The coronavirus pandemic has disproportionally impacted racial and ethnic minority communities in the United States. Patterns of these disparities may be changing over time as outbreaks occur in different communities. Utilizing electronic health record data from the US Department of Veterans Affairs (VA), we estimated odds ratios, stratified by time period and region, for testing positive among 1,313,402 individuals tested for SARS-CoV-2 between February 12, 2020 and August 16, 2021 at VA medical facilities. We adjusted for personal characteristics (sex, age, rural/urban residence, VA facility) and a wide range of clinical characteristics that have been evaluated in prior SARS-CoV-2 reports and could potentially explain racial/ethnic disparities in SARS-CoV-2. Our study found racial and ethnic disparities for testing positive were most pronounced at the beginning of the pandemic and decreased over time. A key finding was that the disparity among Hispanic individuals attenuated but remained elevated, while disparities among Asian individuals reversed by March 1, 2021. The variation in racial and ethnic disparities in SARS-CoV-2 positivity by time and region, independent of underlying health status and other demographic characteristics in a nationwide cohort, provides important insight for strategies to prevent further outbreaks.
The coronavirus pandemic has disproportionally impacted racial and ethnic minority communities in the United States1,2,3. Evidence has highlighted the vast disparities in SARS-CoV-2 infection and subsequent COVID-19 among persons who were Black, Hispanic or Latino, Native Hawaiian/Pacific Islander, American Indian/Alaska Native, or Asian4,5,6,7,8,9,10,11,12. Recently, additional analyses have suggested that racial and ethnic disparities may be changing over time as outbreaks spread from racially and ethnically diverse metropolitan centers to more rural and less diverse areas4,5,13,14. In this report, we updated our previous analyses4,5 to evaluate changes in disparities for testing positive with SARS-CoV-2 over the first 18 months of the pandemic and by geographic region in the largest integrated healthcare system in the United States.
Utilizing national electronic health record data from the US Department of Veterans Affairs (VA), we conducted a retrospective cohort analysis of all Veterans tested for SARS-CoV-2 in VA medical facilities between February 12, 2020 and August 16, 2021. Methods have been previously described in detail4,5. In brief, SARS-CoV-2 tests were identified using a text searching algorithm of laboratory results at VA for terms consistent with SARS-CoV-2 or COVID-19. For individuals with multiple tests, we selected the first positive test. For those without a positive test during the study period, we selected the first negative test. Analysis of test samples was performed in VA, state public health, and commercial laboratories using FDA Emergency Use Authorization-approved SARS-CoV-2 assays. Nearly all the tests utilized nasopharyngeal swabs. We did not include antibody tests in this analysis.
We calculated the crude prevalence of testing positive for SARS-CoV-2 by time and race/ethnicity and calculated confidence intervals using the normal approximation. We used multivariable logistic regression to estimate odds ratios (OR) and 95% confidence intervals (CI) for testing positive for SARS-CoV-2 for Black, Hispanic or Latino (Hispanic), Asian, American Indian/Alaska Native, Native Hawaiian/Pacific Islander, and people of mixed race (Mixed), relative to White individuals. Race and ethnicity were self-reported. Individuals who reported Hispanic ethnicity were included in the Hispanic group regardless of any other self-reported race. A small proportion (4.0%) of individuals tested for SARS-CoV-2 with missing race/ethnicity information were excluded from analysis. All models were adjusted for other personal characteristics (sex, age, rural/urban residence) and a wide range of clinical characteristics that have been evaluated in prior SARS-CoV-2 reports and could potentially explain racial/ethnic disparities in SARS-CoV-2 positivity4,5,15,16. Clinical characteristics included baseline comorbidities (asthma, cancer, chronic kidney disease, chronic obstructive pulmonary disease, diabetes mellitus, hypertension, liver disease, vascular disease), substance use (alcohol consumption, alcohol use disorder, smoking status), medication history (angiotensin converting enzyme inhibitor, angiotensin II receptor blocker). Baseline for personal and clinical characteristics was defined as the date of specimen collection for the selected SARS-CoV-2 test. Models were additionally conditioned on VA site of care.
Models were a priori stratified into five waves based on the temporal distribution of SARS-CoV-2 cases nationally: February 12–May 31, 2020 (wave 1); June 1–September 30, 2020 (wave 2); October 1, 2020–February 28, 2021 (wave 3); March 1, 2021–June 30, 2021 (wave 4); and July 1, 2021–August 16, 2021 (wave 5). Due to the large size of the third national wave, we split this period into two waves containing roughly equal numbers of SARS-CoV-2 cases (October 1–December 11, 2020 (wave 3a); and December 12, 2020–February 28, 2021 (wave 3b).
To evaluate regional differences by time, models were further stratified by US Census region (i.e., West, South, Midwest, and Northeast). Odds ratios in strata by time and region with less than five cases were not reported due to potential privacy concerns and instability of statistical estimates. Data analysis was performed using SAS version 9.4 (SAS Institute, Cary, NC).
