A Stressful Situation: A Mediation Analysis of Racial Disparities in COVID-19 Severity and Chronic Stress
Abstract
Background: Racial and ethnic minorities have experienced a disproportionate burden of severe COVID-19. Chronic stress is also disproportionately experienced by racial and ethnic minorities. Whether chronic stress explains this excess risk in COVID-19 is unknown.
Methods: We identified 9,577 adults (≥18 years) diagnosed with COVID-19 from January 1, 2020 through September 30, 2021 enrolled in Kaiser Permanente Georgia (KPGA) with complete biomarker data. Self-reported race (Black and White) was defined from electronic medical records (EMRs). Chronic stress was defined as allostatic load (AL). AL was quantified as a composite score based on seven cardio-metabolic biomarkers measured at least 45 days prior to COVID-19 diagnosis and was categorized as below (low AL) or above (high AL) the median. All biomarker data was extracted from KPGA EMRs. Severe COVID-19 was defined as hospitalization or mortality within 30 days of COVID-19 diagnosis. The association between race, AL, and severe COVID-19 was assessed using multivariable Poisson regression. The mediating effect of AL was assessed using the Valeri and VanderWeele method. All results were expressed as risk ratios (RRs) with 95% confidence intervals.
Results: Among 9,577 adult KPGA members with COVID-19 and complete biomarkers, 60.8% (n= 5,823), had high AL. Overall, Black (vs. White) KPGA members had an 18% excess risk of AL (RR: 1.18, 95%CI: 1.14 - 1.23) and a 24% excess risk of severe COVID-19 (RR: 1.24, 95%CI: 1.12,1.37). AL explained 21% of the Black-White disparities in severe COVID-19.
Conclusion: In our study, chronic stress, characterized by AL, partially mediated Black-White disparities in severe COVID-19 outcomes. Identifying individuals with high levels of chronic stress prior to COVID infections may be one potential strategy to mitigate excess risk from severe COVID-19 in racial and ethnic minority populations.
Keywords
COVID-19, racial disparities, mediation analysis, chronic stress
A Stressful Situation: A Mediation Analysis of Racial Disparities in COVID-19 Severity and Chronic Stress
Background: Racial and ethnic minorities have experienced a disproportionate burden of severe COVID-19. Chronic stress is also disproportionately experienced by racial and ethnic minorities. Whether chronic stress explains this excess risk in COVID-19 is unknown.
Methods: We identified 9,577 adults (≥18 years) diagnosed with COVID-19 from January 1, 2020 through September 30, 2021 enrolled in Kaiser Permanente Georgia (KPGA) with complete biomarker data. Self-reported race (Black and White) was defined from electronic medical records (EMRs). Chronic stress was defined as allostatic load (AL). AL was quantified as a composite score based on seven cardio-metabolic biomarkers measured at least 45 days prior to COVID-19 diagnosis and was categorized as below (low AL) or above (high AL) the median. All biomarker data was extracted from KPGA EMRs. Severe COVID-19 was defined as hospitalization or mortality within 30 days of COVID-19 diagnosis. The association between race, AL, and severe COVID-19 was assessed using multivariable Poisson regression. The mediating effect of AL was assessed using the Valeri and VanderWeele method. All results were expressed as risk ratios (RRs) with 95% confidence intervals.
Results: Among 9,577 adult KPGA members with COVID-19 and complete biomarkers, 60.8% (n= 5,823), had high AL. Overall, Black (vs. White) KPGA members had an 18% excess risk of AL (RR: 1.18, 95%CI: 1.14 - 1.23) and a 24% excess risk of severe COVID-19 (RR: 1.24, 95%CI: 1.12,1.37). AL explained 21% of the Black-White disparities in severe COVID-19.
Conclusion: In our study, chronic stress, characterized by AL, partially mediated Black-White disparities in severe COVID-19 outcomes. Identifying individuals with high levels of chronic stress prior to COVID infections may be one potential strategy to mitigate excess risk from severe COVID-19 in racial and ethnic minority populations.
