Covid-19 by Race and Ethnicity: A National Cohort Study of 6 Million United States Veterans

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Abstract

Background:

There is growing concern that racial and ethnic minority communities around the world are experiencing a disproportionate burden of morbidity and mortality from symptomatic SARS-Cov-2 infection or coronavirus disease 2019 (Covid-19). Most studies investigating racial and ethnic disparities to date have focused on hospitalized patients or have not characterized who received testing or those who tested positive for Covid-19.

Objective:

To compare patterns of testing and test results for coronavirus 2019 (Covid-19) and subsequent mortality by race and ethnicity in the largest integrated healthcare system in the United States.

Design:

Retrospective cohort study.

Setting:

United States Department of Veterans Affairs (VA).

Participants:

5,834,543 individuals in care, among whom 62,098 were tested and 5,630 tested positive for Covid-19 between February 8 and May 4, 2020.

Exposures:

Self-reported race/ethnicity.

Main outcome measures:

We evaluated associations between race/ethnicity and receipt of Covid-19 testing, a positive test result, and 30-day mortality, accounting for a wide range of demographic and clinical risk factors including comorbid conditions, site of care, and urban versus rural residence.

Results:

Among all individuals in care, 74% were non-Hispanic white (white), 19% non-Hispanic black (black), and 7% Hispanic. Compared with white individuals, black and Hispanic individuals were more likely to be tested for Covid-19 (tests per 1000: white=9.0, [95% CI 8.9 to 9.1]; black=16.4, [16.2 to 16.7]; and Hispanic=12.2, [11.9 to 12.5]). While individuals from minority backgrounds were more likely to test positive (black vs white: OR 1.96, 95% CI 1.81 to 2.12; Hispanic vs white: OR 1.73, 95% CI 1.53 to 1.96), 30-day mortality did not differ by race/ethnicity (black vs white: OR 0.93, 95% CI 0.64 to 1.33; Hispanic vs white: OR 1.07, 95% CI 0.61 to 1.87).

Conclusions:

Black and Hispanic individuals are experiencing an excess burden of Covid-19 not entirely explained by underlying medical conditions or where they live or receive care. While there was no observed difference in mortality by race or ethnicity, our findings may underestimate risk in the broader US population as health disparities tend to be reduced in VA.

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Most cited references 27

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Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

Fei Zhou, Ting Yu, Ronghui Du … (2020)

Summary Background Since December, 2019, Wuhan, China, has experienced an outbreak of coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Epidemiological and clinical characteristics of patients with COVID-19 have been reported but risk factors for mortality and a detailed clinical course of illness, including viral shedding, have not been well described. Methods In this retrospective, multicentre cohort study, we included all adult inpatients (≥18 years old) with laboratory-confirmed COVID-19 from Jinyintan Hospital and Wuhan Pulmonary Hospital (Wuhan, China) who had been discharged or had died by Jan 31, 2020. Demographic, clinical, treatment, and laboratory data, including serial samples for viral RNA detection, were extracted from electronic medical records and compared between survivors and non-survivors. We used univariable and multivariable logistic regression methods to explore the risk factors associated with in-hospital death. Findings 191 patients (135 from Jinyintan Hospital and 56 from Wuhan Pulmonary Hospital) were included in this study, of whom 137 were discharged and 54 died in hospital. 91 (48%) patients had a comorbidity, with hypertension being the most common (58 [30%] patients), followed by diabetes (36 [19%] patients) and coronary heart disease (15 [8%] patients). Multivariable regression showed increasing odds of in-hospital death associated with older age (odds ratio 1·10, 95% CI 1·03–1·17, per year increase; p=0·0043), higher Sequential Organ Failure Assessment (SOFA) score (5·65, 2·61–12·23; p<0·0001), and d-dimer greater than 1 μg/mL (18·42, 2·64–128·55; p=0·0033) on admission. Median duration of viral shedding was 20·0 days (IQR 17·0–24·0) in survivors, but SARS-CoV-2 was detectable until death in non-survivors. The longest observed duration of viral shedding in survivors was 37 days. Interpretation The potential risk factors of older age, high SOFA score, and d-dimer greater than 1 μg/mL could help clinicians to identify patients with poor prognosis at an early stage. Prolonged viral shedding provides the rationale for a strategy of isolation of infected patients and optimal antiviral interventions in the future. Funding Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences; National Science Grant for Distinguished Young Scholars; National Key Research and Development Program of China; The Beijing Science and Technology Project; and Major Projects of National Science and Technology on New Drug Creation and Development.

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Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention

Zunyou Wu, Jennifer M. McGoogan (2020)

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Baseline Characteristics and Outcomes of 1591 Patients Infected With SARS-CoV-2 Admitted to ICUs of the Lombardy Region, Italy

Giacomo Grasselli, Alberto Zangrillo, Alberto Zanella … (2020)

In December 2019, a novel coronavirus (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]) emerged in China and has spread globally, creating a pandemic. Information about the clinical characteristics of infected patients who require intensive care is limited.

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Author and article information

Journal

Journal ID (nlm-ta): medRxiv

Journal ID (publisher-id): MEDRXIV

Title: medRxiv

Publisher: Cold Spring Harbor Laboratory

Publication date (Electronic): 17 May 2020

Electronic Location Identifier: 2020.05.12.20099135

Affiliations

[1. ]VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT, US, 06516

[2. ]Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK, WC1E 7HT

[3. ]Department of Internal Medicine, Yale School of Medicine, New Haven, CT, US, 06520

[4. ]Stanford Center for Population Health Sciences, Stanford University School of Medicine, Stanford, CA, US, 94305

[5. ]Department of Neurosurgery, Yale School of Medicine, New Haven, CT, US, 06520

[6. ]Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT, US, 06520

[7. ]VA Palo Alto Healthcare System, US Department of Veterans Affairs, Palo Alto, CA, US, 94304

[8. ]Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, US, 94305

[9. ]Division of Infectious Diseases, Department of Medicine and Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, US, 19104

[10. ]VA Puget Sound Health Care System and Department of Medicine, University of Washington School of Medicine, Seattle, WA, US, 98104

[11. ]Geriatric Research Education and Clinical Center (GRECC), US Department of Veterans Affairs, Tennessee Valley Health Care System, Nashville, TN, US 37212

[12. ]Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, US, 37232

[13. ]Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, US, 06511

Author notes

Contributorship

CR and AJ conceived and led the project overall and are guarantors. Contributions are as follows: Data curation CR, FK, JT, LP, JK, MS, RH, MH; Formal analysis CR; Funding acquisition AJ; Methodology CR, JT, and AJ led with support from LP, RH, VL, KA, KC, TT, MF; Project administration CR and AJ; Visualization CR, JT, LP, CJ; Writing (original draft) CR and AJ; All authors reviewed, edited, and approved the final manuscript.

[*]

These authors contributed equally

Corresponding author: Christopher.Rentsch@ 123456lshtm.ac.uk

Article

DOI: 10.1101/2020.05.12.20099135

PMC ID: 7273292

PubMed ID: 32511524

SO-VID: d525b4d9-8a9e-4f6b-9faa-04d65114a88d

License:

It is made available under a CC-BY 4.0 International license.

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