1
|
Maleki M, Ghahari S. Comprehensive Clustering Analysis and Profiling of COVID-19 Vaccine Hesitancy and Related Factors across U.S. Counties: Insights for Future Pandemic Responses. Healthcare (Basel) 2024; 12:1458. [PMID: 39120163 PMCID: PMC11311382 DOI: 10.3390/healthcare12151458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Revised: 07/13/2024] [Accepted: 07/19/2024] [Indexed: 08/10/2024] Open
Abstract
This study employs comprehensive clustering analysis to examine COVID-19 vaccine hesitancy and related socio-demographic factors across U.S. counties, using the collected and curated data from Johns Hopkins University. Utilizing K-Means and hierarchical clustering, we identify five distinct clusters characterized by varying levels of vaccine hesitancy, MMR vaccination coverage, population demographics, and political affiliations. Principal Component Analysis (PCA) was conducted to reduce dimensionality, and key variables were selected based on their contribution to cumulative explained variance. Our analysis reveals significant geographic and demographic patterns in vaccine hesitancy, providing valuable insights for public health strategies and future pandemic responses. Geospatial analysis highlights the distribution of clusters across the United States, indicating areas with high and low vaccine hesitancy. In addition, multiple regression analyses within each cluster identify key predictors of vaccine hesitancy in corresponding U.S. county clusters, emphasizing the importance of socio-economic and demographic factors. The findings underscore the need for targeted public health interventions and tailored communication strategies to address vaccine hesitancy across the United States and, potentially, across the globe.
Collapse
Affiliation(s)
- Morteza Maleki
- School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, GA 30332, USA
| | - SeyedAli Ghahari
- Department of Civil and Environmental Engineering, Purdue University, West Lafayette, IN 47907, USA;
| |
Collapse
|
2
|
Leder SC, List JM, Chandra R, Jones KT, Moy E. VA Research and Operations Uniting to Combat COVID-19 Inequities. Health Equity 2023; 7:296-302. [PMID: 37313133 PMCID: PMC10259604 DOI: 10.1089/heq.2023.0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2023] [Indexed: 06/15/2023] Open
Abstract
As novel coronavirus 2019 disease (COVID-19) began to spread across the United States in early 2020, health care systems faced extreme demands on resources. As the country's largest single-payer health care system, the U.S. Department of Veterans Affairs (VA) was uniquely positioned to study how the virus impacted different communities and work to improve care provided to all. Early on, a literature review of prior epidemics revealed that occupational exposures and an inability to socially distance could impact some groups more than others. The VA's Office of Health Equity leveraged a general sense of community to create a collaborative research space and a dedicated analytic space to inform pandemic operations. VA researchers and operations staff were able to quickly share information and respond to updates to produce accurate and reliable publications for medical professionals and the general public. Partnerships with VA Medical Centers and Veteran Service Organizations helped to increase communication across the nation and determine the most critical needs. Although COVID-19 was dynamic in nature, VA's intentional examination of social and structural factors was crucial in informing a more equitable approach. Moving forward, these inequities must be intentionally addressed in future pandemic responses.
Collapse
Affiliation(s)
- Sarah C. Leder
- Office of Health Equity, Veterans Health Administration, Washington, District of Columbia, USA
| | - Justin M. List
- Office of Health Equity, Veterans Health Administration, Washington, District of Columbia, USA
| | - Rachel Chandra
- Office of Health Equity, Veterans Health Administration, Washington, District of Columbia, USA
| | - Kenneth T. Jones
- Office of Health Equity, Veterans Health Administration, Washington, District of Columbia, USA
| | - Ernest Moy
- Office of Health Equity, Veterans Health Administration, Washington, District of Columbia, USA
| |
Collapse
|
3
|
Schons M, Pilgram L, Reese JP, Stecher M, Anton G, Appel KS, Bahmer T, Bartschke A, Bellinghausen C, Bernemann I, Brechtel M, Brinkmann F, Brünn C, Dhillon C, Fiessler C, Geisler R, Hamelmann E, Hansch S, Hanses F, Hanß S, Herold S, Heyder R, Hofmann AL, Hopff SM, Horn A, Jakob C, Jiru-Hillmann S, Keil T, Khodamoradi Y, Kohls M, Kraus M, Krefting D, Kunze S, Kurth F, Lieb W, Lippert LJ, Lorbeer R, Lorenz-Depiereux B, Maetzler C, Miljukov O, Nauck M, Pape D, Püntmann V, Reinke L, Römmele C, Rudolph S, Sass J, Schäfer C, Schaller J, Schattschneider M, Scheer C, Scherer M, Schmidt S, Schmidt J, Seibel K, Stahl D, Steinbeis F, Störk S, Tauchert M, Tebbe JJ, Thibeault C, Toepfner N, Ungethüm K, Vadasz I, Valentin H, Wiedmann S, Zoller T, Nagel E, Krawczak M, von Kalle C, Illig T, Schreiber S, Witzenrath M, Heuschmann P, Vehreschild JJ. The German National Pandemic Cohort Network (NAPKON): rationale, study design and baseline characteristics. Eur J Epidemiol 2022; 37:849-870. [PMID: 35904671 PMCID: PMC9336157 DOI: 10.1007/s10654-022-00896-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 06/22/2022] [Indexed: 11/25/2022]
Abstract
The German government initiated the Network University Medicine (NUM) in early 2020 to improve national research activities on the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) pandemic. To this end, 36 German Academic Medical Centers started to collaborate on 13 projects, with the largest being the National Pandemic Cohort Network (NAPKON). The NAPKON's goal is creating the most comprehensive Coronavirus Disease 2019 (COVID-19) cohort in Germany. Within NAPKON, adult and pediatric patients are observed in three complementary cohort platforms (Cross-Sectoral, High-Resolution and Population-Based) from the initial infection until up to three years of follow-up. Study procedures comprise comprehensive clinical and imaging diagnostics, quality-of-life assessment, patient-reported outcomes and biosampling. The three cohort platforms build on four infrastructure core units (Interaction, Biosampling, Epidemiology, and Integration) and collaborations with NUM projects. Key components of the data capture, regulatory, and data privacy are based on the German Centre for Cardiovascular Research. By April 01, 2022, 34 university and 40 non-university hospitals have enrolled 5298 patients with local data quality reviews performed on 4727 (89%). 47% were female, the median age was 52 (IQR 36-62-) and 50 pediatric cases were included. 44% of patients were hospitalized, 15% admitted to an intensive care unit, and 12% of patients deceased while enrolled. 8845 visits with biosampling in 4349 patients were conducted by April 03, 2022. In this overview article, we summarize NAPKON's design, relevant milestones including first study population characteristics, and outline the potential of NAPKON for German and international research activities.Trial registration https://clinicaltrials.gov/ct2/show/NCT04768998 . https://clinicaltrials.gov/ct2/show/NCT04747366 . https://clinicaltrials.gov/ct2/show/NCT04679584.
Collapse
Affiliation(s)
- Maximilian Schons
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Lisa Pilgram
- Department II of Internal Medicine, Hematology/Oncology, Goethe University, Frankfurt, Germany
| | - Jens-Peter Reese
- Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
| | - Melanie Stecher
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- German Center for Infection Research (DZIF), Partner-Site Cologne-Bonn, Cologne, Germany
| | - Gabriele Anton
- Institute of Epidemiology, Helmholtz Center Munich, Munich, Germany
- German Centre for Infection Research (DZIF), Partner Site Munich, Munich, Germany
| | - Katharina S. Appel
- Department II of Internal Medicine, Hematology/Oncology, Goethe University, Frankfurt, Germany
| | - Thomas Bahmer
- Internal Medicine Department I, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
- Airway Research Center North (ARCN), German Center for Lung Research (DZL), Grosshansdorf, Germany
| | - Alexander Bartschke
- Core Facility Digital Medicine and Interoperability, Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Carla Bellinghausen
- Department of Respiratory Medicine and Allergology, Medical Clinic 1, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Inga Bernemann
- Hannover Medical School, Hannover Unified Biobank, Hannover, Germany
| | - Markus Brechtel
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Folke Brinkmann
- Department of Paediatric Pneumology, Allergy and CF- Centre, University Children’s Hospital, Ruhr- University Bochum, Bochum, Germany
| | - Clara Brünn
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Christine Dhillon
- COVID-19 Task Force, University Hospital Augsburg, Augsburg, Germany
| | - Cornelia Fiessler
- Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
| | - Ramsia Geisler
- Department II of Internal Medicine, Hematology/Oncology, Goethe University, Frankfurt, Germany
| | - Eckard Hamelmann
- Department of Pediatrics, Children’s Center Bethel, University Hospital East Westphalia, University Bielefeld, Bielefeld, Germany
| | - Stefan Hansch
- Department for Infectious Diseases and Infection Control, University Hospital Regensburg, Regensburg, Germany
| | - Frank Hanses
- Department for Infectious Diseases and Infection Control, University Hospital Regensburg, Regensburg, Germany
- Emergency Department, University Hospital Regensburg, Regensburg, Germany
| | - Sabine Hanß
- University Medical Center Göttingen (UMG), Göttingen, Germany
- German Center for Cardiovascular Diseases (DZHK), Berlin, Germany
| | - Susanne Herold
- Department of Internal Medicine V, University Hospital Giessen and Marburg, Justus-Liebig-University Giessen, Giessen, Germany
- Department of Internal Medicine, German Center for Lung Research (DZL), Universities of Giessen and Marburg Lung Center (UGMLC), Justus Liebig University Giessen, Giessen, Germany
- Institute for Lung Health (ILH), Giessen, Germany
| | - Ralf Heyder
- NUM Coordination Office, Charité – Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Anna-Lena Hofmann
- Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
| | - Sina Marie Hopff
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Anna Horn
- Insitute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
| | - Carolin Jakob
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Steffi Jiru-Hillmann
- Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
| | - Thomas Keil
- Insitute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
- Institute of Social Medicine, Epidemiology and Health Economics, Charité - Universitätsmedizin Berlin, Berlin, Germany
- State Institute of Health, Bavarian Health and Food Safety Authority, Bad Kissingen, Germany
| | - Yascha Khodamoradi
- Department of Infectious Diseases, Medical Clinic 2, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt, Germany
| | - Mirjam Kohls
- Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
| | - Monika Kraus
- Institute of Epidemiology, Helmholtz Center Munich, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich, Munich, Germany
| | - Dagmar Krefting
- University Medical Center Göttingen (UMG), Göttingen, Germany
- German Center for Cardiovascular Diseases (DZHK), Berlin, Germany
| | - Sonja Kunze
- Institute of Epidemiology, Helmholtz Center Munich, Munich, Germany
| | - Florian Kurth
- Department of Infectious Diseases and Respiratory Medicine, Charité – Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Department of Tropical Medicine, Bernhard Nocht Institute for Tropical Medicine, and Department of Medicine I, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Wolfgang Lieb
- Institute of Epidemiology, Kiel University, Kiel, Germany
| | - Lena Johanna Lippert
- Department of Infectious Diseases and Respiratory Medicine, Charité – Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Roberto Lorbeer
- Department of Radiology, University Hospital, LMU, Munich, Germany
- Medical Heart Center of Charité and German Heart Institute Berlin, Institute of Computer-Assisted Cardiovascular Medicine, Berlin, Germany
| | - Bettina Lorenz-Depiereux
- Institute of Epidemiology, Helmholtz Center Munich, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich, Munich, Germany
| | - Corina Maetzler
- Department of Neurology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel University, Kiel, Germany
| | - Olga Miljukov
- Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
| | - Matthias Nauck
- Institute of Clinical Chemistry and Laboratory Medicine, University Medicine Greifswald, Greifswald, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Greifswald, Greifswald, Germany
| | - Daniel Pape
- Department I of Internal Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Valentina Püntmann
- German Center for Cardiovascular Diseases (DZHK), Berlin, Germany
- Institute for Experimental and Translational Cardiovascular Imaging, University Hospital Frankfurt am Main, Frankfurt, Germany
| | - Lennart Reinke
- Department of Internal Medicine I, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Christoph Römmele
- COVID-19 Task Force, University Hospital Augsburg, Augsburg, Germany
| | - Stefanie Rudolph
- Charité – Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, Joint Charité and BIH Clinical Study Center, Charitéplatz 1, 10117 Berlin, Germany
| | - Julian Sass
- Core Facility Digital Medicine and Interoperability, Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Christian Schäfer
- Institute of Clinical Chemistry and Laboratory Medicine, University Medicine Greifswald, Greifswald, Germany
- DZHK e.V. (German Centre for Cardiovascular Research), Partner Site Greifswald, Greifswald, Germany
| | - Jens Schaller
- Medical Heart Center of Charité and German Heart Institute Berlin, Institute of Computer-Assisted Cardiovascular Medicine, Berlin, Germany
- Charité – Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt – Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Mario Schattschneider
- Institute of Clinical Chemistry and Laboratory Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Christian Scheer
- Department of Anesthesiology and Intensive Care Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Margarete Scherer
- Department II of Internal Medicine, Hematology/Oncology, Goethe University, Frankfurt, Germany
| | - Sein Schmidt
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Clinical Study Center, Charitéplatz 1, 10117 Berlin, Germany
| | - Julia Schmidt
- Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
| | - Kristina Seibel
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Dana Stahl
- German Center for Cardiovascular Diseases (DZHK), Berlin, Germany
- University Medicine Greifswald, Greifswald, Germany
| | - Fridolin Steinbeis
- Department of Infectious Diseases and Respiratory Medicine, Charité – Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Stefan Störk
- Comprehensive Heart Failure Center, University and University Hospital Würzburg, Würzburg, Germany
- Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Maike Tauchert
- Institute of Epidemiology, Helmholtz Center Munich, Munich, Germany
| | - Johannes Josef Tebbe
- Department of Gastroenterology and Infectious Disease, University Medical Center East Westphalia-Lippe, Klinikum Lippe, Detmold, Germany
| | - Charlotte Thibeault
- Department of Infectious Diseases and Respiratory Medicine, Charité – Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Nicole Toepfner
- Department of Pediatrics, Carl Gustav Carus University Hospital, TU Dresden, Dresden, Germany
| | - Kathrin Ungethüm
- Insitute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
| | - Istvan Vadasz
- Institute for Lung Health (ILH), Giessen, Germany
- Department of Internal Medicine, University Hospital Giessen and Marburg, Justus Liebig University Giessen, Giessen, Germany
- Universities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL), Frankfurt, Germany
| | - Heike Valentin
- German Center for Cardiovascular Diseases (DZHK), Berlin, Germany
- University Medicine Greifswald, Greifswald, Germany
| | - Silke Wiedmann
- NUM Coordination Office, Charité – Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Thomas Zoller
- Department of Infectious Diseases and Respiratory Medicine, Charité – Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Eike Nagel
- German Center for Cardiovascular Diseases (DZHK), Berlin, Germany
- Institute for Experimental and Translational Cardiovascular Imaging, University Hospital Frankfurt am Main, Frankfurt, Germany
| | - Michael Krawczak
- Institute of Medical Informatics and Statistics, Kiel University, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Christof von Kalle
- Charité – Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, Joint Charité and BIH Clinical Study Center, Charitéplatz 1, 10117 Berlin, Germany
| | - Thomas Illig
- Hannover Medical School, Hannover Unified Biobank, Hannover, Germany
| | - Stefan Schreiber
- Department of Internal Medicine I, University Hospital Schleswig Holstein, Kiel University, Kiel, Germany
| | - Martin Witzenrath
- Department of Infectious Diseases and Respiratory Medicine, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
- German Center for Lung Research (DZL), Frankfurt, Germany
| | - Peter Heuschmann
- Insitute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
- Clinical Trial Center Würzburg, University Hospital Würzburg, Würzburg, Germany
| | - Jörg Janne Vehreschild
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Department of Internal Medicine, Hematology/Oncology, Goethe University, Frankfurt,, Germany
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
| | - NAPKON Research Group
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Department II of Internal Medicine, Hematology/Oncology, Goethe University, Frankfurt, Germany
- Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
- German Center for Infection Research (DZIF), Partner-Site Cologne-Bonn, Cologne, Germany
- Institute of Epidemiology, Helmholtz Center Munich, Munich, Germany
- German Centre for Infection Research (DZIF), Partner Site Munich, Munich, Germany
- Internal Medicine Department I, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
- Airway Research Center North (ARCN), German Center for Lung Research (DZL), Grosshansdorf, Germany
- Core Facility Digital Medicine and Interoperability, Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany
- Department of Respiratory Medicine and Allergology, Medical Clinic 1, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
- Hannover Medical School, Hannover Unified Biobank, Hannover, Germany
- Department of Paediatric Pneumology, Allergy and CF- Centre, University Children’s Hospital, Ruhr- University Bochum, Bochum, Germany
- COVID-19 Task Force, University Hospital Augsburg, Augsburg, Germany
- Department of Pediatrics, Children’s Center Bethel, University Hospital East Westphalia, University Bielefeld, Bielefeld, Germany
- Department for Infectious Diseases and Infection Control, University Hospital Regensburg, Regensburg, Germany
- Emergency Department, University Hospital Regensburg, Regensburg, Germany
- University Medical Center Göttingen (UMG), Göttingen, Germany
- German Center for Cardiovascular Diseases (DZHK), Berlin, Germany
- Department of Internal Medicine V, University Hospital Giessen and Marburg, Justus-Liebig-University Giessen, Giessen, Germany
- Department of Internal Medicine, German Center for Lung Research (DZL), Universities of Giessen and Marburg Lung Center (UGMLC), Justus Liebig University Giessen, Giessen, Germany
- Institute for Lung Health (ILH), Giessen, Germany
- NUM Coordination Office, Charité – Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Insitute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
- Institute of Social Medicine, Epidemiology and Health Economics, Charité - Universitätsmedizin Berlin, Berlin, Germany
- State Institute of Health, Bavarian Health and Food Safety Authority, Bad Kissingen, Germany
- Department of Infectious Diseases, Medical Clinic 2, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich, Munich, Germany
- Department of Infectious Diseases and Respiratory Medicine, Charité – Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Department of Tropical Medicine, Bernhard Nocht Institute for Tropical Medicine, and Department of Medicine I, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
- Institute of Epidemiology, Kiel University, Kiel, Germany
- Department of Radiology, University Hospital, LMU, Munich, Germany
- Medical Heart Center of Charité and German Heart Institute Berlin, Institute of Computer-Assisted Cardiovascular Medicine, Berlin, Germany
- Department of Neurology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel University, Kiel, Germany
- Institute of Clinical Chemistry and Laboratory Medicine, University Medicine Greifswald, Greifswald, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Greifswald, Greifswald, Germany
- Department I of Internal Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
- Institute for Experimental and Translational Cardiovascular Imaging, University Hospital Frankfurt am Main, Frankfurt, Germany
- Department of Internal Medicine I, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
- Charité – Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, Joint Charité and BIH Clinical Study Center, Charitéplatz 1, 10117 Berlin, Germany
- Institute of Clinical Chemistry and Laboratory Medicine, University Medicine Greifswald, Greifswald, Germany
- DZHK e.V. (German Centre for Cardiovascular Research), Partner Site Greifswald, Greifswald, Germany
- Charité – Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt – Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
- Department of Anesthesiology and Intensive Care Medicine, University Medicine Greifswald, Greifswald, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Clinical Study Center, Charitéplatz 1, 10117 Berlin, Germany
- University Medicine Greifswald, Greifswald, Germany
- Comprehensive Heart Failure Center, University and University Hospital Würzburg, Würzburg, Germany
- Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany
- Department of Gastroenterology and Infectious Disease, University Medical Center East Westphalia-Lippe, Klinikum Lippe, Detmold, Germany
- Department of Pediatrics, Carl Gustav Carus University Hospital, TU Dresden, Dresden, Germany
- Department of Internal Medicine, University Hospital Giessen and Marburg, Justus Liebig University Giessen, Giessen, Germany
- Universities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL), Frankfurt, Germany
- Institute for Experimental and Translational Cardiovascular Imaging, University Hospital Frankfurt am Main, Frankfurt, Germany
- Institute of Medical Informatics and Statistics, Kiel University, University Hospital Schleswig-Holstein, Kiel, Germany
- Department of Internal Medicine I, University Hospital Schleswig Holstein, Kiel University, Kiel, Germany
- Department of Infectious Diseases and Respiratory Medicine, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
- German Center for Lung Research (DZL), Frankfurt, Germany
- Clinical Trial Center Würzburg, University Hospital Würzburg, Würzburg, Germany
- Department of Internal Medicine, Hematology/Oncology, Goethe University, Frankfurt,, Germany
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
| |
Collapse
|
4
|
Oates GR, Juarez LD, Horswell R, Chu S, Miele L, Fouad MN, Curry WA, Fort D, Hillegass WB, Danos DM. The Association Between Neighborhood Social Vulnerability and COVID-19 Testing, Positivity, and Incidence in Alabama and Louisiana. J Community Health 2021; 46:1115-1123. [PMID: 33966116 PMCID: PMC8106900 DOI: 10.1007/s10900-021-00998-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2021] [Indexed: 11/28/2022]
Abstract
Racial/ethnic and socioeconomic disparities in COVID-19 burden have been widely reported. Using data from the state health departments of Alabama and Louisiana aggregated to residential Census tracts, we assessed the relationship between social vulnerability and COVID-19 testing rates, test positivity, and incidence. Data were cumulative for the period of February 27, 2020 to October 7, 2020. We estimated the association of the 2018 Social Vulnerability Index (SVI) overall score and theme scores with COVID-19 tests, test positivity, and cases using multivariable negative binomial regressions. We adjusted for rurality with 2010 Rural-Urban Commuting Area codes. Regional effects were modeled as fixed effects of counties/parishes and state health department regions. The analytical sample included 1160 Alabama and 1105 Louisiana Census tracts. In both states, overall social vulnerability and vulnerability themes were significantly associated with increased COVID-19 case rates (RR 1.57, 95% CI 1.45-1.70 for Alabama; RR 1.36, 95% CI 1.26-1.46 for Louisiana). There was increased COVID-19 testing with higher overall vulnerability in Louisiana (RR 1.26, 95% CI 1.14-1.38), but not in Alabama (RR 0.95, 95% CI 0.89-1.02). Consequently, test positivity in Alabama was significantly associated with social vulnerability (RR 1.66, 95% CI 1.57-1.75), whereas no such relationship was observed in Louisiana (RR 1.05, 95% CI 0.98-1.12). Social vulnerability is a risk factor for COVID-19 infection, particularly among racial/ethnic minorities and those in disadvantaged housing conditions without transportation. Increased testing targeted to vulnerable communities may contribute to reduction in test positivity and overall COVID-19 disparities.
