Abstract
Background
The COVID-19 pandemic represents an unprecedented global health challenge. Gastrointestinal diseases (GID) have been shown to increase morbidity and mortality in COVID-19 patients, warranting a comprehensive investigation of their combined impact and racial disparities in mortality rates within the United States.
Methods
Data from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) mortality statistics database were analyzed for the period from January 1, 2020, to December 31, 2022. This study focused on adults, considering all deaths related to COVID-19 and GID. Age-adjusted mortality rates (AAMR) per 100,000 population were reported. Sociodemographic data, including age, sex, race/ethnicity, and region of residence, were collected.
Results
Among 9,925,729 total deaths in the US between 2020 and 2022, 3.9% were GID related only, 9.6% were COVID-19 related only, and 0.4% were attributed to both COVID-19 and GID as underlying causes of death. AAMR for COVID-19 was 121.3 per 100,000, significantly higher than the AAMR for GID (50.3 per 100,000). Age-wise, elderly individuals had the highest AAMR for both COVID-19 and GID-related deaths. Stratified by race/ethnicity, Hispanics exhibited the highest AAMR, nearly twice that of Non-Hispanic Black patients and substantially higher than Non-Hispanic White and Asian patients.
Conclusion
Our findings reveal substantial disparities in race/ethnicity-specific AAMR associated with both COVID-19 and GID in the US. Further research is crucial to delve deeper into their root causes and develop targeted interventions to strive for health equity for all.
Keywords: COVID-19, gastrointestinal diseases, mortality
The COVID-19 pandemic represents a pivotal medical and public health challenge of our time.1 While acknowledging the historical significance of health issues like cardiovascular diseases, it is imperative to recognize the unique and unprecedented nature of the COVID-19 pandemic. Previous data showed that gastrointestinal diseases (GID) increase the morbidity and mortality in patients with COVID-19.2 This research sought to comprehensively examine the consequences of the pandemic, particularly in conjunction with GID, and to examine racial disparities in mortality rates among affected populations. This study investigated mortality rates associated with COVID-19, GID, and their intersection within the United States. Of particular interest was the intricate relationship between COVID-19 and GID, as emerging clinical evidence suggests that COVID-19 can significantly impact the gastrointestinal system.2 Additionally, we sought to explore the racial and demographic disparities evident in COVID-19 and GID-related mortality, recognizing the pressing need to elucidate the determinants of these disparities, which encompass socioeconomic factors, healthcare access barriers, and structural inequalities.
METHODS
Data from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) mortality statistics database were used in this study.3 We collected mortality data from January 1, 2020 to December 31, 2022. This project was exempt from institutional review board approval, as the data were deidentified and publicly available, in compliance with 45 CFR §46. Additionally, this study followed the STROBE reporting guidelines.
Our inclusion criteria focused on adults aged 25 and above to narrow the scope of our analysis to the adult population. All deaths related to COVID-19 and GID were considered, with causes of death identified using International Classification of Diseases 10th Revision (ICD-10) codes U07.1 for COVID-19 and K00-K92 for GID. These codes were used to categorize deaths as contributing or underlying causes. Both terms were then queried together to identify patients who had both COVID-19 and GID as contributing or underlying causes of death. We also collected sociodemographic data for all three patient subgroups, including information on age, sex, race/ethnicity, and region of residence. We divided the patients into three age groups: elderly (age ≥65 years), middle-aged adults (45–64 years), and young adults (25–44 years). We also used race/ethnicity to examine racial disparities. Patients were divided based on the database into Hispanics, Non-Hispanic Black, Non-Hispanic White, and Non-Hispanic Asian patients. To provide meaningful comparisons across demographic groups and over time, age-adjusted mortality rates (AAMR) were calculated per 100,000 population, with standardization to the 2000 US population. This adjustment accounts for variations in age distribution, enabling more accurate comparisons between groups.
RESULTS
There were 9,925,729 deaths across the US between 2020 and 2022. While 388,726 (3.9%) deaths were GID related only, 950,992 (9.6%) were COVID-19 related only. A total of 35,048 deaths were attributed to both COVID-19 and GID as underlying causes of death. The AAMR of the COVID-19 group was 121.3 per 100,000 (95% confidence interval [CI] 121.0–121.5), which is more than twice as high as that of the GID group, which had an AAMR of 50.3 per 100,000 (95% CI 50.2–50.5). In the group with both COVID-19 and GID, the AAMR was lower, at 4.4 per 100,000 (95% CI 4.3–.4) (Table 1).
Table 1.
