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Final Paper

Racial and Ethnic Determinants of Covid 19 Risk and Clinical Outcomes Based on Data

Analytics / Synthesis

INFO-5365 Fall 2021

University of North Texas

Dr. Ana Cleveland & Dr. Craig Drayden

Mounika Pothuraju

December 4, 2021
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Abstract

The novel coronavirus illness had significantly impacted racial and ethnic minorities in 2019.

Race and ethnicity are understudied as risk factors for infection, and I performed data

extraction/synthesis to explore this association. Results are drawn based on the prevalence of

disease, hospital or ICU stay, and mortality. The best possible and valid statistical tests were

applied to mitigate the bias and various confounders. A wide range of studies showed that

COVID-19 infection was more common in Blacks and Asians than Whites. However, there

appear to be conflicting or debatable results regarding hospitalizations and mortality outcomes

after adjustment for differences in socio-demographic and clinical characteristics on admission.

This pandemic gives us a window of opportunity in visualizing, extracting, and managing data in

a new perspective to achieve more equity in health care for all vulnerable groups.
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Introduction

The rationale for choosing this topic is the havoc COVID 19 has created /impacted our

lives. Though I am from a less privileged economic country, the turmoil this pandemic has made

is enormous, and every government, irrespective of its financial status, has taken the burnt.

Economically better communities are supposed to have a robust healthcare system that is time-

tested. But this pandemic has brought us down on our knees, and it has shown us how nature's

fury can have a devastating effect on the primary existence of humankind in this world. As of

June 2020, over 6.4 million cases of Covid-19 have been documented worldwide, with nearly

381,000 deaths ("COVID-19 Map - Johns Hopkins Coronavirus Resource Center", 2021).

By and large, every region and every community in the world has witnessed its

devastating effect. According to previous research, Covid-19 has a profound impact on specific

demographics, such as the elderly, males, obese population having underlying health conditions

like diabetes, chronic kidney issues, asthma, lung conditions, HIV, autoimmune diseases,

immunosuppressed, etc. However, large-scale studies at the time of pandemic have gathered

some evidence and have proven the association of co-morbid conditions to covid and its impact

on relative morbidity and mortality. Previous partial pandemics like H1N1 (Placzek & Madoff,

2021), the present full-blown pandemic Covid have shown us some of the fascinating aspects of

the disparities of the population who succumbed to these diseases. According to studies and

literature, racial and ethnic minorities may account for a disproportionate number of Covid-19

deaths and illnesses (Gu et al., 2021). But Large-scale evidence-based studies in proving

potential racial or ethnic as potential determinants or association factors for infection risk are

limited. We have very scant data available to date. Until now, the majority of Covid-19 risk

estimations have been based on reports that have not been gathered regularly. Most of the time,
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we rely on a patchwork of data from local governments. Therefore, to fortify the public health

domain, regulatory authorities should insist in mandating the reporting of Covid-19 testing

results according to race/ethnicity.

AIM

This project aims to look at whether race and ethnicity are the primary determinants in

the causation of such infectious diseases.

Discussion

Ethnicity is a complex entity composed of genetic makeup, social constructs, cultural

identity, and behavioral patterns. Every race and ethnic group will have a unique genetic

morphology. Similarly, they also have specific socio-demographic and economic conditions in

common. These conditions can be described as where people live, learn, earn, work, play,

workshop. Hence, they have common health risk factors and outcomes. Because of this, all these

factors act as the major determinants in the pursuit of providing health equity. Let us enumerate

all these determinants one by one.

Housing and environment

All the economically less privileged members of society will live in densely populated

areas where social distancing is a distant possibility. At the same time, we observe many family

members staying under the same roof, making things worse, especially in this era of prevalent

contagious diseases.

Education

Less access to primary or high-quality education will have a direct or indirect impact on

the human mind in addressing and understanding various issues related to their health such as

smoking, excess alcohol usage, illicit drug usage, non-adherence to prescribed medication, rigid
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in approaching a health care facility at the earliest, not having awareness about the preventable

diseases and so on ("Race and Education: How Race Affects Education", 2021).

Low income

Low-income status naturally can reflect the low literacy status of that particular person or

group, which will have significant repercussions in our daily lives. Because of their low

education rate, they usually have limited job options. They are generally forced to take up

occupations in frontline, essential, critical, and infrastructure areas. They face more significant

challenges like jobs with significantly less pay, less flexibility to leave or find another job,

usually cannot afford to miss work even if they're sick. All these factors might put them at a

higher risk of exposure.

Healthcare access

Multiple hurdles in accessing health care such as Lack of coverage, accessibility, care for

children, and the capacity to take time off from work, Cultural differences, the language barrier

between individuals and healthcare providers, treatment inequalities, and mistrust in the

healthcare system and government ("Unequal Treatment", 2021).

