Diseases with health disparities as drivers of COVID-19 outcome

The Relationship Between Pre-Pandemic Comorbidities With SARS-CoV-2 Infections and Hospitalizations in Black Versus White Military Service Members: A Retrospective Study

INTRODUCTION

Comorbidities such as hypertension, diabetes mellitus, asthma, and cardiovascular conditions have been reported to worsen the clinical progression of coronavirus disease 2019 (COVID-19) and related hospitalizations. Furthermore, the COVID-19 pandemic has disproportionately affected the historically marginalized groups, i.e., Black, Hispanic, and Asian individuals have substantially higher rates of Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) infection, COVID-19 hospitalization, and death compared to White individuals. Despite these findings in civilian populations, the impact of comorbidities and race in SARS-CoV-2 infection and COVID-19 hospitalizations in military populations is unknown. We evaluated the relationship of pre-selected pre-pandemic comorbidities and race with SARS-CoV-2 infections and COVID-19 hospitalizations in U.S. military service members (SMs).

MATERIALS AND METHODS

We conducted a systematic review of Military Health System beneficiaries' records by accessing the Defense Medical Epidemiological Database. Our inclusion criteria were being an active duty SM and having at least one pre-COVID-19 pandemic comorbidity. Retired as well as uninfected healthy active duty SMs and beneficiaries were excluded from the study. A total population of 1.334 million active duty SM records was drawn from Defense Medical Epidemiological Database. The data were stratified, by race (primary outcome), as well as gender, age, and military service branches (secondary outcomes).

RESULTS

We found higher trends in SARS-CoV-2 infection and COVID-19 hospitalization rates in Black compared to White SMs. This seamless inequality was also seen in other viral infections affecting SMs including human immunodeficiency virus and viral hepatitis. We hypothesized this disparity to some extent be associated with the presence of pre-pandemic comorbidities that is affecting this military subpopulation. Supporting our hypothesis, we found trends toward the higher pre-pandemic prevalence of diabetes mellitus, asthma, hypertension, and ischemic heart disease, in Black compared to White military SMs, especially in Black older male adults.

CONCLUSION

Our results highlight the role of pre-pandemic comorbidities and race likely enhancing the frequency of SARS-CoV-2 infections and COVID-19 hospitalizations in military SMs. These preliminary findings underscore the need for future retrospective studies using additional Military Health System data bases reporting data on this military subpopulation, especially in the setting of future pathogens outbreaks or pandemics affecting military populations.

COVID-19 pandemic containment and management in city of Turaif: Understanding the experience

Saudi Arabia implemented precautionary measures earlier before the first COVID-19 case had been confirmed. In March 02, 2020, the first COVID-19 was confirmed in Saudi Arabia which resulted in tightening precautionary measures. Turaif's location and population structure present a challenge for pandemic management. Multidisciplinary approach is essential to ensure efficiency of coordinated effortsbetween local authority and health officials.

Study protocol: Project 2VIDA! SARS-CoV-2 vaccine intervention delivery for adults in Southern California

Background

To date, the United States (US) leads the world in the number of infections and deaths due to the Coronavirus Disease 2019 (COVID-19). Racial and ethnic disparities in COVID-19 morbidity and mortality are staggering. Age-adjusted data show that AA and Latino individuals have had higher rates of death over most of the pandemic and during surges. Project 2VIDA! is community-based participatory research (CBPR) that was developed to address individual, social, and contextual factors related to access and acceptance of the COVID-19 vaccine among African American and Latino communities in Southern California. This paper describes the study protocol and overarching objectives.

Methods and design

Project 2VIDA! is a multilevel intervention that builds on the principals of CBPR and is designed to increase uptake of the COVID-19 vaccine among African American and Latino individuals (≥16 years and older) in San Diego County. The intervention was developed with a working group comprised of representatives from community and academia and centers on targeted COVID-19 individual awareness and education, linkage to medical and supportive services, COVID-19 community outreach and health promotion and offering the COVID-19 vaccine through community pop-up clinics.

Discussion

Findings from 2VIDA! will provide data on the impact, feasibility, and acceptability of the intervention which are all crucial for the adaptation, refinement, and improvement of vaccine outreach interventions for COVID-19 and other vaccine preventable infectious diseases that severely impact African American and Latino communities.

Clinical trial registration

https://clinicaltrials.gov/ct2/show/NCT05022472?term=Project+2VIDA&draw=2&rank=1, NCT05022472.

COVID-19 pneumonia assessed at a private hospital, a field hospital, and a public-referral hospital: population analysis, chest computed tomography findings, and outcomes

Objective

To compare a private quaternary referral hospital, a public tertiary hospital, and a field hospital dedicated to patients with COVID-19, regarding patients' characteristics, clinical parameters, laboratory, imaging findings, and outcomes of patients with confirmed diagnosis of COVID-19.

Methods

Retrospective multicenter observational study that assessed the association of clinical, laboratory and CT data of 453 patients with COVID-19, and also their outcomes (hospital discharge or admission, intensive care unit admission, need for mechanical ventilation, and mortality caused by COVID-19).

