Geographic Variation in Racial Disparities in Mortality From Influenza and Pneumonia in the United States in the Pre-Coronavirus Disease 2019 Era
2021; Elsevier BV; Volume: 159; Issue: 6 Linguagem: Inglês
10.1016/j.chest.2020.12.029
ISSN1931-3543
AutoresSahai Donaldson, Alicia Thomas, Richard F. Gillum, Alem Mehari,
Tópico(s)Emergency and Acute Care Studies
ResumoBackgroundIn 2018, influenza and pneumonia was the eighth leading cause of death in the United States. Since 1950, non-Hispanic blacks (NHBs) have experienced higher rates of mortality than non-Hispanic whites (NHWs). Previous studies have revealed geographic variation in mortality rates by race. The identification of areas with the greatest disparity in influenza and pneumonia mortality may assist policymakers in the allocation of resources, including for the coronavirus disease 2019 pandemic.Research QuestionDoes geographic variation in racial disparity in influenza and pneumonia mortality exist?Study Design and MethodsThe Centers for Disease Control and Prevention database for Multiple Cause of Death between 1999 and 2018 for NHB and NHW decedents ≥ 25 years of age with a Tenth Revision of the International Statistical Classification of Diseases and Related Health Problems code for influenza (J09-J11) and pneumonia (J12-J18) was used. Age-adjusted mortality rates (AAMRs) with 95% CIs were computed by race for Health & Human Services (HHS) regions and urbanization in NHBs and NHWs.ResultsIn 1999 through 2018, there were 540,476 deaths among NHBs and NHWs 25 to 84 years of age. AAMRs were higher in NHBs than NHWs in each age group and in seven of 10 HHS regions. The greatest disparity was in HHS regions 2 (New York and New Jersey) and 9 (Arizona, California, Hawaii, and Nevada). In HHS region 2, NHBs (24.6; 95% CI, 24.1-25.1) were more likely to die than NHWs (15.7; 95% CI, 15.6-15.9). Similarly, in region 9, NHBs (23.2; 95% CI, 22.7-23.8) had higher mortality than NHWs (16.1; 95% CI, 15.9-16.2). Within these regions, disparities were greatest in the core of major metropolitan areas. A very high AAMR in NHBs was noted in large, central metropolitan areas of region 2: 28.2 (95% CI, 27.6-28.9).InterpretationIn 1999 through 2018, the NHB-NHW disparity in AAMRs from influenza and pneumonia was greatest in central metropolitan areas of HHS regions 2 and 9. In 2018, influenza and pneumonia was the eighth leading cause of death in the United States. Since 1950, non-Hispanic blacks (NHBs) have experienced higher rates of mortality than non-Hispanic whites (NHWs). Previous studies have revealed geographic variation in mortality rates by race. The identification of areas with the greatest disparity in influenza and pneumonia mortality may assist policymakers in the allocation of resources, including for the coronavirus disease 2019 pandemic. Does geographic variation in racial disparity in influenza and pneumonia mortality exist? The Centers for Disease Control and Prevention database for Multiple Cause of Death between 1999 and 2018 for NHB and NHW decedents ≥ 25 years of age with a Tenth Revision of the International Statistical Classification of Diseases and Related Health Problems code for influenza (J09-J11) and pneumonia (J12-J18) was used. Age-adjusted mortality rates (AAMRs) with 95% CIs were computed by race for Health & Human Services (HHS) regions and urbanization in NHBs and NHWs. In 1999 through 2018, there were 540,476 deaths among NHBs and NHWs 25 to 84 years of age. AAMRs were higher in NHBs than NHWs in each age group and in seven of 10 HHS regions. The greatest disparity was in HHS regions 2 (New York and New Jersey) and 9 (Arizona, California, Hawaii, and Nevada). In HHS region 2, NHBs (24.6; 95% CI, 24.1-25.1) were more likely to die than NHWs (15.7; 95% CI, 15.6-15.9). Similarly, in region 9, NHBs (23.2; 95% CI, 22.7-23.8) had higher mortality than NHWs (16.1; 95% CI, 15.9-16.2). Within these regions, disparities were greatest in the core of major metropolitan areas. A very high AAMR in NHBs was noted in large, central metropolitan areas of region 2: 28.2 (95% CI, 27.6-28.9). In 1999 through 2018, the NHB-NHW disparity in AAMRs from influenza and pneumonia was greatest in central metropolitan areas of HHS regions 2 and 9. Influenza and pneumonia are the eighth leading cause of death in the United States.1National Center for Health Statistics, Centers for Disease Control and Prevention. Health, United States, 2018 - data finder.https://www.cdc.gov/nchs/hus/contents2018.htmDate