Racial Disparities in Incidence of Legionnaires' Disease and Social Determinants of Health: A Narrative Review

Abstract

Objectives: Racial and socioeconomic disparities in the incidence of Legionnaires' disease have been documented for the past 2 decades; however, the social determinants of health (SDH) that contribute to these disparities are not well studied. The objective of this narrative review was to characterize SDH to inform efforts to reduce disparities in the incidence of Legionnaires' disease.

Methods: We conducted a narrative review of articles published from January 1979 through October 2019 that focused on disparities in the incidence of Legionnaires' disease and pneumonia (inclusive of bacterial pneumonia and/or community-acquired pneumonia) among adults and children (excluding articles that were limited to people aged <18 years). We identified 220 articles, of which 19 met our criteria: original research, published in English, and examined Legionnaires' disease or pneumonia, health disparities, and SDH. We organized findings using the Healthy People 2030 SDH domains: economic stability, education access and quality, social and community context, health care access and quality, and neighborhood and built environment.

Results: Of the 19 articles reviewed, multiple articles examined disparities in incidence of Legionnaires' disease and pneumonia related to economic stability/income (n = 13) and comorbidities (n = 10), and fewer articles incorporated SDH variables related to education (n = 3), social support (none), health care access (n = 1), and neighborhood and built environment (n = 6) in their analyses.

Conclusions: Neighborhood and built-environment factors such as housing, drinking water infrastructure, and pollutant exposures represent critical partnership and research opportunities. More research that incorporates SDH and multilevel, cross-sector interventions is needed to address disparities in Legionnaires' disease incidence.

Keywords: Legionnaires’ disease; environmental health; health disparities; pneumonia; social determinants of health.

Figure 1

Crude incidence of reported confirmed cases of Legionnaires’ disease, by year and race, United States, District of Columbia, and New York City, 2014-2018. The crude incidence of cases per 100 000 population is the number of confirmed Legionnaires’ disease cases reported that year divided by the postcensal population estimate for that year x 100 000. Cases of disease due to Legionella are reported to the National Notifiable Diseases Surveillance System (NNDSS) as legionellosis, which includes Legionnaires’ disease, Pontiac fever, and disease due to Legionella infection at extrapulmonary sites, but is referred to as Legionnaires’ disease in this figure (because almost all legionellosis cases reported in the United States are due to Legionnaires’ disease). The year is when the case was reported to the Centers for Disease Control and Prevention. Data sources: 2014-2018 data are from NNDSS.

Figure 2

Flow diagram of selection of articles on racial disparities in Legionnaires’ disease incidence and social determinants of health published from January 1979 through October 2019.