Racial and Neighborhood-level Disparities in COVID-19 Incidence Among Patients on Hemodialysis in New York City Journal: Journal of the American Society of Nephrology Manuscript ID JASN-2020-11-1606.R1 Manuscript Type: Original Article - Clinical Research Date Submitted by the 24-Feb-2021 Author: Complete List of Authors: Tummalapalli, Sri Lekha; Weill Cornell Medicine, Division of Healthcare Delivery Science & Innovation, Department of Population Health Sciences; Rogosin Institute; Weill Cornell Medicine, Division of Nephrology & Hypertension, Department of Medicine Silberzweig, Jeffrey; Rogosin Institute; Weill Cornell Medicine, Division of Nephrology & Hypertension, Department of Medicine Cukor, Daniel; Rogosin Institute Lin, Jonathan; Rogosin Institute; Weill Cornell Medicine, Division of Nephrology & Hypertension, Department of Medicine Barbar, Tarek; Weill Cornell Medicine, Division of Nephrology & Hypertension, Department of Medicine Liu, Yao; Rogosin Institute Kim, Kwan; Rogosin Institute Parker, Thomas; Rogosin Institute; Weill Cornell Medicine, Department of Biochemistry Levine, Daniel; Rogosin Institute; Weill Cornell Medicine, Department of Biochemistry Ibrahim, Said; Weill Cornell Medicine, Division of Healthcare Delivery Science & Innovation, Department of Population Health Sciences Keywords: COVID-19, hemodialysis, Disparities, Social determinants of health Journal of the American Society of Nephrology Page 1 of 34 1 2 3 Authors: Tummalapalli, Sri Lekha; Silberzweig, Jeffrey; Cukor, Daniel; Lin, Jonathan; Barbar, Tarek; Liu, 4 Yao; Kim, Kwan; Parker, Thomas; Levine, Daniel; Ibrahim, Said 5 6 7 Title: Racial and Neighborhood-level Disparities in COVID-19 Incidence Among Patients on Hemodialysis 8 in New York City 9 10 Running title: Racial and Neighborhood Disparities in COVID-19 11 12 Manuscript Type: Original Article - Clinical Research 13 14 15 Manuscript Category: Clinical dialysis 16 17 Funders: National Institute of Diabetes and Digestive and Kidney Diseases, (Grant / Award Number: 18 'F32DK122627') 19 20 National Kidney Foundation, (Grant / Award Number: 'Young Investigator Grant') 21 22 Financial Disclosure: No Dr. Tummalapalli received consulting fees from Bayer AG unrelated to the 23 submitted work. The remaining authors have nothing to disclose. D. Cukor reports Research Funding 24 from NIH. D. Levine reports Patents and Inventions with The Rogosin Institute. J. Silberzweig reports 25 Consultancy Agreements with Kaneka Pharma, Bayer Pharmaceuticals, Alkahest Biotech; Scientific 26 Advisor or Membership with American Society of Nephrology: COVID-19 Response team, Emergency 27 28 Partnership Initiative. 29 30 Study Group/Organization Name: CUST_STUDY_GROUP/ORGANIZATION_NAME :No data available. 31 32 Study Group Members’ Names: CUST_STUDY_GROUP_MEMBERS :No data available. 33 34 Total number of words: 2775 35 36 37 Abstract: <b>Background</b> The coronavirus disease 2019 (COVID-19) pandemic has 38 disproportionately affected socially disadvantaged populations. Whether disparities in COVID-19 39 incidence related to race/ethnicity and socioeconomic factors exist in the hemodialysis population is 40 unknown. 41 <b>Methods</b> Our study involved patients receiving in-center hemodialysis in New York City. We 42 used a validated index of neighborhood social vulnerability, the Social Vulnerability Index (SVI), which 43 comprises 15 census tract–level indicators organized into four themes: socioeconomic status, 44 household composition and disability, minority status and language, and housing type and 45 46 transportation. We examined the association of race/ethnicity and the SVI with symptomatic COVID-19 47 between March 1, 2020, and August 3, 2020. COVID-19 cases were ascertained using PCR testing. We 48 performed multivariable logistic regression to adjust for demographics, individual-level social factors, 49 dialysis-related medical history, and dialysis facility factors. 50 <b>Results</b> Of the 1378 patients on hemodialysis in the study, 247 (17.9%) developed symptomatic 51 COVID-19. In adjusted analyses, non-Hispanic Black and Hispanic patients had significantly increased 52 odds of COVID-19 compared with non-Hispanic White patients. Census tract–level overall SVI, 53 modeled continuously or in quintiles, was not associated with COVID-19 in unadjusted or adjusted 54 55 analyses. Among non-Hispanic White patients, the socioeconomic status SVI theme, the minority status 56 57 58 59 60 Journal of the American Society of Nephrology Page 2 of 34 1 2 3 and language SVI theme, and housing crowding were significantly associated with COVID-19 in 4 unadjusted analyses. 5 6 <b>Conclusions</b> Among patients on hemodialysis in New York City, there were substantial 7 racial/ethnic disparities in COVID-19 incidence not explained by neighborhood-level social vulnerability. 8 Neighborhood-level socioeconomic status, minority status and language, and housing crowding were 9 positively associated with acquiring COVID-19 among non-Hispanic Whites. Our findings suggest that 10 socially vulnerable patients on dialysis face disparate COVID-19–related exposures, requiring targeted 11 risk-mitigation strategies. 