Document text
Morbidity and Mortality Weekly Report
382 MMWR / March 19, 2021 / Vol. 70 / No. 11 US Department of Health and Human Services/Centers for Disease Control and Preventi onRacial and Ethnic Disparities in COVID-19 Incidence by Age, Sex, and Period Among
Persons Aged <25 Years — 16 U.S. Jurisdictions, January 1–December 31, 2020
Miriam E. Van Dyke, PhD1,2,*; Maria C.B. Mendoza, PhD2,*; Wen Li, PhD2; Erin M. Parker, PhD2; Brook Belay, MD2; Elizabeth M. Davis, MA3;
Joshua J. Quint, PhD4; Ana Penman-Aguilar, PhD5,†; Kristie E.N. Clarke, MD2,†
On March 10, 2021, this report was posted as an MMWR Early
Release on the MMWR website (https://www.cdc.gov/mmwr).
The COVID-19 pandemic has disproportionately
affected racial and ethnic minority groups in the United
States. Whereas racial and ethnic disparities in severe COVID-19–associated outcomes, including mortality, have been documented ( 1–3), less is known about population-
based disparities in infection with SARS-CoV-2, the virus that causes COVID-19. In addition, although persons aged <30 years account for approximately one third of reported infections,
§ there is limited information on racial and ethnic
disparities in infection among young persons over time and by sex and age. Based on 689,672 U.S. COVID-19 cases reported to CDC’s case-based surveillance system by juris-dictional health departments, racial and ethnic disparities in COVID-19 incidence among persons aged <25 years in 16 U.S. jurisdictions
¶ were described by age group and sex and
across three periods during January 1–December 31, 2020. During January–April, COVID-19 incidence was substantially higher among most racial and ethnic minority groups com-pared with that among non-Hispanic White (White) persons (rate ratio [RR] range = 1.09–4.62). During May–August, the RR increased from 2.49 to 4.57 among non-Hispanic Native Hawaiian and Pacific Islander (NH/PI) persons but decreased among other racial and ethnic minority groups (RR range = 0.52–2.82). Decreases in disparities were observed during September–December (RR range = 0.37–1.69); these decreases were largely because of a greater increase in incidence among White persons, rather than a decline in incidence among racial and ethnic minority groups. NH/PI, non-Hispanic American Indian or Alaska Native (AI/AN), and Hispanic or Latino (Hispanic) persons experienced the largest persistent disparities over the entire period. Ensuring equitable and timely access to preventive measures, including testing, safe work and education settings, and vaccination when eligible is important to address racial/ethnic disparities.
Population-based COVID-19 incidence (cases per 100,000
persons) by race and ethnicity, sex, and age was calculated
* These authors contributed equally as first authors.
† These authors contributed equally as senior authors.
§ https://covid.cdc.gov/covid-data-tracker/ (accessed February 14, 2021)
¶ Arkansas, District of Columbia, Florida, Hawaii, Kansas, Kentucky, Maine,
Massachusetts, Michigan, Minnesota, New Mexico, Oklahoma, Oregon, Utah,
Vermont, and Wisconsin.for January 1–December 31, 2020, overall, and for three
approximately equal 4-month periods (January 1–April 30, May 1–August 31, and September 1–December 31) using COVID-19 cases reported to CDC’s case-based surveillance system** by jurisdictional health departments. Incompleteness of race and ethnicity data is a widespread challenge in analyses of COVID-19 disparities.
†† To minimize the impact of miss-
ing data, jurisdictions selected for analyses reported ≥30% of the total number of jurisdictional aggregate cases
§§ to CDC
and had ≥70% of race and ethnicity information complete among cases reported during January 1–December 31, 2020. Fifteen U.S. states and the District of Columbia were included, with a total of 689,672 cases among persons aged <25 years with information on race and ethnicity and sex.
¶¶ Population
denominators were obtained from the 2019 U.S. Census Bureau’s Annual County Resident Population Estimates by Age, Sex, Race, and Hispanic Origin.***
Seven racial and ethnic categories (AI/AN, non-Hispanic
Asian [Asian], non-Hispanic Black or African-American [Black], NH/PI, White, Hispanic, and non-Hispanic multiple race [multiracial]) and five age categories (0–4, 5–9, 10–14, 15–19, and 20–24 years) were examined. RRs with 95%
** CDC implemented a data integration and management platform, Data
Collation and Integration for Public Health Event Response (DCIPHER),
for use in outbreak responses (https://data.cdc.gov/browse?tags = covid-19). This platform enables jurisdictions to directly enter or import and view their data. Individual-level case report data for COVID-19 cases were accessed through the DCIPHER system on January 27, 2021. Data were classified using the earliest available date related to the illness, specimen collection or reporting to CDC. Case surveillance data were received directly from two jurisdictional health departments (Hawaii State Department of Health and New Mexico Department of Health) for all racial/ethnic groups to allow for separate reporting of NH/PI persons. Data from these two jurisdictions were combined in analyses with data accessed through the DCIPHER system from the 14 other jurisdictions.
