Hospitalisation rates differed by city district and ethnicity during the first wave of COVID-19 in Amsterdam, the Netherlands 2 39 INTRODUCTION The first cases of coronavirus disease 2019 (COVID-19) were reported at the end of 2019 in Wuhan, China. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus causing COVID-19, has since rapidly spread across the globe. The World Health Organization (WHO) consequently declared COVID-19 a global epidemic on 11 March 2020. By the end of June 2021, over 180 million cases and almost 4 million COVID-19 related deaths had been reported worldwide(1). In the Netherlands, COVID-19 was declared a Group A notifiable disease under the Public Health legal act on 28th January 2020(2). This required clinicians and laboratories to immediately notify the regional public health service (PHS) every suspected and/ or confirmed case of COVID-19. The first confirmed case of COVID-19 on 27 February 2020 had an epidemiological link to Northern Italy. Initial sporadic clusters led to a subsequent nationwide spread of the virus, including in the capital city of Amsterdam. From 12-15 March, the Dutch government initiated a series of restrictions(3) which were gradually lifted from 11 May onwards. Up to 1 June 2021, the Netherlands had reported approximately 46,000 confirmed cases and over 6,000 COVID-19 deaths(4). The regional PHS of Amsterdam acts upon notifications of infectious diseases including COVID-19 for the wider Amsterdam-Amstelland area, consisting of 6 municipalities including Amsterdam, with a total regional population of about 1,06 million. Anecdotal reports from hospital staff in April 2020 suggested that a disproportionate number of patients of ethnic minority background had been admitted to hospitals and intensive care units (ICU) in Amsterdam. This echoed reports from the United Kingdom(5) (UK) and United States of America(6) (USA) at the time, which suggested that age- and sex-standardised mortality rates were highest among socio-economically deprived groups and ethnic minority groups; findings that were later supported by a systematic review(7). Early analyses also demonstrated that individuals with a migration background in the Netherlands had higher rates of excess mortality (i.e. higher than would be expected in ‘normal’ conditions) compared to individuals of Dutch origin, in particular in those with a non-Western migration background(8). Amsterdam is an increasingly ethnically diverse city with more than half the population having a migration background(9). Disparities in the distribution of communicable and non-communicable diseases have previously been demonstrated in the city between individuals with and without a migration background(10), even when matched for age- and socio-economic status (SES)(11). In addition, health inequalities have been reported between the peripheral city districts of Amsterdam with lower average income (12) and the
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