Racial and Ethnic Disparities in COVID-19-Related Infections, Hospitalizations, and Deaths : A Systematic Review

Katherine Mackey, Chelsea K Ayers, Karli K Kondo, Somnath Saha, Shailesh M Advani, Sarah Young, Hunter Spencer, Max Rusek, Johanna Anderson, Stephanie Veazie, Mia Smith, Devan Kansagara, Katherine Mackey, Chelsea K Ayers, Karli K Kondo, Somnath Saha, Shailesh M Advani, Sarah Young, Hunter Spencer, Max Rusek, Johanna Anderson, Stephanie Veazie, Mia Smith, Devan Kansagara

Abstract

Background: Data suggest that the effects of coronavirus disease 2019 (COVID-19) differ among U.S. racial/ethnic groups.

Purpose: To evaluate racial/ethnic disparities in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection rates and COVID-19 outcomes, factors contributing to disparities, and interventions to reduce them.

Data sources: English-language articles in MEDLINE, PsycINFO, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus, searched from inception through 31 August 2020. Gray literature sources were searched through 2 November 2020.

Study selection: Observational studies examining SARS-CoV-2 infections, hospitalizations, or deaths by race/ethnicity in U.S. settings.

Data extraction: Single-reviewer abstraction confirmed by a second reviewer; independent dual-reviewer assessment of quality and strength of evidence.

Data synthesis: 37 mostly fair-quality cohort and cross-sectional studies, 15 mostly good-quality ecological studies, and data from the Centers for Disease Control and Prevention and APM Research Lab were included. African American/Black and Hispanic populations experience disproportionately higher rates of SARS-CoV-2 infection, hospitalization, and COVID-19-related mortality compared with non-Hispanic White populations, but not higher case-fatality rates (mostly reported as in-hospital mortality) (moderate- to high-strength evidence). Asian populations experience similar outcomes to non-Hispanic White populations (low-strength evidence). Outcomes for other racial/ethnic groups have been insufficiently studied. Health care access and exposure factors may underlie the observed disparities more than susceptibility due to comorbid conditions (low-strength evidence).

Limitations: Selection bias, missing race/ethnicity data, and incomplete outcome assessments in cohort and cross-sectional studies must be considered. In addition, adjustment for key demographic covariates was lacking in ecological studies.

Conclusion: African American/Black and Hispanic populations experience disproportionately higher rates of SARS-CoV-2 infection and COVID-19-related mortality but similar rates of case fatality. Differences in health care access and exposure risk may be driving higher infection and mortality rates.

Primary funding source: Department of Veterans Affairs, Veterans Health Administration, Health Services Research & Development. (PROSPERO: CRD42020187078).

Conflict of interest statement

Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M20-6306.

Figures

Figure.. Study flow diagram.
Figure.. Study flow diagram.
CCRCT = Cochrane Central Register of Controlled Trials; CDSR = Cochrane Database of Systematic Reviews; EBM = Evidence-Based Medicine; * Exclusions applied to July–August search results (second literature search) owing to the high volume of new studies, including those based on individual-level (rather than population-level) data. † Includes 12 preprints from April–June publications (first literature search) as well as 6 published studies that were first identified as preprints.

