Joint Effects of Socioeconomic Position, Race/Ethnicity, and Gender on COVID-19 Mortality among Working-Age Adults in the United States

Inclusion of Sex and Gender to Improve the State of the Science in Women's Health

ABSTRACT

The influence of sex and gender-related factors on health and disease at all levels of scale, across all health conditions, and throughout the entire life course is increasingly clear. A series of policies instituted by the National Institutes of Health (NIH) that require researchers to include appropriate populations and to analyze the data accordingly have strengthened the evidence base around the health of women. Translating these advances to the entire research ecosystem can catalyze rigorous biomedical discovery that can improve health. We encourage journals, publishers, and funders to align their policies and expectations regarding sex and gender considerations in research with those of the NIH and other international funding agencies.

Reimagining Rural Health Equity: Understanding Disparities And Orienting Policy, Practice, And Research In Rural America

A narrative has taken hold that public health has failed the US. We argue instead that the US has chronically failed public health, and nowhere have these failures been more apparent than in rural regions. Decades of underinvestment in rural communities, health care, and public health institutions left rural America uniquely vulnerable to the COVID-19 pandemic. Rural communities outpaced urban ones in deaths, and many rural institutions and communities sustained significant impacts. At the same time, the pandemic prompted creative actions to meet urgent health and social needs, and it illuminated opportunities to address long-standing rural challenges. This article draws on our cross-disciplinary expertise in public health and medical anthropology, as well as our research on COVID-19 and rural health equity in northern New England. In this Commentary, we articulate five principles to inform research, practice, and policy efforts in rural America. We contend that advancing rural health equity beyond the pandemic requires understanding the forces that generate rural disparities and designing policies and practices that account for rural disadvantage.

Gender/Sex Disparities in the COVID-19 Cascade From Testing to Mortality: An Intersectional Analysis of Swiss Surveillance Data

Objectives

This study investigates gender and sex disparities in COVID-19 epidemiology in the Canton of Vaud, Switzerland, focusing on the interplay with socioeconomic position (SEP) and age.

Methods

We analyzed COVID-19 surveillance data from March 2020 to June 2021, using an intersectional approach. Negative binomial regression models assessed disparities between women and men, across SEP quintiles and age groups, in testing, positivity, hospitalizations, ICU admissions, and mortality (Incidence Rate Ratios [IRR], with 95% Confidence Intervals [CI]).

Results

Women had higher testing and positivity rates than men, while men experienced more hospitalizations, ICU admissions, and deaths. The higher positivity in women under 50 was mitigated when accounting for their higher testing rates. Within SEP quintiles, gender/sex differences in testing and positivity were not significant. In the lowest quintile, women's mortality risk was 68% lower (Q1: IRR 0.32, CI 0.20-0.52), with decreasing disparities with increasing SEP quintiles (Q5: IRR 0.66, CI 0.41-1.06).

Conclusion

Our findings underscore the complex epidemiological patterns of COVID-19, shaped by the interactions of gender/sex, SEP, and age, highlighting the need for intersectional perspectives in both epidemiological research and public health strategy development.

Sociodemographic inequities in COVID-19 vaccination among adults in the United States, 2022

BACKGROUND

Despite the availability of COVID-19 vaccines since December 2020, sociodemographic inequities in vaccination and preventable COVID-related deaths persist. To inform efforts for equitable COVID-19 vaccination campaigns, a comprehensive national evaluation of existing inequities is necessary.

OBJECTIVE

To examine sociodemographic inequities in COVID-19 vaccination receipt using data from the 2022 National Health Interview Survey (NHIS).

METHODS

This secondary data analysis used cross-sectional nationally-representative data from the 2022 NHIS to assess vaccination inequities among 27,126 adults. Separate Poisson regressions adjusted for clinical factors (e.g., age, sex, high-risk health conditions) were used to evaluate vaccination inequities across sociographic factors (e.g., race/ethnicity, poverty, health insurance).

