The synchronicity of COVID-19 disparities: Statewide epidemiologic trends in SARS-CoV-2 morbidity, hospitalization, and mortality among racial minorities and in rural America

PLoS One. 2021 Jul 23;16(7):e0255063. doi: 10.1371/journal.pone.0255063. eCollection 2021.


Background: Early studies on COVID-19 identified unequal patterns in hospitalization and mortality in urban environments for racial and ethnic minorities. These studies were primarily single center observational studies conducted within the first few weeks or months of the pandemic. We sought to examine trends in COVID-19 morbidity, hospitalization, and mortality over time for minority and rural populations, especially during the U.S. fall surge.

Methods: Data were extracted from a statewide cohort of all adult residents in Indiana tested for SARS-CoV-2 infection between March 1 and December 31, 2020, linked to electronic health records. Primary measures were per capita rates of infection, hospitalization, and death. Age adjusted rates were calculated for multiple time periods corresponding to public health mitigation efforts. Comparisons across time within groups were compared using ANOVA.

Results: Morbidity and mortality increased over time with notable differences among sub-populations. Initially, hospitalization rates among racial minorities were 3-4 times higher than whites, and mortality rates among urban residents were twice those of rural residents. By fall 2020, hospitalization and mortality rates in rural areas surpassed those of urban areas, and gaps between black/brown and white populations narrowed. Changes across time among demographic groups was significant for morbidity and hospitalization. Cumulative morbidity and mortality were highest among minority groups and in rural communities.

Conclusions: The synchronicity of disparities in COVID-19 by race and geography suggests that health officials should explicitly measure disparities and adjust mitigation as well as vaccination strategies to protect those sub-populations with greater disease burden.

Publication types

  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Aged, 80 and over
  • COVID-19* / ethnology
  • COVID-19* / mortality
  • Ethnicity*
  • Female
  • Health Status Disparities*
  • Hospitalization*
  • Humans
  • Indiana / epidemiology
  • Male
  • Middle Aged
  • Minority Groups*
  • Morbidity
  • Rural Population*
  • SARS-CoV-2*