key: cord-1031159-0e0bux8u
authors: Ferguson, J. M.; Justice, A. C.; Osborne, T. F.; Abdel Magid, H. S.; Purnell, A. L.; Rentsch, C. T.
title: Racial and ethnic disparities for SARS-CoV-2 positivity in the United States: a generalizing pandemic
date: 2021-04-30
journal: nan
DOI: 10.1101/2021.04.27.21256215
sha: d592aabce0ec9d9ecc8d18f2681157cbbed25397
doc_id: 1031159
cord_uid: 0e0bux8u

The coronavirus pandemic has disproportionally impacted racial and ethnic minority communities in the United States. These disparities may be changing over time as outbreaks occur in different communities. Using electronic health record data from the Department of Veterans Affairs, we estimated odds ratios, stratified by region and time period, for testing positive for SARS-CoV-2 among 951,408 individuals tested for SARS-CoV-2 between February 12, 2020 and February 12, 2021. Our study found racial and ethnic disparities for testing positive were most pronounced at the beginning of the pandemic and decreased over time. A key finding was that the disparity among Hispanic individuals attenuated but remained elevated over the entire study period. We identified variation in racial and ethnic disparities in SARS-CoV-2 positivity by time and region independent of underlying health status and other key factors in a nationwide cohort, which provides important insight for strategies to contain and prevent further outbreaks.

The coronavirus pandemic has disproportionally impacted racial and ethnic minority communities in the United States. 1-3 Evidence has highlighted the vast disparities in SARS-CoV-2 infection and subsequent COVID-19 among persons who were Black, Hispanic, or Native Hawaiian/Pacific Islander. [4] [5] [6] [7] Recently, additional analyses have suggested that racial and ethnic disparities may be changing over time as outbreaks spread from racially and ethnically diverse metropolitan centers to more rural and less diverse areas. 4, 5, 8 In this report, we updated our previous analyses 4, 5 to evaluate changes in disparities for testing positive with SARS-CoV-2 over the first full year of the pandemic and by geographic region in the largest integrated healthcare system in the United States.

Using national electronic health record data from the Department of Veterans Affairs (VA), we conducted a retrospective cohort analysis of all individuals tested for SARS-CoV-2 between February 12, 2020 and February 12, 2021. Methods have been previously described in detail. 4, 5 In brief, we used multivariable logistic regression to estimate odds ratios (OR) and 95% confidence intervals (CI) for testing positive for SARS-CoV-2 for non-Hispanic Black, Hispanic, Asian, American Indian/Alaska Native (AI/AN), Native Hawaiian/Pacific Islander (NH/PI), and people of mixed race, relative to non-Hispanic White individuals. All models were adjusted for other demographics (sex, age, rural/urban residence), baseline comorbidity (asthma, cancer, chronic kidney disease, chronic obstructive pulmonary disease, diabetes mellitus, hypertension, liver disease, vascular disease), substance use (alcohol consumption, alcohol use disorder, smoking status), medication history (angiotensin converting enzyme inhibitor, angiotensin II receptor blocker), and conditioned on VA site of care to account for spatial differences in SARS-CoV-2 burden. Models were stratified by time period into waves: February 12 -May 31, 2020 (wave 1); June 1 -September 30, 2020 (wave 2); October 1 -December 11, 2020 (wave 3a); and

December 12, 2020 -February 12, 2021 (wave 3b). The May/June and September/October cut points were defined a priori based on two national waves of SARS-CoV-2 cases. The third national wave between October 2020 and February 2021 was split into two waves containing roughly equal numbers of SARS-CoV-2 cases.

. CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted April 30, 2021. ; https://doi.org/10.1101/2021.04.27.21256215 doi: medRxiv preprint To evaluate regional differences in the most recent wave (3b: December 12, 2020 -February 12, 2021), models were further stratified by US Census region (i.e., West, South, Midwest, and Northeast). Due to low number of events, we combined AI/AN, NH/PI, and patients of mixed race into an "other" category for these models. Data analysis was performed using SAS version 9.4 (SAS Institute, Cary, NC).

Of 951,408 individuals tested during the study period, 111,912 (11.8%) tested positive for SARS-CoV-2 ( Table 1) . All non-White groups had higher crude prevalence of positive tests than White individuals (10.8%), with the largest differences observed among Black (13.0%), Hispanic (15.4%), and AI/AN (13.2%) groups. By region, the crude prevalence of positive tests was highest in Midwest (13.7%) and lowest in Northeast (10.3%). Individuals who were younger or male had a slightly higher crude prevalence of positive tests than those who were older or female. Over time, the prevalence of positive tests increased from 6.9% in wave 1 and 6.2% in wave 2 to 14.8% in wave 3a and 22.0% in wave 3b. Across all groups, the percentage of positive tests increased over time (Figure 1) . In wave 1, White individuals had a higher crude test positivity percentage than all racial and ethnic minorities except for Black individuals. However, by the end of the study period (wave 3b), AI/AN and Hispanic individuals had a higher unadjusted percentage of positive tests than White individuals.