Collapse
Affiliation(s)
- Gabriela R Oates
- School of Medicine, University of Alabama At Birmingham, Birmingham, AL, USA.
| | - Lucia D Juarez
- School of Medicine, University of Alabama At Birmingham, Birmingham, AL, USA
| | | | - San Chu
- Pennington Biomedical Research Center, Baton Rouge, LA, USA
| | - Lucio Miele
- Health Sciences Center, Louisiana State University, New Orleans, LA, USA
| | - Mona N Fouad
- School of Medicine, University of Alabama At Birmingham, Birmingham, AL, USA
| | - William A Curry
- School of Medicine, University of Alabama At Birmingham, Birmingham, AL, USA
| | - Daniel Fort
- Ochsner Center for Outcomes Research, Ochsner Health, New Orleans, LA, USA
| | | | - Denise M Danos
- Health Sciences Center, Louisiana State University, New Orleans, LA, USA
| |
Collapse
|
5
|
Wong MS, Yuan AH, Haderlein TP, Jones KT, Washington DL. Variations by race/ethnicity and time in Covid-19 testing among Veterans Health Administration users with COVID-19 symptoms or exposure. Prev Med Rep 2021; 24:101503. [PMID: 34312589 PMCID: PMC8295495 DOI: 10.1016/j.pmedr.2021.101503] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 05/10/2021] [Accepted: 07/18/2021] [Indexed: 12/19/2022] Open
Abstract
Racial/ethnic disparities in coronavirus disease 2019 (COVID-19) hospitalization and mortality have emerged in the United States, but less is known about whether similar differences exist in testing, and how this changed as COVID-19 knowledge and policies evolved. We examined racial/ethnic variations in COVID-19 testing over time among veterans who sought care for COVID-19 symptoms or exposure. In the national population of all Veterans who sought Veterans Health Administration (VHA) care for COVID-19 symptoms or exposure (n = 913,806), we conducted multivariate logistic regressions to explore race/ethnicity-by-time period differences in testing from 3/1/2020-11/25/2020, and calculated predicted probabilities by race/ethnicity and time period. Early in the pandemic (3/1/2020-4/6/2020) when testing was limited and there was less awareness of racial/ethnic disparities, non-Hispanic Black, Hispanic, and other non-White racial/ethnic minority Veterans who sought care from VHA for COVID-19 symptoms or exposure were more likely than non-Hispanic White Veterans to receive a COVID-19 test (p < 0.05). In subsequent time periods (4/7/2020-11/25/2020), testing was similar among all racial/ethnic groups. Among Veterans with COVID-19 symptoms or exposure, non-Hispanic Black and Hispanic patients were just as likely, and in some cases, more likely, to receive a COVID-19 test versus non-Hispanic White patients. The United States faced testing shortages at the start of the third wave of the pandemic; additional shortages are likely to emerge as the pandemic continues to peak and ebb. It is important to ensure that racial/ethnic minorities and others at greater risk for infection continue to have access to COVID-19 testing with each of these peaks.
Collapse
Affiliation(s)
- Michelle S. Wong
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd., Los Angeles, CA 90073, United States
| | - Anita H. Yuan
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd., Los Angeles, CA 90073, United States
| | - Taona P. Haderlein
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd., Los Angeles, CA 90073, United States
| | - Kenneth T. Jones
- VHA Office of Health Equity, 810 Vermont Ave, NW, Washington, DC 20420, United States
| | - Donna L. Washington
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd., Los Angeles, CA 90073, United States
- Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California Los Angeles Geffen School of Medicine, 1100 Glendon Ave, Suite 850, Los Angeles, CA 90024, United States
| |
Collapse
|
6
|
Pilkington H, Feuillet T, Rican S, Goupil de Bouillé J, Bouchaud O, Cailhol J, Bihan H, Lombrail P, Julia C. Spatial determinants of excess all-cause mortality during the first wave of the COVID-19 epidemic in France. BMC Public Health 2021; 21:2157. [PMID: 34819057 PMCID: PMC8611998 DOI: 10.1186/s12889-021-12203-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 11/09/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The first wave of the COVID-19 pandemic in France was associated with high excess mortality, and anecdotal evidence pointed to differing excess mortality patterns depending on social and environmental determinants. In this study we aimed to investigate the spatial distribution of excess mortality during the first wave of the COVID-19 pandemic in France and relate it at the subnational level to contextual determinants from various dimensions (socioeconomic, population density, overall health status, healthcare access etc.). We also explored whether the determinants identified at the national level varied depending on geographical location. METHODS We used available national data on deaths in France to calculate excess mortality by department for three age groups: 0-49, 50-74 and > 74 yrs. between March 1st and April 27th, 2020. We selected 15 variables at the department level that represent four dimensions that may be related to overall mortality at the ecological level, two representing population-level vulnerabilities (morbidity, social deprivation) and two representing environmental-level vulnerabilities (primary healthcare supply, urbanization). We modelled excess mortality by age group for our contextual variables at the department level. We conducted both a global (i.e., country-wide) analysis and a multiscale geographically weighted regression (MGWR) model to account for the spatial variations in excess mortality. RESULTS In both age groups, excess all-cause mortality was significantly higher in departments where urbanization was higher (50-74 yrs.: β = 15.33, p < 0.001; > 74 yrs.: β = 18.24, p < 0.001) and the supply of primary healthcare providers lower (50-74 yrs.: β = - 8.10, p < 0.001; > 74 yrs.: β = - 8.27, p < 0.001). In the 50-74 yrs. age group, excess mortality was negatively associated with the supply of pharmacists (β = - 3.70, p < 0.02) and positively associated with work-related mobility (β = 4.62, p < 0.003); in the > 74 yrs. age group our measures of deprivation (β = 15.46, p < 0.05) and morbidity (β = 0.79, p < 0.008) were associated with excess mortality. Associations between excess mortality and contextual variables varied significantly across departments for both age groups. CONCLUSIONS Public health strategies aiming at mitigating the effects of future epidemics should consider all dimensions involved to develop efficient and locally tailored policies within the context of an evolving, socially and spatially complex situation.
Collapse
Affiliation(s)
- Hugo Pilkington
- Département de Géographie, Université Paris 8 Vincennes-Saint-Denis, UMR7533 Ladyss, 2 rue de la Liberté, F-93526, Saint-Denis, France.
| | - Thierry Feuillet
- Département de Géographie, Université Paris 8 Vincennes-Saint-Denis, UMR7533 Ladyss, 2 rue de la Liberté, F-93526, Saint-Denis, France
- Sorbonne Paris Cité Epidemiology and Statistics Research Center (CRESS), Inserm U1153, Inra U1125, Cnam, Paris 13 University, Nutritional Epidemiology Research Team (EREN), Bobigny, France
| | - Stéphane Rican
- Département de Géographie-Aménagement, Université Paris Nanterre, UMR7533 Ladyss, 200 avenue de la République, F-9200, Nanterre, France
| | - Jeanne Goupil de Bouillé
- Infectious and Tropical Diseases Department, Avicenne Hospital (AP-HP), Bobigny, France
- LEPS, Laboratoire Educations Pratiques Santé, UR3412, Université Sorbonne Paris Nord Bobigny, Villetaneuse, France
| | - Olivier Bouchaud
- Infectious and Tropical Diseases Department, Avicenne Hospital (AP-HP), Bobigny, France
- LEPS, Laboratoire Educations Pratiques Santé, UR3412, Université Sorbonne Paris Nord Bobigny, Villetaneuse, France
| | - Johann Cailhol
- Infectious and Tropical Diseases Department, Avicenne Hospital (AP-HP), Bobigny, France
- LEPS, Laboratoire Educations Pratiques Santé, UR3412, Université Sorbonne Paris Nord Bobigny, Villetaneuse, France
| | - Hélène Bihan
- LEPS, Laboratoire Educations Pratiques Santé, UR3412, Université Sorbonne Paris Nord Bobigny, Villetaneuse, France
- Endocrinology, Diabetology and Metabolic diseases Department, Avicenne Hospital (AP-HP), Bobigny, France
| | - Pierre Lombrail
- LEPS, Laboratoire Educations Pratiques Santé, UR3412, Université Sorbonne Paris Nord Bobigny, Villetaneuse, France
- Public Health Department, Avicenne Hospital (AP-HP), Bobigny, France
| | - Chantal Julia
- Sorbonne Paris Cité Epidemiology and Statistics Research Center (CRESS), Inserm U1153, Inra U1125, Cnam, Paris 13 University, Nutritional Epidemiology Research Team (EREN), Bobigny, France
- Public Health Department, Avicenne Hospital (AP-HP), Bobigny, France
| |
Collapse
|
7
|
Kahn LG, Ghassabian A, Jacobson MH, Yu K, Trasande L. COVID-19 Symptoms and Diagnoses among a Sociodemographically Diverse Cohort of Children from New York City: Lessons from the First Wave, Spring 2020. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:11886. [PMID: 34831640 PMCID: PMC8623025 DOI: 10.3390/ijerph182211886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/27/2021] [Accepted: 11/10/2021] [Indexed: 11/16/2022]
Abstract
Early in the pandemic, in the North American epicenter, we investigated associations between sociodemographic factors and rates of pediatric COVID-19 diagnoses in a non-clinical setting and whether symptoms varied by child age. From 20 April-31 August 2020, COVID-19-related data were collected on 2694 children aged ≤ 18 years living in households participating in the New York University Children's Health and Environment Study. We examined differences in rates of subjective and objective diagnoses according to sociodemographic characteristics and differences in reported symptoms by child age. Children of women who were non-Hispanic White, had private health insurance, higher income, or more education were more likely to be diagnosed via WHO criteria or healthcare provider. Children of women who were Hispanic or Asian, reported low income, had less education, or were/lived with an essential worker were more likely to test positive. Older children were less likely to experience cough or runny nose and more likely to experience muscle/body aches, sore throat, headache, and loss of smell or taste than younger children. In conclusion, relying on subjective disease ascertainment methods, especially in the early stage of an outbreak when testing is not universally available, may misrepresent the true prevalence of disease among sociodemographic subgroups. Variations in symptoms by child age should be considered when determining diagnostic criteria.
Collapse
Affiliation(s)
- Linda G. Kahn
- Departments of Pediatrics and Population Health, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Akhgar Ghassabian
- Departments of Pediatrics, Population Health, and Environmental Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA; (A.G.); (L.T.)
| | - Melanie H. Jacobson
- Department of Pediatrics, New York University Grossman School of Medicine, New York, NY 10016, USA; (M.H.J.); (K.Y.)
| | - Keunhyung Yu
- Department of Pediatrics, New York University Grossman School of Medicine, New York, NY 10016, USA; (M.H.J.); (K.Y.)
| | - Leonardo Trasande
- Departments of Pediatrics, Population Health, and Environmental Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA; (A.G.); (L.T.)
