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      Racial Disparities in Incidence and Outcomes Among Patients With COVID-19

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          Key Points

          Question

          Is there an association between race and coronavirus disease 2019 (COVID-19) after controlling for age, sex, socioeconomic status, and comorbidities?

          Findings

          In this cross-sectional study of 2595 patients, positive COVID-19 tests were associated with Black race, male sex, and age 60 years or older. Black race and poverty were associated with hospitalization, but only poverty was associated with intensive care unit admission.

          Meaning

          The results of this study indicate that in the first weeks of the COVID-19 pandemic in Milwaukee, Wisconsin, Black race was associated with a positive COVID-19 test and the subsequent need for hospitalization, but only poverty was associated with intensive care unit admission.

          Abstract

          This cross-sectional study characterizes the association of race with incidence and outcomes of coronavirus disease 2019 (COVID-19), while controlling for age, sex, socioeconomic status, and comorbidities.

          Abstract

          Importance

          Initial public health data show that Black race may be a risk factor for worse outcomes of coronavirus disease 2019 (COVID-19).

          Objective

          To characterize the association of race with incidence and outcomes of COVID-19, while controlling for age, sex, socioeconomic status, and comorbidities.

          Design, Setting, and Participants

          This cross-sectional study included 2595 consecutive adults tested for COVID-19 from March 12 to March 31, 2020, at Froedtert Health and Medical College of Wisconsin (Milwaukee), the largest academic system in Wisconsin, with 879 inpatient beds (of which 128 are intensive care unit beds).

          Exposures

          Race (Black vs White, Native Hawaiian or Pacific Islander, Native American or Alaska Native, Asian, or unknown).

          Main Outcomes and Measures

          Main outcomes included COVID-19 positivity, hospitalization, intensive care unit admission, mechanical ventilation, and death. Additional independent variables measured and tested included socioeconomic status, sex, and comorbidities. Reverse transcription polymerase chain reaction assay was used to test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

          Results

          A total of 2595 patients were included. The mean (SD) age was 53.8 (17.5) years, 978 (37.7%) were men, and 785 (30.2%) were African American patients. Of the 369 patients (14.2%) who tested positive for COVID-19, 170 (46.1%) were men, 148 (40.1%) were aged 60 years or older, and 218 (59.1%) were African American individuals. Positive tests were associated with Black race (odds ratio [OR], 5.37; 95% CI, 3.94-7.29; P = .001), male sex (OR, 1.55; 95% CI, 1.21-2.00; P = .001), and age 60 years or older (OR, 2.04; 95% CI, 1.53-2.73; P = .001). Zip code of residence explained 79% of the overall variance in COVID-19 positivity in the cohort (ρ = 0.79; 95% CI, 0.58-0.91). Adjusting for zip code of residence, Black race (OR, 1.85; 95% CI, 1.00-3.65; P = .04) and poverty (OR, 3.84; 95% CI, 1.20-12.30; P = .02) were associated with hospitalization. Poverty (OR, 3.58; 95% CI, 1.08-11.80; P = .04) but not Black race (OR, 1.52; 95% CI, 0.75-3.07; P = .24) was associated with intensive care unit admission. Overall, 20 (17.2%) deaths associated with COVID-19 were reported. Shortness of breath at presentation (OR, 10.67; 95% CI, 1.52-25.54; P = .02), higher body mass index (OR per unit of body mass index, 1.19; 95% CI, 1.05-1.35; P = .006), and age 60 years or older (OR, 22.79; 95% CI, 3.38-53.81; P = .001) were associated with an increased likelihood of death.

          Conclusions and Relevance

          In this cross-sectional study of adults tested for COVID-19 in a large midwestern academic health system, COVID-19 positivity was associated with Black race. Among patients with COVID-19, both race and poverty were associated with higher risk of hospitalization, but only poverty was associated with higher risk of intensive care unit admission. These findings can be helpful in targeting mitigation strategies for racial disparities in the incidence and outcomes of COVID-19.

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          Most cited references15

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          Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

