key: cord-0944495-tdfhl2na authors: Taylor, Tiffany; Yazdany, Jinoos; Gianfrancesco, Milena A. title: The Racial/Ethnic and Sociocultural Aspects of the Pandemic in Rheumatology date: 2021-02-18 journal: Best Pract Res Clin Rheumatol DOI: 10.1016/j.berh.2021.101665 sha: f01af9100c3abc38c71b50456532c396131a7404 doc_id: 944495 cord_uid: tdfhl2na The disproportionate impact of coronavirus-2019 (COVID-19) on communities of color is gaining global attention. Current research demonstrates that historically marginalized populations are experiencing disproportionate levels of SARS-Cov-2 infection and adverse clinical outcomes. However, research examining whether COVID-19 outcomes vary by race and ethnicity within the rheumatic disease population is limited. This paper will review data showing how SARS-CoV-2 infection has differentially affected racial and ethnic minorities in the general population and those with rheumatic disease. We will also highlight disparities in rheumatic disease risk and severity that existed prior to the pandemic, and discuss recent work examining severe outcomes of COVID-19 in rheumatic disease patients by race and ethnicity. Finally, we propose several actionable steps for the rheumatology community to address COVID-19 health disparities, which may have long-term effects on patients with rheumatic disease. challenges that include difficulty accessing clean water and latrine facilities, increased exposure to forms of discrimination, and adhering to social distancing mandates [17] . Additionally, a study found that among COVID-19 cases and mortality rates in Brazil, Black patients had a lower likelihood of survival compared to white patients [18] . Although some major cities and countries around the world are reporting cases, until more consistent and conclusive data becomes available that accurately reflects the true number of occurrences of COVID-19 by racial and ethnic categories, our ability to gain a more holistic understanding of the connections between race, ethnicity and COVID-19 remains limited. Comorbidities Several factors may contribute to the disparities in SARS-CoV-2 infection and severe COVID-19 outcomes by race and ethnicity (Figure 1 ). Racial and ethnic minority communities may be more susceptible to both initial infection and severe outcomes because they have higher rates of comorbidities, namely diabetes and hypertension, that are associated with poor outcomes and mortality [19] . Hypertension disproportionately impacts Black individuals, with this group bearing the burden of heart failure and atherosclerotic disease [20] . Many studies have found that Black patients hospitalized and confirmed to have COVID-19 were more likely than whites to have comorbidities, notably asthma, cancer, chronic kidney disease, congestive heart failure, diabetes, hypertension, obesity, and solid organ transplantation [21] . J o u r n a l P r e -p r o o f Socioeconomic disparities also serve as underlying factors that disproportionately hinder nonwhite communities. Nonwhite individuals are more likely to live in poor, multigenerational, and overcrowded housing situations, making it more difficult to adhere to COVID-19 prevention guidelines [22] . Nonwhite individuals are also more likely to have inadequate access to health insurance and primary care providers and may experience various forms of discrimination when trying to access healthcare services [23] . Certain public-facing roles and other essential occupations can significantly increase the risk of exposure and infection, serving to drive disparities [24] . A study conducted in Utah found that one half of all outbreaks occurred in the following industries: manufacturing, construction, and wholesale trade [25] . Research has also shown that 73% of workplace infection outbreaks were among persons that identified as Hispanic or nonwhite, even though Hispanics or nonwhite individuals only made up 24% of the workforce for 15 identified affected sectors [26] . Additionally, communities of color are less likely to have full access and knowledge concerning appropriate methods to prevent infection, which has the potential to further increase existing disparities if individuals rely on incorrect prevention methods related to crowding and work conditions [19] . Variation in access to testing and treatment across racial and ethnic groups may also contribute to disparities in COVID-19. One study conducted in New York City found that racial minorities had decreased testing compared to white individuals [27] , despite widespread availability of testing to residents with and without insurance. Looking ahead, we may find additional disparities in access to care once a vaccine becomes available, even if distributed regardless of insurance status. Historically, disparities in vaccination rates exist in the general US population, J o u r n a l P r e -p r o o f with Black, Hispanic, and Asian individuals much less likely to receive vaccinations compared with non-Hispanic white individuals [28, 29] . Lower vaccination rates in communities of color, and the reasons for those lower rates, might have implications for immunization for COVID-19, if and when a