key: cord-0737707-jgpxx4ga
authors: Unruh, L.; Dharmapuri, S.; Yinglin, X.; Soyemi, K.
title: Health Disparities and COVID-19: A Retrospective Study Examining Individual and Community Factors Causing Disproportionate COVID-19 Outcomes in Cook County, Illinois, March 16-May 31, 2020
date: 2020-08-24
journal: nan
DOI: 10.1101/2020.08.21.20179317
sha: 6fa63fec19e9a09a37f5ee3c9762fa25c6a54c25
doc_id: 737707
cord_uid: jgpxx4ga

Background: Early data from the COVID-19 pandemic suggests that the disease has had a disproportionate impact on communities of color causing higher infection and mortality rates within those communities. Methods: This study used demographic data from the 2018 US census estimates, mortality data from the Cook County Medical Examiners office, and testing results from the Illinois Department of Public Health to perform both bivariate and multivariate regression analyses to explore the role race plays in COVID-19 outcomes at the individual and community levels. Results: Principal findings show that: 1) while Black Americans make up 22% of Cook County population, they account for 36% of the county COVID-19 related deaths; 2) the average age of death from COVID-19 is seven years younger for minorities compared to Non-Hispanic White (White) decedents; 3) minorities were more likely than Whites to have seven of the top 10 co-morbidities at death; 4) residents of predominantly minority areas were twice as likely to test positive for COVID-19 (p = 0.0001, IRR 1.94, 95% CI 1.50, 2.50) than residents of predominantly White areas; and 5) residents of predominantly minority areas were 1.43 times more likely to die of COVID-19 than those in predominantly White areas (p = 0.03). Conclusions: There are notable differences in COVID-19 related outcomes between racial and ethnic groups at individual and community levels. We hope that this study will scientifically illustrate the health disparities experienced by communities of color and help to address the underlying systemic inequalities still prevalent within our country.

On March 11, 2020, the World Health Organization officially declared the COVID-19 46 respiratory illness caused by the SARS-CoV-2 virus a pandemic. As of June 30, the virus had 47 model using White as the reference. The figures were created using Microsoft Excel™ and 113 statistical analysis was performed using SAS version 9.4 (SAS Inc., Cary, NC, USA). 114

Mortality case sample size included 3,762 COVID-19 related mortalities of which 201 116 cases without Cook County zip codes were removed. Of the 3,561 deaths, 1,281(36%) were 117 Black, 1,387 (39%) were White, 656 (18%) were Latinx, and the rest were classified as Other. 118

Males made up 2,060 (58%) of mortalities. Overall, mean (SD) age at death was 73.8 years 119 (14.73). Hypertension was found to be the most frequent comorbidity and occurred in 2,403 120 (67%) of the decedents, 1,444 (40.5%) had diabetes (Table 1) . 121 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted August 24, 2020. . other races were 63% more likely to die compared with White individuals. Of obese decedents, 156 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted August 24, 2020. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted August 24, 2020. This finding suggests that the Black community is suffering a disproportionate amount of 175 COVID-19 mortality. As outlined in other studies, our data showed that minorities are dying of 176 COVID-19 at significantly younger ages than Whites (median minority age = 72, median White 177 age = 79; p < 0.001). (Figure 1 ) 178

We further explored the differences in average age at death by separating the data by 179 race, which showed that Latinx decedents were, on average, more than 10 years younger than 180

White decedents (Latinx = 67.3, White = 77.5) 16, 17 . Additionally, minorities who died of 181 COVID-19 were significantly more likely to have seven of the top 10 co-morbidities, including 182 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted August 24, 2020. . https://doi.org/10.1101/2020.08.21.20179317 doi: medRxiv preprint diabetes, chronic obstructive pulmonary disease, coronary artery disease, congestive heart 183 failure, obesity, atrial fibrillation, and dementia. 184

Of the many reasons for COVID-19 disparities between races, we explored five: 1) lower 185 socioeconomic status (SES), 2) increased comorbidities, 3 Increased Co-Morbidities: Other research has shown that people with certain co-morbidities 203 (e.g., hypertension, diabetes, obesity) have suffered poorer COVID-19 health outcomes than 204 people without underlying conditions 18 . As we compared comorbidities between ethnic/racial 205 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted August 24, 2020. . groups, we found that minority COVID-19 decedents had statistically significant chances of 206 having seven of the top 10 comorbidities at the time of death. (Table 3) . 207

Multigenerational Living: In a study from Italy published in Eurosurveillance, Sjödin et al. 208 explored factors necessary to mitigate the COVID-19 pandemic. The authors found that small 209 household size was necessary for limiting the spread of the disease 22 . In Chicago, the areas with 210 higher household density are primarily located in low density Black and Latinx neighborhoods. 211

