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Assessment of Exposure to Environmental Toxins and Racial and Ethnic Disparities in COVID-19 Hospitalizations Among US Veterans

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

Residential neighborhood social factors associated with health play a role in the disproportionate impact of the COVID-19 pandemic among racial and ethnic minority populations.1 Exposure to environmental toxins has been understudied as a relevant neighborhood factor associated with health. Structural racism has relegated racial and ethnic minority populations to residential communities with higher, and multiple, risks of exposure to environmental toxins (eg, communities near industrial facilities).2 Although this exposure may be associated with increases in COVID-19–related comorbidities (eg, cancers),3,4 which might explain some of the racial and ethnic disparities in outcomes, it is unknown whether exposure to environmental toxins is independently associated with increases in COVID-19 susceptibility. This cohort study examined the hypothesis that exposure to environmental toxins mediates the association of racial and ethnic disparities with hospitalizations among veterans with COVID-19 after accounting for individual-level risk factors and comorbidities.

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Article Information

Accepted for Publication: June 12, 2022.

Published: July 28, 2022. doi:10.1001/jamanetworkopen.2022.24249

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Wong MS et al. JAMA Network Open.

Corresponding Author: Michelle S. Wong, PhD, Veterans Affairs Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation, and Policy, Veterans Affairs Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, Bldg 206, Los Angeles, CA 90073 (michelle.wong6@va.gov).

Author Contributions: Drs Wong and Washington 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.

Concept and design: Wong, Frochen, Washington.

Acquisition, analysis, or interpretation of data: Wong, Steers, Washington.

Drafting of the manuscript: Wong, Steers.

Critical revision of the manuscript for important intellectual content: Steers, Frochen, Washington.

Statistical analysis: Wong, Steers.

Obtained funding: Washington.

Administrative, technical, or material support: Wong, Frochen, Washington.

Supervision: Washington.

Conflict of Interest Disclosures: Dr Wong reported receiving grants from the Veterans Health Administration during the conduct of the study. Dr Frochen reported receiving grants from the Veterans Affairs (VA) Office of Academic Affiliation (via a fellowship from VA Health Services Research and Development Service at the VA Greater Los Angeles Healthcare System) during the conduct of the study. Dr Washington reported receiving grants from the Veterans Health Administration during the conduct of the study. No other disclosures were reported.

Funding/Support: This work was supported by grant SDR-20-402 from the VA Health Services Research and Development Service (Dr Washington) and grant PEC-15-239 from the Office of Health Equity and the Quality Enhancement Research Initiative (Dr Washington via the VA Health Equity and Quality Enhancement Research Initiative national partnered evaluation center).

Role of the Funder/Sponsor: The funders had no 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 views expressed in this article represent those of the authors and do not necessarily represent the views of the US Department of Veterans Affairs or the United States Government.

Additional Contributions: The authors thank Anita Yuan, PhD, of the VA Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, for her help in obtaining the data for this analysis. Dr Yuan was employed as a data analyst on the grants supporting these analyses at the time of this study.

References
1.
Dalsania  AK , Fastiggi  MJ , Kahlam  A ,  et al.  The relationship between social determinants of health and racial disparities in COVID-19 mortality.   J Racial Ethn Health Disparities. 2022;9(1):288-295. doi:10.1007/s40615-020-00952-y PubMedGoogle ScholarCrossref
2.
Mohai  P , Pellow  D , Roberts  JT .  Environmental justice.   Annu Rev Environ Resour. 2009;34:405-430. doi:10.1146/annurev-environ-082508-094348 Google ScholarCrossref
3.
Kampa  M , Castanas  E .  Human health effects of air pollution.   Environ Pollut. 2008;151(2):362-367. doi:10.1016/j.envpol.2007.06.012 PubMedGoogle ScholarCrossref
4.
Division of Viral Diseases, National Center for Immunization and Respiratory Diseases. Underlying medical conditions associated with higher risk for severe COVID-19: information for healthcare professionals. Centers for Disease Control and Prevention. Updated June 15, 2022. Accessed February 11, 2022. https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-care/underlyingconditions.html
5.
United States Environmental Protection Agency. Learn about RSEI. United States Environmental Protection Agency. Updated July 14, 2021. Accessed December 13, 2021. https://www.epa.gov/rsei/learn-about-rsei
6.
Nguyen  QC , Osypuk  TL , Schmidt  NM , Glymour  MM , Tchetgen Tchetgen  EJ .  Practical guidance for conducting mediation analysis with multiple mediators using inverse odds ratio weighting.   Am J Epidemiol. 2015;181(5):349-356. doi:10.1093/aje/kwu278 PubMedGoogle ScholarCrossref
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