Virus World

NIH-supported studies show variations in symptoms and diagnostic experiences among different racial and ethnic groups. Black and Hispanic Americans appear to experience more symptoms and health problems related to long COVID(link is external), a lay term that captures an array of symptoms and health problems, than white people, but are not as likely to be diagnosed with the condition, according to new research funded by the National Institutes of Health. The findings – from two different studies by NIH’s Researching COVID to Enhance Recovery(link is external) (RECOVER) Initiative – add to a growing body of research aimed to better understand the complex symptoms and other issues associated with long COVID that millions have experienced. “This new evidence suggests that there may be important differences in how long COVID manifests in different racial and ethnic groups,” said Mitchell S.V. Elkind, M.D., a professor of neurology and epidemiology at Columbia University, New York City, and chief clinical science officer for the American Heart Association. “However, further research is needed to better understand the mechanisms for these differences in symptoms and access to care, and also if diagnostic codes assigned by clinicians may play a role.” 

In one analysis, published in the Journal of General Internal Medicine(link is external), researchers looked at the health records of 62,339 adults who received a positive COVID-19 test at one of five academic health centers in New York City, all between March 2020 and October 2021. They tracked the patients’ health for one to six months after the positive test and compared the findings to 247,881 adults who never had COVID. Among 13,106 adults who had severe COVID that required hospital care, the researchers found Black and Hispanic adults were disproportionately represented. Of those who had these severe cases, for example, 1 in 4 were Black adults, 1 in 4 were Hispanic adults, and 1 in 7 were white adults. In the months following infection, Black adults with severe disease were more likely than white adults to be diagnosed with diabetes and experience headaches, chest pain and joint pain, but less likely to have sleep disorders, cognitive problems, or fatigue. Similarly, Hispanic adults who required hospital care were more likely than white adults to have headaches, shortness of breath, joint paint, and chest pain, but less likely to have sleep disorders, cognitive problems, or fatigue. Similar patterns emerged among people with mild to moderate disease. Among patients who were not hospitalized, Black adults were more likely to have blood clots in their lungs, chest pain, joint pain, anemia, or be malnourished. Hispanic adults were more likely than white adults to have dementia, headaches, anemia, chest pain, and diabetes. Conversely, white adults were most likely to have conditions such as cognitive impairment (sometimes referred to as “brain fog”) and fatigue.

The researchers also found that in comparison to people who did not have COVID, those who did were more likely to experience conditions affecting their nervous system, respiratory function, and circulation, and more likely to feel fatigued or have joint pain. “It’s not clear what's behind these symptom variations,” said Dhruv Khullar, M.D., a study author and physician and assistant professor of health policy and economics at Weill Cornell Medicine, New York City. “We hope this work draws attention to possible differences across racial and ethnic groups, stimulates research into the potential mechanisms, and sparks discussion among patients, clinicians, and policymakers.” In the second study, which published in BMC Medicine(link is external), researchers analyzed data from the electronic health records of 33,782 adults and children who received a diagnosis for long COVID between October 2021 and May 2022 at one of 34 U.S. medical centers. All had been given a diagnosis – Post COVID-19 condition, unspecified – the code for the condition first introduced in U.S. health care systems in October 2021. In studying the profile of these patients and their symptoms, the researchers found multiple patterns. Among the more striking: most of the patients were white, female, non-Hispanic, and likely to live in areas with low poverty and greater access to health care. Given what researchers already knew about the disproportionate impact of COVID on people of color and economically disadvantaged populations, the findings stood out. Emily Pfaff, Ph.D., a study author and assistant professor in the Division of Endocrinology and Metabolism at the University of North Carolina, Chapel Hill, said the pattern suggested that not all patients who have long COVID are being diagnosed. The reasons vary. In addition to long-documented health disparities based on race and other factors, she said, women are more likely than men to seek health care in general, and patients with the time and resources to access health care tend to be disproportionally represented in clinical data.

