Intended for healthcare professionals


Covid-19: US studies show racial and ethnic disparities in long covid

BMJ 2023; 380 doi: (Published 06 March 2023) Cite this as: BMJ 2023;380:p535
  1. Janice Hopkins Tanne
  1. New York

Black and Hispanic Americans are more likely than white Americans to have symptoms of long covid and some people who had covid early in the epidemic may have long covid but not be diagnosed as such because of coding changes, show studies funded by the National Institutes of Health.123

Long covid was defined by the Centers for Disease Control and Prevention in December 2022, and includes general symptoms as well as respiratory, cardiovascular, neurological, digestive, and other symptoms.4

Mitchell Elkind, professor of neurology and epidemiology at Columbia University Medical Center in New York and chief clinical officer of the American Heart Association, said, “New evidence suggests that there may be important differences in how long covid manifests in different racial and ethnic groups. Further research is needed to understand better the mechanisms for these differences in symptoms and access to care, and also if diagnostic codes assigned by clinicians may play a role.”

First author of a New York City study,3 Dhruv Khullar, an assistant professor of health policy and economics at Weill Cornell Medcine, told The BMJ, “Overall, black and Hispanic patients had higher rates of long covid.” There were significant racial or ethnic differences in symptoms and conditions among patients who both were and weren’t admitted to hospital.

Khullar and colleagues reviewed electronic health records of 62 339 people who had a positive covid-19 test at one of five academic medical centres in New York City. The patients were treated between March 2020 and October 2021. They were followed for one to six months after their positive test and compared with the findings in 247 881 adults who had not had covid-19. About 20% of all patients developed long covid, with symptoms such as dyspnoea, fatigue, cognitive dysfunction, anxiety, and clotting disorders. Race and ethnicity may be an independent risk factor for developing long covid, the study said.

Black and Hispanic people had higher rates of hospital admission and death from covid-19 than white people. In the months after infection, black and Hispanic adults who had been admitted to hospital with severe disease were more likely than white adults to be diagnosed with diabetes and to have headaches, chest pain, and joint pain, but less likely to have sleep disorders, cognitive problems, or fatigue.

Khullar said, “Doctors in clinical practice should be aware of racial and ethnic differences. Specific symptoms may vary. We will need to see whether these disparities continue over time, and the role of vaccinations and prior infections. We need to ensure diverse enrolment in clinical trials.”

Coding anomalies

In the second study, researchers looked at the use of coding in characterising covid-19, a new disease. The ICD code of U07.1 was initially used for covid-19. The code U09.9 for long covid was only introduced in October 2021, after patients had begun to describe symptoms.

The researchers analysed data from electronic health records of 33 782 adults and children between October 2021 and May 2022 at 34 US medical centres. They found that most long covid patients were white, female, non-Hispanic, and likely to live in areas with low poverty and greater access to healthcare.

Study co-author Emily Pfaff, an assistant professor of endocrinology and metabolism at the University of North Carolina, Chapel Hill, told The BMJ, “Patients who developed long covid prior to October 2021 have missed out on the correct diagnosis for their condition.”

Co-author Charisse Madlock-Brown, a health informatics and information management expert at the University of Tennessee Health Science Center, said, “It’s a question of healthcare access. Not every group has the same access to care, insurance, or funds to cover care. Women are more likely to have health seeking behaviour.”

Pfaff said, “It matters to have the right diagnostic code or patients don’t get the right care and research is skewed. Community awareness of long covid is less in socially deprived areas. There’s a need for education about long covid.” She said people who had fatigue and shortness of breath after covid should seek care and be treated as a potential long covid case.

The Agency for Healthcare Research and Quality said it planned to ask for new studies to learn more about people with covid-19, especially underserved, rural, vulnerable, and minority populations, and to expand services.5

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