Racial and Ethnic Disparities in COVID-19 Hospitalization and Outcomes, March 2020 to February 2021 | Critical Care Medicine | JN Learning | AMA Ed Hub [Skip to Content]
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Racial and Ethnic Disparities in Rates of COVID-19–Associated Hospitalization, Intensive Care Unit Admission, and In-Hospital Death in the United States From March 2020 to February 2021

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  Are rates of COVID-19–associated hospitalization, intensive care unit (ICU) admission, or in-hospital death higher among individuals who belong to racial and ethnic minority groups compared with those who identify as non-Hispanic White?

Findings  In this cross-sectional study of 143 342 individuals hospitalized with COVID-19, non-Hispanic American Indian or Alaska Native, Hispanic or Latino, non-Hispanic Black, and non-Hispanic Asian or Pacific Islander persons were more likely to have a COVID-19-associated hospitalization, ICU admission, or in-hospital death compared with non-Hispanic White individuals during the first year of the pandemic.

Meaning  In this study, US residents who belong to racial and ethnic minority groups experienced severe COVID-19–associated outcomes disproportionately; equitable access to preventive measures, such as COVID-19 vaccines, is needed for these populations.

Abstract

Importance  Racial and ethnic minority groups are disproportionately affected by COVID-19.

Objectives  To evaluate whether rates of severe COVID-19, defined as hospitalization, intensive care unit (ICU) admission, or in-hospital death, are higher among racial and ethnic minority groups compared with non-Hispanic White persons.

Design, Setting, and Participants  This cross-sectional study included 99 counties within 14 US states participating in the COVID-19–Associated Hospitalization Surveillance Network. Participants were persons of all ages hospitalized with COVID-19 from March 1, 2020, to February 28, 2021.

Exposures  Laboratory-confirmed COVID-19–associated hospitalization, defined as a positive SARS-CoV-2 test within 14 days prior to or during hospitalization.

Main Outcomes and Measures  Cumulative age-adjusted rates (per 100 000 population) of hospitalization, ICU admission, and death by race and ethnicity. Rate ratios (RR) were calculated for each racial and ethnic group compared with White persons.

Results  Among 153 692 patients with COVID-19–associated hospitalizations, 143 342 (93.3%) with information on race and ethnicity were included in the analysis. Of these, 105 421 (73.5%) were 50 years or older, 72 159 (50.3%) were male, 28 762 (20.1%) were Hispanic or Latino, 2056 (1.4%) were non-Hispanic American Indian or Alaska Native, 7737 (5.4%) were non-Hispanic Asian or Pacific Islander, 40 806 (28.5%) were non-Hispanic Black, and 63 981 (44.6%) were White. Compared with White persons, American Indian or Alaska Native, Latino, Black, and Asian or Pacific Islander persons were more likely to have higher cumulative age-adjusted rates of hospitalization, ICU admission, and death as follows: American Indian or Alaska Native (hospitalization: RR, 3.70; 95% CI, 3.54-3.87; ICU admission: RR, 6.49; 95% CI, 6.01-7.01; death: RR, 7.19; 95% CI, 6.47-7.99); Latino (hospitalization: RR, 3.06; 95% CI, 3.01-3.10; ICU admission: RR, 4.20; 95% CI, 4.08-4.33; death: RR, 3.85; 95% CI, 3.68-4.01); Black (hospitalization: RR, 2.85; 95% CI, 2.81-2.89; ICU admission: RR, 3.17; 95% CI, 3.09-3.26; death: RR, 2.58; 95% CI, 2.48-2.69); and Asian or Pacific Islander (hospitalization: RR, 1.03; 95% CI, 1.01-1.06; ICU admission: RR, 1.91; 95% CI, 1.83-1.98; death: RR, 1.64; 95% CI, 1.55-1.74).

Conclusions and Relevance  In this cross-sectional analysis, American Indian or Alaska Native, Latino, Black, and Asian or Pacific Islander persons were more likely than White persons to have a COVID-19–associated hospitalization, ICU admission, or in-hospital death during the first year of the US COVID-19 pandemic. Equitable access to COVID-19 preventive measures, including vaccination, is needed to minimize the gap in racial and ethnic disparities of severe COVID-19.

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Article Information

Accepted for Publication: August 16, 2021.

Published: October 21, 2021. doi:10.1001/jamanetworkopen.2021.30479

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Acosta AM et al. JAMA Network Open.

