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Ethnic Differences in COVID-19 Hospitalization and Death
Quick Takes
- Minority ethnic groups in England were at increased risk of testing positive for SARS-CoV-2 and of COVID-19–related hospitalization, ICU admission, and death.
- To reduce ethnic inequalities in COVID-19 risks, action is needed on addressing disadvantage and discrimination, reducing risk of infection and transmission, improving quality of and access to quality clinical care, and improving management of pre-existing clinical conditions.
- Furthermore, these actions need to be tailored for different ethnic groups, as relative importance of each of these measures will differ by ethnic group.
Study Questions:
What were the ethnic differences in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and coronavirus disease 2019 (COVID-19) outcomes during the first and second waves of the COVID-19 pandemic in England?
Methods:
The investigators conducted an observational cohort study of adults (aged ≥18 years) registered with primary care practices in England for whom electronic health records were available through the OpenSAFELY platform, and who had ≥1 year of continuous registration at the start of each study period (February 1–August 3, 2020 [wave 1], and September 1–December 31, 2020 [wave 2]). Individual-level primary care data were linked to data from other sources on the outcomes of interest: SARS-CoV-2 testing and positive test results and COVID-19–related hospital admissions, intensive care unit (ICU) admissions, and death. The exposure was self-reported ethnicity as captured on the primary care record, grouped into five high-level census categories (White, South Asian, Black, other, and mixed) and 16 subcategories across these five categories, as well as an unknown ethnicity category. The authors used multivariable Cox regression to examine ethnic differences in the outcomes of interest. Models were adjusted for age, sex, deprivation, clinical factors and comorbidities, and household size, with stratification by geographical region.
Results:
Of 17,288,532 adults included in the study (excluding care home residents), 10,877,978 (62.9%) were White, 1,025,319 (5.9%) were South Asian, 340,912 (2.0%) were Black, 170,484 (1.0%) were of mixed ethnicity, 320,788 (1.9%) were of other ethnicity, and 4,553,051 (26.3%) were of unknown ethnicity. In wave 1, the likelihood of being tested for SARS-CoV-2 infection was slightly higher in the South Asian group (adjusted hazard ratio, 1.08 [95% confidence interval, 1.07-1.09]), Black group (1.08 [1.06-1.09]), and mixed ethnicity group (1.04 [1.02-1.05]) and was decreased in the other ethnicity group (0.77 [0.76-0.78]) relative to the White group. The risk of testing positive for SARS-CoV-2 infection was higher in the South Asian group (1.99 [1.94-2.04]), Black group (1.69 [1.62-1.77]), mixed ethnicity group (1.49 [1.39-1.59]), and other ethnicity group (1.20 [1.14-1.28]). Compared with the White group, the four remaining high-level ethnic groups had an increased risk of COVID-19–related hospitalization (South Asian group 1.48 [1.41-1.55], Black group 1.78 [1.67-1.90], mixed ethnicity group 1.63 [1.45-1.83], other ethnicity group 1.54 [1.41-1.69]), COVID-19–related intensive care unit (ICU) admission (2.18 [1.92-2.48], 3.12 [2.65-3.67], 2.96 [2.26-3.87], 3.18 [2.58-3.93]), and death (1.26 [1.15-1.37], 1.51 [1.31-1.71], 1.41 [1.11-1.81], 1.22 [1.00-1.48]). In wave 2, the risks of hospitalization, ICU admission, and death relative to the White group were increased in the South Asian group, but attenuated for the Black group compared with these risks in wave 1. Disaggregation into 16 ethnicity groups showed important heterogeneity within the five broader categories.
Conclusions:
The authors concluded that some minority ethnic populations in England have excess risks of testing positive for SARS-CoV-2 and of adverse COVID-19 outcomes compared with the White population, even after accounting for differences in sociodemographic, clinical, and household characteristics.
Perspective:
This population-based cohort study in England reports that minority ethnic groups were at increased risk of testing positive for SARS-CoV-2 and of COVID-19–related hospitalization, ICU admission, and death. Of note, compared with wave 1, the risks of COVID-19–related hospitalization and death in wave 2 were increased for South Asian groups and reduced in all other ethnic minority groups relative to the White group. To reduce ethnic inequalities in COVID-19 risks, action is needed on social determinants including addressing disadvantage and discrimination, reducing risk of infection and transmission, improving quality of and access to quality clinical care, and improving management of pre-existing clinical conditions. Furthermore, these actions need to be tailored for different ethnic groups, as relative importance of each of these measures will differ by ethnic group.
Clinical Topics: COVID-19 Hub, Prevention
Keywords: ACC COVID-19 Podcast, Coronavirus Infections, COVID-19, Comorbidity, Electronic Health Records, Ethnic Groups, Hospitalization, Intensive Care Units, Minority Groups, Primary Health Care, Primary Prevention, Quality of Health Care, Risk, SARS-CoV-2, Social Determinants of Health
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