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April 15, 2020

COVID-19 and African Americans

Author Affiliations
  • 1Department of Internal Medicine, Division of Cardiology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
JAMA. 2020;323(19):1891-1892. doi:10.1001/jama.2020.6548

Much has been published in leading medical journals about the phenomenon of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The resulting condition, coronavirus disease 2019 (COVID-19), has had a societal effect comparable only to the Spanish flu epidemic of 1918. As the flow of clinical science has better informed the contemporary narratives, more is being learned about which individuals and groups experience the most dire complications. Researchers have emphasized older age, male sex, hypertension, diabetes, obesity, concomitant cardiovascular diseases (including coronary artery disease and heart failure), and myocardial injury as important risk factors associated with worse outcomes; specifically, case-fatality rates vary over 100%.1-3 These data sourced from China and Europe have not been replicated in the US, but the US experience may nevertheless represent similarly distressing outcomes in these highest-risk phenotypes.

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    4 Comments for this article
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    We Should Not Neglect the Possibility of Biologic Factors
    Wm Prendergast, MD | Private practice, retired
    I wholeheartedly agree with Dr. Yancy about the many unjust disparities that are suffered by our minority communities, especially in this pandemic time. However, he doesn't mention the widely reported inequalities in the gender and racial distribution of the ACE2 receptor and the possible implications of that to the morbidity and mortality (and possibly susceptibility?) to this SARS Co-V-2 virus.

    To my reading, findings in this area are far from conclusive at this time, but there appears to be some strong evidence, from some of the Chinese reports and from some prior US studies on racial
    difference in hypertension, that there is a tendency toward higher levels of this receptor in males and especially Asian and African American males. Not enough is certain about the pathogenesis of this disease to yet draw any firm conclusion it would seem. But I hardly think that a biological basis for the greater average severity in these groups should be written off in favor of entirely socio-economic factors.
    CONFLICT OF INTEREST: None Reported
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    COVID-19 and African Americans
    Viraj Suvarna, MD MSc | President Medical, Eris Lifesciences Limited
    While I fully understand and agree with what Dr. Yancy has shared, it is interesting that Africans in Africa have not been as badly affected by this novel Coronavirus. So could it also be the lifestyle changes that happen when people migrate? Indians too suffer from this 'Westernization' in terms of diet and physical inactivity, both in India and in the US. Agreed, the African Americans and Indians too carry their genetic traits with them, which make them more susceptible, e.g., RAAS or lipoprotein (a) respectively; there are healthcare disparities; and the luxury of physical distancing may not always be possible among the poor. But I feel the main reason for increased morbidity and mortality is the fact that they are not well controlled from a chronic underlying disease (hypertension, diabetes, chronic heart disease, CKD, etc) perspective, and hence if they get this virus, the complications of uncontrolled chronic underlying disease adds to the complications of severe COVID-19 (dysregulated inflammatory response). One of the reasons could be that they cannot afford healthcare, hence are not at goals, and are therefore susceptible to severe COVID-19.
    CONFLICT OF INTEREST: None Reported
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    Race can not be the problem but education may be the solution
    Giuliano Ramadori, Professor of Medicine | University Clinic Göttingen,Germany
    Dr Yancy mentioned "race" three times as one of the possible reasons for higher infection and death rate amongst the African American and hispanic minorities in the US. Race cannot be the reason for this situation as African-American and Hispanic people the same race as white people. Education is the most important reason for different epidemiology.
    CONFLICT OF INTEREST: None Reported
    Argument Against biologic/ACE2 Receptor Relevance
    Will Jaffee, DO | Baystate Medical Center-UMass Medical School, Springfield, MA
    I too wonder if there are other biological factors at play here. It is curious, however, that the 2009 H1N1 virus also disproportionately affected African Americans (35% of hospitalized H1N1 patients were black compared to 16% of the 10 states' populations studied (1)). This virus had a different mechanism of cell entry, thus the difference is not clearly explained by ACE2 receptor distribution differences between those of different ethnic backgrounds.

    Biological differences in ACE2 expression (or other relevant mechanisms at play) should be sought, as they could lead to helpful treatments.

    This is not a zero-sum
    game, however, and I think we can walk and chew gum simultaneously. No one is going to ask public health researchers to do bench research, and I wouldn't want bench researchers attempting health-disparity interviews to effect policy change.

    REFERENCE

    1. https://www.cdc.gov/h1n1flu/african_americans_qa.htm
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