Lessons Learned from Health Disparities in Coronavirus Disease-2019 in the United States.

In the United States, the coronavirus disease-2019 (COVID-19) pandemic has disproportionally affected Black, Latinx, and Indigenous populations, immigrants, and economically disadvantaged individuals. Such historically marginalized groups are more often employed in low-wage jobs without health insurance and have higher rates of infection, hospitalization, and death from COVID-19 than non-Latinx White individuals. Mistrust in the health care system, language barriers, and limited health literacy have hindered vaccination rates in minorities, further exacerbating health disparities rooted in structural, institutional, and socioeconomic inequities. In this article, we discuss the lessons learned over the last 2 years and how to mitigate health disparities moving forward.

Prevalence of SARS-CoV-2 (Covid-19) in Italians and in immigrants in an area of Northern Italy (Reggio Emilia).

It has been hypothesized that bacille Calmette-Guerin (BCG), the anti-tuberculosis vaccine, can be protective against Covid-19. Using data of performed swabs and RT-PCR results for SARS-CoV-2 in the Reggio Emilia province (Emilia-Romagna Region, Northern Italy) from March 6th to March 26th, 2020, we computed age, gender, and place of birth (Italy or abroad) specific risk of being tested, prevalence of positive tests, and probability of testing positive given that a swab has been taken during the epidemic peak. We report that immigrants resident in Reggio Emilia province, mostly coming from Countries with high BCG vaccination coverage, and Italians had a similar prevalence of infection (odds ratio - OR 0.99; 95%CI 0.82-1.20) and similar probability of being tested (OR 0.93; 95%CI 0.81-1.10). Our data do not support the hypothesis that immigrants from Countries where BCG vaccination is recommended have a lower risk of Covid-19 infection.

Tuberculosis trend among native and foreign-born people over a 17 year period (2004-2020) in a large province in Northern Italy.

Tuberculosis (TB) incidence should decline by 20% in the Europe in 2015-2020, in line with End-TB milestones. We retrospectively evaluated TB notifications in the province of Brescia from 2004 to 2020. Cases were classified per patient origin and entitlement to Health Assistance for foreign born people: Italians (ITA), Foreigners permanently entitled (PEF) or Temporarily Entitled (TEF) to Health Regional Assistance. Poisson regression analysis was performed to assess associations between incidence and age, sex, continent of origin and year of notification. Overall 2279 TB cases were notified: 1290 (56.6%) in PEF, 700 (30.7%) in ITA and 289 (12.7%) in TEF. Notifications declined from 15.2/100,000 in 2004 to 6.9/100,000 in 2020 (54.6% reduction, temporary increase in 2013-2018 for TEF). Age (Incidence Risk Ratio, IRR, 1.02, 1.019-1.024 95%CI), sex (IRR 1.22, 1.12-1.34 95%CI), and continent of origin were positively associated with notifications (IRR 34.8, 30.8-39.2 95%CI for Asiatic, and IRR 20.6, 18.1-23.4 95%CI for African origin), p < 0.001. Notification decline was sharper in 2020, especially among TEF. End-TB milestone for 2020 was reached, but foreigners continue to represent a high risk group for the disease. Discontinuation of services due to the COVID-19 pandemic was associated with a sharp decrease in TB notification in 2020.

Immigrant Communities and COVID-19: Strengthening the Public Health Response.

The COVID-19 pandemic has exposed the many broken fragments of US health care and social service systems, reinforcing extant health and socioeconomic inequities faced by structurally marginalized immigrant communities. Throughout the pandemic, even during the most critical period of rising cases in different epicenters, immigrants continued to work in high-risk-exposure environments while simultaneously having less access to health care and economic relief and facing discrimination. We describe systemic factors that have adversely affected low-income immigrants, including limiting their work opportunities to essential jobs, living in substandard housing conditions that do not allow for social distancing or space to safely isolate from others in the household, and policies that discourage access to public resources that are available to them or that make resources completely inaccessible. We demonstrate that the current public health infrastructure has not improved health care access or linkages to necessary services, treatments, or culturally competent health care providers, and we provide suggestions for how the Public Health 3.0 framework could advance this. We recommend the following strategies to improve the Public Health 3.0 public health infrastructure and mitigate widening disparities: (1) address the social determinants of health, (2) broaden engagement with stakeholders across multiple sectors, and (3) develop appropriate tools and technologies. (Am J Public Health. 2021;111(S3):S224-S231. https://doi.org/10.2105/AJPH.2021.306433).

