Ethnic differences in COVID-19 mortality in the second and third waves of the pandemic in England during the vaccine rollout: a retrospective, population-based cohort study

Abstract

Background: Ethnic minority groups in England have been disproportionately affected by the COVID-19 pandemic and have lower vaccination rates than the White British population. We examined whether ethnic differences in COVID-19 mortality in England have continued since the vaccine rollout and to what extent differences in vaccination rates contributed to excess COVID-19 mortality after accounting for other risk factors.

Methods: We conducted a retrospective, population-based cohort study of 28.8 million adults aged 30-100 years in England. Self-reported ethnicity was obtained from the 2011 Census. The outcome was death involving COVID-19 during the second (8 December 2020 to 12 June 2021) and third wave (13 June 2021 to 1 December 2021). We calculated hazard ratios (HRs) for death involving COVID-19, sequentially adjusting for age, residence type, geographical factors, sociodemographic characteristics, pre-pandemic health, and vaccination status.

Results: Age-adjusted HRs of death involving COVID-19 were elevated for most ethnic minority groups during both waves, particularly for groups with lowest vaccination rates (Bangladeshi, Pakistani, Black African, and Black Caribbean). HRs were attenuated after adjusting for geographical factors, sociodemographic characteristics, and pre-pandemic health. Further adjusting for vaccination status substantially reduced residual HRs for Black African, Black Caribbean, and Pakistani groups in the third wave. Fully adjusted HRs only remained elevated for the Bangladeshi group (men: 2.19 [95% CI 1.72-2.78]; women: 2.12 [1.58-2.86]) and Pakistani men (1.24 [1.06-1.46]).

Conclusions: Lower COVID-19 vaccination uptake in several ethnic minority groups may drive some of the differences in COVID-19 mortality compared to White British. Public health strategies to increase vaccination uptake in ethnic minority groups would help reduce inequalities in COVID-19 mortality, which have remained substantial since the start of the vaccination campaign.

Keywords: COVID-19; Coronavirus; Ethnic group; Ethnicity; Mortality; SARS-CoV-2; Vaccination.

Fig. 1

Sample selection and number of participants

Fig. 2

Age-standardised vaccination rates by ethnic group and wave of the pandemic. Percentage of people in each ethnic group that were unvaccinated or had received one or two doses of a COVID-19 vaccine by 12 June 2021 (left panel). Percentage of people in each ethnic group that were unvaccinated or had received one, two or three doses by 1 December 2021 (right panel)

Fig. 3

HRs for death involving COVID-19 by ethnic group during the second wave of the pandemic (8 December 2020 to 12 June 2021), relative to the White British group, stratified by sex. Results obtained from Cox proportional hazards regression models adjusted for the following: model 1—age; model 2—age plus residence type (private household, care home or other communal establishment); model 3—age and residence type plus geographical factors (region, Rural Urban classification and population density); model 4—age, residence type, and geography, plus sociodemographic factors (highest qualification, IMD decile, NS-SEC, household characteristics [tenure of the household, household deprivation, household size, family status, household composition and key worker in household], key worker type, individual and household exposure to disease, and individual and household proximity to others); model 5—age, residence type, geography, and sociodemographic factors, plus health status (pre-existing health conditions, BMI and hospital admissions over the previous 3 years); and model 6—age, residence type, geography, sociodemographic factors, and health status plus vaccination status (unvaccinated, one dose or two doses). Error bars represent 95% CIs

Fig. 4

HRs for death involving COVID-19 by ethnic group during the third wave of the pandemic (13 June 2021 to 1 December 2021), relative to the White British group, stratified by sex. Results obtained from Cox proportional hazards regression models adjusted for the following: model 1—age; model 2—age plus residence type (private household, care home or other communal establishment); model 3—age and residence type plus geographical factors (region, Rural Urban classification and population density); model 4—age, residence type, and geography, plus sociodemographic factors (highest qualification, IMD decile, NS-SEC, household characteristics [tenure of the household, household deprivation, household size, family status, household composition and key worker in household], key worker type, individual and household exposure to disease, and individual and household proximity to others); model 5—age, residence type, geography, and sociodemographic factors, plus health status (pre-existing health conditions, BMI and hospital admissions over the previous 3 years); and model 6—age, residence type, geography, sociodemographic factors, and health status plus vaccination status (unvaccinated, one dose, two doses or third/booster dose). Error bars represent 95% CIs