Discrimination

We see immigration to rich nations searching for jobs, better living conditions, monetary

benefits, and social security in the modern era. This migrant population plays a vital role in some

of the core and primary essential industries which have a massive influence on our economy.

Despite their valuable contribution to shaping our society, this population faces continuous

discrimination in the system. This structural racism can have a severe and vast impact on the

body and mind. It can lead to chronic stress, contributing to accelerated aging and chronic

inflammatory conditions contributing to COVID-19 risk (Geronimus et al., 2021). This sort of
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stigmatization, discrimination, and marginalization of ethnic minorities needs to be addressed to

protect the community's well-being. Having mentioned some of the social determinants which

can influence race and ethnicity, I tried doing a detailed search and extracting data, and drawing

a few conclusions related to it. To establish excellent clinical care policies and public health

policy, I felt a comprehensive synthesis of available studies evaluating the association between

race/ethnicity and COVID-19 was urgently needed.

Action plan

I aim to select a few articles from some reputed journals like Nejm, lancet, Jama, CDC

database, ResearchGate, etc., and manually curate them, understand, analyze, synthesize all the

possible information about race and ethnicity in covid morbidity and mortality. Most of the

articles in the methodology have done a comprehensive meta-analysis of all the literature

available which addressed this issue.

Data Sources and Searches

Most of the articles I have gone through are retrospective cohort studies from various

database platforms like Ovid MEDLINE, PsycINFO, Embase, CINAHL, Cochrane Library,

MedRxiv, PROSPERO, etc. reporting COVID-19 data disaggregated by ethnicity or race. Some

of the studies used an innovative phone application for self-reporting by patients in a prescribed

format with inputs from scientific committees from various hospitals (Drew et al., 2021). Some

studies are from EHRs from multiple health systems across the United States. Papers based on

predictive modeling’s such as mathematical modeling, machine learning, or computational

mapping were excluded. Articles that covered a more significant number of patients over a more

extended period and peer-reviewed were preferred.

Study Selection and Data Collection

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Most of the studies with clinical data have analyzed three things in common in the

suspectable population: the prevalence of covid 19 infection, hospital or ICU admission and

mortality disaggregated by ethnicity. Most of the studies stratified patients into White, Asian

(including South Asian, Asian/Pacific-Islander and Chinese), Black (including the Black

Caribbean and Black African), Hispanic, Native American, Mixed and Other.

Quality Assessment

I have observed Appraisal Tools were used to assess the quality of evidence for some of

the studies relevant to study design.

Data Analysis and Statistical Methods

An academic librarian was one of the core members of analytical statistics in most of the

studies. Statistical endpoints are p-values <0.05 considered statistically significant. Most of the

analyses were performed using R statistical software. Logistic regression models were applied to

examine the odds ratios, and 95% confidence intervals of all patients tested positive for Covid-19

confirmed by a nasopharyngeal swab or patients seeking and receiving treatment as they had

clinical evidence COVID-19 were also included. Fisher's exact proportions and Kruskal-Wallis

H test for medians were used to test differences identified in descriptive analyses. Multivariable

Cox proportional-hazards analysis was performed to establish the association. Most of the

researchers Attempted to mitigate selection bias through IPW inverse probability weighting and

confounding factors through multivariable adjustment. They employed logistic regression to

determine the adjusted odds ratios for a wide known risk or confounding factors like sex,

obesity, diabetes, smoking status, lung, heart or kidney diseases, education, income, population

density, front line health worker status.

Prevalence of Covid-19
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Results in all articles showed us that racial minorities had an increased prevalence of

covid 19 in unadjusted and adjusted models (age and sex-adjusted odds ratio ranging from 1.52

to 3.69), with the highest risk among Blacks and Asians, when compared to white ethnicity.

Clear evidence was gathered through the 'Pooled prevalence' of infected patients, which is

highest in the black race. These findings can be correlated to a study by (Nédélec et al., 2021).

They found that immune response to pathogens from African ancestry was associated with a

more robust inflammatory response than European ancestry.

In ICU Admission

Here the results are mixed. Some of the meta-analysis research papers have described that

though unadjusted models have shown some association with race (Price-Haywood et al., 2021).

This association was attenuated after adjustment for differences in socio-demographic and

clinical characteristics on admission to the hospital (Yehia et al., 2021). In contrast, some

research papers showed a contrasting view where all the Pooled prevalence was highest among

those of Black ethnicity and in adjusted analyses model for hospitalized patients. Asians were

more likely to be admitted to ICU.

Mortality

Some of the reviews had the evidence of the highest Pooled prevalence amongst the

White and Asian ethnicities, and Adjusted analyses showed an increased risk of death in Asian

individuals compared to Whites (Sze et al., 2021). In some studies, Blacks had higher in-hospital

mortality than white adults in unadjusted models but adjusting for comorbidities attenuated this

association. Though this should be taken with caution, as this attenuation does not indicate any

differences in mortality by race, particularly given the disproportionate burden of comorbidities

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in minority ethnics and its association with increased risk of complications and mortality from

COVID-19 (Navar et al., 2021).

