Department Of State Health Services Research Articles

COVID-19 data driven planning: The SouthEast Texas approach.

This coautoethnographic case study used the Open-Source Public Health Intelligence process to explore and share the South East Texas Regional Advisory Councils' (SETRAC) experience in collecting, processing, disseminating/visualizing, and analyzing COVID-19 data during the pandemic in the largest national medical setting in the United States. Specifically, it details the production of Business Intelligence reports powered by PowerBI both with general publics and with Regional Healthcare Preparedness Program (HPP) Coalition Coordinators, County Judges and City Mayors, Texas Department of State Health Services (DSHS) executive leadership, the Offices of the Texas Governor, and the Federal Pandemic Task Force led by the US Vice President, in order to provide a foundation for situational awareness, inter-regional collaboration, allocation of scare resources, and local, regional, and state policy decisions. It highlights best practices in risk and crisis communications during the COVID-19 response, underscores cross-sector collaboration and standardization of data collection for effective planning and response, discusses pervasive data revealed during the analysis, and evaluates collaborative and feedback processes that have implications for the Health Care System and Homeland Security Enterprise information sharing.

Factors that Increase Risk of an HIV Diagnosis Following a Diagnosis of Syphilis: A Population-Based Analysis of Texas Men.

Studies have consistently shown that diagnosis of a syphilis infection increases the risk of human immunodeficiency virus (HIV) infection. This study examines patterns in HIV incidence among men following a Primary and Secondary (P&S) syphilis diagnosis. P&S syphilis cases among men reported to the Texas Department of State Health Services between January 2010 and June 2018 were linked to the Enhanced HIV/AIDS Reporting System. Risk factors for HIV diagnosis were identified using univariate and multivariate extended Cox proportional hazards models. The 9113 men with syphilis without a concurrent or prior HIV diagnosis contributed a cumulative 35,674 person-years with a mean follow-up time of 3.9years. The multivariate model showed that among men with a P&S syphilis diagnosis, age, race/ethnicity, transmission risk, comorbid STDs, subsequent STDs, and syphilis diagnosing facility were independently associated with a new HIV diagnosis. The results highlight disparities in HIV diagnoses, despite current prevention recommendations. Reducing these disparities will require multi-level, comprehensive interventions that are appropriate for the diverse populations around the state.

Infant Mortality and Maternal Risk Factors in Texas: Highlighting Zip Code Variations in 2 At-Risk Counties, 2011-2015.

IntroductionStark differences in the infant mortality rate (IMR) exist by geography in Texas. The Healthy Families initiative sought to understand how evidence-informed practices implemented in the community can improve pregnancy-related outcomes in 2 counties in Texas with a high prevalence of maternal chronic conditions. The objective of this study was to examine associations between maternal risk factors and infant deaths to inform strategies to improve outcomes.MethodsTwo counties with high prevalence of maternal chronic conditions were selected as Healthy Families sites: one with lower prenatal care usage than other counties in the state but an IMR lower than Texas, and the other with a higher IMR among minority racial and ethnic groups compared with other women in the county and Texas overall. Cohort-linked birth and infant death records from 2011 through 2015 provided by the Texas Department of State Health Services were analyzed by using logistic regression to examine associations of maternal sociodemographic and pregnancy risk factors with infant death. The data were mapped at the zip code level. Analyses were limited to births to women aged 15 to 49 years who resided in Texas from 2011 through 2015 (n = 1,942,899 births).ResultsThe Texas IMR was 5.4 per 1,000 live births, compared with 4.6 and 7.5 per 1,000 live births for Hidalgo and Smith counties, respectively. Congenital malformations were the leading cause of infant death in both counties for infants born in 2015, which was similar to Texas overall. In both counties, maternal marital status, education, multiple gestation, and cesarean delivery were significantly associated with infant mortality. Wide zip code–level variations in IMR and maternal risk factors were observed in both counties.ConclusionVariations in IMR and key maternal risk factors observed at the zip code level helped drive local strategies to maximize outreach of services to disproportionately affected communities.

