Abstract
Descriptive data have revealed significant racial/ethnic disparities in coronavirus disease 2019 (COVID-19) cases in the US, but underlying mechanisms of disparities remain unknown. To examine the association between county-level sociodemographic risk factors and US COVID-19 incidence and mortality. This cross-sectional study analyzed the association between US county-level sociodemographic risk factors and COVID-19 incidence using mixed-effects negative binomial regression, and COVID-19 mortality using zero-inflated negative binomial regression. Data on COVID-19 incidence and mortality were collected from January 20 to July 29, 2020. The association of social risk factors with weekly cumulative incidence and mortality was also examined by interacting time with the index measures, using a random intercept to account for repeated measures. Sociodemographic data from publicly available data sets, including the US Centers for Disease Control and Prevention's Social Vulnerability Index (SVI), which includes subindices of socioeconomic status, household composition and disability, racial/ethnic minority and English language proficiency status, and housing and transportation. As of July 29, 2020, there were a total of 4 289 283 COVID-19 cases and 147 074 COVID-19 deaths in the US. An increase of 0.1 point in SVI score was associated with a 14.3% increase in incidence rate (incidence rate ratio [IRR], 1.14; 95% CI, 1.13-1.16; P < .001) and 13.7% increase in mortality rate (IRR, 1.14; 95% CI, 1.12-1.16; P < .001), or an excess of 87 COVID-19 cases and 3 COVID-19 deaths per 100 000 population for a SVI score change from 0.5 to 0.6 in a midsize metropolitan county; subindices were also associated with both outcomes. A 0.1-point increase in the overall SVI was associated with a 0.9% increase in weekly cumulative increase in incidence rate (IRR, 1.01; 95% CI, 1.01-1.01; P < .001) and 0.5% increase in mortality rate (IRR, 1.01; 95% CI, 1.01-1.01; P < .001). In this cross-sectional study, a wide range of sociodemographic risk factors, including socioeconomic status, racial/ethnic minority status, household composition, and environmental factors, were significantly associated with COVID-19 incidence and mortality. To address inequities in the burden of the COVID-19 pandemic, these social vulnerabilities and their root causes must be addressed.
Highlights
While some have referred to coronavirus disease 2019 (COVID-19) as “the great equalizer,” early reports from hard-hit areas in the US suggest that the disease has a disproportionate burden associated with the longstanding social determinants of health, including racial/ethnic and socioeconomic disparities.[1,2,3] In Michigan, one of the first states to report COVID-19 data by race/ ethnicity and demographic characteristics, African American individuals initially experienced 31% of the state’s 57 397 cases despite representing only 14% of the state’s population.[4]
An increase of 0.1 point in Social Vulnerability Index (SVI) score was associated with a 14.3% increase in incidence rate and 13.7% increase in mortality rate (IRR, 1.14; 95% CI, 1.12-1.16; P < .001), or an excess of 87 COVID-19 cases and 3 COVID-19 deaths per 100 000 population for a SVI score change from 0.5 to 0.6 in a midsize metropolitan county; subindices were associated with both outcomes
Our analysis revealed that racial/ethnic minority status was significantly associated with COVID-19 incidence and mortality, reinforcing anecdotal evidence on disparities from the field and those preliminarily reported by state health departments.[2,3,5,6,8]
Summary
While some have referred to coronavirus disease 2019 (COVID-19) as “the great equalizer,” early reports from hard-hit areas in the US suggest that the disease has a disproportionate burden associated with the longstanding social determinants of health, including racial/ethnic and socioeconomic disparities.[1,2,3] In Michigan, one of the first states to report COVID-19 data by race/ ethnicity and demographic characteristics, African American individuals initially experienced 31% of the state’s 57 397 cases despite representing only 14% of the state’s population.[4]. Emerging data on COVID-19 disparities are concerning. A myriad of factors have been posited, from biological, to medical risk factors, such as diabetes and lung disease, to social risk factors, such as low socioeconomic status, crowded housing, and necessary use of public transportation.[3,9] As states and localities vary in whether and how frequently they report COVID-19 data by race/ethnicity and other sociodemographic characteristics,[1,2,3,5,8,9] our knowledge of risk factors at the individual level is mostly limited to anecdotal reports and ecological studies What underlying factors can explain this inequitable burden of the pandemic on low-income and minority communities? A myriad of factors have been posited, from biological, to medical risk factors, such as diabetes and lung disease, to social risk factors, such as low socioeconomic status, crowded housing, and necessary use of public transportation.[3,9] As states and localities vary in whether and how frequently they report COVID-19 data by race/ethnicity and other sociodemographic characteristics,[1,2,3,5,8,9] our knowledge of risk factors at the individual level is mostly limited to anecdotal reports and ecological studies
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