Trends in Premature Deaths Among Adults in the United States and Latin America

Association of Birthplace for Sleep Duration, Sleep Quality, and Sleep Disorder Symptoms, at the US-Mexico Border

OBJECTIVES

The present study investigated the roles birthplace and acculturation play in sleep estimates among Hispanic/Latino population at the US-Mexico border.

MEASURES

Data were collected in 2016, from N = 100 adults of Mexican descent from the city of Nogales, AZ, at the US-Mexico border. Sleep was assessed with the Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index categorized as none, mild, moderate, and severe, and Multivariable Apnea Prediction Index (MAP) categorized as never, infrequently, and frequently. Acculturation was measured with the Acculturation Rating Scale for Mexican-Americans II (ARSMA-II).

RESULTS

The sample consisted of majority Mexican-born (66%, vs. born in the USA 38.2%). Being born in the USA was associated with 55 fewer minutes of nighttime sleep (p = .011), and 1.65 greater PSQI score (p = .031). Compared to no symptoms, being born in the USA was associated with greater likelihood of severe difficulty falling asleep (OR = 8.3, p = .030) and severe difficulty staying asleep (OR = 11.2, p = .050), as well as decreased likelihood of breathing pauses during sleep (OR = 0.18, P = .020). These relationships remained significant after Mexican acculturation was entered in these models. However, greater Anglo acculturation appears to mediate one fewer hour of sleep per night, poorer sleep quality, and reporting of severe difficulty falling asleep and staying asleep.

CONCLUSIONS

Among individuals of Mexican descent, being born in the USA (vs Mexico) is associated with about 1 hour less sleep per night, worse sleep quality, more insomnia symptoms, and less mild sleep apnea symptoms. These relationships are influenced by acculturation, primarily the degree of Anglo rather than the degree of Mexican acculturation.

Survival outcomes and molecular drivers of testicular cancer in hispanic men

OBJECTIVE

To examine survival outcomes and molecular drivers in testis cancer among Hispanic men using a large national sample and molecular database.

METHODS

We reviewed the SEER registry for testicular cancer from 2000 to 2020. Cox proportional hazards models were used to examine the relationship between race/ethnicity and cancer-specific survival (CSS) by tumor type (seminoma vs. nonseminomatous germ cell tumors [NSGCT]). All models were adjusted for demographic, socioeconomic, and treatment variables. We accessed somatic mutations for testicular cancers through AACR Project GENIE v13.1 and compared mutational frequencies by ethnicity.

RESULTS

Our cohort consisted of 43,709 patients (23.3% Hispanic) with median follow-up 106 months (interquartile range: 45-172). Compared to Non-Hispanic Whites (NWH), Hispanics presented at a younger age but with more advanced disease. Hispanics experienced worse CSS for NSGCT (HR 1.7, 95% CI: 1.5-2.0, P < 0.01) but not seminoma. Somatic mutation data was available for 699 patients. KIT and KRAS mutations occurred in 24.2% and 16.9% of seminoma patients (n = 178), respectively. TP53 and KRAS mutations occurred in 12.1% and 7.9% of NSGCT patients (n = 521), respectively. No differences in mutational frequencies were observed between ethnic groups. There was significant heterogeneity in primary ancestral group for Hispanic patients with available data (n = 53); 14 (26.4%) patients had primary Native American ancestry and 30 (56.6%) had primary European ancestry.

CONCLUSIONS

Cancer-specific survival is worse for Hispanic men with non-seminoma of the testicle. Somatic mutation analysis suggests no differences by ethnicity, though genetic ancestry is heterogeneous among patients identifying as Hispanic.

Long-Term Mortality in Patients With Severe Hypercholesterolemia Phenotype From a Racial and Ethnically Diverse US Cohort

BACKGROUND

Tools for mortality prediction in patients with the severe hypercholesterolemia phenotype (low-density lipoprotein cholesterol ≥190 mg/dL) are limited and restricted to specific racial and ethnic cohorts. We sought to evaluate the predictors of long-term mortality in a large racially and ethnically diverse US patient cohort with low-density lipoprotein cholesterol ≥190 mg/dL.