RESULTS

In 2022, 79.6% of adults received at ≥ 1 vaccine dose, 75.0% received ≥ 2 doses ("fully vaccinated"), 45.7% received ≥ 3 doses (≥ 1 booster), and 17.2% received ≥ 4 doses (≥ 2 boosters). Marked inequities were evident in COVID-19 vaccination across primary and booster doses, especially receipt of at least 1 booster dose (≥ 3 doses). Black (35.7%, prevalence ratio [PR] 0.78 [95% CI 0.74-0.83]) and Latinx (35.5%, PR 0.82 [CI 0.78-0.86]) adults were less likely to receive ≥ 3 doses than Asian (66.5%, PR 1.41 [CI 1.35-1.48]) and White (48.8%) adults. Poverty (31.1% [PR 0.65 {CI 0.61-0.69}] vs. 50.7%) and food insecurity (27.1% [PR 0.63 {CI 0.58-0.68}] vs. 47.3%) were negatively associated with receipt of ≥ 3 vaccine doses. Adults without usual source of care (24.9%, PR 0.61 [CI 0.57-0.65]) or health insurance (17.4%, PR 0.40 [CI 0.36-0.45]) had much lower rates of ≥ 3 doses than those with appropriate health care access (48.7% and 51.9%, respectively).

CONCLUSION

As of 2022, 1-in-5 U.S. adults remain unvaccinated, and more than half have not received any recommended booster doses. Economically/socially marginalized populations-including Black and Latinx adults and those with structural barriers such as poverty, food insecurity, and poor health care access-were less likely to receive a booster. Addressing these vaccination inequities is crucial to achieve equitable COVID-19 protection and reduce preventable deaths among economically/socially marginalized populations.

Epidemiology of COVID-19 in Infants in the United States: Incidence, Severity, Fatality, and Variants of Concern

BACKGROUND

The clinical spectrum of infant COVID-19 ranges from asymptomatic infection to life-threatening illness, yet epidemiologic surveillance has been limited for infants.

METHODS

Using COVID-19 case data (restricted to reporting states) and national mortality data, we calculated incidence, hospitalization, mortality and case fatality rates through March 2022.

RESULTS

Reported incidence of COVID-19 was 64.1 new cases per 1000 infant years (95% CI: 63.3-64.9). We estimated that 594,012 infants tested positive for COVID-19 nationwide by March 31, 2022. Viral variant comparisons revealed that incidence was 7× higher during the Omicron (January-March 2022) versus the pre-Delta period (June 2020-May 2021). The cumulative case hospitalization rate was 4.1% (95% CI: 4.0%-4.3%). For every 74 hospitalized infants, one infant death occurred, but overall COVID-19-related infant case fatality was low, with 7.0 deaths per 10,000 cases (95% CI: 5.6-8.7). Nationwide, 333 COVID-19 infant deaths were reported. Only 13 infant deaths (3.9%) were the result of usually lethal congenital anomalies. The majority of infant decedents were non-White (28.2% Black, 26.1% Hispanic, 8.1% Asian, Indigenous or multiracial).

CONCLUSIONS

More than half a million US infants contracted COVID-19 by March 2022. Longitudinal assessment of long-term infant SARS-CoV-2 infection sequelae remains a critical research gap. Extremely low infant vaccination rates (<5%), waning adult immunity and continued viral exposure risks suggest that infant COVID-19 will remain a persistent public health problem. Our study underscores the need to increase vaccination rates for mothers and infants, decrease viral exposure risks and improve health equity.

