COVID-19 hospitalizations in the United States: Where is the data on race?

 

The United States has shifted its focus on tracking COVID-19 cases to the use of hospitalizations as a primary metric in assessing “community level risk,” based on the recent guidance from the Centers for Disease Control and Prevention (CDC). However, COVID-19 hospitalization data remains murky, inhibiting public health officials to accurately understand who is getting hospitalized. We discuss the gaps in COVID-19 hospitalization data on race and emphasize the importance of investigating racial disparities as the U.S. has effectively removed all mitigation measures in the middle of the pandemic, abandoning the safety of millions of Americans.

Over the course of the pandemic, research studies have demonstrated that people of color are more likely to test positive for COVID-19, be hospitalized for COVID-19 infection and die from COVID-19 in the U.S. Yet, surveillance data on race seems to have faded into the background.  During the recent surge of COVID-19 cases predominantly due to the Omicron SARS-CoV-2 strain, there was a marked increase in hospitalizations across the U.S., with more than a three-fold increase of the 7-day moving average of daily hospitalizations between November, 2021 and January, 2022. Age-specific analysis during this same period showed a children hospitalization rate that was four times higher than that of the Delta variant wave, with the most increase occurring in children in the 0-4 age group. While there are analyses of hospitalizations by age and race separately, little effort has been made to analyze the racial breakdown of hospitalizations together with vaccination status and other important social factors – age, income level, or education status – that drive hospitalization outcomes. For example, the latest CDC Morbidity and Mortality Weekly report (MMWR) highlighted this significant jump in child hospitalizations during the Omicron surge, but there was no analysis of hospitalizations stratified by race and other included factors, such as age, hospitalization outcome or vaccination status.

Using the same hospitalization dataset from the COVID-19-Associated Hospitalization Surveillance Network (COVID-NET), a population-based surveillance system with data from approximately 100 counties in 14 states, we showed that average weekly hospitalization rates for Black, Hispanic/Latino and Asian/Pacific Islander and American Indian/ Alaska Native (AIAN)  across all age groups were significantly higher compared to whites (14.16, 10.60, and 17.91 per 100,000 vs. 7.40 per 100,000, respectively) over a 23-month period (March 7, 2020 to February 16, 2022; Table 1). During the Omicron-predominant period, the average weekly rates for Black, Hispanic/Latino and AIAN people differed greatly compared to white people (41.48, 19.13, and 29.52 per 100,000 vs. 17.28 per 100,000, respectively).

Table 1: Average Weekly Hospitalization Rates per 100,000 People

 Overall: March 7, 2020 – February 16, 2022Omicron Surge: December 19, 2021 – January 22, 2022
Overall 9.3822.43
American Indian/Alaska Native 17.9129.52
Asian/ Pacific Islander 4.509.48
Black 14.1641.48
Hispanic/ Latino 10.6019.13
White 7.40 17.28

Our trend analysis elucidates that hospitalization rates for people of color have been consistently higher compared to their counterparts throughout the pandemic. Racial disparities widened during the Omicron surge. However, using COVID-NET data available to the public, there is no way to analyze racial disparity within age groups or in conjunction with other social determinants of health, such as income, education, and access to healthcare. Stark racial differences in hospitalizations may be due to varying access to testing and vaccination uptake. These factors are critical to illuminate the role of structural racism and inequality affecting hospitalizations and deaths. Despite recommendations to strengthen surveillance data for COVID-19 throughout the pandemic, the U.S. COVID-19 data landscape remains fragmented and incomplete at national, state, and city levels. This conceals who is hospitalized and whether they live or die.

Structural determinants of health and systemic racism are known to contribute to worse COVID-19 hospitalization outcomes for people of color. People of color tend to hold low-income and essential jobs and live in multi-generational households with fewer resources to protect themselves, placing them at greater risk. Therefore, the CDC and local health departments must carefully track data on COVID-19 hospitalization, disaggregated by age, sex/gender, race, income, and vaccination status. This is critical to understand who are most impacted and to craft targeted public health strategies in response.

The recent removal of all mitigation measures across the US, including vaccination or masks requirements for indoor public places, is an abandonment of marginalized communities which may put them at greater risk for hospitalizations. As policymakers move to prioritize hospital admission as the primary metric to track the pandemic, an equity lens is urgently needed to prioritize data surveillance and public health policies that focus on marginalized populations, particularly for people of color. We need to invest in tracking and analyzing COVID-19 hospitalization data by race and other social factors.

 

About the Authors: Thoai D. Ngo, Ph.D., is the Vice President of Social and Behavioral Science Research at the Population Council. An epidemiologist based in New York City, his research focuses on the intersections between gender, health, and poverty globally.

Danielle Richard is a Research Analyst with the Social and Behavioral Science Research department at Population Council and is an MPH Candidate at the Rollins School of Public Health at Emory University.

Competing Interests: None.

Handling Editor: Neha Faruqui

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