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Community Testing and SARS-CoV-2 Rates for Latinxs in Baltimore

Published:February 12, 2021DOI:https://doi.org/10.1016/j.amepre.2021.01.005

      Introduction

      Latinxs have been disproportionately impacted by COVID-19. Latinx immigrants, in particular, face significant barriers to SARS-CoV-2 testing, including lack of insurance, language barriers, stigma, work conflicts, and limited transportation.

      Methods

      In response to a disproportionately high SARS-CoV-2 positivity rate among Latinxs at the Johns Hopkins Health System, investigators implemented free community-based testing by partnering with religious leaders and leveraging the skill of trusted community health workers. Data were extracted from the electronic health record and a Research Electronic Data Capture database. SARS-CoV-2 positivity was evaluated per event stratified by race/ethnicity. Total rates of SARS-CoV-2 positivity and categorical patient characteristics were compared between groups using chi-square tests.

      Results

      Between June 25, 2020 and October 15, 2020, a total of 1,786 patients (57.5% Latinx, 31.2% non-Hispanic White, 5.9% non-Hispanic Black, and 5.3% non-Hispanic other) were tested for SARS-CoV-2 in 18 testing events. Among them, 355 (19.9%) tested positive. The positivity rate was 31.5% for Latinxs, 7.6% for non-Hispanic Blacks, 3.4% for non-Hispanic Whites, and 5.3% for patients of other races/ethnicities. Compared with Latinxs who tested negative, Latinxs who tested positive were more likely to report Spanish as their preferred language (91.6% vs 81.7%, p<0.001), be younger (30.4 vs 33.4 years, p<0.008), and have a larger household size (4.8 vs 4.3 members, p<0.002).

      Conclusions

      Community-based testing identified high levels of ongoing SARS-CoV-2 transmission among primarily Latinxs with limited English proficiency. During this period, the overall positivity rate at this community testing site was almost 10 times higher among Latinxs than among non-Hispanic Whites.

      INTRODUCTION

      Latinxs have been disproportionately affected by coronavirus disease 2019 (COVID-19).
      • Moore JT
      • Ricaldi JN
      • Rose CE
      • et al.
      Disparities in incidence of COVID-19 among underrepresented racial/ethnic groups in counties identified as hotspots during June 5‒18, 2020 - 22 states, February-June 2020.
      • Webb Hooper M
      • Nápoles AM
      • Pérez-Stable EJ
      COVID-19 and racial/ethnic disparities.
      • Page KR
      • Flores-Miller A.
      Lessons we've learned - Covid-19 and the undocumented Latinx community.
      • Page KR
      • Polk S.
      Chilling effect? Post-election health care use by undocumented and mixed-status families.
      Among undocumented immigrants, high infection rates are driven in part by high participation in frontline occupations such as construction, manufacturing, and wholesale trade associated with workplace outbreaks, crowded households, and exclusion from health insurance coverage and unemployment benefits.
      • Bui DP
      • McCaffrey K
      • Friedrichs M
      • et al.
      Racial and ethnic disparities among COVID-19 cases in workplace outbreaks by industry sector - Utah, March 6-June 5, 2020.
      ,
      • Pasco RF
      • Fox SJ
      • Johnston SC
      • Pignone M
      • Meyers LA.
      Estimated association of construction work with risks of COVID-19 infection and hospitalization in Texas.
      Language barriers, fear of medical bills, limited familiarity with the health system, and concern about immigration can dissuade undocumented immigrants from seeking help.
      • Page KR
      • Flores-Miller A.
      Lessons we've learned - Covid-19 and the undocumented Latinx community.
      ,
      • Page KR
      • Venkataramani M
      • Beyrer C
      • Polk S.
      Undocumented U.S. immigrants and Covid-19.
      ,
      • Tenforde MW
      • Billig Rose E
      • Lindsell CJ
      • et al.
      Characteristics of adult outpatients and inpatients with COVID-19 - 11 academic medical centers, United States, March-May 2020.
      Latinxs account for only 5.5% of the Baltimore city population, but they are the fastest growing ethnic group in the city. Compared with the U.S. Latinx population, Baltimore Latinxs are more likely to be foreign born, to be undocumented, and to have low incomes, low educational attainment, no health insurance, and limited English proficiency (LEP).
      Maryland Department of Health and Mental Hygiene, Office of Minority Health and Health Disparities. Hispanics in Maryland: health data and resources.
      ,
      • Rawlings-Blake S
      • Barbot O.
      The health of Latinos in Baltimore city 2011.
      Between March 11, 2020 and May 25, 2020, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positivity rate at the Johns Hopkins Health System (JHHS) was 42.6% among Latinxs compared with 17.6% and 8.8% among non-Hispanic Black and White patients, respectively, and almost 70% of 516 Latinx patients admitted during this period had LEP.
      • Martinez DA
      • Hinson JS
      • Klein EY
      • et al.
      SARS-CoV-2 positivity rate for Latinos in the Baltimore-Washington, DC region.
      In response to these disparities, JHHS partnered with religious leaders and community organizations to implement testing in a neighborhood where 19.0% of the population is Latinx and 17.4% are foreign born. This study describes the positivity rate in community testing events aimed at improving access to SARS-CoV-2 testing for underserved Latinx immigrants.