Results

The mean age of patients was 55 years (±16 years), 58.1% of them were male, and 41.9% were female. Considering stratification by the hospital of care, significant differences were observed in the dyspnea, fever, cough, hypertension, diabetes mellitus parameters, and CT score (p < 0.05). Significant differences were observed in ward admission rates, with a lower rate in the private hospital (40.0%), followed by the public hospital (74.1%), and a higher rate in the field hospital (89.4%). Regarding intensive care unit admission, there was a higher rate in the public hospital (25.2%), followed by the private hospital (15.5%), and a lower rate in the field hospital (9.9%). In the analysis of the discharge and death outcomes, it was found that there was a higher number of patients discharged from the private hospital (94.2%), compared to the field hospital (90.1%) and public hospital (82.3%) and a higher number of deaths in the public hospital (17.7%) compared to the private hospital and field hospital (5.8 and 0% respectively).

Conclusion

The analysis of the data regarding the population treated with COVID-19 during the first wave in different levels of care in the public and private health systems in the city of São Paulo revealed statistically significant differences between the populations, reflecting distinct outcomes.

Assessing the Relationship between Radiology Department Research Funding and Institutional Community Inclusion and Investment

Background Health care access disparities and lack of inclusion in clinical research have been well documented for marginalized populations. However, few studies exist examining the research funding of institutions that serve historically underserved groups. Purpose To assess the relationship between research funding awarded to radiology departments by the National Institutes of Health (NIH) and Lown Institute Hospitals Index rankings for inclusivity and community benefit. Materials and Methods This retrospective study included radiology departments awarded funding from the NIH between 2017 and 2021. The 2021 Lown Institute Hospitals Index rankings for inclusivity and community benefit were examined. The inclusivity metric measures how similar a hospital's patient population is to the surrounding community in terms of income, race and ethnicity, and education level. The community benefit metric measures charity care spending, Medicaid as a proportion of patient revenue, and other community benefit spending. Linear regression and Pearson correlation coefficients (r values) were used to evaluate the relationship between aggregate NIH radiology department research funding and measures of inclusivity and community benefit. Results Seventy-five radiology departments that received NIH funding ranging from $195 000 to $216 879 079 were included. A negative correlation was observed between the amount of radiology department research funding received and institutional rankings for serving patients from racial and/or ethnic minorities (r = -0.34; P < .001), patients with low income (r = -0.44; P < .001), and patients with lower levels of education (r = -0.46; P < .001). No correlation was observed between the amount of radiology department research funding and institutional rankings for charity care spending (r = -0.19; P = .06), community investment (r = -0.04; P = .68), and Medicaid as a proportion of patient revenue (r = -0.10; P = .22). Conclusion Radiology departments that received more NIH research funding were less likely to serve patients from racial and/or ethnic minorities and patients who had low income or lower levels of education. © RSNA, 2024 See also the editorial by Mehta and Rosen in this issue.

Measuring health equity in the ASEAN region: conceptual framework and assessment of data availability

BACKGROUND

Existing research on health equity falls short of identifying a comprehensive set of indicators for measurement across health systems. Health systems in the ASEAN region, in particular, lack a standardised framework to assess health equity. This paper proposes a comprehensive framework to measure health equity in the ASEAN region and highlights current gaps in data availability according to its indicator components.

METHODS

A comprehensive literature review was undertaken to map out a core set of indicators to evaluate health equity at the health system level. Secondary data collection was subsequently conducted to assess current data availability for ASEAN states in key global health databases, national health accounts, and policy documents.

RESULTS

A robust framework to measure health equity was developed comprising 195 indicators across Health System Inputs and Processes, Outputs, Outcomes, and Contextual Factors. Total indicator data availability equated to 72.9% (1423/1950). Across the ASEAN region, the Inputs and Processes sub-component of Health Financing had complete data availability for all indicators (160/160, 100%), while Access to Essential Medicine had the least data available (6/30, 20%). Under Outputs and Outcomes, Coverage of Selected Interventions (161/270, 59.63%) and Population Health (350/350, 100%) respectively had the most data available, while other indicator sub-components had little to none (≤ 38%). 72.145% (384/530) of data is available for all Contextual Factors. Out of the 10 ASEAN countries, the Philippines had the highest data availability overall at 77.44% (151/195), while Brunei Darussalam and Vietnam had the lowest data availability at 67.18% (131/195).

CONCLUSIONS

The data availability gaps highlighted in this study underscore the need for a standardised framework to guide data collection and benchmarking of health equity in ASEAN. There is a need to prioritise regular data collection for overlooked indicator areas and in countries with low levels of data availability. The application of this indicator framework and resulting data availability analysis could be conducted beyond ASEAN to enable cross-regional benchmarking of health equity.