Level II trauma centers have highest charges for hip fractures

Objectives: To evaluate the charges for pertrochanteric hip fracture care in Texas. Design: Database review. Setting: Texas Hospital Inpatient Public Use Data File (PUDF) Intervention: Charges reported by hospitals to the Texas Department of State Health Services for pertrochanteric hip fractures. Main outcome measurement: Charges associated with pertrochanteric hip fracture stratified by implant type and according to facility trauma level designation, urban versus rural, teaching versus non-teaching, and border versus inland status. Results and conclusions: There were a total of 44,853 pertrochanteric hip fracture surgeries performed over the three-year period in the state of Texas. The vast majority were treated at urban (93.4%), inland (non-border) (92.3%), non-teaching (74.2%) facilities with intramedullary fixation (56.9%). A significant increase in charges was associated with treatment at an urban ($32,412), border ($44,919), or teaching ($10,501) facility. Mean inpatient charges at Level II facilities was $113,700. Further study is warranted to determine what drives the differences in charges associated with hip fracture treatment. Level of Evidence: IV; Economic Database Analysis Keywords: hip fracture, access to care, charge analysis, value-based care, Texas. (J Ortho Business 2022; 1:4-6)

How Would Medicaid Expansion Affect Texas Hospitals? Evidence From a Retrospective Quasi-Experimental Study.

This study aims to estimate the impact of a potential Medicaid expansion on Texas hospitals. The Affordable Care Act (ACA) Medicaid expansion increased access to health care and improved health outcomes. Still, several states, including Texas, have not adopted the expansion. This is a retrospective quasi-experimental study. We obtained inpatient data containing discharges from Texas hospitals between 2010 and 2017 from the Texas Department of State Health Services. Texas hospitals receive a significant number of patients from the adjacent states. We use a difference-in-differences methodology, where the patients from the neighboring states that expanded Medicaid in 2014 are the treatment group, and those that reside in Texas are the control group. The outcome variables are the payer mix and the cost of treatment, proxied by Diagnoses Related Group (DRG) weights assigned by the Centers for Medicare and Medicaid Services (CMS). The Medicaid expansion is associated with 4.15% lower costs of treatment among the patients from the expansion states (P < .01). Also, the uninsured rate decreased by 4.7 percentage points (from 11.3%, P < .01), while the share of Medicaid patients increased by 10.9 percentage points (from 30.7%, P < .01). There are no significant changes in the share of privately insured or Medicare patients. Texas hospitals can benefit significantly from Medicaid expansion due to reductions in average treatment costs and the share of the uninsured.

Spatial diffusion of Omicron in Texas: Predictable or Random?

The impacts of Covid-19 on society and the environment have now, three years from its first appearance, ballooned across the scientific literature. But our knowledge of where it originated, and why it spread as it did, has advanced much more slowly. Models of spatial diffusion at national level have been applied to past pandemics with some success, but not yet to Covid-19. One exception is a study of the spread of the original strain of Covid-19 in Texas between March and September 2020. This spread adhered to spatial diffusion theory: first hierarchical, that is into metropolitan areas in proportion to their population sizes; later contagious, that is into adjacent towns based on their proximity to metropolitan areas to which they were tributary; and finally hierarchical once more, into the most isolated towns based on their urban/ rural status. This process took six months. By contrast, the Omicron variant, in less than two months (December 2021 and January 2022), reached case levels three times those of the original Covid surges. The current study focuses on how Omicron diffused across Texas over the period November to February 2021-22. Daily case numbers for Covid-19 were available for all 254 counties from the Texas Department of State Health Services over this period, and the Omicron variant was identifiable from these data. This analysis will reveal whether the Omicron spread across the counties of Texas was predictable, partially predictable, or unpredictable, based on county population, distance to their regional metro, or the gravity concept (the ratio between the two). These insights will be of value if other such variants appear on the horizon for the US and Texas, enabling local health officials to anticipate the onset in their communities.

Entomological Investigation Following a Zika Outbreak in Brownsville, Texas.

In November and December 2016, an outbreak of locally transmitted Zika occurred in Brownsville, TX. The Texas Department of State Health Services requested for a Centers for Disease Control and Prevention (CDC) Epi Aid, and as part of that Epi Aid a team of CDC entomologists was deployed in January 2017. The mission was to improve mosquito-based arbovirus surveillance and evaluate the possibility of continuing local Zika virus (ZIKV) transmission in the city. The mosquito-based arbovirus surveillance program was expanded from 4 to 40 BG-Sentinel traps evenly distributed throughout the city. Over a 2-wk period, 15 mosquito species were detected; the most abundant species were Culex quinquefasciatus, Aedes aegypti, and Ae. albopictus, which accounted for 66.7%, 16.2%, and 5.7% of the total mosquito collection, respectively. The relative abundance of Ae. aegypti (1.0 mosquitoes/trap/day) and Ae. albopictus (0.4 mosquitoes/trap/day) was very low and unlikely to initiate and/or sustain ZIKV transmission. Zika virus was not detected in the mosquitoes collected, suggesting no or extremely low ZIKV transmission at that time.