vaccine is developed-despite the fact that these populations are more likely than white individuals to become infected, experience more severe disease, and die of COVID-19. One study found that non-Hispanic Black individuals were less likely to elect to receive the vaccine for COVID-19, if and when offered [30] . Further, to improve the health conditions of racial and ethnically diverse groups during this pandemic, diversity in clinical trials for a vaccine are imperative. People of color continue to be underrepresented in clinical research and this should be reversed, whenever possible, in order to achieve health equity and lessen the gap in quality healthcare and services among groups [31] . Global health research shows that health disparities within rheumatic diseases, particularly systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), osteoarthritis, and systemic sclerosis, are widespread. Within the United States, American Indian, Alaska Native, Black, Hispanic (of all races) and Asians/Pacific Islander persons are disproportionately affected by SLE compared to white persons [32] [33] [34] [35] . Disparities also exist in Latin America where the prevalence of musculoskeletal disorders was found to be highest in indigenous communities [36] . In addition to experiencing a higher risk of rheumatic disease diagnosis, nonwhite patients with rheumatologic conditions tend to experience a higher burden of disease activity and severity compared to white patients [37] [38] [39] [40] . For example, one study found that Black women experience the highest burden of SLE disease, followed by Hispanic, Asian, and white women [37] . SLE-J o u r n a l P r e -p r o o f to the potential impacts of COVID-19 on their health. Given that rheumatic diseases are often treated with medications that are immunomodulatory or immunosuppressive, additional work is ongoing to determine which specific drugs increase risk of infections. One case study hints at the possibility that SARS-CoV-2 infection may be associated with a new diagnosis of autoimmune conditions [46] . While some studies have shown no increased risk or only slightly increased risk of infection compared to the general population [47] , additional research is needed to evaluate the risk and effect of COVID-19 across comorbidities, rheumatic disease types, and immunosuppressive drugs. Given that racial/ethnic disparities in rheumatic disease diagnosis, severity, and progression exist, growing disparities in COVID-19 in the general population warrant immediate action to address potentially long-standing effects of the pandemic on vulnerable populations. To date, only two studies have examined COVID-19 outcomes among rheumatic disease patients in the context of race and ethnicity. A study conducted in New York found that nonwhite patients with SLE were hospitalized at higher rates than white patients [48] . Specifically, 83% of SLE patients hospitalized were nonwhite and 42% were Hispanic, compared to 59% nonwhite and 29% Hispanic in the ambulatory group. In an exploratory multivariable analysis, authors found that nonwhite race was associated with higher odds of hospitalization. Although this study focused on a small subset of SLE patients in one area, the findings mirror disparities found in the general population. In a second study of over 1,000 rheumatic disease patients with COVID-19 across the United States, differences in hospitalization by race/ethnicity were also demonstrated. White patients were less likely to be hospitalized (29%) compared to Black (51%), Latinx (37%), Asian (43%) and other/mixed race (35%) patients. Further, Black, Latinx, and Asian patients were found to have higher odds of hospitalization compared to white patients in analyses adjusting for age, sex, smoking, rheumatic disease diagnosis, comorbidities, medications taken prior to infection, and rheumatic disease activity [49] . Among those hospitalized, Latinx patients had three-fold increased odds of requiring ventilatory support. This study was not powered to examine mortality, but initial analyses found no differences in mortality by race/ethnicity. Results from these two studies suggest disparities in COVID-19 outcomes by race/ethnicity and highlight the need to proactively address the needs of rheumatic disease patients experiencing inequitable health outcomes during the pandemic. This may be even more of concern for vulnerable groups, given recent evidence of a chronic post-viral syndrome associated with COVID-19 disease, in which patients continue to experience symptoms after SARS-CoV-2 infection has cleared ("long-haulers") [50] . The possibility of patients living with an additional chronic disease has the potential to further impact their rheumatic disease activity and quality of life. Given the higher burden of both rheumatic disease and COVID-19 among racial/ethnic minorities, it is essential for the rheumatology community to appropriately plan and take actions to reduce COVID-19 disparities in this high-risk population [51, 52] . We propose four actionable goals for the rheumatology community to focus on in the immediate future (Table 1) . First, it is important to ensure that