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Figure.  SARS-CoV-2 Positivity Rate by Racial/Ethnic Groups in the Baltimore–Washington, DC Region, March 11 to May 25, 2020
SARS-CoV-2 Positivity Rate by Racial/Ethnic Groups in the Baltimore–Washington, DC Region, March 11 to May 25, 2020

A, Daily positivity rates of SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) as points and 7-day moving averages (number positive/number tested over the plotted date and preceding 6 days) as solid lines by race/ethnicity. Statistically significant differences (P < .001) in daily positivity rates were evaluated across groups with 1-way analysis of variance (ANOVA). Multiple post hoc pairwise comparisons (Tukey test) of each group (black, white, other) to the Latino reference group also demonstrated significant differences (P < .001 for each pairwise comparison). B-E, Testing volume stratified by SARS-CoV-2 test result and grouped by race/ethnicity. This included an omnibus ANOVA comparison with significance (P < .05) resulting in correction for multiple pairwise comparisons using the Latino group as reference.

Table.  Demographics of Patients Tested for SARS-CoV-2 at the Johns Hopkins Health Systema
Demographics of Patients Tested for SARS-CoV-2 at the Johns Hopkins Health Systema
1.
Yancy  CW.  COVID-19 and African Americans.   JAMA. Published online April 15, 2020. doi:10.1001/jama.2020.6548 PubMedGoogle Scholar
2.
US Department of Health and Human Services Office of Minority Health. Profile: Hispanic/Latino Americans. Posted August 22, 2019. Accessed June 6, 2020. https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=64
3.
Health insurance historical tables: HIC series. US Census Bureau. Posted September 26, 2019. Accessed June 6, 2020. https://www.census.gov/data/tables/time-series/demo/health-insurance/historical-series/hic.html
4.
Bureau of Labor Statistics.  Job Flexibilities and Work Schedules—2017-2018 Data From the American Time Use Survey. US Dept of Labor; 2019:32.
5.
Page  KR, Venkataramani  M, Beyrer  C, Polk  S.  Undocumented U.S. immigrants and Covid-19.   N Engl J Med. 2020;382(21):e62. doi:10.1056/NEJMp2005953PubMedGoogle Scholar
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    1 Comment for this article
    Do not overlook the obvious when searching for explanations.
    Ben Park, MD | American Health Network
    I am married to a Latina woman and we are around a lot of Latinos. In spite of my best efforts, invariably greetings include hugs and kisses. If you greet everyone you know with a hug, it only makes sense that COVID would spread more rapidly. It is ingrained in the culture and in my experience very hard to change. She hugs her friends without thinking. This cultural difference in the way one greets friends and family could contribute to the dramatically higher rate of COVID infection among Latinos.
    CONFLICT OF INTEREST: None Reported
    Research Letter
    June 18, 2020

    SARS-CoV-2 Positivity Rate for Latinos in the Baltimore–Washington, DC Region

    Author Affiliations
    • 1Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
    • 2Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
    JAMA. 2020;324(4):392-395. doi:10.1001/jama.2020.11374

    The black community has been disproportionally affected by the coronavirus disease 2019 (COVID-19) pandemic in the US.1 Emerging data highlight sharp increases in cases within the Latino community.1,2 We analyzed temporal trends in positivity rates for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the Baltimore–Washington, DC region by race/ethnicity.

    Methods

    Samples were collected between March 11, 2020, and May 25, 2020, from 5 hospitals, including emergency departments, and 30 outpatient clinics that are part of the Johns Hopkins Health System (JHHS). SARS-CoV-2 testing inclusion criteria broadened over time (ie, initially high-risk individuals only and then all symptomatic patients) as local capacity increased but was standardized across JHHS sites. Samples collected via nasopharyngeal swabs were analyzed using SARS-CoV-2 reverse transcriptase–polymerase chain reaction. Data on patient demographics, comorbidities, SARS-CoV-2 status, and hospitalization were extracted from the integrated electronic health record system.

    Patients self-identified race/ethnicity from fixed categories. Racial/ethnic groups were considered mutually exclusive; ie, Latinos were excluded from other groups (white, black, other) regardless of reported race. Those who self-reported American Indian, Alaska Native, Asian American, Native Hawaiian, Pacific Islander, or multiracial were grouped as “other.”

    Temporal trends in daily positivity rates (7-day moving average; number positive/number tested over the date and preceding 6 days) and testing volumes stratified by race/ethnicity were evaluated. Total rates of SARS-CoV-2 positivity, hospitalization, and categorical patient characteristics were compared between Latinos and each racial/ethnic group using the χ2 test. Analysis of variance (ANOVA) was used to compare trends in positivity rates between groups. An omnibus ANOVA comparison with significance set at P < .05 was performed, followed by pairwise comparisons using the Latino group as reference, with correction for multiple comparisons (Tukey test). All analyses were performed with R version 3.6.2; a 2-sided P < .05 determined statistical significance. This work was deemed exempt by the Johns Hopkins Institutional Review Board, meeting criteria for quality improvement.