HIV Testing Strategies for Health Departments to End the Epidemic in the U.S.

An important goal of the Ending the HIV Epidemic in the U.S. initiative is the timely diagnosis of all people with HIV as early as possible after infection. To end the HIV epidemic, health departments were encouraged to propose new and innovative HIV testing strategies and improve the reach of existing programs. These activities were divided into 3 core strategies: expansion of routine screening in healthcare settings, locally tailored HIV testing initiatives in nonhealthcare settings, and specific efforts to increase the frequency of testing for individuals with increased potential for acquiring HIV. Because HIV testing is such a crucial part of the core activities of the Centers for Disease Control and Prevention's HIV prevention programs, there are many examples of evidence-based programs and best practices for HIV testing in both clinical and nonclinical settings. This article reviews the evidence base for these strategies and some of the activities proposed under the Diagnose pillar to achieve the goal of diagnosing all HIV infections as early as possible. All other Ending the HIV Epidemic in the U.S. activities start with an awareness of HIV status, which is actually the indicator for which most health departments are closest to the proposed targets. There are both proven and emerging approaches to increasing HIV screening and increasing the frequency of HIV screening available. The Ending the HIV Epidemic in the U.S. initiative provides the motivation, the resources, and a coordinated plan to bring them to scale.

Health Disparities of Coronavirus Disease 2019 in Texas, March-July 2020.

Although disparities in coronavirus disease 2019 (COVID-19) prevalence are known, knowledge of the recent surge of COVID-19 in Texas and factors affecting fatality rates is limited. Understanding the health disparities associated with COVID-19 can help healthcare professionals determine the populations that are most in need of COVID-19 preventive care and treatment. The aim of this study was to assess COVID-19-related case and mortality rates. Our cross-sectional analysis used Texas Department of State Health Services COVID-19 case surveillance counts. Case, hospitalization, and mortality counts were obtained from March to July 2020. From March to July 2020, there were 420,397 COVID-19-related cases and 6954 deaths in Texas. There were 3277 new cases and 104 deaths in March, and 261,876 new cases and 3660 deaths in July. The number of new COVID-19 cases was the highest from March to April (relative risk 1.77, 95% confidence interval [CI] 1.76-1.78). Although the death rate in June was a 30% increase over the rate in May, death rates nearly tripled by the end of July, for a total of 3660 deaths. Of the 3958 deaths, demographic data were available for 753 deaths. Of these, 440 were male, 16 Asian, 95 Black, 221 Hispanic, 325 White, and 96 were "Other" or "Unknown." Males were associated with a slightly higher chance of acquiring COVID-19 than females (odds ratio [OR] 1.11, 95% CI 1.09-1.14) and nearly a 29% higher chance of dying of COVID-19 compared with females (OR 1.29, 95% CI 1.11-1.49). Bivariate analysis revealed that the probability of acquiring COVID-19 was 12% higher in older adults compared with individuals younger than 65 years old (OR 1.12, 95% CI 1.08-1.16), and older adults had an 18.8 times higher risk of death when compared with the rate of younger individuals (OR 18.79, 95% CI 15.93-22.15). Hispanics and Blacks were 70% and 48%, respectively, more likely to contract COVID-19 than Whites. All races had lower significant chance of death when compared with Whites. At the end of July, there was a total of 430,485 Texas COVID-19 cases and 6387 fatalities (8.8% of all cases and 4% of all deaths in the United States.). Case fatality ratios were the highest in older adults. As we continued to observe data, in contrast to previous study time points, we found that Asians and Hispanics had no significant difference in COVID mortality rates and were comparable in terms of mortality odds and death case ratios when compared with Whites. This time period represents the highest COVID-19 surge time in Texas. Although our data consist of a short time period of population-level data in an ongoing pandemic and are limited by information reported to the Texas Department of State Health Services, older age, male sex, Hispanics, and Blacks are currently associated with higher infection rates, whereas older age, male sex, and Whites are associated with higher mortality rates. Clinicians and decision makers should be aware of the COVID-19 health disparities and risk factors for mortality to better promote targeted interventions and allocate resources accordingly.

A Checklist of the Mosquito Species in 13 Counties West of San Antonio, Texas.

