New York City (NYC) was an epicenter of the coronavirus disease 2019 (COVID-19) outbreak
in the United States during spring 2020 (
1
). During March–May 2020, approximately 203,000 laboratory-confirmed COVID-19 cases
were reported to the NYC Department of Health and Mental Hygiene (DOHMH). To obtain
more complete data, DOHMH used supplementary information sources and relied on direct
data importation and matching of patient identifiers for data on hospitalization status,
the occurrence of death, race/ethnicity, and presence of underlying medical conditions.
The highest rates of cases, hospitalizations, and deaths were concentrated in communities
of color, high-poverty areas, and among persons aged ≥75 years or with underlying
conditions. The crude fatality rate was 9.2% overall and 32.1% among hospitalized
patients. Using these data to prevent additional infections among NYC residents during
subsequent waves of the pandemic, particularly among those at highest risk for hospitalization
and death, is critical. Mitigating COVID-19 transmission among vulnerable groups at
high risk for hospitalization and death is an urgent priority. Similar to NYC, other
jurisdictions might find the use of supplementary information sources valuable in
their efforts to prevent COVID-19 infections.
This report describes cases of laboratory-confirmed COVID-19 among NYC residents diagnosed
during February 29–June 1, 2020, that were reported to DOHMH. DOHMH began COVID-19
surveillance in January 2020 when testing capacity for SARS-CoV-2 (the virus that
causes COVID-19) using real-time reverse transcription–polymerase chain reaction (RT-PCR)
was limited by strict testing criteria because of limited test availability only through
CDC. The NYC and New York State public health laboratories began testing hospitalized
patients at the end of February and early March. DOHMH encouraged patients with mild
symptoms to remain at home rather than seek health care because of shortages of personal
protective equipment and laboratory tests at hospitals and clinics. Commercial laboratories
began testing for SARS-CoV-2 in mid- to late March. During February 29–March 15, patients
with laboratory-confirmed COVID-19 were interviewed by DOHMH, and close contacts were
identified for monitoring. The rapid rise in laboratory-confirmed cases (cases) quickly
made interviewing all patients, as well as contact tracing, unsustainable. Subsequent
case investigations first included medical chart review for patients who were hospitalized
or who had died, but then progressed to chart review only for patients who had died,
and then finally only for deaths in patients aged <65 years. On April 14, DOHMH began
to report probable COVID-19–associated deaths (i.e., no known positive SARS-CoV-2
test result and death certificate listing cause of death as COVID-19 or an equivalent
term [e.g., COVID, SARS-CoV-2, or another term]).
DOHMH quickly recognized the need for supplementary information sources and relied
on direct data importation and matching of patient identifiers for data on hospitalization
status, the occurrence of death, race/ethnicity, and presence of underlying medical
conditions, including diabetes, lung disease, cancer, immunodeficiency, heart disease,
asthma, kidney disease, gastrointestinal/liver disease, and obesity. These supplementary
data systems included emergency department syndromic surveillance, the New York State
Hospital Emergency Response Data System, regional health information organizations,
NYC public hospitals, DOHMH’s electronic death registry system, and remote access
to hospitals’ electronic health record systems. Even with these supplementary data
sources, many variables (e.g., race/ethnicity) were still incomplete, given variable
data quality.
Descriptive statistics were calculated using SAS software (version 9.4; SAS Institute).
Age-adjusted rates were calculated using direct standardization for age and weighting
by the U.S. 2000 standard population (
2
). Crude rates of cumulative cases, deaths, and testing per 100,000 population were
mapped by modified U.S. Census Bureau ZIP code tabulation area* using ArcGIS software
(version 10.6.1; ESRI). Neighborhood-level poverty was defined as the percentage of
residents within a ZIP code with household incomes <100% of the federal poverty level,
per the American Community Survey 2013–2017 (low: <10%, medium: 10%–19.9%, high: 20%–29.9%,
very high: ≥30%). Population estimates (for 2018) for age, sex, borough (county) of
residence, racial/ethnic group, and neighborhood poverty were produced by DOHMH using
U.S. Census Bureau Population Estimate Program files (unpublished data, NYC DOHMH,
2020).
