Assessing differential impacts of COVID-19 on black communities

Abstract

Purpose: Given incomplete data reporting by race, we used data on COVID-19 cases and deaths in U.S. counties to describe racial disparities in COVID-19 disease and death and associated determinants.

Methods: Using publicly available data (accessed April 13, 2020), predictors of COVID-19 cases and deaths were compared between disproportionately (≥13%) black and all other (<13% black) counties. Rate ratios were calculated, and population attributable fractions were estimated using COVID-19 cases and deaths via zero-inflated negative binomial regression model. National maps with county-level data and an interactive scatterplot of COVID-19 cases were generated.

Results: Nearly 90% of disproportionately black counties (656/677) reported a case and 49% (330/677) reported a death versus 81% (1987/2465) and 28% (684/2465), respectively, for all other counties. Counties with higher proportions of black people have higher prevalence of comorbidities and greater air pollution. Counties with higher proportions of black residents had more COVID-19 diagnoses (Rate Ratio (RR): 1.24, 95% confidence interval: 1.17-1.33) and deaths (RR: 1.18, 95% confidence interval: 1.00-1.40), after adjusting for county-level characteristics such as age, poverty, comorbidities, and epidemic duration. COVID-19 deaths were higher in disproportionally black rural and small metro counties. The population attributable fraction of COVID-19 diagnosis due to lack of health insurance was 3.3% for counties with less than 13% black residents and 4.2% for counties with greater than or equal to 13% black residents.

Conclusions: Nearly 20% of U.S. counties are disproportionately black, and they accounted for 52% of COVID-19 diagnoses and 58% of COVID-19 deaths nationally. County-level comparisons can both inform COVID-19 responses and identify epidemic hot spots. Social conditions, structural racism, and other factors elevate risk for COVID-19 diagnoses and deaths in black communities.

Keywords: African-American; Black; COVID-19; Disparity; Race.

Fig. 1

Rates of COVID-19 diagnoses and deaths per 100,000 in disproportionately black (≥13% of population) versus all other counties (<13% of population) as of April 13, 2020.

Fig. 2

COVID-19 cases per 100,000 (adjusted per day since detection) by increasing proportion of black residents across U.S. counties as of April 13, 2020. (Interactive version of figure available at https://ehe.amfar.org/inequity/).

Fig. 3

Forest plots of COVID-19 cases and deaths for percent black (third vs. first quartile) by urbanicity category. Risk ratios greater than one indicate greater COVID-19 cases or deaths in disproportionally black counties. “Large central metro” are counties in Metropolitan Statistical Areas (MSAs) of 1 million or more population that contain the largest principal city; “large fringe metro” are counties in MSAs of 1 million or more population that do not qualify as large central metro (e.g., largest principal city not in the metro area); “medium metro” are counties in MSAs of 250,000–999,999 population; “small metro” are counties in MSAs of less than 250,000 population; “micropolitan” are counties with populations of at least 10,000 but less than 50,000; “noncore” are counties that do not have a urban core population of 10,000 or more. Data as of April 13, 2020.

Fig. 4

Estimated number of COVID-19 diagnoses due to chronic disease and social/environmental factors by the proportion of black residents. “Chronic disease” includes diabetes diagnoses, heart disease deaths, cerebrovascular and hypertension deaths, and HIV diagnoses. “Social/environmental” includes percent unemployed, percent uninsured, urbanicity (1 = urban, 6 = rural), PM_2.5 (fine particulate matter in the air), and housing density. Social distancing score is a grade (‘A’ = 1, ‘B’ = 2, ‘C’ = 3, ‘D’ = 4, ‘F’ = 5). Data as of April 13, 2020.