Hospitalisation rates differed by city district and ethnicity during the first wave of COVID-19 in Amsterdam, the Netherlands 2 49 with a lower SES may be more likely to work as essential frontline workers – including healthcare workers and those working in sectors such as cleaning, construction, and transport(26) – with a reduced opportunity to work from home(25). Lower SES may also lead to a greater reliance on public transport, larger multi-generational households and smaller house size per person(26), all of which may increase the risk of exposure to infection(23). We therefore postulate that the greater burden of COVID-19 hospitalisation seen in these districts is due to a complex interaction between different factors. Indeed, when restricting to individuals <60 years of age in our analyses, the hospitalisation RR in those with a non-Western migration background compared to the ethnic-Dutch group remained and was even accentuated. This suggests that the differences in hospitalisation rates cannot be fully explained by an increased tendency of non-Western migrants, compared to ethnic-Dutch elderly, to be treated in hospital instead of receiving palliative care in the community setting or in nursing homes. The higher RR in younger age groups might imply that increased exposure secondary to having a public-facing occupation or higher levels of other causes of increased exposure among those with a non-Western migration background may have played an important role. Further elucidating the causal factors underlying SES disparities in COVID-19 burden requires further research. In addition, our analysis demonstrated that individuals with a non-Western migration background, including groups with a Moroccan, Turkish, Surinamese and Ghanaian background, had a higher COVID-19 burden, even when stratifying by city district. This is in line with previous findings from the UK and USA and, more recently, other high-income countries such as Norway(27). In the UK, the risk of death among those with a COVID-19 diagnosis was twice as high for people of Bangladeshi ethnicity compared to people of White ethnicity, after adjusting for sex, age, deprivation and region(22). Additional studies demonstrated that, even when adjusting for age, sex, comorbidities and several SES-related determinants (though notably not public-facing occupation), hospitalisation and ICU admission rates among Black and Asian Minority Ethnic individuals were higher compared to ethnically White individuals(28), suggesting that ethnicity plays an independent role in explaining these disparities. In the US, ageadjusted hospitalisation rates were 5.3 and 4.7 times higher in American Indian or Alaska Native and Black or African American persons respectively, compared to non-Hispanic white persons; although this analysis was not adjusted for social inequalities(6). Whilst these findings consistently demonstrate that the burden of COVID-19 varies by ethnicity, the contribution of underlying cultural norms, health literacy, and differences in healthseeking behaviour has yet to be revealed.
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