†
During February 29–June 1, 2020, a total of 203,792 COVID-19 cases were diagnosed
and reported
§
among residents of NYC, including 54,211 (26.6%) in persons known to have been hospitalized
and 18,679 (9.2%) in persons who died. The age-adjusted cumulative citywide incidences
were 2,263 cases, 582 hospitalizations, and 198 deaths per 100,000 population. Case
counts increased rapidly from a weekly mean of 274 diagnosed cases per day during
the week of March 8 to a peak weekly mean of 5,132 cases per day by the week of March
29 (Figure 1). Hospital admissions also peaked the week of March 29 (weekly mean = 1,566
admissions per day). Deaths peaked during the week of April 5 (weekly mean = 566 per
day). The median duration of hospitalization was 6 days (interquartile range [IQR] = 3–11
days). Among decedents with laboratory-confirmed COVID-19, the median interval from
diagnosis to death was 8 days (IQR = 4–16 days). Among hospitalized patients, 32.1%
were known to have died. The weekly proportion of hospitalized patients who died was
highest among those admitted during March 22–April 5 (mean = 36.4%; range = 33.5%–38.2%).
FIGURE 1
Daily laboratory-confirmed COVID-19 cases, associated hospitalizations, and deaths
— New York City, February 29–June 1, 2020
Abbreviation: COVID-19 = coronavirus disease 2019.
The figure is a series of epidemiologic curves showing the numbers of daily laboratory-confirmed
COVID-19 cases by diagnosis date, associated hospitalizations by admission date, and
confirmed deaths by date of death, in New York City, during February 29–June 1, 2020.
Age-specific incidence was highest among adults aged 45–64 years (7,007 per 100,000)
(Table). Hospitalization and death rates were highest among patients aged ≥75 years
(2,146 and 1,311 per 100,000, respectively); among persons aged ≥75 years with confirmed
cases, 38.3% were known to have died. Age-adjusted incidence, hospitalization rate,
and death rate were higher among males than females, and all increased with increasing
levels of neighborhood poverty. By borough, age-adjusted incidence, hospitalization
rate, and death rate were consistently highest in the Bronx and lowest in Manhattan.
Among the race/ethnicity groups with known identity, incidence was highest among Black/African
American (Black) persons (1,590 per 100,000). Age-adjusted rates of hospitalization
and death were highest among Black (699 and 248 per 100,000, respectively) and Hispanic/Latino
(Hispanic) persons (658 and 260 per 100,000, respectively).
TABLE
Characteristics of cumulative laboratory-confirmed COVID-19 cases, hospitalizations,
and deaths among New York City residents reported to the New York City Department
of Health and Mental Hygiene — New York City, February 29–June 1, 2020*
Characteristic
Cases
Hospitalizations
Deaths
No.
