Association between household composition and severe COVID-19 outcomes in older people by ethnicity: an observational cohort study using the OpenSAFELY platform

Abstract

Background: Ethnic differences in the risk of severe COVID-19 may be linked to household composition. We quantified the association between household composition and risk of severe COVID-19 by ethnicity for older individuals.

Methods: With the approval of NHS England, we analysed ethnic differences in the association between household composition and severe COVID-19 in people aged 67 or over in England. We defined households by number of age-based generations living together, and used multivariable Cox regression stratified by location and wave of the pandemic and accounted for age, sex, comorbidities, smoking, obesity, housing density and deprivation. We included 2 692 223 people over 67 years in Wave 1 (1 February 2020-31 August 2020) and 2 731 427 in Wave 2 (1 September 2020-31 January 2021).

Results: Multigenerational living was associated with increased risk of severe COVID-19 for White and South Asian older people in both waves [e.g. Wave 2, 67+ living with three other generations vs 67+-year-olds only: White hazard ratio (HR) 1.61 95% CI 1.38-1.87, South Asian HR 1.76 95% CI 1.48-2.10], with a trend for increased risks of severe COVID-19 with increasing generations in Wave 2. There was also an increased risk of severe COVID-19 in Wave 1 associated with living alone for White (HR 1.35 95% CI 1.30-1.41), South Asian (HR 1.47 95% CI 1.18-1.84) and Other (HR 1.72 95% CI 0.99-2.97) ethnicities, an effect that persisted for White older people in Wave 2.

Conclusions: Both multigenerational living and living alone were associated with severe COVID-19 in older adults. Older South Asian people are over-represented within multigenerational households in England, especially in the most deprived settings, whereas a substantial proportion of White older people live alone. The number of generations in a household, number of occupants, ethnicity and deprivation status are important considerations in the continued roll-out of COVID-19 vaccination and targeting of interventions for future pandemics.

Keywords: COVID-19; OpenSAFELY; comorbidities; deprivation; ethnicity; household; multigenerational; older people; population-level.

Figure 1

Summary population characteristics of English households by ethnicity. a] Distribution of multigenerational houses by region of England; b] age-generational household composition by ethnic group; c] household size (total number of occupants) by ethnic group; d] age-generational household composition by ethnic group and IMD quintile (Q1: most affluent, Q5: most deprived). IMD, Index of Multiple Deprivation

Figure 2

Association between household composition and (1) severe COVID-19 (death or hospitalization due to COVID-19) and (2) non-COVID-19 death by ethnicity for Wave 1 of the pandemic in England (1 February 2020 to 31 August 2020). Household composition in terms of number of distinct generations that each 67+-year-old in the study cohort is living with (considering the following distinct generations: 0–17 year olds, 18–29-year-olds, 30–66-year-olds, 67+-year-olds), i.e. 67+ & 1 = 67+year-old’s household includes one other younger generation; 67+ & 2 = 67+-year-old’s household includes two other younger generations; 67+ & 3 = 67+-year-old’s household includes three other younger generations. Models stratified by location (Upper Tier Local Authority) and adjusted for sex, number of comorbidities, categories of housing density (rural or urban setting), smoking status, socioeconomic status, and including an interaction between ethnicity and age (as well as the interaction between household composition and ethnicity presented here)

Figure 3

Association between household composition and (1) severe COVID-19 (death or hospitalization due to COVID-19) and (2) non-COVID-19 death by ethnicity for Wave 2 of the pandemic in England (September 2020 and 31 January 2021). Household composition in terms of number of distinct generations that each 67+-year-old in the study cohort is living with (considering the following distinct generations: 0–17-year-olds, 18–29-year-olds, 30–66-year-olds, 67+-year-olds), i.e. 67+ & 1 = 67+-year-old’s household includes one other younger generation; 67+ & 2 = 67+-year-old’s household includes two other younger generations; 67+ & 3 = 67+-year-old’s household includes three other younger generations. Models stratified on location (Upper Tier Local Authority) and adjusted for: sex, smoking, housing density and number of comorbidities, and including interactions between ethnicity and: index of multiple deprivation, age and obesity (as well as the interaction with household composition presented here)