeconomic deprivation and country of birth, Italy, 2021–2024",
  "title_text": "Inequalities in severe COVID-19 by socioeconomic deprivation and country of birth, Italy, 2021–2024",
  "type": "peer-reviewed",
  "updated_at": "2026-11-08T12:22:54Z",
  "url": "https://research.draconitic.com/paper/bznfkazk1zjtm",
  "venue": "International Journal for Equity in Health",
  "versions": []
}