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

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.

Characteristics Associated With Racial/Ethnic Disparities in COVID-19 Outcomes in an Academic Health Care System

“…health conditions, such as obesity, cancer, type 2 diabetes, and renal conditions, were prevalent among patients with worse COVID-19 outcomes. 34,45,46,55 Notably, our findings largely agree with recent published work examining racial/ethnic differences in COVID-19 outcomes, which found Black patients had a higher hospitalization rate, 8 increased odds of positive test results, 12…”

Risk Factors for Hospitalization, Mechanical Ventilation, or Death Among 10 131 US Veterans With SARS-CoV-2 Infection

“…Risk factors that have been identified in prior studies include older age, male sex, hypertension, diabetes, chronic obstructive pulmonary disease, cardiac disease, liver disease, chronic kidney disease, neurologic disorders, cancer, obesity, higher overall burden of comorbidity, and smoking. 1 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 …”

“…Multiple risk factors for developing severe COVID-19 disease have been reported, including sociodemographic factors and comorbid conditions. 1 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 However, most prior studies, particularly those published earlier in the course of the pandemic, did not include multivariable adjustment to identify independent risk factors, and few studies examined a range of different disease outcomes, including hospitalization, mechanical ventilation, and death. Most prior studies have been local or regional, rather than national, in scope.…”

Association of COVID-19 distribution with air quality, sociodemographic factors, and comorbidities: an ecological study of US states

“…It also has been proven that some medical conditions like diabetes and heart diseases can increse the risk of death in COVID-19 patient (Richardson et al 2020;Coccia 2020). Additionally, race and ethnicity were associated with the rate of death in different societies (Rentsch et al 2020;Gross et al 2020).…”