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Journal of the American Society of Nephrology Page 3 of 34 Copyright 2021 by ASN, Published Ahead of Print on 6/3/21, Accepted/Unedited Version. 1 2 Significance Statement 3 4 Coronavirus disease 2019 (COVID-19) has disproportionately affected socially disadvantaged 5 6 populations. Whether racial/ethnic and socioeconomic disparities in COVID-19 incidence exist 7 8 in the hemodialysis population is unknown. The authors examined the association of 9 10 race/ethnicity and a validated neighborhood-level index of social vulnerability (the Social 11 Vulnerability Index) with acquiring symptomatic COVID-19 among patients receiving in-center 12 13 hemodialysis from a dialysis organization in New York City. They found substantial 14 15 racial/ethnic disparities in COVID-19 incidence; Black and Hispanic individuals on hemodialysis 16 17 were more likely than non-Hispanic White patients to acquire COVID-19. Neighborhood-level 18 socioeconomic status, minority status and language, and housing crowding were positively 19 20 associated with COVID-19 acquisition among non-Hispanic white patients but did not explain 21 22 racial/ethnic disparities. These findings indicate that targeted strategies are needed to mitigate 23 excess COVID-19 risk among socially vulnerable patients on dialysis. 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Journal of the American Society of Nephrology Copyright 2021 by ASN, Published Ahead of Print on 6/3/21, Accepted/Unedited Version. Page 4 of 34 1 2 Racial and Neighborhood-Level Disparities in COVID-19 Incidence among Patients on 3 4 Hemodialysis in New York City 5 6 7 Sri Lekha Tummalapalli1,2,3, Jeffrey Silberzweig2,3, Daniel Cukor2, Jonathan T. Lin2,3, Tarek 8 3 2 2 2,4 2,4 1 9 Barbar , Yao Liu , Kwan Kim , Thomas S. Parker , Daniel M. Levine , Said A. Ibrahim 10 11 12 1. Division of Healthcare Delivery Science & Innovation, Department of Population Health 13 14 Sciences, Weill Cornell Medicine, New York, NY 15 16 2. The Rogosin Institute, New York, NY 17 3. Division of Nephrology & Hypertension, Department of Medicine, Weill Cornell 18 19 Medicine, New York, NY 20 21 4. Department of Biochemistry, Weill Cornell Medicine, New York, NY 22 23 24 25 26 27 28 Running Title: Disparities in COVID-19 Incidence in Hemodialysis Patients 29 30 31 32 33 34 35 36 37 38 Corresponding Author: 39 Sri Lekha Tummalapalli 40 Division of Healthcare Delivery Science & Innovation 41 Department of Population Health Sciences 42 th 43 402 East 67 Street 44 New York, NY 10065 45 Ph: 646-962-8001 46 E-mail: [email protected] 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Journal of the American Society of Nephrology Page 5 of 34 Copyright 2021 by ASN, Published Ahead of Print on 6/3/21, Accepted/Unedited Version. 1 2 3 Abstract 4 5 6 Background The coronavirus disease 2019 (COVID-19) pandemic has disproportionately 7 affected socially disadvantaged populations. Whether disparities in COVID-19 incidence related 8 9 to race/ethnicity and socioeconomic factors exist in the hemodialysis population is unknown. 10 11 Methods Our study involved patients receiving in-center hemodialysis in New York City. We 12 13 used a validated index of neighborhood social vulnerability, the Social Vulnerability Index 14 (SVI), which comprises 15 census tract–level indicators organized into four themes: 15 16 socioeconomic status, household composition and disability, minority status and language, and 17 18 housing type and transportation. We examined the association of race/ethnicity and the SVI with 19 20 symptomatic COVID-19 between March 1, 2020, and August 3, 2020. COVID-19 cases were 21 ascertained using PCR testing. We performed multivariable logistic regression to adjust for 22 23 demographics, individual-level social factors, dialysis-related medical history, and dialysis 24 25 facility factors. 26 Results Of the 1378 patients on hemodialysis in the study, 247 (17.9%) developed symptomatic 27 28 COVID-19. In adjusted analyses, non-Hispanic Black and Hispanic patients had significantly 29 30 increased odds of COVID-19 compared with non-Hispanic White patients. Census tract–level 31 32 overall SVI, modeled continuously or in quintiles, was not associated with COVID-19 in 33 unadjusted or adjusted analyses. Among non-Hispanic White patients, the socioeconomic status 34 35 SVI theme, the minority status and language SVI theme, and housing crowding were 36 37 significantly associated with COVID-19 in unadjusted analyses. 38 39 Conclusions Among patients on hemodialysis in New York City, there were substantial 40 racial/ethnic disparities in COVID-19 incidence not explained by neighborhood-level social 41 42 vulnerability. Neighborhood-level socioeconomic status, minority status and language, and 43 44 housing crowding were positively associated with acquiring COVID-19 among non-Hispanic 45 Whites.