There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.
Abstract
The COVID-19 pandemic has shed light on abundant racial and ethnic health
disparities in many countries around the world. In Sweden, statistics
on COVID-19 mortality and morbidity from both the first and the second
wave of the pandemic show that foreign-born individuals have been
disproportionately affected, compared to Swedish-born individuals.
However, as demonstrated in this article, key stakeholders including
politicians, public authorities, mainstream media, and medical
researchers do not draw on the same explanatory framework when
conceptualizing the health disparity. Probing the different discourses
that were articulated through oral and written accounts during the
first wave, the article identifies three different frameworks of how
ethnic health disparities in relation to COVID-19 were understood in
Sweden: the socioeconomic framework, the culturalist framework and the
biological framework. We discuss the importance of our findings for
health policy and argue for continued interrogation of epidemiological
knowledge production from a critical vantage point in order to
successfully combat health inequalities.
Background The relationship between ethnicity and COVID-19 is uncertain. We performed a systematic review to assess whether ethnicity has been reported in patients with COVID-19 and its relation to clinical outcomes. Methods We searched EMBASE, MEDLINE, Cochrane Library and PROSPERO for English-language citations on ethnicity and COVID-19 (1st December 2019-15th May 2020). We also reviewed: COVID-19 articles in NEJM, Lancet, BMJ, JAMA, clinical trial protocols, grey literature, surveillance data and preprint articles on COVID-19 in MedRxiv to evaluate if the association between ethnicity and clinical outcomes were reported and what they showed. PROSPERO:180654. Findings Of 207 articles in the database search, five reported ethnicity; two reported no association between ethnicity and mortality. Of 690 articles identified from medical journals, 12 reported ethnicity; three reported no association between ethnicity and mortality. Of 209 preprints, 34 reported ethnicity – 13 found Black, Asian and Minority Ethnic (BAME) individuals had an increased risk of infection with SARS-CoV-2 and 12 reported worse clinical outcomes, including ITU admission and mortality, in BAME patients compared to White patients. Of 12 grey literature reports, seven with original data reported poorer clinical outcomes in BAME groups compared to White groups. Interpretation Data on ethnicity in patients with COVID-19 in the published medical literature remains limited. However, emerging data from the grey literature and preprint articles suggest BAME individuals are at an increased risk of acquiring SARS-CoV-2 infection compared to White individuals and also worse clinical outcomes from COVID-19. Further work on the role of ethnicity in the current pandemic is of urgent public health importance. Funding NIHR
A recent genetic association study1 identified a gene cluster on chromosome 3 as a risk locus for respiratory failure after infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). A separate study (COVID-19 Host Genetics Initiative)2 comprising 3,199 hospitalized patients with coronavirus disease 2019 (COVID-19) and control individuals showed that this cluster is the major genetic risk factor for severe symptoms after SARS-CoV-2 infection and hospitalization. Here we show that the risk is conferred by a genomic segment of around 50 kilobases in size that is inherited from Neanderthals and is carried by around 50% of people in south Asia and around 16% of people in Europe.
