Structural racism and COVID-19 response: higher risk of exposure drives disparate COVID-19 deaths among Black and Hispanic/Latinx residents of Illinois, USA | BMC Public Health
Structural racism and COVID-19 response: higher risk of exposure drives disparate COVID-19 deaths among Black and Hispanic/Latinx residents of Illinois, USA | BMC Public Health

Structural racism and COVID-19 response: higher risk of exposure drives disparate COVID-19 deaths among Black and Hispanic/Latinx residents of Illinois, USA | BMC Public Health

Racial and ethnic composition of COVID-19 cases, admissions, and deaths in Illinois

From March 1, 2020, to December 31, 2020, Illinois identified 906,647 cases of SARS-CoV-2 infection among its residents, 18,550 of whom died from COVID-19 by February 10, 2021 (Table 1).

Compared to their share of the population, individuals of Hispanic/Latinx, Native American, or “Other” race/ethnicity were overrepresented among Illinois COVID-19 cases (Fig. 1A). Hispanic/Latinx, Black, and Native American populations were hospitalized and died at higher rates than their portion of overall state demographics, and Black people were overrepresented among admitted cases relative to their share of all cases. The combination of a lower share of cases but higher share of hospitalizations/deaths among Black people suggests either increased susceptibility to severe disease, under-testing, or both, in this population.

Fig. 1

Demographics of cumulative COVID-19 cases, hospital admissions, and deaths in the state of Illinois through December 31, 2020, by A race and ethnicity and B age group, compared with the composition of the general population

In Illinois, older adults and the elderly comprise a disproportionate share of admitted cases and deaths, while cases are only slightly skewed toward older individuals (Fig. 1B). The overrepresentation of older adults among hospitalizations and deaths reflects the known association between age and severe COVID-19. More than 40% of all confirmed COVID-19 deaths among cases detected in this period have been traced to clusters in skilled nursing, rehabilitation, and long-term care facilities. Because the Hispanic/Latinx population is younger in Illinois than the Black population, which is younger than the White population (Fig. S3), age effects should be accounted for when quantifying disparities in COVID-19 burden across racial and ethnic groups. Elderly adults over 70 years old are more than 75% White, while younger people under 40 are less than 60% White. Based on these patterns alone, we expect to see the proportion of admissions and deaths that are White to be greater than the White proportion of cases.

The COVID-19 epidemic in Illinois through December 31, 2020, can be divided into three intervals: the initial outbreak and containment from March through the end of May, when mitigations began to be lifted [15] (interval 1); a second period of lower transmission from June to October (interval 2); and a third surge in cases beginning in October (interval 3) (Fig. 2). Interval 1 disproportionately impacted Black and Hispanic/Latinx residents, who comprised roughly half of all cases, hospitalizations, and deaths from March to June. Throughout the epidemic, White individuals comprise a larger share of hospitalizations and deaths than of cases, suggesting a consistently higher fraction of severe disease among White cases. The elevated case fatality and case hospitalization ratios in the White population is consistent with their older age structure but could also be due to under-detection of milder COVID-19 cases in the younger white population.

Fig. 2
figure 2

Changing racial and ethnic composition of COVID-19 cases, admissions, and deaths through three epidemic intervals. 7-day moving averages (top) and weekly fraction by race/ethnicity (bottom) are shown for each indicator from March 1 to December 31, 2020: A cases B admissions and C deaths. COVID-like illness (CLI) admissions outnumber confirmed COVID-19 admissions in I-NEDSS

Data quality limits the scope of analysis on racial and ethnic disparities in COVID-19. Race and ethnicity were not available for 29.2% of all cases, 4.1% of hospital admissions, and 3.5% of confirmed deaths. Since the peak of interval 1 in late April, the weekly portion of cases without reported race/ethnicity has ranged from 25 to 45%. Compared to COVID-like illness (CLI) admission data from hospitals, admitted cases from I-NEDSS are much lower during interval 3 and also lower during interval 1, suggesting limited completeness of this data field. The remaining analyses therefore focus on cases and deaths rather than admissions.