Prediction models of COVID-19 fatality in nine Peruvian provinces: A secondary analysis of the national epidemiological surveillance system

There are initiatives to promote the creation of predictive COVID-19 fatality models to assist decision-makers. The study aimed to develop prediction models for COVID-19 fatality using population data recorded in the national epidemiological surveillance system of Peru. A retrospective cohort study was conducted (March to September of 2020). The study population consisted of confirmed COVID-19 cases reported in the surveillance system of nine provinces of Lima, Peru. A random sample of 80% of the study population was selected, and four prediction models were constructed using four different strategies to select variables: 1) previously analyzed variables in machine learning models; 2) based on the LASSO method; 3) based on significance; and 4) based on a post-hoc approach with variables consistently included in the three previous strategies. The internal validation was performed with the remaining 20% of the population. Four prediction models were successfully created and validate using data from 22,098 cases. All models performed adequately and similarly; however, we selected models derived from strategy 1 (AUC 0.89, CI95% 0.87-0.91) and strategy 4 (AUC 0.88, CI95% 0.86-0.90). The performance of both models was robust in validation and sensitivity analyses. This study offers insights into estimating COVID-19 fatality within the Peruvian population. Our findings contribute to the advancement of prediction models for COVID-19 fatality and may aid in identifying individuals at increased risk, enabling targeted interventions to mitigate the disease. Future studies should confirm the performance and validate the usefulness of the models described here under real-world conditions and settings.

Variability in excess deaths across countries with different vulnerability during 2020-2023

Excess deaths provide total impact estimates of major crises, such as the COVID-19 pandemic. We evaluated excess death trajectories across countries with accurate death registration and population age structure data and assessed relationships with vulnerability indicators. Using the Human Mortality Database on 34 countries, excess deaths were calculated for 2020-2023 (to week 29, 2023) using 2017-2019 as reference, with adjustment for 5 age strata. Countries were divided into less and more vulnerable; the latter had per capita nominal GDP < $30,000, Gini > 0.35 for income inequality and/or at least ≥2.5% of their population living in poverty. Excess deaths (as proportion of expected deaths, p%) were inversely correlated with per capita GDP (r = -0.60), correlated with proportion living in poverty (r = 0.66), and modestly correlated with income inequality (r = 0.45). Incidence rate ratio for deaths was 1.062 (95% CI, 1.038-1.087) in more versus less vulnerable countries. Excess deaths started deviating in the two groups after the first wave. Between-country heterogeneity diminished gradually within each group. Less vulnerable countries had mean p% = -0.8% and 0.4% in 0-64 and >65-y-old strata. More vulnerable countries had mean p% = 7.0% and 7.2%, respectively. Lower death rates were seen in children of age 0-14 y during 2020-2023 versus prepandemic years. While the pandemic hit some countries earlier than others, country vulnerability dominated eventually the cumulative impact. Half the analyzed countries witnessed no substantial excess deaths versus prepandemic levels, while the others suffered major death tolls.

Investigating identification disparities in forensic anthropology casework

Forensic anthropology is shifting to reflect on the impact of its practices within the criminal justice context in important ways. Here, we contribute to this essential work by examining how decedent demographics as well as estimations of biological profile components are related to identification trends in forensic anthropology cases. The study uses data from more than 1,200 identified and unidentified forensic anthropology cases from three agencies (together representing a nation-wide sample). We found the following: i) multivariate analyses indicated that decedent sex, age, and race and/or ethnicity are not related to case identification rates in the pooled United States sample, ii) when identification rate differences do occur, they appear to be smaller effects, more agency-specific, and/or related to the context of a particular agency, iii) for the agency-specific sample with available data, there was no consistent evidence for a discrepancy in the duration of an identification investigation based on a decedent's sex, age, or race and/or ethnicity, iv) forensic anthropological estimations of sex, age, and ancestry can improve the odds of identification for decedents, although these are small effects, and v) reporting an ancestry estimation does not appear to impact decedent race representation among resolved unidentified person cases. Although previous studies have identified demographic discrepancies in other areas of the criminal justice system, the results presented here suggest that decedent demographic estimation practices by forensic anthropologists in general do not appear to be related to discrepancies in identification trends, but more research is needed to examine whether these findings hold. Contextual factors and practices specific to each investigative agency likely contribute to identification trends.

