Patient-Centered Care Through Nurse Practitioner-Led Integrated Behavioral Health: A Case Study.

Integrated behavioral health can improve primary care and mental health outcomes. Access to behavioral health and primary care services in Texas is in crisis because of high uninsurance rates, regulatory restrictions, and lack of workforce. To address gaps in access to care, a partnership formed among a large local mental health authority in central Texas, a federally designated rural health clinic, and the Texas A&M University School of Nursing to create an interprofessional team-based health care delivery model led by nurse practitioners in rural and medically underserved areas of central Texas. Academic-practice partners identified 5 clinics for an integrated behavioral health care delivery model. From July 1, 2020, through December 31, 2021, a total of 3183 patient visits were completed. Patients were predominantly female (n = 1719, 54%) and Hispanic (n = 1750, 55%); 1050 (33%) were living at or below the federal poverty level; and 1400 (44%) were uninsured. The purpose of this case study was to describe the first year of implementation of the integrated health care delivery model, barriers to implementation, challenges to sustainability, and successes. We analyzed data from multiple sources, including meeting minutes and agendas, grant reports, direct observations of clinic flow, and interviews with clinic staff, and identified common qualitative themes (eg, challenges to integration, sustainability of integration, outcome successes). Results revealed implementation challenges with the electronic health record, service integration, low staffing levels during a global pandemic, and effective communication. We also examined 2 patient cases to illustrate the success of integrated behavioral health and highlighted lessons learned from the implementation process, including the need for a robust electronic health record and organizational flexibility.

The Most Vulnerable Hispanic Immigrants in New York City: Structural Racism and Gendered Differences in COVID-19 Deaths.

This paper explores the structural and group-specific factors explaining the excess death rates experienced by the Hispanic population in New York City during the peak years of the coronavirus pandemic. Neighborhood-level analysis of Census data allows an exploration of the relation between Hispanic COVID-19 deaths and spatial concentration, conceived in this study as a proxy for structural racism. This analysis also provides a more detailed exploration of the role of gender in understanding the effects of spatial segregation among different Hispanic subgroups, as gender has emerged as a significant variable in explaining the structural and social effects of COVID-19. Our results show a positive correlation between COVID-19 death rates and the share of Hispanic neighborhood residents. However, for men, this correlation cannot be explained by the characteristics of the neighborhood, as it is for women. In sum, we find: (a) differences in mortality risks between Hispanic men and women; (b) that weathering effects increase mortality risks the longer Hispanic immigrant groups reside in the U.S.; (c) that Hispanic males experience greater contagion and mortality risks associated with the workplace; and (d) we find evidence corroborating the importance of access to health insurance and citizenship status in reducing mortality risks. The findings propose revisiting the Hispanic health paradox with the use of structural racism and gendered frameworks.

A virtual pilot optimization trial for African American/Black and Latino persons with non-suppressed HIV viral load grounded in motivational interviewing and behavioral economics.

