ABSTRACT
Background The 33 recognized megacities comprise approximately 7% of the global population, yet account for 20% COVID-19 deaths. The specific inequities and other factors within megacities that affect vulnerability to COVID-19 mortality remain poorly defined. We assessed individual, community-level and health care factors associated with COVID-19-related mortality in a megacity of Jakarta, Indonesia, during two epidemic waves spanning March 2, 2020, to August 31, 2021. Methods This retrospective cohort included all residents of Jakarta, Indonesia, with PCR-confirmed COVID-19. We extracted demographic, clinical, outcome (recovered or died), vaccine coverage data, and disease prevalence from Jakarta Health Office surveillance records, and collected sub-district level socio-demographics data from various official sources. We used multi-level logistic regression to examine individual, community and sub-district-level health care factors and their associations with COVID-19-mortality. Findings Of 705,503 cases with a definitive outcome by August 31, 2021, 694,706 (98.5%) recovered and 10,797 (1.5%) died. The median age was 36 years (IQR 24-50), 13.2% (93,459) were <18 years, and 51.6% were female. The sub-district level accounted for 1.5% of variance in mortality (p<0.0001). Individual-level factors associated with death were older age, male sex, comorbidities, and, during the first wave, age <5 years (adjusted odds ratio (aOR) 1.56, 95%CI 1.04-2.35; reference: age 20-29 years). Community-level factors associated with death were poverty (aOR for the poorer quarter 1.35, 95%CI 1.17-1.55; reference: wealthiest quarter), high population density (aOR for the highest density 1.34, 95%CI 1.14-2.58; reference: the lowest), low vaccine coverage (aOR for the lowest coverage 1.25, 95%CI 1.13-1.38; reference: the highest). Interpretation In addition to individual risk factors, living in areas with high poverty and density, and low health care performance further increase the vulnerability of communities to COVID-19-associated death in urban low-resource settings.