The aim of this study was to consolidate mosquito information for 13 counties west of San Antonio, Bexar County, Texas, and to create a species checklist for future regional studies. The resulting checklist established a baseline for local mosquito-borne disease surveillance and can serve as a resource for public health officials. The 13 counties in this region were Bandera, Edwards, Kendall, Kerr, Kimble, Kinney, Maverick, Medina, Real, Sutton, Uvalde, Val Verde, and Zavala counties. To develop the checklist, county-level mosquito species data were extracted from 38 peer-reviewed publications and government documents, university reference collections, private collections, and the Texas Department of State Health Services' historical collection data. These data were combined with author field collections to create a comprehensive species list. Overall, 339 county-level records were documented through field studies with a total of 36 species representing 8 genera confirmed as being present in this region. An additional 14 species listed in historical surveillance records were not collected during this study.

Trauma center funding: time for an update

BackgroundUncompensated care (UC) is healthcare provided with no payment from the patient or an insurance provider. UC directly contributes to escalating healthcare costs in the USA and potentially impacts patient...

The epidemiology of human ehrlichiosis in Texas, 2008-2017

Tick-borne diseases in the United States, including ehrlichiosis, represent a growing public health problem. The purpose of this study was to examine the contemporary epidemiology of human ehrlichiosis in Texas by analyzing cases reported to the Texas Department of State Health Services. In Texas, 101 cases of ehrlichiosis were reported during 2008-2017. We observed geographic grouping of cases as well as an increasing trend of reported cases occurring annually from 2009 to 2017. Notably, 27 cases occurred in 2008 in south Texas with unique patient characteristics in that they were younger, less likely to be hospitalized, and presented with disease earlier in the year than typically seen. Our findings highlight the importance of disease awareness and prevention of tick bites as well as further investigation into transmission risk and future disease patterns.

Estimated Prevalence of SARS-CoV-2 Antibodies in the Texas Pediatric Population, 2021

Background: The extent of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in children and adolescents at a population level in 2021 remains unclear. Children and adolescents have been considered to play an important role in transmission regardless of presence of symptoms. The objective of this study was to estimate the prevalence of SARS-CoV-2 antibody status in children ages 5-to-19 years in a sample from the State of Texas in the presence and absence of symptoms.Methods: The TX CARES (Texas Coronavirus Antibody Response Survey) is an ongoing prospective population-based sample from the Texas general population (~29·8 million) that commenced in October 2020. For the current analysis, volunteers ages 5-to-19 years were recruited throughout the state from large pediatric healthcare systems, Federally Qualified Healthcare Centers, urban and rural pediatric and family medicine practices, health insurance providers, and a social media campaign. SARS-CoV-2 antibody status measured via the Roche Elecsys® Anti-SARS-CoV-2 Immunoassay. Prevalence of IgM, IgA, or IgG antibodies were adjusted using sampling weights and post-stratification of age and sex. We report here findings from January 1-June 1, 2021.Findings: This analysis that included 503 children ages 5-to-19 years showed 38·7% (95% CI, 34·5-43·1) of the sample was SARS-CoV-2 antibody positive in fully adjusted estimates. A total of 30·1% (95% CI, 29·4-31·5) of adults (N=6992) in the sample were antibody positive. Over half (55·8%) of those with positive antibody status were reportedly asymptomatic. Headache (25·4%), congestion/runny nose (20·8%), and fatigue (20·3%) and were the most frequently reported symptoms among those with a positive antibody result. The odds of having a positive antibody status was 37% higher in 15-to-19 year olds versus adults (OR 1·37, 95% CI, 1·03-1·83). Interpretation: These results highlight that a majority of the pediatric population remains immunologically naive to SARS-CoV-2, emphasizing the important role vaccines may play in reaching whole population herd immunity.Funding: Texas Department of State Health Services.Declaration of Interest: We declare no competing interests.Ethical Approval: All protocols were reviewed and approved by the University of Texas Health Science Center at Houston Institutional Review Board (IRB), but also deemed public health practice by the Texas Department of State Health Services IRB.

