Racial Disparities in Coronavirus Disease 2019 (COVID-19) Mortality Are Driven by Unequal Infection Risks

Demographic and regional trends in asthma mortality in the United States, 1999-2020

BACKGROUND

Asthma remains a public health concern in the United States, with mortality disproportionately affecting demographic groups. This study aimed to describe national trends in asthma mortality from 1999 to 2020 and identify demographic and regional disparities.

RESEARCH DESIGN AND METHODS

We retrospectively analyzed mortality data from the CDC WONDER database using International Classification of Diseases, Tenth Revision (ICD-10) codes J45 and J46. Age-adjusted mortality rates (AAMRs) were calculated by sex, race, age group, US Census region, state, and urban-rural classification. Joinpoint regression was employed to detect changes over time.

RESULTS

A total of 82,686 asthma-related deaths were identified (37.2% males, 62.8% females). Overall, the AAMR declined from 1.72 in 1999 to 1.14 in 2020. Joinpoint analysis revealed a significant decline from 1999 to 2009, a plateau from 2009 to 2014, a further decline from 2014 to 2018, and a significant increase from 2018 to 2020. Non-Hispanic Black individuals (AAMR 2.73) and older adults (≥65 years) had the highest mortality rates, with females exhibiting higher rates than males (1.30 vs 0.95).

CONCLUSIONS

Despite declining trends, persistent disparities in asthma mortality underscore the need for targeted interventions, improved healthcare access, and ongoing surveillance.

Associations of Individual and Neighborhood Factors with Disparities in COVID-19 Incidence and Outcomes

Introduction

The disproportionate impact of coronavirus 2019 (COVID-19) on Black and Hispanic communities has been widely reported. Many studies have used neighborhood racial/ethnic composition to study such disparities, but less is known about the interplay between individual race/ethnicity and neighborhood racial composition. Therefore, our goal in this study was to assess the relative contributions of individual and neighborhood risk to disparities in COVID-19 incidence and outcomes.

Methods

We performed a cross-sectional study of patients with emergency department (ED) and inpatient visits to an academic health system (12 hospitals; February 1-July 15, 2020). The primary independent variable was race/ethnicity; covariates included individual age, sex, comorbidity, insurance and neighborhood density, poverty, racial/ethnic composition, education and occupation. The primary outcome was severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positivity; secondary outcomes included admission and death after COVID-19. We used generalized estimating equations to assess whether race/ethnicity remained significantly associated with COVID-19 after adjustment for individual and neighborhood factors.

Results

There were 144,982 patients; 5,633 (4%) were SARS-CoV-2 positive. Of those, 2,961 (53%) were admitted and 601(11%) died. Diagnosis of COVID-19, admission, and death were more common among non-Hispanic Black, Hispanic, Spanish-speaking patients, and those with public insurance. In the base model (adjusting for race/ethnicity, age, sex, and comorbidities), race/ethnicity was strongly associated with COVID-19 (non-Hispanic Black odds ratio [OR] 4.64 [95% confidence interval (CI) 4.18-5.14], and Hispanic OR 6.99 [CI 6.21-7.86]), which was slightly attenuated but remained significant after adjustment for neighborhood factors. Among patients with COVID-19, there was no significant association between race/ethnicity and hospital admission, other than for patients with unknown race.

Conclusion

This data demonstrates a persistent association between race/ethnicity and COVID-19 incidence, with Black and Hispanic patients at significantly higher risk, which was not explained by measured individual or neighborhood factors. This suggests that using existing neighborhood factors in studies examining health equity may be insufficient, and more work is needed to quantify and address structural factors and social determinants of health to improve equity.

Timing of Infection as a Key Driver of Racial/Ethnic Disparities in Coronavirus Disease 2019 Mortality Rates During the Prevaccine Period

Disparities in coronavirus disease 2019 mortality are driven by inequalities in group-specific incidence rates (IRs), case fatality rates (CFRs), and their interaction. For emerging infections, such as severe acute respiratory syndrome coronavirus 2, group-specific IRs and CFRs change on different time scales, and inequities in these measures may reflect different social and medical mechanisms. To be useful tools for public health surveillance and policy, analyses of changing mortality rate disparities must independently address changes in IRs and CFRs. However, this is rarely done. In this analysis, we examine the separate contributions of disparities in the timing of infection-reflecting differential infection risk factors such as residential segregation, housing, and participation in essential work-and declining CFRs over time on mortality disparities by race/ethnicity in the US state of Michigan. We used detailed case data to decompose race/ethnicity-specific mortality rates into their age-specific IR and CFR components during each of 3 periods from March to December 2020. We used these estimates in a counterfactual simulation model to estimate that that 35% (95% credible interval, 30%-40%) of deaths in black Michigan residents could have been prevented if these residents were infected along the timeline experienced by white residents, resulting in a 67% (61%-72%) reduction in the mortality rate gap between black and white Michigan residents during 2020. These results clearly illustrate why differential power to "wait out" infection during an infectious disease emergency-a function of structural racism-is a key, underappreciated, driver of inequality in disease and death from emerging infections.

SARS-CoV-2 coinfections among pertussis cases identified through the Enhanced Pertussis Surveillance system in the United States, January 2020-February 2023

BACKGROUND

Bacterial and viral respiratory coinfections are common, but the prevalence of SARS-CoV-2 infections among pertussis cases has not been estimated. We examine the prevalence and temporality of SARS-CoV-2 infections among pertussis patients and describe pertussis clinical severity among patients with and without SARS-CoV-2 coinfections.

METHODS

Confirmed and probable pertussis cases among individuals with cough onset between January 1, 2020 and February 15, 2023 were identified through surveillance in seven Enhanced Pertussis Surveillance (EPS) sites. Pertussis cases with a laboratory-confirmed SARS-CoV-2 infection detected within 30 days before or after pertussis cough onset were defined as coinfections. We describe patient demographics, symptoms, and severe complications and outcomes (seizures, encephalopathy, pneumonia, hospitalization, or death) by coinfection status.

RESULTS

Among 765 pertussis cases reported during the study period, the prevalence of SARS-CoV-2 coinfections was 0.78% [6/765]. Among the six patients meeting the coinfection definition, the majority (83.3% [5/6]) had SARS-CoV-2 infections detected following pertussis cough onset. Compared to those with no known coinfection, a higher proportion of those with coinfections reported severe complications or outcomes (50.0% [3/6] vs. 5.2% [36/694]).

DISCUSSION

Although the prevalence of pertussis patients with SARS-CoV-2 coinfections was low, patients with coinfections reported more severe complications and outcomes compared to those with pertussis alone. Given the decline in reported pertussis cases during the COVID-19 pandemic, continued monitoring of pertussis incidence alongside respiratory viral infections will be important as the pertussis burden returns to pre-pandemic levels.

Communities conquering COVID-19: Black and Latinx community perspectives on the impact of COVID-19 in regions of Michigan hardest hit by the pandemic

Introduction

In Michigan, the COVID-19 pandemic severely impacted Black and Latinx communities. These communities experienced higher rates of exposure, hospitalizations, and deaths compared to Whites. We examine the impact of the pandemic and reasons for the higher burden on communities of color from the perspectives of Black and Latinx community members across four Michigan counties and discuss recommendations to better prepare for future public health emergencies.

Methods

Using a community-based participatory research approach, we conducted semi-structured interviews (n = 40) with Black and Latinx individuals across the four counties. Interviews focused on knowledge related to the pandemic, the impact of the pandemic on their lives, sources of information, attitudes toward vaccination and participation in vaccine trials, and perspectives on the pandemic's higher impact on communities of color.

Results

Participants reported overwhelming effects of the pandemic in terms of worsened physical and mental health, financial difficulties, and lifestyle changes. They also reported some unexpected positive effects. They expressed awareness of the disproportionate burden among Black and Latinx populations and attributed this to a wide range of disparities in Social Determinants of Health. These included racism and systemic inequities, lack of access to information and language support, cultural practices, medical mistrust, and varied individual responses to the pandemic.

Conclusion

Examining perspectives and experiences of those most impacted by the pandemic is essential for preparing for and effectively responding to public health emergencies in the future. Public health messaging and crisis response strategies must acknowledge the concerns and cultural needs of underrepresented populations.

Indoor allergen exposure and its association to upper respiratory infections and pulmonary outcomes among children with asthma

BACKGROUND

Certain environmental allergen exposures are more common in disadvantaged communities and may contribute to differences in susceptibility to upper respiratory infections (URIs).

OBJECTIVES

We examined associations between indoor allergens and: (1) URI; (2) URI + cold symptoms; (3) URI + cold symptoms + pulmonary eosinophilic inflammation (fraction of exhaled nitric oxide ≥20 ppb); and (4) URI + cold symptoms + reduced lung function (percent predicted forced expiratory volume in 1 second of <80%).