References

    1. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. . Accessed at on 3 September 2020.
    1. Artiga S, Orgera K, Pham O. Disparities in health and health care: five key questions and answers. Henry J. Kaiser Family Foundation. 2020. Accessed at on 15 August 2020.
    1. Soyemi K , Medina-Marino A , Sinkowitz-Cochran R , et al. Disparities among 2009 pandemic influenza A (H1N1) hospital admissions: a mixed methods analysis—Illinois, April-December 2009. PLoS One. 2014;9:e84380. [PMID: ] doi:10.1371/journal.pone.0084380
    1. Yancy CW . COVID-19 and African Americans. JAMA. 2020;323:1891-2. [PMID: ] doi:10.1001/jama.2020.6548
    1. Kim EJ , Marrast L , Conigliaro J . COVID-19: magnifying the effect of health disparities [Editorial]. J Gen Intern Med. 2020;35:2441-2. [PMID: ] doi:10.1007/s11606-020-05881-4
    1. Kilbourne AM , Switzer G , Hyman K , et al. Advancing health disparities research within the health care system: a conceptual framework. Am J Public Health. 2006;96:2113-21. [PMID: ]
    1. Thomas SB , Quinn SC . Poverty and elimination of urban health disparities: challenge and opportunity. Ann N Y Acad Sci. 2008;1136:111-25. [PMID: ] doi:10.1196/annals.1425.018
    1. Saha S , Freeman M , Toure J , et al. Racial and ethnic disparities in the VA health care system: a systematic review. J Gen Intern Med. 2008;23:654-71. [PMID: ] doi:10.1007/s11606-008-0521-4
    1. Kupferschmidt K. ‘A completely new culture of doing research.’ Coronavirus outbreak changes how scientists communicate. Science Magazine. 26 February 2020. Accessed at on 27 November 2020.
    1. Moher D , Liberati A , Tetzlaff J , et al; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med. 2009;151:264-9, W64
    1. Agency for Healthcare Research and Quality. Methods Guide for Effectiveness and Comparative Effectiveness Reviews. Rockville, MD: Agency for Healthcare Research and Quality; 2014.
    1. Wells GA, Shea B, O’Connell D, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Ottawa Hospital Research Institute. Accessed at on 25 August 2020.
    1. Quinn SC , Kumar S , Freimuth VS , et al. Racial disparities in exposure, susceptibility, and access to health care in the US H1N1 influenza pandemic. Am J Public Health. 2011;101:285-93. [PMID: ] doi:10.2105/AJPH.2009.188029
    1. Quinn SC , Kumar S . Health inequalities and infectious disease epidemics: a challenge for global health security. Biosecur Bioterror. 2014 Sep-Oct;12:263-73. [PMID: ] doi:10.1089/bsp.2014.0032
    1. Berkman ND , Lohr KN , Ansari MT , et al. Grading the strength of a body of evidence when assessing health care interventions: an EPC update. J Clin Epidemiol. 2015;68:1312-24. [PMID: ] doi:10.1016/j.jclinepi.2014.11.023
    1. Centers for Disease Control and Prevention. COVIDView. Key updates for week 43, ending October 24, 2020. Accessed at on 2 November 2020.
    1. Centers for Disease Control and Prevention, National Center for Health Statistics. Health disparities: race and Hispanic origin. Accessed at on 2 November 2020.
    1. APM Research Lab 2020. Color of coronavirus. American Public Media. Accessed at on 2 November 2020.
    1. Adegunsoye A , Ventura IB , Liarski VM . Association of black race with outcomes in COVID-19 disease: a retrospective cohort study [Letter]. Ann Am Thorac Soc. 2020;17:1336-1339. [PMID: ] doi:10.1513/AnnalsATS.202006-583RL
    1. Ahmed SM, Shah RU, Bale M, et al. Comprehensive testing highlights racial, ethnic, and age disparities in the COVID-19 outbreak. medRxiv. Preprint posted online 9 May 2020. doi:10.1101/2020.05.05.20092031
    1. Anyane-Yeboa A , Sato T , Sakuraba A . Racial disparities in COVID-19 deaths reveal harsh truths about structural inequality in America [Letter]. J Intern Med. 2020;288:479-80. [PMID: ] doi:10.1111/joim.13117