†† https://www.cdc.gov/coronavirus/2019-ncov/covid-data/faq-surveillance.html
§§ Aggregate counts from reporting jurisdictions were downloaded through
HHS Protect Public Database. https://protect-public.hhs.gov/ (accessed January 27, 2021)
¶¶ Among the identified 919,652 persons aged <25 years with COVID-19 in
the 16 jurisdictions, 210,353 (23%) persons were missing information on race and ethnicity and/or sex during January 1–December 31, 2020. Among the 210,353 persons missing information on race and ethnicity and/or sex, 207,659 (99%) were missing information on race and ethnicity. The percentages of persons aged <25 years with COVID-19 in the 16 jurisdictions missing information on race and ethnicity and/or sex were 20.2% during January 1–April 30, 18.9% during May 1–August 31, and 24.3% during September 1–December 31.
*** https://www.census.gov/programs-surveys/popest/technical-documentation/
file-layouts.html (accessed August 20, 2020)
090177e1981d69d2\Final\Final On: 20-Sep-2021 19:00 (GMT)
FDA-CBER-2022-5812-0071469
Morbidity and Mortality Weekly Report
MMWR / March 19, 2021 / Vol. 70 / No. 11 383 US Department of Health and Human Services/Centers for Disease Control and Preventionconfidence intervals (CIs) comparing rates by race and eth-
nicity (combined), age, and/or sex overall and for each period were calculated. Statistical analyses were conducted using SAS software (version 9.4; SAS Institute). Rate ratios with 95% CIs excluding 1.0 were considered to be statistically significant. This activity was reviewed by CDC and was conducted con-sistent with applicable federal law and CDC policy.
†††
The sample of 689,672 cases included 15,068 (2%) cases
identified during January–April; 177,778 (26%) during May–August and 496,826 (72%) during September–December (Table 1). During January–April, COVID-19 incidence ranged from 35 cases per 100,000 among White persons to 163 per 100,000 among AI/AN persons. Compared with White per-sons, rates were higher among AI/AN (RR = 4.62), Hispanic (RR = 3.87), NH/PI (RR = 2.49), Black (RR = 2.46), and Asian persons (RR = 1.53) and were approximately equal among multiracial persons (RR = 1.09).
From January–April to May–August, COVID-19 incidence
increased among all racial and ethnic groups, ranging from 275 per 100,000 among multiracial persons to 2,418 per 100,000 among NH/PI persons. The largest relative increase occurred among NH/PI persons, with incidence increasing 26-fold, from 88 to 2,418 per 100,000. Rate ratios increased among NH/PI persons but decreased among other racial and ethnic minority groups. During May–August, compared with that among White persons, incidence remained higher among NH/PI (RR = 4.57), Hispanic (RR = 2.82), AI/AN (RR = 1.86), and Black persons (RR = 1.63), but was lower among Asian (RR = 0.77) and multiracial persons (RR = 0.52).
From May–August to September–December, COVID-19
incidence increased among all racial and ethnic groups. The largest relative increase occurred among White persons, with incidence increasing approximately 320%, from 530 to 2,222 cases per 100,000 from May–August to September–December. Disparities decreased among all racial and ethnic minority groups. During September–December, compared with that among White persons, incidence remained higher among NH/PI (RR = 1.69), AI/AN (RR = 1.62), and Hispanic persons (RR = 1.18), but was lower among Asian (RR = 0.57), Black (RR = 0.51), and multiracial persons (RR = 0.37).
Incidence was higher among females than among males
during all of 2020 and across periods. Incidence also tended to be lowest among younger children across periods. Lowest incidence was observed among children aged 5–9 years during January–April, those aged 0–9 years during May–August, and those aged 0–4 years during September–December.