Rate†
No. (row %)
Rate†
No. (row %)
Rate†
Total
203,792
2,263
54,211 (26.6)
582
18,679 (9.2)
198
Age group, yrs
0–17
6,016
348
508 (8.4)
29
12 (0.2)
1
18–44
74,654
2,215
8,474 (11.4)
251
686 (0.9)
20
45–64
73,998
7,007
18,219 (24.6)
1,725
4,183 (5.7)
396
65–74
25,182
2,518
12,009 (47.7)
1,201
4,634 (18.4)
463
≥75
23,942
3,425
15,001 (62.7)
2,146
9,164 (38.3)
1,311
Sex
Female
98,992
2,060
23,612 (23.9)
456
7,494 (7.6)
136
Male
104,675
2,511
30,589 (29.2)
744
11,183 (10.7)
283
Race/Ethnicity
Hispanic/Latino
36,498
1,514
15,288 (41.9)
658
5,743 (15.7)
260
Black/African American
32,458
1,590
14,676 (45.2)
699
5,215 (16.1)
248
White
31,029
988
11,057 (35.6)
314
4,745 (15.3)
123
Asian/Pacific Islander
8,122
601
3,441 (42.4)
258
1,403 (17.3)
111
American Indian/Alaska Native
196
973
33 (16.8)
168
5 (2.6)
27
Other race/Missing
95,489
—§
9,716 (10.2)
—§
1,568 (1.6)
—§
Neighborhood poverty¶
Low
33,114
1,787
7,498 (22.6)
358
2,756 (8.3)
125
Medium
79,327
2,169
20,907 (26.4)
551
7,404 (9.3)
193
High
48,998
2,315
15,034 (30.7)
700
5,184 (10.6)
241
Very high
36,642
2,706
10,341 (28.2)
796
3,305 (9)
268
Borough of residence
Bronx
46,085
3,157
12,076 (26.2)
826
3,870 (8.4)
268
Brooklyn
56,548
2,104
15,125 (26.7)
556
5,563 (9.8)
205
Manhattan
25,315
1,369
7,867 (31.1)
408
2,476 (9.8)
123
Queens
62,260
2,507
16,806 (27)
637
5,882 (9.4)
217
Staten Island
13,577
2,701
2,337 (17.2)
423
888 (6.5)
158
Abbreviation: COVID-19 = coronavirus disease 2019.
* Data missing on sex for 138 persons, on borough for nine persons, and on neighborhood
poverty for 6,660 persons.
† Per 100,000 population; rates for sex, race/ethnicity, neighborhood poverty, and
borough of residence were age-adjusted.
§ Rates not calculated because no population denominator.
¶ Neighborhood-level poverty was defined as the percentage of residents in a ZIP code
with household incomes <100% of the federal poverty level, per the American Community
Survey 2013–2017. Low poverty: <10%; medium poverty: 10%–19.9%; high poverty: 20%–29.9%;
very high poverty: ≥30%.
Some neighborhoods with high case rates also had high testing rates (e.g., North Bronx
and Northwest Queens) (Figure 2). However, other neighborhoods had low or medium testing
rates and high percent positivity with medium to high case rates (Southeast Queens,
East Brooklyn, West Bronx, and Northern Manhattan), suggesting possible underascertainment
of cases. Citywide, the percentage of tests with positive results increased from 27%
the week of March 8 to a peak of 65% during the week of March 22. The growth of testing
rates lagged behind the growth of percent positivity but increased steadily from 86
per 100,000 during the week of March 8 to 1,634 per 100,000 by the week of May 24.
FIGURE 2
Cumulative crude rates of COVID-19 testing per 100,000 population, percentage of tests
positive for SARS-CoV-2, and cumulative crude rates of COVID-19 cases per 100,000
population,* by modified ZIP code tabulation areas — New York City, February 29–June
1, 2020
Abbreviation: COVID-19 = coronavirus disease 2019.
* All data are displayed by four levels of natural breaks.
The figure is a series of three maps of New York City showing the cumulative crude
rates of COVID-19 testing per 100,000 population, the percentage of tests positive
for SARS-CoV-2, and the cumulative crude rates of COVID-19 cases per 100,000 population
during February 29–June 1, 2020, by modified ZIP code tabulation areas.
Among 85% of decedents with known underlying medical conditions, the majority (75%)
of decedents with a confirmed laboratory test had two or more underlying conditions;
heart disease (73%), diabetes (58%), and chronic kidney disease (23%) were the most
commonly reported conditions (NYC DOHMH, unpublished data; 2020). During March 11–June
1, 4,516 probable COVID-19–associated deaths were known to have occurred among NYC
residents. These deaths occurred more commonly at home (30%) or in a nursing home
(26%), compared with confirmed COVID-19 deaths (4% at home and 8% in a nursing home).