Corresponding Author: Shikha Garg, MD, MPH, COVID-19–Associated Hospitalization Surveillance Network, US Centers for Disease Control and Prevention (CDC), 1600 Clifton Rd NE, MS-H24-7, Atlanta, GA 30329 (izj7@cdc.gov).

Author Contributions: Drs Acosta and Garg had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Acosta and Garg are co–first authors.

Concept and design: Acosta, Garg, Pham, O’Halloran, Wortham, Meek, Monroe, Lynfield, Barney, Bennett, Talbot, Schaffner, Fry, Kim, Havers.

Acquisition, analysis, or interpretation of data: Acosta, Garg, Pham, Whitaker, Anglin, O’Halloran, Milucky, Patel, Taylor, Wortham, Chai, Daily Kirley, Alden, Kawasaki, Meek, Yousey-Hindes, Anderson, Openo, Weigel, Monroe, Ryan, Reeg, Kohrman, Lynfield, Bye, Torres, Salazar-Sanchez, Muse, Barney, Bennett, Bushey, Billing, Shiltz, Sutton, Abdullah, Talbot, Schaffner, Ortega, Price, Hall, Kim, Havers.

Drafting of the manuscript: Acosta, Garg, Pham, O’Halloran, Bye, Billing, Abdullah.

Critical revision of the manuscript for important intellectual content: Acosta, Garg, Whitaker, Anglin, O’Halloran, Milucky, Patel, Taylor, Wortham, Chai, Daily Kirley, Alden, Kawasaki, Meek, Yousey-Hindes, Anderson, Openo, Weigel, Monroe, Ryan, Reeg, Kohrman, Lynfield, Torres, Salazar-Sanchez, Muse, Barney, Bennett, Bushey, Shiltz, Sutton, Abdullah, Talbot, Schaffner, Ortega, Price, Fry, Hall, Kim, Havers.

Statistical analysis: Acosta, Garg, Pham, Whitaker, O’Halloran, Patel, Ortega.

Obtained funding: Meek, Ryan, Talbot, Schaffner, Hall, Kim, Havers.

Administrative, technical, or material support: Acosta, Garg, Anglin, Milucky, Taylor, Wortham, Chai, Daily Kirley, Kawasaki, Meek, Openo, Weigel, Ryan, Lynfield, Bennett, Billing, Sutton, Abdullah, Talbot, Schaffner, Price, Hall, Kim.

Supervision: Garg, Milucky, Meek, Anderson, Ryan, Bennett, Bushey, Billing, Sutton, Talbot, Schaffner, Fry, Hall, Kim, Havers.

Conflict of Interest Disclosures: Ms Alden reported receiving grants from CDC Emerging Infections Program outside the submitted work. Dr Anderson reported receiving personal fees from Medscape and Kentucky Bioprocessing; grants from MedImmune, Regeneron, PaxVax, GlaxoSmithKline, Merck, and Micron; and grants and personal fees from Pfizer, Sanofi Pasteur, and Janssen Pharmaceuticals outside the submitted work. Mr Weigel reported receiving grants from CDC outside the submitted work. Dr Lynfield reported serving as associate editor for the AAP Red Book outside the submitted work, with the fee donated to the Minnesota Department of Health. Ms Billing reported receiving grants from CDC outside the submitted work. Mr Shiltz reported receiving grants from CDC outside the submitted work. Dr Schaffner reported serving as a consultant to VBI Vaccines outside the submitted work. No other disclosures were reported.

Funding/Support: This work was supported by CDC through an Emerging Infections Program cooperative agreement (grant CK17-1701) and through a Council of State and Territorial Epidemiologists cooperative agreement (grant NU38OT000297-02-00).

Role of the Funder/Sponsor: Drs Acosta and Garg, who are employed by CDC, had a role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The conclusions, findings, and opinions expressed by the authors do not necessarily reflect the official position of the US Department of Health and Human Services, the US Public Health Service, CDC, or the authors’ affiliated institutions.