Testing intensity by age and race/ethnicity

Illinois recorded 12,746,916 total tests and 1,131,284 positive results between March 3 and December 31, 2020, however race/ethnicity was not reported for more than 40% of the dataset (Table 2).

Reporting of COVID-19 cases relies on access to diagnostic testing, and differences in testing rates may contribute to differences in case counts. Testing was low for all groups during interval 1, especially prior to May, just exceeding 1 per 1000 per day in the elderly White population and among Black and Hispanic/Latinx adults (Fig. 3A). Test positivity rates (TPR) for Black and Hispanic/Latinx populations were much higher than in the White population at this time (Fig. 3B), suggesting relatively insufficient testing in Black and Hispanic/Latinx demographics despite their slightly higher rate of per capita testing [16]. TPR exceeded 35% in all Hispanic/Latinx populations over 10 and Black populations over 18 in interval 1, compared with peak values of around 20% in White.

Fig. 3
figure 3

Diagnostic testing intensity and test positivity rate by age and race/ethnicity through December 31, 2020. A 7-day moving average of tests administered per 1000 population. B 7-day moving average of test positivity rate

In May, testing began to expand among Hispanic/Latinx people over 17 years of age, Black people over 22 years, and White people over 60 years, before dropping again for Black people under 41 and Hispanic/Latinx people Under 81 in June. In early July, testing increased sharply for Black adults, who had the highest per capita testing rates outside of the White people over 80. Testing rates for Hispanic/Latinx individuals did not increase as much despite this demographic experiencing the highest caseload during interval 1 and continued high TPR thereafter. During interval 2, test positivity rates remained around 5-10% for Hispanic/Latinx populations, indicating continuous community transmission of SARS-CoV-2.

Testing rates rose rapidly for people ages 18-22 beginning in August, coinciding with the return of students to college campuses where regular routine testing was implemented. The University of Illinois at Urbana-Champaign, for example, was testing its entire on-campus population of more than 25,000 people twice per week [17]. Daily testing rates increased to above 10 per 1000 in for White people ages 18-22 and plateaued at 6 per 1000 and 8 per 1000 for Black and Hispanic/Latinx people ages 18-22 respectively. The higher testing per capita in this age group since September is reflected in their having the lowest test positivity rate (Fig. 3B).

During interval 3, increases in per capita testing were accompanied by increases in TPR for all demographics, indicating that growth in testing failed to keep pace with the growing epidemic. In November, daily testing rates rose above 3 in 1000 for adults in all three major racial and ethnic groups except Hispanic/Latinx people over 70. Testing remained lowest in the Hispanic/Latinx population, which was the only racial/ethnic group to see TPR rise above 20% and for some ages, even above 30% during interval 3.

Temporal trends in age-adjusted disparities in risk of a COVID-19 case

The distribution of COVID-19 cases by age was not the same for the three largest racial and ethnic groups in Illinois. Smoothed daily incidence by race/ethnicity and age group is shown in Fig. 4A. Incidence was highest for Hispanic/Latinx and Black people over 80, exceeding 7-8 per 10,000 per day between April and June, while rates remained below 3 in 10,000 for White people the same age. Meanwhile, daily incidence remained below 1 per 10,000 for White people under 80 years old, lower than for the rate for Black people over 20 and Hispanic-Latinx people in any age group. Incidence in interval 1 was skewed toward the elderly in the White population but less so for Black populations and much less so for Hispanic/Latinx populations.

Fig. 4
figure 4

Age-adjusted disparities in risk of COVID-19 case by race/ethnicity from March 1 to December 31, 2020. A 7-day moving average of COVID-19 cases per 10,000 population, by age and race/ethnicity. BD Relative risk of COVID-19 case over three epidemic intervals. Horizontal lines indicate 95% confidence intervals

During interval 1, the risk of a COVID-19 case was 2.5-5x greater for Black and 2.5-9x greater for Hispanic/Latinx people compared to White people in the same age group (Fig. 4B). Relative risks were lowest in the elderly and increased for younger age groups. For all age groups below 70, relative risks were higher for the Hispanic/Latinx population compared with White than for the Black population compared with White.

