Are clinical outcomes from COVID-19 improving in ethnic minority groups?

Disproportionately worse COVID-19 clinical outcomes in people from ethnic minority groups have been a concern since early in the pandemic.1Pareek M. Bangash M.N. Pareek N. et al.Ethnicity and COVID-19: an urgent public health research priority.Lancet. 2020; 395: 1421-1422Summary Full Text Full Text PDF PubMed Scopus (277) Google Scholar Now as time progresses, it may be useful to look back at the evolving evidence base. We performed the first systematic review on clinical outcomes in ethnic minority groups in May 2020, where we found across several countries a higher proportion of patients from ethnic minority groups infected with SARS-CoV-2, admitted to intensive care units with COVID-19 and dying in hospitals due to COVID-19. However, the collected data was of too poor quality to allow meaningful data synthesis.2Pan D. Sze S. Minhas J.S. et al.The impact of ethnicity on clinical outcomes in COVID-19: a systematic review.eClinicalMedicine. 2020; 23100404Summary Full Text Full Text PDF Scopus (336) Google Scholar Our findings were used as evidence for debate in UK Parliament in June 2020, resulting in a recommendation to mandate comprehensive ethnicity data collection and recording as part of routine hospital data collection systems.3Covid-19 and Black, Asian and minority ethnic communities.https://commonslibrary.parliament.uk/research-briefings/cdp-2020-0074/Date accessed: April 21, 2023Google Scholar After some time, more studies started to emerge. This allowed us to conduct a meta-analysis to disentangle why ethnic minority groups were suffering disproportionately from the pandemic. In our second review, published in November 2020, we found that ethnic minority groups in the UK and USA had an increased risk of SARS-CoV-2 infection compared to those of White ethnicity. However, differences in hospitalization and death rates in this meta-analysis, when synthesised, was less clear.4Sze S. Pan D. Nevill C.R. et al.Ethnicity and clinical outcomes in COVID-19: a systematic review and meta-analysis.eClinicalMedicine. 2020; 29100630PubMed Google Scholar Whilst many studies reported a higher mortality rate from COVID-19 among ethnic minority groups compared to the majority groups, in the generation of mortality estimates, most did not take into account the number of infected individuals from ethnic minority groups in the community (see Fig. 1, Panel A). In our latest meta-analysis published in March 2023, now including over 200 million study participants globally, the risk of infection remained elevated across nearly all ethnic minority groups studied, compared to the majority group in each country.5Irizar P. Pan D. Kapadia D. et al.Ethnic inequalities in COVID-19 infection, hospitalisation, intensive care admission, and death: a global systematic review and meta-analysis of over 200 million study participants.eClinicalMedicine. 2023; 57101977Summary Full Text Full Text PDF Scopus (1) Google Scholar However, we observed far smaller differences for hospitalisation, intensive care admission and death following infection, although there was evidence of ethnic inequalities in these outcomes. Therefore, at least initially, it appeared that increased risk of infection was the main driver of the disproportionate outcomes in ethnic minority groups (see Fig. 1, Panel B). Our work was cited by the World Health Organization's living guideline on COVID-19 infection prevention and control, emphasizing the need for healthcare workers from ethnic minority groups to have equal access to personal protective equipment.6World Health OrganizationInfection prevention and control in the context of coronavirus disease (COVID-19): a living guideline, 7th March 2022.https://apps.who.int/iris/handle/10665/352339Date accessed: May 21, 2023Google Scholar Concrete data identifying and quantifying factors relating to SARS-CoV-2 infection remains limited, compared to risk factors for developing severe disease once infected. In an immunologically naïve population, mathematical models have proposed that the increased risk of infection with an airborne pathogen is related to a higher frequency and/or duration of exposure to individuals who emit high quantities of the virus in poorly ventilated spaces.7Sze To G.N. Chao C.Y. Review and comparison between the Wells-Riley and dose-response approaches to risk assessment of infectious respiratory diseases.Indoor Air. 2010; 20: 2-16Crossref Scopus (220) Google Scholar Infection is therefore most