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COVID-19 infection differences among people with disabilities

Purpose People with disabilities may be at higher risk for COVID-19 infection and death as a result of their impairments and/or medical conditions, and systemic inequities and disadvantages. People with disabilities are also a very heterogenous group, with many people with disabilities being multiply marginalized. The aim of this study was to examine differences in COVID-19 diagnosis and vaccination between people with and without disabilities, and to explore sociodemographic differences in COVID-19 diagnosis and vaccination among the disability community itself. Methods To do so, we analyzed secondary United States Census Bureau data from 444,422 people (52,890 adults with disabilities and 391,532 adults without disabilities) about COVID-19 diagnosis, vaccination, and sociodemographics. Frequency person-weights were applied. Results In this study, 19.3% of adults with disabilities were diagnosed with COVID-19 during the pandemic compared to 16.7% of adults without disabilities. People with disabilities were 1.20 times more likely to be diagnosed with COVID-19 than adults without disabilities. Among people with disabilities, the following groups were more likely to be diagnosed with COVID-19: people with cognitive disabilities; cisgender women; Black people; Hispanic people; people with some college or associate’s degrees; people with employer and/or private insurance; and people who lived in larger households. There was not a significant difference in vaccination between people with and without disabilities; however, there were vaccination disparities among the disability community. Conclusions Many of the people with disabilities who were more likely to face health care disparities prior to the pandemic were also more likely to be diagnosed with COVID-19 during the pandemic.

In addition, people with disabilities are also higher risk because of increased likelihood of living in congregate settings, where they often live with more people, may experience high crowding or share bathrooms and bedrooms, and have frequently rotating support staff [6,[14][15][16][17]. People with disabilities are also more likely to have personal support needs that require close interaction with other people, leaving them unable to isolate, leading to greater transmission rates [15,18]. A lack of accessible information about COVID-19, a lack of access to testing for people with disabilities, such as a lack of at home tests that included braille, also increased the risks people with disabilities face [19,20]. People with disabilities are also at greater risk for infection and mortality due to systemic and social inequities and disadvantages, such as barriers to accessing health care [21,22].
People with disabilities are a very heterogenous group, with many people with disabilities being multiply marginalized, which may put them at further risk for contracting and dying of COVID-19. For example, in the general population, people of color, LGBTQ people, men, and older adults were all at higher risk for COVID-19 [3,9,13,[23][24][25][26][27][28][29][30]. Yet, less attention has been drawn to infections among people with intersecting identities, as well as differences within the disability community itself. As Reed et al. [31] note, "The lack of [COVID-19 disability] data perpetuates the exclusion of disabled people from discussions of health equity and policies that are data driven" (p. e423). For these reasons, the aim of this study was to examine differences in COVID-19 diagnosis and vaccination between people Dialogues in Health 1 (2022) 100083 with and without disabilities, and to explore sociodemographic differences in COVID-19 diagnosis and vaccination among the disability community itself. To do so, we analyzed secondary United States Census Bureau data from 52,890 adults with disabilities and 391,532 adults without disabilities about COVID-19 diagnosis and vaccination from the start of the pandemic to January 10, 2022.

Data
Data for this study came from the United States Census Bureau [32] Household Pulse Survey. (As it was secondary data, our IRB determined it was exempt from review.) The Census Bureau randomly administered the Pulse survey to households in the United States to examine the impact of the pandemic on people in the United States. Adult (18+) members of the randomly selected households were invited by mail and phone to participate in the online survey. Between July 21, 2021 and January 10, 2022, 518,728 unduplicated people completed the survey.
In order to measure disability status, the Census Bureau used questions developed by the Washington Group on Disability Status (a United Nations Statistical Commission City Group) and recommended by the United Nations [33,34]. The four questions used to measure disability were: 1. Do you have difficulty seeing, even when wearing glasses?; 2. Do you have difficulty hearing, even when using a hearing aid?; 3. Do you have difficulty remembering or concentrating?; and, 4. Do you have difficulty walking or climbing stairs?
Answer options for each question were: (0.) Nono difficulty; (1.) Yessome difficulty; (2.) Yesa lot of difficulty; and, (3.) cannot do at all. People who answer "a lot of difficulty" (2) or "cannot do at all" (3) are considered to have the applicable disability (yes (1); no (0)) for each question [33]. In total, 52,890 people in the dataset had disabilities, while 391,532 did not (people who did not answer these questions were removed), resulting in a final sample size of 444,422. Using SPSS27 complex samples, we applied the United Census Bureau's [32] frequency person-weights in order to adjust for population demographics and nonresponses. When weighted, 14.0% of people had disabilities and 86.0% did not.

