High altitudes, population density, and poverty: Unraveling the complexities of COVID-19 in Peru during the years 2020-2022

Background: Several factors related to hospitalizations, morbidity, and mortality from COVID-19 have been identified. However, limited exploration has been done on geographic and socioeconomic factors that could significantly impact these outcomes.Objectives: This study aimed to determine whether altitude, population density, and percentage of population in total poverty are associated with COVID-19 incidence per 1000 inhabitants and COVID-19 case-fatality rate in Peru, from 2020 to 2022.Methods: This study utilized a multiple group ecological design and relied on secondary databases containing daily records of COVID-19 positive cases and deaths due to COVID-19. An epidemiological analysis was per-formed, subsequently processed using a random effects model.Results: As of August 2022, Peru had recorded a total of 3,838,028 COVID-19 positive cases and 215,023 deaths due to COVID-19. Our analysis revealed a statistically significant negative association between altitude and COVID-19 incidence (aBETA:-0.004; Standard Error: 0.001; p < 0.05). Moreover, we observed a positive as-sociation between population density and incidence (aBETA: 0.006; Standard Error: 0.001; p < 0.05). However, we found no significant association between the percentage of population in total poverty and COVID-19 incidence.Conclusion: Our study found that an increase in altitude was associated with a decrease in COVID-19 incidence, while an increase in population density was associated with an increase in COVID-19 incidence. High altitude, population density and percentage of population in total poverty does not change case-fatality rate due to COVID-19.