key: cord-0976748-c1neb5yz authors: Fabiani, Massimo; Mateo-Urdiales, Alberto; Andrianou, Xanthi; Bella, Antonino; Del Manso, Martina; Bellino, Stefania; Rota, Maria C; Boros, Stefano; Vescio, Maria F; D'Ancona, Fortunato P; Siddu, Andrea; Punzo, Ornella; Filia, Antonietta; Brusaferro, Silvio; Rezza, Giovanni; Dente, Maria G; Declich, Silvia; Pezzotti, Patrizio; Riccardo, Flavia title: Epidemiological characteristics of COVID-19 cases in non-Italian nationals notified to the Italian surveillance system date: 2021-01-08 journal: Eur J Public Health DOI: 10.1093/eurpub/ckaa249 sha: fd43f400433fb7ae8a9a992b89f174b55193f703 doc_id: 976748 cord_uid: c1neb5yz BACKGROUND: International literature suggests that disadvantaged groups are at higher risk of morbidity and mortality from SARS-CoV-2 infection due to poorer living/working conditions and barriers to healthcare access. Yet, to date, there is no evidence of this disproportionate impact on non-national individuals, including economic migrants, short-term travellers and refugees. METHODS: We analyzed data from the Italian surveillance system of all COVID-19 laboratory-confirmed cases tested positive from the beginning of the outbreak (20th of February) to the 19th of July 2020. We used multilevel negative-binomial regression models to compare the case fatality and the rate of admission to hospital and intensive care unit (ICU) between Italian and non-Italian nationals. The analysis was adjusted for differences in demographic characteristics, pre-existing comorbidities, and period of diagnosis. RESULTS: We analyzed 213 180 COVID-19 cases, including 15 974 (7.5%) non-Italian nationals. We found that, compared to Italian cases, non-Italian cases were diagnosed at a later date and were more likely to be hospitalized {[adjusted rate ratio (ARR)=1.39, 95% confidence interval (CI): 1.33–1.44]} and admitted to ICU (ARR=1.19, 95% CI: 1.07–1.32), with differences being more pronounced in those coming from countries with lower human development index (HDI). We also observed an increased risk of death in non-Italian cases from low-HDI countries (ARR=1.32, 95% CI: 1.01–1.75). CONCLUSIONS: A delayed diagnosis in non-Italian cases could explain their worse outcomes compared to Italian cases. Ensuring early access to diagnosis and treatment to non-Italians could facilitate the control of SARS-CoV-2 transmission and improve health outcomes in all people living in Italy, regardless of nationality. Introduction I n December 2019, an outbreak of a novel coronavirus (SARS-CoV-2) emerged in China and spread rapidly worldwide, being declared by the World Health Organization a public health emergency of international concern on 30 January 2020 and a global pandemic on 11 March 2020. 1 Since then, as of the 23rd of August, the pandemic has caused $800 000 deaths globally. 2 In order to effectively control the pandemic and assess its impact, it is essential to consider how it affects different population groups. International reports suggest that minority ethnic groups are disproportionally affected by SARS-CoV-2 infection due to cultural, behavioural and societal characteristics, including disadvantaged socioeconomic conditions, diverse health-seeking behaviour and intergenerational cohabitation. [3] [4] [5] [6] [7] Some of these aspects may also apply to migrant populations as recent articles have called to consider. 8 Yet, to date, there is no evidence of this disproportionate impact on this population group. There is evidence, however, that international migrants are more likely to be socioeconomically deprived, to suffer from job insecurity and to be marginalized, all of which are risk factors associated with poor health and poor access to healthcare. 9 International migrants are also more likely to be employed in low-skilled jobs that have been associated with an increased risk of SARS-CoV-2 infection, such as care work, hospitality or construction. 10, 11 There is evidence, as well, that migrants face administrative, cultural and language barriers when accessing healthcare. 12, 13 Italy has been one of the most severely affected countries during the first wave of the pandemic. By mid-August 2020, over 250 000 persons had been diagnosed with the infection, and over 35 000 had died from it. 14 In January 2020, almost 5.3 million foreign citizens were estimated to be living in Italy (8.8% of the total resident population). 15 On one side, there is concern that non-Italian nationals may be affected differently by the SARS-CoV-2 pandemic compared with the local population, in particular, if the barriers described lead to underdiagnosis or to a delayed diagnosis of SARS-CoV-2. On the other side, however, considering the strong association between COVID-19 related deaths and older age and comorbidities, 16, 17 it is also possible that foreign persons may be at lower risk of being severely affected by SARS-CoV-2 infection given that, in spite of the higher risk of unhealthy lifestyles associated with disadvantaged socioeconomic conditions, they are generally younger and healthier compared with the local population. 18 It is also controversial whether Bacillus Calmette-Guérin (BCG) vaccine could have a protective effect against SARS-CoV-2 infection, 19, 20 with possible benefit among foreigners from countries where BCG vaccination is routinely implemented. 21 In this article, we describe the epidemiology of the SARS-CoV-2 infection among non-Italian cases tested positive in Italy, comparing their distribution over time, case fatality, hospitalization rate and rate of admission to intensive care unit (ICU) with those observed in the Italian cases. This study was conducted using routinely collected data and did not rely on a pre-existing analysis plan. We described the methods and presented findings according to the reporting guidelines for observational studies that are based on routinely collected health data (the RECORD statement-checklist of items extended from the STROBE statement) (Supplementary table S1). 22 We used information retrieved from the Italian national case-base COVID-19 surveillance system established on 27 February 2020 and coordinated by the Italian National Institute of Health. 23 As previously described, 16 the system collects data on all cases of SARS-CoV-2 infection in Italy laboratory-confirmed by RT-PCR, following the international case definition. 24 The system collects information on the demographic and clinical characteristics of COVID-19 cases, including reported nationality and outcome of the infection (e.g. hospitalization, admission to ICU and death). Data are collected and entered daily by the 19 regions and the two autonomous provinces using a secure online platform. Data are checked for out-ofrange values, inconsistencies and duplicated records at the coordinating centre. A list of possible errors in data-entry is routinely sent to regions for verification and possible corrections. For the purpose of this study, we used the complete dataset of notifications updated on 25 August 2020 and selected all COVID-19 cases tested positive in Italy from the 20th of February to the 19th of July 2020, thus, accounting for at least 30 days of follow-up since the date of testing and a week of possible delay in information updating. The scientific dissemination of COVID-19 surveillance data was authorized by the Italian Presidency of the Council of Ministers on 27 February 2020 (Ordinance n. 640). Among all notified COVID-19 cases, we defined as non-Italian nationals all people with a reported non-Italian nationality, regardless of citizenship or country of birth. We classified the nationality as Italian vs. non-Italian in general and according to the 2018 human development index (HDI) of the country of origin. 25 To this purpose, we defined three categories based on the tertiles of the world's countries HDI distribution (low-HDI country: HDI 0.651; medium-HDI country: 0.651