METHODS

We used data from the Environmental Control as Add-on Therapy for Childhood Asthma (ECATCh) study. Allergen concentrations were measured in air (mouse) and settled dust (mouse, cockroach, dog, and cat). URI was determined by testing nasal mucus for upper respiratory viruses. We evaluated associations between allergen concentrations and URI-associated outcomes accounting for age, sex, study month, season, health insurance, and household size.

RESULTS

Ninety participants (92% Black, 92% public insurance) with 192 observations were included; 52 (27%) of observations were positive for URI. A doubling in cockroach allergen concentration increased the odds of a URI with cold symptoms by 18% (odds ratio [OR] = 1.18, 95% confidence interval [CI], 0.99-1.40), the odds of a URI + cold symptoms + pulmonary eosinophilic inflammation by 31% (OR = 1.31, 95% CI, 1.10-1.57), and the odds of a URI + cold symptoms + reduced lung function by 45% (OR = 1.45, 95% CI, 1.13-1.85). Mouse allergen concentrations were positively associated with all outcomes. Associations were suggestively stronger among children sensitized to pest allergens.

CONCLUSIONS

Cockroach and mouse, but not dog or cat, allergen exposure may predispose children with asthma to URIs with colds and lower respiratory outcomes.

Recognising the heterogeneity of Indigenous Peoples during the COVID-19 pandemic: a scoping review across Canada, Australia, New Zealand and the USA

Objectives

The COVID-19 pandemic has had a disproportionate impact on the health of Indigenous Peoples in Canada, Australia, New Zealand and the USA, as reflected in the growing literature. However, Indigenous Peoples are often homogenised, with key differences often overlooked, failing to capture the complexity of issues and may lead to suboptimal public health policy-making. The objective of this review was to assess the extent to which the heterogeneity of the Indigenous Peoples in Canada, Australia, New Zealand and the USA has been reflected in COVID-19 research.

Design

This study took the form of a scoping review.

Data sources

Medline, Embase, CINAHL and Web of Science were searched for studies investigating COVID-19 pandemic outcomes among Indigenous Peoples in Canada, Australia, New Zealand and the USA. The search dates included January 2019 to January 2024.

Eligibility criteria

All citations yielded by this search were subjected to title and abstract screening, full-text review and data extraction. We included original, peer-reviewed research investigating COVID-19-related outcomes among Indigenous Peoples in Canada, Australia, New Zealand or the USA.

Data extraction and synthesis

Data extraction was conducted as an iterative process, reaching consensus between two of the study authors. All included studies were analysed through a combination of quantitative descriptive summary and qualitative thematic analysis.

Results

Of the 9795 citations found by the initial search, 428 citations were deemed eligible for inclusion. Of these citations: 72.9% compared Indigenous participants to non-Indigenous participants; 10.0% aggregated Indigenous and non-white participants; and 17.1% provided findings for Indigenous participants exclusively.

Conclusions

By overlooking the heterogeneity that exists among Indigenous Peoples in Canada, Australia, New Zealand and the USA, researchers and policy-makers run the risk of masking inequities and the unique needs of groups of Indigenous Peoples. This may lead to inefficient policy recommendations and unintentionally perpetuate health disparities during public health crises.

Generalized contact matrices allow integrating socioeconomic variables into epidemic models

Variables related to socioeconomic status (SES), including income, ethnicity, and education, shape contact structures and affect the spread of infectious diseases. However, these factors are often overlooked in epidemic models, which typically stratify social contacts by age and interaction contexts. Here, we introduce and study generalized contact matrices that stratify contacts across multiple dimensions. We demonstrate a lower-bound theorem proving that disregarding additional dimensions, besides age and context, might lead to an underestimation of the basic reproductive number. By using SES variables in both synthetic and empirical data, we illustrate how generalized contact matrices enhance epidemic models, capturing variations in behaviors such as heterogeneous levels of adherence to nonpharmaceutical interventions among demographic groups. Moreover, we highlight the importance of integrating SES traits into epidemic models, as neglecting them might lead to substantial misrepresentation of epidemic outcomes and dynamics. Our research contributes to the efforts aiming at incorporating socioeconomic and other dimensions into epidemic modeling.

Differences in SARS-CoV-2 antibody prevalence at the end of the pre-vaccination period between age groups: A cross-sectional analysis of the multi-ethnic population-based HELIUS study

BACKGROUND

During the first waves of the COVID-19 pandemic, SARS-CoV-2 antibody prevalence (seroprevalence) was lower in older compared to younger adults. We studied age group differences in SARS-CoV-2 seroprevalence, across ethnic groups, and assessed the explanatory value of factors that increase the exposure to the virus, and factors related to susceptibility, given the level of exposure.

METHODS

We analysed cross-sectional data from 2,064 participants from the multi-ethnic HELIUS study (Amsterdam, The Netherlands). SARS-CoV-2 seroprevalence at the second wave of infections was compared between age groups (<40, 40-54, and ≥55 years), within ethnic groups, using Poisson regression with robust standard errors. To determine whether age group differences were explained by differences in exposure and in susceptibility, we sequentially adjusted for exposure (job setting, occupation level, health literacy, household size, household member with suspected infection), education level, and susceptibility (vitamin D intake, BMI, systolic blood pressure, haemoglobin level, number of comorbidities).

RESULTS

SARS-CoV-2 seroprevalence did not statistically differ across age groups (p>0.05), but age patterns varied across ethnic groups. Age group differences in SARS-CoV-2 seroprevalence were most pronounced in the Dutch majority group, with the highest prevalence ratio in the youngest group (2.55, 95%CI 0.93-6.97) and the lowest in the oldest group (0.53, 95%CI 0.16-1.74), compared to the middle-aged group. In ethnic minority groups, age group differences were smaller. In all groups, patterns did not substantially change after adjustments for exposure and susceptibility variables.

CONCLUSION

We found no evidence of age group differences in SARS-CoV-2 seroprevalence, particularly for ethnic minority groups, even when accounting for exposure and susceptibility. While early prevention strategies particularly aimed at protecting older adults against SARS-CoV-2 infections, seroprevalence was similar across age groups in ethnic minority groups. Thus, older adults in ethnic minority groups may pose a target group for additional prevention strategies for future infectious disease outbreaks.

Quantifying the magnitude of the general contextual effect in a multilevel study of SARS-CoV-2 infection in Ontario, Canada: application of the median rate ratio in population health research

BACKGROUND

Regional variations in SARS-CoV-2 infection were observed in Canada and other countries. Studies have used multilevel analyses to examine how a context, such as a neighbourhood, can affect the SARS-CoV-2 infection rates of the people within it. However, few multilevel studies have quantified the magnitude of the general contextual effect (GCE) in SARS-CoV-2 infection rates and assessed how it may be associated with individual- and area-level characteristics. To address this gap, we will illustrate the application of the median rate ratio (MRR) in a multilevel Poisson analysis for quantifying the GCE in SARS-CoV-2 infection rates in Ontario, Canada.

METHODS

We conducted a population-based, two-level multilevel observational study where individuals were nested into regions (i.e., forward sortation areas [FSAs]). The study population included community-dwelling adults in Ontario, Canada, between March 1, 2020, and May 1, 2021. The model included seven individual-level variables (age, sex, asthma, diabetes, hypertension, congestive heart failure, and chronic obstructive pulmonary disease) and four FSA census-based variables (household size, household income, employment, and driving to work). The MRR is a median value of the rate ratios comparing two patients with identical characteristics randomly selected from two different regions ordered by rate. We examined the attenuation of the MRR after including individual-level and FSA census-based variables to assess their role in explaining the variation in rates between regions.

RESULTS

Of the 11 789 128 Ontario adult community-dwelling residents, 343 787 had at least one SARS-CoV-2 infection during the study period. After adjusting for individual-level and FSA census-based variables, the MRR was attenuated to 1.67 (39% reduction from unadjusted MRR). The strongest FSA census-based associations were household size (RR = 1.88, 95% CI: 1.71-1.97) and driving to work (RR = 0.68, 95% CI: 0.65-0.71).

CONCLUSIONS

The individual- and area-level characteristics in our study accounted for approximately 40% of the between-region variation in SARS-CoV-2 infection rates measured by MRR in Ontario, Canada. These findings suggest that population-based policies to address social determinants of health that attenuate the MRR may reduce the observed between-region heterogeneity in SARS-CoV-2 infection rates.

Heart Failure with Reduced Ejection Fraction and COVID-19, when the Sick Get Sicker: Unmasking Racial and Ethnic Inequities During a Pandemic

Minoritized racial and ethnic groups have the highest incidence, prevalence, and hospitalization rate for heart failure. Despite improvement in medical therapies and overall survival, the morbidity and mortality of these groups remain elevated. The reasons for this disparity are multifactorial, including social determinant of health (SDOH) such as access to care, bias, and structural racism. These same factors contributed to higher rates of COVID-19 infection among minoritized racial and ethnic groups. In this review, we aim to explore the lessons learned from the COVID-19 pandemic and its interconnection between heart failure and SDOH. The pandemic presents a window of opportunity for achieving greater equity in the health care of all vulnerable populations.