- Wagner School of Public Service, New York University, New York, NY 10012, USA
- College of Global Public Health, New York University, New York, NY 10003, USA
| |
Collapse
|
8
|
Monnig MA, Treloar Padovano H, Sokolovsky AW, DeCost G, Aston ER, Haass-Koffler CL, Szapary C, Moyo P, Avila JC, Tidey JW, Monti PM, Ahluwalia JS. Association of Substance Use With Behavioral Adherence to Centers for Disease Control and Prevention Guidelines for COVID-19 Mitigation: Cross-sectional Web-Based Survey. JMIR Public Health Surveill 2021; 7:e29319. [PMID: 34591780 PMCID: PMC8582757 DOI: 10.2196/29319] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 06/11/2021] [Accepted: 09/21/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Substance use is a risk factor for COVID-19 infection and adverse outcomes. However, reasons for elevated risk for COVID-19 in substance users are not well understood. OBJECTIVE The aim of this study was to evaluate whether alcohol or other drug use is associated with adherence to Centers for Disease Control and Prevention (CDC) guidelines for COVID-19 mitigation. Preregistered analyses tested the hypothesis that greater use of alcohol and other drugs would be associated with lower CDC guideline adherence. A secondary objective was to determine whether substance use was associated with the likelihood of COVID-19 testing or outcome. METHODS A cross-sectional web-based survey was administered to a convenience sample recruited through Amazon's Mechanical Turk platform from June 18 to July 19, 2020. Individuals aged 18 years or older and residing in Connecticut, Massachusetts, New Jersey, New York, or Rhode Island were eligible to participate. The exposure of interest was past 7-day use of alcohol, cigarettes, electronic cigarettes, cannabis, stimulants, and nonmedical opioids. The primary outcome was CDC guideline adherence measured using a scale developed from behaviors advised to reduce the spread of COVID-19. Secondary outcomes were likelihood of COVID-19 testing and a positive COVID-19 test result. All analyses accounted for the sociodemographic characteristics. RESULTS The sample consisted of 1084 individuals (mean age 40.9 [SD 13.4] years): 529 (48.8%) men, 543 (50.1%) women, 12 (1.1%) other gender identity, 742 (68.5%) White individuals, 267 (24.6%) Black individuals, and 276 (25.5%) Hispanic individuals. Daily opioid users reported lower CDC guideline adherence than nondaily users (B=-0.24, 95% CI -0.44 to -0.05) and nonusers (B=-0.57, 95% CI -0.76 to -0.38). Daily alcohol drinkers reported lower adherence than nondaily drinkers (B=-0.16, 95% CI -0.30 to -0.02). Nondaily alcohol drinkers reported higher adherence than nondrinkers (B=0.10, 95% CI 0.02-0.17). Daily opioid use was related to greater odds of COVID-19 testing, and daily stimulant use was related to greater odds of a positive COVID-19 test. CONCLUSIONS In a regionally-specific, racially, and ethnically diverse convenience sample, adults who engaged in daily alcohol or opioid use reported lower CDC guideline adherence for COVID-19 mitigation. Any opioid use was associated with greater odds of COVID-19 testing, and daily stimulant use was associated with greater odds of COVID-19 infection. Cigarettes, electronic cigarettes, cannabis, or stimulant use were not statistically associated with CDC guideline adherence, after accounting for sociodemographic covariates and other substance use variables. Findings support further investigation into whether COVID-19 testing and vaccination should be expanded among individuals with substance-related risk factors.
Collapse
Affiliation(s)
- Mollie A Monnig
- Department of Behavioral and Social Sciences, Brown University, Providence, RI, United States
- Center for Addiction and Disease Risk Exacerbation, Brown University, Providence, RI, United States
| | - Hayley Treloar Padovano
- Department of Behavioral and Social Sciences, Brown University, Providence, RI, United States
- Center for Addiction and Disease Risk Exacerbation, Brown University, Providence, RI, United States
- Department of Psychiatry and Human Behavior, Brown University, Providence, RI, United States
| | - Alexander W Sokolovsky
- Department of Behavioral and Social Sciences, Brown University, Providence, RI, United States
- Center for Addiction and Disease Risk Exacerbation, Brown University, Providence, RI, United States
| | - Grace DeCost
- Center for Addiction and Disease Risk Exacerbation, Brown University, Providence, RI, United States
| | - Elizabeth R Aston
- Department of Behavioral and Social Sciences, Brown University, Providence, RI, United States
- Center for Addiction and Disease Risk Exacerbation, Brown University, Providence, RI, United States
| | - Carolina L Haass-Koffler
- Department of Behavioral and Social Sciences, Brown University, Providence, RI, United States
- Center for Addiction and Disease Risk Exacerbation, Brown University, Providence, RI, United States
- Department of Psychiatry and Human Behavior, Brown University, Providence, RI, United States
| | - Claire Szapary
- Center for Addiction and Disease Risk Exacerbation, Brown University, Providence, RI, United States
| | - Patience Moyo
- Center for Addiction and Disease Risk Exacerbation, Brown University, Providence, RI, United States
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University, Providence, RI, United States
| | - Jaqueline C Avila
- Center for Addiction and Disease Risk Exacerbation, Brown University, Providence, RI, United States
| | - Jennifer W Tidey
- Department of Behavioral and Social Sciences, Brown University, Providence, RI, United States
- Center for Addiction and Disease Risk Exacerbation, Brown University, Providence, RI, United States
- Department of Psychiatry and Human Behavior, Brown University, Providence, RI, United States
| | - Peter M Monti
- Department of Behavioral and Social Sciences, Brown University, Providence, RI, United States
- Center for Addiction and Disease Risk Exacerbation, Brown University, Providence, RI, United States
| | - Jasjit S Ahluwalia
- Department of Behavioral and Social Sciences, Brown University, Providence, RI, United States
- Center for Addiction and Disease Risk Exacerbation, Brown University, Providence, RI, United States
| |
Collapse
|
9
|
Sempere A, Salvador F, Monforte A, Sampol J, Espinosa-Pereiro J, Miarons M, Bosch-Nicolau P, Guillén-del-Castillo A, Aznar ML, Campos-Varela I, Sánchez-Montalvá A, Leguízamo-Martínez LM, Oliveira I, Antón A, Almirante B. COVID-19 Clinical Profile in Latin American Migrants Living in Spain: Does the Geographical Origin Matter? J Clin Med 2021; 10:5213. [PMID: 34830495 PMCID: PMC8622310 DOI: 10.3390/jcm10225213] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 11/03/2021] [Indexed: 01/08/2023] Open
Abstract
The aim of this study was to describe and compare the clinical characteristics of hospitalized patients with COVID-19 pneumonia according to their geographical origin. This is a retrospective case-control study of hospitalized patients with confirmed COVID-19 pneumonia treated at Vall d'Hebron University Hospital (Barcelona) during the first wave of the pandemic. Cases were defined as patients born in Latin America and controls were randomly selected among Spanish patients matched by age and gender. Demographic and clinical variables were collected, including comorbidities, symptoms, vital signs and analytical parameters, intensive care unit admission and outcome at 28 days after admission. Overall, 1080 hospitalized patients were registered: 774 (71.6%) from Spain, 142 (13.1%) from Latin America and the rest from other countries. Patients from Latin America were considered as cases and 558 Spanish patients were randomly selected as controls. Latin American patients had a higher proportion of anosmia, rhinorrhea and odynophagia, as well as higher mean levels of platelets and lower mean levels of ferritin than Spanish patients. No differences were found in oxygen requirement and mortality at 28 days after admission, but there was a higher proportion of ICU admissions (28.2% vs. 20.2%, p = 0.0310). An increased proportion of ICU admissions were found in patients from Latin America compared with native Spanish patients when adjusted by age and gender, with no significant differences in in-hospital mortality.
Collapse
Affiliation(s)
- Abiu Sempere
- Department of Infectious Diseases, Vall d’Hebron University Hospital, PROSICS Barcelona, 08035 Barcelona, Spain; (A.S.); (A.M.); (J.E.-P.); (P.B.-N.); (M.L.A.); (A.S.-M.); (I.O.); (B.A.)
| | - Fernando Salvador
- Department of Infectious Diseases, Vall d’Hebron University Hospital, PROSICS Barcelona, 08035 Barcelona, Spain; (A.S.); (A.M.); (J.E.-P.); (P.B.-N.); (M.L.A.); (A.S.-M.); (I.O.); (B.A.)
| | - Arnau Monforte
- Department of Infectious Diseases, Vall d’Hebron University Hospital, PROSICS Barcelona, 08035 Barcelona, Spain; (A.S.); (A.M.); (J.E.-P.); (P.B.-N.); (M.L.A.); (A.S.-M.); (I.O.); (B.A.)
| | - Júlia Sampol
- Department of Pneumology, Vall d’Hebron University Hospital, 08035 Barcelona, Spain;
| | - Juan Espinosa-Pereiro
- Department of Infectious Diseases, Vall d’Hebron University Hospital, PROSICS Barcelona, 08035 Barcelona, Spain; (A.S.); (A.M.); (J.E.-P.); (P.B.-N.); (M.L.A.); (A.S.-M.); (I.O.); (B.A.)
| | - Marta Miarons
- Department of Pharmacy, Vall d’Hebron University Hospital, 08035 Barcelona, Spain;
| | - Pau Bosch-Nicolau
- Department of Infectious Diseases, Vall d’Hebron University Hospital, PROSICS Barcelona, 08035 Barcelona, Spain; (A.S.); (A.M.); (J.E.-P.); (P.B.-N.); (M.L.A.); (A.S.-M.); (I.O.); (B.A.)
| | | | - Maria Luisa Aznar
- Department of Infectious Diseases, Vall d’Hebron University Hospital, PROSICS Barcelona, 08035 Barcelona, Spain; (A.S.); (A.M.); (J.E.-P.); (P.B.-N.); (M.L.A.); (A.S.-M.); (I.O.); (B.A.)
| | - Isabel Campos-Varela
- Liver Unit, Vall d’Hebron Hospital Universitari, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain;
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Adrián Sánchez-Montalvá
- Department of Infectious Diseases, Vall d’Hebron University Hospital, PROSICS Barcelona, 08035 Barcelona, Spain; (A.S.); (A.M.); (J.E.-P.); (P.B.-N.); (M.L.A.); (A.S.-M.); (I.O.); (B.A.)
| | - Lina María Leguízamo-Martínez
- Department of Pharmacovigilance and Pharmacoepidemiology, Vall d’Hebron University Hospital, 08035 Barcelona, Spain;
| | - Inés Oliveira
- Department of Infectious Diseases, Vall d’Hebron University Hospital, PROSICS Barcelona, 08035 Barcelona, Spain; (A.S.); (A.M.); (J.E.-P.); (P.B.-N.); (M.L.A.); (A.S.-M.); (I.O.); (B.A.)
| | - Andrés Antón
- Department of Microbiology, Vall d’Hebron University Hospital, 08035 Barcelona, Spain;
| | - Benito Almirante
- Department of Infectious Diseases, Vall d’Hebron University Hospital, PROSICS Barcelona, 08035 Barcelona, Spain; (A.S.); (A.M.); (J.E.-P.); (P.B.-N.); (M.L.A.); (A.S.-M.); (I.O.); (B.A.)
| |
Collapse
|
10
|
Paramanathan P, Abbas M, Huda SA, Huda S, Mortazavi M, Taravati P. Comparing racial health disparities in pandemics a decade apart: H1N1 and COVID-19. Future Healthc J 2021; 8:e722-e728. [PMID: 34888475 PMCID: PMC8651308 DOI: 10.7861/fhj.2021.0030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND AIMS The Centers for Disease Control and Prevention has reported disproportionate health disparities with respect to disease for Blacks/African Americans (AAs) compared to Whites in the USA. In this paper, we identify and compare the factors involved in creating these disparities among these populations during the 2009 H1N1 and current COVID-19 pandemics. METHODS We included studies describing health disparities towards Blacks/AAs in the USA during the H1N1 and COVID-19 pandemics. Only observational empirical studies with free full-text availability in English from PubMed, PubMed Central and Google Scholar were included. RESULTS A total of 31 papers were included: 19 pertaining to the H1N1 pandemic and 12 to the COVID-19 pandemic. Qualitative analysis for health disparities resulted in 43 different factors, which were subdivided into nine overarching themes. DISCUSSION The similarities that exist between the two pandemics indicate that there are many neglected issues in American healthcare that need to be addressed. The listed factors have led to disparities in screening and treating for disease resulting in disparities in infection rates, severity of illness and mortality. This calls for a change in healthcare dynamics to improve access to healthcare, remove any form of possible discrimination, and regain the lost trust with the Black/AA communities, repairing historical damage. CONCLUSIONS Effective utilisation of social media and faith-based centres to educate patients, implementation of new policies improving access to healthcare, and culture-sensitive education for healthcare providers are suggested to decrease health disparities and improve health outcomes across the USA.
Collapse
Affiliation(s)
- Prathayini Paramanathan
- All Saints University College of Medicine, Saint Vincent and the Grenadines, and clinical research coordinator, McMaster University, Canada
| | | | - Sajjad Ali Huda
- Avalon University School of Medicine, Curacao, and Canadian pharmacist, Kingston University, London, UK
| | | | | | - Parastoo Taravati
- Saint James School of Medicine, Saint Vincent and the Grenadines, and public health extern, Illinois Academy of Family Physicians, Chicago, USA
| |
Collapse
|
11
|
Charoenngam N, Ilori TO, Holick MF, Hochberg NS, Apovian CM. Self-identified Race and COVID-19-Associated Acute Kidney Injury and Inflammation: a Retrospective Cohort Study of Hospitalized Inner-City COVID-19 Patients. J Gen Intern Med 2021; 36:3487-3496. [PMID: 34100227 PMCID: PMC8183592 DOI: 10.1007/s11606-021-06931-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 05/11/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND Black individuals have been disproportionately affected by the coronavirus disease 2019 (COVID-19). However, it remains unclear whether there are any biological factors that predispose Black patients to COVID-19-related morbidity and mortality. OBJECTIVE To compare in-hospital morbidity, mortality, and inflammatory marker levels between Black and White hospitalized COVID-19 patients. DESIGN AND PARTICIPANTS This single-center retrospective cohort study analyzed data for Black and White patients aged ≥18 years hospitalized with a positive SARS-CoV-2 PCR test between March 1, 2020, and August 4, 2020. MAIN MEASURES The exposure was self-identified race documented in the medical record. The primary outcome of was in-hospital death. Secondary outcomes included intensive care unit admission, hospital morbidities, and inflammatory marker levels. KEY RESULTS A total of 1,424 Black and White patients were identified. The mean ± SD age was 56.1 ± 17.4 years, and 663 (44.5%) were female. There were 683 (48.0%) Black and 741 (52.0%) White patients. In the univariate analysis, Black patients had longer hospital stays (8.1 ± 10.2 vs. 6.7 ± 8.3 days, p = 0.011) and tended to have higher rates of in-hospital death (11.0% vs. 7.3%), myocardial infarction (6.9% vs. 4.5%), pulmonary embolism (PE; 5.0% vs. 2.3%), and acute kidney injury (AKI; 39.4% vs. 23.1%) than White patients (p <0.05). However, after adjusting for potential confounders, only PE (adjusted odds ratio [aOR] 2.07, 95% CI, 1.13-3.79) and AKI (aOR 2.16, 95% CI, 1.57-2.97) were statistically significantly associated with Black race. In comparison with White patients, Black patients had statistically significantly higher peak plasma D-dimer (standardized β = 0.10), erythrocyte sedimentation rate (standardized β = 0.13), ferritin (standardized β = 0.09), and lactate dehydrogenase (standardized β = 0.11), after adjusting for potential confounders (p<0.05). CONCLUSIONS Black hospitalized COVID-19 patients had increased risks of developing PE and AKI and higher inflammatory marker levels compared with White patients. This observation may be explained by differences in the prevalence and severity of underlying comorbidities and other unmeasured biologic risk factors between Black and White patients. Future research is needed to investigate the mechanism of these observed differences in outcomes of severe COVID-19 infection in Black versus White patients.
Collapse
Affiliation(s)
- Nipith Charoenngam
- Section Endocrinology, Diabetes, Nutrition and Weight Management, Department of Medicine, Boston University School of Medicine, 85 E Newton St, M-1013, Boston, MA, 02118, USA.
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
| | - Titilayo O Ilori
- Section of Nephrology, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Michael F Holick
- Section Endocrinology, Diabetes, Nutrition and Weight Management, Department of Medicine, Boston University School of Medicine, 85 E Newton St, M-1013, Boston, MA, 02118, USA
| | - Natasha S Hochberg
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Caroline M Apovian
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
12
|
Russo T, Pizuorno A, Oskrochi G, Latella G, Massironi S, Schettino M, Aghemo A, Pugliese N, Brim H, Ashktorab H. Gastrointestinal Manifestations, Clinical Characteristics and Outcomes of COVID-19 in Adult and Pediatric Patients. SOJ MICROBIOLOGY & INFECTIOUS DISEASES 2021; 8:109. [PMID: 35611315 PMCID: PMC9126507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Italy was the first country in Europe to report a SARS-CoV-2 case. Since then, the country has suffered a large number of COVID-19 infections both in adults and children. This disease has been shown to lead to different outcomes in these two groups, which often present varying symptoms and comorbidities. AIM Therefore, we aimed to evaluate the symptoms, comorbidities and laboratory values in adults and children. METHODS We present the characteristics of 1,324 adults and 563 pediatric COVID-19 Italian patients. The data was retrieved from studies published in Italy and found via PubMed and Google Scholar. RESULTS The virus appeared to affect adults more than children and men more than women, and to result in more severe outcomes in patients with abnormal laboratory values and a higher number of comorbidities. Adults are at higher risk for complications and death, and they usually present with fever, respiratory symptoms, cough, fatigue, diarrhea, myalgia, and/or loss of taste, smell, or appetite. Children usually have a milder disease progression and usually present with fever, cough, rhinorrhea, pharyngitis, sore throat, pneumonia, GI symptoms (diarrhea, vomiting, abdominal pain), fatigue, and dyspnea. CONCLUSION Our findings support early reports that showed that SARS-CoV-2 is associated with more common asymptomatic cases and milder clinical outcome in children than in adults. Acute respiratory distress syndrome and Multisystem inflammatory syndrome in children (systemic vasculitis) are the most severe disease progressions for adults and children, respectively.