accessed: May 14, 2020Google Scholar Because influenza can lead to pneumonia, the two diseases are often grouped together in vital statistics. For example, in 2013, there were a total of 56,832 deaths from influenza and pneumonia, of which only 3,550 were attributed to influenza (6%), whereas 53,282 deaths were attributed to pneumonia.2American Lung AssociationTrends in pneumonia and influenza morbidity and mortality.https://www.lung.org/research/trends-in-lung-diseaseGoogle Scholar Hence, influenza is chiefly a cause of morbidity. In the 1997 Atlas of United States Mortality, there was important geographic variation in mortality from influenza and pneumonia; for example, rates in white men were highest in Appalachia and lowest in the Pacific Northwest (e-Fig 1).3Pickle L.W. Mungiole M. Jones G.K. White A.A. Atlas of United States mortality.https://www.cdc.gov/nchs/data/misc/atlasmet.pdfGoogle Scholar In black men, the highest rates were seen in New York and New Jersey (e-Fig 2).3Pickle L.W. Mungiole M. Jones G.K. White A.A. Atlas of United States mortality.https://www.cdc.gov/nchs/data/misc/atlasmet.pdfGoogle Scholar A number of previous reports have appeared on influenza and pneumonia mortality, which document racial disparities at the local and national level.4Hausmann L.R.M. Ibrahim S.A. Mehrotra A. et al.Racial and ethnic disparities in pneumonia treatment and mortality.Med Care. 2009; 47: 1009-1017Crossref PubMed Scopus (43) Google Scholar, 5Dickerson J.B. Smith M.L. Disparity of risk-adjusted inpatient outcomes among African American and white patients hospitalized with community-acquired pneumonia.Popul Health Manag. 2012; 15: 201-206Crossref PubMed Scopus (1) Google Scholar, 6Cordoba E. Maduro G. Huynh M. Varma J.K. Vora N.M. Deaths from pneumonia—New York City, 1999–2015.Open Forum Infect Dis. 2018; 5Crossref PubMed Scopus (14) Google Scholar In New York City between 1999 and 2015, non-Hispanic blacks (NHBs) experienced a higher annualized age-adjusted pneumonia death rate than non-Hispanic whites (NHWs).6Cordoba E. Maduro G. Huynh M. Varma J.K. Vora N.M. Deaths from pneumonia—New York City, 1999–2015.Open Forum Infect Dis. 2018; 5Crossref PubMed Scopus (14) Google Scholar In the United States, influenza and pneumonia age-adjusted mortality rates were persistently higher in NHBs compared with NHWs in years 1950, 1960, 1970, 1980, 1990, 2000, 2010, and 2017.7National Center for Health Statistics, Centers for Disease Control and Prevention. Health, United States - infographics.https://www.cdc.gov/nchs/hus/spotlight/2019-heart-disease-disparities.htmDate accessed: May 20, 2020Google Scholar The coronavirus disease 2019 (COVID-19) pandemic has focused national attention on black-white disparities in respiratory morbidity and mortality by region.10Yancy C.W. COVID-19 and African Americans.JAMA. 2020; 323: 1891-1892Crossref PubMed Scopus (1430) Google Scholar, 8Holtgrave D.R. Barranco M.A. Tesoriero J.M. Blog D.S. Rosenberg E.S. Assessing racial and ethnic disparities using a COVID-19 outcomes continuum for New York State.Ann Epidemiol. 2020; 48: 9-14Crossref PubMed Scopus (98) Google Scholar, 9Holmes L. Enwere M. Williams J. et al.Black–white risk differentials in COVID-19 (SARS-COV2) transmission, mortality and case fatality in the united states: translational epidemiologic perspective and challenges.Int J Environ Res Public Health. 2020; 17Crossref Scopus (137) Google Scholar The identification of areas with the greatest racial disparity in influenza and pneumonia mortality may assist policymakers in the allocation of resources to address disparities during the COVID-19 pandemic. In this study, the hypothesis was tested that geographic variation existed in the magnitude of black-white racial disparities in mortality rates from influenza and pneumonia from 1999 through 2018. The Centers for Disease Control and Prevention (CDC) database for Multiple Cause of Death (MCOD) 1999-2018 was used for this study.11Centers for Disease Control and Prevention, National Center for Health StatisticsAbout Multiple Cause of Death, 1999-2019 on CDC WONDER Online Database.http://wonder.cdc.gov/mcd-icd10.htmlDate accessed: May 6, 2020Google Scholar MCOD data are taken from death certificates of US residents, including underlying cause of death (UCOD) and demographics, with up to 20 additional multiple causes of death. The UCOD is defined as the chief reason for death identified on the death certificate. The data used are publicly available and