COVID rates among African Americans

Clinical Question

What are the rates of COVID-19 among African Americans and what are proposed reasons for disparities in infection, hospitalization, severity, and case fatality rates?

Key Findings

  • A recent CDC report[1] found that black populations may be disproportionately affected by COVID-19, although their findings need to be confirmed with additional data.
  • Factors that may explain the disparity in infection, severity, and mortality include but are not limited to: higher incidence of comorbidities, difficulty accessing care (insurance issues, lack of medical resources in AA-predominant communities), higher rates of exposure (occupational exposure, living in dense urban areas, need to visit public places such as food banks due to food insecurity), mistrust of authority and the medical system from historical trauma, and implicit bias within the healthcare system.

Summary of Information

Is the incidence of COVID cases and deaths higher among African American patients?

Summary of recent CDC publication[1]

In the COVID-NET catchment population (14 U.S. states, ~10% of the US population; 1,482 laboratory confirmed patients), approximately 59% of residents are white, 18% are black, and 14% are Hispanic. Among hospitalized patients with race/ethnicity data (580), 261 (45.0%) were non-Hispanic white (white), 192 (33.1%) were non-Hispanic black (black), 47 (8.1%) were Hispanic, 32 (5.5%) were Asian, two (0.3%) were American Indian/Alaskan Native, and 46 (7.9%) were of other or unknown race. As such, the CDC suggests, “Black populations might be disproportionately affected by COVID-19. These findings, including the potential impact of both sex and race on COVID-19-associated hospitalization rates, need to be confirmed with additional data.”

Base Population

Hospitalized Population

White

59%

45%

Non-Hispanic black

18%

33.1%

Hispanic

14%

8.1%

State census data

  1. In Milwaukee, life expectancy for Black people is reportedly 14 years shorter. As of April 3, 2020, almost half of patients infected with COVID-19 were African American, although Milwaukee is 39% African American. In addition, African Americans accounted for 81% of the city’s deaths from COVID-19.
  2. Michigan is 14% Black, yet African Americans made up 35% of cases and 40% of deaths as of April 3, 2020.
  3. The high morbidity and mortality of COVID-19 in predominantly African American cities, such as New Orleans and Detroit, is also consistent with this data.[2]
    Descriptive text is not available for this image
  4. Age-adjusted mortality by race in New York City published by NYC Health with data from Bureau of Communicable Disease Surveillance System:
    Descriptive text is not available for this image

Why might this difference exist?

More Comorbidities

CDC data shows between March 1–30, 89.3% of hospitalized adults had one or more underlying conditions; the most commonly reported were: hypertension (49.7%), obesity (48.3%), chronic lung disease including asthma (34.6%), diabetes mellitus (28.3%), and cardiovascular disease (27.8%).[1]

  1. Hypertension: From 2015-2016, hypertension prevalence was higher among non-Hispanic black patients (40.3%) than non-Hispanic white patients (27.8%). Moreover, a smaller proportion of non-Hispanic black patients (44.6%) had controlled hypertension compared to non-Hispanic white patients (50.8%).[3]
  2. Obesity: From 2015-2017, non-Hispanic black adults had the highest prevalence of obesity (38.4%) overall in the US, followed by Hispanic adults (32.6%) and non-Hispanic white adults (28.6%).[4]
  3. Chronic lung disease/asthma: In 2014, African Americans were ~3x more likely to die from asthma related complications than white patients. In 2015, African American women were 20% more likely to have asthma than non-Hispanic white women. Compared to non-Hispanic white children, African American children are 4x more likely to be admitted to the hospital for asthma, and in 2015 African American children had a 10x higher death rate.[5]
  4. Diabetes mellitus: From 2013-2016, approximately 16.4% of non-Hispanic Black patients had DM2, compared to 11.9% of non-Hispanic white patients.[6] Moreover, non-Hispanic blacks are more likely to experience diabetes-associated morbidity (e.g., 3.5x more likely to be diagnosed with end stage renal disease; 2.3x more likely to be hospitalized for lower limb amputations) and morality (e.g., twice as likely to die from diabetes) compared to non-Hispanic white patients.[7]
  5. Cardiovascular disease: Black individuals are 2-3x as likely as white individuals to die of preventable heart disease and stroke. Although mortality from heart disease overall has declined in reason years, racial disparities have not been eliminated.[8]

Access to care/Health insurance

  1. Higher rates of being uninsured: Extensive disparities in coverage have historically existed by race/ethnicity. Although all racial/ethnic groups had large gains in health coverage under the ACA, according to 2018 US census date, Black individuals remain more likely to be uninsured compared to Whites (9.7% vs. 5.4%).[9] Moreover, uninsured Black individuals are more likely than Whites to live in states that have not implemented the Medicaid expansion, leading to a coverage gap (15% vs. 9%).[10] Although Congressional legislation ensures free COVID-19 testing, uninsured patients may lack a usual source of care, may not know how to obtain testing, or may still forego testing/treatment due to fears of costs.
  2. Lack of healthcare providers and resources in the American South: There are higher rates of death from COVID-19 in patients under 70 in the South compared with reports from other states and countries, and 1/10th of COVID deaths occur in the four state arc of Alabama, Louisiana, Georgia, and Mississippi. This may be because poor, Black, Latino, and rural individuals in the South are less likely to have access to care. The South is also the poorest region of the US, and 9 of 14 states that refused to expand Medicaid to the poor are in the South. The South also has the highest proportion of incarceration.[11]
  3. Poor access to health care in incarcerated populations: Prisons have higher rates of racial minorities and other people vulnerable to social determinants of health, yet these people are unprotected against COVID-19 due to "restricted movement, confined spaces, and limited medical care." In the H1N1 epidemic of 2009, vaccines became readily available to most populations by 2010, yet most small jails never received the vaccine.[12]

