Factors Associated with Health Inequalities in Infectious Disease Pandemics Predating COVID-19 in the United States: A Systematic Review

Karli K. Kondo, Beth E. Williams, Chelsea K. Ayers, Devan Kansagara, Mia Smith, Shailesh M. Advani, Sarah Young, Somnath Saha

Research output: Contribution to journalReview articlepeer-review


Objective: Previous pandemics may offer evidence on mediating factors that contributed to disparities in infection and poor outcomes, which could inform the effort to mitigate potential unequal outcomes during the current COVID-19 pandemic. This systematic review sought to examine those factors. Methods: We searched MEDLINE, PsycINFO, and Cochrane to May 2020. We included studies examining health disparities in adult U.S. populations during infectious disease epidemics or pandemics. Two investigators screened abstracts and full text. We assessed study quality using the Newcastle/Ottawa Scale or the Critical Appraisal Skills Programme Checklist for Qualitative Studies. Results: Sixteen articles were included, of which 14 focused on health disparities during the 2009 H1N1 influenza pandemic. Studies showed that disparities during the H1N1 pandemic were more related to differential exposure to the virus than to susceptibility or access to care. Overall, pandemic-related disparities emanate primarily from inequalities in social conditions that place racial and ethnic minorities and low socioeconomic status populations at greater risk of exposure and infection, rather than individual-level factors such as health behaviors and comorbidities. Conclusions: Policy- and systems-level interventions should acknowledge and address these social determinants of heightened risk, and future research should evaluate the effects of such interventions to avoid further exacerbation of health inequities during the current and future pandemics.

Original languageEnglish (US)
Pages (from-to)254-269
Number of pages16
JournalHealth Equity
Issue number1
StatePublished - Mar 1 2022


  • health disparities
  • low income
  • minority health
  • pandemic
  • racial minorities

ASJC Scopus subject areas

  • Health(social science)
  • Health Policy
  • Public Health, Environmental and Occupational Health
  • Health Information Management


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