Health Equity and the Impact on Infectious Disease

Health equity has been a concept familiar in the public health sector for many years. As the COVID-19 pandemic spread, the impacts on certain groups were made evident and acknowledged on a broader scale. Now health equity is part of daily conversations in the acute care world and in particular regarding infectious disease. Health equity and disparities play a role in emerging infectious diseases and disease transmission, and until those roles are better understood and incorporated into prevention efforts, health outcomes for those affected will be at risk. Health equity is defined as the state in which everyone has a fair and just opportunity to attain their highest level of health.¹ Social determinants of health are the conditions in which people live, work, play, worship, and learn that impact health risks and outcomes.¹ Finally, health-related social needs are the individual factors that affect a person’s ability to meet health goals.² A recent article described 4 main concepts as to how health inequities can influence disease transmission and emerging infectious disease: unequal exposure, unequal transmission, unequal susceptibility, and unequal treatment.³ Exposure risk varies based on social determinants. For example, in areas with poor sanitation, less running water is available for hand hygiene. This increases the risk of transmission for diarrheal illness and pathogens transmitted through fecal-oral routes. An example of unequal transmission was seen during the COVID-19 pandemic, when individuals working in service and frontline positions did not have the ability to work from home or socially distance themselves. Unequal susceptibility describes the host factors that influence disease transmission and infection. A basic tenet of infection prevention is the chain of infection, in which a susceptible host is the final step. But even if all the other steps occur, if the person who encounters the pathogen is not susceptible, infection and disease are less likely to occur. However, comorbidities and preexisting conditions can increase the risk of infection and more severe disease. Some examples of significant measures of susceptibility include chronic conditions such as heart disease, cancer, and diabetes, as well as poor nutritional status and chronic stress. Unequal treatment essentially concerns access to care. Although this is a simple statement, it is a complex issue, stemming from structural biases, implicit biases of health care workers, lack of trust in governmental institutions, and more. Inadequate access to care can result in delays in seeking care for conditions, exacerbations of chronic illness, and the inability to receive treatment or preventive measures (vaccination, prophylactic medication, personal protective equipment). However, it is important to be aware that health inequities are not to be used as a way to point to cultural differences as being the cause of disease. For example, during Ebola virus disease outbreaks, concerns are often discussed regarding the funeral practices of certain cultures.⁴ Health care providers and policy makers must be careful to avoid blaming cultural traditions and trying to change cultures to reflect a more Western mind-set as a way to decrease risk. Instead, they must understand how those practices can influence disease transmission and work with local groups to help empower them to practice their traditions in the safest ways possible. Another example is multigenerational family units sharing 1 home. For some cultures, this is a practice that is not dependent on socioeconomic factors, but the preferred way to live together. Therefore, when communicating information and developing interventions, it is important to understand the nuances of the groups one is addressing in order to have meaningful outcomes.

One challenge to understanding the impact of health equity on infectious diseases is the lack of information and studies on the subject. Investigators of a recent systematic review sought to pull articles related to health inequalities and disease pandemics in the United States and found only 16 articles that met the criteria for inclusion.⁵ Upon further stratification based on race, ethnicity, and other social determinants of health, the number of articles for each subgroup ranged from 1 to 6.⁵ Based on these findings alone, a lack of data and research is clearly a limiting factor to understanding the true effects of health inequities and social determinants of health on infectious diseases.

Large-scale interventions, such as national policy change and global advocacy, are needed to bring awareness of the issues to the forefront. For example, when developing national grant programs to fund research in infectious disease, one requirement for application could be to specify a research population that experiences health inequities. Breaking down the status quo and removing structural barriers that exist are necessary steps to begin the work of addressing health needs of all populations. To prevent health disparities when the next disease outbreak, emerging infectious disease, or pandemic arises, work must begin now to address inequities and health-related social needs to set up our populations for healthier outcomes overall. To help achieve these goals, policy and public health guidelines need to have diverse points of view and input from groups that are most affected to bring forward innovative program designs and policy development. For example, vaccination recommendations need to address both medical and social risks.⁶ Therefore, criteria for vaccine risk groups should include not only include age and comorbidities, but also consider a person’s type of work or living situation.