Still Separate, Still Not Equal: An Ecological Examination of Redlining and Racial Segregation with COVID-19 Vaccination Administration in Washington D.C

Racial residential segregation has been deemed a fundamental cause of health inequities. It is a result of historical and contemporary policies such as redlining that have created a geographic separation of races and corresponds with an inequitable distribution of health-promoting resources. Redlining and racial residential segregation may have contributed to racial inequities in COVID-19 vaccine administration in the early stages of public accessibility. We use data from the National Archives (historical redlining), Home Mortgage Disclosure Act (contemporary redlining), American Community Survey from 1940 (historical racial residential segregation) and 2015-2019 (contemporary racial residential segregation), and Washington D.C. government (COVID-19 vaccination administration) to assess the relationships between redlining, racial residential segregation, and COVID-19 vaccine administration during the early stages of vaccine distribution when a tiered system was in place due to limited supply. Pearson correlation was used to assess whether redlining and racial segregation, measured both historically and contemporarily, were correlated with each other in Washington D.C. Subsequently, linear regression was used to assess whether each of these measures associate with COVID-19 vaccine administration. In both historical and contemporary analyses, there was a positive correlation between redlining and racial residential segregation. Further, redlining and racial residential segregation were each positively associated with administration of the novel COVID-19 vaccine. This study highlights the ongoing ways in which redlining and segregation contribute to racial health inequities. Eliminating racial health inequities in American society requires addressing the root causes that affect access to health-promoting resources.

Missing data and missed infections: investigating racial and ethnic disparities in SARS-CoV-2 testing and infection rates in Holyoke, Massachusetts

Routinely collected testing data have been a vital resource for public health response during the COVID-19 pandemic and have revealed the extent to which Black and Hispanic persons have borne a disproportionate burden of SARS-CoV-2 infections and hospitalizations in the United States. However, missing race and ethnicity data and missed infections due to testing disparities limit the interpretation of testing data and obscure the true toll of the pandemic. We investigated potential bias arising from these 2 types of missing data through a case study carried out in Holyoke, Massachusetts, during the prevaccination phase of the pandemic. First, we estimated SARS-CoV-2 testing and case rates by race and ethnicity, imputing missing data using a joint modeling approach. We then investigated disparities in SARS-CoV-2 reported case rates and missed infections by comparing case rate estimates with estimates derived from a COVID-19 seroprevalence survey. Compared with the non-Hispanic White population, we found that the Hispanic population had similar testing rates (476 tested per 1000 vs 480 per 1000) but twice the case rate (8.1% vs 3.7%). We found evidence of inequitable testing, with a higher rate of missed infections in the Hispanic population than in the non-Hispanic White population (79 infections missed per 1000 vs 60 missed per 1000).

Epidemiological approaches to multivariable models of health inequity: A study of race, rurality, and occupation during the COVID-19 pandemic

PURPOSE

Methods for assessing the structural mechanisms of health inequity are not well established. This study applies a phased approach to modeling racial, occupational, and rural disparities on the county level.

METHODS

Rural counties with disparately high rates of COVID-19 incidence or mortality were randomly paired with in-state control counties with the same rural-urban continuum code. Analysis was restricted to the first six months of the pandemic to represent the baseline structural reserves for each county and reduce biases related to the disruption of these reserves over time. Conditional logistic regression was applied in two phases-first, to examine the demographic distribution of disparities and then, to examine the relationships between these disparities and county-level social and structural reserves.

RESULTS

In over 200 rural county pairs (205 for incidence, 209 for mortality), disparities were associated with structural variables representing economic factors, healthcare infrastructure, and local industry. Modeling results were sensitive to assumptions about the relationships between race and other social and structural variables measured at the county level, particularly in models intended to reflect effect modification or mediation.

CONCLUSIONS

Multivariable modeling of health disparities should reflect the social and structural mechanisms of inequity and anticipate interventions that can advance equity.

The Impact of Language on Hospital Outcomes for COVID-19 Patients: A Study of Non-English Speaking Hispanic Patients

BACKGROUND

The COVID-19 pandemic has highlighted and exacerbated health inequities, as demonstrated by the disproportionate rates of infection, hospitalization, and death in marginalized racial and ethnic communities. Although non-English speaking (NES) patients have substantially higher rates of COVID-19 positivity than other groups, research has not yet examined primary language, as determined by the use of interpreter services, and hospital outcomes for patients with COVID-19.

METHODS

Data were collected from 1,770 patients with COVID-19 admitted to an urban academic health medical center in the Chicago, Illinois area from March 2020 to April 2021. Patients were categorized as non-Hispanic White, non-Hispanic Black, NES Hispanic, and English-speaking (ES) Hispanic using NES as a proxy for English language proficiency. Multivariable logistic regression was used to compare the predicted probability for each outcome (i.e., ICU admission, intubation, and in-hospital death) by race/ethnicity.

RESULTS

After adjusting for possible confounders, NES Hispanic patients had the highest predicted probability of ICU admission (p-value < 0.05). Regarding intubation and in-hospital death, NES Hispanic patients had the highest probability, although statistical significance was inconclusive, compared to White, Black, and ES Hispanic patients.

CONCLUSIONS

Race and ethnicity, socioeconomic status, and language have demonstrated disparities in health outcomes. This study provides evidence for heterogeneity within the Hispanic population based on language proficiency that may potentially further contribute to disparities in COVID-19-related health outcomes within marginalized communities.

Racial and Ethnic Inequities in Cancer Care Continuity During the COVID-19 Pandemic Among Those With SARS-CoV-2

Importance

Racially and ethnically minoritized US adults were disproportionately impacted by the COVID-19 pandemic and experience poorer cancer outcomes, including inequities in cancer treatment delivery.

Objective

To evaluate racial and ethnic disparities in cancer treatment delays and discontinuations (TDDs) among patients with cancer and SARS-CoV-2 during different waves of the COVID-19 pandemic in the United States.

Design, Setting, and Participants

This cross-sectional study used data from the American Society of Clinical Oncology Survey on COVID-19 in Oncology Registry (data collected from April 2020 to September 2022), including patients with cancer also diagnosed with SARS-CoV-2 during their care at 69 US practices. Racial and ethnic differences were examined during 5 different waves of the COVID-19 pandemic in the United States based on case surge (before July 2020, July to November 2020, December 2020 to March 2021, April 2021 to February 2022, and March to September 2022).

Exposures

Race and ethnicity.

Main Outcomes and Measures

TDD was defined as any cancer treatment postponed more than 2 weeks or cancelled with no plans to reschedule. To evaluate TDD associations with race and ethnicity, adjusted prevalence ratios (aPRs) were estimated using multivariable Poisson regression, accounting for nonindependence of patients within clinics, adjusting for age, sex, body mass index, comorbidities, cancer type, cancer extent, and SARS-CoV-2 severity (severe defined as death, hospitalization, intensive care unit admission, or mechanical ventilation).

Results

A total of 4054 patients with cancer and SARS-CoV-2 were included (143 [3.5%] American Indian or Alaska Native, 176 [4.3%] Asian, 517 [12.8%] Black or African American, 469 [11.6%] Hispanic or Latinx, and 2747 [67.8%] White; 2403 [59.3%] female; 1419 [35.1%] aged 50-64 years; 1928 [47.7%] aged ≥65 years). The analysis focused on patients scheduled (at SARS-CoV-2 diagnosis) to receive drug-based therapy (3682 [90.8%]), radiation therapy (382 [9.4%]), surgery (218 [5.4%]), or transplant (30 [0.7%]), of whom 1853 (45.7%) experienced TDD. Throughout the pandemic, differences in racial and ethnic inequities based on case surge with overall TDD decreased over time. In multivariable analyses, non-Hispanic Black (third wave: aPR, 1.56; 95% CI, 1.31-1.85) and Hispanic or Latinx (third wave: aPR, 1.35; 95% CI, 1.13-1.62) patients with cancer were more likely to experience TDD compared with non-Hispanic White patients during the first year of the pandemic. By 2022, non-Hispanic Asian patients (aPR, 1.51; 95% CI, 1.08-2.12) were more likely to experience TDD compared with non-Hispanic White patients, and non-Hispanic American Indian or Alaska Native patients were less likely (aPR, 0.37; 95% CI, 0.16-0.89).

Conclusions and Relevance

In this cross-sectional study of patients with cancer and SARS-CoV-2, racial and ethnic inequities existed in TDD throughout the pandemic; however, the disproportionate burden among racially and ethnically minoritized patients with cancer varied across SARS-CoV-2 waves. These inequities may lead to downstream adverse impacts on cancer mortality among minoritized adults in the United States.

Disparities in COVID-19 Hospitalization at the Intersection of Race and Ethnicity and Income

BACKGROUND

Existing studies have elucidated racial and ethnic disparities in COVID-19 hospitalizations, but few have examined disparities at the intersection of race and ethnicity and income.