Collapse
Affiliation(s)
- Tiziano Russo
- Department of Medicine, Department of Pathology and Cancer Center, Department of Biochemistry & Molecular Biology, Howard University College of Medicine, Washington DC
| | - Antonio Pizuorno
- College of Engineering and Technology, American University of the Middle East, Kuwait
| | - Gholamreza Oskrochi
- College of Engineering and Technology, American University of the Middle East, Kuwait
| | - Giovanni Latella
- Gastroenterology Unit, Department of Life, Health and Environmental Sciences, University of L’Aquila, Italy
| | - Sara Massironi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, and European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
| | - Mario Schettino
- Gastroenterology Unit, ASST Rhodense, Garbagnate Milanese, Lombardia, Italy
| | - Alessio Aghemo
- Division of Internal Medicine and Hepatology, Department of Gastroenterology, Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy
| | - Nicola Pugliese
- Division of Internal Medicine and Hepatology, Department of Gastroenterology, Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy
| | - Hassan Brim
- Department of Medicine, Department of Pathology and Cancer Center, Department of Biochemistry & Molecular Biology, Howard University College of Medicine, Washington DC
| | - Hassan Ashktorab
- Department of Medicine, Department of Pathology and Cancer Center, Department of Biochemistry & Molecular Biology, Howard University College of Medicine, Washington DC
| |
Collapse
|
13
|
Little C, Alsen M, Barlow J, Naymagon L, Tremblay D, Genden E, Trosman S, Iavicoli L, van Gerwen M. The Impact of Socioeconomic Status on the Clinical Outcomes of COVID-19; a Retrospective Cohort Study. J Community Health 2021; 46:794-802. [PMID: 33387149 PMCID: PMC7775835 DOI: 10.1007/s10900-020-00944-3] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2020] [Indexed: 01/22/2023]
Abstract
There have been limited data assessing the influence of disadvantaged socioeconomic status (SES) on the incidence and clinical outcomes of COVID-19 patients within the diverse communities of the United States. Here, we aim to investigate the association between poverty level, as an indicator of SES, and COVID-19 related clinical outcomes including hospitalization and all-cause mortality. This retrospective cohort study included 3528 patients with laboratory confirmed COVID-19 seen at a large New York City health system between March 1, 2020 and April 1, 2020. Data for neighborhood level poverty was acquired from the American Community Survey 2014-2018 and defined as the percent of residents in each ZIP code whose household income was below the federal poverty threshold (FPT): 0% to < 20% below FPT (low poverty) and > 20% below FPT (high poverty). COVID-19 positive patients who resided in high poverty areas were significantly younger, had a higher prevalence of comorbidities and were more likely to be of female gender or a racial minority when compared to individuals living in low poverty areas. Residence in a high poverty area was not associated with an increased risk of COVID-19 related hospitalization and was found to be associated with a decreased risk of in-hospital mortality. This study suggests the existence of an unequal socioeconomic gradient in the demographic and clinical presentation of COVID-19 patients including differences in age, gender and race between poverty groups. Further studies are needed to fully assess the intersectionality of SES with the COVID-19 pandemic.
Collapse
Affiliation(s)
- Christine Little
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Mathilda Alsen
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY, 10029, USA
| | - Joshua Barlow
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Leonard Naymagon
- Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Douglas Tremblay
- Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Eric Genden
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY, 10029, USA
| | - Samuel Trosman
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY, 10029, USA
| | - Laura Iavicoli
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Maaike van Gerwen
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY, 10029, USA.
- Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York, USA.
| |
Collapse
|
14
|
Clancy C, Goodrich K, Moody-Williams J, Sheares KD, O'Kane ME, Cha S, Agrawal S. Quality, Safety, and Standards Organizations COVID-19 Impact Assessment: Lessons Learned and Compelling Needs. NAM Perspect 2021; 2021:202107d. [PMID: 34611603 PMCID: PMC8486423 DOI: 10.31478/202107d] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
|
15
|
Kouser HN, Barnard-Mayers R, Murray E. Complex systems models for causal inference in social epidemiology. J Epidemiol Community Health 2021; 75:702-708. [PMID: 33172839 PMCID: PMC8849440 DOI: 10.1136/jech-2019-213052] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 09/24/2020] [Accepted: 10/21/2020] [Indexed: 02/06/2023]
Abstract
Systems models, which by design aim to capture multi-level complexity, are a natural choice of tool for bridging the divide between social epidemiology and causal inference. In this commentary, we discuss the potential uses of complex systems models for improving our understanding of quantitative causal effects in social epidemiology. To put systems models in context, we will describe how this approach could be used to optimise the distribution of COVID-19 response resources to minimise social inequalities during and after the pandemic.
Collapse
Affiliation(s)
- Hiba N Kouser
- Epidemiology, Boston University, Boston, Massachusetts, USA
| | | | - Eleanor Murray
- Epidemiology, Boston University, Boston, Massachusetts, USA
| |
Collapse
|
16
|
Sarfraz A, Sarfraz Z, Barrios A, Agadi K, Thevuthasan S, Pandav K, Kc M, Sarfraz M, Rad P, Michel G. Understanding and Promoting Racial Diversity in Healthcare Settings to Address Disparities in Pandemic Crisis Management. J Prim Care Community Health 2021; 12:21501327211018354. [PMID: 34024164 PMCID: PMC8150435 DOI: 10.1177/21501327211018354] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background: Health disparities have become apparent since the beginning of the COVID-19 pandemic. When observing racial discrimination in healthcare, self-reported incidences, and perceptions among minority groups in the United States suggest that, the most socioeconomically underrepresented groups will suffer disproportionately in COVID-19 due to synergistic mechanisms. This study reports racially-stratified data regarding the experiences and impacts of different groups availing the healthcare system to identify disparities in outcomes of minority and majority groups in the United States. Methods: Studies were identified utilizing PubMed, Embase, CINAHL Plus, and PsycINFO search engines without date and language restrictions. The following keywords were used: Healthcare, raci*, ethnic*, discriminant, hosti*, harass*, insur*, education, income, psychiat*, COVID-19, incidence, mortality, mechanical ventilation. Statistical analysis was conducted in Review Manager (RevMan V.5.4). Unadjusted Odds Ratios, P-values, and 95% confidence intervals were presented. Results: Discrimination in the United States is evident among racial groups regarding medical care portraying mental risk behaviors as having serious outcomes in the health of minority groups. The perceived health inequity had a low association to the majority group as compared to the minority group (OR = 0.41; 95% CI = 0.22 to 0.78; P = .007), and the association of mental health problems to the Caucasian-American majority group was low (OR = 0.51; 95% CI = 0.45 to 0.58; P < .001). Conclusion: As the pandemic continues into its next stage, efforts should be taken to address the gaps in clinical training and education, and medical practice to avoid the recurring patterns of racial health disparities that become especially prominent in community health emergencies. A standardized tool to assess racial discrimination and inequity will potentially improve pandemic healthcare delivery.
Collapse
Affiliation(s)
- Azza Sarfraz
- Larkin Health System, South Miami, FL, USA.,Aga Khan University, Karachi, Pakistan
| | - Zouina Sarfraz
- Larkin Health System, South Miami, FL, USA.,Fatima Jinnah Medical University, Lahore, Pakistan
| | - Alanna Barrios
- Larkin Health System, South Miami, FL, USA.,Instituto Tecnológico y de Estudios Superiores de Monterrey, México
| | | | | | | | - Manish Kc
- Larkin Health System, South Miami, FL, USA
| | | | - Pedram Rad
- Larkin Health System, South Miami, FL, USA
| | | |
Collapse
|
17
|
Lobelo F, Bienvenida A, Leung S, Mbanya A, Leslie E, Koplan K, Shin SR. Clinical, behavioural and social factors associated with racial disparities in COVID-19 patients from an integrated healthcare system in Georgia: a retrospective cohort study. BMJ Open 2021; 11:e044052. [PMID: 34011589 PMCID: PMC8136804 DOI: 10.1136/bmjopen-2020-044052] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES To identify sociodemographic, clinical and behavioural drivers of racial disparities and their association with clinical outcomes among Kaiser Permanente Georgia (KPGA) members with COVID-19. DESIGN Retrospective cohort of patients with COVID-19 seen from 3 March to 29 October 2020. We described the distribution of underlying comorbidities, quality of care metrics, demographic and social determinants of health (SDOH) indicators across race groups. We also described clinical outcomes in hospitalised patients including length of stay, intensive care unit (ICU) admission, readmission and mortality. We performed multivariable analyses for hospitalisation risk among all patients with COVID-19 and stratifyied by race and sex. SETTING KPGA, an integrated healthcare system. PARTICIPANTS 5712 patients who all had laboratory-confirmed COVID-19. Of them, 57.8% were female, 58.4% black, 29.5% white, 8.5% Hispanic and 3.6% Asian. RESULTS Black patients had the highest proportions of living in neighborhoods under the federal poverty line (12.4%) and in more deprived locations (neighbourhood deprivation index=0.4). Overall, 14.4% (n=827) of this cohort was hospitalised. Asian patients had the highest rates of ICU admission (53.1%) and mechanical ventilation (21.9%). Among all patients, Hispanics (adjusted 1.60, 95% CI (1.08, 2.37)), blacks (1.43 (1.13, 1.83)), age in years (1.03 (1.02, 1.04)) and living in a zip code with high unemployment (1.08 (1.03, 1.13)) were associated with higher odds of hospitalisation. COVID-19 patients with chronic obstructive pulmonary disease (2.59 (1.67, 4.02)), chronic heart failure (1.79 (1.31, 2.45)), immunocompromised (1.77 (1.16, 2.70)), with glycated haemoglobin >8% (1.68 (1.19, 2.38)), depression (1.60 (1.24, 2.06)), hypertension (1.5 (1.21, 1.87)) and physical inactivity (1.25 (1.03, 1.51)) had higher odds of hospitalisation. CONCLUSIONS Black and Hispanic KPGA patients were at higher odds of hospitalisation, but not mortality, compared with other race groups. Beyond previously reported sociodemographics and comorbidities, factors such as quality of care, lifestyle behaviours and SDOH indicators should be considered when designing and implementing interventions to reduce COVID-19 racial disparities.
Collapse
Affiliation(s)
- Felipe Lobelo
- The Southeast Permanente Medical Group, Kaiser Permanente Georgia, Atlanta, Georgia, USA
- Global Health Department, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Alan Bienvenida
- The Southeast Permanente Medical Group, Kaiser Permanente Georgia, Atlanta, Georgia, USA
| | - Serena Leung
- The Southeast Permanente Medical Group, Kaiser Permanente Georgia, Atlanta, Georgia, USA
| | - Armand Mbanya
- The Southeast Permanente Medical Group, Kaiser Permanente Georgia, Atlanta, Georgia, USA
| | - Elizabeth Leslie
- The Southeast Permanente Medical Group, Kaiser Permanente Georgia, Atlanta, Georgia, USA
| | - Kate Koplan
- The Southeast Permanente Medical Group, Kaiser Permanente Georgia, Atlanta, Georgia, USA
| | - Sangmin Ryan Shin
- The Southeast Permanente Medical Group, Kaiser Permanente Georgia, Atlanta, Georgia, USA
| |
Collapse
|
18
|
Snyder T, Ravenhurst J, Cramer EY, Reich NG, Balzer LB, Alfandari D, Lover AA. Serological surveys to estimate cumulative incidence of SARS-CoV-2 infection in adults (Sero-MAss study), Massachusetts, July-August 2020: a mail-based cross-sectional study. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2021:2021.03.05.21249174. [PMID: 33758898 PMCID: PMC7987057 DOI: 10.1101/2021.03.05.21249174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND The SARS-CoV-2 pandemic is an unprecedented global health crisis. The state of Massachusetts was especially impacted during the initial stages; however, the extent of asymptomatic transmission remains poorly understood due to limited asymptomatic testing in the "first wave." To address this gap, a geographically representative and contact-free seroprevalence survey was conducted in July-August 2020, to estimate prior undetected SARS-CoV-2 infections. METHODS Students, faculty, librarians and staff members at the University of Massachusetts, Amherst without a previous COVID-19 diagnosis were invited to participate in this study along with one member of their household in June 2020. Two separate sampling frames were generated from administrative lists: all undergraduates and their household members (primary sampling group) were randomly selected with probability proportional to population size. All staff, faculty, graduate students and librarians (secondary sampling group) were selected as a simple random sample. After informed consent and a socio-behavioral survey, participants were mailed test kits and asked to return self-collected dried blood spot (DBS) samples. Samples were analyzed via ELISA for anti-SARS-CoV-2 IgG antibodies, and then IgM antibodies if IgG-positive. Seroprevalence estimates were adjusted for survey non-response. Binomial models were used to assess factors associated with seropositivity in both sample groups separately. RESULTS Approximately 27,000 persons were invited via email to assess eligibility. Of the 1,001 individuals invited to participate in the study, 762 (76%) returned blood samples for analysis. In the primary sampling group 548 returned samples, of which 230 enrolled a household member. Within the secondary sampling group of 214 individuals, 79 enrolled a household member. In the primary sample group, 36 (4.6%) had IgG antibodies detected for an estimated weighed prevalence for this population of 5.3% (95% CI: 3.5 to 8.0). In the secondary sampling group, 10 (3.4%) of 292 individuals had IgG antibodies detected for an estimated adjusted prevalence of 4.0% (95% CI: 2.2 to 7.4). No samples were IgM positive. No association was found in either sample group between seropositivity and self-reported work duties or customer-facing hours. In the primary sampling group, self-reported febrile illness since Feb 2020, male sex, and minority race (Black or American Indian/Alaskan Native) were associated with seropositivity. No factors except geographic regions within the state were associated with evidence of prior SARS-CoV-2 infection in the secondary sampling group. INTERPRETATION This study provides insight into the seroprevalence of university-related populations and their household members across the state of Massachusetts during the summer of 2020 of the pandemic and helps to fill a critical gap in estimating the levels of sub-clinical and asymptomatic infection. Estimates like these can be used to calibrate models that estimate levels of population immunity over time to inform public health interventions and policy.
Collapse
Affiliation(s)
- Teah Snyder
- Department of Biostatistics and Epidemiology, School of Public Health and Health Sciences, University of Massachusetts- Amherst, Amherst MA
| | - Johanna Ravenhurst
- Department of Biostatistics and Epidemiology, School of Public Health and Health Sciences, University of Massachusetts- Amherst, Amherst MA
| | - Estee Y. Cramer
- Department of Biostatistics and Epidemiology, School of Public Health and Health Sciences, University of Massachusetts- Amherst, Amherst MA
| | - Nicholas G. Reich
- Department of Biostatistics and Epidemiology, School of Public Health and Health Sciences, University of Massachusetts- Amherst, Amherst MA
| | - Laura B. Balzer
- Department of Biostatistics and Epidemiology, School of Public Health and Health Sciences, University of Massachusetts- Amherst, Amherst MA
| | - Dominique Alfandari
- Department of Veterinary and Animal Sciences, College of Natural Sciences, University of Massachusetts- Amherst, Amherst MA
| | - Andrew A. Lover
- Department of Biostatistics and Epidemiology, School of Public Health and Health Sciences, University of Massachusetts- Amherst, Amherst MA
| |
Collapse
|
19
|
Wong MS, Haderlein TP, Yuan AH, Moy E, Jones KT, Washington DL. Time Trends in Racial/Ethnic Differences in COVID-19 Infection and Mortality. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:4848. [PMID: 34062806 PMCID: PMC8124342 DOI: 10.3390/ijerph18094848] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 04/22/2021] [Accepted: 04/28/2021] [Indexed: 11/20/2022]
Abstract
Studies documenting coronavirus disease 2019 (COVID-19) racial/ethnic disparities in the United States were limited to data from the initial few months of the pandemic, did not account for changes over time, and focused primarily on Black and Hispanic minority groups. To fill these gaps, we examined time trends in racial/ethnic disparities in COVID-19 infection and mortality. We used the Veteran Health Administration's (VHA) national database of veteran COVID-19 infections over three time periods: 3/1/2020-5/31/2020 (spring); 6/1/2020-8/31/2020 (summer); and 9/1/2020-11/25/2020 (fall). We calculated COVID-19 infection and mortality predicted probabilities from logistic regression models that included time period-by-race/ethnicity interaction terms, and controlled for age, gender, and prior diagnosis of CDC risk factors. Racial/ethnic groups at higher risk for COVID-19 infection and mortality changed over time. American Indian/Alaskan Natives (AI/AN), Blacks, Hispanics, and Native Hawaiians/Other Pacific Islanders experienced higher COVID-19 infections compared to Whites during the summertime. There were mortality disparities for Blacks in springtime, and AI/ANs, Asians, and Hispanics in summertime. Policy makers should consider the dynamic nature of racial/ethnic disparities as the pandemic evolves, and potential effects of risk mitigation and other (e.g., economic) policies on these disparities. Researchers should consider how trends in disparities change over time in other samples.
Collapse
Affiliation(s)
- Michelle S. Wong
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System 11301 Wilshire Blvd, Los Angeles, CA 90073, USA; (T.P.H.); (A.H.Y.); (D.L.W.)
| | - Taona P. Haderlein
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System 11301 Wilshire Blvd, Los Angeles, CA 90073, USA; (T.P.H.); (A.H.Y.); (D.L.W.)
| | - Anita H. Yuan
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System 11301 Wilshire Blvd, Los Angeles, CA 90073, USA; (T.P.H.); (A.H.Y.); (D.L.W.)
| | - Ernest Moy
- VHA Office of Health Equity, 810 Vermont Ave NW, Washington, DC 20420, USA; (E.M.); (K.T.J.)
| | - Kenneth T. Jones
- VHA Office of Health Equity, 810 Vermont Ave NW, Washington, DC 20420, USA; (E.M.); (K.T.J.)
| | - Donna L. Washington
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System 11301 Wilshire Blvd, Los Angeles, CA 90073, USA; (T.P.H.); (A.H.Y.); (D.L.W.)