National regulatory and advisory bodies have also started integrating health equity into their standards. The Joint Commission (TJC) recently added health equity as one of their standards starting in January 2023.⁷ Health care facilities that are accredited through TJC will be required to appoint a health equity officer and show evidence of work being done to address health-related social needs. Similarly, leading infection prevention organizations are also joining the push to integrate health equity into research and guidance for infection prevention programs. The Association for Professionals in Infection Control and Epidemiology released a statement in 2021 commending the Centers for Disease Control and Prevention for recognizing racism as a public health issue, and committed to supporting research focused on health disparities and infection prevention.⁸

At the local community and facility level, what can health care professionals do to help address health inequity and infectious disease risk? For infection prevention programs, first they need to understand how health equity impacts their patients. They should start to collect data on race, ethnicity, gender, health insurance status, zip code, primary language, and disability status. This is not a new concept from a public health or chronic disease perspective, but for programs in infection prevention, social determinants of health have not been looked at consistently. Other risk factors are used to stratify data, but those are usually based on clinical indicators. Currently, national reporting does not have fields for entering health equity–related factors, so no national database is available to look at trends and compare across states. Even within local regions, these data sources do not exist.

Local infection prevention programs can partner with health equity officers in their facilities to determine how the concepts of health equity can be applied to reduce health care–associated infections. Local public health agencies can also collaborate with acute care programs to develop continuity of care and programs that address health-related social needs of patients. Similar collaborations occurred with the mpox (monkey pox) virus response. Local public health departments partnered with community programs for outreach and vaccine administration to high-risk communities, to meet those clients where they live and bring preventive care directly to them.

Addressing health inequities in infectious disease response is a growing concern. With the recent pandemic and outbreaks of emerging infectious diseases and high-consequence diseases, it has become more evident that social determinants of health will continue to play a significant impact in disease transmission. More information is needed from local and national bodies to enable data-driven decisions as well as collaboration with community leaders to ensure health-related social needs are addressed.

References

1.What is health equity? Centers for Disease Control and Prevention. Updated July 1, 2022. Accessed December 18, 2022. https://www.cdc.gov/healthequity/whatis/index.html

2.Hagland M. Social determinants of health, health-related social needs: what’s complex. Healthcare Innovation. July 19, 2021. Accessed December 18, 2022. https://www.hcinnovationgroup.com/population-health-management/social-determinants-of-health/blog/21230966/social-determinants-of-health-healthrelated-social-needs-whats-complex

3.Bambra C. Pandemic inequalities: emerging infectious diseases and health equity. Int J Equity Health. 2022;21(1):6. doi:10.1186/s12939-021-01611-2

4.Maxmen A. How the fight against Ebola tested a culture’s traditions. National Geographic. January 30, 2015. Accessed December 19, 2022. https://www.nationalgeographic.com/adventure/article/150130-ebola-virus-outbreak-epidemic-sierra-leone-funerals-1

5.Kondo KK, Williams BE, Ayers CK, et al. Factors associated with health inequalities in infectious disease pandemics predating COVID-19 in the United States: a systematic review. Health Equity. 2022;6(1):254-269. doi:10.1089/heq.2021.0049

6.Mamelund SE, Dimka J. Social inequalities in infectious diseases. Scand J Public Health. 2021;49(7):675-680. doi:10.1177/1403494821997228

7.Advancing health care equity, together. The Joint Commission. Accessed December 19, 2022. https://www.jointcommission.org/our-priorities/health-care-equity/

8.APIC applauds CDC for declaring racism a serious public health threat.Association for Professionals in Infection Control and Epidemiology. Accessed December 19, 2022. https://apic.org/apic-applauds-cdc-for-declaring-racism-a-serious-public-health-threat/#:~:text=APIC%20will%20be%20focused%20on%20conducting%20research%20on,racial%20disparities%20in%20healthcare-associated%20infections%20and%20improve%20outcomes