METHODS

We used a population-based probability survey of non-institutionalized adults in Michigan with a polymerase chain reaction-positive SARS-CoV-2 test before November 16, 2020. We categorized respondents by race and ethnicity and annual household income: low-income (< $50,000) Non-Hispanic (NH) Black, high-income (≥ $50,000) NH Black, low-income Hispanic, high-income Hispanic, low-income NH White, and high-income NH White. We used modified Poisson regression models, adjusting for sex, age group, survey mode, and sample wave, to estimate COVID-19 hospitalization prevalence ratios by race and ethnicity and income.

RESULTS

Over half of the analytic sample (n = 1593) was female (54.9%) and age 45 or older (52.5%), with 14.5% hospitalized for COVID-19. Hospitalization was most prevalent among low-income (32.9%) and high-income (31.2%) Non-Hispanic (NH) Black adults, followed by low-income NH White (15.3%), low-income Hispanic (12.9%), high-income NH White (9.6%), and high-income Hispanic adults (8.8%). In adjusted models, NH Black adults, regardless of income (low-income prevalence ratio [PR]: 1.86, 95% CI: 1.36-2.54; high-income PR: 1.57, 95% CI: 1.07-2.31), and low-income NH White adults (PR: 1.52, 95% CI: 1.12-2.07), had higher prevalence of hospitalization compared to high-income NH White adults. We observed no significant difference in the prevalence of hospitalization among Hispanic adults relative to high-income NH White adults.

CONCLUSIONS

We observed disparities in COVID-19 hospitalization at the intersection of race and ethnicity and income for NH Black adults and low-income NH White adults relative to high-income NH White adults, but not for Hispanic adults.

Insights into Covid-19 mortality: A comprehensive study of cardiovascular sensitivity, gender, race, and geography trends in the United States (2020-2023)

This investigation meticulously explores the evolving landscape of Covid-19-related mortality in the United States from 2020 to 2023. Leveraging the comprehensive CDC WONDER database, the study conducts a detailed analysis of age-adjusted mortality rates (AAMRs), considering various demographic and regional parameters. The identified pattern illustrates an initial surge in AAMRs from 2020 to 2021, followed by a subsequent decline until 2023. Notably, there is a discernible reduction in AAMRs for both the elderly (85 years and older) and infants (below one year). Within specific demographic segments, heightened AAMRs are observed among NH American Indian or Alaska Native individuals, men, and residents in particular states and regions. Emphasizing the significant impact of Covid-19 on cardiovascular health, the study underscores increased mortality rates associated with the cardiovascular and respiratory systems. AAMR rates were standardized per 100,000 population, providing a comparative metric. Noteworthy states with elevated AAMRs include Mississippi, Oklahoma, Kentucky, New Mexico, and Alabama, with the Southern region exhibiting the highest AAMR. The research sheds light on demographic and regional disparities in Covid-19-related mortality, calling for intensified efforts in prevention and treatment strategies. These findings, offering nuanced insights, serve as a guide for strategic public health initiatives to mitigate the multifaceted repercussions of the pandemic, especially among vulnerable populations.

Racial and Ethnic Identity and Vulnerability to Upper Respiratory Viral Infections Among US Children

BACKGROUND

It is unclear whether there are racial/ethnic disparities in the risk of upper respiratory viral infection acquisition and/or lower respiratory manifestations.

METHODS

We studied all children and children with asthma aged 6 to 17 years in the National Health and Nutrition Examination Survey (2007-2012) to evaluate (1) the association between race/ethnicity and upper respiratory infection (URI) and (2) whether race/ethnicity is a risk factor for URI-associated pulmonary eosinophilic inflammation or decreased lung function.

RESULTS

Children who identified as Black (adjusted odds ratio [aOR], 1.38; 95% CI, 1.10-1.75) and Mexican American (aOR, 1.50; 95% CI, 1.16-1.94) were more likely to report a URI than those who identified as White. Among those with asthma, Black children were more than twice as likely to report a URI than White children (aOR, 2.28; 95% CI, 1.31-3.95). Associations between URI and pulmonary eosinophilic inflammation or lung function did not differ by race/ethnicity.

CONCLUSIONS

Findings suggest that there may be racial and ethnic disparities in acquiring a URI but not in the severity of infection. Given that upper respiratory viral infection is tightly linked to asthma exacerbations in children, differences in the risk of infection among children with asthma may contribute to disparities in asthma exacerbations.

Characteristics and outcomes of a hospitalized cohort with reduced mortality from COVID-19, White Mountain apache tribal lands, April 1 - July 31, 2020

BACKGROUND

Widespread transmission of COVID-19 continues to threaten public health, particularly of rural, American Indian communities. Although COVID-19 risk factors for severe disease and clinical characteristics are well described in the general population, there has been little shared on hospitalized American Indian populations.

METHODS

In this observational study, we performed chart extractions on all persons hospitalized with COVID-19 from April 1 through July 31, 2020 among an exclusively American Indian population living on or near Tribal lands in eastern Arizona. We provide descriptive statistics for the cohort stratified by presentation, comparing those who self-presented or were referred by an outreach program. Exploratory analyses were performed to identify risk factors for morbidity and mortality.

RESULTS

During the observation period, 2262 persons were diagnosed with COVID-19 and 490 (22%) were hospitalized. Hospitalized persons had a median age of 54 years; 92% had at least one comorbidity, 72% had greater than one comorbidity, and 60% had a BMI of > 30. Most persons required supplemental oxygen (83%), but the majority (62%) only required nasal cannula and only 11% were intubated. The case fatality rates were 1.7% for the population, 7.1% among hospitalizations, and 9.3% among hospitalized patients 50 years and older. All rates that are significantly lower than those reported nationally during the same period.

CONCLUSIONS

We observed a cohort of American Indian patients hospitalized secondary to COVID-19 with greater number of comorbidities compared to the general population but with lower mortality rates. We posit that the primary driver of mortality reduction for this population and the hospitalized cohort was a community-based referral program that led to disproportionately lower fatality rates among the oldest persons.

Demographic and Geographic Characterization of Excess Mortality During the COVID-19 Pandemic in Baltimore City, Maryland, March 2020 to March 2021

Estimates of excess mortality can provide insight into direct and indirect impacts of the coronavirus disease 2019 (COVID-19) pandemic beyond deaths specifically attributed to COVID-19. We analyzed death certificate data from Baltimore City, Maryland, from March 1, 2020, to March 31, 2021, and found that 1,725 individuals (95% confidence interval: 1,495, 1,954) died in excess of what was expected from all-cause mortality trends in 2016-2019; 1,050 (61%) excess deaths were attributed to COVID-19. Observed mortality was 23%-32% higher than expected among individuals aged 50 years and older. Non-White residents of Baltimore City also experienced 2 to 3 times higher rates of excess mortality than White residents (e.g., 37.4 vs. 10.7 excess deaths per 10,000 population among Black residents vs. White residents). There was little to no observed excess mortality among residents of hospice, long-term care, and nursing home facilities, despite accounting for nearly 30% (312/1,050) of recorded COVID-19 deaths. There was significant geographic variation in excess mortality within the city, largely following racial population distributions. These results demonstrate the substantial and unequal impact of the COVID-19 pandemic on Baltimore City residents and the importance of building robust, timely surveillance systems to track disparities and inform targeted strategies to remediate the impact of future epidemics.

Lessons Learned About Trauma Related to Racial Discrimination During COVID-19 in the United States

Race scholars have discussed how the pandemic has disproportionately burdened marginalized communities and exacerbated pre-existing inequities, particularly for Black Indigenous People of Color (BIPOC) in the United States (U.S.). One glaring social determinant during the time of the COVID-19 is racial discrimination. This chapter will discuss lessons learned regarding the negative impact of discrimination on BIPOC, especially as it pertains to their experiences of trauma. Some of these lessons include (1) the need for clinical psychologist to improve access to treatment through increased research on culturally adaptive interventions, (2) increased research on the effects of race-based trauma on mental health symptomatology, (3) policy and institutional changes that reduce disparities in access to care, and (4) increased education for psychologists around billing procedures for individuals with race-based stress.

Neighborhood Factors Associated with COVID-19 Cases in California

BACKGROUND

There is a need to assess neighborhood-level factors driving COVID-19 disparities across racial and ethnic groups.

OBJECTIVE

To use census tract-level data to investigate neighborhood-level factors contributing to racial and ethnic group-specific COVID-19 case rates in California.

DESIGN

Quasi-Poisson generalized linear models were used to identify neighborhood-level factors associated with COVID-19 cases. In separate sequential models for Hispanic, Black, and Asian, we characterized the associations between neighborhood factors on neighborhood COVID-19 cases. Subanalyses were conducted on neighborhoods with majority Hispanic, Black, and Asian residents to identify factors that might be unique to these neighborhoods. Geographically weighted regression using a quasi-Poisson model was conducted to identify regional differences.

