Race, ethnicity, community-level socioeconomic factors, and risk of COVID-19 in the United States and the United Kingdom

Chun-Han Lo^{1

2

3}, Long H Nguyen^{1

2

4}, David A Drew^{1

2}, Erica T Warner^{1

5}, Amit D Joshi^{1

2}, Mark S Graham⁶, Adjoa Anyane-Yeboa², Fatma M Shebl⁷, Christina M Astley^{8

9}, Jane C Figueiredo¹⁰, Chuan-Guo Guo^{1

2

11}, Wenjie Ma^{1

2}, Raaj S Mehta^{1

2

4}, Sohee Kwon^{1

2}, Mingyang Song^{1

2

3

12}, Richard Davies¹³, Joan Capdevila¹³, Carole H Sudre⁶, Jonathan Wolf¹³, Yvette C Cozier¹⁴, Lynn Rosenberg¹⁴, Lynne R Wilkens¹⁵, Christopher A Haiman^{16

17}, Loïc Le Marchand¹⁵, Julie R Palmer¹⁴, Tim D Spector¹⁸, Sebastien Ourselin⁶, Claire J Steves^{18

19}, Andrew T Chan^{1

2

9

20}; COPE Consortium

Affiliations

¹ Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, 100 Cambridge Street, 15th Floor, Boston, MA 02114, USA.
² Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
³ Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
⁴ Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
⁵ Harvard/MGH Center on Genomics, Vulnerable Populations, And Health Disparities, Massachusetts General Hospital, Boston, MA, USA.
⁶ School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK.
⁷ Medical Practice Evaluation Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
⁸ Computational Epidemiology Lab and Division of Endocrinology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.
⁹ Broad Institute of Harvard and MIT, Cambridge, MA, USA.
¹⁰ Department of Medicine, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles California, USA.
¹¹ Department of Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, China.
¹² Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
¹³ Zoe Limited, London, UK.
¹⁴ Slone Epidemiology Center, Boston University, Boston, MA, USA.
¹⁵ Epidemiology Program, University of Hawaii Cancer Center, Honolulu, HI, USA.
¹⁶ Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Norris Comprehensive Cancer Center, Los Angeles, CA, USA.
¹⁷ Center for Genetic Epidemiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
¹⁸ Department of Twin Research and Genetic Epidemiology, King's College London, London, UK.
¹⁹ Department of Ageing and Health, Guy's and St Thomas's NHS Foundation Trust, London, UK.
²⁰ Department of Immunology and Infectious Disease, Harvard T.H. Chan School of Public Health, Boston, MA, USA.

PMID: 34308322
PMCID: PMC8285255
DOI: 10.1016/j.eclinm.2021.101029

Race, ethnicity, community-level socioeconomic factors, and risk of COVID-19 in the United States and the United Kingdom

Chun-Han Lo et al. EClinicalMedicine. 2021 Aug.

. 2021 Aug:38:101029.

doi: 10.1016/j.eclinm.2021.101029. Epub 2021 Jul 17.

Authors

Affiliations

¹ Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, 100 Cambridge Street, 15th Floor, Boston, MA 02114, USA.
² Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
³ Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
⁴ Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
⁵ Harvard/MGH Center on Genomics, Vulnerable Populations, And Health Disparities, Massachusetts General Hospital, Boston, MA, USA.
⁶ School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK.
⁷ Medical Practice Evaluation Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
⁸ Computational Epidemiology Lab and Division of Endocrinology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.
⁹ Broad Institute of Harvard and MIT, Cambridge, MA, USA.
¹⁰ Department of Medicine, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles California, USA.
¹¹ Department of Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, China.
¹² Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
¹³ Zoe Limited, London, UK.
¹⁴ Slone Epidemiology Center, Boston University, Boston, MA, USA.
¹⁵ Epidemiology Program, University of Hawaii Cancer Center, Honolulu, HI, USA.
¹⁶ Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Norris Comprehensive Cancer Center, Los Angeles, CA, USA.
¹⁷ Center for Genetic Epidemiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
¹⁸ Department of Twin Research and Genetic Epidemiology, King's College London, London, UK.
¹⁹ Department of Ageing and Health, Guy's and St Thomas's NHS Foundation Trust, London, UK.
²⁰ Department of Immunology and Infectious Disease, Harvard T.H. Chan School of Public Health, Boston, MA, USA.

PMID: 34308322
PMCID: PMC8285255
DOI: 10.1016/j.eclinm.2021.101029

Abstract

Background: There is limited prior investigation of the combined influence of personal and community-level socioeconomic factors on racial/ethnic disparities in individual risk of coronavirus disease 2019 (COVID-19).

Methods: We performed a cross-sectional analysis nested within a prospective cohort of 2,102,364 participants from March 29, 2020 in the United States (US) and March 24, 2020 in the United Kingdom (UK) through December 02, 2020 via the COVID Symptom Study smartphone application. We examined the contribution of community-level deprivation using the Neighborhood Deprivation Index (NDI) and the Index of Multiple Deprivation (IMD) to observe racial/ethnic disparities in COVID-19 incidence. ClinicalTrials.gov registration: NCT04331509.