Understanding the blended impacts of COVID-19 and systemic inequalities on sub-Saharan African immigrants in Canada.

The COVID-19 pandemic poses a grave health threat and has serious socio-economic implications for all. However, crises are not experienced equally; the pandemic has disproportionately affected immigrants in several countries, including Canada and the United States. The effects of COVID-19 have exposed the realities of societal and structural inequities, worsened the socio-economic status of many immigrants, and placed them at higher risks of poor health outcomes. Emerging research on COVID-19 and race in Canada addresses the structural inequities that shape the disproportionate harms of COVID-19 on immigrants. For sub-Saharan African immigrants, these inequities are worse due to the intersecting systems of race, gender, and class marginalization. They tend to be more exposed and less protected amid the pandemic. Given the lack of research on sub-Saharan African immigrants' experiences in Canada, this paper discusses how multiple axes of inequities shape their health and livelihood during COVID-19. The objective is to provide a broader scientific understanding of issues related to systemic inequities and health for sub-Saharan African immigrants in Canada and the related implications for public health advocates, policymakers, and the public.

RéSUMé: La pandémie de COVID-19 pose une grave menace pour la santé et a de graves conséquences socioéconomiques pour tous. Les crises ne touchent cependant pas tout le monde également; la pandémie a démesurément touché les immigrants dans plusieurs pays, entre autres au Canada et aux États-Unis. Les effets de la COVID-19 ont mis au jour la réalité des iniquités sociétales et structurelles, réduit le statut socioéconomique de nombreux immigrants et exposé ces immigrants à de plus grands risques de mauvais résultats cliniques. Des études émergentes sur la COVID-19 et la race au Canada abordent les iniquités structurelles qui déterminent les préjudices disproportionnés causés par la COVID-19 aux immigrants. Pour les immigrants d'Afrique subsaharienne, ces iniquités sont pires en raison de l'entrecroisement des systèmes de marginalisation fondés sur la race, le sexe et la classe sociale. Ces immigrants tendent à être plus exposés et moins protégés au milieu de la pandémie. Étant donné le manque d'études sur les expériences des immigrants d'Afrique subsaharienne au Canada, nous abordons ici l'influence des nombreux axes de l'iniquité sur leur santé et leurs moyens de subsistance durant la COVID-19. Notre objectif est de présenter une interprétation scientifique plus vaste des problèmes liés aux iniquités systémiques et à la santé chez les immigrants d'Afrique subsaharienne au Canada et des conséquences qui en découlent pour les défenseurs de la santé publique, les responsables des politiques et le grand public.

Provider and administrator-level perspectives on strategies to reduce fear and improve patient trust in the emergency department in times of heightened immigration enforcement.

STUDY OBJECTIVES: Heightened immigration enforcement may induce fear in undocumented patients when coming to the Emergency Department (ED) for care. Limited literature examining health system policies to reduce immigrant fear exists. In this multi-site qualitative study, we sought to assess provider and system-level policies on caring for undocumented patients in three California EDs. METHODS: We recruited 41 ED providers and administrators from three California EDs (in San Francisco, Oakland, and Sylmar) with large immigrant populations. Participants were recruited using a trusted gatekeeper and snowball sampling. We conducted semi-structured interviews and analyzed the transcripts using constructivist grounded theory. RESULTS: We interviewed 10 physicians, 11 nurses, 9 social workers, and 11 administrators, and identified 7 themes. Providers described existing policies and recent policy changes that facilitate access to care for undocumented patients. Providers reported that current training and communication around policies is limited, there are variations between who asks about and documents status, and there remains uncertainty around policy details, laws, and jurisdiction of staff. Providers also stated they are taking an active role in building safety and trust and see their role as supporting undocumented patients. CONCLUSIONS: This study introduces ED-level health system perspectives and recommendations for caring for undocumented patients. There is a need for active, multi-disciplinary ED policy training, clear policy details including the extent of providers' roles, protocols on the screening and documentation of status, and continual reassessment of our health systems to reduce fear and build safety and trust with our undocumented communities.