Additional Contributions: We would like to thank the following individuals for their contributions to this work. Kareena Hundal, MPH, Jeremy Roland, MPH, Maria Rosales, BS, Joelle Nadle, MPH, and Erin Denleah, MPH (California Emerging Infections Program); Sarah McLafferty, MPH, and Millen Tsegaye, MHA (Colorado Department of Public Health and Environment); Amber Maslar, MPA, Paula Clogher, MPH, Danyel Olson, MPH, Hazal Kayalioglu, BS, Adam Misiorski, MPH, Christina Parisi, MPH, Maria Correa, MPH, Tessa Carter, MPH, Gaggan Brar, MD, Carol Lyons, MPH (Connecticut Emerging Infections Program); Emily Fawcett, MPH, Jeremiah Williams, MPH, Katelyn Ward, MPH, Siyeh Gretzinger, MPH, Jana Manning, MPH, Asmith Joseph, MPH, Allison Roebling, DVM, MPH, Chandler Surell, MPH, Stephanie Lehman, RN, BSN, Taylor Eisenstein, MPH, Gracie Chambers, Chris Bower, MPH, Andrew Revis, MPH, Dana Goodenough, MPH, Robin Dhonau, MPH, Sam Sefton, MPH, Stepy Thomas, MSPH, Suzanne Segler, MPH, Grayson Kallas, BS, and Amy Tunali, MPH (Georgia Emerging Infections Program, Georgia Department of Health); Alicia Brooks, MPH, Elisabeth Vaeth, MPH, Cindy Zerrlaut, David Blythe, MD, MPH, Rachel Park, MSc, and Michelle Wilson, MPH (Maryland Department of Health); Jim Collins, MPH, RS, Justin Henderson, MPH, Shannon Johnson, MPH, Sue Kim, MPH, Sam Hawkins, MPH, and Val Tellez Nunez, MPH (Michigan Department of Health and Human Services); Kathryn Como-Sabetti, MPH, Austin Bell, MS, Kayla Bilski, MPH, Emma Contestabile, BS, Claire Henrichsen, BS, Katherine Schleiss, MPH, Samantha Siebman, MPH, Emily Holodnick, MPH, Lisa Nguyen, BS, Kristen Ehresmann, MPH, and Richard Danila, MPH, PhD (Minnesota Department of Health); Kathy M. Angeles, MPH, Emily B. Hancock, MS, Meaghan Novi, MPH, Sarah A. Khanlian, MPH, Caroline Habrun, DVM, MPHTM, Melissa Christian, BUS, BA, Dominic Rudin, BS, Mayvilynne Poblete, MA, MPH, and Nancy Eisenberg, MPH (New Mexico Emerging Infections Program); Nancy Spina, MPH, Adam Rowe, BA, Suzanne McGuire, MPH, and Kerianne Engesser, MPH (New York State Department of Health); Virginia Cafferky, BS, Christina Felsen, MPH, Maria Gaitan, BS, RaeAnne Kurtz, Christine Long, MPH, Kevin Popham, MPH, Savanah Russ, MPH, Marissa Tracey, MPH (University of Rochester School of Medicine and Dentistry); Ama Owusu-Dommey, MPH (Public Health Division; Oregon Health Authority); Kylie Seeley, MD, MPH (Oregon Health & Science University School of Medicine); Tiffanie Markus, PhD, Karen Leib, RN, Katie Dyer, Terri McMinn, Danielle Ndi, MPH, Anise Elie, MPH, BSN, RN, Kathy Billings, MSPH, Manideepthi Pemmaraju, MPH, John Ujwok, MPH, Gail Hughett, RN, Isaac Schlotterbeck, BS, Bentley Akoko, MPH, Lin Ammar, MPH, Victoria Umutoni, MPH, Gerrica Alexander, BS, Abigail Peterson, BS, Rachel Jameson, BS, Rebecca Lee, BS (Vanderbilt University Medical Center); Melanie Crossland, MPH, Andrea George, MPH, Ashley Swain, CHES, Laine McCullough, MPH, Jake Ortega, MPH, Ryan Chatelain, MPH, Ilene Risk, MPA, Keegan McCaffrey, BA, Ian Buchta, MPH, Tyler Riedesel, MPH, Andrew Haraghey, BS, Caitlin Shaw, BS, Mary Hill, MPH, and Amanda Carter, BS (Salt Lake County Health Department); Charisse Cummings, MPH, Rachel Holstein, MPH, Rainy Amos, Sonja Mali Nti-Berko, MPH, and Robert Pinner, MD (CDC); and Mimi Hyunh, MPH (Council of State and Territorial Epidemiologists). None of these individuals were compensated specifically for this analysis.

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