Working on behalf of NHS England, researchers have conducted a study showing that ethnic minorities have been disproportionately affected by the coronavirus disease 2019 (COVID-19) endemic in the UK.
In the most extensive European analysis to date, the researchers identified substantial ethnic differences in the risk of testing positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) – the agent responsible for the current COVID-19 pandemic.
The study, which assessed the clinical records of more than 17 million adults, also identified inequalities in the risk of needing admission to ICU and the risk of COVID-19-related death.
The observed ethnic differences persisted even after accounting for potential explanatory factors such as underlying health conditions, geographic region, and large household size.
Compared with white British individuals, Indian, African, Pakistani, Bangladeshi, and Caribbean groups were more likely to test positive for SARS-CoV-2, more likely to require ICU admission, and more likely to die due to COVID-19.
Chinese groups were less likely to test positive for SARS-CoV-2, but more likely to be admitted to ICU, and equally likely to die from COVID-19.
Ben Goldacre (Oxford University) and colleagues say some of this excess risk probably relates to factors that have not been captured in clinical records such as high-exposure occupations, 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,” warns the team.
A pre-print version of the paper is available on the server medRxiv*, while the article undergoes peer review.
The research was a collaborative effort between the London School of Hygiene and Tropical Medicine, the University of Oxford, The Phoenix Partnership, Intensive Care National Audit and Research Centre, University of Leicester, and the University College London.
The studies so far
The increased risk for SARS-CoV-2 infection and severe COVID-19 outcomes among ethnic minority groups has already been reported, both in the UK and internationally. It has been proposed that the disparities may be accounted for by factors such as living in large households, frontline occupations, and poor access to health services.
However, to date, much of the evidence for these ethnic differences have been derived from small studies conducted within single healthcare settings, such as those assessing COVID-19 patients who have been admitted to hospital.
Such studies cannot explore COVID-19 infection and hospitalization in an unbiased way, since they involve select study cohorts that are not representative of the general population.
The studies have also reported on broader ethnic groups, such as whites, south Asians, and blacks, which may conceal significant heterogeneity. Bangladeshi and African populations, for instance, are more likely to live in deprived areas, compared with the general population. In contrast, Indian and Chinese populations are more likely to live in more affluent areas, where they experience less material deprivation.
“Therefore, it is vital to disaggregate broad ethnic groupings to model better the overlapping contributions of health and social factors on COVID-19 infection, severity, and mortality,” say the researchers.
The current study’s approach
Now, Goldacre and team have set out to determine ethnic differences across the full COVID-19 pathway, from being tested for SARS-CoV-2, through to testing positive, requiring ICU admission and COVID-19-related death.
Multivariable Cox proportional hazards regression was used to adjust for socio-demographic factors, household size, co-existing health problems, geographic region, and care home residency across both broad and disaggregated ethnic groups.
The team conducted an observational study using linked primary care records for 17,510,002 adults between February 1st and August 3rd, 2020.
Sixty-three percent of the cohort was 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).
What were the findings?
Compared with white individuals, South Asian, black, and mixed groups were slightly more likely to be tested for SARS-CoV-2 and significantly more likely to test positive for infection.
The risk of ICU admission for COVID-19 was significantly greater among all ethnic minority groups; south Asians, blacks, mixed and other were 2.22, 3.07, 2.86, and 2.86 times more likely, respectively, to be admitted than whites.
Compared with whites, the risk of COVID-19 mortality was 1.27-fold greater among Asians, 1.55-fold greater among blacks, 1.4-fold greater among mixed and 1.25-fold more significant among others.
Following disaggregation of the broader ethnic groupings, the team observed significant heterogeneity between more specific ethnic groups.
Pakistani and Bangladeshi groups were less likely to be tested for SARS-CoV-2, but more likely to test positive, require admission to ICU and die due to COVID-19.
Caribbean groups were equally as likely to be tested, but more likely to test positive, require ICU admission, and die as a result of COVID-19.
Chinese groups were less likely to be tested, less likely to be positive for infection, but more likely to require ICU and equally as likely to die as a result of COVID-19.
Better data and more engagement with ethnic minority groups is needed
“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,” say Goldacre and colleagues.
The researchers say improved and more readily available linked data is needed to help better characterize ethnic disparities, and investigate whether discrimination, access to protective equipment, lifestyle, behaviors, or access to health care are contributing factors.
“Engaging with ethnic minority communities to understand their lived experiences will be essential for generating evidence to prevent further widening of inequalities in a timely and actionable manner,” concludes the team.
medRxiv publishes preliminary scientific reports that are not peer-reviewed and, therefore, should not be regarded as conclusive, guide clinical practice/health-related behavior, or treated as established information.