Association of Race/Ethnicity and Severe Housing Problems with COVID-19 Deaths in the United States: Analysis of the First Three Waves

Background: Severe housing problems are prevalent among racial/ethnic minority populations in the US. Early in the pandemic, several studies examined a snapshot of the association of racial/ethnic composition and severe housing problems with COVID-19 mortality. Our analysis provides a window into the dynamics of COVID-19 mortality during the first three and most deadly waves of the pandemic.Method: We conducted a cross-sectional study using a negative binomial regression model to estimate factors associated with COVID-19 deaths in 3063 US counties between March 2020 and July 2021 by wave and pooled across all three waves.Findings: We found that in Wave 1, counties with larger percentages of Black, Hispanic, American Indian and Alaska Native and Asian American and Pacific Islander residents experienced a greater risk of deaths per 100,000 residents of 22·82 (95% CI [15·09, 30·56], P<0·0001), 7·50 (95% CI [1·74, 13·26], P=0·01), 13·52 (95% CI [8·07, 18·98], P<0·0001), and 5·02 (95% CI [0·92, 9·12], P=0·02), respectively, relative to counties with larger White populations. By Wave 3, however, the mortality gap declined considerably in counties with large Black, AIAN and AAPI populations: 10·38 (95% CI [4·44, 16·32], P=0·001), 7·14 (95% CI [1·14, 13·15], P=0·02), and 3·72 (95% CI [0·81, 6·63], P=0·01), respectively. In contrast, the gap increased for counties with a large Hispanic population: +13 (95% CI [8·81, 17·20], P<0·0001)). Housing problems were an important predictor of COVID-19 deaths. However, while housing problems were associated with increased COVID-19 mortality in Wave 1, by Wave 3, they became associated with a reduction in mortality and, importantly, magnified mortality in counties with large racial/ethnic minority groups.Interpretation: COVID-19 mortality initially took hold in areas characterized by large racial/ethnic minority populations and poor housing conditions. Over time, as the virus spread to predominantly White counties, these disparities decreased substantially but remained sizable.Funding: None reported.Declaration of Interest: None reported.Ethical Approval: Owing to the nature of the data, the Pennsylvania State University Institutional Review Board (IRB) determined that this study did not require IRB approval and was exempt from the informed consent requirement.