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

Objectives To assess whether ethnic differences in COVID-19 mortality in England have continued into the third wave and to what extent differences in vaccination rates contributed to excess COVID-19 mortality after accounting for other risk factors. Design Cohort study of 28.8 million adults using data from the Office for National Statistics Public Health Data Asset. Setting People living in private households or communal establishments in England. Participants 28,816,020 adults (47% male) aged 30-100 years in 2020 (mean age = 56), who were present at the 2011 Census and alive on 8 December 2020. Main outcome measures Death involving COVID-19 during the second (8 December 2020 to 12 June 2021) and third wave (13 June 2021 to 1 December 2021) of the pandemic. We calculated hazard ratios (HRs) separately for males to females to summarise the association between ethnic group and death involving COVID-19 in each wave, 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 higher for most ethnic minority groups than the White British group during both waves, particularly for groups with lowest vaccination rates (Bangladeshi, Pakistani, Black African and Black Caribbean). In both waves, 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. The only groups where fully-adjusted HRs remained elevated were the Bangladeshi group (men: 2.19, 95% CI 1.72 to 2.78; women: 2.12, 95% CI 1.58 to 2.86) and men from the Pakistani group (1.24, 95% CI 1.06 to 1.46). Conclusion Public health strategies to increase vaccination uptake in ethnic minority groups could reduce disparities in COVID-19 mortality that cannot be accounted for by pre-existing risk factors. What is already known on this topic Ethnic minority groups in England have been disproportionately affected by the COVID-19 pandemic during the first and second waves. COVID-19 vaccination uptake is also lower among many ethnic minority groups, particularly Bangladeshi, Black African, Black Caribbean, and Pakistani groups. There is a paucity of research into whether ethnic disparities in COVID-19 mortality have continued into the third wave and the extent to which differences in vaccination uptake contribute to differences in COVID-19 mortality. What this study adds Using linked data on 28.8 million adults in England, we find that rates of COVID-19 mortality have remained higher than the White British group for most ethnic minority groups during the vaccine roll-out, notably for the Bangladeshi, Black African, Black Caribbean, and Pakistani groups. After adjustment for geographical factors, sociodemographic characteristics, pre-pandemic health status, and vaccination status, the only groups with elevated rates of COVID-19 mortality during the third wave were the Bangladeshi group and men from the Pakistani group, suggesting that increasing vaccination uptake in ethnic minority groups could reduce ethnic disparities in COVID-19 mortality.

Effect of COVID-19 on inequalities in premature mortality in England: an analysis of excess mortality by deprivation and ethnicity (preprint)

Objectives: To examine the impact of the COVID-19 pandemic on inequalities in premature mortality in England by deprivation and ethnicity. Design: A statistical model to estimate increased mortality in population sub-groups during the COVID-19 pandemic by comparing observed with expected mortality in each group based on trends over the previous five years. Setting: Information on deaths registered in England since 2015 was used, including age, sex, area of residence, and cause of death. Ethnicity was obtained from Hospital Episode Statistics (HES) records linked to death registration data. Participants: Population study of England, including all 569,824 deaths from all causes registered between 21 March 2020 and 26 February 2021. Main outcome measures: Excess mortality in each sub-group over and above the number expected based on trends in mortality in that group over the previous five years. Results: The gradient in excess mortality by deprivation was greater in the under 75s (most deprived had 1.25 times as many deaths as expected, least deprived 1.14) than in all ages (most deprived had 1.24 times as many deaths as expected, least deprived 1.20). Among the Black and Asian groups, all deprivation quintiles had significantly larger excesses than the most deprived White group and there were no clear gradients across quintiles. Among the White group, only the most deprived had more excess deaths than deaths directly involving COVID-19. Among the Black group all deprivation quintiles experienced more excess deaths than deaths directly involving COVID-19. Conclusion: The COVID-19 pandemic has widened inequalities in premature mortality by deprivation. Among those under 75, the direct and indirect effects of the pandemic on deaths have disproportionately impacted ethnic minority groups irrespective of deprivation, and the most deprived White group. Statistics limited to deaths directly involving COVID-19 understate the pandemic's impact on inequalities by deprivation and ethnic group at younger ages.

