Elke Wynberg

COVID-19 burden differed by city district and ethnicity during the pre-vaccination era in Amsterdam, the Netherlands 3 69 BACKGROUND The pandemic of coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), emerged in December 2019 in Wuhan, China and the virus spread globally within months(1, 2). Consequencently, the World Health Organization (WHO) declared COVID-19 a public health emergency of international concern (PHEIC) on March 11th 2020(3). By January 1st 2023, almost 652 million infections and more than 6.7 million deaths have been reported worldwide(4). The COVID-19 pandemic was declared no longer to be a PHEIC on 5 May 2023(5). In the Netherlands, SARS-CoV-2 was first notified in February 2020, after which the first wave of infections occurred until June 2020(3). In order to mitigate spread of the virus and relieve pressure on healthcare services, a series of non-pharmaceutical interventions were introduced as part of a national lockdown, including working from home and the closure of many public facilities. By 1 June 2020, testing with polymerase chain reaction (PCR) for SARS-CoV-2 infection was made available to all persons with COVID-19 symptoms, having previously been restricted to a few select groups. The second wave of infections emerged in the Netherlands by the end of August 2020 and persisted beyond January 2021(6). Again, this led to a set of restrictions, although less stringent than for the first wave(7). From 1 December 2020, close contacts of COVID-19 cases were also eligible for testing on day 5 of quarantine, regardless of their symptoms. The Netherlands implemented COVID-19 vaccination from early January 2021 for healthcare workers and the older adult population. Vaccination was subsequently widely available for decreasing age groups from March 2021 onwards(8). In Amsterdam, largest city in the Netherlands, more than half of 900.000 thousand inhabitants has a migration background(9, 10). We previously reported that a disproportional number of persons with a minority ethnic background were hospitalised as a result of SARS-CoV-2 infection during the first wave of COVID-19 in Amsterdam(9). Differences in the age- and sex standardised COVID-19 hospitalisation rates per 100,000 population between city districts and migration background were stark(9): individuals living in peripheral city districts with a lower socio-economic status (SES) were hospitalised for COVID-19 almost twice as often as age- and sex-matched individuals living in central, higher SES districts(11). With the assumption that increased risk of COVID-19 hospitalisation was at least partly due to increased exposure as well as inability to access testing services, targeted programs were rolled out in order to increase access to information and testing.

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