MAIN MEASURES

All COVID-19 cases and tests reported through January 31, 2021, to the California Department of Public Health. Neighborhood-level data from census tracts were obtained from American Community Survey 5-year estimates (2015-2019), United States Census (2010), and United States Department of Housing and Urban Development.

KEY RESULTS

The neighborhood factors associated with COVID-19 case rate were racial and ethnic composition, age, limited English proficiency (LEP), income, household size, and population density. LEP had the largest influence on the positive association between proportion of Hispanic residents and COVID-19 cases (- 2.1% change). This was also true for proportion of Asian residents (- 1.8% change), but not for the proportion of Black residents (- 0.1% change). The influence of LEP was strongest in areas of the Bay Area, Los Angeles, and San Diego.

CONCLUSION

Neighborhood-level contextual drivers of COVID-19 burden differ across racial and ethnic groups.

Heart Failure with Reduced Ejection Fraction and COVID-19, when the Sick Get Sicker: Unmasking Racial and Ethnic Inequities During a Pandemic

Minoritized racial and ethnic groups have the highest incidence, prevalence, and hospitalization rate for heart failure. Despite improvement in medical therapies and overall survival, the morbidity and mortality of these groups remain elevated. The reasons for this disparity are multifactorial, including social determinant of health (SDOH) such as access to care, bias, and structural racism. These same factors contributed to higher rates of COVID-19 infection among minoritized racial and ethnic groups. In this review, we aim to explore the lessons learned from the COVID-19 pandemic and its interconnection between heart failure and SDOH. The pandemic presents a window of opportunity for achieving greater equity in the health care of all vulnerable populations.

Use of RT-PCR in conjunction with a respiratory pathogen assay to concurrently determine the prevalence of bacteria and SARS-CoV-2 from the nasopharynx of outpatients

Introduction

COVID-19 has emerged as a highly contagious and debilitating disease caused by the SARS-CoV-2 virus and has claimed the lives of over 7.7 million people worldwide. Bacterial co-infections are one of many co-morbidities that have been suggested to impact the outcome of COVID-19 in patients. The goals of this study are to elucidate the presence of bacteria in the nasopharynx of SARS-CoV-2 positive and negative patients and to describe demographic categories that may be associated with the detection of these organisms during one of the initial waves of the COVID-19 pandemic.

Methods

To this end, we investigated SARS-CoV-2 and bacterial co-detection from outpatient RT-PCR testing in Texas.

Results

The results indicate that Staphylococcus aureus, Streptococcus pneumoniae, Klebsiella pneumoniae, Moraxella catarrhalis, and Haemophilus influenzae were the most frequently detected bacteria in both SARS-CoV-2 positive and SARS-CoV-2 negative patients and that these bacteria were present in these two patient populations at similar proportions. We also detected Staphylococcus aureus in a significantly larger proportion of males relative to females and people under 65 years of age relative to those 65 and over. Finally, we observed that SARS-CoV-2 was more commonly detected in Hispanics compared to non-Hispanics; however, low disclosure rates make volunteer bias a concern when interpreting the effects of demographic variables.

Discussion

This study describes the bacteria present in the nasopharynx of SARS-CoV-2 positive and negative patients, highlights associations between patient demographics and SARS-CoV-2 as well as bacterial co-detection. In addition, this study highlights RT-PCR based molecular testing as a tool to detect bacteria simultaneously when SARS-CoV-2 tests are performed.

Effects of environmental conditions on COVID-19 morbidity as an example of multicausality: a multi-city case study in Italy

The coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), broke out in December 2019 in Wuhan city, in the Hubei province of China. Since then, it has spread practically all over the world, disrupting many human activities. In temperate climates overwhelming evidence indicates that its incidence increases significantly during the cold season. Italy was one of the first nations, in which COVID-19 reached epidemic proportions, already at the beginning of 2020. There is therefore enough data to perform a systematic investigation of the correlation between the spread of the virus and the environmental conditions. The objective of this study is the investigation of the relationship between the virus diffusion and the weather, including temperature, wind, humidity and air quality, before the rollout of any vaccine and including rapid variation of the pollutants (not only their long term effects as reported in the literature). Regarding them methodology, given the complexity of the problem and the sparse data, robust statistical tools based on ranking (Spearman and Kendall correlation coefficients) and innovative dynamical system analysis techniques (recurrence plots) have been deployed to disentangle the different influences. In terms of results, the evidence indicates that, even if temperature plays a fundamental role, the morbidity of COVID-19 depends also on other factors. At the aggregate level of major cities, air pollution and the environmental quantities affecting it, particularly the wind intensity, have no negligible effect. This evidence should motivate a rethinking of the public policies related to the containment of this type of airborne infectious diseases, particularly information gathering and traffic management.

Social inequalities and the early provision and dispersal of COVID-19 vaccinations in the United States: A population trends study

BACKGROUND

In December 2020 the U.S. began a massive COVID-19 vaccination campaign, an action that researchers felt could catalyze inequalities in COVID-19 vaccination utilization. While vaccines have the potential to be accessible regardless of social status, the objective of this study was to examine how and when socioeconomic status (SES) and racial/ethnic inequalities would emerge in vaccination distribution.

METHODS

Population vaccination rates reported at the county level by the Centers for Disease Control and Prevention across 46 states on 3/30/2021. Correlates included SES, the share of the population who were Black, Hispanic, Female, or aged ≥65 years, and urbanicity (thousands of residents per square mile). Multivariable-adjusted analyses relied on zero-inflated negative binomial regression to estimate the odds of providing any vaccine, and vaccination rate ratios (aVRR) comparing the distribution rate for vaccinations across the U.S.

RESULTS

Across the U.S., 16.3 % of adults and 37.9 % of adults aged 65 and older were vaccinated in lower SES counties, while 20.45 % of all adults and 48.15 % of adults aged 65 and older were vaccinated in higher SES counties. Inequalities emerged after 41 days, when < 2 % of Americans were vaccinated. Multivariable-adjusted analyses revealed that higher SES was associated with improved vaccination distribution (aVRR = 1.127, [1.100-1.155], p < 1E-06), while increases in the percent reporting Black or Hispanic race/ethnicity was associated with lower vaccination distribution (aVRR = 0.998, [0.996-0.999], p = 1.03E-04).

CONCLUSIONS

Social inequalities in COVID-19 vaccines reflect an inefficient and inequitable distribution of these technologies. Future efforts to improve health should recognize the central role of social factors in impacting vaccine delivery.

Quantifying the impact of SARS-CoV-2 temporal vaccination trends and disparities on disease control

SARS-CoV-2 vaccines have been distributed at unprecedented speed. Still, little is known about temporal vaccination trends, their association with socioeconomic inequality, and their consequences for disease control. Using data from 161 countries/territories and 58 states, we examined vaccination rates across high and low socioeconomic status (SES), showing that disparities in coverage exist at national and subnational levels. We also identified two distinct vaccination trends: a rapid initial rollout, quickly reaching a plateau, or sigmoidal and slow to begin. Informed by these patterns, we implemented an SES-stratified mechanistic model, finding profound differences in mortality and incidence across these two vaccination types. Timing of initial rollout affects disease outcomes more substantially than final coverage or degree of SES disparity. Unexpectedly, timing is not associated with wealth inequality or GDP per capita. While socioeconomic disparity should be addressed, accelerating initial rollout for all over focusing on increasing coverage is an accessible intervention that could minimize the burden of disease across socioeconomic groups.

COVID-19 and All-Cause Mortality by Race, Ethnicity, and Age Across Five Periods of the Pandemic in the United States

Racial/ethnic and age disparities in COVID-19 and all-cause mortality during 2020 are well documented, but less is known about their evolution over time. We examine changes in age-specific mortality across five pandemic periods in the United States from March 2020 to December 2022 among four racial/ethnic groups (non-Hispanic White, non-Hispanic Black, Hispanic, and non-Hispanic Asian) for ages 35+. We fit Gompertz models to all-cause and COVID-19 death rates by 5-year age groups and construct age-specific racial/ethnic mortality ratios across an Initial peak (Mar-Aug 2020), Winter peak (Nov 2020-Feb 2021), Delta peak (Aug-Oct 2021), Omicron peak (Nov 2021-Feb 2022), and Endemic period (Mar-Dec 2022). We then compare to all-cause patterns observed in 2019. The steep age gradients in COVID-19 mortality in the Initial and Winter peak shifted during the Delta peak, with substantial increases in mortality at working ages, before gradually returning to an older age pattern in the subsequent periods. We find a disproportionate COVID-19 mortality burden on racial and ethnic minority populations early in the pandemic, which led to an increase in all-cause mortality disparities and a temporary elimination of the Hispanic mortality advantage at certain age groups. Mortality disparities narrowed over time, with racial/ethnic all-cause inequalities during the Endemic period generally returning to pre-pandemic levels. Black and Hispanic populations, however, faced a younger age gradient in all-cause mortality in the Endemic period relative to 2019, with younger Hispanic and Black adults in a slightly disadvantageous position and older Black adults in a slightly advantageous position, relative to before the pandemic.