use does not constitute research with human subjects according to title 45, part 45 of the Code of Federal Regulations because data were deidentified and of aggregate nature. The total number of decedents with a Tenth Revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) code for influenza (J09-J11) and pneumonia (J12-J18) in the MCOD database was identified for 1999 through 2018. Analyses were limited to NHBs and NHWs. To assess geographic variation in racial disparity of influenza and pneumonia as an UCOD, we used age-adjusted mortality rates grouped by Health & Human Services (HHS) regions and race. See e-Table 1 for definitions of regions. Further detailed analysis in mortality between whites and blacks was limited to two of the 10 HHS regions (regions 2 and 9). The age-adjusted mortality rate was computed by 2006 urbanization (e-Table 2) and race for HHS regions 2 and 9. Large central metropolitan counties are counties in metropolitan statistical areas (MSAs) of ≥ 1 million population that (1) contain the entire population of the largest principal city of the MSA, (2) are completely contained in the largest principal city of the MSA, or (3) contain at least 250,000 residents of any principal city of the MSA. Large fringe metropolitan counties are counties in MSAs of ≥ 1 million population that do not qualify as large central. Medium metropolitan counties are counties in MSAs of 250,000 to 999,999 population. Small metropolitan counties are counties in MSAs of < 250,000 population. Micropolitan counties are counties in micropolitan statistical areas. Noncore counties are nonmetropolitan counties that are not in a micropolitan statistical area.12Ingram DD, Franco SJ. NCHS urban-rural classification scheme for counties. Natl Cent Health Stat. 2012;Vital Health Stat 2(154):72.Google Scholar The crude death rate by race and 10-year age groups was computed for decedents ≥ 25 years of age. For ages 25 to 84 years, age-adjusted mortality rates per 100,000 were computed using the 2,000 US standard population as recommended by the CDC for all studies using CDC data. The 95% CI was calculated for age-adjusted mortality rates for all analyses (e-Table 3). Mortality rates were considered significantly different if the 95% CIs did not overlap. The 95% CI was assessed using normal approximation. In 1999 to 2018 combined, there were 1,038,348 deaths from influenza and pneumonia among NHBs and NHWs ≥ 25 years of age. The UCOD crude death rate was significantly higher in NHBs than NHWs at each 10-year age group in those ≥ 25 years of age (e-Fig 3, Table 1). The black-white relative disparity was greatest at 45 to 54 years of age and least at 75 to 84 years of age. At ≥ 85 years of age, the rate was higher in NHWs, likely because of residual confounding by age in this wide age interval.Table 1Age-Specific Death Rates of Influenza and Pneumonia (Tenth Revision of the International Statistical Classification of Diseases and Related Health Problems J09-J18) as an Underlying Cause of Death in Non-Hispanic Blacks and Whites ≥ 25 Years of Age Between 1999 and 201810-Year Age GroupsRaceDeathsPopulationCrude RateCrude Rate 95% CI25-34Black1,864110,800,1101.681.61-1.7625-34White4,747494,084,9770.960.93-0.9935-44Black4,096107,895,5203.803.68-3.9135-44White11,249543,346,6072.072.03-2.1145-54Black8,781101,411,4668.668.48-8.8445-54White27,723594,643,6714.664.61-4.7255-64Black13,54472,918,03218.5718.26-18.8955-64White54,949511,925,00710.7310.64-10.8265-74Black18,69941,612,85344.9444.29-45.5865-74White106,432350,832,89630.3430.15-30.5275-84Black27,26221,132,803129.00127.47-130.5375-84White261,130218,350,899119.59119.13-120.05≥ 85Black32,1627,604,689422.92418.30-427.55≥ 85White465,71089,741,899518.94517.45-520.43TotalBlack106,408463,375,47322.9622.83-23.1TotalWhite931,9402,802,925,95633.2533.18-33.32TotalBlack-white1,038,3483,266,301,42931.7931.73-31.85 Open table in a new tab All further analyses are limited to decedents 25 to 84 years of age to avoid this problem. Of these, 540,476 had influenza and pneumonia (J09-J18) as an UCOD, of which influenza (J09-J11) accounted for 25,538 and pneumonia (J12-J18) 514,938. Between 1999 and 2018, the age-adjusted mortality rate for influenza and pneumonia was higher in NHBs than NHWs (e-Fig 4, Table 2). The age-adjusted mortality peaked in 2008 for both groups; rates were significantly higher in NHBs than NHWs in each year.Table 2Annual Age-Adjusted Mortality Rate of Influenza and Pneumonia (Tenth Revision of the International