Authors: Megan Hoffer, DO; and Aisha T. Terry, MD, MPH, FACEP
Racial and ethnic minority groups warrant special consideration when screening and treating for COVID-19. In the United States, which is perhaps the most ethnically diverse country in the world, emerging statistics from epicenter cities are showing significant disparities in rates of COVID-19 infection and mortality in Latino/Hispanic and African American populations.
These disparities have been demonstrated in New York City, which showed the highest mortality rates among Latino/Hispanic Americans, followed by African Americans, disproportionate to their representative populations. Although they make up 29% of the population, 34% of COVID-19 deaths in New York City were among Latino/Hispanic Americans, and although they make up 22% of the population, 28% of deaths were among African American patients.1 Similarly in Chicago, 50% of the reported infections were in African Americans and up to 70% of COVID-19–associated deaths were among African Americans, although they represent only 29% of the Chicago population. In Chicago, Latino/Hispanic Americans did not see the same elevated mortality rates, representing just 15% of deaths in a city where they make up 28% of the population.2
The disparities persist in states as well. In Michigan, 40% of COVID-19 mortality was among African Americans, despite the fact that they make up only 14% of the population. In Louisiana, 70% of deaths have been among African Americans, despite them making up 30% of the population. These patterns have also been reported in Wisconsin, North Carolina, and Georgia.
There is little published information about the effects of COVID-19 on these populations, as other epicenter cities in China and Italy have more ethnically homogenous populations compared to the United States. Additionally, during the SARS outbreak in 2003, there were approximately 8,000 cases worldwide, and the majority were in China, leaving minimal information about how these groups were affected during a similar outbreak.
Early reports published in China show that the greatest risk factors for COVID-19 infection are diabetes and coronary artery disease (CAD). Analysis of data collected during the SARS outbreak in 2003 demonstrated that diabetes and heart disease were independently associated with mortality.3 In China this year, data analyzing mortality rates and comorbidities from 1,590 patients with COVID-19 showed the most prevalent risk factors associated with mortality were hypertension, diabetes, COPD, and malignancy.4
African American and Latino/Hispanic Americans have higher rates of type 2 diabetes, obesity, and heart disease. The prevalence of diabetes mellitus is 21% in African Americans, compared to 11% in non-Hispanic whites.5 One study published in JAMA in 2017 showed that African Americans have nearly double the rate of development of type 2 diabetes during middle adulthood compared to non-Hispanic white Americans. The same study also demonstrated that biological factors, including fasting blood glucose levels and body mass index, were the most strongly associated with the disparity when adjustments for behavioral, socioeconomic, and psychological factors were made.6 Forty-two percent of African American men and 44% of African American women have diagnosed or undiagnosed hypertension, which is 10% higher than other racial groups in the US and one of the highest rates worldwide.7 Rates of CAD are not significantly statistically different between African Americans (6.5%) and non-Hispanic white Americans (5.8%), as reported by the CDC. When analyzed further, rates of CAD were slightly higher in non-Hispanic white men at 7.7%, compared to African American men at 7.3%. However, African American women had a higher rate of CAD at 5.9%, compared to non-Hispanic white women at 4%.8
Latino/Hispanic Americans are now one of the largest ethnic minorities in the US. Overall, less data exist analyzing Hispanic American risk factors, as they represent both a younger population as well as a population more recently immigrated to the US. However, trends in younger populations indicate that Latino/Hispanic Americans are at higher risk for cardiovascular complications. Latino/Hispanic Americans have a 17% rate of diagnosed and undiagnosed diabetes, compared to 10.7% of non-Hispanic white men and 19.1% of non-Hispanic African Americans. Latino/Hispanic women have a 16.4% rate of diabetes, while non-Hispanic white Americans have a rate of 8.4%. African American women have a rate of 18.7%. Furthermore, the rate of pre-diabetes among Latino/Hispanic Americans is among the highest of any ethnic group at 44%.9 This may be representative of Latino/Hispanics generally being young and may indicate that future cardiovascular risk will increase as the population ages.
Socioeconomic status, independent of race, may be a significant risk factor for primary COVID-19 infection. Middle-class and upper middle-class Americans are more easily able to telecommute, and they receive a salary that is more resistant to economic downturns. By contrast, working class Americans rely on their ability to work a consistent number of hours to maintain their pay. As a result, working class individuals are far more likely to continue to work, use public transportation, and risk health-related complications for economic stability.
Population statistics from Chicago demonstrate this phenomenon, where the rate of infection is highest in African Americans, correlating with poverty levels in that city. African Americans make up 36% of those living in poverty in Chicago, yet they represent 50% of COVID-19 infections. Latino/Hispanic Americans in Chicago have poverty rates of 23%, which is lower than both African American and non-Hispanic white Chicagoans.2,10 In New York City, Latino/Hispanic Americans have the highest mortality rate from COVID-19 as well as the second highest poverty levels at 22%. Asian Americans have the highest percentage of poverty in New York City at 23%. African Americans have the third highest with 20%, with non-Hispanic white New Yorkers at 12%.
Asian Americans have been the subject of intense scrutiny over the course of the pandemic, with some experiencing racism due to the origin of the virus in Asia. However, as a minority population in the US, they have had the lowest infection rates of any racial or ethnic group. In New York City, Asian Americans are reported to have the highest poverty levels, making up 23% of those living in poverty. However, their rate of death from COVID-19 in New York City has been significantly lower, representing just 7% of the mortality while making up 14% of the population.1 In Chicago, Asian Americans have the lowest poverty levels of any race, with 4% of Asian Americans living below the poverty level, and they had similarly low rates of COVID-19 infection at 3.6%.2,10
Emergency physicians should be aware of these epidemiological trends in the US, so they can better screen, test, and treat patients. There should be heightened suspicion for COVID-19 prevalence and disproportionate morbidity and mortality among underserved minority populations. Aggressive education, adequate access to screening and testing, and proactive management strategies should be prioritized. All patients with mild symptoms who are discharged from the emergency department or hospital should be questioned about the people with whom they live and any risk factors they may have. It is critical to ensure that there is adequate understanding of recommendations among patients who speak a language other than English. A translator should be used to communicate with such patients, and they should be provided with educational material in their own language. Patients who are to be admitted to the hospital should have standard management of COVID-19 as outlined by published official recommendations.
It is important to be aware that some underserved racial and ethnic groups may have underlying comorbidities that may not be diagnosed or treated due to limited access to primary care. Hispanics and African Americans who are over age 40 years should be treated as higher risk for developing severe COVID-19 infection. Additionally, COVID-19 may create a hypercoagulable state, making individuals prone to true myocardial infarction, pulmonary embolism, or DVT.11 These populations would benefit from baseline troponin and ECG screening in the emergency department, in addition to other diagnostic management, as troponin has been shown to correlate with mortality. Those with more severe illness with risk factors would also benefit from an echocardiogram early in admission to screen for the development of myocarditis.3
Robust tracking of granular demographic data relative to COVID-19 incidence, morbidity, and mortality is necessary to better understand the factors associated with the disproportionate impact of this disease on underserved racial and ethnic minority groups. This data should be collected and accessible in order to foster research and analysis of this phenomenon.