Changes in the associations of race and rurality with SARS-CoV-2 infection, mortality, and case fatality in the United States from February 2020 to March 2021: A population-based cohort study

PLoS MedicineIoannou GN, Ferguson JM, O’Hare AM, et al. | October 25, 2021


A population-based cohort study was conducted to determine the changes in key sociodemographic and clinical risk factors for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection and mortality over time.

  • The associations were assessed in a cohort of nearly 9.1 million persons enrolled in the national US Veterans Affairs (VA) healthcare system, including 216,046 who tested positive and 10,230 who died of COVID-19 during the study period.

  • In February to March 2020, there appeared a 5-fold higher risk of SARS-CoV-2 infection, a 4-fold higher risk of mortality, and a 2.5-fold higher risk of case fatality in strong correlation with Black (vs White) race; but these associations attenuated over time and were no longer statistically significant by November 2020 for infection and mortality and were reversed for case fatality.

  • Early in the pandemic, an association of American Indian/Alaska Native (AI/AN vs White) race was observed with SARS-CoV-2 infection, but this correlation declined over time and reversed by March 2021.

  • In February to April 2020, there appeared 2-fold higher risk of infection, a 2.5-fold higher risk of mortality, and 2.2-fold higher risk of case fatality in correlation with urban (vs rural) residence, but these associations attenuated over time and reversed by September 2020.

  • High comorbidity burden, younger age, Hispanic ethnicity, and obesity were consistently linked with infection throughout the observation period, while there was consistent association of high comorbidity burden, older age, Hispanic ethnicity, and male gender with mortality.

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