59-OR: The Diabetes Garage: Using Automotive Maintenance Analogies to Engage Mexican-American Men to Participate in a Diabetes Self-Management and Education Program

Mexican-American (MA) men are three times more likely to have diabetes compared to non-Hispanic whites. Despite the availability of diabetes management programs, MA men are underrepresented. The CDC reports that woman (75%) disproportionately participate in diabetes programs compared to men (25%). MA men in particular, have less diabetes knowledge, are less likely to visit a diabetes specialist or adhere to treatments, and are more likely to have complications. Purpose: The Diabetes Garage (DG) is designed to engage MA men in self-management behaviors, improve glycemic and physical health outcomes. Methods: The DG was implemented 2 hours weekly/4 weeks and co-taught by CDCES and automotive technicians. Pre-posttests of self-management behaviors and physical indicators were collected at workshop 1 and at the end of workshop 4. Wilcoxon matched-pairs signed-rank tests were conducted to assess pre-post test differences in behavior (food portion/carbohydrate intake, physical activity) and paired t-tests were conducted to examine differences in health outcomes (i.e., A1c, BP, weight, waist). Results: Data from 2018-2020 (N=74) indicate 77% retention rate. Statistically significant improvements were found in self-reported food portion (Z= -2.030, p &amp;lt;.05) and carbohydrate intake (Z= -2.787, p &amp;lt;.01). Statistically significant improvements were found in systolic BP (t=2.91, mean diff=9.47, p=.01) and improvements in diastolic BP (t=1.41, mean diff=8.18, p =.176). Satisfaction surveys show that men enjoyed the workshops: “The information, the presenters, the diabetes education was totally empowering ⋯ I am looking forward to better managing my diabetes and driving my human-mobile for a long-time...with good quality of life.” Conclusion: Use of automotive maintenance analogies is a feasible approach for engaging men in diabetes management programs, self-management behaviors, and improving health indicators. Disclosure J. B. Concha: None. G. Schober: None. D. N. Portillo: None. R. F. Ruiz: None. R. Ramos: None. R. L. Romero: None. A. Lopez: None. P. Winkler: None. Funding Texas Department of State Health Services

Mathematical Modeling and COVID-19 Forecast in Texas, USA: A Prediction Model Analysis and the Probability of Disease Outbreak.

Response to the unprecedented coronavirus disease 2019 (COVID-19) outbreak needs to be augmented in Texas, United States, where the first 5 cases were reported on March 6, 2020, and were rapidly followed by an exponential rise within the next few weeks. This study aimed to determine the ongoing trend and upcoming infection status of COVID-19 in county levels of Texas. Data were extracted from the following sources: published literature, surveillance, unpublished reports, and websites of Texas Department of State Health Services (DSHS), Natality report of Texas, and WHO Coronavirus Disease (COVID-19) Dashboard. The 4-compartment Susceptible-Exposed-Infectious-Removal (SEIR) mathematical model was used to estimate the current trend and future prediction of basic reproduction number and infection cases in Texas. Because the basic reproduction number is not sufficient to predict the outbreak, we applied the Continuous-Time Markov Chain (CTMC) model to calculate the probability of the COVID-19 outbreak. The estimated mean basic reproduction number of COVID-19 in Texas is predicted to be 2.65 by January 31, 2021. Our model indicated that the third wave might occur at the beginning of May 2021, which will peak at the end of June 2021. This prediction may come true if the current spreading situation/level persists, i.e., no clinically effective vaccine is available, or this vaccination program fails for some reason in this area. Our analysis indicates an alarming ongoing and upcoming infection rate of COVID-19 at county levels in Texas, thereby emphasizing the promotion of more coordinated and disciplined actions by policy-makers and the population to contain its devastating impact.

Changes to Timeliness and Completeness of Infectious Disease Reporting in Texas After Implementation of an Epidemiologic Capacity Program.

The objective of this study was to characterize the changes in timeliness and completeness of disease case reporting in Texas in response to an increasing number of foodborne illnesses and high-consequence infectious disease investigations and the Texas Department of State Health Services' new state-funded epidemiologist (SFE) program. We extracted electronic disease case reporting data on 42 conditions from 2012 through 2016 in all local health department (LHD) jurisdictions. We analyzed data on median time for processing reports and percentage of complete reports across time and between SFE and non-SFE jurisdictions using Mann-Whitney t tests and z scores. The median time of processing improved from 13 days to 10 days from 2012 to 2016, and the percentage of disease case reports that were complete improved from 19.6% to 27.7%. Most reports were for foodborne illnesses; both timeliness (11 to 7 days) and completeness (20.9% to 23.5%) improved for these reports. Disease reporting improvements in timeliness and completeness were associated with the SFE program and its enhancement of epidemiologic capacity. SFEs were shown to improve surveillance metrics in LHDs, even in jurisdictions with a high volume of case reports. Adding epidemiologist positions in LHDs produces a tangible outcome of improved disease surveillance.