Introduction: Virtual and low-touch behavioral interventions are needed for African American/Black and Latino persons living with HIV (PLWH) with barriers to HIV viral suppression, particularly during COVID-19. Guided by the multiphase optimization strategy, we explored three components for PLWH without viral suppression, grounded in motivational interviewing and behavioral economics: (1) motivational interviewing counseling, (2) 21-weeks of automated text messages and quiz questions about HIV management, and (3) financial rewards for viral suppression (lottery prize vs. fixed compensation). Methods: This pilot optimization trial used sequential explanatory mixed methods to explore the components' feasibility, acceptability, and preliminary evidence of effects using an efficient factorial design. The primary outcome was viral suppression. Participants engaged in baseline and two structured follow-up assessments over an 8-month period, and provided laboratory reports to document HIV viral load. A subset engaged in qualitative interviews. We carried out descriptive quantitative analyses. Then, qualitative data were analyzed using directed content analysis. Data integration used the joint display method. Results: Participants (N = 80) were 49 years old, on average (SD = 9), and 75% were assigned male sex at birth. Most (79%) were African American/Black, and the remainder were Latino. Participants were diagnosed with HIV 20 years previously on average (SD = 9). Overall, components were feasible (>80% attended) and acceptability was satisfactory. A total of 39% (26/66) who provided laboratory reports at follow-up evidenced viral suppression. Findings suggested no components were entirely unsuccessful. The lottery prize compared to fixed compensation was the most promising component level. In qualitative analyses, all components were seen as beneficial to individual wellbeing. The lottery prize appeared more interesting and engaging than fixed compensation. However, structural barriers including financial hardship interfered with abilities to reach viral suppression. The integrated analyses yielded areas of convergence and discrepancy and qualitative findings added depth and context to the quantitative results. Conclusions: The virtual and/or low-touch behavioral intervention components tested are acceptable and feasible and show enough potential to warrant refinement and testing in future research, particularly the lottery prize. Results must be interpreted in the context of the COVID-19 pandemic. Trial registration: NCT04518241 (https://clinicaltrials.gov/ct2/show/NCT04518241).

Predictors of Alcohol Use Among Latinx Men in South Florida: Machismo as a Correlate of Alcohol Use Frequency and Quantity.

Previous studies have found Latinx cultural values to be positively associated with healthy behaviors. This study aims to examine socioeconomic and cultural correlates of alcohol use among Latinx adult men living in Miami-Dade County, Florida. The study sample included 122 Latinx adult men (mean age = 44, SD = 10), predominantly of South and Central American origin. Data was collected using REDCap. Interviews included the Timeline Follow-Back scale for alcohol use. Results indicate that Caribbean participants were significantly less likely to report drinking in the past 90 days (aOR = 0.08, p = 0.042) compared to their Venezuelan counterparts. Higher machismo scores were associated with low drinking frequency (aRR = 0.67, p = 0.043), while no significant associations were found between machismo and other drinking outcomes. Drinking quantity and frequency are significantly associated with higher income and authorized immigration status in the US among Latinx men in South Florida. Higher machismo scores were associated with low drinking frequency.

Implementation of a brief online skills group of dialectical behaviour therapy for emotional dysregulation in Latinx: a withdrawal experimental single-case design.

BACKGROUND: Dialectical behaviour therapy (DBT) skills groups have shown promise as an effective treatment for clients with emotional dysregulation, especially when combined with individual DBT. However, their efficacy is not well established as an online therapy, or in the Latinx population. AIMS: This study aimed to explore satisfaction, retention and effects of an internet-based DBT group added to individual online sessions. METHOD: An ABAB withdrawal experimental single-case design was conducted to evaluate the effect of a brief online DBT skills group on emotional dysregulation, anxiety and depression for five Latinx participants. DBT skills group (phase B) were compared with placebo group sessions (phase A) and fortnightly individual DBT sessions were offered throughout to manage risk. RESULTS: Visual inspection showed a decrease in level of emotional dysregulation and a large effect size according to the Nonoverlap of All Pairs when comparing group DBT and placebo phases. Although depression symptoms decreased after introducing group DBT, anxiety indicators decreased most during the second round of group placebo sessions. DISCUSSION: Whilst only a pilot, this study suggests that online group DBT in Latinx populations is feasible and effective for changing emotional regulation processes but may not effectively target anxiety. Future research might increase the number of DBT sessions in order to enhance learning opportunities and generalization. Replication with larger sample sizes and diverse modalities is needed.

Understanding the Barriers to COVID-19 Vaccine Among Hispanic/Latinx Communities.

