key: cord-0695176-h5zd36e3
authors: Patel, Jenil R.; Amick, Benjamin C.; Vyas, Keyur S.; Bircan, Emine; Boothe, Danielle; Nembhard, Wendy N.
title: Racial Disparities in Symptomatology and Outcomes of COVID-19 among Adults of Arkansas
date: 2022-05-24
journal: Prev Med Rep
DOI: 10.1016/j.pmedr.2022.101840
sha: a3d2ebdb3ddcc4b655df7dde6b5c37a0364e4084
doc_id: 695176
cord_uid: h5zd36e3

Few reports have suggested that non-Hispanic (NH) blacks may present with different symptoms for COVID-19 than NH-whites. The objective of this study was to investigate patterns in symptomatology and COVID-19 outcomes by race/ethnicity among adults in Arkansas. Data on COVID-19 symptoms was collected at day of testing, 7th day and 14th day among participants at UAMS mobile testing units throughout the state of Arkansas. Diagnosis for SARS-CoV-2 infection was confirmed via nasopharyngeal swab and RT-PCR methods. Data analysis was conducted using Chi-square test and Poisson regression to assess the differences in characteristics by race/ethnicity. A total of 60,648 individuals were RT-PCR tested from March 29, 2020 through October 7, 2020. Among adults testing positive, except shortness of breath, Hispanics were more likely to report all symptoms than NH-whites or NH-blacks. NH-whites were more likely to report fever (19.6% vs. 16.6%), cough (27.5% vs. 26.1%), shortness of breath (13.6% vs. 9.6%), sore throat (16.7% vs. 10.7%), chills (12.5% vs. 11.8%), muscle pain (15.6% vs. 12.4%), and headache (20.3% vs. 17.8%). NH-blacks were more likely to report loss of taste/smell (10.9% vs. 10.6%). To conclude, we found differences in COVID-19 symptoms by race/ethnicity, with NH-blacks and Hispanics more often affected with specific or all symptoms, compared to NH-whites. Due to the cross-sectional study design, these findings do not necessarily reflect biological differences by race/ethnicity; however, they suggest that certain race/ethnicities may have underlying differences in health status that impact COVID-19 outcomes.

 Few reports have suggested that non-Hispanic Blacks may present with different symptoms for COVID-19 than non-Hispanic Whites.  In this novel study comprising of representative sample of over 60,000 racially diverse population of Arkansas adults, we investigated patterns in symptomatology and outcomes of COVID-19.  We found differences in COVID-19 symptoms by race/ethnicity, with NH-blacks and Hispanics affected more, with specific or all symptoms, compared to NH-whites.  Acknowledging differences in presentation in symptoms at clinical setting will aid in accurate diagnoses of patients that present with COVID-19. The Coronavirus disease 2019 is caused by severe acute respiratory 3 syndrome novel coronavirus (SARS-nCoV or SARS-CoV-2). As of July 2021, the disease has 4 rapidly spread worldwide, in an ongoing pandemic for over a year. Over 184 million cases and 5 more than 3.9 million deaths due to COVID-19 have been reported globally, with numbers 6 continuing to rise.

[1] In Arkansas, there are currently over 622,000 cases as of July 2, 2021 with 7 over 30,000 hospitalizations and more than 3,000 patients on ventilators.

[2] 8 Several studies from the United States (US) and United Kingdom (UK) demonstrate a 9 strong association between SARS-CoV-2 and race/ethnicity. [3] [4] [5] Racial/ethnic minorities in 10 both countries have poorer outcomes from SARS-CoV-2 infection than their white 11 counterparts. [3] [4] [5] In the US, non-Hispanic (NH) blacks have 4.5 and 5.0 times and Hispanics 12 have 4.0 times higher hospitalization and mortality rates, from COVID-19 compared to NH 13 whites. [6] [7] [8] [9] [10] [11] [12] Explanations for these disparities in incidence, severity and mortality are unclear 14 but may reflect socioeconomic, biological, environmental, behavioral, health care or other 15 factors, including higher rates of pre-existing co-morbidities and racism and discrimination.[9, 16 12-21] Distrust and misinformation in minority communities can affect differences in outcomes 17 by racial/ethnic group. Furthermore, testing sites for COVID-19 in many US states were 18 disproportionately located in predominantly white neighborhoods, [22] [23] [24] limiting access for 19 minorities to testing and subsequent contact tracing, which would reduce disease transmission in 20 their communities. Likewise, among patients with COVID-19 from a large Midwestern academic 21 health system, NH-black race was associated with COVID-19 test positivity, and both race and 22 low poverty level was associated with higher risk of hospitalization. [25] Increased burden of 23 comorbidity among NH-blacks [26] has found to place them at higher risk for adverse COVID- 24 19 outcomes. [27] 25 Anecdotal reports suggested that NH blacks might present with different symptoms for 26 COVID-19 than NH whites resulting in not being tested or misdiagnosis. [9, 12, 14] However, 27 very few studies have investigated whether the symptoms specific to COVID-19 differ by 28 race/ethnicity. Only two prior studies have explored the differences in symptomatology of 29 COVID-19 by race/ethnicity, one conducted using social media and another using a cohort of 30 hospitalized patients. [28, 29] These studies noted a higher prevalence of some symptoms such as sore throat and fever among Hispanic populations. However, no studies have specifically 32 investigated the Black-White disparity in the symptomatology patterns of COVID-19. There is 33 thus a need for a comprehensive assessment with a larger sample to assess the racial/ethnic 34 differences by natural history and symptomatology effectively. The aim of this study is to 35 investigate patterns in symptomatology and outcomes of COVID-19 among a diverse population 36 of adults in Arkansas, with a focus on healthcare interactions and/or screening and racial/ethnic 37 disparities. Gradually as the cases started to rise rapidly, testing was then performed regardless of symptom 57 or exposure history. Trained UAMS nurses and physicians or National Guard medics following 58 appropriate laboratory, manufacturer, and Centers for Disease Control and Prevention guidelines 59 obtained nasopharyngeal swabs. The samples were processed at the UAMS Clinical lab. Tests 60 were performed either in-house on Genemark, Cepheid, or Biofire multiplex PCR platforms, or 61 on Roche PCR systems, or were sent to regional or national public health and reference 62 laboratories for PCR testing. The period for receiving the test results was variable and dependent 63 on whether the sample was sent out, the volume of tests and the availability of reagents, ranging 64 from several hours up to seven or more days. After data linkage, the data were checked for errors and consistency. Descriptive analyses 84 were performed using Chi-square tests to assess differences in age (<18, 18 to <65, ≥65 years), Chi-square tests were used to assess differences in prevalence of symptoms at time of 91 testing, days 7 and 14 by race/ethnicity separately among adults testing positive and negative for 92 COVID-19. We used Poisson regression with robust variance estimation to estimate prevalence 93 ratios (PRs) and 95% confidence interval (CI) of each symptom by race/ethnicity with NH white 94 as the reference group. All analyses were performed using STATA v15 (Statacorp, College 95 Station, TX).