During January–December, overall, the highest COVID-19
incidence relative to that among White persons was among
††† 45 C.F .R. part 46.102(l)(2), 21 C.F .R. part 56; 42 U.S.C. Sect. 241(d); 5
U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq.TABLE 1. COVID–19 incidence* and rate ratios, by race/ethnicity, sex,
and age group among persons aged <25 years across three periods — 16 U.S. jurisdictions,
† January 1–December 31, 2020
Date/CharacteristicNo. of
casesCases per 100,000
population (95% CI) RR (95% CI)
January 1–April 30, 2020
All 15,068 63 (62–64) —
Sex
Male 6,884 57 (55–58) 0.80 (0.78–0.83)
Female 8,184 70 (69–72) Ref
Race/Ethnicity
AI/AN, non-Hispanic 536 163 (150–177) 4.62 (4.22–5.05)
Asian, non-Hispanic 498 54 (49–59) 1.53 (1.39–1.67)
Black, non-Hispanic 2,461 87 (83–90) 2.46 (2.34–2.58)
NH/PI, non-Hispanic 73 88 (70–111) 2.49 (1.98–3.14)
White, non-Hispanic 4,947 35 (34–36) RefHispanic/Latino 6,129 137 (133–140) 3.87 (3.73–4.02)
Multiple, non-Hispanic 424 38 (35–42) 1.09 (0.98–1.20)
Age group (yrs)0–4 956 21 (20–23) 1.28 (1.17–1.41)
5–9 772 17 (16–18) Ref10–14 1,184 25 (23–26) 1.49 (1.36–1.63)
15–19 3,267 67 (65–70) 4.03 (3.72–4.36)
20–24 8,889 175 (171–178) 10.47 (9.72–11.26)
May 1–August 31, 2020
All 177,778 747 (744–751) —
Sex
Male 84,270 693 (688–698) 0.86 (0.85–0.87)
Female 93,508 804 (799–809) Ref
Race/Ethnicity
AI/AN, non-Hispanic 3,245 986 (952–1,020) 1.86 (1.80–1.93)
Asian, non-Hispanic 3,781 409 (396–422) 0.77 (0.75–0.80)
Black, non-Hispanic 24,501 862 (852–873) 1.63 (1.61–1.65)
NH/PI, non-Hispanic 2,007 2,418 (2,314–2,526) 4.57 (4.37–4.77)White, non-Hispanic 74,259 530 (526–533) RefHispanic/Latino 66,938 1,493 (1,481–1,504) 2.82 (2.79–2.85)Multiple, non-Hispanic 3,047 275 (266–285) 0.52 (0.50–0.54)
Age group (yrs)0–4 14,017 314 (309–319) 1.01 (0.98–1.03)
5–9 14,406 312 (307–317) Ref10–14 20,490 430 (424–436) 1.38 (1.35–1.41)
15–19 50,210 1,034 (1,025–1,043) 3.32 (3.26–3.38)20–24 78,655 1,547 (1,536–1,557) 4.96 (4.88–5.05)
September 1–December 31, 2020
All 496,826 2,088 (2,082–2,094) —
Sex
Male 236,237 1,943 (1,935–1,951) 0.87 (0.86–0.87)Female 260,589 2,240 (2,231–2,248) Ref
Race/Ethnicity
AI/AN, non-Hispanic 11,870 3,605 (3,541–3,671) 1.62 (1.59–1.65)Asian, non-Hispanic 11,680 1,263 (1,240–1,286) 0.57 (0.56–0.58)Black, non-Hispanic 32,200 1,133 (1,121–1,146) 0.51 (0.50–0.52)NH/PI, non-Hispanic 3,119 3,757 (3,628–3,891) 1.69 (1.63–1.75)White, non-Hispanic 311,591 2,222 (2,214–2,230) RefHispanic/Latino 117,305 2,616 (2,601–2,631) 1.18 (1.17–1.19)Multiple, non-Hispanic 9,061 819 (803–836) 0.37 (0.36–0.38)
Age group (yrs)0–4 33,595 752 (744–760) 0.71 (0.70–0.72)
5–9 48,824 1,056 (1,047–1,066) Ref10–14 76,922 1,615 (1,604–1,627) 1.53 (1.51–1.55)15–19 149,660 3,083 (3,067–3,098) 2.92 (2.89–2.95)20–24 187,825 3,693 (3,677–3,710) 3.50 (3.46–3.53)
See table footnotes on the next page.
090177e1981d69d2\Final\Final On: 20-Sep-2021 19:00 (GMT)
FDA-CBER-2022-5812-0071470
Morbidity and Mortality Weekly Report
384 MMWR / March 19, 2021 / Vol. 70 / No. 11 US Department of Health and Human Services/Centers for Disease Control and Preventi onTABLE 1. (Continued) COVID–19 incidence* and rate ratios, by race/
ethnicity, sex, and age group among persons aged <25 years across three periods — 16 U.S. jurisdictions,
† January 1–December 31, 2020
Date/CharacteristicNo. of
casesCases per 100,000
population (95% CI) RR (95% CI)
January 1–December 31, 2020
All 689,672 2,899 (2,892–2,906) —
Sex
Male 327,391 2,693 (2,684–2,702) 0.86 (0.86–0.87)Female 362,281 3,114 (3,104–3,124) Ref
Race/Ethnicity
AI/AN, non-Hispanic 15,651 4,754 (4,680–4,829) 1.71 (1.68–1.73)Asian, non-Hispanic 15,959 1,725 (1,699–1,752) 0.62 (0.61–0.63)Black, non-Hispanic 59,162 2,083 (2,066–2,099) 0.75 (0.74–0.75)NH/PI, non-Hispanic 5,199 6,263 (6,095–6,436) 2.25 (2.19–2.31)White, non-Hispanic 390,797 2,787 (2,778–2,795) RefHispanic/Latino 190,372 4,245 (4,226–4,264) 1.52 (1.52–1.53)Multiple, non-Hispanic 12,532 1,133 (1,113–1,153) 0.41 (0.40–0.41)
Age group (yrs)
0–4 48,568 1,087 (1,078–1,097) 0.79 (0.78–0.79)5–9 64,002 1,385 (1,374–1,395) Ref10–14 98,596 2,070 (2,057–2,083) 1.50 (1.48–1.51)15–19 203,137 4,184 (4,166–4,202) 3.02 (2.99–3.05)20–24 275,369 5,415 (5,394–5,435) 3.91 (3.88–3.94)
Abbreviations: AI/AN = American Indian or Alaska Native; CI = confidence
interval; NH/PI = Native Hawaiian and Pacific Islander; Ref = referent group;
RR = rate ratio.* Rates for each period and for the full period were calculated using the following