OBJECTIVE: COVID-19 disproportionally affected Hispanic/Latinx populations exacerbating systemic health inequities. The pilot study aimed to explore barriers to COVID-19 vaccination across Hispanic/Latinx communities in Southern California. METHODS: Cross-sectional survey of 200 participants to identify common barriers to vaccine hesitancy among Hispanics/Latinx individuals in Southern California utilizing a 14-item survey and questionnaire in English and Spanish. RESULTS: Of the 200 participants that completed questionnaires, 37% identified a knowledge deficit, 8% identified misinformation, and 15% identified additional barriers such as awaiting appointments, immigration status, transportation issues, or religious reasons as barriers to not receiving the COVID-19 vaccine. Wald statistics denoted that household members with COVID-19 infection within the past 3 months saw a medical provider within the last year, wearing a mask in public often, and barriers to vaccination (not knowing enough about the vaccine) predicted vaccine. These variables indicated changes in the likelihood of obtaining vaccination. CONCLUSION: The most crucial factor for increasing vaccination rates was directly reaching out to the community and actively conducting surveys to address the barriers and concerns encountered by Hispanic/Latinx participants.

Changes in Prenatal Care Utilization:United States, 2019-2021.

Objectives-This report describes changes in prenatal care use (utilization) in the United States before and during the COVID-19 pandemic by month of birth and the mother's race and Hispanic origin.

Association between distance to community health care facilities and COVID-19-related mortality across U.S. counties in the COVID-19-vaccine era.

OBJECTIVE: COVID-19 has caused tremendous damage to U.S. public health, but COVID vaccines can effectively reduce the risk of COVID-19 infections and related mortality. Our study aimed to quantify the association between proximity to a community healthcare facility and COVID-19 related mortality after COVID vaccines became publicly available and explore how this association varied across racial and ethnic groups. RESULTS: Residents living farther from a facility had higher COVID-19-related mortality across U.S. counties. This increased mortality incidence associated with longer distances was particularly pronounced in counties with higher proportions of Black and Hispanic populations.

Unequal outcomes: The effects of the COVID-19 pandemic on mental health and wellbeing among Hispanic/Latinos with varying degrees of 'Belonging'.

BACKGROUND: The COVID-19 pandemic has brought disparities in mental and physical health faced by ethnic minorities to the forefront. In the U.S., Hispanic/Latino communities are plagued by elevated rates of psychiatric conditions and trauma. Exacerbating this burden, common discourse often implicates Hispanic/Latino ethnicity as a causal factor, despite clear evidence of systemic causes, including lack of access to resources, and discrimination. AIMS: To parse apart Hispanic/Latino ethnicity from determinants of wellbeing (such as trauma, financial status, and loneliness), we examined mental and physical health during COVID-19 via an online, anonymous survey available in both English and Spanish. METHODS: We examined wellbeing across three participant groups, including two groups of Hispanic/Latino adults with varying degrees of 'belonging' to the dominant culture in their country of residence: Hispanic/Latino individuals living in Spanish-speaking and/or Central or Latin American countries (Group 1), Hispanic/Latino individuals living in the U.S. (Group 2), and non-Hispanic/Latino individuals living in the U.S. (Group 3). RESULTS: Results demonstrated there were significant differences between groups in specific aspects of wellbeing. Most importantly, results showed Hispanic/Latino ethnicity does not significantly predict psychosocial wellbeing or psychosis risk, and identified several predictors of these outcomes, including U.S. residence, trauma, loneliness, and age. CONCLUSION: Our results demonstrate that Hispanic/Latino ethnicity itself is not a causal factor of poor psychosocial wellbeing or elevated psychosis risk and instead identify several social and systemic causal factors commonly faced by Hispanic/Latino Americans. We suggest that language reporting on minority mental health acknowledge systemic factors as contributing to poor outcome rather than referring to ethnicity as if it were a causal factor.

US Racial-Ethnic Mortality Gap Adjusted for Population Structure.