Measure
Data about COVID-19 diagnosis and vaccination was obtained from the Pulse survey. In particular, the Pulse survey asked participants: "Has a doctor or other health care provider ever told you that you have COVID-19?" Answer options included: 'Yes,' 'No,' and 'Not sure.' As our aim was to explore those who had diagnosis versus those who did not, we removed 'not sure' answers from the analyses. Participants were also asked if they had received at least one dose of a COVID-19 vaccine. Answer options included 'Yes' and 'No.' It is important to note that the Census Bureau did not impose a time limitation on these questions; that is, people answered the questions about diagnosis and vaccination at any time of the pandemic (i.e., January 2020 through January 10, 2022) instead of it being limited to the specific time people participated in the survey itself.

Analysis
We first conducted complex samples descriptive statistics. We utilized complex samples binary logistic regressions to examine differences in COVID-19 diagnosis (dependent variable [DV]; no [0], yes [1]) and vaccination (DV; no [0], yes [1]) based on disability (independent variable [IV]), while controlling for all other sociodemographics. Finally, we used complex samples binary logistic regressions to explore sociodemographic differences (IVs) in COVID-19 diagnosis (DV) and vaccination (DV) in the disability community. Missing data were excluded using case wise deletion. We used a 95.0% confidence interval (CI) for odds ratios (ORs).

Demographics
The most common types of disabilities were cognitive disability (43.5%) and mobility disability (40.3%; Table 1). Most people with disabilities were cisgender women (56.6%), straight (82.3%), White (76.4%), had some college or less education (70.3%), were currently married (45.7%), and had a household income of less than $75,000 (75.9%). The most common forms of health insurance/coverage among people with disabilities were employer insurance (46.8%), Medicare (36.7%), and Medicaid (30.1%). Demographics of the comparison group of people without disabilities are also available in Table 1.

Differences in COVID-19 diagnosis and vaccination among people with and without disabilities
In total, 19.3% of people with disabilities were diagnosed with COVID-19, compared to 16.7% of people without disabilities ( Table 2). In fact, people with disabilities were 1.20 times (CI = 1.13, 1.27) more likely to be diagnosed with COVID-19 than people without disabilities, even when all sociodemographics and COVID-19 vaccination status were controlled.
The majority of people with disabilities (82.3%) and people without disabilities (85.5%) received at least one dose of a COVID-19 vaccine. When sociodemographic factors were controlled, there was not a significant difference in vaccination of people with and without disabilities (OR[CI] = 0.97 [0.91, 1.04]).