Statistical Classification of Diseases and Related Health Problems J09-J18) as an Underlying Cause of Death in Non-Hispanic Blacks and Whites 25 to 84 Years of Age Between 1999 and 2018YearRaceDeathsPopulationCrude RateAge-Adjusted RateAge-Adjusted Rate 95% CI1999Black3,61319,498,79518.5324.0123.22-24.811999White26,105131,306,16119.8817.9817.76-18.202000Black3,83419,743,80019.4225.4524.63-26.272000White26,731131,508,23220.3318.3018.08-18.522001Black3,62920,095,37418.0623.4922.71-24.262001White25,019131,892,97918.9716.9716.76-17.182002Black3,70420,388,93618.1723.5222.75-24.282002White26,725132,220,39620.2117.9517.73-18.162003Black3,83320,674,84718.5423.5222.76-24.282003White26,284132,526,97619.8317.5817.37-17.792004Black3,65521,016,70417.3922.2821.54-23.012004White24,309133,006,53718.2816.1615.95-16.362005Black3,79921,381,81617.7722.4221.69-23.142005White25,383133,550,75719.0116.7616.55-16.972006Black3,41521,761,50215.6919.8819.19-20.562006White22,877134,157,31317.0515.0614.86-15.252007Black3,35722,131,53915.1718.9718.31-19.632007White20,643134,717,90815.3213.5513.36-13.732008Black3,70422,501,43716.4620.4019.72-21.072008White22,203135,313,29416.4114.4514.26-14.642009Black3,59622,866,19215.7319.0518.40-19.692009White22,121135,864,84616.2814.4214.23-14.612010Black3,27123,154,81814.1317.3516.74-17.962010White19,866136,309,09814.5712.8212.64-13.002011Black3,44323,562,86114.6117.4416.84-18.042011White21,397136,932,70715.6313.6413.46-13.832012Black3,34223,926,81013.9716.4815.90-17.062012White19,711137,482,49514.3412.3712.19-12.542013Black3,81424,309,10615.6917.9417.35-18.522013White22,315138,013,13516.1713.8113.62-13.992014Black3,85324,794,52415.5417.3916.82-17.962014White22,926138,553,06616.5513.9913.81-14.182015Black3,90725,286,62915.4517.3716.81-17.932015White22,458139,202,55816.1313.4013.22-13.582016Black3,96025,734,60815.3916.9216.38-17.472016White21,453139,796,01415.3512.5812.41-12.762017Black4,04626,269,76215.4016.8216.29-17.362017White22,814140,251,65716.2713.0112.83-13.182018Black4,47126,670,72416.7617.9517.41-18.492018White24,890140,577,92817.7113.8813.70-14.05TotalBlack-white540,4763,168,954,84117.0615.4715.43-15.52 Open table in a new tab In 1999 to 2018, age-adjusted mortality rates varied by regions in NHBs and NHWs (e-Figs 5, 6). The age-adjusted mortality rate was higher in NHBs than NHWs in seven of 10 HHS regions for decedents 25 to 84 years of age (e-Figs 5, 6; Table 3). Most notably, in HHS region 2 (New York and New Jersey), NHBs (24.59; 95% CI, 24.12-25.06) were significantly more likely to die than NHWs (15.71; 95% CI, 15.56-15.86). Similarly, in region 9 (Arizona, California, Hawaii, and Nevada), NHBs (23.24; 95% CI, 22.67-23.82) were significantly more likely to die than NHWs (16.06; 95% CI, 15.92-16.19). Mortality rates in NHBs and NHWs were similar in HHS regions 1, 8, and 10.Table 3Age-Adjusted Mortality Rate for Influenza and Pneumonia (Tenth Revision of the International Statistical Classification of Diseases and Related Health Problems J09-J18) as an Underlying Cause of Death by HHS Regions in Non-Hispanic Blacks and Whites 25 to 84 Years of Age During 1999 to 2018HHS Region CodeRaceDeathsPopulationCrude RateAge-Adjusted RateAge-Adjusted Rate 95% CI1Black1,0461,034,20610.1213.3212.49-14.151White25,858159,031,38916.2614.1713.99-14.342Black10,86650,794,24721.3924.5924.12-25.062White43,691231,331,01118.8915.7115.56-15.863Black9,62362,883,31015.3017.6817.32-18.043White50,111288,920,97717.3414.8514.72-14.984Black23,038149,309,43015.4318.7618.51-19.014White101,833538,679,91618.9015.5815.48-15.675Black11,65868,656,20616.9819.6719.31-20.045White82,800534,120,48215.513.9313.84-14.036Black9,05759,910,45415.1219.1718.76-19.586White49,141271,635,85918.0916.1115.97-16.267Black1,78011,705,91115.2118.6717.78-19.567White26,621148,514,22317.9215.5215.33-15.718Black2673,079,0088.6712.2310.67-13.788White13,993108,255,57712.9312.8912.67-13.109Black6,59334,764,51918.9623.2422.67-23.829White57,538299,995,54119.1816.0615.92-16.1910Black3184,333,4937.3411.179.86-12.4910White14,644132,699,08211.0410.4010.23-10.57TotalBlack-white540,4763,168,954,84117.0615.4715.43-15.52HHS = Health & Human Services. Open table in a new tab HHS = Health & Human Services. Analysis by urbanization level was done for regions 2 (e-Fig 7, Table 4) and 9. The age-adjusted mortality rate in HHS region 2 was significantly higher for NHBs in medium (19.09; 95% CI, 17.46-20.71 vs NHWs: 15.45; 95% CI, 15.05-15.84) to large central metropolitan (28.23; 95% CI, 27.61-28.85 