The intersectionality-based policy analysis framework: demonstrating utility through application to the pre-vaccine U.S. COVID-19 policy response

Few guidelines exist for the development of socially responsible health policy, and frameworks that balance considerations of data, strategy, and equity are limited. The Intersectionality-Based Policy Analysis (IBPA) framework utilizes a structured questioning process to consider problems and policies, while applying guiding principles of equity, social justice, power, intersectionality, and diversity of knowledge and input. We apply the IBPA framework's guiding principles and questions to the pre-vaccine U.S. COVID-19 policy response. Results suggest the IBPA approach is a promising tool for integrating equity considerations in the development of policy solutions to urgent US public health challenges, including the COVID-19 pandemic. We found the IBPA framework particularly useful in differentiating between problems or policies and representations of problems or policies, and in considering the impacts of representations on different groups. The explicit inclusion of short-, medium- and long-term solutions is a reminder of the importance of holding a long-term vision of the equitable public health system we want while working towards immediate change.

Barriers and shortcomings in access to cardiovascular management and prevention for familial hypercholesterolemia during the COVID-19 pandemic

Familial hypercholesterolemia (FH) is a hereditary condition caused by mutations in the lipid pathway. The goal in managing FH is to reduce circulating low-density lipoprotein cholesterol and, therefore, reduce the risk of developing atherosclerotic cardiovascular disease (ASCVD). Because FH patients were considered high risk groups due to an increased susceptible for contracting COVID-19 infection, we hypothesized whether the effects of the pandemic hindered access to cardiovascular care. In this review, we conducted a literature search in databases Pubmed/Medline and ScienceDirect. We included a comprehensive analysis of findings from articles in English related and summarized the effects of the pandemic on cardiovascular care through direct and indirect effects. During the COVID-19 pandemic, FH patients presented with worse outcomes and prognosis, especially those that have suffered from early ASCVD. This caused avoidance in seeking care due to fear of transmission. The pandemic severely impacted consultations with lipidologists and cardiologists, causing a decline in lipid profile evaluations. Low socioeconomic communities and ethnic minorities were hit the hardest with job displacements and lacked healthcare coverage respectively, leading to treatment nonadherence. Lock-down restrictions promoted sedentary lifestyles and intake of fatty meals, but it is unclear whether these factors attenuated cardiovascular risk in FH. To prevent early atherogenesis in FH patients, universal screening programs, telemedicine, and lifestyle interventions are important recommendations that could improve outcomes in FH patients. However, the need to research in depth on the disproportionate impact within different subgroups should be the forefront of FH research.

Perceived COVID-19 risk and testing experiences in the San Ysidro U.S./Mexico border region

Racial and ethnic disparities in COVID-19 incidence are pronounced in underserved U.S./Mexico border communities. Working and living environments in these communities can lead to increased risk of COVID-19 infection and transmission, and this increased risk is exacerbated by lack of access to testing. As part of designing a community and culturally tailored COVID-19 testing program, we surveyed community members in the San Ysidro border region. The purpose of our study was to characterize knowledge, attitudes, and beliefs of prenatal patients, prenatal caregivers, and pediatric caregivers at a Federally Qualified Health Center (FHQC) in the San Ysidro region regarding perceived risk of COVID-19 infection and access to testing. A cross-sectional survey was used to collect information on experiences accessing COVID-19 testing and perceived risk of COVID-19 infection within San Ysidro between December 29, 2020 and April 2, 2021. A total of 179 surveys were analyzed. Most participants identified as female (85%) and as Mexican/Mexican American (75%). Over half (56%) were between the age of 25 and 34 years old. Perceived Risk: 37% reported moderate to high risk of COVID-19 infection, whereas 50% reported their risk low to none. Testing Experience: Approximately 68% reported previously being tested for COVID-19. Among those tested, 97% reported having very easy or easy access to testing. Reasons for not testing included limited appointment availability, cost, not feeling sick, and concern about risk of infection while at a testing facility. This study is an important first step to understand the COVID-19 risk perceptions and testing access among patients and community members living near the U.S./Mexico border in San Ysidro, California.

Health Care Disparities in Outpatient Diabetes Management During the Coronavirus Disease 2019 Pandemic: Where Do We Stand Now?

OBJECTIVE

We examined diabetes outpatient management during the first 2 years of the Coronavirus Disease 2019 pandemic in an endocrinology practice with a focus on health care disparities in outcomes.

METHODS

We conducted a retrospective cohort study examining adults with diabetes during 3 time periods: T1 (March 2019-February 2020), T2 (March 2020-February 2021), and T3 (March 2021-February 2022). Clinical outcomes included body mass index (BMI), systolic blood pressure (SBP), Hemoglobin A1c (HgbA1c), low-density lipoprotein cholesterol (LDL), and urine albumin:creatinine ratio. Appointment types (virtual vs in-person) were also collected.

