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


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

In This Article


These findings illustrate the disproportionate incidence of COVID-19 among communities of color, as has been shown by other studies, and suggest that a high percentage of cases in hotspot counties are among persons of color.[1–5,7] Among all underrepresented racial/ethnic groups in these hotspot counties, Hispanic persons were the largest group living in hotspot counties with a disparity in cases identified within that population (3.5 million persons). This finding is consistent with other evidence highlighting the disproportionate incidence of COVID-19 among the Hispanic population.[2,7] The disproportionate incidence of COVID-19 among black populations is well documented.[1–3] The findings from this analysis align with other data indicating that black persons are overrepresented among COVID-19 cases, associated hospitalizations, and deaths in the United States. The analysis found few counties with disparities among AI/AN populations. This finding is likely attributable to the smaller proportions of cases and populations of AI/AN identified in hotspot counties, as well as challenges with data for this group, including a lack of surveillance data and misclassification problems in large data sets. Asian populations were disproportionately affected by COVID-19 in a small number of hotspot counties. Few studies have assessed COVID-19 disparities among Asian populations in the United States.** The Asian racial category is broad, and further subgroup analyses might provide additional insights regarding the incidence of COVID-19 in this population. Disparities in COVID-19 cases in NHPI populations were identified in nearly one quarter of hotspot counties. For some hotspot counties with small NHPI populations, this finding might be related, in part, to the analytic methodology used. Using a ratio of ≥1.5 in the proportion of population and proportion of cases to indicate disparities is sensitive to small differences in these groups. More complete county-level race/ethnicity data are needed to fully evaluate the disproportionate incidence of COVID-19 among communities of color.

Disparities in COVID-19–associated mortality in hotspot counties were not assessed because the available county-level mortality data disaggregated by race/ethnicity were not sufficient to generate reliable estimates. Existing national analyses highlight disparities in mortality associated with COVID-19; similar patterns are likely to exist at the county level.[5] As more complete data are made available in the future, county-level analyses examining disparities in mortality might be possible. COVID-19 disparities among underrepresented racial/ethnic groups likely result from a multitude of conditions that lead to increased risk for exposure to SARS-CoV-2, including structural factors, such as economic and housing policies and the built environment,†† and social factors such as essential worker employment status requiring in-person work (e.g., meatpacking, agriculture, service, and health care), residence in multigenerational and multifamily households, and overrepresentation in congregate living environments with an increased risk for transmission.[4,7–9] Further, long-standing discrimination and social inequities might contribute to factors that increase risk for severe disease and death, such as limited access to health care, underlying medical conditions, and higher levels of exposure to pollution and environmental hazards§§.[4] The conditions contributing to disparities likely vary widely within and among groups, depending on location and other contextual factors.

Rates of SARS-CoV-2 transmission vary by region and time, resulting in nonuniform disease outbreak patterns across the United States. Therefore, using epidemiologic indicators to identify hotspot counties currently affected by SARS-CoV-2 transmission can inform a data-driven emergency response. Tailoring strategies to control SARS-CoV-2 transmission could reduce the overall incidence of COVID-19 in communities. Using these data to identify disproportionately affected groups at the county level can guide the allocation of resources, development of culturally and linguistically tailored prevention activities, and implementation of focused testing efforts.

The findings in this report are subject to at least five limitations. First, more than half of the hotspot counties did not report sufficient race data and were therefore excluded from the analysis. In addition, many hotspot counties included in the analyses were missing data on race for a significant proportion of cases (mean = 28.3%; range = 2.6%–48.7%). These data gaps might result from jurisdictions having to reconcile data from multiple sources for a large volume of cases while data collection and management processes are rapidly evolving.¶¶ Second, health departments differ in the way race/ethnicity are reported, making comparisons across counties and states more difficult. Third, differences in how race/ethnicity data are collected (e.g., self-report versus observation) likely varies by setting and could lead to miscategorization. Fourth, differences in access to COVID-19 testing could lead to underestimates of prevalence in some underrepresented racial/ethnic populations. Finally, the number of cases that had available race/ethnicity data for the period of study of hotspots (June 5–18) was too small to generate reliable estimates, so cumulative case counts by county during February–June 2020 were used to identify disparities. This approach describes the racial/ethnic breakdown of cumulative cases only. Therefore, these data might not provide an accurate estimate of disparities during June 5–18, which could be under- or overestimated, or change over time.

Developing culturally responsive, targeted interventions in partnership with trusted leaders and community-based organizations within communities of color might reduce disparities in COVID-19 incidence. Increasing the proportion of cases for which race/ethnicity data are collected and reported can help inform efforts in the short-term to better understand patterns of incidence and mortality. Existing health inequities amplified by COVID-19 highlight the need for continued investment in communities of color to address social determinants of health*** and structural racism that affect health beyond this pandemic.[4,8] Long-term efforts should focus on addressing societal factors that contribute to broader health disparities across communities of color.

††The built environment includes the physical makeup of where persons live, learn, work, and play, including homes, schools, businesses, streets and sidewalks, open spaces, and transportation options. The built environment can influence overall community health and individual. Behaviors, such as physical activity and healthy eating. https://www.cdc.gov/nccdphp/dnpao/state-local-programs/built-environment-assessment/.
§§ https://www.medrxiv.org/content/10.1101/2020.04.05.20054502v2.
¶¶ https://www.hhs.gov/about/news/2020/06/04/hhs-announces-new-laboratory-data-reporting-guidance-for-covid-19-testing.html.