METHODS

We conducted a retrospective analysis of all patients with a low-density lipoprotein cholesterol ≥190 mg/dL seeking care at Montefiore from 2010 through 2020. Patients <18 years of age or with previous malignancy were excluded. The primary end point was all-cause mortality. Analyses were stratified by age, sex, and race and ethnicity. Patients were stratified by primary and secondary prevention. Cox regression analyses were used to adjust for demographic, clinical, and treatment variables.

RESULTS

A total of 18 740 patients were included (37% non-Hispanic Black, 30% Hispanic, 12% non-Hispanic White, and 2% non-Hispanic Asian patients). The mean age was 53.9 years, and median follow-up was 5.2 years. Both high-density lipoprotein cholesterol and body mass index extremes were associated with higher mortality in univariate analyses. In adjusted models, higher low-density lipoprotein cholesterol and triglyceride levels were associated with an increased 9-year mortality risk (adjusted hazard ratio [HR], 1.08 [95% CI, 1.05-1.11] and 1.04 [95% CI, 1.02-1.06] per 20-mg/dL increase, respectively). Clinical factors associated with higher mortality included male sex (adjusted HR, 1.31 [95% CI, 1.08-1.58]), older age (adjusted HR, 1.19 per 5-year increase [95% CI, 1.15-1.23]), hypertension (adjusted HR, 2.01 [95% CI, 1.57-2.57]), chronic kidney disease (adjusted HR, 1.68 [95% CI, 1.36-2.09]), diabetes (adjusted HR, 1.79 [95% CI, 1.50-2.15]), heart failure (adjusted HR, 1.51 [95% CI, 1.16-1.95]), myocardial infarction (adjusted HR, 1.41 [95% CI, 1.05-1.90]), and body mass index <20 kg/m2 (adjusted HR, 3.36 [95% CI, 2.29-4.93]). A significant survival benefit was conferred by lipid-lowering therapy (adjusted HR, 0.57 [95% CI, 0.42-0.77]). In the primary prevention group, high-density lipoprotein cholesterol <40 mg/dL was independently associated with higher mortality (adjusted HR, 1.49 [95% CI, 1.06-2.09]). Temporal trend analyses showed a reduction in statin use over time (P<0.001). In the most recent time period (2019-2020), 56% of patients on primary prevention and 85% of those on secondary prevention were on statin therapy.

CONCLUSIONS

In a large, diverse cohort of US patients with the severe hypercholesterolemia phenotype, we identified several patient characteristics associated with increased 9-year all-cause mortality and observed a decrease in statin use over time, in particular for primary prevention. Our results support efforts geared toward early recognition and consistent treatment for patients with severe hypercholesterolemia.

Special Issue "Ethnopharmacology in Latin America"

Latin America is a multicultural region encompassing 43 countries, with 665 million inhabitants with a mean age of 31 years old, 84% of whom live in urban areas [...].

Trends in Mortality From Poisonings, Firearms, and All Other Injuries by Intent in the US, 1999-2020

Importance

Although deaths due to external causes are a leading cause of mortality in the US, trends over time by intent and demographic characteristics remain poorly understood.

Objective

To examine national trends in mortality rates due to external causes from 1999 to 2020 by intent (homicide, suicide, unintentional, and undetermined) and demographic characteristics. External causes were defined as poisonings (eg, drug overdose), firearms, and all other injuries, including motor vehicle injuries and falls. Given the repercussions of the COVID-19 pandemic, US death rates for 2019 and 2020 were also compared.

Design, Setting, and Participants

Serial cross-sectional study using national death certificate data obtained from the National Center for Health Statistics and including all external causes of 3 813 894 deaths among individuals aged 20 years or older from January 1, 1999, to December 31, 2020. Data analysis was conducted from January 20, 2022, to February 5, 2023.

Exposures

Age, sex, and race and ethnicity.

Main Outcomes and Measures

Trends in age-standardized mortality rates and average annual percentage change (AAPC) in rates calculated by intent (suicide, homicide, unintentional, and undetermined), age, sex, and race and ethnicity for each external cause.