    1. Azar KMJ , Shen Z , Romanelli RJ , et al. Disparities in outcomes among COVID-19 patients in a large health care system in California. Health Aff (Millwood). 2020;39:1253-62. [PMID: ] doi:10.1377/hlthaff.2020.00598
    1. Baggett TP, Keyes H, Sporn N, Gaeta JM. COVID-19 outbreak at a large homeless shelter in Boston: implications for universal testing. medRxiv. Preprint posted online 15 April 2020. doi:10.1101/2020.04.12.20059618
    1. Blitz MJ , Rochelson B , Prasannan L , et al. Racial and ethnic disparity and spatiotemporal trends in severe acute respiratory syndrome coronavirus 2 prevalence on obstetrical units in New York. Am J Obstet Gynecol MFM. 2020;2:100212. [PMID: ] doi:10.1016/j.ajogmf.2020.100212
    1. Caraballo C , McCullough M , Fuery MA , et al. COVID-19 infections and outcomes in a live registry of heart failure patients across an integrated health care system. PLoS One. 2020;15:e0238829. [PMID: ] doi:10.1371/journal.pone.0238829
    1. Chamie G , Marquez C , Crawford E , et al; CLIAhub Consortium. SARS-CoV-2 community transmission disproportionately affects Latinx population during shelter-in-place in San Francisco. Clin Infect Dis. 2020. [PMID: ] doi:10.1093/cid/ciaa1234
    1. Chow DS, Soun J, Gavis-Bloom J, et al. The disproportionate rise in COVID-19 cases among Hispanic/Latinx in disadvantaged communities of Orange County, California: a socioeconomic case-series. medRxiv. Preprint posted online 7 May 2020. doi:10.1101/2020.05.04.20090878
    1. Ebinger JE , Achamallah N , Ji H , et al. Pre-existing traits associated with Covid-19 illness severity. PLoS One. 2020;15:e0236240. [PMID: ] doi:10.1371/journal.pone.0236240
    1. Emeruwa UN , Spiegelman J , Ona S , et al. Influence of race and ethnicity on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection rates and clinical outcomes in pregnancy. Obstet Gynecol. 2020;136:1040-1043. [PMID: ] doi:10.1097/AOG.0000000000004088
    1. Flannery DD , Gouma S , Dhudasia MB , et al. SARS-CoV-2 seroprevalence among parturient women in Philadelphia. Sci Immunol. 2020;5. [PMID: ] doi:10.1126/sciimmunol.abd5709
    1. Goldfarb IT , Clapp MA , Soffer MD , et al. Prevalence and severity of coronavirus disease 2019 (COVID-19) illness in symptomatic pregnant and postpartum women stratified by Hispanic ethnicity [Letter]. Obstet Gynecol. 2020;136:300-302. [PMID: ] doi:10.1097/AOG.0000000000004005
    1. Golestaneh L , Neugarten J , Fisher M , et al. The association of race and COVID-19 mortality. EClinicalMedicine. 2020;25:100455. [PMID: ] doi:10.1016/j.eclinm.2020.100455
    1. Gross CP , Essien UR , Pasha S , et al. Racial and ethnic disparities in population-level Covid-19 mortality [Letter]. J Gen Intern Med. 2020;35:3097-3099. [PMID: ] doi:10.1007/s11606-020-06081-w
    1. Gu T , Mack JA , Salvatore M , et al. Characteristics associated with Racial/Ethnic disparities in COVID-19 outcomes in an academic health care system. JAMA Netw Open. 2020;3:e2025197. [PMID: ] doi:10.1001/jamanetworkopen.2020.25197
    1. Holtgrave DR , Barranco MA , Tesoriero JM , et al. Assessing racial and ethnic disparities using a COVID-19 outcomes continuum for New York State. Ann Epidemiol. 2020;48:9-14. [PMID: ] doi:10.1016/j.annepidem.2020.06.010
    1. Jehi L , Ji X , Milinovich A , et al. Individualizing risk prediction for positive coronavirus disease 2019 testing: results from 11,672 patients. Chest. 2020;158:1364-75. [PMID: ] doi:10.1016/j.chest.2020.05.580
    1. Killerby ME , Link-Gelles R , Haight SC , et al; CDC COVID-19 Response Clinical Team. Characteristics associated with hospitalization among patients with COVID-19 - metropolitan Atlanta, Georgia, March-April 2020. MMWR Morb Mortal Wkly Rep. 2020;69:790-4. [PMID: ] doi:10.15585/mmwr.mm6925e1