Both gastrointestinal-related and COVID-19–related mortality, 2020–2022
| Population | Deaths, n |
Overall age-adjusted mortality
rate per 100,000 (95% CI) |
|---|---|---|
| Entire cohort | 35,048 | 4.4 (4.3–4.4) |
| Sex | ||
| Men | 19,762 | 5.5 (5.4–5.6) |
| Women | 15,286 | 3.5 (3.5–3.6) |
| Race | ||
| Asian | 1,079 | 2.7 (2.5–2.8) |
| Black or African American | 4,279 | 5.1 (4.9–5.3) |
| White | 28,674 | 4.4 (4.4–4.5) |
| Hispanic | 6,349 | 7.2 (7.0–7.3) |
| US census region | ||
| Northeast | 5,539 | 3.8 (3.7–3.9) |
| Midwest | 6,839 | 4.1 (4.0–4.2) |
| South | 14,810 | 4.9 (4.8–5.0) |
| West | 7,860 | 4.4 (4.3–4.5) |
| Age group (years) | ||
| Young adults (25–44) | 1,687 | 0.6 (0.6–0.7) |
| Middle age (45–64) | 9,913 | 3.6 (3.5–3.7) |
| Elderly (65+) | 23,448 | 14.7 (14.5–14.9) |
For both COVID-19–related and GID-related deaths, the elderly age group had the highest AAMR of 14.7 per 100,000 (95% CI 14.5–14.9), followed by middle-aged adults (AAMR 3.6 per 100,000, 95% CI 3.5–3.7). The lowest rates were observed among young adults (AAMR 0.6 per 100, 000, 95% CI 0.6–0.7) (Table 1).
When stratified by race/ethnicity, the AAMR among Hispanics (7.2 per 100,000, 95% CI 7.0–7.3) was almost twice as high as that for Non-Hispanic Black patients (5.1 per 100,000, 95% CI 4.9–5.3) and Non-Hispanic White patients (4.4 per 100,000, 95% CI 4.4–4.5). The lowest AAMR was observed in Non-Hispanic Asian patients (2.5 per 100,000, 95% CI 2.5–2.8), which was approximately one-third of the AAMR observed in Hispanic patients (Table 1).
When examining AAMR stratified by census region, the South exhibited the highest AAMR at 4.9 per 100,000 (95% CI 4.8–5.0), followed by the West with an AAMR of 4.4 per 100,000 (95% CI 4.3–4.5), the Midwest with an AAMR of 4.1 per 100,000 (95% CI 4.0–4.2), and finally the Northeast with the lowest AAMR at 3.8 per 100,000 (95% CI 3.7–3.9) (Table 1). When AAMR was examined according to race by region, the highest rates in the West (8.2 vs 4.8), Northeast (5.2 vs 4.4), Midwest (5.9 vs 5.4), and South (7.3 vs 5.3) were observed among Hispanic patients followed by Non-Hispanic Black patients (Table 2 and Figure 1).
Table 2.
Age-adjusted mortality rate per 100,000 according to race by region (95% CI)
| Race | Northeast | Midwest | South | West |
|---|---|---|---|---|
| Asian | 2.5 (2.1–2.8) | 2.7 (2.2–3.2) | 2.9 (2.5–3.2) | 2.6 (2.3–2.8) |
| Black or African American | 4.4 (4.1–4.8) | 5.4 (5.0–5.8) | 5.3 (5.0–5.5) | 4.8 (4.3–5.3) |
| White | 3.8 (3.7–3.9) | 3.9 (3.8–4.0) | 5.0 (4.9–5.1) | 4.5 (4.4–4.6) |
| Hispanic | 5.2 (4.8–5.6) | 5.9 (5.2–6.5) | 7.3 (7.0–7.6) | 8.2 (7.8–8.5) |
Figure 1.
Age-adjusted mortality rate per 100,000 according to race by region.
The highest COVID-19–only related AAMR was in Hispanic patients (183 per 100,000, 95% CI 182–183.9), while the highest AAMR in GI only was observed in Non-Hispanic White patients (53.1 per 100,000, 95% CI 52.9–43.2) (Table 3).
Table 3.
Age-adjusted mortality rate per 100,000 according to race for gastrointestinal disease only and COVID-19 only (95% CI)
| Race | Gastrointestinal disease only | COVID–19 only |
|---|---|---|
| Asian | 19.9 (19.4–20.3) | 78.0 (77.2–78.9) |
| Black or African American | 43.8 (43.4–44.3) | 167.5 (166.6–168.4) |
| White | 53.1 (52.9–53.2) | 118.2 (118.0–118.5) |
| Hispanic | 49.2 (48.7–49.6) | 183.0 (182.0–183.9) |
DISCUSSION
The findings of our study reveal substantial disparities in age-specific and race/ethnicity-specific AAMR associated with both COVID-19 and GID in the US. These disparities underscore the complex interplay of demographic factors that influence health outcomes, shedding light on the vulnerabilities and challenges faced by different population groups during the COVID-19 pandemic.