Results

Between 1999 and 2020, there were 3 813 894 deaths due to external causes in the US. From 1999 to 2020, poisoning death rates increased annually (AAPC, 7.0%; 95% CI, 5.4%-8.7%). From 2014 to 2020, poisoning death rates increased the most among men (APC, 10.8%; 95% CI, 7.7%-14.0%). During the study period, poisoning death rates increased in all the racial and ethnic groups examined; the most rapid increase was among American Indian and Alaska Native individuals (AAPC, 9.2%; 95% CI, 7.4%-10.9%). During the study period, death rates for unintentional poisoning had the most rapid rate of increase (AAPC, 8.1%; 95% CI, 7.4%-8.9%). From 1999 to 2020, firearm death rates increased (AAPC, 1.1%; 95% CI, 0.7%-1.5%). From 2013 to 2020, firearm mortality increased by an average of 4.7% annually (95% CI, 2.9%-6.5%) among individuals aged 20 to 39 years. From 2014 to 2020, mortality from firearm homicides increased by an average of 6.9% annually (95% CI, 3.5%-10.4%). From 2019 to 2020, mortality rates from external causes accelerated further, largely from increases in unintentional poisoning, and homicide due to firearms and all other injuries.

Conclusions and Relevance

Results of this cross-sectional study suggest that from 1999 to 2020, death rates due to poisonings, firearms, and all other injuries increased substantially in the US. The rapid increase in deaths due to unintentional poisonings and firearm homicides is a national emergency that requires urgent public health interventions at the local and national levels.

Unequal outcomes: The effects of the COVID-19 pandemic on mental health and wellbeing among Hispanic/Latinos with varying degrees of 'Belonging'

BACKGROUND

The COVID-19 pandemic has brought disparities in mental and physical health faced by ethnic minorities to the forefront. In the U.S., Hispanic/Latino communities are plagued by elevated rates of psychiatric conditions and trauma. Exacerbating this burden, common discourse often implicates Hispanic/Latino ethnicity as a causal factor, despite clear evidence of systemic causes, including lack of access to resources, and discrimination.

AIMS

To parse apart Hispanic/Latino ethnicity from determinants of wellbeing (such as trauma, financial status, and loneliness), we examined mental and physical health during COVID-19 via an online, anonymous survey available in both English and Spanish.

METHODS

We examined wellbeing across three participant groups, including two groups of Hispanic/Latino adults with varying degrees of 'belonging' to the dominant culture in their country of residence: Hispanic/Latino individuals living in Spanish-speaking and/or Central or Latin American countries (Group 1), Hispanic/Latino individuals living in the U.S. (Group 2), and non-Hispanic/Latino individuals living in the U.S. (Group 3).

RESULTS

Results demonstrated there were significant differences between groups in specific aspects of wellbeing. Most importantly, results showed Hispanic/Latino ethnicity does not significantly predict psychosocial wellbeing or psychosis risk, and identified several predictors of these outcomes, including U.S. residence, trauma, loneliness, and age.

CONCLUSION

Our results demonstrate that Hispanic/Latino ethnicity itself is not a causal factor of poor psychosocial wellbeing or elevated psychosis risk and instead identify several social and systemic causal factors commonly faced by Hispanic/Latino Americans. We suggest that language reporting on minority mental health acknowledge systemic factors as contributing to poor outcome rather than referring to ethnicity as if it were a causal factor.

The impact of the COVID-19 pandemic on mortality: life expectancy reduction and geographical disparities in Argentina

OBJECTIVE

To assess the impact of the COVID-19 pandemic on mortality in Argentina, considering temporal trends in life expectancy at birth and premature mortality rate during 2010-2020.

METHODS

Based on demographic projections, this ecological time-series study compares a "normal" versus a "COVID-19" mortality scenario for 2020 over a set of 11 Argentine provinces. Annual life expectancy at birth and age-standardized rates of premature mortality were estimated from 2010 to 2020. Joinpoint regression and multilevel models were used.