To Sum up the Results

Most studies concluded that the prevalence of the disease in ethical minorities is high

compared to other communities, and this is a concerning factor in public health policymaking.

What made this particular group vulnerable is debatable? There is no clear-cut evidence to show

whether their genetic makeup/biological milieu plays a role or the societal, cultural, and

behavioral patterns interplay in spreading the virus.

My Comments

As rightly stated by (Yancy, 2021), it is a privilege to be socially isolated, and everyone

cannot afford that. Until now, minority ethnic groups have been underrepresented in most

medical research ("Racial Disproportionality in Covid Clinical Trials | NEJM", 2021). However,

this new illness presents both fortunate and terrible opportunities to perform trials or studies that

can focus on the origin and extent of health inequities in a way that is relevant to the general

public. Most of the analyses helped visualize the available data, which helped to see the various

limitations in the data we have, like vast heterogeneity, missing data, unstandardized data,

intrinsically low-quality data, and high risk of bias across the multiple research papers. There is

always a possibility of improvisation of data collection and analysis with greater standardization

in adjusted analyses.
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Conclusion

Rigorous research is highly recommended to identify the root causes of inequities in

healthcare delivery at an individual level but also at the community level to establish a robust

healthcare system. This should be achieved by ensuring the inclusion of high-quality,

comprehensive race and ethnicity data in every possible dataset. At the outset of future

pandemics, this information shall be a precursor in making tactical decisions by public health

authorities for the utilization of limited resources in an effective way.

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References

References

COVID-19 Map - Johns Hopkins Coronavirus Resource Center. Johns Hopkins Coronavirus

Resource Center. (2021). Retrieved 3 December 2021, from

https://coronavirus.jhu.edu/map.html.

Drew, D., Nguyen, L., Steves, C., Menni, C., Freydin, M., & Varsavsky, T. et al. (2021). Rapid

implementation of mobile technology for real-time epidemiology of COVID-19.

Retrieved 3 December 2021, from https://pubmed.ncbi.nlm.nih.gov/32371477/

Geronimus, A., Hicken, M., Keene, D., & Bound, J. (2021). “Weathering” and Age Patterns of

Allostatic Load Scores Among Blacks and Whites in the United States. Retrieved 3

December 2021, from https://pubmed.ncbi.nlm.nih.gov/16380565/

Gu, T., Mack, J., Salvatore, M., Prabhu Sankar, S., Valley, T., & Singh, K. et al. (2021).

Characteristics Associated with Racial/Ethnic Disparities in COVID-19 Outcomes in an

Academic Health Care System. Retrieved 3 December 2021, from

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2771935

Navar, A., Purinton, S., Hou, Q., Taylor, R., & Peterson, E. (2021). The impact of race and

ethnicity on outcomes in 19,584 adults hospitalized with COVID-19. Retrieved 3

December 2021, from https://journals.plos.org/plosone/article?

id=10.1371%2Fjournal.pone.0254809

Nédélec, Y., Sanz, J., Baharian, G., Szpiech, Z., Pacis, A., & Dumaine, A. et al. (2021). Genetic

Ancestry and Natural Selection Drive Population Differences in Immune Responses to

Pathogens. Retrieved 3 December 2021, from.

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https://experts.umn.edu/en/publications/genetic-ancestry-and-natural-selection-drive-

population-differenc

Placzek, H., & Madoff, L. (2021). Effect of Race/Ethnicity and Socioeconomic Status on

Pandemic H1N1-Related Outcomes in Massachusetts. Retrieved 3 December 2021, from

https://pubmed.ncbi.nlm.nih.gov/24228651/

Price-Haywood, E., Burton, J., Fort, D., & Seoane, L. (2021). Hospitalization and Mortality

among Black Patients and White Patients with Covid-19. Retrieved 3 December 2021,

from https://pubmed.ncbi.nlm.nih.gov/32459916/

Race And Education: How Race Affects Education. The Annie E. Casey Foundation. (2021).

Retrieved 4 December 2021, from https://www.aecf.org/resources/race-matters-how-

race-affects-education-opportunities.

Racial Disproportionality in Covid Clinical Trials | NEJM. New England Journal of Medicine.

(2021). Retrieved 3 December 2021, from

https://www.nejm.org/doi/full/10.1056/NEJMc2029374.

Sze, S., Pan, D., Nevill, C., Gray, L., Martin, C., & Nazareth, J. et al. (2021). Ethnicity and

clinical outcomes in COVID-19: A systematic review and meta-analysis. Retrieved 3

December 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7658622/

Unequal Treatment. (2021). Retrieved 3 December 2021, from

https://psnet.ahrq.gov/issue/unequal-treatment-confronting-racial-and-ethnic-disparities-

health-care.
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