SARS-CoV-2, the novel coronavirus that causes coronavirus disease 2019 (COVID-19),
was first detected in the United States during January 2020 (
1
). Since then, >980,000 cases have been reported in the United States, including >55,000
associated deaths as of April 28, 2020 (
2
). Detailed data on demographic characteristics, underlying medical conditions, and
clinical outcomes for persons hospitalized with COVID-19 are needed to inform prevention
strategies and community-specific intervention messages. For this report, CDC, the
Georgia Department of Public Health, and eight Georgia hospitals (seven in metropolitan
Atlanta and one in southern Georgia) summarized medical record–abstracted data for
hospitalized adult patients with laboratory-confirmed* COVID-19 who were admitted
during March 2020. Among 305 hospitalized patients with COVID-19, 61.6% were aged
<65 years, 50.5% were female, and 83.2% with known race/ethnicity were non-Hispanic
black (black). Over a quarter of patients (26.2%) did not have conditions thought
to put them at higher risk for severe disease, including being aged ≥65 years. The
proportion of hospitalized patients who were black was higher than expected based
on overall hospital admissions. In an adjusted time-to-event analysis, black patients
were not more likely than were nonblack patients to receive invasive mechanical ventilation
†
(IMV) or to die during hospitalization (hazard ratio [HR] = 0.63; 95% confidence interval
[CI] = 0.35–1.13). Given the overrepresentation of black patients within this hospitalized
cohort, it is important for public health officials to ensure that prevention activities
prioritize communities and racial/ethnic groups most affected by COVID-19. Clinicians
and public officials should be aware that all adults, regardless of underlying conditions
or age, are at risk for serious illness from COVID-19.
Hospitalized cases were selected to describe patients with severe manifestations of
COVID-19 that warranted inpatient management. Data were collected from a convenience
sample of 305 patients at seven hospitals in metropolitan Atlanta (five community
hospitals, one university hospital, and one public hospital) and one community hospital
in southern Georgia. Patients were selected sequentially from lists provided in real
time by hospitals from a total of 698 patients aged ≥18 years who were hospitalized
with laboratory-confirmed COVID-19 during March 1–March 30, 2020, including stays
for observation and deaths in the emergency department. Over a 3-week period, data
were abstracted from electronic medical records and recorded using Research Electronic
Data Capture software (version 8.8.0; Vanderbilt University) (
3
). Hospitalizations for patients transferred between participating hospitals or admitted
multiple times to the same hospital were analyzed as a single hospitalization. Data
on patient race/ethnicity, age, sex, body mass index (BMI), insurance status, residence
(e.g., in a long-term care facility), risk factors for severe COVID-19 (based on currently
available data and clinical expertise)
§
(
4
), and outcomes were abstracted from medical records. Race was categorized as black
(non-Hispanic) or nonblack (all other racial/ethnic groups), and age was analyzed
in three groups: 18–49, 50–64, and ≥65 years. Fisher’s exact tests for proportions
and the Wilcoxon rank sum test or the Kruskal-Wallis H test for medians were used
to test differences identified in descriptive analyses. Multivariable Cox proportional-hazards
analysis was performed on the association between race and time to meeting a composite
outcome of IMV or death, adjusting for age, sex, BMI, hospital, admission date, and
underlying medical conditions (selected through a stepwise Akaike information criterion
approach, which balances a model’s fit against its complexity); censoring was used
to account for patients still hospitalized without receiving IMV. P-values <0.05 were
considered statistically significant. R statistical software (version 3.6.3; The R
Foundation) was used to conduct all analyses.
Among 305 patients hospitalized with COVID-19, the median age was 60 years (range = 23–95
years, interquartile range [IQR] = 46–69 years) (Figure 1); 50.5% of patients were
female, and 284 (93%) were hospitalized in metropolitan Atlanta. Data on race/ethnicity
were available for 297 (97.4%) patients, among whom, 247 (83.2%) were black, 32 (10.8%)
were non-Hispanic white, eight (2.7%) were non-Hispanic Asian or Pacific Islander,
and 10 (3.4%) were Hispanic (Figure 2). Median age was not significantly different
between black patients (60 years, IQR = 45.5–69.0 years) and nonblack patients (64.5
years, IQR = 44.8–74.0 years). Most patients had private insurance (40.1%) or Medicare
(33.4%); 10.9% had Medicaid, and 14.9% were uninsured. Compared with nonblack patients,
black patients were more likely to have Medicaid (13.5% versus 0.0%, p = 0.002) but
not more likely to be uninsured. Overall, 20 (6.6%) patients resided in long-term
care facilities before hospitalization. Current smoking was reported for 5.2% of patients.