RESULTS

A potential reduction in life expectancy at birth (a gap between scenarios >1 year) was observed. A significant (negative) point of inflection in temporal trends was identified for the country and most of the provinces, under the COVID-19 mortality scenario. However, our findings reveal disparities between provinces in the estimated life expectancy reduction toward 2020 (values range from -0.63 to -1.85 year in females and up to -2.55 years in males). While men showed more accentuated declines in life expectancy at birth in 2020 (a national gap between scenarios of -1.47 year in men vs. -1.35 year in women), women experienced more unfavorable temporal trends of premature mortality. In the absence of COVID-19, an improvement in both indicators was estimated toward 2020 in both sexes, while a return to levels reported in the past was observed under the COVID-19 scenario.

CONCLUSION

The COVID-19 pandemic might seriously affect the trends of mortality and exacerbate health disadvantages in Argentina. A temporal and contextual perspective of health inequities merits special attention in the COVID-19 research.

Latino Children's Obesity Risk Varies by Place of Birth: Findings from New York City Public School Youth, 2006-2017

Introduction: Research showing that place of birth (POB) predicts excess weight gain and obesity risk among Latino adults has not prompted similar research in Latino children, although childhood is a critical period for preventing obesity. Objective: To identify differences in obesity risk among Latino children by POB. Methods: Longitudinal cohort observational study on public school children self-identified by parent/guardian as Latino in grades K-12 for school years 2006-07 through 2016-17 with measured weight and height (n = 570,172_students; 3,103,642_observations). POB reported by parent/guardian was categorized as continental United States [not New York City (NYC)] (n = 295,693), NYC (n = 166,361), South America (n = 19,452), Central America (n = 10,241), Dominican Republic (n = 57,0880), Puerto Rico (n = 9687), and Mexico (n = 9647). Age- and sex-specific BMI percentiles were estimated based on established growth charts. Data were analyzed in 2020. Results: Prevalence of obesity was highest among US (non-NYC)-born girls (21%) and boys (27%), followed by NYC-born girls (19%) and boys (25%). Among girls, South Americans (9%) had the lowest prevalence of all levels of obesity, while Puerto Ricans (19%) and Dominicans (15%) had the highest prevalence. Among boys, South Americans also had the lowest prevalence of all levels of obesity (15%), while Puerto Ricans (22%) and Mexicans (21%) had the highest. In adjusted models, obesity risk was highest in US (non-NYC)-born children, followed by children born in NYC (p < 0.001). Immigrant Latino children exhibited an advantage even after controlling for individual and neighborhood sociodemographic features, particularly Dominicans, South Americans, and Puerto Ricans. Conclusions: The heterogeneity of obesity risk among Latino children highlights the importance of POB.

Hypothesized Explanations for the Observed Lung Cancer Survival Benefit Among Hispanics/Latinos in the United States

Hispanic/Latino ethnicity is associated with improved survival from non-small cell lung cancer compared to that for non-Hispanic Whites even though Hispanics/Latinos are more likely to potentially have inferior access-to-care and experience greater health disparities. To this end, we conducted a literature review to identify possible explanations for this survival benefit, including the role of chronic obstructive pulmonary disease and cardiovascular diseases, genetic variation, cultural influences, and immigration factors. Overall, intermittent smoking patterns, genetic variation, co-morbidities, and cultural influences were all factors likely to partially explain this survival benefit. On the other hand, immigration factors, acculturation, and access-to-care were less likely to support the survival advantage. Future research should analyze relevant Hispanic/Latino subgroups (e.g., Mexican, Puerto Rican, Cuban, Dominican, Central American, South American) and specifically focus on the relationship between Hispanic/Latino ethnicity and different lung cancer subtypes. If the Hispanic/Latino mortality benefit observed in lung cancer truly exists, a better understanding of the underlying mechanism(s) may help extend these benefits to other ethnic and racial groups.

Demographic characteristics associated with circadian rest-activity rhythm patterns: a cross-sectional study

BACKGROUND

Rest-activity rhythm (RAR), a manifestation of circadian rhythms, has been associated with morbidity and mortality risk. However, RAR patterns in the general population and specifically the role of demographic characteristics in RAR pattern have not been comprehensively assessed. Therefore, we aimed to describe RAR patterns among non-institutionalized US adults and age, sex, and race/ethnicity variation using accelerometry data from a nationally representative population.

