Contributions of occupation characteristics and educational attainment to racial/ethnic inequities in COVID-19 mortality

Background: Racial/ethnic inequities in COVID-19 mortality are hypothesized to be driven by education and occupation, but limited empirical evidence has assessed these mechanisms. Objective: To quantify the extent to which educational attainment and occupation explain racial/ethnic inequities in COVID-19 mortality. Design: Observational cohort. Setting: California. Participants: Californians aged 18-65 years. Measurements: We linked all COVID-19-confirmed deaths in California through February 12, 2021 (N=14,783), to population estimates within strata defined by race/ethnicity, sex, age, USA nativity, region of residence, education, and occupation. We characterized occupations using measures related to COVID-19 exposure including essential sector, telework-ability, and wages. Using sex-stratified regressions, we predicted COVID-19 mortality by race/ethnicity if all races/ethnicities had the same education and occupation distribution as White people and if all people held the safest educational/occupational positions. Results: COVID-19 mortality per 100,000 ranged from 15 for White and Asian females to 139 for Latinx males. Accounting for differences in age, nativity, and region, if all races/ethnicities had the education and occupation distribution of Whites, COVID-19 mortality would be reduced for Latinx males (-22%) and females (-23%), and Black males (-1%) and females (-8%), but increased for Asian males (+22%) and females (+23%). Additionally, if all individuals had the COVID-19 mortality associated with the safest educational and occupational position (Bachelor9s degree, non-essential, telework, highest wage quintile), there would have been 57% fewer COVID-19 deaths. Conclusion: Educational and occupational disadvantage are important risk factors for COVID-19 mortality across all racial/ethnic groups, especially Latinx individuals. Eliminating avoidable excess risk associated with low-education, essential, on-site, and low-wage jobs may reduce COVID-19 mortality and inequities, but is unlikely to be sufficient to achieve equity.