key: cord-0281568-g5sxvekz authors: Debarre, F.; Lecoeur, E.; Guimier, L.; Jauffret-Roustide, M.; Jannot, A.-S. title: The French domestic "sanitary pass" did not solve Covid-19 vaccination inequities in France date: 2022-01-05 journal: nan DOI: 10.1101/2022.01.03.22268676 sha: 24176789453919250b09bdfd31453c1fbfa9c86d doc_id: 281568 cord_uid: g5sxvekz The French sanitary pass led to an increase in vaccination rates in France, but local heterogeneities in vaccination rates remain. To identify potential determinants of these heterogeneities and how the French sanitary pass influenced them, we used a data-driven approach on exhaustive nationwide data, gathering 181 socio-economic and geographic factors. Our analysis reveals that, both before and after the introduction of the French sanitary pass, factors with the largest impact are related to poverty, with the most deprived areas having greater than 10 times the odds of being among the districts with lower vaccination rates. ASJ designed the study with inputs from all authors. EL extracted socio-economic data at district scale and computed indicators. ASJ, EL and FD had full access to aggregated data used for this study and take responsibility for the integrity of the data. EL did the analyses and takes responsibility for the accuracy of the data analysis. FD drafted the paper with the help of ASJ, MR. All authors critically revised the manuscript for important intellectual content and gave final approval for the version to be published. Data sources -INSEE: https://www.insee.fr/fr/statistiques/5359146#consulter -Assurance Maladie: https://datavaccin-covid.ameli.fr/explore/dataset/donneesdevaccination-par-epci/https://datavaccin-covid.ameli.fr/explore/dataset/donnees-devaccination-parcommune/information/ . CC-BY-ND 4.0 International license It is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted January 5, 2022. Attitudes toward vaccination are known to be influenced by social and territorial inequalities. Surveys conducted in 2020 in France showed that respondents with lower education [Schwarzinger21, Spire21], lower income levels or less trust in authorities [Spire21] were more likely to be hostile to COVID-19 vaccines. Whether differential intentions translated into effective differences in vaccination, as described in other countries [Caspi21, Murthy21], remained to be shown in France. To speed up vaccination, President Macron announced on 12 July 2021 the implementation of a domestic "sanitary pass" (le passe sanitaire), which came fully into force on 9 August 2021. It was required in most cultural venues, for both indoor and outdoor dining and in health structures. This announcement led to an unprecedented demand for vaccination, which was celebrated internationally. Vaccination rates climbed from 54% of the whole population by 12 July 2021 to 69% on 4 September 2021. Because it targeted pay-for social activities, however, the "sanitary pass" was feared to have a limited impact on vaccination inequities. This study aims to obtain further insights into the association between social inequities, vaccination and sanitary pass implementation in France using nationwide data. The French state health insurance service (Assurance Maladie) provides public datasets of exhaustive weekly first-dose vaccination data at the district scale nationally and at the suburban scale for the Paris, Lyon, and Marseille metropolitan areas. Our data included 1552 . CC-BY-ND 4.0 International license It is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted January 5, 2022. ; https://doi.org/10.1101/2022.01.03.22268676 doi: medRxiv preprint districts in mainland France (63,601,670 individuals; median district size 22,705 inhabitants; interquartile range 6,282--39,128). We associated these data with 176 socioeconomic and 5 geographic indicators at the same geographic scales from public datasets. We considered the association between being a district in the lowest quartile of the firstdose vaccination rate and being above the median value of each indicator. We computed odds ratios and their 95% confidence intervals at three time points: week 27 (just before the sanitary pass announcement), week 31 (when the sanitary pass came fully into force), and week 35 (end of data collection). For the two indicators achieving the highest odds ratios, we computed vaccination levels for each indicator quartile on the same dates. Analyses were done using R (v4.0.3). The two indicators most associated with local vaccination rates (figure 1) were the income rate coming from unemployment benefits (w27: OR=12. Our results based on exhaustive national datasets indicate that the most deprived areas have greater than 10 times the odds of being among the districts with lower vaccination rates. Lower vaccination rates in France are still associated with poverty, meaning that the sanitary pass did not resolve vaccine inequities. Specifically, living in a district with a large fraction of overcrowded housing or in which unemployment benefits represent a large share of the local income is a strong determinant of a lower COVID-19 vaccination rate in France. Our study confirms the strong impact of social inequalities on COVID-19. The most deprived areas have already been shown to have been disproportionately infected and hospitalized during the pandemic [Jannot21, Bajos21]. We show that poorer districts are also the least vaccinated and, hence, the most still at risk, despite the widely celebrated domestic sanitary pass. There is an urgent need to define new vaccination policies that truly address social inequities. . CC-BY-ND 4.0 International license It is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted January 5, 2022. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted January 5, 2022. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted January 5, 2022. ; https://doi.org/10.1101/2022.01.03.22268676 doi: medRxiv preprint When Lockdown Policies Amplify Social Inequalities in COVID-19 Infections: Evidence from a Cross-Sectional Population-Based Survey in France Socioeconomic Disparities and COVID-19 Vaccination Acceptance: A Nationwide Ecologic Study'. Clinical Microbiology and Infection Low-Income Neighbourhood Was a Key Determinant of Severe COVID-19 Incidence during the First Wave of the Epidemic in Paris A Global Survey of Potential Acceptance of a COVID-19 Vaccine' Disparities in COVID-19 Vaccination Coverage Between Urban and Rural Counties -United States CoviPrev : Une Enquête Pour Suivre l'évolution Des Comportements et de La Santé Mentale Pendant l'épidémie de COVID-19 COVID-19 Vaccine Hesitancy in a Representative Working-Age Population in France: A Survey Experiment Based on Vaccine Characteristics'. The Lancet Public Health Social Inequalities in Hostility toward Vaccination against Covid-19'. Preprint. Public and Global Health A Beautiful Idea: How COVAX Has Fallen Short We thank the producers of public datasets, in particular David Levy at INSEE and and Antoine Rachas at Assurance Maladie.Funding EL received funding to match socio-economic data with medical data from AP-HP Centre Université de Paris.