Invited Commentary: To Make Long-Term Gains Against Infection Inequity, Infectious Disease Epidemiology Needs to Develop a More Sociological Imagination

In a recent article in the Journal, Noppert et al. (Am J Epidemiol. 2023;192(3):475-482) articulated in detail the mechanisms connecting high-level "fundamental social causes" of health inequity to inequitable infectious disease outcomes, including infection, severe disease, and death. In this commentary, we argue that while intensive focus on intervening mechanisms is welcome and necessary, it cannot occur in isolation from examination of the way that fundamental social causes-including racism, socioeconomic inequity, and social stigma-sustain infection inequities even when intervening mechanisms are addressed. We build on the taxonomy of intervening mechanisms laid out by Noppert et al. to create a road map for strengthening the connection between fundamental cause theory and infectious disease epidemiology and discuss its implications for future research and intervention.

The citizenship shield: Mediated and moderated links between immigration status, discrimination, food insecurity, and negative health outcomes for latinx immigrants during the COVID-19 pandemic

A framework termed "the citizenship shield" is introduced to conceptualize how legal protections buffer against negative health outcomes among Latinx immigrants in the United States. In this study, we tested the citizenship shield framework in the context of the disproportionate impact of the COVID-19 pandemic on Latinx immigrants. We investigated the connection between immigration status, discrimination, food insecurity, and negative health outcomes. Analyses involved testing mediation and moderation models among a community-based sample of 536 Latinx immigrants holding five statuses (i.e., U.S. citizenship, permanent residency, Deferred Action for Childhood Arrivals, undocumented, and temporary status). Results suggested that food insecurity mediated the link between discrimination and negative impacts from the pandemic for Latinx immigrants across all statuses. Follow up analyses suggested that two of the three paths were moderated by immigration status. This research provides novel, important data to inform health interventions and federal policy targeted for the most vulnerable immigrants in the United States.

COVID-19 Vaccine Uptake and Attitudes Within Two Cohorts of Younger Adult Cannabis Users

It is crucial to understand COVID-19 vaccine uptake and attitudes among young adult cannabis users given the lowest vaccination rates among young adults and negative association between cannabis use and willingness to get vaccinated. 18-21-year-old and 26-33-year-old cohorts of cannabis users, recruited in California, were surveyed about the COVID-19 vaccine uptake/attitudes between March-August 2021. Cannabis use/demographic differences were investigated by vaccination status. Vaccine attitudes data were categorized and presented descriptively. 44.4% of the older and 71.8% of the younger cohorts were vaccinated. Non-Hispanic Black/African American race/ethnicity, lack of health insurance, and medicinal orientation towards cannabis use were negatively associated with vaccine receipt within the older cohort. For both cohorts, top reasons for vaccine hesitancy and rejection were concerns about speed of development, potential side effects, natural immunity, and lack of trust of vaccines. Our results highlight greater vaccine hesitance/rejection and need for targeted interventions among mid-20's-early-30's cannabis users.

Disproportionate impacts of COVID-19 in a large US city

COVID-19 has disproportionately impacted individuals depending on where they live and work, and based on their race, ethnicity, and socioeconomic status. Studies have documented catastrophic disparities at critical points throughout the pandemic, but have not yet systematically tracked their severity through time. Using anonymized hospitalization data from March 11, 2020 to June 1, 2021 and fine-grain infection hospitalization rates, we estimate the time-varying burden of COVID-19 by age group and ZIP code in Austin, Texas. During this 15-month period, we estimate an overall 23.7% (95% CrI: 22.5-24.8%) infection rate and 29.4% (95% CrI: 28.0-31.0%) case reporting rate. Individuals over 65 were less likely to be infected than younger age groups (11.2% [95% CrI: 10.3-12.0%] vs 25.1% [95% CrI: 23.7-26.4%]), but more likely to be hospitalized (1,965 per 100,000 vs 376 per 100,000) and have their infections reported (53% [95% CrI: 49-57%] vs 28% [95% CrI: 27-30%]). We used a mixed effect poisson regression model to estimate disparities in infection and reporting rates as a function of social vulnerability. We compared ZIP codes ranking in the 75th percentile of vulnerability to those in the 25th percentile, and found that the more vulnerable communities had 2.5 (95% CrI: 2.0-3.0) times the infection rate and only 70% (95% CrI: 60%-82%) the reporting rate compared to the less vulnerable communities. Inequality persisted but declined significantly over the 15-month study period. Our results suggest that further public health efforts are needed to mitigate local COVID-19 disparities and that the CDC's social vulnerability index may serve as a reliable predictor of risk on a local scale when surveillance data are limited.

Trust in government actors and COVID-19 vaccination uptake among Hispanics and Latinos in the U.S

Although the federal government has made official recommendations to the public advocating vaccinations against COVID-19 various communities have decided against doing so. In this regard, various studies have indicated that trust in government to provide accurate information about vaccines during a pandemic are related to whether people get vaccinated. Various studies have investigated factors contributing to vaccine decision-making, but none specifically focus on Hispanic and Latinos in the United States. This study identifies factors associated with COVID-19 vaccination among Hispanics and Latinos using a nation-wide, phone-based survey. Using data generated by the Kaiser Family Foundation's COVID-19 Vaccine Monitor, collected in June 2021, a logistic regression on the decision to get vaccinated, trust in various governmental actors, in addition to demographic variables such as age, race, employment status, parental status, employment status, and income are observed to be significant in Hispanics' and Latinos' decision to be vaccinated against COVID-19. As a byproduct of these findings, recommendations for future research are provided that relate to expanding our understanding of these factors among different ethnicities of Latinos.

Landlords' rental businesses before and after the COVID-19 pandemic: Evidence from a National Cross-Site Survey

This paper uses a survey of over 2500 rental property owners in ten cities across the United States to determine the impact of the COVID-19 pandemic on landlords' rent collection and business behavior. Our findings show that yearly rent collection was down significantly in 2020 relative to 2019-both within and across rental markets-and that an increasing number of owners have a large share of their portfolio behind on rent. Small owners and owners of color faced the highest exposure to deep tenant arrears in 2020, challenges they were also more likely to face prior to pandemic. Our findings show that owner business practices changed dramatically in 2020, with a higher share of landlords granting tenants rent extensions or forgiving back rent during the pandemic relative to prior. However, many owners also disinvested in their rental properties through deferred maintenance, missed mortgage payments, and property sale listings. Landlords of color pursued disinvestment strategies during the pandemic at an elevated rate compared to white landlords. Owners of properties in neighborhoods with more non-white residents were both more likely to experience decreased rent collection and more likely to pursue evictions and rental late fees holding constant rental payment rates, implying the pandemic has disproportionately affected renters in communities of color. Overall, our findings highlight the strain the pandemic has placed on the housing stock, which has implications for the long-term viability and affordability of many of these units. More concerningly, our results show that households of color-which have been disproportionately affected by the pandemic in other domains-were more likely to face punitive measures from landlords in both 2019 and 2020, suggesting the pandemic has exacerbated existing racial inequality in housing markets.

Social divisions and risk perception drive divergent epidemics and large later waves

During infectious disease outbreaks, individuals may adopt protective measures like vaccination and physical distancing in response to awareness of disease burden. Prior work showed how feedbacks between epidemic intensity and awareness-based behaviour shape disease dynamics. These models often overlook social divisions, where population subgroups may be disproportionately impacted by a disease and more responsive to the effects of disease within their group. We develop a compartmental model of disease transmission and awareness-based protective behaviour in a population split into two groups to explore the impacts of awareness separation (relatively greater in- vs. out-group awareness of epidemic severity) and mixing separation (relatively greater in- vs. out-group contact rates). Using simulations, we show that groups that are more separated in awareness have smaller differences in mortality. Fatigue (i.e. abandonment of protective measures over time) can drive additional infection waves that can even exceed the size of the initial wave, particularly if uniform awareness drives early protection in one group, leaving that group largely susceptible to future infection. Counterintuitively, vaccine or infection-acquired immunity that is more protective against transmission and mortality may indirectly lead to more infections by reducing perceived risk of infection and therefore vaccine uptake. Awareness-based protective behaviour, including awareness separation, can fundamentally alter disease dynamics. Social media summary: Depending on group division, behaviour based on perceived risk can change epidemic dynamics & produce large later waves.