appropriate data sources are being used that capture the experience of nonwhite populations diagnosed with COVID-19. Race and ethnicity, along with socioeconomic status, and social determinants of health must be systematically and accurately captured in electronic health records and research studies, as it is crucial to understanding whether health disparities exist in relation to disease outcomes, including COVID-19 [53] . Rheumatologists within health systems may consider spearheading efforts to capture this information within their clinics and any studies being conducted at their sites. Research has also shown that diverse communities are likely to contribute COVID-19 related content on social media [54] ; therefore, researchers may consider harnessing the power of digital health among these communities to capture information on patient-reported outcomes [55] , while also implementing programs to address health literacy among rheumatic disease patients with COVID-19 [56] . Second, it is essential to ensure that high-risk patients are aware of COVID-19 risks and precautions, and tested appropriately, and testing efforts should be targeted to racial and ethnic minorities who may develop severe infection, including those who: 1) are essential workers, or share a household with someone who is an essential worker; 2) have comorbidities; 3) are over the age of 65; 4) are on medications that increase the risk of infections and/or severe COVID-19 outcomes (e.g. glucocorticoids); and/or 5) are living in a high-density household. This will involve targeted outreach in areas with a high incidence of disease [57] . In the case that hospitals and clinics do not already provide this type of information to their patients, rheumatologists J o u r n a l P r e -p r o o f should consider developing materials or counseling patients (in person or remotely) as best as possible. Materials should aid in improving patient education not only regarding SARS-CoV-2 infection, but also generate healthy behaviors that could potentially aid in reducing other types of infections. Effective control of COVID-19 and reduced burden of disease will also require increasing testing sites and availability in areas of high incidence and making testing available to patients regardless of insurance or symptoms. Rheumatologists should advocate for their patients to have access to testing and help them navigate testing procedures, especially those that are at highest risk. Third, once a vaccine is available and thought to be safe in people with rheumatic diseases, targeted outreach will be needed in areas of high incidence of disease but also in populations that are less likely to receive a vaccination. Plans for outreach might incorporate digital health and social media with specialized outreach plans for communities of color [58] . The American College of Rheumatology (ACR) is in full support of the rigorous testing of a safe and effective vaccine before its widespread use and encourages researchers to create clinical trials that represent diverse populations [59] . Ensuring that the vaccine is available and that all patients are provided an opportunity to receive one will be essential, especially in patients who are high-risk. The devastating effects of SARS-CoV-2 are unprecedented. Nonwhite communities are disproportionately affected by COVID-19, and this is also seen among patients with rheumatic disease. There are currently only two studies that address the racial and ethnic differences in rheumatic patients with COVID-19 [48, 49] . Additional research is needed to understand the disproportionate adverse health outcomes among minority patients with rheumatic disease, and whether these disparities exist across cities, states, and countries around the world. Furthermore, research is needed to discover how communities are addressing the social, racial, and ethnic inequalities for COVID-19, and attention should be drawn to mitigating the underlying factors contributing to health disparities, including structural racism [60, 61] . The pandemic has highlighted a multitude of health disparities across the world, proving to be devastating to all people, including those with rheumatic disease. Although the effects of COVID-19 have impacted millions, work remains in the fight against the pandemic, and rheumatologists can play an important role in improving the health of our most vulnerable patients. J o u r n a l P r e -p r o o f • Evidence shows that racial and ethnic minority patients with rheumatic disease experience worse COVID-19 outcomes compared to white patients. • Disparities in outcomes are multifactorial, likely including comorbidities, socioeconomic factors, and access to testing and treatment. • Actionable steps are needed to improve health outcomes of rheumatic disease patients at high-risk of developing severe infection at the rheumatologist, community, and government/public policy level. • More work is needed in designing and conducting diverse studies on racial/ethnic disparities in rheumatic disease patients diagnosed with COVID-19, including those related to vaccine development. 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