    1. Kim L , Garg S , O’Halloran A , et al. Risk factors for intensive care unit admission and in-hospital mortality among hospitalized adults identified through the U.S. coronavirus disease 2019 (COVID-19)-associated hospitalization surveillance network (COVID-NET). Clin Infect Dis. 2020. [PMID: ] doi:10.1093/cid/ciaa1012
    1. Lara OD , O’Cearbhaill RE , Smith MJ , et al. COVID-19 outcomes of patients with gynecologic cancer in New York City. Cancer. 2020. [PMID: ] doi:10.1002/cncr.33084
    1. Martinez DA , Hinson JS , Klein EY , et al. SARS-CoV-2 positivity rate for Latinos in the Baltimore-Washington, DC region. JAMA. 2020;324:392-5. [PMID: ] doi:10.1001/jama.2020.11374
    1. McCarty TR , Hathorn KE , Redd WD , et al. How do presenting symptoms and outcomes differ by race/ethnicity among hospitalized patients with COVID-19 infection? Experience in Massachusetts. Clin Infect Dis. 2020. [PMID: ] doi:10.1093/cid/ciaa1245
    1. Moscola J , Sembajwe G , Jarrett M , et al; Northwell Health COVID-19 Research Consortium. Prevalence of SARS-CoV-2 antibodies in health care personnel in the New York City area. JAMA. 2020;324:893-5. [PMID: ] doi:10.1001/jama.2020.14765
    1. Petrilli CM , Jones SA , Yang J , et al. Factors associated with hospital admission and critical illness among 5279 people with coronavirus disease 2019 in New York City: prospective cohort study. BMJ. 2020;369:m1966. [PMID: ] doi:10.1136/bmj.m1966
    1. Price-Haywood EG , Burton J , Fort D , et al. Hospitalization and mortality among black patients and white patients with Covid-19. N Engl J Med. 2020;382:2534-2543. [PMID: ] doi:10.1056/NEJMsa2011686
    1. Reichberg SB , Mitra PP , Haghamad A , et al; Northwell COVID-19 Research Consortium. Rapid emergence of SARS-CoV-2 in the greater New York metropolitan area: geolocation, demographics, positivity rates, and hospitalization for 46,793 persons tested by Northwell Health. Clin Infect Dis. 2020. [PMID: ] doi:10.1093/cid/ciaa922
    1. Rentsch CT , Kidwai-Khan F , Tate JP , et al. Covid-19 testing, hospital admission, and intensive care among 2,026,227 United States veterans aged 54-75 years. med. Rxiv. 2020. [PMID: ] doi:10.1101/2020.04.09.20059964
    1. Rentsch CT , Kidwai-Khan F , Tate JP , et al. Covid-19 by race and ethnicity: a national cohort study of 6 million United States veterans. med. Rxiv. 2020. [PMID: ] doi:10.1101/2020.05.12.20099135
    1. Rosenberg ES , Tesoriero JM , Rosenthal EM , et al. Cumulative incidence and diagnosis of SARS-CoV-2 infection in New York. Ann Epidemiol. 2020;48:23-29.e4. [PMID: ] doi:10.1016/j.annepidem.2020.06.004
    1. Salacup G , Lo KB , Gul F , et al. Characteristics and clinical outcomes of COVID-19 patients in an underserved-inner city population: a single tertiary center cohort. J Med Virol. 2020. [PMID: ] doi:10.1002/jmv.26252
    1. Shah P , Owens J , Franklin J , et al. Demographics, comorbidities and outcomes in hospitalized Covid-19 patients in rural southwest Georgia. Ann Med. 2020;52:354-60. [PMID: ] doi:10.1080/07853890.2020.1791356
    1. Vahidy FS , Nicolas JC , Meeks JR , et al. Racial and ethnic disparities in SARS-CoV-2 pandemic: analysis of a COVID-19 observational registry for a diverse US metropolitan population. BMJ Open. 2020;10:e039849. [PMID: ] doi:10.1136/bmjopen-2020-039849
    1. van Gerwen M, Alsen M, Little C, et al. Risk factors and outcomes of COVID-19 in New York City; a retrospective cohort study. J Med Virol. 2020. [PMID: ] doi:10.1002/jmv.26337
    1. Wang Z, Zheutlin AB, Kao YH, et al. Analysis of hospitalized COVID-19 patients in the Mount Sinai Health System using electronic medical records (EMR) reveals important prognostic factors for improved clinical outcomes. medRxiv. Preprint posted online 4 May 2020. doi:10.1101/2020.04.28.20075788
