As the coronavirus disease 2019 (COVID-19) pandemic continues advancing globally,
reporting of clinical outcomes and risk factors for intensive care unit admission
and mortality are emerging. Early Chinese and Italian reports associated increasing
age, male sex, smoking, and cardiometabolic comorbidity with adverse outcomes.
Striking differences between Chinese and Italian mortality indicate ethnicity might
affect disease outcome, but there is little to no data to support or refute this.
Ethnicity is a complex entity composed of genetic make-up, social constructs, cultural
identity, and behavioural patterns.
Ethnic classification systems have limitations but have been used to explore genetic
and other population differences. Individuals from different ethnic backgrounds vary
in behaviours, comorbidities, immune profiles, and risk of infection, as exemplified
by the increased morbidity and mortality in black and minority ethnic (BME) communities
in previous pandemics.
As COVID-19 spreads to areas with large cosmopolitan populations, understanding how
ethnicity affects COVID-19 outcomes is essential. We therefore reviewed published
papers and national surveillance reports on notifications and outcomes of COVID-19
to ascertain ethnicity data reporting patterns, associations, and outcomes.
Only two (7%) of 29 publications reported ethnicity disaggregated data (both were
case series without outcomes specific to ethnicity). We found that none of the ten
highest COVID-19 case-notifying countries reported data related to ethnicity; UK mortality
reporting, for example, does not require information on ethnicity. This omission seems
stark given the disproportionate number of deaths among health-care workers from BME
backgrounds.4, 5 Recent UK data from intensive care units indicate that over a third
of patients are from BME backgrounds.
Given previous pandemic experience, it is imperative that policy makers urgently ensure
ethnicity forms part of a minimum dataset. More importantly, ethnicity-disaggregated
data must occur to permit identification of potential outcome risk factors through
adjustment for recognised confounders.
BME communities might be at increased risk of acquisition, disease severity, and poor
outcomes in COVID-19 for several reasons (figure
). Specific ethnic groups, such as south Asians, have higher rates of some comorbidities,
such as diabetes, hypertension, and cardiovascular diseases, which have been associated
with severe disease and mortality in COVID-19.
Ethnicity could interplay with virus spread through cultural, behavioural, and societal
differences including lower socioeconomic status, health-seeking behaviour, and intergenerational
cohabitation. Disentangling the relative importance of these factors requires both
prospective studies, focusing on quantifying absolute risks and outcomes, and qualitative
studies of behaviours and responses to pandemic control messages.
The potential interaction of ethnicity related factors on SARS-CoV-2 infection likelihood
and COVID-19 outcomes
COVID-19=coronavirus disease 2019. SARS-CoV-2=severe acute respiratory syndrome coronavirus
If ethnicity is found to be associated with adverse COVID-19 outcomes, this must directly,
and urgently, inform public health interventions globally.