Smoke and Spike: Benzo[a]pyrene Enhances SARS-CoV-2 Infection by Boosting NR4A2-Induced ACE2 and TMPRSS2 Expression

Cigarette smoke aggravates severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. However, the underlying mechanisms remain unclear. Here, they show that benzo[a]pyrene in cigarette smoke extract facilitates SARS-CoV-2 infection via upregulating angiotensin-converting enzyme 2 (ACE2) and transmembrane protease serine 2 (TMPRSS2). Benzo[a]pyrene trans-activates the promoters of ACE2 and TMPRSS2 by upregulating nuclear receptor subfamily 4 A number 2 (NR4A2) and promoting its binding of NR4A2 to their promoters, which is independent of functional genetic polymorphisms in ACE2 and TMPRSS2. Benzo[a]pyrene increases the susceptibility of lung epithelial cells to SARS-CoV-2 pseudoviruses and facilitates the infection of authentic Omicron BA.5 in primary human alveolar type II cells, lung organoids, and lung and testis of hamsters. Increased expression of Nr4a2, Ace2, and Tmprss2, as well as decreased methylation of CpG islands at the Nr4a2 promoter are observed in aged mice compared to their younger counterparts. NR4A2 knockdown or interferon-λ2/λ3 stimulation downregulates the expression of NR4A2, ACE2, and TMPRSS2, thereby inhibiting the infection. In conclusion, benzo[a]pyrene enhances SARS-CoV-2 infection by boosting NR4A2-induced ACE2 and TMPRSS2 expression. This study elucidates the mechanisms underlying the detrimental effects of cigarette smoking on SARS-CoV-2 infection and provides prophylactic options for coronavirus disease 2019, particularly for the elderly population.

Variability in excess deaths across countries with different vulnerability during 2020-2023

Excess deaths provide total impact estimates of major crises, such as the COVID-19 pandemic. We evaluated excess death's trajectories during 2020-2023 across countries with accurate death registration and population age structure data; and assessed relationships with economic indicators of vulnerability. Using the Human Mortality Database on 34 countries, excess deaths were calculated for 2020-2023 (to week 29, 2023) using 2017-2019 as reference, with weekly expected death calculations and adjustment for 5 age strata. Countries were divided into less and more vulnerable; the latter had per capita nominal GDP<$30,000, Gini>0.35 for income inequality and/or at least 2.5% of their population living in poverty. Excess deaths (as proportion of expected deaths, p%) were inversely correlated with per capita GDP (r=-0.60), correlated with proportion living in poverty (r=0.66) and modestly correlated with income inequality (r=0.45). Incidence rate ratio for deaths was 1.06 (95% confidence interval, 1.04-1.08) in the more versus less vulnerable countries. Excess deaths started deviating in the two groups after the first wave. Between-country heterogeneity diminished over time within each of the two groups. Less vulnerable countries had mean p%=-0.8% and 0.4% in 0-64 and >65 year-old strata while more vulnerable countries had mean p%=7.0% and 7.2%, respectively. Usually lower death rates were seen in children 0-14 years old during 2020-2023 versus pre-pandemic years. While the pandemic hit some countries earlier than others, country vulnerability dominated eventually the cumulative impact. Half of the analyzed countries witnessed no substantial excess deaths versus pre-pandemic levels, while the other half suffered major death tolls.

State of vulnerable populations in the techquity framework in Hungary

Digital health solutions could alleviate the needs of vulnerable populations in the recent period of the permacrisis, however, there are several barriers that limit their use for certain individuals. We use the four-pillar model of the novel concept of techquity to provide original evidence of the discrepancy in the willingness to try and the ability to harness healthtech in Hungary. We identified three underserved segments of society: older adults, people with long-term activity-limiting conditions, and people experiencing homelessness who could greatly benefit from digital technologies and yet use them less than the general population. We also discuss potential strategic considerations in order to promote techquity and digital inclusion among people living in vulnerable situations.

