Racial/Ethnic Disparities in Exposure, Disease Susceptibility, and Clinical Outcomes during COVID-19 Pandemic in National Cohort of Adults, United States

McKaylee M. Robertson; Meghana G. Shamsunder; Ellen Brazier; Mekhala Mantravadi; Rebecca Zimba; Madhura S. Rane; Drew A. Westmoreland; Angela M. Parcesepe; Andrew R. Maroko; Sarah G. Kulkarni; Christian Grov; Denis Nash


Emerging Infectious Diseases. 2022;28(11):2171-2180. 

In This Article

Abstract and Introduction


We examined racial/ethnic disparities for COVID-19 seroconversion and hospitalization within a prospective cohort (n = 6,740) in the United States enrolled in March 2020 and followed-up through October 2021. Potential SARS-CoV-2 exposure, susceptibility to COVID-19 complications, and access to healthcare varied by race/ethnicity. Hispanic and Black non-Hispanic participants had more exposure risk and difficulty with healthcare access than white participants. Participants with more exposure had greater odds of seroconversion. Participants with more susceptibility and more barriers to healthcare had greater odds of hospitalization. Race/ethnicity positively modified the association between susceptibility and hospitalization. Findings might help to explain the disproportionate burden of SARS-CoV-2 infections and complications among Hispanic/Latino/a and Black non-Hispanic persons. Primary and secondary prevention efforts should address disparities in exposure, vaccination, and treatment for COVID-19.


Researchers have identified underlying medical conditions, comorbidities, older age, and male sex as biologic vulnerabilities for more severe COVID-19 outcomes.[1,2] Evidence also suggests a disproportionate burden of COVID-19 infection, hospitalization, and death among Hispanic/Latino/a, Black non-Hispanic, and American Indian and Alaskan Native populations in the United States..[3–6] Early in the pandemic (March 2020), the Centers for Disease Control and Prevention (CDC) reported that twice as many Black persons were hospitalized because of COVID-19 than are proportionally represented in the United States..[3] Long-standing health and social inequities probably contribute to disparities in COVID-19 illness and death.[7–9]

Public health interventions and policies with the potential to improve health might inadvertently amplify existing health disparities.[7] Prevention efforts, such as social distancing or work from home policies, might have inequitable benefits across racial and ethnic groups because of differential employment in essential work settings or likelihood of living in multigenerational households.[7,8,10] Less access to or use of healthcare also result in differential COVID-19 outcomes among racial and ethnic minority groups because later care presentation might limit treatment options.[6,8] Blumenshine et al. proposed a pandemic disease model in which differences in exposure to the pathogen, susceptibility to severe illness if infected, and poor/delayed access to treatment might lead to disproportionate infection, illness, and death during a pandemic.[11] To avoid exacerbating existing disparities, effective public health interventions and pandemic guidelines need to anticipate and mitigate the contribution of social determinants to disparities in exposure, susceptibility if exposed and access to treatment.[9,11,12]

Our objective was to examine the influence of racial and ethnic differences in social determinants on COVID-19 outcomes within a large US national cohort of adults that was enrolled during the spring of 2020, the early phase of the COVID-19 pandemic. Using the Blumenshine model as a framework, we created 3 indices to assess social determinants: the ability to social distance as a measure of potential SARS-CoV-2 exposure, susceptibility to COVID-19 complications, and access to healthcare. We examined the relationship between each index with COVID-19 outcomes (COVID-19 hospitalization or seroconversion). Considering race/ethnicity as a social, rather than biologic construct,[13] we assessed it as a potential effect measure modifier (EMM) of the relationship between each index and COVID-19 outcome.