- This cross-sectional study, nested within the prospective COVID Symptom Study, analyzed data on 2,102,364 participants in the U.S. and U.K. who provided daily reports on their COVID-19–related symptoms, health care visits and test results
- Participants in most racial/ethnic minority groups were more likely than white participants to become infected with COVID-19, particularly Black and Hispanic participants in the U.S. and Black, South Asian and Middle Eastern participants in the U.K.
- Comorbid conditions did not explain the increased likelihood of COVID-19 infection in those groups
- Contact with someone who had suspected or confirmed COVID-19 was a significant factor in the association between race/ethnicity and excess COVID-19 risk
- Community-level socioeconomic deprivation explained 17% of the excess risk among Black participants in the U.S., 6% among Hispanic/Latinx participants in the U.S. and 8% among Black participants in the U.K., even after adjustment for personal risk factors
It's well established that people from racial/ethnic minority groups have disproportionately high rates of COVID-19 infection, hospitalization and death. Most studies of these disparities have focused on either individual or community-level socioeconomic risk factors, but not both.
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To address this gap in knowledge, Chun-Han Lo, MD, MPH, a postdoctoral research fellow in the Clinical and Translational Epidemiology Unit at Massachusetts General Hospital, Andrew T. Chan, MD, MPH, chief of the unit, and colleagues used data from a very large sample in the U.S. and U.K. to jointly examine the contribution of personal and community-level risk factors.
Their report in EClinicalMedicine shows structural socioeconomic disparities have a substantial influence on the increased likelihood of COVID-19 among people from racial/ethnic minority groups, even after accounting for personal risk.
The prospective COVID Symptom Study was conducted by smartphone starting on March 24, 2020, in the U.K. and March 29, 2020, in the U.S. The researchers conducted a nested cross-sectional analysis of 258,788 participants in the U.S. (median age 52), and 1,843,576 participants in the U.K. (median age 48) who reported their race and ethnicity.
Participants received daily smartphone prompts to report any COVID-19–related symptoms, health care visits and test results. On first use of the app, they also reported whether they had ever been exposed to someone with presumed or confirmed COVID-19. Participants were followed for as long as they used the app (median, 17 days).
The community-level risk was calculated on the Neighborhood Deprivation Index (NDI) in the U.S. and the Index of Multiple Deprivation (IMD) in the U.K. These indexes reflect factors such as income/poverty, education, employment, housing, health and crime.
Risk of Infection
Particularly during the first wave of the pandemic, the age-adjusted odds of a positive COVID-19 test were higher for participants from most racial/ethnic minority groups than for white participants:
- In the U.S., the risk was especially high for Black (OR, 1.52) and Hispanic/Latino/a/x participants (OR, 1.73)
- In the U.K., after accounting for the likelihood of receiving a test, the risk was especially high for Black (OR, 1.41), South Asian (OR, 1.56) and Middle Eastern participants (OR, 1.54)
Influence of Comorbidities and Occupation
Neither medical comorbidities nor occupation as a frontline health care provider explained the excess risk experienced by people from these racial and ethnic minority groups.
Influence of Community-level Deprivation
Community-level socioeconomic factors significantly influenced the association between race/ethnicity and risk of COVID-19:
- In the U.S., participants living in communities in the most deprived quintile of the NDI had 24% greater odds of contact with someone with suspected or confirmed COVID-19, and 71% greater odds of testing positive compared with those in communities in the least deprived quintile (Ptrend < 0.001, both comparisons)
- In the U.K., the respective figures were 11% and 26% greater odds (Ptrend < 0.001, both comparisons)
- Compared with white participants, the odds of living in a community in the highest quintile of deprivation was two-fold greater for U.S. Black and Hispanic/Latino/a/x participants and three-fold greater for U.K. Black participants
Using structural equation models, the researchers determined:
- In the U.S., 24% of increased COVID-19 risk in Black participants was mediated by community-level socioeconomic deprivation. After considering prior exposure to COVID-19, occupation and comorbidities, 17% of increased risk was still mediated by community-level deprivation. For Hispanic/Latino/a/x participants, the corresponding figures were 9% and 6%
- In the U.K., the proportion of increased COVID-19 risk mediated by community-level deprivation was 18% in Black participants, 4% in South Asian and 4% in Middle Eastern participants. Black participants still had 8% of excess risk mediated by community-level factors after considering the three personal risk factors
These data show systemic socioeconomic inequities are responsible for a substantial portion of the excess COVID-19 risk in certain racial/ethnic minority groups in the U.S. and U.K., especially in Black communities. This study highlights the importance of allocating resources to specific communities and the need to make robust public health infrastructure accessible to all.
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