      METHODS

      A total of 18 free community testing events were conducted at the Sacred Heart of Jesus Church in Baltimore city between June 25, 2020 and October 15, 2020. Events were advertised in English and Spanish through social media influencers, media outlets, and community partners. People could preregister for testing but walk-ins were allowed.
      Samples collected by nasopharyngeal swabs were analyzed using SARS-CoV-2 real-time reverse transcriptase–polymerase chain reaction. All patients with a positive test result were contacted by bilingual community health workers (CHWs) who delivered the results and referred patients with moderate-to-severe symptoms or predisposing conditions for severe COVID-19 to a JHHS COVID-19 telemedicine follow-up service. CHWs assessed each patient's needs for safe isolation and enrolled patients in food delivery programs, cash assistance, or isolation hotel as needed. Household contacts were referred for testing. Patients were provided notes to excuse them from work during the isolation period, and after recovery, they could request a return to work note releasing them from isolation per Centers for Disease Control and Prevention guidelines.
      Data on patient demographics and SARS-CoV-2 status were extracted from the electronic health record system and a Research Electronic Data Capture database. Patients self-identified their race/ethnicity from fixed categories. Groups were mutually exclusive; that is, Latinxs were excluded from other groups regardless of the reported race.
      Positivity was evaluated per event stratified by race/ethnicity (Figure 1). Patients who retested were removed from the analysis after their first positive sample. Total rates of SARS-CoV-2 positivity and categorical patient characteristics were compared between Latinxs and each racial/ethnic group using chi-square tests. The characteristics among Latinx patients who tested positive or negative for SARS-CoV-2 were compared using chi-square tests for categorical characteristics and 2-sample t-tests for continuous variables. All comparisons were made using Stata, version 16. This work was exempt by the Johns Hopkins IRB.
      Figure 1 XXX (
      Figure 1.(A) Positivity rate per community testing event in Latinx compared with that in non-Latinx patients. A 7-day rolling average positivity rate for all SARS-CoV-2 tests conducted in Maryland between June 25 and October 15, 2020 added for reference. (B) Testing volume and number of positive SARS-CoV-2 tests per community testing event, stratified by Latinx ethnicity..
      Aug, August; Jul, July; Jun, June; No. number; Oct, October; Sept, September.