The study was reviewed and approved by the Institutional Review Board at UAMS. Table 5 shows the prevalence ratios listed in Table 4 adjusted for age and gender. The estimates 140 did not differ noticeably with the adjustment.

Earlier in the pandemic, anecdotal reports of racial/ethnic differences in COVID-19 143 symptoms were reported. Our study found initial evidence to support these reports. At the time 144 of testing, NH blacks were less likely to report having symptoms of fever, cough, shortness of 145 breath, sore throat, chills, muscle pain, headache but were more likely to report loss of taste and 146 smell compared to NH Whites. This difference persisted among individuals testing positive for 147 COVID-19, but not among those testing negative. In contrast, Hispanics were more likely to 148 report all symptoms except shortness of breath, compared to NH blacks and whites. Some of our results are similar to the two studies that also investigated this topic. A 150 recent cross-sectional study conducted on social media by Jones and colleagues, involving 1,435 151 participants found that sore throat, to be less frequently reported by Asian (5.8%), non-Hispanic 152 Black (5.7%), and other/multiple race (8.9%) participants compared to those who were Hispanic 153 (18.1%) or NH white (16.2%) [28] . Another study of 379 hospitalized patients in Massachusetts 154 by McCarty and colleagues showed that LatinX patients more frequently reported fever and 155 myalgia [29] . While findings from these studies were partly similar to our findings of Hispanics 156 reporting greater prevalence of all symptoms except shortness of breath, our study noted greater 157 disparities in symptomatology also among NH blacks. In our study, NH blacks had a greater 158 prevalence of loss of taste or smell compared to NH whites, which no other studies in literature 159 have noted.

The COVID-19 pandemic has consistently shown minority populations to be 161 disproportionately affected by higher incidence, hospitalizations and deaths [32] [33] [34] [35] [36] . Reasons for 162 these disparities are poorly understood. Compared to Whites, Blacks and Hispanics have lower 163 rates of insurance coverage, which reduces direct access to COVID-19 related medical care (e. 164 g., reduced access to testing, postponed treatment), as well as indirect effects related to COVID-165 19 (e.g., less and less consistent management of pre-existing clinical comorbidities such as 166 diabetes and hypertension), which increase the risk of death from the virus [37] . While the pre-167 existing social inequalities that occurs due to the structural racism place Black and Hispanic 168 communities at greater risk of the pandemic, the differences in natural history and 169 symptomatology found in our study further demonstrate that racial/ethnic disparities in COVID- 170 19 prevalence and outcomes are also influenced by differences in clinical presentation which 171 subsequently may impact disease progression. In our study, we observed Hispanics to report 172 classic COVID-19 symptoms (fever, cough, sore throat), and potentially having a greater 173 likelihood of receiving care than NH blacks who did not present with classic COVID-19 174 symptoms. There is also a possibility of a period effect since during the pandemic these rates In summary, we found differences in presentation of COVID-19 symptoms by 197 race/ethnicity, with NH blacks to be affected more by loss of taste and smell, and Hispanics to be 198 affected by all symptoms compared to NH whites. Our findings indicate that certain 199 race/ethnicities may have underlying differences in health status that affect outcomes of COVID- 

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Jenil Patel: Visualization, Investigation, Methodology, Data curation, Formal Analysis, Software, Writing -Original Draft Preparation, Writing-Review and Editing Benjamin Amick: Investigation, Methodology, Writing-Review and Editing. Keyur Vyas: Investigation, Methodology, Writing-Review and Editing. Emine Bircan: Methodology, Writing-Review and Editing Danielle Boothe: Methodology, Writing-Review and Editing Wendy Nembhard: Conceptualization, Visualization, Supervision, Investigation, Methodology, Writing-Original draft, Writing-Reviewing and Editing