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BACKGROUND: COVID-19 has had a disproportionate impact on older adults. Mexico's 23 population is younger, yet COVID-19’s impact on older adults is comparable to countries with 24 older population structures. Here, we aim to identify health and structural determinants that 25 increase susceptibility to COVID-19 in older Mexican adults beyond chronological aging. 26 METHODS: We analyzed confirmed COVID-19 cases in older adults using data from the 27 General Directorate of Epidemiology of Mexican Ministry of Health. We modeled risk factors 28 for increased COVID-19 severity and mortality, using mixed models to incorporate multilevel 29 data concerning healthcare access and marginalization. We also evaluated structural factors 30 and comorbidity profiles compared to chronological age for improving COVID-19 mortality 31 risk prediction. 32

RESULTS: We analyzed 7,029 confirmed SARS-CoV-2 cases in adults aged≥ 60 years. Male 33 sex, smoking, diabetes, and obesity were associated with pneumonia, hospitalization and ICU 34 admission in older adults, CKD and COPD were associated with hospitalization. High social 35 lag indexes and access to private care were predictors of COVID-19 severity and mortality. 36 Age was not a predictor of COVID-19 severity in individuals without comorbidities and 37 structural factors and comorbidities were better predictors of COVID-19 lethality and severity 38 compared to chronological age. COVID-19 baseline lethality hazards were heterogeneously 39 distributed across Mexican municipalities, particularly when comparing urban and rural areas. 40 CONCLUSIONS: Structural factors …