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Ethnicity and risk of death in patients hospitalised for COVID-19 infection in the UK: an observational cohort study in an urban catchment area
  1. Elizabeth Sapey1,2,
  2. Suzy Gallier3,
  3. Chris Mainey4,
  4. Peter Nightingale5,
  5. David McNulty4,
  6. Hannah Crothers4,
  7. Felicity Evison6,
  8. Katharine Reeves4,
  9. Domenico Pagano7,
  10. Alastair K Denniston8,
  11. Krishnarajah Nirantharakumar9,
  12. Peter Diggle10,11 and
  13. Simon Ball12
  14. All clinicians and students at University Hospitals Birmingham NHS Foundation Trust
    1. 1PIONEER HDR-UK Hub, University of Birmingham, Birmingham, West Midlands, UK
    2. 2Acute Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
    3. 3PIONEER Technical Director, Health Informatics, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
    4. 4Health Informatics, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
    5. 5Statistics, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
    6. 6Department of Informatics, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
    7. 7Cardiothoracic Surgery, University Hospitals Birmingham, Birmingham, UK
    8. 8INSIGHT: HDRUK Health Data Research Hub for Eye Health, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
    9. 9Public Health, University of Birmingham, Birmingham, UK
    10. 10Faculty of Health and Medicine, Lancaster University, Lancaster, Lancashire, UK
    11. 11Epidemiology and Population Health, University of Liverpool, Liverpool, Merseyside, UK
    12. 12HDR-UK Midlands Physical Site, University Hospitals Birmingham, Birmingham, UK
    1. Correspondence to Dr Elizabeth Sapey; e.sapey{at}


    Background Studies suggest that certain black and Asian minority ethnic groups experience poorer outcomes from COVID-19, but these studies have not provided insight into potential reasons for this. We hypothesised that outcomes would be poorer for those of South Asian ethnicity hospitalised from a confirmed SARS-CoV-2 infection, once confounding factors, health-seeking behaviours and community demographics were considered, and that this might reflect a more aggressive disease course in these patients.

    Methods Patients with confirmed SARS-CoV-2 infection requiring admission to University Hospitals Birmingham NHS Foundation Trust (UHB) in Birmingham, UK between 10 March 2020 and 17 April 2020 were included. Standardised admission ratio (SAR) and standardised mortality ratio (SMR) were calculated using observed COVID-19 admissions/deaths and 2011 census data. Adjusted HR for mortality was estimated using Cox proportional hazard model adjusting and propensity score matching.

    Results All patients admitted to UHB with COVID-19 during the study period were included (2217 in total). 58% were male, 69.5% were white and the majority (80.2%) had comorbidities. 18.5% were of South Asian ethnicity, and these patients were more likely to be younger and have no comorbidities, but twice the prevalence of diabetes than white patients. SAR and SMR suggested more admissions and deaths in South Asian patients than would be predicted and they were more likely to present with severe disease despite no delay in presentation since symptom onset. South Asian ethnicity was associated with an increased risk of death, both by Cox regression (HR 1.4, 95% CI 1.2 to 1.8), after adjusting for age, sex, deprivation and comorbidities, and by propensity score matching, matching for the same factors but categorising ethnicity into South Asian or not (HR 1.3, 95% CI 1.0 to 1.6).

    Conclusions Those of South Asian ethnicity appear at risk of worse COVID-19 outcomes. Further studies need to establish the underlying mechanistic pathways.

    • viral infection
    • respiratory infection
    • clinical epidemiology

    This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:

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    • Collaborators The manuscript was prepared and submitted on behalf of all of the staff and students at UHB NHS Foundation Trust, with particular thanks to medical students Lylah Irshad, Maxim Harris and Theodore Nabavi, and health informatics A Kolesnyk, M Ahmed, A Liaqat, Tanya Pankhurst, Jamie Coleman, Chirag Dave, Khaled ElFandi, Rifat Rashid and Paul Cockwell.

    • Contributors ES designed the study, collated the data, performed some analyses and wrote the manuscript. SG collated the data, performed the analysis and wrote the manuscript. CM, DM, HC, FE and KR performed the statistical analysis. PN performed the statistical analysis and helped write the manuscript. DP assisted with the design of the study and manuscript preparation. PD assisted with analysis. KN and AKD assisted with analysis and manuscript writing. SB designed the study, oversaw data collection and helped write the manuscript. All authors amended the manuscript and approved the final version. Data were curated and analysed on behalf of all clinicians at UHB.

    • Funding This work was supported by PIONEER, the Health Data Research UK (HDR-UK) Health Data Research Hub in acute care. HDR-UK is an initiative funded by the UK Research and Innovation, Department of Health and Social Care (England) and the devolved administrations, and leading medical research charities.

    • Competing interests SB reports funding support from the HDR-UK. KR reports funding support from the NIHR. ES reports funding support from HDR-UK, MRC, Wellcome Trust, NIHR and British Lung Foundation. KN reports funding from MRC, Wellcome Trust, NIHR, Vifor and AstraZeneca. AKD reports funding from HDR-UK, Wellcome Trust and Fight for Sight.

    • Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

    • Patient consent for publication Not required.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data availability statement Data are available upon reasonable request. To facilitate knowledge in this area, the anonymised participant data and a data dictionary defining each field will be available to others through application to PIONEER via the corresponding author.