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First 5000 Characters:The coronavirus pandemic has disproportionally impacted racial and ethnic minority communities in the United States. These disparities may be changing over time as outbreaks occur in different communities. Using electronic health record data from the Department of Veterans Affairs, we estimated odds ratios, stratified by region and time period, for testing positive for SARS-CoV-2 among 951,408 individuals tested for SARS-CoV-2 between February 12, 2020 and February 12, 2021. Our study found racial and ethnic disparities for testing positive were most pronounced at the beginning of the pandemic and decreased over time. A key finding was that the disparity among Hispanic individuals attenuated but remained elevated over the entire study period. We identified variation in racial and ethnic disparities in SARS-CoV-2 positivity by time and region independent of underlying health status and other key factors in a
The coronavirus pandemic has disproportionally impacted racial and ethnic minority communities in the United States. 1-3 Evidence has highlighted the vast disparities in SARS-CoV-2 infection and subsequent COVID-19 among persons who were Black, Hispanic, or Native Hawaiian/Pacific Islander.     Recently, additional analyses have suggested that racial and ethnic disparities may be changing over time as outbreaks spread from racially and ethnically diverse metropolitan centers to more rural and less diverse areas. 4, 5, 8 In this report, we updated our previous analyses 4, 5 to evaluate changes in disparities for testing positive with SARS-CoV-2 over the first full year of the pandemic and by geographic region in the largest integrated healthcare system in the United States.
Using national electronic health record data from the Department of Veterans Affairs (VA), we conducted a retrospective cohort analysis of all individuals tested for SARS-CoV-2 between February 12, 2020 and February 12, 2021. Methods have been previously described in detail. 4, 5 In brief, we used multivariable logistic regression to estimate odds ratios (OR) and 95% confidence intervals (CI) for testing positive for SARS-CoV-2 for non-Hispanic Black, Hispanic, Asian, American Indian/Alaska Native (AI/AN), Native Hawaiian/Pacific Islander (NH/PI), and people of mixed race, relative to non-Hispanic White individuals. All models were adjusted for other demographics (sex, age, rural/urban residence), baseline comorbidity (asthma, cancer, chronic kidney disease, chronic obstructive pulmonary disease, diabetes mellitus, hypertension, liver disease, vascular disease), substance use (alcohol consumption, alcohol use disorder, smoking status), medication history (angiotensin converting enzyme inhibitor, angiotensin II receptor blocker), and conditioned on VA site of care to account for spatial differences in SARS-CoV-2 burden. Models were stratified by time period into waves: February 12 -May 31, 2020 (wave 1); June 1 -September 30, 2020 (wave 2); October 1 -December 11, 2020 (wave 3a); and
December 12, 2020 -February 12, 2021 (wave 3b). The May/June and September/October cut points were defined a priori based on two national waves of SARS-CoV-2 cases. The third national wave between October 2020 and February 2021 was split into two waves containing roughly equal numbers of SARS-CoV-2 cases.
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The copyright holder for this preprint this version posted April 30, 2021. ; https://doi.org/10.1101/2021.04.27.21256215 doi: medRxiv preprint To evaluate regional differences in the most recent wave (3b: December 12, 2020 -February 12, 2021), models were further stratified by US Census region (i.e., West, South, Midwest, and Northeast). Due to low number of events, we combined AI/AN, NH/PI, and patients of mixed race into an "other" category for these models. Data analysis was performed using SAS version 9.4 (SAS Institute, Cary, NC).
Of 951,408 individuals tested during the study period, 111,912 (11.8%) tested positive for SARS-CoV-2 ( Table 1) . All non-White groups had higher crude prevalence of positive tests than White individuals (10.8%), with the largest differences observed among Black (13.0%), Hispanic (15.4%), and AI/AN (13.2%) groups. By region, the crude prevalence of positive tests was highest in Midwest (13.7%) and lowest in Northeast (10.3%). Individuals who were younger or male had a slightly higher crude prevalence of positive tests than those who were older or female. Over time, the prevalence of positive tests increased from 6.9% in wave 1 and 6.2% in wave 2 to 14.8% in wave 3a and 22.0% in wave 3b. Across all groups, the percentage of positive tests increased over time (Figure 1) . In wave 1, White individuals had a higher crude test positivity percentage than all racial and ethnic minorities except for Black individuals. Howeve