During February 12–October 15, 2020, the coronavirus disease 2019 (COVID-19) pandemic resulted in approximately 7,900,000 aggregated reported cases and approximately 216,000 deaths in the United States.* Among COVID-19–associated deaths reported to national case surveillance during February 12–May 18, persons aged ≥65 years and members of racial and ethnic minority groups were disproportionately represented ( 1 ). This report describes demographic and geographic trends in COVID-19–associated deaths reported to the National Vital Statistics System † (NVSS) during May 1–August 31, 2020, by 50 states and the District of Columbia. During this period, 114,411 COVID-19–associated deaths were reported. Overall, 78.2% of decedents were aged ≥65 years, and 53.3% were male; 51.3% were non-Hispanic White (White), 24.2% were Hispanic or Latino (Hispanic), and 18.7% were non-Hispanic Black (Black). The number of COVID-19–associated deaths decreased from 37,940 in May to 17,718 in June; subsequently, counts increased to 30,401 in July and declined to 28,352 in August. From May to August, the percentage distribution of COVID-19–associated deaths by U.S. Census region increased from 23.4% to 62.7% in the South and from 10.6% to 21.4% in the West. Over the same period, the percentage distribution of decedents who were Hispanic increased from 16.3% to 26.4%. COVID-19 remains a major public health threat regardless of age or race and ethnicity. Deaths continued to occur disproportionately among older persons and certain racial and ethnic minorities, particularly among Hispanic persons. These results can inform public health messaging and mitigation efforts focused on prevention and early detection of infection among disproportionately affected groups. In NVSS data, confirmed or presumed COVID-19–associated deaths are assigned the International Classification of Diseases, Tenth Revision code U07.1 as a contributing or underlying cause of death on the death certificate. The underlying cause of death is the condition that began the chain of events ultimately leading to the person’s death. COVID-19 was the underlying cause for approximately 92% of COVID-19–associated deaths and was a contributing cause for approximately 8% during the investigation period ( 2 ). NVSS data in this report exclude deaths among residents of territories and foreign countries. Using NVSS data from May 1 through August 31, 2020, CDC tabulated the numbers and percentages of COVID-19–associated deaths by age, sex, race and ethnicity (categorized as Hispanic, White, Black, non-Hispanic Asian [Asian], non-Hispanic American Indian or Alaska Native [AI/AN], non-Hispanic Native Hawaiian or other Pacific Islander [NHPI], non-Hispanic multiracial [multiracial], and unknown), U.S. Census region, § and location of death (e.g., hospital, nursing home or long-term care facility, or residence). Because only 0.5% of COVID-19 decedents were either NHPI or multiracial, and counts <10 are suppressed in NVSS to maintain confidentiality, these groups were combined into one group for analyses. Age, race and ethnicity, and place of death were unknown for two (<0.01%), 465 (0.4%), and 46 (0.04%) deaths, respectively. To describe changes in demographic features over time, percentages of deaths among two age groups (≥65 years and <65 years), racial and ethnic groups, and U.S. Census region were calculated for each month. R statistical software (version 3.6.3; The R Foundation) was used to tabulate death counts and generate histograms. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy. ¶ During May 1–August 31, 2020, a total of 114,411 COVID-19–associated deaths were reported to NVSS (Table). The number of COVID-19–associated deaths decreased from 37,940 in May to 17,718 in June; subsequently, counts increased to 30,401 in July and declined to 28,352 in August. Among decedents, the majority were male (53.3%), White (51.3%), aged ≥65 years (78.2%), and died in an inpatient health care setting (64.3%). Overall, 24.2% of decedents were Hispanic, 18.7% were Black, 3.5% were Asian, 1.3% were AI/AN, and 0.5% were either NHPI or multiracial. During the period studied, the largest percentage of COVID-19–associated deaths occurred in the South Census region (45.7%), followed by the Northeast (20.5%), the West (18.3%), and the Midwest (15.5%). Twenty-two percent of decedents died in a nursing home or long-term care facility. TABLE Demographic characteristics of persons who died because of COVID-19* (N = 114,411) — National Vital Statistics System (NVSS), United States, May 1–August 31, 2020 † Characteristic Deaths,§ % Age group, yrs <1 <0.1 1–4 <0.1 5–17 <0.1 18–29 0.5 30–39 1.4 40–49 3.5 50–64 16.4 65–74 21.7 75–84 26.0 ≥85 30.4 Unknown <0.1 Sex Male 53.3 Female 46.7 Other 0.0 Race/Ethnicity White, non-Hispanic 51.3 Hispanic or Latino 24.2 Black, non-Hispanic 18.7 Asian, non-Hispanic 3.5 American Indian or Alaska Native, non-Hispanic 1.3 Other, non-Hispanic¶ 0.5 Unknown race/ethnicity 0.4 U.S. Census region of