- Department of Medicine, Division of General Internal Medicine and Health Services Research, University of California Los Angeles Geffen School of Medicine, 1100 Glendon Ave STE 850, Los Angeles, CA 90024, USA
| |
Collapse
|
20
|
Tsai S, Nguyen H, Ebrahimi R, Barbosa MR, Ramanan B, Heitjan DF, Hastings JL, Modrall JG, Jeon-Slaughter H. COVID-19 associated mortality and cardiovascular disease outcomes among US women veterans. Sci Rep 2021; 11:8497. [PMID: 33875764 PMCID: PMC8055870 DOI: 10.1038/s41598-021-88111-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 04/01/2021] [Indexed: 12/13/2022] Open
Abstract
The burden of COVID-19 has been noted to be disproportionately greater in minority women, a population that is nevertheless still understudied in COVID-19 research. We conducted an observational study to examine COVID-19-associated mortality and cardiovascular disease outcomes after testing (henceforth index) among a racially diverse adult women veteran population. We assembled a retrospective cohort from a Veterans Affairs (VA) national COVID-19 shared data repository, collected between February and August 2020. A case was defined as a woman veteran who tested positive for SARS-COV-2, and a control as a woman veteran who tested negative. We used Kaplan-Meier curves and the Cox proportional hazards model to examine the distribution of time to death and the effects of baseline predictors on mortality risk. We used generalized linear models to examine 60-day cardiovascular disease outcomes. Covariates studied included age, body mass index (BMI), and active smoking status at index, and pre-existing conditions of diabetes, chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), and a history of treatment with antiplatelet or anti-thrombotic drug at any time in the 2 years prior to the index date. Women veterans who tested positive for SARS-CoV-2 had 4 times higher mortality risk than women veterans who tested negative (Hazard Ratio 3.8, 95% Confidence Interval CI 2.92 to 4.89) but had lower risk of cardiovascular events (Odds Ratio OR 0.78, 95% CI 0.66 to 0.92) and developing new heart disease conditions within 60 days (OR 0.67, 95% CI 0.58 to 0.77). Older age, obesity (BMI > 30), and prior CVD and COPD conditions were positively associated with increased mortality in 60 days. Despite a higher infection rate among minority women veterans, there was no significant race difference in mortality, cardiovascular events, or onset of heart disease. SARS-CoV-2 infection increased short-term mortality risk among women veterans similarly across race groups. However, there was no evidence of increased cardiovascular disease incidence in 60 days. A longer follow-up of women veterans who tested positive is warranted.
Collapse
Affiliation(s)
- Shirling Tsai
- Veterans Affairs North Texas Health Care System, Dallas, TX, USA
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Hang Nguyen
- Veterans Affairs North Texas Health Care System, Dallas, TX, USA
- Southern Methodist University, Dallas, TX, USA
| | - Ramin Ebrahimi
- Veterans Affairs Greater Los Angeles Health Care System, Los Angeles, CA, USA
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | - Monica R Barbosa
- Veterans Affairs North Texas Health Care System, Dallas, TX, USA
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Bala Ramanan
- Veterans Affairs North Texas Health Care System, Dallas, TX, USA
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Daniel F Heitjan
- Southern Methodist University, Dallas, TX, USA
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jeffrey L Hastings
- Veterans Affairs North Texas Health Care System, Dallas, TX, USA
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - J Gregory Modrall
- Veterans Affairs North Texas Health Care System, Dallas, TX, USA
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Haekyung Jeon-Slaughter
- Veterans Affairs North Texas Health Care System, Dallas, TX, USA.
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| |
Collapse
|
21
|
Latkin C, Dayton LA, Yi G, Konstantopoulos A, Park J, Maulsby C, Kong X. COVID-19 vaccine intentions in the United States, a social-ecological framework. Vaccine 2021; 39:2288-2294. [PMID: 33771392 PMCID: PMC7945864 DOI: 10.1016/j.vaccine.2021.02.058] [Citation(s) in RCA: 110] [Impact Index Per Article: 36.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 12/23/2020] [Accepted: 02/24/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND COVID-19 vaccine hesitancy is a major obstacle for pandemic mitigation. As vaccine hesitancy occurs along multiple dimensions, we used a social-ecological framework to guide the examination of COVID-19 vaccine intentions. METHODS Using an online survey in the US conducted in July 2020, we examined intentions to obtain a COVID-19 vaccine, once available. 592 respondents provided data, including measures of demographics, vaccine history, social norms, perceived risk, and trust in sources of COVID-19 information. Bivariate and multivariate multinomial models were used to compare respondents who intended to be vaccinated against COVID-19 to respondents who did not intend or were ambivalent about COVID-19 vaccination. RESULTS Only 59.1% of the sample reported that they intended to obtain a COVID-19 vaccine. In the multivariate multinomial model, those respondents who did not intend to be vaccinated, as compared to those who did, had significantly lower levels of trust in the CDC as a source of COVID-19 information (aOR = 0.29, CI = 0.17-0.50), reported lower social norms of COVID-19 preventive behaviors (aOR = 0.67, CI 0.51-0.88), scored higher on COVID-19 Skepticism (aOR = 1.44, CI = 1.28-1.61), identified as more politically conservative (aOR = 1.23, CI = 1.05-1.45), were less likely to have obtained a flu vaccine in the prior year (aOR = 0.21, CI = 0.11-0.39), were less likely to be female (aOR = 0.51, CI = 0.29-0.87), and were much more likely to be Black compared to White (aOR = 10.70, CI = 4.09-28.1). A highly similar pattern was observed among those who were ambivalent about receiving a COVID-19 vaccine compared to those who intended to receive one. CONCLUSION The results of this study suggest several avenues for COVID-19 vaccine promotion campaigns, including social network diffusion strategies and cross-partisan messaging, to promote vaccine trust. The racial and gender differences in vaccine intentions also suggest the need to tailor campaigns based on gender and race.
Collapse
Affiliation(s)
- Carl Latkin
- Department of Health, Behavior and Society, Bloomberg School of Public Health, Johns Hopkins University, United States; Division of Infectious Diseases, Johns Hopkins University School of Medicine, United States.
| | - Lauren A Dayton
- Department of Health, Behavior and Society, Bloomberg School of Public Health, Johns Hopkins University, United States
| | - Grace Yi
- Department of Health, Behavior and Society, Bloomberg School of Public Health, Johns Hopkins University, United States
| | | | - Ju Park
- Department of Health, Behavior and Society, Bloomberg School of Public Health, Johns Hopkins University, United States
| | - Catherine Maulsby
- Department of Health, Behavior and Society, Bloomberg School of Public Health, Johns Hopkins University, United States
| | - Xiangrong Kong
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, United States
| |
Collapse
|
22
|
Kaseb AO, Mohamed YI, Malek AE, Raad II, Altameemi L, Li D, Kaseb OA, Kaseb SA, Selim A, Ma Q. The Impact of Angiotensin-Converting Enzyme 2 (ACE2) Expression on the Incidence and Severity of COVID-19 Infection. Pathogens 2021; 10:379. [PMID: 33809851 PMCID: PMC8004186 DOI: 10.3390/pathogens10030379] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 03/17/2021] [Accepted: 03/19/2021] [Indexed: 01/08/2023] Open
Abstract
The novel coronavirus disease 2019 (COVID-19) pandemic has led to an unprecedented threat to the international community and raised major concerns in terms of public health safety. Although our current understanding of the complexity of COVID-19 pathogenesis remains limited, the infection is largely mediated by the interaction of viral spike protein and angiotensin-converting enzyme 2 (ACE2). The functional importance of ACE2 in different demographic and comorbid conditions may explain the significant variation in incidence and mortality of COVID-19 in vulnerable groups, and highlights its candidacy as a potential therapeutic target. We provide evidence supporting the idea that differences in incidence and severity of COVID-19 infection may be related to ACE2. Emerging data based on the prevalence and severity of COVID-19 among those with established high levels of ACE2 expression strongly support our hypothesis. Considering the burden of COVID-19 infection in these vulnerable groups and the impact of the potential therapeutic and preventive measures that would result from adopting ACE2-driven anti-viral strategies, our hypothesis may expedite global efforts to control the current COVID-19 pandemic.
Collapse
Affiliation(s)
- Ahmed O. Kaseb
- Departments of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (Y.I.M.); (L.A.)
| | - Yehia I. Mohamed
- Departments of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (Y.I.M.); (L.A.)
| | - Alexandre E. Malek
- Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (A.E.M.); (I.I.R.)
| | - Issam I. Raad
- Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (A.E.M.); (I.I.R.)
| | - Lina Altameemi
- Departments of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (Y.I.M.); (L.A.)
| | - Dan Li
- Department of Hematopoietic Biology and Malignancy, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (D.L.); (Q.M.)
| | - Omar A. Kaseb
- Iman Academy, Webster, TX 77598, USA; (O.A.K.); (S.A.K.)
| | - Safa A. Kaseb
- Iman Academy, Webster, TX 77598, USA; (O.A.K.); (S.A.K.)
| | - Abdelhafez Selim
- Philadelphia College of Osteopathic Medicine (PCOM), Philadelphia, PA 19131, USA;
| | - Qing Ma
- Department of Hematopoietic Biology and Malignancy, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (D.L.); (Q.M.)
| |
Collapse
|
23
|
Differences in COVID-19-Related Testing and Healthcare Utilization by Race and Ethnicity in the Veterans Health Administration. J Racial Ethn Health Disparities 2021; 9:519-526. [PMID: 33694124 PMCID: PMC7945621 DOI: 10.1007/s40615-021-00982-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 01/25/2021] [Accepted: 01/27/2021] [Indexed: 11/21/2022]
Abstract
Importance Recent reports indicate differences in COVID-19-related care and outcomes between Black and White Americans. Objective We examine the COVID-19-related healthcare utilization and mortality by race and ethnicity of patients tested for SARS-CoV-2 in the Veterans Health Administration (VHA). Design A retrospective cohort study. Setting We used the VHA COVID-19 shared data resources between February 1 and June 30, 2020. Participants Veterans tested for SARS-CoV-2 virus by VHA. Exposure(s) Three racial-ethnicity groups of Black, Hispanic, and White (as reference) veterans. Main Outcome(s) and Measure(s) Main outcomes are testing rate, positivity rate, hospitalization rate, ICU admission rate, and in-hospital mortality. Controlling for sex, age, and Elixhauser comorbidity index, we report adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) from logistic regression models. Results Of the 8,667,996 active veteran enrollees, 252,702 were tested by VHA from February to June, 2020, with 20,500 positive results and 4,790 hospitalizations. The testing rate was 4.4% among Black and 4.7% among Hispanic veterans compared to White veterans, 2.8%. The testing positivity rate was similarly elevated among Black (12.2%) and Hispanic (11.6%) veterans compared to White veterans (6.0%). The aORs of hospitalization in Black veterans (1.88; 95% CI 1.74, 2.03) and Hispanic veterans (1.41; 95% CI 1.25, 1.60) were higher compared to White veterans. No significant differences by race and ethnicity were observed in OR or aOR of ICU admission and in-hospital death among hospitalized patients. Conclusions and Relevance On a national level, the VHA was more likely to test and hospitalize Black and Hispanic veterans compared to White veterans, but there were no significant differences in ICU admission or in-hospital mortality among those hospitalized. This pattern of differences may relate to social determinants of health, factors affecting access to non-VHA care, or preferences for VHA care affecting initial care seeking, but not in-hospital outcomes. Supplementary Information The online version contains supplementary material available at 10.1007/s40615-021-00982-0.
Collapse
|
24
|
Clinical predictors of poor outcomes in patients with sickle cell disease and COVID-19 infection. Blood Adv 2021; 5:207-215. [PMID: 33570644 PMCID: PMC7802524 DOI: 10.1182/bloodadvances.2020003456] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 11/25/2020] [Indexed: 12/19/2022] Open
Abstract
SCD patients with COVID-19 display a broad range of severity, with a higher case fatality than the non-SCD population (10.9% vs 3.3%). Older patients not treated with hydroxyurea with end organ damage who present with acute kidney injury, and elevated LDH and D-dimer level are at higher risk of death.
We aimed to identify predictors of outcomes and survival in patients living in 4 major metropolitan areas who had sickle cell disease (SCD) and COVID-19 to inform best approaches to prevention and care. Data were collected at baseline and during the clinical course in SCD patients diagnosed with COVID-19 in four COVID-19 epicenters. Patients were followed up posthospital discharge for up to 3 months. Of sixty-six SCD patients with COVID-19, fifty patients (75%) required hospitalization, and seven died (10.6%). Patients with preexisting kidney disease (chronic kidney disease) were more likely to be hospitalized. The most common presenting symptom was vaso-occlusive pain. Acute chest syndrome occurred in 30 (60%) of the 50 hospitalized patients and in all who died. Older age and histories of pulmonary hypertension, congestive heart failure, chronic kidney disease, and stroke were more prevalent in patients who died, as were higher creatinine, lactate dehydrogenase, and D-dimer levels. Anticoagulation use while inpatient was twice less common in patients who died. All deaths occurred in individuals not taking hydroxyurea or any other SCD-modifying therapy. Patients with SCD and COVID-19 exhibited a broad range of disease severity. We cannot definitively state that the overall mortality is higher in patients with SCD, although our case fatality rate was ∼10% compared with ∼3% in the general population, despite a median age of 34 years. Individuals with SCD aged >50 years, with preexisting cardiopulmonary, renal disease, and/or stroke not receiving hydroxyurea, who present with high serum creatinine, lactate dehydrogenase, and D-dimer levels, are at higher risk of death, irrespective of genotype or sex.
Collapse
|
25
|
Ebinger JE, Botwin GJ, Albert CM, Alotaibi M, Arditi M, Berg AH, Binek A, Botting P, Fert-Bober J, Figueiredo JC, Grein JD, Hasan W, Henglin M, Hussain SK, Jain M, Joung S, Karin M, Kim EH, Li D, Liu Y, Luong E, McGovern DPB, Merchant A, Merin N, Miles PB, Minissian M, Nguyen TT, Raedschelders K, Rashid MA, Riera CE, Riggs RV, Sharma S, Sternbach S, Sun N, Tourtellotte WG, Van Eyk JE, Sobhani K, Braun JG, Cheng S. Seroprevalence of antibodies to SARS-CoV-2 in healthcare workers: a cross-sectional study. BMJ Open 2021; 11:e043584. [PMID: 33579769 PMCID: PMC7883610 DOI: 10.1136/bmjopen-2020-043584] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 11/30/2020] [Accepted: 01/20/2021] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE We sought to determine the extent of SARS-CoV-2 seroprevalence and the factors associated with seroprevalence across a diverse cohort of healthcare workers. DESIGN Observational cohort study of healthcare workers, including SARS-CoV-2 serology testing and participant questionnaires. SETTINGS A multisite healthcare delivery system located in Los Angeles County. PARTICIPANTS A diverse and unselected population of adults (n=6062) employed in a multisite healthcare delivery system located in Los Angeles County, including individuals with direct patient contact and others with non-patient-oriented work functions. MAIN OUTCOMES Using Bayesian and multivariate analyses, we estimated seroprevalence and factors associated with seropositivity and antibody levels, including pre-existing demographic and clinical characteristics; potential COVID-19 illness-related exposures; and symptoms consistent with COVID-19 infection. RESULTS We observed a seroprevalence rate of 4.1%, with anosmia as the most prominently associated self-reported symptom (OR 11.04, p<0.001) in addition to fever (OR 2.02, p=0.002) and myalgias (OR 1.65, p=0.035). After adjusting for potential confounders, seroprevalence was also associated with Hispanic ethnicity (OR 1.98, p=0.001) and African-American race (OR 2.02, p=0.027) as well as contact with a COVID-19-diagnosed individual in the household (OR 5.73, p<0.001) or clinical work setting (OR 1.76, p=0.002). Importantly, African-American race and Hispanic ethnicity were associated with antibody positivity even after adjusting for personal COVID-19 diagnosis status, suggesting the contribution of unmeasured structural or societal factors. CONCLUSION AND RELEVANCE The demographic factors associated with SARS-CoV-2 seroprevalence among our healthcare workers underscore the importance of exposure sources beyond the workplace. The size and diversity of our study population, combined with robust survey and modelling techniques, provide a vibrant picture of the demographic factors, exposures and symptoms that can identify individuals with susceptibility as well as potential to mount an immune response to COVID-19.