RESULTS

Frequencies of HgbA1c, BMI, and SBP measurements reduced by 36.0%, 46.3%, and 48.5% in T2, respectively, and remaining 8.7% (HgbA1c), 13.4% (BMI), and 15.2% (SBP) lower at the end of the study period (P < .001) compared to prepandemic levels. However, the average HgbA1c and LDL slightly improved. Clinic appointments per patient increased during the pandemic, fueled by telehealth utilization. Women had fewer in-person visits during T2, those older than 65 had better HgbA1c, and the most socioeconomically deprived group had the worst HgbA1c during every time period. In addition, black patients had worse HgbA1c, LDL, and SBP values throughout the study, which did not worsen over the pandemic.

CONCLUSION

While the frequency of health measurements had not fully recovered 2 years into the pandemic, this did not translate to worse diabetes management or a widening of pre-existing disparities. Our study emphasizes the role of equitable health care in minimizing inequalities in diabetes, particularly during times of crisis.

Increased Difficulties Managing Chronic Medical Conditions During the COVID-19 Pandemic Are Associated With Increased Alcohol and Cannabis Use Among Unhoused and Unstably Housed Women

OBJECTIVES

The COVID-19 pandemic caused dramatic upsurges in stress and anxiety across the United States, as well as increased substance use to cope with pandemic-related stress. Few studies have focused exclusively on extremely disadvantaged individuals who are already at risk for substance use. We sought to understand factors associated with increased alcohol and cannabis use during the first 10 months of the COVID-19 pandemic among unsheltered and unstably housed women.

METHODS

Between July and December 2020, we conducted phone surveys with San Francisco unhoused and unstably housed women regarding substance use, health, and health services use since the beginning of the pandemic (March 2020).

RESULTS

Among 128 participants, increased use of alcohol and cannabis were reported by 15% and 23%, respectively. The odds of increased use of both substances were 4 times higher in participants who also had increased difficulties managing symptoms of a chronic medical condition during the pandemic.

CONCLUSIONS

An intentional and comprehensive approach to managing the health of particularly vulnerable individuals during the COVID pandemic could help alleviate its exacerbating influences. Such an approach should include resources, tools and interventions for managing substance use, as well as chronic, non-COVID medical conditions, which are common and strongly tied to substance use in unhoused and unstably housed women.

A review of disparities in peripheral artery disease and diabetes-related amputations during the COVID-19 pandemic

The COVID-19 pandemic has profoundly affected health care delivery. In addition to the significant morbidity and mortality associated with acute illness from COVID-19, the indirect impact has been far-reaching, including substantial disruptions in chronic disease care. As a result of pandemic disruptions in health care, vulnerable and minority populations have faced health inequalities. The aim of this review was to investigate how the COVID-19 pandemic has impacted vulnerable populations with limb-threatening peripheral artery disease and diabetic foot infections.

Community Perceptions of Health Equity: A Qualitative Study

INTRODUCTION

Notable inequities in patient experiences exist in the healthcare system. Communities with a large concentration of blacks and immigrants are often marginalized rather than centralized in the healthcare system. These inequities may fuel distrust and exacerbate adverse outcomes, thereby widening the health gap. Addressing differences in patients' experiences of care is paramount for reducing health inequities.

METHODS

In this qualitative study, we used a purposive sampling method to recruit 62 participants to conduct 10 FGs (44 participants total) and 18 key informant interviews with stakeholders across Central Brooklyn.

RESULTS

The data revealed three primary themes: Trust, Discrimination, and Social Determinants of Health (SDOHs). Each theme comprised subthemes as follows: For Trust, the subthemes included (1) confidence in the healthcare professional, (2) provider empathy, and (3) active participation in healthcare decisions. Regarding Discrimination, the subthemes involved (1) racism and identity, as well as (2) stigma related to diagnosis, disease state, and pain management. Lastly, for Social Determinants of Health, the key subtheme was the acknowledgment by providers that patients encounter competing priorities acting as barriers to care, such as housing instability and food insecurity. For the first theme, participants' interactions with the healthcare system were prompted by a necessity for medical attention, and not by trust. The participants reported that experiences of discrimination resulting from identity and stigma associated with diagnosis, disease state, and pain management amplified the disconnect between the community, the patients, and the healthcare system. This also exacerbated the poor healthcare experiences suffered by many people of color. For SDOHs, the participants identified housing, food security, and other various social factors that may undermine the effectiveness of the healthcare that patients receive.

CONCLUSIONS

Improvements in the health system, based on feedback from patients of color regarding their unique care experiences, are important initiatives in combating inequities in healthcare.

Racial and ethnic variation in COVID-19 care, treatment, and outcomes: A retrospective cohort study from the MiCOVID-19 registry

BACKGROUND

Racial and ethnic disparities in COVID-19 outcomes exist, but whether in-hospital care explains this difference is not known. We sought to determine racial and ethnic differences in demographics, comorbidities, in-hospital treatments, and in-hospital outcomes of patients hospitalized with COVID-19.