residence South 45.7 Northeast 20.5 West 18.3 Midwest 15.5 Place of death Health care setting, inpatient 64.3 Nursing home or long-term care facility 21.5 Decedent's home 5.2 Hospice facility 3.7 Health care setting, outpatient or emergency department 3.1 Other 2.0 Health care setting, dead on arrival 0.1 Unknown <0.1 Abbreviation: COVID-19 = coronavirus disease 2019. * Deaths with confirmed or presumed COVID-19, coded to International Classification of Diseases, Tenth Revision code U07.1. These data exclude deaths among foreign residents and territories. † NVSS data from August are incomplete given reporting lags. § Percentages may not sum to 100 because of rounding. For two (<0.01%) COVID-19 deaths, age was unknown. Sex and region were known for all decedents. For 465 (0.4%) deaths, race or ethnicity were unknown. For 46 (0.04%) deaths, place of death was unknown. ¶ Other race/ethnicity includes persons who were non-Hispanic Native Hawaiian or other Pacific Islander or were non-Hispanic multiracial. During May–August 2020, the percentage of COVID-19–associated deaths occurring in the South increased from 23.4% in May to 62.7% in August, and in the West from 10.6% to 21.4%; the percentages occurring in the Northeast decreased from 44.2% in May to 4.0% in August, and in the Midwest declined from 21.8% to 11.8% (Figure 1). The percentage of decedents aged ≥65 years decreased from 81.8% to 77.6%, and the percentage of deaths occurring in nursing homes or long-term care facilities decreased from 29.8% to 16.6% (Figure 1). FIGURE 1 Monthly COVID-19–associated deaths* as a percentage of all deaths, by U.S. Census region, all ages (A), and for persons aged ≥65 years or persons of any age who died in a nursing home or long-term care facility (B) (N = 114,411) — National Vital Statistics System, United States, May 1–August 31, 2020 Abbreviation: COVID-19 = coronavirus disease 2019. * Age data were missing for two (<0.01%) COVID-19 deaths, and place of death data were missing for 46 (0.04%) deaths. Total numbers of deaths might vary because of suppression of counts with <10 deaths. The figure is a line chart showing monthly COVID-19–associated deaths as a percentage of all deaths, by U.S. Census region, all ages, and for persons aged ≥65 years or persons of any age who died in a nursing home or long-term care facility (N = 114,411), using data from the National Vital Statistics System, in the United States, during May 1–August 31, 2020. From May to August, the percentage of decedents who were White decreased from 56.9% to 51.5%, and the percentage who were Black decreased from 20.3% to 17.4%, whereas the percentage who were Hispanic increased from 16.3% to 26.4% (Figure 2). Hispanics were the only racial and ethnic group among whom the overall percentage of deaths increased. Among persons aged ≥65 years, the monthly percentage of Hispanic decedents increased in the South (from 10.3% to 21.7%) and West (from 29.6% to 35.4%) and decreased in the Northeast (from 11.3% to 9.3%) and Midwest (from 7.8% to 4.2%). The monthly percentage of Hispanic decedents aged <65 years increased in the South (from 29.2% to 38.1%) and West (from 51.8% to 62.3%) and decreased in the Northeast (from 34.9% to 30.7%) and Midwest (31.1% to 20.4%) (Supplementary Figure, https://stacks.cdc.gov/view/cdc/95229). FIGURE 2 Monthly deaths, by race/ethnicity* as a percentage of all COVID-19–associated deaths (N = 114,411) — National Vital Statistics System, United States, May 1–August 31, 2020 Abbreviations: AI/AN = American Indian or Alaska Native; COVID-19 = coronavirus disease 2019; NH = non-Hispanic; NHPI = Native Hawaiian or other Pacific Islander. * Race or ethnicity data were unknown for 465 (0.4%) deaths. Total numbers of deaths might vary because of suppression of counts with <10 deaths. The figure is a bar chart showing monthly deaths, by race/ethnicity as a percentage of all COVID-19–associated deaths (N = 114,411), using data from the National Vital Statistics System, in the United States, during May 1–August 31, 2020. Discussion Based on NVSS data on 114,411 persons who died from COVID-19 in the United States during May–August 2020, the predominant U.S. Census regions shifted from the Northeast to the South and West. The majority of COVID-19–associated deaths occurred among White persons (51.3%), but Black and Hispanic persons were disproportionately represented. Although a small decrease (2.9 percentage points between May and August) in decedents who were Black was observed, Black persons still accounted for 18.7% of overall deaths despite representing just 12.5% of the U.S. population ( 3 ). Similarly, Hispanic persons were disproportionately represented among decedents: 24.2% of decedents were Hispanic compared with 18.5% of the U.S. population. In addition, the percentage of decedents who were Hispanic increased 10.1 percentage points from May through August. Whereas Hispanic persons accounted for 14% of COVID-19–associated deaths in the United States during February 