FIGURE 1
Age distribution of adults hospitalized with COVID–19 (N = 305) — eight hospitals,
Georgia, March 2020
Abbreviation: COVID-19 = coronavirus disease 2019.
The figure is a bar chart showing the age distribution of adults hospitalized with
COVID–19 (N = 305) in eight hospitals in Georgia during March 2020.
FIGURE 2
Number of hospitalized patients with COVID-19 (N = 305)* (A) and percentage who received
invasive mechanical ventilation or died (B),
†
by race/ethnicity
§
— eight hospitals, Georgia, March 2020
Abbreviations: COVID-19 = coronavirus disease 2019; IMV = invasive mechanical ventilation.
* A total of 273 patients had available race/ethnicity data and known hospitalization
outcomes.
† Vertical bars represent 95% confidence intervals for proportions.
§ Black was defined as non-Hispanic black race/ethnicity; other includes all other
racial/ethnic groups.
The figure is a bar chart (A) and scatter plot (B) showing the number of hospitalized
patients with COVID-19 (N = 305) and percentage who received invasive mechanical ventilation
or died, by race/ethnicity, in eight hospitals in Georgia during March 2020.
Overall, 225 (73.8%) patients had conditions considered high-risk for severe COVID-19
(Table 1). Diabetes was documented in 39.7% of patients. Diabetes was most common
in patients aged 50–64 years (46.5%; p = 0.001) but was not significantly more common
in black patients than in nonblack patients (41.7% versus 32.0%; p = 0.21). Cardiovascular
disease, documented in 25.6% of patients, was more prevalent in those aged ≥65 years
(47.0%; p<0.001) but prevalence was similar in black (25.1%) and nonblack patients
(30.0%) (p = 0.48). Overall, 20.3% of patients had chronic lung disease, with no significant
differences by age or race. Asthma was documented in 10.5% of all patients and chronic
obstructive pulmonary disease in 5.2%. Severe obesity (BMI ≥40), present in 12.7%
of patients, was most common in those aged 18–49 years (21.8%; p<0.001). Severe obesity
did not differ significantly by race, although median BMI was higher in black (31.4
[IQR = 27.6–36.9]) than in nonblack patients (29.6 [IQR = 24.3–32.5]; p = 0.003).
Hypertension (not considered a high-risk condition) was documented in 67.5% of patients
and was more common among black versus nonblack patients (69.6% versus 54.0%; p=0.047).
TABLE 1
Underlying medical conditions of adults hospitalized with COVID-19 (N = 305), by age
group and race/ethnicity* — eight hospitals, Georgia, March 2020
Characteristic
All patients, no. (%) (N = 305)
Age group (yrs)
Race/Ethnicity*,§
No. (%)
P-value†
No. (%)
P-value†
18–49 (n = 89)
50–64 (n = 99)
≥65 (n = 117)
Black (n = 247)
Other (n = 50)
High-risk conditions
None¶
80 (26.2)
47 (52.8)
33 (33.3)
N/A
0.008
62 (25.1)
16 (32.0)
0.38
Any
225 (73.8)
42 (47.2)
66 (66.7)
N/A
N/A
185 (74.9)
34 (68.0)
N/A