Collapse
Affiliation(s)
- Joseph E Ebinger
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Gregory J Botwin
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Christine M Albert
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Mona Alotaibi
- Division of Pulmonary and Critical Care Medicine, University of California, San Diego, La Jolla, California, USA
| | - Moshe Arditi
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Departments of Pediatrics, Division of Infectious Diseases and Immunology, and Infectious and Immunologic Diseases Research Center (IIDRC), Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Anders H Berg
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Aleksandra Binek
- Advanced Clinical Biosystems Institute, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Patrick Botting
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Justyna Fert-Bober
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jane C Figueiredo
- Cedars-Sinai Cancer and Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jonathan D Grein
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Department of Epidemiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Wohaib Hasan
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Biobank & Translational Research Core Laboratory, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Mir Henglin
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Shehnaz K Hussain
- Department of Public Health Sciences and Comprehensive Cancer Center, University of California, Davis, Davis, California, USA
| | - Mohit Jain
- Department of Medicine and Pharmacology, University of California, San Diego, La Jolla, California, USA
| | - Sandy Joung
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Michael Karin
- Department of Pharmacology, University of California San Diego School of Medicine, La Jolla, California, USA
| | - Elizabeth H Kim
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Dalin Li
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Yunxian Liu
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Eric Luong
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Dermot P B McGovern
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Akil Merchant
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Noah Merin
- Department of Internal Medicine, Division of Hematology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Peggy B Miles
- Employee Health Services, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Margo Minissian
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Brawerman Nursing Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Trevor Trung Nguyen
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Koen Raedschelders
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Advanced Clinical Biosystems Institute, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Mohamad A Rashid
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Celine E Riera
- Center for Neural Science and Medicine, Department of Biomedical Sciences, Board of Governors Regenerative Medicine Institute, Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, California, USA
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Richard V Riggs
- Chief Medical Officer, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Sonia Sharma
- La Jolla Institute for Allergy and Immunology, La Jolla, California, USA
| | - Sarah Sternbach
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Nancy Sun
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Warren G Tourtellotte
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Biobank & Translational Research Core Laboratory, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jennifer E Van Eyk
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Advanced Clinical Biosystems Institute, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Barbra Streisand Women's Heart Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Kimia Sobhani
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jonathan G Braun
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Susan Cheng
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Barbra Streisand Women's Heart Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| |
Collapse
|
26
|
Ward H, Atchison C, Whitaker M, Ainslie KEC, Elliott J, Okell L, Redd R, Ashby D, Donnelly CA, Barclay W, Darzi A, Cooke G, Riley S, Elliott P. SARS-CoV-2 antibody prevalence in England following the first peak of the pandemic. Nat Commun 2021; 12:905. [PMID: 33568663 PMCID: PMC7876103 DOI: 10.1038/s41467-021-21237-w] [Citation(s) in RCA: 126] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 01/06/2021] [Indexed: 12/20/2022] Open
Abstract
England has experienced a large outbreak of SARS-CoV-2, disproportionately affecting people from disadvantaged and ethnic minority communities. It is unclear how much of this excess is due to differences in exposure associated with structural inequalities. Here, we report from the REal-time Assessment of Community Transmission-2 (REACT-2) national study of over 100,000 people. After adjusting for test characteristics and re-weighting to the population, overall antibody prevalence is 6.0% (95% CI: 5.8-6.1). An estimated 3.4 million people had developed antibodies to SARS-CoV-2 by mid-July 2020. Prevalence is two- to three-fold higher among health and care workers compared with non-essential workers, and in people of Black or South Asian than white ethnicity, while age- and sex-specific infection fatality ratios are similar across ethnicities. Our results indicate that higher hospitalisation and mortality from COVID-19 in minority ethnic groups may reflect higher rates of infection rather than differential experience of disease or care.
Collapse
Affiliation(s)
- Helen Ward
- School of Public Health, Imperial College London, London, UK.
- National Institute for Health Research Imperial Biomedical Research Centre, London, UK.
- Imperial College Healthcare NHS Trust, London, UK.
| | | | | | - Kylie E C Ainslie
- School of Public Health, Imperial College London, London, UK
- MRC Centre for Global Infectious Disease Analysis Imperial College London, London, UK
| | - Joshua Elliott
- School of Public Health, Imperial College London, London, UK
| | - Lucy Okell
- School of Public Health, Imperial College London, London, UK
- MRC Centre for Global Infectious Disease Analysis Imperial College London, London, UK
| | - Rozlyn Redd
- School of Public Health, Imperial College London, London, UK
| | - Deborah Ashby
- School of Public Health, Imperial College London, London, UK
| | - Christl A Donnelly
- School of Public Health, Imperial College London, London, UK
- MRC Centre for Global Infectious Disease Analysis Imperial College London, London, UK
- Department of Statistics, University of Oxford, Oxford, UK
| | - Wendy Barclay
- National Institute for Health Research Imperial Biomedical Research Centre, London, UK
- Department of Infectious Disease, Imperial College London, London, UK
| | - Ara Darzi
- National Institute for Health Research Imperial Biomedical Research Centre, London, UK
- Institute of Global Health Innovation, Imperial College London, London, UK
| | - Graham Cooke
- National Institute for Health Research Imperial Biomedical Research Centre, London, UK
- Department of Infectious Disease, Imperial College London, London, UK
| | - Steven Riley
- School of Public Health, Imperial College London, London, UK
- MRC Centre for Global Infectious Disease Analysis Imperial College London, London, UK
| | - Paul Elliott
- School of Public Health, Imperial College London, London, UK.
- National Institute for Health Research Imperial Biomedical Research Centre, London, UK.
- MRC Centre for Environment and Health, Imperial College London, London, UK.
| |
Collapse
|
27
|
Schneider JG, Relich RF, Datta D, Bond C, Goings M, Hall D, Lei GS, Kedra J, John CC. Identifying Risk Factors That Distinguish Symptomatic Severe Acute Respiratory Syndrome Coronavirus 2 Infection From Common Upper Respiratory Infections in Children. Cureus 2021; 13:e13266. [PMID: 33728202 PMCID: PMC7948314 DOI: 10.7759/cureus.13266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2021] [Indexed: 01/08/2023] Open
Abstract
Background Demographic and clinical risk factors for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in children presenting with respiratory viral symptoms are not well defined. An understanding of risk factors for SARS-CoV-2 infection can help prioritize testing. Methodology We evaluated potential demographic and clinical factors in children who had respiratory viral symptoms and were tested by polymerase chain reaction (PCR) for SARS-CoV-2 and other respiratory viral infections. Results Among the 263 symptomatic children tested for routine seasonal respiratory viruses by PCR, 18 (6.8%) tested positive for SARS-CoV-2. Overall, 22.2% of SARS-CoV-2-infected children and 37.1% of SARS-CoV-2-uninfected children had infection with one or more non-SARS-CoV-2 pathogens (p = 0.31). Higher proportions of children with compared to without SARS-CoV-2 infection were male (77.8 vs. 51.8%, p = 0.05), Hispanic (44.4% vs. 9.8%, p < 0.001), or had the symptoms of fatigue (22.2% vs. 2.5%, p = 0.003) or anosmia/ageusia (11.1% vs. 0%, p = 0.004). History of hypoxic-ischemic encephalopathy (HIE) and obesity were more common in children with versus without SARS-CoV-2 infection (11.1% vs. 1.2%, p = 0.04, and 11.1% vs. 0%, p = 0.004, respectively). In a multivariate analysis, Hispanic ethnicity, symptoms of fatigue or anosmia/ageusia, and presence of obesity (as noted on physical examination) or HIE were independently associated with SARS-CoV-2 infection. Numbers in each category were small, and these preliminary associations require confirmation in future studies. Conclusions In this area of the United States, infection with other viruses did not rule out infection with SARS-CoV-2. Additionally, children with respiratory viral symptoms who were of Hispanic ethnicity, had symptoms of weakness/fatigue, or had obesity or HIE were at an increased risk for SARS-CoV-2 infection. Future studies should assess if these factors are associated with risk in populations in other areas of the United States.
Collapse
Affiliation(s)
- Jack G Schneider
- Department of Infectious Diseases, Indiana University School of Medicine, Indianapolis, USA
| | - Ryan F Relich
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, USA
| | - Dibyadyuti Datta
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, USA
| | - Caitlin Bond
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, USA
| | - Michael Goings
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, USA
| | - Dylan Hall
- Department of Internal Medicine and Pediatrics, Indiana University School of Medicine, Indianapolis, USA
| | - Guang-Sheng Lei
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, USA
| | - Jennifer Kedra
- Department of Pathology and Laboratory Medicine, Indiana University Health, Indianapolis, USA
| | - Chandy C John
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, USA
| |
Collapse
|
28
|
Mitigating SARS-CoV-2 Transmission in Hispanic and Latino Communities-Prince William Health District, Virginia, June 2020. J Racial Ethn Health Disparities 2021; 9:390-398. [PMID: 33543447 PMCID: PMC7860999 DOI: 10.1007/s40615-021-00968-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/11/2021] [Accepted: 01/12/2021] [Indexed: 11/08/2022]
Abstract
Objectives To identify factors contributing to disproportionate rates of COVID-19 among Hispanic or Latino persons in Prince William Health District, Virginia, and to identify measures to better engage Hispanic and Latino communities in COVID-19 mitigation. Methods Data collection proceeded via three methods in June 2020: a quantitative survey of Hispanic or Latino residents, key informant interviews with local leaders familiar with this population, and focus group discussions with Hispanic or Latino community members. Results Those who worked outside the home, lived in larger households, or lived with someone who had tested positive were more likely to report testing positive for SARS-CoV-2 (unadjusted odds ratios of 2.5, 1.2, and 12.9, respectively). Difficulty implementing COVID-19 prevention practices (reported by 46% of survey respondents), immigration-related fears (repeatedly identified in qualitative data), and limited awareness of local COVID-19 resources (57% of survey respondents spoke little or no English) were identified. Survey respondents also reported declines in their food security (25%) and mental health (25%). Conclusions Specific attention to the needs of Hispanic or Latino communities could help reduce the burden of COVID-19. The investigation methods can also be used by other jurisdictions to evaluate the needs of and services provided to diverse underserved populations.
Collapse
|
29
|
Tesoriero JM, Swain CAE, Pierce JL, Zamboni L, Wu M, Holtgrave DR, Gonzalez CJ, Udo T, Morne JE, Hart-Malloy R, Rajulu DT, Leung SYJ, Rosenberg ES. COVID-19 Outcomes Among Persons Living With or Without Diagnosed HIV Infection in New York State. JAMA Netw Open 2021; 4:e2037069. [PMID: 33533933 PMCID: PMC7859843 DOI: 10.1001/jamanetworkopen.2020.37069] [Citation(s) in RCA: 247] [Impact Index Per Article: 82.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 12/19/2020] [Indexed: 12/17/2022] Open
Abstract
Importance New York State has been an epicenter for both the US coronavirus disease 2019 (COVID-19) and HIV/AIDS epidemics. Persons living with diagnosed HIV may be more prone to COVID-19 infection and severe outcomes, yet few studies have assessed this possibility at a population level. Objective To evaluate the association between HIV diagnosis and COVID-19 diagnosis, hospitalization, and in-hospital death in New York State. Design, Setting, and Participants This cohort study, conducted in New York State, including New York City, between March 1 and June 15, 2020, matched data from HIV surveillance, COVID-19 laboratory-confirmed diagnoses, and hospitalization databases to provide a full population-level comparison of COVID-19 outcomes between persons living with diagnosed HIV and persons living without diagnosed HIV. Exposures Diagnosis of HIV infection through December 31, 2019. Main Outcomes and Measures The main outcomes were COVID-19 diagnosis, hospitalization, and in-hospital death. COVID-19 diagnoses, hospitalizations, and in-hospital death rates comparing persons living with diagnosed HIV with persons living without dianosed HIV were computed, with unadjusted rate ratios and indirect standardized rate ratios (sRR), adjusting for sex, age, and region. Adjusted rate ratios (aRRs) for outcomes specific to persons living with diagnosed HIV were assessed by age, sex, region, race/ethnicity, transmission risk, and CD4+ T-cell count-defined HIV disease stage, using Poisson regression models. Results A total of 2988 persons living with diagnosed HIV (2109 men [70.6%]; 2409 living in New York City [80.6%]; mean [SD] age, 54.0 [13.3] years) received a diagnosis of COVID-19. Of these persons living with diagnosed HIV, 896 were hospitalized and 207 died in the hospital through June 15, 2020. After standardization, persons living with diagnosed HIV and persons living without diagnosed HIV had similar diagnosis rates (sRR, 0.94 [95% CI, 0.91-0.97]), but persons living with diagnosed HIV were hospitalized more than persons living without diagnosed HIV, per population (sRR, 1.38 [95% CI, 1.29-1.47]) and among those diagnosed (sRR, 1.47 [95% CI, 1.37-1.56]). Elevated mortality among persons living with diagnosed HIV was observed per population (sRR, 1.23 [95% CI, 1.07-1.40]) and among those diagnosed (sRR, 1.30 [95% CI, 1.13-1.48]) but not among those hospitalized (sRR, 0.96 [95% CI, 0.83-1.09]). Among persons living with diagnosed HIV, non-Hispanic Black individuals (aRR, 1.59 [95% CI, 1.40-1.81]) and Hispanic individuals (aRR, 2.08 [95% CI, 1.83-2.37]) were more likely to receive a diagnosis of COVID-19 than White individuals, but they were not more likely to be hospitalized once they received a diagnosis or to die once hospitalized. Hospitalization risk increased with disease progression to HIV stage 2 (aRR, 1.29 [95% CI, 1.11-1.49]) and stage 3 (aRR, 1.69 [95% CI, 1.38-2.07]) relative to stage 1. Conclusions and Relevance In this cohort study, persons living with diagnosed HIV experienced poorer COVID-related outcomes relative to persons living without diagnosed HIV; Previous HIV diagnosis was associated with higher rates of severe disease requiring hospitalization, and hospitalization risk increased with progression of HIV disease stage.
Collapse
Affiliation(s)
- James M. Tesoriero
- New York State Department of Health, Albany
- Department of Health Policy Management and Behavior, University at Albany School of Public Health, State University of New York, Rensselaer
- Center for Collaborative HIV Research in Practice and Policy, University at Albany School of Public Health, State University of New York, Rensselaer
| | | | | | | | - Meng Wu
- New York State Department of Health, Albany
| | - David R. Holtgrave
- Department of Health Policy Management and Behavior, University at Albany School of Public Health, State University of New York, Rensselaer
- Center for Collaborative HIV Research in Practice and Policy, University at Albany School of Public Health, State University of New York, Rensselaer
| | | | - Tomoko Udo
- Department of Health Policy Management and Behavior, University at Albany School of Public Health, State University of New York, Rensselaer
- Center for Collaborative HIV Research in Practice and Policy, University at Albany School of Public Health, State University of New York, Rensselaer
| | - Johanne E. Morne
- New York State Department of Health, Albany
- Center for Collaborative HIV Research in Practice and Policy, University at Albany School of Public Health, State University of New York, Rensselaer
| | - Rachel Hart-Malloy
- New York State Department of Health, Albany
- Center for Collaborative HIV Research in Practice and Policy, University at Albany School of Public Health, State University of New York, Rensselaer
- Department of Epidemiology and Biostatistics, University at Albany School of Public Health, State University of New York, Rensselaer
| | | | | | - Eli S. Rosenberg
- Center for Collaborative HIV Research in Practice and Policy, University at Albany School of Public Health, State University of New York, Rensselaer
- Department of Epidemiology and Biostatistics, University at Albany School of Public Health, State University of New York, Rensselaer
| |
Collapse
|
30
|
Cardemil CV, Dahl R, Prill MM, Cates J, Brown S, Perea A, Marconi V, Bell L, Rodriguez-Barradas MC, Rivera-Dominguez G, Beenhouwer D, Poteshkina A, Holodniy M, Lucero-Obusan C, Balachandran N, Hall AJ, Kim L, Langley G. COVID-19-Related Hospitalization Rates and Severe Outcomes Among Veterans From 5 Veterans Affairs Medical Centers: Hospital-Based Surveillance Study. JMIR Public Health Surveill 2021; 7:e24502. [PMID: 33338028 PMCID: PMC7836907 DOI: 10.2196/24502] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 12/05/2020] [Accepted: 12/14/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND COVID-19 has disproportionately affected older adults and certain racial and ethnic groups in the United States. Data quantifying the disease burden, as well as describing clinical outcomes during hospitalization among these groups, are needed. OBJECTIVE We aimed to describe interim COVID-19 hospitalization rates and severe clinical outcomes by age group and race and ethnicity among US veterans by using a multisite surveillance network. METHODS We implemented a multisite COVID-19 surveillance platform in 5 Veterans Affairs Medical Centers located in Atlanta, Bronx, Houston, Palo Alto, and Los Angeles, collectively serving more than 396,000 patients annually. From February 27 to July 17, 2020, we actively identified inpatient cases with COVID-19 by screening admitted patients and reviewing their laboratory test results. We then manually abstracted the patients' medical charts for demographics, underlying medical conditions, and clinical outcomes. Furthermore, we calculated hospitalization incidence and incidence rate ratios, as well as relative risk for invasive mechanical ventilation, intensive care unit admission, and case fatality rate after adjusting for age, race and ethnicity, and underlying medical conditions. RESULTS We identified 621 laboratory-confirmed, hospitalized COVID-19 cases. The median age of the patients was 70 years, with 65.7% (408/621) aged ≥65 years and 94% (584/621) male. Most COVID-19 diagnoses were among non-Hispanic Black (325/621, 52.3%) veterans, followed by non-Hispanic White (153/621, 24.6%) and Hispanic or Latino (112/621, 18%) veterans. Hospitalization rates were the highest among veterans who were ≥85 years old, Hispanic or Latino, and non-Hispanic Black (430, 317, and 298 per 100,000, respectively). Veterans aged ≥85 years had a 14-fold increased rate of hospitalization compared with those aged 18-29 years (95% CI: 5.7-34.6), whereas Hispanic or Latino and Black veterans had a 4.6- and 4.2-fold increased rate of hospitalization, respectively, compared with non-Hispanic White veterans (95% CI: 3.6-5.9). Overall, 11.6% (72/621) of the patients required invasive mechanical ventilation, 26.6% (165/621) were admitted to the intensive care unit, and 16.9% (105/621) died in the hospital. The adjusted relative risk for invasive mechanical ventilation and admission to the intensive care unit did not differ by age group or race and ethnicity, but veterans aged ≥65 years had a 4.5-fold increased risk of death while hospitalized with COVID-19 compared with those aged <65 years (95% CI: 2.4-8.6). CONCLUSIONS COVID-19 surveillance at the 5 Veterans Affairs Medical Centers across the United States demonstrated higher hospitalization rates and severe outcomes among older veterans, as well as higher hospitalization rates among Hispanic or Latino and non-Hispanic Black veterans than among non-Hispanic White veterans. These findings highlight the need for targeted prevention and timely treatment for veterans, with special attention to older aged, Hispanic or Latino, and non-Hispanic Black veterans.
