COVID-19 Among American Indian and Alaska Native Persons

23 States, January 31-July 3, 2020

Sarah M. Hatcher, PhD; Christine Agnew-Brune, PhD; Mark Anderson, MD; Laura D. Zambrano, PhD; Charles E. Rose, PhD; Melissa A. Jim, MPH; Amy Baugher, MPH; Grace S. Liu, MPH; Sadhna V. Patel, MPH; Mary E. Evans, MD; Talia Pindyck, MD; Christine L. Dubray, MD; Jeanette J. Rainey, PhD; Jessica Chen, PhD; Claire Sadowski, MPH; Kathryn Winglee, PhD; Ana Penman-Aguilar, PhD; Amruta Dixit, PhD; Eudora Claw, MPH; Carolyn Parshall, MPH; Ellen Provost, DO; Aurimar Ayala, MPH; German Gonzalez, MD; Jamie Ritchey, PhD; Jonathan Davis, PhD; Victoria Warren-Mears, PhD; Sujata Joshi, MSPH; Thomas Weiser, MD; Abigail Echo-Hawk, MA; Adrian Dominguez, MS; Amy Poel, MPH; Christy Duke, MPH; Imani Ransby, MPH; Andria Apostolou, PhD; Jeffrey McCollum, DVM

Disclosures

Morbidity and Mortality Weekly Report. 2020;69(34):1166-1169.

Abstract and Introduction

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.^[1] 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)^[2] 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,^[3] 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.^[4] CDC's National Center for Health Statistics (NCHS) postcensal bridged-race estimates were used as population denominators.^[5] 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.

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Abstract and Introduction
Discussion
References
Sidebar

*Based on 2018 U.S. Census single-race estimates for non-Hispanic AI/AN (https://wonder.cdc.gov/Single-Race-v2018.HTML). This represents a subset of the AI/AN population. The total AI/AN population (AI/AN alone or in combination with other races/ethnicities) constitutes 1.4% of the United States population (https://wonder.cdc.gov/Bridged-Race-v2019.HTML). Some have estimated the AI/AN population to constitute up to 1.7% of the United States population (https://www.census.gov/history/pdf/c2010br-10.pdf).
^†The first laboratory-confirmed case in the 23 analyzed states was reported on January 31, 2020.
^§Alabama, Alaska, Florida, Iowa, Kansas, Kentucky, Maine, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Mexico, North Carolina, Ohio, Oregon, Tennessee, Utah, Wisconsin, and Wyoming.
^¶ https://www.cdc.gov/coronavirus/2019-ncov/php/reporting-pui.html.
**https://wwwn.cdc.gov/nndss; https://wwwn.cdc.gov/nndss/covid-19-response.html.
^††A laboratory-confirmed COVID-19 case was defined as a person with a positive test result for SARS-CoV-2, the virus that causes COVID-19, from a respiratory specimen, using real time reverse transcription–polymerase chain reaction testing.
^§§According to the Council of State and Territorial Epidemiologists position statement Interim 20-ID-01, a probable case must 1) meet clinical criteria and epidemiologic criteria with no confirmatory laboratory testing performed; 2) have presumptive laboratory evidence, including detection of specific antigen or antibody in a clinical specimen, and meet clinical criteria or epidemiologic criteria; or 3) meet vital records criteria with no confirmatory laboratory testing performed. (https://cdn.ymaws.com/www.cste.org/resource/resmgr/2020ps/interim-20-id-01_covid-19.pdf).
^¶¶New Mexico accounts for 6,130 (68%) of the AI/AN cases but 16% of the total AI/AN population of the 23 states analyzed.

Table. Demographic characteristics and data quality among laboratory-confirmed COVID-19 cases, by race/ethnicity — 23 states,* January 31–July 3, 2020
Characteristic	No. (%)
Characteristic	American Indian and Alaska Native^† (N = 9,072)	White, non-Hispanic (N = 138,960)
Age group, yrs
Median (IQR)	40 (26–56)	51 (32–67)
0–18	1,171 (12.9)	6,000 (4.3)
19–44	4,091 (45.1)	50,772 (36.5)
45–54	1,384 (15.3)	19,923 (14.3)
55–64	1,284 (14.2)	22,518 (16.2)
≥65	1,141 (12.6)	39,737 (28.6)
Missing	1 (—)	10 (—)
Sex
Female	4,819 (53.5)	72,921 (52.6)
Male	4,181 (46.5)	65,701 (47.4)
Missing	72 (—)	338 (—)
Symptoms known^§
Yes	998 (11.0)	39,225 (28.2)
No	8,074 (89.0)	99,735 (71.8)
Underlying health conditions known ^¶
Yes	762 (8.4)	37,993 (27.3)
No	8,310 (91.6)	100,967 (72.7)
Hospitalization status known^††**
Yes	2,197 (24.2)	109,638 (78.9)
No	6,875 (75.8)	29,322 (21.1)
ICU admission status known^††
Yes	855 (9.4)	37,150 (26.7)
No	8,217 (90.6)	101,810 (73.3)
Death status known^††
Yes	2,039 (22.5)	103,371 (74.4)
No	7,033 (77.5)	35,589 (25.6)

Abbreviations: COVID-19 = coronavirus disease 2019; ICU = intensive care unit; IQR = interquartile range.
*Alabama, Alaska, Florida, Iowa, Kansas, Kentucky, Maine, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Mexico, North Carolina, Ohio, Oregon, Tennessee, Utah, Wisconsin, and Wyoming.
^†Alone or in combination with other races and ethnicities.
^§Symptoms were classified as "known" if any of the following symptoms were reported as present or absent: fever (measured >100.4°F [38°C] or subjective), cough, shortness of breath, wheezing, difficulty breathing, chills, rigors, myalgia, rhinorrhea, sore throat, chest pain, nausea or vomiting, abdominal pain, headache, fatigue, diarrhea (≥3 loose stools in a 24-hour period), or other symptom not otherwise specified on the form.
^¶Underlying health conditions were classified as "known" if any of the following conditions were reported as present or absent: diabetes mellitus, cardiovascular disease (including hypertension), severe obesity (body mass index ≥40 kg/m²), chronic renal disease, chronic liver disease, chronic lung disease, immunocompromising condition, autoimmune condition, neurologic condition (including neurodevelopmental, intellectual, physical, visual, or hearing impairment), psychologic/psychiatric condition, and other underlying medical condition not otherwise specified.
**Includes hospitalization with or without ICU admission.
^††Hospitalization, ICU admission, and death status were considered known if the response was "yes" or "no" (not "missing" or "unknown").