Diabetes mellitus
121 (39.7)
21 (23.6)
46 (46.5)
54 (46.2)
0.001
103 (41.7)
16 (32.0)
0.21
Cardiovascular disease
78 (25.6)
10 (11.2)
13 (13.1)
55 (47.0)
<0.001
62 (25.1)
15 (30.0)
0.48
Coronary artery disease
35 (11.5)
1 (1.1)
8 (8.1)
26 (22.2)
<0.001
27 (10.9)
7 (14.0)
0.63
Congestive heart failure
33 (10.8)
8 (9.0)
4 (4.0)
21 (17.9)
0.004
29 (11.7)
4 (8.0)
0.62
Arrhythmia
18 (5.9)
2 (2.2)
1 (1.0)
15 (12.8)
<0.001
11 (4.5)
7 (14.0)
0.018
Chronic lung disease
62 (20.3)
14 (15.7)
26 (26.3)
22 (18.8)
0.18
53 (21.5)
6 (12.0)
0.17
Asthma
32 (10.5)
12 (13.5)
13 (13.1)
7 (6.0)
0.12
30 (12.1)
2 (4.0)
0.13
COPD
16 (5.2)
0 (—)
7 (7.1)
9 (7.7)
0.011
14 (5.7)
1 (2.0)
0.48
Severe obesity (BMI ≥40)**
37 (12.7)
19 (21.8)
14 (14.6)
4 (3.7)
<0.001
33 (13.9)
2 (4.2)
0.088
Immunocompromising conditions or therapies§§
28 (9.2)
9 (10.1)
8 (8.1)
11 (9.4)
0.91
20 (8.1)
7 (14.0)
0.18
End-stage renal disease, on dialysis
16 (5.2)
4 (4.5)
5 (5.1)
7 (6.0)
0.95
15 (6.1)
1 (2.0)
0.49
Liver disease
7 (2.3)
0 (—)
4 (4.0)
3 (2.6)
0.18
4 (1.6)
2 (4.0)
0.27
Other underlying conditions
No underlying conditions
18 (5.9)
13 (14.6)
1 (1.0)
4 (3.4)
<0.001
12 (4.9)
6 (12.0)
0.094
Hypertension
206 (67.5)
30 (33.7)
75 (75.8)
101 (86.3)
<0.001
172 (69.6)
27 (54.0)
0.047
Neurologic disorder
38 (12.5)
8 (9.0)
10 (10.1)
20 (17.1)
0.17
30 (12.1)
6 (12.0)
>0.99
Chronic kidney disease, without dialysis
32 (10.5)
2 (2.2)
12 (12.1)
18 (15.4)
0.003
24 (9.7)
8 (16.0)
0.21
Cancer
12 (3.9)
3 (3.4)
3 (3.0)
6 (5.1)
0.76
10 (4.0)
2 (4.0)
>0.99
Rheumatologic or autoimmune condition
8 (2.6)
1 (1.1)
5 (5.1)
2 (1.7)
0.22
6 (2.4)
2 (4.0)
0.63
Abbreviations: BMI = body mass index; COPD = chronic obstructive pulmonary disease;
COVID-19 = coronavirus disease 2019; IQR = interquartile range; N/A = not applicable.
* Black was defined as non-Hispanic black race/ethnicity; other includes all other
racial/ethnic groups.
† P-values were calculated using Fisher’s exact tests for proportions.
§ Eight patients were excluded from race comparisons because race and ethnicity data
were missing.
¶ Age ≥65 years was considered a high-risk condition.
** BMI data were missing for 13 patients.
§§ Documented conditions included solid organ transplant (eight), human immunodeficiency
virus infection (eight), cancer with chemotherapy receipt within the previous year
(three), stem cell transplant (three), and leukemia (two); 16 patients were taking
immunosuppressive medications.
Among the 305 hospitalized patients, the median duration of hospitalization was 8.5
days and duration increased with age (Table 2). Intensive care unit (ICU) admission
occurred among 119 (39.0%) patients and increased significantly with age group: among
patients aged ≥65 years, 53.8% were admitted to an ICU (p<0.001). Overall, 92 (30.2%)
patients received IMV, representing 77.3% of those admitted to an ICU.
