Department of Epidemiology - Regional Health Service, ASL Roma 1, Rome, Italy.
Sapienza University of Rome, Rome, Italy.
BMC Public Health. 2023 Feb 14;23(1):329. doi: 10.1186/s12889-023-15246-1.
To face the second wave of COVID-19, Italy implemented a tiered restriction system with different limitation levels (yellow = medium; orange = medium-high, red = high) at the beginning of November 2020. The restrictions systematically reduced the transmission of SARS-CoV-2 with increasing strength for increasing tier. However, it is unknown whether the effect of limitations was equal between provinces with different socioeconomic levels. Therefore, we investigated the association between the province's socioeconomic level and SARS-CoV-2 infection daily reproduction number in each restriction level.
We measured the province's socioeconomic level as the percentage of individuals whose 2019 total yearly income was lower than 10,000€, using the measure as a proxy of economic disadvantage. We estimated the daily reproduction number (Rt) at the province level using the SARS-CoV-2 daily incidence data from November 2020 to May 2021. We then used multilevel linear regression models with random intercepts stratified by restriction level to estimate the association between economic disadvantage and Rt. We also adjusted the analyses for potential confounders of the association between the province's economic disadvantage and the Rt: the percentage of people with 0-5 years, the quartiles of population density, and the geographical repartition.
Overall, we found increasing Rt in yellow (+ 0.004 p < 0.01, from Rt = 0.99 to 1.08 in three weeks) and containing effects for the orange (-0.005 p < 0.01, from Rt = 1.03 to 0.93) and the red tier (-0.014 p < 0.01, from Rt = 1.05 to 0.76). More economically disadvantaged provinces had higher Rt levels in every tier, although non-significantly in the yellow level (yellow = 0.001 p = 0.19; orange = 0.002 p = 0.02; red = 0.004 p < 0.01). The results showed that the association between economic disadvantage and Rt differed by level of restriction. The number of days into the restriction and the economic disadvantage had statistically significant interactions in every adjusted model. Compared to better off, more economically disadvantaged provinces had slower increasing trends in yellow and steeper Rt reductions in orange, but they showed slower Rt reductions in the highest tier.
Lower tiers were more effective in more economically disadvantaged provinces, while the highest restriction level had milder effects. These results underline the importance of accounting for socioeconomic level when implementing public health measures.
为应对第二波 COVID-19 疫情，意大利于 2020 年 11 月初实施了分级限制制度，不同限制级别（黄色=中度；橙色=中高度；红色=高度）有不同的限制水平。这些限制措施系统地降低了 SARS-CoV-2 的传播，随着限制级别的增加，其效果也逐渐增强。然而，我们尚不清楚在社会经济水平不同的省份之间，限制措施的效果是否相同。因此，我们研究了各省的社会经济水平与每个限制级别中 SARS-CoV-2 感染日繁殖数之间的关系。
我们使用 2019 年总收入低于 10000 欧元的个体比例作为衡量经济劣势的指标，来衡量各省的社会经济水平。我们使用 2020 年 11 月至 2021 年 5 月期间 SARS-CoV-2 的日发病率数据，在省级水平上估计日繁殖数（Rt）。然后，我们使用分层限制水平的具有随机截距的多水平线性回归模型来估计经济劣势与 Rt 之间的关联。我们还针对省份经济劣势与 Rt 之间关联的潜在混杂因素调整了分析：0-5 岁人群的比例、人口密度四分位数和地理分布。
总体而言，我们发现黄色级别（Rt 从三周内的 0.99 增加到 1.08，增加 0.004，p<0.01）和橙色级别（-0.005，p<0.01，Rt 从 1.03 降低到 0.93）的 Rt 呈上升趋势，并且红色级别也有抑制作用（-0.014，p<0.01，Rt 从 1.05 降低到 0.76）。在每个级别中，经济较不发达的省份的 Rt 水平都较高，尽管在黄色级别中不显著（黄色：0.001，p=0.19；橙色：0.002，p=0.02；红色：0.004，p<0.01）。结果表明，经济劣势与 Rt 之间的关联因限制级别而异。在每个调整后的模型中，经济劣势与限制天数均存在统计学显著的交互作用。与经济条件较好的省份相比，经济较不发达的省份在黄色级别中呈现出较慢的 Rt 增长趋势，而在橙色级别中则呈现出较陡的 Rt 降低趋势，但在最高级别中呈现出较慢的 Rt 降低趋势。
在经济较不发达的省份中，较低的限制级别更为有效，而最高限制级别则效果较为温和。这些结果强调了在实施公共卫生措施时考虑社会经济水平的重要性。