Differences in COVID-19 diagnosis in the disability community
There were differences in COVID-19 diagnosis in the disability community itself ( Table 3). The following people with disabilities were more likely to receive a COVID-19 diagnosis: people with cognitive disabilities; cisgender women with disabilities; Black people with disabilities; Hispanic people with disabilities; people with disabilities with some college or associate's degrees; people with disabilities with employer insurance; people with disabilities with private insurance; and people with disabilities in larger households. Conversely, people with disabilities who received a COVID-19 vaccine, people with disabilities had a sexual orientation of 'something else,' Asian people with disabilities, and Medicare beneficiaries with disabilities were less likely to be diagnosed with COVID-19 than people with disabilities that did not fall into these groups.
In addition, there were differences in vaccination (at least one dose) in the disability community. The following people with disabilities were more likely to receive a COVID-19 vaccine: people with disabilities 45 years old and older; people with disabilities who were gay, lesbian, bisexual, or had a sexual orientation of 'something else;' Black and Asian people with disabilities; Hispanic people with disabilities; people with disabilities with employer insurance; and people with disabilities with Medicare. The following were less likely to receive a COVID-19 vaccine: people with visual disabilities; people with hearing disabilities; people with cognitive disabilities; people with mobility disabilities; people with disabilities with less than a bachelor's degree; people with disabilities with household incomes of less than $35,000; people with disabilities who received health care from Veteran Affairs; people with disabilities who received health care from the Indian Health Services; and people with disabilities who lived in larger households.

Discussion
While there is evidence indicating some types of disabilities lead people to be at higher risk for COVID-19 infection and death [1][2][3][4][5][6][7][8][9][10][11][12][13], less attention has been drawn to differences in and among the disability community itself. For these reasons, the aim of this study was to examine differences in COVID-19 diagnosis and vaccination between people with and without disabilities, and to explore sociodemographic differences in COVID-19 diagnosis and vaccination among the disability community itself. We found that 19.3% of people with disabilities were diagnosed with COVID-19 and 82.3% had received at least one COVID-19 vaccine as of January 2022. People with disabilities were significantly more likely to be diagnosed with COVID-19 than people without disabilities even when sociodemographics and vaccination status were controlled. In fact, the odds of people being diagnosed with COVID-19 increased by 20% when they had disabilities. This finding mirrors previous research which indicates many people with disabilities are at higher risk for infection and death than people without disabilities due to certain disabilities, the need for personal care that requires close interactions, living in congregate settings, and other systemic inequities [1][2][3][4][5][6][7][8][9][10][11][12][13][14]16,17,27,35,36].
While research indicates people with disabilities are higher risk for COVID-19, less research has explored differences in infection within the disability community itself. In addition to differences based on if a person had a disability, our findings indicate differences in diagnosis rates among the disability community. For example, regardless of vaccination status and other demographic characteristics, people with cognitive disabilities were more likely to be diagnosed with COVID-19 than people with other types of disabilities. People with IDD, dementia, and Alzheimer's fall under cognitive disabilities, all of which higher risk disabilities [3][4][5][6][11][12][13]. People with cognitive disabilities may also need personal care that requires close contact; they are more likely to live in congregate settings which increases their risks for COVID-19 [4,6,14,16,17,27,35,36].
Despite higher vaccination rates, Black and Hispanic people with disabilities were more likely to be diagnosed with COVID-19 than White and non-Hispanic people with disabilities, respectively, even when all other sociodemographic factors were controlled. While research about the general population indicates Black and Hispanic people are more likely to be infected, hospitalized, and die of COVID-19 as a result of structural racism, including socioeconomic disadvantages [3,9,26,27], less attention has been drawn to Black and Hispanic people with disabilities in particular.
In addition, additional research about the intersection between disability and gender are necessary as findings from this study as well as two other studies [9,27] about the disability community significantly diverge from almost all evidence about gender, sex, and COVID-19 in the general population. In the general population, research that indicates males are more likely to contract and die of COVID-19 than females because of both biology (including co-morbidities) and behavioral factors [13,[23][24][25][26]. Yet, in this study cisgender women with disabilities had higher rates of COVID-19 diagnosis than cisgender men with disabilities. This finding mirrors Chakraborty's [27] findings that counties with more females (sex) with disabilities had higher rates of COVID-19 infection and Wang et al.'s [9] findings that women with ADHD, bipolar disorder, depression, and schizophrenia had higher odds of COVID-19 infection than men with the same disabilities, even when age, ethnicity, and medical comorbidities were controlled. Given these differences, it is critical that more research be conducted about the relationship between disability, sex, gender, and COVID-19 to further explore risk factors for women with disabilities.
People with disabilities with a sexual orientation of 'something else' were less likely to be diagnosed with COVID-19 than straight people with disabilities in our study. While LBGTQ people are more likely to have health conditions that put them at higher risk for COVID-19 [29], LGBTQ people also have higher confidence in vaccines and had higher vaccination rates in this study [37]. Given this finding and the Center for Disease Control's (CDC's) [29] recognition that the LGBTQ community represents a COVID-19 data gap, more efforts to collect COVID-19 infection and mortality data about LGBTQ people with disabilities is needed. Given differences in diagnosis and vaccination rates based on household income and insurance we believe further efforts need to be made to expand access for testing and other preventative measures, such as vaccines, including by removing barriers [38]. For example, people with disabilities with household incomes of less than $25,000 were less likely to be diagnosed with COVID-19 and less likely to receive a vaccine than those with incomes of $150,000. This may be in part due to an inability to get tested because they could not afford transportation, could not afford to take time off work, and/or believed they would not be able to afford testing or vaccination. Furthermore, while people with disabilities who had employer and/or private insurance were more likely to be diagnosed with COVID-19, people with disabilities with Medicare were less likely to be diagnosed with COVID-19. We believe this may be due to differences in access to health care, with the people with employer insurance having fewer barriers to care based on insurance coverage than Medicare beneficiaries. In fact, Medicare beneficiaries faced more logistical challenges to getting provider COVID-19 testing covered, and were not eligible for at-home test reimbursement until recently [39]. This finding may also be due to increased vaccination rates among Medicare beneficiaries with disabilities in this study.
Our findings also indicate vaccinated people with disabilities were significantly less likely be diagnosed with COVID-19 than unvaccinated people with disabilities, which bodes well for the success of vaccines. However, it is also important to note there were a number of disparities in vaccination among people with disabilities, such as based on education and income. As such, efforts need to be made to reduce the barriers people with disabilities' face when it comes to vaccine access.