Ethnicity, Household Composition and COVID-19 Mortality: A National Linked Data Study (preprint)

BackgroundEthnic minorities have experienced disproportionate COVID-19 mortality rates. We estimated associations between household composition and COVID-19 mortality in older adults ([≥] 65 years) using a newly linked census-based dataset, and investigated whether living in a multi-generational household explained some of the elevated COVID-19 mortality amongst ethnic minority groups. MethodsUsing retrospective data from the 2011 Census linked to Hospital Episode Statistics (2017-2019) and death registration data (up to 27th July 2020), we followed adults aged 65 years or over living in private households in England from 2 March 2020 until 27 July 2020 (n=10,078,568). We estimated hazard ratios (HRs) for COVID-19 death for people living in a multi-generational household compared with people living with another older adult, adjusting for geographical factors, socio-economic characteristics and pre-pandemic health. We conducted a causal mediation analysis to estimate the proportion of ethnic inequalities explained by living in a multi-generational household. ResultsLiving in a multi-generational household was associated with an increased risk of COVID-19 death. After adjusting for confounding factors, the HRs for living in a multi-generational household with dependent children were 1.13 [95% confidence interval 1.01-1.27] and 1.17 [1.01-1.35] for older males and females. The HRs for living in a multi-generational household without dependent children were 1.03 [0.97 - 1.09] for older males and 1.22 [1.12 - 1.32] for older females. Living in a multi-generational household explained between 10% and 15% of the elevated risk of COVID-19 death among older females from South Asian background, but very little for South Asian males or people in other ethnic minority groups. ConclusionOlder adults living with younger people are at increased risk of COVID-19 mortality, and this is a notable contributing factor to the excess risk experienced by older South Asian females compared to White females. Relevant public health interventions should be directed at communities where such multi-generational households are highly prevalent. FundingThis research was funded by the Office for National Statistics.

Religious affiliation and the risk of COVID 19 related mortality; a retrospective analysis of variation in pre and post lockdown risk by religious group in England and Wales. (preprint)

Background COVID 19 mortality risk is associated with demographic and behavioural factors; furthermore religious gatherings have been linked with the spread of COVID. We sought to understand the variation in the risk of COVID 19 related death across religious groups in the UK both before and after lockdown. Methods We conducted a retrospective cohort study of usual residents in England and Wales enumerated at the 2011 Census (n = 48,422,583), for risk of death involving COVID-19 using linked death certificates. Cox regression models were estimated to compare risks between religious groups. Time dependent religion coefficients were added to the model allowing hazard ratios (HRs) pre and post lockdown period to be estimated separately. Results Compared to Christians all religious groups had an elevated risk of death involving COVID-19; the largest age adjusted HRs were for Muslim and Jewish males at 2.5 (95% confidence interval 2.3-2.7) and 2.1 (1.9-2.5), respectively. The corresponding HRs for Muslim and Jewish females were 1.9 (1.7-2.1) and 1.5 (1.7-2.1). The difference in risk between groups contracted after lockdown. Those who affiliated with no religion had the lowest risk of COVID 19 related death before and after lockdown. Conclusion The majority of the variation in COVID 19 mortality risk was explained by controlling for socio demographic and geographic determinants; however, Jews remained at a higher risk of death compared to all other groups. Lockdown measures were associated with reduced differences in COVID 19 mortality rates between religious groups, further research is required to understand the causal mechanisms.

Ethnic minority groups in England and Wales - factors affecting the size and timing of elevated COVID-19 mortality: a retrospective cohort study linking Census and death records (preprint)

Objectives: To estimate population-level associations between ethnicity and coronavirus disease 2019 (COVID-19) mortality, and to investigate how ethnicity-specific mortality risk evolved over the course of the pandemic. Design: Retrospective cohort study using linked administrative data. Setting: England and Wales, deaths occurring 2 March to 15 May 2020. Participants: Respondents to the 2011 Census of England and Wales aged [≤]100 years and enumerated in private households, linked to death registrations and adjusted to account for emigration before the outcome period, who were alive on 1 March 2020 (n=47,872,412). Main outcome measure: Death related to COVID-19, registered by 29 May 2020. Statistical methods: We estimated hazard ratios (HRs) for ethnic minority groups compared with the White population using Cox regression models, controlling for geographical, demographic, socio-economic, occupational, and self-reported health factors. HRs were estimated on the full outcome period and separately for pre- and post-lockdown periods in the UK. Results: In the age-adjusted models, people from all ethnic minority groups were at elevated risk of COVID-19 mortality; the HRs for Black males and females were 3.13 [95% confidence interval: 2.93 to 3.34] and 2.40 [2.20 to 2.61] respectively. However, in the fully adjusted model for females, the HRs were close to unity for all ethnic groups except Black (1.29 [1.18 to 1.42]). For males, COVID-19 mortality risk remained elevated for the Black (1.76 [1.63 to 1.90]), Bangladeshi/Pakistani (1.35 [1.21 to 1.49]) and Indian (1.30 [1.19 to 1.43]) groups. The HRs decreased after lockdown for all ethnic groups, particularly Black and Bangladeshi/Pakistani females. Conclusions: Differences in COVID-19 mortality between ethnic groups were largely attenuated by geographical and socio-economic factors, although some residual differences remained. Lockdown was associated with reductions in excess mortality risk in ethnic minority populations, which has major implications for a second wave of infection or local spikes. Further research is needed to understand the causal mechanisms underpinning observed differences in COVID-19 mortality between ethnic groups.