Benjamin Seligman1,2,3, Maddalena Ferranna4, David E Bloom4. 1. New England Geriatric Research, Education, and Clinical Center, VA Boston Healthcare System, Boston, Massachusetts, United States of America. 2. Harvard Medical School, Boston, Massachusetts, United States of America. 3. Harvard Center for Population and Development Studies, Cambridge, Massachusetts, United States of America. 4. Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America.
Abstract
BACKGROUND: The COVID-19 epidemic in the United States is widespread, with more than 200,000 deaths reported as of September 23, 2020. While ecological studies show higher burdens of COVID-19 mortality in areas with higher rates of poverty, little is known about social determinants of COVID-19 mortality at the individual level. METHODS AND FINDINGS: We estimated the proportions of COVID-19 deaths by age, sex, race/ethnicity, and comorbid conditions using their reported univariate proportions among COVID-19 deaths and correlations among these variables in the general population from the 2017-2018 National Health and Nutrition Examination Survey (NHANES). We used these proportions to randomly sample individuals from NHANES. We analyzed the distributions of COVID-19 deaths by race/ethnicity, income, education level, and veteran status. We analyzed the association of these characteristics with mortality by logistic regression. Summary demographics of deaths include mean age 71.6 years, 45.9% female, and 45.1% non-Hispanic white. We found that disproportionate deaths occurred among individuals with nonwhite race/ethnicity (54.8% of deaths, 95% CI 49.0%-59.6%, p < 0.001), individuals with income below the median (67.5%, 95% CI 63.4%-71.5%, p < 0.001), individuals with less than a high school level of education (25.6%, 95% CI 23.4% -27.9%, p < 0.001), and veterans (19.5%, 95% CI 15.8%-23.4%, p < 0.001). Except for veteran status, these characteristics are significantly associated with COVID-19 mortality in multiple logistic regression. Limitations include the lack of institutionalized people in the sample (e.g., nursing home residents and incarcerated persons), the need to use comorbidity data collected from outside the US, and the assumption of the same correlations among variables for the noninstitutionalized population and COVID-19 decedents. CONCLUSIONS: Substantial inequalities in COVID-19 mortality are likely, with disproportionate burdens falling on those who are of racial/ethnic minorities, are poor, have less education, and are veterans. Healthcare systems must ensure adequate access to these groups. Public health measures should specifically reach these groups, and data on social determinants should be systematically collected from people with COVID-19.
BACKGROUND: The COVID-19 epidemic in the United States is widespread, with more than 200,000 deaths reported as of September 23, 2020. While ecological studies show higher burdens of COVID-19 mortality in areas with higher rates of poverty, little is known about social determinants of COVID-19 mortality at the individual level. METHODS AND FINDINGS: We estimated the proportions of COVID-19 deaths by age, sex, race/ethnicity, and comorbid conditions using their reported univariate proportions among COVID-19 deaths and correlations among these variables in the general population from the 2017-2018 National Health and Nutrition Examination Survey (NHANES). We used these proportions to randomly sample individuals from NHANES. We analyzed the distributions of COVID-19 deaths by race/ethnicity, income, education level, and veteran status. We analyzed the association of these characteristics with mortality by logistic regression. Summary demographics of deaths include mean age 71.6 years, 45.9% female, and 45.1% non-Hispanic white. We found that disproportionate deaths occurred among individuals with nonwhite race/ethnicity (54.8% of deaths, 95% CI 49.0%-59.6%, p < 0.001), individuals with income below the median (67.5%, 95% CI 63.4%-71.5%, p < 0.001), individuals with less than a high school level of education (25.6%, 95% CI 23.4% -27.9%, p < 0.001), and veterans (19.5%, 95% CI 15.8%-23.4%, p < 0.001). Except for veteran status, these characteristics are significantly associated with COVID-19 mortality in multiple logistic regression. Limitations include the lack of institutionalized people in the sample (e.g., nursing home residents and incarcerated persons), the need to use comorbidity data collected from outside the US, and the assumption of the same correlations among variables for the noninstitutionalized population and COVID-19 decedents. CONCLUSIONS: Substantial inequalities in COVID-19 mortality are likely, with disproportionate burdens falling on those who are of racial/ethnic minorities, are poor, have less education, and are veterans. Healthcare systems must ensure adequate access to these groups. Public health measures should specifically reach these groups, and data on social determinants should be systematically collected from people with COVID-19.