Limitations
When interpreting the findings from this study, a number of limitations should be noted. Data about COVID-19 diagnosis was from the Census Bureau Pulse survey, which is a voluntary survey, rather than the CDC's confirmed infection data; this was necessary because CDC data about disability and COVID-19 is not available, which relates to the larger problem of pandemic data not being collected about people with disabilities [31]. Although the infection data in this study came from the Pulse survey, rather than the CDC, given people were asked if they were specifically diagnosed with COVID-19 by a doctor or health care provider we believe it to be a useful proxy, especially given the need for more research about people with disabilities and COVID-19. It should be noted though that this framing of the question would likely not include home-tests or infections of untested people; it also would not include responses from people who died from COVID-19 prior to survey administration. People with disabilities may have been more likely to receive formal testing, which could have impacted the results about higher infection rates. People were asked if they receive at least one dose of the COVID-19 vaccine; there may be additional differences between people who received multiple doses and a single dose that were not explored in this study.
In addition, while the questions the Census Bureau asked about disability are used in censuses around the world, they do not capture all types of disabilities and have been found to not include all people with disabilities [40]. Moreover, there was not information about which specific disabilities people had, which could have impacted their likelihood of diagnosis.

Conclusion
Not only did this study find that adults with disabilities were diagnosed with COVID-19 at greater rates than nondisabled people during the pandemic (as of January 10, 2022), we also found differences in COVID-19 diagnosis in the disability community, regardless of vaccination status, based on cognitive disability, gender, sexual orientation, race, ethnicity, education, income, health insurance, and household size. There were also differences in vaccination in the disability community based on disability type, age, sexual orientation, race, ethnicity, education, income, health insurance, and household size. Many of the people with disabilities who were more likely to face health care disparities prior to the pandemic, were also more likely to be diagnosed with COVID-19 during the pandemic.