METHODS

This cross-sectional study was conducted using the US National Health and Nutrition Examination Survey (NHANES) 2011-2014. Participants aged ≥20 years who were enrolled in the physical activity monitoring examination and had at least four 24-h periods of valid wrist accelerometer data were included in the present analysis. 24-h RAR metrics were generated using both extended cosinor model (amplitude, mesor, acrophase and pseudo-F statistic) and nonparametric methods (interdaily stability [IS] and intradaily variability [IV]). Multivariable linear regression was used to assess the association between RAR and age, sex, and race/ethnicity.

RESULTS

Eight thousand two hundred participants (mean [SE] age, 49.1 [0.5] years) were included, of whom 52.2% were women and 67.3% Whites. Women had higher RAR amplitude and mesor, and also more robust (pseudo-F statistic), more stable (higher IS) and less fragmented (lower IV) RAR (all P trend < 0.001) than men. Compared with younger adults (20-39 years), older adults (≥ 60 years) exhibited reduced RAR amplitude and mesor, but more stable and less fragmented RAR, and also reached their peak activity earlier (advanced acrophase) (all P trend < 0.001). Relative to other racial/ethnic groups, Hispanics had the highest amplitude and mesor level, and most stable (highest IS) and least fragmented (lowest IV) RAR pattern (P trend < 0.001). Conversely, non-Hispanic blacks had the lowest peak activity level (lowest amplitude) and least stable (lowest IS) RAR pattern (all P trend < 0.001).

CONCLUSIONS

In the general adult population, RAR patterns vary significantly according to sex, age and race/ethnicity. These results may reflect demographic-dependent differences in intrinsic circadian rhythms and may have important implications for understanding racial, ethnic, sex and other disparities in morbidity and mortality risk.

Urban-rural differences in pregnancy-related deaths, United States, 2011-2016

BACKGROUND

The US pregnancy-related mortality ratio has not improved over the past decade and includes striking disparities by race and ethnicity and by state. Understanding differences in pregnancy-related mortality across and within urban and rural areas can guide the development of interventions for preventing future pregnancy-related deaths.

OBJECTIVE

We sought to compare pregnancy-related mortality across and within urban and rural counties by race and ethnicity and age.

STUDY DESIGN

We conducted a descriptive analysis of 3747 pregnancy-related deaths during 2011-2016 (the most recent available data) with available zone improvement plan code or county data in the Pregnancy Mortality Surveillance System, among Hispanic and non-Hispanic White, Black, American Indian or Alaska Native, and Asian or Pacific Islander women aged 15 to 44 years. We aggregated data by US county and grouped counties per the National Center for Health Statistics Urban-Rural Classification Scheme for Counties. We used R statistical software, epitools, to calculate the pregnancy-related mortality ratio (number of pregnancy-related deaths per 100,000 live births) for each urban-rural grouping, obtain 95% confidence intervals, and perform exact tests of ratio comparisons using the Poisson distribution.

RESULTS

Of the total 3747 pregnancy-related deaths analyzed, 52% occurred in large metro counties, and 7% occurred in noncore (rural) counties. Large metro counties had the lowest pregnancy-related mortality ratio (14.8; 95% confidence interval, 14.2-15.5), whereas noncore counties had the highest (24.1; 95% confidence interval, 21.4-27.1), including race and ethnicity and age groups. Pregnancy-related mortality ratio age disparities increased with rurality. Women aged 25 to 34 years and 35 to 44 years living in noncore counties had pregnancy-related mortality ratios 1.5 and 3 times higher, respectively, than women of the same age groups in large metro counties. Within each urban-rural category, pregnancy-related mortality ratios were higher among non-Hispanic Black women than non-Hispanic White women. Non-Hispanic American Indian or Alaska Native pregnancy-related mortality ratios in small metro, micropolitan, and noncore counties were 2 to 3 times that of non-Hispanic White women in the same areas.

CONCLUSION

Although more than half of pregnancy-related deaths occurred in large metro counties, the pregnancy-related mortality ratio rose with increasing rurality. Disparities existed in urban-rural categories, including by age group and race and ethnicity. Geographic location is an important context for initiatives to prevent future deaths and eliminate disparities. Further research is needed to better understand reasons for the observed urban-rural differences and to guide a multifactorial response to reduce pregnancy-related deaths.