BACKGROUND: US racial-ethnic mortality disparities are well documented and central to debates on social inequalities in health. Standard measures, such as life expectancy or years of life lost, are based on synthetic populations and do not account for the real underlying populations experiencing the inequalities. METHODS: We analyze US mortality disparities comparing Asian Americans, Blacks, Hispanics, and Native Americans/Alaska Natives to Whites using 2019 CDC and NCHS data, using a novel approach that estimates the mortality gap, adjusted for population structure by accounting for real-population exposures. This measure is tailored for analyses where age structures are fundamental, not merely a confounder. We highlight the magnitude of inequalities by comparing the population structure-adjusted mortality gap against standard metrics' estimates of loss of life due to leading causes. RESULTS: Based on the population structure-adjusted mortality gap, Black and Native American mortality disadvantage exceedsmortality from circulatory diseases. The disadvantage is 72% among Blacks (men: 47%, women: 98%) and 65% among Native Americans (men: 45%, women: 92%), larger than life expectancy measured disadvantage. In contrast, estimated advantages for Asian Americans are over three times (men: 176%, women: 283%) and, for Hispanics, two times (men: 123%; women: 190%) larger than those based on life expectancy. CONCLUSIONS: Mortality inequalities based on standard metrics' synthetic populations can differ markedly from estimates of the population structure-adjusted mortality gap. We demonstrate that standard metrics underestimate racial-ethnic disparities through disregarding actual population age structures. Exposure-corrected measures of inequality may better inform health policies around allocation of scarce resources.

Community Health Workers as Puentes/Bridges to Increase COVID-19 Health Equity in Latinx Communities of the Southwest U.S.

This study documents the pivotal role that Community Health Workers (CHW) played while supporting underserved Latinx communities affected by COVID-19-related health inequities. With the support of CHWs' agencies historically serving three Latinx-dense counties in Arizona, we recruited CHWs who participated in a state-wide COVID-19 testing project. Using phenomenology and narrative qualitative research methods, five focus groups were facilitated in Spanish between August and November 2021. Bilingual research team members conducted the analysis of the Spanish verbatim transcripts and CHWs reviewed the results for validity. Three interconnected themes reflected the CHWs experiences: (1) CHWs as puentes/bridges with deep community embeddedness through shared experiences and social/cultural context, (2) CHWs as communication brokers and transformational agents, playing a pivotal role in responding to the health and socioeconomic challenges posed by the COVID-19 pandemic, (3) CHWs satisfaction and frustration due to their dual role as committed community members but unrecognized and undervalued frontline public health workers. These findings emphasize the CHWs' commitment towards supporting their communities, even amidst the stressors of the pandemic. It is important to continue to integrate the role of CHWs into the larger healthcare system as opposed to relegating them to short term engagements as was the case during the COVID-19 pandemic. This article provides a set of practice, policy, and future research recommendations, emphasizing the need to allocate greater budgetary and training resources in support of CHWs.

Race and Ethnicity-Adjusted Age Recommendation for Initiating Breast Cancer Screening.

Importance: Breast cancer (BC) is the second leading cause of cancer death in women, and there is a substantial disparity in BC mortality by race, especially for early-onset BC in Black women. Many guidelines recommend starting BC screening from age 50 years; however, the current one-size-fits-all policy to start screening all women from a certain age may not be fair, equitable, or optimal. Objective: To provide race and ethnicity-adapted starting ages of BC screening based on data on current racial and ethnic disparities in BC mortality. Design, Setting, and Participants: This nationwide population-based cross-sectional study was conducted using data on BC mortality in female patients in the US who died of BC in 2011 to 2020. Exposures: Proxy-reported race and ethnicity information was used. The risk-adapted starting age of BC screening by race and ethnicity was measured based on 10-year cumulative risk of BC-specific death. Age-specific 10-year cumulative risk was calculated based on age group-specific mortality data without modeling or adjustment. Main Outcomes and Measures: Disease-specific mortality due to invasive BC in female patients. Results: There were BC-specific deaths among 415 277 female patients (1880 American Indian or Alaska Native [0.5%], 12 086 Asian or Pacific Islander [2.9%], 62 695 Black [15.1%], 28 747 Hispanic [6.9%], and 309 869 White [74.6%]; 115 214 patients died before age 60 years [27.7%]) of any age in the US in 2011 to 2020. BC mortality per 100 000 person-years for ages 40 to 49 years was 27 deaths in Black females, 15 deaths in White females, and 11 deaths in American Indian or Alaska Native, Hispanic, and Asian or Pacific Islander females. When BC screening was recommended to start at age 50 years for all females with a 10-year cumulative risk of BC death of 0.329%, Black females reached this risk threshold level 8 years earlier, at age 42 years, whereas White females reached it at age 51 years, American Indian or Alaska Native and Hispanic females at age 57 years, and Asian or Pacific Islander females 11 years later, at age 61 years. Race and ethnicity-adapted starting ages for Black females were 6 years earlier for mass screening at age 40 years and 7 years earlier for mass screening at age 45 years. Conclusions and Relevance: This study provides evidence-based race-adapted starting ages for BC screening. These findings suggest that health policy makers may consider a risk-adapted approach to BC screening in which individuals who are at high risk are screened earlier to address mortality due to early-onset BC before the recommended age of mass screening.