equation: (cases/population) x 100,000 persons. COVID–19 cases were identified using CDC’s Data Collation and Integration for Public Health Event Response system (https://data.cdc.gov/browse?tags=covid-19 [accessed January 27, 2021]). Case surveillance data were received directly from two jurisdictional health departments (Hawaii State Department of Health and New Mexico Department of Health) for all racial/ethnic groups to allow for separate reporting of NH/PI persons. Population estimates were provided by the 2019 U.S. Census Bureau’s Annual County Resident Population Estimates by Age, Sex, Race, and Hispanic Origin (https://www.census.gov/programs-surveys/popest/technical-documentation/file-layouts.html [accessed August 20, 2020]). 2019 population estimates in the 16 selected jurisdictions were as follows: persons aged <25 years: all (23,792,864), males (12,157,933), females (11,634,931), non-Hispanic AI/AN (329,235), non-Hispanic Asian (925,072), non-Hispanic Black or African-American (2,840,777), non-Hispanic NH/PI (83,012), non-Hispanic White (14,024,304), Hispanic or Latino (4,484,434), and non-Hispanic persons of multiple races (1,106,030); and persons aged 0–4 years (4,467,369), 5–9 years (4,622,261), 10–14 years (4,762,433), 15–19 years (4,855,127), and 20–24 years (5,085,674). No measures were calculated for non-Hispanic persons of other races with COVID-19 (n = 19,627) because of lack of population denominator information from U.S. Census Bureau.
† Arkansas, District of Columbia, Florida, Hawaii, Kansas, Kentucky, Maine,
Massachusetts, Michigan, Minnesota, New Mexico, Oklahoma, Oregon, Utah, Vermont, and Wisconsin.
NH/PI persons of most age groups, with the largest differences
among those aged 0–4 (RR = 4.03) and 5–9 years (RR = 3.21) (Figure) (Supplementary Table, https://stacks.cdc.gov/view/cdc/103733). During January–December, among persons aged ≤14 years, incidence relative to White persons was initially higher among Black and Asian persons and persistently higher among NH/PI, AI/AN, and Hispanic persons; among persons aged 15–24 years, incidence relative to White persons was initially higher among Black, Asian, and multiracial persons, and persistently higher among NH/PI, AI/AN, and Hispanic persons. Overall, during January–December, differences compared with White persons among AI/AN, NH/PI, and Hispanic persons were larger in persons aged ≤14 years than among those aged 15–24 years. Racial and ethnic disparities were similar in magnitude and direction for both females and males across age groups (Table 2).
Discussion
Analysis of CDC’s case-based surveillance data in 16 U.S.
jurisdictions during January–December 2020 indicates that racial and ethnic differences in COVID-19 incidence among persons aged <25 years changed over time. Disparities were substantial early in the pandemic among most racial and ethnic minority groups compared with White persons and then decreased over time, largely because of a greater increase in incidence among White persons. Among NH/PI persons, disparities increased from January–April to May–August and then decreased by September–December. The largest persis-tent disparities in COVID-19 incidence were among NH/PI, AI/AN, and Hispanic persons. Other studies have reported disproportionately higher percentages of COVID-19 cases among Hispanic, Black, Asian, and AI/AN children ( 4,5);
however, no published studies to date have described national COVID-19 incidence among NH/PI children.
Social determinants of health influence racial and ethnic
disparities in case incidence.
§§§ The large racial and ethnic
COVID-19 disparities identified early in the pandemic in this analysis might reflect differential ability to participate in early mitigation measures, such as stay-at-home orders ( 6).
Racial and ethnic minority groups are disproportionately represented in essential work settings, making it difficult for youths and parents to stay at home; a higher likelihood of liv-ing in a multigenerational household also increases the risk for household exposures to SARS-CoV-2.
¶¶¶ For example, NH/PI
persons, a group with some of the largest persistent disparities in this analysis, most often reside in multigenerational homes compared with other racial and ethnic groups ( 7). Despite
on average having lower income and educational attainment, NH/PI persons are often grouped in analyses with Asian persons (8), thereby obscuring disparities influenced by these social determinants of health.