12–May 18, 2020 ( 1 ), that percentage increased to approximately 25% in August. Although there has been a geographic shift in COVID-19–associated deaths from the Northeast to the West and South, where Hispanic persons account for a higher percentage of the population, this analysis found that ethnic disparities among decedents in the West and South increased during May–August, 2020, suggesting that the geographic shift alone does not entirely account for the increase in percentage of Hispanic decedents nationwide. Disparities in COVID-19 incidence and deaths among Hispanic persons and other underrepresented racial and ethnic groups are well documented ( 4 – 6 ) and might be related to increased risk for exposure to SARS-CoV-2, the virus that causes COVID-19. Inequities in the social determinants of health can lead to increased risk for SARS-CoV-2 exposure among some racial and ethnic groups. For example, persons from underrepresented racial and ethnic groups might be more likely to live in multigenerational and multifamily households, reside in congregate living environments, hold jobs requiring in-person work (e.g., meatpacking, agriculture, service, and health care), have limited access to health care, or experience discrimination ( 5 , 6 ). Differences in the prevalence of underlying conditions (e.g., diabetes and obesity) among racial and ethnic groups might also be associated with increased susceptibility to COVID-19–associated complications and death ( 4 ). The shift in COVID-19–associated deaths during May–August 2020 from the Northeast (where 17.1% of the U.S. population resides) into the South and West (where 38.3% and 23.9% of the U.S. population resides, respectively)** is consistent with recent findings documenting the emergence of COVID-19 hotspots †† in these regions during June–July 2020 ( 7 ). The decreasing percentage of deaths occurring among persons aged ≥65 years and persons in nursing homes, which were important sites of COVID-19–associated deaths early in the pandemic, suggests a continued shift toward noninstitutionalized and younger populations. The observed geographic shifts in COVID-19–associated deaths might be related to differential implementation of community mitigation efforts throughout the nation, including earlier reopening efforts in selected jurisdictions. To prevent the spread of COVID-19, CDC continues to recommend the use of masks, frequent handwashing, and maintenance of social distancing, including avoidance of large gatherings ( 8 ). The findings in this report are subject to at least two limitations. First, NVSS provisional death data are continually updated and subject to delays. Therefore, this report likely underestimates the number of deaths that occurred, particularly during August 2020, for which data are less complete than previous months. Furthermore, in focusing only on COVID-19–associated deaths captured by NVSS, this report did not address long-term morbidity faced by some persons who survive COVID-19 infections, nor does it account for deaths and morbidity related to the indirect effects of interrupted health care and socioeconomic disruption caused by the pandemic ( 9 ). For example, one report indicated that by June 30, 2020, an estimated 41% of U.S. adults had delayed or avoided medical care because of concerns about the pandemic, including 12% who reported having avoided urgent or emergency care ( 10 ). Despite these limitations, this report provides information on how demographic and geographic factors have changed among COVID-19–associated deaths during May–August 2020. Racial and ethnic disparities among COVID-19 decedents have persisted over the course of the pandemic and continue to increase among Hispanic persons. These results can inform public health messaging and mitigation efforts focused on prevention and early detection of infection among disproportionately affected groups so as to minimize subsequent mortality. Summary What is already known about this topic? Persons aged ≥65 years and members of minority racial and ethnic groups are disproportionately represented among COVID-19–associated deaths. What is added by this report? Analysis of 114,411 COVID-19–associated deaths reported to National Vital Statistics System during May–August 2020, found that 51.3% of decedents were non-Hispanic White, 24.2% were Hispanic or Latino (Hispanic), and 18.7% were non-Hispanic Black. The percentage of Hispanic decedents increased from 16.3% in May to 26.4% in August. What are the implications for public health practice? These results can inform public health messaging and mitigation efforts focused on prevention and early detection of infection among disproportionately affected groups so as to minimize subsequent mortality.
scite shows how a scientific paper has been cited by providing the context of the citation, a classification describing whether it supports, mentions, or contrasts the cited claim, and a label indicating in which section the citation was made.
Smart Citations