Differential mortality of infectious disease in Italian polities: COVID-19, past plague epidemics, and currently endemic respiratory disease.

Coronavirus disease 2019 (COVID-19) has harshly impacted Italy since its arrival in February 2020. In particular, provinces in Italy's Central and Northern macroregions have dealt with disproportionately greater case prevalence and mortality rates than those in the South. In this paper, we compare the morbidity and mortality dynamics of 16th and 17th century Plague outbreaks with those of the ongoing COVID-19 pandemic across Italian regions. We also include data on infectious respiratory diseases which are presently endemic to Italy in order to analyze the regional differences between epidemic and endemic disease. A Growth Curve Analysis allowed for the estimation of time-related intercepts and slopes across the 16th and 17th centuries. Those statistical parameters were later incorporated as criterion variables in multiple General Linear Models. These statistical examinations determined that the Northern macroregion had a higher intercept than the Southern macroregion. This indicated that provinces located in Northern Italy had historically experienced higher plague mortalities than Southern polities. The analyses also revealed that this geographical differential in morbidity and mortality persists to this day, as the Northern macroregion has experienced a substantially higher COVID-19 mortality than the Southern macroregion. These results are consistent with previously published analyses. The only other stable and significant predictor of epidemic disease mortality was foreign urban potential, a measure of the degree of interconnectedness between 16th and 17th century Italian cities. Foreign urban potential was negatively associated with plague slope and positively associated with plague intercept, COVID-19 mortality, GDP per capita, and immigration per capita. Its substantial contribution in predicting both past and present outcomes provides a temporal continuity not seen in any other measure tested here. Overall, this study provides compelling evidence that temporally stable geographical factors, impacting both historical and current foreign pathogen spread above and beyond other hypothesized predictors, underlie the disproportionate impact COVID-19 has had throughout Central and Northern Italian provinces.

Tuberculosis - United States, 2020.

Tuberculosis (TB) disease incidence has decreased steadily since 1993 (1), a result of decades of work by local TB programs to detect, treat, and prevent TB disease and transmission. During 2020, a total of 7,163 TB cases were provisionally reported to CDC's National Tuberculosis Surveillance System (NTSS) by the 50 U.S. states and the District of Columbia (DC), a relative reduction of 20%, compared with the number of cases reported during 2019.* TB incidence per 100,000 persons was 2.2 during 2020, compared with 2.7 during 2019. Since 2010, TB incidence has decreased by an average of 2%-3% annually (1). Pandemic mitigation efforts and reduced travel might have contributed to the reported decrease. The magnitude and breadth of the decrease suggest potentially missed or delayed TB diagnoses. Health care providers should consider TB disease when evaluating patients with signs and symptoms consistent with TB (e.g., cough of >2 weeks in duration, unintentional weight loss, and hemoptysis), especially when diagnostic tests are negative for SARS-CoV-2, the virus that causes COVID-19. In addition, members of the public should be encouraged to follow up with their health care providers for any respiratory illness that persists or returns after initial treatment. The steep, unexpected decline in TB cases raises concerns of missed cases, and further work is in progress to better understand factors associated with the decline.

Association between Preferred Language and Risk of Severe Acute Respiratory Syndrome Coronavirus 2 Infection in Children in the United States.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has had a disproportionate impact on Black, Hispanic, and other individuals of color, although data on the effect of a person's language on SARS-CoV-2 infection are limited. Considering the barriers suffered by immigrants and non-English-speaking families, we tested whether children with a preferred language other than English was associated with SARS-CoV-2 infection. Children from families with a preferred language other than English had a higher predicted probability of SARS-CoV-2 test positivity (adjusted odds ratio, 3.76; 95% CI, 2.07-6.67) during the first wave of the pandemic. This discrepancy continued into the second wave (adjusted odds ratio, 1.64; 95% CI, 1.10-2.41), although the difference compared with families who prefer to speak English decreased over time. These findings suggest that children from non-English-speaking families are at increased risk of SARS-CoV-2 infection, and efforts to reverse systemic inequities causing this increased risk are needed.