          Summary Background Since December, 2019, Wuhan, China, has experienced an outbreak of coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Epidemiological and clinical characteristics of patients with COVID-19 have been reported but risk factors for mortality and a detailed clinical course of illness, including viral shedding, have not been well described. Methods In this retrospective, multicentre cohort study, we included all adult inpatients (≥18 years old) with laboratory-confirmed COVID-19 from Jinyintan Hospital and Wuhan Pulmonary Hospital (Wuhan, China) who had been discharged or had died by Jan 31, 2020. Demographic, clinical, treatment, and laboratory data, including serial samples for viral RNA detection, were extracted from electronic medical records and compared between survivors and non-survivors. We used univariable and multivariable logistic regression methods to explore the risk factors associated with in-hospital death. Findings 191 patients (135 from Jinyintan Hospital and 56 from Wuhan Pulmonary Hospital) were included in this study, of whom 137 were discharged and 54 died in hospital. 91 (48%) patients had a comorbidity, with hypertension being the most common (58 [30%] patients), followed by diabetes (36 [19%] patients) and coronary heart disease (15 [8%] patients). Multivariable regression showed increasing odds of in-hospital death associated with older age (odds ratio 1·10, 95% CI 1·03–1·17, per year increase; p=0·0043), higher Sequential Organ Failure Assessment (SOFA) score (5·65, 2·61–12·23; p<0·0001), and d-dimer greater than 1 μg/mL (18·42, 2·64–128·55; p=0·0033) on admission. Median duration of viral shedding was 20·0 days (IQR 17·0–24·0) in survivors, but SARS-CoV-2 was detectable until death in non-survivors. The longest observed duration of viral shedding in survivors was 37 days. Interpretation The potential risk factors of older age, high SOFA score, and d-dimer greater than 1 μg/mL could help clinicians to identify patients with poor prognosis at an early stage. Prolonged viral shedding provides the rationale for a strategy of isolation of infected patients and optimal antiviral interventions in the future. Funding Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences; National Science Grant for Distinguished Young Scholars; National Key Research and Development Program of China; The Beijing Science and Technology Project; and Major Projects of National Science and Technology on New Drug Creation and Development.
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            Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus–Infected Pneumonia in Wuhan, China

            In December 2019, novel coronavirus (2019-nCoV)-infected pneumonia (NCIP) occurred in Wuhan, China. The number of cases has increased rapidly but information on the clinical characteristics of affected patients is limited.
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              Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention

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                Author and article information

                Journal
                JAMA Netw Open
                JAMA Netw Open
                JAMA Netw Open
                JAMA Network Open
                American Medical Association
                2574-3805
                25 September 2020
                September 2020
                25 September 2020
                : 3
                : 9
                : e2021892
                Affiliations
                [1 ]Division of Infectious Diseases, Department of Medicine, Medical College of Wisconsin, Milwaukee
                [2 ]Division of General Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee
                [3 ]Collaborative for Healthcare Delivery Science, Medical College of Wisconsin, Milwaukee
                [4 ]Froedtert Health, Milwaukee, Wisconsin
                [5 ]School of Medicine, Medical College of Wisconsin, Milwaukee
                [6 ]Department of Pathology, Medical College of Wisconsin, Milwaukee
                [7 ]Institute for Health and Equity, Medical College of Wisconsin, Milwaukee
                Author notes
                Article Information
                Accepted for Publication: August 14, 2020.
                Published: September 25, 2020. doi:10.1001/jamanetworkopen.2020.21892
                Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Muñoz-Price LS et al. JAMA Network Open.
                Corresponding Author: L. Silvia Muñoz-Price, MD, PhD, Division of Infectious Diseases, Department of Medicine, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI 53226 ( smunozprice@ 123456mcw.edu ).
                Author Contributions: Drs Muñoz-Price and Pezzin had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
                Concept and design: Muñoz-Price, Nattinger, Rivera, Singh, Buchan, Pezzin.
                Acquisition, analysis, or interpretation of data: Muñoz-Price, Hanson, Gmehlin, Perez, Singh, Ledeboer, Pezzin.
                Drafting of the manuscript: Muñoz-Price, Rivera, Gmehlin, Pezzin.
                Critical revision of the manuscript for important intellectual content: Muñoz-Price, Nattinger, Hanson, Perez, Singh, Buchan, Ledeboer, Pezzin.
                Statistical analysis: Muñoz-Price, Hanson, Pezzin.
                Administrative, technical, or material support: Muñoz-Price, Singh, Ledeboer.
                Supervision: Muñoz-Price, Buchan.
                Conflict of Interest Disclosures: Dr Nattinger reported receiving grants from the National Institutes of Health and the Advancing Healthier Wisconsin Endowment outside the submitted work. Dr Singh reported receiving consulting fees from Astra Zeneca outside the submitted work. Dr Buchan reported receiving grants and personal fees from BioFire Diagnostics outside the submitted work. No other disclosures were reported.
                Article
                zoi200740
                10.1001/jamanetworkopen.2020.21892
                7519420
                32975575
                36b4075b-b196-435b-bf29-9fe253e53b70
                Copyright 2020 Muñoz-Price LS et al. JAMA Network Open.

                This is an open access article distributed under the terms of the CC-BY License.

                History
                : 9 June 2020
                : 14 August 2020
                Categories
                Research
                Original Investigation
                Online Only
                Infectious Diseases

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