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?Evidence-Based Medicine InfoSheet: Epidemiology and Health SystemsUpdated [9/10/20]Review completed by: [Rose Ann Huynh, MD, Swetha Maddipudi (MS3), Laureen Gbordzoe (MS2), Cameron Holguin (MS2)]Peer Review by: [Jason Rosenfeld, DrPH]PICO - Is there increased risk for morbidity and mortality in the Black population from COVID-19?Key Findings:The Johns Hopkins University and American Community Survey indicate that to date, of 131 predominantly Black counties in the US, the infection rate is 137.5/100,000 and the death rate is 6.3/100,000. This is in contrast to an infection rate of 19.5/100,000 and a death rate of 0.5/100,000 in predominately Asian counties, 27.2/100,000 and 0.6/100,000 in predominately Hispanic counties, and 39.8/100,000 and 1.1/100,000 in predominately White counties1. Infection ratesInfection rate is more than 3-fold higher in black counties than that in predominantly white counties2. Black males are incarcerated at a rate that is at least six times those of white males.13African Americans made up almost half of Milwaukee County's 945 cases. In Michigan, where the state's population is 14% black, African Americans made up 35% of cases as of April 3rd. 15In a New Orleans community clinic from March 16th - April 10th, 117/345 patients that were screened tested positive; 68/117 patients were African American.18 Nationally from March 9, 2020 to May 31st, 2020, there was an increasing trend in SARS-CoV-2 NAAT positivity rate in Black non-Hispanic people while there was decreasing trend in SARS-CoV-2 NAAT positivity in White people19. Nationally, 15% of cancer patients who tested positive for SARS-CoV-2 were African American compared to just 5.5% of White cancer patients. Mortality ratesDeath rate for predominantly black counties is 6-fold higher than in predominantly white counties2. A higher mortality from COVID-19 has been locally documented in Black populations from New Orleans, LA, Chicago, IL, Milwaukee, WI and Detroit, MI and even rural Albany, GA. Some of the reasons attributed to this are increased prevalence of comorbidities among the Black population2 as well as preexisting healthcare disparities in some of these cities4,5,6.One study used existing data to model death rates and found that Blacks have a higher death rate overall, especially states that have higher proportions of Black and Medicare-insured residents. They observed lower death rates due to COVID-19 in the Black population in states with more children and states with a higher population density. The effects of the difference in population density may be explained by differences in resource availability, urban distribution, and other demographic differences that are hard to clarify11.326/3626 COVID-19 positive patients died from COVID-19 in the Louisiana Ochsner Health System, and 70.6% of these patients were black. Black race was not associated with higher in-hospital mortality than white race (hazard ratio for death vs. white race, 0.89; 95% confidence interval, 0.68 to 1.17). 12 In Milwaukee, the blacks population made up 81% of its 27 deaths due to COVID-19; the county population is 26% black. In Michigan, the black population made up 40% of deaths due to COVID-19 as of April 3rd and the state is 14% black.15Nationally, African Americans account for 24% of total COVID-19 deaths despite only making up 12% of the US population.19 The Bronx reported more COVID-19 hospitalizations and death than any other New York City Borough. The Bronx has the highest black population, lowest median household income, lowest level of education, and lowest proportion of adults over the age of 65 compared to other New York City Boroughs20.African American life expectancy is expected to drop 1.5 years due to COVID-19 compared to only a 0.5 year drop in whites. This will increase the life expectancy gap between African Americans and Whites from 3.6 year to 4.7 years, erasing a decade of reductions in this gap.21Nationally, the African American death rate from COVID-19 is 85/100,000 compared to 35/100,000 of White Americans. 24Hospitalization ratesIn California, the odds of hospitalization is 2.7x higher for Black patients when compared to non-hispanic whites3. Examination of hospitalization rates and trends within the Ochsner Health System in Louisiana found that 39.7% of COVID-19 positive patients (n=1382) were hospitalized and 76.9% were Black. Higher numbers of Black patients presented with elevated lab markers and, of patients who received critical care of mechanical ventilation, approximately 80% were black.126/117 patients from a New Orleans community clinic were hospitalized (3 African American, 2 Latinx, and 1 white).18Co-morbidities and other potential factors contributing to the disproportionate COVID-19 rates in African Americans/BlacksIn LA alone, the top 3 underlying conditions among COVID-19 deaths are hypertension (59.76%), diabetes (38.10%) and chronic kidney disease (22.50%). 