METHODS AND FINDINGS

This was a cohort study using MiCOVID-19, a multi-center, retrospective, collaborative quality improvement registry, which included data on patients hospitalized with COVID-19 across 38 hospitals in the State of Michigan. 2,639 adult patients with COVID-19 hospitalized at a site participating in the MiCOVID-19 Registry were randomly selected. Outcomes included in-hospital mortality, age at death, intensive care unit admission, and need for invasive mechanical ventilation by race and ethnicity. Baseline comorbidities differed by race and ethnicity. In addition, Black patients had higher lactate dehydrogenase, erythrocyte sedimentation rate, C-reactive protein, creatine phosphokinase, and ferritin levels. Black patients were less likely to receive dexamethasone and remdesivir compared with White patients (4.2% vs 14.3% and 2.2% vs. 11.8%, p < 0.001 for each). Black (18.7%) and White (19.6%) patients experienced greater mortality compared with Asian (13.0%) and Latino (5.9%) patients (p < 0.01). The mean age at death was significantly lower by 8 years for Black patients (69.4 ± 13.3 years) compared with White (77.9 ± 12.6), Asian (77.6 ± 6.6), and Latino patients (77.4 ± 15.5) (p < 0.001).

CONCLUSIONS

COVID-19 mortality appears to be driven by both pre-hospitalization clinical and social factors and potentially in-hospital care. Policies aimed at population health and equitable application of evidence-based medical therapy are needed to alleviate the burden of COVID-19.

Non-Communicable Diseases and Transitioning Health System in the Democratic People’s Republic of Korea during COVID-19 Lockdown

While there are increasing concerns on COVID-19 situation in Democratic People’s Republic of Korea (DPRK, or North Korea), little is known about North Korea’s health system function for Non-Communicable Diseases. Given the scarcity of available evidence, a scoping review was conducted in peer review articles from MEDLINE, SCOPUS, and Web of Science, and policy literatures from Rodongshinmun, state-run media in North Korea to analyze the North Korea health system and COVID-19 pandemic. The transition to a market economy is expected to deepen the gap between the rich and the poor over access to health care, causing a new type of health inequality in North Korea. COVID-19 lockdown intensified the DPRK’s economic predicament exacerbating shortage of health financing on non-communicable diseases. The case study of mixed evidence from scoping review indicates that NCDs prevention and management are not functional in the transitioning health system under chronic economic crisis and isolation. This study indicates that NCDs prevention and management are not functional in the transitioning health system under chronic economic crisis and isolation. The destabilized markets under COVID-19 lockdown intensified the DPRK’s economic predicament and exacerbated the chronic shortage of health financing especially to NCDs.

Influence of biologic and conventional disease-modifying antirheumatic drugs on COVID-19 incidence among rheumatic patients during the first and second wave of the pandemic in Iran

Introduction

During the SARS-CoV-2 virus pandemic, immunosuppressive agents in treating chronic disease have become a concern, and rheumatic patients are not an exception. The controversies about the deteriorating effects of such medications led this study to evaluate the influence of biologic and conventional disease-modifying antirheumatic drugs (DMARDs) on the incidence of COVID-19 infection in rheumatic patients.

Material and methods

In the present cohort-analytical study, 512 patients with rheumatic diseases were enrolled during the COVID-19 pandemic (2020–2021). The incidence of COVID-19 infection was diagnosed according to the definition of the Iranian Ministry of Health. The frequency of COVID-19 infection in patients treated with biological and conventional DMARDs and glucocorticosteroids were compared.

Results

Among 512 rheumatic patients, 19.9% were definitely infected with COVID-19, and 23.3% of infected patients were hospitalized. Only one patient with vasculitis died during the two outbreaks. Our study showed that adding biologic DMARDs to conventional DMARDs did not increase the risk of COVID-19 infection. However, unlike biologic DMARDs, in conventional DMARDs, methotrexate increased, and hydroxychloroquine decreased COVID-19 infection. Regression analysis showed that prednisolone at a dosage higher than 10 mg/day increased the risk of COVID-19 infection 5-fold; hydroxychloroquine had a protective impact and reduced the risk of infection by 40%.

Conclusions

Biologic DMARDs and the type of selected rheumatic diseases in our study did not influence the susceptibility to COVID-19 infection. Prednisolone raised the coronavirus infection, and hydroxychloroquine played a protective role in the current study. Most of our patients showed good adherence to the health protocols. Further studies after worldwide vaccination are now required to reevaluate the influence of rheumatic diseases and DMARDs on COVID-19 infection.

Characteristics of Hospitalized COVID-19 Patients in the Four Southern Regions Under the Proposed Southern Business Unit of Saudi Arabia

Background

This is the first descriptive and comparative study conducted of COVID-19 inpatients from multi-centers in the four administrative southern regions and proposed Southern Business Unit (Jazan, Najran, Bisha, and Aseer) of the Kingdom of Saudi Arabia (KSA).

Methods

Participants were 809 randomly selected patients admitted to the eight sampled hospitals with confirmed COVID-19 between March 2020 and February 2021. We assessed and compared socio-demographics, clinical characteristics, and clinical outcomes of the four regions.