Modeling COVID-19 positivity rates and hospitalizations in Texas

The aim of this study was to jointly model COVID-19 test positivity rates and hospitalizations in Texas using Bayesian joinpoint regression. The data for both test positivity rates and hospitalizations were obtained from the Texas Department of State Health Services between April 5 and October 19, 2020. The stage 1 model identifies four significant shifts in test positivity rates, three of which occur roughly 9 days after documented policy or behavioral changes statewide. Estimated positivity rates from the first model were then used to predict hospitalization rates and to estimate lag time between changes in positivity and hospitalization. The resulting lag time is 9.056 days (± 3.808). Both models are valuable to policy makers and public health officials as they study the impact of behavioral patterns on disease prevalence and resulting hospitalizations.

Epidemiology Surveillance and Capacity Improvement: A Characterization of Texas, 2017.

In response to increasing caseloads of foodborne illnesses and high consequence infectious disease investigations, the Texas Department of State Health Services (DSHS) requested funding from the Texas Legislature in 2013 and 2015 for a new state-funded epidemiologist (SFE) program. Primary cross-sectional survey data were collected from 32 of 40 local health departments (LHDs) via an online instrument and analyzed to quantify roles, responsibilities, and training of epidemiologists in Texas in 2017 and compared to similar state health department assessments. Sixty-six percent of SFEs had epidemiology-specific training (eg, master's in public health) compared to 45% in state health department estimates. For LHDs included in this study, the mean number of epidemiologists per 100 000 was 0.73 in medium LHDs and 0.46 in large LHDs. SFE positions make up approximately 40% of the LHD epidemiology workforce of all sizes and 56% of medium-sized LHD epidemiology staff in Texas specifically. Through this program, DSHS increased epidemiology capacity almost twofold from 0.28 to 0.47 epidemiologists per 100 000 people. These findings suggest that capacity funding programs like this improve epidemiology capacity in local jurisdictions and should be considered in other regions to improve general public health preparedness and epidemiology capacity.

County-Level Records for Culex stigmatosoma and Culex thriambus in Texas

Populations of Culex stigmatosoma and Cx. thriambus have been documented in the southwestern USA with a southward range extension to northern South America and Central America, respectively. Studies conducted in California indicate both species are potential vectors of West Nile virus. However, vector competence studies are lacking for other parts of the USA. During a multicounty regional surveillance study west of San Antonio, Texas, multiple errors were observed in the Texas distributional literature of these species. These errors involved incorrect distributional information in Texas and US publications. Evidence to correct these errant records was found upon further analysis of Texas literature and curated specimens. Therefore, the aims of this study were to present that evidence and then combine the corrected records with additional records from the Texas Department of State Health Services and from larval collections made during other Texas surveillance studies.

County-Level Determinants of COVID-19 Testing and Cases: Are There Racial/Ethnic Disparities in Texas?

Reports suggest that COVID-19 affects people of color disproportionately. Texas ranks second in the count of confirmed US cases. This study examined the relationship between county-level racial/ethnic composition and COVID-19 testing/cases in Texas, adjusting for population-level demographic characteristics, health factors, and health care access measures. County-level testing and case data, obtained from the Texas Department of State Health Services, were combined with the 2020 Robert Wood Johnson Foundation County Health Rankings data. Outcome variables were tests per 100,000 population and cases per 100,000 population. The independent variable of interest was percent of racial and ethnic composition. Multivariable linear regression analyses were used. There was a statistically significant increase in COVID-19 testing/100,000 population with every 1% increase in the proportion of African Americans/Blacks (β = 2065.4; P = 0.009), Asians (β = 2056.2; P = 0.015), and Hispanics (β = 1641.1; P = 764.7). After controlling for county characteristics and cases/100,000 population, these relationships were no longer significant. However, primary care physician rate was significantly associated with testing/100,000 population (β = 64.0; P = 0.027), as was the percent of uninsured (β = -469.9; P = 0.024). An analysis of case data showed that African Americans had the largest number of cases/100,000 (β = 432.2; P = 0.001), followed by Hispanics (β = 422.8; P < 0.001) and Asians (β = 415.4; P = 0.004). As in other parts of the United States, African Americans and Hispanics are most affected by COVID-19 in Texas. Community-based strategies to improve access to testing or reduce community spread outside clinical settings should target counties with low primary care physician rates or a high proportion of uninsured residents.