Our data showed that of the top 20 ZCTAs with the highest average number of people per 212 household, 16 (80%) of them were in predominantly minority ZCTAs, and 12 (60%) of them 213

were also in the top 20 for numbers of COVID-19 positive cases per 100,000 decedents. Our 214 analysis confirms that larger household size is a statistically significant cause of COVID-19 215 mortality. Among all combined cases, for each one person increase in household size there is a 216 65.75% increase in mortality (p = 0.04). 217

Densely Populated Urban Areas: Given that the virus spreads primarily through 218 respiratory/droplet transmission, close contact with an infected individual is required for the 219 virus to spread. It seems logical to assume that more highly populated ZCTAs have higher rates 220 of infection and worse outcomes 23,24 . In Cook County, however, the more densely populated 221 areas are the city center areas that are predominantly inhabited by wealthy, White individuals. Of 222 the 20 ZCTAs with the highest population density, 12 are predominantly White, and 15 are 223 above the average household income for Illinois. Additionally, these areas had lower infection 224 rates with only one ZCTA in the top 20 for positive tests and lower mortality with two ZCTAs in 225 the top 20 for mortality rate. At least in Chicago, infection and mortality rates seem to be more 226 related to the density within households than overall population density. 227 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted August 24, 2020. .

Department of Corrections, one of the largest jail systems in the country, gained media attention 229 about a large COVID-19 outbreak among both the facility's employees and inmates 25-28 . As with 230 many prisons, it has an over-representation of minority inmates. As of July 1, 2020, the Cook 231 County Sheriff's Department estimated that around 75% of Cook County inmates are Black 29 . 232

The demographics of the ZCTA that houses the Cook County Jail (60608) show that 233 55.4% of its inhabitants are male. This over-representation of the male population may be due to 234 the presence of the prison system. The average number of people per household is 3.09, and the 235 median age is 32.4 years. The population of the ZCTA is largely Latinx (50.7%) and Black 236 (17.24%) with an average income of $21,447 (well below Illinois average household income). 237

The COVID-19 data for the 60608 ZCTA shows that it ranks 26 th out of 176 for the most 238 COVID-19 deaths and 9 th for the most positive cases in Cook County. Incidence analysis showed 239 that of the deaths in the 60608 ZCTA, 24 of the 42 mortalities (57%) were Latinx, and 7 (16.6%) 240

were Black. Therefore, although there is an over-representation of Black individuals within the 241 jail, and the ZCTA had one of the highest incidents of COVID-19 positives, mortality data does 242 not show that this ZCTA was an outlier area for COVID-19 mortality. 243

This study had several limitations. First, because we had data about individual mortality 245 cases and broad ZCTA demographic data but lacked information about the demographics of 246 those who did not die or who never tested positive for COVID-19, we were unable to perform a 247 case-control analysis. Second, we used zip code demographic data as a proxy for an individual's 248 circumstances. Because that data was essentially an average, not everyone in that ZCTA was 249 accurately represented. Third, because the study focused on Cook County, it may be 250 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted August 24, 2020. . https://doi.org/10.1101/2020.08.21.20179317 doi: medRxiv preprint generalizable only to large urban counties with high levels of racial and ethnic diversity. Fourth, 251 census data is never fully able to capture the entirety of a population and may especially miss 252 undocumented individuals. Fifth, because all death data was obtained from the Cook County 253

Medical Examiner's office, the completeness of that data depended on the Examiner's reporting. 254

Sixth, since the analysis relied on zip code level data, and zip codes do not remain constant over 255 time, it was subject to the inherent issues associated with small area analyses. Seventh, we do not 256 currently have data to indicate whether some ZCTAs with high mortalities had an 257 overrepresentation of congregate care facilities such as long-term care or rehabilitation facilities 258 which might skew the data. 259

While we agree that caution is important when making statements about race and disease 261 outcomes, our data indicate that the public health crisis created by inbuilt barriers within 262 minority communities has contributed to the disproportionate mortality burden in Black and 263

Latinx communities. It is time to not only to address the disparities that exist between 264 racial/ethnic groups as they relate to COVID-19 but also the underlying structural issues that 265 permit these disparities. 266

Our study shows that race, more than SES, is the only statistically significant factor for 267 COVID-19 related mortality in Cook County. Other factors being equal, Black individuals are 268 significantly more likely to die from COVID-19 overall, and Latinx individuals are dying at 269 significantly younger ages than Whites. The question of why people of color suffer 270 disproportionate COVID-19 mortality is more complicated than simply identifying that 271 disproportionality. These data indicate that many of the deaths were not inevitable but were the 272 byproducts of ingrained structural inequality resulting in diminished opportunities. We hope that 273 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted August 24, 2020. . https://doi.org/10.1101/2020.08.21.20179317 doi: medRxiv preprint the lessons from this study can help illuminate the persistent inequalities in our country so that, 274 as a society, we can better address these issues. As we brace for a second wave of coronavirus 275 outbreaks and a possible third wave, we must acknowledge who within our society suffers the 276 most and find ways to focus our efforts to keep those populations safe and healthy. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted August 24, 2020. . https://doi.org/10.1101/2020.08.21.20179317 doi: medRxiv preprint

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