    1. Yehia BR , Winegar A , Fogel R , et al. Association of race with mortality among patients hospitalized with coronavirus disease 2019 (COVID-19) at 92 US hospitals. JAMA Netw Open. 2020;3:e2018039. [PMID: ] doi:10.1001/jamanetworkopen.2020.18039
    1. Abedi V , Olulana O , Avula V , et al. Racial, economic, and health inequality and COVID-19 infection in the United States. J Racial Ethn Health Disparities. 2020. [PMID: ] doi:10.1007/s40615-020-00833-4
    1. Bilal U, Barber S, Tabb L, Diez-Roux AV. Spatial inequities in COVID-19 testing, positivity, incidence and mortality in three US cities: a longitudinal ecological study. Version posted online 6 May 2020. medRxiv. 2020:2020.05.01.20087833.
    1. Goldstein JR , Atherwood S . Improved measurement of racial/ethnic disparities in COVID-19 mortality in the United States. med. Rxiv. 2020. [PMID: ] doi:10.1101/2020.05.21.20109116
    1. Guha A, Bonsu J, Dey A, Addison D. Community and socioeconomic factors associated with COVID-19 in the United States: zip code level cross sectional analysis. medRxiv. Preprint posted online 22 April 2020. doi:10.1101/2020.04.19.20071944.
    1. Karaye IM , Horney JA . The impact of social vulnerability on COVID-19 in the U.S.: an analysis of spatially varying relationships. Am J Prev Med. 2020;59:317-25. [PMID: ] doi:10.1016/j.amepre.2020.06.006
    1. Khanijahani A. County-level proportions of Black and Hispanic populations, and socioeconomic characteristics in association with confirmed COVID-19 cases and deaths in the United States. medRxiv. Preprint posted online 5 June 2020. doi:10.1101/2020.06.03.20120667
    1. Khazanchi R , Beiter ER , Gondi S , et al. County-level association of social vulnerability with COVID-19 cases and deaths in the USA [Letter]. J Gen Intern Med. 2020;35:2784-7. [PMID: ] doi:10.1007/s11606-020-05882-3
    1. Khose S , Moore JX , Wang HE . Epidemiology of the 2020 pandemic of COVID-19 in the state of Texas: the first month of community spread. J Community Health. 2020;45:696-701. [PMID: ] doi:10.1007/s10900-020-00854-4
    1. Li AY , Hannah TC , Durbin JR , et al. Multivariate analysis of black race and environmental temperature on COVID-19 in the US. Am J Med Sci. 2020;360:348-56. [PMID: ] doi:10.1016/j.amjms.2020.06.015
    1. Millett GA , Jones AT , Benkeser D , et al. Assessing differential impacts of COVID-19 on black communities. Ann Epidemiol. 2020;47:37-44. [PMID: ] doi:10.1016/j.annepidem.2020.05.003
    1. Nayak A , Islam SJ , Mehta A , et al. Impact of social vulnerability on COVID-19 incidence and outcomes in the United States. med. Rxiv. 2020. [PMID: ] doi:10.1101/2020.04.10.20060962
    1. Sehra ST , Fundin S , Lavery C , et al. Differences in race and other state-level characteristics and associations with mortality from COVID-19 infection [Letter]. J Med Virol. 2020. [PMID: ] doi:10.1002/jmv.26095
    1. Sy KTL , Martinez ME , Rader B , et al. Socioeconomic disparities in subway use and COVID-19 outcomes in New York City. med. Rxiv. 2020. [PMID: ] doi:10.1101/2020.05.28.20115949
    1. Whittle RS , Diaz-Artiles A . An ecological study of socioeconomic predictors in detection of COVID-19 cases across neighborhoods in New York City. BMC Med. 2020;18:271. [PMID: ] doi:10.1186/s12916-020-01731-6
    1. Zhang CH , Schwartz GG . Spatial disparities in coronavirus incidence and mortality in the United States: an ecological analysis as of may 2020. J Rural Health. 2020;36:433-45. [PMID: ] doi:10.1111/jrh.12476
    1. Fox T , Ruddiman K , Lo KB , et al. The relationship between diabetes and clinical outcomes in COVID-19: a single-center retrospective analysis. Acta Diabetol. 2020. [PMID: ] doi:10.1007/s00592-020-01592-8
    1. Pan D , Sze S , Minhas JS , et al. The impact of ethnicity on clinical outcomes in COVID-19: a systematic review. EClinicalMedicine. 2020;23:100404. [PMID: ] doi:10.1016/j.eclinm.2020.100404

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