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.

Discussion

In 23 states with sufficient COVID-19 patient race/ethnicity data, the overall COVID-19 incidence among AI/AN persons was 3.5 times that among white persons. Although this disparity is mostly influenced by the elevated RR in New Mexico, variability in the RR among states is reflected in the wide confidence interval (95% CI = 1.2, 10.1). Among 345,093 COVID-19 cases meeting the study inclusion criteria, 2.7% of cases occurred in AI/AN persons, more than twice the percentage of non-Hispanic AI/AN cases reported in CDC COVID-19 case surveillance data from all states (1.3%).^[1] However, this analysis included AI/AN persons who identified as multiple races and ethnicities, which increased AI/AN case identification by 4%, from 8,691 to 9,072 cases in the 23 states. The higher proportion of AI/AN persons in this analysis is also the result of the more completely reported race/ethnicity data in these states.

Historical trauma and persisting racial inequity have contributed to disparities in health and socioeconomic factors between AI/AN and white populations that have adversely affected AI/AN communities; these factors likely contribute to the observed elevated incidence of COVID-19 among the AI/AN population.^[6] The elevated incidence within this group might also reflect differences in reliance on shared transportation, limited access to running water, household size, and other factors that might facilitate COVID-19 community transmission.^[6] Although the elevated prevalence of underlying health conditions among AI/AN persons is well documented,^[7,8] in this analysis, data on underlying health conditions were unknown or missing for 91.6% of AI/AN patients compared with 72.7% of white patients, preventing examination of the association between underlying health conditions and COVID-19 incidence. The excessive absence of data among AI/AN persons represents an important gap in public health data for AI/AN persons and suggests a need for additional resources to support case investigation and reporting infrastructure in AI/AN communities.

The findings in this report are subject to at least three limitations. First, data are presented as reported to CDC through a passive case surveillance system. Case data are voluntarily reported to CDC by states without active case finding. The high prevalence of missing data on symptoms, underlying health conditions, hospitalization, ICU admission, and death precluded the analysis of these characteristics and outcomes. Missing data likely reflect state, local, and tribal health jurisdictions' ability to collect these data given their current case loads, incomplete reporting to CDC, or both. Second, this analysis represents an underestimate of the actual COVID-19 incidence among AI/AN persons for several reasons. Reporting of detailed case data to CDC by states is known to be incomplete; therefore, this analysis was restricted to 23 states with more complete reporting of race and ethnicity. As a result, the analysis included only one half of reported laboratory-confirmed COVID-19 cases among AI/AN persons nationwide, and the examined states represent approximately one third of the national AI/AN population.*** In addition, AI/AN persons are commonly misclassified as non-AI/AN races and ethnicities in epidemiologic and administrative data sets, leading to an underestimation of AI/AN morbidity and mortality.^[9] Finally, the NCHS bridged-race estimates used as population denominators are known to inflate the Hispanic AI/AN population in the United States, resulting in the underestimation of mortality rates among AI/AN populations that include Hispanic AI/AN persons.^[10]

Despite these limitations, these findings suggest that the AI/AN population in the 23 examined states, particularly AI/AN persons aged <65 years, has been disproportionately affected by the COVID-19 pandemic, compared with the white population. More complete case information is needed to more effectively guide the public health response to COVID-19 among the AI/AN population. The collection of this information can be facilitated by more consistent, complete, and accurate collection and reporting by providers, reporting laboratories, and local, state, federal, and tribal public health practitioners, and ensuring the resources to do so. Race/ethnicity data should be collected following best practices for AI/AN data collection, including allowing for the reporting of multiple races and ethnicities and providing adequate training about asking about race and ethnicity in a culturally sensitive manner.^§§§ Further, among federally recognized tribes, AI/AN race is a political status that confers access to health care services under treaty obligations of the U.S. government^¶¶¶; these findings highlight the important contribution of adequate health care and public health infrastructure resources to culturally responsive public health efforts intended to sustain the strengths of AI/AN communities.

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Acknowledgments
State, local, tribal, and territorial health department personnel; William Duck, Adam Langer, Ellyn Marder, Jason Price, Kala Raz, Jessica Rinsky, Benjamin Silk, Erin Sizemore, Danielle Tack.

***https://wonder.cdc.gov/Bridged-Race-v2018.html.
^§§§ https://www.uihi.org/resources/best-practices-for-american-indian-and-alaska-native-data-collection/.
^¶¶¶ https://www.ihs.gov/aboutihs/.

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").