Authors: Daniel Murphy; Charles E McCulloch; Feng Lin; Tanushree Banerjee; Jennifer L Bragg-Gresham; Mark S Eberhardt; Hal Morgenstern; Meda E Pavkov; Rajiv Saran; Neil R Powe; Chi-Yuan Hsu Journal: Ann Intern Med Date: 2016-08-02 Impact factor: 25.391
Authors: Rishi K Wadhera; Priya Wadhera; Prakriti Gaba; Jose F Figueroa; Karen E Joynt Maddox; Robert W Yeh; Changyu Shen Journal: JAMA Date: 2020-06-02 Impact factor: 56.272
Authors: Andrew S Levey; Lesley A Stevens; Christopher H Schmid; Yaping Lucy Zhang; Alejandro F Castro; Harold I Feldman; John W Kusek; Paul Eggers; Frederick Van Lente; Tom Greene; Josef Coresh Journal: Ann Intern Med Date: 2009-05-05 Impact factor: 25.391
Authors: Trevon L Fuller; Guilherme Calvet; Camila Genaro Estevam; Jussara Rafael Angelo; Gbenga J Abiodun; Umme-Aiman Halai; Bianca De Santis; Patricia Carvalho Sequeira; Eliane Machado Araujo; Simone Alves Sampaio; Marco Cesar Lima de Mendonça; Allison Fabri; Rita Maria Ribeiro; Ryan Harrigan; Thomas B Smith; Claudia Raja Gabaglia; Patrícia Brasil; Ana Maria Bispo de Filippis; Karin Nielsen-Saines Journal: PLoS One Date: 2017-11-16 Impact factor: 3.240
Authors: Saman Khalatbari-Soltani; Robert C Cumming; Cyrille Delpierre; Michelle Kelly-Irving Journal: J Epidemiol Community Health Date: 2020-05-08 Impact factor: 3.710
Authors: José María Mayoral; Jordi Alonso; Olatz Garín; Zaida Herrador; Jenaro Astray; Maretva Baricot; Jesús Castilla; Rafael Cantón; Ady Castro; Miguel Delgado-Rodríguez; Alicia Ferri; Pere Godoy; Fernando Gónzález-Candelas; Vicente Martín; Tomás Pumarola; José María Quintana; Núria Soldevila; Sonia Tamames; Angela Domínguez Journal: BMC Public Health Date: 2013-02-07 Impact factor: 3.295
Authors: Henry Surendra; Ngabila Salama; Karina D Lestari; Verry Adrian; Widyastuti Widyastuti; Dwi Oktavia; Rosa N Lina; Bimandra A Djaafara; Ihsan Fadilah; Rahmat Sagara; Lenny L Ekawati; Ahmad Nurhasim; Riris A Ahmad; Aria Kekalih; Ari F Syam; Anuraj H Shankar; Guy Thwaites; J Kevin Baird; Raph L Hamers; Iqbal R F Elyazar Journal: BMJ Glob Health Date: 2022-06
Authors: Rachael D Dombrowski; Alex B Hill; Bree Bode; Kathryn A G Knoff; Hadis Dastgerdizad; Noel Kulik; James Mallare; Kibibi Blount-Dorn; Winona Bynum Journal: Nutrients Date: 2022-05-20 Impact factor: 6.706
Authors: Laura Matrajt; Julia Eaton; Tiffany Leung; Dobromir Dimitrov; Joshua T Schiffer; David A Swan; Holly Janes Journal: Nat Commun Date: 2021-06-08 Impact factor: 14.919
Authors: Tara L Upshaw; Chloe Brown; Robert Smith; Melissa Perri; Carolyn Ziegler; Andrew D Pinto Journal: PLoS One Date: 2021-03-31 Impact factor: 3.240
Authors: Chun-Han Lo; Long H Nguyen; David A Drew; Erica T Warner; Amit D Joshi; Mark S Graham; Adjoa Anyane-Yeboa; Fatma M Shebl; Christina M Astley; Jane C Figueiredo; Chuan-Guo Guo; Wenjie Ma; Raaj S Mehta; Sohee Kwon; Mingyang Song; Richard Davies; Joan Capdevila; Carole H Sudre; Jonathan Wolf; Yvette C Cozier; Lynn Rosenberg; Lynne R Wilkens; Christopher A Haiman; Loïc Le Marchand; Julie R Palmer; Tim D Spector; Sebastien Ourselin; Claire J Steves; Andrew T Chan Journal: EClinicalMedicine Date: 2021-07-17