likely to occur in homes and workplaces with poor ventilation and in occupations involving public-facing roles such as healthcare, even during mandated national lockdowns, all of which are common among those from ethnic minority groups. The higher prevalence of multi-generational occupancy within the homes of ethnic minority groups, which are more likely to have poorer ventilation, may also predispose them to a higher risk of infection. To complicate matters, we now know that past infection with SARS-CoV-2 provides immune protection against severe disease for at least 40 weeks following infection, regardless of variants.8COVID-19 Forecasting TeamPast SARS-CoV-2 infection protection against re-infection: a systematic review and meta-analysis.Lancet. 2023; 401: 833-842Summary Full Text Full Text PDF PubMed Google Scholar While COVID-19 in immunologically naïve populations may have resulted in worse clinical outcomes for ethnic minority groups compared to the majority groups, a history of previous infection in those who have survived their first infection, and therefore have existing immunity that protects against severe disease may have reduced the proportion of those who are susceptible to hospitalisation, intensive care admission and death from COVID-19 (see Fig. 1, Panel C). This could explain the UK's Office for National Statistics most recent report, which shows that the proportion of deaths from COVID-19 in ethnic minority groups are now comparable, and in some cases lower than that of the White British majority.9Updating ethnic and religious contrasts in deaths involving the coronavirus (COVID-19), England: 24 January 2020 to 23 2022.https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/articles/updatingethniccontrastsindeathsinvolvingthecoronaviruscovid19englandandwales/24january2020to23november2022Date accessed: April 21, 2023Google Scholar Going forwards, we must implement tangible interventions that reduce the likelihood of infection among ethnic minority groups, which may still be ongoing. This will require policy-makers to address the longstanding inequalities that have led to an elevated risk of virus exposure in ethnic minority groups. In 2010, the Marmot review highlighted the need to reduce systemic racial inequalities in the UK and set clear policy objectives to address this. Ten years later, in the peak of the pandemic, the 2020 Marmot Review on Health Inequalities reported that housing affordability, declines in education funding, and an increase in zero-hour contracts are worse for ethnic minority groups compared to the previous report.10Health equity in England: the Marmot review 10 years on. Institute of Health Equity, 2020https://www.health.org.uk/sites/default/files/upload/publications/2020/Health%20Equity%20in%20England_The%20Marmot%20Review%2010%20Years%20On_full%20report.pdfGoogle Scholar Over the past three years, one thing has become clear: systemic inequality is likely the root cause of disproportionate deaths from the COVID-19 pandemic in ethnic minority groups. We now have a unique opportunity to rebuild, plan ahead and work with communities from ethnic minority groups. Only by reducing the systemic gap in the risk of infection can we reduce preventable deaths from the next global pandemic. DP, SS, PI and MP conceived the idea of the manuscript. DP wrote the initial draft of the manuscript. All authors reviewed the manuscript and approved the final version prior to submission. KK is Chair of the Ethnicity Subgroup of the UK Government Scientific Advisory Group for Emergencies (SAGE) and a member of SAGE. SVK was co-chair of the Scottish Government Expert Reference Group on Ethnicity and COVID-19 and a member of the Ethnicity Subgroup of SAGE. MP reports grants from the UKRI-MRC, NIHR, Sanofi and Gilead outside the current work and has received consulting fees from QIAGEN. DP is supported by a NIHR doctoral research fellowship (NIHR302338). SS is supported by a NIHR Academic Clinical Lectureship. RFB is supported by a NIHR advanced fellowship (NIHR302494). MP is funded by a NIHR Development and Skills Enhancement Award and is supported by the Leicester NIHR Biomedical Research Centre (BRC). LJG and KK are supported by the National Institute for Health and Care Research (NIHR) Applied Research Collaboration East Midlands (ARC EM) and Leicester NIHR BRC. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. SVK acknowledges funding from the Medical Research Council (MC_UU_00022/2) and the Scottish Government Chief Scientist Office (SPHSU17).