Results

Socio-demographic and clinical characteristics of the participants are a mean age of 60 ± 17.7 years, 70% Saudi male, the prevalence of diabetes (DM2) 58%, hypertension (HTN) 48%, obesity 43%, cardiac diseases 15%, and immunity or cancer diseases almost 1%. The prevalence of complications during admission were bacterial pneumonia 65%, acquired respiratory distress syndrome (ARDS) 32%, sepsis 20%, multi-organ failure 18%, acute kidney diseases 15%, and arrhythmia 4%. Clinical outcomes were: admitted to intensive care unit (ICU) 52%, mortality rate 25%, referred to other facilities 9%, and mean length of stay (LOS) was 11± 9.5 days. We observed statistically significant variation in many variables among the four regions. Najran and Aseer had a higher prevalence of risk factors for severity including age and comorbidities accompanied by higher rates of complications, ICU admissions, LOS, and mortality. Bisha and Jazan had lower prevalence of risk factors and LOS with lower rates of complications, ICU admissions, and mortality.

Conclusion

This study reveals that the geographic region in which the patient was cared for was related to the severity and outcome of COVID-19 infection. Policy makers should search for solutions to regional differences in underlying health conditions such as DM2, HTN, and obesity to plan for improvements in preventive care as well as resource distribution to ensure quality for all Saudi citizens. This study will serve as guidance to begin to form strategies for these improvements as envisioned in the future New Model of Care.

The lockdown, mobility, and spatial health disparities in COVID-19 pandemic: A case study of New York City

The world has adopted unprecedented lockdown as the key method to mitigate COVID-19; yet its effect on pandemic outcomes and health disparities remains largely unknown. Adopting a multilevel conceptual framework, this research investigates how city-level lockdown policy and public transit system shape mobility and thus intra-city health disparities, using New York City as a case study. With a spatial method and multiple sources of data, this research demonstrates the uneven impact of the lockdown policy and public transit system in shaping local pandemic outcomes. Census tracts with people spending more time at home have lower infection and death rates, while those with a higher density of transit stations have higher infection and death rates. Residential profile matters and census tracts with a higher concentration of disadvantaged population, such as Blacks, Hispanics, poor and elderly people, and people with no health insurance, have higher infection and death rates. Spatial analyses identify clusters where the lockdown policy was not effective and census tracts that share similar pandemic characteristics. Through the lens of mobility, this research advances knowledge of health disparities by focusing on institutional causes for health disparities and the role of the government through intervention policy and public transit system.

Identifying Louisiana communities at the crossroads of environmental and social vulnerability, COVID-19, and asthma

The COVID-19 pandemic has disproportionately affected the socially and environmentally vulnerable, including through indirect effects on other health conditions. Asthma is one such condition, which may be exacerbated by both prolonged adverse in-home exposures if quarantining in unhealthy homes and prolonged outdoor exposures if the ambient air quality is unhealthy or hazardous. As both are often the case in Environmental Justice (EJ) communities, here we have analyzed data at the census tract (CT) level for Louisiana to assess any correlation between social and environmental vulnerability, and health issues like COVID-19 and asthma. Higher Social Vulnerability Index (SVI), Particulate Matter less than 2.5 μm in diameter (PM2.5) and Ozone levels were associated with higher rates of cumulative COVID-19 incidence at various time points during the pandemic, as well as higher average annual asthma hospitalization rates and estimated asthma prevalence. Further, cumulative COVID-19 incidence during the first three months of the pandemic was moderately correlated with both asthma hospitalizations and estimated prevalence, suggesting similar underlying factors may be affecting both conditions. Additionally, 137 CTs were identified where social and environmental vulnerabilities co-existed, of which 75 (55%) had high estimated prevalence of asthma. These areas are likely to benefit from asthma outreach that considers both social and environmental risk factors. Fifteen out of the 137 CTs (11%) not only had higher estimated prevalence of asthma but also a high burden of COVID-19. Further research in these areas may help to elucidate any common social determinants of health that underlie both asthma and COVID-19 burdens, as well as better clarify the possible role of the environment as related to the COVID-19 burden in Louisiana.

Staffing Levels and COVID-19 Infections and Deaths in Korean Nursing Homes

The novel coronavirus disease 2019 (COVID-19) spread rapidly worldwide. Nursing home (NH) residents are the most vulnerable high-risk population to infection. Professional registered nurses' (RNs') infection control is irreplaceable. We used a secondary data analysis method using the government's senior citizen welfare department large data set about all NHs (N = 3,389) across Korea between January 20 and October 20, 2020. Bed size positively associated with the mortality rate (No. of COVID-19 resident deaths / No. of total residents) (p = .048). When the proportion of RNs to total nursing staff was higher, the infection rate was 0.626% lower (p = .049), the mortality rate was 0.088% lower (p = .076), the proportion of confirmed COVID-19 cases per resident out of the total number of NHs was 44.472% lower (p = .041), and the proportion of confirmed COVID-19 deaths per resident out of the total number of NHs was 6.456% lower (p = .055). This study highlighted nurse staffing criteria and suggests that increasing RNs in NHs will reduce infection and mortality rates during the COVID-19 pandemic. We strongly suggest NHs hire at least one RN per day to properly function, and a minimum of four RNs to provide a fully competent RN workforce in long-term care settings in Korean NHs.