SARS-CoV-2 Antibody Prevalence among Industrial Livestock Operation Workers and Nearby Community Residents, North Carolina, 2021 to 2022

Industrial livestock operations (ILOs), particularly processing facilities, emerged as centers of coronavirus disease 2019 (COVID-19) outbreaks in spring 2020. Confirmed cases of COVID-19 underestimate true prevalence. To investigate the prevalence of antibodies against SARS-CoV-2, we enrolled 279 participants in North Carolina from February 2021 to July 2022: 90 from households with at least one ILO worker (ILO), 97 from high-ILO intensity areas (ILO neighbors [ILON]), and 92 from metropolitan areas (metro). More metro (55.4%) compared to ILO (51.6%) and ILON participants (48.4%) completed the COVID-19 primary vaccination series; the median completion date was more than 4 months later for ILO compared to ILON and metro participants, although neither difference was statistically significant. Participants provided a saliva swab we analyzed for SARS-CoV-2 IgG using a multiplex immunoassay. The prevalence of infection-induced IgG (positive for nucleocapsid and receptor binding domain) was higher among ILO (63%) than ILON (42.9%) and metro (48.7%) participants (prevalence ratio [PR], 1.38; 95% confidence interval [CI], 1.06 to 1.80; reference category ILON and metro combined). The prevalence of infection-induced IgG was also higher among ILO participants than among an Atlanta health care worker cohort (PR, 2.45; 95% CI, 1.80 to 3.33) and a general population cohort in North Carolina (PRs, 6.37 to 10.67). The infection-induced IgG prevalence increased over the study period. Participants reporting not masking in public in the past 2 weeks had higher infection-induced IgG prevalence (78.6%) than participants reporting masking (49.3%) (PR, 1.59; 95% CI, 1.19 to 2.13). Lower education, more people per bedroom, Hispanic/Latino ethnicity, and more contact with people outside the home were also associated with higher infection-induced IgG prevalence. IMPORTANCE Few studies have measured COVID-19 seroprevalence in North Carolina, especially among rural, Black, and Hispanic/Latino communities that have been heavily affected. Antibody results show high rates of COVID-19 among industrial livestock operation workers and their household members. Antibody results add to evidence of health disparities related to COVID-19 by socioeconomic status and ethnicity. Associations between masking and physical distancing with antibody results also add to evidence of the effectiveness of these prevention strategies. Delays in the timing of receipt of COVID-19 vaccination reinforce the importance of dismantling vaccination barriers, especially for industrial livestock operation workers and their household members.

Evaluating an online self-distancing intervention to promote emotional regulation and posttraumatic growth during the COVID-19 pandemic

OBJECTIVES

Three online studies were conducted to elucidate the role of emotional regulation (ER) in posttraumatic growth (PTG), evaluate the ability of an online self-distancing intervention to achieve ER, and test whether increasing the use of ER strategies promotes PTG.

DESIGN

Cross-sectional (Study 1) and longitudinal randomized controlled trials (RCT) (Studies 2 and 3).

METHOD

In Study 1, 626 adults completed measures of ER, PTG, and psychosocial functioning during the COVID-19 pandemic. In Study 2, 149 adults participated in a five-week RCT comparing self-immersed, spatially self-distanced, and temporally self-distanced reflection in their ability to regulate negative affect. In Study 3, 117 adults replicated the RCT of Study 2 and completed the measures from Study 1 a week pre- and post-intervention.

RESULTS

Path analyses confirmed that ER strategies were relevant to COVID-19-related PTG. MANOVAs revealed that self-distancing was effective in regulating state negative affect. However, ANOVAs suggest that this was not due to increased use of ER strategies and did not improve PTG or psychosocial functioning.

CONCLUSIONS

These findings support further research into the relevance of ER to PTG, and provide a foundation to understand PTG and develop PTG-promoting interventions within a broader stress-coping framework.