The decrease in racial and ethnic disparities observed over
time was largely driven by a greater increase in COVID-19 incidence among White persons, rather than a decrease among racial and ethnic minority groups. This narrowing in differences should be considered in the context of geographic
§§§ https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/
race-ethnicity.html
¶¶¶ https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/
racial-ethnic-disparities/increased-risk-exposure.html
090177e1981d69d2\Final\Final On: 20-Sep-2021 19:00 (GMT)
FDA-CBER-2022-5812-0071471
Morbidity and Mortality Weekly Report
MMWR / March 19, 2021 / Vol. 70 / No. 11 385 US Department of Health and Human Services/Centers for Disease Control and PreventionFIGURE. Rate ratios* comparing COVID-19 incidence† among racial and ethnic minority persons to COVID-19 incidence among non-Hispanic
White persons, among persons aged <25 years, by age group in three periods — 16 U.S. jurisdictions,§ January 1–December 31, 2020
16:1
8:1
4:12:11:11:21:4
0–4 5–9 10–14 15–19 20–24
Age group (yrs)AI/AN, non-Hispanic
0–4 5–9 10–14 15–19 20–24
Age group (yrs)Asian, non-Hispanic
0–4 5–9 10–14 15–19 20–24
Age group (yrs)Black, non-HispanicJanuary 1–April 30 May–August 31 September 1–December 31 January 1–December 31
0–4 5–9 10–14 15–19 20–24Rate ratio
(ref = White, non-Hispanic persons)
Age group (yrs)NH/PI, non-Hispanic16:1
8:1
4:12:11:11:21:4
16:1
8:1
4:12:11:11:21:416:1
8:1
4:12:11:11:21:4Rate ratio
(ref = White, non-Hispanic persons) Rate ratio
(ref = White, non-Hispanic persons)
Rate ratio
(ref = White, non-Hispanic persons)
See figure footnotes on the next page.
aspects of community spread over time and potential changes
in access to or participation in mitigation measures or testing over time by race and ethnicity. For example, future studies could consider whether variations in state-mandated mitigation policies and other aspects of the policy environment led to the observed differential adherence in some mitigation measures by race/ethnicity (9). Further study of whether some testing strategies (e.g., repeat testing of students in some academic settings****) might have been differentially available by race and ethnicity over time is also needed.
The findings in this report are subject to at least five limita-
tions. First, reporting of detailed case data and race and ethnicity
**** https://www.washingtonpost.com/local/education/welcome-to-
college-now-get-tested-for-the-coronavirus--again-and-
again/2020/09/04/2d087722-ed2f-11ea-b4bc-3a2098fc73d4_story.htmlto CDC is incomplete. Although this analysis was restricted to
16 jurisdictions with more complete case and race and ethnicity information, 23% of cases from these jurisdictions were miss-ing data on race and ethnicity. Differences in data complete-ness by race and ethnicity could lead to underestimation of disparities (10). Restriction to 16 jurisdictions also limits the generalizability of these findings, because they are based on only 23% of the national population of persons aged <25 years; in addition, disparities could vary at geographic subdivisions within states. Second, these data likely underestimate the incidence of COVID-19 among persons aged <25 years because individual-level cases reported to CDC represent a portion of jurisdictional aggregate cases and asymptomatic persons are less likely to be tested. Third, cases among racial and ethnic minority groups might be disproportionately underreported given disparities
090177e1981d69d2\Final\Final On: 20-Sep-2021 19:00 (GMT)
FDA-CBER-2022-5812-0071472
Morbidity and Mortality Weekly Report
386 MMWR / March 19, 2021 / Vol. 70 / No. 11 US Department of Health and Human Services/Centers for Disease Control and Preventi on †††† https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/
racial-ethnic-disparities/disparities-illness.htmlFIGURE. ( Continued ) Rate ratios* comparing COVID-19 incidence† among racial and ethnic minority persons to COVID-19 incidence among
non-Hispanic White persons, among persons aged <25 years, by age group in three periods — 16 U.S. jurisdictions,§ January 1–December 31, 2020
0–4 5–9 10–14 15–19 20–24
Age group (yrs)Multiracial, non-Hispanic
0–4 5–9 10–14 15–19 20–24
Age group (yrs)Hispanic or Latino
Non-HispanicAI/AN,
Non-HispanicAsian,
Non-HispanicBlack,
Non-HispanicNH/PI, Hispanic or
Latino Non-HispanicMultiracial,Racial/Ethnic group16:1
8:1
4:12:11:11:21:416:1
8:1
4:12:11:11:21:4
16:1
8:1
4:1
2:1
1:11:2
1:4
Rate ratio
(ref = White, non-Hispanic persons) Rate ratio
(ref = White, non-Hispanic persons)
Rate ratio
(ref = White, non-Hispanic persons) January 1–April 30 May–August 31 September 1–December 31 January 1–December 31
Abbreviations: AI/AN=American Indian or Alaska Native; NH/PI=Native Hawaiian and P acific Islander; ref = referent group.
* Rate ratios were calculated during each period and over all. Data used to generate this figure are included in the Supplementary Table, https://stacks.cdc.gov/view/
cdc/103733. Rate ratios are not available in situations where data were suppressed because of <20 cases being reported for a given race/ethnicity and age group
during a period. During January 1–April 30, 2020, <20 cases were reported for non-Hispanic NH/PI persons aged 0–4, 5–9, 10–14, and 15–19 years. Rate ratios were similar and thus corresponding rate ratio symbols overlap in the figure for the following categories: AI/AN persons aged 15–19 and 20–24 years during May 1–August 31 and September 1–December 31; Black persons aged 5–9 years during January 1–April 30 and May 1–August 31; and NH/PI pe rsons aged 20–24 years
during January 1–April 30 and September 1–December 31.
