Association of Poor Housing Conditions with COVID-19 Incidence and Mortality Across US Counties

Abstract

Background: The association between poor housing conditions, which can compromise physical distancing, and COVID-19 incidence and mortality across US counties remains unknown. Methods: We conducted cross-sectional analysis of county-level data from the US Centers for Disease Control, US Census Bureau and John Hopkins Coronavirus Resource Center for 3141 US counties. The exposure of interest was percentage of households with poor housing conditions (one or more of: overcrowding, high housing cost, incomplete kitchen facilities, or incomplete plumbing facilities). Outcomes were incidence rate ratios (IRR) and mortality rate ratios (MRR) of COVID-19 across US counties through 4/21/2020. Multilevel generalized linear modeling was utilized with adjustment for population density and county characteristics including demographics, income, education, prevalence of medical comorbidities, access to healthcare insurance and emergency rooms, and state-level COVID-19 test density. Findings: Across 3135 US counties, the mean percentage of households with poor housing conditions was 14.2% (range 2.7% to 60.2%). In the fully adjusted models, with each 5% increase in percent households with poor housing conditions, there was a 50% higher risk of COVID-19 incidence (IRR 1.50, 95% CI: 1.38 – 1.62) and a 42% higher risk of COVID-19 mortality (MRR 1.42, 95% CI: 1.25 – 1.61). Results remained similar using earlier timepoints (3/31/2020 and 4/10/2020). Interpretation: Counties with a higher percentage of households with poor housing had higher incidence of, and mortality associated with, COVID-19. These findings suggest targeted health policies to support individuals living in poor housing conditions should be considered to mitigate adverse outcomes associated with COVID-19. Funding Statement: None. Declaration of Interests: None. Ethics Approval Statement: Since there is no individual identifying information, the data were in aggregate by county, and publicly available from the Centers for Disease Control (CDC), US census Bureau and John Hopkins Coronavirus Resource Center, the protocol received exemption from the Providence Veterans Affairs Medical Center Institutional Review Board.