Race, employment, and the pandemic: An exploration of covariate explanations of COVID-19 case fatality rate variance

We derive a simple asymptotic approximation for the long-run case fatality rate of COVID-19 (alpha and delta variants) and show that these estimations are highly correlated to the interaction between US State median age and projected US unemployment rate (Adj. r2 = 60%). We contrast this to the high level of correlation between point (instantaneous) estimates of per state case fatality rates and the interaction of median age, population density and current unemployment rates (Adj. r2 = 50.2%). To determine whether this is caused by a "race effect," we then analyze unemployment, race, median age and population density across US states and show that adding the interaction of African American population and unemployment explains 53.5% of the variance in COVID case fatality rates for the alpha and delta variants when considering instantaneous case fatality rate. Interestingly, when the asymptotic case fatality rate is used, the dependence on the African American population disappears, which is consistent with the fact that in the long-run COVID does not discriminate on race, but may discriminate on access to medical care which is highly correlated to employment in the US. The results provide further evidence of the impact inequality can have on case fatality rates in COVID-19 and the impact complex social, health and economic factors can have on patient survival.

Prevalence and epidemiological trends in mortality due to COVID-19 in Saudi Arabia

OBJECTIVES

This article describes the prevalence and epidemiological trends of COVID-19 mortality in the largest registry in the Kingdom of Saudi Arabia (KSA).

STUDY DESIGN

A prospective epidemiological cohort study using data from all healthcare facilities in KSA collected between March 23, 2020, and April 30, 2022. Data on the number of daily deaths directly related to COVID-19 were gathered, analyzed, and reported.

METHOD

Data analysis was carried out using national and regional crude case fatality rate and death per 100,000 population. Descriptive statistics using numbers and proportions were used to describe age, gender, nationality, and comorbidities. The mortality trend was plotted and compared with international figures. In addition, the most common comorbidities associated with mortality and the proportion of patients who received COVID-19 vaccine were reported.

RESULTS

The total reported number of deaths between March 23, 2020, and April 30, 2022, was 9085. Crude case fatality rate was 1.21%, and death per 100,000 population was 25.38, which compared favorably to figures reported by several developed countries. The highest percentages of deaths were among individuals aged between 60 and 69 years, males (71%), and individuals with diabetes (60%). Only 2.8% of mortalities occur in patients who received COVID-19 vaccine. Diabetes, hypertension, and heart failure had the highest attributable risk of mortality among patients who died due to COVID-19.

CONCLUSION

Case fatality rate and death per 100,000 population in KSA are among the lowest in the world due to multiple factors. Several comorbidities have been identified, namely, diabetes, hypertension, obesity, and cardiac arrhythmias.

Racial inequality in COVID-treatment and in-hospital length of stay in the US over time

Introduction

Demonstrated health inequalities persist in the United States. SARS-CoV-2 (COVID) has been no exception, with access to treatment and hospitalization differing across race or ethnic groups. Here, we aim to assess differences in treatment with remdesivir and hospital length of stay across the four waves of the pandemic.

Materials and methods

Using a subset of the Truveta data, we examine the odds ratio (OR) of in-hospital remdesivir treatment and risk ratio (RR) of in-hospital length of stay between Black or African American (Black) to White patients. We adjusted for confounding factors, such as age, sex, and comorbidity status.

Results

There were statistically significant lower rates of remdesivir treatment and longer in-hospital length of stay comparing Black patients to White patients early in the pandemic (OR for treatment: 0.88, 95% confidence interval [CI]: 0.80, 0.96; RR for length of stay: 1.17, CI: 1.06, 1.21). Rates became close to parity between groups as the pandemic progressed.

Conclusion

While inpatient remdesivir treatment rates increased and length of stay decreased over the beginning course of the pandemic, there are still inequalities in patient care.

An exploration of structural determinants driving racial disparities in COVID-19 deaths in Michigan

Aim

Racial disparities in COVID-19 death rates have largely been driven by structural racism in health, housing, and labor systems that place Black, Brown, and Indigenous populations at greater risk for COVID-19 exposure, transmission, and severe illness, compared to non-Hispanic White populations. Here we examine the association between taxable property values per capita, an indicator influenced by historical and contemporary housing policies that have disproportionately impacted people of color, and COVID-19 deaths.

Methods

Taxable values serve as a proxy for fiscal health providing insight on the county's ability to address imminent needs, including COVID-19 responses. Therefore, higher taxable values indicate local governments that are better equipped to deliver these public services. We used county-level data from the American Community Survey, the Michigan Community Financial Dashboard, The Atlantic's COVID Tracking Project, and the Community Health Rankings and Roadmap for this cross-sectional study. Maps were created to examine the geographic distribution of cumulative death rates and taxable values per capita, and regression models were used to examine the association between the two while controlling for population density, age, education, race, income, obesity, diabetes, and smoking rates.

Results

Seventy-five counties were included. The mean taxable value per capita was $43,764.50 and the mean cumulative death rate was 171.86. Findings from the regression analysis showed that counties with higher taxable values were associated with lower COVID-19 death rates (B = -2.45, P < 0.001).

Conclusion

Our findings reveal a need to reevaluate current policies surrounding taxable property values in the state of Michigan, not solely for their inequitable impact on local governments' financial solvency and service quality, but also for their negative consequences for population health and racial health equity.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10389-022-01817-w.

Current Challenges and Solutions for Clinical Management and Care of People with HIV: Findings from the 12th Annual International HIV and Aging Workshop

People with HIV on combination antiretroviral therapy (ART) have longer life expectancy and are increasingly experiencing age-related comorbidities. Thus, aging with HIV has become a central issue in clinical care and research, which has been particularly challenging with the intersection of the ongoing coronavirus (COVID)-19 pandemic. Since 2009, the International Workshop on HIV and Aging has served as a multidisciplinary platform to share research findings from cross-disciplinary fields along with community advocates to address critical issues in HIV and aging. In this article, we summarize the key oral presentations from the 12th Annual International Workshop on HIV and Aging, held virtually on September 23rd and 24th, 2021. The topics ranged from basic science research on biological mechanisms of aging to quality of life and delivery of care under the COVID-19 pandemic. This workshop enriched our understanding of HIV and aging under the COVID-19 pandemic, identified challenges and opportunities to combat the impact of COVID-19 on HIV communities, and also provided updated research and future directions of the field to move HIV and aging research forward, with the ultimate goal of successful aging for older people with HIV.

Context and Considerations for the Development of Community-Informed Health Communication Messaging to Support Equitable Uptake of COVID-19 Vaccines Among Communities of Color in Washington, DC

BACKGROUND

Communities of color have been disproportionately impacted by COVID-19. We explored barriers and facilitators to COVID-19 vaccine uptake among African American, Latinx, and African immigrant communities in Washington, DC.

METHODS

A total of 76 individuals participated in qualitative interviews and focus groups, and 208 individuals from communities of color participated in an online crowdsourcing contest.

RESULTS

Findings documented a lack of sufficient, accurate information about COVID-19 vaccines and questions about the science. African American and African immigrant participants spoke about the deeply rooted historical underpinnings to their community's vaccine hesitancy, citing the prior and ongoing mistreatment of people of color by the medical community. Latinx and African immigrant participants highlighted how limited accessibility played an important role in the slow uptake of COVID-19 vaccines in their communities. Connectedness and solidarity were found to be key assets that can be drawn upon through community-driven responses to address social-structural challenges to COVID-19 related vaccine uptake.

CONCLUSIONS

The historic and ongoing socio-economic context and realities of communities of color must be understood and respected to inform community-based health communication messaging to support vaccine equity for COVID-19 and other infectious diseases.

Racism measurement and influences, variations on scientific racism, and a vision

The knowledge base regarding the impact of racism and discrimination on African American health and well-being has grown significantly since the first models of racism and health, but many questions remain. In this commentary, I discuss three challenges requiring attention in future research. The first is measurement. The second is consideration of individual and contextual influences that shape vulnerability to racism. The third challenge is racism in science itself (e.g., racial disparities in funding, absence, and erasure of African American voices in scientific discourse on health disparities). I discuss the benefits of addressing these challenges and offer a vision of what research on racism and African American health and well-being might look like as we move toward the eradication of racism and promotion of health equity.

Post-Assault Health Care for Sexual Assault Survivors During COVID-19: A Mixed Methods Analysis of Service Rates in a Predominately African American Community

This study examined how the COVID-19 pandemic affected sexual assault healthcare services in a predominately African American U.S. city. In mixed methods research design, we used quantitative interrupted time series modeling to evaluate changes in service rates for three core post-assault healthcare services-medical forensic exams (MFEs), medical advocacy MFE accompaniment, and counseling-from January 2019 through June 2021. We also conducted qualitative interviews with 12 sexual assault advocates to understand how their clients were impacted by COVID and how their agency adapted services to respond to the needs of their community. Both the quantitative and qualitative data revealed marked disruptions in service provision. The number of MFEs, medical advocacy accompaniments, and counseling sessions significantly decreased during the pandemic's initial surge, and survivors feared seeking hospital-based health care due to concerns that they might contract COVID-19 in hospital emergency departments. The number of MFEs performed by program staff did not return to pre-pandemic levels during this study's observation period, but the number of medical advocacy accompaniments and counseling sessions did significantly rebound. Counseling services eventually exceeded pre-pandemic levels as agency staff supported clients with both assault- and COVID-related trauma and loss. These results underscore the need for community-based sexual assault healthcare services, so that if public health emergencies limit the availability, accessibility, and safety of hospital emergency department care, sexual assault survivors have other settings for obtaining post-assault health care.