Social/Income inequality vs. Occupation exposure

  1. Lower income: A report on 27,344 symptomatic patients identified by the biotech data firm Rubix Life Sciences and matched with final diagnosis using billing (claims) codes (February 9, 2020-March 20, 2020), found that the majority of Black and Hispanic patients reporting COVID-19 symptoms had an estimated household income of under $50,000 per year.[13] Prior to the COVID-19 pandemic, a Kaiser Family Foundation report found over a quarter of Black individuals were low-wage workers, compared to less than 17% of White individuals.[10] In this way, Black patients may be less able to absorb income declines from social distancing and work closure, or unexpected medical costs.
  2. Occupation exposure: The increased proportion of Black individuals (24% vs. 16% White)[14] in the service industry creates a large pool of people at risk for increased risk of exposure to symptomatic individuals and subsequent COVID-19 infection as many jobs in the service industry are considered essential and cannot be done from home while still requiring engagement with other individuals (transportation, sanitation, groceries, etc).
  3. Food/Housing: Individuals who live in densely populated urban areas, crowded living spaces and/or multi-family dwellings likely have a higher risk for exposure. The Pew Research Center reported that people of color account for more than half (56%) of the population in urban counties, while White individuals account for the majority in suburban (68%) and rural (79%) counties.[15] About 41% of Black individuals reported living in an area with multi-unit residential buildings compared to 23% of White individuals where the capacity to social distance is limited.[10] Finally, Black households experience food insecurity at nearly double the rate of the national average (21.2% vs. 11.1%) contributing to decreased overall health.[16]

Mistrust of authority from historical trauma

  1. Police and inspectors in Milwaukee report that they are receiving information about businesses breaking social distancing guidelines in predominantly Black communities.[2] Due to repeated incidents of injustice performed by those in authority, black communities have been socialized to be cautious of government-based efforts to control way of life.

Healthcare system bias/Implicit bias

  1. Discimintarion in healthcare setting: Using survey data from a nationally representative sample during the H1N1 influenza epidemic, one study showed that Blacks (adjusted OR 3.9, P < 0.001), as well as English- (aOR 2.8, P =0.02) and Spanish-speaking Hispanics (aOR 6.1, P < 0.001), were more likely than Whites to report having been discriminated against when accessing health care.[17] One article reports that racial differences in outcomes are likely multifactorial in cause, including physiologic, psychosocial and societal causes. For example, chronic stress and poverty are closely linked, and individuals with higher levels of stress have been shown to have higher rates of infection when exposed to a virus--thus placing Hispanics and African Americans at higher risk of infection. It is also well reported that there is pre-existing bias among health care workers, leading to fewer procedures and lower quality care in black and Hispanic patients compared to white patients. This inequality is only amplified during a pandemic.[18]
  2. Inequity in SARS-CoV-2 virus testing: The above mentioned Rubix Life Sciences report, which matched 27,344 symptomatic patients with final diagnosis using billing codes (February 9, 2020-March 20, 2020), found the total number of patients exhibiting COVID-19 symptoms greatly exceeded publicly reported cases in each state. Notably, the Rubix group of patients was predominantly racial/ethnic minorities (53% Black, 30% Hispanic, ~12% Native American, 3.3% Other, 1.8% White), suggesting there may be inequities in referring for SARS-CoV-2 viral testing and COVID-19 treatment; in addition to other factors (testing availability, subjectivity of testing criteria, variability in presentation of COVID-19 symptoms).[13]

Gaps in knowledge

Currently, no trials have investigated differences in use of ACEI/ARBs among African Americans with COVID-19, variances in ACE2-receptor or other biological explanations for disparities. However, this is likely the least contributory factor to current disparities.