Regional Differences in COVID-19 Mortality Rates in the Kingdom of Saudi Arabia: A Simulation of the New Model of Care

Background This study aimed to assess regional COVID-19 mortality rates and compare the five proposed business units (BUs).  Methods A cross-sectional study was conducted in the Ministry of Health (MOH) hospitals in the Kingdom of Saudi Arabia (KSA). We included 1743 adults (≥ 18 years of age) with COVID-19 admitted to any of 30 MOH hospitals. Results The inpatients had confirmed mild to severe COVID-19 between March and mid-July 2020. The central BU (Riyadh) was used as the reference. MOH electronic health record data were reviewed and utilized, including variables reflecting hospital course (mortality and discharge status). The primary outcome was COVID-19-related inpatient death. Covariates included patient demographics, pre-existing chronic diseases, and COVID-19-related complications. The data were analysed using univariate and multivariate logistic regression. KSA inpatient mortality was 30%. Univariate and multivariate logistic regression analysis suggested that COVID-19-related mortality was significantly higher in the northern and western BUs and significantly lower in the southern and eastern BUs than in the central BU. On controlling for other variables, adjusted odds ratios (AORs) for essential COVID-19 mortality predictors during admission, using the central BU as a reference, were as 9.90 [95% CI, 4.53-21.61] and 1.55 [95% CI, 1.04-2.13] times higher in the northern and western BUs, respectively, and 0.60 [95% CI, 0.36-0.99] and 0.23 [95% CI, 0.14-0.038] times lower in the southern and eastern BUs, respectively. Conclusion The five BUs differed in COVID-19 mortality rates after adjusting for patient and disease characteristics, with the differences consistent with those in the regions comprising the BUs. These outcome differences apparently relate to differences in healthcare resources and quality.

Hospitalised versus outpatient COVID-19 patients' background characteristics and comorbidities: A systematic review and meta-analysis

This study aimed to systematically assess COVID-19 patient background characteristics and pre-existing comorbidities associated with hospitalisation status. The meta-analysis included cross-sectional, cohort, and case-series studies with information on hospitalisation versus outpatient status for COVID-19 patients, with background characteristics and pre-existing comorbidities. A total of 1,002,006 patients from 40 studies were identified. Significantly higher odds of hospitalisation were observed in Black individuals (OR = 1.33, 95% CI: 1.04-1.70), males (OR = 1.59, 95% CI: 1.43-1.76), and persons with current/past smoking (OR = 1.59, 95% CI: 1.34-1.88). Additionally, individuals with pre-existing comorbidities were more likely to be hospitalised [asthma (OR = 1.22, 95% CI: 1.02-1.45), COPD (OR = 3.68, 95% CI: 2.97-4.55), congestive heart failure (OR = 6.80, 95% CI: 4.97-9.31), coronary heart disease (OR = 4.40, 95% CI: 3.15-6.16), diabetes (OR = 3.90, 95% CI: 3.29-4.63), hypertension (OR = 3.89, 95% CI: 3.34-4.54), obesity (OR = 1.98, 95% CI: 1.59-2.46) and renal chronic disease (OR = 5.84, 95% CI: 4.51-7.56)]. High heterogeneity and low publication bias among all factors were found. Age was not included due to the large variability in the estimates reported. In this systematic review/meta-analysis for patients with COVID-19, Black patients, males, persons who smoke, and those with pre-existing comorbidities were more likely to be hospitalised than their counterparts. Findings provide evidence of populations with higher odds of hospitalisation for COVID-19.

Witnesses and Victims Both: Healthcare Workers and Grief in the Time of COVID-19

Heathcare Workers (HCWs) recognize their responsibility to support the bereaved loved ones of our patients, but we also must attend to our own professional and personal grief in the COVID-19 pandemic. COVID-19 grief is occurring in the setting of incomplete grief, disenfranchised grief, fractured US governmental leadership, and evidence of great mistrust, systemic racism, and social injustice. In the intensity and pervasiveness of COVID-19, HCW fears for themselves, their colleagues, and their own loved ones are often in conflict with professional commitments. Even at the dawn of promising national and global vaccination programs, significant HCW morbidity and mortality in COVID-19 has already become clear, will continue to grow, and these effects likely will last far into the future. Given the risks of complicated grief for HCWs in the setting of COVID-19 deaths, individual HCWs must put every effort into their own preparation for these deaths as well as into their own healthy grieving. Equally importantly, our healthcare systems have a primary responsibility both to prepare HCWs and to support them in their anticipatory and realized grief. Special attention must be paid to our HCW trainees, who may have not yet developed personal or professional grief management strategies and are coming into healthcare practice during a time of great disruption to both teaching and clinical care.