4,5,6Disparities may be due to a higher rate of comorbidities in the Black population, as well as persisting social inequities, such as poverty, racial discrimination and spatial exclusion7. Incarcerated communities are especially susceptible to COVID-19 due to higher risk for transmission caused by close indoor confinement, overcrowding, poor nutrition, and inadequate healthcare13.Obesity is associated with higher risk of contracting severe COVID-19 infection. African-Americans have higher rates of obesity than their white counterparts.14In a New York study based on zip-codes, the second strongest unadjusted bivariate predictor of positive COVID-19 tests was self-identifying as African American/Black; the strongest predictor was having COPD. This may be due to environmental factors such as population and housing density; 80% of non-medical staff working at some of the hardest hit New York Hospital are African American/Black or Hispanic .17Cardiovascular disease, hypertension, diabetes, and chronic respiratory diseases have increased in African American populations. All of these factors are associated with increased risk for COVID-19 complications.22 Air pollution has been found to have a significant correlation with increased number of positive COVID cases. African Americans are at greater risk of being negatively affected by air pollution.22Many African Americans are employed in professions that place them at an increased risk of contracting COVID-19. Many African Americans work in service industry, transportation, and health care jobs which place them at an increased risk for contracting COVID-1919. Additionally, only 1/5 African Americans is employed in a profession that is suitable for work from home20. African Americans are more likely to live in high density housing. COVID-19 positive individuals are at a much higher risk of transmitting COVID to their family and neighbors if they live in high density housing.25,26 Additionally, from March 2020 to May 2020, the unemployment rate of African Americans rose to 6.7% to 16.8%. This likely exacerbated existing crowding in homes, raising the risk of exposure to COVID-19.26 Individual habits aimed at preventing the spread of COVID-19 were nearly identical in African American communities compared to White and Latino communities. Therefore, the heightened rates of infection, hospitalization, and mortality from COVID-19 in African American communities cannot be attributed to individual habits.26 Vitamin D deficiency is significantly higher in African American populations compared to White populations. Vitamin D deficiency has been linked to increased length of COVID-19 hospitalizations. Additionally, it has been postulated that Vitamin D deficiency can worsen the body’s response to SARs-CoV-2 infection.27Recommendations:The potential impact of both sex and race on COVID-19-associated hospitalization rates, need to be confirmed with additional data8.Current evidence in this area suggests that Black individuals may experience higher hospitalization rates and receive mechanical ventilation at a higher rate than white individuals. These differences may be attributable to different risk factors in daily life through job exposure and delays in accessing care that are a common barrier the Black patient population faces1-6,12.It is important to assess the effects that differences in resource availability, urban distribution, and other demographic differences may have on population density and the resulting effect on death rates.11Systematic and structural factors such as Implicit bias from provider needs to be further investigated with a special attention to Do Not Resuscitate (DNR) orders in their patients10.In order to account for the vast overrepresentation of African-Americans in COVID cases, it must be determined whether this stems from comorbidities, job exposure, or overall systemic racism in healthcare/society at large.15 Some evidence suggests that environmental factors (e.g. population and housing density) may being contributing to the disproportionate effect on African Americans/Blacks.17, 22Efforts towards eliminating co-morbidities, providing health equity, and increasing professional opportunities for African American communities should be a public health priority.24Concretive Concrete efforts should be made into provideing rehabilitative services to African American survivors of COVID-19 due to the disproportionate effect it has had.28References: John Hopkins University; FAQ-Covid-19 United States Cases by County; Table generated by Associates at Washington Post; using coronavirus.jhu.edu; < ;; (7?April?2020).Yancy CW. COVID-19 and African Americans. JAMA. Published online April 15, 2020. doi:10.1001/jama.2020.6548Azar 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). May 2020:101377hlthaff202000598. doi:10.1377/hlthaff.2020.00598Broussard, D., Richardson, L., Wallace, M., & Theall, K. (2018). Advancing Health Equity in New Orleans?: Building on Positive Change in Health. %0AHirschtick JL, Benjamins MR, Homan S. Community Health Counts: Sinai Community Health Survey 2.0. Sinai Urban Health Institute, Sinai Health System. Chicago, IL. March 2017. Greer DM, Baumgardner DJ, Bridgewater FD, Frazer DA, Kessler CL, LeCounte ES, Swain GR, Cisler RA. Milwaukee Health Report 2013: Health Disparities in Milwaukee by Socioeconomic Status. Center for Urban Population Health : Milwaukee, WI. 2013.Millett GA, Jones AT, Benkeser D, et al. Assessing Differential Impacts of COVID-19 on Black Communities. Ann Epidemiol. May 2020. doi:10.1016/j.annepidem.2020.05.003Garg S, Kim L, Whitaker M, et al. Hospitalization Rates and Characteristics of Patients Hospitalized with Laboratory-Confirmed Coronavirus Disease 2019 — COVID-NET, 14 States, March 1–30, 2020. MMWR Morb Mortal Wkly Rep 2020;69:458–464. DOI: icon.Ferdinand, K. C., & Nasser, S. A. (2020). African American COVID-19 Mortality: A Sentinel Event. Journal of the American College of Cardiology. AJ, Furr-Holden D, Edwards-Johnson J, et al. Are Clinicians Contributing to Excess African American COVID-19 Deaths? Unbeknownst to Them, They May Be. Heal Equity. 