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Changes in the associations of race and rurality with SARS-CoV-2 infection, mortality, and case fatality in the United States from February 2020 to March 2021: A population-based cohort study.
Ioannou, George N; Ferguson, Jacqueline M; O'Hare, Ann M; Bohnert, Amy S B; Backus, Lisa I; Boyko, Edward J; Osborne, Thomas F; Maciejewski, Matthew L; Bowling, C Barrett; Hynes, Denise M; Iwashyna, Theodore J; Saysana, Melody; Green, Pamela; Berry, Kristin.
  • Ioannou GN; Divisions of Gastroenterology, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, Washington, United States of America.
  • Ferguson JM; Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, United States of America.
  • O'Hare AM; Center for Innovation to Implementation, VA Palo Alto Healthcare System, US Department of Veterans Affairs, Palo Alto, California, United States of America.
  • Bohnert ASB; Nephrology, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, Washington, United States of America.
  • Backus LI; Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan, United States of America.
  • Boyko EJ; Department of Veterans Affairs, Population Health, Palo Alto Healthcare System, Palo Alto, California, United States of America.
  • Osborne TF; General Internal Medicine, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, Washington, United States of America.
  • Maciejewski ML; Veterans Affairs Palo Alto Healthcare System, Palo Alto, and Department of Radiology, Stanford University School of Medicine, Stanford, California, United States of America.
  • Bowling CB; Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina, United States of America.
  • Hynes DM; Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, United States of America.
  • Iwashyna TJ; Duke-Margolis Center for Health Policy, Duke University School of Medicine, Durham, North Carolina, United States of America.
  • Saysana M; Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America.
  • Green P; Durham Veterans Affairs Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center (VAMC), Durham, NC and Department of Medicine, Duke University, Durham, North Carolina, United States of America.
  • Berry K; Center of Innovation to Improve Veteran Involvement in Care, VA Portland Healthcare System, Portland, Oregon, United States of America.
PLoS Med ; 18(10): e1003807, 2021 10.
Article in English | MEDLINE | ID: covidwho-1484840
ABSTRACT

BACKGROUND:

We examined whether key sociodemographic and clinical risk factors for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection and mortality changed over time in a population-based cohort study. METHODS AND

FINDINGS:

In a cohort of 9,127,673 persons enrolled in the United States Veterans Affairs (VA) healthcare system, we evaluated the independent associations of sociodemographic and clinical characteristics with SARS-CoV-2 infection (n = 216,046), SARS-CoV-2-related mortality (n = 10,230), and case fatality at monthly intervals between February 1, 2020 and March 31, 2021. VA enrollees had a mean age of 61 years (SD 17.7) and were predominantly male (90.9%) and White (64.5%), with 14.6% of Black race and 6.3% of Hispanic ethnicity. Black (versus White) race was strongly associated with SARS-CoV-2 infection (adjusted odds ratio [AOR] 5.10, [95% CI 4.65 to 5.59], p-value <0.001), mortality (AOR 3.85 [95% CI 3.30 to 4.50], p-value < 0.001), and case fatality (AOR 2.56, 95% CI 2.23 to 2.93, p-value < 0.001) in February to March 2020, but these associations were attenuated and not statistically significant by November 2020 for infection (AOR 1.03 [95% CI 1.00 to 1.07] p-value = 0.05) and mortality (AOR 1.08 [95% CI 0.96 to 1.20], p-value = 0.21) and were reversed for case fatality (AOR 0.86, 95% CI 0.78 to 0.95, p-value = 0.005). American Indian/Alaska Native (AI/AN versus White) race was associated with higher risk of SARS-CoV-2 infection in April and May 2020; this association declined over time and reversed by March 2021 (AOR 0.66 [95% CI 0.51 to 0.85] p-value = 0.004). Hispanic (versus non-Hispanic) ethnicity was associated with higher risk of SARS-CoV-2 infection and mortality during almost every time period, with no evidence of attenuation over time. Urban (versus rural) residence was associated with higher risk of infection (AOR 2.02, [95% CI 1.83 to 2.22], p-value < 0.001), mortality (AOR 2.48 [95% CI 2.08 to 2.96], p-value < 0.001), and case fatality (AOR 2.24, 95% CI 1.93 to 2.60, p-value < 0.001) in February to April 2020, but these associations attenuated over time and reversed by September 2020 (AOR 0.85, 95% CI 0.81 to 0.89, p-value < 0.001 for infection, AOR 0.72, 95% CI 0.62 to 0.83, p-value < 0.001 for mortality and AOR 0.81, 95% CI 0.71 to 0.93, p-value = 0.006 for case fatality). Throughout the observation period, high comorbidity burden, younger age, and obesity were consistently associated with infection, while high comorbidity burden, older age, and male sex were consistently associated with mortality. Limitations of the study include that changes over time in the associations of some risk factors may be affected by changes in the likelihood of testing for SARS-CoV-2 according to those risk factors; also, study results apply directly to VA enrollees who are predominantly male and have comprehensive healthcare and need to be confirmed in other populations.

CONCLUSIONS:

In this study, we found that strongly positive associations of Black and AI/AN (versus White) race and urban (versus rural) residence with SARS-CoV-2 infection, mortality, and case fatality observed early in the pandemic were ameliorated or reversed by March 2021.
Subject(s)

Full text: Available Collection: International databases Database: MEDLINE Main subject: Rural Population / Urban Population / Population Surveillance / United States Department of Veterans Affairs / COVID-19 Type of study: Diagnostic study / Etiology study / Incidence study / Observational study / Prognostic study / Risk factors / Screening study Limits: Aged / Female / Humans / Male / Middle aged Country/Region as subject: North America Language: English Journal: PLoS Med Journal subject: Medicine Year: 2021 Document Type: Article Affiliation country: Journal.pmed.1003807

Full text: Available Collection: International databases Database: MEDLINE Main subject: Rural Population / Urban Population / Population Surveillance / United States Department of Veterans Affairs / COVID-19 Type of study: Diagnostic study / Etiology study / Incidence study / Observational study / Prognostic study / Risk factors / Screening study Limits: Aged / Female / Humans / Male / Middle aged Country/Region as subject: North America Language: English Journal: PLoS Med Journal subject: Medicine Year: 2021 Document Type: Article Affiliation country: Journal.pmed.1003807