Racial/Ethnic Segregation and Access to COVID-19 Testing: Spatial Distribution of COVID-19 Testing Sites in the Four Largest Highly Segregated Cities in the United States.

Objectives. To quantify the relationship between the segregation of Black, Indigenous, and Latinx communities and COVID-19 testing sites in populous US cities. Methods. We mapped testing sites as of June 2020 in New York City; Chicago, Illinois; Los Angeles, California; and Houston, Texas; we applied Bayesian methods to estimate the association between testing site location and the proportion of the population that is Black, Latinx, or Indigenous per block group, the smallest unit for which the US Census collects sociodemographic data. Results. In New York City, Chicago, and Houston, the expected number of testing sites decreased by 1.29%, 3.05%, and 1.06%, respectively, for each percentage point increase in the Black population. In Chicago, Houston, and Los Angeles, testing sites decreased by 5.64%, 1.95%, and 1.69%, respectively, for each percentage point increase in the Latinx population. Conclusions. In the largest highly segregated US cities, neighborhoods with more Black and Latinx residents had fewer COVID-19 testing sites, likely limiting these communities' participation in the early response to COVID-19. Public Health Implications. In light of conversations on the ethics of racial vaccine prioritization, authorities should consider structural barriers to COVID-19 control efforts. (Am J Public Health. 2022;112(3):518-526. https://doi.org/10.2105/AJPH.2021.306558).

Race and ethnic minority, local pollution, and COVID-19 deaths in Texas.

The costs of COVID-19 are extensive, and, like the fallout of most health and environmental crises in the US, there is growing evidence that these costs weigh disproportionately on communities of color. We investigated whether county-level racial composition and fine particulate pollution (PM2.5) are indicators for COVID-19 incidence and death rates in the state of Texas. Using county-level data, we ran linear regressions of percent minority as well as historic 2000-2016 PM2.5 levels against COVID-19 cases and deaths per capita. We found that a county's percent minority racial composition, defined as the percentage of population that identifies as Black or Hispanic, highly correlates with COVID-19 case and death rates. Using Value-of-Statistical-Life calculations, we found that economic costs from COVID-19 deaths fall more heavily on Black and Hispanic residents in Harris County, the most populous county in Texas. We found no consistent evidence or significant correlations between historic county-average PM2.5 concentration and COVID-19 incidence or death. Our findings suggest that public health and economic aid policy should consider the racially-segregated burden of disease to better mitigate costs and support equity for the duration and aftermath of health crises.

Racial and Ethnic Disparities in Receipt of Medications for Treatment of COVID-19 - United States, March 2020-August 2021.

The COVID-19 pandemic has magnified longstanding health care and social inequities, resulting in disproportionately high COVID-19-associated illness and death among members of racial and ethnic minority groups (1). Equitable use of effective medications (2) could reduce disparities in these severe outcomes (3). Monoclonal antibody (mAb) therapies against SARS-CoV-2, the virus that causes COVID-19, initially received Emergency Use Authorization (EUA) from the Food and Drug Administration (FDA) in November 2020. mAbs are typically administered in an outpatient setting via intravenous infusion or subcutaneous injection and can prevent progression of COVID-19 if given after a positive SARS-CoV-2 test result or for postexposure prophylaxis in patients at high risk for severe illness.† Dexamethasone, a commonly used steroid, and remdesivir, an antiviral drug that received EUA from FDA in May 2020, are used in inpatient settings and help prevent COVID-19 progression§ (2). No large-scale studies have yet examined the use of mAb by race and ethnicity. Using COVID-19 patient electronic health record data from 41 U.S. health care systems that participated in the PCORnet, the National Patient-Centered Clinical Research Network,¶ this study assessed receipt of medications for COVID-19 treatment by race (White, Black, Asian, and Other races [including American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, and multiple or Other races]) and ethnicity (Hispanic or non-Hispanic). Relative disparities in mAb** treatment among all patients†† (805,276) with a positive SARS-CoV-2 test result and in dexamethasone and remdesivir treatment among inpatients§§ (120,204) with a positive SARS-CoV-2 test result were calculated. Among all patients with positive SARS-CoV-2 test results, the overall use of mAb was infrequent, with mean monthly use at 4% or less for all racial and ethnic groups. Hispanic patients received mAb 58% less often than did non-Hispanic patients, and Black, Asian, or Other race patients received mAb 22%, 48%, and 47% less often, respectively, than did White patients during November 2020-August 2021. Among inpatients, disparities were different and of lesser magnitude: Hispanic inpatients received dexamethasone 6% less often than did non-Hispanic inpatients, and Black inpatients received remdesivir 9% more often than did White inpatients. Vaccines and preventive measures are the best defense against infection; use of COVID-19 medications postexposure or postinfection can reduce morbidity and mortality and relieve strain on hospitals but are not a substitute for COVID-19 vaccination. Public health policies and programs centered around the specific needs of communities can promote health equity (4). Equitable receipt of outpatient treatments, such as mAb and antiviral medications, and implementation of prevention practices are essential to reducing existing racial and ethnic inequities in severe COVID-19-associated illness and death.