Collapse
Affiliation(s)
- Cristina V Cardemil
- Centers for Disease Control and Prevention, Atlanta, GA, United States.,United States Public Health Service, Rockville, MD, United States
| | - Rebecca Dahl
- Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Mila M Prill
- Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Jordan Cates
- Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Sheldon Brown
- James J. Peters VA Medical Center, New York, NY, United States.,Icahn School of Medicine at Mt. Sinai, New York, NY, United States
| | - Adrienne Perea
- James J. Peters VA Medical Center, New York, NY, United States
| | - Vincent Marconi
- Atlanta VA Medical Center, Atlanta, GA, United States.,Emory University School of Medicine, Atlanta, GA, United States.,Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - LaSara Bell
- Atlanta VA Medical Center, Atlanta, GA, United States
| | - Maria C Rodriguez-Barradas
- Infectious Diseases Section, Department of Medicine, Baylor College of Medicine, Houston, TX, United States.,Michael E. DeBakey VA Medical Center, Houston, TX, United States
| | - Gilberto Rivera-Dominguez
- Infectious Diseases Section, Department of Medicine, Baylor College of Medicine, Houston, TX, United States.,Michael E. DeBakey VA Medical Center, Houston, TX, United States
| | - David Beenhouwer
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States.,David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | | | - Mark Holodniy
- Public Health Surveillance and Research, Department of Veterans Affairs, Washington, DC, United States.,VA Palo Alto Health Care System, Palo Alto, CA, United States.,Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, United States
| | - Cynthia Lucero-Obusan
- Public Health Surveillance and Research, Department of Veterans Affairs, Washington, DC, United States.,VA Palo Alto Health Care System, Palo Alto, CA, United States
| | - Neha Balachandran
- Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Aron J Hall
- Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Lindsay Kim
- Centers for Disease Control and Prevention, Atlanta, GA, United States.,United States Public Health Service, Rockville, MD, United States
| | - Gayle Langley
- Centers for Disease Control and Prevention, Atlanta, GA, United States
| |
Collapse
|
31
|
Noel-London KC, Grimsley C, Porter J, Breitbach AP. "The Tip of the Iceberg": Commentary on Sports, Health Inequity, and Trauma Exacerbated by COVID-19. J Athl Train 2021; 56:5-10. [PMID: 33290542 DOI: 10.4085/1062-6050-0350.20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To discuss the relevance of system-level health inequities and their interplay with race in sports and athletic training, particularly during and after the coronavirus disease 2019 (COVID-19) pandemic. BACKGROUND Health inequity is a systemic and longstanding concern with dire consequences that can have marked effects on the lives of minority patients. As a result of the unequal consequences of the COVID-19 pandemic, the magnitude of the outcomes from health inequity in all spheres of American health care is being brought to the fore. The discourse within athletic training practice and policy must shift to intentionally creating strategies that acknowledge and account for systemic health inequities in order to facilitate an informed, evidence-based, and safe return to sport within the new normal. CONCLUSIONS To continue to evolve the profession and solidify athletic trainers' role in public health spaces post-COVID-19, professionals at all levels of athletic training practice and policy must intentionally create strategies that acknowledge and account for not only the social determinants of health but also the effects of racism and childhood trauma on overall health and well-being.
Collapse
Affiliation(s)
| | | | | | - Anthony P Breitbach
- Department of Physical Therapy and Athletic Training, Saint Louis University, MO
| |
Collapse
|
32
|
Sarmadi M, Moghanddam VK, Dickerson AS, Martelletti L. Association of COVID-19 distribution with air quality, sociodemographic factors, and comorbidities: an ecological study of US states. AIR QUALITY, ATMOSPHERE, & HEALTH 2021; 14:455-465. [PMID: 33078068 PMCID: PMC7556602 DOI: 10.1007/s11869-020-00949-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 09/29/2020] [Indexed: 05/18/2023]
Abstract
This ecological study investigated the association between COVID-19 distribution and air quality index (AQI), comorbidities and sociodemographic factors in the USA. The AQI factors included in the study are total AQI, ozone, carbon monoxide, sulfur dioxide, and nitrogen dioxide (NO2). Other demographic, socioeconomic, and geographic variables were included as covariates. The correlations of COVID-19 variables-proportion of cases and deaths in each population, as well as case fatality rate with independent variables were determined by Pearson and Spearman correlation and multiple linear regression analyses. The results revealed that AQI-NO2, population density, longitude, gross domestic product per capita, median age, total death of disease, and pneumonia per population were significantly associated with the COVID-19 variables (P < 0.05). Air pollutants, especially NO2 in the US case, could be addressed as an important factor linked with COVID-19 susceptibility and mortality.
Collapse
Affiliation(s)
- Mohammad Sarmadi
- Department of Environmental Health Engineering, School of Health, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran
- Health Sciences Research Center, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran
| | - Vahid Kazemi Moghanddam
- Department of Environmental Health Engineering, Neyshabur University of Medical Sciences, Neyshabur, Iran
| | - Aisha S. Dickerson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Luigi Martelletti
- Energy and Environmental Technology and Economics, City University of London, London, UK
| |
Collapse
|
33
|
Kavecansky J, Dusendang JR, Tavakoli J, Schmittdiel J, Ho G, Loyles J, Pai A. Association of anticoagulation use with SARS-CoV2 detection. Thromb Res 2020; 198:99-102. [PMID: 33310348 PMCID: PMC7709610 DOI: 10.1016/j.thromres.2020.11.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 09/27/2020] [Accepted: 11/23/2020] [Indexed: 12/30/2022]
Abstract
Patients who warrant chronic warfarin can safely continue warfarin therapy with precautions during the COVID-19 pandemic. Chronic warfarin therapy is not associated with a higher rate of positively testing for SAR-CoV2. Patients on warfarin during the COVID-19 pandemic maintained TTR rates consistent with those prior to the COVID-19 pandemic.
Collapse
Affiliation(s)
| | | | - Jahan Tavakoli
- Kaiser Permanente, San Francisco, CA, United States of America
| | - Julie Schmittdiel
- Kaiser Permanente, Division of Research, Oakland, CA, United States of America
| | - Gwendolyn Ho
- Kaiser Permanente, Sacramento, CA, United States of America
| | - Jodi Loyles
- Kaiser Permanente, Pharmacy Services, Oakland, CA, United States of America
| | - Ashok Pai
- Kaiser Permanente, Oakland, CA, United States of America
| |
Collapse
|
34
|
Pickell Z, Gu K, Williams AM. Virtual volunteers: the importance of restructuring medical volunteering during the COVID-19 pandemic. MEDICAL HUMANITIES 2020; 46:537-540. [PMID: 32820042 PMCID: PMC7445098 DOI: 10.1136/medhum-2020-011956] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/20/2020] [Indexed: 05/05/2023]
Abstract
Healthcare systems have postponed medical volunteering services in response to the COVID-19 pandemic. However, much of the aid provided by these volunteers is crucial to patient care and hospital functioning in the American healthcare system. The adoption of online video conferencing platforms in healthcare-telehealth-offers a novel solution for volunteering during this pandemic. Virtual volunteering can alleviate pressures on medical workers, enhance patient experiences, reduce the risk of viral infection and provide a sense of normalcy for patients and families. Although further study is required, this should be an avenue considered by health systems.
Collapse
Affiliation(s)
- Zachary Pickell
- Department of Biology, University of Michigan, College of Literature Science and the Arts, Ann Arbor, Michigan, USA
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Kathleen Gu
- Department of Biology, University of Michigan, College of Literature Science and the Arts, Ann Arbor, Michigan, USA
| | - Aaron M Williams
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
| |
Collapse
|
35
|
Mihalopoulos C, Chatterton ML, Engel L, Le LKD, Lee YY. Whither economic evaluation in the case of COVID-19: What can the field of mental health economics contribute within the Australian context? Aust N Z J Psychiatry 2020; 54:1157-1161. [PMID: 33008268 DOI: 10.1177/0004867420963724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
COVID-19 has resulted in broad impacts on the economy and aspects of daily life including our collective mental health and well-being. The Australian health care system already faces limitations in its ability to treat people with mental health diagnoses. Australia has responded to the COVID-19 outbreak by, among other initiatives, providing reimbursement for telehealth services. However, it is unclear if these measures will be enough to manage the psychological distress, depression, anxiety and post-traumatic distress shown to accompany infectious disease outbreaks and economic shocks. Decision making has focused on the physical health ramifications of COVID-19, the avoidance of over-burdening the health care system and saving lives. We propose an alternative framework for decision making that combines life years saved with impacts on quality of life. A framework that simultaneously includes mental health and broader economic impacts into a single decision-making process would facilitate transparent and accountable decision making that can improve the overall welfare of Australian society as we continue to address the considerable challenges that the COVID-19 pandemic is creating.
Collapse
Affiliation(s)
- Cathrine Mihalopoulos
- Deakin Health Economics, Institute for Health Transformation, Deakin University, Burwood, VIC, Australia
| | - Mary Lou Chatterton
- Deakin Health Economics, Institute for Health Transformation, Deakin University, Burwood, VIC, Australia
| | - Lidia Engel
- Deakin Health Economics, Institute for Health Transformation, Deakin University, Burwood, VIC, Australia
| | - Long Khanh-Dao Le
- Deakin Health Economics, Institute for Health Transformation, Deakin University, Burwood, VIC, Australia
| | - Yong Yi Lee
- Deakin Health Economics, Institute for Health Transformation, Deakin University, Burwood, VIC, Australia
| |
Collapse
|
36
|
Rosenthal N, Cao Z, Gundrum J, Sianis J, Safo S. Risk Factors Associated With In-Hospital Mortality in a US National Sample of Patients With COVID-19. JAMA Netw Open 2020; 3:e2029058. [PMID: 33301018 PMCID: PMC7729428 DOI: 10.1001/jamanetworkopen.2020.29058] [Citation(s) in RCA: 316] [Impact Index Per Article: 79.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
IMPORTANCE Coronavirus disease 2019 (COVID-19) has infected more than 8.1 million US residents and killed more than 221 000. There is a dearth of research on epidemiology and clinical outcomes in US patients with COVID-19. OBJECTIVES To characterize patients with COVID-19 treated in US hospitals and to examine risk factors associated with in-hospital mortality. DESIGN, SETTING, AND PARTICIPANTS This cohort study was conducted using Premier Healthcare Database, a large geographically diverse all-payer hospital administrative database including 592 acute care hospitals in the United States. Inpatient and hospital-based outpatient visits with a principal or secondary discharge diagnosis of COVID-19 (International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis code, U07.1) between April 1 and May 31, 2020, were included. EXPOSURES Characteristics of patients were reported by inpatient/outpatient and survival status. Risk factors associated with death examined included patient characteristics, acute complications, comorbidities, and medications. MAIN OUTCOMES AND MEASURES In-hospital mortality, intensive care unit (ICU) admission, use of invasive mechanical ventilation, total hospital length of stay (LOS), ICU LOS, acute complications, and treatment patterns. RESULTS Overall, 64 781 patients with COVID-19 (29 479 [45.5%] outpatients; 35 302 [54.5%] inpatients) were analyzed. The median (interquartile range [IQR]) age was 46 (33-59) years for outpatients and 65 (52-77) years for inpatients; 31 968 (49.3%) were men, 25 841 (39.9%) were White US residents, and 14 340 (22.1%) were Black US residents. In-hospital mortality was 20.3% among inpatients (7164 patients). A total of 5625 inpatients (15.9%) received invasive mechanical ventilation, and 6849 (19.4%) were admitted to the ICU. Median (IQR) inpatient LOS was 6 (3-10) days. Median (IQR) ICU LOS was 5 (2-10) days. Common acute complications among inpatients included acute respiratory failure (19 706 [55.8%]), acute kidney failure (11 971 [33.9%]), and sepsis (11 910 [33.7%]). Older age was the risk factor most strongly associated with death (eg, age ≥80 years vs 18-34 years: odds ratio [OR], 16.20; 95% CI, 11.58-22.67; P < .001). Receipt of statins (OR, 0.60; 95% CI, 0.56-0.65; P < .001), angiotensin-converting enzyme inhibitors (OR, 0.53; 95% CI, 0.46-0.60; P < .001), and calcium channel blockers (OR, 0.73; 95% CI, 0.68-0.79; P < .001) was associated with decreased odds of death. Compared with patients with no hydroxychloroquine or azithromycin, patients with both azithromycin and hydroxychloroquine had increased odds of death (OR, 1.21; 95% CI, 1.11-1.31; P < .001). CONCLUSIONS AND RELEVANCE In this cohort study of patients with COVID-19 infection in US acute care hospitals, COVID-19 was associated with high ICU admission and in-hospital mortality rates. Use of statins, angiotensin-converting enzyme inhibitors, and calcium channel blockers were associated with decreased odds of death. Understanding the potential benefits of unproven treatments will require future randomized trials.
Collapse
Affiliation(s)
- Ning Rosenthal
- Premier Applied Sciences, Premier Inc, Charlotte, North Carolina
| | - Zhun Cao
- Premier Applied Sciences, Premier Inc, Charlotte, North Carolina
| | - Jake Gundrum
- Premier Applied Sciences, Premier Inc, Charlotte, North Carolina
| | - Jim Sianis
- Premier Applied Sciences, Premier Inc, Charlotte, North Carolina
| | - Stella Safo
- Premier Applied Sciences, Premier Inc, Charlotte, North Carolina
| |
Collapse
|
37
|
Tesoriero JM, Swain CAE, Pierce JL, Zamboni L, Wu M, Holtgrave DR, Gonzalez CJ, Udo T, Morne JE, Hart-Malloy R, Rajulu DT, Leung SYJ, Rosenberg ES. Elevated COVID-19 outcomes among persons living with diagnosed HIV infection in New York State: Results from a population-level match of HIV, COVID-19, and hospitalization databases. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2020. [PMID: 33173901 DOI: 10.1101/2020.11.04.20226118] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND New York State (NYS) has been an epicenter for both COVID-19 and HIV/AIDS epidemics. Persons Living with diagnosed HIV (PLWDH) may be more prone to COVID-19 infection and severe outcomes, yet few population-based studies have assessed the extent to which PLWDH are diagnosed, hospitalized, and have died with COVID-19, relative to non-PLWDH. METHODS NYS HIV surveillance, COVID-19 laboratory confirmed diagnoses, and hospitalization databases were matched. COVID-19 diagnoses, hospitalization, and in-hospital death rates comparing PLWDH to non-PLWDH were computed, with unadjusted rate ratios (RR) and indirect standardized RR (sRR), adjusting for sex, age, and region. Adjusted RR (aRR) for outcomes among PLWDH were assessed by age/CD4-defined HIV disease stage, and viral load suppression, using Poisson regression models. RESULTS From March 1-June 7, 2020, PLWDH were more frequently diagnosed with COVID-19 than non-PLWDH in unadjusted (RR [95% confidence interval (CI)]: 1.43[1.38-1.48), 2,988 PLWDH], but not in adjusted comparisons (sRR [95% CI]: 0.94[0.91-0.97]). Per-population COVID-19 hospitalization was higher among PLWDH (RR [95% CI]: 2.61[2.45-2.79], sRR [95% CI]: 1.38[1.29-1.47], 896 PLWDH), as was in-hospital death (RR [95% CI]: 2.55[2.22-2.93], sRR [95%CI]: 1.23 [1.07-1.40], 207 PLWDH), albeit not among those hospitalized (sRR [95% CI]: 0.96[0.83-1.09]). Among PLWDH, hospitalization risk increased with disease progression from HIV Stage 1 to Stage 2 (aRR [95% CI]:1.27[1.09-1.47]) and Stage 3 (aRR [95% CI]: 1.54[1.24-1.91]), and for those virally unsuppressed (aRR [95% CI]: 1.54[1.24-1.91]). CONCLUSION PLWDH experienced poorer COVID-related outcomes relative to non-PLWDH, with 1-in-522 PLWDH dying with COVID-19, seemingly driven by higher rates of severe disease requiring hospitalization.