TABLE 2
Health care use, interventions, and outcomes in adults hospitalized with COVID-19
(N = 305), by age group and race/ethnicity* — eight hospitals, Georgia, March 2020
Characteristic of hospitalization
Total no. (%) (N = 305)
Age group (yrs)
Race/Ethnicity*,†
No. (%)
P-value§
No. (%)
P-value§
18–49 (n = 89)
50–64 (n = 99)
≥65 (n = 117)
Black (n = 247)
Other (n = 50)
Health care use
Median hospital duration, days¶
8.5 (5.0–14.0)
7.0 (4.3–11.8)
8.0 (5.0–12.8)
10.0 (6.0–16.0)
0.001
8.0 (5.0–13.8)
8.0 (4.0–14.0)
0.084
Any supplemental oxygen
232 (76.1)
58 (65.2)
70 (70.7)
104 (88.9)
<0.001
186 (75.3)
40 (80.0)
0.59
Nasal cannula
220 (72.1)
57 (64.0)
67 (67.7)
96 (82.1)
0.007
177 (71.7)
37 (74.0)
0.86
Noninvasive ventilation
11 (3.6)
2 (2.2)
4 (4.0)
5 (4.3)
0.80
10 (4.0)
0 (—)
0.22
High-flow nasal cannula
69 (22.6)
13 (14.6)
17 (17.2)
39 (33.3)
0.002
55 (22.3)
14 (28.0)
0.37
ICU admission and interventions
Admitted to ICU
119 (39.0)
24 (27.0)
32 (32.3)
63 (53.8)
<0.001
96 (38.9)
21 (42.0)
0.75
Median ICU duration, days¶
8.0 (5.0–12.0)
7.0 (4.0–14.0)
8.0 (6.0–11.0)
9.0 (5.0–12.0)
0.74
8.0 (5.0–12.0)
9.0 (6.0–11.0)
0.92
Invasive mechanical ventilation
92 (30.2)
17 (19.1)
27 (27.3)
48 (41.0)
0.003
75 (30.4)
16 (32.0)
0.87
Median ventilator days¶
9.0 (5.0–12.0)
8.5 (5.0–13.3)
9.0 (5.5–10.5)
10.0 (6.0–12.0)
0.74
9.0 (5.0–11.5)
9.5 (6.3–13.3)
0.20
Acute renal replacement therapy
23 (7.5)
2 (2.2)
8 (8.1)
13 (11.1)
0.037
19 (7.7)
3 (6.0)
>0.99
Vasopressor support
84 (27.5)
13 (14.6)
21 (21.2)
50 (42.7)
<0.001
70 (28.3)
13 (26.0)
0.86
Cardiopulmonary resuscitation
13 (4.3)
2 (2.2)
3 (3.0)
8 (6.8)
0.25
11 (4.5)
2 (4.0)
>0.99
Outcome
Discharged alive
233 (76.4)
85 (95.5)
83 (83.8)
65 (55.6)
<0.001
192 (77.7)
34 (68.0)
0.15
Still hospitalized
24 (7.9)
1 (1.1)
7 (7.1)
16 (13.7)
0.002
18 (7.3)
6 (12.0)
0.26
Died**
48 (17.1)
3 (3.4)
9 (9.8)
36 (35.6)
<0.001
37 (16.2)
10 (22.7)
0.28
Invasive mechanical ventilation or death**
86 (30.6)
16 (18.2)
22 (23.9)
48 (47.5)
<0.001
69 (30.1)
16 (36.4)
0.48
Abbreviations: COVID-19 = coronavirus disease 2019; ICU = intensive care unit; IQR = interquartile
range.
* Black was defined as non-Hispanic black race/ethnicity; other includes all other
racial/ethnic groups.
† Eight patients were excluded from race comparisons because race and ethnicity data
were missing.
§ P-values were calculated using Fisher’s exact tests for proportions and the Wilcoxon
rank-sum test or the Kruskal-Wallis H test for medians.
¶ Continuous variables are presented as median (IQR).
** Among 281 total patients who were no longer hospitalized, 88 (31.3%) were aged
18–49 years, 92 (32.7%) were aged 50–64 years, and 101 (35.9%) were aged ≥65 years;
among 273 patients with available race/ethnicity data who were no longer hospitalized,
229 (83.9%) were non-Hispanic black, and 44 (16.1) were of other race/ethnicity.
Among 281 (92.1%) patients who were no longer hospitalized at the time of data abstraction,
48 (17.1%) died. Case fatality among patients aged 18–49 years, 50–64 years, and ≥65
years was 3.4%, 9.8%, and 35.6%, respectively (p<0.001). Black patients were not more
likely than were nonblack patients to receive IMV, to die, or to experience the composite
outcome of IMV or death (Figure 2). Among patients without high-risk conditions, 22.5%
were admitted to the ICU, 15.0% received IMV, and 5.1% died while in the hospital.
