Abstract and Introduction
Although non-Hispanic American Indian and Alaska Native (AI/AN) persons account for 0.7% of the U.S. population,* a recent analysis reported that 1.3% of coronavirus disease 2019 (COVID-19) cases reported to CDC with known race and ethnicity were among AI/AN persons. To assess the impact of COVID-19 among the AI/AN population, reports of laboratory-confirmed COVID-19 cases during January 22†–July 3, 2020 were analyzed. The analysis was limited to 23 states§ with >70% complete race/ethnicity information and five or more laboratory-confirmed COVID-19 cases among both AI/AN persons (alone or in combination with other races and ethnicities) and non-Hispanic white (white) persons. Among 424,899 COVID-19 cases reported by these states, 340,059 (80%) had complete race/ethnicity information; among these 340,059 cases, 9,072 (2.7%) occurred among AI/AN persons, and 138,960 (40.9%) among white persons. Among 340,059 cases with complete patient race/ethnicity data, the cumulative incidence among AI/AN persons in these 23 states was 594 per 100,000 AI/AN population (95% confidence interval [CI] = 203–1,740), compared with 169 per 100,000 white population (95% CI = 137–209) (rate ratio [RR] = 3.5; 95% CI = 1.2–10.1). AI/AN persons with COVID-19 were younger (median age = 40 years; interquartile range [IQR] = 26–56 years) than were white persons (median age = 51 years; IQR = 32–67 years). More complete case report data and timely, culturally responsive, and evidence-based public health efforts that leverage the strengths of AI/AN communities are needed to decrease COVID-19 transmission and improve patient outcomes.
Individual COVID-19 case reports submitted to CDC using the CDC COVID-19 case report form¶ and through the National Notifiable Diseases Surveillance System** during January 22–July 3, 2020 were analyzed. Laboratory-confirmed†† and probable§§ COVID-19 cases are reported by state and local health jurisdictions based on reports submitted by health care providers and laboratories. Cases with missing report date were excluded. Probable cases (12,081) and cases among persons repatriated to the United States from Wuhan, China (two cases), and the Diamond Princess cruise ship (41 cases) were also excluded. Analysis was limited to the 23 states with >70% complete race/ethnicity information and five or more laboratory-confirmed cases each among AI/AN and white persons. Arizona, which accounts for at least one third of all COVID-19 cases among AI/AN persons nationwide, was excluded from analysis because >30% of race/ethnicity data were missing. Because approximately 2.3 million of 5.2 million AI/AN persons identify with multiple races, AI/AN race/ethnicity was classified as either AI/AN alone or in combination with other races and ethnicities. White (non-Hispanic) was chosen as the comparator group to avoid comparing rates among AI/AN persons to other marginalized populations that experience similar health disparities. Whereas previous reports focused on COVID-19 incidence among black and Hispanic persons, the race/ethnicity categorization in this analysis maximized these data to allow for the calculation of more stable RR estimates. A generalized estimating equations Poisson regression model was used to calculate cumulative incidence (cumulative cases per 100,000 population), RRs, and 95% CIs for AI/AN and white race/ethnicity categories. Generalized estimating equations models, which perform well for estimating rates with correlated data, were used to account for nonindependence (i.e., clustering) by state. CDC's National Center for Health Statistics (NCHS) postcensal bridged-race estimates were used as population denominators. Symptoms, underlying health conditions, hospitalizations, intensive care unit (ICU) admissions, and deaths were not analyzed because a large percentage of these data were missing. Analyses were conducted using SAS software (version 9.4; SAS Institute).
Among the 1,613,949 laboratory-confirmed COVID-19 cases voluntarily reported to CDC during January 22–July 3, 2020, 424,899 (26.3%) were reported by the 23 included states. Among these cases, 340,059 (80.0%) had complete race/ethnicity data, including 9,072 (2.7%) among AI/AN persons and 138,960 (40.9%) among white persons. These cases represented 51% of 17,709 reported cases among AI/AN persons and 41% of 339,789 reported cases among whites in all U.S. states and territories. Among the 340,059 cases with complete race/ethnicity data, the cumulative incidence among AI/AN persons was 594 cases per 100,000 (95% CI = 203–1,740), 3.5 (95% CI = 1.2–10.1) times that among white persons (169 per 100,000; 95% CI = 137–209). The magnitude of this reported RR estimate is affected by the elevated RR in New Mexico (RR = 14.9).¶¶ Median age among AI/AN and white patients was 40 years (IQR = 26–56 years) and 51 years (IQR = 32–67 years), respectively. AI/AN persons with COVID-19 tended to be younger than white persons with COVID-19: a higher proportion of AI/AN patients were aged <18 years (12.9%) and a smaller proportion were aged ≥65 years (12.6%), compared with white patients aged <18 and ≥65 years (4.3% and 28.6%, respectively) (Table).
Completeness of data on underlying health conditions (e.g., cardiovascular disease and diabetes), symptoms, hospitalization status, ICU admission, and death was lower for AI/AN patients than for white patients. Data on underlying health conditions were available for 762 (8.4%) AI/AN patients and 37,993 (27.3%) white patients, and symptom data were available for 998 (11.0%) AI/AN patients and 39,225 (28.2%) white patients. Whereas hospitalization status, ICU admission status, and vital status (i.e., outcome of death) were known for 78.9%, 26.7%, and 74.4%, respectively, of white COVID-19 patients, this information was available for approximately one third of those percentages of AI/AN patients (24.2%, 9.4%, and 22.5%, respectively). Because of the high prevalence of these missing data elements among AI/AN patients, analysis to identify overall prevalence, possible risk factors for COVID-19, and patient outcomes was not possible.
Morbidity and Mortality Weekly Report. 2020;69(34):1166-1169. © 2020 Centers for Disease Control and Prevention (CDC)