Comparison of Weighted and Unweighted Population Data to Assess Inequities in Coronavirus Disease 2019 Deaths by Race/Ethnicity Reported by the US Centers for Disease Control and Prevention

Surveillance and mortality data show large inequities in the impact of coronavirus disease 2019 (COVID-19) by race/ethnicity. 1 Currently, the US Centers for Disease Control and Prevention (CDC) does not report mortality rates by race/ethnicity. Instead, the percentage distribution of COVID-19 deaths by race/ethnicity is presented alongside a weighted distribution of the population from the CDC’s National Center for Health Statistics, 2 which weights each county’s population by its share of COVID-19 deaths, not population ( Figure ). We investigated whether the resulting magnitude of inequities using the weighted population underestimates those observed using the total population (unweighted)


Introduction
Surveillance and mortality data show large inequities in the impact of coronavirus disease 2019 (COVID-19) by race/ethnicity. 1 Currently, the US Centers for Disease Control and Prevention (CDC) does not report mortality rates by race/ethnicity.Instead, the percentage distribution of COVID-19 deaths by race/ethnicity is presented alongside a weighted distribution of the population from the CDC's National Center for Health Statistics, 2 which weights each county's population by its share of COVID-19 deaths, not population (Figure).We investigated whether the resulting magnitude of inequities using the weighted population underestimates those observed using the total population (unweighted).

Methods
This cross-sectional study used publicly available, aggregated data downloaded May 13, 2020. 2 Because the data were deidentified, institutional review board approval and informed consent were

Results
In total, 54 861 COVID-19 deaths were reported as of May 13, 2020.Applying the US Census population distribution, Black individuals were the most overrepresented among COVID-19 deaths, accounting for 9.9% greater than their share of the US Census population, whereas White individuals were underrepresented (−8.1%).In contrast, comparisons with the weighted data suggest that White individuals are most overrepresented among COVID-19 deaths (10.9%) (Table ).Discrepancies were also noted when comparing deaths with the unweighted vs weighted populations among Latinx (−1.7% vs −10.2%) and Asian (0.1% vs −5.7%) individuals (Table ).The CDC's weighting approach inflates the proportion of residents of color in the weighted population, as shown in our hypothetical example in panel A of the Figure , where the state's true population is 30% people of color, but the CDC's weighted population is 46.7% people of color.For example, in New York, large urban counties with higher percentages of crowded households and residents of color are weighted more heavily compared with their share of the population than smaller, suburban, and rural counties, where residents are predominantly White, as shown in panel B of the Figure.The figure shows examples of CDC geographical population weighting using a fictitious state with 3 counties (A) and actual CDC weighting of counties in New York State (B) by population, household crowding, and percentage of county population who are people of color (POC).The impact of the CDC's method of geographical reweighting is demonstrated by juxtaposing the hypothetical example in panel A with actual county population data in panel B. By up-weighting counties such as county A (eg, Bronx), down-weighting counties such as county C (eg, Albany), and excluding counties such as county B (eg, Saratoga), the CDC inflates the proportion of residents of color in the weighted population, making their risk of death appear lower, while deflating the proportion of White residents, making their risk of death appear greater.g The American Indian and Alaska Native data should be viewed as likely inaccurate, given well-known issues with undercount of deaths and problems with US Census counts of these populations.
h Indicates an excess in absolute or relative COVID-19 mortality compared with the population distribution (ie, overrepresentation among COVID-19 deaths).
i Includes Native Hawaiian and other Pacific Islander, more than 1 race, race unknown, and Hispanic/Latinx origin unknown.
not required, in accordance with 45 CFR §46.This study follows the relevant portions of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines.We compared the distribution of COVID-19 deaths by race/ethnicity with 2 separate population distributions provided by the CDC: National Center for Health Statistics weighted population and US Census unweighted population.Data analysis was performed from May to June 2020 using R statistical software version 3.6.3(R Project for Statistical Computing).
Author affiliations and article information are listed at the end of this article.Open Access.This is an open access article distributed under the terms of the CC-BY License.JAMA Network Open.2020;3(7):e2016933.doi:10.1001/jamanetworkopen.2020.16933(Reprinted)July 28, 2020 1/4

a
All racial/ethnic groups are shown directly as presented by the CDC in their weekly provisional death counts for COVID-19.b In total, 54 861 COVID-19 deaths were reported to the CDC as of May 13, 2020.c Percentage of COVID-19 deaths minus percentage CDC-NCHS-weighted population.d Percentage of COVID-19 deaths divided by percentage CDC-NCHS-weighted population.e Percentage of COVID-19 deaths minus percentage US Census population.f Percentage of COVID-19 deaths divided by percentage US Census population.
Figure.Examples of US Centers for Disease Control and Prevention (CDC) Geographical Population Weighting Actual CDC weighting of counties in New York State by population, household crowding, and percentage of population who are POC Downloaded From: https://jamanetwork.com/ on 09/29/2023 A

Table . Percentage
Distribution by Race/Ethnicity for COVID-19 Deaths, CDC-NCHS-Weighted Population, and US Census Population and Absolute and Relative Differences Using Data as of May 13, 2020