vs NHWs: 20.16; 95% CI, 19.84-20.48) areas, with the greatest disparity in the large central metropolitan areas. However, rates were nearly equal in small metropolitan areas and higher in whites in nonmetropolitan areas (Table 4). Similarly, in region 9 (e-Table 4), NHBs had significantly higher mortality rates in medium (19.57; 95% CI, 17.97-21.17) to large central metropolitan (24.57; 95% CI, 23.89-25.24) areas compared with NHWs (medium metropolitan: 15.96; 95% CI, 15.65-16.26; large central metropolitan: 16.53; 95% CI, 16.35-16.71). However, in small metropolitan areas, the mortality rates were nearly equal and in micropolitan areas NHBs were less likely to die. The age-adjusted mortality rate for NHBs was unreliable in nonmetropolitan areas and not shown (e-Fig 8). Much of the disparity was caused by extremely high mortality rates in NHBs in these areas; for example, the highest rate observed was in NHBs in region 2 (large central metropolitan areas: 28.23; 95% CI, 27.61-28.85). The lowest rate observed was in NHWs in region 10 (10.4; 95% CI, 10.23-10.57).Table 4Age-Adjusted Mortality Rate for Influenza and Pneumonia (Tenth Revision of the International Statistical Classification of Diseases and Related Health Problems J09-J18) as an Underlying Cause of Death in Health & Human Services Region 2 by 2006 Urbanization in Non-Hispanic Blacks and Whites 25 to 84 Years of Age During 1999 to 20182006 UrbanizationRaceDeathsPopulationCrude RateAge-Adjusted RateAge-Adjusted Rate 95% CILarge central metropolitanBlack8,19832,567,02925.1728.2327.61-28.85Large central metropolitanWhite15,48365,067,29623.8020.1619.84-20.48Large fringe metropolitanBlack1,93613,172,73614.7016.9516.17-17.72Large fringe metropolitanWhite16,538102,897,90816.0713.1112.91-13.31Medium metropolitanBlack5613,636,95715.4219.0917.46-20.71Medium metropolitanWhite5,99833,496,67817.9115.4515.05-15.84Small metropolitanBlack114816,78213.9619.5215.77-23.26Small metropolitanWhite2,11011,144,23418.9315.2914.63-15.95Micropolitan (nonmetropolitan)Black35411,5498.5017.6111.88-25.14Micropolitan (nonmetropolitan)White2,56913,471,74519.0716.0315.41-16.66Noncore (nonmetropolitan)Black22189,19411.6319.2611.77-29.75Noncore (nonmetropolitan)White9935,253,15018.9015.2614.30-16.22TotalBlack-white54,557282,125,25819.3417.0116.87-17.16 Open table in a new tab This analysis of black-white disparities in mortality from influenza and pneumonia in the United States in the years 1999 to 2018 documents major disparities throughout the period at 25 to 84 years of age. However, these disparities varied by region, being greatest in HHS region 2 (New York and New Jersey) and region 9 which includes California. Within regions 2 and 9, disparities were greatest in core areas of major metropolitan areas. There was a nearly threefold difference between the highest and lowest rates observed. However, no racial disparities were observed in HHS regions 1, 8, and 10. Why did some regions have racial disparities while others did not? It may be helpful to compare characteristics of regions with large racial disparities vs those without racial disparities. Characteristics of regions with large disparities (HHS regions 2 and 9) include the following: (1) large NHB populations, in excess of 34 million people; (2) a high percentage of NHBs in regions 2 (18%) and 9 (10%); (3) levels of mortality rates in NHBs much higher than NHBs or NHWs in other regions; and (4) two of the largest cities in the United States (New York City and Los Angeles). Within regions 2 and 9, the greatest disparities were in large central metropolitan areas, which had extremely high rates in NHBs. Characteristics of regions without racial disparities (HHS regions 1, 8, and 10) include the following. First, there were relatively small NHB populations. Second, there were relatively low percentages of NHBs in regions 1 (6%), 8 (3%), and 10 (3%). Third, mortality rates were relatively low for NHBs and NHWs compared with other regions. Fourth, there were few if any large cities. Finally, no racial disparity was seen in the small metropolitan and micropolitan areas of region 9. These findings suggest that the main factors driving large disparities in regions 2 and 9 are the extremely high rates of blacks in large central metropolitan areas of New York City, Los Angeles, and other major metropolitan areas. What factors are likely to explain the extremely high pneumonia mortality rate among NHBs in large metropolitan areas in regions 2 and 9 (eg, New