The pathways from perceived discrimination to self-rated health among the Chinese diaspora during the COVID-19 pandemic: investigation of the roles of depression, anxiety, and social support.

BACKGROUND: Research indicates the adverse impacts of perceived discrimination on health, and discrimination inflamed by the COVID-19 pandemic, a type of social exclusion, could affect the well-being of the Chinese diaspora. We analyzed the relationship and pathways of perceived discrimination's effect on health among the Chinese diaspora in the context of the pandemic to contribute to the literature on discrimination in this population under the global public health crisis. METHODS: We analyzed data from 705 individuals of Chinese descent residing in countries outside of China who participated in a cross-sectional online survey between April 22 and May 9, 2020. This study utilized a structural equation model (SEM) to evaluate both direct and indirect effects of perceived discrimination on self-rated health (SRH) and to assess the mediating roles of psychological distress (namely, anxiety and depression) and social support from family and friends. RESULTS: This online sample comprised predominantly young adults and those of relatively high socioeconomic status. This study confirmed the total and direct effect of recently perceived discrimination on SRH and found the indirect effect was mainly mediated by depression. Mediating roles of anxiety and social support on the discrimination-health relationship were found insignificant in this SEM. CONCLUSIONS: Our findings suggest discrimination negatively affected the well-being of the Chinese diaspora, and depression acted as a major mediator between the discrimination-health relationship. Therefore, interventions for reducing discrimination to preserve the well-being of the Chinese diaspora are necessary. Prompt intervention to address depression may partially relieve the disease burden caused by the surge of discrimination.

The onset of COVID-19, common identity, and intergroup prejudice.

The research presented here examined the relationship between the onset of the COVID-19 pandemic, social group identity, intergroup contact, and prejudice. Utilizing a common ingroup identity approach, two datasets, which were composed of data from university students collected via online questionnaires before and after the onset of COVID-19, were combined (N = 511). Participants identified as either one of two subordinate student identities: domestic (i.e. U.S. citizen or permanent resident) or international (i.e. non-U.S. citizen or foreign resident), then reported on the strength of their subordinate and superordinate identity (university identity). Participants also reported on their contact experiences with outgroup members, outgroup stereotypes, and completed a novel intergroup bias task. Results indicated that after the onset of the pandemic, participants more strongly identified with the superordinate group, which predicted greater perceived intergroup contact and lower intergroup bias. Theoretical implications and future directions are discussed.

Spatial clustering and temporal trend analysis of international migrants diagnosed with tuberculosis in Brazil.

BACKGROUND: Tuberculosis (TB) in migrants is of concern to health authorities worldwide and is even more critical in Brazil, considering the country´s size and long land borders. The aim of the study was to identify critical areas in Brazil for migrants diagnosed with TB and to describe the temporal trend in this phenomenon in recent years. METHODS: This is an ecological study that used spatial analysis and time series analysis. As the study population, all cases of migrants diagnosed with TB from 2014 to 2019 were included, and Brazilian municipalities were considered as the unit of ecological analysis. The Getis-Ord Gi* technique was applied to identify critical areas, and based on the identified clusters, seasonal-trend decomposition based on loess (STL) and Prais-Winsten autoregression were used, respectively, to trace and classify temporal trend in the analyzed series. In addition, several municipal socioeconomic indicators were selected to verify the association between the identified clusters and social vulnerability. RESULTS: 2,471 TB cases were reported in migrants. Gi* analysis showed that areas with spatial association with TB in immigrants coincide with critical areas for TB in the general population (coast of the Southeast and North regions). Four TB clusters were identified in immigrants in the states of Amazonas, Roraima, São Paulo, and Rio de Janeiro, with an upward trend in most of these clusters. The temporal trend in TB in immigrants was classified as increasing in Brazil (+ 60.66% per year [95% CI: 27.21-91.85]) and in the clusters in the states of Amazonas, Roraima, and Rio de Janeiro (+1.01, +2.15, and + 2.90% per year, respectively). The cluster in the state of São Paulo was the only one classified as stationary. The descriptive data on the municipalities belonging to the clusters showed evidence of the association between TB incidence and conditions of social vulnerability. CONCLUSIONS: The study revealed the critical situation of TB among migrants in the country. Based on the findings, health authorities might focus on actions in regions identified, stablishing an intensive monitoring and following up, ensuring that these cases concluded their treatment and avoiding that they could spread the disease to the other regions or scenarios. The population of migrants are very dynamic, therefore strategies for following up them across Brazil are really urgent to manage the tuberculosis among international migrants in an efficient and proper way.

