Ethnic differences in SARS-CoV-2 infection and COVID-19-related hospitalisation, intensive care unit admission, and death in 17 million adults in England: an observational cohort study using the OpenSAFELY platform

OpenSAFELY Collaborative

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Abstract

Background: COVID-19 has disproportionately affected minority ethnic populations in the UK. Our aim was to quantify ethnic differences in SARS-CoV-2 infection and COVID-19 outcomes during the first and second waves of the COVID-19 pandemic in England. Methods: We 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 at least 1 year of continuous registration at the start of each study period (Feb 1 to Aug 3, 2020 [wave 1], and Sept 1 to Dec 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. We 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. Findings: 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% CI 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 hospitalisation (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 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 hospitalisation, 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. Interpretation: 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. Causes are likely to be multifactorial, and delineating the exact mechanisms is crucial. Tackling ethnic inequalities will require action across many fronts, including reducing structural inequalities, addressing barriers to equitable care, and improving uptake of testing and vaccination. Funding: Medical Research Council.

Original languageEnglish
Pages (from-to)1711-1724
Number of pages14
JournalThe Lancet
Volume397
Issue number10286
Early online date30 Apr 2021
DOIs
Publication statusPublished - 6 May 2021
Externally publishedYes

Bibliographical note

Funding Information:
BG has received research funding from Health Data Research UK, the Laura and John Arnold Foundation, the Wellcome Trust, the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, the NHS NIHR School of Primary Care Research, the Mohn-Westlake Foundation, the Good Thinking Foundation, the Health Foundation, and WHO; and receives personal income from speaking and writing for lay audiences on the misuse of science. IJD has received unrestricted research grants from and holds shares in GlaxoSmithKline. KK is the director for the University of Leicester Centre for BME Health, Trustee of the South Asian Health Foundation, the NIHR Applied Research Collaboration lead for Ethnicity and Diversity, and a member of the Independent Scientific Advisory Group for Emergencies (SAGE) and chair for the SAGE Ethnicity Subgroup. RM, BG, and RME are members of the SAGE Ethnicity Subgroup. RM reports personal fees from AMGEN. AS is employed by the London School of Hygiene & Tropical Medicine (LSHTM) on a fellowship sponsored by GlaxoSmithKline. All other authors declare no competing interests.

Funding Information:
This work was supported by the UK Medical Research Council (MRC; grant number MR/V015737/1). RM holds a fellowship funded by the Wellcome Trust (201375/Z/16/Z). BG's work on better use of data in health care more broadly is currently funded in part by the NIHR Oxford Biomedical Research Centre, the NIHR Applied Research Collaboration Oxford and Thames Valley, the Mohn-Westlake Foundation, NHS England, and the Health Foundation; all DataLab staff are supported by BG's grants on this work. AS is employed by LSHTM on a fellowship sponsored by GlaxoSmithKline. KB holds a Sir Henry Dale fellowship jointly funded by Wellcome and the Royal Society. HIM is funded by the NIHR Health Protection Research Unit in Immunisation, a partnership between Public Health England and LSHTM. AYSW holds a fellowship from the British Heart Foundation. EJW holds grants from the MRC. IJD holds grants from the NIHR and GlaxoSmithKline. HF holds a UK Research and Innovation fellowship. RME is funded by Health Data Research UK and the MRC. The views expressed are those of the authors and not necessarily those of the NIHR, NHS England, Public Health England, or the Department of Health and Social Care. TPP provided technical expertise and infrastructure within their data centre pro bono in the context of a national emergency. The authors are very grateful for all the support received from the TPP Technical Operations team throughout this work, and for generous assistance from the information governance and database teams at NHS England and NHSX.

Funding Information:
This work was supported by the UK Medical Research Council (MRC; grant number MR/V015737/1 ). RM holds a fellowship funded by the Wellcome Trust ( 201375/Z/16/Z ). BG's work on better use of data in health care more broadly is currently funded in part by the NIHR Oxford Biomedical Research Centre, the NIHR Applied Research Collaboration Oxford and Thames Valley, the Mohn-Westlake Foundation, NHS England, and the Health Foundation; all DataLab staff are supported by BG's grants on this work. AS is employed by LSHTM on a fellowship sponsored by GlaxoSmithKline. KB holds a Sir Henry Dale fellowship jointly funded by Wellcome and the Royal Society. HIM is funded by the NIHR Health Protection Research Unit in Immunisation, a partnership between Public Health England and LSHTM. AYSW holds a fellowship from the British Heart Foundation. EJW holds grants from the MRC. IJD holds grants from the NIHR and GlaxoSmithKline. HF holds a UK Research and Innovation fellowship. RME is funded by Health Data Research UK and the MRC. The views expressed are those of the authors and not necessarily those of the NIHR, NHS England, Public Health England, or the Department of Health and Social Care. TPP provided technical expertise and infrastructure within their data centre pro bono in the context of a national emergency. The authors are very grateful for all the support received from the TPP Technical Operations team throughout this work, and for generous assistance from the information governance and database teams at NHS England and NHSX.

ASJC Scopus subject areas

  • Medicine(all)

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