Spatial Inequities in COVID-19 Testing, Positivity, Confirmed Cases and Mortality in 3 US Cities: an Ecological Study

Background Preliminary evidence has shown inequities in COVID-19 related cases and deaths in the US. Objective We explored the emergence of spatial inequities in COVID-19 testing, positivity, confirmed cases, and mortality in New York City, Philadelphia, and Chicago during the first six months of the pandemic. Design Ecological, observational study at the zip code tabulation area (ZCTA) level from March to September 2020. Setting Chicago, New York City and Philadelphia. Participants All populated ZCTAs in the three cities. Measures Outcomes were ZCTA-level COVID-19 testing, positivity, confirmed cases, and mortality cumulatively through the end of September. Predictors were the CDC social vulnerability index and its four domains, obtained from the 2014-2018 American Community Survey. We examined the spatial autocorrelation of COVID-19 outcomes using global and local Moran’s I and estimated associations using spatial conditional autoregressive negative binomial models. Results We found spatial clusters of high and low positivity, confirmed cases and mortality, co-located with clusters of low and high social vulnerability. We also found evidence for the existence of spatial inequities in testing, positivity, confirmed cases and mortality for the three cities. Specifically, neighborhoods with higher social vulnerability had lower testing rates, higher positivity ratios, confirmed case rates and mortality rates. Limitations ZCTAs are imperfect and heterogeneous geographical units of analysis. We rely on surveillance data, which may be incomplete. Conclusion We found spatial inequities in COVID-19 testing, positivity, confirmed cases, and mortality in three large cities of the US. Registration N/A Funding source NIH (DP5OD26429) and RWJF (77644)