Environmental and Mobility Strategies During Early COVID-19: Insights From an Empirical Study Focusing on Park Visitations in El Paso, TX.

OBJECTIVES: We explored the importance of environmental and mobility strategies during early COVID-19 by age and ethnicity and investigated predictors of park visitations considering the COVID-19 impacts. BACKGROUND: Parks are safe and accessible venues to stay active and reduce social isolation, which is especially important considering COVID-19 and the associated lockdowns. METHODS: We analyzed online survey data from 683 residents (collected July 2020) of El Paso, TX, and objective measures of neighborhood park characteristics. Chi-square tests and mixed-effects logistic regression analyses were performed to examine the environmental/mobility strategies, personal and environmental factors, and park visitations, considering the COVID-19 impacts. RESULTS: The percentage of those who visited (1+ times/week) parks or trails/paths in the neighborhood dropped from 41.7% to 19.5% since the start of COVID-19 (OR = 0.015, p < .001). Before COVID-19, middle-aged and older adults were less likely to visit parks than younger adults, while this difference became insignificant during early COVID-19. Hispanic adults were more likely to visit parks than non-Hispanics both before and during early COVID-19. Positive environmental predictors of park visitations included park availability in the neighborhood, proximity to the closest park, seeing people being physically active in the neighborhood, and neighborhood aesthetics. CONCLUSIONS: Proximately located parks, trails, and paths well integrated into residential communities, and high aesthetic quality of the neighborhood are the potential features of pandemic-resilient communities and should be considered an important national priority to maintain and promote the health and well-being of the population, especially during pandemics like COVID-19.

Telehealth Usage Among Low-Income Racial and Ethnic Minority Populations During the COVID-19 Pandemic: Retrospective Observational Study.

