A case-control and cohort study to determine the relationship between ethnic background and severe COVID-19

Abstract

Background: People of minority ethnic backgrounds may be disproportionately affected by severe COVID-19. Whether this relates to increased infection risk, more severe disease progression, or worse in-hospital survival is unknown. The contribution of comorbidities or socioeconomic deprivation to ethnic patterning of outcomes is also unclear.

Methods: We conducted a case-control and a cohort study in an inner city primary and secondary care setting to examine whether ethnic background affects the risk of hospital admission with severe COVID-19 and/or in-hospital mortality. Inner city adult residents admitted to hospital with confirmed COVID-19 (n = 872 cases) were compared with 3,488 matched controls randomly sampled from a primary healthcare database comprising 344,083 people residing in the same region. For the cohort study, we studied 1827 adults consecutively admitted with COVID-19. The primary exposure variable was self-defined ethnicity. Analyses were adjusted for socio-demographic and clinical variables.

Findings: The 872 cases comprised 48.1% Black, 33.7% White, 12.6% Mixed/Other and 5.6% Asian patients. In conditional logistic regression analyses, Black and Mixed/Other ethnicity were associated with higher admission risk than white (OR 3.12 [95% CI 2.63-3.71] and 2.97 [2.30-3.85] respectively). Adjustment for comorbidities and deprivation modestly attenuated the association (OR 2.24 [1.83-2.74] for Black, 2.70 [2.03-3.59] for Mixed/Other). Asian ethnicity was not associated with higher admission risk (adjusted OR 1.01 [0.70-1.46]). In the cohort study of 1827 patients, 455 (28.9%) died over a median (IQR) of 8 (4-16) days. Age and male sex, but not Black (adjusted HR 1.06 [0.82-1.37]) or Mixed/Other ethnicity (adjusted HR 0.72 [0.47-1.10]), were associated with in-hospital mortality. Asian ethnicity was associated with higher in-hospital mortality but with a large confidence interval (adjusted HR 1.71 [1.15-2.56]).

Interpretation: Black and Mixed ethnicity are independently associated with greater admission risk with COVID-19 and may be risk factors for development of severe disease, but do not affect in-hospital mortality risk. Comorbidities and socioeconomic factors only partly account for this and additional ethnicity-related factors may play a large role. The impact of COVID-19 may be different in Asians.

Funding: British Heart Foundation; the National Institute for Health Research; Health Data Research UK.

Keywords: COVID-19; Case-control study; Comorbidities; Deprivation; Ethnicity.

Fig. 1

Study flow chart.

Fig. 2

Association between ethnicity and risk of hospital admission for COVID-19. Odds ratios are compared to White ethnicity Model 1 – adjusted for age and sex Model 2 – adjusted for age, sex and index of multiple deprivation Model 3 – adjusted for age, sex and cardiometabolic comorbidities* Model 4 – adjusted for age, sex, and all comorbidities** Model 5 (fully adjusted model) – adjusted for age, sex, index of multiple deprivation, and all comorbidities *Cardiometabolic comorbidities include hypertension, coronary heart disease, heart failure, previous stroke/TIA, diabetes, chronic kidney disease. **Cardiometabolic comorbidities, asthma, chronic obstructive pulmonary disease.

Fig. 3

Association between ethnicity and risk of in-hospital mortality with COVID-19. Hazard ratios are compared to White ethnicity Model 1 – adjusted for age and sex Model 2 – adjusted for age, sex and index of multiple deprivation Model 3 – adjusted for age, sex and cardiometabolic comorbidities* Model 4 – adjusted for age, sex, and all comorbidities** Model 5 (fully adjusted model) – adjusted for age, sex, index of multiple deprivation, and all comorbidities *Cardiometabolic comorbidities include hypertension, coronary heart disease, heart failure, previous stroke/TIA, diabetes, chronic kidney disease. **Cardiometabolic comorbidities, asthma, chronic obstructive pulmonary disease.

Fig. 4

Association between ethnicity and risk of ICU admission with COVID-19. Hazard ratios are compared to White ethnicity Model 1 – adjusted for age and sex Model 2 – adjusted for age, sex and index of multiple deprivation Model 3 – adjusted for age, sex and cardiometabolic comorbidities* Model 4 – adjusted for age, sex, and all comorbidities** Model 5 (fully adjusted model) – adjusted for age, sex, index of multiple deprivation, and all comorbidities *Cardiometabolic comorbidities include: hypertension, coronary heart disease, heart failure, previous stroke/TIA, diabetes, chronic kidney disease. **Cardiometabolic comorbidities, asthma, chronic obstructive pulmonary disease.