As of April 24, 2020, 24 (7.9%) patients remained hospitalized, including 14 (58.3%)
in the ICU and nine (37.5%) on IMV. Overall, the estimated percentage of deaths among
patients who received ICU care ranged from 37.0%, assuming all remaining ICU patients
survived, to 48.7%, assuming all remaining ICU patients died. In an adjusted time-to-event
analysis of IMV or death as a composite outcome, no significant difference was found
between black and nonblack patients (HR = 0.63; 95% CI = 0.35–1.13).
Discussion
This report characterizing a cohort of hospitalized adults with COVID-19 in Georgia
(primarily metropolitan Atlanta) found that most patients in the cohort were black,
and black patients had a similar probability of receiving IMV or dying during hospitalization
compared with nonblack patients. Although a larger proportion of older patients had
worse outcomes (IMV or death), a considerable proportion of patients aged 18–64 years
who lacked high-risk conditions received ICU-level care and died (23% and 5%, respectively).
Estimated case fatality among patients who received ICU care was high (37%–49%) but
comparable with that observed in a smaller case series of COVID-19 patients in the
state of Washington (
5
). Among hospitalized patients, 26% lacked high-risk factors for severe COVID-19,
and few patients (7%) lived in institutional settings before admission, suggesting
that SARS-CoV-2 infection can cause significant morbidity in relatively young persons
without severe underlying medical conditions. Community mitigation recommendations
(e.g., social distancing) should be widely instituted, not only to protect older adults
and those with underlying medical conditions, but also to prevent the spread of SARS-CoV-2
among persons in the general population who might not consider themselves to be at
risk for severe illness (
6
).
The proportion of hospitalized patients who were black was higher than expected based
on overall hospitalizations. At four affiliated hospitals, which accounted for 67%
of patients in the cohort, 80% of cohort patients were black compared with 47% of
hospitalized patients overall during March 2020 (D. Murphy, personal communication,
April 7, 2020). Similarly, COVID-NET, which conducts population-based surveillance
for laboratory-confirmed COVID-19–associated hospitalizations across 14 sites nationwide,
¶
found that black persons were disproportionately represented among hospitalized patients
with COVID-19 (
7
). It is important to continue ongoing efforts to understand why black persons are
disproportionately hospitalized for COVID-19, including the role of social and economic
factors (including occupational exposures) in SARS-CoV-2 acquisition risk. It is critical
that public health officials ensure that prevention activities prioritize communities
and racial groups most affected by COVID-19.
The findings in this report are subject to at least three limitations. First, the
data are from a convenience sample of hospitalized adult patients in metropolitan
Atlanta and southern Georgia, and data collection for this assessment was limited
by the intention to conduct the investigation quickly. These patients do not necessarily
represent all hospitalized patients with COVID-19 at those hospitals, or within Georgia.
Second, patients were not tracked after discharge in this investigation. Finally,
race and ethnicity were abstracted from medical records, and methods for recording
these categories might have differed across hospitals, which could result in misclassification.
This report provides valuable clinical data on a large cohort of hospitalized patients.
Although frequency of IMV and fatality did not differ by race, black patients were
disproportionately represented among hospitalized patients, reflecting greater severity
of COVID-19 among this population. Public officials should consider racial differences
among patients affected by COVID-19 when planning prevention activities. Approximately
one quarter of patients had no high-risk conditions, and 5% of these patients died,
suggesting that all adults, regardless of underlying conditions or age, are at risk
for serious COVID-19–associated illness.
Summary
What is already known about this topic?
Older adults and persons with underlying medical conditions are at higher risk for
severe COVID-19. Non-Hispanic black patients are overrepresented among hospitalized
U.S. COVID-19 patients.
What is added by this report?
In a cohort of 305 hospitalized adults with COVID-19 in Georgia (primarily metropolitan
Atlanta), black patients were overrepresented, and their clinical outcomes were similar
to those of nonblack patients. One in four hospitalized patients had no recognized
risk factors for severe COVID-19.
What are the implications for public health practice?
Prevention activities should prioritize communities and racial groups most affected
by severe COVID-19. Increased awareness of the risk for serious illness among all
adults, regardless of underlying medical conditions or age, is needed.