Soon after the first death of a UK health care worker linked to COVID-19 was reported at the end of March, an alarming trend quickly appeared – the majority of those dying on the front line were from an ethnic minority. To date, just under two-thirds have been from a Black, Asian or Minority Ethnic (BAME) group (1). By contrast, 14% of the UK population and approximately 20% of the National Health Service workforce are from a BAME group. Whilst the media reports of deaths amongst frontline workers relayed an early warning about ethnic disproportionalities, only more recently have data about the issue in the wider UK public started to emerge.
Last week, the Office for National Statistics (ONS) published an analysis of 14,745 COVID-19 related deaths in England and Wales, stratified by ethnic group, through linkage with patient characteristics captured in the 2011 Census (2). Across all ages, 16% of deaths occurred in BAME groups – predominantly Indian, Bangladeshi, Pakistani and Black patients. Compared to their White counterparts, the age-adjusted likelihood of death for Black men and women was more than 4-times greater, for Bangladeshi or Pakistani men and women was more than 3-times greater and for Indian men and women was more than 2-times greater. After further adjustment for sociodemographic factors (region, rural and urban classification, area deprivation, household composition, socioeconomic position, highest qualification held, household tenure, and health or disability), the association was attenuated by around half for all groups, but not removed.
A substantial part of the inequality in outcomes from COVID-19 is explained by differences in geographic and socioeconomic factors. This is not only the case in the UK, but also in America, where similar disparities have been reported. However, other drivers not accounted for in the analyses by ONS, such as health behaviours, employment (i.e. higher-risk occupations), specific underlying health conditions and, possibly, genetic factors, are likely to be important and the relationship between these factors complex.
Differences in the prevalence of cardiovascular diseases, which adversely affect prognosis, may also be relevant. Amongst Italian patients who died, 71% had a history of hypertension, 28% of coronary artery disease and 16% of heart failure (3). The development of cardiovascular disease is driven by an extensive number of risk factors, and ethnicity is well-established as one of these. Coronary artery disease is more common in South Asians than in Europeans (4), and Black men and women more frequently develop hypertension than other groups (5). Multimorbidity, which itself is more common in BAME than in White patients, further increases the risk of adverse cardiovascular events and death from any cause in patients with established cardiovascular disease (6). Although not accounted for by ONS, two UK-based groups have reported the effect of adjusting for comorbidities on the association between ethnicity and risk of death from COVID-19. In one population study, national primary care electronic health record data was linked to in-hospital death data for more than 17 million patients (7), and in the other, specific data was collected from the electronic health records of 2217 patients (8). In both studies, despite adjusting for comorbidities, the point estimates for the risk of death remained well above 1.0 for patients from BAME groups (although in some cases, due to small numbers of events, the confidence intervals were wide).
Better understanding the interplay between ethnicity and cardiovascular disease within the context of COVID-19 is important. However, although this may account for part of the ethnicity trend observed, there remains factors that are, as yet, unexplained. Research into identifying what these are is urgently needed. Whether the observations in the UK population extend to other ethnically diverse countries remains to be seen.
- Cook T, Kursumovic E, Lennane S. Exclusive: deaths of NHS staff from covid-19 analysed. Health Serv J 2020 Apr 22. https://www.hsj.co.uk/exclusive-deaths-of-nhs-staff-from-covid-19-analysed/7027471.article.
- Coronavirus (COVID-19) related deaths by ethnic group, England and Wales: 2 March 2020 to 10 April 2020. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/articles/coronavirusrelateddeathsbyethnicgroupenglandandwales/2march2020to10april2020
- Characteristics of SARS-CoV-2 patients dying in Italy. Report based on available data on April 13 2020. https://www.epicentro.iss.it/en/coronavirus/bollettino/Report-COVID-2019_13_april_2020.pdf
- Tillin T, Hughes AD, Mayet J et al. The Relationship Between Metabolic Risk Factors and Incident Cardiovascular Disease in Europeans, South Asians, and African Caribbeans: SABRE (Southall and Brent Revisited)—A Prospective Population-Based Study. J Am Coll Cardiol. 2013;61(17):1777-1786. https://doi.org/10.1016/j.jacc.2012.12.046
- Spence JD, Rayner BL. Hypertension in Blacks. Hypertension. 2018;72(2):263-269. https://doi.org/10.1161/HYPERTENSIONAHA.118.11064
- Glynn LG, Buckley B, Reddan D, et al. Multimorbidity and risk among patients with established cardiovascular disease: a cohort study. Br J Gen Practice. 2008;58(552):488-494. 10.3399/bjgp08X319459
- Williamson E, Walker AJ, Bhaskaran K et al. OpenSAFELY: factors associated with COVID-19-related hospital death in the linked electronic health records of 17 million adult NHS patients. medRxiv preprint 7 May 2020. https://doi.org/10.1101/2020.05.06.20092999
- Sapay E, Gallier S, Mainey C et al. Ethnicity and risk of death in patients hospitalised for COVID-19 infection: an observational cohort study in an urban catchment area. medRxiv preprint 9 May 2020. https://doi.org/10.1101/2020.05.05.20092296
The Heart in the Time of COVID-19 