One notable observation from our analysis is the stark contrast in AAMR across different age groups. The elderly population exhibited the highest AAMR for both COVID-19 and GID-related deaths. Specifically, the AAMR for the elderly was 14.7 per 100,000, emphasizing the heightened vulnerability of this age group to the combined effects of COVID-19 and GID. This finding aligns with existing evidence highlighting the elevated risk of severe illness and mortality among older adults when exposed to infectious diseases.4 Several factors contribute to the heightened vulnerability of this age group. First and foremost, advanced age is often accompanied by a higher prevalence of chronic medical conditions, such as cardiovascular disease, diabetes, and respiratory conditions.5 These comorbidities can increase the severity of COVID-19 and exacerbate preexisting GID, leading to worse outcomes.6 Additionally, age-related changes in the immune system, known as immunosenescence, can compromise the ability to mount an effective immune response against infections.7
Conversely, young adults exhibited the lowest AAMR. These findings likely reflect the relatively lower prevalence of severe comorbidities and the greater physiological resilience typically associated with younger age groups. However, it’s crucial to recognize that the risks associated with COVID-19 and GID are not uniform within this age group. Certain subpopulations within this age bracket, such as individuals with specific comorbidities or those in high-exposure occupations, may still face elevated risks.8
Another compelling aspect of our findings revolves around the significant disparities in AAMR among various racial and ethnic groups. This could be partially explained by racial differences that significantly affect the mortality and outcomes of COVID-19.9 Hispanic patients, in particular, exhibited markedly higher AAMR for both COVID-19 and GID-related deaths, with an AAMR of 7.2 per 100,000. This rate was nearly double that of non-Hispanic Black and substantially higher than that of non-Hispanic White and Asian patients, indicating a substantial disparity in mortality rates between these groups. These findings underscore the profound impact of race and ethnicity on COVID-19 and GID-related mortality rates,9,10 suggesting that Hispanic populations may face unique challenges and vulnerabilities in the face of these health threats.
Several factors may contribute to the elevated mortality rates among Hispanic populations. Socioeconomic disparities, including lower income levels and limited access to healthcare, can result in delayed or suboptimal medical care, potentially leading to poorer health outcomes.11–13 Additionally, a higher prevalence of comorbidities such as diabetes and obesity within Hispanic communities may exacerbate the severity of COVID-19 and GID.14 Cultural factors, including multigenerational households and reliance on communal living arrangements, may increase the risk of virus transmission within Hispanic families and communities.10,15 Language barriers may also impede access to timely and accurate healthcare information and services.16
It is crucial to recognize that these disparities may be driven by a complex interplay of socioeconomic factors, healthcare access, cultural considerations, and underlying health conditions. Understanding racial and ethnic disparities in COVID-19 and GID-related mortality rates is critical for tailoring public health interventions and healthcare delivery. There is an urgent need for targeted strategies to address the unique challenges faced by different racial and ethnic groups.
Efforts to mitigate these disparities should include multilevel interventions. First, equitable access to healthcare and ensuring that healthcare services are accessible to all, regardless of race or ethnicity, is paramount. This includes addressing barriers such as language, transportation, and affordability. Second, community outreach and education through targeted campaigns should provide culturally sensitive information about preventive measures, testing, and vaccination. Engaging community leaders and organizations can enhance outreach efforts. Additionally, addressing systemic inequalities related to housing, education, and employment can help reduce disparities in comorbidities and healthcare access.17
This study has several limitations, including potential racial misclassification and limited covariates and coding reliability that is inherent to the database. Additionally, the research faced challenges in establishing the temporal relationship between GID and COVID-19, specifically determining whether GID developed as a direct result of COVID-19 or whether preexisting GID was exacerbated in relation to COVID-19.
In conclusion, the racial and ethnic disparities observed in COVID-19 and GID-related mortality rates underscore the need for a comprehensive, multifaceted approach to public health. Achieving health equity requires addressing the root causes of these disparities, including social determinants of health and systemic inequalities, while also recognizing and respecting the unique cultural contexts within different communities.17 Reducing these disparities is not only a public health imperative but also a moral and ethical imperative. Further research is warranted to delve deeper into the root causes of these disparities and to develop targeted interventions aimed at reducing them, ultimately striving for health equity for all.
Conflict of Interest
The authors declare that they have no funding or conflict of interest.
DISCLOSURE STATEMENT
No potential conflict of interest was reported by the authors.
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