Neighbourhood Social Determinants of Health and Geographical Inequalities in Premature Mortality in Taiwan: A Spatiotemporal Approach

Geographical inequalities in premature mortality and the role of neighbourhood social determinants of health (SDOH) have been less explored. This study aims to assess the geographical inequalities in premature mortality in Taiwan and how neighbourhood SDOH contribute to them and to examine the place-specific associations between neighbourhood SDOH and premature mortality. We used township-level nationwide data for the years 2015 to 2019, including age-standardized premature mortality rates and three upstream SDOH (ethnicity, education, and income). Space-time scan statistics were used to assess the geographical inequality in premature mortality. A geographical and temporal weighted regression was applied to assess spatial heterogeneity and how neighbourhood SDOH contribute to geographic variation in premature mortality. We found geographical inequality in premature mortality to be clearly clustered around mountainous rural and indigenous areas. The association between neighbourhood SDOH and premature mortality was shown to be area-specific. Ethnicity and education could explain nearly 84% variation in premature mortality. After adjusting for neighbourhood SDOH, only a handful of hotspots for premature mortality remained, mainly consisting of rural and indigenous areas in the central-south region of Taiwan. These findings provide empirical evidence for developing locally tailored public health programs for geographical priority areas.

Effect of the covid-19 pandemic in 2020 on life expectancy across populations in the USA and other high income countries: simulations of provisional mortality data

OBJECTIVE

To estimate changes in life expectancy in 2010-18 and during the covid-19 pandemic in 2020 across population groups in the United States and to compare outcomes with peer nations.

DESIGN

Simulations of provisional mortality data.

SETTING

US and 16 other high income countries in 2010-18 and 2020, by sex, including an analysis of US outcomes by race and ethnicity.

POPULATION

Data for the US and for 16 other high income countries from the National Center for Health Statistics and the Human Mortality Database, respectively.

MAIN OUTCOME MEASURES

Life expectancy at birth, and at ages 25 and 65, by sex, and, in the US only, by race and ethnicity. Analysis excluded 2019 because life table data were not available for many peer countries. Life expectancy in 2020 was estimated by simulating life tables from estimated age specific mortality rates in 2020 and allowing for 10% random error. Estimates for 2020 are reported as medians with fifth and 95th centiles.

RESULTS

Between 2010 and 2018, the gap in life expectancy between the US and the peer country average increased from 1.88 years (78.66 v 80.54 years, respectively) to 3.05 years (78.74 v 81.78 years). Between 2018 and 2020, life expectancy in the US decreased by 1.87 years (to 76.87 years), 8.5 times the average decrease in peer countries (0.22 years), widening the gap to 4.69 years. Life expectancy in the US decreased disproportionately among racial and ethnic minority groups between 2018 and 2020, declining by 3.88, 3.25, and 1.36 years in Hispanic, non-Hispanic Black, and non-Hispanic White populations, respectively. In Hispanic and non-Hispanic Black populations, reductions in life expectancy were 18 and 15 times the average in peer countries, respectively. Progress since 2010 in reducing the gap in life expectancy in the US between Black and White people was erased in 2018-20; life expectancy in Black men reached its lowest level since 1998 (67.73 years), and the longstanding Hispanic life expectancy advantage almost disappeared.

CONCLUSIONS

The US had a much larger decrease in life expectancy between 2018 and 2020 than other high income nations, with pronounced losses among the Hispanic and non-Hispanic Black populations. A longstanding and widening US health disadvantage, high death rates in 2020, and continued inequitable effects on racial and ethnic minority groups are likely the products of longstanding policy choices and systemic racism.

