A study of nearly 1 million US adults who died of COVID-19 in the first 2 years of the pandemic suggests that the decrease in disparities between Black and White deaths can be explained by increased deaths among White adults and shifts in geographic spread.
The research, led by Boston University investigators, was published today in JAMA Network Open.
The team analyzed data from the Centers for Disease Control and Prevention (CDC) on COVID-19 deaths among the 977,018 adults aged 25 years and older who died of their infections from March 2020 through February 2022, a period that spanned the predominance of the wild-type to Omicron SARS-CoV-2 variants. The average age was 73.6 years, 44.6% were women, 64.4% were White, 16.1% were Hispanic, and 14.4% were Black.
The researchers noted that age-standardized COVID-19 death rates in 2020 were 2.6 times higher for American Indian and Alaska Native populations than for their White peers. Death rates were also higher for Hispanic (2.3 times higher) and Black (2.1 times higher) than for White adults. "Structural racism has been a key driver of national disparities throughout the pandemic," they wrote. Differences in COVID-19 vaccine uptake have also been reported by race and the urban/rural divide.
Black/White gap fell from 339 to 45 per 100,000
Throughout the pandemic, the proportion of White Americans living in nonmetropolitan areas (17.9%) was 2.8 times larger than that of Hispanic adults (6.3%) and 2.0 times larger than that of the Black population (8.8%).
The proportion of COVID-19 deaths among residents of nonmetropolitan areas rose from 5,944 of 110,526 (5.4%) during the wild-type virus surge (March through May 2020), peaking at 40,360 of 172,515 (23.4%) amid Delta (June through October 2021), then declining to 45,183 of 210,554 (21.5%) during Omicron (November through February 2022). The gap in age-standardized COVID-19 deaths per 100,000 person-years for Black relative to White adults fell from 339 to 45 per 100,000 over the study period.
Nationally, death rates fell for Hispanic (−34.0%), Asian (−71.2%), and Black (−49.3%) adults between the wild-type and Delta waves. Death rates rose for American Indian and Alaska Native (36.4%) and White (22.7%) adults from the wild-type to the Delta wave. For American Indian and Alaska Native adults, death rates climbed in both metropolitan and nonmetropolitan areas. For White adults, the increase could be explained by rises in nonmetropolitan areas (465.1%) and small to medium cities (124.4%). Similar trends were seen when comparing the wild-type and Omicron waves.
For American Indian and Alaska Native adults, death rates climbed in both metropolitan and nonmetropolitan areas.
Standardizing for age and racial differences by urban versus nonurban residence, rises in death rates among White adults accounted for 120 deaths per 100,000 person-year of the decrease (40.7%). Fifty-eight deaths per 100,000 person-years of the decrease (19.6%) could be attributed to shifts in mortality to nonurban areas. The remaining 116 deaths per 100,000 of the decrease (39.6%) could be explained by declines in death rates among Black adults.
Policy changes needed
"This study found that most of the national decrease in racial and ethnic disparities in COVID-19 mortality between the initial and Omicron waves was explained by increased mortality among non-Hispanic White adults and changes in the geographic spread of the pandemic," the study authors wrote. "These findings suggest that despite media reports of a decline in disparities, there is a continued need to prioritize racial health equity in the pandemic response."
The rural disadvantage in death rates could be attributed to higher rates of chronic diseases, underfunded healthcare systems, lower access to healthcare, the pandemic's socioeconomic impact, and lower COVID-19 vaccination rates, the researchers said.
"Beyond vaccination, additional policy changes could further support racial health equity during the pandemic," they wrote. "Paid sick time and medical leave may ensure that essential workers are able to isolate and recover if they develop COVID-19. Continued rent, eviction, and foreclosure moratoriums and extended unemployment benefits may reduce financial and housing insecurity."