† Rates for each period and for the full period were calculated using the following equation: (cases/population) x 100,000 perso ns. COVID-19 cases were identified
using CDC’s Data Collation and Integration for Public Health Event Response system (https://data.cdc.gov/browse?tags=covid-19 [accessed January 27, 2021]). Case
surveillance data were received directly from two jurisdictional health departments (Hawaii State Department of Health and New Mexico Department of Health)
for all racial/ethnic groups to allow for separate reporting of NH/PI persons. Population estimates were provided by the 2019 U .S. Census Bureau’s Annual County
Resident Population Estimates by Age, Sex, Race, and Hispanic Origin (https://www.census.gov/programs-surveys/popest/technical- documentation/file-layouts.
html [accessed August 20, 2020]).
§ Arkansas, District of Columbia, Florida, Hawaii, Kansas, Kentucky, Maine, Massachusetts, Michigan, Minnesota, New Mexico, Okla homa, Oregon, Utah, Vermont, and Wisconsin.
in access to testing, leading to underestimation of disparities.
Fourth, potential differences in testing, reporting, and com-pleteness of data by race and ethnicity over time call for caution in interpretation of the observed changes in racial and ethnic disparities in this report. Finally, racial and ethnic disparities in COVID-19 incidence (and changes over time) might not reflect disparities in severe outcomes (1 –3).
††††
090177e1981d69d2\Final\Final On: 20-Sep-2021 19:00 (GMT)
FDA-CBER-2022-5812-0071473
Morbidity and Mortality Weekly Report
MMWR / March 19, 2021 / Vol. 70 / No. 11 387 US Department of Health and Human Services/Centers for Disease Control and PreventionTABLE 2. Sex-specific COVID-19 incidence* and rate ratios among persons aged <25 years, by age group, sex, and race/ethnicity — 16 U.S.
jurisdictions,† January 1–December 31, 2020
Age group,
race/ethnicitySex
Female Male
No. of casesCases per 100,000
population (95% CI) Rate ratio (95% CI) No. of casesCases per 100,000
population (95% CI) Rate ratio (95% CI)
0–4 yrs
All 23,272 1,067 (1,053–1,081) — 25,296 1,107 (1,093–1,120) —
AI/AN, non-Hispanic 658 2,247 (2,082–2,425) 2.69 (2.49–2.91) 677 2,208 (2,048–2,381) 2.54 (2.35–2.75)
Asian, non-Hispanic 642 858 (794–927) 1.03 (0.95–1.11) 721 913 (849–982) 1.05 (0.98–1.13)
Black, non-Hispanic 2,541 940 (904–977) 1.13 (1.08–1.18) 2,844 1,028 (991–1,067) 1.18 (1.14–1.23)
NH/PI, non-Hispanic 266 3,576 (3,171–4,033) 4.28 (3.79–4.83) 258 3,306 (2,926–3,735) 3.81 (3.37–4.31)
White, non-Hispanic 10,391 835 (820–852) Ref 11,382 868 (852–884) Ref
Hispanic/Latino 8,299 1,901 (1,861–1,943) 2.28 (2.21–2.34) 8,889 1,951 (1,910–1,992) 2.25 (2.19–2.31)
Multiple, non-Hispanic 475 399 (365–436) 0.48 (0.44–0.52) 525 420 (386–458) 0.48 (0.44–0.53)
5–9 yrs
All 31,333 1,389 (1,374–1,404) — 32,669 1,381 (1,366–1,396) —
AI/AN, non-Hispanic 917 2,901 (2,719–3,095) 2.40 (2.24–2.56) 941 2,861 (2,684–3,050) 2.39 (2.24–2.56)
Asian, non-Hispanic 741 904 (841–971) 0.75 (0.69–0.80) 890 1,048 (981–1,119) 0.88 (0.82–0.94)
Black, non-Hispanic 3,019 1,081 (1,043–1,120) 0.89 (0.86–0.93) 3,155 1,096 (1,058–1,135) 0.92 (0.88–0.95)
NH/PI, non-Hispanic 287 3,676 (3,275–4,127) 3.04 (2.70–3.42) 326 4,040 (3,624–4,503) 3.38 (3.03–3.77)
White, non-Hispanic 15,609 1,210 (1,191–1,229) Ref 16,280 1,195 (1,177–1,214) Ref
Hispanic/Latino 10,174 2,271 (2,227–2,315) 1.88 (1.83–1.92) 10,564 2,264 (2,221–2,308) 1.89 (1.85–1.94)
Multiple, non-Hispanic 586 501 (462–543) 0.41 (0.38–0.45) 513 414 (380–452) 0.35 (0.32–0.38)
10–14 yrs
All 49,235 2,112 (2,094–2,131) — 49,361 2,030 (2,012–2,048) —
AI/AN, non-Hispanic 1,477 4,461 (4,239–4,694) 2.31 (2.19–2.44) 1,520 4,492 (4,272–4,723) 2.42 (2.30–2.55)
