Social vulnerability and spatial patterns of COVID-19 mortality: Global implications for respiratory health equity

Background: The pandemic highlighted geographic inequities in COVID-19 mortality worldwide, reflecting structural and social vulnerabilities that exacerbated respiratory disease outcomes. The primary aim of this study was to examine the spatial relationship between COVID-19 mortality and communities characterized by greater social disadvantage in North Carolina. This application highlights the value of spatial analytic approaches when considering inequities in respiratory mortality. Methods: This study analyzed 25,051 COVID-19 deaths occurring in North Carolina from March 2020 through April 2022 using state vital statistics data and the Centers for Disease Control and Prevention, Social Vulnerability Index data. SaTScan™ was used to identify mortality hot spots, and Moran’s I in ArcGIS Pro was used to assess spatial autocorrelation at the ZIP-Code Tabulation Area level. The Mann–Whitney U test was used to assess differences in social vulnerability index scores in mortality hot spots areas and non-hot spots areas. Results: Local bivariate analysis identified moderate spatial clustering characterized by high–high (mortality–vulnerability) hot spots and spatial outliers. In non-parametric testing, COVID-19 mortality hot spot areas had significantly higher, but modestly elevated, median overall social vulnerability index scores compared with non–hot spot areas (0.58 vs. 0.45; p