Jessica Arrazola, Council of State and Territorial EpidemiologistsFollow
Scott Erickson, Seattle Indian Health BoardFollow
Chiao Wen Lan, Northwest Portland Area Indian Health BoardFollow
Adrian Dominguez, Seattle Indian Health BoardFollow
Sujata Joshi, Northwest Portland Area Indian Health BoardFollow
Andria Apostolou, Indian Health ServiceFollow
Ashley Busacker, Wyoming Department of Health, Centers for Disease Control and PreventionFollow
David Casey, New York State Department of HealthFollow
Christiana Coyle, South Dakota Department of HealthFollow
Kathryn Helfrich, State of Alaska Division of Public HealthFollow
Jennifer Kraszewski, Albuquerque Area Indian Health BoardFollow
Thomas Kim, California Tribal Epidemiology CenterFollow
Genelle Lamont, Minnesota Department of HealthFollow
Richard Leman, Oregon Public Health DivisionFollow
Pamela LeMaster, Minnesota Department of HealthFollow
Nick Lehnertz, Minnesota Department of HealthFollow
Mike Mannell, Oklahoma State Department of HealthFollow
Dakota Matson, Oklahoma State Department of HealthFollow
Alex Merrill, Utah Department of HealthFollow
Tracy Miller, North Dakota Department of Health, Division of Disease ControlFollow
Benjamin Schram, North Dakota Department of HealthFollow
Ozair Naqvi, Oklahoma State Department of HealthFollow
Samantha Rice, Washington State Department of HealthFollow
Samantha Hyde-Rolland, Washington State Department of HealthFollow
Alyssa Rowell, New York State Department of HealthFollow
Dean Seneca, Seneca Scientific Solutions+Follow
Victoria Warren-Mears, Northwest Tribal Epidemiology CenterFollow
Laura Williamson, Montana Department of Public Health and Human ServicesFollow


Epidemiology; COVID-19; American Indian/Alaska Native; Surveillance; Tribal Epidemiology


Community Health and Preventive Medicine | Epidemiology | Public Health | Respiratory Tract Diseases | Virus Diseases


Objective: To compare rates and risk factors of severe COVID-19-related outcomes between American Indian/Alaska Native (AI/AN) and non-Hispanic White people (NHW).

Methods: Aggregate Social Vulnerability Index (SVI), COVID-19-related risk factor, hospitalization, and mortality data were obtained from 16 states for January 1, 2020-March 31, 2021. Generalized estimating equation Poisson regression models calculated age-adjusted cumulative incidences, incidence ratios (IR), and 95% confidence intervals (CI) comparing AI/AN and NHW persons by age, sex, and county-level SVI status.

Results: Race data were missing for 42.7% of COVID-19 cases, 24.7% of hospitalizations, and 10.1% of deaths. Risk of AI/AN COVID-19 mortality was 2.6 times that of NHW persons (IR 2.6, 95% CI: 1.7 – 3.4); risk of COVID-19-related hospitalization among AI/AN persons was 3.5 times that of NHW (IR: 3.5, 95% CI: 2.7 – 4.3). Severe COVID-19 outcomes were significantly higher for AI/AN persons compared to NHW persons across all age and sex groups. There was no statistically significant difference in COVID-19 outcomes by SVI status. Associations between severe COVID-19 outcomes and co-morbid risk factors were inconsistent.

Conclusions: Results describe increased risk of severe COVID-19 outcomes for AI/AN persons compared to NHW persons despite quality issues in public health surveillance data. Data linkages and improved ascertainment reduce race/ethnicity misclassification and improve data quality. COVID-19-related health burdens among AI/AN persons warrant improved access for AI/AN communities to medical countermeasures and healthcare resources.