BACKGROUND: Despite considerable efforts to encourage telehealth use during the COVID-19 pandemic, we witnessed a potential widening of health inequities that may continue to plague the US health care system unless we mitigate modifiable risk factors. OBJECTIVE: This study aimed to examine the hypothesis that there are systemic differences in telehealth usage among people who live at or below 200% of the federal poverty level. Factors that we consider are age, gender, race, ethnicity, education, employment status, household size, and income. METHODS: A retrospective observational study was performed using the COVID-19 Research Database to analyze factors contributing to telehealth inequities. The study period ranged from March 2020 to April 2021. The Office Ally database provided US claims data from 100 million unique patients and 3.4 billion claims. The Analytics IQ PeopleCore Consumer database is nationally representative of 242.5 million US adults aged 19 years and older. We analyzed medical claims to investigate the influence of demographic and socioeconomic factors on telehealth usage among the low-income racial and ethnic minority populations. We conducted a multiple logistic regression analysis to determine the odds of patients in diverse groups using telehealth during the study period. RESULTS: Among 2,850,831 unique patients, nearly 60% of them were female, 75% of them had a high school education or less, 49% of them were unemployed, and 62% of them identified as non-Hispanic White. Our results suggest that 9.84% of the patients had ≥1 telehealth claims during the study period. Asian (odds ratio [OR] 1.569, 95% CI 1.528-1.611, P<.001) and Hispanic (OR 1.612, 95% CI 1.596-1.628, P<.001) patients were more likely to use telehealth than non-Hispanic White and -Black patients. Patients who were employed full-time were 15% (OR 1.148, 95% CI 1.133-1.164, P<.001) more likely to use telehealth than unemployed patients. Patients who identified as male were 12% (OR 0.875, 95% CI 0.867-0.883, P<.001) less likely to use telehealth than those who identified as female. Patients with high school education or less were 5% (OR 0.953, 95% CI 0.944-0.962, P<.001) less likely to use telehealth than those with a bachelor's degree or higher. Patients in the 18-44-year age group were 32% (OR 1.324, 95% CI 1.304-1.345, P<.001) more likely to use telehealth than those in the ≥65-year age group. CONCLUSIONS: Factors that impact telehealth usage include age, gender, race, education, employment status, and income. While low-income racial and ethnic minority communities are at greater risk for health inequities among this group, Hispanic communities are more likely to use telehealth, and non-Hispanic Black patients continue to demonstrate telehealth inequity. Gender, age, and household income contribute to health inequities across gradients of poverty. Strategies to improve health use should consider characteristics of subgroups, as people do not experience poverty equally.

Effect Modification of Racial Differences in Pediatric COVID-19 Inpatient Admissions in a Large Healthcare Database.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has been more severe in racial and ethnic minorities relative to non-Hispanic White populations. Here, we investigate how these disparities vary across effect modifiers in a pediatric population. METHODS: Using the TriNetX Dataworks Network from April 2020 to September 2021, we compared inpatient rates between non-Hispanic Black and non-Hispanic White patients among pediatric COVID-19 cases. Following propensity score matching, comparisons were performed within subgroups of 4 potential effect modifiers: age group (0-2, 3-5, 6-11 and 12-18 years), presence of complex comorbidities, quarter of the year (from 2020 Q2 to 2021 Q3) and geographic regions of the United States. RESULTS: The cohort included 47,487 COVID-19 cases, of which 13,130 were Black patients. Among most subgroups of effect modifiers, inpatient rates were higher among the Black patients. The largest variation in disparities was observed across age groups and the presence of complex comorbidities. Twelve to 18 years old Black children had a 1.7% point [confidence interval (CI): 0.8-2.4] higher inpatient rate than the matched White children, whereas 0-2 years old Black children had a 2.5% point (CI: 0.9-4.1) lower rate than the matched White children. Among children with complex comorbidities, inpatient rates for Black children was 6.2 (CI: 3.4-8.9) percentage points higher than the White children; however, among kids without complex comorbidities, inpatient rates were comparable. CONCLUSIONS: Among pediatric patients experiencing COVID-19, higher inpatient rates for Black compared with White patients were observed among older children and those with complex comorbidities. These findings can spur discussions of potential root causes of these disparities, including structural racism.

Factors Associated With Marshallese and Hispanic Adults' Willingness to Receive a COVID-19 Booster Dose.

