Sociodemographic Predictors of SARS-CoV-2 Infection in Obstetric Patients, Georgia, USA

We conducted a cohort study to determine sociodemographic risk factors for severe acute respiratory syndrome coronavirus 2 infection among obstetric patients in 2 urban hospitals in Atlanta, Georgia, USA. Prevalence of infection was highest among women who were Hispanic, were uninsured, or lived in high-density neighborhoods.

D ata from New York, New York, USA, have highlighted the disproportionate burden of coronavirus disease (COVID-19) in minority and low socioeconomic status communities in the United States (1), yet data are lacking from southeastern states, which are home to a large share of the nation's racial and ethnic minority populations (2,3). The information is imperative in states like Georgia, which has average of 3,000-4,000 new cases daily and an urgent need for improved public health mitigation and containment strategies (4). The objective of this study was to determine associated sociodemographic and neighborhood risk factors for infection in an obstetric cohort undergoing testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in 2 urban hospitals in Atlanta, Georgia. Emory University School of Medicine Institutional Review Board and Grady Memorial Hospital Research Oversight Committee approved the study.
Universal testing for SARS-CoV-2 was initiated on all parturients admitted to labor and delivery at Grady Memorial Hospital, a safety-net hospital in Atlanta, starting on April 20, 2020, and at Emory University Hospital Midtown, an academic hospital in Atlanta, starting on April 24. Both hospitals serve a diverse, predominantly minority population; the safety-net hospital captures a larger proportion of uninsured and Medicaid patients (5). The safety-net hospital performs ≈2,500 and the academic hospital ≈5,000 deliveries annually. We abstracted test results, age, race, and ZIP code from electronic medical records and validated the data for all deliveries at both hospitals through July 29, 2020. Patient residential ZIP code was linked with data from the US Census Bureau to estimate median household income, proportion of households below federal poverty limit, use of public transit to travel to work, average household size, proportion of crowded households (>1 person per room), population density per square mile, neighborhood deprivation index, and proportion minority (nonwhite) residents (2). Data on neighborhood characteristics were derived from American Community Survey 5-year estimates for 2014-2018. Characteristics were calculated at the census tract level and linked to patient resident address using a validated ZIP code to tract crosswalk (6). To calculate the neighborhood deprivation index, we conducted principal components analysis using data for all census tracts in Georgia on 8 sociodemographic indicators, framed around domains of income, education, employment, and housing quality, producing a summary score ranging from −1.85 to 3.87, centered at 0; higher values indicated higher deprivation or more disadvantage.
We examined distributions of sociodemographic (age, race/ethnicity, and insurance status) and neighborhood characteristics by delivery hospital; we then combined data from both institutions to calculate prevalence rates and 95% CIs. For prevalence calculations, we dichotomized median income, proportion nonwhite residents, proportion below federal poverty limit, use of public transit, household crowding, neighborhood density, and neighborhood deprivation index by <50th percentile and >50th percentile. We performed data analysis using R (https://www.r-project.org); p values <0.05 were considered statistically significant.
We conducted a cohort study to determine sociodemographic risk factors for severe acute respiratory syndrome coronavirus 2 infection among obstetric patients in 2 urban hospitals in Atlanta, Georgia, USA. Prevalence of infection was highest among women who were Hispanic, were uninsured, or lived in high-density neighborhoods.

RESEARCH LETTERS
This study leveraged a universal SARS-COV-2 testing program in an obstetric cohort to determine sociodemographic and neighborhood risk factors for infection. Infection was significantly associated with Hispanic ethnicity, uninsured status, high neighborhood density. The counterintuitive findings for household size may be due to chance or the narrow range of average household size across included neighborhoods (1.5-3.8 persons/household) (1).
This study has several limitations, including retrospective data collection and limited generalizability. However, its strengths include reporting of rates during a period of universal testing in an area outside of New York, and the use of census data to approximate neighborhood factors associated with increased risk for infection.
These data suggest that concentrated socioeconomic and neighborhood disadvantage, such as race/ethnicity, uninsured status, and neighborhood density, account for some of the disparate burden of COVID-19 illness in pregnant patients, a unique population at increased risk for perinatal illness (7). Research that considers specific features of neighborhood is needed to inform communitytargeted mitigation strategies if viral containment is to be achieved.

About the Author
Dr. Joseph is a clinical fellow in the Division of Maternal Fetal Medicine in Department of Gynecology and Obstetrics at Emory University School of Medicine. *Lower/less/small categories indicate <50th percentile; higher/more/large categories indicate >50th percentile. IQR, interquartile range; NDI, neighborhood deprivation index; Pr., proportion. †Prevalence is for entire cohort. Nine women provided out-of-state zip codes and were excluded from the neighborhood analysis; all 9 tested negative. To the Editor: We read with interest the recent description of pulmonary Nocardia ignorata infection (1). We report a similar infection in an orthotopic heart transplant recipient, which likely began as a pulmonary infection with dissemination to soft tissue, without known exposure. Risk factors included tacrolimus, steroids, older age, and posttransplant intensive care unit admission (2).

Nocardia ignorata Infection in Heart Transplant Patient
The patient was a 66-year-old African American man with a history of ischemic cardiomyopathy. After implantation of a left ventricular assist device, infectious complications included Enterococcus faecalis device infection and extended spectrum β-lactamase-producing (ESBL) Klebsiella urosepsis. The course after left ventricular assist device explantation and orthotopic heart transplant was complicated by tamponade requiring a pericardial window and an ESBL Klebsiella urinary tract infection treated with meropenem. Because of leukopenia, Pneumocystis prophylaxis was changed from trimethoprim/ sulfamethoxazole to atovaquone 2 weeks posttransplant. ESBL Klebsiella bacteremia recurred 6 weeks later, again treated with meropenem.
The patient returned 6 months posttransplant with 10 days of cough and dyspnea. Chest computed tomography demonstrated bilateral nodules with cavitation, bronchiectasis, and spiculation. We initially treated the patient with meropenem and doxycycline. Results from severe acute respiratory syndrome coronavirus 2 swab test, respiratory pathogen panel, fungal studies, and sputum culture were nondiagnostic. We obtained no additional pulmonary samples.
Due to severe left calf pain, venous duplex was performed, revealing a nonvascular mass. The patient reported no trauma, soil contact, or recent travel. The abscess was aspirated, demonstrating branching gram-positive beaded rods. The isolate was identified by a reference laboratory (Mycobacteria and Nocardia Laboratory, University of Texas Health Center at Tyler, Tyler, TX, USA) by partial 16S rRNA sequencing as a 99.51% match with Nocardia ignorata, with susceptibilities identical to the isolate in Rahdar et al. (1). Brain magnetic resonance imaging results were unremarkable. The patient's respiratory status and leg pain quickly

COMMENT LETTERS
Her current research investigates the impact of Social Determinants of Health needs and interventions on severe maternal morbidity and maternal mortality in an attempt to improve parity in maternal/neonatal health outcomes.