Deaths occurring in a hospital were frequently laboratory-confirmed as COVID-19–associated
(86%). Among 23,195 probable and confirmed deaths, 22.5% (5,226) were known to have
occurred among residents of a nursing home.
Discussion
Phylogenetic analysis and sentinel surveillance suggest that the introduction of COVID-19
into NYC from travelers started during early to mid-February 2020 (
3
,
4
), although the first case of laboratory-confirmed COVID-19 in NYC was diagnosed on
February 29. The subsequent 3-month period was characterized by a rapid acceleration
in the epidemic, resulting in approximately 203,000 cases and 18,600 deaths among
persons with laboratory-confirmed COVID-19. Reported diagnoses of cases peaked 1 week
after physical distancing orders were enacted (March 22). The overall crude case fatality
rate of 9.2% is an overestimate because of underascertainment of cases, given the
restrictive testing guidance and limited availability of tests for the first 2 months
of the epidemic.
¶
Similar to findings from the United Kingdom,** approximately 30% of hospitalized patients
with laboratory-confirmed COVID-19 were known to have died. The increased case fatality
rate among hospitalized patients during the peak period of reported cases suggests
that health care system capacity constraints might have influenced patient outcomes.
As has been previously reported (
5
), COVID-19 incidence and related hospitalization and mortality were elevated among
Black and Hispanic persons and among residents of high-poverty neighborhoods. The
finding of neighborhoods with low testing rates and a high percentage of positive
test results suggests barriers to accessing testing in areas with considerable community
transmission.
The rapid spread of COVID-19, combined with a lack of testing availability early in
2020, led to considerable surveillance challenges. DOHMH quickly ceased labor-intensive
individual case investigations for all patients and sought supplementary sources of
information. In addition, publishing NYC DOHMH data online in real-time
††
allowed the public to access basic and important information on COVID-19 in NYC.
The findings in this report are subject to at least four limitations. First, these
data are based primarily on laboratory-confirmed disease, which is more likely to
represent severe illness, especially early in the epidemic when COVID-19 testing was
mostly limited to hospitalized patients. Second, hospitalizations were underestimated
because of incomplete ascertainment from external sources. Third, race and ethnicity
information was missing for a large proportion of nonhospitalized, nonfatal cases.
Finally, rates are likely underestimated for more affluent neighborhoods because denominators
do not reflect the differential exodus of wealthy NYC residents (
6
).
The initial wave of COVID-19 in NYC demonstrated that persons who were older, had
underlying medical conditions, or resided in poorer neighborhoods, and racial and
ethnic minority populations suffered disproportionately from SARS-Cov-2 infection
and death. These trends represent the downstream effect of long-term policies, practices,
attitudes, and cultural messages that promote, reinforce, and fail to eliminate inequities
(
7
). In addition, Black and Hispanic persons are disproportionately employed in lower-paid,
often frontline industries and occupations, work with limited ability to social distance,
and are more likely to lack employer-based health insurance (
8
). Mitigating future morbidity and mortality from COVID-19 across NYC in the absence
of a vaccine,
§§
particularly among persons who are at increased risk, is an urgent priority.
Summary
What is already known about this topic?
New York City (NYC) was an early epicenter of the COVID-19 pandemic in the United
States.
What is added by this report?
Approximately 203,000 cases of laboratory-confirmed COVID-19 were reported in NYC
during the first 3 months of the pandemic. The crude fatality rate among confirmed
cases was 9.2% overall and 32.1% among hospitalized patients. Incidence, hospitalization
rates, and mortality were highest among Black/African American and Hispanic/Latino
persons, as well as those who were living in neighborhoods with high poverty, aged
≥75 years, and with underlying medical conditions.
What are the implications for public health practice?
Mitigating COVID-19 transmission among vulnerable groups at high risk for hospitalization
and death is an urgent priority.