COVID-19 Was 3.5 Times as Common Among American Indian and Alaska Native People, 2020

In the first months of the pandemic, confirmed COVID-19 was 3.5 times as common among American Indian and Alaska Native (AI/AN) people as among non-Hispanic white people, in the 23 states whose data were complete enough to tell. AI/AN patients were also younger. And so much information about them was missing that it was impossible to say how sick they got, or why.

The numbers

Non-Hispanic AI/AN people make up 0.7% of the U.S. population, but an earlier analysis found they accounted for 1.3% of COVID-19 cases reported to CDC with known race and ethnicity. To measure the impact more precisely, CDC analyzed laboratory-confirmed cases from January 22 to July 3, 2020 — the first in the 23 states came on January 31 — in states where more than 70% of cases had race and ethnicity recorded and there were at least five cases each among AI/AN and white people.

The rate ratio was 3.5 (95% CI 1.2–10.1). The wide interval reflects big differences between states, and the overall figure was driven mostly by New Mexico, where the ratio was 14.9 — New Mexico had 6,130 (68%) of the AI/AN cases but 16% of the AI/AN population of the 23 states.

The states: Alabama, Alaska, Florida, Iowa, Kansas, Kentucky, Maine, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Mexico, North Carolina, Ohio, Oregon, Tennessee, Utah, Wisconsin and Wyoming. Arizona, which accounts for at least a third of AI/AN COVID-19 cases nationwide, was left out because more than 30% of its race and ethnicity data were missing.

How it was counted

Because about 2.3 million of the 5.2 million AI/AN people in the U.S. identify with more than one race, AI/AN people were counted whether they identified as AI/AN alone or in combination with other races and ethnicities; that raised the AI/AN case count by 4%, from 8,691 to 9,072. White people were chosen for comparison to avoid comparing AI/AN rates with those of other marginalized groups facing similar health disparities. Probable cases and cases among people repatriated from Wuhan, China, or the Diamond Princess cruise ship were excluded.

The missing data

Information that would show how severe the illness was, and who was most at risk, was far more often missing for AI/AN patients:

So although AI/AN people are well documented to have higher rates of underlying conditions, their link to COVID-19 could not be examined. The gap, the authors write, points to a need for more resources for case investigation and reporting in AI/AN communities.

Why the burden was higher

Historical trauma and persistent racial inequity have created health and socioeconomic disparities that likely contributed. The higher incidence might also reflect greater reliance on shared transportation, limited access to running water, household size and other factors that can help the virus spread.

An undercount

The true toll was likely higher. States report voluntarily, without active case finding, and the analysis covered only about half of AI/AN cases nationwide, in states holding about a third of the AI/AN population. AI/AN people are often misclassified as other races in health data, and the population estimates used inflate the Hispanic AI/AN population, which leads to underestimated rates.

What's needed

More complete, consistent and accurate reporting by providers, laboratories and local, state, federal and tribal health agencies — and the resources to do it. Race and ethnicity should be collected following best practices for AI/AN data, including allowing more than one race and training staff to ask in a culturally sensitive way. For members of federally recognized tribes, AI/AN identity is a political status that carries access to health care under the U.S. government's treaty obligations; adequate health care and public health resources are central to a culturally responsive response that builds on the strengths of AI/AN communities.

Sources

Based on Sarah M. Hatcher, Christine Agnew-Brune, Mark Anderson, et al., "COVID-19 Among American Indian and Alaska Native Persons — 23 States, January 31–July 3, 2020," Morbidity and Mortality Weekly Report, volume 69, Centers for Disease Control and Prevention, posted as an Early Release on August 19, 2020; a work of the United States government in the public domain. Authors included staff of tribal epidemiology centers, the Indian Health Service and the Urban Indian Health Institute.