This study was approved by the institutional review boards of VA Connecticut Healthcare System (VA AJ0013) and Yale University (1506016006). It has been granted a waiver of informed consent and is Health Insurance Portability and Accountability Act compliant.
Views expressed are those of the authors and the contents of this article do not represent the views of the US Department of Veterans Affairs or the United States Government.
Of 1,313,402 individuals tested for SARS-CoV-2 in the VA between February 2020 and August 2021, there were 144,597 (11.0%) who tested positive for SARS-CoV-2 (Table 1). All non-White groups except for Asian individuals had higher crude prevalence of positive tests than White individuals (10.2%), with the largest differences observed among Black (12.2%), Hispanic (14.1%), and American Indian/Alaska Native (12.0.%) groups. By region, the crude prevalence of positive tests was highest in West (12.3%) and lowest in South (9.6%).
Individuals who were younger or male had a slightly higher crude prevalence of positive tests than those who were older or female. Over time, the prevalence of positive tests increased from 7.0% in wave 1, 6.3% in wave 2, 15.0% in wave 3a, and peaked at 20.5% in wave 3b. There was a marked decrease in the crude prevalence for positive tests in wave 4 to 5.8%, followed by a large increase to 16.2% in wave 5. In wave 1, all racial and ethnic minority groups had a higher unadjusted percentage of positive tests relative to White individuals, with the highest percentage observed among Black individuals at 12.0% (Fig. 1). In wave 3b, the highest percentage was observed among Hispanic individuals at 24.5%. By the end of wave 5, all racial and ethnic minority groups had a higher unadjusted percentage of positive tests relative to White individuals (15.2%), with the exception of Asian individuals who had the lowest at 12.9%. Over the study period, White individuals experienced the steepest increase in test positivity percentage (a 3.2-fold relative increase from 4.6% in wave 1 to 19.5% in the peak wave 3b and a 2.3-fold relative increase overall from 4.6% in wave 1 to 15.2% in wave 5) compared to increases observed in all other racial and ethnic minority groups.
After adjustment for personal and clinical characteristics, those who were Black (OR 1.18, 95% CI 1.17–1.20), Hispanic (1.42, 1.39–1.44), American Indian/Alaska Native (1.14, 1.07–1.21), or Native Hawaiian/Pacific Islander (1.13, 1.06–1.20) had elevated odds of testing positive, with no evidence of disparities among people of Mixed race (0.99, 0.94–1.05) compared to White individuals over the entire study period. Asian individuals had lower odds of testing positive compared to White individuals (0.90, 0.86–0.95) over the entire study period. However, there was substantial variation over time. Disparities for testing positive decreased for all racial and ethnic minorities over the study period (Fig. 2) with the largest disparities present in wave 1. In wave 1, disparities in test positivity were observed among Black (1.98, 1.87–2.11), Hispanic (1.87, 1.71–2.05), Asian (1.44, 1.12–1.84), and American Indian/Alaska Native (1.70, 1.25–2.32) individuals compared to White individuals. There was weak evidence of a disparity for testing positive among Native Hawaiian/Pacific Islander individuals (1.33, 0.97–1.83) and no observed disparity among people of mixed race (1.15, 0.89–1.50) in wave 1. By wave 3b, the peak of test positivity, disparities were not observed among any racial or ethnic minority group, apart from Hispanic individuals (1.34, 1.29–1.40). A notable decrease in test positivity disparity was seen among Black individuals, from a near doubling of odds for testing positive in wave 1 (1.98, 1.87–2.11) to only marginally elevated odds by wave 3b (1.03, 1.00–1.06) compared to White individuals. There was a slight elevation in the odds among Black individuals for wave 4, but by wave 5 there was no observed dispairity in testing positive compared to White individuals. While Asian and American Indian/Alaska Native individuals had increased odds of testing positive in wave 1, this association attenuated rapidly and reversed for some. By the end of wave 4, Asian individuals had a 33% lower odds of testing positive (0.67, 0.55–0.82) compared to White individuals, which persisted into wave 5.
We found some evidence of regional variation in the disparity for testing positive by time. While wave 1 disparities for Black individuals were found in all regions, they were notably higher in the Midwest (2.72, 2.39–3.09) and the South (2.25, 2.03–2.50) compared with the Northeast (1.58, 1.41–1.76) and the West (1.30, 1.07, 1.58) (Fig. 3). Disparities for testing positive among Hispanic individuals were present in all regions across all time points, apart from wave 5. We found evidence of disparities for Asian individuals in wave 1 in the Northeast (1.79, 1.13–2.82) and Midwest (2.05, 1.03–4.09). American Indian/Alaska Native individuals had elevated odds of testing positive in the West in all time periods apart from wave 5, with the highest odds observed in wave 1 (2.23, 1.36–3.66) (Fi
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