Measuring the COVID-19 Mortality Burden in the United States : A Microsimulation Study.

BACKGROUND: Fully assessing the mortality burden of the COVID-19 pandemic requires measuring years of life lost (YLLs) and accounting for quality-of-life differences. OBJECTIVE: To measure YLLs and quality-adjusted life-years (QALYs) lost from the COVID-19 pandemic, by age, sex, race/ethnicity, and comorbidity. DESIGN: State-transition microsimulation model. DATA SOURCES: Health and Retirement Study, Panel Study of Income Dynamics, data on excess deaths from the Centers for Disease Control and Prevention, and nursing home death counts from the Centers for Medicare & Medicaid Services. TARGET POPULATION: U.S. population aged 25 years and older. TIME HORIZON: Lifetime. PERSPECTIVE: Individual. INTERVENTION: COVID-19 pandemic through 13 March 2021. OUTCOME MEASURES: YLLs and QALYs lost per 10 000 persons in the population. The estimates account for the age, sex, and race/ethnicity of decedents, along with obesity, smoking behavior, lung disease, heart disease, diabetes, cancer, stroke, hypertension, dementia, and nursing home residence. RESULTS OF BASE-CASE ANALYSIS: The COVID-19 pandemic resulted in 6.62 million QALYs lost (9.08 million YLLs) through 13 March 2021, with 3.6 million (54%) lost by those aged 25 to 64 years. The greatest toll was on Black and Hispanic communities, especially among men aged 65 years or older, who lost 1138 and 1371 QALYs, respectively, per 10 000 persons. Absent the pandemic, 38% of decedents would have had average or above-average life expectancies for their subgroup defined by age, sex, and race/ethnicity. RESULTS OF SENSITIVITY ANALYSIS: Accounting for uncertainty in risk factors for death from COVID-19 yielded similar results. LIMITATION: Estimates may vary depending on assumptions about mortality and quality-of-life projections. CONCLUSION: Beyond excess deaths alone, the COVID-19 pandemic imposed a greater life expectancy burden on persons aged 25 to 64 years, including those with average or above-average life expectancies, and a disproportionate burden on Black and Hispanic communities. PRIMARY FUNDING SOURCE: National Institute on Aging.

Disaggregating Asian Race Reveals COVID-19 Disparities Among Asian American Patients at New York City's Public Hospital System.

