County-Level Sociodemographic Factors Associated with COVID-19 Incidence and Mortality in North and South Carolina

BACKGROUND There is limited research regarding associations between county-level factors and COVID-19 incidence and mortality. While the Carolinas are geographically connected, they are not homogeneous, with statewide political and intra-state socioeconomic differences leading to heterogeneous spread between and within states.METHODS Infection and mortality data from Johns Hopkins University during the 7 months since the first reported case in the Carolinas was combined with county-level socioeconomic/demographic factors. Time series imputations were performed whenever county-level reported infections were implausible. Multivariate Poisson regression models were fitted to extract incidence (infection and mortality) rate ratios by county-level factor. State-level differences in filtered trends were also calculated. Geospatial maps and Kaplan-Meier curves were constructed stratifying by median county-level factor. Differences between North and South Carolina were identified.RESULTS Incidence and mortality rates were lower in North Carolina than South Carolina. Statistically significant higher incidence and mortality rates were associated with counties in both states with higher proportions of Black/African American populations and those without health insurance aged < 65 years. Counties with larger populations aged ≥ 75 years were associated with increased mortality (but decreased incidence) rates.LIMITATIONS COVID-19 data contained multiple inconsistencies, so imputation was needed, and covariate-based data was not synchronous and potentially insufficient in granularity given the epidemiology of the disease. County-level analyses imply within-county homogeneity, an assumption increasingly breached by larger counties.CONCLUSION While statewide interventions were initially implemented, inter-county racial/ethnic and socioeconomic variability points to the need for more heterogeneous interventions, including policies, as populations within particular counties may be at higher risk.