Over the entire study period and compared to White individuals, those who were Black and no observed disparity among people of mixed race (1.15, 0.89-1.50) in wave 1. In wave 3b, disparities for testing positive were not observed among any racial or ethnic minority group, . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) We found some evidence of regional variation in the disparity for testing positive in the most recent wave (Figure 3) . Black individuals and people of other race (i.e., AI/AN, PI/NH, and mixed race) had marginally higher odds for testing positive in the South (1.07, 1.03-1.11 for Black; 1.13, 1.01-1.26 for other race). Disparities for testing positive among Hispanic individuals were present in all regions, most notably in the West (1.49, 1.39-1.59). There was no evidence of variation in disparities for testing positive across geographic regions for Asian; however, confidence intervals were wide due to low numbers testing positive for this group in most regions.

Our study found that racial and ethnic disparities for testing positive for SARS-CoV-2 were most pronounced at the beginning of the pandemic and that these disparities decreased over time. By the end of the first 12 months of the pandemic, disparities for testing positive were attenuated but remained elevated for Hispanic individuals and were no longer observed for any other group. This attenuation in disparities may be due to an increase in the test positivity percentage among White individuals rather than a decline in test positivity among racial and ethnic minority groups as the pandemic moves from diverse metropolitan areas to less diverse rural areas.

Our findings on disparities for testing positive among Black and Hispanic individuals in the first months of the pandemic have been demonstrated previously. 1-5 This study extended previously published models to evaluate patterns in disparities over the first full year of the pandemic. A novel finding was that disparities for testing positive dramatically attenuated and were no longer observed among all racial and ethnic groups apart from Hispanic individuals.

Another novel finding was the identification of disparity among Asian individuals in the first wave of the pandemic, which was obscured in the time-pooled model.

A key finding was that the disparity for testing positive among Hispanic individuals attenuated but remained elevated over the study period. In the last wave assessed between . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted April 30, 2021. ; https://doi.org/10.1101/2021.04.27.21256215 doi: medRxiv preprint December 2020 and February 2021, Hispanic individuals had 34% elevated odds for testing positive compared to White individuals. This persistent disparity among Hispanic individuals was observed across all geographic regions, with the greatest disparity in the West. A deeper understanding of the mechanism for this association is needed but may be due to the lack of nationwide media coverage and targeted and appropriate outreach to Hispanic populations in the United States. Hispanic individuals are also overrepresented in essential and frontline jobs, which increases their likelihood of SARS-CoV-2 exposure and they may face barriers (e.g., precarious employment or financial limitations) to taking sick leave that would help reduce the spread of SARS-CoV-2. 9

Our findings of racial and ethnic disparities for testing positive for SARS-CoV-2 provide important insight to help tailor strategies to contain and prevent further outbreaks in the United States. Early in the pandemic, tailored interventions to groups with higher risks may have been most effective. Now that the epidemic has generalized from large metropolitan centers with very high incidence to a more consistent rate of incidence across the country, racial and ethnic groups may be affected more equally suggesting that widescale prevention interventions for all persons may be most effective. However, the continued disparities among Hispanic groups suggest that targeted assessment and data informed interventions are required. Furthermore, while there is a more consistent rate of SARS-CoV-2 across the United States, targeted assessment may still be useful for curtailing local infection hotspots. SARS-CoV-2 is impacting all communities and is now much less concentrated in specific vulnerable groups compared to early in the pandemic.

This does not imply that the overall cumulative burden of COVID-19 may be equal, as marginalized populations such as persons of color experienced substantial excess rates earlier in the epidemic and may experience excess extended effects from infection. Of note, access to free or subsidized care at VA may help reduce the impact of negative social determinants of health as prior reports state little disparities in mortality were found among patients treated for COVID-19 at VA. 4 The VA electronic health record database offers the single largest nationwide data resource available in the United States with the necessary information on system-wide testing and detailed medical histories to examine racial and ethnic disparities. Our analysis identified time and regional variation in racial and ethnic disparities in SARS-CoV-2 positivity over the first full year of the pandemic independent of underlying health status and other key factors in a . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted April 30, 2021. ; https://doi.org/10.1101/2021.04.27.21256215 doi: medRxiv preprint large, nationwide cohort. However, our analysis should be interpreted with some limitations, which include limitations we previously described in detail. 4, 5 In brief, we only examined tests that administered in the VA; therefore, our results may not be representative of all Veterans tested for SARS-CoV-2. Second, although this population was primarily male, it included over 100,000 women. Third, as is the case with most electronic health record data sources, we did not have the necessary information to account for social determinants of health (e.g., occupation or household details) in our analysis, which are critical to understanding and preventing health inequities particularly in infectious disease outbreaks. Careful research is needed to evaluate the association between social determinants of health and disparities seen during the COVID-19 pandemic as they may operate as confounders or may be on the causal pathway.

. CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) Wave 1 (February 12 -May 31, 2020); Wave 2 (June 1 -September 30, 2020); Wave 3a (October 1 -December 11, 2020); and Wave 3b (December 12, 2020 -February 12, 2021).

. CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted April 30, 2021. ; https://doi.org/10.1101/2021.04.27.21256215 doi: medRxiv preprint is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted April 30, 2021. ; https://doi.org/10.1101/2021.04.27.21256215 doi: medRxiv preprint

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