Compared with interval 1, incidence was lower in interval 2 (Fig. 4A). Cases in interval 2 in the White population were nearly absent and limited to young adults, especially after universities began to reopen in August. Hispanic/Latinx individuals continued to experience the highest case burden, with incidence above 1 per 10,000 per day for all age groups and above 2 per 100,000 adults ages 21-60, from mid-July onward. In Black demographics, incidence was lower for older age groups, a reversal of the trend seen in the first interval.

Risk of a COVID-19 case in Black and Hispanic/Latinx populations relative to White also decreased in interval 2, although disparities persisted. Hispanic/Latinx individuals of all ages and Black individuals ages 31-80 were 1.5-2.5x more likely to experience a case of COVID-19 than age-matched White individuals during interval 2 (Fig. 4C).

During interval 3, cases increased rapidly beginning in October and quickly exceeded peak numbers from interval 1 for most demographic groups. Compared with interval 1, cases in interval 3 were much younger. Daily incidence rose above 4 per 10,000 for all demographics older than 21. Black and White daily incidence was highest among adults under 50, rising above 5 and 6 per 10,000 respectively. Case burden was especially heavy in the Hispanic/Latinx population, with daily incidence above 10 per 10,000 for working-age adults (ages 21-60). The relative risk of a COVID-19 case compared to White decreased for all demographics in interval 3: the risk of cases in Black demographics was equal to or lower than White, but risk remained elevated for all Hispanic/Latinx demographics (Fig. 4D).

Temporal trends in county-level COVID-19 case disparities by age

We assessed relative risk of a COVID-19 case in non-White vs White individuals at the county level for each age group and each of the 3 epidemic intervals (Fig. 5). When significant, relative risk was always higher in the non-White than in the White population.

Fig. 5
figure 5

Relative risk of COVID-19 cases for non-White individuals compared with White individuals, by county and age group, during each epidemic interval from March 1 to December 31, 2020. Color indicates x-fold increase in risk for non-White vs. White residents. Counties colored white had relative risk that was not significantly different from 1 based on a 95% CI. Relative risk was not calculated (gray) when a minimum of 10 non-White cases and 10 White cases was not met

Cases in interval 1 were primarily located in northeastern Illinois around Cook County, where Chicago is located, and in southwestern counties across the border from St. Louis, Missouri. Disparities were highest in the more suburban counties surrounding Cook County and in the southwest. During intervals 2 and 3, the epidemic spread throughout the state, and the magnitude of disparities decreased across age groups in most counties impacted during interval 1. However, relative risk remained above 1 in the northeast counties for all age groups. In interval 3, disparities were highest among working-age adults in several counties in south central Illinois.

Temporal trends in age-adjusted disparities in risk of a COVID-19 death

Black and Hispanic/Latinx people in Illinois died from COVID-19 at higher rates than White people in 2020 (Fig. 6). Losses were particularly high among minority elders: cumulatively 0.88 and 1.04% of Illinois’ Black and Hispanic/Latinx populations over the age of 60 died from COVID-19 in 2020, compared to 0.54% of the White population over the age of 60.

Fig. 6
figure 6

Age-adjusted disparities in risk of COVID-19 death by race/ethnicity from March 1 to December 31, 2020. A 7-day moving average of COVID-19 deaths per 100,000 population, by age and race/ethnicity. BD Relative risk of COVID-19 death over three epidemic intervals. Horizontal lines indicate 95% confidence intervals. Deaths are binned into intervals based on the date of case, and interval 3 is truncated to remove lagged deaths

Disparities in COVID-19 mortality were largest during interval 1. Throughout the epidemic, the daily per capita death rate remained below 3 per 100,000 for White people under 71. In interval 1, death rates exceeded 3 per 100,000 for Hispanic/Latinx and Black people ages 61-70, 9 per 100,000 for those ages 71-80, and 24 per 100,000 for those over 80. For 1 week in May, the death rate for Hispanic/Latinx people over 80 surpassed 30 per 100,000.