Exploring the role of non-pharmaceutical interventions (NPIs) in flattening the Greek COVID-19 epidemic curve.

Due to the COVID-19 pandemic originating in China in December 2019, apart from the grave concerns on the exponentially increasing casualties, the affected countries are called to deal with severe repercussions in all aspects of everyday life, from economic recession to national and international movement restrictions. Several regions managed to handle the pandemic more successfully than others in terms of life loss, while ongoing heated debates as to the right course of action for battling COVID-19 have divided the academic community as well as public opinion. To this direction, in this paper, an autoregressive COVID-19 prediction model with heterogeneous explanatory variables for Greece is proposed, taking past COVID-19 data, non-pharmaceutical interventions (NPIs), and Google query data as independent variables, from the day of the first confirmed case-February 26th-to the day before the announcement for the quarantine measures' softening-April 24th. The analysis indicates that the early measures taken by the Greek officials positively affected the flattening of the epidemic curve, with Greece having recorded significantly decreased COVID-19 casualties per million population and managing to stay on the low side of the deaths over cases spectrum. In specific, the prediction model identifies the 7-day lag that is needed in order for the measures' results to actually show, i.e., the optimal time-intervention framework for managing the disease's spread, while our analysis also indicates an appropriate point during the disease spread where restrictive measures should be applied. Present results have significant implications for effective policy making and in the designing of the NPIs, as the second wave of COVID-19 is expected in fall 2020, and such multidisciplinary analyses are crucial in order to understand the evolution of the Daily Deaths to Daily Cases ratio along with its determinants as soon as possible, for the assessment of the respective domestic health authorities' policy interventions as well as for the timely health resources allocation.

Health-seeking behaviour of foreign workers in Singapore: Insights from emergency department visits.

INTRODUCTION: Foreign workers (FWs) on work permit face unique health challenges and potential barriers to healthcare. We aimed to examine the epidemiology, attendance patterns, disposition, and adherence to follow-up, by FWs on work permit to two emergency departments (EDs) in Singapore. METHODS: In this retrospective observational study, we included consecutive FWs on work permit who registered at the EDs of two public restructured hospitals from 1 May 2016 to 31 October 2016. Data obtained from electronic medical records included patient demographics, triage acuity, disposition, ED diagnoses and bill information. RESULTS: There were 6,429 individual FWs on work permit who contributed to 7,157 ED visits over the 6-month study period, with male predominance (72.7%, 4672/6429), and median age of 31 (interquartile range 26 to 38) years. A high proportion of these FWs were triaged to low-acuity status compared to the general ED population (66.9% versus 45.9%, P<0.001). Trauma-related injuries contributed to 34.4% of their visits, and were more likely to result in admission compared to non-trauma-related conditions (18.7% vs 15.2%, P<0.001). FWs engaged in shipyard, construction and process industries were more likely to be discharged "against medical advice" (14.8% vs 3.2%, P<0.001), and default their specialist outpatient follow-up (50.1% vs 34.2%, P<0.001) for non-trauma-related conditions compared to trauma-related injuries. CONCLUSION: In Singapore, the EDs of public restructured hospitals provide healthcare safety nets to FWs on work permit. These workers made more low-acuity visits compared to the general population during the study period and may face potential barriers to admission and follow-up.

Time for Inclusion of Racial and Gender Discrimination in Routine Clinical Assessment.

