Misinformation and Mistrust The Disproportionate Burder of COVID19
Misinformation and Mistrust The Disproportionate Burder of COVID-19 and Its Health Consequences Julius Wilder MD, Ph. D Assistant Professor of Medicine Diversity Chair, Duke Division of Gastroenterology Duke School of Medicine
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Objectives §Describe the disproportionate burden of COVID-19 §Describe the morbidity of COVID-19 §Discuss key next steps for addressing disparities in COVID-19 as well as future pandemics
Pandemic Timeline Wiersinga et al. JAMA. 2020; 324(8): 782 -793
US Deaths in Wars Battlefields. org
US COVID-19 Cases and Deaths The COVID Tracking Project
COVID-19 The Disproportionate Burden of Disease
North Carolina Data Percent Positive by County NCDHHS
COVID 19 Case Rate by Zip Code, New York City Bronx Manhattan Staten Island Queens Brooklyn NYSDOH
Source: COVID Tracking Project; Credit: Daniel Wood/NPR
Source: COVID Tracking Project; Credit: Daniel Wood/NPR
Source: COVID Tracking Project; Credit: Daniel Wood/NPR
Source: COVID Tracking Project; Credit: Daniel Wood/NPR
Source: COVID Tracking Project; Credit: Daniel Wood/NPR
Source: COVID Tracking Project; Credit: Daniel Wood/NPR
COVID-19 Morbidity
What is COVID-19? § Symptoms occur on average about 5 days after exposure – Almost all patients develop symptoms within 12 days. § COVID-19 is typically diagnosed by a swab of the nose that measures the coronavirus § Virus typically enters through the eyes, mouth, or nose then travels down the throat § About 1 in 20 patients with COVID-19 dies § No cure or vaccine – Steroids may help the severely ill Wiersinga and Prescott, JAMA. 2020; 324(8): 816
Co-morbidities and COVID-19 § Biological predisposition to more severe infection – Contribute to racial/ethnic disparities § Due to comorbidities associated with worse COVID-19 outcomes – – – Diabetes Hypertension Obesity CAD Chronic Kidney disease – Biological Mechanisms Aren’t Always Just Biology The co-morbid conditions making COVID-19 outcomes worst disproportionately affect minorities because of social determinants
GI and Hepatology § Increased liver enzymes – AST+ALT – Associated with worse outcomes § Inpatients with cirrhosis and COVID-19 had higher mortality risk than inpatients with COVID-19 infection alone. § GI: Anorexia, nausea, vomiting, and diarrhea Bajaj JS, Garcia-Tsao G, Biggins SW, et al Comparison of mortality risk in patients with cirrhosis and COVID-19 compared with patients with cirrhosis alone and COVID-19 alone: multicentre matched cohort. Gut
Cardiology § Selective binding to the angiotensin-converting enzyme 2 (ACE 2) receptor § Thrombosis – Vascular injury and the prothrombotic cytokines released during the intense systemic inflammatory and immune responses § Myocardial injury – Elevated troponin, creatinine kinase-MB, and myoglobin. – High risk of in-hospital mortality Arq. Bras. Cardiol. vol. 114 no. 5 São Paulo May 2020 Epub May 11, 2020 Bonow et al. JAMA. 2020; 324(12): 1131 -1132
Nephrology § Patients with kidney disease are vulnerable to SARS-Co. V-2 § Acute kidney injury (AKI) occurs at severalfold higher rates in hospitalized patients with COVID-19 in the US than in earlier series in China § Pathologic series suggest that acute tubular necrosis is the predominant form of kidney injury – Likely multifactorial Forbes Winkelmater et al. JAMA. 2020; 324(12): 1137 -1138
Dermatology § Broad spectrum of skin manifestations has been reported. – Estimated as high as 20% prevalence in adults, who rarely present with viral exanthems – SARS-Co. V-2 infection disproportionately affects people of color yet there have been almost no reports of dermatologic findings in this population § COVID-19 Toes – Acral chilblainslike lesions NBC Chicago Shinkai and Bruckner. JAMA. 2020; 324(12): 1133 -1134
Pediatrics § Less than 6% of COVID cases have occurred in children, and most of those cases have involved minor symptoms – Age-dependent expression of angiotensin -converting enzyme 2 in nasal epithelium § Multisystem Inflammatory Syndrome – Mimics Kawasaki disease/toxic shock syndrome – Cardiac, fever, diarrhea, and shock § Psychological and educational well-being NAMI Greenville. How To Ease anxiety About COVID-19 Christakis, DA. JAMA. 2020; 324(12): 1147 -1148
Vaccines § COVID-19 and m. RNA Vaccine – New technology – Allows for a quicker development • Clinical Trial began 66 days after RNA sequenced Moderna, Inc NIAID Bio. NTech and Pfizer, both entered phase 3 trials § Inactivated vaccine – Recent interim analyses from phase 1 and 2 clinical trials – Inactivated COVID-19 vaccine had a low rate of adverse reactions and demonstrated immunogenicity et al. 2020; 324(12): 1125 -1127 JAMA. 2020; 324(10): 951 Abbasi, J. Xia JAMA. 960
Vaccine Hesitancy § Less than half of US adults receive an influenza vaccine each year § Disparities persist as well – Vaccine coverage estimates remained substantially lower for non-Hispanic Black, Hispanic, and American Indian/Alaskan Native adults relative to non-Hispanic White adults Grohskopf et al. JAMA. 2020; 324(11): 1029 -1030
SES: The Virus and The Quarantine § Black median household income is three-fifths that of whites § Black family wealth is less than one-sixth that of whites § Older White households have an average net worth of $258 K, the averages for older Black and Latinx households are only $13 k and $39 k, respectively – Explains why Blacks and Latinx are more likely to live in crowded, multi-generational households than Whites Brown et al, TJGS
Our ability to defeat the pandemic that is COVID-19 will depend on our willingness to fight and defeat the pandemic of social determinants of health and racism. Failure to do so will mean further adverse health and economic consequences with this and subsequent pandemics for not just people of color, but for every American.
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