Asian, non-Hispanic 949 1,089 (1,022–1,160) 0.56 (0.53–0.60) 1,066 1,210 (1,140–1,285) 0.65 (0.61–0.69)
Black, non-Hispanic 4,192 1,510 (1,465–1,556) 0.78 (0.76–0.81) 4,042 1,416 (1,373–1,461) 0.76 (0.74–0.79)
NH/PI, non-Hispanic 424 4,803 (4,367–5,283) 2.49 (2.26–2.74) 445 4,779 (4,355–5,245) 2.58 (2.35–2.83)
White, non-Hispanic 26,147 1,930 (1,907–1,954) Ref 26,360 1,853 (1,831–1,876) Ref
Hispanic/Latino 15,128 3,335 (3,282–3,389) 1.73 (1.69–1.76) 15,020 3,175 (3,125–3,226) 1.71 (1.68–1.75)
Multiple, non-Hispanic 918 794 (744–847) 0.41 (0.39–0.44) 908 760 (712–811) 0.41 (0.38–0.44)
15–19 yrs
All 109,350 4,601 (4,574–4,628) — 93,787 3,784 (3,760–3,808) —
AI/AN, non-Hispanic 2,432 7,218 (6,937–7,511) 1.55 (1.49–1.61) 1,971 5,634 (5,391–5,889) 1.54 (1.47–1.61)
Asian, non-Hispanic 2,133 2,181 (2,090–2,275) 0.47 (0.45–0.49) 1,960 2,065 (1,975–2,158) 0.56 (0.54–0.59)
Black, non-Hispanic 8,056 2,915 (2,852–2,979) 0.63 (0.61–0.64) 7,774 2,715 (2,655–2,776) 0.74 (0.72–0.76)
NH/PI, non-Hispanic 715 8,679 (8,066–9,339) 1.86 (1.73–2.01) 633 7,253 (6,709–7,840) 1.98 (1.83–2.14)
White, non-Hispanic 66,431 4,655 (4,620–4,691) Ref 54,869 3,661 (3,630–3,691) Ref
Hispanic/Latino 27,571 6,361 (6,286–6,436) 1.37 (1.35–1.39) 24,846 5,497 (5,430–5,566) 1.50 (1.48–1.52)
Multiple, non-Hispanic 2,012 2,010 (1,924–2,100) 0.43 (0.41–0.45) 1,734 1,689 (1,612–1,771) 0.46 (0.44–0.48)
20–24 yrs
All 149,091 5,987 (5,957–6,018) — 126,278 4,865 (4,839–4,892) —
AI/AN, non-Hispanic 2,881 8,386 (8,086–8,698) 1.43 (1.38–1.48) 2,177 6,253 (5,995–6,521) 1.34 (1.29–1.40)
Asian, non-Hispanic 3,558 2,997 (2,900–3,097) 0.51 (0.49–0.53) 3,299 2,805 (2,711–2,903) 0.60 (0.58–0.62)
Black, non-Hispanic 12,708 4,316 (4,241–4,391) 0.74 (0.72–0.75) 10,831 3,534 (3,468–3,601) 0.76 (0.74–0.78)
NH/PI, non-Hispanic 941 11,453 (10,744–12,209) 1.95 (1.83–2.08) 904 10,546 (9,880–11,256) 2.27 (2.12–2.42)
White, non-Hispanic 89,490 5,867 (5,829–5,906) Ref 73,838 4,649 (4,615–4,682) Ref
Hispanic/Latino 36,744 8,775 (8,685–8,865) 1.50 (1.48–1.51) 33,137 7,418 (7,339–7,499) 1.60 (1.58–1.62)
Multiple, non-Hispanic 2,769 3,059 (2,947–3,175) 0.52 (0.50–0.54) 2,092 2,251 (2,156 –2,349) 0.48 (0.46–0.51)
Abbreviations: AI/AN = American Indian or Alaska Native; CI = confidence inte rval; NH/PI = Native Hawaiian and Pacific Islander; Ref = referent group.
* Rates for each period and for the full period were calculated using the following equation: (cases/population) x 100,000 pers ons. COVID-19 cases were identified
using CDC’s Data Collation and Integration for Public Health Event Response system (https://data.cdc.gov/browse?tags=covid-19 [ accessed January 27, 2021]). Case
surveillance data were received directly from two jurisdictional health departments (Hawaii State Department of Health and New Mexico Department of Health)
for all racial/ethnic groups to allow for separate reporting of NH/PI persons. Population estimates were provided by the 2019 U .S. Census Bureau’s Annual County
Resident Population Estimates by Age, Sex, Race, and Hispanic Origin (https://www.census.gov/programs-surveys/popest/technical- documentation/file-layouts.
html [accessed August 20, 2020]).
† Arkansas, District of Columbia, Florida, Hawaii, Kansas, Kentucky, Maine, Massachusetts, Michigan, Minnesota, New Mexico, Oklahoma, Oregon, Utah, Vermont, and Wisconsin.
090177e1981d69d2\Final\Final On: 20-Sep-2021 19:00 (GMT)
FDA-CBER-2022-5812-0071474
Morbidity and Mortality Weekly Report
388 MMWR / March 19, 2021 / Vol. 70 / No. 11 US Department of Health and Human Services/Centers for Disease Control and Preventi onSummary
What is already known about this topic?