York City, Los Angeles)? In a US Census 2000 special report, 86.5% of blacks were living in metropolitan areas.13US Census BureauRacial and ethnic residential segregation in the United States: 1980-2000.https://www.census.gov/prod/2002pubs/censr-3.pdfGoogle Scholar These areas feature high rates of poverty in NHBs, lack of well-paying jobs, and limited access to quality health-care and preventative services. Blumenshine et al14Blumenshine P. Reingold A. Egerter S. Mockenhaupt R. Braveman P. Marks J. Pandemic influenza planning in the United States from a health disparities perspective.Emerg Infect Dis. 2008; 14: 709-715Crossref PubMed Scopus (173) Google Scholar in 2008 proposed a theoretical model to address health disparities.15Quinn S.C. Kumar S. Freimuth V.S. Musa D. Casteneda-Angarita N. Kidwell K. Racial disparities in exposure, susceptibility, and access to health care in the US H1N1 influenza pandemic.Am J Public Health. 2011; 101: 285-293Crossref PubMed Scopus (188) Google Scholar Racial and ethnic inequality was later analyzed in three broad categories: exposure, susceptibility, and access to health care.14Blumenshine P. Reingold A. Egerter S. Mockenhaupt R. Braveman P. Marks J. Pandemic influenza planning in the United States from a health disparities perspective.Emerg Infect Dis. 2008; 14: 709-715Crossref PubMed Scopus (173) Google Scholar Prevalence of chronic diseases and advanced age affects susceptibility and mortality from pneumonia. The pneumococcal vaccine is recommended to help prevent pneumonia for all adults ≥ 65 years of age and in high risk groups.2American Lung AssociationTrends in pneumonia and influenza morbidity and mortality.https://www.lung.org/research/trends-in-lung-diseaseGoogle Scholar In 2014, blacks ≥ 65 years of age were less likely to report pneumonia vaccination (47%) than whites (62%); additionally blacks (37.4%) also had lower influenza vaccination rates than whites (46.3%).2American Lung AssociationTrends in pneumonia and influenza morbidity and mortality.https://www.lung.org/research/trends-in-lung-diseaseGoogle Scholar The CDC's influenza vaccination reports for 2010 to 2011 in the most affected HHS regions (2 and 9) showed nonsignificantly lower rates in NHBs than NHWs.16Centers for Disease Control and Prevention2010-11 through 2019-20 influenza seasons vaccination coverage trend report.https://www.cdc.gov/flu/fluvaxview/reportshtml/trends/index.htmlDate accessed: December 17, 2020Google Scholar In region 2, NHBs had 40.4% (95% CI, 36.5-44.3) influenza vaccination rate compared with 44.7% in NHWs (95% CI, 43.1-46.3). This was similar to the rates in region 9: NHBs had a 36.8% (95% CI, 31.3-42.3) influenza vaccination rate compared with 41.4% in NHWs (95% CI, 40.0-42.8). Pneumococcal vaccination coverage for 2018 did show disparity in HHS region 2 for people ≥ 65 years of age (NHBs: 52.0%; 95% CI, 45.2-58.8 vs NHWs: 70.2%; 95% CI, 67.4-73).17Centers for Disease Control and Prevention2018 adult vaccination coverage general population dashboard.https://www.cdc.gov/vaccines/imz-managers/coverage/adultvaxview/data-reports/general-population/dashboard/2018.htmlDate accessed: December 17, 2020Google Scholar However, this disparity was not seen in people 18 to 64 years of age (NHBs: 29.0%; 95% CI, 23.6-34.4 vs NHWs: 28.0%; 95% CI, 25.4-30.6). There was also no significant disparity seen in HHS regions 9 for either people ≥ 65 years of age (NHBs: 64.0%; 95% CI, 54.1-73.9 vs NHWs: 74.9%; 95% CI, 72.8-77) or in people 18 to 64 years of age (NHBs: 27.7%; 95% CI, 19.5-35.9 vs NHWs: 36.2%; 95% CI, 33.2-39.2). In another cross-sectional study in 2013 including participants in four cities (Rochester, New York; Milwaukee, Wisconsin; Chicago, Illinois; and 19 delta counties in Mississippi) belonging to HHS regions 2, 4, and 5, NHBs were less likely than NHWs to receive both the pneumococcal and influenza vaccines.18Winston C.A. Wortley P.M. Lees K.A. Factors associated with vaccination of Medicare beneficiaries in five U.S. communities: results from the racial and ethnic adult disparities in immunization initiative survey, 2003.J Am Geriatr Soc. 2006; 54: 303-310Crossref PubMed Scopus (141) Google Scholar Although NHBs have lower influenza and pneumococcal vaccination rates than NHWs nationally, the variation in influenza and pneumonia mortality seen in HHS regions 2 and 9 in this study cannot be explained by vaccination uptake rates alone. A greater burden of chronic illnesses among NHBs is well documented when compared with NHWs. NHBs have the highest overall coronary heart disease mortality rate of any racial/ethnic group.7National Center for Health Statistics, Centers for Disease Control and Prevention. Health, United States - infographics.https://www.cdc.gov/nchs/hus/spotlight/2019-heart-disease-disparities.htmDate accessed: May 20, 2020Google Scholar Diabetes mellitus is also five times more common in minorities when compared with NHWs.15Quinn S.C. Kumar S. Freimuth V.S. Musa D. Casteneda-Angarita N. Kidwell K. Racial disparities in exposure, susceptibility, and access to health care in the US H1N1 influenza pandemic.Am J Public Health. 