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Peer-reviewedCC BY-NC-ND 4.0International Journal for Equity in Health

Inequalities in severe COVID-19 by socioeconomic deprivation and country of birth, Italy, 2021–2024

  • Emmanouil Alexandros Fotakis1,2
  • Alberto Mateo Urdiales1
  • Aldo Rosano3
  • Stefano Merler2
  • Patrizio Pezzotti1
  • Massimo Fabiani1
  1. 1Department of Infectious Diseases, Istituto Superiore Di Sanità, Rome, Italy
  2. 2Center for Health Emergencies, Bruno Kessler Foundation, Trento, Italy
  3. 3National Institute for the Analysis of Public Policy, Rome, Italy
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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.

Methods: 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.

Results: 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).

Conclusions: 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.

Supplementary information: The online version contains supplementary material available at https://doi.org/10.1186/s12939-026-02976-y.

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Cite

BibTeXRIS
BibTeX
@article{fotakis2026inequalities,
  title = {{Inequalities in severe COVID-19 by socioeconomic deprivation and country of birth, Italy, 2021–2024}},
  author = {Emmanouil Alexandros Fotakis and Alberto Mateo Urdiales and Aldo Rosano and Stefano Merler and Patrizio Pezzotti and Massimo Fabiani},
  journal = {International Journal for Equity in Health},
  year = {2026},
  month = aug,
  doi = {10.1186/s12939-026-02976-y},
  url = {https://doi.org/10.1186/s12939-026-02976-y},
  note = {CC BY-NC-ND 4.0},
}
RIS
TY  - JOUR
TI  - Inequalities in severe COVID-19 by socioeconomic deprivation and country of birth, Italy, 2021–2024
AU  - Emmanouil Alexandros Fotakis
AU  - Alberto Mateo Urdiales
AU  - Aldo Rosano
AU  - Stefano Merler
AU  - Patrizio Pezzotti
AU  - Massimo Fabiani
PY  - 2026
DA  - 2026/08/07
JO  - International Journal for Equity in Health
DO  - 10.1186/s12939-026-02976-y
UR  - https://doi.org/10.1186/s12939-026-02976-y
AB  - 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.  Methods: 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.  Results: 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).  Conclusions: 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.  Supplementary information: The online version contains supplementary material available at https://doi.org/10.1186/s12939-026-02976-y.
SN  - 1475-9276
ER  -