ASSOCIATION BETWEEN ETHNICITY AND SEVERE COVID-19 DISEASE: A SYSTEMATIC REVIEW AND META-ANALYSIS

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Abstract

Background

Multiple reports suggest a disproportionate impact of Covid-19 on ethnic minorities. Whether ethnicity is an independent risk factor for severe Covid-19 disease is unclear.

Purpose

Review the association between ethnicity and poor outcomes including all-cause mortality, hospitalisation, critical care admission, respiratory and kidney failure.

Data Sources

MEDLINE, EMBASE, Cochrane COVID-19 Study Register, WHO COVID-19 Global Research Database up to 15/06/2020, and preprint servers. No language restriction.

Study Selection

All studies providing ethnicity-aggregated data on the pre-specified outcomes, except case reports or interventional trials.

Data Extraction

Pairs of investigators independently extracted data, assessed risk of bias using Newcastle-Ottawa scale (NOS), and rated certainty of evidence following GRADE framework.

Data Synthesis

Seventy-two articles (59 cohort studies with 17,950,989 participants; 13 ecological studies; 54 US-based and 15 UK-based; 41 peer-reviewed) were included for systematic review and 45 for meta-analyses. Risk of bias was low, with median NOS 7 of 9 (interquartile range 6-8). In the unadjusted analyses, compared to white ethnicity, all-cause mortality risk was similar in Black (RR:0.96 [95%CI: 0.83-1.08]), Asian (RR:0.99 [0.85-1.16]) but reduced in Hispanic ethnicity (RR:0.69 [0.57-0.84]). Age and sex-adjusted-risks were significantly elevated for Black (HR:1.38 [1.09-1.75]) and Asian (HR:1.42 [1.15-1.75]), but not for Hispanic (RR:1.14 [0.93-1.40]). Further adjusting for comorbidities attenuated these association to non-significance; Black (HR:0.95 [0.72-1.25]); Asian (HR:1.17 [0.84-1.63]); Hispanic (HR:0.94 [0.63-1.44]). Similar results were observed for other outcomes. In subgroup analysis, there was a trend towards greater disparity in outcomes for UK ethnic minorities, especially hospitalisation risk.

Limitations

Paucity of evidence on native ethnic groups, and studies outside the US and UK.

Conclusions

Currently available evidence cannot confirm ethnicity as an independent risk factor for severe Covid-19 illness, but indicates that disparity may be partially attributed to greater burden of comorbidities.

Registration

PROSPERO, CRD42020188421

Funding source

none

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