COVID-19: US federal accountability for entry, spread, and inequities-lessons for the future

The United States (US) has been among those nations most severely affected by the first-and subsequent-phases of the pandemic of COVID-19, the disease caused by SARS-CoV-2. With only 4% of the worldwide population, the US has seen about 22% of COVID-19 deaths. Despite formidable advantages in resources and expertise, presently the per capita mortality rate is over 585/million, respectively 2.4 and 5 times higher compared to Canada and Germany. As we enter Fall 2020, the US is enduring ongoing outbreaks across large regions of the country. Moreover, within the US, an early and persistent feature of the pandemic has been the disproportionate impact on populations already made vulnerable by racism and dangerous jobs, inadequate wages, and unaffordable housing, and this is true for both the headline public health threat and the additional disastrous economic impacts. In this article we assess the impact of missteps by the Federal Government in three specific areas: the introduction of the virus to the US and the establishment of community transmission; the lack of national COVID-19 workplace standards and enforcement, and lack of personal protective equipment (PPE) for workplaces as represented by complaints to the Occupational Safety and Health Administration (OSHA) which we find are correlated with deaths 16 days later (ρ = 0.83); and the total excess deaths in 2020 to date already total more than 230,000, while COVID-19 mortality rates exhibit severe-and rising-inequities in race/ethnicity, including among working age adults.

Variation in racial/ethnic disparities in COVID-19 mortality by age in the United States: A cross-sectional study

BACKGROUND

In the United States, non-Hispanic Black (NHB), Hispanic, and non-Hispanic American Indian/Alaska Native (NHAIAN) populations experience excess COVID-19 mortality, compared to the non-Hispanic White (NHW) population, but racial/ethnic differences in age at death are not known. The release of national COVID-19 death data by racial/ethnic group now permits analysis of age-specific mortality rates for these groups and the non-Hispanic Asian or Pacific Islander (NHAPI) population. Our objectives were to examine variation in age-specific COVID-19 mortality rates by racial/ethnicity and to calculate the impact of this mortality using years of potential life lost (YPLL).

METHODS AND FINDINGS

This cross-sectional study used the recently publicly available data on US COVID-19 deaths with reported race/ethnicity, for the time period February 1, 2020, to July 22, 2020. Population data were drawn from the US Census. As of July 22, 2020, the number of COVID-19 deaths equaled 68,377 for NHW, 29,476 for NHB, 23,256 for Hispanic, 1,143 for NHAIAN, and 6,468 for NHAPI populations; the corresponding population sizes were 186.4 million, 40.6 million, 2.6 million, 19.5 million, and 57.7 million. Age-standardized rate ratios relative to NHW were 3.6 (95% CI 3.5, 3.8; p < 0.001) for NHB, 2.8 (95% CI 2.7, 3.0; p < 0.001) for Hispanic, 2.2 (95% CI 1.8, 2.6; p < 0.001) for NHAIAN, and 1.6 (95% CI 1.4, 1.7; p < 0.001) for NHAP populations. By contrast, NHB rate ratios relative to NHW were 7.1 (95% CI 5.8, 8.7; p < 0.001) for persons aged 25-34 years, 9.0 (95% CI 7.9, 10.2; p < 0.001) for persons aged 35-44 years, and 7.4 (95% CI 6.9, 7.9; p < 0.001) for persons aged 45-54 years. Even at older ages, NHB rate ratios were between 2.0 and 5.7. Similarly, rate ratios for the Hispanic versus NHW population were 7.0 (95% CI 5.8, 8.7; p < 0.001), 8.8 (95% CI 7.8, 9.9; p < 0.001), and 7.0 (95% CI 6.6, 7.5; p < 0.001) for the corresponding age strata above, with remaining rate ratios ranging from 1.4 to 5.0. Rate ratios for NHAIAN were similarly high through age 74 years. Among NHAPI persons, rate ratios ranged from 2.0 to 2.8 for persons aged 25-74 years and were 1.6 and 1.2 for persons aged 75-84 and 85+ years, respectively. As a consequence, more YPLL before age 65 were experienced by the NHB and Hispanic populations than the NHW population-despite the fact that the NHW population is larger-with a ratio of 4.6:1 and 3.2:1, respectively, for NHB and Hispanic persons. Study limitations include likely lag time in receipt of completed death certificates received by the Centers for Disease Control and Prevention for transmission to NCHS, with consequent lag in capturing the total number of deaths compared to data reported on state dashboards.

CONCLUSIONS

In this study, we observed racial variation in age-specific mortality rates not fully captured with examination of age-standardized rates alone. These findings suggest the importance of examining age-specific mortality rates and underscores how age standardization can obscure extreme variations within age strata. To avoid overlooking such variation, data that permit age-specific analyses should be routinely publicly available.