On behalf of NHS England, researchers conducted a study that found ethnic minorities were disproportionately affected by coronavirus disease 2019 (COVID-19), which is endemic in the UK.
In the most extensive European analysis to date, the researchers identified significant ethnic differences in the risk of testing positive for coronavirus 2 (SARS-CoV-2) with severe acute respiratory syndrome (SARS-CoV-2) – the drug used for current COVID -19 pandemic is responsible.
The study, which evaluated the clinical records of more than 17 million adults, also found inequalities in ICU risk admission and risk of death associated with COVID-19.
The observed ethnic differences persisted even after considering possible explanatory factors such as underlying health conditions, geographic region, and large household size.
Compared to white Brits, Indian, African, Pakistani, Bangladeshi and Caribbean groups were more likely to be positive for SARS-CoV-2, more likely to require admission to the intensive care unit, and more likely to die from COVID-19.
Chinese groups tested positive for SARS-CoV-2 less often, but were more likely to be admitted to the intensive care unit and died of COVID-19 just as frequently.
Ben Goldacre (University of Oxford) and colleagues say some of this excessive risk is likely due to factors not recorded in clinical records, such as high-exposure occupations, experience of structural discrimination, or unequal access to health and social services.
“Prioritizing the linking of health, social and employment data, as well as working with ethnic minorities to better understand their experiences, is important to generate evidence to prevent inequalities from growing in a timely and actionable manner,” warns the team.
A pre-print version of the paper is available on the medRxiv * server while the article is being peer reviewed.
The research was a collaboration between the London School of Hygiene and Tropical Medicine, Oxford University, the Phoenix Partnership, the National Critical Care Examination and Research Center, the University of Leicester and University College London.
The studies so far
The increased risk of SARS-CoV-2 infection and serious COVID-19 results in ethnic minorities has been reported both in the UK and internationally. It has been suggested that factors such as living in large households, frontline jobs, and poor access to health services can explain the differences.
So far, however, much evidence of these ethnic differences has been derived from small studies conducted in individual health care facilities, such as evaluating COVID-19 patients who have been hospitalized.
Such studies cannot examine COVID-19 infection and hospitalization with an open mind because they include selected study cohorts that are not representative of the general population.
The studies have also reported broader ethnic groups such as Whites, South Asians, and Blacks, which may hide significant heterogeneity. For example, Bangladeshi and African populations are more likely to live in deprived areas compared to the general population. In contrast, Indian and Chinese populations are more likely to live in more affluent areas where they experience less material deprivation.
“Hence, it is important to disaggregate broad ethnic groups in order to better model the overlapping contributions of health and social factors to COVID-19 infection, severity and mortality,” say the researchers.
The approach of the current study
Now Goldacre and his team have attempted to determine ethnic differences across the entire COVID-19 path, from testing for SARS-CoV-2 to positive tests that could result in ICU admission and death related to COVID- 19 require.
The multivariable regression of proportional Cox risks was used to account for sociodemographic factors, household size, co-existing health problems, geographic region, and residence in broad and disaggregated ethnic groups.
The team conducted an observational study of linked primary care records for 17,510,002 adults between February 1 and August 3, 2020.
63% of the cohort were 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 results?
Compared to white individuals, South Asian, black, and mixed groups tested positive for SARS-CoV-2 slightly more often and significantly more often for infections.
The ICU risk of COVID-19 was significantly higher among all ethnic minorities. South Asians, blacks, mixed race, and others were 2.22, 3.07, 2.86, and 2.86 times more likely than whites.
Compared to whites, the risk of COVID-19 mortality was 1.27 times for Asians, 1.55 times for blacks, 1.4 times for mixed people, and 1.25 times for others times higher.
After disaggregating the broader ethnic groups, the team found significant heterogeneity between more specific ethnic groups.
It was less likely that Pakistani and Bangladeshi groups tested for SARS-CoV-2, but more positive that they had to be admitted to the intensive care unit and died from COVID-19.
Caribbean groups tested just as frequently, but tended to test positive, had to be admitted to intensive care, and died from the effects of COVID-19.
Chinese groups were tested less often, were less positive for infection, but were more likely to require an intensive care unit, and were just as likely to die from the effects of COVID-19.
Better data and more engagement with ethnic minorities are needed
“We found evidence of significant ethnic inequalities in the risk of testing positive for SARS-CoV-2, ICU admissions, and mortality that persisted after considering explanatory factors, including household size,” say Goldacre and colleagues.
The researchers say that improved and more readily available linked data are needed to better characterize ethnic differences and to examine whether discrimination, access to protective equipment, lifestyle, behavior, or access to health care contribute.
“Working with ethnic minority communities to understand their experiences will be critical in generating evidence to prevent inequalities from growing in a timely and actionable manner,” the team concludes.
* Important NOTE
medRxiv publishes preliminary scientific reports that are not peer-reviewed and, therefore, should not be considered conclusive, guide clinical practice / health-related behavior, or treated as established information.