INTRODUCTION/OBJECTIVES: New variants of the SARS-CoV-2 virus that causes COVID-19 will continue to develop and spread globally. The Omicron variant identified in November 2021 has many lineages. Variants spread quickly and can infect previously vaccinated individuals, prompting the Centers for Disease Control and Prevention to update vaccination recommendations. While ~230 million Americans received the initially-recommended vaccine sequence, booster uptake has been much lower; less than half of fully vaccinated individuals report receiving a booster. Racial disparities also mark patterns of COVID-19 vaccination booster uptake. This study explored willingness and motivations to get a COVID-19 booster among a diverse sample of participants. METHODS: We used convenience sampling to recruit participants 18 years of age or older who attended a community vaccine event. We conducted informal interviews during the recommended 15-min post-vaccination wait time with 55 participants who attended vaccine events at Marshallese and Hispanic community locations and comprised the recruitment pool for individual interviews. Using a qualitative descriptive design, we conducted in-depth follow-up interviews with 9 participants (Marshallese n = 5, Hispanic n = 4) to explore willingness and motivations to get boosted. We used rapid thematic template analysis to review informal interview summaries and formal interviews. The research team resolved data discrepancies by consensus. RESULTS: Participants reported high willingness to get boosted, especially if boosters were recommended in the future to protect against serious illness and mitigate the spread of COVID-19. This finding underscores how essential including recommendations to get a COVID-19 booster from trusted sources in health messaging and educational campaigns may be for increasing booster uptake. Participants described their preference for receiving future COVID-19 boosters, reporting that they would attend similar vaccine events, especially those held at faith-based organizations and facilitated by the same community partners, community health workers, and research staff. This finding shows how community engagement can overcome barriers to vaccination (ie, transportation, language, and fear of discrimination) by providing services in preferred community locations with trusted community partners. CONCLUSIONS: Findings document high willingness to get a COVID-19 booster, emphasize the role of recommendations from trusted sources in motivating booster uptake, and highlight the importance of community engagement to address disparities in vaccination coverage and reach.

COVID-19 Mortality by Race and Ethnicity in US Metropolitan and Nonmetropolitan Areas, March 2020 to February 2022.

Importance: Prior research has established that Hispanic and non-Hispanic Black residents in the US experienced substantially higher COVID-19 mortality rates in 2020 than non-Hispanic White residents owing to structural racism. In 2021, these disparities decreased. Objective: To assess to what extent national decreases in racial and ethnic disparities in COVID-19 mortality between the initial pandemic wave and subsequent Omicron wave reflect reductions in mortality vs other factors, such as the pandemic's changing geography. Design, Setting, and Participants: This cross-sectional study was conducted using data from the US Centers for Disease Control and Prevention for COVID-19 deaths from March 1, 2020, through February 28, 2022, among adults aged 25 years and older residing in the US. Deaths were examined by race and ethnicity across metropolitan and nonmetropolitan areas, and the national decrease in racial and ethnic disparities between initial and Omicron waves was decomposed. Data were analyzed from June 2021 through March 2023. Exposures: Metropolitan vs nonmetropolitan areas and race and ethnicity. Main Outcomes and Measures: Age-standardized death rates. Results: There were death certificates for 977 018 US adults aged 25 years and older (mean [SD] age, 73.6 [14.6] years; 435 943 female [44.6%]; 156 948 Hispanic [16.1%], 140 513 non-Hispanic Black [14.4%], and 629 578 non-Hispanic White [64.4%]) that included a mention of COVID-19. The proportion of COVID-19 deaths among adults residing in nonmetropolitan areas increased from 5944 of 110 526 deaths (5.4%) during the initial wave to a peak of 40 360 of 172 515 deaths (23.4%) during the Delta wave; the proportion was 45 183 of 210 554 deaths (21.5%) during the Omicron wave. The national disparity in age-standardized COVID-19 death rates per 100 000 person-years for non-Hispanic Black compared with non-Hispanic White adults decreased from 339 to 45 deaths from the initial to Omicron wave, or by 293 deaths. After standardizing for age and racial and ethnic differences by metropolitan vs nonmetropolitan residence, increases in death rates among non-Hispanic White adults explained 120 deaths/100 000 person-years of the decrease (40.7%); 58 deaths/100 000 person-years in the decrease (19.6%) were explained by shifts in mortality to nonmetropolitan areas, where a disproportionate share of non-Hispanic White adults reside. The remaining 116 deaths/100 000 person-years in the decrease (39.6%) were explained by decreases in death rates in non-Hispanic Black adults. Conclusions and Relevance: This study found that most of the national decrease in racial and ethnic disparities in COVID-19 mortality between the initial and Omicron waves was explained by increased mortality among non-Hispanic White adults and changes in the geographic spread of the pandemic. These findings suggest that despite media reports of a decline in disparities, there is a continued need to prioritize racial health equity in the pandemic response.