      RESULTS

      A total of 1,786 patients (57.5% Latinx, 31.2% non-Hispanic White, 5.9% non-Hispanic Black, and 5.3% non-Hispanic other) were tested for SARS-CoV-2, and 355 patients (19.9%) were positive. The positivity rate was 31.5% (n=323) for Latinxs, 7.6% (n=8) for non-Hispanic Blacks, 3.4% (n=19) for non-Hispanic Whites, and 5.3% (n=5) for patients of other races/ethnicities (Table 1). Overall, tested Latinx community members were younger than those of other races/ethnicities. Among 264 tested children, 204 (77.2%) were Latinx, and 74 were positive for SARS-CoV-2 (98.6% Latinx).
      Table 1Demographics of Patients Tested for SARS-CoV-2 at JHHS Community Testing From June 25 to October 15, 2020
      VariablesLatinxWhitep-value
      p-values were calculated using chi-square test for categorical variables and t-test for continuous variables, with Latinxs as reference for each pairwise comparison. The 95% CIs for proportions were calculated using the Wilson score method without continuity correction. JHHS, Johns Hopkins Health System.
      Blackp-value
      p-values were calculated using chi-square test for categorical variables and t-test for continuous variables, with Latinxs as reference for each pairwise comparison. The 95% CIs for proportions were calculated using the Wilson score method without continuity correction. JHHS, Johns Hopkins Health System.
      Other race/ethnicityp-value
      p-values were calculated using chi-square test for categorical variables and t-test for continuous variables, with Latinxs as reference for each pairwise comparison. The 95% CIs for proportions were calculated using the Wilson score method without continuity correction. JHHS, Johns Hopkins Health System.
      Tested, n1,02755810695
      Female sex, n (%)538 (52.4)325 (58.2)0.02547 (44.3)0.11553 (55.8)0.525
      Mean age in years32.534.50.01539.5<0.00129.30.077
        <18, n (%)204 (19.9)33 (5.9)<0.00114 (13.2)0.09813 (13.7)0.145
        18‒29, n (%)238 (23.2)177 (31.7)<0.00119 (17.9)0.21937 (39.0)0.001
        30‒44, n (%)358 (34.9)251 (45.0)<0.00132 (30.2)0.33533 (34.7)0.981
        45‒64, n (%)182 (17.7)68 (12.2)0.00429 (27.4)0.01511 (11.6)0.129
        65‒74, n (%)35 (3.4)20 (3.6)0.85510 (9.4)0.0021 (1.1)0.213
        >74, n (%)10 (1.0)9 (1.6)0.2642 (1.9)0.3820 (0.0)0.334
      Demographics of patients testing positive for SARS-CoV-2
       Positive, n3231985
        % Tested (95% CI)31.5

      (28.7, 34.4)
      3.4

      (2.2, 5.3)
      <0.0017.6

      (3.9, 14.2)
      <0.0015.3

      (2.3, 11.7)
      <0.001
       Female sex, n1781031
        % Positives (95% CI)55.1

      (49.7, 60.4)
      52.6

      (31.7, 72.7)
      0.83337.5

      (13.7, 69.4)
      0.32320.0

      (3.6, 62.4)
      0.118
       Mean age in years30.437.20.07042.90.02824.40.404
        <18, n73001
         % Positives (95% CI)22.6

      (18.4, 27.5)
      0.0

      (0.0, 16.8)
      0.0190.0

      (0.0, 32.4)
      0.12820.0

      (3.6, 62.4)
      0.890
        18‒29, n76713
         % Positives (95% CI)23.5

      (19.2, 28.4)
      36.8

      (19.1, 59.0)
      0.18812.5

      (2.2, 47.1)
      0.46660.0

      (23.1, 88.2)
      0.058
        30‒44, n121941
         % Positives (95% CI)37.5

