In the largest study to date on the risk factors associated with COVID-19, UK researchers have found that people of Asian and Black ethnic backgrounds are at a higher risk of death from the virus, but were still unable to fully explain why. The study, carried out by academics at the University of Oxford and the London School of Hygiene and Tropical Medicine (LSHTM), analysed National Health Service data from 17.4m UK adults between early February and the end of April. This makes it the largest study on COVID-19 conducted by any country to date, and it offers the strongest evidence currently available on risk factors associated with COVID-19.
Notable findings from the study include the fact that people of Asian and Black ethnic backgrounds were found to be at higher risk of death than white people.
Commentators and researchers have previously speculated that this may be due to a higher prevalence of medical problems such as cardiovascular disease or diabetes, or socio-economic factors such as high rates of deprivation among black and ethnic minority (BAME) communities.
However, the study concluded that this higher risk was only partially attributable to pre-existing clinical risk factors or deprivation. Consequently, researchers are calling for further work to be conducted in order to fully understand why BAME people are at such an increased risk of death. Additionally, people from deprived social backgrounds were also found to be at a higher risk of death, which also could not be explained by other risk factors.
Other key factors found to be most heavily associated with COVID-19 death included being male, older in age, or suffering uncontrolled diabetes and severe asthma.
Professor Liam Smeeth, professor of clinical epidemiology at LSHTM and co-lead on the study, said that highly accurate data on which patients are most at risk is needed in order to manage the pandemic and improve patient care. “The answers provided by this OpenSAFELY analysis are of crucial importance to countries around the world. For example, it is very concerning to see that the higher risks faced by people from BAME backgrounds are not attributable to identifiable underlying health conditions.”
Dr Ben Goldacre, director of the DataLab in the Nuffield department of primary care health sciences at the University of Oxford and also co-lead on the study, said that during a global health emergency “we need answers quickly and accurately,” which means very large and current datasets are needed.
The study linked data about patients that had been hospitalised with COVID-19 with data held in primary care records processed by TPP. This was carried via the ‘OpenSAFELY’ analytics platform, a new secure mechanism that allowed health records to be linked where they are stored for individual care. This is designed to minimise the security risks associated with transferring and storing data elsewhere, to deliver analyses quickly and safely while preserving patient privacy. The data is pseudonymised before it can be accessed by researchers.
Further analyses using OpenSAFELY are currently underway, including investigations into the effects of specific drugs routinely prescribed in primary care.
Official figures from the UK’s Office of National Statistics found black people are more than four times more likely to die from COVID-19 than white people, exposing a dramatic divergence in the impact of the coronavirus pandemic in England and Wales. The Guardian reports that the ONS found that the difference in the virus’s impact was caused not only by pre-existing differences in communities’ wealth, health, education and living arrangements.
It discovered that after taking into account age, measures of self-reported health and disability and other socio-demographic characteristics, black people were still almost twice as likely as white people to die a COVID-19-related death.
Bangladeshi and Pakistani males were 1.8 times more likely to die from COVID-19 than white males, after other pre-existing factors had been accounted for, and females from those ethnic groups were 1.6 times more likely to die from the virus than their white counterparts. The risk of COVID-19 death for people from Chinese and mixed ethnic groups was found to be similar to that for white people.
Meanwhile, Wasim Hanif, a professor of diabetes and endocrinology at University Hospital Birmingham, said the ONS data was not robust enough to give the full reasons for the difference in the likelihood of dying from COVID-19.
The research accounts for health problems reported by people who filled in the 2011 census, but Hanif said differences in the extent of other underlying diseases in different ethnic groups in Britain – so-called co-morbidities – which have not been accounted for by the ONS, may be significant. For example, in the UK people of Pakistani and Bangladeshi descent are three to four times more likely to get diabetes earlier in life than white people, and the ratio is between two and three for black and Indian-origin people, he said.
However, deprivation, which is a strong predictor for ill-health, was factored into the ONS analysis, so it remains unclear how much the inclusion of co-morbidities would change the results.
Meanwhile, thousands of existing health records for people who have had COVID-19 are to be examined as part of a major exercise to establish more robust data on the factors impacting the number of cases and health outcomes for different groups within the population. The exercise is part of a rapid review being led by Public Health England (PHE) to better understand how different factors such as ethnicity, deprivation, age, gender and obesity could impact on how people are affected by COVID-19.
The review will also look at vulnerable groups such as people experiencing homelessness and rough sleeping to understand how the virus affects them and their health outcomes. Where PHE has access to the occupation of cases, particularly related to health workers, analysis will be done on the outcome of infections for this group*.
UK Health and Social Care Secretary, Matt Hancock said: “Every death from this virus is a tragedy and behind each statistic is a name, a loss and a family that will never be the same again. As part of our continued effort to understand even more about COVID-19, we have commissioned work from PHE to consider the impact of various factors such as ethnicity, obesity, age, gender and geographical location and how these may have an impact on someone’s susceptibility to the virus. The more we know about this virus and its impact, the more we will be able protect lives and limit the spread.”
The review will help provide insight into emerging evidence to suggest COVID-19 may be having a disproportionate impact on different groups and examine the potential effects of other factors such as ethnicity, level of obesity or gender. The review will also match laboratory records of COVID-19 cases to existing health records to draw down accurate data such as ethnicity and describe the association with COVID-19 cases, alongside other factors such as sex, age and geographical location.
Professor Kevin Fenton, public health director for London will lead the review, supported by a wide group including Trevor Phillips, OBE.
Fenton said: “Having an accurate understanding of how diseases affect different groups of people is a really important issue and a fundamental part of PHE’s role. Detailed and careful work is being done so that we can better understand this and explore the possible reasons for any disparities.
“Increasing evidence and concern around the disproportionate impact of COVID-19 on black and minority ethnic groups highlights an important focus of this review. PHE is rapidly building robust data and undertaking detailed analysis to develop our understanding of the impact of this novel coronavirus on different groups which can inform actions to mitigate the risks it presents. PHE is engaging a wide range of external experts and independent advisors, representing diverse constituencies including devolved administrations, faith groups, voluntary and community sector organisations, local government, public health, academic, royal colleges and others. We are committed to hearing voices from a variety of perspectives on the impact of COVID-19 on people of different ethnicities.”
Findings from the review will be published by the end of May 2020. This analysis will initially focus on doctors and nurses in conjunction with the General Medical Council and Nursing Midwifery Council.Euractive material OpenSAFELY analytics platform Full report in The Guardian ONS material Public Health England material