Association of Poor Housing Conditions with COVID-19 Incidence and Mortality Across US Counties

Ahmad, Khansa; Erqou, Sebhat; Shah, Nishant; Nazir, Umair; Morrison, Alan; Choudhary, Gaurav; Wu, Wen-Chih

Objective: Poor housing conditions have been linked with worse health outcomes and infectious spread in communities but its relationship with incidence and mortality of COVID19 is unknown. Therefore, we undertook this study to determine the association between poor housing condition and COVID19 incidence and mortality in US counties. Methods: We conducted cross sectional analysis of county level data from the US Centers for Disease Control, US Census Bureau and John Hopkins Coronavirus Resource Center for 3141 US counties. The exposure of interest was percentage of households with poor housing conditions (one or more of: overcrowding, high housing cost, incomplete kitchen facilities, or incomplete plumbing facilities). Outcomes were incidence rate ratios (IRR) and mortality rate ratios (MRR) of COVID19 across US counties through 4/21/2020. Multilevel generalized linear modeling was utilized with adjustment for population density and county characteristics including demographics, income, education, prevalence of medical comorbidities, access to healthcare insurance and emergency rooms, and state level COVID19 test density. Results: Across 3135 US counties, the mean percentage of households with poor housing conditions was 14.2% (range 2.7%, 60.2%). The mean (SD) incidence and mortality of COVID19 were 255.68 (2877.03) cases and 13.90 (272.22) deaths per county, respectively. In the fully adjusted models, with each 5% increase in percent households with poor housing conditions, there was a 50% higher risk of COVID19 incidence (IRR 1.50, 95% CI: 1.38,1.62) and a 42% higher risk of COVID19 mortality (MRR 1.42, 95% CI: 1.25,1.61). Results remained similar using earlier timepoints (3/31/2020 and 4/10/2020). Conclusions and Relevance: Counties with a higher percentage of households with poor housing had higher incidence of, and mortality associated with, COVID19. These findings suggest targeted health policies to support individuals living in poor housing conditions should be considered in further efforts to mitigate adverse outcomes associated with COVID19.