2011; 101: 285-293Crossref PubMed Scopus (188) Google Scholar Racial differences in severity of illnesses exist because NHBs are more likely to be hospitalized with pneumonia19Hayes B.H. Haberling D.L. Kennedy J.L. Varma J.K. Fry A.M. Vora N.M. Burden of pneumonia-associated hospitalizations.Chest. 2018; 153: 427-437Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar and have a higher incidence of bacteremic pneumonia compared with NHWs, even when controlled for age and poverty level.20Burton D.C. Flannery B. Bennett N.M. et al.Socioeconomic and racial/ethnic disparities in the incidence of bacteremic pneumonia among US adults.Am J Public Health. 2010; 100: 1904-1911Crossref PubMed Scopus (99) Google Scholar A retrospective cohort study, with 1,183,753 adults hospitalized for pneumonia between January 2005 and June 2006, showed that NHBs were more likely to not receive antibiotics within 4 h and more likely to die than NHWs at the same hospital.4Hausmann L.R.M. Ibrahim S.A. Mehrotra A. et al.Racial and ethnic disparities in pneumonia treatment and mortality.Med Care. 2009; 47: 1009-1017Crossref PubMed Scopus (43) Google Scholar The increased incidence of severe illness from pneumonia and decreased access to standard care for NHBs may explain the racial disparities in pneumonia mortality when compared with NHWs. This analysis of influenza and pneumonia mortality may have particular interest because of the current racial disparities in the COVID-19 pandemic.8Holtgrave D.R. Barranco M.A. Tesoriero J.M. Blog D.S. Rosenberg E.S. Assessing racial and ethnic disparities using a COVID-19 outcomes continuum for New York State.Ann Epidemiol. 2020; 48: 9-14Crossref PubMed Scopus (98) Google Scholar,9Holmes L. Enwere M. Williams J. et al.Black–white risk differentials in COVID-19 (SARS-COV2) transmission, mortality and case fatality in the united states: translational epidemiologic perspective and challenges.Int J Environ Res Public Health. 2020; 17Crossref Scopus (137) Google Scholar In preliminary data from John Hopkins University and American Community survey of 130 predominant black counties in the United States, the death rate was sixfold higher than in predominantly white counties.10Yancy C.W. COVID-19 and African Americans.JAMA. 2020; 323: 1891-1892Crossref PubMed Scopus (1430) Google Scholar NHBs are dying disproportionately from COVID-19 infection. What is interesting about the results of this study is that the current HHS regions with the greatest racial disparities in influenza and pneumonia mortality are also the current hotspots of COVID-19. It is hypothesized that the geographic variation in racial disparities in pneumonia mortality reported here will also be observed for COVID-19 mortality.21Adhikari S. Pantaleo N.P. Feldman J.M. Ogedegbe O. Thorpe L. Troxel A.B. Assessment of community-level disparities in Coronavirus Disease 2019 (COVID-19) infections and deaths in large US metropolitan areas.JAMA Netw Open. 2020; 3e2016938Crossref PubMed Scopus (212) Google Scholar,22Wadhera R.K. Wadhera P. Gaba P. et al.Variation in COVID-19 hospitalizations and deaths across New York City boroughs.JAMA. 2020; 323: 2192-2195Crossref PubMed Scopus (485) Google Scholar Strength of this study includes the following: data were available from all states and District of Columbia via the same reporting mechanisms provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative. Death numbers do not rely on sampling but are complete counts. Mortality rates at 25 to 84 years of age were all age-adjusted by the 2000 US Standard population. However, there were several limitations. There is no required training mandated nationwide for death certificate completion and death certificates may be completed with varying diagnostic accuracy. Autopsy rates are very low. Data on death certificates do not include variables such as