OBJECTIVES: Data on the health burden of COVID-19 among Asian American people of various ethnic subgroups remain limited. We examined COVID-19 outcomes of people of various Asian ethnic subgroups and other racial and ethnic groups in an urban safety net hospital system. METHODS: We conducted a retrospective analysis of 85 328 adults aged ≥18 tested for COVID-19 at New York City's public hospital system from March 1 through May 31, 2020. We examined COVID-19 positivity, hospitalization, and mortality, as well as demographic characteristics and comorbidities known to worsen COVID-19 outcomes. We conducted adjusted multivariable regression analyses examining racial and ethnic disparities in mortality. RESULTS: Of 9971 Asian patients (11.7% of patients overall), 48.2% were South Asian, 22.2% were Chinese, and 29.6% were in other Asian ethnic groups. South Asian patients had the highest rates of COVID-19 positivity (30.8%) and hospitalization (51.6%) among Asian patients, second overall only to Hispanic (32.1% and 45.8%, respectively) and non-Hispanic Black (27.5% and 57.5%, respectively) patients. Chinese patients had a mortality rate of 35.7%, highest of all racial and ethnic groups. After adjusting for demographic characteristics and comorbidities, only Chinese patients had significantly higher odds of mortality than non-Hispanic White patients (odds ratio = 1.44; 95% CI, 1.04-2.01). CONCLUSIONS: Asian American people, particularly those of South Asian and Chinese descent, bear a substantial and disproportionate health burden of COVID-19. These findings underscore the need for improved data collection and reporting and public health efforts to mitigate disparities in COVID-19 morbidity and mortality among these groups.

Variation in COVID-19 Mortality in the US by Race and Ethnicity and Educational Attainment.

Importance: Racial and ethnic inequities in COVID-19 mortality have been well documented, but little prior research has assessed the combined roles of race and ethnicity and educational attainment. Objective: To measure inequality in COVID-19 mortality jointly by race and ethnicity and educational attainment. Design, Setting, and Participants: This cross-sectional study analyzed data on COVID-19 mortality from the 50 US states and the District of Columbia for the full calendar year 2020. It included all persons in the United States aged 25 years or older and analyzed them in subgroups jointly stratified by age, sex, race and ethnicity, and educational attainment. Main Outcomes and Measures: Population-based cumulative mortality rates attributed to COVID-19.F. Results: Among 219.1 million adults aged 25 years or older (113.3 million women [51.7%]; mean [SD] age, 51.3 [16.8] years), 376 125 COVID-19 deaths were reported. Age-adjusted cumulative mortality rates per 100 000 ranged from 54.4 (95% CI, 49.8-59.0 per 100 000 population) among Asian women with some college to 699.0 (95% CI, 612.9-785.0 per 100 000 population) among Native Hawaiian and Other Pacific Islander men with a high school degree or less. Racial and ethnic inequalities in COVID-19 mortality rates remained when comparing within educational attainment categories (median rate ratio reduction, 17% [IQR, 0%-25%] for education-stratified estimates vs unstratified, with non-Hispanic White individuals as the reference). If all groups had experienced the same mortality rates as college-educated non-Hispanic White individuals, there would have been 48% fewer COVID-19 deaths among adults aged 25 years or older overall, including 71% fewer deaths among racial and ethnic minority populations and 89% fewer deaths among racial and ethnic minority populations aged 25 to 64 years. Conclusions and Relevance: Public health research and practice should attend to the ways in which populations that share socioeconomic characteristics may still experience racial and ethnic inequity in the distribution of risk factors for SARS-CoV-2 exposure and infection fatality rates (eg, housing, occupation, and prior health status). This study suggests that a majority of deaths among racial and ethnic minority populations could have been averted had all groups experienced the same mortality rate as college-educated non-Hispanic White individuals, thus highlighting the importance of eliminating joint racial-socioeconomic health inequities.

County-Level Social Determinants of Health and COVID-19 in Nursing Homes, United States, June 1, 2020-January 31, 2021.

