In San Francisco, a steady trend in coronavirus (COVID-19) deaths has gone largely unnoticed until recently: Asian Americans consistently account for nearly half of COVID-19 deaths. For a city that is one-third Asian American, the disproportionate number of deaths appears striking, yet this highlights an even more worrisome statistic—Asian Americans experience a four times higher case fatality rate (CFR) than that of the overall population (5.2 percent versus 1.3 percent).
Further investigation revealed that the relatively high CFR in San Francisco reflects a pattern found across many states and counties with at least 5 percent of the population Asian American (exhibit 1). The Asian American CFR is three times that of the overall population in California (8.4 percent versus 2.6 percent) and exceeds 10 percent in Los Angeles, Chicago, New York City, and New Jersey. In Clark County, Nevada, the 2.5 times higher CFR results in a proportion of deaths (16.8 percent) that far exceeds Asian American and Pacific Islanders’ (AAPI) share of the population (10.4 percent).
Across the country, a high Asian American case fatality has emerged as another health disparity from COVID-19 impacting a minority population. Policy makers can help ameliorate these disparities by mandating standardized case and fatality reporting requirements and directing public health agencies to investigate why particular populations, including Asian Americans, face a seemingly heightened risk of death from COVID-19.
Hypotheses For Higher Case Fatality
A higher observed case fatality indicates that either Asian Americans lack sufficient diagnostic testing, face a higher risk of death from COVID-19 on average, or both. Importantly, the case fatality does not reflect the population infection rate, which tends to be lower in Asian Americans. For instance, Asian Americans comprise just 12 percent of positive cases in San Francisco despite making up nearly half of deaths (exhibit 1). Instead, it is the proportion of deaths from cases that has proven especially high in Asian Americans with COVID-19.
Several Public Health Questions Are Of Particular Concern:
- What are the characteristics of those who have died from COVID-19?
- Are Asian Americans receiving inadequate testing leading to inadequate case identification?
- Could COVID-19 be more deadly due to medical conditions or socioeconomic factors more common in Asian Americans?
Few reporting entities (for example, states and counties) provide data stratified simultaneously by race and age, but data from Santa Clara County, California, suggest Asian American deaths are clustered among older adults, ages 80 and older. Still, age alone cannot explain the magnitude of the disparity in case fatality.
The question becomes whether the high observed CFR reflects a truly heightened risk of death among Asian Americans or disproportionately low testing. Although few places report testing recipient demographics, data from Los Angeles County and Illinois suggest that Asian Americans may be receiving disproportionately low rates of testing.
With regards to medical conditions, the person-level data on deaths in Santa Clara County showed that cerebrovascular accidents (11 percent versus 5 percent) and dementia (11 percent versus 3 percent) were notably more common to deaths among Asians than non-Asians, respectively, although numbers are small. Diabetes, hypertension, and hyperlipidemia were comorbidities common to both Asian and non-Asian deaths. Although data from one county with a unique composition of Asian ethnicities may not necessarily generalize nationally, it provides early insights into what comorbidities may contribute to risk of death in Asian Americans.
Finally, socioeconomic factors may play a role. As 59 percent of Asian Americans are born outside the US, factors such as health literacy and English proficiency may impact access to and quality of care. Expert opinion and discussions with many community health centers serving Asian American populations highlight delayed presentation for care in the COVID era as a growing concern. Employment type may be another contributing factor. AAPI comprise a large share of workers in many frontline, essential jobs including nursing, medicine, food manufacturing, and food retail that may play a role in increasing risk of case severity.
Importantly, there is no evidence that Asian Americans face a higher case fatality due to ethnicity itself. In comparison, the CFR in Asian countries are substantially lower than those observed among Asian Americans in many US states and counties. For instance, the CFRs in China, the Philippines, and South Korea are 5.5 percent, 3.1 percent, and 2.2 percent, respectively, in the context of a 4.6 percent CFR in the United States. False perceptions associating Asian lives with sickness coupled with xenophobic politicization of the COVID-19 pandemic have fueled rising hate crimes against Asians in the US and worldwide. To be clear, there is no evidence that Asian Americans are any more or less likely to contract or transmit the virus than the general population.
Data Inadequacy
As health disparities emerge in disproportionate rates of COVID-19 infection and mortality among communities of color, the impact on Asian Americans is not well understood. In most states and counties, the relatively small proportion of Asian Americans in the population makes awareness of cases and deaths in this community more challenging. Other than coverage on rising incidents of xenophobia, Asian American issues have largely been overlooked in the public discourse surrounding the disparate impact of COVID-19. California is one of few states with a sufficiently sizable Asian American population for their COVID-19 burden to become unmistakable in the aggregate.
One primary issue is the lack of data standardization with respect to AAPI people. Reporting entities lack a common definition for Asian and Pacific Islander groups with some reporting them separately, together, or not at all. Another issue is varying degrees of cases and deaths with “unknown” race, which reflects underlying issues with data collection and quality. The lack of data and reporting consistency hinders efforts to recognize, evaluate, and address disparities.
Recommendations
Data Reporting
First, state and federal governments should require reporting entities to provide data disaggregated by race and ethnicity using standard definitions. Some progress was attained on June 4, when the Department of Health and Human Services (HHS) issued a directive requiring testing laboratories to report detailed demographics including race and ethnicity by August 1. However, the guidance does not specify a standard method for categorizing race and ethnicity. The Office of Management and Budget (OMB) previously defined racial and ethnic categories in notice NOT-OD-15-089, which separated “Asian” and “Native Hawaiian or Other Pacific Islander.” This definition is an important starting point for immediate data standardization. However, the OMB definition falls short of disaggregation by national origin, which respects the diversity of ethnic groups and lived experiences encompassed within the “Asian” category and how these identities influence one’s experience with health and disease. As a model, Hawaii recently became the first state to publicly report case data by Asian national origin. A further limitation of the HHS guidance is its application only to testing, meaning hospitalization and mortality data related to COVID-19 are not subject to its requirements.
Fatality Reports
Second, state and local health departments should release deidentified COVID-19 fatality data with at least age, sex, race, cause of death, and comorbidities so that researchers and local communities can identify patterns and disparities, develop public health interventions, and, in the context of Asian Americans, begin understanding the factors contributing to the higher observed CFR from COVID-19. Santa Clara County, California, and Cook County, Illinois’ transparent reporting serves as a model for others.
Local Awareness
Finally, frontline health care providers and local leaders can advocate for Asian Americans and other communities at risk through multiple means including calling attention to notable observations such as higher case fatality; monitoring and addressing delays in presentation to care; and demanding accountability from public health officials, including with data transparency on COVID-19 testing, cases, and deaths. Providers can help encourage testing for COVID-19 when appropriate and make education about risk mitigation strategies a standard part of each clinical encounter.
Future Directions
The high COVID-19 case fatality rate among Asian Americans requires urgent investigation to parse out potential causes such as testing inadequacy and delayed presentation to care, as well as factors common to deaths to better understand risk factors. Public health officials and health care providers possess tools to take data-driven approaches to addressing this health disparity. As minority communities including black, Hispanic, Pacific Islander, and Native Americans face further health disparities from COVID-19, awareness, advocacy, and data transparency become essential tools in collective efforts to advance health equity for all minority communities.
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July 13, 2020 at 07:08PM
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Asian Americans Facing High COVID-19 Case Fatality - Health Affairs
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