“You can see all the different ways these diagnostic codes can provide insight, but they can also skew the whole story,” Pfaff said. Still, she added, the insights help. She and her team found, for example, that most of the patients with long COVID had just mild to moderate, not severe, symptoms of acute infection. They also discovered that long-term symptoms could be grouped into common clusters – cardiopulmonary, neurological, gastrointestinal, and coexisting conditions – as well as by age. Children and teens were more likely to experience gastrointestinal and upper respiratory problems, including stomach aches and coughing. Adults ages 21-45 commonly experienced neurological problems, such as brain fog and fatigue. Adults ages 66 and older were more likely to have coexisting conditions, such as heart problems and diabetes, which the authors suspect is more likely present because of age than long COVID.  The authors of both papers said additional studies are needed to confirm and further categorize these trends. “This research contributes to our understanding of symptom clusters in long COVID that may be differentiated by race, ethnicity, and influenced by social determinants of health,” said Gary H. Gibbons, M.D., director of the National Heart, Lung, and Blood Institute. “It also provides vital insights into the utility, as well as the constraints, of the diagnostic code now in use for long COVID.” Both studies were funded by RECOVER (HL161847-01). The National Center for Advancing Translational Sciences provided additional support for the review published in BMC Medicine through the National COVID Cohort Collaborative (N3C) Data Enclave (U24TR002306).

Cited Studies:

https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-023-02737-6 

https://link.springer.com/article/10.1007/s11606-022-07997-1 

The National Medical Association committee is meant to safeguard against any unscientific guidance from the CDC and FDA. As trust in federal health agencies has withered over the last few months, a group of Black physicians has been working on an antidote: creating their own expert task force to independently vet regulators’ decisions about Covid-19 drugs and vaccines as well as government recommendations for curbing the pandemic. Organized by the National Medical Association — founded in 1895 as an answer to racist professional societies excluding Black doctors — the committee is meant to safeguard against any unscientific guidance from the Centers for Disease Control and Prevention and the Food and Drug Administration. “It’s necessary to provide a trusted messenger of vetted information to the African American community,” said Leon McDougle, a family physician and president of the NMA. “There is a concern that some of the recent decisions by the Food and Drug Administration have been unduly influenced by politicians.”

Just one of the examples he gave was the agency’s go-ahead to use hydroxychloroquine against Covid-19 even though there was no reliable evidence that it worked, and some indication that it could cause heart damage. The FDA later back-tracked and revoked the authorization. McDougle frames the new task force as a way to address the suspicion that has sprouted up around Covid-19 vaccines. Some worry that, in being developed at “warp speed,” the shots might not be safe or properly tested before they’re approved, and the anxiety is only heightened for those who’ve been alienated by the medical system. That’s part of the reason that certain patients of color are especially wary of taking part in the clinical trials — and those concerns may well persist even if adequate studies are done and a vaccine hits the market. “I think this will help to increase uptake in the African American community, if members of our task force give it the green light,” McDougle said. But he emphasized that their stamp of approval would come only if data show that the vaccine is, in fact, effective and safe. They’ll also be evaluating how well the clinical trial participants represent the demographic breakdown of the American population, as well as the fairness of the federal plans to distribute a vaccine — both of which are especially important given the disproportionate impact that the pandemic has had on Black, Latino, and Native American communities.

“There is a need for this task force. We need a trusted organization to take the lead on this effort,” said emergency physician Uché Blackstock, the founder and CEO of the consulting firm Advancing Health Equity, who is not a member of the NMA. “What we’ve seen in terms of political interference in the FDA and CDC has really undermined what little trust the Black community had.” While the NMA may not be a household name for the lay public, Blackstock added, “because they are an organization of Black physicians led by Black physicians, what they ultimately say and recommend will have significant influence on whether people take the vaccine or not.” (McDougle didn’t know how many members the NMA currently has, and the executive director did not respond to repeated requests for comment.) The task force’s leaders are still figuring out exactly how it will work. When asked what would happen if the FDA authorizes the use of a product without releasing the full data to support it — as was the case with the antiviral drug remdesivir in May — McDougle said that because some of the members are also involved with federal committees, he hopes that they would have access to those statistics, and that there wouldn’t be much of a lag between a governmental decision and the NMA’s review.  To scholars who study vaccine acceptance, the task force has the potential to either increase immunization rates or deepen mistrust. Under normal circumstances, Saad Omer, director of the Yale Institute for Global Health, would prefer that everyone simply look to the FDA and the CDC’s Advisory Committee on Immunization Practices. “As a public health professional, the more the mainstream process is followed, the better,” he said...