COVID-19 Mortality Among American Indian and Alaska Native Persons — 14 States, January–June 2020

Abstract

On August 19, 2020, this report was posted as an MMWR Early Release on the MMWR website (https://www.cdc.gov/mmwr). Although non-Hispanic American Indian and Alaska Native (AI/AN) persons account for 0.7% of the U.S. population,* a recent analysis reported that 1.3% of coronavirus disease 2019 (COVID-19) cases reported to CDC with known race and ethnicity were among AI/AN persons (1). To assess the impact of COVID-19 among the AI/AN population, reports of laboratory-confirmed COVID-19 cases during January 22 †-July 3, 2020 were analyzed. The analysis was limited to 23 states § with >70% complete race/ethnicity information and five or more laboratory-confirmed COVID-19 cases among both AI/AN persons (alone or in combination with other races and ethnicities) and non-Hispanic white (white) persons. Among 424,899 COVID-19 cases reported by these states, 340,059 (80%) had complete race/ethnicity information; among these 340,059 cases, 9,072 (2.7%) occurred among AI/AN persons, and 138,960 (40.9%) among white persons. Among 340,059 cases with complete patient race/ethnicity data, the cumulative incidence among AI/AN persons in these 23 states was 594 per 100,000 AI/AN population (95% confidence interval [CI] = 203-1,740), compared with 169 per 100,000 white population (95% CI = 137-209) (rate ratio [RR] = 3.5; 95% CI = 1.2-10.1). AI/AN persons with COVID-19 were younger (median age = 40 years; inter-quartile range [IQR] = 26-56 years) than were white persons (median age = 51 years; IQR = 32-67 years). More complete case report data and timely, culturally responsive, and evidence-based public health efforts that leverage the strengths of AI/AN communities are needed to decrease COVID-19 transmission and improve patient outcomes. * Based on 2018 U.S. Census single-race estimates for non-Hispanic AI/AN (https://wonder.cdc.gov/Single-Race-v2018.HTML). This represents a subset of the AI/AN population. The total AI/AN population (AI/AN alone or in combination with other races/ethnicities) constitutes 1.4% of the United States population (https://wonder.cdc.gov/Bridged-Race-v2019.HTML). Some have estimated the AI/AN population to constitute up to 1.7% of the United States population were analyzed. Laboratory-confirmed † † and probable § § COVID-19 cases are reported by state and local health jurisdictions based on reports submitted by health care providers and laboratories. Cases with missing report date were excluded. Probable cases (12,081) and cases among persons repatriated to the United States from Wuhan, China (two cases), and the Diamond Princess cruise ship (41 cases) (2) were also excluded. Analysis was limited to the 23 states with >70% complete race/ethnicity information and five or more laboratory-confirmed cases each among AI/AN and white persons. Arizona, which accounts for at least one third of all COVID-19 cases among AI/AN persons nationwide, was excluded from analysis because >30% of race/ethnicity data were missing. Because approximately 2.3 million of 5.2 million AI/AN persons identify with multiple races (3), AI/AN race/ ethnicity was classified as either AI/AN alone or in combination with other races and ethnicities. White (non-Hispanic) was chosen as the comparator group to avoid comparing rates among AI/AN persons to other marginalized populations that experience similar health disparities. Whereas previous reports focused on COVID-19 incidence among black and Hispanic persons, the race/ethnicity categorization in this analysis maximized these data to allow for the calculation of more stable RR estimates. A generalized estimating equations Poisson regression model was used to calculate cumulative incidence (cumulative cases per 100,000 population), RRs, ¶ https://www.cdc.gov/coronavirus/2019-ncov/php/reporting-pui.html. ** https://wwwn.cdc.gov/nndss; https://wwwn.cdc.gov/nndss/covid-19-response.html. † † A laboratory-confirmed COVID-19 case was defined as a person with a positive test result for SARS-CoV-2, the virus that causes COVID-19, from a respiratory specimen, using real time reverse transcription-polymerase chain reaction testing. § § According to the Council of State and Territorial Epidemiologists position statement Interim 20-ID-01, a probable case must 1) meet clinical criteria and epidemiologic criteria with no confirmatory laboratory testing performed; 2) have presumptive laboratory evidence, including detection of specific antigen or antibody in a clinical specimen, and meet clinical criteria or epidemiologic criteria; or 3) meet vital records criteria with no confirmatory laboratory testing performed.