Disparities in SARS-CoV-2 case rates by ethnicity, religion, measures of socio-economic position, English proficiency, and self-reported disability: cohort study of 39 million people in England during the Alpha and Delta waves (preprint)

Objective To examine socio-demographic disparities in SARS-CoV-2 case rates during the second (Alpha) and third (Delta) waves of the COVID-19 pandemic. Design Retrospective, population-based cohort study. Setting Resident population of England. Participants 39,006,194 people aged 10 years and over who were enumerated at the 2011 Census, registered with the National Health Service (NHS) and alive on 1 September 2020. Main outcome measures Testing positive for SARS-CoV-2 during the second wave (1 September 2020 to 22 May 2021) or third wave (23 May to 10 December 2021) of the pandemic. We calculated age-standardised case rates by socio-demographic characteristics and used logistic regression models to estimate adjusted odds ratios (ORs). Results During the study period, 5,767,584 individuals tested positive for SARS-CoV-2. In the second wave, the fully-adjusted odds of having a positive test, relative to the White British group, were highest for the Bangladeshi (OR: 1.88, 95% CI 1.86 to 1.90) and Pakistani (1.81, 1.79 to 1.82) ethnic groups. Relative to the Christian group, Muslim and Sikh religious groups had fully-adjusted ORs of 1.58 (1.57 to 1.59) and 1.74 (1.72 to 1.76), respectively. Greater area deprivation, disadvantaged socio-economic position, living in a care home and low English language proficiency were also associated with higher odds of having a positive test. However, the disparities between groups varied over time. Being Christian, White British, non-disabled, and from a more advantaged socio-economic position were all associated with increased odds of testing positive during the third wave. Conclusion There are large socio-demographic disparities on SARS-CoV-2 cases which have varied between different waves of the pandemic. Research is now urgently needed to understand why these disparities exist to inform policy interventions in future waves or pandemics. What is already known on this topic People with pre-existing health conditions or disability, ethnic minority groups, the elderly, some religious groups, people with low socio-economic status, and those living in deprived areas have been disproportionately affected by the COVID-19 pandemic in terms of risk of infection and adverse outcomes. What this study adds Using linked data on 39 million people in England, we found that during the second wave, COVID-19 case rates were highest among the Bangladeshi and Pakistani ethnic groups, the Muslim religious group, individuals from deprived areas and of low socio-economic position; during the third wave, being Christian, White British, non-disabled, and from a more advantaged socio-economic position were all associated with increased odds of receiving a positive test Adjusting for geographical factors, socio-demographic characteristics, and pre-pandemic health status explained some, but not all, of the excess risk When stratifying the dataset by broad age groups, the odds of receiving a positive test remained higher among the Bangladeshi and Pakistani ethnic groups aged 65 years and over during the third wave, which may partly explain the continued elevated mortality rates in these groups

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.