Racial-ethnic disparities in case fatality ratio narrowed after age standardization: A call for race-ethnicity-specific age distributions in State COVID-19 data
Authors: Pathak Ishaan , Choi Yoonjoung , Jiao Dazhi , Yeung Diana , Liu Li 
Published: October 2020

AbstractImportanceCOVID-19 racial disparities have gained significant attention yet little is known about how age distributions obscure racial-ethnic disparities in COVID-19 case fatality ratios (CFR).ObjectiveWe filled this gap by assessing relevant data availability and quality across states, and in states with available data, investigating how racial-ethnic disparities in CFR changed after age adjustment.Design/Setting/Participants/ExposureWe conducted a landscape analysis as of July 1st, 2020 and developed a grading system to assess COVID-19 case and death data by age and race in 50 states and DC. In states where age- and race-specific data were available, we applied direct age standardization to compare CFR across race-ethnicities. We developed an online dashboard to automatically and continuously update our results.Main Outcome and MeasureOur main outcome was CFR (deaths per 100 confirmed cases). We examined CFR by age and race-ethnicities.ResultsWe found substantial variations in disaggregating and reporting case and death data across states. Only three states, California, Illinois and Ohio, had sufficient age- and race-ethnicity-disaggregation to allow the investigation of racial-ethnic disparities in CFR while controlling for age. In total, we analyzed 391,991confirmed cases and 17,612 confirmed deaths. The crude CFRs varied from, e.g. 7.35% among Non-Hispanic (NH) White population to 1.39% among Hispanic population in Ohio. After age standardization, racial-ethnic differences in CFR narrowed, e.g. from 5.28% among NH White population to 3.79% among NH Asian population in Ohio, or an over one-fold difference. In addition, the ranking of race-ethnic-specific CFRs changed after age standardization. NH White population had the leading crude CFRs whereas NH Black and NH Asian population had the leading and second leading age-adjusted CFRs respectively in two of the three states. Hispanic population’s age-adjusted CFR were substantially higher than the crude. Sensitivity analysis did not change these results qualitatively.Conclusions and RelevanceThe availability and quality of age- and race-ethnic-specific COVID-19 case and death data varied greatly across states. Age distributions in confirmed cases obscured racial-ethnic disparities in COVID-19 CFR. Age standardization narrows racial-ethnic disparities and changes ranking. Public COVID-19 data availability, quality, and harmonization need improvement to address racial disparities in this pandemic.Key PointsQuestionWhat are the racial-ethnic disparities in COVID-19 case fatality ratios (CFR) across states after adjusting for age?FindingsWe conducted direct standardization among 391,991 COVID-19 cases and 17,612 deaths from California, Illinois and Ohio to compare age-adjusted CFR across race-ethnicities. The racial-ethnic disparities in CFR narrowed and the ranking changed after age standardization.MeaningAge distributions in confirmed cases obscured racial-ethnic disparities in COVID-19 CFR.