2020;4(1):139-141. doi:10.1089/heq.2020.0015Sehra ST, Fundin S, Lavery C, Baker JF. Differences in race and other state‐level characteristics and associations with mortality from COVID‐19 infection. J Med Virol. Published online May 30, 2020. doi:10.1002/jmv.26095Price-Haywood EG, Burton J, Fort D, Seoane L. Hospitalization and Mortality among Black Patients and White Patients with Covid-19. N Engl J Med. 2020;0(0):null. doi:10.1056/NEJMsa2011686Okonkwo NE, Aguwa UT, Jang M, et al. COVID-19 and the US response: accelerating health inequities. BMJ Evid-Based Med. Published online June 3, 2020. doi:10.1136/bmjebm-2020-111426Townsend MJ, Kyle TK, Stanford FC. Outcomes of COVID-19: disparities in obesity and by ethnicity/race. International Journal of Obesity. July 2020. doi:10.1038/s41366-020-0635-2.Johnson A, Buford T. African Americans Contracting and Dying from Coronavirus at an Alarming Rate. Emergency Medicine News. 2020;42(7):30-31. doi:10.1097/01.eem.0000688840.98792.8f.Campos-Castillo C, Laestadius LI. Racial and Ethnic Digital Divides in Posting COVID-19 Content on Social Media Among US Adults: Secondary Survey Analysis. Journal of Medical Internet Research. 2020;22(7). doi:10.2196/20472.DiMaggio C, Klein M, Berry C, Frangos S. Blacks/African American Communities are at Highest Risk of COVID-19: Spatial Modeling of New York City ZIP Code-Level Testing Results [published online ahead of print, 2020 Aug 20]. Ann Epidemiol. 2020;S1047-2797(20)30293-3. doi:10.1016/j.annepidem.2020.08.012Kalayjian BC, Conner K, Butler I, et al. Race, Heart Rate and Temperature are Strongly Associated with COVID-19 at a Community-based Clinic in New Orleans [published online ahead of print, 2020 Aug 15]. Mayo Clin Proc Innov Qual Outcomes. 2020;10.1016/j.mayocpiqo.2020.07.005. doi:10.1016/j.mayocpiqo.2020.07.005Kaufman HW, Niles JK, Nash DB. Disparities in SARS-CoV-2 Positivity Rates: Associations with Race and Ethnicity [published online ahead of print, 2020 Sep 23]. Popul Health Manag. 2020;10.1089/pop.2020.0163. doi:10.1089/pop.2020.0163Bhargava A, Sharma M, Riederer K, Fukushima EA, Szpunar SM, Saravolatz L. Risk Factors for In-hospital Mortality from COVID-19 Infection among Black Patients - An Urban Center Experience [published online ahead of print, 2020 Sep 28]. Clin Infect Dis. 2020;ciaa1468. doi:10.1093/cid/ciaa1468Andrasfay T, Goldman N. Reductions in 2020 US life expectancy due to COVID-19 and the disproportionate impact on the Black and Latino populations. MedRxiv. 2020. doi:10.1101/2020.07.12.20148387 (Pre-publication)Luo, Y., Yan, J. & McClure, S. Distribution of the environmental and socioeconomic risk factors on COVID-19 death rate across continental USA: a spatial nonlinear analysis. Environ Sci Pollut Res (2020). NR, La J, Szalat RE, Tuck DP, Nguyen V, Yildirim C, Do NV, Brophy MT, Munshi NC. Prevalence and outcome of COVID-19 infection in cancer patients: a national Veterans Affairs study. J Natl Cancer Inst. 2020 Oct 8:djaa159. doi: 10.1093/jnci/djaa159. Epub ahead of print. PMID: 33031532.Newman L, Winn RA, Carethers JM. Similarities in Risk for COVID-19 and Cancer Disparities [published online ahead of print, 2020 Oct 13]. Clin Cancer Res. 2020;clincanres.3421.2020. doi:10.1158/1078-R-20-3421Cuomo RE. Shift in racial communities impacted by COVID-19 in California [published online ahead of print, 2020 Oct 16]. J Epidemiol Community Health. 2020;jech-2020-215148. doi:10.1136/jech-2020-215148Sauceda JA, Neilands TB, Lightfoot M, Saberi P. Findings From a Probability-Based Survey of United States Households About Prevention Measures Based on Race, Ethnicity, and Age in Response to Severe Acute Respiratory Syndrome Coronavirus 2. J Infect Dis. 2020 Oct 13;222(10):1607-1611. doi: 10.1093/infdis/jiaa554. PMID: 32860499; PMCID: PMC7499587.Jain SK, Parsanathan R, Levine SN, Bocchini JA, Holick MF, Vanchiere JA. The potential link between inherited G6PD deficiency, oxidative stress, and vitamin D deficiency and the racial inequities in mortality associated with COVID-19 [published online ahead of print, 2020 Oct 7]. Free Radic Biol Med. 2020;161:84-91. doi:10.1016/j.freeradbiomed.2020.10.002Odonkor CA, Sholas MG, Verduzco-Gutierrez M, Zafonte RD, Silver JK. African American Patient Disparities in COVID-19 Outcomes: A Call to Action for Physiatrists to Provide Rehabilitation Care to Black Survivors. Am J Phys Med Rehabil. 2020;99(11):986-987. doi:10.1097/PHM.0000000000001568 ................
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