U.S. racial and ethnic minority groups have been disproportion-
ately affec t
ed by COVID-19.
What is added by this report?
Racial and ethnic disparities in COVID-19 incidence among
persons aged <25 years in 16 U.S. jurisdictions ev
olved during
the pandemic. Disparities were substantial during January–April and generally decreased during May–December, largely because of a greater increase in incidence among White persons, rather than a decline among racial and ethnic minority groups. The largest persistent disparities involved Native Hawaiian and Pacific Islander, American Indian or Alaska Native, and Hispanic persons.
What are the implications for public health practice?
Ensuring equitable and timely access to preventive measures,
including testing, saf e w
ork and education settings, and vaccina-
tion when eligible is important to address racial/ethnic disparities.
During January 1–December 31, 2020, substantial racial and
ethnic disparities in COVID-19 incidence, observed early in the
pandemic among persons aged <25 years in 16 jurisdictions, decreased over time, driven largely by a greater increase in reporting of cases among White persons. The largest persistent disparities were among NH/PI, AI/AN, and Hispanic persons. Ensuring equitable and timely access to preventive measures, including testing, safe work and education settings and vaccination when eligible is important to address racial/ethnic disparities.
§§§§
Acknowledgments
Courtni Andrews, Office of Minority Health and Health Equity,
CDC; Joseph T. H
icks, New Mexico Department of Health,
Epidemic Intelligence Service, CDC; Hawaii Department of
Health Disease Outbreak Control Division Investigations Team; Oluwatomiloba Ademokun, Jayleen Gunn, Katherine E. Center, COVID-19 Emergency Response Team, CDC.
Corresponding author: Miriam Van Dyke, [email protected].
1Epidemic Intelligence Service, CDC; 2CDC COVID-19 Response Team;
3New Mexico Department of Health; 4Hawaii State Department of Health;
5Office of Minority Health and Health Equity, CDC. §§§§ https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/
racial-ethnic-disparities/what-we-do.htmlAll authors have completed and submitted the International
Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.
References
1. Bixler D, Miller AD, Mattison CP , et al.; Pediatric Mortality Investigation
Team. SARS-CoV-2–associated deaths among persons aged <21 years—
United States, February 12–July 31, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1324–9. PMID:32941417 https://doi.org/10.15585/mmwr.mm6937e4
2. Rossen LM, Branum AM, Ahmad FB, Sutton P , Anderson RN. Excess
deaths associated with COVID-19, by age and race and ethnicity—United States, January 26–October 3, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1522–7. PMID:33090978 https://doi.org/10.15585/mmwr.mm6942e2
3. Kim L, Whitaker M, O’Halloran A, et al.; COVID-NET Surveillance
Team. Hospitalization rates and characteristics of children aged <18 years hospitalized with laboratory-confirmed COVID-19—COVID-NET, 14 states, March 1–July 25, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1081–8. PMID:32790664 https://doi.org/10.15585/mmwr.mm6932e3
4. Bailey LC, Razzaghi H, Burrows EK, et al. Assessment of 135 794
pediatric patients tested for severe acute respiratory syndrome coronavirus 2 across the United States. JAMA Pediatr 2021;175:176–84. PMID:33226415 https://doi.org/10.1001/jamapediatrics.2020.5052
5. Hatcher SM, Agnew-Brune C, Anderson M, et al. COVID-19 among
American Indian and Alaska Native persons—23 states, January 31–July 3, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1166–9. PMID:32853193 https://doi.org/10.15585/mmwr.mm6934e1
6. Webb Hooper M, Nápoles AM, Pérez-Stable EJ. COVID-19 and racial/
ethnic disparities. JAMA 2020;323:2466–7. PMID:32391864 https://doi.org/10.1001/jama.2020.8598
7. Raine S, Liu A, Mintz J, Wahood W, Huntley K, Haffizulla F . Racial
and ethnic disparities in COVID-19 outcomes: social determinants of health. Int J Environ Res Public Health 2020;17:8115. PMID:33153162 https://doi.org/10.3390/ijerph17218115
8. Nguyen AB. Disaggregating Asian American and Native Hawaiian and
Other Pacific Islander (AANHOPI) adult tobacco use: findings from wave 1 of the population assessment of tobacco and health (PATH) study, 2013–2014. J Racial Ethn Health Disparities 2019;6:356–63. PMID:30610569 https://doi.org/10.1007/s40615-018-00532-1
9. Fisher KA, Barile JP , Guerin RJ, et al. Factors associated with cloth face
covering use among adults during the COVID-19 pandemic—United States, April and May 2020. MMWR Morb Mortal Wkly Rep 2020;69:933–7. PMID:32673303 https://doi.org/10.15585/mmwr.
mm6928e3
10. Labgold K, Hamid S, Shah S, et al. Estimating the unknown: greater
racial and ethnic disparities in COVID-19 burden after accounting for missing race and ethnicity data. Epidemiology 2021;32:157–61. PMID:33323745 https://doi.org/10.1097/EDE.0000000000001314
090177e1981d69d2\Final\Final On: 20-Sep-2021 19:00 (GMT)
FDA-CBER-2022-5812-0071475