Disparities in Incidence of COVID-19 Among Underrepresented Racial/Ethnic Groups in Counties Identified as Hotspots During June 5–18, 2020

22 States, February-June 2020

Jazmyn T. Moore, MSc, MPH; Jessica N. Ricaldi, MD, PhD; Charles E. Rose, PhD; Jennifer Fuld, PhD; Monica Parise, MD; Gloria J. Kang, PhD; Anne K. Driscoll, PhD; Tina Norris, PhD; Nana Wilson, PhD; Gabriel Rainisch, MPH; Eduardo Valverde, DrPH; Vladislav Beresovsky, PhD; Christine Agnew Brune, PhD; Nadia L. Oussayef, JD; Dale A. Rose, PhD; Laura E. Adams, DVM; Sindoos Awel; Julie Villanueva, PhD; Dana Meaney-Delman, MD; Margaret A. Honein, PhD

Disclosures

Morbidity and Mortality Weekly Report. 2020;69(33):1122-1126. 

In This Article

Abstract and Introduction

Introduction

During January 1, 2020–August 10, 2020, an estimated 5 million cases of coronavirus disease 2019 (COVID-19) were reported in the United States.* Published state and national data indicate that persons of color might be more likely to become infected with SARS-CoV-2, the virus that causes COVID-19, experience more severe COVID-19–associated illness, including that requiring hospitalization, and have higher risk for death from COVID-19.[1–5] CDC examined county-level disparities in COVID-19 cases among underrepresented racial/ethnic groups in counties identified as hotspots, which are defined using algorithmic thresholds related to the number of new cases and the changes in incidence. Disparities were defined as difference of ≥5% between the proportion of cases and the proportion of the population or a ratio ≥1.5 for the proportion of cases to the proportion of the population for underrepresented racial/ethnic groups in each county. During June 5–18, 205 counties in 33 states were identified as hotspots; among these counties, race was reported for ≥50% of cumulative cases in 79 (38.5%) counties in 22 states; 96.2% of these counties had disparities in COVID-19 cases in one or more underrepresented racial/ethnic groups. Hispanic/Latino (Hispanic) persons were the largest group by population size (3.5 million persons) living in hotspot counties where a disproportionate number of cases among that group was identified, followed by black/African American (black) persons (2 million), American Indian/Alaska Native (AI/AN) persons (61,000), Asian persons (36,000), and Native Hawaiian/other Pacific Islander (NHPI) persons (31,000). Examining county-level data disaggregated by race/ethnicity can help identify health disparities in COVID-19 cases and inform strategies for preventing and slowing SARS-CoV-2 transmission. More complete race/ethnicity data are needed to fully inform public health decision-making. Addressing the pandemic's disproportionate incidence of COVID-19 in communities of color can reduce the community-wide impact of COVID-19 and improve health outcomes.

This analysis used cumulative county-level data during February–June 2020, reported to CDC by jurisdictions or extracted from state and county websites and disaggregated by race/ethnicity. Case counts, which included both probable and laboratory-confirmed cases, were cross-referenced with counts from the HHS Protect database (https://protect-public.hhs.gov/). Counties missing race data for more than half of reported cases (126) were excluded from the analysis.§ The proportion of the population for each county by race/ethnicity was calculated using data obtained from CDC WONDER.[6] For each underrepresented racial/ethnic group, disparities were defined as a difference of ≥5% between the proportion of cases and the proportion of the population consisting of that group or a ratio of ≥1.5 for the proportion of cases to the proportion of the population in that racial/ethnic group. The county-level differences and ratios between proportion of cases and the proportion of population were used as a base for a simulation accounting for missing data using different assumptions of racial/ethnic distribution of cases with unknown race/ethnicity. An intercept-only logistic regression model was estimated for each race/ethnicity category and county to obtain the intercept regression coefficient and standard error. The simulation used the logistic regression-estimated coefficient and standard error to produce an estimated mean and confidence interval (CI) for the percentage difference between and ratio of proportions of cases and population. This simulation was done for each racial/ethnic group within each county. The lower bound of the CI was used to identify counties with disparities (as defined by percentage differences or ratio). The mean of the estimated differences and mean of the estimated ratios were calculated for all counties with disparities. Analyses were conducted using SAS software (version 9.4; SAS Institute).

During June 5–18, a total of 205 counties in 33 states were identified as hotspots. These counties have a combined total population of 93.5 million persons, and approximately 535,000 cumulative probable and confirmed COVID-19 cases. Among the 205 identified hotspot counties, 79 (38.5%) counties in 22 states, with a combined population of 27.5 million persons and approximately 162,000 COVID-19 cases, had race data available for ≥50% of cumulative cases and were included in the analysis (range = 51.3%–97.4%). Disparities in cases were identified among underrepresented racial/ethnic groups in 76 (96.2%) analyzed counties (Table 1). Disparities among Hispanic populations were identified in approximately three quarters of hotspot counties (59 of 79, 74.7%) with approximately 3.5 million Hispanic residents (Table 2). Approximately 2.0 million black persons reside in 22 (27.8%) hotspot counties where black residents were disproportionately affected by COVID-19, approximately 61,000 AI/AN persons live in three (3.8%) hotspot counties where AI/AN residents were disproportionately affected by COVID-19, nearly 36,000 Asian persons live in four (5.1%) hotspot counties where Asian residents were disproportionately affected by COVID-19, and approximately 31,000 NHPI persons live in 19 (24.1%) hotspot counties where NHPI populations were disproportionately affected by COVID-19.

The mean of the estimated differences between the proportion of cases and proportion of the population consisting of each underrepresented racial/ethnic group in all counties with disparities ranged from 4.5% (NHPI) to 39.3% (AI/AN) (Table 3). The mean of the estimated ratio of the proportion of cases to the proportions of population were also generated for each underrepresented racial/ethnic group and ranged from 2.3 (black) to 8.5 (NHPI).

*https://www.cdc.gov/coronavirus/2019-ncov/cases-in-us.html.
Hotspot counties are defined as those meeting all of the following baseline criteria: 1) >100 new COVID-19 cases in the most recent 7 days, 2) an increase in the most recent 7-day COVID-19 incidence over the preceding 7-day incidence, 3) a decrease of <60% or an increase in the most recent 3-day COVID-19 incidence over the preceding 3-day incidence, and 4) the ratio of 7-day incidence to 30-day incidence exceeds 0.31. In addition, hotspots must have met at least one of the following criteria: 1) >60% change in the most recent 3-day COVID-19 incidence, or 2) >60% change in the most recent 7-day incidence.
§Data from 10 of the 126 excluded counties were excluded due to pending data questions.

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