COVID-19 mortality rates during interval 1 were greater in all Hispanic/Latinx and Black demographics than in White, and the relative risk of death increased with younger age (Fig. 6B). Relative risk of COVID-19 death in the Hispanic/Latinx population was significantly higher than in the Black population for the 51-60 age group but not significantly different in other groups. While the absolute risk of death was low for younger adults, Hispanic/Latinx and Black populations under 41 had mortality rates more than 12 times that of the White population during interval 1. Risk of COVID-19 death for Black and Hispanic/Latinx compared to White was 4-6 times higher for those 61-80 and 2 times higher for those over 80.

In interval 2, daily per capita death rates fell below 3 per 100,000 for all demographics except Hispanic/Latinx people over 80. Death rates began to rise again in early October during interval 3. The daily death rate among Hispanic/Latinx people over 80 reached 27 per 100,000 in early December, and death rates were also higher for Hispanic/Latinx individuals 51-80 compared to Black and White populations. In December 2020, the daily death rate for the White over-80 population rose above 15 per 100,000: the highest rate seen in this demographic in 2020. Death rates for Black people of all ages remained below 12 per 100,000 during interval 3.

The relative risk of COVID-19 death for Black and Hispanic/Latinx people compared to Whites fell during intervals 2 and 3 (Fig. 6C, D), reaching 1 for the over-80 age group. Disparities persisted for ages below 70. At the end of 2020, relative risk of COVID-19 death compared to White for ages 51-80 remained significantly higher for Hispanic/Latinx individuals than for Black individuals the same age. Risk of COVID-19 death in individuals under 41 was still 5-10 times higher for Black and Hispanic/Latinx individuals than for White.

To investigate the drivers of disparities in COVID-19 mortality rate, we considered counterfactuals where minoritized populations experienced incidence, case fatality ratio (CFR), or mortality rate at the same level as White people (Fig. 7A). All three counterfactuals reduced mortality for minoritized populations during interval 1, and counterfactual incidence reduced mortality more than counterfactual CFR. This difference suggests that the disparities in COVID-19 mortality early in the epidemic were driven primarily by higher exposure of minoritized populations to SARS-CoV-2, rather than elevated risk of death given detected infection.

Fig. 7
figure 7

COVID-19 deaths attributable to differences in age-adjusted incidence, case fatality ratio, or both, between Asian, Black, and Hispanic/Latinx populations compared to White. A Weekly actual and counterfactual deaths by date of first positive specimen. Solid lines represent the average of 1000 simulation runs; shaded areas are 95% confidence intervals. B Cumulative percent reduction of deaths, counterfactual vs. actual deaths

Starting in June for Asian and September for Black, counterfactual deaths predicted using White incidence begin to exceed the actual deaths observed, reflecting an increased incidence in White populations that outpaced incidence in Asian and Black demographics. Counterfactual deaths remained less than actual deaths among Hispanic/Latinx people, regardless of parameter substitution, indicating continued elevated exposure risk in this demographic.

Cumulatively, substituting age-matched White incidence without adjusting CFR reduced Black deaths by 1402 (41.8%) and Hispanic/Latinx deaths by 1700 (57.6%) (Fig. 7B). Substituting White CFR without adjusting incidence only reduced deaths in these groups by 17-19%. For Asians, substituting White case fatality ratio resulted in fewer deaths than have been reported, although substituting White incidence had the opposite effect. Had they experienced the same average per capita mortality rate as White demographics each week, 1945 (95% CI = 1703- 2189) Hispanic/Latinx people, 1754 (95% CI = 1393-2116) Black people, 45 (95% CI = − 94-187) Asian people, 11 (95% CI = 6-16) Native people, and 79 (95% CI = 61-97) people of “Other” race would not have died of COVID-19 (Fig. 7). By this approach, racial/ethnic disparities account for 3834 (95%CI = 3066-4605) total COVID-19 deaths in Illinois in 2020.

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