Disparities in Coronavirus Disease 2019 Mortality by Country of Birth in Stockholm, Sweden: A Total-Population-Based Cohort Study

Abstract

Preliminary evidence points to higher morbidity and mortality from coronavirus disease 2019 (COVID-19) in certain racial and ethnic groups, but population-based studies using microlevel data are lacking so far. We used register-based cohort data including all adults living in Stockholm, Sweden, between January 31, 2020 (the date of the first confirmed case of COVID-19) and May 4, 2020 (n = 1,778,670) to conduct Poisson regression analyses with region/country of birth as the exposure and underlying cause of COVID-19 death as the outcome, estimating relative risks and 95% confidence intervals. Migrants from Middle Eastern countries (relative risk (RR) = 3.2, 95% confidence interval (CI): 2.6, 3.8), Africa (RR = 3.0, 95% CI: 2.2, 4.3), and non-Sweden Nordic countries (RR = 1.5, 95% CI: 1.2, 1.8) had higher mortality from COVID-19 than persons born in Sweden. Especially high mortality risks from COVID-19 were found among persons born in Somalia, Lebanon, Syria, Turkey, Iran, and Iraq. Socioeconomic status, number of working-age household members, and neighborhood population density attenuated up to half of the increased COVID-19 mortality risks among the foreign-born. Disadvantaged socioeconomic and living conditions may increase infection rates in migrants and contribute to their higher risk of COVID-19 mortality.

Keywords: COVID-19; Sweden; coronavirus disease 2019; country of birth; total population data.

Figure 1

A) Relative risk (RR) of coronavirus disease 2019 (COVID-19) mortality among migrants to Sweden, by region of origin, as compared with the Swedish-born population, January 31–May 4, 2020. In model 1 (gray circles), the RRs were adjusted for age and sex only, while in model 3 (white circles) they were adjusted for socioeconomic status, housing, and neighborhood characteristics. Disposable income was categorized into 4 quartiles (Q1–Q4) and population density was categorized into 5 quintiles (Q1–Q5). B) RRs for all-cause mortality excluding COVID-19 deaths. The estimates for age are not shown, because the values were on a different scale. Black circles represent the reference group for each risk factor analyzed. Bars, 95% confidence intervals (CIs). HH, household.

Figure 2

A) Relative risk (RR) of coronavirus disease 2019 (COVID-19) mortality among migrants to Sweden, by birth country, as compared with the Swedish-born population, January 31–May 4, 2020. In model 1 (gray circles), the RRs were adjusted for age and sex only, while in model 3 (white circles) they were adjusted for socioeconomic status, housing, and neighborhood characteristics. B) RRs for all-cause mortality excluding COVID-19 deaths. Only estimates for birth country are shown. Black circles represent the reference group (birth in Sweden). Bars, 95% confidence intervals (CIs). DACH, Deutschland, Austria, Confoederatio Helvetica (Germany, Austria, and Switzerland).