education, income, country of birth, and access to health insurance for use in investigation of racial disparities. Another limitation was that statistically significances among rates were determined by pairwise comparisons of CIs and not multiple regression statistical analysis and did not account for multiple comparisons. However, large numbers of deaths result in narrow CIs. Continuing detailed monitoring of racial disparities at the national, regional, state, and local level is warranted to guide public health action. Multiple harmful biosocial conditions (poverty, homelessness, and lack of health insurance) interact synergistically resulting in excess burden of disease in the NHB population.23Tsai A.C. Venkataramani A.S. Syndemics and health disparities: a methodological note.AIDS Behav. 2016; 20: 423-430Crossref PubMed Scopus (106) Google Scholar To adequately address racial disparity in pneumonia, mortality interventions should target NHBs in areas with the greatest racial disparities, mainly large central metropolitan areas of HHS regions 2 and 9. The uptake of the influenza and pneumonia vaccines by NHBs in each HHS region will need to be further studied to identify barriers to decrease the mortality from influenza and pneumonia. The impact of immigration, regarding attitudes toward vaccination and uptake is also an area of interest. Additionally, the enrollment in health insurance regarding poverty levels by HHS regions will also need to be assessed. Interventions targeting NHBs in regions 2 and 9 might include the following: (1) improving prevention and management of chronic diseases; (2) increasing prevalence of influenza and pneumonia vaccination in NHBs; (3) enhancing access to health care providers who follow evidence-based guidelines for pneumonia treatment in hospitals serving NHBs; (4) mandate training on implicit bias in medical education; and (5) continuing efforts to achieve Healthy People 2030 in health equity and eliminating health disparity. The disparity in influenza and pneumonia mortality rates for 1999 to 2018 between NHBs and NHWs was greatest in HHS regions 2 (New York and New Jersey) and 9 (California, Arizona, Hawaii, and 19 delta counties inNevada), compared with other geographic regions, particularly in the largest metropolitan areas. There was a nearly threefold difference between the highest and lowest rates observed. Further research is needed to inform targeting resources to reduce these disparities.Take-home PointDoes geographic variation in the non-Hispanic black-white disparity in influenza and pneumonia mortality exist? In 1999 through 2018, the greatest disparity was in HHS regions 2 (New York and New Jersey) and 9 (Arizona, California, Hawaii, and Nevada). Within these regions, disparities were greatest in the core of major metropolitan areas. Racial disparity from influenza and pneumonia mortality varied by region and urbanization for the last two decades. The identification of areas with the largest disparity can assist policymakers in the allocation of resources. Does geographic variation in the non-Hispanic black-white disparity in influenza and pneumonia mortality exist? In 1999 through 2018, the greatest disparity was in HHS regions 2 (New York and New Jersey) and 9 (Arizona, California, Hawaii, and Nevada). Within these regions, disparities were greatest in the core of major metropolitan areas. Racial disparity from influenza and pneumonia mortality varied by region and urbanization for the last two decades. The identification of areas with the largest disparity can assist policymakers in the allocation of resources. Author contributions: S. V. D. takes responsibility for the content of the manuscript, including the data and analysis. R. F. G., S. V. D., and A. M. contributed to the conception and design of the study. S. V. D., R. F. G., and A. M. authored the manuscript. S. V. D., R. F. G., A. M., and A. N. T. contributed to the analysis and interpretation of the data and provided critical review of the manuscript. Financial/nonfinancial disclosures:None declared. Other contributions: Andrew Wright-Hall, MS, provided graphical support regarding pictorial presentation of the results of this study. Annika Diaz-Campbell, BS, provided a full proofread of this document. Additional information: The e-Figures and e-Tables can be found in the Supplemental Materials section of the online article. Download .pdf (.87 MB) Help with pdf files e-Online Data
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