OBJECTIVES: Nursing homes are a primary setting of COVID-19 transmission and death, but research has primarily focused only on factors within nursing homes. We investigated the relationship between US nursing home-associated COVID-19 infection rates and county-level and nursing home attributes. METHODS: We constructed panel data from the Centers for Medicare & Medicaid Services (CMS) minimum dataset, CMS nursing home data, 2010 US Census data, 5-year (2012-2016) American Community Survey estimates, and county COVID-19 infection rates. We analyzed COVID-19 data from June 1, 2020, through January 31, 2021, during 7 five-week periods. We used a maximum likelihood estimator, including an autoregressive term, to estimate effects and changes over time. We performed 3 model forms (basic, partial, and full) for analysis. RESULTS: Nursing homes with nursing (0.005) and staff (0.002) shortages had high COVID-19 infection rates, and locally owned (-0.007) or state-owned (-0.025) and nonprofit (-0.011) agencies had lower COVID-19 infection rates than privately owned agencies. County-level COVID-19 infection rates corresponded with COVID-19 infection rates in nursing homes. Racial and ethnic minority groups had high nursing home-associated COVID-19 infection rates early in the study. High median annual personal income (-0.002) at the county level correlated with lower nursing home-associated COVID-19 infection rates. CONCLUSIONS: Communities with low rates of nursing home infections had access to more resources (eg, financial resources, staffing) and likely had better mitigation efforts in place earlier in the pandemic than nursing homes that had access to few resources and poor mitigation efforts. Future research should address the social and structural determinants of health that are leaving racial and ethnic minority populations and institutions such as nursing homes vulnerable during times of crises.

Racial and Ethnic Disparities in Excess Deaths During the COVID-19 Pandemic, March to December 2020.

BACKGROUND: Although racial/ethnic disparities in U.S. COVID-19 death rates are striking, focusing on COVID-19 deaths alone may underestimate the true effect of the pandemic on disparities. Excess death estimates capture deaths both directly and indirectly caused by COVID-19. OBJECTIVE: To estimate U.S. excess deaths by racial/ethnic group. DESIGN: Surveillance study. SETTING: United States. PARTICIPANTS: All decedents. MEASUREMENTS: Excess deaths and excess deaths per 100 000 persons from March to December 2020 were estimated by race/ethnicity, sex, age group, and cause of death, using provisional death certificate data from the Centers for Disease Control and Prevention (CDC) and U.S. Census Bureau population estimates. RESULTS: An estimated 2.88 million deaths occurred between March and December 2020. Compared with the number of expected deaths based on 2019 data, 477 200 excess deaths occurred during this period, with 74% attributed to COVID-19. Age-standardized excess deaths per 100 000 persons among Black, American Indian/Alaska Native (AI/AN), and Latino males and females were more than double those in White and Asian males and females. Non-COVID-19 excess deaths also disproportionately affected Black, AI/AN, and Latino persons. Compared with White males and females, non-COVID-19 excess deaths per 100 000 persons were 2 to 4 times higher in Black, AI/AN, and Latino males and females, including deaths due to diabetes, heart disease, cerebrovascular disease, and Alzheimer disease. Excess deaths in 2020 resulted in substantial widening of racial/ethnic disparities in all-cause mortality from 2019 to 2020. LIMITATIONS: Completeness and availability of provisional CDC data; no estimates of precision around results. CONCLUSION: There were profound racial/ethnic disparities in excess deaths in the United States in 2020 during the COVID-19 pandemic, resulting in rapid increases in racial/ethnic disparities in all-cause mortality between 2019 and 2020. PRIMARY FUNDING SOURCE: National Institutes of Health Intramural Research Program.

Association between first language and SARS-CoV-2 infection rates, hospitalization, intensive care admissions and death in Finland: a population-based observational cohort study.

