Racial and Neighborhood-Level Disparities in COVID-19 Incidence among Patients on Hemodialysis in New York City
Authors: Tummalapalli Sri Lekha , Silberzweig Jeffrey , Cukor Daniel , Lin Jonathan T. , Barbar Tarek , Liu Yao , Kim Kwan , Parker Thomas S. , Levine Daniel M. , Ibrahim Said A. 
Published: June 2021

Significance Statement
Coronavirus disease 2019 (COVID-19) has disproportionately affected socially disadvantaged populations. Whether racial/ethnic and socioeconomic disparities in COVID-19 incidence exist in the hemodialysis population is unknown. The authors examined the association of race/ethnicity and a validated neighborhood-level index of social vulnerability (the Social Vulnerability Index) with acquiring symptomatic COVID-19 among patients receiving in-center hemodialysis from a dialysis organization in New York City. They found substantial racial/ethnic disparities in COVID-19 incidence; Black and Hispanic individuals on hemodialysis were more likely than non-Hispanic White patients to acquire COVID-19. Neighborhood-level socioeconomic status, minority status and language, and housing crowding were positively associated with COVID-19 acquisition among non-Hispanic White patients but did not explain racial/ethnic disparities. These findings indicate that targeted strategies are needed to mitigate excess COVID-19 risk among socially vulnerable patients on dialysis.

Background
The coronavirus disease 2019 (COVID-19) pandemic has disproportionately affected socially disadvantaged populations. Whether disparities in COVID-19 incidence related to race/ethnicity and socioeconomic factors exist in the hemodialysis population is unknown.

Methods
Our study involved patients receiving in-center hemodialysis in New York City. We used a validated index of neighborhood social vulnerability, the Social Vulnerability Index (SVI), which comprises 15 census tract–level indicators organized into four themes: socioeconomic status, household composition and disability, minority status and language, and housing type and transportation. We examined the association of race/ethnicity and the SVI with symptomatic COVID-19 between March 1, 2020 and August 3, 2020. COVID-19 cases were ascertained using PCR testing. We performed multivariable logistic regression to adjust for demographics, individual-level social factors, dialysis-related medical history, and dialysis facility factors.

Results
Of the 1378 patients on hemodialysis in the study, 247 (17.9%) developed symptomatic COVID-19. In adjusted analyses, non-Hispanic Black and Hispanic patients had significantly increased odds of COVID-19 compared with non-Hispanic White patients. Census tract–level overall SVI, modeled continuously or in quintiles, was not associated with COVID-19 in unadjusted or adjusted analyses. Among non-Hispanic White patients, the socioeconomic status SVI theme, the minority status and language SVI theme, and housing crowding were significantly associated with COVID-19 in unadjusted analyses.

Conclusions
Among patients on hemodialysis in New York City, there were substantial racial/ethnic disparities in COVID-19 incidence not explained by neighborhood-level social vulnerability. Neighborhood-level socioeconomic status, minority status and language, and housing crowding were positively associated with acquiring COVID-19 among non-Hispanic Whites. Our findings suggest that socially vulnerable patients on dialysis face disparate COVID-19–related exposures, requiring targeted risk-mitigation strategies.