Recently, there has been an increasing amount of scientific interest towards the broad theme of racial inequalities and their impact on human health, specifically exploring how ethnic discrimination affects the wellness of black people and the COVID-19 pandemic. Some of these conditions of inequity also affect black children. Discrimination and racism should be routinely considered as causative agents or triggers of disease and routinely included in clinical examination, during history collection and evaluation of vital signs. This will benefit child and family health, worldwide. We shared our recent experience by reporting a case of a 13-year-old black girl who came to Italy from Niger about 3 years earlier through the traumatizing migratory journey. She was evaluated in the Pediatric Emergency Department (PED) for sleepiness that had progressively worsened during the last days. We describe the case and how it was handled differently by pediatricians and pediatric trainees with equally different personal and professional backgrounds.We also report the preliminary results of a national survey aimed to assess discrimination and inequalities in Italian Paediatric Residency Schools. Medical ability has been allowing us to respond rapidly to a novel virus in order to save lives. The expertise of doctors and researchers must be used to evaluate this hidden crisis as well, to address racism and injustice and to protect vulnerable people from harm. Our case showed us how it is essential including racial and gender discrimination in a diagnostic process.

Deterioration of mental health and insufficient Covid-19 information among disadvantaged immigrants in the greater Paris area.

OBJECTIVES: The aim of this study is to provide information on changes in mental health among disadvantaged immigrants from Sub-Saharan Africa in the Greater Paris area and their level of information about Covid-19. METHODS: Prior to the Covid-19 epidemic, the Makasi community-based cohort followed 850 immigrants from sub-Saharan Africa in the Greater Paris area. Between the 1st of April and the 7th of June 2020, all participants scheduled for a follow-up survey were systematically included into an additional COVID-19-related wave of data collection (N = 100). We compared participants' type of housing, level of food insecurity, work and mental health (PHQ9) before and during the first COVID-19-related lockdown, using paired-Mc Nemar chi-2 tests. We next described their level of information on Covid-19 and policy measures, broken down by sex. RESULTS: Among the 100 participants, 68% had no legal residence permit. Food insecurity was more often reported during lockdown than before (62% vs 52%). 9% of participants had a score indicative of severe depression (PHQ9) before lockdown and 17% afterwards (p = 0.17). Only 51% knew about the possibility of asymptomatic transmission of the COVID-19 virus. CONCLUSIONS: This study brings original information on a hard-to-reach population group. Our results suggest that the lockdown had a detrimental impact on various economic and mental health aspects among disadvantaged migrants residing in the Greater Paris area.

COVID-19 among immigrants in Norway, notified infections, related hospitalizations and associated mortality: A register-based study.

Aim: Research concerning COVID-19 among immigrants is limited. We present epidemiological data for all notified cases of COVID-19 among the 17 largest immigrant groups in Norway, and related hospitalizations and mortality. Methods: We used data on all notified COVID-19 cases in Norway up to 18 October 2020, and associated hospitalizations and mortality, from the emergency preparedness register (including Norwegian Surveillance System for Communicable Diseases) set up by The Norwegian Institute of Public Health to handle the pandemic. We report numbers and rates per 100,000 people for notified COVID-19 cases, and related hospitalizations and mortality in the 17 largest immigrant groups in Norway, crude and with age adjustment. Results: The notification, hospitalization and mortality rates per 100,000 were 251, 21 and five, respectively, for non-immigrants; 567, 62 and four among immigrants; 408, 27 and two, respectively, for immigrants from Europe, North-America and Oceania; and 773, 106 and six, respectively for immigrants from Africa, Asia and South America. The notification rate was highest among immigrants from Somalia (2057), Pakistan (1868) and Iraq (1616). Differences between immigrants and non-immigrants increased when adjusting for age, especially for mortality. Immigrants had a high number of hospitalizations relative to notified cases compared to non-immigrants. Although the overall COVID-19 notification rate was higher in Oslo than outside of Oslo, the notification rate among immigrants compared to non-immigrants was not higher in Oslo than outside. Conclusions: We observed a higher COVID-19 notification rate in immigrants compared to non-immigrants and much higher hospitalization rate, with major differences between different immigrant groups. Somali-, Pakistani- and Iraqi-born immigrants had especially high rates.