Two studies published today describe COVID-19 racial disparities among black and Hispanic patients in New York City and Denver that may be related to living and working conditions and other factors such as insurance status.
Rates of infection, severe illness
The first study, published in JAMA Network Open, involved 4,843 patients tested for coronavirus from Mar 1 to Apr 8 at New York University Langone Health System.
Of the 2,623 patients hospitalized (54.2%), 1,047 (39.9%) were white, 375(14.3%) were black, 715 (27.3%) were Hispanic, 180 (6.9%) were Asian, and 207 (7.9%) identified as multiracial/other. In fully adjusted models, black and Hispanic patients were 30% to 50% more likely than whites to test positive for COVID-19 (black odds ratio [OR], 1.3; Hispanic OR, 1.5).
While the odds of hospitalization were similar among white, black, and Hispanic patients, Asian and multiracial patients were more likely than whites to be admitted (Asian OR, 1.6; multiracial OR, 1.4). In a finding that contrasts with those of similar previous studies, hospitalized black patients were 40% less likely than whites to become severely ill (OR, 0.6) and 30% less likely to die or be released to hospice (hazard ratio, 0.7).
Black COVID-19 patients had the highest prevalence of high blood pressure and chronic kidney disease (CKD; 13.3% of blacks vs 7.7% of whites), and black and Hispanic patients had the highest prevalence of diabetes (28.9% of Hispanics vs 19.3% of whites). Asians had the lowest prevalence of all underlying illnesses except diabetes.
In total, 4.7% of patients were self-paying or uninsured, with the lowest rates among white patients (2.9%) and 5.0% to 6.2% for the other groups. Blacks and whites had similar rates of Medicaid insurance, at 9.5% and 8.6%, respectively, while 31.9% of Hispanic patients reported Medicaid coverage. White patients had the highest median neighborhood socioeconomic status index (56.6), compared with 54.4 for Asians, 52.0 for blacks, and 49.9 for Hispanics.
Of the hospitalized patients, 70.8% were released, 36.3% were critically ill, 24.7% died or transferred to hospice, and 4.5% remained hospitalized as of the May 13 follow-up.
Surprising results
"Our findings support the notion that Black and Hispanic populations are not inherently more susceptible to having poor COVID-19 outcomes than other groups and, more importantly, that if they make it to the hospital they fare as well as or better than their White counterparts," the authors said.
The researchers said that neighborhood factors in black and Hispanic communities may account for the racial disparities revealed in the study, such as crowding, a tendency to work in essential jobs that can't be done remotely, reduced access to healthcare, delays in seeking care, receiving care in clinics or hospitals lacking resources, higher rates of underlying diseases such as high blood pressure, low socioeconomic status, and lower educational attainment.
"Although Black patients were more likely than White patients to test positive for COVID-19, after hospitalization they had lower mortality, suggesting that neighborhood characteristics may explain the disproportionately higher out-of-hospital COVID-19 mortality among Black individuals," the authors wrote.
The higher coronavirus-related death rate reported for black patients in previous studies could be explained by disproportionately high rates of COVID-19 among blacks and Hispanics, which could elevate absolute death rates, even if the risk of death were no different after testing positive, the researchers said.
"Second, Black populations are more likely to be uninsured and underinsured than White populations and thus have poorer access to care, which may lead to deaths at home that are not observed in studies of hospitalized patients," they said.
Cultural, socioeconomic factors
In the second study, published in Morbidity and Mortality Weekly Report, researchers from the Denver Health and Hospital Authority and the University of Colorado analyzed data on adult COVID-19 patients in Denver from Mar 6 to Oct 6.
Most COVID-19 infections (54.8%), hospitalizations (62.1%), and deaths (51.2%) were among Hispanics, while they make up only 24.9% of the population. In contrast, whites accounted for 32.3% of COVID-19 patients, while they make up 56.8% of the population, and blacks constituted 6.4% of COVID-19 cases and 8.5% of the population.
"The pandemic’s initial surge (March 1–June 14, 2020) included more cases and persisted longer among persons of Hispanic ethnicity compared with those of other racial/ethnic groups," the authors said. "During subsequent surges (June 14–September 5 and September 6–October 3), patterns among Hispanic and White persons were similar, with consistently higher numbers among Hispanic persons."
These disparities, the authors said, could be partly attributable to Hispanics' living and working conditions. More Hispanic COVID-19 patients reported working while ill (86.4%) than their non-Hispanic counterparts (77.3%). Of the 2,982 patients with detailed employment information, 68.8% of Hispanics said they worked in essential jobs, versus 60.2% of non-Hispanics. Of the 3,917 COVID-19 patients with information about household size, 38.3% said that they lived with at least four other people, compared with 13.4% of non-Hispanic patients.
Hispanic patients were also more likely to report exposure to infected household contacts (23.7%) than non-Hispanics (15.2%) and to report exposures both in and outside of their households (2.4% vs 1.7%). While a close social network is usually considered protective, the researchers pointed out that it can undermine public health efforts in the context of an infectious disease with no available vaccine or treatment.
"Although a higher prevalence of underlying health conditions (e.g., diabetes and obesity) among persons who identify as Hispanic might increase risk for severe disease, cultural and socioeconomic factors related to how persons live and work influence COVID-19 exposure, incidence, and clinical course," the authors wrote.
The researchers called for public health and healthcare systems to work with social service organizations and community health workers to address Hispanic patients' unmet social, medical, and mental health needs.
"Reducing the disproportionate incidence of COVID-19 morbidity and mortality among Hispanic persons will require implementation of strategies that address upstream social and environmental factors that contribute to an increased risk for both infection and transmission and that facilitate improved access to culturally congruent care," the authors said.