Findings: Compared with non-Hispanic White participants, the risk for a positive COVID-19 test was increased in the US for non-Hispanic Black (multivariable-adjusted odds ratio [OR], 1.32; 95% confidence interval [CI], 1.18-1.47) and Hispanic participants (OR, 1.42; 95% CI, 1.33-1.52) and in the UK for Black (OR, 1.17; 95% CI, 1.02-1.34), South Asian (OR, 1.39; 95% CI, 1.30-1.49), and Middle Eastern participants (OR, 1.38; 95% CI, 1.18-1.61). This elevated risk was associated with living in more deprived communities according to the NDI/IMD. After accounting for downstream mediators of COVID-19 risk, community-level deprivation still mediated 16.6% and 7.7% of the excess risk in Black compared to White participants in the US and the UK, respectively.

Interpretation: Our results illustrate the critical role of social determinants of health in the disproportionate COVID-19 risk experienced by racial and ethnic minorities.

Keywords: COVID-19; Epidemiology; Ethnicity; Inequity; Race; Socioeconomic factor.

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Conflict of interest statement

JC reports personal fees from Zoe Ltd. during the conduct of the study and outside the submitted work and is an employee of Zoe Ltd. TDS is a consultant to Zoe Ltd. LLM reports grants from National Cancer Institute during the conduct of the study. SO reports grants from Wellcome Trust, grants from Innovate UK (UKRI), grants from Chronic Disease Research Foundation (CDRF) outside the submitted work. DAD reports grants from National Institutes of Health, grants from American Gastroenterological Association during the conduct of the study and that he previously served as an investigator for a clinical trial of diet and lifestyle using a separate mobile application that was supported by Zoe Ltd. RD reports grants from Department of Health and Social Care (UK), personal fees from Zoe Ltd. during the conduct of the study and outside the submitted work and is an employee of Zoe Ltd. CJS reports grants from Chronic Disease Research Foundation during the conduct of the study. CHS reports grants from Alzheimer's Society during the conduct of the study. CMA reports grants from National Institutes of Health K23 DK120899 and Boston Children's Hospital Office of Faculty Development Career Development Award during the conduct of the study. ATC reports personal fees from Bayer Pharma AG, Pfizer Inc., Boehringer Ingelheim, and grants from Zoe Ltd. outside the submitted work and that he previously served as an investigator for a clinical trial of diet and lifestyle using a separate mobile application that was supported by Zoe Ltd. JW is the CEO of Zoe Ltd. Other authors have no conflict of interest to declare.

Figures

Fig 1 — **Fig. 1**
*Risk of living in a community within the highest quintile of community-level deprivation according to race and ethnicity*. Data points represent the odds ratios with 95% confidence intervals. In both countries, White participants were used as the reference group. “Hispanic” in the United States was defined as any race of Hispanic or Latino ancestry, while other racial categories were defined as each respective race not of Hispanic or Latino ancestry. Community-level deprivation was represented by the Neighborhood Deprivation Index in the United States and the Index of Multiple Deprivation in the United Kingdom. Higher scores represented more deprived communities.

Fig 2 — **Fig. 2**
*Risk of living in community with specific measures of deprivation according to race and ethnicity in the United States*. Data points represent the odds ratios with 95% confidence intervals. White participants were used as the reference group. “Hispanic” was defined as any race of Hispanic or Latino ancestry, while other racial categories were defined as each respective race not of Hispanic or Latino ancestry. Census data from the US Census Bureau were assigned to each participant based on ZIP Code Tabulation Areas. Each domain categorized based on these cutoffs was associated with an increased risk of personal contact with COVID-19 and testing positive for COVID-19 in **Supplementary Fig. 1**.

Fig 3 — **Fig. 3**
*Risk of living in community with specific measures of deprivation according to race and ethnicity in the United Kingdom*. Data points represent the odds ratios with 95% confidence intervals. White participants were used as the reference group. Data from the Office for National Statistics (England), the Welsh Government (Wales), the Scottish Government (Scotland), and the Northern Ireland Statistics and Research Agency (Northern Ireland) were assigned to each participant based on Lower Layer Super Output Areas. Each domain except for housing categorized based on these cutoffs was associated with an increased risk of personal contact with COVID-19 and testing positive for COVID-19 in **Supplementary Fig. 2**.

Fig 4 — **Fig. 4**
*Connections and consequences of social determinants of health in the context of COVID-19 risk*. We propose that social determinants of health are the root causes of health disparities at the population level. Upstream social determinants contribute to midstream factors, such as environmental conditions and occupational factors, which in turn mediate the effects of social determinants of health on downstream health outcomes, including obesity and diabetes, among others. Finally, excess downstream COVID-19 risk is proposed to result from the upstream and midstream factors. Examples of each determinant and their contribution to COVID-19 risk are presented.

See this image and copyright information in PMC

References

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Race, ethnicity, community-level socioeconomic factors, and risk of COVID-19 in the United States and the United Kingdom

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Race, ethnicity, community-level socioeconomic factors, and risk of COVID-19 in the United States and the United Kingdom

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