Publication date: Sep 21, 2023

Despite growing evidence suggesting increased COVID-19 mortality among people from ethnic minorities, little is known about milder forms of SARS-CoV-2 infection. We sought to explore the association between ethnic background and the probability of testing, testing positive, hospitalisation, COVID-19 mortality and vaccination uptake. A multistate cohort analysis. Participants were followed between 8 April 2020 and 30 September 2021. The UK Biobank, which stores medical data on around half a million people who were recruited between 2006 and 2010. 405 541 subjects were eligible for analysis, limited to UK Biobank participants living in England. 23 891 (6%) of participants were non-white. The associations between ethnic background and testing, testing positive, hospitalisation and COVID-19 mortality were studied using multistate survival analyses. The association with single and double-dose vaccination was also modelled. Multistate models adjusted for age, sex and socioeconomic deprivation were fitted to estimate adjusted HRs (aHR) for each of the multistate transitions. 18 172 (4. 5%) individuals tested positive, 3285 (0. 8%) tested negative and then positive, 1490 (6. 9% of those tested positive) were hospitalised, and 129 (0. 6%) tested positive at the moment of hospital admission (ie, direct hospitalisation). Finally, 662 (17. 4%) died after admission. Compared with white participants, Asian participants had an increased risk of negative to positive transition (aHR 1. 24 (95% CI 1. 02 to 1. 52)), testing positive (95% CI 1. 44 (1. 33 to 1. 55)) and direct hospitalisation (1. 61 (95% CI 1. 28 to 2. 03)). Black participants had an increased risk of hospitalisation following a positive test (1. 71 (95% CI 1. 29 to 2. 27)) and direct hospitalisation (1. 90 (95% CI 1. 51 to 2. 39)). Although not the case for Asians (aHR 1. 00 (95% CI 0. 98 to 1. 02)), black participants had a reduced vaccination probability (0. 63 (95% CI 0. 62 to 0. 65)). In contrast, Chinese participants had a reduced risk of testing negative (aHR 0. 64 (95% CI 0. 57 to 0. 73)), of testing positive (0. 40 (95% CI 0. 28 to 0. 57)) and of vaccination (0. 78 (95% CI 0. 74 to 0. 83)). We identified inequities in testing, vaccination and COVID-19 outcomes according to ethnicity in England. Compared with whites, Asian participants had increased risks of infection and admission, and black participants had almost double hospitalisation risk, and a 40% lower vaccine uptake.

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