Emerging Health Disparities during the COVID-19 Pandemic

The coronavirus disease 2019 (COVID-19) pandemic has underscored social and racial discrimination in global health, showing that health equity is still a goal to be achieved. Understanding the impact of COVID-19 on public health potential is vital to present a fair opportunity for people of different backgrounds to be as healthy as possible. As such, this communication discusses the emerging health disparities in light of the COVID-19 pandemic and analyzes their implications. Original research, effective health communication, and promotion strategies ought to be leveraged to step closer toward national and international health equity.

Neurofilament light chain and vaccination status associate with clinical outcomes in severe COVID-19

Blood neurofilament light chain (NFL) is proposed to serve as an estimate of disease severity in hospitalized patients with coronavirus disease 2019 (COVID-19). We show that NFL concentrations in plasma collected from 880 patients with COVID-19 within 5 days of hospital admission were elevated compared to controls. Higher plasma NFL associated with worse clinical outcomes including the need for mechanical ventilation, intensive care, prolonged hospitalization, and greater functional disability at discharge. No difference in the studied clinical outcomes between black/African American and white patients was found. Finally, vaccination associated with less disability at time of hospital discharge. In aggregate, our findings support the utility of measuring NFL shortly after hospital admission to estimate disease severity and show that race does not influence clinical outcomes caused by COVID-19 assuming equivalent access to care, and that vaccination may lessen the degree of COVID-19-caused disability.

The Use of Five Public Health Themes in Understanding the Roles of Misinformation and Education Toward Disparities in Racial and Ethnic Distribution of COVID-19

The distribution of coronavirus disease 2019 (COVID-19) infection across the historically marginalized populations in the United States (US) has consistently been inequitable. In addition, systemic racism and prejudice, which have existed for decades, have caused a lack of faith in public health and medical experts and have resulted in the epidemic of misinformation. To counteract the COVID-19 pandemic and widespread misinformation, the political establishment and public health experts must work collaboratively. And because they are closely associated, there had been a significant increase in the prevalence of the disease as well as a spike in the number of hospitalizations and fatalities. Public health professionals have investigated a number of epidemiological strategies to stop the spread of the virus and mitigate its effects, but false information released via various media sources has caused serious harm to a number of people. To create the framework and guidelines for protecting audiences from lies and deceit, and eradicating false information before taking root in society, it is essential to understand the types of misinformation that are being spread since the disadvantaged and uneducated communities suffer disproportionately as a result. According to studies, spreading false information could have a negative impact on a country's health outcomes, as well as its economic and social well-being, if not immediately refuted. Public health themes, such as evidence-based programs, health communication, and health policy, among others need to be evaluated and put into action in order to prevent the dissemination of incorrect information. This review examines a number of public health themes, such as policy and evidence-based strategies that might help in the fight against misinformation that has wreaked havoc on families and communities, particularly the underserved and uninformed populations.

Exploration of Multilevel Barriers and Strategies That Affected Early COVID-19 Vaccination and Testing in Rural Latino Communities in Southwest Florida

The COVID-19 pandemic has disproportionately impacted multiple racial and ethnic minority groups, including Latinos residing in rural communities. Low rates of vaccination and testing combined with social determinants of health have contributed significantly to this disparate impact. Given the needs and constraints unique to rural Latino migrant and immigrant communities, this qualitative study examined multilevel barriers and strategies that affect COVID-19 vaccination and testing uptake among these communities in southwest Florida. Four focus groups (n = 25) were conducted between March and April 2021 with various key stakeholders, including rural Latino community members, local leaders, and community health workers ('Promotoras de Salud'). Themes that aligned with barriers to COVID-19 vaccination and testing included fear, lack of control, misinformation, lack of accessibility, and institutional/policy issues; themes that aligned with strategies to improve COVID-19 vaccination and testing uptake included faith, taking care of self, and community and family resilience. Recommendations for improving future pandemic responses for rural Latino communities include incorporating multiple levels of intervention, such as consideration of the role of the family, involving trusted community members, and ensuring the development and implementation of fair and consistent policies.