Disparities in SARS-CoV-2 seroprevalence among individuals presenting for care in central North Carolina over a six-month period

BackgroundRobust community-level SARS-CoV-2 prevalence estimates have been difficult to obtain in the American South and outside of major metropolitan areas. Furthermore, though some previous studies have investigated the association of demographic factors such as race with SARS-CoV-2 exposure risk, fewer have correlated exposure risk to surrogates for socioeconomic status such as health insurance coverage. MethodsWe used a highly specific serological assay utilizing the receptor binding domain of the SARS-CoV-2 spike-protein to identify SARS-CoV-2 antibodies in remnant blood samples collected by the University of North Carolina Health system. We estimated the prevalence of SARS-CoV-2 in this cohort with Bayesian regression, as well as the association of critical demographic factors with higher prevalence odds. FindingsBetween April 21st and October 3rd of 2020, a total of 9,624 unique samples were collected from clinical sites in central NC and we observed a seroprevalence increase from 2{middle dot}9 (1{middle dot}7, 4{middle dot}3) to 9{middle dot}1 (7{middle dot}2, 11{middle dot}1) over the study period. Individuals who identified as Latinx were associated with the highest odds ratio of SARS-CoV-2 exposure at 7{middle dot}77 overall (5{middle dot}20, 12{middle dot}10). Increased odds were also observed among Black individuals and individuals without public or private health insurance. InterpretationOur data suggests that for this care-accessing cohort, SARS-CoV-2 seroprevalence was significantly higher than cumulative total cases reported for the study geographical area six months into the COVID-19 pandemic in North Carolina. The increased odds of seropositivity by ethnoracial grouping as well as health insurance highlights the urgent and ongoing need to address underlying health and social disparities in these populations. RESEARCH IN CONTEXTO_ST_ABSEvidence before this studyC_ST_ABSWe searched PubMed for studies published through March 21st, 2021. We used search terms that included "COVID-19", "SARS-CoV-2", "prevalence" and "seroprevalence". Our search resulted in 399 papers, from which we identified 58 relevant studies describing SARS-CoV-2 seroprevalence at sites around the United States from March 1 to December 9, 2020, 12 of which utilized remnant clinical samples and three of which overlapped with our study area. Most notably, one study of 4,422 asymptomatic inpatients and outpatients in central NC from April 28-June 19, 2020 found an estimated seroprevalence of 0{middle dot}7 -0{middle dot}8%, and another study of 177,919 inpatients and outpatients (3,817 from NC) from July 27-September 24, 2020 found an estimated seroprevalence of 2{middle dot}5 -6{middle dot}8%. Added value of this studyThis is the largest SARS-CoV-2 seroprevalence cohort published to date in NC. Importantly, we used a Bayesian framework to account for uncertainty in antibody assay sensitivity and specificity and investigated seropositivity by important demographic variables that have not yet been studied in this context in NC. This study corroborates other reports that specific demographic factors including race, ethnicity and the lack of public or private insurance are associated with elevated risk of SARS-CoV-2 infection. Furthermore, in a subset of serum samples, we identify other SARS-CoV-2 antibodies elicited by these individuals, including functionally neutralizing antibodies. Implications of all the available evidenceIt is difficult to say the exact seroprevalence in the central North Carolina area, but a greater proportion of the population accessing healthcare has been infected by SARS-CoV-2 than is reflected by infection cases confirmed by molecular testing. Furthermore, local governments need to prioritize addressing the many forms of systemic racism and socioeconomic disadvantage that drive SARS-CoV-2 exposure risk, such as residential and occupational risk, and an urgent need to provide access to SARS-CoV-2 testing and vaccination to these groups.