Disparities in COVID-19 Outcomes by Race, Ethnicity, and Socioeconomic Status: A Systematic-Review and Meta-analysis

Abstract

Importance: COVID-19 has disproportionately affected racial and ethnic minority groups, and race and ethnicity have been associated with disease severity. However, the association of socioeconomic determinants with racial disparities in COVID-19 outcomes remains unclear.

Objective: To evaluate the association of race and ethnicity with COVID-19 outcomes and to examine the association between race, ethnicity, COVID-19 outcomes, and socioeconomic determinants.

Data sources: A systematic search of PubMed, medRxiv, bioRxiv, Embase, and the World Health Organization COVID-19 databases was performed for studies published from January 1, 2020, to January 6, 2021.

Study selection: Studies that reported data on associations between race and ethnicity and COVID-19 positivity, disease severity, and socioeconomic status were included and screened by 2 independent reviewers. Studies that did not have a satisfactory quality score were excluded. Overall, less than 1% (0.47%) of initially identified studies met selection criteria.

Data extraction and synthesis: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Associations were assessed using adjusted and unadjusted risk ratios (RRs) and odds ratios (ORs), combined prevalence, and metaregression. Data were pooled using a random-effects model.

Main outcomes and measures: The main measures were RRs, ORs, and combined prevalence values.

Results: A total of 4 318 929 patients from 68 studies were included in this meta-analysis. Overall, 370 933 patients (8.6%) were African American, 9082 (0.2%) were American Indian or Alaska Native, 101 793 (2.4%) were Asian American, 851 392 identified as Hispanic/Latino (19.7%), 7417 (0.2%) were Pacific Islander, 1 037 996 (24.0%) were White, and 269 040 (6.2%) identified as multiracial and another race or ethnicity. In age- and sex-adjusted analyses, African American individuals (RR, 3.54; 95% CI, 1.38-9.07; P = .008) and Hispanic individuals (RR, 4.68; 95% CI, 1.28-17.20; P = .02) were the most likely to test positive for COVID-19. Asian American individuals had the highest risk of intensive care unit admission (RR, 1.93; 95% CI, 1.60-2.34, P < .001). The area deprivation index was positively correlated with mortality rates in Asian American and Hispanic individuals (P < .001). Decreased access to clinical care was positively correlated with COVID-19 positivity in Hispanic individuals (P < .001) and African American individuals (P < .001).

Conclusions and relevance: In this study, members of racial and ethnic minority groups had higher risks of COVID-19 positivity and disease severity. Furthermore, socioeconomic determinants were strongly associated with COVID-19 outcomes in racial and ethnic minority populations.

Figure 1.. Adjusted, Sex-Adjusted, and Sex- and Age-Adjusted Risk Ratios (RRs) for White, African American, Hispanic, and Asian American Individuals According to COVID-19 Positivity, Hospitalization, Intensive Care Unit (ICU) Admission, and Mortality

Figure 2.. Adjusted, Sex-Adjusted, and Sex- and Age-Adjusted Odds Ratios (ORs) for White, African American, Hispanic, and Asian American Individuals According to COVID-19 Positivity, Hospitalization, Intensive Care Unit (ICU) Admission, and Mortality

Figure 3.. Metaregression of Area Deprivation Index in White Individuals Who Tested Positive for COVID-19 and Asian American and Hispanic Individuals Who Died From COVID-19

The solid line represents the association between the 2 variables. The dashed lines represent the 95% CI. The circles represent the different studies this particular graph is accounting for, while the sizes of the circles represent the weight of each of the studies.

Figure 4.. Metaregression of County Median Income in African American and Hispanic Individuals Who Tested Positive for COVID-19 and African American and Hispanic Individuals Who Died From COVID-19

The solid line represents the association between the 2 variables. The dashed lines represent the 95% CI. The circles represent the different studies this particular graph is accounting for, while the sizes of the circles represent the weight of each of the studies.