OBJECTIVES: Motivated by reports of increased risk of coronavirus disease 2019 (COVID-19) in ethnic minorities of high-income countries, we explored whether patients with a foreign first language are at an increased risk of COVID-19 infections, more serious presentations, or worse outcomes. METHODS: In a retrospective observational population-based quality registry study covering a population of 1.7 million, we studied the incidence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), admissions to specialist healthcare and the intensive care unit (ICU), and all-cause case fatality in different language groups between 27th February and 3rd August 2020 in Southern Finland. A first language other than Finnish, Swedish or Sámi served as a surrogate marker for a foreign ethnic background. RESULTS: In total, 124 240 individuals were tested, and among the 118 300 (95%) whose first language could be determined, 4005 (3.4%) were COVID-19-positive, 623 (0.5%) were admitted to specialized hospitals, and 147 (0.1%) were admitted to the ICU; 254 (0.2%) died. Those with a foreign first language had lower testing rates (348, 95%CI 340-355 versus 758, 95%CI 753-762 per 10 000, p < 0.0001), higher incidence (36, 95%CI 33-38 versus 22, 95%CI 21-23 per 10 000, p < 0.0001), and higher positivity rates (103, 95%CI 96-109 versus 29, 95%CI 28-30 per 1000, p < 0.0001). There was no significant difference in ICU admissions, disease severity at ICU admission, or ICU outcomes. Case fatality by 90 days was 7.7% in domestic cases and 1.2% in those with a foreign first language, explained by demographics (age- and sex-adjusted HR 0.49, 95%CI 0.21-1.15). CONCLUSIONS: The population with a foreign first language was at an increased risk for testing positive for SARS-CoV-2, but when hospitalized they had outcomes similar to those in the native, domestic language population. This suggests that special attention should be paid to the prevention and control of infectious diseases among language minorities.

Socioeconomic and Demographic Disparities in the Use of Telemedicine for Ophthalmic Care during the COVID-19 Pandemic.

PURPOSE: To identify disparities in the use of telemedicine during the coronavirus disease 2019 (COVID-19) pandemic. DESIGN: A cross-sectional study of completed clinical encounters in an academic ophthalmology center from March 2020 through August 2020. PARTICIPANTS: A total of 5023 patients comprising 8116 ophthalmic clinical encounters. METHODS: Medical charts were abstracted for demographic information. We identified zip code-level socioeconomic characteristics, which were drawn from the 2019 American Community Survey 5-year estimates. MAIN OUTCOME MEASURES: The completion of a synchronous video encounter, the completion of a telephone (audio-only) encounter in the absence of any video encounters, or the completion of in-person encounters only. RESULTS: During the study period, 8116 total clinical encounters were completed for 5023 unique patients. Of these patients, 446 (8.9%) participated in a video encounter, 642 (12.8%) completed a telephone encounter, and 3935 (78.3%) attended clinical appointments in person only. In adjusted analysis, patients who were Black (odds ratio [OR], 0.65; 95% confidence interval [CI], 0.52-0.80; P < 0.001) or Hispanic/Latino (OR, 0.65; 95% CI, 0.49-0.85; P = 0.002) were significantly less likely to complete a video or telephone appointment. Older patients (OR, 0.99; 95% CI, 0.98-0.99; P < 0.001), patients whose primary language was not English (OR, 0.49; 95% CI, 0.28-0.82; P = 0.01), Black patients (OR, 0.45; 95% CI, 0.32-0.62; P < 0.001), and Hispanic/Latino patients (OR, 0.56; 95% CI, 0.37-0.83; P = 0.005) were significantly less likely to complete a video encounter. Finally, among patients completing any type of telemedicine encounter, older age, (OR, 1.02; 95% CI, 1.01-1.03; P < 0.001), Medicare insurance (OR, 1.55; 95% CI, 1.11-2.17; P = 0.01), and Black race (OR, 1.97; 95% CI, 1.33-2.94; P < 0.001) were associated with using only phone visits. CONCLUSIONS: Ethnic/racial minorities, older patients, and non-English-speaking individuals were significantly less likely to complete a video telehealth encounter. With the expansion of telemedicine and the need to reduce the disparate impact of COVID-19 on minorities, it will be increasingly important to identify barriers to telehealth use and opportunities to improve access.