Abstract
BackgroundHousing characteristics and neighbourhood context are considered risk factors for COVID-19 mortality among older adults. The aim of this study was to investigate how individual-level housing and neighbourhood characteristics are associated with COVID-19 mortality in older adults.MethodsFor this population-based, observational study, we used data from the cause-of-death register held by the Swedish National Board of Health and Welfare to identify recorded COVID-19 mortality and mortality from other causes among individuals (aged ≥70 years) in Stockholm county, Sweden, between March 12 and May 8, 2020. This information was linked to population-register data from December, 2019, including socioeconomic, demographic, and residential characteristics. We ran Cox proportional hazards regressions for the risk of dying from COVID-19 and from all other causes. The independent variables were area (m2) per individual in the household, the age structure of the household, type of housing, confirmed cases of COVID-19 in the borough, and neighbourhood population density. All models were adjusted for individual age, sex, country of birth, income, and education.FindingsOf 279 961 individuals identified to be aged 70 years or older on March 12, 2020, and residing in Stockholm in December, 2019, 274 712 met the eligibility criteria and were included in the study population. Between March 12 and May 8, 2020, 3386 deaths occurred, of which 1301 were reported as COVID-19 deaths. In fully adjusted models, household and neighbourhood characteristics were independently associated with COVID-19 mortality among older adults. Compared with living in a household with individuals aged 66 years or older, living with someone of working age (<66 years) was associated with increased COVID-19 mortality (hazard ratio 1·6; 95% CI 1·3–2·0). Living in a care home was associated with an increased risk of COVID-19 mortality (4·1; 3·5–4·9) compared with living in independent housing. Living in neighbourhoods with the highest population density (≥5000 individuals per km2) was associated with higher COVID-19 mortality (1·7; 1·1–2·4) compared with living in the least densely populated neighbourhoods (0 to <150 individuals per km2).InterpretationClose exposure to working-age household members and neighbours is associated with increased COVID-19 mortality among older adults. Similarly, living in a care home is associated with increased mortality, potentially through exposure to visitors and care workers, but also due to poor underlying health among care-home residents. These factors should be considered when developing strategies to protect this group.FundingSwedish Research Council for Health, Working Life and Welfare (FORTE), Swedish Foundation for Humanities and Social Sciences.
Highlights
This information is linked through unique personal identity numbers to administrative populationregister data, including socioeconomic, demographic, and residential characteristics of all individuals living in Stockholm county, Sweden, in December, 2019, and who had been resident in Sweden for at least 2 years
217 individuals were excluded for not having lived in Sweden for 2 years, and a further 5032 individuals were excluded because of missing data. 274 712 individuals were included in the study population. 3386 individuals died during the study period and 1301 of these deaths were reported as COVID-19 deaths by the Swedish National Board of Health and Welfare
COVID-19 was identified as the underlying cause of death in 1252 of 1301 cases and in the remaining 49 cases, ICD emergency codes U07.1, U07.2, or B34.2 were listed as contributing causes of death
Summary
Older individuals are overrepresented among COVID-19 deaths,[1,2,3,4,5,6] raising questions of how to best mitigate patterns of social contact as the pandemic progresses.[7,8,9,10] Researchers have underlined the importance of living arrangements and household composition, such as care homes, crowded housing, and mixed-age households, as well as social contacts outside the household for understanding the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).[1,2,3,4,7,8,11,12,13,14,15,16,17] Living arrangements shape the contact that older adults have with individuals from within or outside the household. Residential clustering of infections has received considerable attention in previous studies.[12,14,15] In attempting to understand the structural features responsible for differences in the spread of the virus across neighbourhoods, early hypoth eses pointed to population density as an important contributor, but the evidence has been mixed.[11]
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