      (32.4, 42.9)
      47.4

      (27.3, 68.3)
      0.38750.0

      (21.5, 78.5)
      0.47020.0

      (3.6, 62.4)
      0.423
        45‒64, n47120
         % Positives (95% CI)14.6

      (11.1, 18.8)
      5.3

      (0.9, 24.6)
      0.25725.0

      (7.1, 59.1)
      0.4110.0

      (0.0, 43.4)
      0.357
        65‒74, n4010
         % Positives (95% CI)1.2

      (0.5, 3.1)
      0.0

      (0.0, 16.8)
      0.62612.5

      (2.2, 47.1)
      0.0100.0

      (0.0, 43.4)
      0.802
        >74, n2200
         % Positives (95% CI)0.6

      (0.2, 2.2)
      10.5

      (2.9, 31.4)
      <0.0010.0

      (0.0, 32.4)
      0.8230.0

      (0.0, 43.4)
      0.860
      Notes: Boldface indicates statistical significance (p<0.05).
      a p-values were calculated using chi-square test for categorical variables and t-test for continuous variables, with Latinxs as reference for each pairwise comparison. The 95% CIs for proportions were calculated using the Wilson score method without continuity correction.JHHS, Johns Hopkins Health System.
      Latinxs who tested positive were more likely to report Spanish as their preferred language (91.6% vs 81.7%, p<0.001), be younger (30.4 vs 33.4 years, p<0.008), and have a larger household size (4.8 vs 4.3 members, p<0.002) than those who tested negative (Table 2). There were no differences observed by sex or having a primary care provider. Among 289 positive Latinx patients who reported symptom severity, 52.9% were asymptomatic. Children were more likely to be asymptomatic than adults (63.0% vs 42.8%, p=0.002). Among patients with symptoms, body aches (41%), fever (39%), cough (33%), sore throat (25%), and loss of taste or smell (24%) were most commonly reported, and shortness of breath (7%) was infrequent.
      Table 2Comparison of Latinxs Testing Positive or Negative for SARS-CoV-2 at JHHS Community Testing From June 25 to October 15, 2020
      Latinxs tested for SARS-CoV-2Positive SARS-CoV-2 test, n% Positives (95% CI) or mean (min, max)Negative SARS-CoV-2 test, n% Negatives (95% CI) or mean (min, max)p-value
      p-values were calculated using chi-square test for categorical variables and t-test for continuous variables. The 95% CIs for proportions were calculated using the Wilson score method without continuity correction.
      Overall32331.5
      % Tested.


      (28.7, 34.4)
      70468.5
      % Tested.


      (65.6, 71.3)
      Spanish language preference29691.6
      % Positives.


      (88.1, 94.2)
      57581.7
      % Negatives.


      (78.6, 84.4)
      <0.001
      Age in years30.4
      Data missing for 193 respondents (39 positives, 154 negatives).


      (0.8, 93.8)
      33.4
      Mean among positives.


      (1.3, 87.4)
      0.008
      Female sex17855.1
      % Positives.


      (49.7, 60.4)
      36051.1
      % Negatives.


      (47.4, 54.8)
      0.237
      No primary care provider (self-reported only)
      Data missing for 193 respondents (39 positives, 154 negatives).
      21776.4
      % Positives.


      (71.1, 81.0)
      42076.4
      % Negatives.


      (72.6, 79.7)
      0.988
      Household size4.8 members
      Mean among positives.


      (1, 10)
      4.3 members
      Mean among negatives. JHHS, Johns Hopkins Health System; max, maximum; min, minimum.


      (1, 13)
      0.002
      Notes: Boldface indicates statistical significance (p<0.05).
      a p-values were calculated using chi-square test for categorical variables and t-test for continuous variables. The 95% CIs for proportions were calculated using the Wilson score method without continuity correction.
      b % Tested.
      c % Positives.
      d % Negatives.
      e Data missing for 193 respondents (39 positives, 154 negatives).
      f Mean among positives.
      g Mean among negatives.JHHS, Johns Hopkins Health System; max, maximum; min, minimum.

