Ethnic differences in COVID-19 infection, hospitalisation, and mortality: an OpenSAFELY analysis of 17 million adults in England

Abstract

Background: COVID-19 has had a disproportionate impact on ethnic minority populations, both in the UK and internationally. To date, much of the evidence has been derived from studies within single healthcare settings, mainly those hospitalised with COVID-19. Working on behalf of NHS England, the aim of this study was to identify ethnic differences in the risk of COVID-19 infection, hospitalisation and mortality using a large general population cohort in England. Methods: We conducted an observational cohort study using linked primary care records of 17.5 million adults between 1 February 2020 and 3 August 2020. Exposure was self-reported ethnicity collapsed into the 5 and 16 ethnicity categories of the English Census. Multivariable Cox proportional hazards regression was used to identify ethnic differences in the risk of being tested and testing positive for SARS-CoV-2 infection, COVID-19 related intensive care unit (ICU) admission, and COVID-19 mortality, adjusted for socio-demographic factors, clinical co-morbidities, geographic region, care home residency, and household size. Results: A total of 17,510,002 adults were included in the study; 63% white (n=11,030,673), 6% south Asian (n=1,034,337), 2% black (n=344,889), 2% other (n=324,730), 1% mixed (n=172,551), and 26% unknown (n=4,602,822). After adjusting for measured explanatory factors, south Asian, black, and mixed groups were marginally more likely to be tested (south Asian HR 1.08, 95%CI 1.07-1.09; black HR 1.08; 95%CI 1.06-1.09, mixed HR 1.03, 95%CI 1.01-1.05), and substantially more likely to test positive for SARS-CoV-2 compared with white adults (south Asian HR 2.02. 95% CI 1.97-2.07; black HR 1.68, 95%CI 1.61-1.76; mixed HR 1.46, 95%CI 1.36-1.56). The risk of being admitted to ICU for COVID-19 was substantially increased in all ethnic minority groups compared with white adults (south Asian HR 2.22, 95%CI 1.96-2.52; black HR 3.07, 95%CI 2.61-3.61; mixed HR 2.86, 95%CI 2.19-3.75, other HR 2.86, 95%CI 2.31-3.63). Risk of COVID-19 mortality was increased by 25-56% in ethnic minority groups compared with white adults (south Asian HR 1.27, 95%CI 1.17-1.38; black HR 1.55, 95%CI 1.38-1.75; mixed HR 1.40, 95%CI 1.12-1.76; other HR 1.25, 95%CI 1.05-1.49). We observed heterogeneity of associations after disaggregation into detailed ethnic groupings; Indian and African groups were at higher risk of all outcomes; Pakistani, Bangladeshi and Caribbean groups were less or equally likely to be tested for SARS-CoV-2, but at higher risk of all other outcomes, Chinese groups were less likely to be tested for and test positive for SARS-CoV-2, more likely to be admitted to ICU, and equally likely to die from COVID-19. Conclusions: We found evidence of substantial ethnic inequalities in the risk of testing positive for SARS-CoV-2, ICU admission, and mortality, which persisted after accounting for explanatory factors, including household size. It is likely that some of this excess risk is related to factors not captured in clinical records such as occupation, experiences of structural discrimination, or inequitable access to health and social services. Prioritizing linkage between health, social care, and employment data and engaging with ethnic minority communities to better understand their lived experiences is essential for generating evidence to prevent further widening of inequalities in a timely and actionable manner.

Ethnic differences in COVID-19 mortality during the first two waves of the Coronavirus Pandemic: a nationwide cohort study of 29 million adults in England

“…In line with existing studies investigating ethnic inequalities in SARS-CoV-2 infection and COVID-19 mortality [15,3,4,16,17], we find that most ethnic minority groups were disproportionally affected in the first wave. Our findings that the ethnic inequalities in COVID-19 mortality differed between the two waves is consistent with the evidence that these disparities are likely to be driven by differences in exposure to infection and therefore can change over time.…”

“…A recent systematic review of 50 studies have showed that people from ethnic minority background in the UK and other countries, particularly Black and South Asian groups, have been disproportionately affected by the Coronavirus (COVID-19) pandemic compared to people of White ethnic background [1] While several studies have investigated whether adjusting for sociodemographic and economic factors and medical history reduces the estimated difference in risk of mortality and hospitalisation [2,3,4], the reasons for the differences in the risk of experiencing harms from COVID-19 are still being explored during the course of the pandemic. Factors including structural racism [5,6], social vulnerability [7,8] social and material deprivation, [9] have widely been suggested as potential mechanisms for these reported inequalities.…”

Development and validation of the patient history COVID-19 (PH-Covid19) scoring system: a multivariable prediction model of death in Mexican patients with COVID-19

“…One limitation of our study is that certain diseases (cancer, haematological malignancies and neurologic diseases) and specific states of a disease (obesity class, former or current smoker and control of diabetes, hypertension and asthma) which increase the risk of dying from COVID-19 [11] were not studied since they are not provided in the datasets. Furthermore, we were not able to study other social determinants and population factors which could be having an important impact in patient outcomes [39, 40]. However, our model accounts for the main risk factors associated with death in patients with COVID-19, and not requiring inputting specific disease states makes it easier to be used by clinicians while minimising the risk of not having enough data to use the score with precision.…”

Risk mitigating behaviours in people with inflammatory joint and skin disease during the COVID-19 pandemic differ by treatment type: a cross-sectional patient survey

“…The COVID-19 pandemic, caused by the highly infectious SARS-CoV-2 virus, represents an unprecedented global health crisis 1,2 . Death from COVID-19 is associated with male gender, older age, Asian/Black ethnicity, and coexisting conditions including cardiovascular disease and obesity 3,4 . Guided by international recommendations from the World Health Organization (WHO), public health risk mitigating measures such as social/physical distancing were introduced early in the pandemic to limit community transmission of COVID-19 [5][6][7][8] .…”