Health care disparities during the COVID-19 pandemic

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2, is a pandemic with more than 32 million cases and more than 500,000 deaths nationwide. With the significant health consequences seen secondary to COVID-19, health care disparities have been further exacerbated. Mechanisms that have been proposed to account for the increased disparity seen during the COVID-19 pandemic are multifactorial. This review of the literature outlines the unique barriers to health and disparities that are associated with vulnerable communities who have been most impacted by the COVID-19 pandemic in the United States.

Impact of COVID-19 on motor vehicle injuries and fatalities in older adults in Ontario, Canada

BACKGROUND

Older adults constitute the group most vulnerable to COVID-19 mortality. As a result, in North America and elsewhere, older adults have been strongly advised to shelter in place. Older adults also represent the fastest growing segment of licensed drivers.

OBJECTIVE

We examined the change in injuries and fatalities sustained by younger and older drivers and pedestrians during the first month of the COVID-19 pandemic. We hypothesized that adults ages 80 years and over would have a proportionally larger reduction than the other drivers and pedestrians.

METHODS

Using a cohort design, we compared the proportion of drivers and pedestrians involved in injuries and fatalities attributable to individuals aged 80 years and over, as recorded in the Ministry of Transportation of Ontario (Canada) database, between the 30 days prior to shelter-in-place related to the COVID-19 pandemic and the subsequent 30 days. By way of comparison, we conducted a similar comparison for younger age cohorts (16-24 years, 25-34 years, 35-54 years, 55-64 years, and 65-79 years).

RESULTS

Drivers aged 80 years and over represented 21 per 1000 injuries and fatalities in the 30 days prior to March 17, 2020 (95 % CI: 15-29), and 8 per 1000 injuries and fatalities in the 30 days beginning on that date (95 % CI: 2-20), a 64.7 % reduction (exp (β) post 0.353, 95 % CI 0.105-0.892). Drivers in the 35-54 year age range underwent a significant but smaller reduction of 22.9 %; no significant changes were seen for drivers in other age groups, or for pedestrians of any age.

CONCLUSIONS AND RELEVANCE

The physical distancing measures that aimed to reduce the spread of COVID-19 resulted in a marked reduction in driver injuries and fatalities in the oldest old, illustrating the impact of physical distancing recommendations in this population. The excess mortality burden faced by the oldest adults during the COVID-19 pandemic, by direct exposure to the virus, may be indirectly mitigated by the reduction in road-related deaths in this cohort.

COVID-19 associated mortality and cardiovascular disease outcomes among US women veterans

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.

Integration of sociocultural and behavioral factors into the clinical framework of cardiovascular studies in Hispanic/Latino populations: Relevance during the SARS-COV-2 pandemic

Recent reports on the burden of cardiovascular disease (CVD) in the USA indicate that despite significant declines in CVD mortality in the late 20th century, this decline is now decelerating and may be worsened by inequalities in health care. Social factors contribute to most of the cardiovascular health disparities documented to date. Hispanics/Latinos and African-Americans share a higher prevalence of cardiovascular risk factors and experience higher rates of poverty and social stressors than non-Hispanic Whites. We propose that the use of social and behavioral data beyond basic and sometimes loose identifiers of race/ethnicity, educational attainment, and occupation would inform clinical practice and greatly facilitate the provision of adequate guidance and support to patients regarding continuity of care, adherence to medications and treatment plans, and engagement of participants in future research. This perspective briefly highlights factors deemed to be critical for the advancement of Hispanic/Latino health and delineates pathways toward future applications.

Health Disparities in COVID-19: Addressing the Role of Social Determinants of Health in Immune System Dysfunction to Turn the Tide

It is evident that health disparities exist during the COVID-19 pandemic, a pandemic caused by the novel coronavirus SARS-CoV-2. Underlying reasons for COVID-19 health disparities are multi-factorial. However, social determinants, including those regarding socioeconomic status, social inequalities, health behaviors, and stress, may have implications on these disparities. Exposure to one or more of these social determinants is associated with heightened inflammatory responses, particularly increases in the cytokine interleukin-6 (IL-6), as well as immune system dysfunction. Thus, an amplified effect during COVID-19 could occur, potentially resulting in vulnerable patients experiencing an intensified cytokine storm due to a hyperactive and dysfunctional immune response. Further understanding how social determinants play a mechanistic role in COVID-19 disparities could potentially help reduce health disparities overall and in future pandemics.

Diseases with health disparities as drivers of COVID-19 outcome

The COVID-19 pandemic has forced our society to come face to face with complex issues that were once theoretical but are now being played out in real time. As data from the pandemic accumulates, it is clear that COVID-19 is impacting some parts of society more than others. Unfortunately, there is an almost complete overlap between COVID-19 risk factors and conditions that are already represented as health disparities, such as hypertension, diabetes, heart disease, lung disease and immune disorders. In this review, we discuss our current understanding of the physiological and pathophysiological pathways that link these diseases to COVID-19 outcome. An increased awareness of the factors underlying this issue, both societal and medical, is needed to understand the long-term implications and possible solutions needed going forward.