Racial Disparities in the Perceived Risk of COVID-19 and in Getting Needed Medical Care

BACKGROUND

The COVID-19 pandemic disproportionately affected minorities in population rates of infection, hospitalization, and mortality. However, little is known about the broader racial disparities in fears and perceptions about the pandemic and getting treated.

OBJECTIVE

To examine disparities in perceived risks of COVID-19 and getting medical care.

METHODS

Using the nationally representative Stanford University School of Medicine Coronavirus Attitudes and Behaviors Survey fielded in May of 2020, we examine racial and ethnic disparities in eight measures on the perceived risks of COVID-19. We use regression analysis to risk adjust perceptions controlling for 10 socioeconomic, demographic, and health variables.

RESULTS

Black respondents were 15 percentage points more likely than White respondents to believe the pandemic would not end by Summer 2020 (92% vs 77%, p < .01), and were 19 percentage points more likely than any other race to feel a need to protect their family from COVID-19 (81% vs 62%, p < .01). Latinx respondents were 10 percentage points more fearful than White respondents of catching COVID-19 in public places (55% vs 45%, p < 0.01). Black respondents were 20 percentage points more likely than White respondents to think they would need medical care if infected (71% vs 51%, p < .01), and 18 percentage points more likely to think they would need to be hospitalized (59% vs 41%, p < .01). The proportion of Black respondents believing that the hospital would not have enough capacity to treat them if infected with COVID-19 was 12 percentage points higher than White respondents (41% vs 29%, p < 0.05).

CONCLUSION

Disparities in the COVID-19-related perceived risks and mistrust in healthcare across racial and ethnic groups existed at the beginning of the COVID-19 pandemic. As we enter into a post-COVID New Normal, new policies must ensure that the causes of this widespread fear and distrust in the healthcare system are understood and reversed.

A stakeholder-driven framework for measuring potential change in the health risks of people who inject drugs (PWID) during the COVID-19 pandemic

BACKGROUND

People who inject drugs (PWID) have likely borne disproportionate health consequences of the COVID-19 pandemic. PWID experienced both interruptions and changes to drug supply and delivery modes of harm reduction, treatment, and other medical services, leading to potentially increased risks for HIV, hepatitis C virus (HCV), and overdose. Given surveillance and research disruptions, proximal, indirect indicators of infectious diseases and overdose should be developed for timely measurement of health effects of the pandemic on PWID.

METHODS

We used group concept mapping and a systems thinking approach to produce an expert stakeholder-generated, multi-level framework for monitoring changes in PWID health outcomes potentially attributable to COVID-19 in the U.S. This socio-ecological measurement framework elucidates proximal and distal contributors to infectious disease and overdose outcomes, many of which can be measured using existing data sources.

RESULTS

The framework includes multi-level components including policy considerations, drug supply/distribution systems, the service delivery landscape, network factors, and individual characteristics such as mental and general health status and service utilization. These components are generally mediated by substance use and sexual behavioral factors to cause changes in incidence of HIV, HCV, sexually transmitted infections, wound/skin infections, and overdose.

CONCLUSION

This measurement framework is intended to increase the quality and timeliness of research on the impacts of COVID-19 in the context of the current pandemic and future crises. Next steps include a ranking process to narrow the drivers of change in health risks to a concise set of indicators that adequately represent framework components, can be written as measurable indicators, and are quantifiable using existing data sources, as well as a publicly available web-based platform for summary data contributions.

Federal Food Assistance Program Participation during the COVID-19 Pandemic: Participant Perspectives and Reasons for Discontinuing

This study aims to describe reasons for discontinuing participation and experiences participating in the Supplemental Nutrition Assistance Program (SNAP) and the Special Supplemental Nutrition Assistance Program for Women, Infants, and Children (WIC) during the COVID-19 pandemic. We analyzed data from a cross-sectional online survey distributed to a national sample, restricted to (1) households that discontinued participating in SNAP (n = 146) or WIC (n = 149) during the pandemic and (2) households that participated in SNAP (n = 501) or WIC (n = 141) during spring 2021—approximately one year into the pandemic. We conducted thematic analyses of open-ended survey questions and descriptive statistics for Likert-scale items. Themes raised by respondents who discontinued participating in SNAP or WIC included difficulty recertifying and virus exposure concerns. Former WIC participants reported the program was not worth the effort and former SNAP participants reported failing to requalify. Respondents participating in WIC or SNAP during the pandemic mentioned transportation barriers and insufficient benefit value. WIC participants had trouble redeeming benefits in stores and SNAP participants desired improved online grocery purchasing experiences. These results suggest that enhancements to WIC and SNAP, such as expanded online purchasing options, program flexibilities, and benefit increases, can improve program participation to ensure access to critical nutrition supports, especially during emergencies.

Municipal Ethnic Composition and Disparities in COVID-19 Infections in New Jersey: A Blinder-Oaxaca Decomposition Analysis

COVID-19 has disproportionally impacted Latinx and Black communities in the US. Our study aimed to extend the understanding of ethnic disparities in COVID-19 case rates by using a unique dataset of municipal case rates across New Jersey (NJ) during the first 17 months of the pandemic. We examined the extent to which there were municipal-level ethnic disparities in COVID-19 infection rates during three distinct spikes in case rates over this period. Furthermore, we used the Blinder-Oaxaca decomposition analysis to identify municipal-level exposure and vulnerability factors that contributed to ethnic disparities and how the contributions of these factors changed across the three initial waves of infection. Two clear results emerged. First, in NJ, the COVID-19 infection risk disproportionally affected Latinx communities across all three waves during the first 17 months of the pandemic. Second, the exposure and vulnerability factors that most strongly contributed to higher rates of infection in Latinx and Black communities changed over time as the virus, alongside medical and societal responses to it, also changed. These findings suggest that understanding and addressing ethnicity-based COVID-19 disparities will require sustained attention to the systemic and structural factors that disproportionately place historically marginalized ethnic communities at greater risk of contracting COVID-19.

Thanksgiving and Christmas gatherings before the 2020-21 winter surge of COVID-19 in the United States

Objective

COVID-19 in the US disproportionately affected, and continues to affect, racial/ethnic minorities. Although risky social gatherings for Thanksgiving and Christmas in 2020 contributed substantially to the "winter surge" in cases and deaths, no research examines potential racial/ethnic differences in behaviors related to holiday gatherings.

Design

We used the Understanding America Survey (UAS) - Coronavirus Tracking, a nationally representative study of US adults, to examine associations between race/ethnicity and risky holiday gathering behavior (i.e., gathering with non-household members and with little to no social distancing or mask-wearing). We applied logistic regression models to examine racial/ethnic and socioeconomic differences in risky holiday gatherings while accounting for a person's pre-holiday perception of COVID-19 risk as well as related behaviors.

Results

Non-Hispanic Black adults showed a lower prevalence of attending a risky Thanksgiving gathering than did non-Hispanic White adults (15 % vs 43 %, p <.001). The magnitude of this racial/ethnic difference was also found for risky Christmas gatherings. Hispanic and "Other" race/ethnicity adults also appeared less likely than non-Hispanic whites to attend a risky holiday gathering. Higher-income households attended a risky holiday gathering more frequently, when compared with lower income households (p <.001). Logistic regression results, which controlled for other COVID-19 related behaviors, support these main findings.

Conclusions

Racial/ethnic minorities, and non-Hispanic Black adults in particular, appeared least likely to have engaged in risky holiday gatherings in late 2020. If replicated, our findings appear consistent with the notion that behavioral modification among racial/ethnic minorities may have reduced the intensity of the 2020/21 "winter surge" in COVID-19.

Racial Disparities in Mortality During the 1918 Influenza Pandemic in United States Cities

Against a backdrop of extreme racial health inequality, the 1918 influenza pandemic resulted in a striking reduction of non-White to White influenza and pneumonia mortality disparities in United States cities. We provide the most complete account to date of these reduced racial disparities, showing that they were unexpectedly uniform across cities. Linking data from multiple sources, we then examine potential explanations for this finding, including city-level sociodemographic factors such as segregation, implementation of nonpharmaceutical interventions, racial differences in exposure to the milder spring 1918 "herald wave," and racial differences in early-life influenza exposures, resulting in differential immunological vulnerability to the 1918 flu. While we find little evidence for the first three explanations, we offer suggestive evidence that racial variation in childhood exposure to the 1889-1892 influenza pandemic may have shrunk racial disparities in 1918. We also highlight the possibility that differential behavioral responses to the herald wave may have protected non-White urban populations. By providing a comprehensive description and examination of racial inequality in mortality during the 1918 pandemic, we offer a framework for understanding disparities in infectious disease mortality that considers interactions between the natural histories of particular microbial agents and the social histories of those they infect.