Impact of Social Vulnerability on COVID-19 Incidence and Outcomes in the United States
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Abstract
Importance
Prior pandemics have disparately affected socially vulnerable communities. Whether regional variations in social vulnerability to disasters influence COVID-19 outcomes and incidence in the U.S. is unknown.
Objective
To examine the association of Social Vulnerability Index (SVI), a percentile-based measure of county-level social vulnerability to disasters, and its sub-components (socioeconomic status, household composition, minority status, and housing type/transportation accessibility) with the case fatality rate (CFR) and incidence of COVID-19.
Design
Ecological study of counties with at least 50 confirmed COVID-19 cases as of April 4 th , 2020. Generalized linear mixed-effects models with state-level clustering were applied to estimate county-level associations of overall SVI and its sub-component scores with COVID-19 CFR (deaths/100 cases) and incidence (cases/1000 population), adjusting for population percentage aged ≥65 years, and for comorbidities using the average Hierarchical Condition Category (HCC) score. Counties with high SVI (≥median) and high CFR (≥median) were identified.
Setting
Population-based study of U.S. county-level data.
Participants
U.S. counties with at least 50 confirmed COVID-19 cases.
Main outcomes and measures
COVID-19 CFR and incidence.
Results
Data from 433 counties including 283,256 cases and 6,644 deaths were analyzed. Median SVI was 0.46 [Range: 0.01-1.00], and median CFR and incidence were 1.9% [Range: 0-13.3] and 1.2 per 1000 people [Range: 0.6-38.8], respectively. Higher SVI, indicative of greater social vulnerability, was associated with higher CFR (RR: 1.19 [1.05, 1.34], p=0.005, per-1 unit increase), an association that strengthened after adjustment for age≥65 years and comorbidities (RR: 1.63 [1.38, 1.91], p<0.001), and was further confirmed in a sensitivity analysis limited to six states with the highest testing levels. Although the association between overall SVI and COVID-19 incidence was not significant, the SVI sub-components of socioeconomic status and minority status were both predictors of higher incidence and CFR. A combination of high SVI (≥0.46) and high adjusted CFR (≥2.3%) was observed in 28.9% of counties.
Conclusions and Relevance
Social vulnerability is associated with higher COVID-19 case fatality. High social vulnerability and CFR coexist in more than 1 in 4 U.S. counties. These counties should be targeted by public policy interventions to help alleviate the pandemic burden on the most vulnerable population.
KEY POINTS
Question
Is county-level social vulnerability to disasters associated with the case fatality rate (CFR) and incidence of SARS-CoV-2 infection during the COVID-19 pandemic in the U.S.?
Findings
Each unit increase in county-level social vulnerability, measured using the Social Vulnerability Index (SVI), was associated with a 63% higher CFR after adjusting for age and comorbidities. Both CFR and incidence of COVID-19 were significantly higher in counties with lower socio-economic status and higher proportion of minority populations.
Meaning
U.S. counties with higher social vulnerability are experiencing greater mortality rates during the COVID-19 pandemic.
Article activity feed
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SciScore for 10.1101/2020.04.10.20060962: (What is this?)
Please note, not all rigor criteria are appropriate for all manuscripts.
Table 1: Rigor
Institutional Review Board Statement not detected. Randomization 5,6 Given differences in COVID-19 testing by state, state-specific random intercepts were incorporated in models to account for correlations among counties within the same state. Blinding not detected. Power Analysis not detected. Sex as a biological variable not detected. Table 2: Resources
No key resources detected.
Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).
Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:A major limitation of the study is our inability to account …
SciScore for 10.1101/2020.04.10.20060962: (What is this?)
Please note, not all rigor criteria are appropriate for all manuscripts.
Table 1: Rigor
Institutional Review Board Statement not detected. Randomization 5,6 Given differences in COVID-19 testing by state, state-specific random intercepts were incorporated in models to account for correlations among counties within the same state. Blinding not detected. Power Analysis not detected. Sex as a biological variable not detected. Table 2: Resources
No key resources detected.
Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).
Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:A major limitation of the study is our inability to account for the contribution of county-level COVID-19 testing. However, in sensitivity analyses that included states with the highest level of testing, we observed similar associations. In addition, we have only included 433 (13.8%) U.S. counties in our report, but these counties represent the breadth of existing social vulnerability. This important and timely report demonstrates associations between social vulnerability to disaster and adverse outcomes in the evolving stages of the COVID-19 pandemic in the U.S. Our findings can help guide public policy interventions and resource allocations to improve outcomes in vulnerable communities.
Results from TrialIdentifier: No clinical trial numbers were referenced.
Results from Barzooka: We found bar graphs of continuous data. We recommend replacing bar graphs with more informative graphics, as many different datasets can lead to the same bar graph. The actual data may suggest different conclusions from the summary statistics. For more information, please see Weissgerber et al (2015).
Results from JetFighter: We did not find any issues relating to colormaps.
Results from rtransparent:- Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
- Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
- No protocol registration statement was detected.
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