    Results

    A total of 6162 (16.3% [95% CI, 16.0%-16.7%]) of 37 727 patients tested positive for SARS-CoV-2. The positivity rate for Latino patients was 42.6% (95% CI, 41.1%-44.1%), significantly higher than the rate for white patients (8.8% [95% CI, 8.4%-9.2%]), black patients (17.6% [95% CI, 16.6%-18.3%]), or those of other race/ethnicity (17.2% [95% CI, 16.2%-18.3%]) (P < .001 for each pairwise comparison) (Table).

    The daily positivity rate was higher for Latino patients than patients in the other racial/ethnic groups (P < .001 for each pairwise comparison; Figure, A). Moving average trends in positivity rate peaked later for Latino patients at 53.4% (95% CI, 49.6%-57.3%) on May 10, 2020, compared with white patients (16.1% [95% CI, 14.1%-18.3%]) on April 16, 2020, and black patients (29.6% [95% CI, 26.9%-32.6%]) on April 19, 2020. As testing volume increased over time for all racial/ethnic groups (Figure, B, C, D, and E), positivity rates declined (Figure, A).

    Among those who tested positive, 2212 (35.9% [95% CI, 34.7%-37.1%]) patients were admitted to a JHHS hospital. The admission rate was lower for Latino patients (29.1% [95% CI, 27.0%-31.2%]) than for white patients (40.1% [95% CI, 37.6%-42.5%]) or black patients (41.7% [95% CI, 39.5%-43.8%]) (P < .001 for each pairwise comparison) (Table). Hospitalized Latino patients were younger (a greater proportion aged 18-44 years), more likely to be male, and had lower rates of hypertension, congestive heart failure, pulmonary disease, and chronic obstructive pulmonary disease than white or black patients (P < .001 for each pairwise comparison) (Table).

    Discussion

    More than 40% of Latinos in the Baltimore–Washington, DC metropolitan region who were tested for SARS-CoV-2 were positive, a much higher proportion than for any other racial/ethnic group. While SARS-CoV-2 testing inclusion criteria were standardized, differential access to testing may have contributed to higher rates of positivity; Latino patients have historically demonstrated lower rates of insurance and health care utilization.3 However, an alternative explanation may be higher disease prevalence, with the spread of infection among Latinos driven by decreased opportunity for social distancing in the setting of dense housing and continued work engagement due to essential worker status and economic necessity.1,4,5

    This study was limited to patients visiting JHHS, excluding those tested for SARS-CoV-2 elsewhere in the region. In addition, this study cannot determine whether differences in Latino patient SARS-CoV-2 positivity represent a higher disease prevalence, differences in access to health care (eg, reluctance in seeking care), or both.

    Addressing the unique needs of the Latino community may help mitigate the spread of SARS-CoV-2 infection and prevent COVID-19.

    Section Editor: Jody W. Zylke, MD, Deputy Editor.
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    Article Information

    Corresponding Author: Diego A. Martinez, PhD, Department of Emergency Medicine, Johns Hopkins University School of Medicine, 5801 Smith Ave, Davis Bldg, Ste 3220, Baltimore, MD 21209 (dmart101@jhmi.edu).

    Accepted for Publication: June 10, 2020.

    Published Online: June 18, 2020. doi:10.1001/jama.2020.11374

    Author Contributions: Dr Klein had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: All authors.

    Acquisition, analysis, or interpretation of data: Martinez, Hinson, Klein, Saheed, Page, Levin.

    Drafting of the manuscript: Martinez, Hinson, Klein, Irvin, Saheed, Levin.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Martinez, Klein, Levin.

    Obtained funding: Klein, Levin.

    Administrative, technical, or material support: Hinson, Irvin, Saheed.

    Supervision: Hinson, Klein, Saheed, Levin.

    Conflict of Interest Disclosures: Dr Martinez reported receiving grants from the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Disease Control and Prevention (CDC) and personal fees from the Johns Hopkins Health System during the conduct of the study. Drs Hinson and Levin reported receiving grants from AHRQ during the conduct of the study. Dr Klein reported receiving grants from the CDC during the conduct of the study. No other disclosures were reported.

    References
    1.
    Yancy  CW.  COVID-19 and African Americans.   JAMA. Published online April 15, 2020. doi:10.1001/jama.2020.6548 PubMedGoogle Scholar
    2.
    US Department of Health and Human Services Office of Minority Health. Profile: Hispanic/Latino Americans. Posted August 22, 2019. Accessed June 6, 2020. https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=64
    3.
    Health insurance historical tables: HIC series. US Census Bureau. Posted September 26, 2019. Accessed June 6, 2020. https://www.census.gov/data/tables/time-series/demo/health-insurance/historical-series/hic.html
    4.
    Bureau of Labor Statistics.  Job Flexibilities and Work Schedules—2017-2018 Data From the American Time Use Survey. US Dept of Labor; 2019:32.
    5.
    Page  KR, Venkataramani  M, Beyrer  C, Polk  S.  Undocumented U.S. immigrants and Covid-19.   N Engl J Med. 2020;382(21):e62. doi:10.1056/NEJMp2005953PubMedGoogle Scholar
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