Racial-ethnic disparities in case fatality ratio narrowed after age standardization: A call for race-ethnicity-specific age distributions in State COVID-19 data

Importance

COVID-19 racial disparities have gained significant attention yet little is known about how age distributions obscure racial-ethnic disparities in COVID-19 case fatality ratios (CFR).

Objective

We filled this gap by assessing relevant data availability and quality across states, and in states with available data, investigating how racial-ethnic disparities in CFR changed after age adjustment.

Design/Setting/Participants/Exposure

We conducted a landscape analysis as of July 1st, 2020 and developed a grading system to assess COVID-19 case and death data by age and race in 50 states and DC. In states where age- and race-specific data were available, we applied direct age standardization to compare CFR across race-ethnicities. We developed an online dashboard to automatically and continuously update our results.

Main Outcome and Measure

Our main outcome was CFR (deaths per 100 confirmed cases). We examined CFR by age and race-ethnicities.

Results

We found substantial variations in disaggregating and reporting case and death data across states. Only three states, California, Illinois and Ohio, had sufficient age- and race-ethnicity-disaggregation to allow the investigation of racial-ethnic disparities in CFR while controlling for age. In total, we analyzed 391,991confirmed cases and 17,612 confirmed deaths. The crude CFRs varied from, e.g. 7.35% among Non-Hispanic (NH) White population to 1.39% among Hispanic population in Ohio. After age standardization, racial-ethnic differences in CFR narrowed, e.g. from 5.28% among NH White population to 3.79% among NH Asian population in Ohio, or an over one-fold difference. In addition, the ranking of race-ethnic-specific CFRs changed after age standardization. NH White population had the leading crude CFRs whereas NH Black and NH Asian population had the leading and second leading age-adjusted CFRs respectively in two of the three states. Hispanic population’s age-adjusted CFR were substantially higher than the crude. Sensitivity analysis did not change these results qualitatively.

Conclusions and Relevance

The availability and quality of age- and race-ethnic-specific COVID-19 case and death data varied greatly across states. Age distributions in confirmed cases obscured racial-ethnic disparities in COVID-19 CFR. Age standardization narrows racial-ethnic disparities and changes ranking. Public COVID-19 data availability, quality, and harmonization need improvement to address racial disparities in this pandemic.

Key Points