Author Information

Authors: Rebecca Gold MS4, Sonya Gleicher MS4, Lucas Keyt MS4; UC San Diego School of Medicine
Completed on: April 11, 2020
Last updated on: April 21, 2020

Reviewed by: Marsha-Gail Davis, MD
Reviewed on: April 20, 2020

This summary was written as part of the CoRESPOND Earth 2.0 COVID-19 Rapid Response at UC San Diego. For more information about the project, please visit http://earth2-covid.ucsd.edu

References

  1. Garg S, Kim L, Whitaker M, et al. Hospitalization Rates and Characteristics of Patients Hospitalized with Laboratory-Confirmed Coronavirus Disease 2019 - COVID-NET, 14 States, March 1-30, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(15):458-464.  [PMID:32298251]
  2. Johnson A, Buford T. Early Data Shows African Americans Have Contracted, Died of Coronavirus at an Alarming Rate. Medscape. http://www.medscape.com/viewarticle/928164. Accessed April 21, 2020.
  3. Fryar C, Ostchega Y, Hales CM, Zhang G, Kruszon-Moran D. Hypertension Prevalence and Control Among Adults: United States, 2015–2016. Data Briefs - Number 289 - October 2017. CDC, National Center for Health Statistics. https://www.cdc.gov/nchs/products/databriefs/db289.htm. Published June 6, 2019. Accessed April 21, 2020.
  4. Petersen R, Pan L, Blanck HM. Racial and Ethnic Disparities in Adult Obesity in the United States: CDC's Tracking to Inform State and Local Action. Prev Chronic Dis. 2019;16:E46.  [PMID:30974071]
  5. Asthma and African Americans - The Office of Minority Health. U.S. Department of Helath and Human Services, Office of Minority Health. https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=15. Published April 9, 2020. Accessed April 21, 2020.
  6. National Diabetes Statistics Report. CDC National Diabetes Statistics Report. https://www.cdc.gov/diabetes/data/statistics/statistics-report.html. Published February 18, 2020. Accessed April 21, 2020.
  7. Diabetes and African Americans. U.S. Department of Helath and Human Services, Office of Minority Health. https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=18. Accessed April 21, 2020.
  8. Ferdinand KC, Yadav K, Nasser SA, et al. Disparities in hypertension and cardiovascular disease in blacks: The critical role of medication adherence. J Clin Hypertens (Greenwich). 2017;19(10):1015-1024.  [PMID:28856834]
  9. Berchick ER, Barnett JC, Upton RD. Health Insurance Coverage in the United States: 2018.; :44.
  10. Artiga S, Garfield R, Orgera K. Communities of Color at Higher Risk for Health and Economic Challenges due to COVID-19. Henry J Kais Fam Found. April 2020. https://www.kff.org/disparities-policy/issue-brief/communities-of-color-at-higher-risk-for-health-and-economic-challenges-due-to-covid-19/. Accessed April 9, 2020.
  11. Newkirk II VR. The Coronavirus’s Unique Threat to the South. The Atlantic. https://www.theatlantic.com/politics/archive/2020/04/coronavirus-unique-threat-south-young-people/609241/. Published April 2, 2020. Accessed April 21, 2020.
  12. Akiyama MJ, Spaulding AC, Rich JD. Flattening the Curve for Incarcerated Populations - Covid-19 in Jails and Prisons. N Engl J Med. 2020.  [PMID:32240582]
  13. Swift R. COVID-19 & Minority Health Access. Rubix Life Sciences; 2020:8. https://rubixls.com/wp-content/uploads/2020/04/COVID-19-Minority-Health-Access-7.pdf.
  14. Labor force characteristics by race and ethnicity, 2018 : BLS Reports: U.S. Bureau of Labor Statistics. https://www.bls.gov/opub/reports/race-and-ethnicity/2018/home.htm. Accessed April 21, 2020.
  15. Parker K, Horowitz JM, Brown A, Fry R, Cohen D, Igielnik R. Demographic and economic trends in urban, suburban and rural communities. Pew Res Center’s Soc Demogr Trends Proj. May 2018. https://www.pewsocialtrends.org/2018/05/22/demographic-and-economic-trends-in-urban-suburban-and-rural-communities/. Accessed April 21, 2020.
  16. Coleman-Jensen A, Rabbitt MP, Gregory CP, Singh A. Household Food Security in the United States in 2018. U.S. Department of Agriculture, Economic Research Service; 2019:47. https://www.ers.usda.gov/webdocs/publications/94849/err-270.pdf?v=963.1.
  17. Quinn SC, Kumar S, Freimuth VS, et al. Racial disparities in exposure, susceptibility, and access to health care in the US H1N1 influenza pandemic. Am J Public Health. 2011;101(2):285-93.  [PMID:21164098]
  18. Aubrey A. Who’s Hit Hardest By COVID-19? Why Obesity, Stress And Race All Matter. NPR.org. https://www.npr.org/sections/health-shots/2020/04/18/835563340/whos-hit-hardest-by-covid-19-why-obesity-stress-and-race-all-matter. Accessed April 21, 2020.
  19. Rates of Cases, Hospitalizations and Deaths by Race/Ethnicity GroupCOVID-19: Data - NYC Health. COVID-19: Data - NYC Health. https://www1.nyc.gov/assets/doh/downloads/pdf/imm/covid-19-deaths-race-ethnicity-04162020-1.pdf. Accessed April 12, 2020.
  20. Thebault R, Tran AB, Williams V. The coronavirus is infecting and killing black Americans at an alarmingly high rate. Washington Post. https://www.washingtonpost.com/nation/2020/04/07/coronavirus-is-infecting-killing-black-americans-an-alarmingly-high-rate-post-analysis-shows/. Published April 7, 2020. Accessed April 21, 2020.