Longitudinal analysis of SARS-CoV-2 infection and vaccination in the LA-SPARTA cohort reveals increased risk of infection in vaccinated Hispanic participants.

Introduction: SARS-CoV-2 is the etiologic agent of coronavirus disease 2019 (COVID-19). Questions remain regarding correlates of risk and immune protection against COVID-19. Methods: We prospectively enrolled 200 participants with a high risk of SARS-CoV-2 occupational exposure at a U.S. medical center between December 2020 and April 2022. Participant exposure risks, vaccination/infection status, and symptoms were followed longitudinally at 3, 6, and 12 months, with blood and saliva collection. Serological response to the SARS-CoV-2 spike holoprotein (S), receptor binding domain (RBD) and nucleocapsid proteins (NP) were quantified by ELISA assay. Results: Based on serology, 40 of 200 (20%) participants were infected. Healthcare and non-healthcare occupations had equivalent infection incidence. Only 79.5% of infected participants seroconverted for NP following infection, and 11.5% were unaware they had been infected. The antibody response to S was greater than to RBD. Hispanic ethnicity was associated with 2-fold greater incidence of infection despite vaccination in this cohort. Discussion: Overall, our findings demonstrate: 1) variability in the antibody response to SARS-CoV-2 infection despite similar exposure risk; 2) the concentration of binding antibody to the SARS-CoV-2 S or RBD proteins is not directly correlated with protection against infection in vaccinated individuals; and 3) determinants of infection risk include Hispanic ethnicity despite vaccination and similar occupational exposure.

Racial and ethnic disparities in excess mortality among U.S. veterans during the COVID-19 pandemic.

OBJECTIVE: The COVID-19 pandemic disproportionately affected racial and ethnic minorities among the general population in the United States; however, little is known regarding its impact on U.S. military Veterans. In this study, our objectives were to identify the extent to which Veterans experienced increased all-cause mortality during the COVID-19 pandemic, stratified by race and ethnicity. DATA SOURCES: Administrative data from the Veterans Health Administration's Corporate Data Warehouse. STUDY DESIGN: We use pre-pandemic data to estimate mortality risk models using five-fold cross-validation and quasi-Poisson regression. Models were stratified by a combined race-ethnicity variable and included controls for major comorbidities, demographic characteristics, and county fixed effects. DATA COLLECTION: We queried data for all Veterans residing in the 50 states plus Washington D.C. during 2016-2020. Veterans were excluded from analyses if they were missing county of residence or race-ethnicity data. Data were then aggregated to the county-year level and stratified by race-ethnicity. PRINCIPAL FINDINGS: Overall, Veterans' mortality rates were 16% above normal during March-December 2020 which equates to 42,348 excess deaths. However, there was substantial variation by racial and ethnic group. Non-Hispanic White Veterans experienced the smallest relative increase in mortality (17%, 95% CI 11%-24%), while Native American Veterans had the highest increase (40%, 95% CI 17%-73%). Black Veterans (32%, 95% CI 27%-39%) and Hispanic Veterans (26%, 95% CI 17%-36%) had somewhat lower excess mortality, although these changes were significantly higher compared to White Veterans. Disparities were smaller than in the general population. CONCLUSIONS: Minoritized Veterans experienced higher rates excess of mortality during the COVID-19 pandemic compared to White Veterans, though with smaller differences than the general population. This is likely due in part to the long-standing history of structural racism in the United States that has negatively affected the health of minoritized communities via several pathways including health care access, economic, and occupational inequities.