Purpose: The purpose of this ecological study was to understand the impact of the density of African American (AA) communities on coronavirus disease 2019 (COVID-19) prevalence and death rate within the three most populous counties in each U.S. state and territory (n=152).

Methods: An ecological design was employed for the study. The top three most populous counties of each U.S. state and territory were included in analyses for a final sample size of n=152 counties. Confirmed COVID-19 cases and deaths that were accumulated between January 22, 2020 and April 12, 2020 in each of the three most populous counties in each U.S. state and territory were included. Linear regression was used to determine the association between AA density and COVID-19 prevalence (defined as the percentage of cases for the county population), and death rate (defined as number of deaths per 100,000 population). The models were adjusted for median age and poverty.

Results: There was a direct association between AA density and COVID-19 prevalence; COVID-19 prevalence increased 5% for every 1% increase in county AA density (p<0.01). There was also an association between county AA density and COVID-19 deaths; the death rate increased 2 per 100,000 for every percentage increase in county AA density (p=0.02).

Conclusion: These findings indicate that communities with a high AA density have been disproportionately burdened with COVID-19. To help develop effective interventions and programs that address this disparity, further study is needed to understand social determinants of health driving inequities for this community.