Collapse
|
38
|
An Ecologic Study of Disparities in COVID-19 Incidence and Case Fatality in Oakland County, MI, USA, During a State-Mandated Shutdown. J Racial Ethn Health Disparities 2020; 8:1467-1474. [PMID: 33124003 PMCID: PMC7595050 DOI: 10.1007/s40615-020-00909-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 10/22/2020] [Accepted: 10/23/2020] [Indexed: 12/16/2022]
Abstract
Introduction Data from the USA reveal disparities in hospitalization and mortality from coronavirus disease 2019 (COVID-19). Social determinants of health (SDoH) could account for disparities in disease incidence and outcomes. We investigated the association between zip code racial composition and COVID-19 incidence and case fatality in Oakland County, MI. Methods We conducted an ecological study using publicly available data on COVID-19 in 70 zip codes in Oakland County, MI. We obtained demographic surrogate markers of SDoH by zip code from the US Census Bureau website. Using negative binomial regression models, we investigated the association between the percentage of Blacks in each zip code and COVID-19 incidence and case fatality, including markers of SDoH as potential confounders. Results Reported COVID-19 cases ranged from 13.2 to 255.2 per 10,000 population. Each percentage increase in Blacks within a zip code was associated with a 3% increase in COVID-19 cases (95% CI: 1.02 to 1.04, p ≤ 0.0001), and this remained significant after adjusting for income or poverty level, number of persons per household, mode of transportation, age, and level of education (incidence rate ratio: 1.02, 95% CI: 1.01 to 1.03, p ≤ 0.0001). Zip codes with a higher percentage of Blacks also experienced a faster increase in COVID-19 rates from April 3 to May 16. However, the proportion of Blacks in a zip code was not associated with case fatality. Conclusion Zip codes with larger Black populations were disproportionately affected by COVID-19. Supplementary Information The online version contains supplementary material available at 10.1007/s40615-020-00909-1.
Collapse
|
39
|
Poulson M, Neufeld M, Geary A, Kenzik K, Sanchez SE, Dechert T, Kimball S. Intersectional Disparities Among Hispanic Groups in COVID-19 Outcomes. J Immigr Minor Health 2020; 23:4-10. [PMID: 33090300 PMCID: PMC7579850 DOI: 10.1007/s10903-020-01111-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2020] [Indexed: 01/03/2023]
Abstract
Previous geographically limited studies have shown differential impact of COVID-19 on Hispanic individuals. Data were obtained from the Centers for Disease Control and Prevention. We performed multivariate Poisson regression assessing risk of hospitalization and death in Hispanic White (HW), Hispanic Black (HB), and Hispanic Multiracial/Other (HM) groups compared to non-Hispanic Whites (NHW). The relative risk of hospitalization was 1.35, 1.58, and 1.50 (p < 0.001) for HW, HB, and HM individuals respectively when compared to NHW. Relative risk of death was 1.36, 1.72, 1.68 (p < 0.001) times higher in HW, HB, and HM compared to NHW. HW, HB, and HM individuals also had significantly increased risk of requiring mechanical ventilation and ICU admission when compared to NHW. Hispanic individuals are more likely to be hospitalized and die from COVID-19 infection than White, which underscores the need for more precise data and policies aimed at unique Hispanic groups to decrease disparities.
Collapse
Affiliation(s)
- Michael Poulson
- Department of Surgery, Boston Medical Center, Boston, USA.,Boston University School of Medicine, Boston, USA
| | - Miriam Neufeld
- Department of Surgery, Boston Medical Center, Boston, USA.,Boston University School of Medicine, Boston, USA
| | - Alaina Geary
- Department of Surgery, Boston Medical Center, Boston, USA.,Boston University School of Medicine, Boston, USA
| | - Kelly Kenzik
- Department of Surgery, Boston Medical Center, Boston, USA.,Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sabrina E Sanchez
- Department of Surgery, Boston Medical Center, Boston, USA.,Boston University School of Medicine, Boston, USA
| | - Tracey Dechert
- Department of Surgery, Boston Medical Center, Boston, USA.,Boston University School of Medicine, Boston, USA
| | - Sarah Kimball
- Boston University School of Medicine, Boston, USA. .,Immigrant and Refugee Health Center, Boston Medical Center, 801 Massachusetts Ave, 6th Floor, Boston, MA, 02119, USA.
| |
Collapse
|
40
|
Trinh-Shevrin C. Applying a Population Health Equity Framework in the Clinical Setting-Incorporating Social and Behavioral Determinants of Health Into Estimations of Risk. JAMA Netw Open 2020; 3:e2021771. [PMID: 33079193 PMCID: PMC8628362 DOI: 10.1001/jamanetworkopen.2020.21771] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Chau Trinh-Shevrin
- Department of Population Health, NYU Grossman School of Medicine, New York, New York
| |
Collapse
|
41
|
Ioannou GN, Locke E, Green P, Berry K, O’Hare AM, Shah JA, Crothers K, Eastment MC, Dominitz JA, Fan VS. Risk Factors for Hospitalization, Mechanical Ventilation, or Death Among 10 131 US Veterans With SARS-CoV-2 Infection. JAMA Netw Open 2020; 3:e2022310. [PMID: 32965502 PMCID: PMC7512055 DOI: 10.1001/jamanetworkopen.2020.22310] [Citation(s) in RCA: 259] [Impact Index Per Article: 64.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 08/18/2020] [Indexed: 01/08/2023] Open
Abstract
Importance Identifying independent risk factors for adverse outcomes in patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can support prognostication, resource utilization, and treatment. Objective To identify excess risk and risk factors associated with hospitalization, mechanical ventilation, and mortality in patients with SARS-CoV-2 infection. Design, Setting, and Participants This longitudinal cohort study included 88 747 patients tested for SARS-CoV-2 nucleic acid by polymerase chain reaction between Feburary 28 and May 14, 2020, and followed up through June 22, 2020, in the Department of Veterans Affairs (VA) national health care system, including 10 131 patients (11.4%) who tested positive. Exposures Sociodemographic characteristics, comorbid conditions, symptoms, and laboratory test results. Main Outcomes and Measures Risk of hospitalization, mechanical ventilation, and death were estimated in time-to-event analyses using Cox proportional hazards models. Results The 10 131 veterans with SARS-CoV-2 were predominantly male (9221 [91.0%]), with diverse race/ethnicity (5022 [49.6%] White, 4215 [41.6%] Black, and 944 [9.3%] Hispanic) and a mean (SD) age of 63.6 (16.2) years. Compared with patients who tested negative for SARS-CoV-2, those who tested positive had higher rates of 30-day hospitalization (30.4% vs 29.3%; adjusted hazard ratio [aHR], 1.13; 95% CI, 1.08-1.13), mechanical ventilation (6.7% vs 1.7%; aHR, 4.15; 95% CI, 3.74-4.61), and death (10.8% vs 2.4%; aHR, 4.44; 95% CI, 4.07-4.83). Among patients who tested positive for SARS-CoV-2, characteristics significantly associated with mortality included older age (eg, ≥80 years vs <50 years: aHR, 60.80; 95% CI, 29.67-124.61), high regional COVID-19 disease burden (eg, ≥700 vs <130 deaths per 1 million residents: aHR, 1.21; 95% CI, 1.02-1.45), higher Charlson comorbidity index score (eg, ≥5 vs 0: aHR, 1.93; 95% CI, 1.54-2.42), fever (aHR, 1.51; 95% CI, 1.32-1.72), dyspnea (aHR, 1.78; 95% CI, 1.53-2.07), and abnormalities in the certain blood tests, which exhibited dose-response associations with mortality, including aspartate aminotransferase (>89 U/L vs ≤25 U/L: aHR, 1.86; 95% CI, 1.35-2.57), creatinine (>3.80 mg/dL vs 0.98 mg/dL: aHR, 3.79; 95% CI, 2.62-5.48), and neutrophil to lymphocyte ratio (>12.70 vs ≤2.71: aHR, 2.88; 95% CI, 2.12-3.91). With the exception of geographic region, the same covariates were independently associated with mechanical ventilation along with Black race (aHR, 1.52; 95% CI, 1.25-1.85), male sex (aHR, 2.07; 95% CI, 1.30-3.32), diabetes (aHR, 1.40; 95% CI, 1.18-1.67), and hypertension (aHR, 1.30; 95% CI, 1.03-1.64). Notable characteristics that were not significantly associated with mortality in adjusted analyses included obesity (body mass index ≥35 vs 18.5-24.9: aHR, 0.97; 95% CI, 0.77-1.21), Black race (aHR, 1.04; 95% CI, 0.88-1.21), Hispanic ethnicity (aHR, 1.03; 95% CI, 0.79-1.35), chronic obstructive pulmonary disease (aHR, 1.02; 95% CI, 0.88-1.19), hypertension (aHR, 0.95; 95% CI, 0.81-1.12), and smoking (eg, current vs never: aHR, 0.87; 95% CI, 0.67-1.13). Most deaths in this cohort occurred in patients with age of 50 years or older (63.4%), male sex (12.3%), and Charlson Comorbidity Index score of at least 1 (11.1%). Conclusions and Relevance In this national cohort of VA patients, most SARS-CoV-2 deaths were associated with older age, male sex, and comorbidity burden. Many factors previously reported to be associated with mortality in smaller studies were not confirmed, such as obesity, Black race, Hispanic ethnicity, chronic obstructive pulmonary disease, hypertension, and smoking.
Collapse
Affiliation(s)
- George N. Ioannou
- Division of Gastroenterology, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle
| | - Emily Locke
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Pamela Green
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Kristin Berry
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Ann M. O’Hare
- Division of Nephrology, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle
| | - Javeed A. Shah
- Division of Allergy and Infectious Disease, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle
| | - Kristina Crothers
- Division of Pulmonary and Critical Care, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle
| | - McKenna C. Eastment
- Division of Allergy and Infectious Disease, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle
| | - Jason A. Dominitz
- Division of Gastroenterology, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle
| | - Vincent S. Fan
- Division of Pulmonary and Critical Care, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle
| |
Collapse
|
42
|
Urashima M, Otani K, Hasegawa Y, Akutsu T. BCG Vaccination and Mortality of COVID-19 across 173 Countries: An Ecological Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E5589. [PMID: 32756371 PMCID: PMC7432030 DOI: 10.3390/ijerph17155589] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 07/24/2020] [Accepted: 07/31/2020] [Indexed: 12/20/2022]
Abstract
Ecological studies have suggested fewer COVID-19 morbidities and mortalities in Bacillus Calmette-Guérin (BCG)-vaccinated countries than BCG-non-vaccinated countries. However, these studies obtained data during the early phase of the pandemic and did not adjust for potential confounders, including PCR-test numbers per population (PCR-tests). Currently-more than four months after declaration of the pandemic-the BCG-hypothesis needs reexamining. An ecological study was conducted by obtaining data of 61 factors in 173 countries, including BCG vaccine coverage (%), using morbidity and mortality as outcomes, obtained from open resources. 'Urban population (%)' and 'insufficient physical activity (%)' in each country was positively associated with morbidity, but not mortality, after adjustment for PCR-tests. On the other hand, recent BCG vaccine coverage (%) was negatively associated with mortality, but not morbidity, even with adjustment for percentage of the population ≥ 60 years of age, morbidity, PCR-tests and other factors. The results of this study generated a hypothesis that a national BCG vaccination program seems to be associated with reduced mortality of COVID-19, although this needs to be further examined and proved by randomized clinical trials.
Collapse
Affiliation(s)
- Mitsuyoshi Urashima
- Division of Molecular Epidemiology, The Jikei University School of Medicine, Tokyo 105-8461, Japan; (K.O.); (Y.H.); (T.A.)
| | - Katharina Otani
- Division of Molecular Epidemiology, The Jikei University School of Medicine, Tokyo 105-8461, Japan; (K.O.); (Y.H.); (T.A.)
- Advanced Therapies Innovation Department, Siemens Healthcare K.K., Tokyo 141-8644, Japan
| | - Yasutaka Hasegawa
- Division of Molecular Epidemiology, The Jikei University School of Medicine, Tokyo 105-8461, Japan; (K.O.); (Y.H.); (T.A.)
- Hitachi, Ltd. Research & Development Group, Tokyo 185-8601, Japan
| | - Taisuke Akutsu
- Division of Molecular Epidemiology, The Jikei University School of Medicine, Tokyo 105-8461, Japan; (K.O.); (Y.H.); (T.A.)
| |
Collapse
|
43
|
Mendy A, Apewokin S, Wells AA, Morrow AL. Factors Associated with Hospitalization and Disease Severity in a Racially and Ethnically Diverse Population of COVID-19 Patients. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2020. [PMID: 32607513 DOI: 10.1101/2020.06.25.20137323] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND The coronavirus disease (COVID-19) first identified in Wuhan in December 2019 became a pandemic within a few months of its discovery. The impact of COVID-19 is due to both its rapid spread and its severity, but the determinants of severity have not been fully delineated. OBJECTIVE Identify factors associated with hospitalization and disease severity in a racially and ethnically diverse cohort of COVID-19 patients. METHODS We analyzed data from COVID-19 patients diagnosed at the University of Cincinnati health system from March 13, 2020 to May 31, 2020. Severe COVID-19 was defined as admission to intensive care unit or death. Logistic regression modeling adjusted for covariates was used to identify the factors associated with hospitalization and severe COVID-19. RESULTS Among the 689 COVID-19 patients included in our study, 29.2% were non-Hispanic White, 25.5% were non-Hispanic Black, 32.5% were Hispanic, and 12.8% were of other race/ethnicity. About 31.3% of patients were hospitalized and 13.2% had severe disease. In adjusted analyses, the sociodemographic factors associated with hospitalization and/or disease severity included older age, non-Hispanic Black or Hispanic race/ethnicity (compared to non-Hispanic White), and smoking. The following comorbidities: diabetes, hypercholesterolemia, asthma, COPD, chronic kidney disease, cardiovascular diseases, osteoarthritis, and vitamin D deficiency were associated with hospitalization and/or disease severity. Hematological disorders such as anemia, coagulation disorders, and thrombocytopenia were associated with both hospitalization and disease severity. CONCLUSION This study confirms race and ethnicity as predictors of severe COVID-19. It also finds clinical risk factors for hospitalization and severe COVID-19 not previously identified such a vitamin D deficiency, hypercholesterolemia, osteoarthritis, and anemia.
Collapse
|
44
|
Gu T, Mack JA, Salvatore M, Sankar SP, Valley TS, Singh K, Nallamothu BK, Kheterpal S, Lisabeth L, Fritsche LG, Mukherjee B. COVID-19 outcomes, risk factors and associations by race: a comprehensive analysis using electronic health records data in Michigan Medicine. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2020:2020.06.16.20133140. [PMID: 32793920 PMCID: PMC7418735 DOI: 10.1101/2020.06.16.20133140] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
IMPORTANCE Blacks/African-Americans are overrepresented in the number of COVID-19 infections, hospitalizations and deaths. Reasons for this disparity have not been well-characterized but may be due to underlying comorbidities or sociodemographic factors. OBJECTIVE To systematically determine patient characteristics associated with racial/ethnic disparities in COVID-19 outcomes. DESIGN A retrospective cohort study with comparative control groups. SETTING Patients tested for COVID-19 at University of Michigan Medicine from March 10, 2020 to April 22, 2020. PARTICIPANTS 5,698 tested patients and two sets of comparison groups who were not tested for COVID-19: randomly selected unmatched controls (n = 7,211) and frequency-matched controls by race, age, and sex (n = 13,351). Main Outcomes and Measures: We identified factors associated with testing and testing positive for COVID-19, being hospitalized, requiring intensive care unit (ICU) admission, and mortality (in/out-patient during the time frame). Factors included race/ethnicity, age, smoking, alcohol consumption, healthcare utilization, and residential-level socioeconomic characteristics (SES; i.e., education, unemployment, population density, and poverty rate). Medical comorbidities were defined from the International Classification of Diseases (ICD) codes, and were aggregated into a comorbidity score. RESULTS Of 5,698 patients, (median age, 47 years; 38% male; mean BMI, 30.1), the majority were non-Hispanic Whites (NHW, 59.2%) and non-Hispanic Black/African-Americans (NHAA, 17.2%). Among 1,119 diagnosed, there were 41.2% NHW and 37.4% NHAA; 44.8% hospitalized, 20.6% admitted to ICU, and 3.8% died. Adjusting for age, sex, and SES, NHAA were 1.66 times more likely to be hospitalized (95% CI, 1.09-2.52; P=.02), 1.52 times more likely to enter ICU (95% CI, 0.92-2.52; P=.10). In addition to older age, male sex and obesity, high population density neighborhood (OR, 1.27 associated with one SD change [95% CI, 1.20-1.76]; P=.02) was associated with hospitalization. Pre-existing kidney disease led to 2.55 times higher risk of hospitalization (95% CI, 1.62-4.02; P<.001) in the overall population and 11.9 times higher mortality risk in NHAA (95% CI, 2.2-64.7, P=.004). CONCLUSIONS AND RELEVANCE Pre-existing type II diabetes/kidney diseases and living in high population density areas were associated with high risk for COVID-19 susceptibility and poor prognosis. Association of risk factors with COVID-19 outcomes differed by race. NHAA patients were disproportionately affected by obesity and kidney disease.
Collapse
Affiliation(s)
- Tian Gu
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI
| | - Jasmine A. Mack
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI
| | - Maxwell Salvatore
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI
| | - Swaraaj Prabhu Sankar
- Rogel Cancer Center, University of Michigan Medicine, Ann Arbor, MI
- Data Office for Clinical and Translational Research, University of Michigan, Ann Arbor, MI
| | - Thomas S. Valley
- Division of Pulmonary and Critical Care Medicine and Department of Internal Medicine, University of Michigan, Ann Arbor, MI
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - Karandeep Singh
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI
| | - Brahmajee K. Nallamothu
- Division of Cardiovascular Medicine and Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Sachin Kheterpal
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI
| | - Lynda Lisabeth
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI
| | - Lars G. Fritsche
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI
- Rogel Cancer Center, University of Michigan Medicine, Ann Arbor, MI
- Center for Statistical Genetics, University of Michigan School of Public Health, Ann Arbor, MI
| | - Bhramar Mukherjee
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI
- Rogel Cancer Center, University of Michigan Medicine, Ann Arbor, MI
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI
| |
Collapse
|