      DISCUSSION

      This community-based intervention expanded access to SARS-CoV-2 testing for Latinx immigrants and identified a high burden of infection in this population. The majority of Latinxs at these events had no primary care provider, and positive tests were associated with large household size and LEP. These findings demonstrate that LEP Latinxs comprise an important subgroup impacted by COVID-19 and highlight the need to tailor programs and research to meet their needs.
      Although disparities in COVID-19 among Latinxs are well documented, data on LEP Latinxs are scarce.
      • Moore JT
      • Ricaldi JN
      • Rose CE
      • et al.
      Disparities in incidence of COVID-19 among underrepresented racial/ethnic groups in counties identified as hotspots during June 5‒18, 2020 - 22 states, February-June 2020.
      ,
      • Webb Hooper M
      • Nápoles AM
      • Pérez-Stable EJ
      COVID-19 and racial/ethnic disparities.
      ,
      • Tai DBG
      • Shah A
      • Doubeni CA
      • Sia IG
      • Wieland ML.
      The disproportionate impact of COVID-19 on racial and ethnic minorities in the United States.
      • Wortham JM
      • Lee JT
      • Althomsons S
      • et al.
      Characteristics of persons who died with COVID-19 - United States, February 12-May 18, 2020.
      • Bixler D
      • Miller AD
      • Mattison CP
      • et al.
      SARS-CoV-2-associated deaths among persons aged <21 years - United States, February 12-July 31, 2020.
      Among undocumented immigrants, the heavy toll of COVID-19 is driven by poverty, exclusion from benefits, and political disempowerment. The pressure to work, informal labor arrangements, limited agency to demand occupational protections, and shared transportation have contributed to rapid transmission in the workplace.
      • Page KR
      • Flores-Miller A.
      Lessons we've learned - Covid-19 and the undocumented Latinx community.
      The association of household size with positive SARS-CoV-2 tests is not surprising because sharing rent is common among low-income Latinxs ineligible for housing assistance.
      This testing initiative was developed with community leaders and through iterative adaptation. During the initial rollout, Latinx patients expressed reluctance to get tested in fear of losing their job.
      • Page KR
      • Flores-Miller A.
      Lessons we've learned - Covid-19 and the undocumented Latinx community.
      In response, CHWs provided work letters following Centers for Disease Control and Prevention isolation guidelines. A bilingual COVID-19 line at a community partner site facilitated access to reliable information and linkage to testing. Trusted and experienced bilingual CHWs contacted >99% of patients who tested positive and offered warm handoffs to food delivery, cash assistance, and the option to stay in a hotel.
      The high proportion of asymptomatic patients with COVID-19 identified through community testing has important public health implications. It is estimated that approximately 40%–45% of individuals infected with SARS-CoV-2 are asymptomatic.
      • Oran DP
      • Topol EJ.
      Prevalence of asymptomatic SARS-CoV-2 infection: a narrative review.
      Developing strategies to identify asymptomatic infected individuals are critical to mitigate the ongoing transmission.
      Although these data from JHHS community testing may not be generalizable to other settings, serologic studies are finding similar evidence of high burden of COVID-19 in areas with large immigrant Latinx populations, and they underscore the importance of considering immigrant status and language proficiency when studying health disparities.
      • Menachemi N
      • Yiannoutsos CT
      • Dixon BE
      • et al.
      Population point prevalence of SARS-CoV-2 infection based on a statewide random sample - Indiana, April 25-29, 2020.
      It should be noted that non-Latinxs tested at the study site may not be representative of all non-Latinx Whites and Blacks in Baltimore. In the authors’ experience, the partnership among JHHS, religious leaders, and community organizations was critical to ensure that testing at their site was acceptable, accessible, trusted, and responsive to the needs expressed by the community.

      CONCLUSIONS

      The JHHS community testing initiative was launched after the COVID-19 wave in Maryland had passed, and the SARS-CoV-2 positivity rate in the general population was <5%. The persistently high positivity rate in Latinxs may not have been detected without the implementation of low-barrier community outreach and testing. The CHWs’ high success rate in contacting positive patients underscores the importance of implementing approaches responsive to the unique needs of vulnerable populations.

      ACKNOWLEDGMENTS

      The authors would like to acknowledge the John Hopkins GoTeam volunteers, the Latinx outreach team (Alejandra Flores-Miller, Ana Cervantes, Ana Ortega Meza, and Melissa Cuesta), and the support from Alicia Wilson, the Vice President of Economic Development for Johns Hopkins University, and Inez Stewart, the Senior Vice President of Human Resources at Johns Hopkins Medicine. This work could not have been possible without the advocacy from Baltimoreans United in Leadership Development, especially that from Reverend George Hopkins, Bishop Bruce Lewandowski, and Rachel Brooks.
      This work was in part supported by the NIH Rapid Acceleration of Diagnostics-Underserved Populations initiative (Grant R01 DA045556-04S1).
      No financial disclosures were reported by the authors of this paper.

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